EMERGENCY MEDICAL SERVICES 4-0 PARAMEDIC … · EMERGENCY MEDICAL SERVICES 4-0 ... Obstetrics—Gynecology ... Protocols as a basis for paramedic patient care guidelines

IN EFFECT JUNE 2016

Table of Contents________________________________ General Operations………………………………………………….....Pages 4-15

Introductions 4 Physicians Orders 4 Transportation Codes 5 Special Transportation Considerations 6 Behavioral Emergencies 7 Physician on Scene 8 DNR Orders 9 Code 4 Patients 11 Out of Hospital Confirmation of Death 12 Refusal of Care 14

Omaha Fire Department Standard Operating Procedures

EMERGENCY MEDICAL SERVICES 4-0 PARAMEDIC TREATMENT PROTOCOL

REVISION HISTORY

REVISION # REVISION DESCRIPTION DATE REVISED AUTHOR REVIEWED BY APPROVED BY

1 Periodic Revision Oct 2015 Rupp 578 Mancuso 802 Hunter 723

2 Ketamine, D10, Glucagon, &

Epi Drip June 2016 Brown 750 Rupp 578 Hunter 723

Standard Operating Procedures EMS 4-0

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General Principles …………………………………………………Pages 16-22 Airway, Oxygen, and Ventilation 16 CPAP 17 IV Therapy/Medications 18 Body Substance Isolation (BSI) 19 Restraints 19 Pain Management - Adult Criteria 21 Pain Management - Pediatric Criteria 22

Cardiac Emergencies (Adult)……………………………………….Pages 22-31 General Guidelines 22 Ventricular Fibrillation (VF) and Pulseless VT 23 Asystole 24 Pulseless Electrical Activity (PEA) 24 Return of Spontaneous Circulation (ROSC) 25 Bradycardia 26 Ventricular Tachycardia with a Pulse 27 Supraventricular Tachycardia (PSVT) 27 A-Fib and A-Flutter with Rapid Ventricular Rate 28 Ventricular Ectopy with Runs of V-Tach 29 Acute Coronary Syndrome (ACS) 29 Pulmonary Edema 30 Cardiogenic Shock 31

Acute Trauma Emergencies………………………………………..Pages 31-38 General Trauma Management 31 Penetrating Injuries to Head, Neck, Chest, and Abdomen 33 Head Injuries 33 Chest Injuries 33 Abdominal Injuries 34

Eye Trauma 34 Burns 34 Snakebites 35 Crush Syndrome 36

Decision Scheme for Trauma Patients 36 Trauma Center Rotation for Mass Casualty Incidents (MCI) 38

Medical Emergencies………………………………………………..Pages 38-49 Upper Airway Obstruction 38 Altered Mental Status 39 Excited Delirium 41 Seizures 43 Difficulty Breathing 44 Exposure 45 Hypotension in the Absence of Trauma 46 Poisons 46 Nerve Agents 46 Overdose/Toxic Ingestion 47 Toxic Inhalation 47 Cyanide Poisoning 48 Stroke (TIA, CVA) 48 Behavioral Emergencies 49 Nausea and / or Vomiting 49

Standard Operating Procedures EMS 4-0

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Obstetrics—Gynecology……………………………………………..Pages 49-51 Imminent Delivery 49 Neonatal Care 49 Meconium Stained Fluid 50 Childbirth Complications 50 Postpartum Hemorrhage 51 Hypertensive Disorders of Pregnancy 51 Vaginal Bleeding 51

Pediatrics………………………………………………………………Pages 52-60 General Guidelines 52 Airway Management/O2 Therapy 52 IV Therapy 53 Pediatric Cardiac Arrest 53 V-Fib/Pulseless V-Tach 53 Asystole/PEA 54 Pediatric General Cardiac Dysrhythmia 55 Bradycardia (Unstable) 55 V-Tach with a Pulse 56 SVT (Unstable) 56 Difficulty Breathing 57 Seizures 58 Altered Mental Status 59

Procedure A, B, C, D, E, F, G, H…………………………………Pages 61-78 A. Rapid Sequence Intubation 61 B. Cincinnati Pre-hospital Stroke Scale 64 C. Cervical Spine Immobilization Considerations 65 D. Nerve Agent/Organophosphate

Mark 1 Kits / DuoDotes 67

E. 12-Lead ECG Procedures 71 F. Cyanide Poisoning – Cyanokit 73 G. Trauma Scoring and GCS 76

H. Epinephrine Drip 78

Appendix A…………………...…………………………………… Pages 79 - 83 A. OFD EMS Abbreviations 79

Standard Operating Procedures EMS 4-0 Table of Contents

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GENERAL OPERATIONS

A. Introduction

1. The Omaha Fire Department has adopted the current Midlands Protocol

Committee Paramedic Treatment Protocol and the State of Nebraska EMS Model

Protocols as a basis for paramedic patient care guidelines. This document consists

of these two protocols with modifications from the Omaha Fire Department Medical

Director for Omaha Fire specific policies and procedures.

2. The Omaha Fire Department Physician Medical Director is responsible for

developing and approving these protocols. This protocol, in its entirety, is

considered a standing order.

3. The Omaha Fire Department will follow all EMS rules and regulations set forth by

the Authority Having Jurisdiction.

4. This document utilizes current American Heart Association BLS, ACLS and PALS

guidelines. In addition, current PHTLS guidelines are used when referring to

trauma situations. Changes to any of these national guidelines will be adopted and

implemented as they occur.

5. At least one Paramedic must be present on all runs governed by this protocol.

6. Definitions:

Bypassed Patient – A patient that the receiving hospital has chosen to divert to another facility or diverts a trauma patient to the trauma center.

ePCR (Electronic Patient Care Reporting) – The OFD mechanism used for

documentation of EMS patients and EMS runs (patient care report) Receiving Hospital – The hospital that receives the patient.

B. Physician Orders / Communications

This protocol, in its entirety, is considered a standing order. Radio communications are

not required prior to performing any protocol action.

If at any point the paramedic determines guidance is necessary, the paramedic may

contact the receiving facility or the Omaha Fire Department Medical Director or the

Paramedic Shift Supervisor (PSS) for further direction or confirmation of orders whenever

the patient’s condition or the situation warrants.


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C. Transport Codes and Guidelines

Code 1 Minimal or no apparent disease or injury. Patient transported for Examination.

Code 2 Obvious illness or injury, not a serious injury or illness but needs medical attention.

Code 2 Trauma Trauma patient with an obvious injury but doesn’t clearly meet the criteria for a Code 3. Enough questionable signs, symptoms or MOI exists to warrant the expertise of the Trauma Center.

Code 3 Apparent serious / life-threatening medical illness needing immediate medical attention.

Code 3 Stroke Patient has been identified as having a stroke (stroke alert). All stroke patients will be transported Code 3 Stroke to a hospital with stroke care capabilities.

Code 3 STEMI Patient has been identified as having ST-segment elevation myocardial infarction (STEMI alert). All STEMI patients will be transported Code 3 STEMI to a hospital with cardiac catheterization lab capabilities.

Code 3 Trauma Trauma patient with an actual or potential life or limb threatening injury.

Code 99 Cardiopulmonary arrest with resuscitation in progress.

Code 4 Dead patient.

Code 5 For suspected SIDS patient, (patient meets criteria for Code 4, and transport is for the family/bystanders). CPR only (basic life support).

Hospital of Choice

With the exception of hemodynamically unstable patients, the patient/patient’s family shall

be given the choice of the receiving hospital to which they would like to be transported.

Trauma Center of the Day Schedule:

For patients who are hemodynamically unstable or who do not express a hospital

preference, transport to:

Nebraska Medicine – Odd Days

CHI Alegent Creighton Health – Even Days

MCI (Mass Casualty Incident) – In the event of an MCI, the Omaha Trauma Centers will

both open and receive Code 3 (RED) patients with a 4 and 4 rotation. See Trauma Center

Rotation Protocol.


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D. Special Transport Considerations

Families – Every effort should be made to keep injured family members together and

transported to the same appropriate hospital.

