Download Aurora Fire Rescue Prehospital Protocols

Aurora Fire Rescue / Falck Rocky Mountain
Authorized Version
of
Denver Metropolitan Prehospital Protocols
Approved January 23, 2017
Version 1.6
Approved January 23, 2017
1
Table of Contents 1
Introduction
Confidentiality
Consent
Decision Making Capacity
Physician at the Scene / Medical Direction
Physician at the Scene / Medical Direction Algorithm
Adult Pulseless Arrest - General
Termination of Resuscitation
Advanced Medical Directives
Patient Determination: Patient or No Patient Algorithm
Patient Non-Transport or Refusal Algorithm
Emergency Department Divert and Advisory
Emergency Department Capabilities Chart
Emergent vs. Non-Emergent Patient Transport
Prehospital Trauma Triage Guideline for patients 15 years and older
Prehospital Trauma Triage Guideline for patients less than 15 years old
Multiple Patient Incident Criteria
Free-Standing ED as EMS Destination
START Triage
JumpSTART Pediatric MCI Triage
Multiple Patient Incident-Distribution Worksheet
Procedures:
10 Orotracheal Intubation
15 Nasotracheal Intubation
20 Percutaneous Cricothyrotomy
25 i-gel Airway
30 Continuous Positive Airway Pressure Algorithm
35 Capnography
40 Synchronized Cardioversion Algorithm
45 Transcutaneous Cardiac Pacing
55 Restraint
60 Tourniquet
65 Needle Thoracostomy for Tension Pneumothorax
70 Intraosseous Catheter
75 Vascular Access Devices
Approved January 23, 2017
Index
2
Table of Contents 2
Protocols:
Respiratory
100 Adult Epistaxis Management Algorithm
105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations
110 Adult Obstructed Airway Algorithm: Conscious Patient
110 Adult Obstructed Airway Algorithm: Unconscious Patient
115 Adult Respiratory Distress Algorithm
120 Adult Asthma
121 Adult COPD
125 Adult CHF / Pulmonary Edema Algorithm
130 Adult Allergy and Anaphylaxis Algorithm
Cardiac
2000 Adult Cardiac Arrest-ACLS
2001 Adult Cardiac Arrest Algorithm-ACLS
2010 Adult Pulseless Arrest – BLS Algorithm-AED
2020 Adult Pulseless Arrest – VF / VT
2021 Adult Pulseless Arrest – Asystole / PEA
2025 Adult Return of Spontaneous Circulation (ROSC)
2030 Adult Tachyarrhythmia Algorithm-ACLS
2040 Adult Bradycardia Algorithm-ACLS
2050 Adult Chest Pain
2051 Adult Cardiac Alert
2100 Adult Hypertension
Neuro
3000 Adult Syncope
3010 Adult Stroke Algorithm
3011 Adult Mobile Stroke Treatment Unit
3020 Adult Altered Mental Status Algorithm
3030 Adult Seizure Algorithm
Medical
4010 Adult Abdominal Pain / Vomiting Algorithm
4020 Adult Overdose and Acute Poisoning Algorithm
4025 Adult Hypoglycemia Algorithm
4030 Adult Medical Hypotension / Shock Algorithm
4031 Adult Adrenal Insufficiency
4040 Adult Drowning Algorithm
4050 Adult Hypothermia Algorithm
4060 Adult Hyperthermia Algorithm
4070 Adult Insect / Arachnid Bite and Stings Algorithm
4080 Adult Snake Bite Algorithm
Behavioral
5000 Adult Psychiatric / Behavioral Emergency
5010 Adult Combative Patient Algorithm
5020 Adult Transport of the Handcuffed Patient
5030 Adult Tasered Patients
5040 Adult Drug / Alcohol Intoxication Algorithm
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Index
3
Table of Contents 3
Obstetrics
6000 Pre-Eclampsia / Eclampsia Algorithm
6010 Emergency Childbirth Algorithm
6020 Abnormal Delivery Algorithm
6030 Postpartum Hemorrhage Algorithm
Trauma
7000 Adult General Trauma Care Algorithm
7005 Adult Special Trauma Scenarios Algorithm
7010 Adult Trauma in Pregnancy Algorithm
7015 Adult Traumatic Pulseless Arrest Algorithm
7020 Adult Traumatic Shock Algorithm
7025 Adult Amputations Algorithm
7026 Adult Extremity Injuries
7029 Adult Head Trauma
7030 Adult Face and Neck Trauma Algorithm
7035 Adult Spinal Trauma Algorithm
7040 Adult Selective Spinal Stabilization Algorithm
7045 Adult Chest Trauma Algorithm
7050 Adult Abdominal Trauma Algorithm
7055 Adult Burns Algorithm
Pediatrics
001p General Guidelines for Pediatric Patients
002p Pediatric Assessment Algorithm
003p Pediatric Shock
004p Transport of the Pediatric Patient
Pediatric Respiratory
100p Pediatric Epistaxis Management
105p Pediatric Respiratory Failure / Arrest Algorithm
110p Pediatric Obstructed Airway Algorithm: Conscious Patient
110p Pediatric Obstructed Airway Algorithm: Unconscious Patient
115p Pediatric Respiratory Distress
120p Pediatric Asthma
125p Pediatric Croup
126p Pediatric Bronchiolitis
130p Pediatric Allergy and Anaphylaxis
Pediatric Cardiac
2000p Pediatric Cardiac Arrest General Principles
2010p Pediatric Pulseless Arrest BLS / AED Algorithm
2020p Pediatric Pulseless Arrest - VF / VT
2021p Pediatric Pulseless Arrest – Asystole / PEA
2025p Pediatric Return of Spontaneous Circulation (ROSC)
2030p Pediatric Tachycardia
2040p Pediatric Bradycardia
2200p Newborn Resuscitation Algorithm
Approved January 23, 2017
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Index
Table of Contents 4
Pediatric Neuro
3000p Pediatric Syncope
3010p Pediatric Stroke Algorithm
3020p Pediatric Altered Mental Status
3030p Pediatric Seizure Algorithm
Pediatric Medical
4010p Pediatric Abdominal Pain / Vomiting
4020p Pediatric Overdose and Acute Poisoning Algorithm
4025p Pediatric Hypoglycemia
4031p Pediatric Adrenal Insufficiency
4040p Pediatric Drowning
4050p Pediatric Hypothermia
4060p Pediatric Hyperthermia
4070p Pediatric Insect/Arachnid Bite and Sting
4080p Pediatric Snake Bite
4090p Pediatric Apparent Life Threatening Event (ALTE) Algorithm
4095p Care of the Child with Special Needs
Pediatric Behavioral
5000p Pediatric Psychiatric / Behavioral Emergencies
5040p Pediatric Alcohol Intoxication
Pediatric Trauma
7000p Pediatric General Trauma Care
7010p Pediatric Special Trauma Scenarios
7015p Pediatric Traumatic Pulseless Arrest
7020p Pediatric Traumatic Shock
7025p Pediatric Amputations
7029p Pediatric Head Trauma
7030p Pediatric Face and Neck Trauma
7035p Pediatric Spinal Trauma
7040p Pediatric Spinal Immobilization Considerations
7045p Pediatric Chest Trauma
7050p Pediatric Abdominal Trauma
7055p Pediatric Burns
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5
Index
Table of Contents 5
Medications:
Albuterol Sulfate (Proventil,Ventolin)
Adenosine (Adenocard)
Amiodarone (Cordarone)
Aspirin (ASA)
Atropine Sulfate
Calcium Gluconate
Calcium Chloride
Dextrose 50%
Diphenhydramine (Benadryl)
Dopamine (Intropin)
Epinephrine (Adrenalin)
Fentanyl (Sublimaze)
Glucagon
Ipratropium Bromide (Atrovent)
Magnesium Sulfate
Methylprednisolone (Solu-Medrol)
Midazolam (Versed)
Naloxone (Narcan)
Nerve Agent Kit (DuoDote)
Nitrogylcerine (NitroStat)
Odansetron (Zofran)
Oral Glucose (Glutose, Insta-Glucose)
Oxygen
Phenylephrine (Intranasal)
Racemic Epinephrine (Vaponephrine)
Sodium Bicarbonate
Topical Ophthalmic Anesthetics
Core Competencies:
Adult Medical Arrest – Compressor
Adult Medical Arrest – Ventilator
Adult Medical Arrest – Lead Paramedic
Adult Traumatic Arrest – Compressor
Adult Traumatic Arrest – Ventilator
Adult Traumatic Arrest – Lead Paramedic
Pediatric Medical Arrest – Compressor
Pediatric Medical Arrest – Ventilator
Pediatric Medical Arrest – Lead Paramedic
Pediatric Traumatic Arrest – Compressor
Pediatric Traumatic Arrest – Ventilator
Pediatric Traumatic Arrest – Lead Paramedic
Index
Approved January 23, 2017
6
General Guidelines: Introduction
INTRODUCTION
The following protocols have been developed and approved by the Aurora Fire Rescue Medical
Directors and is based on the consensus document produced by the Denver Metropolitan EMS
Medical Directors (DMEMSMD) group. These protocols define the standard of care for EMS providers
in the City of Aurora, and delineate the expected practice, actions, and procedures to be followed.
No protocol can account for every clinical scenario encountered, and the Medical Directors recognize
that in rare circumstances deviation from these protocols may be necessary and in a patientʼs best
interest. Variance from protocol should always be done with the patientʼs best interest in mind and
backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct
verbal order from base station physician is preferred. Additionally, all variance from protocol should
be documented and submitted for review in a timely fashion.
The protocols have a new look and are presented in an algorithm format. An algorithm is intended
to reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical
scenario can be represented. Although the algorithm implies a specific sequence of actions, it may
often be necessary to provide care out of sequence from that described in the algorithm if dictated by
clinical needs. An algorithm provides decision-making support, but is no substitute for sound clinical
judgment.
In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug
dosing has not been included in the algorithms. It is expected the EMTs will be familiar with standard
drug doses. Drug dosages are included with the medications section of the protocols as a reference.
If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol
by clicking on the hyperlink, which is underlined.
PROTOCOL KEY
Boxes without any color fill describe actions applicable to all levels of EMT.
Splint with bulky dressing
Boxes with blue fill are for EMT-paramedic level.
12 lead ECG to identify STEMI if
present
When applicable, actions requiring base contact are identified in the protocol:
CONTACT BASE for consideration of field pronouncement
Teaching points deemed sufficiently important to be included in the protocol are on the second page
of the applicable protocol.
PEDIATRIC PROTOCOLS
For the purposes of these clinical care protocols, pediatric patients are those < 12 years of age,
except where identified in a specific protocol.
Index
Approved January 23, 2017
7
General Guidelines: Confidentiality
A. The patient-physician relationship, the patient-registered nurse relationship, and the
patient-EMT relationship are recognized as privileged. This means that the physician, nurse,
or EMT may not testify as to confidential communications unless:
1. The patient consents
2. The disclosure is allowable by law (such as Medical Board or Nursing Board
proceedings, or criminal or civil litigation in which the patient's medical condition is
in issue)
B. The prehospital provider must keep the patient's medical information confidential. The
patient likely has an expectation of privacy, and trusts that personal, medical information
will not be disclosed by medical personnel to any person not directly involved in the
patient's medical treatment.
1. Exceptions
i. The patient is not entitled to confidentiality of information that does not
pertain to the medical treatment, medical condition, or is unnecessary for
diagnosis or treatment.
ii. The patient is not entitled to confidentiality for disclosures made publicly.
iii. The patient is not entitled to confidentiality with regard to evidence of a
crime.
C. Additional Considerations:
1. Any disclosure of medical information should not be made unless necessary for the
treatment, evaluation or diagnosis of the patient.
2. Any disclosures made by any person, medical personnel, the patient, or law
enforcement should be treated as limited disclosures and not authorizing further
disclosures to any other person.
3. Any discussions of prehospital care by and between the receiving hospital, the
crewmembers in attendance, or at in-services or audits are done strictly for
educational or performance improvement purposes. Further disclosures are not
authorized.
4. Radio communications should not include disclosure of patient names.
5. This procedure does not preclude or supersede the Aurora Fire Department’s
HIPAA policy and procedures.
Approved January 23, 2017
Index
8
General Guidelines: Consent
General Principles
A. Consent is a legal concept. Decision Making Capacity (DMC) is a medical concept.
B. A person is deemed to have decision-making capacity if he/she:
(Must meet all criteria)
1. Is not clinically intoxicated with alcohol or drugs
2. Understands nature of illness or injury
3. Understands consequences of refusal of care
4. Given the risks and options, voluntarily refuses treatment or transport
5. Criteria that does NOT meet a Mental Health Hold:
a. Not homicidal or suicidal
b. Not gravely disabled or psychotic
c. Not a danger to self or others
General Principles: Adult
A. An adult in the State of Colorado is 18 years of age or older.
B. Every adult is presumed capable of making medical treatment decisions. This includes the
right to make "bad" decisions that the prehospital provider believes are not in the best
interests of the patient.
C. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient with DMC
may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the
patient of the need for therapies, offer again, and treat to the extent possible.
D. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing
treatment.
E. Implied Consent: An unconscious adult is presumed to consent to treatment for lifethreatening injuries/illnesses.
F. Involuntary Consent: a person other than the patient in rare circumstances may authorize
Consent. This may include a court order (guardianship), authorization by a law enforcement
officer for prisoners in custody or detention, or for persons under a mental health hold or
commitment who are a danger to themselves or others or are gravely disabled.
G. Consent may be inferred by the patient's actions or by express statements. If you are not
sure that you have consent, clarify with the patient or CONTACT BASE (AIP, Children’s
TMCA, CMP, SaddleRock). This may include consent for treatment decisions or
transport/destination decisions.
H. If the patient lacks decision-making capacity and the patient's life or health is in danger, and
there is no reasonable ability to obtain the patient's consent, proceed with transport and
treatment of life-threatening injuries/illnesses. If you are not sure how to proceed,
CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock).
I. For patients who refuse medical treatment, if you are unsure whether or not a situation of
involuntary consent applies, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock).
Approved January 23, 2017
Index
9
General Guidelines: Consent
General Principles: Minors
A. A parent, including a parent who is a minor, may consent to, or refuse medical or emergency
treatment of his/her child. There are exceptions:
1. Neither the child nor the parent may refuse medical treatment on religious grounds
if the child is in imminent danger as a result of not receiving medical treatment, or
when the child is in a life-threatening situation, or when the condition will result in
serious handicap or disability.
2. If a minor has an injury or illness, but not a life-threatening medical emergency, you
should attempt to contact the parent(s) or legal guardian. If this cannot be done
promptly, transport.
3. If the minor has a life-threatening injury or illness, transport and treat per protocols.
If the parent objects to treatment, CONTACT BASE (AIP, Children’s TMCA, CMP,
SaddleRock) immediately and treat to the extent allowable, and notify police to
respond and assist.
4. The consent of a parent is not necessary to authorize hospital or emergency health
care when an EMT in good faith relies on a minor's consent, if the minor is at least
15 years of age and emancipated or married.
5. Minors may seek treatment for abortion, drug addiction, and venereal disease
without consent of parents. Minors > 15 years may seek treatment for mental
health.
6. BASE CONTACT (AIP, Children’s TMCA, CMP, SaddleRock) is required any time
a minor patient is left on scene.
B. When in doubt, your actions should be guided by what is in the minor's best interests and
base contact.
10
Approved January 23, 2017
Index
General Guidelines: Physician at the scene / Medical Direction
Purpose
A. To provide guidelines for prehospital personnel who encounter a physician at the scene of
an emergency
General Principles
A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and
conduct an assessment of the patient to the extent possible.
B. A physician who voluntarily offers or renders medical assistance at an emergency scene is
generally considered a "Good Samaritan." However, once a physician initiates treatment,
he/she may feel a physician-patient relationship has been established.
C. Good patient care should be the focus of any interaction between prehospital care providers
and the physician.
Procedure
A. See algorithm below and sample note to physician at the scene
Special notes
A. Every situation may be different, based on the physician, the scene, and the condition of the
patient.
B. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) when any question(s) arise.
Approved January 23, 2017
Index
11
General Guidelines: Physician at the scene/Medical Direction
NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PROVIDERS
THANK YOU FOR OFFERING YOUR ASSISTANCE.
The prehospital personnel at the scene of this emergency operate under standard policies,
procedures, and protocols developed by their Medical Director. The drugs carried and procedures
allowed are restricted by law and written protocols.
After identifying yourself by name as a physician licensed in the State of Colorado and providing
identification, you may be asked to assist in one of the following ways:
1.
2.
Offer your assistance or suggestions, but the prehospital care providers will remain
under the medical control of their base physician, or
With the assistance of the prehospital care providers, talk directly to the base
physician and offer to direct patient care and accompany the patient to the
receiving hospital. Prehospital care providers are required to obtain an order
directly from the base physician for this to occur.
THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.
_____________________________
Medical Director
Approved January 23, 2017
___________________________________
Agency
Index
12
General Guidelines: Physician at the scene/Medical Direction
EMS arrives on
scene
EMT attempts
patient care
Physician reports on patient and
relinquishes patient care
Physician wants to help or is involved
in or will not relinquish patient care
Prehospital provider identifies self and
level of training
Provide care per protocol
Physician willing to just
help out
Provide general
instructions and utilize
physician assistance
Physician does not
relinquish patient
care and
continues with
care inconsistent
with protocols
CONTACT BASE
for Medical
Consult
Approved January 23, 2017
Index
Physician requests or performs
care inappropriate or
inconsistent with protocols
Shares Physician At The
Scene/Medical Direction
Note with physician and
advise physician of your
responsibility to the patient
Physician
complies
Provide care per
protocol
13
Adult Pulseless Arrest - General
Dependent lividity
Or
Rigor mortis
Or
Decomposition
Yes
No
Place patient on
cardiac monitor
Not Asystole
Asystole *
Advanced Directives indicating
DNR
Yes
CONTACT BASE for
consideration of field
pronouncement
No
Ref. Asystole / PEA or VF / VT if medical
cause
OR
Ref. Adult Traumatic Pulseless Arrest if
traumatic cause
Cardiac arrest from the following causes
should approached as a medical cardiac
arrest:
 Overdose
 Respiratory arrest
 Airway obstruction
 Asphyxiation
 Hanging
 Drowning
 Electrocution
 Lightning/high voltage
* Asystole is defined as the absence of any electrical activity and must be observed in two or more
leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the
EMS Operations Captain. Include the AFR incident number on the strip.
Approved January 23, 2017
14
Index
Termination of Resuscitation
Purpose
A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac
arrest in the prehospital setting
General Principles
A. Attempt resuscitation for all patients found pulseless and apneic, unless any of the
following are present:
1. Physician orders as specified on the Colorado Medical Orders for Scope of
Treatment (MOST) form: “No CPR. Do Not Resuscitate/DNR/Allow Natural
Death”, present with the patient
2. A valid CPR directive present with the patient
3. Dependent lividity with Asystole: OR
4. Rigor Mortis with Asystole: OR
5. Decomposition with Asystole
Medical Pulseless Arrest:
A. Continue Resuscitation until:
1. ROSC
2. Continuous asystole for at least 15 minutes after ALS care
a. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for
consideration of TOR at any point if continuous asystole for at least 15
minutes after ALS care.
b. Regardless of cardiac rhythm, the following patients should be
aggressively resuscitated and transported as soon as possible:
i. Hypothermia
ii. Drowning with hypothermia and submersion < 60 minutes
iii. Pregnant patient with estimated gestational age ≥ 20 weeks
c. After pronouncement, do not alter condition in any way or remove
equipment (lines, tubes, etc.), as the patient is now a potential coroner’s
case.
Traumatic Pulseless Arrest:
A. Follow guidelines per 7015 Adult Traumatic Pulseless Arrest
Index
Approved January 23, 2017
15
General Guidelines: Advanced Medical Directives
A. These guidelines apply to both adult and pediatric patients.
B. There are several types of advance medical directives (documents in which a patient
identifies the treatment to be withheld in the event the patient is unable to communicate or
participate in medical treatment decisions).
C. Some patients may have specific physician orders on a Colorado Medical Orders for Scope of
Treatment (MOST) form. A MOST form order to withhold CPR or resuscitation should be
honored by EMS.
D. Resuscitation may be withheld from, or terminated for, a patient who has a valid CPR
Directive, Do Not Resuscitate Order (DNR), or other advance medical directive when:
1. It is clear to the prehospital provider from the document that resuscitation is
refused by the patient or by the patient's attending physician who has signed the
document; and
2. Base physician (AIP, Children’s, TMCA, CMP, SaddleRock) has approved
withholding of or ceasing resuscitation.
E. Suspected suicide does not necessarily negate an otherwise valid CPR Directive, DNR order
or other advanced medical directive. CONTACT BASE (AIP, Children’s, TMCA, CMP,
SaddleRock)
F. The Colorado CPR Directive directs EMS providers to withhold CPR in the event of cardiac
or respiratory arrest or malfunction.
1. “Cardiopulmonary Resuscitation” (CPR) means measures to restore cardiac function
or to support breathing in the event of cardiac or respiratory arrest or malfunction.
“CPR” includes, but is not limited to, artificial ventilation, chest compression,
delivering electric shock, placing tubes in the airway to assist breathing or other
basic and advanced resuscitative therapies.
2. CPR Directive bracelet or necklace may be used by an individual and shall be
complied with in the same manner as a written CPR Directive.
3. A signed CPR directive form that has been photocopied, scanned, faxed is valid.
G. A Living Will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a
terminal condition, as certified in the patient's hospital chart by two physicians.
H. Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health
Care Proxy". Each of these documents can be very complex and require careful review and
verification of validity and application to the patient's existing circumstances. Therefore, the
consensus is that resuscitation should be initiated until a physician can review the document
or field personnel can discuss the patient’s situation with the base physician. If there is
disagreement at the scene about what should be done, CONTACT BASE (AIP,
Children’s, TMCA, CMP, SaddleRock) for guidance.
I. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family
or an attending physician directs resuscitation be ceased, the prehospital provider should
immediately CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). The prehospital
provider should accept verbal orders to cease resuscitation only from the Base physician.
J. There may be times in which the prehospital provider feels compelled to perform or
continue resuscitation, such as a hostile scene environment, family members adamant that
"everything be done," or other highly emotional or volatile situations. In such circumstances,
the prehospital provider should attempt to confer with the BASE (AIP, Children’s, TMCA,
CMP, SaddleRock) for direction and if this is not possible, the prehospital provider must use
his or her best judgment in deciding what is reasonable and appropriate, including
transport, based on the clinical and environmental conditions, and establish base contact as
soon as possible.
Approved January 23, 2017
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Index
General Guidelines: Advanced Medical Directives
Additional Considerations:
A. Patients with valid DNR orders or advanced medical directives should receive supportive or
comfort care, e.g. medication by any route, positioning and other measures to relieve pain
and suffering. Also the use of oxygen, suction and manual treatment of an airway
obstruction as needed for comfort.
B. Mass casualty incidents are not covered in detail by these guidelines.
C. If the situation appears to be a potential crime scene, EMS providers should disturb the
scene as little as possible and communicate with law enforcement regarding any items that
are moved or removed from the scene.
D. In all cases of unattended deaths occurring outside of a medical facility, the Aurora Police
Department should be contacted immediately.
17
Approved January 23, 2017
Index
General Guidelines: Patient Determination: “Patient or No Patient”
Acute illness or injury possible based on history or appearance or
mechanism.
No
Is the person a minor (< 18)?
Yes
No
Airbag Deployment?
Yes
No
MVC Rollover?
Yes
Individual meets
definition of a
Patient
(PCR Required)
No
Involved person’s vehicle has broken glass?
Yes
No
Yes
Person lacks decision-making capacity ref. Consent
No
Person has an acute medical complaint resulting in a call for help
Yes
No
3rd party* indicates individual is ill, injured or gravely disabled
Yes
No
Person does not meet definition of a patient, and does not require PCR or refusal of care
*Cell phone call by concerned citizen driving by a perceived emergency excluded.
18
Approved January 23, 2017
Index
General Guidelines: Patient Non-Transport or Refusal
Dispatch
Arrived on
scene
Cancelled
PTA
Not a patient
ref. Patient Determination
Patient
Pt refusing
transport
Pt requesting
transport
Standing Order Refusal
Base Contact Refusal
No Base Contact required if
ALL criteria met:
All calls not meeting criteria
for Standing Order Refusal
“CONTACT BASE (AIP,
Children’s, TMCA, CMP,
Saddle Rock) for
documentation of refusal
and / or consult”
 Adult patient (≥18)
 Decision-making
capacity*
 Minor isolated soft tissue
injury to an extremity
Documentation Requirements for Refusal
Clarify calling to document vs authorization





*A person who has decision-making
capacity may refuse examination,
treatment and transport
Ref: GENERAL GUIDELINES: CONSENT
for Decision-Making Capacity guidelines

Approved January 23, 2017
Index
Confirm decision-making capacity
EMS assistance offered and declined
Risks of refusal explained to patient
Patient understands risks of refusal
Name of Base Station physician authorizing refusal of
care unless standing order refusal
Signed refusal of care and against medical advice
document, if applicable.
19
General Guidelines: Emergency Department Divert and Advisory
Purpose
A. To provide a standard approach to ambulance diversion that is practical for field use
B. To facilitate unobstructed access to hospital emergency departments for ambulance
patients
C. To allow for optimal destination policies in keeping with general EMS principles and
Colorado State Trauma System Rules and Regulations
General Principles
A. EMSystem, an internet-based tracking system, is used to manage diversion in the
Denver Metro area
B. The only time an ambulance can be diverted from a hospital is when that hospital is
posted on EMSystem as being on official divert (RED) status.
C. Overriding factors: the following are appropriate reasons for a paramedic to
override ED Divert and, therefore, deliver a patient to an emergency department
that is on ED divert:
1. Cardiopulmonary arrest
2. Imminent cardiopulmonary arrest
3. Unmanageable airway emergencies
4. Unstable trauma and burn patients transported to Level I and Level II
Trauma Centers
5. Patients meeting “Cardiac Alert“ criteria (participating hospitals)
6. Patients meeting “Stroke Alert“ criteria (participating hospitals)
7. Imminent delivery
D. Prehospital personnel should honor advisory categories, when possible, considering
patient’s condition, travel time, and weather. Patients with specific problems that
fall under an advisory category should be transported to a hospital not on that
specific advisory when feasible.
E. There are several categories that are considered advisory (yellow) alert categories.
These categories are informational only and should alert field personnel that a
hospital listed as being on an advisory alert may not be able to optimally care for a
patient that falls under that advisory category.
F. The following are advisory (yellow) categories recognized by the State. Individual
facilities may not utilize these categories often, or ever:
1. ICU (Intensive Care Unit)
2. Psych (Psychiatric)
G. Zone saturation exists when all hospitals within that zone are on ED Divert.
H. A Zone Master is the designated hospital within a Zone responsible for determining
and tracking hospital assignments when the zone is saturated.
I. When an ambulance is transporting a patient that the paramedic feels cannot go
outside the zone due to patient acuity or other concerns, the paramedic should
contact the Zone Master and request a destination assignment.
J. In general, patients contacted within a zone should be transported to an appropriate
facility within the zone. Patients may be transported out of the primary zone at the
paramedic’s discretion, if it is in the patient’s best interest or if the transport to an
appropriate facility is shorter.
K. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone
numbers are listed on EMSystem.
Approved January 23, 2017
20
Index
General Guidelines: Emergency Department Divert and Advisory
Purpose
A. To provide a set of guidelines to help ensure proper disposition of the various patients
encountered in the field.
Philosophy
A. Critical patients with a special medical need should be taken to the nearest facility that can
best provide for that need.
B. Critical patients without a special need (i.e., cardiopulmonary arrest) should be taken to the
closest emergency department.
C. All other patients should have their request accommodated, consistent with the ability of the
system to meet that request.
D. Aurora Fire Rescue Paramedics are required to accompany any patient(s) that require or
may require advanced life support care who are being transported by ambulance to any
hospital emergency department.
Special Needs
A. Burns
1. Patients older than 12 years of age, with second degree or third degree burns greater
than 20% body surface area, should be transported directly to the AIP emergency
department. Patients 12 years of age and younger, with second degree or third degree
burns greater than 20% body surface area, should be transported directly to The
Children's Hospital emergency department.
2. Special Considerations. Complications of airway compromise or cardiovascular
instability, require transport to the nearest appropriate emergency department. Burns
associated with multi-system trauma should be transported to the closest appropriate
Trauma Center.
B. Trauma
1. Trauma patients should be transported to the closest appropriate Trauma Center.
C. Psychiatric patients
1. Patients placed on a MHH shall be taken to the closest appropriate facility.
2. Patients with psychiatric problems not on an MHH shall be taken to the closest
appropriate facility.
3. Patients with psychiatric problems who have an acute medical or traumatic concern
shall be treated according to the appropriate medical or trauma protocol.
4. MHH may be placed by a state-certified EMT-P under the auspices of the receiving
physician.
D. Obstetric/Gynecologic
1. For patients in uncomplicated labor:
a. Delivery not imminent:
i.
If the patient has a private obstetrician or gynecologist, then follow the patient's
request for destination, when possible.
b. If the patient has no private physician, then follow the patient's request for
destination (if expressed), or transport to the closest hospital.
2. Imminent delivery
a. If the patient has a private obstetrician/care giver, then follow the patient's request
for destination, when appropriate. If the requested facility does not meet these time
constraints and the patient still requests the facility, CONTACT BASE (AIP,
Children’s TMCA, CMP, SaddleRock) physician.
b. If the patient has no private physician, then transport to the closest appropriate
hospital.
21
Approved January 23, 2017
Index
General Guidelines: Emergency Department Capabilities
Hospital
AIP
Children's
(< 21 yrs)
Littleton
DHMC
Parker
Adventist
Porter
Denver
PSL
Rose
Saint
Joseph's
Swedish
TMCA
Sky Ridge
Centennial
Southlands
Saddlerock
Cardiac
Alert
Stroke
Alert
Trauma
Level
Pediatrics
OB/GYN
YES
II
Ped – I
> 40kg
YES
NO
YES
NO
YES
YES
(<12yo)
YES
NO
II
I
YES
YES
YES
NO
YES
YES
YES
YES
II
YES
YES
YES
YES
YES
YES
YES
NO
NO
IV
NO
NO
YES
YES
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
NO
NO
NO
NO
I
II
II
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
Special
Considerations
> 20% burns
over 12 yrs
> 20% burns up
to 12 yrs
22
Approved January 23, 2017
Index
General Guidelines: Emergent vs. Non-Emergent Patient Transport
Background:
1. Emergent (“lights and sirens”) transport of patients has not been demonstrated to
improve patient outcomes.
2. Emergent patient transports place EMS providers and the public at risk.
Emergent patient transports should be reserved for situations that meet the following two
criteria.
1. Patient has injury or illness that requires emergent hospital intervention not immediately
available to the EMS providers.
AND
2. Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers,
and the public that are created by emergency transport.
Criteria 1
Patient is has injury or illness that may require emergent hospital intervention.
Examples:
1. Airway
a. Inability to establish or maintain a patent airway
b. Upper airway stridor
2. Breathing
a. Severe respiratory distress
3. Circulation
a. Cardiac Arrest
b. Hemodynamic instability
c. Severe, uncontrolled hemorrhage
4. Neurologic
a. GCS <8
b. Seizure activity unresponsive to treatment
5. Obstetric
a. Complicated Delivery
6. Trauma
a. Penetrating/blunt trauma to head, neck, or torso
b. Two or more suspected proximal long bone fractures with symptoms of shock
or absence of distal pulses after manipulation
Criteria 2
Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers,
and the public that are created by emergency transport.
Notes:
 In most situations time saved by emergent transport will not outweigh risks when transport
time is short (< 10 minutes)
 Emergent transport should never be used solely to “get the attention” of the receiving
facility.
 The decision to transport emergent should be made jointly by the primary treating EMS
provider (who must consider patient condition and availability of treatments enroute) and
the Emergency vehicle operator (who must consider time of day, anticipated transport time,
and road/traffic conditions at time of call).
23
Approved January 23, 2017
Index
Patients 15 years old and over
Transport to a Level I or II Trauma
Center
Transport to a Level I or II
Trauma Center
24
Approved January 23, 2017
Index
Patients less than 15 years old
Transport to a designated
pediatric Level I or II
Trauma Center.
Transport to a designated
pediatric Level I or II
Trauma Center.
Transport to a designated
pediatric Level I or II
Trauma Center.
Transport to a
designated pediatric
Level I or II Trauma
Center.
25
Approved January 23, 2017
Index
Multiple Patient Incident – Patient Criteria
The Multiple Patient Incident Criteria should be used on all incidents involving more than one
patient. If the total number of patients in any one category exceeds the maximum number indicated,
the event should be considered a Mass Casualty Incident (MCI). If START Triage criteria have been
utilized to initially triage patients, the Multiple Patient Criteria should be used as a secondary triage
method and the Multiple Patient Incident Distribution Worksheet should be utilized.
Category:
Injury Types:
Maximum Number:
Category:
Injury Types:
Maximum Number:
Category:
Injury Types:
Maximum Number:
Approved January 23, 2017
CRITICAL
GCS Motor < 5 (Pt. can’t localize pain)
Assisted Ventilations
Respiratory rate <10 or >29
Uncontrolled, severe bleeding
Traumatic Shock / Absent radial pulse
Penetrating injury to neck / torso
12 (2 per Trauma Center)
SERIOUS
Altered Mental Status
Suspected femur fracture
Open long bone fracture
Motor or sensory deficits
No critical criteria (see above)
24 (4 per Trauma Center)
MODERATE
Closed, single extremity fracture
Isolated soft tissue injury
No critical criteria (see above)
No serious criteria (see above)
56 (8 per Emergency Dept.)
26
Index
Free-Standing Emergency Departments as EMS Destination
The term “free-standing emergency department” (FSED) may refer to both
licensed emergency departments that accept EMS traffic as an extension of an
affiliated hospital, as well as independent emergency departments unaffiliated with
a hospital. The following recommendations apply to those FSEDs that accept EMS
traffic as an extension of its affiliated hospital:
Patients may be considered for transport to a hospital-affiliated FSED with the
following exceptions:
1. No OB patients > 20 weeks estimated gestational age
2. No trauma patients meeting RETAC trauma center destination guidelines.
3. No Alerts (e.g. STEMI, Stroke).
4. No cardiac arrest or post-cardiac arrest patients unless unable to oxygenate or
ventilate
Hospital-affiliated free-standing emergency departments accepting EMS traffic
include:
Centennial Medical Plaza (The Medical Center of Aurora)
Saddle Rock ER (The Medical Center of Aurora)
Southlands ER (Parker Adventist)
Approved January 23, 2017
Index
27
START Triage
Approved January 23, 2017
Index
28
29
Approved January 23, 2017
Index
Multiple Patient Incident – Destination Distribution Worksheet
Approved January 23, 2017
30
Index
10 Procedure Protocol: Orotracheal Intubation
Indications:
 In general the primary goals of airway management are adequate oxygenation and ventilation,
and these should be achieved in the least invasive manner possible.
 Inability to oxygenate / ventilate via BVM using two person technique with OPA / NPA
AND
 Inability to oxygenate / ventilate via i-gel O2.
Contraindications:
 Endotracheal intubation is contraindicated in pediatric patients (< 12 years)
 Endotracheal intubation is contraindicated prior to attempting i-gel O2 Airway.
 Endotracheal intubation is contraindicated prior to reattempting via BVM and OPA/NPA with
corrective actions after i-gel
 Endotracheal intubation is contraindicated in the absence of measurable end tidal CO2 by
continuous wave form capnography/capnometry
o Measurable end tidal CO2 is not required when using ETT to push foreign body into
mainstem bronchus.
o An atypical report is required and to be submitted to the Medical Branch at the
conclusion of the incident if Intubation is performed without measureable CO2
 General:
 Orotracheal intubation is associated with worse outcomes among pediatric patients and head
injured patients when compared to BLS airway maneuvers.
 Intubation is associated with interruptions in chest compressions during CPR, which is
associated with worse patient outcomes. Additionally, intubation itself has not been shown to
improve outcomes in cardiac arrest
Technique:
1.
2.
3.
4.
5.
6.
7.
8.
Continue BLS airway sequence
Suction airway and pre-oxygenate with BVM ventilations using two person technique and
capnography
Check equipment and position patient:
a. If trauma: have assistant hold in-line spinal immobilization in neutral position
b. If no trauma, sniffing position or slight cervical hyperextension is preferred
Perform laryngoscopy
a. To improve laryngeal view, use right hand to manipulate larynx, or have assistant
apply backwards, upwards, rightward pressure (BURP)
Place ETT. Confirm tracheal location and appropriate depth and secure tube
a. Correct tube depth may be estimated as 3 times the internal diameter of tube at
teeth or gums (e.g: 7.0 ETT is positioned at 21 cm at teeth)
Confirm and document tracheal location by:
a. ETCO2
b. Presence and symmetry of breath sounds
c. Rising SpO2
d. Other means as needed
Ventilate with Ambu Bag. Assess adequacy of ventilations
During transport, continually reassess ventilation, oxygenation and tube position with
continuous ETCO2 and SpO2
31
Approved January 23, 2017
Index
10 Procedure Protocol: Orotracheal Intubation
Precautions:
 Ventilate at age-appropriate rates. Do not hyperventilate
 If the intubated patient deteriorates, think “DOPE”
o Dislodgement
o Obstruction
o Pneumothorax
o Equipment failure (no oxygen)
 Reconfirm and document correct tube position before and after moving patient
32
Approved January 23, 2017
Index
15 Procedure Protocol: Nasotracheal Intubation
Indications:



