Adult ALS Protocol

8/13/2019 Adult ALS Protocol

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Advanced Life SupportTreatment Protocol

St. Mary Medical Center

EMS Program_________________________________________________________ _________________________________________________________John P. Mulligan, M.D. Robert Boby, R.N.

EMS Medical Director EMS Coordinator

Revision #12 (02/21/13)


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St. Mary Medical Center ALS Protocol

Table of Contents

Medical

Code Description

1 Routine Patient Care

2 Radio Report

3 Accelerated Transport

4 Refusal of Services

5 DNR Orders, Out of Hospital

6 Hazmat Response

7 Mass Casualty Response

8 Abdominal Emergencies

9 Pain Management10 Suspected Cardiac Patient

11 Pulmonary Edema

12 Cardiogenic Shock

13 PVCs

14 Asystole

15 VF/Pulseless VT

16 Bradycardia

17 Tachycardia

18 PEA

19 Airway Obstruction20 Asthma/COPD

21 Allergic Reaction/Anaphylaxis

22 Diabetic Emergencies

23 Drug Overdose

24 Coma

25 Seizures

26 Stroke Brain Attack

27 Near Drowning

28 Cold Emergencies

29 Heat Emergencies

Code Description

30 Psychological Emergencies

31 Implanted defibrillator

32 Medication Assisted Intubation

33 Hypertensive Crisis

39 Poison/Toxin Emergencies

Trauma

Code Description

40 Routine Trauma Care

41 Suspected SCI

42 Hemorrhagic Shock

43 Head Trauma

44 Amputated parts

45 Burns

46 Chest Trauma

47 Trauma in Pregnancy

48 Trauma Arrest

49 Ophthalmic Emergencies

OB

Code Description

50 Emergency Childbirth

51 Maternal Care

52 Newborn Care

53 Prolapsed Cord

54 Breech Birth

55 Pre-Eclampsia

56 Third Trimester Bleeding

57

58

59

Pediatric

Code Description

60 Pediatric Bradycardia

61 Pediatric VF/Pulseless VT

62 Pediatric PEA

63 Pediatric Asystole

64 Pediatric Diabetic Emergencies65 Pediatric Seizures

66 Pediatric Respiratory Distress

67 Pediatric Allergic Anaphylactic

Reaction

68 Pediatric Narrow Tachycardia

69 Pediatric Wide Tachycardia

70 Pediatric Altered Level of

Consciousness71 Pediatric Airway Obstruction


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St. Mary Medical Center ALS Protocol

Revision Sheet

Revision Date Codes Amended System Approval Medical Director Approval Comments


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Code 1

Routine Medical Care

1. Perform Scene Survey and ensure the safety of all personnel.2. Reassure patient, provide comfort, and loosen tight clothing.3. Place patient in position of comfort.4. Assess and maintain ABCs.5. Supplemental oxygen at 2-6 L/min nasal cannula

10-15 L/min mask

6. Perform EKG And perform 12-lead if indicated7. Obtain IV access if appropriate, Attempt x 2-3. See IV Access Appendix.8. Contact receiving hospital as soon as patients condition permits.

Transmit assessment information. Contact supervising hospital as needed.

9. Recheck vitals every 15 minutes for stable patients and every 5 minutes for unstablepatients and record on the run form with proper times noted.

10. Transport to the closest most appropriate hospital.11. If medical direction is ever needed you may speak to a St. Mary Medical Center ER

Physician at (219) 947-6232.

Note: In a combative or uncooperative patient, the requirement to initiate routine patient care,

as written, may be altered or waived in favor of rapidly transporting the patient for definitive

care. Document the patients actions or behaviors which interfered with the performance ofany assessments and/or interventions.

SAMPLE HISTORYS= Signs & SymptomA= Allergies

M= Medications

P = Past History

L= Last Oral Intake

E= Events Leading To

Incident or Illness

Trauma AssessmentD= Deformity

C= Contusions

A= Abrasions

P= Puncture

B= Burns

T= Tenderness

L= Lacerations

S= Swelling

Medical AssessmentO= Onset

P= Precipitating

Q= Quality

R= Radiating

S= Severity

T= Time

Level of Consciousness

A= ALERT

V= VERBAL STIMULI

P= PAINFUL STIMULI

U= UNRESPONSIVE

* Nausea/Vomiting

If no contraindications

are present, may

administer a one time

dose of zofran 4mg IV


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Code 2

Radio Re ort

Outline for Radio Report(Transmitting as few words as possible)

1. Name and unit number of provider.2. ALS or BLS designation3. Age, Sex, and approximate weight of patient.4. Chief complaint, to include symptoms and degree of distress.5. Level of consciousness, orientation.6. Vital signs (include pain scale)7. Clinical condition: Focused and detailed patient assessment findings (only pertinent +/- findings)8. History of present illness/injury.9. History: allergies, medications, past history, last oral intake, events surrounding incident.10. Treatment rendered and response.11. Destination and ETA

Trauma

1. Name and unit number of provider.2. Age, Sex, and mechanism of injury.3. Chief complaint, to include symptoms and degree of distress.4. Level of consciousness, orientation.5. Vital signs (include pain scale)6. Focused and detailed patient assessment findings (only pertinent +/- findings)7. Medical history: allergies, medications, past history, last oral intake, events surrounding incident.8. Treatment rendered and response.9. Destination and ETA.

Mass Casualty Incident

1. Name and unit number of provider.2. Approximate number of victims and approximate triage levels: green, yellow, red, black.3. Mechanism of injury.4. Report any scene hazards.5. Medical communication should utilize the IHERN radio frequency unless otherwise specified by

local plans.


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Code 3

Accelerated Trans ort

Certain situations require treatment within minutes. These situations occur when a problem is discovered in the primary

survey that cannot be rapidly resolved by field intervention. Only airway and spinal immobilization should be managed prior totransport. Further efforts at stabilization should be performed en route and should not delay transport.

If circumstances demand hospital care for patient stability, rapid transport is indicated. Each case will be unique and

compelling reasons must be documented. Notify receiving hospital of the situation so that preparations can be made. Primary

resuscitative measures must be initiated. Contact receiving hospital/medical control ASAP.