Transplant/Dialysis Patients – If a patient is identified as a transplant or dialysis patient,

they shall be taken to the hospital where they are currently receiving care. An exception

is the patient who suffers a respiratory or medical cardiac arrest. In this case, the patient

shall be taken to the closest hospital.

Use prudent judgment if a dialysis or transplant patient is resuscitated. Go to the institution

that can best care for the patient (usually the hospital where they are currently receiving

care).

LVAD (Left Ventricular Assist Device) Patients – If a patient is identified as an LVAD

patient, they shall be taken to the hospital where they are currently receiving their care.

Law Enforcement - Police officers are not permitted the right to dictate the hospital that

patients will be transported to by OFD medic units.

Pediatric Transport Considerations

A pediatric patient is a patient up to and including 15 years of age.

Pediatric Medical Patients – Code 3 medical pediatric patients should be transported

to the closest hospital.

Pediatric patients with extreme hypothermia exhibiting signs of altered mental status or

cardiac dysfunction and no signs or suspicion of trauma should be transported to

Children’s Hospital.

If the receiving hospital diverts an OFD medic unit attempting to transport a Code 3

medical (non-trauma) pediatric patient, the OFD medic unit should transport the patient

based on the medic unit’s actual physical location at the point of being diverted (go to

closest of):

If west of 60th Street in Omaha, transport to Children’s Hospital.

If east of 60th Street in Omaha, transport to CHI Alegent Creighton Health or Nebraska Medicine.

Pediatric Trauma Patients – All Code 2 (Level 2) pediatric trauma patients should be

transported to either Children’s Hospital or Nebraska Medicine (see below.)


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The following injured children are best served by evaluation and treatment at

Children’s Hospital. These children must be transported to Children’s Hospital:

Traumatically injured children who do NOT require major immediate resuscitation

Hemodynamically stable

GCS greater than 9

Low risk mechanisms of injury

o Victims of asphyxiation (example: drowning, hangings, smoke inhalation

without burns)

All Code 3 (Level 1) pediatric trauma patients will be transported to The Nebraska Medical

Center. All pediatric patients with asphyxiation injuries will be transported to Children’s

Medical Center. Code 3 pediatric trauma patients will not be transported to Creighton.

For the purposes of this protocol, a child is defined as up to and including 15 years old.

This protocol applies 24/7 regardless of “trauma center of the day” for adult patients.

The following injured children are best served by evaluation and treatment at

Nebraska Medicine. These children must be transported to Nebraska Medicine:

Traumatically injured children who DO require major, immediate resuscitation

Code 99 (traumatic cardiac arrest except asphyxiation – see below)

Hemodynamic instability or poor perfusion

Respiratory compromise, including need to maintain airway and intubation

Neurologic compromise, GCS <9 or deteriorating status

All burn patients

Traumatic amputations

Significant vascular injuries

High risk mechanisms: i.e. ejection, GSW

Unstable pelvic fractures

Spinal cord injury or paralysis

Code 4 Patients – For safety reasons, when appropriate, certain Code 4 patients may

be evacuated from the scene and transported to the appropriate hospital.

E. Behavioral Emergencies (Psychiatric, Overdose and Suicidal Patients)

Transport Considerations

Code 1 and Code 2 psychiatric, overdose and suicidal patients and their families will be

offered hospital of choice options for transports. If they do not indicate a hospital of choice,

they will be transported to the catchment area hospital.


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Patients who are rational and present no risk to OFD EMS personnel or to themselves

may be transported to hospital of choice.

Behavioral, psychiatric, overdose and suicidal patients that are Code 3, Code 99 or a

potential risk to the safety of OFD medic unit personnel will be transported to the

catchment area hospital.

ALWAYS consider a medical etiology for a behavioral emergency.

F. Physician on Scene

There are times that a physician, not affiliated with OFD, but licensed to practice

traditional medicine in the state of Nebraska will identify him/her on a scene and may wish

to direct the actions of OFD EMS personnel. This protocol is intended to provide guidance

to OFD EMS personnel while ensuring the best care possible for the patient. When a

physician is present on the scene and desires to direct the run, OFD EMS personnel

should:

1. Inform the physician that if the physician directs the run, the physician must ride

along, in the rear of the medic unit with the patient to the hospital and transfer care

and treatment history to the emergency room staff.

2. Inform the physician at the onset of the run that OFD paramedic personnel have

strict legal guidelines and established protocols and they may not exceed those

guidelines or protocols.

3. Inform the physician that any procedure outside of these legal guidelines must be

carried out by the physician him/herself.

4. OFD EMS personnel have the right and obligation at any time there is gross

deviation from the accepted protocol to contact the receiving hospital for further

instruction. The physician on the scene should be informed if contact with the

hospital is being made.

5. Only traditional medical practices will be allowed. At no time shall a physician

perform non-traditional procedures. Examples of non-traditional procedures

include chiropractic procedures, acupuncture or spiritual healing.

6. If at any time there is a problem or discrepancy in procedures, OFD EMS personnel

may contact the receiving hospital by phone or radio and have the receiving

hospital physician speak directly to the physician at the scene.


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G. “Do Not Resuscitate” (DNR) Orders and Identification of CPR Only

(Adopted from “Nebraska EMS Model Protocols”)

With the advent of individuals taking greater responsibility for their own health care,

decisions made by the individuals themselves, to not prolong their own life, is recognized

as valid and has become more common. Health Care Power of Attorney, Living Wills and

“Do Not Resuscitate” (DNR) orders are encountered frequently by OFD personnel.

Occasionally, a family member will call 911 even when a DNR order exists or a Living Will

is present. There are also times when OFD will arrive on scene, begin resuscitation

procedures and a DNR or Living Will is discovered. This protocol is designed to provide

guidance for such situations.

“Do Not Resuscitate” (DNR) – A DNR is a written order by a physician stating that no

cardiopulmonary resuscitation will be initiated. A DNR must be signed by a physician,

dated and have the patient’s name on it. OFD EMS personnel can honor a DNR. The

OFD EMS provider must be identified in the patient care report. Verbal confirmation of a

DNR by a family member or friend without verification of a written DNR is not sufficient to

withhold resuscitation efforts.

Health Care Power of Attorney (HCPA) – is a legal document stating the name of the

person the individual (patient) has named as the person who will make medical decisions

for their care. It should be signed by the patient and the patient’s attorney, and only

applies to adults.

Living Will – This document states the patient’s wishes should they require resuscitation

or life support measures. The document must be signed by the patient and the patient’s

physician and only applies to adults.

1. OFD EMS providers will not initiate or continue cardiopulmonary resuscitation on

a patient in cardiac arrest once a valid DNR order is confirmed. In the event of

uncertainty, resuscitative measures should be initiated.

2. DNR does not mean that emergency medical care for any other medical condition

will be changed or limited. Patients shall receive emergency medical treatment

(BVM / airway management, IV therapy and pharmacology) up until the point of

cardiac arrest.

3. Physicians may designate a patient as DNR by written order, verbally – when the

physician is physically present at the scene or by telephone consult from the

paramedic on scene to the patient’s physician.

4. A written DNR order must contain the patient’s name and be signed by the

physician or by the RN who received the order from the physician.


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5. If a physician physically present at the scene designates the patient as a DNR, the

paramedic shall ask the physician to document the DNR designation on the OFD

179 or ePCR and sign it. If the physician refuses to document and sign the OFD

179 or ePCR, the paramedic shall initiate resuscitative measures.

6. In a skilled care facility (nursing home), DNR orders documented in the patient’s

medical record are considered valid if signed by the physician or by the RN for the

physician. A DNR form may be used, but is not required in the nursing home

setting. The OFD EMS provider who observed the DNR order must be identified

on the patient care report.

7. An OFD EMS provider can honor an effective Living Will or Health Care Power of

Attorney. This must be directly observed. OFD EMS providers can presume the

validity of this document if signed in Nebraska. Documents from other states in

compliance with that state’s laws are also valid in Nebraska.

8. If the family desires CPR and/or resuscitation in the presence of a DNR or HCPA,

the family’s wishes shall be honored.