In general the primary goals of airway management are adequate oxygenation and
ventilation, and these should be achieved in the least invasive manner possible
Age ≥ 12 years spontaneously breathing patient with indication for
intubation who cannot tolerate either supine position or laryngoscopy
Nasotracheal Intubation may be considered for failure to oxygenate and ventilate in the
presence of:
a. Respiratory failure
b. Absence of protective airway reflexes
c. Present or impending complete airway obstruction
Contraindications:




Age < 12 years
Absence of measurable end tidal CO2 by continuous wave form capnography/capnometry
Apnea
Severe mid-face trauma
Technique:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Initiate BLS airway sequence
Suction airway and pre-oxygenate with BVM ventilations and capnography
Check equipment, choose correct ETT size (usually 7.0 in adult, limit is size of naris)
Position patient with head in midline, neutral position
If trauma: cervical collar may be in place, or assistant may hold in-line stabilization in
neutral position
If no trauma, patient may be sitting upright
Administer phenylephrine nasal drops in each nostril
Lubricate ETT with Lidocaine jelly or other water-soluble lubricant
With gentle steady pressure, advance the tube through the nose to the posterior pharynx.
Use the largest nostril. Abandon procedure if significant resistance is felt
Keeping the curve of the tube exactly in midline, continue advancing slowly
There will be slight resistance just before entering trachea. Wait for an inspiratory effort
before final passage through cords. Listen for loss of breath sounds
Continue advancing tube until air is definitely exchanging through tube, then advance 2 cm
more and inflate cuff
Note tube depth and tape securely
Confirm and document endotracheal location by:
a. ETCO2
b. Presence and symmetry of breath sounds
c. Rising SpO2
d. Other means as needed
Ventilate with Ambu Bag. Assess adequacy of ventilations
During transport, continually reassess ventilation, oxygenation and tube position with
continuous ETCO2 and SpO2
33
Approved January 23, 2017
Index
15 Procedure Protocol: Nasotracheal Intubation
Precautions:





Before performing BNTI, consider if patient can be safely ventilated with non-invasive
means such as CPAP or BVM
Ventilate at age-appropriate rates. Do not hyperventilate
If the intubated patient deteriorates, think “DOPE”
o Dislodgement
o Obstruction
o Pneumothorax
o Equipment failure (no oxygen)
Reconfirm and document correct tube position after moving patient and before
disconnecting from monitor in ED
Blind nasotracheal intubation is a very gentle technique. The secret to success is perfect
positioning and patience.
Approved January 23, 2017
34
Index
20 Procedure Protocol: Percutaneous Cricothyrotomy
Introduction:
 Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in
extraordinary circumstances as defined below. An atypical with the reason for performing this
procedure must be documented and submitted for review to the Medical Branch at conclusion of
the incident.
Indications:
 A life-threatening condition exists AND advanced airway management is indicated, AND
adequate oxygenation and ventilation cannot be accomplished by other less invasive means.
Contraindications:
 Age < 12 is a contraindication
Technique: Perform cricothyrotomy according to manufacturer’s instructions for Rusch Quick Trach
(Rusch Quick Trach Training Video Link
1. Place the patient in a supine position. Assure stable positioning of the neck and
hyperextend the neck (unless cervical spine injury suspected)
2. Secure the larynx laterally between the thumb and forefinger. Find the cricothyroid
membrane (in the midline between the thyroid cartilage and the cricoid cartilage). This is
puncture site.
3. Prep the site by vigorously scrubbing with alcohol or iodine preps.
4. Using the scalpel make a 3mm vertical incision into the skin
5. Firmly hold device and puncture cricothyroid membrane at a 90-degree angle.
a. After puncturing the cricothyroid membrane, check the entry of the needle into the
trachea by aspirating air through the syringe.
b. If air is present, needle is within trachea, change the angle of insertion to 60
degrees (from the head) and advance the device forward into the trachea to the level
of the stopper. The stopper reduces the risk of inserting the needle too deeply and
causing damage to the rear wall of the trachea.
c. Should no aspiration of air be possible because of an extremely thick neck, it is
possible to remove the stopper and carefully insert the needle further until entrance
into the trachea is made.
6. Remove the stopper. After the stopper is removed, be careful not to advance the device
further with the needle still attached.
7. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into
the trachea until the flange rests on the neck. Carefully remove the needle and syringe.
8. Secure the cannula with the neck strap
9. Apply the connecting tube to the 15 mm connection and connect the other end to the bagvalvemask with supplemental oxygen.
10. Continue ventilation with 100 percent oxygen and periodically assess the airway
Complications:
1. Respiratory arrest and patient demise due to:
a. Severity of patient's airway injury.
b. Lack of attention to other potential airway maneuvers.
c. Subcutaneous air due to improper tube or catheter positioning, along with
positive ventilation.
d. Bleeding from superficial neck vessels is very common. Use direct pressure after
QuickTrach is in place.
e. Perforations of the back wall of the trachea and the esophagus from excessively
deep penetration by the QuickTrach. With stopper in place, this should be an
extremely rare complication.
Approved January 23, 2017
Index
35
Precautions:


Success of procedure is dependent on correct identification of cricothyroid membrane
Bleeding will occur, even with correct technique. Straying from the midline is dangerous and
likely to cause hemorrhage
Approved January 23, 2017
36
Index
25 Procedure Protocol: i-gel Airway
Indications:
 In general the primary goals of airway management are adequate oxygenation and ventilation, and
these should be achieved in the least invasive manner possible.
 Cardiac arrest:
o The i-gel O2 Airway is the primary advanced airway for adult and pediatric cardiac
arrest patients
 Respiratory Failure/Arrest requiring assisted ventilations
o Primary advanced airway if less invasive ventilation measures are ineffective
Contraindications:
 Intact gag reflex
 Caustic ingestion
 Suspected esophageal disease
Technique:
1. Initiate BLS airway sequence
2. For adult patients select proper size i-gel O2 based on IDEAL patient body weight (not what
the pt actually weighs) :
a. # 3 Small adult 30-60kg (65-130 lbs)
b. # 4 Medium adult 50-90kg (110-200 lbs)
c. # 5 Large adult 90 + kg (200 + lbs)
3. For Pediatric patients refer to length based tape and AFR pediatric field guide
a. #1 Neonate 2-5 kg
b. #1.5 Infant 5-12 kg
c. # 2 Small pediatric 10-25 kg
d. # 2.5 Large pediatric 25-35 kg
4. Open packaging and remove inner tray, setting the support strap (adult) and packet of lubricant to
one side within easy reach. Remove the i-gel O2.
5. Open the packet of lubricant and place a small bolus on the inner side of the main shell of the
packaging.
6. Grasp the i-gel O2 along the integral bite block and lubricate the back, sides and front of the
cuff with a thin layer of lubricant. (Ensuring any excess is removed prior to insertion.)
7. Grasp the lubricated i-gel O2 firmly along the bite block. The patient should be in the ‘sniffing the
morning air’ position with head extended and neck flexed. * Unless suspected spinal trauma.
8. Position the device so that the i-gel O2 cuff outlet is facing towards the chin of the patient.
Introduce the leading soft tip into the mouth of the patient towards the hard palate.
9. Glide the device downwards and backwards along the hard palate with a continuous but
gentle push until a definitive resistance is felt.
10. Once insertion has been completed, the tip of the airway should be located into the upper
esophageal opening, with the cuff located against the laryngeal framework. The incisors
should be resting on the bite block.
11. Secure the device underneath the patient’s neck with a head strap (or tape). Take care to
ensure there is sufficient tension to hold the i-gel O2 securely in place, but not excessive
tension that may cause trauma. Some adjustment of the strap may be needed to ensure
optimal positioning.
12. For pediatric patients secure with tape
13. Place extension elbow and capnography sensor on the end of i-gel O2
14. Confirm tube placement by auscultation, chest movement and ETCO2 .
15. Lubricate and insert appropriate size suction catheater into gastric lumen.
a. Size # 5 use 14F
b. Size # 2 through # 4 use 12F
c. Size # 1.5 use 10F
d. Size # 1 not applicable
16. Once the i-gel O2 has been correctly prepared, inserted and secured, positive pressure
ventilation can commence.
Precautions:
1. Do not remove a properly functioning i-gel O2 Airway in order to attempt intubation.
Approved January 23, 2017
Index
37
30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP)
Routine Medical
Assessment
Moderate to severe respiratory distress as evidenced by at least
two (2) of the following:
 Rales (crackles)
 Dyspnea with hypoxia (SpO2 < 90% despite O2)
 Dyspnea with verbal impairment – i.e. cannot speak in full
sentences
 Accessory muscle use
 Respiratory rate > 24/minute despite O2
 Diminished tidal volume
Talk pt through procedure


Adjust oxygen flow to 15 Lpm initially. Monitor
patient continuously, recording vital signs every 5
minutes
Start with the lowest continuous pressure that
appears to be effective. Adjust pressure following
manufacturer instructions to achieve the most stable
respiratory status
Assess patient for improvement as evidenced by the following:
 Reduced dyspnea
 Reduced verbal impairment, respiratory rate and heart
rate
 Increased SpO2
 Stabilized blood pressure
 Increased tidal volume
Observe for signs of deterioration or failure of response to
CPAP:
 Decrease in level of consciousness
 Sustained or increased heart rate, respiratory rate
or increased blood pressure
 Sustained low or decreasing SpO2 readings
 Diminished or no improvement in tidal volume








Contraindications:
Respiratory or cardiac arrest
Systolic BP < 90mmHg
Lack of airway protective reflexes
Significant altered level of consciousness such that
unable to follow verbal instructions or signal distress
Vomiting or active upper GI bleed
Suspected pneumothorax
Trauma
Patient size or anatomy prevents adequate mask seal
Approved January 23, 2017
38
Index
30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP)
Indications:
 Symptomatic patients with moderate-to-severe respiratory distress as evidenced by at least
two (2) of the following:
o Rales (crackles)
o Dyspnea with hypoxia (SpO2 < 90% despite O2)
o Dyspnea with verbal impairment – i.e. cannot speak in full sentences
o Accessory muscle use
o Respiratory rate > 24/minute despite O2
o Diminished tidal volume
Contraindications:
 Respiratory or cardiac arrest
 Systolic BP < 90mmHg
 Lack of airway protective reflexes
 Significant altered level of consciousness such that unable to follow verbal instructions or
signal distress
 Vomiting or active upper GI bleed
 Suspected pneumothorax
 Trauma
 Patient size or anatomy prevents adequate mask seal
Technique:
1. Place patient in a seated position and explain the procedure to him or her
2. Assess vital signs (BP, HR, RR, SpO2, and ETCO2)
3. Apply the CPAP mask and secure with provided straps, progressively tightening as tolerated
to minimize air leak
4. Operate CPAP device according to manufacturer specifications
5. For oxygen flow driven devices:
a. Adjust oxygen flow to 15 Lpm initially. Monitor patient continuously, recording vital
signs every 5 minutes
b. Start with the lowest continuous pressure that appears to be effective. Adjust
pressure following manufacturer instructions to achieve the most stable respiratory
status utilizing the signs described below as a guide
6. Assess patient for improvement as evidenced by the following:
a. Reduced dyspnea
b. Reduced verbal impairment, respiratory rate and heart rate
c. Increased SpO2
d. Stabilized blood pressure
e. Appropriate ETCO2 values and waveforms
f. Increased tidal volume
7. Observe for signs of deterioration or failure of response to CPAP:
a. Decrease in level of consciousness
b. Sustained or increased heart rate, respiratory rate or increased blood pressure
c. Sustained low or decreasing SpO2 readings
d. Diminished or no improvement in tidal volume
Precautions:
 Should patient deteriorate on CPAP:
o Troubleshoot equipment
o Consider other means of ensuring oxygenation and ventilation
o Assess need for possible chest decompression due to pneumothorax
o Assess for possibility of hypotension due to significantly reduced preload from
positive pressure ventilation
 In-line nebulized medications may be given during CPAP as indicated and in accordance with
manufacturer guidelines
Approved January 23, 2017
Index
39
35 Procedure Protocol: Capnography
Indications:
 MANDATORY to be used any time patient is being ventilated.
Contraindications:
 None
Technique:
1. Patients without ETT or advanced airway in place: place ETCO2 detector in-line between
Ambu bag and face mask.
2. In patient with ETT or advanced airway: place ETCO2 detector in-line between airway
adaptor and BVM after airway positioned and secured
3. Assess and document both capnography waveform and ETCO2 value
Precautions:
1. To understand and interpret capnography, remember the 3 determinants of ETCO 2:
a. Alveolar ventilation
b. Pulmonary perfusion
c. Metabolism
2. Sudden loss of ETCO2:
a. Tube dislodged
b. Circuit disconnected
c. Cardiac arrest
3. Cardiac Arrest:
a. In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant
of ETCO2 is blood flow, so ETCO2 is a good indicator of quality of CPR
b. If ETCO2 is dropping, change out person doing chest compressions
Approved January 23, 2017
Index
40
40 Procedure Protocol: Synchronized Cardioversion
Tachyarrythmia with poor
perfusion
Check:
O2 via NRBM
IV
Suction
Airway equipment ready
ref. Fentanyl for pain
Perform synchronized
cardioversion
Adult: 100J
Pediatric: 1-2J/Kg, or
Pediatric Field Guide
recommendation
Reassess pt
Reassess cardiac rhythm
Tachyarrythmia with
poor perfusion
YES
NO
Repeat cardioversion x1
Contact Base
Approved January 23, 2017
Reassess pt
Transport
41
Index
40 Procedure Protocol: Synchronized Cardioversion
This procedure protocol applies to conscious patients with signs of poor
perfusion due to tachyarrhythmia in whom synchronized cardioversion is
indicated according to Tachyarrhythmia with a Pulse protocol.






If defibrillator does not discharge in “synch” mode, then deactivate “synch” and
reattempt
If sinus rhythm achieved, however briefly, then dysrhythmia resumes
immediately, repeated attempts at cardioversion at higher energies are unlikely to
be helpful. First correct hypoxia, hypovolemia, etc. prior to further attempts at
cardioversion
If pulseless, treat according to Asystole / PEA or VF / VT Algorithm
Chronic atrial fibrillation is rarely a cause of hemodynamic instability, especially if
rate is <150 bpm. First correct hypoxia, hypovolemia, before considering
cardioversion of chronic
atrial fibrillation, which may be difficult, or impossible and poses risk of stroke
Sinus tachycardia rarely exceeds 150 bpm in adults or 220 bpm in children < 8
years and does not require or respond to cardioversion. Treat underlying causes.
Transient dysrhythmias or ectopy are common immediately following
cardioversion and rarely require specific treatment other than supportive care
Approved January 23, 2017
42
Index
45 Procedure Protocol: Transcutaneous Cardiac Pacing
Indications
Symptomatic bradyarrhythmias not responsive to medical therapy
Precautions
Conscious patient will experience discomfort; ref. fentanyl if blood pressure allows.
Technique
1. Apply limb leads, and pacing pads as per manufacturer specifications: (-) left anterior, (+)
left posterior.
2. Turn pacer unit on.
3. Set initial current to 40 mAmps .
4. Select pacing rate at 80 beats per minute (BPM)
5. Select “Fixed” mode
6. Start pacing unit.
7. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually
captures around 100 mAmps).
8. If there is electrical capture, check for femoral pulse.
9. If no capture occurs with maximum output, discontinue pacing and resume ACLS.
Complications
1. Ventricular fibrillation and ventricular tachycardia are rare complications, follow
appropriate protocols if either occur.
2. Pacing is rarely indicated in patients under the age of 12 years.
3. Muscle tremors may complicate evaluation of pulses, femoral pulse may be more
accurate.
4. Pacing may cause diaphragmatic stimulation and apparent hiccups.
Approved January 23, 2017
Index
43
55 Procedure Protocol: Restraint Protocol
Indications:
A. Physical restraint of patients is permissible and encouraged if the patient poses a danger to
him/her self or to others. Only reasonable force is allowable, i.e., the minimum amount of
force necessary to control the patient and prevent harm to the patient or others. Try
alternative methods first (e.g., verbal de-escalation should be used first if the situation
allows).
B. Restraints may be indicated for patients who meet any of the following criteria:
1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury,
psychiatric condition, etc) and lacks decision-making capacity regarding his
or her own care.
2. A patient who exhibits violent, combative or uncooperative behavior who does
not respond to verbal de-escalation.
3. A patient who is suicidal and considered to be a risk for behavior dangerous to
his/ herself or to healthcare providers.
4. A patient who is on a Mental Health Hold
C. Paramedic: Consider pharmacological treatment (sedation) of agitation in patients that
require transport and are behaving in a manner that poses a threat to him/her-self or
others and in whom physical restraint is not possible or effective.
1. ref. Combative Patient Protocol: (The term “chemical restraint” is no
longer preferred)
Precautions:
A. When appropriate, involve law enforcement
B. Restraints shall be used only when necessary to prevent a patient from seriously injuring him/
herself or others (including the ambulance crew), and only if safe transportation and
treatment of the patient cannot be accomplished without restraints. They may not be used as
punishment, or for the convenience of the crew.
C. Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts
to restrain a patient should only be done with adequate assistance present.
D. Be sure to evaluate the patient adequately to determine his/ her medical condition,
mental status and decision-making capacity.
E. Do not use hobble restraints and do not restrain the patient in the prone position or any position
that is impairing the airway or breathing.
F. Search the patient for weapons.
G. Handcuffs are not appropriate medical restraints and should only be placed by law
enforcement personnel. ref. Handcuffed Pt Protocol.
Technique:
A. Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done
prior to the use of restraints. To the extent possible, explain what is being done and why.
B. Have all equipment and personnel ready (restraints, suction, a means to promptly remove
restraints).
C. Use assistance such that, if possible, 1 rescuer handles each limb and 1 manages the
head or supervises the application of restraints.
D. Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient.
Inadequate-restraint may place patient and provider at greater risk.
E. After application of restraints, check all limbs for circulation. During the time that a patient is in
restraints, continuous attention to the patient’s airway, circulation and vital signs is mandatory. A
restrained patient may never be left unattended.
44
Approved January 23, 2017
Index
55 Procedure Protocol: Restraint Protocol
Documentation :
Document the following in all cases of restraint:
A. Description of the facts justifying restraint
B. Efforts to de-escalate prior to restraint
C. Type of restraints used
D. Condition of the patient while restrained, including reevaluations during transport
E. Condition of the patient at the time of transfer of care to emergency department staff
F. Any injury to patient or to EMS personnel
Complications:
A. Aspiration: continually monitor patients airway
B. Nerve injury: assess neurovascular status of patients limbs during transport
C. Complications of medical conditions associated with need for restraint
1. Patients may have underlying trauma, hypoxia, hypoglycemia, hyperthermia,
hypothermia, drug ingestion, intoxication or other medical conditions.
D. Excited Delirium Syndrome. This is a life-threatening medical emergency. These patients
are truly out of control. They will have some or all of the following symptoms: paranoia,
disorientation, hyper-aggression, hallucination, tachycardia, increased strength, and
hyperthermia.
Approved January 23, 2017
45
Index
60 Procedure Protocol: Tourniquet Protocol
Indications
A. A tourniquet may be used to control potentially fatal hemorrhage only after other means
of hemorrhage control have failed.
Precautions
A. A tourniquet applied incorrectly can increase blood loss.
B. Applying a tourniquet can cause nerve and tissue damage whether applied correctly or
not. Proper patient selection is of utmost importance.
C. Injury due to tourniquet is unlikely if the tourniquet is removed within 1 hour. In cases of
life threatening bleeding benefit outweighs theoretical risk.
D. A commercially made tourniquet is the preferred tourniquet. If none is available, a blood
pressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative.
Other improvised tourniquets are not allowed.
E. Do not place tourniquet to control bleeding from a Fistula or port. Control those bleeds
with direct pressure or “pinching” the line directly.
Technique
A. First attempt to control hemorrhage by using direct pressure over bleeding area.
B. If a discrete bleeding vessel can be identified, point pressure over bleeding vessel is more
effective than a large bandage and diffuse pressure.
C. If unable to control hemorrhage using direct pressure, apply tourniquet according to
manufacturer specifications and using the steps below:
1. Cut away any clothing so that the tourniquet will be clearly visible. NEVER
obscure a tourniquet with clothing or bandages.
2. Apply tourniquet proximal 2-4” above the wound and not across any joints.
3. Tighten tourniquet until bleeding stops. Applying tourniquet too loosely will only
increase blood loss by inhibiting venous return.
4. Mark the time and date of application on the patient’s skin next to the tourniquet.
5. Keep tourniquet on throughout hospital transport – a correctly applied
tourniquet should only be removed by the receiving hospital.
46
Approved January 23, 2017
Index
65 Procedure Protocol: Needle Thoracostomy for Tension Pneumothorax
Decompression
Indication:
A. Needle decompression of tension pneumothorax is a standing order for Paramedics.
B. All of the following clinical indicators must be present:
1. Severe respiratory distress / Hypotension / Unilateral, absent, or decreased breath
sounds
OR
2. Traumatic Pulseless arrest with trauma to trunk (perform bilateral needle
thoracostomy)
Technique:
A. Expose entire chest
B. Clean skin overlying site with available skin prep
C. > 12 year old:
Insert Air Release System (ARS) catheter at 2nd intercostal space at midclavicular line.
D. < 12 year old use 18g 1 ½ “ angiocath at 2nd intercostal space at midclavicular line.
E. Notify receiving hospital of needle decompression attempt
Precautions:
A. A simple pneumothorax is NOT an indication for needle decompression
Approved January 23, 2017
Index
47
70 Procedure Protocol: Intraosseous Catheter Protocol
Indications
A. Primary vascular access device in a patient with critical illness defined as:
1. Cardiopulmonary arrest or impending arrest
2. Profound shock (systolic BP < 80) with poor perfusion (Adult patient)
3. Decompensated shock (adult patient)
4. Decompensated shock based on hypotension for age. (pediatric patient)
B. Utilization of IO access for all other patients requires BASE CONTACT WITH (AIP,
Chilren’s, TMCA, CMP, SaddleRock)
E.g.: Hypoglycemia with severe symptoms (e.g. unresponsive) and no venous
access
Technique:
A. Site: tibial plateau, 2 fingerbreadths below the tibial tuberosity on the
anteromedial surface of tibia.
B. Clean skin with povidone-iodine.
C. Place intraosseous needle perpendicular to the bone.
D. Follow manufacturer’s guidelines specific to the device being used for insertion.
E. Entrance into the bone marrow is indicated by a sudden loss of resistance.
F. Flush line with 10 cc saline. Do not attempt to aspirate marrow
G. Secure line
1. Even if properly placed, the needle will not be secure. The needle must be
secured and the IV tubing taped. The IO needle should be stabilized at all times.
H. Observe for signs of limb swelling, decreased perfusion to distal extremity that would
indicate a malpositioned IO catheter or other complication. If limb becomes tense or
malperfused, disconnect IO tubing immediately and leave IO in place.
I. A person should be assigned to monitor the IV at the scene and en route to the hospital.
J. Do not make more than one IO placement attempt per bone.
K. Do not remove IO needles in the field.
L. Notify hospital staff of all insertion sites/attempts and apply patient wristband included
with kit to identify IO patient.
Complications:
A. Fracture
B. Compartment syndrome
C. Infection
Contraindications:
A. DO NOT USE EZ IO Drill for patients less than 3kg (Shorter than grey color on Broselow)
– Pink EZ IO needle should be placed by hand.
B. DO NOT USE EZ IO Drill for newborns (pts less than 24 hours old)
– Pink EZ IO needle should be placed by hand.
C. Fracture of target bone
D. Cellulitis (skin infection overlying insertion site)
E. Osteogenesis imperfecta (rare condition predisposing to fractures with minimal trauma)
F. Total knee replacement (hardware will prevent placement)
Side Effects and Special Notes:
A. Aspiration of marrow fluid or tissue to confirm needle location is not recommended for
field procedures, as it increases the risk of plugging the needle.
B. Expect flow rates to be slower than peripheral IVs. Pressure bags may be needed. Any
drug or IV fluid may be infused.
Approved January 23, 2017
Index
48
75 Vascular Access Devices
Specific Information Needed:
A. Obtain pertinent medical history if possible.
B. Obtain any information possible regarding the type of Vascular Access Device (VAD),
number of lumens, purpose of the VAD, etc.
Indications
A. To obtain rapid venous access for the critical patient when peripheral access cannot be
obtained.
Precautions
A. Obtain information and assistance from family members or home health professionals who
are familiar with the device.
B. Discontinue any intermittent or continuous infusion pumps.
C. Assure placement and patency of the VAD prior to infusing any fluids or medications.
D. Flush the catheter completely with sterile normal saline.
E. Use aseptic technique.
Central Venous Catheters or PICC Lines
A. Attempt peripheral or external jugular access first unless patient or patient's family insist on
the direct usage of VAD.
B. Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted
central catheter).
C. Utilize knowledgeable family members, significant others or home visiting nurse if available.
D. Discontinue and/or disconnect any pumps or medications.
E. Clamp the VAD closed to prevent air embolus.
F. If multiple lumen, identify the lumen to be used.
G. Utilize aseptic technique.
H. Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad.
I. Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive blood
return. Obtain blood samples if necessary. Then flush the line with solution.
J. Insert the needle (attached to a medication syringe or IV tubing) and infuse medications or
fluids.
K. Secure the IV tubing.
L. Reassess the infusion site.
M. Reassess patient condition.
Implanted Ports
A. Attempt peripheral or external jugular access first unless patient or patient's family insist on
the direct usage of the VAD.
B. Identify the location and type of VAD (e.g. implanted port).
C. Utilize knowledgeable family members, significant others or home visiting nurse if available.
D. Discontinue and/or disconnect any pumps or medications.
E. Carefully palpate the location of the implanted port.
F. If multiple ports, identify the port to be used.
G. Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from
the center outward three times in a circular motion.
H. Using a sterile gloved hand, press the skin firmly around the edges of the port.
I. Using a syringe filled with solution, insert the needle perpendicular to the skin.
J. Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood
from a VAD, use a syringe that is 10cc or less to avoid complications.
K. Secure the IV tubing.
L. Reassess the infusion site.
M. Reassess the patient.
Approved January 23, 2017
49
Index
75 Vascular Access Devices
Complications
A. Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at
all times.
B. Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not
utilize the lumen.
C. Rarely, a catheter will migrate. The symptoms may include the following:
1. burning with infusion
2. site bleeding
3. shortness of breath
4. chest pain
5. tachycardia
6. hypotension
D. If a catheter migration is suspected, do not use the VAD and treat the patient according to
symptoms.
E. Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs
and may cause burning and tissue damage. Clamp the catheter and do not use.
F. Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by
properly clamping the catheter and preventing air from entering the system.
Approved January 23, 2017
50
Index
100 Adult Epistaxis Management
Active Nosebleed
ABCs
Compress nostrils with clamp or
fingers, pinching over fleshy part of
nose, not bony nasal bridge, for 10
minutes
Transport in position of comfort,
usually sitting upright
Tilt Head Forward
Have pt blow nose to expel clots
Spray both nares with ref. Phenylephrine
Reapply clamp or fingers pinching over
fleshy part of not, not bony nasal bridge
for 10 minutes.
IV access and IV fluid bolus if signs of
ref. hypoperfusion/shock.
Approved January 23, 2017
51
Index
100 Adult Epistaxis Management
General Guidelines:
• Most nose bleeding is from an anterior source and may be easily controlled
• Avoid phenylephrine in pts with known CAD
• Anticoagulantion with aspirin, clopidogrel (Plavix), warfarin (Coumadin) will make epistaxis much harder
to control. Note if your patient is taking these or other anticoagulant medications
• Posterior epistaxis is a true emergency and may require advanced ED techniques such as balloon
tamponade or interventional radiology. Do not delay transport. Be prepared for potential airway issues.
• Patients using nasal cannula oxygen may have cannula placed in mouth while nares are clamped or
compressed for nosebleed.
Approved January 23, 2017
52
Index
105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations
In general the primary goals of airway management are adequate oxygenation and
ventilation, and these should be achieved in the least invasive manner possible
2 Person BVM with OPA/NPA and capnography
Effective oxygenation and ventilation? *
No
Yes
Ref. i-gel O2 Airway
Yes
Effective oxygenation and ventilation? *
No
2 Person BVM with OPA/NPA and capnography
Effective oxygenation and ventilation? *
Yes
No
Ref. Orotracheal Intubation, Nasotracheal Intubation
Yes
Effective oxygenation and ventilation? *
No
2 Person BVM with OPA/NPA and capnography
Effective oxygenation and ventilation? *
Yes
No
Ref. Cricothyrotomy
Continue Oxygenating and
Ventilating patient
Ref. i-gel O2 Airway in all cases of
cardiac arrest
Approved January 23, 2017
* Signs of adequate oxygenation / ventilation
Examples include:
a. Good CO2 Waveform
b. Compliance with BVM
c. Chest rise and fall
d. Bilateral breath sounds
e. Positive response to therapy
53
Index
105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations
Indications
A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory
depression.
B. To apply positive pressure ventilation in patients with pulmonary edema and severe fatigue.
C. To ventilate patients in respiratory arrest.
D. To ventilate patients in cardiac arrest.
Precautions
A. Two people are required to obtain an adequate mask fit and also ventilate.
B. Assisted ventilation will not hurt a patient, and should be used whenever the breathing
pattern seems shallow, slow, or otherwise abnormal. Do not be afraid to be aggressive about
assisting ventilation, even in patients who do not require or will not tolerate advanced
airways.
Technique
A.
B.
C.
D.
E.
F.
G.
Open the airway. Check for ventilation.
Administer ventilations. If unsuccessful, go to Airway Obstruction protocol.
Check pulse. If absent, go to Cardiac Arrest protocol.
Attach oxygen to BVM.
Attach Capnography sensor to BVM.
Measure and insert OPA / NPA as indicated / tolerated
Position yourself above patient's head, continue to hold airway position, seat mask firmly on
face, and begin assisted ventilation.
H. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as
needed.
I. If patient resumes spontaneous respirations, ref. oxygen. Intermittent assistance with
ventilation may still be needed.
J. Continuous monitoring of pulse oximetry is required.
Complications
A.
B.
C.
D.
E.
Continued aspiration of blood, vomitus, and other upper airway debris
Inadequate ventilations due to poor seal between patient's mouth and ventilatory device
Gastric distention, possibly causing vomiting
Trauma to the upper airway from forcible use of airways
Pneumothorax
Signs of Adequate oxygenation / ventilation
A.
B.
C.
D.
E.
Compliance with bag
Chest rise and fall
Bilateral breath sounds
Good CO2 waveform
Positive response to therapy
Approved January 23, 2017
Index
54
110 Adult Obstructed Airway: Conscious Patient
Attempt to determine cause of
obstruction
Does patient show signs of choking?
Assess severity of obstruction
Mild or Partial Obstruction
(patient can speak)
Severe or Complete Obstruction
(mute, silent cough, severe stridor)
Perform abdominal thrusts until obstruction relieved or
patient loses consciousness
 For visibly pregnant or obese patients perform chest
thrusts instead
 Consider chest thrusts in any patient if abdominal
thrust ineffective
 If patient loses consciousness. Ref. Adult Obstructed
Airway: Unconscious
 Do not interfere with a spontaneously breathing or
coughing patient
 Position of comfort
 Give high flow oxygen
 Suction if needed
Is obstruction cleared?
Yes




Transport POC
O2 via NRB 15 Lpm
Monitor ABCs, SpO2, vital
signs
Suction PRN and be prepared
for vomiting, which commonly
occurs after obstruction
relieved
No
 Supportive care and rapid
transport
 If patient deteriorating or
develops worsening distress
proceed as for complete
obstruction
55
Approved January 23, 2017
Index
111 Adult Obstructed Airway: Unconscious Patient
If cause of airway obstruction is readily apparent, attempt removal
 Open airway with head tilt-chin lift
 Open airway with jaw thrust if craniofacial trauma present / suspected
Ventilate pt with BVM / capnography using two person technique.
Ability to ventilate?
Yes
No
 Perform laryngoscopy
 Use McGill forceps to remove object if possible
Ref. Adult Resp. Failure / Arrest
Requiring Assisted Ventilation
Ability to ventilate?
Yes
No
Ref. Adult Resp. Failure / Arrest
Requiring Assisted Ventilation
Perform 30 chest compressions
Open pt mouth and remove obstruction if seen.
Open airway and ventilate pt with BVM /
capnography using two person technique.
Ability to ventilate?
Yes
No
 Ref. oral intubation & attempt to push object into mainstem
bronchus with ETT if suspected subglottic obstruction.
Ref. Adult Resp. Failure / Arrest Requiring
Assisted Ventilation
Ability to ventilate?
Yes
Ref. Adult Resp. Failure / Arrest Requiring
Assisted Ventilation
No
 Ref. percutaneous cricothyrotomy if suspected
supraglottic obstruction.
 Transport
 Notify medial branch of Cricothyrotomy
attempt
56
Approved January 23, 2017
Index
115 Adult Respiratory Distress
Respiratory Distress
For all patients:
While assessing ABCs: give
supplemental O2, monitor vital
signs, cardiac rhythm, and SpO2
Patent Airway?
NO
YES
Are ventilations adequate for
physiologic state?
NO
ref. Obstructed Airway
Protocol: Conc.
Obstructed Airway Protocol:
Unconc.
Ref. Adult Respiratory Failure
/ Arrest
YES
Is SpO2 > 90% with high flow O2
NO
ref. CPAP
YES
Is anaphylaxis likely?
YES
ref. Allergy/Anaphylaxis
NO
Is Asthma likely?
YES
ref. Asthma
NO
Is COPD likely?
YES
ref. COPD
NO
Is CHF/Pulmonary edema likely?
YES
ref. CHF or Pulmonary
edema
NO
Transport
• Provide supportive care
• Maximize oxygenation and ventilation
• CONTACT BASE if needed for consult
• 12 lead ECG q 5 min
Approved January 23, 2017
57
Index
115 Adult Respiratory Distress
Consider pulmonary and non-pulmonary causes of respiratory distress:
• Pulmonary embolism
• Pneumonia
• Heart attack
• Pneumothorax
• Sepsis
• Metabolic acidosis (e.g.: DKA)
• Anxiety
Mixed picture may exist:
• Goal is maximization of oxygenation and ventilation in all cases
• CPAP may be particularly useful in mixed picture with hypoxia and/or hypoventilation
• Avoid albuterol in suspected pulmonary edema
Don’t over-diagnose psychogenic causes of respiratory distress in the field. Your patient could
have a pulmonary embolus or other serious problem; give him/her the benefit of the doubt.
Treatment with oxygen will not harm the “hyperventilator”, and it will keep you from
underestimating the problem.
58
Approved January 23, 2017
Index
120 Adult Asthma
Routine Medical Assessment
Respiratory Distress Protocol and prepare for transport
Severe Attack
Grossly abnormal
respiratory rate, loud
wheezes, or so tight no
wheezes are heard, anxiety,
gray or ashen skin color,
diaphoresis
Moderate Attack
Marked increase in
respiratory rate, wheezes
easily heard and accessory
muscle breathing.
ref. Albuterol + ref. Ipratropium
ref. Epinephrine IM
ref. Albuterol + ref. Ipratropium
Adequate response to treatment?
Yes
Monitor response to
treatment
Continue cardiac monitoring
and SPO2 en route
Be prepared to assist
ventilations as needed
Transport
Mild Attack
Slight increase in
respiratory rate, mild
wheezes, good skin
color.
Adequate response to treatment?
Yes
No
ref. Epinephrine IM
No
Adequate response to treatment?
Yes
Monitor response to
treatment
Continue cardiac monitoring
and SPO2 en route
Be prepared to assist
ventilations as needed
Transport
No
Concern for impending respiratory failure?
ref. CPAP
ref. Adult Resp Failure/Arrest
Adequate response to treatment?