Examples include, but are not limited to:

Inability to secure airway Severe head trauma Profound shock Respiratory failure Penetrating wounds to chest, neck, abdomen Trauma arrest Pediatric arrest

Trauma Transports

Consider transporting to the nearest appropriate Trauma Center (Within a 45 minute transport time) whenyour patient meets these criteria:

They fall under Level I or II under the CDC 2011 Field Triage Guidelines. (See ALS Appendicies)

A thorough assessment determines that your patient is stable enough to endure a 45 minute transport time.

The EMS personnel can be reasonably certain that the transport time will take no longer than 45 minutes

taking into account weather conditions, traffic problems, construction, etc.

If any of the above conditions are not met, then transport to the closest appropriate Emergency Department.

If any questions arise, contact Medical Control.


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Code 4

Refusal of Services

Begin evaluation and care

The patient refuses care

Altered Mental Status

(i.e., alcohol, drugs, head trauma,

mental retardation, etc.)

If No, Age >18 years, (unless

emancipated or parent or guardian

present)

Altered medical decision capacity?

If yes, Deny refusal and refer to

appropriate SOP

1. Document situation in all cases of refusal and contact medical control as needed.2. List the presence or absence of factors that enable refusal.3. For refusals, initiate a refusal form. Obtain a full set of vital signs, if patient refuses, document the refusal.4. List the consequences of refusal and have each refusing patient or guardian sign.5. Each refusing patient should be evaluated and each should sign a refusal form.6. If a patient wishes to refuse, and yet will not sign the refusal form, document the situation on the EMS report

form.

7. All personnel who witness the event should sign the EMS report form.8. Patients signature should be witnessed by family, friends, police,(EMS personnel when no one else is available).9. For minors, attempt to contact parents or adult caregiver to inform them of situation. Obtain phone consent of

refusal and document who you spoke with.


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General Guidelines:

-Provide comfort care and compassion for the patient.

- Treat acute airway obstruction, even if intubation is required.

- Treat problems not specifically listed (i.e., atropine for symptomatic

Bradycardia with

Code 5

DNR, Out of Hospital

DNR

Identify Patient

Identify Valid DNR

Orders

Revocation of a Valid

DNR Order

Care Instructions

Cause of action prescribed by a physician to withhold resuscitation measures on a

victim of cardiac arrest.

- Pre-hospital personnel must make a reasonable attempt to verify the

identification

of the patient named in a valid DNR Order.

- Patient should be a resident of a long-term care facility; hospice patient;

home

care patient; or inter-hospital transfer.

- Must contain the following information:

1) State form #49559 (Indiana State Form)2) Patients name and signature (or legal representative)3) Name and signature of attending physician4) Effective Date5) Signature of witnesses- The patient, physician who signed the DNR Order, or the consenting party to

the DNR

Transport


9/52

Code 6

Hazardous Materials

Scene survey: Ensure scene safety

Request additional resources

Isolate scene, Notify Medical Control and receiving hospital ASAP

Identify hazard (DOT Emergency Response Guide)

Product Name, U.N. number, STML number, MSDS, Container Type

Maintain Airway, Administer 100%

oxygen

IV Normal Saline TKO

Cardiac Monitoring

Treat per SOP:

Shock, Arrhythmias, PulmonaryEdema, Seizures, Burns, Hypothermia

Unconsciousness, Wheezing

If indicated, flush skin with copious amounts of water

Other Treatment: per Medical Control

Transport


10/52

Code 7

Mass Casualt Incident Res onse

Basic IMS Structure

Incident Command

Safety Officer

Medical Command

Treatment StagingTriage Supply Transport

With this format, resources can be managed for any size incident, large or small. Medical communication should

utilize the IHERN Radio frequency, unless otherwise specified by local plans.

The use of the S.T.A.R.T. triage system wi ll help maintain the continuity of care and control of every victim,injured or uninjured. Every victim will be placed into one of the four Triage categories listed below with

necessary information completed on the corresponding Triage tags.

Green Yellow Red Black

Minor Injuries

Uninjured

BurnsFractures

Non-life Threats

Multi-SystemTrauma

Head Injuries

Chest TraumaLife-Threats

Dead PatientsNon-salvageable

Patients


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Code 8

Abdominal

Routine Patient Care

Position Patient for Comfort

Assess Pain Level

Administer 0.9% Normal Saline Bolus

250-500cc

I f nausea and vomiting occur and no

contraindications are present, may

administer 4mg Zofran IV

Monitor patient conditionIf continued pain and SBP greater than 100mmHg,

may administer morphine 2-4 mg IV

Transport

* Analgesic AlternativePatients with right flank pain and

history of kidney stones with nocontraindications mayreceive

Toradol 30mg IV.

If unsure, contact medical control


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Code 9

Pain Management

Routine Patient Care

Position Patient for Comfort

Assess Pain Level (0-10)Appropriate splinting, ice, positioning

Indications

1. Extremity injury (including hip and shoulder injury)2. Back or flank pain3. Burns4. Chest Pain5. Crush Injuries6. Minor Traumatic Injuries

CONTACT MEDICAL CONTROL FOR OTHER

INDICATIONS OR UNSURE OF DOSAGE

Contraindications

Contact Medical Control prior to administration of pain medication if any of the

following are observed:1. Altered level of consciousness, any etiology

2. Hypotension, auscultated BP less than 90 mmHG

3. Respiratory compromise, hypoxemia4. Mechanism of injury meeting multi-system trauma criteria

5. Pregnancy

6. Known allergy or hypersensitivity to pain medication

7. Toradol may only be given to patients 15-70 years old, no renal/dialysis patients,

no diabetics, no NSAID/ASA allergies.

May administer:

1. Toradol 30 mg IV2. Morphine Sulfate 2-4 mg slow IV / IO every five (5) minutes until pain

resolved, or to a total of 10mg in adults. Burn patients up to a maximum of

20 mg.

OR

Fentanyl 25-50 mcg slow IV / IO with 1 repeat dosage

3. May administer MORPHINE SULFATE 5 10 mg IM or FENTANYL 50-100mcg IM if unable to establish IV.

4. Weight based dosing of morphine is 0.1 mg/kg IV for patients


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Consider medical controlcontact (for Nitro order

and/or MS orders)

Code 10

Suspected Cardiac Patient(Based on chest pain or equivalent)


SBP < 90 mmHg SBP > 90mm Hg

Nitroglycerine 0.4mg SL or spray

May repeat X2. (if no IV, considerhospital contact prior to

administration).