9. Observation of an original or a photocopy of a living will or health care power of

attorney must be documented in the patient care report. An OFD EMS provider

shall not honor a living will if there is no information or evidence that a physician

has determined the patient is in a terminal condition or in a persistent vegetative

state. If there is information or evidence that a physician has determined the patient

is in a terminal condition or in a persistent vegetative state, this information should

be documented in the patient care report. The patient care report must also contain

information that the patient is an adult (is 19 or older or has been married).

10. If a telephone consult with the patient’s physician or the physician’s designee

verifies a DNR, the OFD paramedic can honor the order. Authorization shall be

documented on the patient care report and include the physician’s or physician

designee’s name, telephone number and time of the telephone call from the

paramedic to the physician.

11. Once CPR has been initiated, resuscitative measures may be discontinued when

any one of the following occurs:

A DNR or no code order is confirmed.

A Living Will or HCPA for an adult is being followed.

A physician physically present at the scene or the medical director, based on

information from the OFD EMS provider on scene, determines that CPR is

futile or should be discontinued.

An OFD EMS provider is following termination of CPR protocols that have

been authorized by the OFD Physician Medical Director.

Any time the scene becomes unsafe for rescuers.


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When signs of late death or all early signs of death are identified, the OFD

paramedic may discontinue CPR if previously started (see Code 4 protocol).

The paramedic will document a one minute printed rhythm strip from the

cardiac monitor if no signs of late death are apparent.

Management of Home Hospice Patient – Attempts should be made to contact the

hospice representative to provide additional guidance and support to the family prior to

transporting. If the family desires CPR and/or resuscitation in the presence of a DNR or

HCPA, the family’s wishes shall be honored.

Resuscitation of a DNR Patient – If inadvertently, a DNR patient is resuscitated, and in

the absence of physician directives, care should be continued and the patient should be

taken to the catchment area hospital.

Notification to OFD Dispatch – Once resuscitative measures are terminated, notify OFD

dispatch and request an OPD cruiser if one has not already been dispatched. OFD

personnel will remain on scene until OPD arrives. Give a brief history to the officer. Obtain

the officer’s name and badge number and document in the FRMS patient care report in

the narrative section.

H. Code 4 Patients

OFD personnel may be called to a scene where biologic and clinical death is evident. In

such cases, it is not necessary to begin resuscitation. Situations may also occur where

CPR has been initiated on an obviously deceased patient prior to the arrival of OFD EMS

personnel. This protocol is intended to assist OFD personnel in the identification of such

situations.

If the patient meets code 4 criteria, OFD EMS providers may discontinue CPR or may

choose not to initiate CPR.

A Code 4 patient is identified if he/she is described by one of the following categories:

1. Patient with obvious lethal injury – trauma cardiac arrest with injuries incompatible

with life (i.e. massive blood loss, displacement of brain tissue, decapitation)

2. Patient with one or more of the signs of late death:

– Wrinkled cornea – Rigor mortis – Postmortem lividity – Decomposition

Paramedic shall obtain and document a 1 minute ECG rhythm strip demonstrating

asystole.


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3. Patient with all the following signs of early death:

– Unresponsive to all stimuli – No pulse – No spontaneous respirations – Pupils which are fixed and dilated

Paramedic shall obtain and document a 1 minute ECG rhythm strip demonstrating asystole.

4. Valid DNR form

5. Physician authorization

No patient will be declared Code 4 without a complete, hands-on physical evaluation

including:

1. No pulse, respirations or blood pressure

2. No response to painful stimulation, no corneal reflex, and no response to a sternal

rub

*All of the above will be documented in the patient care report (PCR)

The rhythm strip will be uploaded into the ePCR or mounted and sent to the EMS office for review.

The only exceptions to the above are the following:

1. Injury not compatible with life

2. Advanced whole body decomposition. Remember that smell is NOT an advanced sign of death.

Anytime the exceptions are used to declare death, the state of the body should be

documented in the Narrative section of the PCR.

NOTE: Care should be taken to rule out hypothermia, acute alcoholic intoxication, and

drug overdose.

I. Out of Hospital Confirmation of Death

The purpose of this protocol is to allow Paramedics to confirm / declare a patient dead

based on certain criteria with permission of the base station. This does not include

patients already concluded to be Code 4. Permission for declaration of death will be called

to the Nebraska Medicine ER over radio, cell phone, or landline. Nebraska Medicine

phone number is 402-507-3600.

Only Nebraska Medicine ED physicians can authorize this protocol over the radio or cell

phone.


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CRITERIA FOR REQUESTING DECLARATION OF DEATH IN THE FIELD:

Medical Code 99 patient

1. Patient found down for unknown period of time (or more than 10 minutes).

2. No CPR in progress when paramedics arrive on scene.

3. Patient assessed and found to have no signs of life.

4. Paramedic EKG evaluation is asystole.

Trauma code 99 patient

1. No recent signs of life documented by bystanders or initially responding EMS

personnel.

2. Patient assessed and found to have no signs of life.

3. Asystole on EKG.

Field Protocol for Requesting Termination of Resuscitation Efforts

1. Paramedics who initially assess patient and meet the listed requirements should

have BLS being performed on the patient.

2. Nebraska Medicine will be contacted via standard radio procedures or cell phone.

3. Paramedic will describe circumstances around the arrest, length of time patient

down without CPR, and EKG findings.

4. Nebraska Medicine will either suggest continuing resuscitation and transport or

give the order to terminate resuscitation attempt.

5. Paramedics should confirm that the family agrees with the termination of efforts.

6. If resuscitation is to continue, the patient will be brought to closest appropriate

hospital based on protocol.

7. If patient is declared dead at scene, documentation will be completed, including

the above criteria and time the patient was confirmed/pronounced dead by the

Nebraska Medicine ED physician. The Coroner’s Office will then be notified (in

appropriate circumstances) and the patient will either be transported to County

Hospital or left at the scene with the appropriate authorities (usually local law

enforcement) for the Coroner’s Office to collect.

8. A one minute cardiac rhythm strip will be obtained to document asystole.


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J. Refusal of Care

The patient has the right to refuse either or both care and transportation. However, OFD personnel have both a moral and legal obligation to provide adequate medical care, according to the provider’s level of training and certification, until the patient is delivered to the receiving hospital. In situations in which the patient is refusing care, the following guidelines shall be followed.

Adults

An adult is an individual 19 years old or older or who is or has been married (NEB

REV STAT §43-2101). A competent adult can refuse medical services and/or

transportation to a health care facility.

A legal guardian can consent to or refuse medical services and/or transportation to

a health care facility for an incompetent adult.

A person appointed as a Health Care Power of Attorney can consent or refuse

consent for medical services and/or transportation to a health care facility for the

incompetent adult named in the power of attorney.

Minors

A minor is an individual under 19 years of age that has never been married or

emancipated.

A parent or legal guardian can consent or refuse consent on behalf of a minor, for

medical services and/or transportation to a health care facility.

In cases of suspected abuse/neglect and refusal of care and/or transport, law

enforcement shall be notified.

Documentation (required)

Each patient shall be given a minimal physical assessment consisting of pupil

evaluation, level of consciousness, vital signs, lung sounds and/or respiratory rate

and effort and a general head to toe physical exam (palpation as indicated).

If a patient refuses to submit to a physical exam, the OFD EMS provider in charge

of patient care shall document this refusal in the narrative of the patient care report.

The narrative shall also document the following:

1. Results of the minimal physical assessment. Fill in the appropriate areas of the

patient care report.

2. Visual assessment, for example: “The patient is up and walking at the scene with

no apparent injury.”


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3. Patient is alert, coherent and articulate, for example:

alert – “The patient states his name, location and time of day correctly.”

coherent – “The patient is speaking in complete sentences with logical thought flow.”

articulate – “Speech is distinct.”

Absence of any one of these may indicate insufficient ability to make good decisions.

Therefore, all efforts to convince the patient to allow treatment / transport should be

attempted.