Therapeutic Goals:
Maximize oxygenation / ventilation
Decrease work of breathing
Identify cardiac ischemia (Obtain
12 lead ECG q 5 min)
Identify complications, e.g.
pneumothorax
Yes
No
ref. Magnesium IV
ref. Methylprednisone IV
59
Approved January 23, 2017
Index
121 Adult COPD
Routine Medical Assessment
Respiratory Distress Protocol and prepare for transport
Severe Attack
Grossly abnormal
respiratory rate, loud
wheezes, or so tight no
wheezes are heard, anxiety,
gray or ashen skin color,
diaphoresis
ref. Albuterol + ref. Ipratropium
ref. Albuterol + ref. Ipratropium
Adequate response to treatment?
Adequate response to treatment?
Yes
Monitor response to
treatment
Continue cardiac
monitoring and
SPO2 en route
Be prepared to assist
ventilations as
needed
Transport
Mild Attack
Slight increase in
respiratory rate,
mild wheezes, good
skin color.
Moderate Attack
Marked increase in
respiratory rate, wheezes
easily heard and accessory
muscle breathing.
Yes
No
No
Adequate response to treatment?
Yes
No
Concern for impending respiratory
failure?
Monitor response to
treatment
Continue cardiac
monitoring and SPO2
en route
Be prepared to assist
ventilations as needed
Transport
ref. CPAP
ref. Adult Resp Failure/Arrest
Adequate response to treatment?
Yes
No
ref. Methylprednisone IV
60
Approved January 23, 2017
Index
121 Adult COPD
Therapeutic Goals:
Maximize oxygenation / ventilation
Decrease work of breathing
Identify cardiac ischemia (Obtain 12 lead ECG q 5 min)
Identify complications, e.g. pneumothorax
NOTES:
• Correct hypoxia: do not withhold maximum oxygen for fear of CO2 retention
• Consider pulmonary and non-pulmonary causes of respiratory distress: Examples:
pulmonary embolism, pneumonia, pulmonary edema, anaphylaxis, heart attack,
pneumothorax, sepsis, metabolic acidosis (e.g.: DKA), Anxiety
• Patients with COPD are older and have comorbidities, including heart disease.
• Wheezing may be a presentation of pulmonary edema, “cardiac asthma”
• Common triggers for COPD exacerbations include: Infection, dysrhythmia (e.g.:
atrial fibrillation), myocardial ischemia
• CPAP may be very helpful in severe COPD exacerbation, however these patients are
at increased risk of complications of CPAP
Nosuch as hypotension and pneumothorax.
 Cardiopulmonary monitoring is mandatory.
61
Approved January 23, 2017
Index
Index
125 Adult CHF / Pulmonary Edema
Routine Medical Assessment
Respiratory Distress Protocol and prepare for
immediate transport
ref. Nitroglycerine
Yes
Is oxygenation and ventilation
adequate?
No


Yes
ref. CPAP
12 lead ECG q 5 min: rule out unstable rhythm, ACS
Is response to treatment
adequate?
No
If failing above therapy:
Remove CPAP and ventilate with BVM
Assess for Pneumothorax
Consider alternative
causes/complications
Monitor response to treatment
Continue cardiac monitoring (12 lead ECG q 5 min), SPO2 en route
Be prepared to assist ventilations as needed
Therapeutic Goals:
Maximize oxygenation
Decrease work of breathing
Identify cardiac ischemia (Obtain 12 lead ECG q 5 min)
Approved January 23, 2017
Index
62
130 Adult Allergy and Anaphylaxis
Allergic reaction, anaphylaxis or angioedema




Assess ABCs, give oxygen
If possible, determine likely trigger
Determine PMH, medications, allergies
Classify based on symptom severity and
systems involved
 Other specific protocols may apply: e.g.:
obstructed airway, bites & envenomations
Localized Reaction
Including isolated tongue, airway
Generalized or Systemic Reaction
Multisystem involvement: skin, lungs, airway, etc
Does patient have any 2 of the following
signs or symptoms of anaphylaxis?
 Hypotension
 Signs of poor perfusion
 Bronchospasm, stridor
 Altered mental status
 Urticaria
No
ref. diphenhydramine
No
Airway involvement?
Tongue or uvula swelling, stridor
Transport and reassess for
signs of deterioration
Yes
Impending airway obstruction?
Yes
Yes
No
 ref. epinephrine IM, then:
 Start IV and give IV fluid
bolus 20cc/kg NS
 ref. diphenhydramine
 ref. methylprednisolone
 ref. albuterol if wheezing
Immediately ref.
epinephrine IM & manage
airway and ref. Adult
Resp Failure/Arrest
 Start IV
 ref. diphenhydramine
 ref. methylprednisolone
 Monitor ABCs, SpO2,
cardiac rhythm
 Reassess for signs of
deterioration
If persistent signs of severe
shock with hypotension not
responsive to IM epinephrine
and fluid bolus:
 Repeat IM ref. epinephrine
 Contact Base
63
Approved January 23, 2017
Index
130 Adult Allergy and Anaphylaxis
Definitions:
 Anaphylaxis: severe allergic reaction that is rapid in onset and potentially life-threatening.
Multisystem signs and symptoms are present including skin and mucus membranes
o Mainstay of treatment is epinephrine
 Angioedema: deep mucosal edema causing swelling of mucus membranes of upper airway. May
accompany hives
Document:
 History of allergen exposure, prior allergic reaction and severity, medications or treatments
administered prior to EMS assessment
 Specific symptoms and signs presented: itching, wheezing, respiratory distress, nausea, weakness,
rash, anxiety, swelling of face, lips, tongue, throat, chest tightness, etc.
 EMT-B may use pt prescribed Epipen auto injector if available.
64
Approved January 23, 2017
Index
2000 Adult Cardiac Arrest General Principles - ACLS
General Considerations
• Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime
before CPR and duration of CPR
• Past History: medications, medical history, suspicion of ingestion, trauma, environmental
factors (hypothermia, inhalation, asphyxiation)
 Penetrating and Blunt trauma arrest: Ref. Trauma Arrest
 Cardiac arrest from the following causes should approached as a medical cardiac arrest:
overdose, respiratory arrest, airway obstruction, asphyxiation, hanging, drowning,
electrocution, and lightning/high voltage
Document Specific Objective Findings
• Unconscious, unresponsive
• Agonal, or absent respirations
• Absent pulses
• Any signs of trauma, blood loss
• Skin temperature
General Guidelines: Chest Compressions
• Push hard and push fast (at least 100/minute)
• Ensure full chest recoil
• Rotate compressors every 2 minutes with rhythm checks
• During CPR, any interruption in chest compressions deprives heart and brain of
necessary blood flow and lessens chance of successful defibrillation
o Continue CPR while defibrillator is charging, and resume CPR immediately after all
shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at
rhythm check
General Guidelines: Defibrillation
• In unwitnessed cardiac arrest, give first 2 minutes of CPR.
If arrest is witnessed by EMS, immediate defibrillation is first priority
• All shocks should be given as single maximum energy shocks
o Manual biphasic: 150J (Phillips MRx)
o AED: device specific
General Guidelines: Ventilation during CPR
• EMS personnel must use good judgment in assessing likely cause of pulseless arrest. In
patients suspected of having a primary respiratory cause of cardiopulmonary arrest, (e.g.:
COPD or status asthmaticus), adequate ventilation and oxygenation are a priority
• In general, patients with cardiac arrest initially have adequately oxygenated blood, but are
in circulatory arrest. Therefore, chest compressions are initially more important than
ventilation to provide perfusion to coronary arteries
• Do not interrupt chest compressions and do not hyperventilate. Hyperventilation
decreases effectiveness of CPR and worsens outcome.
•Compressions should be given continuously and breaths given asynchronously at 8-10 per
minute
• Always confirm ventilator effectiveness with ETCO2 (continuous waveform capnography)
• i-gel O2 is preferred for adult patients in cardiac arrest and should be placed according to
ref. Adult Cardiac Arrest Core Competencies
Approved January 23, 2017
65
Index
2000 Adult Cardiac Arrest General Principles - ACLS
General Guidelines: Pacing
• Pacing is not indicated for asystole and PEA. Instead start chest compressions according to
Ref. Asystole / PEA
• Pacing should not be undertaken if it follows unsuccessful defibrillation of VT/VF as it will
only interfere with CPR and is not effective
General Guidelines: ICD/Pacemaker patients
• If cardiac arrest patient has an implantable cardioverter defibrillator (ICD) or pacemaker:
place pacer/defib pads at least 1 inch from device (anterior / posterior).
66
Approved January 23, 2017
Index
2001 Adult Cardiac Arrest General Principles – ACLS
START CPR
Give Oxygen
Attach
monitor/defibrillator
CHECK
RHYTHM
IF VF/VT
SHOCK
Drug Therapy
IV/IO Access
Epi q 3-5
4 minutes
Amiodarone for refractory VF/VF
Oxygenate and Ventilate
Quantitative waveform
capnography
Treat Reversible
Causes
Approved January 23, 2017
Index
67
2010 Adult Pulseless Arrest– BLS / AED
No movement or response?
Open airway and check breathing
If not breathing give 2 breaths that cause
chest to rise
If still not responsive, check pulse.
Is there a DEFINITE pulse?
NO
Yes
Give 1 breath every 6
seconds.
Recheck pulse every 2
minutes.
Give 200 uninterrupted chest
compressions (2 minutes)
Continue compressions and
ventilations until AED arrives, ALS
assumes care, or patient starts to
move.
AED arrives
Turn AED on, follow voice prompts.
Approved January 23, 2017
68
2020 Adult Pulseless Arrest – VF / VT



Start chest compressions
Consider circumstances of arrest:
Witnessed by EMS = immediate rhythm check
Unwitnessed by EMS = 2 minutes CPR
o OPA / NPA / Capnography / BVM
o Attach monitor/defibrillator
Routine medical assessment
VF / VT
SHOCK
2 min CPR
Ref. Adult Respiratory Failure/Arrest
ROSC
Rhythm Check
ASYSTOLE/PEA
VF / VT
SHOCK
2 min CPR
ref. IO / IV
ROSC
ASYSTOLE/PEA
AA Rhythm Check
VF / VT
SHOCK
2 min CPR
ref. Epinephrine q 4 min
ROSC
Rhythm Check
ASYSTOLE/PEA
VF / VT
Ref. ROSC
SHOCK
Ref. Asystole / PEA
2 min CPR
ref. Amiodarone
Go To Box “A”
Approved January 23, 2017
After 15 minutes of ALS Care:
Continue resuscitation and
Transport
Index
Index
69
2020 Adult Pulseless Arrest – ALS – ACLS
Pulseless arrest associated with any of the following clinical conditions:
o Known hyperkalemia
o Renal failure with or without hemodialysis history
1 g of Calcium gluconate /or 500mg of Calcium chloride and 2 amps Sodium bicarbonate.
Flush IV line between meds
Suspected Torsades de Pointe:
Ref. Magnesium
Suspected Hypothermia: Single dose of Epinephrine IV/ IO for Pulseless Arrests associated
with Asystole, Vfib/ VT. For Vfib/ VT: single attempt defibrillation only
Shock energy:
All shocks at 150joules (Philips MRx)
Reversible Causes:
Hypovolemia
Hypoxia
H+ (Acidosis)
Hypo/Hyperkalemia
Hypothermia
Tension Pneumothorax
Approved January 23, 2017
Tamponade (cardiac)
Toxins
Thrombosis: PE, AMI
70
2021 Adult Pulseless Arrest Asystole / PEA



Start chest compressions
Consider circumstances of arrest:
2 minutes CPR
o OPA / NPA / Capnography / BVM
o Attach monitor/defibrillator
Routine medical assessment
Treat reversible causes
Asystole / PEA
2 min CPR
Ref. Adult Respiratory Failure/Arrest
ROSC
Rhythm Check
VF / VT
Asystole / PEA
2 min CPR
ref. IO / IV
ROSC
VF / VT
A
Rhythm Check
Asystole / PEA
Ref. ROSC
2 min CPR
ref. Epinephrine q 4 min
Ref. VF / VT
Go To Box “A”
After 15 minutes of ALS Care:
 Asystole = CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for consideration of TOR at
any point if continuous asystole.
 Asystole is defined as the absence of any electrical activity and must be observed in two or more leads
for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS
Operations Captain. Include the AFR incident number on the strip.
 PEA = Continue resuscitation and Transport
71
Approved January 23, 2017
Index
2025 Adult Return of Spontaneous Circulation
ROSC after Cardiac Arrest
Reassess ABCs
Obtain baseline vitals
12 lead EKG q 5 minutes
Recurrent dysrhythmia?
STEMI?
YES
Treat per protocol
YES
Initiate Cardiac Alert
Place head of bed at 30degrees elevation
Systolic BP <90
YES
Assess for purposeful
response
Purposeful Response?
Approved January 23, 2017
If NOT hypervolemic, administer
1000 ml Normal Saline bolus
If persistent SBP < 90 after 1000ml
saline bolus, ref. Dopamine
YES
Continue to monitor cardiac
rhythm / pulse
72
Index
2030 Adult Tachyarrhythmia
Assess appropriateness for clinical condition
Heart rate typically > 150/min if tachyarrhythmia
Routine Medical Assessment
Identify and treat underlying cause
YES
NO
Search for and treat
underlying cause:
e.g.: dehydration, fever,
hypoxia, hypovolemia, pain
Sinus
Tachycardia?
IS PATIENT UNSTABLE?
A
YES
Unstable signs include any two of the following:
 Altered mental status
 Symptoms compatible with Acute Coronary
Syndrome (ACS) (chest pain, diaphoresis,
dyspnea, etc)
 Hypotension
B
UNSTABLE
Ref. Synchronized
Cardioversion
NO
STABLE
12 Lead EKG q 5 minutes
Narrow QRS
< 0.12sec
REGULAR
Valsalva
maneuver
ref. Adenosine if
suspected
AVNRT (formerly
known as PSVT)
Wide QRS
> 0.12sec
IRREGULAR
A-Fib, A-Flutter or MAT
Do NOT give Adenosine
If pt. becomes unstable
go to box B
Monitor in transport
Does rhythm convert?
REGULAR
V-Tach (>80%) or
SVT with aberrancy
Contact Base ref.
Amiodarone
IRREGULAR
Contact Base for consult
Do NOT give adenosine
If pt becomes unstable
go to box B
If regular and
polymorphic
(Torsades de Pointes)
Magnesium
NO
YES
CONVERTS
Monitor in Transport
If recurrent dysrhythmia
go to box A
DOESN’T CONVERT
Contact base for consult
Monitor in transport
If unstable, go to box B
Approved January 23, 2017
73
Index
Index
2040 Adult Bradycardia
HR <50 and inadequate for
clinical condition
Routine Medical Assessment
Identify and treat underlying cause
IS PATIENT UNSTABLE?
Unstable signs include any two of the following:
 Altered mental status
 Symptoms compatible with Acute Coronary Syndrome (ACS) (chest
pain, diaphoresis, dyspnea, etc)
 Hypotension
NO
YES
STABLE
UNSTABLE
Vascular Access?
NO
YES
ref. Atropine
If atropine ineffective begin pacing
ref. Dopamine if pacing ineffective
12 lead EKG q 5 minutes
Transport and Monitor
for deterioration
Prepare for immediate pacing
If pacing ineffective ref. Atropine
ref. Dopamine if atropine ineffective
If the pt is not being paced perform
12 lead EKG q 5 minutes
Transport and Monitor for
deterioration
Approved January 23, 2017
Index
74
2050 Adult Chest Pain
Consider life threatening causes of chest pain* in all
patients.
 While assessing ABCs ref. Oxygen, monitor vital
signs, cardiac rhythm, start IV.
 12 lead EKG q 5 min if possible acute coronary
syndrome
 Ref. Aspirin if possible acute coronary syndrome
STEMI?
YES
Initiate Cardiac Alert
Ref. Nitroglycerine if suspected acute
coronary syndrome.
For hypotension following NTG
administration give 250mL NS bolus.
Reassess and repeat bolus as needed.
Do not administer additional NTG.
Ref. Fentanyl for persistent pain that is not
relieved by 3 doses of SL Nitroglycerine in noninferior wall MIs and without prior Nitroglycerin
in inferior wall MIs.
*Life Threatening Causes of Chest Pain
Acute coronary syndrome (ACS)
Pulmonary embolism
Thoracic aortic dissection
Tension Pneumothorax
Considerations:
20-30% of patients in the cath. lab, who
have confirmed AMI’s, have reproducible
chest pain upon palpation
Only 30% of patients experiencing an
Acute Myocardial Infarction will present
with ST Segment Elevation.
Approved January 23, 2017
75
Index
Index
2050 Adult Chest Pain
General:
A. Consider life-threatening causes of chest pain first in all patients:
1. Acute coronary syndromes (ACS)
2. Pulmonary embolism (PE)
3. Thoracic aortic dissection (TAD)
4. Tension pneumothorax (PTX)
B. Do not delay obtaining 12 lead ECG, if available, and notify receiving facility immediately
if Cardiac Alert criteria met.
Document specific findings:
A. Complete set of vital signs
B. General appearance: skin color, diaphoresis
C. Cardiovascular exam: presence of irregular heart sounds, JVD, murmur, pulse
asymmetry, dependent edema
D. Pulmonary exam: crackles/râles and/or wheezes/rhonchi
E. Chest wall and abdominal tenderness
Treatment:
A. ABCs
B. Reassure patient and place in position of comfort
C. Place patient on cardiac monitor
D. Ref. oxygen
E. Start IV
F. Paramedics:
1. Obtain 12-lead ECG.
a. If patient has at least 1 mm ST segment elevation in at least 2
anatomically contiguous leads (STEMI), notify receiving hospital and request
CARDIAC ALERT (ref. Cardiac Alert Protocol).
2. If history and physical exam suggest possible ACS:
a. ref. aspirin
b. ref. nitroglycerine
c. ref. fentanyl for persistent pain that is not relieved by 3 doses
SL nitroglycerine
3. Consider CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for
additional medication orders if pain persists.
G. EMTs:
1. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for verbal order for
patient-assisted and supplied nitroglycerine if applicable
Contraindications:
A. If hypotension develops following nitroglycerine administration in any patient, treat with
250cc NS boluses.
B. Nitroglycerine is contraindicated in patients taking medication for erectile dysfunction
(phosphodiesterase inhibitors, e.g.: Viagra, Cialis, Revatio).
C. Nitroglycerine is contraindicated in patients with pulmonary hypertension who are taking
Revatio.
D. Nitroglycerine is contraindicated in patients with Inferior STEMI pattern (Lead II, III,
aVF)
Approved January 23, 2017
76
2051 Adult Cardiac Alert
Goal:
A. To identify patients with ST-segment elevation myocardial infarction (STEMI) in the
prehospital setting and provide advanced receiving hospital notification in order to
minimize door-to-balloon times for percutaneous coronary intervention (PCI)
Inclusion Criteria: (MUST MEET ALL 3 CRITERIA)
A. Chest discomfort consistent with Acute Coronary Syndrome (ACS) or post ROSC (and)
B. 12-lead ECG showing ST-segment elevation (STEMI) at least 2 mm in two or more
anatomically contiguous leads (and)
C. Age 35-85 years old
*If STEMI patient outside inclusion criteria, advise receiving hospital of assessment/ findings*
Exclusion Criteria:
A. Paced rhythm, Left Bundle Branch Block
B. If unsure if patient is appropriate for Cardiac Alert, discuss with receiving hospital MD
Actions:
A. ref. chest pain protocol en route
B. Notify receiving hospital ASAP with ETA and request CARDIAC ALERT. Do not delay
hospital notification. If possible, notify ED before leaving scene
C. Start 2 large bore peripheral IVs
D. Transport
E. Acute coronary syndrome may present without chest discomfort and include symptoms
such as upper abdominal pain, back/ shoulder/ arm pain, nausea/ vomiting, or shortness of
breath. One should have a low threshold to obtain EKG in patients with such symptoms are
reflective of ACS. CONTACT APPROPRIATE RECEIVING HOSPITAL PHYSICIAN for
consultation and possible initiation of Cardiac Alert.
Additional Documentation Requirements:
A. Time of first patient contact
B. Time of first ECG
Approved January 23, 2017
77
Index
2100 Adult Hypertension
Intent:
A. Even with extremes of blood pressure, treat the medical emergency associated with
hypertension (“treat the patient, not the number”)
1. Treat chest pain, pulmonary edema, or stroke according to standard protocols
(pain control will usually improve BP significantly)
B. Do not use medication to treat hypertension
Approved January 23, 2017
78
Index
3000 Adult Syncope
Specific Information Needed
A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient
sitting, standing, or lying? Pregnant?
B. Past history: medications, diseases, prior syncope
C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache,
palpitations
Specific Objective Findings
A.
B.
C.
D.
Vital signs
Neurological status: level of consciousness, residual neurological deficit
Signs of trauma to the head or mouth or incontinence
Neck stiffness
Treatment
A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral
positioning if not completely alert
B. Monitor vital signs and level of consciousness closely for changes or recurrence.
C. Establish venous access and administer Normal Saline if indicated.
D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Hypoglycemia
E. If vital signs unstable or age > 40 years:
1. Ref. Oxygen
2. Keep patient supine.
3. Establish venous access.
4. Monitor cardiac rhythm (12-lead EKG)
Specific Precautions
A. Syncope is by definition a transient state of unconsciousness from which the patient has
recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat
according to Altered Mental Status protocol.
B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes.
Recumbent position should be sufficient to restore vital signs and level of consciousness to
normal.
C. Syncope that occurs without warning or while in a recumbent position is potentially serious
and often caused by an arrhythmia.
D. Patients with syncope, even though apparently normal, should be transported. In middleaged or elderly patients, syncope can be due to a number of potentially serious problems.
The most important of these to monitor and recognize are arrhythmias, occult GI bleeding,
seizure, or ruptured abdominal aortic aneurysm.
E. Any elderly patient with syncope and back pain should be considered to have a
ruptured abdominal aortic aneurysm until proven otherwise.
Approved January 23, 2017
Index
79
3010 Adult Stroke
POSSIBLE STROKE
(Acute onset neurological deficit not likely
due to trauma)
Assess and stabilize ABCs, ref.O2
Assess Cincinnati Prehospital Stroke
Scale
(Presence of single sign sufficient)
Rule out or treat ref. hypoglycemia
 Determine when last KNOWN to be
normal and document specific time
 “At 2:15 PM”, not “1 hour ago”
 Obtain medical history
 Document medications
 Identify family or friend who may assist
with history and decision-making, get
contact info and strongly encourage to
come to ED as they may be needed for
consent for treatments
 Start IV and draw blood
 Document cardiac rhythm
 Ensure full monitoring in place:
cardiac, SpO2
Fully monitor patient and continually
reassess:
 Improvement or worsening of deficit
 Adequacy of ventilation and
oxygenation
 Cardiovascular stability
 Transport to CHC for pts < 12 years old.
 Notify receiving hospital of Stroke Alert
Approved January 23, 2017
80
Index
3010 Adult Stroke
Cincinnati Prehospital Stroke Scale
Think “FAST” (face, arm, speech, time)
Assess Facial Droop
Say: “Smile for me”, or “Show me your teeth”
Assess Arm Pronator Drift
Demonstrate, and say: “Put your arms up for me like this and hold them while I count to 10”
Assess Speech
Say: “Repeat after me: you can’t teach on old dog new tricks”, or “No ifs, ands, or buts”
The Cincinnati Prehospital Stroke Scale (CPSS) is designed to be very reproducible and identify
those strokes most likely to benefit from reperfusion therapy, but does not identify all strokes.
 The CPSS is highly specific for stroke, but is not extremely sensitive, meaning if you have a positive
CPSS, you are almost certainly having a stroke, but if you do not have a positive CPSS, you still may
be having a stroke
 Stroke signs may be very subtle, therefore it is important to know other signs of stroke, which
include:
o Impaired balance or coordination
o Vision loss
o Headache
o Confusion or altered mental status
o Seizure
Stroke Mimics
 Hypoglycemia
 Post-ictal paralysis
 Complex migraine
 Overdose
 Trauma
 Bell’s palsy
1.
2.
3.
Stroke Alert Criteria
Last known normal 8 hours or less
BGL > 60
No seizure at onset or recent head trauma
AND
1.
2.
3.
Must have one or more new clinical signs
New Speech impairment or aphasia
Unequal smile or obvious facial asymmetry
Arm weakness or drift
81
Approved January 23, 2017
Index
3011 Mobile Stroke Treatment Unit – Activation and Transfer of Care
AFD Dispatched to Incident
Review of CAD notes reveals possible Stroke patient
AND
Pt > 18 years old
NO
YES
Do not request MSTU Response
Request dispatch of MSTU via Aurora
Comm. Center
Treat and transport per protocol
AFD arrival on scene
Request 10 minute ticker
Treat per protocol
Does pt. meet Stroke Alert Criteria
AND
Pt > 18 years old
YES
NO
Cancel MSTU response
Treat per protocol
Prepare pt for transport
Treat and transport per protocol
10 minutes after AFD arrival
MSTU NOT on scene
Cancel MSTU Response
Treat and transport per protocol
MSTU Team DOES NOT accept
transfer of care
Treat and transport per protocol
MSTU on scene
Pt report made to MSTU team
MSTU team ACCEPTS
transfer of care
Assist MSTU team loading pt into
MSTU
Pt care transferred to MSTU team
82
Approved January 23, 2017
Index
3020 Adult Altered Mental Status
Altered Mental Status (AMS)
Assess ABCs
ref. Asystole / PEA or . VF / VT, respiratory
distress or obstructed airway protocol as
appropriate.
 Determine character of event
 Consider seizure, syncope and TIA
 Monitor and transport with
supportive care
No
Persistent AMS?
Yes
Check BGL
BGL < 60 mg/dL or clinical
condition suggests hypoglycemia?
Yes
ref. Hypoglycemia
protocol
No
Yes
Seizure activity present?
ref. Seizure protocol
protocolprotocol
No
Perform rapid neurologic
assessment including LOC
and Cincinnati Prehospital
Stroke Scale (CPSS)
Focal neuro deficit or
positive CPSS?
Yes
ref. Stroke protocol
No
Consider other causes of AMS: ref.
overdose, Shock, heat emergency,
cold emergency, EtOH Intoxication
 During transport: ref.O2,
monitor vital signs, airway,
breathing, and ECG.
 Give fluid bolus if volume
depletion suspected
Approved January 23, 2017
83
Index
Index
3030 Adult Seizure





Support ABCs:
ref.O2
Seizure precautions
Check BGL and ref. hypoglycemia
Identify and treat reversible causes
Actively
Seizing?
 Check pulse and reassess ABC
 Give supplemental oxygen
 If seizure < 5 min medication not
necessary
 If > 5 min or recurrent seizure then treat
as follows:
 Transport and monitor ABCs, vital
signs, and neurological condition
 Complete head to toe assessment
ref. Midazolam via most
readily available route
Actively
Seizing?
No
Common Causes of Seizures
ref. Midazolam via most readily
available route, IV preferred
Actively
Seizing?









Epilepsy
EtOH withdrawal or intoxication
Hypoglycemia
Stimulant use
Trauma
Intracranial hemorrhage
Overdose (TCA)
Eclampsia
Infection: Meningitis, sepsis
No
Yes
CONTACT BASE
Approved January 23, 2017
84
Index
3030 Adult Seizure
Seizure Precautions:






Ensure airway patency, but do not force anything between teeth. NPA may be useful
Give oxygen
Suction as needed
Protect patient from injury
Check pulse immediately after seizure stops
Keep patient on side
Document:
 Document: Seizure history: onset, time interval, previous seizures, type of seizure
 Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with
anticonvulsants, pregnancy
Pregnancy and Seizure:
 If 3rd trimester pregnancy or post-partum: ref. pre eclampsia / eclampsia
85
Approved January 23, 2017
Index
4010 Adult Abdominal Pain / Vomiting
Abdominal pain
and/or vomiting




Assess ABCs
ref.O2
Complete set of Vital Signs
Physical exam
 Ref. Hypotension / Shock as indicated
 Cardiac monitor and 12 lead ECG q 5 min if any one or more of the following:
1. Age > 50
2. Diabetic
3. Upper abdominal pain
4. Unstable vital signs

ref.Ondansetron

ref. Fentanyl
 Monitor and transport
 Frequent reassessment for deterioration and response to treatment
86
Approved January 23, 2017
Index
4010 Adult Abdominal Pain / Vomiting
Abdominal exam:
 Gently palpate 4 quadrants, noting areas of tenderness, guarding, rigidity or distension
 Note any pulsatile mass
 Note surgical scars
History:
 Onset, location, duration, radiation of pain
 Associated sx: vomiting, GU sx, hematemesis, coffee ground emesis, melena, rectal
bleeding, vaginal bleeding, known or suspected pregnancy, recent trauma
Elderly Patients:
 Much more likely to have life-threatening cause of symptoms
 Always consider vascular emergencies: AAA, MI
 Shock may be occult, with absent tachycardia in setting of severe hypovolemia
87
Approved January 23, 2017
Index
4020 Adult Overdose and Acute Poisoning
PPE and decontaminate when appropriate
ABCs
IV, ref.O2, monitor
Need for airway
management?
Yes
 ref. Naloxone
 Airway adjuncts and
BVM ventilations as
needed
ref. resp.failure protocol
No
Hypotension?
Yes
IV fluid bolus ref.
hypotension/shock protocol
Yes
Altered Mental
Status Protocol
ref. dopamine if no response
to 20cc/kg NS bolus
No
Altered mental
status?
 Consider specific
ingestions
No
Known Specific
ingestion?
No
 Monitor
 Transport
Yes
Stimulant
Tachycardia,
HTN, agitation,
sweating,
psychosis
ref.Combative
Pt
Tricyclic
antidepressant
Organophosphate
or nerve agent
Calcium Channel
Blocker
Wide complex
tachycardia, seizure
DUMBELS/SLUDGE
syndrome
Bradycardia, heart
block, hypotension
ref. Sodium bicarb
for QRS > 120 msec
ref.Atropine
20 cc/kg NS bolus
Ref. Seizure
ref.Nerve Agent
Antidote Kit
ref. Calcium and
ref.dopamine
ß-Blocker
Bradycardia, heart
block, hypotension
20 cc/kg NS bolus
ref.Dopamine
ref.Glucagon
ref.Glucagon
Approved January 23, 2017
Index
88
4020 Adult Overdose and Acute Poisoning
Obtain specific information:
 Type of ingestion(s)
 What, when and how much ingested?
 Bring the poison, container, all medication and other questionable substances to the ED
 Note actions taken by bystanders or patient (e.g.: induced emesis, “antidotes”, etc)
 Supportive Care is key to overdose management
89
Approved January 23, 2017
Index
4025 Adult Hypoglycemia
Check blood glucose level in ANY patient with signs
or symptoms consistent with hypoglycemia. Use
Capilarry blood for BGL sample
Examples:
Altered MS, agitation, focal neurologic deficit, seizure,
weakness, diaphoresis, decreased motor tone, pallor
If hypoglycemia still most likely
despite normal reading on
glucometer, administer sugar
while considering other causes
of ref. altered mental status
No
Is BGL < 60?
Yes
Can the patient safely tolerate
oral glucose?
intact gag reflex, follows
verbal commands
Yes
ref. Oral Glucose
Reassess patient
No
Yes
 ref. Glugacon IM
No
Still symptomatic?
No
Are you able to establish IV
access?
Yes
ref. dextrose IV & reassess
patient
No
Symptoms resolved?
Recheck BGL and
consider other causes of
altered mental status
Yes
Monitor and transport or
CONTACT BASE for
refusal if indicated
90
Approved January 23, 2017
Index
4025 Adult Hypoglycemia
Regarding refusals after a hypoglycemic episode:
ref. Patient Non Transport protocol
Transport is always indicated for the following patients:
 All pts with unexplained hypoglycemia
 Pts taking oral hypoglycemic meds
 Pts not taking PO
 Pts who do not have competent adult to monitor
91
Approved January 23, 2017
Index
4030 Adult Medical Hypotension / Shock
Adult with SBP < 90 mmHg AND/OR
signs of poor perfusion






ABCs
Complete set of vital signs
Full monitoring
O2 via NRB facemask @ 15L/min
IV access
Transport
Signs of poor perfusion?
Altered mental status
Tachycardia
Cool, clammy skin
No
Recheck and monitor
If patient remains
asymptomatic and clinically
stable, further treatment
may not be necessary
Yes
Life-threatening bradycardia or
tachycardia?
Yes
Ref. bradycardia
Ref. tachycardia
No
 Consider etiology of shock state
 Give 20cc/kg NS bolus and reassess
Repeat 20cc/kg boluses, reassessing for
pulmonary edema, up to 2 liters total or
until goal of SBP > 90 mmHg and signs
adequate perfusion
If patient is at risk for adrenal insufficiency,
ref. Adrenal Insufficiency
For ongoing hypotension, poor perfusion
or pulmonary edema, CONTACT BASE
ref.dopamine
92
Approved January 23, 2017
Index
Index
4030 Adult Medical Hypotension
Shock is a state of decreased tissue oxygenation. Significant vital organ hypoperfusion may be present without hypotension.
Home medications and/or comorbidities may also limit development of tachycardia
Goal is to maximize oxygen delivery with supplemental oxygen and assisted ventilations (if needed), and to maximize
perfusion with IV fluids
Consider the etiology of your patient’s shock state:






Sepsis
Hemorrhage
Anaphylaxis
Overdose
Cyanide or Carbon Monoxide Poisoning
Other: PE, MI, tension pneumothorax
Approved January 23, 2017
93
4031 Adult Adrenal Insufficiency
Patient at risk for adrenal insufficiency:

Identified by family or medical alert bracelet

Chronic steroid use

Congenital Adrenal Hyperplasia

Addison’s disease
Assess for signs of acute adrenal crisis:

Pallor, weakness, lethargy

Vomiting, abdominal pain

Hypotension, shock

Congestive heart failure
All symptomatic patients:

Check blood glucose and treat hypoglycemia, if
present

Start IV and ref.O2

Give NS bolus IV 20 cc/kg up to 2 liters
Does patient have hypotension and signs of poor perfusion?