Transport

Repeat Vital Signs

Note:

Contraindications to ASA would include ASA allergy,

Asthma, active bleeding or inability to swallow.

Thrombolytic Checklist

Clinical Presentation

Y N Chest Pain

Y N Unrelieved with Ntg x3

Y N Last > 30 Minutes

Contraindications to Thrombolytics

Y N History of CVA or TIA (6mo)

Y N Active Internal Bleeding

Y N Hx of Bleeding Disorders

Y N Uncontrolled HypertensionY N Intracranial or Intraspinal surgery past 2 months

Y N Intracranial or Intraspinal neoplasm, AVM or aneurysm

Y N Hx Trauma or Surgery Within 2 weeks

Y N PregnancyY N Previous Thrombolytic Use

Y N Recent (1 month) Head Trauma

Y N Suspected aortic dissectionY N Suspected Pericarditis

4 baby ASA (324MG) chew

and swallow

Transport

MS 2mg slow IV to a maximum of 10

mg for chest pain as needed. UseNarcan 2 mg IV to reverse effect if

necessary. Repeat vitals after q 2 mg

4 baby ASA (324MG) chew and

swallow unless contraindicated

12-lead

12-lead

If 12 lead EKG is positive for

STEMI, notify receiving hospital ofa Cardiac Alert


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Code 11

Pulmonary Edema


SBP100mm Hg

Lasix40mg IV push

(may double home dose up to 80mg)

Refer to Cardiogenic Shock Code 12with limited fluid bolus of 200ml NS

TransportNitroglycerine 1.2mg SL

or spray.

May repeat every 5

minutes X2. If no IV,

consider hospital contact

Administer Morphine

2-4mg increments to a maximum

of 10 mg IV Push

Contact Medical Control for

additional medication

Transport

* Consider initiating the use of

CPAP with patients in respiratory

distress associated with pulmonary

edema. If CPAP does not improve

patient condition consider

intubation as per protocol.


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Code 12

Cardio enic Shock


SBP < 100mm Hgwithout Dysrhythmias

SBP > 100mm Hgwith Dysrhythmias

Transport ASAP Treat underlying dysrhythmia and

transport ASAP

IV NS fluid challenge in200ml increments up to

1000ml (if lungs are

clear)

SBP > 100mm Hg

YES NO

Continue Routine

Medical Care and Rapid

Transport

Dopamine drip at5-20mcg/kg/min titrate

to maintain SBP >

100mm Hg

Continue Routine MedicalCare and Rapid Transport

Dopamine Drip Chart

400mg/250ml D5W

Starting Drip Rate (5mcg/kg/min)

WeightLb Kg Hypotension

88 40 8gtts/min

99 45 8 gtts/min

110 50 9gtts/min

154 70 13gtts/min

176 80 15gtts/min

198 90 17gtts/min

209 95 18gtts/min220 100 19gtts/min

253 115 22gtts/min


17/52

Code 13

Premature Ventricular Contractions

Do not treat PVCs unless directed by medical control.

See VT protocol if necessary



18/52

Code 14

*may give double the dose via ETT

As stole

Assess and Maintain CABs

Begin CPR within 10 seconds of finding pulses absent

EKG Monitor(Confirm asystole in 2 leads)

Intubate & ventilate with 100%

Oxygen

Establish IV/IO access

Consider possible

causes and treatments:

**Administer Epinephrine 1:10,000*1mg IVP/IO

May repeat every 3-5 minutes

Consider Sodium Bicarb Administration0.5-1.0mEq/kg IVP/IO for extended down

time

Transport

Possible Causes & Management:

Hypoxia:

Confirm ET tube placement

Pre-oxygenate with 100% Oxygen

Hypovolemia:Administer IV/IO bolus 20ml/kg

Tension Pneumothorax:

Perform needle decompression

Overdose:

Administer Naloxone 2mg IV/IO push

Consider D50if hypoglycemic

Electrolyte imbalance (Dialysis Patient):

Consider CaCl 10ml IV/IO push

Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO

Consider D50 if hypoglycemic

Consider Magnesium Sulfate 12 gm IVP/IO

Acidosis:

Confirm adequate airway tube placementPre-oxygenate with 100% Oxygen

Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO

Hypothermia:

Passive rewarming

Active rewarming

*IO insertion may be consideredif no other IV access is available

*May give 1 dose of vasopressin 40 UIV/IO to replace first or second dose of

epinephrine.

ROSC? Induce Hypothermia

(See Appendices)


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Consider Magnesium Sulfate (see insert)

Code 15

Ventricular Fibrillation / Pulseless V-Tach

Assess and maintain CABs

Begin CPR within 10 seconds of finding pulses absentdefibrillate at maximum joules

(360j monophasic) or biphasic (200j)

resume CPR immediately

Rh thm after first 5 c cles of CPR?

Persistent VF/VT Return of Spontaneous

Circulation

PEA

Refer to Code 18

Asystole

Refer to Code 14

CPR, Intubate, IV

Defibrillate at maximum joules

Epinephrine(1:10,000) 1mg IVP/IO

or 2mg ETT *(see insert)

Repeat every 3-5 minutes

Consider an Anti-arrhythmic:

Consider Amiodarone bolus: 300mg IV/IO

Repeat Amiodarone @ 150mg IV/IO

OR

Lidocaine 1-1.5mg/kg IVP/IO

Repeat Lidocaine @ .5 1.5mg/kg

Continue drug-shock-drug-shock sequence

Routine Medical

Care

Lidocaine 1-1.5mg/kg IVP/IO

Begin Lidocaine drip at

2mg/min

Transport

Lidocaine Drip: (premixed) (2 gm/500ml)

60 gtt tubing =

Drops/min = 15 30 45 60

mg/min = 1 2 3 4

Titrate to effect

Magnesium Sulfate: dilute 1gm in 10ml NS. Give

slow IVP/IO or dilute 1gm in 100ml NS and give

rapid IV drip.

*May give 1 dose of vasopressin 40 U IV/IO to

replace first or second dose of epinephrine.

*IO insertion may be considered

if no other IV access is available

Consider Calcium Chloride if dialysis patient.

Consider Sodium Bicarb Administration0.5-1.0mEq/kg IVP/IO

Induce Hypothermia

(See Appendices)


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Code 16

Bradycardias


Protocol

Hemodynamically Unstable Patient

(Signs of hypoperfusion or altered

mental status)

Administer Atropine 0.5-1.0mgIV/IO*

May repeat every 3-5 min

(max dose 0.04mg/kg or 3.0 mg total)

Consider External Pacing at rate

of 70, increase mA until capture.