NOTE: ETOH does NOT justify inaction. If after appropriate assessment, treatment is

not necessary, contact OPD for transport to appropriate facility.

1. Reason for the patient’s refusal, for example:

“Patient states he has no pain, injury or medical problem.” or “Patient refuses

treatment / transport for religious reasons.”

2. Attempt to get others involved, for example: “Family members also failed in efforts

to encourage patient to be transported to the hospital.”

3. Consequences explained, for example: “Patient informed that he may suffer

serious physical harm or death as a result of not being treated / transported.”

4. Alternatives explained, for example: “Patient instructed to use alternate means for

transport, or if condition worsens or change of mind occurs, to call 911.”

5. Concluding statement to each incident of patient refusal shall be the following:

“Patient strongly advised to seek medical care as soon as possible.”

6. Signature of patient and witness on OFD 179 form or ePCR. A valid witness shall

be any family member of legal age, a police officer, bystander, or at the very least,

another OFD firefighter on the call. If the patient refuses to sign the refusal form,

then the OFD firefighter documenting the run shall note this in the narrative.

Complete documentation shall include all applicable portions of ePCR and/or the OFD

179 form. From a legal standpoint, this documentation shall provide the basic defense

that appropriate actions were taken. Any omitted patient care documentation can be

challenged whether or not appropriate care was actually provided at the time of the

incident.

NOTE: If a patient needs treatment and/or transport to the hospital but the hospital of

choice is NOT a hospital that the OFD medic unit services (i.e. Mercy Hospital, Council

Bluffs or Offutt) and the patient refuses transport by OFD, the person in charge shall

instruct the patient to call a private ambulance for transport. After a patient assessment,

and if the patient condition warrants, Omaha Fire can remain on scene to monitor the

patient and treat as necessary until the private ambulance has arrived. Contact the PSS

if there is any question regarding the patient’s condition.


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GENERAL PRINCIPLES

A. Airway, Oxygen and Ventilation

An intact airway and adequate oxygenation and ventilation are essential for all patients

with medical or traumatic conditions. Throughout this protocol it is assumed that OFD

personnel will maintain a patent airway and provide appropriate supplemental

oxygenation.

1. Maintain patent airway with head-tilt/chin-lift or jaw thrust maneuver and consider

oral or nasal airway adjunct.

2. If ventilating adequately, apply nasal cannula at 2-6 L/min or non-rebreather mask

at 10-15 L/min.

3. If NOT ventilating adequately, assist ventilations with BVM and 100% oxygen –

advanced airway management may be required.

4. Consider assisting ventilations in those patients whose respiratory status does not

improve after receiving oxygen by non-rebreather mask.

5. Adjust oxygen delivery devices to maintain a blood oxygen saturation of >94%

unless contraindicated.

6. Record all vital signs (blood pressure, pulse, respirations, Oxygen saturation, CO2)

- pulse oximetry is required.

7. Utilize CO2 monitoring when available (Nasal Cannula, ET, King Airway etc)

8. Consider the use of CPAP if indicated by protocol.

9. Use trauma advanced airway techniques with patients who have suspected

compromised cervical spines.

10. Always confirm endotracheal tube placement by:

Attaching an EtCO2 monitoring device and verifying CO2 production by colorimetric, waveform or mmHg.

Observing for chest rise and fall.

Verifying the presence of bilateral lung sounds at the axilla and the absence of epigastric sounds by auscultation with a stethoscope.

Confirming improvement in saturations by pulse oximetry.

*Confirmation of endotracheal tube placement is required with capnography and documentation in ePCR.

11. Immobilize the head with a c-collar or by using tape on the head to prevent

excessive head movement during transport when a patient is intubated.

Commercial securing devices are recommended over tape to secure the ET tube

in place.

12. If unable to intubate after two attempts; consider alternate airway management

methods - BVM ventilation or King Airway, etc.


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13. Consider RSI for patients with the following indications (also see RSI protocol):

Altered mental status with airway compromise.

Head injuries with signs of increased ICP (GCS < 8), but whose combativeness or gag reflex make them difficult to intubate.

Conscious but unable to maintain airway.

Severe respiratory distress with hypoxia / cyanosis.

14. If the adult intubated patient becomes combative, consider administering one or

both of the following:

Versed 1-5 mg slow IV push or 5-10 mg intranasal

Morphine Sulfate 2-4 mg slow IV push

15. Required documentation.

Reason for intubation.

All vital signs prior to intubation including BP, pulse, respirations, and oxygen saturation.

All medications administered and doses.

Post – Intubation:

a) Repeat all vital signs (including oxygen saturation). b) Bilateral breath sounds. c) No sounds over stomach. d) CO2 production. e) Repeat all of above on arrival at hospital.

B. CPAP

Indications:

Any adult patient presenting with respiratory distress, is awake and able to follow

commands, has the ability to maintain a patent airway with adequate mask seal, and

displaying findings in the medical history or assessment suggestive of any of the following

conditions:

COPD

CHF

Asthma

Pulmonary Edema

Pneumonia

Near Drowning

Carbon Monoxide poisoning


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Contraindications

Systolic blood pressure less than 90 mmHg

Suspected pneumothorax

Insufficient respiratory effort

Tracheostomy

Active vomiting

Upper GI or airway bleeding

Altered mental status

Suspected facial fractures

Special Considerations

1. CPAP is to be a continuous therapy and should only be discontinued in the case

of the patient being unable to tolerate the mask or in case of progression to

respiratory failure.

2. Advise the receiving hospital of your patient’s CPAP therapy as soon as practical

so they may prepare for continuation of therapy.

3. Observe patient for signs of gastric distention.

4. Monitor patient closely for changes in hemodynamic or respiratory status.

5. Other therapies, as described in these protocols, may be performed in conjunction

with CPAP.

6. Provide patient instruction and reassurance as required.

7. Reassess mental status, hemodynamic and respiratory status continuously during

CPAP therapy and record every 5minutes.

8. Discontinue CPAP therapy and consider BVM / intubation if either decreased

mental status or respiratory insufficiency become present.

9. Add an in-line nebulized Duo-neb (bronchodilator) treatment when indicated.

Consider Versed 1-5mg IV or 5-10mg intranasal if systolic BP is greater than 90 mmHg

and patient is not tolerating CPAP mask. Assure agitation is not a result of hypoxia or

that the patient needs to be intubated.

C. IV Therapy / Medications

1. All IV insertions refer to peripheral IV's (extremities and external jugular vein),

including saline locks and intraosseous (IO) lines. IO insertion is authorized for

unstable pediatric and adult patients. All medications administered IV can also be

administered IO (D50 should be diluted to D25 prior to administering via IO).

2. For trauma patients, IV’s should be started enroute to the hospital, except when

there is an unavoidable delay such as prolonged extrication time.

3. Large bore IV's refer to 14ga or 16ga IV catheters - infuse at rate as indicated by

pulse and blood pressure (90 mmHg systolic or MAP of 70).


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4. IV fluid refers to (NS) Normal Saline (0.9% Sodium Chloride).

5. Use micro drip (minidrip) IV tubing for all IV infusions and with all premixed and

diluted medications. Establish a 2nd IV whenever infusing medications.

6. This protocol permits 2 attempts per paramedic on the call to a maximum of 4

attempts per patient for IV insertion. If unsuccessful and the patient requires

medication administration, establish IO access. Peripheral IV’s should be

attempted prior to IO access.

7. Pre-existing Venous Access Devices (VAD) may be used in emergency situations

(Code 3 / Code 99 patients).

8. A fluid bolus refers to 200 – 500 ml of fluid for the adult patient and 20 ml / kg of

fluid for the pediatric patient.

9. Use a filtered needle or a filtered straw when drawing up any medication from a

glass ampule.

D. Body Substance Isolation

It is protocol policy to practice body substance isolation when caring for ALL patients. This

means wearing gloves and protective eyewear when administering patient care. BSI shall

be observed when handling blood and body fluids or surfaces or items soiled by blood

and body fluids; masks and protective eyewear during procedures likely to generate

droplets of blood or body fluid; and aprons or gowns during procedures likely to generate

splashes of blood or body fluid. This includes washing hands after each patient care

incident even if gloves were worn or waterless soap was used.