Altered mental status

Tachycardia

Cool, clammy skin
Yes
No
Ref. Methylprednisolone
20 cc/kg NS bolus, as needed

Continue to monitor for
development of Hypoglycemia

If otherwise considering
administration of corticosteroid,
CONTACT BASE for consult.
Monitor 12 lead ECG q 5 min for signs of hyperkalemia
Approved January 23, 2017
94
Index
4031 Adult Adrenal Insufficiency
Notes:
 If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or
chronic use of systemic steroids) that could lead to acute adrenal insufficiency or Addisonian
crisis, then the administration of steroids may be life-saving and necessary for reversing
shock or preventing cardiovascular collapse.
 Patients at risk for adrenal insufficiency may develop Addisonian crisis when under
physiologic stress which would not lead to cardiovascular collapse in normal patients. Such
triggers may include trauma, dehydration, infection, myocardial ischemia, etc.
 If no corticosteroid is available during transport, notify receiving hospital of need for
immediate corticosteroid upon arrival.
95
Approved January 23, 2017
Index
4040 Adult Drowning
ABCs
Ref; Spinal Stabilization before moving
patient if trauma suspected
Assess mental status
Awake and alert
Awake but altered LOC
 Remove wet garments, dry
and insulate patient
 Transport, even if initial
assessment normal
 Monitor ABC, VS, mental
status
 Remove wet garments, dry and
insulate patient
 Suction as needed
 Start IV, check BGL, ref.O2
 Transport
 Monitor ABC, VS, mental status
Comatose or unresponsive
Pulse Present?
No
Yes
 Monitor cardiac rhythm
Start CPR, attach AED/monitor/defibrillator and treat Ref.
Asystole / PEA or . VF / VT
If suspected hypothermia ref. Hypothermia
 Remove wet garments,
dry and insulate patient
 Heimlich maneuver NOT
indicated
 Consider all causes of
Altered Mental Status
 Suction as needed
 Start IV, obtain BGL and
ref.O2
 Monitor ABC, VS, mental
status
 Monitor cardiac rhythm
Approved January 23, 2017
Index
96
4040 Adult Drowning
Specific Information Needed:
 Length of submersion
 Degree of contamination of water
 Water temperature
 Diving accident and/or suspected trauma
Notes:
 Drowning/submersion commonly associated with hypothermia.
 Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased
O2 demand
 Good outcomes after even prolonged hypothermic arrest are possible
 Patients should not be pronounced dead until rewarmed in hospital
 BLS: pulse and respirations may be very slow and difficult to detect if patient is severely
hypothermic. If no definite pulse, and no signs of life, begin CPR
 If not breathing, start rescue breathing
 ALS: Resuscitation medications are indicated
97
Approved January 23, 2017
Index
4050 Adult Hypothermia
Hypothermia and
Frostbite
Localized cold injury
Systemic hypothermia
Presumed to be primary problem
based on clinical scenario
Frostbite, frostnip
 Remove wet garments, dry
and insulate patient
 Transport, even if initial
assessment normal
 Monitor ABC, VS, mental
status
 Dress injured area lightly in
clean cloth to protect from
further injury
 Do not rub, do not break
blisters
 Do not allow injured part to
refreeze. Repeated thaw
freeze cycles are especially
harmful
 Monitor for signs of systemic
hypothermia
 High flow O2
 ABCs
Awake but altered LOC
 Remove wet garments, dry
and insulate patient
 Suction as needed
 Start IV, BGL, oxygen
 Transport
 Monitor ABC, VS, mental
status
Comatose or unresponsive
Pulse Present?
No
 Monitor cardiac rhythm
Start CPR, attach AED/monitor/defibrillator and treat per
Pulseless Arrest VF / VT or Pulseless Arrest Asystole / PEA
with following changes:
Yes
 Remove wet garments, dry
and insulate patient
 ref. Altered Mental Status
 Suction as needed
 Start IV, check BGL and give
oxygen
 Transport
 Monitor ABC, VS, mental
status
 ref. Resp Failure
PEA
 Handle very gently
 Start IV w. warm IVF
 Insulate patient
Asystole or V-fib/VT
 Monitor cardiac rhythm
 Single dose ref. Epinephrine IV/IO
 For Vfib/VT: single attempt
defibrillation only
 ref. Resp Failure
 Monitor cardiac rhythm
Approved January 23, 2017
Index
98
4050 Adult Hypothermia
 Regardless of cardiac rhythm, the following patients should be aggressively resuscitated and transported as
soon as possible: (per Termination of Resuscitation protocol)
i. Hypothermia
ii. Drowning with hypothermia and submersion < 60 minutes
 Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased O 2 demand
 Good outcomes after even prolonged hypothermic arrest are possible
 Patients should not be pronounced dead until rewarmed in hospital
 BLS: pulse and respirations may be very slow and difficult to detect if patient is severely hypothermic. If no
definite pulse, and no signs of life, begin CPR
 If not breathing, start rescue breathing
 One round of ALS resuscitation medications are indicated only on V-Fib/ VT or Asystole NOT used in PEA
for hypothermia
99
Approved January 23, 2017
Index
4060 Adult Hyperthermia
Hyperthermia
 Classify by clinical syndrome
 Consider non-environmental
causes (see below)
Heat Cramps
 Normal or slightly elevated body
temperature
 Warm, moist skin
 Generalized weakness
 Diffuse muscle cramping
Heat Stroke
Heat Exhaustion
 Elevated body
temperature
 Cool, diaphoretic skin
 Generalized weakness
 Anxiety
 Headache
 Tachypnea
 Possible syncope






Very high core body temperature
Hot, dry skin w. cessation of sweating
Hypotension
Altered mental status
Seizure
Coma
Immediate Transport indicated
20cc/kg bolus NSL
Monitor VS and transport
Adequate airway
and breathing?
No
Yes
Ref. adult respiratory failure
Start IV, ref.O2
20cc/kg bolus NSL unless
signs of volume overload
 Remove excess clothing
 For heat stroke, consider external cooling
measures if prolonged transport
 ref. seizures, cardiac arrhythmias per protocol
 Monitor and transport
Approved January 23, 2017
Index
100
4060 Adult Hyperthermia
Consider other causes of hyperthermia besides environment exposure, including:
 Neuroleptic malignant syndrome (NMS): patients taking antipsychotic medications
 Sympathomimetic overdose: cocaine, methamphetamine
 Anticholingergic toxidrome: overdose (“Mad as a hatter, hot as a hare, blind as a bat, red as a beet”)
common w. ODs on psych meds, OTC cold medications, Benadryl, Jimson weed, etc.
 Infection: fever (sepsis)
 Thyrotoxicosis: goiter (enlarged thyroid)
 Excited Delirium
101
Approved January 23, 2017
Index
4070 Adult Insect/Arachnid Bite and Stings Protocol
Initiate general care for bites
and stings
Assess for localized vs.
systemic signs and symptoms
and depending on animal
involved
Localized Symptoms:
Systemic Symptoms:
 Pain, warmth and
swelling
 Hives, generalized
erythema, swelling,
angioedema
 Hypotension
 Altered mental status
 Other signs of shock
ref. fentanyl for black
widow spider and /or
ref. diphenhydramine
if needed for itching
 ref.O2
 Start IV
ref.allergy & anaphylaxis
protocol
Approved January 23, 2017
Index
102
4070 Adult Insect/Arachnid Bite and Stings Protocol
General Care
 For bees/wasps:
Remove stinger mechanism by scraping with a straight edge. Do not
squeeze venom sac
 For spiders:
Bring in spider if captured or dead for identification
Specific Information Needed:
 Timing of bite/sting
 Identification of spider, bee, wasp, other insect, if possible
 History of prior allergic reactions to similar exposures
 Treatment prior to EMS eval: e.g. Epipen, diphenhydramine, etc.
Specific Precautions:
 For all types of bites and stings, the goal of prehospital care is to prevent further
envenomation and to treat allergic reactions
 BLS personnel may assist patient with administering own Epipen and oral antihistamine
 Anaphylactoid reactions may occur upon first exposure to allergen, and do not require prior
sensitization
 Anaphylactic reactions typically occur abruptly, and rarely > 60 minutes after exposure
103
Approved January 23, 2017
Index
4080 Adult Snake Bite
Assess ABCs, mental status
ref.O2
Start IV
Monitor Vital signs
Remove patient from proximity to snake
Remove all constricting items from bitten limb (e.g.: rings,
jewelry, watch, etc.)
Immobilize bitten part
Initiate prompt transport
• Do NOT use ice, refrigerants, tourniquets,
scalpels or suction devices
• Mark margins of erythema and/or edema with
pen
or marker and include time measured.
Transport
Assess for localized vs. systemic
signs and symptoms
Systemic Symptoms:
• Metallic or peculiar taste in
mouth
• Hypotension
• Altered mental status
• Widespread bleeding
• Other signs of shock
Localized Symptoms:
• Pain and swelling
• Numbness, tingling to bitten part
• Bruising/ecchymosis
Monitor pt and ref. Adult Respiratory
Distress as indicated
Immobilize bitten part
ref. Fentanyl
ref. Hypotension/Shock as
indicated
104
Approved January 23, 2017
Index
4080 Adult Snake Bite
Obtain specific information:
• Appearance of snake (rattle, color, thermal pit, elliptical pupils)
• Appearance of wound: location, # of fangs vs. entire jaw imprint
• Timing of bite
• Prior 1st aid
• To help with identification of snake, photograph snake, if possible. Include image of head, tail, and
any distinctive markings.
• Do not bring snake to ED
Specific Precautions:
• The prairie rattlesnake is native to Denver Metro region and is most common venomous snake bite
in the region
• Exotic venomous snakes, such as pets or zoo animals, may have different signs and symptoms than
those of pit vipers. In case of exotic snake bite, CONTACT BASE (AIP, Children’s TMCA, CMP,
SaddleRock) and consult zoo staff or poison center for direction.
• Never pick up a presumed-to-be-dead snake by hand. Rather, use a shovel or stick. A dead snake
may reflexively bite and envenomate.
• > 25% of snake bites are “dry bites”, without envenomations.
• Conversely, initial appearance of bite may be deceiving as to severity of envenomation.
• Fang marks are characteristic of pit viper bites (e.g. rattlesnakes).
• Jaw prints, without fang marks, are more characteristic of non-venomous species.
Index
Approved January 23, 2017
105
5000 Adult Psychiatric / Behavioral Emergency
Scene Safety
A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a
concern.
B. Refer to restraint protocol as needed, especially as it relates to A.
Specific Information Needed
A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol,
emotional trauma, and suicidal or homicidal ideation.
B. Obtain past history; inquire about previous psychiatric and medical problems, medications.
Specific Objective Findings
A. Evaluate general appearance
1. E.g.: Well groomed, disheveled, debilitated, bizarrely dressed
B. Evaluate vital signs.
1. Is a particular toxidrome suggested, e.g.: symphathomimetic?
C. Note medic alert tags, breath odors suggesting intoxication.
D. Determine if patient has decision making capacity.
E. Note behavior. Consider known predictors of violence:
1. Is the patient male, clinically intoxicated, paranoid or displaying aggressive or
threatening behavior or language?
Treatment
A. If patient combative, see Combative Patient Protocol
B. Attempt to establish rapport
C. Assess ABCs
D. Transport to closest Emergency Department
E. Be alert for possible elopement
F. Consider organic causes of abnormal behavior (trauma, overdose, intoxication,
hypoglycemia)
G. If patient restraint considered necessary for patient or EMS safety, refer to Restraint
Protocol.
H. Check blood sugar ref. Hypoglycemia
I. If altered mental status or unstable vital signs:
1. Ref. Oxygen.
2. Establish venous access.
3. Refer to Altered Mental Status Protocol.
106
Approved January 23, 2017
Index
5000 Adult Psychiatric / Behavioral Emergency
Mental Health Holds
A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a
medical complaint or need specific medical intervention, then that patient may be
appropriately transported by law enforcement according to their protocols.
B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose,
altered mental status, chest pain, etc), then the patient should be transported by EMS
C. If a patient with a psychiatric complaint is clinically intoxicated or otherwise lacks decision
making capacity for any other reason, no Mental Health Hold is needed and such a patient
should be brought to an emergency department for evaluation and stabilization with implied
consent.
D. If EMS is called to evaluate a patient with an isolated psychiatric complaint who is not
clinically intoxicated, or otherwise lacking decision making capacity, and who refuses
treatment or transport, and law enforcement are not willing to transport patient, then EMS
should CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for medical consult
with BASE PHYSICIAN.
E. If there is a reasonable concern for suicidal or homicidal ideation, or grave disability from
another mental health condition, then BASE PHYSICIAN may give a verbal order placing the
patient on a Mental Health Hold and direct EMS personnel to transport the patient against
his or her will in accordance with Colorado State statutes. The physician’s name, and time
and date of the Mental Health Hold must be recorded on the PCR. Effort should be made to
obtain consent for transport from the patient, and to preserve the patient’s dignity
throughout the process.
F. A patient being transported on a Mental Health Hold may be transported to any appropriate
receiving emergency department, as it may not be operationally feasible to transport
exclusively to the Base Station hospital, although this is preferred if time and conditions
allow.
G. It is expected that receiving facilities will receive such patients and perform an appropriate
evaluation to determine if continuation of a Mental Health Hold is indicated at the time of
their assessment.
H. Although there is always a risk of accusations of kidnapping or assault in such cases, such
accusations are extremely rare, and the Aurora Fire Department EMS Medical Directors feel
strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired
patient far outweigh any theoretical risk of allegations of kidnapping when actions are taken
in the interest of patient safety.
Specific Precautions
A. Psychiatric patients often have an organic basis for mental disturbances. Be suspicious of
hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion.
B. If emergency treatment is unnecessary, do as little as possible except to reassure while
transporting. Try not to violate the patient's personal space.
C. If the situation appears threatening, consider a show of force involving police before
attempting to restrain.
D. Beware of weapons. These patients can become very violent.
E. An EMT or paramedic may initiate a Mental Health Hold only by direct verbal order from the
BASE PHYSICIAN (AIP, Children’s, TMCA, CMP, SaddleRock).
F. Document name of BASE PHYSICIAN.
107
Approved January 23, 2017
Index
5010 Adult Combative Patient
Patient is combative and a
danger to self or others
 Attempt to reasonably address
patient concerns
 Assemble personnel
Excited Delirium Syndrome
Treat reversible causes
Yes
Does patient have signs of the
Excited Delirium Syndrome?
These patients are truly out of control and
have a life-threatening medical emergency
they will have some or all of the following sx:
Paranoia, disorientation, hyper-aggression,
hallucination, tachycardia, increased
strength, hyperthermia
No
Patient does not respond to verbal
de-escalation techniques
 ref. midazolam
ref. Restraint Protocol
Obtain IV access as soon as may be
safely accomplished
Still significantly combative?
 Reassess ABCs post
sedation
 High flow O2 & prepare
to assist Ventilations
 Start 2 large bore IVs
as soon as may be
safely accomplished
 Administer 2 liters NS
bolus
No
Yes
Sedate
 Consider cause of agitation
 ref.Midazolam
Start external cooling
measures
Yes
Still significantly combative?
No
Full cardiac and SpO2,
monitoring and transport.
Yes
 CONTACT BASE for re-sedation
 After re-sedation and if still
significantly combative
CONTACT BASE for further
consultation
Approved January 23, 2017
Monitor Patient
Transport
Index
108
5010 Adult Combative Patient
General Guideline:
Emphasis should be placed on scene safety, appropriate use of restraints and aggressive treatment of the
patient’s agitation.
Restraints:
Do not transport in hobble or prone position. Do not inhibit patient breathing / ventilations
109
Approved January 23, 2017
Index
5020 Adult Transport of the Handcuffed Patient
Purpose:
1.
Guideline for transport of patients in handcuffs placed by law enforcement
Guideline:
1.
2.
3.
4.
5.
Handcuffs are only to be placed by law enforcement. EMS personnel are not permitted to
use handcuffs.
Request that law enforcement remain with the patient in the ambulance, if possible. If not
possible, request that police ride behind ambulance so as to be readily available to remove
handcuffs if needed in an emergency situation to facilitate medical care of the patient.
EMS personnel are not responsible for the law enforcement hold on these patients.
Handcuffed patients will not be placed in the prone position.
Handcuffs may be used with spinal immobilization. Medical priorities should take priority in
the positioning of the handcuffs.
110
Approved January 23, 2017
Index
5030 Adult Tasered Patients
Indications:
Patient with TASER probe(s) embedded in skin.
Contraindications:
1. TASER probe embedded in the eye or genitals. In such cases, transport patient to an
emergency department for removal.
Precautions:
The prehospital provider should consider the nature of the incident, potential mechanism(s) of
injury, as well as patient complaints.
The prehospital provider is responsible for a reasonable assessment of the patient to determine
if there is an injury/illness or reason for transport or treatment.
Use of the Taser device does not necessarily require the patient to be transported.
Use of the Taser device does not relieve the prehospital provider of the responsibility to
assess and treat the patient in a manner consistent with the body of the Aurora Authorized
version of the Denver Metropolitan Emergency Medical Directors protocol.
TASER Barb Removal Technique:
1. Confirm the TASER has been shut off and the barb cartridge has been disconnected.
2. Using a pair of shears cut the TASER wires at the base of the probe.
3. Place one hand on the patient in area where the probe is embedded and stabilize the skin
surrounding the puncture site. Using the other hand (or use pliers/forceps) firmly
grasp the probe.
4. In one uninterrupted motion, pull the probe out of the puncture site maintaining a 90°
angle to the skin. Avoid twisting or bending the probe.
5. Repeat the process for any additional probes.
6. Once the probes are removed, inspect and assure they have been removed intact. In the
event the probe is not removed intact or there is suspicion of a retained probe, the
patient must be transported to the emergency department for evaluation.
7. Cleanse the probe site and surrounding skin with betadine and apply sterile dressing.
(TASER barb removal demonstration)
8. Advise patient to watch for signs of infection including increased pain at the site, redness
swelling or fever.
9. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Required for patient nontransport.
111
Approved January 23, 2017
Index
5040 Adult Drug / Alcohol Intoxication
Clinically Intoxicated Patient:
(Ataxia or Slurred Speech or Slow motor response)
(Clinical impression of provider that patient is clinically intoxicated means patient does not
have decision making capacity. EMS Provider must make medical decisions for pt.)
No
Refer to appropriate
section of protocol
Yes
Incapacitated due to intoxication
(Inability to stand from seated position and walk
independently or unable to maintain airway)
No
Acute illness or injury suspected based on appearance, MOI,
etc. or signs/symptoms/history of acute illness or injury?
Yes
No
Yes
Can patient be released to responsible person
in a safe environment?
Transport to ED
Yes
Document on PCR
Base Contact not
required
No
CONTACT BASE
112
Approved January 23, 2017
Index
5040 Adult Drugs / Alcohol Intoxication
Introduction:
When applying this protocol please remember:
A.
B.
C.
D.
E.
F.
G.
H.
This protocol does not replace current protocols pertaining to Altered Mental Status,
Overdose and Poisonings, Trauma etc. which supersede any and all applications of the
alcohol protocol.
A clear understanding that this protocol requires a thorough assessment of the situation to
determine if there is any history, signs, or symptoms of an injury or illness.
There remains a very low threshold for checking a blood sugar level as hypoglycemia may
mimic and/or co-exist with intoxication.
A clinically intoxicated person should never be left in an unsafe environment, and will not be
left on scene in the absence of a responsible person who assures patient safety (e.g. law
enforcement, family, friend) unless approved by BASE CONTACT (AIP, Children’s TMCA,
CMP, SaddleRock) physician.
This protocol is intended to aid with the disposition of acutely intoxicated patients. The
criteria set forth are not all-inclusive, and do not take the place of a thorough patient
assessment or sound clinical judgment.
A thorough patient assessment is essential in every case as many medical and psychiatric
conditions can mimic intoxication.
In general, if a patient lacks decision-making capacity for reasons of clinical intoxication with
alcohol and there is reasonable concern about the possibility of an acute illness or injury,
then the patient should be transported to an emergency department for evaluation,
including against the patient’s will if necessary.
Clinical judgment about who does or does not have decision-making capacity may be difficult
and consultation with On-line Medical Control is prudent if there is any question.
Special Notes:
A. Not every clinically intoxicated patient requires transport to an emergency department.
Every effort should be made to determine the capacity of a patient to care for his or herself if
transport is not immediately indicated.
Definitions:
Acute Illness or Injury
 Abnormal vital signs
 Physical complaints that might indicate an underlying medical emergency, e.g.: chest pain
 Seizure or hypoglycemia
 Signs of trauma or history of acute trauma
Approved January 23, 2017
Index
113
6000 Pre-Eclampsia / Eclampsia
Routine medical assessment
IV
BGL
NO
(Pre-Eclamptic)
Patient Seizing?
Position of Comfort
(if supine elevate right side)
Yes
(Eclamptic)
ref. Midazolam
Give immediately via most
readily available route
ref. Resp Distress / ref. Resp Failure
ref. Magnesium
114
Approved January 23, 2017
Index
6010 Emergency Childbirth
Routine medical assessment
Ominous signs?
Yes
ref. Abnormal Delivery
NO
Place mother supine and
prepare delivery equipment
Yes
Imminent Delivery?
Have mother “pant” during
each contraction and relax
between contractions.
Spontaneous respirations
and HR >100 within 30
seconds?
As head emerges, check for
cord around neck (If it can’t
be slipped overhead, clamp
x2 and cut immediately)
Put newborn on mother’s
abdomen and prevent heat
loss. Record APGAR at 1 and
5 minutes.
If signs of obstruction
present immediately suction
mouth then nose.
Abnormally heavy bleeding?
NO
NO
Transport
Ref. Newborn Resuscitation
NO
Yes
ref. Postpartum Hemorrhage
Dry newborn and keep at
level of mother’s vagina until
cord stops pulsating and is
double clamped.
Transport
Double clamp cord 6” from
newborn’s abdomen and cut
between clamps with sterile
scalpel.
115
Approved January 23, 2017
Index
6010 Emergency Childbirth
Overview:
1.
2.
EMS providers called to a possible prehospital childbirth should determine if there is
enough time to transport expectant mother to hospital or if delivery is imminent
If imminent, stay on scene and immediately prepare to assist with the delivery
Specific Information Needed:
Obstetrical history:
Number of pregnancies (gravida)
Live births (PARA)
Expected delivery date
Length of previous labors
Narcotic use in past 4 hours
Emergency Childbirth Procedure
1.
If there is a prolapsed umbilical cord or apparent breech presentation, go to abnormal
delivery protocol and initiate immediate transport
2. For otherwise uncomplicated delivery:
1. Position mother supine on flat surface, if possible
2. Do not attempt to impair or delay delivery
3. Support and control delivery of head as it emerges
4. Protect perineum with gentle hand pressure
5. Check for cord around neck, gently remove from around neck, if
present
6. If signs of obstruction present, suction mouth, then nose of infant
7. If delivery not progressing, baby is “stuck”, see obstetrical
complications protocol and begin immediate transport
8. As shoulders emerge, gently guide head and neck downward to
deliver anterior shoulder. Support and gently lift head and neck to
deliver posterior shoulder. Rest of infant should deliver with
passive participation – get a firm hold on baby
9. Keep newborn at level of motherʼs vagina until cord stops
pulsating and is double clamped
Critical Thinking:
1.
2.
3.
4.
5.
6.
Normal pregnancy is accompanied by higher heart rates and lower blood pressures
Shock will be manifested by signs of poor perfusion
Labor can take 8-12 hours, but as little as 5 minutes if high PARA
The higher the PARA, the shorter the labor is likely to be
High risk factors include: no prenatal care, drug use, teenage pregnancy, DM, htn, cardiac
disease, prior breech or C section, preeclampsia, twins
Note color of amniotic fluid for meconium staining
116
Approved January 23, 2017
Index
6010 Emergency Childbirth
For All Patients with obstetrical complications
 Do not delay: immediate rapid transport
 Give high-flow oxygen
 Start IV en route if time and conditions allow. Treat signs of shock w. IV fluid boluses per Medical Hypotension/Shock
Protocol
Possible actions for specific complications
The actions listed may not be feasible in every case, nor may every obstetrical complication by anticipated or effectively
managed in the field. These should be considered “best advice” for rare, difficult scenarios. In every case, initiate
immediate transport to definite care at hospital
Postpartum Care Infant
 Suction mouth and nose only if signs of obstruction by secretions
 Respirations should begin within 15 seconds after stimulating reflexes. If not,
begin artificial ventilations at 30-40 breaths/min
 If apneic, cyanotic or HR < 100, ref. Newborn resuscitation
 Dry baby and wrap in warm blanket
 After umbilical cord stops pulsating, double clamp 6” from infant abdominal wall
and cut between clamps with sterile scalpel. If no sterile cutting instrument
available, lay infant on mother’s abdomen and do not cut clamped cord
 Document 1 and 5 minute APGAR scores
Complications of Late Pregnancy
3rd Trimester Bleeding (6-8 months)






High flow O2 via NRB, IV access
Suspect placental abruption or placenta previa
Initiate rapid transport
Position patient on left side
Note type and amount of bleeding
IV NS bolus for significant bleeding or shock
Pre Eclampsia/Eclampsia/Toxemia




High flow O2 via NRB, IV access
SBP > 140, DBP > 90, peripheral edema, headache, seizure
Transport position of comfort
Ref. Eclampsia
Postpartum Care Mother
 Placenta should deliver in 20-30 minutes. If delivered, collect in plastic bag and bring to hospital. Do not pull cord to
facilitate placenta delivery and do not delay transport awaiting placenta delivery
 If the perineum is torn and bleeding, apply direct pressure with sanitary pads
 Ref. Postpartum Hemorrhage
 Initiate transport once delivery of child is complete and mother can tolerate movement
Approved January 23, 2017
117
6020 Abnormal Delivery
Routine medical assessment
Ominous signs?
Transport
Meconium
Staining
Prolapsed Cord
Breech
(Buttocks)
Limb
presentation
Shoulder
Dystocia
Suction prior
to stimulation
and
ventilation.
Cover exposed
cord with
moistened
towel.
Deliver baby to
waist then
rotate to facedown position.
Do not pull on
presenting
part.
Do not pull
on baby’s
head.
Quickly tie
and cut 1st
cord.
ref. Newborn
Resus Algo
Put mother in
Trendelenburg in
knee-chest
position
Create
breathing
space around
baby’s face
with gloved
hand.
Cover
exposed part
with
moistened
towel.
Support
baby’s head
Suction oral
and nasal
passages
Proceed with
subsequent
deliveries.
With gloved hand,
push presenting
part off of vaginal
wall to
decompress cord.
Place mother
left side
down.
Multiple
Births
Place mother
with buttocks
just off the
end of bed.
Flex mother’s
thighs upward,
apply gentle
open hand
pressure above
the pubic bone
Monitor Pts.
118
Approved January 23, 2017
Index
Index
6030 Postpartum Hemorrhage
Routine medical assessment
ref. Resp Distress
ref. Resp Failure as indicated
Check BP
ref. Hypotension Protocol
IV NS
(2 Lines if possible)
Use vigorous external uterine massage
to promote uterine tone.
Transport
Approved January 23, 2017
Index
119
7000 Adult General Trauma Care




BSI
Scene safety
Consider mechanism
Consider need for
additional resources




General impression
ABCs and LOC
Rapid Trauma Assessment
Ref. Adult Traumatic Pulseless
Arrest
 Prepare for immediate transport
 SAMPLE history




Ref. Oxygen
ref. Resp Distress as indicated
ref. Resp Failure as indicated
ref. Spinal Stabilization as indicated
Control exsanguinating hemorrhage:
 Direct pressure
 ref. Tourniquet protocol if indicated
 Pelvic stabilization if indicated
Assess disability and limitation:
 Brief neuro assessment
 Ref. Extremity splinting if indicated
 Transport to closest appropriate facility
 Large bore IV, 2nd if unstable
 Consider IV fluid bolus 20cc/kg if unstable
or suspected significant injuries. ref.
Traumatic Shock Protocol
 Monitor vital signs, ABCs, neuro status, GCS
120
Approved January 23, 2017
Index
7005 Adult Special Trauma Scenarios
ref. General Trauma Care
Sexual Assault
Abuse / neglect
Confine history to
pertinent medical needs
Observe pt’s behavior
around caregivers
Watch out for:
 Injury inconsistent with
stated mechanism
 Delayed treatment
 Spreading blame
 Conflicting stories
 Prior/ healing injuries
 Respect patient’s
emotional needs
Don’t judge, accuse or
confront victim
Don’t judge, accuse or
confront victim or
suspected assailant
Protect evidence:
No washing or
changing clothes
Transport patient if suspected
abuse or neglect, no matter
how minor the injury may
appear.
Transport
Notify Aurora Police
Department of all suspected
abuse / assault
Request APD officer to respond to
receiving facility if not on scene
prior to patient transport.
121
Approved January 23, 2017
Index
7010 Adult Trauma in Pregnancy
ref. General Trauma Care
Protocol
Pregnant Trauma
(EGA > 20 weeks)
Pregnant Trauma
(EGA < 20 weeks)
 Priority is mother.
 Assure hospital is aware of
pregnancy and EGA
 Priority is mother.
 Patients with any thoracic,
abdominal, pelvic injury or
complaint who are refusing
transport require base
contact for AMA refusal.
Patients with any thoracic, abdominal,
or pelvic complaint or injury may require
prolonged fetal monitoring in hospital,
even if asymptomatic at time of
evaluation, and even for seemingly
minor mechanism. Encourage transport
of all patients.
 Avoid supine position:
o Place in left lateral recumbent
position if possible
o If immobilized tilt backboard 15 to
30 degrees to the left side
Interpret VS with caution. Pregnant
patient has:
 Increased heart rate
 Decreased blood pressure
 Increased blood volume
Approved January 23, 2017
122
Index
Index
7010 Adult Trauma in Pregnancy
Estimated Gestational Age (EGA)
If EGA > 20 weeks, consider two patients: mother and fetus. Estimation of
gestational age may be made based on fundal height by palpating for top of
uterus:
If uterus is at umbilicus then EGA > 20 weeks
Estimation by Last Menstrual Period:
Due Date = LMP + 9 months + 7 days
EGA = due date – current date
123
Approved January 23, 2017
Index
7015 Adult Traumatic Pulseless Arrest
CPR until cardiac monitor applied
Place pt on Cardiac Monitor1
Asystole? *
No
Yes
CONTACT BASE for
consideration of Field
Pronouncement
 Immediate transport to closest appropriate trauma center
 Control life threatening external bleeding
 Begin continuous compressions – change compressors q 2
min
 1 breath every 6 seconds
o OPA/NPA/Capnography/BVM
1Load
and go is always a reasonable
approach to penetrating trauma arrest.
Ref. Adult Respiratory Failure/Arrest
Ref. bilateral needle thoracostomy on all
traumatic arrests with trauma to trunk
Traumatic pulseless arrest is a unique
situation.
Do not apply “combo pads”
Do not defibrillate
Do not administer ACLS medications
Do not treat as medical arrest
IV. ref. IO access with NS bolus enroute
Transport to closest Trauma Center
Cardiac arrest from the following causes should
approached as a medical cardiac arrest:
 Overdose Monitor cardiac
rhythm
 Respiratory arrest
 Airway obstruction
 Asphyxiation
 Hanging
 Drowning
 Electrocution
 Lightning/high voltage
* Asystole is defined as the absence of any electrical activity and must be observed in two or more
leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to
the EMS Operations Captain. Include the AFR incident number on the strip.
124
Approved January 23, 2017
Index
7020 Adult Traumatic Shock
Trauma w. suspected
serious injury and/or
signs of shock
ref. General Trauma Care
Pelvic sheet if indicated
 ref.O2
 Large bore IV
 2nd IV preferred
Yes
SBP < 90 and/or definite
signs of shock?
 IV NS bolus 20 cc/kg
 Ref. Intraosseous Access
x
No
 Treat en route
 Keep patient warm
Evaluate breath sounds,
respiratory effort, and
consider tension
pneumothorax
Repeat NS bolus 20
cc/kg as needed
Reassess
ref. needle thoracostomy
if arrest or impending
arrest
Monitor:
 ABCs, VS, mental
status
 Rapid transport to
appropriate trauma
center
Monitor cardiac rhythm
Approved January 23, 2017
Index
125
7020 Adult Traumatic Shock
Shock is defined as impaired tissue perfusion and may be manifested by any of the following:
 Altered mental status
 Tachycardia
 Poor skin perfusion
 Low blood pressure
Traditional signs of shock may be absent early in the process, therefore, maintain a high index of
suspicion and be vigilant for subtle signs of poor perfusion
Prehospital End-Points of Fluid Resuscitation:
Over aggressive resuscitation with IV fluid before hemorrhage is controlled may worsen bleeding,
hypothermia and coagulopathy.
Do not withhold IV fluids in a critically injured patient, but give judiciously with goal to improve signs of
perfusion and mental status rather than to achieve a “normal” blood pressure.
Approved January 23, 2017
126
7025 Adult Amputations
ref. General Trauma Care
Bleeding Controlled
Uncontrolled Bleeding
Control with direct pressure to
bleeding area or vessel
 Large bore IV
 If hypotensive, ref. Traumatic Shock
 Document neurovascular exam
If bleeding not controlled with direct
pressure, ref. Tourniquet
Partial/Near-Amputation
Complete Amputation
Amputated part:




Wrap in moist, sterile dressing
Place in sealed plastic bag
Place bag in ice water
Do not freeze part
 Cover with moist sterile dressing
 Splint near-amputated part in anatomic
position
Stump:
 Cover with moist sterile dressing
covered by dry dressing
ref. fentanyl
 Monitor and transport to
appropriate Trauma Center
 Treat other injuries per protocol
Approved January 23, 2017
127
Index
Index
7026 Adult Extremity Injuries
Specific Information Needed
A. Mechanism of injury: direction of forces, if known
B. Areas of pain, swelling or limited movement
C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations,
movement of patient
D. Past medical history: medications, medical illnesses
Specific Objective Findings
A. Vital signs
B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone fragments,
loss of function, guarding
C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation
D. Note estimated blood loss at scene.
Treatment
A. Treat airway, breathing, and circulation as first priorities.
B. Immobilize cervical spine when appropriate.
C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with
higher priority first.
D. If patient unstable, transport rapidly, treating life threatening problems en route. Splint
patient to minimize fracture movement by securing to long board.
E. If patient stable, or isolated extremity injury exists:
1. Check and record distal pulses and sensation prior to immobilization of injured
extremity.
2. Apply sterile dressing to open fractures. Note carefully wounds that appear to
communicate with bone.
3. Splint areas of tenderness or deformity: apply gentle traction throughout treatment and
try to immobilize the joint above and below the injury in the splint.
4. Realign angulated fractures by applying gentle axial traction if necessary to restore
circulation distally or to immobilize adequately, i.e., realign femur fracture.
5. Check and record distal pulses and sensation after reduction and splinting.
6. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries allow.
7. Monitor circulation (pulse and skin temperature), sensation, and motor function distal
to site of injury during transport.
8. Establish venous access.
9. ref. Fentanyl
Special precautions
A. Patients with multiple injuries have a limited capacity to recognize areas which have been
injured. A patient with a femur fracture may be unable to recognize that he has other areas
of pain. Be particularly aware of missing injuries proximal to the obvious ones (e.g., a hip
dislocation with a femur fracture, or a humerus fracture with a forearm fracture).
B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels or leave
cooling for hospital setting.
C. Injuries around joints may become more painful and circulation may be lost with attempted
realignment. If this occurs, stabilize the limb in the position of most comfort with the best
distal circulation.
Approved January 23, 2017
Index
128
7029 Head Trauma
ref. General Trauma Care




ref. Oxygen
ref. Spinal Stabilization as indicated
ref. Seizure as indicated
ref. Combative patient as indicated
Ref. Adult Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated
Systolic BP < 90 and/or definite signs of shock?
Yes
No
 Rapid Trauma Assessment
 Treat other injuries per protocol
 Watch for status changes
Ref. Adult Traumatic Shock
GCS < 8?
Yes
Head of bed should be elevated 300 unless BP < 90
 IV Access
No
 Monitor cardiac rhythm
 Transport to appropriate Trauma Center
 Continue to monitor for developing hypoxemia and shock
Cushing’s Triad is a sign of increased intracranial pressure and consists of:

Hypertension (often with a widening pulse pressure)

Bradycardia

Irregular respirations
Approved January 23, 2017
Index
129
7030 Adult Face and Neck Trauma
ref. General Trauma Care




Clear airway
Rapid trauma assessment
ref. Spinal immobilization
ref. Resp Distress as
indicated
 ref. Resp Failure as indicated
Laryngeal
trauma*
Yes
Transport
No
Severe airway
Bleeding?
Direct pressure if
appropriate
Yes
No





Complete neuro exam
Asses for subcutaneous air
Cover/protect eyes as indicated
Do not try to block drainage from ears, nose
Save avulsed teeth in saline-soaked gauze,
do not scrub clean
 Transport ASAP to closest
appropriate facility
 IV access en route
 Treat other injuries per protocol
 Suction airway as needed
 ref. Fentanyl
 Monitor ABCs, VS, mental status, SpO2
Spinal Immobilization not routinely indicated for
penetrating neck injury
Penetrating injury is very rarely associated with unstable
spinal column
*Suspect laryngeal trauma with:




Laryngeal tenderness, swelling, bruising
Voice changes
Respiratory distress
Stridor
130
Approved January 23, 2017
Index
7035 Adult Spinal Trauma
ref. General Trauma Care
 Full spinal immobilization if
suspected spine injury
 Document neuro assessments
before and after immobilization
Rapid transport to appropriate Trauma
Center
Large bore IV and consider 2nd line
If BP < 90 and/or signs of shock,
resuscitate ref. Traumatic Shock
 Complete patient assessment
 Treat other injuries per protocol
 Monitor for status changes
Monitor ABCs, VS, mental status, SpO2.
ref. Fentanyl
Approved January 23, 2017
Index
131
7040 Adult Selective Spinal Stabilization
Mechanisms of injury that imply potential need for spinal stabilization and for whom stabilization should be considered
include but are not limited to:
MVC/MCC/Bicycle/Equestrian Accident
Diving / Axial Load
Fall from twice patient’s height
o
o
o
Establish manual in-line cervical
stabilization







Does the pt have /complain of any of the following?
Clinical intoxication with ETOH or drugs
Altered mentation
Barrier to evaluate for spinal injury (e.g. language or development barrier)
Distracting injury
Midline C/T/L spine tenderness on palpation
Subjective: (numbness, tingling, or weakness)
Objective: (motor or sensory deficit)
Yes
No
If NONE of above, spinal
stabilization not indicated.
Place appropriately sized c-collar or utilize
improvised c-spine techniques if the rigid c-collar
cannot be effectively utilized.
*
Obvious motor or sensory deficit on exam consisting of:
 Lack of Equal Bilateral grip, push/pull
and/or
 Lack of Light touch sensation to extremity(s)

No
Yes
Is pt able to cooperate and lay still?

No
Stabilize and secure torso/head
utilizing scoop or backboard.
Transport to closest Level I or
Level II Trauma Center
Yes
Stabilize and secure
torso/head utilizing
scoop or backboard.


Spinal stabilization is only indicated
in penetrating trauma when there is
obvious motor or sensory deficit on
exam.
Stabilize and secure unconscious
blunt trauma patients
Elderly patients are more
susceptible to spinal injury
Do not remove previously placed
stabilization device(s).
Manual in line stabilization may be released.
Scoop/backboard NOT indicated.
If the patient is capable, self-extrication is
preferred.
Place patient in position of comfort on gurney.
132
Approved January 23, 2017
Index
7045 Adult Chest Trauma
ref. General Trauma Care
Rapid transport to Trauma Center
Are you able to oxygenate and
ventilate effectively?
No
Airway management and
assisted ventilations as indicated
ref. needle thoracostomy
Yes
Penetrating
trauma?
Yes
Rapid transport &
stabilize in route
Yes
Splint with
bulky dressing
Occlusive dressings
for sucking wounds
No
Large bore IV and
consider 2nd line
Flail Chest?
Assess for need for
assisted ventilations
ref. Resp Distress as indicated
ref. Resp Failure as indicated
No
SBP < 90 and/or shock?
No
Yes
ref. traumatic shock enroute
No
ref. Fentanyl
Monitor ABCs, VS,
mental status, SpO2.
133
Approved January 23, 2017
Index
7045 Adult Chest Trauma
Tension pneumothorax should be suspected with presence of the following:
 Unilateral absent breath sounds AND: JVD, hypotension, difficult/unable to ventilate
 Needle decompression is NEVER indicated for simple pneumothorax
End points of fluid resuscitation should be improved mental status and pulses, not necessarily a normal blood pressure.
This is especially true for penetrating chest trauma.
134
Approved January 23, 2017
Index
7050 Adult Abdominal Trauma
ref. General Trauma Care
Transport to closest appropriate Trauma Center


IV access
Consider 2nd line if
MOI significant
Penetrating trauma?
Yes
Cover wounds, viscera with saline
moistened gauze dressing
No
Do not attempt to repack exposed
viscera
SBP < 90 and/or
shock?
Yes
ref. Traumatic Shock
No
ref. Fentanyl
Monitor ABCs, VS, mental
status, SpO2.
Approved January 23, 2017
135
7050 Adult Abdominal Trauma
End points of fluid resuscitation should be improved mental status and pulses, not
necessarily a normal blood pressure. This is especially true for abdominal trauma.
Documentation
 MOI
 Time of injury
 Initial GCS
 Penetrating trauma
 Weapon/projectile/trajectory






Blunt vehicular trauma
Condition of vehicle
Speed
Ejection
Airbag deployment
Restraints, helmets
Approved January 23, 2017
136
7055 Adult Burns
 ref. General Trauma Care
 Transport to Trauma Center
Stop burning process:
 Remove clothes if not
adhered to patient’s skin
 Flood with water only if
flames/smoldering present
Respiratory
Distress?
Yes
 O2 NRB 15 lpm
 ref. Resp Distress as indicated
 ref. Resp Failure as indicated
No
Evaluate degree and body
surface area involved
Critical Burn?*
Yes
No
 Start 2 large-bore IVs TKO
 2º > 30% BSA
 3º > 10% BSA
 Respiratory injury, facial burn
 Associated injuries, electrical or deep chemical
burns, underling PMH (cardiac, DM), age > 50
If hypotensive ref. Shock
IV NS TKO




*Critical Burn:
Remove rings, jewelry, constricting items
Dress burns with dry sterile dressings
Treat other injuries per protocol
Cover patient to keep warm
Ref. Fentanyl
Monitor ABCs, VS, mental
status, SpO2
Approved January 23, 2017
Index
137
7055 Adult Burns
Document:
 Type and degree of burn(s)
 % BSA
 Respiratory status
 Singed nares, soot in mouth
 SpO2
 PMH
 Confined space
*Critical Burn:
 2º > 30% BSA
 3º > 10% BSA
 Respiratory injury, facial burn
 Associated injuries, electrical or deep chemical burns,
underling PMH (cardiac, DM), age < 10 or > 50 yrs
Types of Burns:
 Thermal: remove from environment, put out fire
 Chemical: brush off or dilute chemical. Consider HAZMAT
 Electrical: make sure victim is de-energized and suspect
internal injuries
 Consider CO if enclosed space
 Consider CN if plastics, shock, pulseless arrest
Designated Regional Burn Centers
Consider direct transport of isolated burns if time and
conditions allow
 Age ≤ 12 Children’s Hospital Colorado
 Age ≥ 13 University of Colorado Hospital
138
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Index
001p General Guidelines for Pediatric Patients
General Guideline:
A. Pediatric patients, defined as age < 12 years for the purpose of these protocols, have
unique anatomy, physiology, and developmental needs that affect prehospital care.
Because children make up a small percentage of total calls and few pediatric calls are
critically ill or injured, it is important to stay attuned to these differences to provide
good care. Therefore, CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)
early for guidance when treating pediatric patients with significant complaints,
including abnormalities of vital signs. Pediatric emergencies are usually not preceded
by chronic disease. If recognition of compromise occurs early, and intervention is swift
and effective, the child will often be restored to full health.
Specific Considerations:
A. The following should be kept in mind during the care of children in the prehospital
setting:
1. Airways are smaller, softer, and easier to obstruct or collapse.
2. Respiratory reserves are small. A minor insult like improper position, vomiting,
or airway narrowing can result in major deficits in ventilation and oxygenation.
3. Circulatory reserves are also small. The loss of as little as one unit of blood can
produce severe shock in an infant. Conversely, it is difficult to fluid overload
most children. You can be confident that a good hands-on circulation
assessment will determine fluid needs accurately.
4. Assessment of the pediatric patient can be done using your knowledge of the
anatomy and physiology specific to infants and children.
5. Listen to the parents' assessment of the patient's problem. They often can detect
small changes in their child's condition. This is particularly true if the patient
has chronic disease.
6. The proper equipment is very important when dealing with the pediatric
patient. A complete selection of pediatric airway management equipment, IV
catheters, cervical collars, and drugs has been mandated by the state. This
equipment should be stored separately to minimize confusion.
139
Approved January 23, 2017
Index
002p Pediatric Assessment
Airway / Appearance
Abnormal:
Abnormal or absent cry or
speech. Decreased response to
parents or environmental stimuli.
Floppy or rigid muscle tone or
not moving.
Normal:
Normal cry or speech.
Responds to parents or to
environmental stimuli.
Good muscle tone.
Moves extremities well.
Work of Breathing
Abnormal:
Increased (nasal flaring, retractions or
abdominal muscle use)
OR
Decreased/absent respiratory effort or
noisy breathing
Normal:
Breathing appears regular without excessive
respiratory muscle effort
or audible respiratory sounds.
Normal RR by age: neonates > 40, infants >
20, children > 12
Circulation / Color
Abnormal:
Cyanosis, mottling, paleness/pallor
or obvious, significant bleeding.
Unexplained tachycardia
Normal:
Color appears normal for racial group of
child. No significant bleeding.
Ref. Pediatric Field Guide
and
Refer to appropriate protocol.
Approved January 23, 2017
Index
140
003p Pediatric Shock
Ref. Oxygen
Ref. Pediatric Field Guide
Decompensated:
Altered Mental Status
Hypotensive2
Weak Femoral/Brachial
Pulses
Compensated:
Normal Mental Status
Tachycardia1
Normotensive2
Delayed Peripheral Cap. Refill
Ref. IO
Obtain IV access
If unable to start IV after 2
attempts, Contact Base for ref. IO
Pull / Push 20ml/kg NS bolus IV/ IO and begin transport
Reassess
Repeat 20ml/kg NS boluses up to 40ml/kg until goal met of:
Threshold heart rate for age
Normal Systolic Blood Pressure for age and
Capillary refill < 2 seconds
If patient is at risk for adrenal insufficiency, ref. Adrenal Insufficiency
REFERENCE PEDIATRIC FIELD GUIDE FOR NORMAL VALUES
1 Tachycardia
<1 y
1y-2y
2y-5y
5y-12y
>12y
2 Hypotension
for age:
>160bpm
>150bpm
>140bpm
>120bpm
>100bpm
<1 mo
1mo-1y
1y-10y
>10y
for age:
<60mmHg
<70mmHg
<70+ (2 x age in years)
<90mmHg
Normal RR by age:
neonates / infants = 40-60 per min
children > 12 = < 20 breaths per minute
141
Approved January 23, 2017
Index
003p Pediatric Shock
Specific Information Needed
A. History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine
output, oral intake, recent trauma, possible drug ingestion
B. Past medical history
Document Specific physical findings
A.
B.
C.
D.
E.
F.
General appearance: LOC, muscle tone, color
ABCs and vital signs
Skin: warmth of distal extremities, color, skin turgor, blood pressure, pulses
Mucous membranes: wetness of mouth, presence of tears
Musculoskeletal: evaluate for trauma
The signs of dehydration are:
1. EARLY - tachycardia and tachypnea for age, decreased LOC, cool skin, mucous
membranes dry, sunken eyes and fontanelle;
2. LATE - loss of skin turgor, diminished pulses, hypotension, and shock
Treatment
A.
B.
C.
D.
Use appropriate airway adjuncts as indicated.
Ref. Oxygen
Breathing: ventilation as indicated
Circulation:
1. Establish pulse rate and blood pressure
2. Establish peripheral venous access.
3. Consider fluid bolus of normal saline 20cc/kg.
4. Do not delay transport for IV attempts.
5. The patient with simple dehydration is not a candidate for intraosseous infusion,
CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) for approval of IO if shock
is present.
Specific Precautions
A. Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but
they are nonspecific.
B. Determination of tachycardia or hypotension is based on age.
C. Monitor carefully for signs of decreased tissue perfusion (shock). Early shock is present if
there are poor pulses, muscle tone and color, or decreased mental status. Decompensated
shock is present if systolic BP is < normal for age
Adrenal Insufficiency
A. Patients at risk for adrenal insufficiency include:
1. Chronic steroid use
2. Addison’s disease
3. Congenital adrenal hyperplasia
4. Other patients identified as such by family, medical record, or physician note
142
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Index
004p General Guidelines: Transportation of the Pediatric Patient1
General Principles:
For the purpose of the protocols, pediatric patients are defined as <12 years of age. The
unique anatomy, physiology and developmental needs of children in this age range
affect prehospital care. Several specific differences include:
A. Airways are smaller, softer and easier to obstruct or collapse. Actions such as
neck hyperflexion, hyperextension, or cricoid pressure may create an upper
airway obstruction in a child
B. Respiratory reserves are small, resulting in the possibility of rapid desaturation in
the setting of increased demand. One of the earliest signs of physiologic stress in
a child may be an unexplained increase in respiratory rate
C. Infants and young children utilize their abdominal musculature to assist with
respirations. Tight, abdominally-placed straps used to secure children to spine
boards may result in onset of or worsening respiratory distress
D. Circulatory reserves are small. The loss of as little as one unit of blood can
produce severe shock in an infant. Conversely, it is difficult to fluid overload most
children
E. Pediatric medication dosing and equipment size recommendations vary by length
and/or weight. As such, an assessment tool such as a length-based tape should
be utilized on every pediatric patient to guide medication dosing and equipment
size
F. The developmental stage of a child impacts their ability to cooperate and their
fear of strangers. The perception and memory of pain is escalated by anxiety.
Discuss or forewarn of what will be done with any child over 2 years of age.
Infants, especially those under 6 months of age, tolerate painful procedures
better if allowed to suck on a pacifier (especially if dipped in D25W) during the
procedure. Utilize the parent or familiar guardian whenever possible to
distract/comfort (tell a story, sing a song, etc) for all pediatric patients during
painful procedures.
Approved January 23, 2017
Index
143
004p General Guidelines: Transportation of the Pediatric Patient cont.
Specific Considerations:
A. Transportation safety
Children represent a unique challenge for safe transportation in emergency vehicles.
The National Highway Traffic Safety Administration has established guidelines to ensure
the safe restraint and positioning of children in emergency vehicles. Children should
never be transported unrestrained or held in an adult’s arms. Transportation of children
on the side bench seat in the rear compartment is also not recommended. The published
goals are to prevent forward motion/ejection of the child, secure the torso, and protect
the head, neck and spine in each of the following scenarios:
1. For a child who is uninjured/not ill, but requires transport to a facility
If transport in a vehicle other than a ground ambulance is not possible, transport
in a size-appropriate child restraint system in the front passenger seat (with air
bags off) or rear-facing EMS provider’s seat in the ground ambulance
2. For a child who is injured/ill and whose condition does not require
continuous monitoring or interventions:
Transport child in a size-appropriate child restraint system secured appropriately
on a cot (rear-facing) or in an integrated seat in the EMS provider’s seat. Do not
use a rear-facing child restraint system in a rear-facing EMS provider’s seat. If no
child restraint system is available, secure the child on the cot using three
horizontal restraints across the child’s chest, waist and knees and one vertical
restraint across each of the child’s shoulders.
3. For a child whose condition requires continuous or intensive monitoring or
interventions:
Transport child in a size-appropriate child restraint secured appropriately on a
cot. If no child restraint system is available, secure the child on the cot using
three horizontal restraints across the child’s chest, waist and knees and one
vertical restraint across each of the child’s shoulders.
4. For a child whose condition requires spinal immobilization or lying flat
Secure the child to a size-appropriate spineboard and secure the spineboard to
the cot, head first, with a tether at the foot to prevent forward movement. Use
three horizontal restraints across the chest, waist (not abdomen), and knees, and
a vertical restraint across each shoulder. We do not recommend utilizing the child
restraint system if spinal immobilization is required, as upright positioning places
additional axial load on the patient’s neck and emergent airway intervention is not
possible.
5. For a child requiring transport as part of a multiple patient transport
(newborn with mother, multiple children, etc)
If possible, transport each as a single patient. When available resources prevent
single patient transportation, transport patients using safe, designated space
available exercising extreme caution and driving at reduced speeds. For mother
and newborn, the newborn should be transported in a rear-facing EMS provider
seat using a convertible or integrated child restraint system. Do not use a rearfacing child restraint system in a rear-facing EMS provider’s seat.
144
Approved January 23, 2017
Index
004p General Guidelines: Transportation of the Pediatric Patient cont.
B. Transportation of the child with special health care needs
1. Treat the child, not the equipment. Starting with the ABCs still applies to
medically complicated or medical technology-dependent children.
2. The parent/guardian of a special needs child is the expert on that child and
knows the details of that illness, typical responses, and baseline interactions
better than anyone. Utilize and trust his/her knowledge and concerns. This may
include vital signs, medication responses, or physical positioning (ie of contracted
limbs) that may not be typical.
3. Medically complicated children are often given healthcare notes describing their
unique medical history and emergency healthcare needs. Ask the
parent/guardian for an emergency information sheet or emergency healthcare
form
4. Ask the parent/guardian for the “go bag” for medical technology-dependent
children. This will contain the child’s spare equipment and supplies that may be
needed on scene, during transport or in the hospital
5. Transport the child to their medical “home” hospital whenever possible
Approved January 23, 2017
Index
145
100p Pediatric Epistaxis Management
Active Nosebleed
ABCs
Compress nostrils with clamp or
fingers, pinching over fleshy part of
nose, not bony nasal bridge for 10
minutes.
Transport in position of comfort,
usually sitting upright
Tilt Head Forward
Have pt blow nose to expel clots
Spray both nares with ref. phenylephrine
IV access and IV fluid bolus if signs of
ref. hypoperfusion/shock based on age
Approved January 23, 2017
146
Index
105p Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations
In general the primary goals of airway management are adequate oxygenation and
ventilation, and these should be achieved in the least invasive manner possible
Ref. Pediatric Field Guide
 Begin BVM ventilations with OPA and capnography – use two
rescuers
 If no indication for spinal immobilization, place towel roll under
shoulders for pts <8 y.o. to optimize airway positioning
 BVM rate:
o
Neonates 30 - 40/min,
o
Infants 20-30/min
o
Children 12-20/min
Signs of adequate oxygenation / ventilation?
Examples include:
Good CO2 Waveform
Compliance with BVM
Chest rise and fall
Bilateral breath sounds
Positive response to therapy
Yes
Complete assessment
Transport
No
Reposition airway
Ensure adequate mask seal
Reassess airway adjunct
(OPA/NPA/Mask size)
Signs of adequate oxygenation / ventilation?
Examples include:
Good CO2 Waveform
Compliance with BVM
Chest rise and fall
Bilateral breath sounds
Positive response to therapy
Yes
No
Ref FBAO
Yes
Possible FBAO?
No
Able to adequately oxygenate and ventilate with BVM?*
Yes
No
 Ref i-gel O2
 Place i-gel ONLY if unable to adequately
ventilate with BVM and oral airway*
* Ref i-gel O2 in all cases of cardiac arrest.
Approved January 23, 2017
Index
147
110p Pediatric Obstructed Airway: Conscious Patient
Attempt to determine cause of
obstruction
Does patient show signs of choking?
Assess severity of obstruction
Severe or Complete Obstruction
(mute, silent cough, severe stridor)
INFANT (< 1 yr)
 5 Back slaps, 5 Chest thrusts
until object is expelled.
Mild or Partial Obstruction
(patient can speak / cry)
 Do not interfere with a spontaneously breathing
or coughing patient
 Position of comfort
 Give high flow oxygen
 Suction if needed
CHILD (> 1yr)
 Abdominal thrusts until
object expelled.
Is obstruction cleared?
Is obstruction cleared?
No
Yes




No
Yes
Ref. Pediatric Obstructed
Airway: Unconscious
 Supportive care and rapid
transport
 If patient deteriorating or develops
worsening distress proceed as for
complete obstruction
Transport POC
O2 via NRB 15 Lpm
Monitor ABCs, SpO2, vital signs
Suction PRN and be prepared for vomiting, which commonly occurs after obstruction relieved
148
Approved January 23, 2017
Index
Index
111p Pediatric Obstructed Airway: Unconscious Patient
If cause of airway obstruction is readily apparent, attempt removal
 Open airway with head tilt-chin lift
 If no indication for spinal immobilization, place towel roll under
shoulders for pts < 8 y.o. to optimize airway positioning
 Open airway with jaw thrust if craniofacial trauma present / suspected
Ventilate pt with BVM / capnography using two person technique.
Ability to ventilate?
Yes
No
 Perform laryngoscopy
 Use McGill forceps to remove object if possible
Ref. Pediatric Resp. Failure / Arrest
Requiring Assisted Ventilation
Ability to ventilate?
No
Yes
30 Chest compressions
Ref. Pediatric Resp. Failure / Arrest
Requiring Assisted Ventilation
Open pt mouth and remove obstruction if seen.
Open airway and ventilate pt with BVM / capnography
using two person technique.
Ability to ventilate?
Yes
Ref. Pediatric Resp. Failure / Arrest
Requiring Assisted Ventilation
Foreign body seen below
vocal cords
 Use 3.5 or 6.0 ETT to push FB
into right mainstem bronchus
 Withdraw ETT and reattempt to
ventilate using BLS techniques
No
 Perform direct visualization with laryngoscope
Foreign body not seen
Foreign body seen above
vocal cords
 Remove laryngoscope and
reattempt to ventilate using BLS
techniques.
 Use McGill forceps to remove
foreign body
 Reattempt to ventilate using
BLS techniques
Ability to ventilate?
Yes
No
 Transport
 Base Contact for consult
Ref. Pediatric Resp. Failure / Arrest
Requiring Assisted Ventilation
Approved January 23, 2017
Index
149
115p Pediatric Respiratory Distress
For all patients:
While assessing ABCs: ref.O2,
monitor vital signs, cardiac rhythm,
and SpO2
NO
Patent Airway?
Ref. Pediatric Obstructed Airway
YES
Are ventilations adequate for age?
NO
Ref. Pediatric Respiratory Failure/Arrest
YES
Is anaphylaxis likely?
YES
ref. Pediatric Allergy/Anaphylaxis
NO
YES
Is asthma likely?
ref. Pediatric Asthma
NO
YES
Is Croup likely?
ref. Pediatric Croup
NO
Is Bronchiolitis likely?
YES
ref. Pediatric Bronchiolitis
NO
Transport
• Provide supportive care
• Maximize oxygenation and ventilation
• CONTACT BASE if needed for consult
150
Approved January 23, 2017
Index
115p Pediatric Respiratory Distress
General Assessment:
 Attempt to determine cause of respiratory distress based on clinical scenario, age, past history and exam
 Assess Airway, Breathing, perfusion and mental status in all patients
Airway Assessment
 If obstructed, see Obstructed Airway Protocol
 Observe for stridor, hoarseness, drooling
 Consider foreign body if sudden onset stridor in young child
 Early suctioning of secretions may dramatically improve respiratory distress in bronchiolitis
Breathing Assessment
 Note rate and effort (“work of breathing”)
 Listen for upper airway abnormal sounds which may mimic wheezing: stridor, hoarseness, barky cough (suggests
croup)
 Note grunting, nasal flaring, head bobbing, chest wall movement, retractions, accessory muscle use
 Auscultate breath sounds for wheezing, crackles, decreased air movement (suggests bronchospasm)
151
Approved January 23, 2017
Index
120p Pediatric Asthma
Ref. Pediatric Assessment
Respiratory Distress Protocol and prepare for transport
Severe Attack
Grossly abnormal
respiratory rate, loud
wheezes, or so tight no
wheezes are heard, anxiety,
gray or ashen skin color,
diaphoresis
Moderate Attack
Marked increase in
respiratory rate, wheezes
easily heard and accessory
muscle breathing.
ref. Albuterol + ref. Ipratropium
ref. Epinephrine IM
ref. Albuterol + ref. Ipratropium
Adequate response to treatment?
Adequate response to treatment?
Yes
No
Yes
Monitor response to
treatment
Continue cardiac monitoring
and SPO2 en route
Be prepared to assist
ventilations as needed
Transport
Mild Attack
Slight increase in
respiratory rate, mild
wheezes, good skin
color.
No
ref. Epinephrine IM
Adequate response to treatment?
Yes
Monitor response to
treatment
Continue cardiac
monitoring and SPO2
en route
Be prepared to assist
ventilations as
needed
Transport
Concern for impending respiratory failure?
 Worsening mental status
 Pt becoming tired (accessory muscle usage
decreases)
 Ref. Pediatric Respiratory Failure/Arrest
 Start IV / ref. IO
Contact Base
Adequate response to treatment?
Yes
No
ref. Magnesium IV
ref. Methylprednisone IV
152
Approved January 23, 2017
Index
125p Pediatric Croup
Ref. Pediatric Assessment
Respiratory Distress Protocol and prepare for transport
 Transport in position of comfort appropriately secured
 ref.O2





Severe Symptoms?
SpO2 < 90% despite O2
Stridor at rest
Severe retractions
Cyanosis
Altered LOC
No
Monitor SPO2 en route
Be prepared to assist
ventilations as needed
Transport
Yes
 Mushroom tip Nasal suctioning if indicated
 Give nebulized racemic epinephrine
Inadequate response to treatment?
CONTACT BASE for consult
Croup
Age 6 months to 5 years w. stridor, barky cough, URI sx. Sx often rapid, nocturnal onset
Consider pulmonary and non-pulmonary causes of respiratory distress in all cases:
Common: croup, bronchiolitis, asthma.
Less common: foreign body aspiration, allergic reaction, pneumonia.
Rare: epiglottitis, bacterial tracheitis.
Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of
metabolism)
153
Approved January 23, 2017
Index
125p Pediatric Bronchiolitis
Ref. Pediatric Assessment
Respiratory Distress Protocol and prepare for transport
 Transport in position of comfort appropriately secured
 ref.O2




Severe Symptoms?
SpO2 < 90% despite O2
Severe retractions
Cyanosis
Altered LOC
No
Monitor SPO2 en route
Be prepared to assist
ventilations as needed
Transport
Yes
 Mushroom tip Nasal suctioning if indicated
Inadequate response to treatment?
CONTACT BASE for consult
Bronchiolitis
Age < 2 yrs w. cough, fever, resp. distress, copious secretions, November-April
Consider pulmonary and non-pulmonary causes of respiratory distress in all cases:
Common: croup, bronchiolitis, asthma.
Less common: foreign body aspiration, allergic reaction, pneumonia.
Rare: epiglottitis, bacterial tracheitis.
Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism)
154
Approved January 23, 2017
Index
130p Pediatric Allergy and Anaphylaxis