May sedate if conscious,

Administer Versed 2.5 5 mg IV or

Diazepam 2-10mg slow IV

(Contact medical control foradditional sedation

Consider Dopamine 5mcg/kg/min

IV/IO Drip

(See chart)

to maintain SPB > 100mm Hg

Transport

Hemodynamically Stable Patient

Continue monitoring

Transport

Note:

1. Signs of hypoperfusion include: severe chest pain, severe SOB, SBP < 100mm Hg,diaphoresis, altered mental status.

2. Do Not delay transcutaneous pacer while awaiting IV/IO access or for Atropine to takeeffect if patient is symptomatic.

3. Do not give Lidocaine to patients with AV blocks, idoventricular rhythm, or severehypoperfusion.

Dopamine Drip Chart400mg/250ml D5W

Starting Drip Rate (5mcg/kg/min)

Weight

Lb Kg Hypotension

88 40 8gtts/min

99 45 8 gtts/min

110 50 9gtts/min


198 90 17gtts/min


253 115 22gtts/min

*May double-dose via ETT




21/52

Code 17

Tachycardias (with pulse)

(of Cardiac Origin)

Routine Medical Care Protocol

Consider non-cardiac causes and treatment

Stable

Patient is alert, without any signs of

hypoperfusion

Unstable

(signs of hypoperfusion)

Narrow Complex*

( RS 0.12 sec)

Vagal Maneuvers x 2Lidocaine 1.5mg/kg

Lidocaine 0.75mg/kg

Supraventicular tachycardiaAdenosine (Adenocard) 6mg Rapid IVP

Followed by 12mg Rapid IVP

May Repeat x1.

If no result, consider cardizem.

Continue Routine Medical Care and Transport

Consider sedation with Versed

2.5 5 mg slow IV or

Diazepam (Valium) 2-10 mg slow IV

(if conscious)

Synchronized Cardioversion @ 100J

(no response-200J)

(no reponse-360J)(or bi hasic e uivalent

Wide Complex

Lidocaine 1.5mg/kg

SynchronizedCardioversion @ 360J

Or biphasic equivalent

Narrow Complex

Contact MedicalControl

Accelerated

Transport

Note:

1. Signs of hypoperfusion: severe chestpain, severe SOB, SBP.12sec.

At Discretion of Physician or Radio Nurse:Adenosine (Adenocard) for children < 15 yrs. 0.05mg/kg may be increased to 0.1mg and

0.15mg/kg maximum 12mg/dose. Bolus 5-20ml saline.

Cardioversion for children < 15 yrs., 0.5J/kg up to 1.0J/kg

Fluid Bolus for Hypotension.

For uncontrolled SVT, atrial fibrillation or atrial flutter

administer Cardizem (diltiazem)

0.25mg/kg initial and 0.35 mg/kg for the repeat, with a max

dose of 20mg and 25mg respectively

*0.12 seconds = 3 small boxes


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Code 18

Pulseless Electrical Activity (PEA)

Assess and maintain CABs

Begin CPR within 10 seconds of finding pulses absent

Intubate and Ventilate with 100% Oxygen

Apply and interpret EKG

Establish IV Access

Apply Pulse Oximetry (if available)

Consider Causes and Treatment

Administer **

Epinephrine 1:10,000

1mg IV/IO Push or 2 mgETT

May repeat every 3-5 min

Monitor Patient Condition Initiate

Transport

Contact Medical Control

Causes and Management:

Hypoxia:

Confirm ET tube placement

Hyperventilate with 100% Oxygen

Hypovolemia:

Administer IV/IO Bolus 20ml/kg

Repeat as needed

Tension Pneumothorax:

Perform Needle Decompression

Overdose:Refer to Code 23

Electrolyte imbalance (Dialysis Patient):Consider Calcium Chloride 10ml IV/IO Push

slowly

Consider Sodium Bicarb 1-2mEq/kg IV/IOConsider D50if hypoglycemic

Consider Magnesium Sulfate 1 gm IVP/IO

Acidosis:

Hyperventilate with 100% oxygen

Consider Sodium Bicarb 1-2mEq/kg IV/IO

Hypothermia:

Passively rewarm

Actively rewarm



***May give 1 dose of vasopressin

40 U IV/IO to replace first or

second dose of epinephrine.

ROSC? Induce Hypothermia

(See Appendices)


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Code 19

Airwa

Assess and Maintain ABCs

Conscious Patient

(Unable to Speak)

Unconscious Patient

Position Patient Supine

Perform 5 Chest Thrusts

Clear Airway &Ventilate

Repeat if NecessaryPerform Heimlich Maneuver

Provide support for patient

Cleared Obstructed

Administer

supplemental

oxygenRe-assess

Patient Condition

Repeat Heimlich or

Abdominal Thrusts

Clear Airway & Attempt

Ventilation

Initiate Transport


Monitor Patient Condition

If still obstructed refer to

unconscious patient

Remains Obstructed

Attempt to visualize obstruction &

remove with Magill forceps

Ventilate with 100% Oxygen

Remains Obstructed

Consider appropriate

Cricothyroidotomy procedure

Assess & Maintain Airway

If still unable to ventilate, intubate

and pass tube pushing foreign body

into right mainstem bronchus, then

pull back tube and ventilate left lung

Transport STAT


24/52

Code 20

Asthma/COPD with Wheezing

Routine Medical Care *Prepare and initiate Transport

Begin Albuterol (2.5mg) Nebulizer Treatment(May repeat times 3)

For severe cases consider adding a one time

dose of 0.5 mg Atrovent to the albuterol

nebulizer treatment.

Patient Improving?

Yes No

Monitor Patient Continue

Transport

Transport

Consider administration of 125mg

Solumedrol IV Push for continued

dyspnea, if taking Prednisone p.o. or

Cortisone Inhalers

*Do not withhold oxygen to COPD patients in acute, severe distress. Be prepared to

support patients respirations or intubate, if necessary.

If patient < 50 years old

and Pulse < 150

and no history of heart diseaseand patient not having chest pain

Administer Epinephrine 1:1,000

0.1mg - 0.3mg SQ or IM

* Consider initiating the use of

CPAP with conscious patients inrespiratory distress. If CPAP

does not improve patient

condition consider intubation as

per protocol.