All needles and sharps shall be immediately placed in a disposable impervious container.

There will be no recapping of needles.

All personnel should don N-95 or HEPA masks when in contact with patients in which an

airborne communicable disease is suspected or confirmed by history (e.g. tuberculosis,

influenza). Personnel should also place N-95, HEPA, or surgical masks on these

patients.

E. Restraints

Purpose – OFD personnel occasionally encounter patients who require transport to a

receiving hospital but who also pose a threat to themselves, others or to OFD personnel.

Because of this threat of physical harm, it may be impossible to transport without

restraining the patient. This protocol is intended to provide guidance in the use of

restraints and a procedure to follow in such cases.


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Note: OFD personnel/rigs are prohibited from carrying or using metal handcuffs.

1. Indications:

A patient who needs to be transported for medical care, who is refusing

transport of care, and who is incompetent to refuse.

A person, who appears to be mentally ill and who as a result of such mental

illness, appears to be an imminent danger to others (including OFD personnel)

or to himself/herself or to be gravely disabled.

2. Precautions / Considerations:

Do not restrain a patient in the prone position.

Any attempt at restraint involves risk to the patient and to OFD personnel.

The firefighter’s safety must come before patient considerations. Do not

attempt to restrain the patient without adequate assistance.

Physical restraints are a last resort. All possible means of verbal persuasion

should be attempted first.

A patient who is alert, oriented, aware of his/her condition, and capable of

understanding the consequences of his/her refusal is entitled to refuse

treatment. He/she may not be restrained and treated against his/her will.

(Review consent guidelines and confer with PSS or medical director if in doubt.)

Any restrained patient may vomit, be prepared to suction and reposition as

needed. Once restrained, the patient is never to be left alone. Aspiration can

occur if patient is restrained on his/her back and cannot protect his/her own

airway.

The airway must be free and accessible for airway control.

Do not restrain a patient sandwiched between backboards, scoop stretchers or

other immobilization devices.

Do not “hog tie” patients (hands restrained behind back, feet restrained

together and the two restrained attached together).

Check restraints as soon as applied and every 10 minutes thereafter to ensure

no injury to extremities.

Remove restraints only with sufficient personnel available to control the patient

- generally, only in the hospital setting.

Other than primary psychiatric disorders, medical causes of combativeness

include hypoglycemia, hypoxia, head injury and drug ingestion.

Written and verbal reports must completely document the necessity for the use

of physical restraints. Record condition of extremities before applying restraints

and recheck and record condition on arrival at hospital.


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Metal handcuffs are not an authorized method of restraint for OFD personnel.

The only exception to this policy is for OFD Fire Investigators whom have been

specifically trained in the use of handcuffs.

If a patient is already handcuffed by law enforcement, an officer must ride with

the patient to the hospital.

Law enforcement should be asked to remove handcuffs as soon as possible

for the patient’s own safety. However, if an officer deems handcuffs are

necessary, place patient supine on stretcher and secure handcuffs to the base

of the stretcher.

Consider utilizing more personnel to restrain patient.

Refer to Altered Mental Status Protocol for additional treatment considerations.

F. Pain Management - Adult Criteria (Severe Pain Ranked as ≥ 6 on 0 -10

Scale)

1. Systolic BP > 90 mmHg.

Consider Morphine Sulfate 2-5 mg slow IV push or 2-5 mg intranasal.

Reassess pain scale and vital signs.

Repeat every 5 minutes as necessary if no response or pain remains severe.

2. Systolic BP = 80-90 mm Hg

Consider Morphine Sulfate 1-2 mg slow IV push or 1-2 mg intranasal



3. If respiratory depression occurs, begin BVM ventilations and administer Narcan

0.4 – 2.0 mg IV push followed by a fluid bolus or 0.4 – 2.0 mg intranasal (repeat

as needed).

4. If hypotension develops, administer Narcan 0.4 – 2.0 mg IV push followed by a

fluid bolus or 0.4 – 2.0 mg intranasal (IN) (repeat as needed) – titrate to vital signs.


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G. Pain Management - Pediatric Criteria (Severe Pain Ranked as ≥ 6 on 0-10

Scale or Wong-Baker Faces Scale)

1. Systolic BP appropriate for age.

Consider Morphine Sulfate 0.1 mg / kg slow IV push or 0.1 mg / kg intranasal

to a maximum of 2 mg increments (IV route preferred).



2. If respiratory depression occurs, begin BVM ventilations and administer Narcan

0.4 – 2.0 mg IV or IN followed by a fluid bolus.

3. If hypotension develops, administer Narcan 0.4 – 2.0 mg IV push followed by a

fluid bolus or 0.4 – 2.0 mg intranasal – titrate to vital signs.

CARDIAC EMERGENCIES - ADULT

A. General Guidelines

1. If cardiac arrest occurs in presence of the paramedic, assess rhythm and

immediately shock X 1 if indicated.

2. If patient is in cardiac arrest on arrival, start or continue basic life support (BLS) for

2 minutes. Consider Auto Pulse, if available.

3. CPR (30:2) Compression rate at least 100 / minute.

Ventilations at 8 – 10 / minute, do not hyperventilate.

ROTATE person doing compressions (compressor) every 2 minutes.

4. Reassess rhythm & pulse check after each 5 cycles (2 minutes) of CPR.

5. Limit interruptions of CPR during pulse & rhythm checks to < 10 seconds for airway

management and/or medication administration. CPR should not be stopped for

advanced airway placement.

6. Preferred medication administration route is IV or IO. IV / IO of NS should be

established during 2 minute period of continuous CPR.


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7. Secure ET airway during pulse & rhythm check, continue CPR immediately then

secure & confirm placement by auscultation of breath sounds & epigastric sounds,

followed by confirmation with capnography.

NOTE: CO2 reading should be present but below normal values during CPR. If

“zero” CO2 reading, immediately reevaluate ET tube placement.

8. If failed IV access or IO access, a final option for medication administration is via

the ET tube for designated ET meds at 2 to 2.5 times IV dose. Meds for Code 99

for ET route are lidocaine, epinephrine, atropine and Narcan (LEAN).

9. If the patient regains a pulse, see the Adult Post Cardiac Arrest – ROSC (Return

of Spontaneous Circulation) protocol.

10. Unless otherwise noted, all defibrillations refer to:

Shock # Biphasic

1 120 j

2 150 j

3 and on 200 j

11. If patient hypothermic from exposure, follow Hypothermia Protocol for cardiac

arrest guidelines.

12. If the patient has known or highly suspected cyanide poisoning, smoke filled

environment (smoke inhalation) consider Toxic Inhalation Protocol Cyanide

Poisoning and Procedure ‘F’.

B. Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT)

1. Follow General Guidelines for Adult Cardiac Arrest.

2. Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR. Witnessed arrest – go

directly to confirming VF and defibrillation.

3. Assess and confirm pulseless VT / VF, then shock X 1, immediately resume CPR

(no pulse check, go straight to compressions).

4. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue

CPR while defibrillator charges, then shock X 1, immediately resume CPR.

5. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 – 5 minutes.

6. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue

CPR while defibrillator charges, then shock X 1, immediately resume CPR.

7. Consider administration of anti-arrhythmic.

Amiodarone 300 mg IV/IO, may repeat once in 3–5 minutes at 150 mg IV/IO

OR

*Lidocaine 1 – 1.5 mg / kg IV/IO, may repeat in 3-5 minutes at 0.5 mg to 0.75

mg / kg IV/IO push (max dose of 3 mg / kg).


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*Only use Lidocaine if Amiodarone is NOT available

8. Consider Mag Sulfate (50%) 1 – 2 gm IV/IO over 2 minutes (For Torsades de

pointes).

9. Consider Sodium Bicarb 1 mEq / kg IV/IO (For suspected hyperkalemia, TCA

overdose or metabolic acidosis).

C. Asystole


Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR.

Witnessed arrest – go directly to confirming the rhythm.