Assess ABCs, ref.O2
If possible, determine likely trigger
Determine PMH, medications, allergies
Classify based on symptom severity and
systems involved
 Other specific protocols may apply: e.g.:
obstructed airway, bites & envenomations
Generalized or Systemic Reaction
Multisystem involvement: skin, lungs, airway, etc
Does patient have any 2 of the
following signs or symptoms of
anaphylaxis?
 Hypotension for age
 Signs of poor perfusion
 Bronchospasm, stridor
 Altered mental status
 Urticaria
No
Localized Reaction
Including isolated tongue, airway
ref. diphenhydramine
Airway involvement?
Tongue or uvula swelling,
stridor
No
Transport and reassess for
signs of deterioration
Yes
Impending airway obstruction?
Yes
Yes
No
Immediately ref. epinephrine
IM & manage airway
ref. Ped respiratory failure
 ref. epinephrine IM, then:
 Start IV Ref. IO and give IV
fluid bolus 20cc/kg NS
 ref. diphenhydramine
 ref. methylprednisolone
 ref. albuterol if wheezing
 Start IV / Ref. IO
 ref. diphenhydramine
 ref. methylprednisolone
 Monitor ABCs, SpO2, cardiac
rhythm
 Reassess for signs of
deterioration
If persistent signs of severe
shock with hypotension not
responsive to IM epinephrine
and fluid bolus:
 Repeat ref. epinephrine IM
 Contact Base
155
Approved January 23, 2017
Index
2000p Pediatric Cardiac Arrest – General Principles
General Guideline:
A. Pediatric cardiac arrest more frequently represents progressive respiratory deterioration
or shock rather than primary cardiac etiologies. Unrecognized deterioration may lead to
bradycardia, agonal breathing, and ultimately asystole. Resulting hypoxic and ischemic
insult to the brain and other vital organs make neurologic recovery extremely unlikely,
even in the doubtful event that the child survives the arrest. Children who respond to
rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of
advanced life support are much more likely to survive neurologically intact. Therefore, it is
essential to recognize the child who is at risk for progressing to cardiopulmonary arrest
and to provide aggressive intervention before asystole occurs
B. Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime
before CPR and duration of CPR
• Past History: medications, medical history, suspicion of ingestion, trauma, environmental
factors (hypothermia, inhalation, asphyxiation)
 Penetrating and Blunt trauma arrest: Ref. Pediatric Trauma Arrest
 Cardiac arrest from the following causes should approached as a medical cardiac arrest:
overdose, respiratory arrest, airway obstruction, asphyxiation, hanging and ref.
Pediatric drowning
Document Specific Objective Findings
A. Unconscious, unresponsive
B. Agonal, or absent respirations
C. Absent pulses
D. Any signs of trauma, blood loss
E. Skin temperature
General Treatment Guidelines
A. Treat according to Pediatric BLS and ALS pulseless arrest algorithms
B. Primary cardiac arrest from ventricular arrhythmia, while less common than in adults,
does occur in children. If history suggests primary cardiac event (e.g.: sudden collapse
during exercise), then rapid defibrillation is most effective treatment
C. Most pediatric pulseless arrest is the result of primary asphyxial event, therefore initial
sequence is chest compressions with ventilations, unlike adult pulseless arrest
D. Call for ALS assistance if not already on scene or responding
156
Approved January 23, 2017
Index
2000p Pediatric Cardiac Arrest General Principles
General Guidelines: Chest Compressions for 2 Rescuers
Newborn (≤ 1 month old)
A. 1 cycle of CPR = 3:1 chest compressions: breaths.
Infant and Child (1 month to 12 years old)
A. 1 cycle of CPR = 15:2 chest compressions: breaths
B. Utilize CPR feedback device “puck” on all patients with a Broselow measurement of Purple
or greater
B. Push hard and fast at a compression rate of 100/minute
C. Minimize interruption to chest compressions
a. Continue CPR while defibrillator is charging, and resume CPR immediately after
all shocks. Do not check pulses except at end of CPR cycle and if rhythm is
organized at rhythm check
b. Increase in compression interruption correlates with decrease in likelihood of
successful defibrillation
D. Ensure full chest recoil
a. Represents diastolic phase for cardiac filling due to negative intrathoracic
pressure
E. Avoid hyperventilation
a. Associated with barotrauma and air trapping
b. Makes CPR less effective by inhibiting cardiac output by increasing intrathoracic
pressure and decreasing venous return to the heart
F. Rotate compressors every 2 minutes during rhythm checks
General Guidelines: Defibrillation
A. First shock delivered at 2 J/kg biphasic
B. All subsequent shocks delivered at 4 J/kg biphasic
General Guidelines: Ventilation during CPR
A. Do not hyperventilate
B. Contrary to adult cardiac arrest, pediatric arrest is much more likely to be from asphyxia.
During this period, blood continues to flow to the tissues causing oxygen
saturation to decrease and carbon dioxide to increase. Pediatric patients need both
prompt ventilation and chest compressions.
C. Hyperventilation decreases effectiveness of CPR and worsens outcome
General Guidelines: Timing Of Placement Of Advanced Airway
A. No intubation for cardiac arrest < age 12
B. i-gel O2 Airway preferred for all patients < 12 years old and should be placed according
to ref. Pediatric Medical Arrest Core Competencies to allow for continuous chest
compressions
C. If advanced airway(i-gel O2) in place, ventilate continuously at 10 breaths/minute
D. If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio
E. Avoid hyperventilation
General Guidelines: Pacing
A. Effectiveness of transcutaneous pediatric pacing has not been established and is not
Recommended
General Guidelines: Transport
A. Outcomes for non-shockable pulseless arrest are improved with timely transport.
Approved January 23, 2017
Index
157
2000p Pediatric Cardiac Arrest General Principles
Special Notes:
Consider reversible causes of cardiac arrest (“Hs And Ts”):
Hypovolemia = IV Fluid bolus
Hypoxia = Ventilation
Hydrogen Ion (acidosis) = Ventilation
Hyperkalemia = Sodium bicarbonate
Hypothermia = See hypothermia protocol
Toxins: e.g.: opioid overdose = Naloxone 2mg IVP
Tamponade (cardiac)
Tension pneumothorax = Needle thoracostomy
Thrombosis (coronary)
Trauma
158
Approved January 23, 2017
Index
2010p Pediatric Pulseless Arrest BLS / AED
Unresponsive and not breathing or
only gasping
Pulse > 60
 Give 1 breath every 3
seconds
 Recheck pulse every 2
minutes
Check pulse (< 10 sec)
Is there a definite pulse?
Pulse < 60
 Infant/child: start CPR
 Age < 12: start CPR if
signs of poor perfusion
 ref. Peds Bradycardia
Definite Pulse
Check Rate
No Pulse
Infant/Child (> 1 month)
Neonate (< 1 month)
Patient > 12 years
 Start CPR cycles in 15:2
 Start CPR cycles in 3:1
 ref. Newborn resuscitation
 Follow adult ref. Asystole / PEA or .
VF / VT algorithm
Apply AED/Defibrillator
 Use pediatric system if available
for ages 1 year to 8 years
Check Rhythm
Shockable rhythm?
Shockable
 Give 1 shock
 Resume CPR immediately
for 2 minutes after shock
 Check rhythm every 2
minutes
Use CPR feedback device “puck” for all patients with
Broselow measurement of purple or greater.
Approved January 23, 2017
Not Shockable
 Resume CPR immediately
for 2 minutes
 Check rhythm every 2
minutes
High quality CPR
 Rate > 100/min
 Compression depth 1 ½ inches in infants, 2 inches in
children
 Allow complete chest recoil after compression
 Minimize interruptions of chest compressions
 Avoid excessive ventilation
159
Index
2020p Pediatric Pulseless Arrest – VF / VT
Start chest compressions
Consider circumstances of arrest:
Witnessed by EMS = immediate rhythm check
Unwitnessed by EMS = 2 minutes CPR
o OPA / NPA / Capnography / BVM
o Attach monitor/defibrillator
Routine medical assessment



VF / VT
Use CPR feedback device
“puck” for all patients with
Broselow measurement of
purple or greater.
SHOCK
2 min CPR
Ref. Pediatric Respiratory Failure / Arrest
ROSC
Rhythm Check
ASYSTOLE/PE
A
VF / VT
DEFIB at Pediatric Field Guide Recommended Joules
2 min CPR
ref. IO / IV
ROSC
A
Rhythm Check
ASYSTOLE/PE
A
VF / VT
DEFIB at Pediatric Field Guide Recommended Joules
2 min CPR
ref. Epinephrine q 4 min
ROSC
Rhythm Check
ASYSTOLE/PE
A
VF / VT
DEFIB at Pediatric Field Guide Recommended Joules
Ref. PediatricROSC
2 min CPR
ref. Amiodarone
Ref. Asystole / PEA
Go To Box “A”
Approved January 23, 2017
After 15 minutes of ALS Care:
Continue resuscitation and Transport
Index
Index
160
2021p Pediatric Pulseless Arrest Asystole / PEA



Start chest compressions
Consider circumstances of arrest:
2 minutes CPR
o OPA / NPA / Capnography / BVM
o Attach monitor/defibrillator
Routine medical assessment
Treat reversible causes
Use CPR feedback device
“puck” for all patients with
Broselow measurement of
purple or greater.
Asystole * / PEA
2 min CPR
Ref. Pediatric Respiratory Failure / Arrest
ROSC
Rhythm Check
VF / VT
Asystole / PEA
2 min CPR
ref. IO / IV
ROSC
A
Rhythm Check
VF / VT
Asystole / PEA
Ref.
PediatricROSC
2 min CPR
ref. Epinephrine q 4 min
Ref. VF / VT
Go To Box “A”
After 15 minutes of ALS Care:
1. Asystole = CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for
consideration of TOR at any point if continuous asystole.
2. PEA = Continue resuscitation and Transport
* Asystole is defined as the absence of any electrical activity and must be observed in two or more
leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the
EMS Operations Captain. The AFR incident number should be included on the strip.
161
Approved January 23, 2017
Index
2020p Pediatric Pulseless Arrest ALS
CPR, Ventilation and Advanced Airway:
• No intubation for cardiac arrest < age 12
• i-gel O2Airway preferred for all patients < 12 years old and should be placed as soon as possible to
allow for continuous chest compressions
• If advanced airway (i-gel O2) in place, ventilate continuously at 10 breaths/minute
• If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio
• Avoid hyperventilation
Shock energy for defibrillation:
• 1st shock 2 J/kg, or Broselow recommendation, subsequent shocks 4 J/kg, or Pediatric Field Guide
recommendation
Family Members
• Family presence during resuscitation is recommended, unless disruptive to resuscitation efforts
Reversible Causes:
Hypovolemia
Hypoxia
H+ (Acidosis)
Hypo/Hyperkalemia
Hypothermia
Tension Pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis: PE,AMI
Index
Approved January 23, 2017
162
2025p Pediatric Return of Spontaneous Circulation
ROSC after Cardiac Arrest
Transport patient to Children’s Hospital Colorado main campus
Reassess ABCs
Obtain baseline vitals
Continuous cardiac monitoring
Recurrent dysrhythmia?
YES
Treat per protocol
Hypotension for age?
Ref. Pediatric Field Guide
Pull
- Push
20ml/kg NS bolus
IV/ IO
Signs
or symptoms
of poor
Reassess
perfusion caused by
bradycardia?
(altered
mental
chest
Repeat 20ml/kg
NS boluses
up tostatus,
40ml/kg
until goal met of:
Threshold
heart
rate
for
age
pain, signs of shock)
Normal Systolic Blood Pressure for age
and
Capillary refill < 2 seconds
163
Approved January 23, 2017
Index
Index
2030p Pediatric Tachyarrhythmia
Routine Medical Assessment
Identify andBradycardia
treat underlying cause
 HR
ref.O2
< 60 and inadequate for clinical
 Monitor ECG: identify rhythm
condition
 Start IV / ref. IO
YES
Search for and treat
underlying cause:
e.g.: dehydration, fever,
hypoxia, hypovolemia, pain
Bradycardia
Probable Sinus Tachycardia
HR < 60 and inadequate for
 Infants: rate usually < 220
clinical
condition
 Children:
rate usually < 180
NO
Persistent tachyarrhythmia
causing:
(Any of the following)
YES
Hypotension for age, altered mental
status or other signs of poor
perfusion
Contact base: Ref.
Synchronized
Cardioversion
NO
Wide QRS?
> 0.09sec
YES
NO
Valsalva maneuver
ref. Adenosine if regular,
narrow complex.
Transport
Monitor for deterioration
Signs of Poor Perfusion:
-Cool, pale extremities
-Prolonged Cap Refill time
(>2 sec)
-Lethargy/ alt mental status
-Hypotension
Approved January 23, 2017
164
Index
2040p Pediatric Bradycardia
Bradycardia
HR < 60 and inadequate for
clinical condition
Maintain airway
Bradycardia
Assist breathing as needed
HR <Ref.
60Oxygen
and inadequate for
Monitor
ECG: identify rhythm
clinical
condition
Start IV / Ref. IO
Signs of Poor Perfusion:
-Cool, pale extremities
-Prolonged Cap Refill time
(>2 sec)
-Lethargy/ alt mental status
-Hypotension
Maintain airway
Persistent bradyarrhythmia causing:
Assist
breathing
as
(Any
of the following)
needed
Hypotension
for age, altered mental
Give oxygen
status or other signs of Poor Perfusion
No
Monitor ECG: identify
rhythm
Start IV
Yes
Poor Perfusion
Adequate Perfusion
Yes
Begin CPR
Monitor and
Transport
No
Monitor and
Transport
Persistent bradycardia?
Yes


Reminders:
 If pulseless arrest develops, ref. VF / VT or
Asystole / PEA algorithm
 Search for possible reversible causes:
“5Hs and 5 Ts”
 Increased Vagal Tone:
-Child has increased ICP not responsive to
Oxygen
-Possible toxic ingestions ie: clonidine,
digoxin, blood pressure medications,
nitro, lithium, nasal spray decongestants
(taken orally)

Ref. epinephrine IV/IO
Ref. atropine IV/IO For increased
vagal tone or primary AV block
For further considerations Contact
Base
Index
Approved January 23, 2017
165
Pediatric Non-Traumatic Pulseless Arrest
Dependent lividity
Or
Rigor mortis
Or
Decomposition
Place patient on cardiac
monitor
Asystole*
Not Asystole
Advanced Directives
indicating DNR
Ref. VF / VT or Asystole / PEA algorithm
CONTACT BASE for
consideration of field
pronouncement
Cardiac arrest from the following causes should
approached as a medical cardiac arrest:
 Overdose
 Respiratory arrest
 Airway obstruction
 Asphyxiation
 Hanging
 Drowning
 Electrocution
 Lightning/high voltage
* Asystole is defined as the absence of any electrical activity and must be observed in two or more
leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to
the EMS Operations Captain. The AFR incident number should be included on the strip.
166
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Index
2200p Newborn Resuscitation (< 24 Hours Old)
Breathing and crying
and
good tone?
Birth
Routine Care:
Warm
Suction airway if necessary
Dry
Ongoing evaluation
Yes
No
Warm, clear airway if
necessary, dry, stimulate
No
30 sec.
HR < 100, gasping or
apnea
Labored breathing or
persistent cyanosis?
No
Yes
Yes
BVM 40 – 60 / min
(30 seconds)
SpO2 monitoring
Clear airway
SpO2 monitoring
60 sec.
No
HR < 100 ?
Supportive care
Yes
BVM 40 – 60 / min
(30 seconds)
SpO2 monitoring
HR < 60 ?
Treat reversible
causes (Hs&Ts)
No
Yes
CPR (1 minute)
Ratio: 3 to 1
Depth: 1/3 depth of chest
Rate: 120 per minute
No
REVERSIBLE CAUSES
Cause
Treatment
Hypovolemia
30mL Saline Bolus
Hypoxia
Ventilation
Hypothermia
Warming
Toxins
CONTACT BASE
Tension Pneumo
Chest Decompression
HR < 60 after 1 minute of CPR?
Yes
ref. Epinephrine
DO NOT USE EZ IO Drill for newborns
Pink EZ IO needle should be placed by hand.
Full Resuscitation
CPR (2 minute cycles)
Ratio: 3 to 1
Depth: 1/3 depth of chest
Rate: 120 per minute
Transport to Children’s
Hospital Colorado
Approved January 23, 2017
Index
167
2200p Newborn Resuscitation
General Considerations
(From 2010 AHA Guidelines)
• Newborn infants who do not require resuscitation can be identified generally based on 3 questions:
• Term gestation?
• Crying or breathing?
• Good muscle tone?
• If answer to all 3 questions is “yes” then baby does not require resuscitation and should be dried,
placed skin-to-skin on mother and covered to keep warm
• If answer to any of 3 questions is “no” then infant should receive 1 or more of following 4 categories
of intervention in sequence:
• Initial steps in stabilization (warm, clear airway, dry, stimulate)
• Ventilation
• Chest compression
• Administration of epinephrine and/or volume expansion
• It should take approx. 60 seconds to complete initial steps
• The decision to progress beyond initial steps is based on an assessment of respirations (apnea,
gasping, labored or unlabored breathing) and heart rate (>/< 100 bpm)
Assisting Ventilations:
• Assist ventilations at rate of 40-60 breaths per minute to maintain HR > 100
Chest compressions:
• Indicated for HR < 60 despite adequate ventilation w. supplemental O2 for 30 seconds
• 2 thumb – encircling hands technique preferred
• Allow chest recoil
• Coordinate with ventilations so not delivered simultaneously
• 3:1 ratio of compressions to ventilations w. exhalation occurring during 1st compression after each
ventilation
168
Approved January 23, 2017
Index
2200p Newborn Considerations
General Considerations:
A. Neonate/Newborn refers to a newly born child under the age of 30 days. While most
neonates transition to post-natal life without difficulty, 10% will require medical assistance.
Respiratory insufficiency is the most common complication observed in the newly born.
B. Neonates born precipitously may exhibit signs of stress such as apnea, grunting respirations,
lethargy or poor tone
1. Provide warmth, bulb suction mouth and then nose, and dry the infant
2. If breathing spontaneously, HR >100 and infant is vigorous, continue to monitor
3. If apneic, cyanotic, lethargic, or HR <100, provide 100% oxygen via BVM
ventilations at a rate of 40-60 bpm
4. If HR < 60, begin CPR at 3:1 compression : ventilation ratio.
C. For neonates who do not respond to initial interventions as above:
1. Obtain blood glucose level and if < 60, administer dextrose IV/IO (D10 5 mL/kg)
2. Administer epinephrine IV for persistent HR < 60
3. Consider hypovolemia and administer 10-20ml/kg NS over 5-10 minutes
D. Neonates with congenital heart disease may not be detected prior to hospital discharge after
delivery. Consider a cardiac cause of shock in the neonate who remains hypoxic or has
persistent cyanosis despite 100% oxygen. These neonates may decompensate precipitously
and fluid administration should be used judiciously (10ml/kg NS)
E. Newborns are at high risk for hypothermia. Provide early warming measures, keep covered
as much as possible (especially the head) and increase the temperature in the ambulance
F. Acrocyanosis (cyanosis of only the hands and feet) is normal in newborns and does not
require intervention
G. Prolonged apnea without bradycardia or cyanosis may indicate respiratory depression
caused by narcotics. However, naloxone should be avoided in infants of a known or
suspected narcotic-addicted mother as this may induce a withdrawal reaction. Respiratory
support alone is recommended
H. Obtain pregnancy history, gestational age of the neonate, pregnancy complications, and any
illicit drug use during pregnancy.
169
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Index
3000p Pediatric Syncope
Specific Information Needed
A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient
sitting, standing, or lying? Pregnant?
B. Past history: medications, diseases, prior syncope
C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache,
palpitations
Specific Objective Findings
A.
B.
C.
D.
Vital signs
Neurological status: level of consciousness, residual neurological deficit
Signs of trauma to the head or mouth or incontinence
Neck stiffness
Treatment
A. Place patient in position of comfort: do not sit patient up prematurely; supine or
lateral positioning if not completely alert
B. Monitor vital signs and level of consciousness closely for changes or recurrence.
C. Establish venous access and administer Normal Saline if indicated.
D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Pediatric
Hypoglycemia
E. If vital signs abnormal for age
1. Ref. Oxygen.
2. Keep patient supine.
3. Establish venous access.
4. Monitor cardiac rhythm (12-lead EKG)
Specific Precautions
A. Syncope is by definition a transient state of unconsciousness from which the patient
has recovered. If the patient is still unconscious, treat as coma. If the patient is
confused, treat according to Pediatric Altered Mental Status.
B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes.
Recumbent position should be sufficient to restore vital signs and level of consciousness
to normal.
C. Syncope that occurs without warning or while in a recumbent position is potentially
serious and often caused by an arrhythmia.
D. Patients with syncope, even though apparently normal, should be transported
170
Approved January 23, 2017
Index
3010p Pediatric Stroke
POSSIBLE STROKE
(Acute onset neurological deficit not
likely due to trauma)
Assess and stabilize ABCs, ref.O2
 ref.O2
 Start IV / ref. IO
Assess Cincinnati Prehospital Stroke Scale
(Presence of single sign sufficient)
Rule out or treat ref. Ped hypoglycemia
 Determine when last KNOWN to be
normal and document specific time
 “At 2:15 PM”, not “1 hour ago”
 Obtain medical history
 Document medications
 Identify family or friend who may assist
with history and decision-making, get
contact info and strongly encourage to
come to ED as they may be needed for
consent for treatments
 Start IV and draw blood
 Document cardiac rhythm
 Ensure full monitoring in place: cardiac,
SpO2
Fully monitor patient and continually
reassess:
 Improvement or worsening of deficit
 Adequacy of ventilation and oxygenation
 Cardiovascular stability
 Transport to Children’s Hospital Main Campus for pts < 12 years old.
 Notify receiving hospital of Stroke Alert
171
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Index
3020p Pediatric Altered Mental Status
Assess ABCs
ref. VF / VT or Asystole / PEA, respiratory distress
or obstructed airway protocol as appropriate.
Persistent AMS?
 Determine character of event
 Consider seizure, syncope
and TIA
 Monitor and transport with
supportive care
No
Yes
Check BGL
BGL < 60 mg/dL or clinical
condition suggests hypoglycemia?
Seizure activity
present?
Yes
ref. Hypoglycemia
protocol
Yes
ref. Seizure protocol
No
Perform rapid neurologic
assessment including LOC
and Cincinnati Prehospital
Stroke Score (CPSS)
Focal neuro deficit or
positive CPSS?
Yes
ref. Stroke protocol
No
Consider other causes of AMS:
ref.
overdose, Shock, heat/cold
emergency, EtOH Intoxication
 During transport:
 ref.O2
 Start IV / ref. IO
 Monitor vital signs, airway, breathing, and ECG.
Approved January 23, 2017
172
3030p Pediatric Seizure




Support ABCs:
ref.O2
Monitor BGL and ref. hypoglycemia
Identify and treat reversible causes (see below)
Actively Seizing?
Yes
No
 If seizure < 5 min medication not necessary
 If seizure > 5 min or recurrent sz, then treat
as follows:
Check pulse and reassess ABCs
Give supplemental oxygen
 Transport and monitor ABCs, vital signs,
and neurological condition
 Complete head to toe assessment
ref. Midazolam via most readily available route
(IN preferred)
Actively Seizing?
No
Common Causes of Seizures








Yes
 Start IV / ref. IO
 ref. Midazolam IV/ IM/ IN. IV preferred
Actively Seizing?
Epilepsy
Febrile seizure
Trauma/NAT
Hypoglycemia
Intracranial hemorrhage
Overdose (TCA)
Meningitis
Stimulant use (cocaine, meth)
No
Yes
CONTACT BASE
173
Approved January 23, 2017
Index
3030p Pediatric Seizure
Seizure Precautions






Ensure airway patency, but do not force anything between teeth. NPA may be useful
Give oxygen
Suction as needed
Protect patient from injury
Check pulse immediately after seizure stops
Keep patient on side
Document:
 Document: Seizure history: onset, time interval, previous seizures, type of seizure
 Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with anticonvulsants,
pregnancy
Approved January 23, 2017
174
Index
3050p Pediatric Alcohol Intoxication
A. Minors that are clinically intoxicated should be transported for evaluation.
a. Parents may wish to take their children home to “sleep it off”. The clinically intoxicated
minor is at risk for adverse outcome and often benefits from evaluation of both
medical and psychosocial concerns.
b. The parent or guardian must speak with the base physician if he or she is refusing
transport of the minor.
175
Approved January 23, 2017
Index
4010p Pediatric Abdominal Pain / Vomiting
Abdominal pain
and/or vomiting




Assess ABCs
ref.O2
Complete set of Vital Signs
Physical exam
Ref. Pediatric Shock as indicated
ref.Ondansetron
ref. Fentanyl
 Monitor and transport
 Frequent reassessment for deterioration and response to treatment
176
Approved January 23, 2017
Index
Index
4020p Pediatric Overdose and Acute Poisoning
PPE and decontaminate when appropriate
ABCs
 ref.O2
 Start IV / ref. IO
 monitor
Need for airway
management?
 ref. Naloxone
 Airway adjuncts and BVM
ventilations as needed
Yes
ref. resp.failure protocol
No
Hypotension?
Yes
ref. dopamine if no
response to 20cc/kg NS
bolus
IV / ref. IO fluid bolus ref.
hypotension/shock protocol
No
Altered mental
status?
Yes
Altered Mental Status
Protocol
 Consider specific
ingestions
No
Known Specific
ingestion?
No
 Monitor
 Transport
Yes
Stimulant
Tricyclic
antidepressant
Organophosphate
or nerve agent
Calcium Channel
Blocker
Tachycardia,
HTN, agitation,
sweating,
psychosis
Wide complex
tachycardia,
seizure
DUMBELS/SLUDGE
syndrome
Bradycardia, heart
block, hypotension
CONTACT BASE
ref. Sodium
bicarb
ref.Atropine
20 cc/kg NS bolus
Ref. Seizure
ref.Nerve Agent
Antidote Kit
ß-Blocker
Bradycardia, heart
block, hypotension
20 cc/kg NS bolus
ref.Dopamine
ref. Calcium and
ref.dopamine
ref.Glucagon
ref.Glucagon
177
Approved January 23, 2017
Index
4025p Pediatric Hypoglycemia
Check blood glucose level in ANY patient with signs or
symptoms consistent with hypoglycemia
Examples:
Altered MS, agitation, focal neurologic deficit, seizure,
weakness, diaphoresis, decreased motor tone, pallor
If hypoglycemia still most likely
despite normal reading on
glucometer, administer sugar
while considering other causes
of ref. altered mental status
No
Is BGL < 60?
Yes
Can the patient safely tolerate
oral glucose?
intact gag reflex, follows verbal
commands
Yes
ref. Oral Glucose
Reassess patient
No
ref. Glugacon IM
ref. IO
No
Are you able to establish IV
access?
Yes
Still symptomatic?
No
Yes
ref. dextrose IV & reassess patient
Symptoms resolved?
No
Recheck BGL and
consider other causes of
altered mental status
Yes
Monitor and transport or CONTACT
BASE for refusal
178
Approved January 23, 2017
Index
4031p Pediatric Adrenal Insufficiency
Patient at risk for adrenal insufficiency:

Identified by family or medical alert bracelet

Chronic steroid use

Congenital Adrenal Hyperplasia

Addison’s disease
Assess for signs of acute adrenal crisis:

Pallor, weakness, lethargy

Vomiting, abdominal pain

Hypotension, shock

Congestive heart failure
All symptomatic patients:

Check blood glucose and treat hypoglycemia, if
present

Start IV / ref. IO / ref.O2

Give NS bolus IV 20 cc/kg up to 1 liter
Does patient have hypotension and signs of poor perfusion?

Altered mental status

Tachycardia

Cool, clammy skin
Yes
No
Ref.
Methylprednisolone



20 cc/kg NS bolus, as needed
Continue to monitor for development of
Hypoglycemia
If otherwise considering administration of
corticosteroid, CONTACT BASE for consult.
Monitor 12 lead ECG q 5 min for signs of hyperkalemia
179
Approved January 23, 2017
Index
4031p Pediatric Adrenal Insufficiency
Notes:
If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or chronic use of
systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the
administration of steroids may be life-saving and necessary for reversing shock or preventing
cardiovascular collapse.
• Patients at risk for adrenal insufficiency may develop Addisonian crisis when under physiologic
stress which would not lead to cardiovascular collapse in normal patients. Such triggers may include
trauma, dehydration, infection, myocardial ischemia, etc.
• If no corticosteroid is available during transport, notify receiving hospital of need for immediate
corticosteroid upon arrival.
180
Approved January 23, 2017
Index
4040p Pediatric Drowning
ABCs
Ref. Spinal Immobilization before
moving patient if trauma suspected
Assess mental status
Awake and alert
Awake but altered LOC
 Remove wet garments, dry
and insulate patient
 Transport, even if initial
assessment normal
 Monitor ABC, VS, mental
status
 Remove wet garments, dry and
insulate patient
 Suction as needed
 Start IV, ref. IO, check BGL, ref.O2
 Transport
 Monitor ABC, VS, mental status
Comatose or unresponsive
Pulse Present?
No
Yes
 Monitor cardiac rhythm

Start CPR, attach AED/monitor/defibrillator
and treat per Pediatric ref. VF / VT or
Asystole / PEA algorithm If suspected
hypothermia ref. Hypothermia
 Remove wet garments, dry and
insulate patient
 Heimlich maneuver NOT indicated
 Consider all causes of Altered
Mental Status
 Suction as needed
 Start IV, obtain BGL and give
oxygen
 Monitor ABC, VS, mental status
 Monitor cardiac rhythm
181
Approved January 23, 2017
Index
4050p Pediatric Hypothermia
Hypothermia
and Frostbite
Systemic hypothermia
Presumed to be primary problem
based on clinical scenario
Localized cold injury
Frostbite, frostnip
 Remove wet garments,
dry and insulate patient
 Transport, even if initial
assessment normal
 Monitor ABC, VS, mental
status
 Dress injured area lightly
in clean cloth to protect
from further injury
 Do not rub, do not break
blisters
 Do not allow injured part
to refreeze. Repeated
thaw freeze cycles are
especially harmful
 Monitor for signs of
systemic hypothermia
 High flow O2
 ABCs
Comatose or unresponsive
Awake but altered LOC
 Remove wet
garments, dry and
insulate patient
 Suction as needed
 Start IV, ref. IO, BGL,
oxygen
 Transport
 Monitor ABC, VS,
 Monitor
cardiac
mental status
rhythm
Start CPR, attach AED/monitor/defibrillator and treat ref. VF / VT or
Asystole / PEA algorithm with following changes:
Pulse Present?
No
Yes
 Remove wet garments, dry and
insulate patient
 ref. Altered Mental Status
 Suction as needed
 Start IV, check BGL and give
oxygen
 Transport
 Monitor ABC, VS, mental status
 ref. Resp Failure
 Monitor cardiac rhythm
PEA
 Handle very gently
 Start IV w. warm IVF
 Insulate patient
Asystole or V-fib/VT
 Single dose ref. Epinephrine
IV/IO
 For Vfib/VT: single attempt
defibrillation only
 ref. Resp Failure
 Monitor cardiac rhythm
182
Approved January 23, 2017
Index
4060p Pediatric Hyperthermia
Hyperthermia
 Classify by clinical syndrome
 Consider non-environmental
causes (see below)
Heat Exhaustion
Heat Cramps
 Normal or slightly
elevated body
temperature
 Warm, moist skin
 Generalized weakness
 Diffuse muscle cramping







Heat Stroke
Elevated body temperature
Cool, diaphoretic skin
Generalized weakness
Anxiety
Headache
Tachypnea
Possible syncope






Very high core body temperature
Hot, dry skin w. cessation of sweating
Hypotension
Altered mental status
Seizure
Coma
Immediate Transport indicated
20cc/kg bolus NS
Adequate airway
and breathing?
Monitor VS and transport
No
Yes
Ref. respiratory failure
Start IV. ref. IO, ref.O2,
20cc/kg bolus NS unless signs of
volume overload
 Remove excess clothing
 For heat stroke, consider external cooling
measures if prolonged transport
 ref. seizures, cardiac arrhythmias per
protocol
 Monitor and transport
183
Approved January 23, 2017
Index
Index
4070p Pediatric Insect/Arachnid Bite and Stings Protocol
Initiate general care for bites
and stings
Assess for localized vs. systemic
signs and symptoms and depending
on animal involved
Localized
Symptoms:
 Pain, warmth
and swelling
Systemic Symptoms:
 Hives, generalized
erythema, swelling,
angioedema
 Hypotension
 Altered mental status
 Other signs of shock
ref. Fentanyl for black widow spider
and /or
ref. diphenhydramine if needed for itching
 ref.O2
 Start IV. ref. IO
ref. allergy & anaphylaxis
protocol
Approved January 23, 2017
184
4080p Pediatric Snake Bite
Assess ABCs, mental status
ref.O2
Start IV, ref. IO
Monitor Vital signs
Remove patient from proximity to snake
Remove all constricting items from bitten limb (e.g.: rings,
jewelry, watch, etc.)
Immobilize bitten part
Initiate prompt transport
• Do NOT use ice, refrigerants, tourniquets,
scalpels or suction devices
• Mark margins of erythema and/or edema with
pen
or marker and include time measured.
Transport
Assess for localized vs.
systemic signs and symptoms
Systemic Symptoms:
• Metallic or peculiar taste
in mouth
• Hypotension
• Altered mental status
• Widespread bleeding
• Other signs of shock
Localized Symptoms:
• Pain and swelling
• Numbness, tingling to bitten
part
• Bruising/ecchymosis
Immobilize bitten part
Monitor pt and ref. Respiratory Distress
as indicated
ref. Fentanyl
ref. Hypotension/Shock as indicated
185
Approved January 23, 2017
Index
4090p Pediatric Apparent Life Threatening Event (ALTE)
DEFINITION:
An infant < 1 year of age with episode frightening
to the observer characterized by apnea,
choking/gagging, color change or change in muscle
tone
Support ABCs as necessary
Obtain detailed history of event and
medical history
Complete head-to-toe assessment
Regardless of the infant’s appearance at the time of EMS assessment,
the history of an apparent life-threatening event (ALTE) must always
result in:
A. Ambulance transport to an emergency department
OR
B. Base contact to consult with ER physician to discuss
leaving patient on scene Against Medical Advice.
186
Approved January 23, 2017
Index
4090p Pediatric Apparent Life Threatening Event (ALTE)
Clinical history to obtain from observer of event:





Document observer’s impression of the infant’s color, respirations and muscle tone
For example, was the child apneic, or cyanotic or limp during event?
Was there seizure-like activity noted?
Was any resuscitation attempted or required, or did event resolve spontaneously?
How long did the event last?
Past Medical History:





Recent trauma, infection (e.g. fever, cough)
History of GERD
History of Congenital Heart Disease
History of Seizures
Medication history
Examination/Assessment






Head to toe exam for trauma, bruising, or skin lesions
Check anterior fontanelle: is it bulging, flat or sunken?
Pupillary exam
Respiratory exam for rate, pattern, work of breathing and lung sounds
Cardiovascular exam for murmurs and symmetry of brachial and femoral pulses
Neuro exam for level of consciousness, responsiveness and any focal weakness
187
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Index
4095p Care Of the Child with Special Needs
General Guideline:
A. Children with special health care needs include those with chronic physical, developmental,
behavioral or emotional health issues. These children often have complex medical needs and
may be technology-dependent. Parents or caregivers for such children can be a wealth of
knowledge about their child’s care and may carry a reference care sheet. CONTACT BASE
(AIP, Children’s TMCA, CMP, SaddleRock) for any concerns.
Feeding Tubes:
A. Feedings tubes are used for administration of medications and to provide feeds to children
with an impaired ability to take oral feeds. Always ask caretaker the type of feeding tube
(does the tube end in the stomach or jejunum?) and when it was placed
B. Tubes may be placed through the nose, mouth or abdomen and end in the stomach or
jejunum (upper intestine)
C. Consider venting and/or gently aspirating the feeding tube in a child with respiratory or
abdominal distress to allow removal of gastric contents and decompression
D. Feeding tubes that have been placed less than 6 weeks ago are not well established and may
close within 1 hour of tube removal. If transport time is prolonged, place an 8 Fr suction
catheter tube 2 inches into the stoma to maintain patency. Do NOT use the tube.
Tracheostomy:
A. A tracheostomy is a surgical opening between the trachea and the anterior surface of the
neck. Its purpose is to bypass the upper airway for chronically ventilated patients, upper
airway obstructions, or to facilitate secretion removal in those with ineffective gag or
swallow reflexes.
B. Use bag-valve attached to the tracheostomy to assist ventilations if needed. May also attempt
BVM with gloved finger over the tracheostomy
C. Inability to ventilate and/or signs of respiratory distress (nasal flaring, retractions, hypoxia,
etc) may indicate tracheostomy obstruction. Suction tracheostomy, passing the suction
catheter no further than 6 cm. Limit suctioning time to minimum amount of time necessary
to accomplish effective suctioning. Oxygenate between passes with the suction catheter.
D. 0.5ml of saline may be instilled into the tracheostomy to assist suctioning of thick secretions
E. If unable to ventilate through the tracheostomy tube and patient is apneic, bradycardic, or in
pulseless arrest, remove tracheostomy tube and pass an appropriately sized endotracheal
tube through the stoma approximately 1-2 inches, secure and ventilate. Appropriate depth
must be based upon breath sounds, as right mainstem intubation is likely.
F. Remember that caregivers are often the best people to change and suction a tracheostomy
tube. Use them as your resource when possible.
Central Venous Catheters (CVCs):
A. Because of their size and location, a much greater risk of serious bacterial infections exist
with CVCs compared to peripheral intravenous lines. Special care must be used when
accessing such lines
B. Prior to accessing a CVC, hands should be washed and gloves worn. Vigorously scrub the CVC
hub with an alcohol swab. While alcohol possesses some antimicrobial properties, the
friction produced by scrubbing is the most effective
C. A port is an implanted venous central venous catheter (below the surface of the skin). These
devices require a non-coring (e.g. Huber) needle for accessing and should not be accessed in
the field
Approved January 23, 2017
188
Index
5000p Pediatric Psychiatric / Behavioral Emergency
Scene Safety
A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a
concern.
Specific Information Needed
A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol,
emotional trauma, and suicidal or homicidal ideation.
B. Obtain past history; inquire about previous psychiatric and medical problems, medications.
Treatment
A. Attempt to establish rapport
B. Assess ABCs
C. Transport to closest Emergency Department.
D. Be alert for possible elopement.
E. Consider organic causes of abnormal behavior (trauma, overdose, intoxication, hypoglycemia)
F. Check blood sugar ref. Hypoglycemia
G. If altered mental status or unstable vital signs:
1. Ref. Oxygen.
2. Establish venous access.
3. Refer to Altered Mental Status Protocol.
Approved January 23, 2017
Index
189
7000p Pediatric General Trauma Care