25/52

Code 21

Allergic Reaction/Anaphylactic Shock

ABCs


Remove insult

Cryotherapy to bite, sting

Mild

Local reaction onlyLocal redness, itching etc.

Alert, oriented, normo-tensive

SevereAny respiratory distress, severe allergic symptoms, altered

level of consciousness, hypotensive

Transport

Cool packs to site

(if not contraindicated)

Moderate

Generalized itching, hives etc.

Mild respiratory signs/symptoms

normotensive

Benadryl

25-50 mg slow IVP

Epinephrine (1:1,000)

0.3-0.5 ml subQ or IMor

Epi-pen

If wheezing or respiratory

symptoms, Albuterol Nebulizer

May add .5mg atrovent x1

Transport ASAP

If severely compromised, attempt intubation. Ifunsuccessful: appropriate cricothyroidotomy procedure

IV wide open

If IV present:

Epi (1:10,000): 0.5mg slow IVP. May repeat in 3-5min.If no IV present:

Epi pen or Epi 1:1000 subQ (0.5ml) or IM or

Benadryl 25-50 mg IVP (may give IM if no IV)

Albuterol/Atrovent

Nebulizer

(if able)

Dopamine drip

Transport STAT

Dopamine Drip Chart

400mg/250ml D5WStarting Drip Rate (5mcg/kg/min)

Weight

Lb Kg Hypotension88 40 8gtts/min

99 45 8 gtts/min

110 50 9gtts/min

154 70 13gtts/min

176 80 15gtts/min

198 90 17gtts/min

209 95 18gtts/min

220 100 19gtts/min

253 115 22gtts/min


26/52

Code 22

Diabetic Emer encies


Obtain Random Blood Sugar*

Blood Sugar 180mg/dl

Signs & Symptoms of ketoacidosis

Administer 50% Dextrose 50ml IVP (slow)

or

Administer Glucagon 1mg IM

(if unable to establish IV access)

If no response, may repeat

50% Dextrose 50ml IVP


Recheck blood sugar

Transport

Administer 250ml IV Bolus

of NS

If lungs remain clear, repeat 250ml bolus


Transport

Note to Pre-hospital Personnel:

If after treatment, patient is awake, alert, and

competent, and refuses transport, contact medical

control for assistance*If unable to obtain blood sugar in an unconscious,

known diabetic, administer 50% dextrose IV or

GlucagonIM.


27/52

Code 23

Dru Overdose


Obtain Random Blood Sugar

Treat per suspected overdose:

Narcotic: (Respiratory depression, pinpoint pupils)Narcan (Naloxone): 2mg IVP to a maximum of 6mg

Cyclic: (wide QRS, hypoperfusion)

IV wide open

Sodium Bicarbonate: 1mEq/kg IVP

Beta/Calcium Channel Blockers (Bradycardia, hypoperfusion): Glucagon 1mg slow IVP. May repeat X 1

For known meth-amphetamine type overdose, i.e. Bath Salts,: Consider ativan 1-2 mg IV/IM for extreme agitation.

Call medical control for any additional orders.

Narcotic or Synthetic Narcotic: Morphine, Demerol, Heroin, Methadone, Codeine, Fentanyl, Vicodin,Hydrocodone, Dilaudid, Darvon.

Tricyclic antidepressants include: Elavil, Amtiriptyline, Triavil, Norpramine, Tofranil, Pamelor, Sinequan,

Ludiomil, Desyrel, Clomipramine (Anafranil), Endep, Doxepine (Sinequan),

Imipramine, Trimipramine (Surmontil), Amoxapine (Ascendin), Despramine

(Norpramin), Nortriptyline, Aventyl, Protriptyline (Vivactil).

Benzodiazepines: Halcion, Ativan, Centrax, Doral, Restoril, Versed, Valium, Xanax, Librium,

Klonopin, Dalmane, Rophynol.

Beta-Blocker: Enderal, Corgard, Lopressor, Atenolol, Labetalol, Propanolol,

Calcium Channel Blocker: Cardizem, Procardia, Calan/Verapamil/Isoptin/Adalat, Diltiazem

Code 22 for diabetic

emergencies

Manage ABCs


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Code 24

Coma (No History of Trauma)


Assess Level of Consciousness

Glasgow Coma Scale

AVPU Scale

Wave ONE broken Ammonia

Capsule under patients nose

Note Response


Consider Naloxone (Narcan) 2mg IVP Slowly


Secure Patient Using Spinal Precautions(if indicated)

Protect airway.

Transport

If Diabetic Emergency

Refer to Code 22

Identify Possible

Causes:

A = Alcohol

E = Endocrine

I = InsulinO = Oxygen/Opiates

U = Uremia, Renal

T = Trauma

I = Infection

P = Psychiatric

S = Space occupying


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Code 25

Seizures


Protect patient from injury

Protect Airway


If seizure activity last > 2-3 minutesAtivan 1-2mg IVP Slowly

May give Ativan 2 mg IM if unable to obtain IV

Monitor respiratory status closely and be

prepared to support patient

Observe patients sensorium during

postictal period. Note any injuries

incurred and/or incontinence

Transport

Treat as per Code 22 if

Hypoglycemic

If allergic to ativan may administervalium 2-10mg IV

(titrate to end seizure activity)


30/52

Code 26

Stroke/ Brain Attack


100% Oxygen

Limit scene time

Obtain stroke time of onset

Random blood glucose

treat per protocol

Monitor respiratory status closely

and be prepared to support patient

Perform Pre-hospital Stroke Scale

Transport Family member with

patient to hospital if possible

Notify Receiving Hospital of Stroke Alert i f Pre-

hospital stroke scale is positive

Pre-hospital Stroke Screen

1. Facial Droop (ask patient to show teeth or smile).Normal-(Both sides of face move equally well).

Abnormal-(one side doesnt move as well as other).

2. Arm driftNormal-Both arms remain steady

Abnormal-(one arm doesnt move at all or drifts

down as compared to other arm).

3. Speech (Have the patient say, Its a sunny day atSuperior).

Normal-Clear speech

Abnormal-(patient slurs words, says wrong words,unable to speak).