2. Verify / confirm true asystole in another lead.

Rapid scene survey – any evidence that resuscitation should not be

attempted? (DNR orders, signs of death, see Code 4 Protocol).

If yes, withhold resuscitation efforts. See ‘Out of Hospital Confirmation of Death

Protocol’ if needed for assistance.

3. Immediately resume CPR.

4. Establish IV / IO NS while providing 2 minutes of continuous CPR.

5. During CPR, administer Epinephrine 1 mg (1:10,000) IV every 3 – 5 minutes.

6. Secure airway during pulse & rhythm check, continue CPR immediately then



7. Provide continuous CPR, reassess rhythm & pulse after every 5 cycles (2 mins) of

CPR.

8. Consider Sodium Bicarbonate 1 mEq/kg IV/IO push (for suspected acidosis or

hyperkalemia).

9. If pulse restored, refer to ROSC protocol.

D. Pulseless Electrical Activity (PEA)


Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR.

Witnessed arrest – go directly to confirming the rhythm.

2. Establish IV / IO NS while providing 2 minutes of continuous CPR.

3. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 – 5 minutes.

4. Secure airway during pulse & rhythm check, continue CPR immediately then




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5. Provide continuous CPR and reassess rhythm & pulse after every 5 cycles (2

minutes) of CPR.

6. Review causes for PEA. Treat per protocols if condition is present:

Hypovolemia Toxins (overdoses)

Hypoxia Tamponade – cardiac

Hydrogen ion (acidosis) Tension pneumothorax

Hyper / hypokalemia Thrombosis – coronary

Hypothermia Thrombosis – pulmonary embolism

Hypoglycemia Trauma

For suspected hypovolemia - administer fluid bolus of normal saline of 250 – 500

cc, repeating boluses up to 1 Liter of NS (especially with narrow QRS and rapid

rate).

For suspected TCA overdose, acidosis or hyperkalemia, administer Sodium

Bicarbonate 1 mEq/kg IV/IO Push.

For tension pneumothorax, perform needle decompression.

For hypothermia, provide warming measures.

For hypoglycemia, administer D10, if not available administer D50

7. If pulse restored, refer to ROSC protocol.

E. Return of Spontaneous Circulation (ROSC)

If return of spontaneous circulation (ROSC) for non-trauma patients:

1. Reassess airway and breathing.

Maintain ventilation rate at 8-10/min – Avoid routine hyperventilation.

Continuously evaluate the Capnography waveform on monitor and maintain

ETCo2 of 35-45mmHg.

Use the minimum flow rate of Oxygen to maintain a saturation of >94%

2. If BP < 90 systolic:

Consider a fluid bolus of 250 – 500 cc, repeating boluses up to 1 Liter of NS.

Consider Epinephrine drip at 2-10 mcg / min

Titrate to BP of > 90

3. Obtain 12-Lead ECG, transmit to receiving facility.

4. Establish 2nd IV.

5. Initiate hypothermic efforts by applying ice packs to the groin and axilla.


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F. Bradycardias

For heart rates below 60 beats per minute.

STABLE

1. Airway, oxygen, monitor, obtain 12-Lead ECG.

2. Start IV with NS TKO

3. Transport and OBSERVE

UNSTABLE - (Verify serious signs / symptoms are due to the slow rate):

1. Airway, oxygen, monitor, obtain 12 Lead ECG

2. Start IV with NS TKO

3. Give Atropine 0.5 mg IV push, repeat every 3 to 5 minutes as needed up to

maximum dose of 3 mg (0.04mg/kg).

*Atropine is not effective in 2° Type II AV block, 3° heart block or Idioventricular

rhythms. If these rhythms are present and patient is unstable, go directly to

transcutaneous pacing (TCP).

4. If Atropine administration will be delayed or is ineffective, begin transcutaneous

pacing (TCP). Preferred placement for pacing pads is anterior-posterior position.

Start at a rate of 60-70 beats per minute. Adjust milliamps upward as needed

to achieve capture. May consider increasing rate to a maximum of 100 beats

per minute to obtain a BP of > 90 systolic.

Consider patient comfort as milliamps are increased. If pacing is successful

(capture is established and BP improves), consider mild sedation for discomfort

related to pacing.

Versed 1 – 5 mg slow IV, or Versed 5 – 10 mg intra-nasal

Consider Epinephrine drip at 2 – 10 mcg/minute – titrate to blood pressure of

>90 systolic (see Procedure H)

Monitor vital signs every 2 – 5 minutes.

NOTES:

Do not delay TCP while waiting for IV access or for atropine to take effect if patient is unstable.

Never treat the combination of 3º heart block and ventricular escape beats with amiodarone, lidocaine or any agent that suppresses ventricular escape rhythms.

Atropine is not effective for denervated transplanted hearts.


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G. Monomorphic Ventricular Tachycardia with Pulse

For wide complex [> 0.12 seconds] tachydysrhythmias

STABLE patient / NO serious signs and symptoms


2. Start IV with NS TKO.

3. Consider Medications:

Adenosine 6 mg rapid IVP (over 1 second) and flush the line, may repeat once

in 2 min at 12 mg.

Amiodarone infusion - 150 mg in D5W 100 cc over 10 minutes.

UNSTABLE patient / Displays serious signs and symptoms

1. Airway, oxygen, monitor.

2. Start IV NS TKO.

3. Consider fluid bolus 250 - 500cc.

4. Consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once

5. Perform synchronized cardioversion at 100 J.

IF NO RESPONSE, continue synchronized cardioversion with increasing joule

settings as necessary (120J, 150J, 200J).

6. If successful and time allows, obtain and transmit a 12-Lead EKG.

IF SUCCESSFUL (at any point), maintain status with anti-arrhythmic infusion (see

above).

NOTE: If polymorphic or Torsades de pointes, give Magnesium Sulfate 1 – 2 grams slow IV push (over 5 minutes).

H. Supraventricular Tachycardia (SVT)

For narrow complex QRS <0.12 seconds




3. Consider vagal maneuvers.

4. Give Adenosine 6 mg rapid IV push (over 1 second) and flush the line.

IF NO RESPONSE in 2 minutes:

5. Give Adenosine 12 mg rapid IV push (over 1 - 2 seconds) and flush the line.


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IF NO RESPONSE in 2 minutes:

6. Consider Adenosine 12 mg rapid IV push (over 1 - 2 seconds) and flush the line.




3. Consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once.

4. Perform synchronized cardioversion at 50 J.

5. IF NO RESPONSE, continue synchronized cardioversion with increasing joule

settings as necessary (75J, 100J, 120J, 150J, 200J).

6. If successful and time allows, obtain and transmit a 12-Lead ECG.

I. Atrial Fibrillation and Atrial Flutter with Rapid Ventricular Rate

Greater than 150 beats per minute




3. Observe and transport.




3. Prepare for immediate cardioversion, consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once.

4. Perform synchronized cardioversion at 120J for atrial fibrillation.

5. Perform synchronized cardioversion at 50J for a-flutter.

6. IF NO RESPONSE, continue synchronized cardioversion with increasing joule

settings as necessary.

7. If successful and time allows, obtain and transmit a 12-Lead EKG.

NOTE: In the absence of a characteristic saw tooth pattern, the rhythm is atrial fibrillation until proven otherwise

*Use caution in converting an atrial fibrillation rhythm that has an unknown duration

or a known duration of greater than 48 hours. Prolonged atrial fibrillation has been

documented to create clots and converting the rhythm may disseminate these clots

throughout the body.


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J. Ventricular Ectopy / Presence of Runs of V-Tach

Runs of V-Tach = 3 or more PVCs in a row



For couplets, multi-focal PVCs or bigeminy, continue oxygen therapy maintaining a

saturation of > 94%.

Follow applicable protocol based on patient presentation (signs & symptoms) i.e. Acute Coronary Syndrome (Chest Pain), Bradycardias, Dyspnea, Hypotension Protocols.

For runs of V-Tach AND underlying heart rate is below 60:

Administer Atropine 0.5 mg to a max of 3 mg (0.04 mg/kg) slow IV push to

speed up underlying rhythm and “overdrive” the rhythm.