BSI
Scene safety
Consider mechanism
Consider need for additional
resources






General impression
ABCs and LOC
Rapid Trauma Assessment
Ref. Traumatic Pulseless Arrest
Prepare for immediate transport
SAMPLE history




Give high flow oxygen
ref. Resp Distress as indicated
ref. Resp Failure as indicated
Spinal immobilization if indicated
Control exsanguinating hemorrhage:
 Direct pressure
 ref. Tourniquet protocol if indicated
 Pelvic stabilization if indicated
Assess disability and limitation:
 Brief neuro assessment
 Ref. Extremity splinting if indicated
 Transport to closest appropriate facility
 Large bore IV, 2nd if unstable. ref. IO
 Consider fluid bolus 20cc/kg if unstable or
suspected significant injuries. ref. Shock
 Monitor vital signs, ABCs, neuro status, GCS
 Ref. Fentanyl
190
Approved January 23, 2017
Index
7010p Pediatric Special Trauma Scenarios
ref. General Trauma
Care
Sexual Assault
Abuse/neglect
Confine history to
pertinent medical needs
Observe pt’s behavior
around caregivers
Watch out for:
 Injury inconsistent with
stated mechanism
 Delayed treatment
 Spreading blame
 Conflicting stories
 Prior/ healing injuries
Respect patient’s
emotional needs
Don’t judge, accuse or
confront victim
Don’t judge, accuse or
confront victim or
suspected assailant
Protect evidence:
No washing or changing
clothes
Transport patient if
suspected abuse or
neglect, no matter how
minor the injury may
appear.
Transport
Notify Aurora Police Department
of all suspected abuse / assault
Request APD officer to respond
to receiving facility if not on
scene prior to patient transport.
191
Approved January 23, 2017
Index
7015p Pediatric Traumatic Pulseless Arrest
7015p Pediatric Traumatic Pulseless Arrest
CPR until cardiac monitor applied
Place pt on Cardiac Monitor1
Asystole*?
No
Yes
CONTACT BASE for
consideration of Field
Pronouncement
 Immediate transport to closest appropriate
trauma center
 Control life threatening external bleeding
 Continue chest compressions and ventilations
as per AFR Pediatric Field Guide
 Ref. LMA
Ref. bilateral needle thoracostomy on all
traumatic arrests with trauma to trunk
1Load
and go is always a reasonable
approach to penetrating trauma arrest.
IV. ref. IO access with NS bolus enroute
Cardiac arrest from the following causes
should be approached as a medical cardiac
arrest:
 Overdose
 Respiratory arrest
 Airway obstruction
 Asphyxiation
 Hanging
 Drowning
 Electrocution
 Lightning/high voltage
Traumatic pulseless arrest is a unique
situation.
Do not apply “combo pads”
Do Monitor
not defibrillate
cardiac
Do not administer
ACLS medications
rhythm
Do not treat as medical arrest
* Asystole is defined as the absence of any electrical activity and must be observed in two or
more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be
sent to the EMS Operations Captain. Include the AFR incident number on the strip.
Approved January 23, 2017
192
Index
7020p Pediatric Traumatic Shock
Trauma w. suspected
serious injury and/or
signs of shock
ref. General Trauma Care
Pelvic sheet if indicated
 Administer
oxygen
 Large bore IV
 2nd IV preferred
 ref. IO
Hypotension for age?
Yes
Ref. Intraosseous Access
Pull / Push 20 cc/kg NS Bolus
No
Evaluate breath
sounds, respiratory
effort, and consider
tension pneumothorax
x
 Treat en route
 Keep patient warm
Repeat Pull / Push
NS bolus 20 cc/kg
Reassess
ref. needle thoracostomy if
arrest or impending arrest
Monitor:
 ABCs, VS, mental
status
 Rapid transport to
appropriate trauma
center
Monitor cardiac rhythm
193
Approved January 23, 2017
Index
7025p Pediatric Amputations
ref. General Trauma Care
Bleeding Controlled
Uncontrolled Bleeding
Control with direct pressure to
bleeding area or vessel
 Large bore IV. ref. IO
 If hypotensive, ref. Shock
 Document neurovascular exam
If bleeding not controlled with direct
pressure, ref. Tourniquet
Partial / NearAmputation
Complete Amputation
Amputated part:




 Cover with moist sterile dressing
 Splint near-amputated part in
anatomic position
Wrap in moist, sterile dressing
Place in sealed plastic bag
Place bag in ice water
Do not freeze part
Stump:
 Cover with moist sterile dressing
covered by dry dressing
ref. fentanyl
 Monitor and transport to appropriate
Trauma Center
 Treat other injuries per protocol
Approved January 23, 2017
194
Index
7029p Pediatric Head Trauma
ref. General Trauma Care
 ref. Oxygen
 ref. Pediatric Spinal Immobilization as indicated
 ref. Pediatric Seizure as indicated
ref. Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated
Hypotension for age and / or definite signs of shock?
Yes
No
 Rapid Trauma Assessment
 Treat other injuries per protocol
 Watch for status changes
Ref. Pediatric Traumatic Shock
GCS < 8?
Yes
0
Head of bed should be elevated 30 unless hypotensive for age.
No
 IV Access
 Monitor cardiac rhythm
 Transport to Children’s Hospital Main Campus for pts < 12 years old.
 Continue to monitor for developing hypoxemia and shock
Cushing’s Triad is a sign of increased intracranial pressure and consists of:

Hypertension (often with a widening pulse pressure)

Bradycardia

Irregular respirations
195
Approved January 23, 2017
Index
7030p Pediatric Face and Neck Trauma
ref. General Trauma Care





Clear airway
Rapid trauma assessment
ref. Spinal immobilization
ref. Resp Distress as indicated
ref. Resp Failure as indicated
Laryngeal
trauma*
Yes
Transport
No
Severe airway
Bleeding?
Yes
Direct pressure
if appropriate
No





Complete neuro exam
Asses for subcutaneous air
Cover/protect eyes as indicated
Do not try to block drainage from ears, nose
Save avulsed teeth in saline-soaked gauze, do not
scrub clean
 Transport ASAP to closest
appropriate facility
 IV access en route. ref. IO
 Treat other injuries per protocol
 Suction airway as needed
ref. Fentanyl
 Monitor ABCs, VS, mental status, SpO2
Approved January 23, 2017
196
Index
Index
7035p Pediatric Spinal Trauma
ref. General Trauma Care
 Full spinal immobilization if
suspected spine injury
 Document neuro assessments
before and after immobilization
Rapid transport to appropriate Trauma Center
If vital signs abnormal for age ref. Shock
Large bore IV and consider 2nd line
ref. IO
 Complete patient assessment
 Treat other injuries per protocol
 Monitor for status changes
ref. Fentanyl
Monitor ABCs, VS, mental status, SpO2.
Approved January 23, 2017
197
7040p Pediatric Spinal Immobilization Considerations
Spinal Immobilization
A. Context/Special Considerations:
B. 60-80% of spine injuries in children occur at the cervical level
C. Children < 8 age year are more likely to sustain high C1-C3 injuries
D. Less force is required to injure the cervical spine in children than adults
E. Children with Down Syndrome are at risk for cervical spine injury
F. Avoid strapping abdomen- children are abdominal breathers
G. Use age/size appropriate immobilization devices
H. Proper immobilization of pediatric patients should prevent:
1. Flexion/extension, rotation, lateral bending or axial loading of the neck
(car seats do not prevent axial loading and are not considered proper
immobilization technique)
2. Non-neutral alignment or alteration in normal curves of the spine for age
(consider the large occiput)
3. Twisting, sliding or bending of the body during transport or care
Spinal Immobilization criteria:
A. Be conservative. Children are difficult to assess and “clinical clearance” criteria
are not well established, as in adults
B. Immobilize the following patients as well as any child you suspect clinically may
have a spine injury:
1.
2.
3.
4.
5.
6.
7.
8.
Mechanisms of injury that imply potential need for spinal stabilization and for
whom stabilization should be considered include but are not limited to:
 MVC/MCC/Bicycle/Equestrian Accident
 Diving / Axial Load
 Fall > 3 feet
Altered Mental Status (GCS < 15, AVPU < A, or intoxication)
Barrier to evaluate for spinal injury (e.g. language or development barrier)
Focal neurologic findings (paresthesias, loss of sensation, weakness)
Non-ambulatory patient
Any complaint of neck pain
Torticollis (limited range of motion, difficulty moving neck in history or
physical)
Substantial torso Injury (thorax, abdomen, pelvis)
Approved January 23, 2017
198
Index
7045p Pediatric Chest Trauma
 ref. General Trauma Care
 Rapid Transport to closest appropriate
Trauma Center
No
Airway management and
assisted ventilations as
indicated
Are you able to oxygenate and
ventilate effectively?
ref. needle thoracostomy
Yes
Penetrating
trauma?
Yes
Occlusive
dressings for
sucking wounds
Rapid transport &
stabilize in route
No
Large bore IV and consider 2nd line
ref. IO
Flail Chest?
Yes
Assess for need for
assisted ventilations
Splint with
bulky dressing
ref. Resp Distress as indicated
ref. Resp Failure as indicated
No
Vital signs
abnormal for age?
Yes
ref. shock enroute
No
ref. Fentanyl
Monitor ABCs, VS, mental status, SpO2.
Index
Approved January 23, 2017
199
7050p Pediatric Abdominal Trauma
 ref. General Trauma Care
 Rapid transport to closest appropriate Trauma
Center



IV access
Consider 2nd line if
MOI significant
ref. IO
Yes
Cover wounds, viscera with saline
moistened gauze dressing
Penetrating trauma?
Do not attempt to repack exposed
viscera
No
Vital signs abnormal
for age?
Yes
ref. Shock
No
ref. Fentanyl
Monitor ABCs, VS, mental status, SpO2.
Index
Approved January 23, 2017
200
7055p Pediatric Burns
 ref. General Trauma Care
 Transport to Trauma Center
Stop burning process:
 Remove clothes if not adhered
to patient’s skin
 Flood with water only if
flames/smoldering present
Respiratory
Distress?
Yes
 O2 NRB 15 lpm
 ref. Resp Distress as indicated
 ref. Resp Failure as indicated
No
Evaluate degree and body surface
area involved
Critical Burn?*
Yes
 Start 2 large-bore IVs
 20 cc/kg NS bolus
 ref. IO
No
IV NS TKO
 Remove rings, jewelry, constricting
items
 Dress burns with dry sterile
dressings
 Treat other injuries per protocol
 Cover patient to keep warm
ref, Fentanyl
Monitor ABCs, VS, mental status, SpO2
*Critical Burn:
 2º > 30% BSA
 3º > 10% BSA
 Respiratory injury, facial burn
 Associated injuries, electrical or deep chemical burns, underling PMH (cardiac, DM), age < 10
Approved January 23, 2017
Index
201
ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)
Description
Albuterol is a selective ß-2 adrenergic receptor agonist. It is a bronchodilator and positive
chronotrope.
Onset & Duration
 Onset: 5-15 min. after inhalation
 Duration: 3-4 hours after inhalation
Indications
 Bronchospasm secondary to asthma, COPD or allergic reaction
Contraindications
 Severe tachycardia is a relative contraindication
Adverse Reactions
 Tachycardia
 Palpitations
 Dysrhythmias
Drug Interactions
 Sympathomimetics may exacerbate adverse cardiovascular effects.
 ß-blockers may antagonize albuterol.
How Supplied
Pre-diluted nebulized solution: 2.5 mg in 3 ml NS (0.083%)
Dosage and Administration
Asthma
Adult:
Dose
Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow
rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes. May be repeated twice
(total of 3 doses).
Pediatric:
Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8
lpm) that will deliver the solution over 5-15 minutes. May be repeated twice during
transport (total of 3 doses).
Protocol
 Adult Asthma
 Adult COPD
 Pediatric Respiratory Distress
 Adult Allergy and Anaphylaxis
 Pediatric Asthma
 Pediatric Allergy and Anaphylaxis
Special Considerations
 Consider inline nebs for patients requiring endotracheal intubation or CPAP.
 May precipitate angina pectoris and dysrhythmias
 Should be used with caution in patients with suspected or known coronary disease,
diabetes mellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder
 Wheezing associated with anaphylaxis should first be treated with epinephrine IM.
Index
Approved January 23, 2017
202
ADENOSINE (ADENOCARD)
Description
Adenosine transiently blocks conduction through the AV node thereby terminating reentrant
tachycardias involving the AV node. It is the drug of choice for AV nodal reentrant
tachycardia (AVNRT, often referred to as “PSVT”). It will not terminate dysrhythmias that do
not involve the AV node as a reentrant limb (e.g. atrial fibrillation).
Onset & Duration
 Onset: almost immediate
 Duration: 10 sec
Indications
 Stable, narrow-complex supraventricular tachyarrhythmia (suspected AVNRT)
Contraindications
 Any irregular tachycardia. Specifically never administer to an irregular wide-complex
tachycardia, which may be lethal
 Post cardiac transplant patients should not receive adenosine
Adverse Reactions
 Chest pain
 Shortness of breath
 Diaphoresis
 Palpitations
 Lightheadedness
Drug Interactions
 Methylxanthines (e.g. caffeine) antagonize adenosine, a higher dose may be required
 Dipyridamole (persantine) potentiates the effect of adenosine; reduction of adenosine dose
may be required
 Carbamazepine may potentiate the AV-nodal blocking effect of adenosine
Dosage and Administration
Adult:
12 mg IV bolus, rapidly, followed by a normal saline flush. May repeat x 1. Total of 2
doses.
For further considerations CONTACT BASE (AIP, Children’s, TMCA, CMP,
SaddleRock)
Pediatric: Reference Pediatric Field Guide
0.2 mg/kg IV bolus, Maximum single dose of 12mg, rapidly followed by normal saline
flush. May repeat x 1. Total of 2 doses
For further considerations CONTACT BASE (AIP, Children’s, TMCA, CMP,
SaddleRock)
Approved January 23, 2017
203
Index
ADENOSINE (ADENOCARD) cont.
Protocol
 Adult Tachyarrhythmia
 Pediatric Tacharrhythmia
Special Considerations
 Reliably causes short lived but very unpleasant chest discomfort. Always warn your patient
of this before giving medication and explain that it will be a very brief sensation
 May produce bronchospasm in patients with asthma
 Transient asystole and AV blocks are common at the time of cardioversion
 Adenosine is not effective in atrial flutter or fibrillation
 Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome if the
rhythm is regular and QRS complex is narrow
 A 12-lead EKG should be performed and documented
 Adenosine requires continuous EKG monitoring throughout administration
 Print continuous EKG while administering adenosine and deliver to attending physician.
204
Approved January 23, 2017
Index
AMIODARONE (CORDARONE)
Description
Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset.
The dominant effect is prolongation of the action potential duration and the refractory
period.
Indications
 Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and
defibrillation
 Stable, wide complex tachycardia BASE CONTACT REQUIRED (AIP, Children’s,
TMCA, CMP, SaddleRock)
Precautions
 Wide complex irregular tachycardia
 Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose
 NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms
Contraindications
 Hypotension
Adverse Reactions
 Severe hypotension
 Bradycardia
Dosage and Administration
Adult: Max dose 450mg
Pulseless Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine,
and defibrillation
Arrest (Refractory VT/VF)
Initial 300 mg IV/IO bolus.
Additional 150 mg IV/IO bolus in 4 minutes if pt continues to have VF/VT
Wide Complex tachycardia with adequate perfusion
CONTACT BASE REQUIRED for order (AIP, Children’s, TMCA, CMP, SaddleRock)
150 mg slow push
Pediatric: Reference Pediatric Field Guide
Pulseless Arrest (Refractory VT/VF) Cardiac arrest in patients who continue to have
VF/VT after CPR, 2 doses of epinephrine, and defibrillation
5mg/kg IV/IO slow push. For additional doses CONTACT BASE (AIP, Children’s,
TMCA, CMP, SaddleRock).
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Pulseless Arrest Algorithm Asystole / PEA
 Pediatric Pulseless Arrest VF / VT
 Pediatric Pulseless Arrest Asystole / PEA
 Adult Tachycardia
Special Considerations
 A 12-lead EKG should be performed and documented.
Approved January 23, 2017
205
Index
ASPIRIN (ASA)
Description
Aspirin inhibits platelet aggregation and blood clotting and is indicated for treatment of
acute coronary syndrome in which platelet aggregation is a major component of the
pathophysiology. It is also an analgesic and antipyretic
Indications
 Suspected acute coronary syndrome. (chest pain, diaphoresis, dyspnea, etc)
Contraindications
 Active gastrointestinal bleeding
 Aspirin allergy
How Supplied
Chewable tablets 81mg
Dosage and Administration
 324mg PO
Protocol
 Adult Chest Pain
Special Considerations
 Patients with suspected acute coronary syndrome taking warfarin (Coumadin) or
clopidogrel (Plavix) may still be given aspirin
Approved January 23, 2017
206
Index
ATROPINE SULFATE
Description
Atropine is an endogenous antimuscarinic, anticholinergic substance. It is the prototypical
anticholinergic medication with the following effects:
 Increased heart rate and AV node conduction
 Decreased GI motility
 Urinary retention
 Pupillary dilation (mydriasis)
 Decreased sweat, tear and saliva production (dry skin, dry eyes, dry mouth)
Indications
 Adult Bradycardia with poor perfusion including:
o 2nd and 3rd degree heart block
 Organophosphate poisoning
 Pediatric Bradycardia with Poor Perfusion associated with increased vagal tone or
Primary AV Block
Precautions
 Should not be used without medical control direction for stable bradycardias
 Closed angle glaucoma
Adverse Reactions
 Anticholinergic toxidrome in overdose, think “blind as a bat, mad as a hatter, dry as a
bone, red as a beet”
Dosage and Administration
Adult Bradycardia with Poor Perfusion
Adult:
Initial dose of 0.5 mg IV / IO bolus.
Additional dose of 1.0 mg IV / IO bolus if needed at 4 minute interval, May repeat x 1.
Total of 2.5mg
(Stop at ventricular rate which provides adequate mentation and blood pressure)
Pediatric Bradycardia with Poor perfusion associated with increased vagal tone or
primary AV Block
Reference Pediatric Field Guide
0.02mg/kg, IV/IO bolus.
Minimum dose 0.1mg
Maximum single dose is 0.5mg
Maximum total dose 1.0mg
Poisoning/Overdose
For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)
Protocol
 Adult Bradycardia
 Pediatric Bradycardia
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
Approved January 23, 2017
Index
207
CALCIUM GLUCONATE
Description
 Cardioprotective agent in hyperkalemia.
 10% calcium gluconate solution contains 1 g calcium gluconate per 10 mL, which is only
90mg of elemental calcium.
 Doses below refer to dose of calcium gluconate solution, not elemental calcium.
 Calcium chloride contains 3 times the concentration of elemental calcium compared to
calcium gluconate.
 If calcium gluconate not available, calcium chloride is an acceptable substitution.
Indications
 Not indicated for routine treatment of pulseless arrest
 Adult Pulseless arrest associated with any of the following clinical conditions:
o Known hyperkalemia
o Renal failure with or without hemodialysis history
o Calcium channel blocker overdose
 Calcium channel blocker overdose with bradycardia and hypotension/shock
Contraindications
 Known hypercalcemia
 Suspected digoxin toxicity (i.e. digoxin overdose)
Precautions
 Must flush IV / IO or give in separate line from Sodium bicarb to prevent
precipitation/formation of calcium carbonate
 Extravasation may cause tissue necrosis
 In setting of digoxin toxicity, may worsen cardiovascular function
Dosage and Administration
Adult:
 Pulseless arrest assumed due to hyperkalemia:
o To be administered before Sodium Bicarbonate
 Must flush IV/IO line between meds.
o 1 g slow IV / IO push (10 mL of a 10% solution).
 Calcium channel blocker overdose with bradycardia and hypotension/shock:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 1 g
slow IV / IO push over 2-3 minutes. Dose may be repeated every 10 minutes for
total of 3 doses (10 mL of a 10% solution).
Pediatric: Reference Pediatric Field Guide
 Calcium channel blocker overdose with bradycardia and hypotension/shock:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)
 Pulseless Arrest assumed due to hyperkalemia:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)
Index
Approved January 23, 2017
208
CALCIUM GLUCONATE
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Pulseless Arrest Algorithm Asystole / PEA
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
209
Approved January 23, 2017
Index
CALCIUM CHLORIDE
Description
 If calcium gluconate not available, calcium chloride is an acceptable substitution. Calcium
chloride has 3 times the concentration of elemental calcium as calcium gluconate, so the
volume given should be decreased. Calcium chloride is more likely to cause tissue
necrosis in the event of extravasation and is therefore reserved for immediately lifethreatening conditions when given via peripheral line.
 Cardioprotective agent in hyperkalemia.
Indications
 Not indicated for routine treatment of cardiac arrest
 Pulseless arrest associated with any of the following clinical conditions:
o Known hyperkalemia
o Renal failure with or without hemodialysis history
o Calcium channel blocker overdose
 Calcium channel blocker overdose with bradycardia and hypotension/shock
Contraindications
 Known hypercalcemia
 Suspected digoxin toxicity (i.e. digoxin overdose)
Precautions
 Must flush IV / IO or give in separate line from Sodium bicarb to prevent
precipitation/formation of calcium carbonate
 Extravasation may cause tissue necrosis
 In setting of digoxin toxicity, may worsen cardiovascular function
Dosage and Administration
Adult:
 Pulseless arrest assumed due to hyperkalemia:
o To be administered before Sodium Bicarbonate
 Must flush IV / IO line between meds.
o 500 mg slow IV / IO push (5 mL of a 10% solution)
 Calcium channel blocker overdose with bradycardia and hypotension/shock:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock).500
mg slow IV / IO push over 2-3 minutes (5 mL of a 10% solution). Dose may be
repeated every 10 minutes for total of 3 doses.
Pediatric: Reference Pediatric Field Guide
 Calcium channel blocker overdose with bradycardia and hypotension/shock:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock).
 Pulseless Arrest assumed due to hyperkalemia:
o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock).
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Pulseless Arrest Algorithm Asystole / PEA
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
Approved January 23, 2017
Index
210
DEXTROSE 50%
Description
Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in
blood sugar level will result in disturbances of normal metabolism, manifested clinically as
a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar
may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by
insulin, which stimulates storage of excess glucose from the blood stream, and glucagon,
which mobilizes stored glucose into the blood stream.
Indications
 Hypoglycemia (BGL< 60 mg / dL)
 Not indicated for routine treatment of pulseless arrest
Precautions
 None
Dosage and Administration
Adult:
25 gm (50 ml of a 50% solution) IV / IO bolus. May repeat if needed.
Pediatric: Reference Pediatric Field Guide
1-8 years: 2 ml/kg IV/IO of a 25% solution
<1 year: 5 ml/kg IV/IO of a 10% solution
Protocol
 Adult Hypoglycemia
 Altered Mental Status
 Adult Seizures
 Pediatric Altered Mental Status
 Pediatric Seizures
 Overdose / Acute Poisoning
 Psych/Behavioral
 Newborn Resuscitation
 Pediatric Hypoglycemia
Special Considerations
 Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to
ensure route patency.
 Dextrose can be irritable to the vein and the vein should be flushed after administration.
 Dextrose should be diluted 1:1 with normal saline (to create D 25W) for patient 1-8 years
old.
 Dextrose should be diluted 1:10 with normal saline (to create D10W) for patient < 1 year
old.
Index
Approved January 23, 2017
211
DIPHENHYDRAMINE (BENADRYL)
Description
Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also
Anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused
by antiphsychotic and antiemetic medications (e.g.: haloperidol, droperidol, compazine,
etc).
Indications
 Allergic reaction
 Dystonic medication reactions or akathesia (restlessness)
Precautions
 Asthma or COPD, thickens bronchial secretions
 Narrow-angle glaucoma
Side effects
 Drowsiness
 Dilated pupils
 Dry mouth and throat
 Flushing
Drug Interactions
 CNS depressants and alcohol may have additive effects.
 MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.
Dosage and Administration
Adults:
50 mg IV / IO / IM
Pediatrics: Reference Pediatric Field Guide
1 mg/kg slow IV /IO / IM (not to exceed 50 mg)
Protocol
 Adult Allergy and Anaphylaxis
 Adult Insect / Arachnid Bite and Stings
 Pediatric Allergy and Anaphylaxis
 Pediatric Insect / Arachnid Bite and Stings
212
Approved January 23, 2017
Index
DOPAMINE (INTROPIN)
Description
Endogenous catecholamine chemically related to epinephrine and norepinephrine.
Increases blood pressure through combination of dopamine, alpha and beta receptor
effects leading to increased heart rate, contractility and peripheral vasoconstriction.
Indications
 Adult Hypotension refractory to adequate fluid resuscitation
 Adult Symptomatic bradycardia with signs of poor perfusion
Contraindications
 Hypovolemia
 Hemorrhagic shock
Adverse Reactions
 Tachydysrhythmias
 Hypertension
 Increased myocardial oxygen demand
Dosage and Administration: CARRIED ONLY ON THE TRANSPORTING AMBULANCE
CONTACT BASE FOR DIRECT PHYSICIAN ORDER (AIP, Children’s, TMCA, CMP,
SaddleRock)
Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600
mcg/ml.
Adult IV/IO:
2~20 mcg/kg/min, Start at 5 mcg/kg/min, Titrate dose up 5 mcg/kg/min every 5
min to a max of 20 mcg/kg/min to achieve desired effect.
Pediatric: Reference Pediatric Field Guide
2~20 mcg/kg/min, Start at 5 mcg/kg/min, Titrate dose up 5 mcg/kg/min every 5
min to a max of 20 mcg/kg/min to achieve desired effect.
Protocol
 Adult Medical Hypotension/Shock Protocol
 Adult Bradycardia
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
Special Considerations
 May become ineffective if added to alkaline solution.
 Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be
sure to make Emergency Department personnel aware if there has been any
extravasation of dopamine-containing solutions so that proper treatment can be
instituted.
Approved January 23, 2017
213
Index
DOPAMINE (INTROPIN) cont.
INTRAVENOUS DRIP RATES FOR DOPAMINE
Concentration: 1600 mcg/ml
Dose (mcg/kg/min)
5
10
15
20
50 kg
10
20
30
40
60 kg
10
25
35
45
70 kg
15
25
40
50
80 kg
15
30
45
60
90 kg
15
35
50
70
100 kg
20
35
55
75
110 kg
20
40
60
85
Weight
microdrips/min
Approved January 23, 2017
214
Index
EPINEPHRINE (ADRENALIN)
Description
Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist.
Causes dose-related increase in heart rate, myocardial contractility and oxygen demand,
peripheral vasoconstriction and bronchodilation.
Indications
 Pulseless Arrest
 Anaphylaxis ( 2 or more of the following signs or symptoms)
 Hypotension
 Signs of poor perfusion
 Bronchospasm, stridor
 Altered mental status
 Urticaria
 Asthma