4. Glucose level5. Symptom duration6. Hx seizures?7. Anticoagulant therapy? (Coumadin, Ticlid)


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Code 27

Near Drownin

Initial Trauma Care(C-spine precautions as indicated)

100% OxygenEstablish and maintain airway

Intubate if Necessary

Remove wet clothingConsider hypothermia

Awake, alert, or semiconscious withpurposeful response to pain, normal

respirations and pupil response

Comatose, unresponsive to verbalstimuli, abnormal response to pain,

abnormal respirations or pupil

response

TransportBegin CPR if indicated

Hypothermic

See Cold EmergenciesCode 28

Transport

Normothermic

Treat dysrhythmias perappropriate SOP

Transport


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Code 28

Cold Emer encies

Move Patient to a warm environment

as soon as possible

Frostbite Severe HypothermiaSystemic Hypothermia

Mild/Moderate 95-90F (35-32C):

Conscious or altered sensorium

with shivering

Oxygen 10-15L/mask

IV NS TKO

Re-warm patient

Place patient in a warm

environment.

Remove wet clothing.Apply hot packs wrapped in towels

to axilla, groin, neck, thorax.

Wrap patient in blankets.

Transport ASAP

Rapidly warm frozen area with tepid

water (105F)

Hands or hotpacks wrapped intowels may be used. DO NOT RUB.

Do not thaw if there is a chance of

refreezing.

-Handle skin like a burn

-Protect with light sterile dressings.

-Do not let skin rub on skin (between

fingers or toes.

Cover with warm blankets and

prevent re-exposure.

Transport

90F or less (


33/52

Code 29

Heat Emergencies

Move patient to a cool environment

Initial Medical Care

Heat Cramps or Tetany

(IV may not be necessary)

Allow for oral intake of water or electrolyte replacement

fluids

Do not massage cramped muscles

Transport

Heat Stroke

100% 02Manage Airway

IV NS boluses (200ml) up to1000ml -or-

SBP>100

(check lungs after each bolus)

Heat Exhaustion or Syncope

IV NS rapid rate

Place patient in supine position with feet

elevated Trendelenberg

Remove as much clothing as possible to

facilitate cooling

Transport

Seizure precautions(Code 25 if seizures)

Initiate rapid cooling:Remove as much clothing as possible.

Cool packs to lateral chest wall, groin, axilla, carotid arteries, temples, and

behind knees and/or sponge with cool water or cover with wet sheet and

fan body. Wet head if possible, avoid shivering.Transport

Position with head elevatedunless contraindicated

Rapid cooling while preparing IV


34/52

Code 30

Ps cholo ical Emer encies

I. Purpose/DefinitionGiven the magnitude of the problems of abuse and violence in our society, early detection of domestic violence

victims, appropriate legal and social service referrals and the delivery of timely medical care are essential.

Domestic violence is a pattern of coercive behavior engaged in by someone who is or who was in an intimate

relationship with the recipient. These behaviors may include: repeated battering, psychological abuse, sexual assault

or social isolation such as restricted access to money, friends, transportation, healthcare or employment. Typically,

the victims are female but it must be recognized that males can be victims of abuse as well.

II. Domestic Violence IndicatorsWhile sometimes the specific history of abuse is offered, many times the victim of abuse, (either out of fear or

because of the coercive nature of the relationship or out of the desire to protect the abuser) will not volunteer a true

history but instead ascribe injuries to another cause. Therefore, an appropriate review must be undertaken with

respect to patients presenting with injuries:

-That do not seem to correspond with the explanation offered.

-That are of varying ages.-That have the contour of objects commonly used to inflict injury (i.e. hand, belt, rope, chain, teeth, cigarette)

-During pregnancy

Other factors include:

-Partner accompanies patient and answers all questions directed to patient.-Patient reluctant to speak in front of partner.

-Denial or minimalization of injury by partner or patient.

-Intensive, irrational jealously or possessiveness expressed by partner.

Physical injuries commonly associated with domestic violence:

-Central injuries, specifically to the face, head, neck, chest, breasts, abdomen, or genital areas.

-Contusions, lacerations, abrasions, stab wounds, burns human bites, fractures (particularly of nose and orbits), andspiral wrist fractures.

-Complaints of acute or chronic pain without tissue injury

-Signs of sexual assault-Injuries or vaginal bleeding during pregnancy, spontaneous or threatened miscarriage

-Multiple injuries in different stages of healing

Direct impact of domestic violence on pregnancy may include:

-Abdominal trauma leading to abruption, pre-term labor, and delivery-Fetal fracture

-Ruptured maternal liver, spleen, uterus

-Antepartum hemorrhage

-Exacerbation of chronic illness


35/52

Code 30 (Continued)

Code 31

III. Approaches for Interviewing the patientThe goals of the physical examination are to identify injuries requiring further medical intervention and to make

observations and collect evidence that may corroborate the patients report of abuse. A thorough physical examination isessential to uncover hidden injuries or compensated trauma. If the patient reports sexual assault, the sexual assault

protocol should be followed:

-Always interview the patient in a private place, away from anyone accompanying them to the ED. Questioning the patient

in front of the batterer may place the patient and any children in danger.

-You may be the first person or professional to acknowledge the abuse. It is important that you convey your concerns

about what has happened to the patient to the Emergency Physician and Nurse.

-When interviewing, do not ask patients if they were battered or abused (many battered persons do not consider

themselves in this light). Instead, you can ask the patient:

Have you had a fight with someone?

Did anyone hurt you?Many times we have seen these types of injuries in patients who are hurt by someone else, did someone hurt you?

I am concerned that someone may be hurting you or scaring you, can you tell me what has happened?

-Most battered persons feel very shamed and humiliated about what has happened to them.

It is important to acknowledge that you understand how difficult it is to talk about what happened.

-Most battered persons will minimize the abuse or blame themselves for what happened.

It is important that you repeatedly reinforce that no one deserves to be hurt no matter what they may or may not have

done.

-Questions/attitudes Not to ask/Express:

-What keeps you with a person like that?

-Do you get something out of violence?

-What did you do at the moment that caused them to hit you?

-What could you have done to avoid or defuse the situation?

IV. Practice-Treat obvious injuries: transport

-Report your suspicion and supporting findings to the Emergency Department Physician and on the prehospital report form.

-If the patient refuses transport, make appropriate referral and documentation on run sheet.

-Document your findings on the prehospital report form:-Presenting condition.

-Any suspicious indicators.

-Physical exam including any evidence of abuse.-Treatment rendered.