For runs of V-Tach AND underlying heart rate is above 60:

Consider medications - choose ONE of the following agents (Amiodarone is the

preferred medication):

Amiodarone infusion - 150 mg in D5W 100 cc over 10 minutes. (If successful

conversion, start Amiodarone drip at 1 mg / minute).

OR

*Lidocaine 0.5 to 0.75 mg / kg IV push (If successful conversion, start

Lidocaine infusion at 1 – 4 mg / minute).

*Only use Lidocaine if Amiodarone is NOT available

K. Acute Coronary Syndrome (ACS)

(Chest Pain, Acute MI / STEMI, Suspected Cardiac Event, etc.)

1. Airway, oxygen, monitor, obtain 12-Lead ECG within 10 minutes of arrival.


3. Administer medications:

ASA (2 to 4 baby aspirin) 162 – 324 mg PO (chewable).

Nitroglycerin 0.4 mg SL, every 5 minutes if systolic BP remains greater than 90

mmHg up to 3 doses.

Repeat Nitroglycerin as needed until cardiac symptoms are relieved or patient

becomes symptomatic from the medication (i.e., headache becomes the chief

complaint, hypotension develops, etc)


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*Do NOT administer Nitroglycerin if:

a. The patient has used any erectile dysfunction (ED) medication

(Viagra/sildenafil, Levitra/vardenafil, and Cialis/tadalafil) within the

previous 48 hours.

b. 12 Lead shows Inferior MI (ST Elevation in any two of the following

leads – II, III, aVF).

Morphine Sulfate 2 - 5 mg slow IV/IO/Intranasal for chest pain may repeat up

to a maximum of 10 mg (if systolic blood pressure remains greater than 90

mmHg). Use with caution in unstable angina / non-STEMI.

4. Correct perfusion-altering dysrhythmias according to protocol guidelines.

5. Transport Code 3 STEMI to closest hospital with emergency cardiac

catheterization lab availability.

6. Contact receiving hospital as early as possible and notify of any S-T elevation, call

a STEMI Alert.

7. Transmit 12-Lead ECG to receiving hospital.

8. Start 2nd IV en route.

L. CHF/Pulmonary Edema

Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy sputum with a BP that is hypertensive or within normal limits


2. CPAP w/ supplemental O2.

3. Upright position (45o - 90o), maintain this position and treat before moving.

4. Obtain and transmit 12-Lead ECG.


6. Administer Medications:

Nitroglycerin SL:

a. If systolic BP is > 180, give 0.4 mg per dose (1 tablet, may repeat once after 3 - 5 minutes)

b. If systolic BP is < 180, give 0.4 mg (1 tablet)

c. Continue if systolic BP remains greater than 90 mmHg

d. Monitor pulse and blood pressure before each dose


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Morphine Sulfate, 2 - 5 mg slow IV/IO/Intranasal (to a maximum dose of 10 mg).

Use with caution in patients who are elderly, have COPD history or who

are hypotensive.

Consider DuoNeb by nebulizer. Consider CPAP protocol.

M. Cardiogenic Shock

Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy sputum with a BP that is hypotensive



3. Correct perfusion altering dysrhythmias according to protocol guidelines.

4. Obtain and transmit 12-Lead ECG.

5. Consider fluid bolus 250 - 500 cc NS up to 1 Liter.

6. Administer Epinephrine Drip: (Procedure H)

Begin infusion at 2 – 10 mcg / min

Pulse and BP should be monitored every 2 - 5 minutes.

Goal is to maintain systolic BP at > 90 mmHg.

ACUTE TRAUMATIC EMERGENCIES

A. General Trauma Management

Priorities for Treatment

1. Provide airway management.

2. Control the cervical spine. Assume cervical spine injury is present in any patient

with:

Evidence of high impact with a distracting injury.

Any head or neck injury.

Neck pain following trauma.

Altered mental status.

Presence of any neurological deficit.

3. In trauma code situations (Usually PEA) attempt all mechanical interventions, i.e.:

CPR, ET/King airway, IV/IO, and Needle decompression prior to administering first

line cardiac drugs.

REMINDER: Pain, loss of sensation or motor activity MAY NOT be present

initially with cervical spine fractures.


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Also see Spinal Injury Assessment Protocol.

4. Consider helicopter transport to the Trauma Center if:

Incident is located well north of I-680 or west of 150th Street.

Transportation by ground to the Trauma Center will be greater than 20 minutes.

Extrication time and ground transport time to the Trauma Center will be greater

than 20 minutes.

Consider requesting standby status while enroute to the scene. This will be

based on the incident location and information given by dispatch regarding the

nature of the call.

If the helicopter is not on scene when the medic unit is ready to transport, do

not wait for the helicopter to arrive. Transport the patient in the medic unit to

the Trauma Center unless traffic conditions warrant otherwise.

See OFD SOP OPS 17-0 Helicopter Procedures for more information.

5. Helmet Removal:

Remove all helmets to avoid airway management problems according to ACS

and PHTLS guidelines. The exception may be football helmets with shoulder

pads in place. In these cases, removal of the football helmet is an option, but

removal of the face guard is required. Cervical immobilization is without the c-

collar, utilizing other resources, i.e. towel rolls, commercial head immobilization

devices.

6. Control external hemorrhage:

Direct pressure

Apply a wide band tourniquet 2” above the injury for life-threatening extremity

hemorrhage, mangled extremity, or traumatic amputation that is not controlled

by direct pressure. Document tourniquet application time and do not cover the

tourniquet.

7. Hypovolemic shock (assume shock present when pulse greater than 120 and/or

systolic BP less than 100 mmHg in a previously normotensive patient; or systolic

drops 40 - 50 mmHg in a previously hypertensive patient, especially if

accompanied by pale, clammy skin and decreased level of consciousness).

Apply oxygen and ventilate if necessary.

Keep patient warm and dry.

Start 1 or 2 large bore IV's with warm NS, fluid bolus titrating to a systolic blood

pressure of 90mmHg. DO NOT delay transport for IV starts.

8. Apply ECG monitor enroute.

9. Extremity Injuries (fractures/dislocations) - General Guidelines:

Check and record peripheral pulses and neurological status before and after

manipulating or splinting fractures.


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Apply gentle in-line traction to fractures with the exception of dislocations or

fractures involving joints (especially the elbow).

May straighten severely angulated fractures of extremities with the exception

of those involving knee or elbow. For knee or elbow with neurovascular deficit,

attempt once to realign extremity to restore neurovascular status.

Immobilize fractures, including joint above and joint below.

For suspected femur fracture (open or closed), consider traction splint.

For suspected unstable pelvic fractures, tie a sheet snugly around pelvis.

10. DO NOT remove any impaled objects unless obstructing airway or interfering with

CPR.

11. All life or limb-threatening injuries should be transported immediately to the

Trauma Center.

12. If Quik Clot, Celox, or other similar coagulation agent has been applied for bleeding

control prior to O FD arrival, leave in place. Do not remove. Follow standard

bleeding control measures.

13. Place all amputated parts in NS solution and keep cool if possible

B. Penetrating Injuries to Head, Neck, Chest and Abdomen


2. Consider c-collar and backboard if appropriate.

3. Start IVs enroute, NOT on scene.

4. Scene time should be < 5 minutes.

C. Head Injuries

1. Maintain / manage airway and apply oxygen, monitor. Maintain oxygen saturation

> 94%.

2. Consider RSI.

3. Ventilate with adequate tidal volume at normal respiratory rate for patient age.

Using capnography, maintain CO2 at 35-45mmHg.

4. Start large bore IV with NS enroute and titrate to vital signs. Maintain blood

pressure > 90 systolic.

D. Chest Injuries


2. For tension pneumothorax WITH EVIDENCE OF SHOCK, insert 12 gauge

catheter at 2nd intercostal space in mid-clavicular line.

Perform bilateral needle decompression in all Code 99 patients with penetrating

or blunt thoracic trauma.


Page 34 of 83

3. Cover sucking chest wounds with occlusive dressing, remove if patient’s condition

deteriorates.