Bradycardia with Poor Perfusion (symptomatic) (pediatric patients)
Adverse Reactions
 Tachycardia and tachydysrhythmia
 Hypertension
 Anxiety
 May precipitate angina pectoris
Drug Interactions
 Should not be added to sodium bicarbonate or other alkaloids as epinephrine will be
inactivated at higher pH.
Dosage and Administration
Adult:
Pulseless Arrest
1 mg (10 ml of a 1:10,000 solution), IV/IO bolus.
Repeat every 4 minutes.
o Only a Single Dose of Epi if suspected Systemic Hypothermia in Cardiac Arrest
Asthma:
0.3 mg (0.3 ml of a 1:1,000 solution) IM.
Anaphylaxis:
0.3 mg (0.3 ml of a 1:1,000 solution) IM.
Repeat in 5 minutes X 1.
215
Approved January 23, 2017
Index
EPINEPHRINE (ADRENALIN) cont.
Pediatric: Reference Pediatric Field Guide
Cardiac arrest:
0.01 mg/kg IV / IO (0.1 ml/kg of 1:10,000 solution).
Repeat every 4 minutes.
Bradycardia with Poor Perfusion for order CONTACT BASE (AIP, Children’s,
TMCA, CMP, Saddle Rock)
0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV / IO
Asthma
0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM
Anaphylaxis
0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM. May repeat in 5 minutes x 1.
Newborn (< 24 hours old): (PINK EZ IO placed by hand NOT drill)
Cardiac arrest:
0.3mL of 1:10,000 solution IO / IV
Repeat every 4 minutes.
Bradycardia (heart rate < 60 beats per minute after adequate positive pressure
ventilation and chest compressions)
0.3mL of 1:10,000 solution IO / IV
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Pulseless Arrest Algorithm Asystole / PEA
 Adult Hypothermia
 Pediatric Pulseless Arrest VF / VT
 Pediatric Pulseless Arrest Asystole / PEA
 Newborn Resuscitation
 Adult Allergy and Anaphylaxis
 Adult Asthma
 Pediatric Respiratory Distress
 Pediatric Asthma
 Pediatric Croup
 Pediatric Allergy and Anaphylaxis
 Pediatric Bradycardia
 Pediatric Hypothermia
Special Considerations
 May increase myocardial oxygen demand and angina pectoris. Use with caution in
patients with known or suspected CAD
 Only a single dose of Epi if suspected Systemic Hypothermia in Pulseless Arrest
associated with Asystole, Vfib, VT
Approved January 23, 2017
Index
216
FENTANYL (SUBLIMAZE)
Description
Potent synthetic opioid analgesic. Fentanyl is 100 times more potent than morphine.
Onset & Duration
 Onset: Within 2~3 minutes
 Duration: 30 minutes
Indications
 Moderate to severe pain
 The objective of pain management is not the removal of all pain. Use fentanyl to make
the patient’s pain tolerable enough to allow for adequate assessment, treatment and
transport
 Persistent chest pain that is not relieved by 3 doses of SL Nitroglycerine in non- inferior
wall MIs and without prior Nitroglycerin in inferior wall MIs.
 For pain management during Transcutaneous Cardiac Pacing and Synchronized
Cardioversion
Contraindications
 Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics)
 The use of parenteral narcotics in the presence of parenteral benzodiazepines is not
allowed
Side Effects
 Respiratory depression and apnea: May occur suddenly, and is more common in children
and the elderly
 Hypotension, especially when used in combination with other sedatives such as alcohol
or benzodiazepines.
 Can increase intracranial pressure
 Chest wall rigidity has been reported with rapid administration
 Pediatric patients may develop apnea without manifesting significant mental status
changes
Dosage and Administration
Adult:
IV route: 1-2 mcg/kg, SLOW IV bolus.
Dose may be repeated after 5 minutes x 1 and titrated to clinical effect to a maximum
cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over
65 years
Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP,
Saddle Rock)
IN route: 1-2 mcg/kg IN single dose. Additional dose only via IV route.
May give 1 additional dose 5 minutes after initial IN dose up to a maximum
cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over
65 years.
Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP,
Saddle Rock)
Index
Approved January 23, 2017
217
FENTANYL (SUBLIMAZE) cont.
Pediatric (1-12 years): REFERENCE PEDIATRIC FIELD GUIDE
IV route:
1 mcg/kg SLOW IV bolus.
Dose may be repeated after 5 minutes and titrated to clinical effect to a maximum
cumulative dose of 3 mcg/kg
IN route: Requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
and approval for any indication other than isolated orthopedic injury or burns
2 mcg/kg IN single dose. Additional dose only via IV route.
May give 1 additional dose 5 minutes after initial IN dose up to a maximum
cumulative dose of 3 mcg/kg
Pediatric < 1 year: REQUIRES CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
NOTE: IV route is preferred for more accurate titration. Continuous pulse oximetry is mandatory.
Frequent evaluation of the patient’s vital signs is also indicated. Emergency resuscitation
equipment and naloxone must be immediately available.
Protocol
Adult Extremity Injuries
Adult Amputation
Adult Chest Pain
Adult Abdominal Pain / vomiting
Adult Insect / Arachnid Bite and Stings
Adult Snake Bite
Adult Face and Neck Trauma
Adult Spinal Trauma
Adult Chest Trauma
Adult Abdominal Trauma
Adult Burns
Synchronized Cardioversion
Transcutaneous Pacing
Pediatric Abdominal Pain/Vomiting
Pediatric Insect / Arachnid Bite and Stings
Pediatric Snake Bite
Pediatric Amputations
Pediatric Face and Neck Trauma
Pediatric Spinal Trauma
Pediatric Chest Trauma
Pediatric Abdominal Trauma
Pediatric Burns
Index
Approved January 23, 2017
218
GLUCAGON
Description
Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon
also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and
colon.
Onset & Duration
 Onset: variable
Indications
 Hypoglycemia BGL < 60 mg/dL and IV access is unavailable.
 Hypotension, bradycardia from beta-blocker or calcium channel overdose.
Side Effects
 Tachycardia
 Headache
 Nausea and vomiting
Dosage and Administration
Adult:
Hypoglycemia 1.0 mg, IM
Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s,
TMCA, CMP, SaddleRock) 2.0 mg IV bolus
Pediatric: Reference Pediatric Field Guide
Hypoglycemia 0.1 mg/kg IM. Maximum dose 1.0 mg IM
Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s,
TMCA, CMP, SaddleRock) 2.0 mg IV bolus
Protocol
Adult Seizure
Pediatric Seizure
Adult Overdose / Acute Poisoning
Adult Hypoglycemia
Pediatric Overdose and Acute Poisoning
Pediatric Hypoglycemia
Approved January 23, 2017
Index
Index
219
IPRATROPIUM BROMIDE (ATROVENT)
Description
Ipratropium is a anticholinergic antimuscarinic bronchodilator chemically related to
atropine.
Onset & Duration
 Onset: 5-15 min. after inhalation
 Duration: 6-8 hr. after inhalation
Indications
 Bronchospasm secondary to asthma and COPD
Contraindications
 Do not administer to children < 2 years
 Soy or peanut allergy is a contraindication to use of Atrovent metered dose inhaler, not
the nebulized solution, which does not have the allergen contained in propellant
Adverse Reactions
 Palpitations
 Tremors
 Dry mouth
How Supplied
Premixed Container:
0.5 mg in 2.5ml NS
Dosage and Administration
Not indicated for repetitive dose or continuous neb use
Adult
Mild- Mod- Severe Bronchospasm:
Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat.
Child (2yrs – 12yrs)
Mild- Mod- Severe Bronchospasm
Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat.
Protocol
 Adult Asthma
 Adult COPD
 Pediatric Respiratory Distress
 Pediatric Asthma
Index
Index
Approved January 23, 2017
220
MAGNESIUM SULFATE
Description
Magnesium sulfate reduces striated muscle contractions and blocks peripheral
neuromuscular transmission by reducing acetylcholine release at the myoneural junction.
In cardiac patients, it stabilizes the potassium pump, correcting repolarization. It also
shortens the Q-T interval in the presence of ventricular arrhythmias due to drug toxicity or
electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in acute
bronchospasm due to asthma or other bronchospastic diseases. In patients suffering
from eclampsia, it controls seizures by blocking neuromuscular transmission and lowers
blood pressure as well as decreases cerebral vasospasm.
Indications
Antiarrhythmic
 Torsade de pointes associated with prolonged QT interval
Respiratory
 Severe bronchospasm secondary to asthma; unresponsive to all of the following:
albuterol and ipratropium, continuous albuterol, and IM epinephrine.
Obstetrics
 Pregnancy > 20 weeks gestational age with evidence of eclampsia
Precautions
 Bradycardia
 Hypotension
 Respiratory depression
Adverse Reactions
 Bradycardia
 Hypotension
 Respiratory depression
Dosage and Administration
Torsades de Pointes suspected caused by prolonged QT interval:
2 gm, IV / IO bolus.
Refractory Severe Bronchospasm:
For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV
push.
Eclampsia:
For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV
push.
Pediatric: Reference Pediatric Field Guide
For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
Asthma 25-50mg/kg IV bolus. Maximum dose 2.0 grams
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Asthma
 Adult Eclampsia
 Adult Seizure
 Pediatric Asthma
221
Approved January 23, 2017
Index
METHYLPREDNISOLONE (SOLU-MEDROL)
Description
Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation
and may alter the immune response. In addition, it potentiates vascular smooth muscle
relaxation by beta-adrenergic agonists and may alter airway hyperactivity.
Indications
 Anaphylaxis
 Severe asthma
 COPD
 Shock with history of adrenal insufficiency
Contraindications
 Evidence of active GI bleed
Adverse Reactions
Most adverse reactions are a result of long-term therapy and include:
 Gastrointestinal bleeding
 Hypertension
 Hyperglycemia
Dosage and Administration
Anaphylaxis, Severe Asthma, COPD: After primary treatment priorities are completed
Adult:
125 mg, Slow IV Push
Pediatric: Reference Pediatric Field Guide
2.0 mg/kg Slow IV Push, Maximum dose 60.0 mg
Shock with history of adrenal insufficiency:
Adult:
125 mg, Slow IV Push, IO slowly
Pediatric: Reference Pediatric Field Guide
2.0 mg/kg Slow IV Push , IO slowly. Maximum dose 125mg
Protocol
 Adult Asthma
 Adult COPD
 Adult Allergy and Anaphylaxis
 Adult Adrenal Insufficiency
 Pediatric Asthma
 Pediatric Allergy and Anaphylaxis
 Pediatric Adrenal Insufficiency
222
Approved January 23, 2017
Index
METHYLPREDNISOLONE (SOLU-MEDROL)
Special Considerations
 Must be reconstituted and used immediately
 The effect of methylprednisolone is generally delayed for several hours.
 Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s
primary treatment priorities (i.e. airway, ventilation, beta-agonist nebulization, fluid bolus)
first. If primary treatment priorities have been completed and there is time while in route
to the hospital, then methylprednisolone can be administered. Do not delay transport to
administer this drug
223
Approved January 23, 2017
Index
MIDAZOLAM (Versed)
Description
Midazolam HCl is a water-soluble short acting benzodiazepine sedative-hypnotic. It is
believed that benzodiazepines exert their effect on the GABA receptor to create
anxiolysis, sedation and muscle relaxation.
Indications
 Seizures > 5min or multiple seizures
 Eclampsia
 Sedation of the combative patient
 Sedation of the Excited Delirium patient
Contraindications
 Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics)
Adverse Reactions
 Respiratory depression, including apnea
 Hypotension
 Sedative effect of midazolam may be heightened by associated use of opioids, alcohol,
or other CNS depressants.
Dosage and Administration
Sedation of combative patient:
Adult:
A single dose of 2 mg IV or if no IV in place 5 mg IM / IN. In elderly pts over 65
years or small adults <50kg administer ½ dose. For repeat dose CONTACT
BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
Pediatric: Reference Pediatric Field Guide
For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
Seizure / Eclampsia:
Adult:
2 mg, IV may repeat x 1 in 5 minutes. Total of 2 doses.
5mg, IM / IN may repeat x 1 in 5 minutes. Total of 2 doses.
For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
Pediatric: Reference Pediatric Field Guide
0.1 mg/kg, IV / IM may repeat x1 in 5 minutes. Maximum single dose 2 mg.
0.2 mg/kg, IN (divided into each nare may repeat x1 in 5 minutes. Maximum
single dose 5 mg.
For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)
Excited Delirium:
Adult: STANDING ORDER of:
Initial dose of 2mg IV. REPEAT doses of 2mg IV in 5 minutes x 2 for a MAX of up
to 6mg IV.
OR
Initial dose of 10mg IM / IN if no IV in place. Additional doses of 5mg IM / IN x 2.
For MAX of up to 20mg IM / IN.
Approved January 23, 2017
224
Index
MIDAZOLAM (Versed) cont.
Protocol
 Synchronized Cardioversion
 Adult Tachycardia
 Transcutaneous Pacing
 Adult Seizure
 Adult Eclampsia
 Pediatric Seizure
 Adult Combative Patient
 Excited Delirium
Special Considerations
 Provide continuous cardiac and pulse-oximetry monitoring
 Have resuscitation equipment readily at hand.
 Due to increased risk of hypotension and respiratory depression, the use of parenteral
benzodiazepines in the presence of parenteral narcotics is not allowed
 In elderly patients > 65 years old or small adults < 50kg, administer ½ dose.
Approved January 23, 2017
Index
225
NALOXONE (NARCAN)
Description
Naloxone is a competitive opioid receptor antagonist
Onset & Duration
Onset: Within 5 minutes
Duration: Approximately 1 hour
Indications
 For reversal of suspected opioid-induced respiratory depression

Not Indicated for routine treatment of Pulseless arrest
Adverse Reactions
 Tachycardia
 Nausea and vomiting
 Pulmonary Edema
Dosage and Administration
Adult:
0.5 mg IV / IN / IO and titrate to desired effect, up to 2 mg total
In Adult cases where IV / IN access is not feasible, 2 mg bolus IM is appropriate
Pediatric: Reference Pediatric Field Guide
0.5 mg IV / IN / IO and titrate to desired effect, up to 2 mg total
Protocol
 Altered Mental Status
 Adult Overdose / Acute Poisoning
 Pediatric Altered Mental Status
 Pediatric Overdose / Acute Poisoning
Special Considerations
 Not intended for use unless respiratory depression or impaired airway reflexes are
present. Reversal of suspected mild-moderate opioid toxicity is not indicated in the field
as it may greatly complicate treatment and transport as narcotic-dependent patients may
experience violent withdrawal symptoms
 Patients receiving EMS administered naloxone should be transported to a hospital.
 In the State of Colorado, bystanders, law enforcement, and other first responders can
administer naloxone if they feel a person is experiencing an opiate-related drug overdose
event (Colorado Revised Statutes §12-36-117.7).
 There are significant concomitant inherent risks in patients who have received naloxone,
including:
o Recurrent respiratory/CNS depression given short half-life of naloxone
o Co-existing intoxication from alcohol or other recreational or prescription drugs
o Acetaminophen toxicity from combination opioid/acetaminophen prescriptions
o Non-cardiogenic pulmonary edema associated with naloxone use
o Acute psychiatric decompensation, overdose, SI/HI or psychosis requiring ED
evaluation
o Sudden abrupt violent withdrawal symptoms which may limit decision making
capacity (continued next page)
Approved January 23, 2017
Index
226


Given the above risks, it is strongly preferred that patients who have received naloxone
be transported and evaluated by a physician. However, if the patient clearly has decisionmaking capacity he/she does have the right to refuse transport. If adamantly refusing,
patients must be warned of the multiple risks of refusing transport.
If the patient is refusing transport contact base. If any concerns or doubts about
decision-making capacity exist, err on the side of transport.
227
Approved January 23, 2017
Index
NERVE AGENT KIT (DUODOTE)
Description
A streamlined, easy-to-use replacement for the Mark I™Kit. FDA approved for
Emergency Medical Services (EMS) use in the treatment of organophosphorus nerve agent and
organophosphorus insecticide poisoning. Contains two antidotes in 1 auto-injector; 2.1 mg of
atropine in a 0.7-mL solution and 600 mg of pralidoxime chloride in a 2-mL solution. Delivered
sequentially into separate areas of the muscle–Easy to use: only 1 injection with 1 needle
Onset & Duration
Onset: Within 5 minutes
Duration: 1-4 hours
Indications
Treatment of poisoning by organophosphorus nerve agents as well as organophosphorus
insecticides.
Should be administered as soon as symptoms of organophosphorus poisoning appear.
Adverse Reactions
 Tachycardia
 Nausea and vomiting
 Pulmonary Edema
Dosage and Administration
MILD symptoms:
Blurred vision, miosis (excessive constriction of the pupils)
Excessive, unexplained teary eyes
Excessive, unexplained runny nose
Increased salivation such as sudden drooling
Chest tightness or difficulty breathing
Tremors throughout the body or muscular twitching
Nausea and/or vomiting
Unexplained wheezing, coughing, or increased airway secretions
Acute onset of stomach cramps
Tachycardia or bradycardia
Treatment for MILD Symptoms:
FIRST DOSE: In the situation of known or suspected organophosphorus poisoning,
administer one DuoDote™ injection into the mid-outer thigh if the patient experiences two
or more MILD symptoms of nerve gas or insecticide exposure
Wait 10 to 15 minutes for DuoDote™ to take effect. If, after 10 to 15 minutes, the patient
does not develop any SEVERE symptoms, no additional DuoDote™ injections are
recommended, but definitive medical care should ordinarily be sought immediately.
ADDITIONAL DOSES: If, at any time after the first dose, the patient develops any
SEVERE symptoms, administer two additional DuoDote™ injections in rapid succession,
and immediately seek definitive medical care
228
Approved January 23, 2017
Index
NERVE AGENT KIT (DUODOTE) cont.
SEVERE Symptoms:
Strange or confused behavior
Severe difficulty breathing or copious secretions from lungs/airway
Severe muscular twitching and general weakness
Involuntary urination and defecation
Convulsions
Loss of consciousness
Respiratory arrest (possibly leading to death)
Treatment for SEVERE Symptoms:
Immediately administer three DuoDote™ injections into the patient’s mid-outer thigh in
rapid succession, and immediately transport.
No more than 3 doses of DuoDote™ should be administered unless definitive
medical care is available.
Protocol
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
Special Considerations
Before injecting
Tear open plastic pouch at any of the notches, and remove the DuoDote™ Auto-Injector
Place DuoDote™ in your dominant hand and firmly grasp it, with the Green Tip pointing
downward
With your other hand, pull off the Gray Safety Release, taking care never to touch the
Green Tip
Keep fingers clear of both ends of the auto-injector
You are now ready to inject
Select site and inject
The injection site is the mid-outer thigh area.
You can inject through clothing, but make sure that pockets are empty
Firmly push Green Tip straight down (at a 90ºangle) against mid-outer thigh, continuing
to push firmly until you feel the auto-injector trigger
After the DuoDote™ Auto-Injector triggers, hold it firmly in place against the injection site
for 10 seconds
After injecting
Remove the DuoDote™ Auto-Injector from thigh and inspect the Green Tip; if the needle
is visible, then the injection was successful
If the needle is not visible, make sure the Gray Safety Release is removed and repeat the
preceding injection steps
Push the exposed needle against a hard surface until it bends back, then put the used
auto-injector back in the plastic pouch
Keep used auto-injector(s) with the patient so other medical personnel will be aware of
how many injections were administered
229
Approved January 23, 2017
Index
NITROGLYCERINE (NITROSTAT, etc)
Description
Short-acting peripheral vasodilator decreasing cardiac preload and afterload
Onset & Duration
Onset: 1-3 min.
Duration: 20-30 min.
Indications
 Pain or discomfort due to suspected Acute Coronary Syndrome
 Pulmonary edema due to congestive heart failure
Contraindications
 SBP < 100
 Recent use (48 hours) of erectile dysfunction (ED) medication (e.g. Viagra, Cialis)
 Patients with pulmonary hypertension who are taking Revatio.
 Inferior STEMI Pattern (ST elevation II, III, aVF)
Adverse Reactions
 Hypotension
 Headache
 Syncope
Dosage and Administration
0.4 mg (1/150 gr) sublingually or spray, every 4 minutes PRN up to a total of 3 doses
Protocol
 Adult Chest Pain
 Adult CHF / Pulmonary Edema
230
Approved January 23, 2017
Index
ONDANSETRON (ZOFRAN)
Description
Ondansetron is a selective serotonin 5-HT3 receptor antagonist antiemetic.
Indications
 Nausea and/or vomiting
Contraindications
 None
Dosage and Administration
Adult:
4 mg IV/IM/PO. May repeat x 1 dose as needed.
Pediatric less than 4 years old: Reference Pediatric Field Guide
2 mg IV
Pediatric greater than 4 years old: Reference Pediatric Field Guide
4 mg IV/IM/PO
Protocol
 Adult Abdominal Pain/Vomiting
 Pediatric Abdominal Pain/Vomiting
231
Approved January 23, 2017
Index
ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE)
Description
Glucose is the body's basic fuel and is required for cellular metabolism
Indications
 Known or suspected hypoglycemia (BGL < 60 mg/dL) and able to take PO
Contraindications
Inability to swallow or protect airway
Unable to take PO meds for another reason
Administration
One full tube 15 g buccal.
Protocol
 Altered Mental Status
 Adult Hypoglycemia
 Pediatric Altered Mental Status
 Pediatric Hypoglycemia
232
Approved January 23, 2017
Index
OXYGEN
Description
Oxygen added to the inspired air increases the amount of oxygen in the blood, and
thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell damage
and death. Breathing, in most people, is regulated by small changes in the acid-base
balance and CO2 levels. It takes relatively large decreases in oxygen concentration to
stimulate respiration.
Indications
 Low / Moderate flow O2 for the following:
o All patients unable to achieve SpO2 > 90% on room air
 Titrate to goal of > 90%
 High flow O2 for the following:
o BVM
o Hypotension/shock states from any cause
o Multi-systems Trauma
o Suspected carbon monoxide poisoning
o Obstetrical complications, childbirth
o All patients unable to achieve SpO2 > 90% with low/moderate flow oxygen
 Titrate to goal of > 90%
Administration
Flow
Low Flow
Moderate Flow
High Flow
LPM Dosage
1-2 LPM
3-9 LPM
10-15 LPM
Special Notes
 Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen,
use a single patient use device.
 Adequate oxygenation is assessed clinically and with the SpO2 while adequate ventilation
is assessed clinically and with ETCO2.
 If the patient is not breathing adequately, the treatment of choice is assisted ventilation,
not just oxygen.
 Do not withhold oxygen from a COPD patient out of concerns for loss of hypoxic
respiratory drive. This is never a concern in the prehospital setting with short transport
times
233
Approved January 23, 2017
Index
PHENYLEPHRINE (INTRANASAL)
Description
Used for topical nasal administration, phenylephrine primarily exhibits alpha adrenergic
stimulation. This stimulation can produce moderate to marked vasoconstriction and
subsequent nasal decongestion.
Indications
 Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa
 Nose bleed
Precautions
 Avoid in pts with known CAD
 Avoid administration into the eyes, which will dilate pupil
Dosage and Administration
 Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation
 Administer 2 sprays in affected naris in patient with active nosebleed after having
patient blow nose to expel clots.
Protocol
 Nasotracheal intubation
 Adult Epistaxis
 Pediatric Epistaxis
Approved January 23, 2017
234
Index
RACEMIC EPINEPHRINE (VAPONEPHRINE)
Description
Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for use by oral
inhalation only. Inhalation causes local effects on the upper airway as well as systemic
effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and ß
effects on bronchial smooth muscle may relieve bronchospasm.
Onset & Duration
 Onset: 1-5 minutes
 Duration: 1-3 hours
Indications
 Stridor at rest
Side Effects
 Tachycardia
 Palpitations
Dosage and Administration
0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml saline, via
nebulizer at 6-8 LPM to create a fine mist
Protocol
 Pediatric Respiratory Distress
 Pediatric Croup
Special Considerations
 Racemic epi is heat and photo-sensitive
 Do not confuse the side effects with respiratory failure or imminent respiratory arrest.
Approved January 23, 2017
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Index
SODIUM BICARBONATE
Description
Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body.
Acids are increased when body tissues become hypoxic due to cardiac or respiratory
arrest.
Indications
 Not indicated for routine treatment of pulseless arrest
 Pulseless arrest associated with any of the following clinical conditions:
o Known hyperkalemia
o Renal failure with or without hemodialysis history
o To be administered after Calcium Gluconate or Calcium Chloride

Must flush IV / IO line between meds.
 Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures
Contraindications
 Metabolic and respiratory alkalosis
 Hypocalcemia
 Hypokalemia
Adverse Reactions
 Metabolic alkalosis
 Hyperosmolarity may occur, causing cerebral impairment
Dosage and Administration
Adults
Tricyclic OD with hypotension or prolonged QRS > 0.10 sec
1.0 mEq/kg slow IV/IO push
Repeat if needed in 10 minutes.
Pediatrics (>10kg) Reference Pediatric Field Guide (purple or larger)
Tricyclic OD with hypotension or prolonged QRS > 0.10 sec
1.0 mEq/kg slow IV / IO push
Repeat if needed in 10 minutes.
Pediatrics (<10kg) Reference Pediatric Field Guide
For Order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Requires
Dilution
Suspected hyperkalemia-related pulseless arrest in ADULT:
 To be administered after Calcium Chloride or Calcium Gluconate
 Must flush IV / IO line between meds
 2 amps IV / IO
Suspected hyperkalemia-related pulseless arrest in PEDIATRIC: For order
CONTACT BASE (AIP, Children’s, TMCA)
Index
Approved January 23, 2017
236
SODIUM BICARBONATE
Protocol
 Adult Pulseless Arrest Algorithm VF / VT
 Adult Pulseless Arrest Algorithm Asystole / PEA
 Adult Overdose / Acute Poisoning
 Pediatric Overdose and Acute Poisoning
Drug Interactions
 May precipitate in calcium solutions.
 Alkalization of urine may increase half-lives of certain drugs.
 Vasopressors may be deactivated.
Special Considerations
 Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a
paradoxical intracellular acidosis.
 Sodium bicarb is no longer recommended for routine use in prolonged cardiac
arrest. Its use in pulseless arrest should be limited to known or suspected
hyperkalemia (e.g. dialysis patient).
Index
Approved January 23, 2017
237
TOPICAL OPHTHALMIC ANESTHETICS
Description
Used for topical administration as a pain reliever for eye irritation. Only proparacaine and
tetracaine are approved for use.
Indications
 Pain secondary to eye injuries and corneal abrasions
 Topical anesthetic to facilitate eye irrigation
Contraindications
 Known allergy to local anesthetics
 Globe lacerations or rupture
Precautions
 Transient burning/stinging when initially applied
Dosage and Administration
Instill two drops into affected eye.
For repeat dose: required to CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle
Rock)
Protocol
 May be used for the above listed indications as needed
Special Considerations
 This is single patient use. Unused portions are to be discarded and only new bottles are
to be used.
 Do not administer until patient consents to transport and transport has begun
 Topical ophthalmic anesthetics should never be given to a patient for self-administration
Approved January 23, 2017
Index
238
Core Competency
Adult Medical Arrest – Compressor
Performance Criteria
Skills Demonstration
0-2 MINUTES (BLS Airway)
Start Chest Compressions
Paramedic will set up the MRx and hand Compressor the CPR puck.
Compressor uses Q-CPR information displayed on MRx to give effective
compressions
 At least 100 compressions per minute
 At least 2 inches deep
 Allow full recoil
 Once deployed, use Q-CPR for duration of the arrest
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
2-4 MINUTES (ALS Airway)
New Compressor uses Q-CPR information displayed on MRx to give
effective compressions
 At least 100 compressions per minute
 At least 2 inches deep
 Allow full recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
Approved January 23, 2017
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Index
Core Competency
Adult Medical Arrest – Ventilator
Performance Criteria
Skills Demonstration
0-2 MINUTES (BLS airway)
Correctly size and insert an OPA
Connect ETCO2 to MRx and BVM
Connect BMV to O2 source, set regulator to 15 lpm
Using 2-rescuer Technique, give the pt 1 breath every 6 seconds
 First rescuer squeezes bag 1 breath every 6 seconds
 Second rescuer seals mask to pt’s face use “C-E” Technique
2-4 MINUTES (ALS airway)
Continue using 2-rescuer BVM Technique until i-gel O2 airway placed
(1 breath every 6 seconds)
Verify effective ventilations using capnography
Once i-gel O2 Airway is in place:
 Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every
6 seconds
 Second rescuer to set up IV/IO or other task as assigned by attending
paramedic
4-6 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilations using capnography
6-8 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilations using capnography
Approved January 23, 2017
Index
240
Core Competency
Adult Medical Arrest – Lead Paramedic
Performance Criteria
Skills Demonstration
0-2 MINUTES (BLS)
Check patient’s responsiveness, breathing and pulse – verify pt is in medical
arrest
Delegates a rescuer to begin chest compressions
Delegates 2 rescuers to begin ventilations
Turn MRx energy level to 150J.
Hand CPR puck to the Compressor
Apply Combo Pads – If arrest witnessed by EMS, Correctly interpret and treat
rhythm
Verifies appropriate compressions and ventilations
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
2-4 MINUTES (Advanced Airway)
Directs resumption of compressions and ventilations if needed
Delegates or places i-gel O2 Airway and inserts suction catheter
Connect ETCO2 to the i-gel O2 Airway
Verifies appropriate compressions and ventilations (1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
4-6 MINUTES (IV/IO access)
Directs resumption of compressions and ventilations if needed
Delegates or places IV/IO
Verifies appropriate compressions and ventilations (1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
6-8 MINUTES (Medication Administration)
Directs resumption of compressions and ventilations if needed
Delegates or administers indicated medication(s)
Verifies appropriate compressions and ventilations (1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
Approved January 23, 2017
241
Core Competency
Adult Traumatic Arrest – Compressor
Performance Criteria
0-2 MINUTES (BLS Airway)
Start Chest Compressions
Paramedic will set up the MRx and hand Compressor the CPR puck.
Pumper uses Q-CPR information displayed on MRx to give effective
compressions
 At least 100 compressions per minute
 At least 2 inches deep
 Once deployed, use Q-CPR for duration of the arrest
Call out times:
 At 1 minute and 30 seconds plan rotation of personnel
 At 2 minutes switch compressors
2-4 MINUTES (Advanced Airway)
Continue using Q-CPR
 At least 100 compressions per minute
 At least 2 inches deep
 Once deployed, use Q-CPR for duration of the arrest
Call out times:
 At 1 minute and 30 seconds plan rotation of personnel
 At 2 minutes switch compressors
4-6 MINUTES (IV/IO access)
Continue using Q-CPR
 At least 100 compressions per minute
 At least 2 inches deep
 Once deployed, use Q-CPR for duration of the arrest
Call out times:
 At 1 minute and 30 seconds plan rotation of personnel
 At 2 minutes switch compressors
6-8 MINUTES (Medication Administration)
Continue using Q-CPR
 At least 100 compressions per minute
 At least 2 inches deep
 Once deployed, use Q-CPR for duration of the arrest
Call out times:
 At 1 minute and 30 seconds plan rotation of personnel
 At 2 minutes switch compressors
Index
Approved January 23, 2017
242
Core Competency
Adult Traumatic Arrest – Ventilator
Performance Criteria
0-2 MINUTES (BLS airway)
Maintain manual in-line stabilization if indicated
Correctly size and insert an OPA
Connect ETCO2 to MRx and BVM
Connect BMV to O2 source, set regulator to 15 lpm
Using 2-rescuer Technique, give the pt 1 breath every 6 seconds
 First rescuer squeezes bag 1 breath every 6 seconds
 Second rescuer seals mask to pt’s face use “C-E” Technique
2-4 MINUTES (ALS airway)
Continue using 2-rescuer BVM Technique until i-gel O2 airway placed
(1 breath every 6 seconds)
Verify effective ventilations using capnography
Once i-gel O2 Airway is in place:
 Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every
6 seconds
 Second rescuer to set up IV/IO or other task as assigned by attending
paramedic
4-6 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilation using capnography
6-8 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilations using capnography
Approved January 23, 2017
Index
243
Core Competency
Adult Traumatic Arrest – Lead Paramedic
Performance Criteria
0-2 MINUTES (BLS)
Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic
arrest
Delegates or controls life threatening external bleeding
Delegates a rescuer to begin continuous chest compressions
Delegates 2 rescuers to begin ventilations ( 1 breath every 6 seconds) with inline
spinal immobilization if indicated
Hand CPR puck to the Compressor
Place patient on MRx (interpret EKG)
Prepare for immediate transport
or
Contact Base if asystole
Perform physical exam
Address life threatening injuries
Verify continuous compressions and ventilations ( 1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
2-4 MINUTES (Advanced Airway)
Directs resumption of continuous compressions and ventilations
(1 breath every 6 seconds)
Direct or places i-gel O2 Airway with suction catheter
Connect ETCO2 to i-gel O2 Airway
Verify effective ventilations ( 1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
Address life threatening injuries
4-6 MINUTES (Needle Decompression if indicated)
Directs resumption of continuous compressions and ventilations ( 1 breath every
6 seconds)
Perform bilateral needle thoracostomy for trunk trauma
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
6-8 MINUTES (IV/IO) (Fluid Administration)
Directs resumption of continuous compressions and ventilations
(1 breath every 6 seconds)
Directs or places IV/IO
Directs or administers fluid bolus(s)
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
Index
Approved January 23, 2017
244
Core Competency
Pediatric (<12years)
Medical Cardiac Arrest - Compressor
Performance Criteria
0-2 MINUTES (BLS Airway)
Start Chest Compressions
Paramedic will set up the MRx and hand Compressor the CPR puck if indicated.
Compressor uses Q-CPR information displayed on MRx to give effective compressions
(Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth – 1 month, 3:1 compression to ventilation ration
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
2-4 MINUTES (Advanced Airway)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth – 1 month, 3:1 compression to ventilation ration
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Switch to continuous compressions after advanced airway placement
4-6 MINUTES (IV/IO access)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth – 1 month, 3:1 compression to ventilation ration
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
Approved January 23, 2017
245
Core Competency
Pediatric (<12years)
Medical Cardiac Arrest - Compressor
6-8 MINUTES (Medication Administration)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth – 1 month, 3:1 compression to ventilation ration
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
Approved January 23, 2017
246
Index
Core Competency
Pediatric (<12years)
Medical Cardiac Arrest - Ventilator
Performance Criteria
0-2 MINUTES (BLS airway)
Correctly size and insert an OPA
Connect ETCO2 to MRx and BVM
Connect BMV to O2 source, set regulator to 15 lpm
Using 2-rescuer Technique
Pt age >1 month to 12 years
 First rescuer uses 15:2 compression to ventilation ratio
 Second rescuer seals mask to patients face with “C-E” Technique
Pt age birth to 1 month
 First rescuer uses 3:1 compression to ventilation ratio
 Second rescuer seals mask to patients face with “C-E” Technique
2-4 MINUTES (ALS airway)
Continue using 2-rescuer BVM Technique until i-gel O2 airway placed
Verify effective ventilations using capnography
Once i-gel O2 Airway is in place:
 Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every
6 seconds
 Second rescuer to set up IV/IO or other task as assigned by attending
paramedic
4-6 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilations using capnography
6-8 MINUTES (ALS airway)
Continue with 1 rescuer BVM (1 breath every 6 seconds)
Verify effective ventilations using capnography
Approved January 23, 2017
Index
247
Core Competency
Pediatric (<12years)
Medical Cardiac Arrest – Lead Paramedic
Performance Criteria
0-2 MINUTES (BLS)
Check patient’s responsiveness, breathing and pulse – verify pt is in medical
arrest
Delegates a rescuer to begin chest compressions (15:2) for pt 1month – 12 years
Delegates a rescuer to begin chest compressions (3:1) for pt birth – 1 month
Delegates 2 rescuers to begin ventilations (15:2)(3:1)
Measure patient with Length Based Tape – Determine patient’s “color”
Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc
Monitor turned on to appropriate energy level
Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer)
Apply Combo Pads – Anterior / Posterior placement recommended
Verifies appropriate compressions and ventilations
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
2-4 MINUTES (Advanced Airway)
Directs resumption of compressions and ventilations (15:2)(3:1), if needed
Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide
Connect ETCO2 to igel-O2 Airway. Verify effective ventilations
Verifies switch to continuous compressions and appropriate ventilatory rate
(1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
4-6 MINUTES (IV/IO access)
Directs resumption of compressions and ventilations, if needed
Directs or places IV/IO
Verifies appropriate compressions and ventilations (1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
6-8 MINUTES (Medication Administration)
Directs resumption of compressions and ventilations, if needed
Directs or administers indicated medication(s)
Verifies appropriate compressions and ventilations (1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 1 minute and 45 seconds charge monitor
At 2 minutes ensures hands-off patient for rhythm check
5-10 second pre-shock pause for rhythm identification
Correctly interpret and treat rhythm
Approved January 23, 2017
248
Core Competency
Pediatric (<12years)
Pediatric Trauma Arrest – Ventilator
Performance Criteria
Skills Demonstration
0-2 MINUTES (BLS airway)
Correctly size and insert an OPA
Connect ETCO2 to MRx and BVM
Connect BMV to O2 source, set regulator to 15 lpm
Using 2-rescuer Technique
Pt age >1 month to 12 years
 First rescuer uses 15:2 compression to ventilation ratio
 Second rescuer seals mask to patients face with “C-E” Technique
Pt age birth -1 month
 First rescuer uses 3:1 compression to ventilation ratio
 Second rescuer seals mask to patients face with “C-E” Technique
2-4 MINUTES (ALS airway)
Continue using 2-rescuer BVM Technique until i-gel O2 airway placed
Verify effective ventilations using capnography
Once i-gel O2 Airway is in place:
 Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every
6 seconds
 Second rescuer to set up IV/IO or other task as assigned by attending
paramedic
4-6 MINUTES (ALS airway)
Continue with 1 rescuer BVM technique (1 breath every 6 seconds)
Verify effective ventilations using capnography
6-8 MINUTES (ALS airway)
Continue with 1 rescuer BVM (1 breath every 6 seconds)
Verify effective ventilations using capnography
Index
Approved January 23, 2017
249
Core Competency
Pediatric (<12years)
Pediatric Trauma Arrest – Compressor
Performance Criteria
0-2 MINUTES (BLS Airway)
Skills Demonstration
Start Chest Compressions
Paramedic will set up the MRx and hand Compressor the CPR puck if indicated
(please see AFD Pediatric Field Guide). Compressor uses Q-CPR information
displayed on MRx to give effective compressions (Length Based Tape purple
and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth - 1 month, 3:1 compression to ventilation ratio
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
2-4 MINUTES (Advanced Airway)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth - 1 month, 3:1 compression to ventilation ratio
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Switch to continuous compressions after advanced airway placement
4-6 MINUTES (Needle Decompression-if indicated)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth - 1 month, 3:1 compression to ventilation ratio
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
6-8 MINUTES (Fluid Administration)
New Compressor uses Q-CPR information displayed on MRx to give effective
compressions (Length Based Tape purple and longer)
 Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
 Pt age birth - 1 month, 3:1 compression to ventilation ratio
 2 inches deep or 1/3 the depth of the chest.
 Allow complete recoil
Call out times:
 At 1 minute and 30 seconds
 At 1 minute and 45 seconds
 At 2 minutes hands-off patient and rotate to new assigned task
Approved January 23, 2017
250
Index
Core Competency
Pediatric (< 12years)
Pediatric Trauma Arrest – Lead Paramedic
Performance Criteria
Skills Demonstration
0-2 MINUTES (BLS)
Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic arrest
Delegates or controls life threatening external bleeding
Delegates a rescuer to begin chest compressions
Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio
Pt age birth - 1 month, 3:1 compression to ventilation ratio
Delegates 2 rescuers to begin ventilations utilizing ETCO2. Maintain in line spinal
stabilization if indicated
Measure patient with Length Based Tape – Determine patient’s “color”
Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc
Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer)
Place patient on MRx (interpret EKG)
Prepare for immediate transport
or
Contact Base if asystole
Perform physical exam
Address life threatening injuries
Verify continuous compressions and ventilations
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
2-4 MINUTES (Advanced Airway)
Directs resumption of compressions and ventilations (15:2)(3:1), if needed
Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide
Verifies that ETCO2 is being utilized with the i-gel O2
Verifies switch to continuous compressions and appropriate ventilatory rate
(1 breath every 6 seconds)
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
Address life threatening injuries
4-6 MINUTES (Needle Decompression if indicated)
Directs resumption of continuous compressions and ventilations
(1 breath every 6 seconds)
Perform bilateral needle thoracostomy for trunk trauma
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
6-8 MINUTES (IV/IO) (Fluid Administration)
Directs resumption of continuous compressions and ventilations
(1 breath every 6 seconds)
Directs or places IV/IO
Directs or administers fluid bolus(s), bolus amount as indicated in the AFD Pediatric
Field Guide.
At 1 minute and 30 seconds plan rotation of personnel
At 2 minutes switch compressors
Approved January 23, 2017
251