36/52

Implanted Cardiac Defibrillation

(ICD, PCD, AICD)

1. Treat Dysrhythmias per appropriate SOP.2. If external defibrillation is required:

Avoid placement of pads or paddles over the ICD unit or path of wires (if possible) Defibrillate at 360 joules or biphasic equivalent; repeat as indicated

3. If ICD is repeatedly firing and patient is stable, may administer sedation order (Versed in 2mg increments)


37/52

Code 32

Medication Assisted Intubation

Indications:1. Patients with actual or potential airway compromise due to

altered mental status, GCS less than 8.

2. Patients whose combativeness and agitation threatens theairway or spinal cord stability.

3. Patients who demonstrate a high probability of airwaycompromise for any reason prior to, or during transport.

4. Patients requiring ventilator assistance or airway protection.5. CONTACT MEDICAL CONTROL PRIOR TO

USE.

Premedicate:1. Lidocaine: 1.5 mg/kg IV, IO (utilize for patients with a

head injury)

2. Atropine : 0.5 mg/IV,IO for adult patients withbradycardia

Induction:1. Versed 2.5 5 mg IV, IO

ORAFTER CONSULTATION WITH MEDICAL CONTROL:

2. Etomidate 0.3mg/kg IV, IO, may repeat one time

Post Intubation Sedation:1. Versed 2mg IV, IO increments unless patient is hemodynamically unstable.2. Ativan 1-2 mg IV, IO may also be used for post intubation sedation unless patient

is hemodynamically unstable.

3. Etomidate 0.3mg/kg IV, IO may be utilized one time for post intubation sedation.4. Consider pain management with patients with high probability of pain and

normal sedation is not working adequately. Follow pain management protocol

where indicated.

Etomidate dosing chart0.3 mg/kg IV

Weight

Lb Kg Dose

88 40 12 mg IVP

99 45 13.5 mg IVP

110 50 15 mg IVP

154 70 21 mg IVP

176 80 24 mg IVP

198 90 27 mg IVP

209 95 28.5 mg IVP

220 100 30 mg IVP

253 115 34.5 mg IVP


38/52

Code 33

Hypertensive Crisis

Aggressive

prehospital

treatment of the

A hypertensive emergency exists when the systolic blood pressure is > 200mmHg or diastolic BP is > 100mmHg

and the patient is symptomatic. Symptomatic examples include but are not limited to headache, diaphoresis,

chest pain. Contact medical control prior to any medication administration if patient has signs and symptoms

of CVA. Pregnant patients with hypertension follow protocol 55.

Establish Code 1

Nitroglycerin 0.4mg SL. May repeat

every five minutes up to three doses, if

no relief and systolic blood pressure

>100 mmHg

If no improvement, administer Lopressor

(metoprolol) 5mg IV over 1-2 minutes. Repeat 5mg

IV every 5 minutes up to three doses.

Code 33


39/52

Code 39

Poisoning Toxic Ingestion or Exposure


Maintain ABCs

1. Exposure protection as indicated2. Contact Poison Control 1-800-222-12223. Be prepared for seizures4. Be prepared for vomiting

Bring all medication, poison bottles to the hospital (unless HAZMAT)

Monitor closely

Do not induce vomiting

Contact medicalcontrol for permission

to Administer activated

Charcoal*

Adult dose: 50gm

Pediatric dose: 1 gm/kg

Transport STAT

Conscious Patient Unconscious Patient

Support ABC's

Recovery position

Be Prepared to SuctionMonitor closely

Treat per appropriate protocol

Transport STAT


40/52

Code 40

Routine Trauma Care

Assess Scene Safety

(Consider Crime Scene)

Body Substance Isolation

Primary Patient

Assessment

Resuscitation:

Secure & maintain airway Perform spinal immobilization Transport as soon as possible

performing treatment enroute

Establish TWO (2) large-bore IVsenroute (if able)

Evaluate ECG See analgesia insert

Analgesia Order

May give Morphine

Sulfate 2-4mg slow

IV repeating in 2mg

increments (max

10mg) or Fentanyl

25-50 mcg slow

IVfor:

severe burns isolated fx isolated crush amputationsCall medical control for

Secondary Patient Assessment: Vital Signs Systematic head-to-toe exam Obtain SAMPLE History Contact hospital as soon as patients

condition permits, transmit

assessment information and await

orders. Refer to appropriate protocolif unable to contact medical control

Re-assess patient

1) Airway:- secure with c-spine precautions- remove foreign bodies- provide 100% oxygen

2) Breathing:- assess rate: depth; and adequacy- note & manage JVD & tracheal deviation- inspect, palpate, auscultate, and percuss

the chest

3) Circulation:- stop life threatening hemorrhage- assess peripheral pulses- check capillary refill

4) Disability:- AVPU Score- motor & sensory exam- pupillary size and reactivity

5) Expose:- fully expose patient- log roll to evaluate back for injuries

Note to Pre-hospital Personnel:

- In a combative or uncooperative patient, the requirement to

initiate initial trauma care, as written, may be altered or waived in

favor of rapidly transporting the patient for definitive care.

Document the patients actions and behaviors which interferedwith the performance of any assessment and/or interventions.

- Initiate Trauma Alert for the following mechanisms of injury:

ejection from motor vehicle death in same passenger compartment falls greater than 20 feet pediatric falls of greater than 3 times the

height of the patient

pregnant patient of greater than 24 weeksgestation

Analgesia Alternative

May give 30mg Toradol IVP

Or 60 mg Toradol IM

Be aware of contraindications

*IO insertion may be

considered if unable to obtain

IV access


41/52

Code 41

Sus ected S inal Cord

Routine Trauma Care

Secure Airway with C-spine precautions

in-line intubation di ital etc.

Immobilize patient using backboard,

c-collar, blanket rolls or other

device, and secure patient to

backboard

Monitor for spinal shock

(low BP, normal HR or relative

bradycardia)

If no motor or sensory deficit, record as

such and transport

Vomiting precautionshave suction

ready, be prepared to log roll patient

if needed

Transport

Note to Prehospital Providers:1. Suspect spinal injuries in all patients

with:

A. Any head or facial trauma (ie.

injuries above the clavicle).B. Decreased or altered level of

consciousness.

C. Suspected deceleration injuries.D. Complaints of neck or back pain.

E. Physical findings suggesting neck

or back in ur .

Guidelines for Field Clearance of Cervical Spine

No reported or suspected loss ofconsciousness

No complaints of head, neck, back pain Must be alert and oriented x 3 No neuro deficits i.e. numbness,

tingling, confusion

Must weigh more than 100 pounds Must be less than 70 years of age and

greater than 18 years of age Must not have any history of

osteoporosis or other skeletal

conditions

No alcohol ingestion No midline cervical tenderness No significant mechanism of injury or

obvious distracting injury (high-speed

collision, open penetrating wounds,

dislocations, electrocution, high-impact

blunt trauma to the head)

* Please Note: These are guidelines, if there is

any question regarding the potential for acervical spine injury, the patient should be

boarded and collared.


42/52

Code 42

Hemorrhagic Shock

Routine Trauma Care

ABCs

Control significant external

hemorrhage

Initiate TWO (2) large-bore IVs

enroute

(Wide Open Rate)


Transport

If Patient in Cardiac Arrest:

Treat per appropriate

Treatment Protocol

*IO insertion may be considered if

unable to obtain IV access


43/52

Code 43

Head Trauma Unconscious Patient

Routine Trauma Care

Alert ?Yes No

Transport Record GCS

Record pupil size

100% oxygen

random blood glucose

- Sedation orders

Follow medication assisted intubationprotocol if needed.

- ET intubation with in-line manual

stabilization

Accelerated Transport

C-Spine Precautions


if unable to obtain IV access


44/52

Code 44

Am utated and Avulsed Parts

Initial Trauma Care

Control bleeding with direct pressure and elevation

(tourniquet as last resort)

DO NOT use a tourniquet unless allelse fails and the patient is

hemorrhaging:

-Note time of placement-Apply as close to injury as

possible

-DO NOT release once applied

-Wrap part in moist sterile gauze, sheet or towel.-Place part in waterproof bag or container and seal.

-DO NOT immerse part in any solutions.

-Place this container in a second one filled with ice, cold water or cold

pack.

Transport part with patient to hospital

Transport


45/52

Code 45

Burns

Routine Trauma Care

Accelerated transport if airway involvement

Consider Burn Center

Thermal Chemical Electrical

Maintain body temperature

Burn wound care*

Consider analgesic

IV Parkland formula*

Transport STAT

Brush off excess chemical

Flush with copious amount of

water/saline unless

contraindicated.

Protect unaffected eye

Burn wound care*

Attempt to ID chemical

Transport STAT

Do not enter area until scene

is safe.

Assess for entrance and exit

wounds

Immobilize as needed

Treat dysrhythmias

Burn wound care*

Cover with dry, sterile

dressings/sheets

Transport STAT


46/52

Code 45

(continued)

1. Assessment ABCs rapid transport if airway involvement Neurovascular status Depth of burn (partial vs full thickness) Percentage of burn (Rule of 9 vs Palm Rule) Visual acuity if indicated

2. Interventions Stop the burning process

- Cool with tepid saline/water until skin temperature is normal- Remove jewelry and clothing (do not pull away clothing that is stuck to burn)- Do not use ice or ice water

Wound care- Wear gloves/mask if 2nddegree or 3rddegree burns- Do not break blister or use dressings that will stick to burn- Do not apply ointments or creams- Cover cooled skin with appropriate dressing

If 1stdegree burn < 10% BSA, dress with sterile dry dressing If 2ndor 3rddegree burn or > 10% BSA, dress with sterile dry sheets/dressings

Analgesia- Morphine sulfate in 2 mg increments up to 10 mg IVP- Call Medical Control for pediatric dosing and/or for greater than 10mg in adult

Maintain body temperature- Cover patient with dry sheets/blankets over sheets- Prevent hypothermia at all costs

Burns Wound Care


47/52

Code 45

(continued)

Fluid replacement

3. SOP for other problems

Burns Wound Care

Parkland Formula = 4 ml/kg/BSA burned

to be given in the first 8 hours

to be given in the next 8 hours

to be given in the next 8 hours


48/52

Code 46

Chest Trauma

Routine Trauma Care

Chest Assessment

Massive

Hemothorax

Tension

PneumothoraxPericardial

Tamponade

Sucking Chest

Wound

Hemorrhagic Shock

Refer to Code 42

Monitor Condition

Transport

STAT

Hemorrhagic Shock

Refer to Code 42

Needle Decompression

Stabilize with

Partial Occlusive

Dressing*

Monitor Condition

TransportSTAT

Re-assess Patient

Monitor

Condition

Transport

STAT

Re-assess Patient

MonitorCondition

Transport

STAT

*If patient deteriorates, temporarily

remove dressing for air to escape.


49/52

Code 47

Trauma in Pre nanc

Routine Trauma Care

Check EXTERNALLY for uterine contractions

Document Findings

Check EXTERNALLY for vaginal bleeding

Document Findings

Elevate the right side of the backboard 20-30 in order

to minimize uterine compression of the inferior vena

cava while maintaining spinal immobilization.(transport on left side)


Transport

IV NS wide open if hypotensive

If CPR indicated, manually displace the

uterus to the left.


50/52

Code 48

Trauma Arrest

Bilateral pleural

Initial Trauma Care

Accelerated transport

Rapid extrication

Spinal immobilization

Refer to appropriate code*

CPR

*

Give EPI via ETT if no IV Do not delay transport to in initiate IV May attempt IVx2 enroute IO insertion may be considered


51/52

Code 49

O hthalmic Emer encies

Initial care:

Assess pain scale Quickly obtain gross visual acuity Elevate head (if not contraindicated) Vomiting precautions Remove contact lenses

Corneal Abrasions

Immediately irrigate eyes if no chance ofpenetrating injury

Contact Medical Controlfor Tetracaine 0.5% 1-2 gtt order

Transport STAT

Chemical Splash

Immediate irrigation withcopious amounts of NS

(at least 1000 per eye)


for Tetracaine 0.5% 1-2 gtt order

Transport STAT

Penetrating injury/ruptured globe

Transport STAT

Do not remove impaled objectDo not irrigate eye

Do not instill any drips

Do not apply any pressure

Cover eye with cup or metal protective

shield. Patch unaffected eye also.

Gross Visual Acuity Test

1. Determine if patient wears glasses/contacts2. Determine distance they can see3. Determine vision by holding up fingers at 1, 2, and 3 foot distance.


52/52

Documents

Adult ALS Protocol