4. Start 1 or 2 large bore IV’s with NS enroute and titrate to a systolic blood pressure

of 90mmHg.

E. Abdominal Injuries


2. Dress any penetrating wound with a dry sterile dressing or occlusive dressing.

3. For evisceration: DO NOT REPLACE eviscerated tissue. Cover with a moist sterile

dressing. Place a dry sterile dressing over moist dressing to maintain warmth.

4. Start 1 or 2 large bore IV's with NS during transport titrating to a systolic blood

pressure of 90mmHg.

F. Eye Trauma

1. Chemicals - Flush with Normal Saline or water continuously enroute to the

receiving hospital. Remove contacts prior to irrigation.

2. Foreign body or punctured eye - Leave foreign body in place. Apply loose

protective covering over impaled eye. Patch other eye. DO NOT apply a pressure

dressing.

3. Loss of eye tissue - If possible, transport tissue with patient. Keep eyes moist with

NS.

4. Keep patient from rubbing eye(s).

G. Burns


2. Assess for inhalation burns, consider ET intubation, RSI if indicated.

3. Protect from hypothermia.

4. Remove rings, bracelets and other constricting items in burned areas.

5. Thermal burns.

Remove any clothing near area of burn wound.

Apply clean, dry dressings or sheets.

If an isolated burn of less than 10% BSA, consider moistening with saline

(prevent hypothermia).

6. Chemical burns (wet)

Flush with large volumes of fluid.


7. Chemical burns (dry)


Page 35 of 83

Safely brush off as much of the chemical as possible.

Flush with large volumes of fluid.


8. Electrical burns

Apply clean, dry dressings to entrance and exit wounds.

Apply ECG monitor and follow applicable protocol as indicated.

9. Consider large bore IV with NS. Titrate to vital signs.

10. Consider pain control.

11. Transport to the Trauma Center for suspected airway involvement and/or burns

greater than 10% of total body surface area, circumferential burns, burns to the

hands, feet, or genitalia.

H. Snakebite

In the event of an actual or probable snakebite:

1. Confirm that the responsible snake or snakes have been appropriately and safely

contained and there is no danger of additional bites to patient or OFD personnel.

2. Keep patient calm (minimize patient movement).

3. For incidents at Henry Doorly Zoo – obtain and confirm appropriate antivenom for

snake involved. Quickly package patient and initiate Code 3 transport directly to

Nebraska Medicine. Establish early radio contact to hospital to inform them of

situation.


5. Splint any bitten extremity and maintain the extremity in a position below the level

of the heart.

6. Remove any rings or jewelry on the bitten extremity.

7. Apply a blood pressure (BP) cuff, as a tourniquet, one-inch above the site of the

bite on the extremity. Inflate cuff to 60 - 70 mmHg and maintain this pressure. If no

BP cuff available, may use other resources for constricting bands (tourniquet, cling,

Coban, etc.). Goal is to apply just enough pressure to occlude only superficial

veins and the lymphatics. A pulse should be palpable below the bite site after

application.

8. Attempt IV enroute in a non-affected extremity.

9. Do not rinse bite site.

10. Do not cut or incise the bite site, or apply ice or cold packs.

11. Do not administer antivenom in the field.


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I. Crush Syndrome

This protocol is to be used for adult patients who are being rescued from being trapped by having an extremity muscle mass compressed for more than four hours or more than two hours in a cold climate, but also who have pulses distal to the compression. Preventive treatment for Crush Syndrome is secondary to primary interventions for acute traumatic injuries. The risks of Crush Syndrome are greater if the patient’s extremity is hard, swollen, cold and insensitive. 1. Airway, oxygen, monitor – patients should have high flow oxygen applied,

especially at time of release.

2. Start two (2) large bore IVs of NS at TKO rate prior to extrication and releasing

compression.

3. Adjust one of the IVs to wide open at the time muscle compression is released.

4. After the first 1000 cc of NS has been infused, mix 50 cc of Sodium Bicarbonate

into the second IV bag and adjust the second IV to 500 cc per hour.

5. Continue running 1st IV of NS wide open (change to new bag as needed).

6. Administer up to three (3) L of normal saline (clear lung sounds and no shortness

of breath), over the first 90 minutes following release of compression.

7. Transport to the trauma center.

J. Decision Scheme for Trauma Patients

Metropolitan Omaha Triage Decision Scheme for Trauma Patients

Vital Signs and Level of Consciousness

Glasgow Coma Scale ≤ 13

Systolic BP 90 mmHg or less

Respiratory Rate < 10 or > 29 Or need for ventilatory support

(<20 in infant less than one year old)

Injuries

All penetrating injuries to head, neck, torso and extremities proximal to elbow

and knee

Chest wall instability or deformity (flail chest)

Two or more proximal long bone fractures

Crushed, degloved, mangled or pulseless extremity

Amputation proximal to wrist or ankle


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Suspected pelvic fracture

Open or depressed skull fracture

Paralysis

Combination trauma and burns

Suspected airway involvement and/or burns greater than 10% of total body

surface

Mechanism of Injury and/or Evidence of High Energy Impact

Falls

Adults: > 20 ft. (one story is equal to 10 ft.)

Children: > 10 ft. or 2 – 3 times the height of the child

High Risk Auto Crash

Intrusion (including roof) > 12 inch occupant site and/or 18 inch any site

Ejection (partial or complete) from automobile

Death in same passenger compartment

Vehicle telemetry data consistent with high risk injury

Auto versus Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20

mph) Impact

Motorcycle Crash > 20 mph

Consider transport to the Trauma Center for the following conditions/situations:

Patient age of 55 years old or greater

Systolic BP < 100 in patients 65 years old or older

Anticoagulation and Bleeding Disorders

Time Sensitive Extremity Injury

End Stage Renal Disease Requiring Dialysis

Pregnancy > 20 weeks

EMS Provider Judgment

The Trauma Center is the only hospital to contact if the above criteria are met. Trauma

patients that do not meet these guidelines, and are stable, may be taken to any hospital.

ANY HOSPITAL OR EMS PROVIDER HAS THE OPTION TO BYPASS TO THE

TRAUMA CENTER IF IT IS FELT IT IS IN THE BEST INTEREST OF THE PATIENT


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Trauma Center of the Day Designation (Omaha area Trauma Center days rotate at 0700

every day):

Nebraska Medicine Odd Days

CHI Alegent Creighton Health Even Days

K. Trauma Center Rotation for Mass Casualty Incidents (MCI)

In the event of an MCI, both Omaha Trauma Centers will open for trauma patients.

1. Follow Standard Operating Procedures EMS 5-0 Multi-Casualty Response.

2. The Incident Commander at the scene will notify Omaha Fire Dispatch of a MCI

event along with the estimated number of victims. Dispatch will then contact the

Trauma Center of the Day.

3. The ED staff at the Trauma Center of the Day will then contact the ED staff at the

non-Trauma Center of the Day to inform them of the situation and need for both

Trauma Centers to open for trauma patients.

4. When 4 critically injured / RED patients arrive or are being transported to the open

Trauma Center of the Day, the alternating Trauma Center will receive the next 4

critically injured / RED patients. This rotation of 4 and 4 will continue until all

critically injured / RED patients have been transported.

5. Minor injury / GREEN patients should be transported to the other local hospitals,

not to the Trauma Centers. For a large scale incident with more than 20 critically

injured / RED patients, consider transporting all serious injury / YELLOW patients

to the other hospitals.

6. Each Trauma Center will be responsible for informing Omaha Fire Dispatch when

they are no longer able to accept any additional patients in the rotation.

7. If both Trauma Centers are overwhelmed, critically injured / RED patients should

then be transported to the other local hospitals.

MEDICAL EMERGENCIES

A. Upper Airway Obstruction (Choking)

1. Attempt to relieve obstruction according to the American Heart Association Foreign

Body Airway Obstruction (FBAO) guidelines.

2. If unsuccessful:

Attempt to visualize obstruction with laryngoscope and remove with Magill

Forceps.

Administer oxygen, monitor.

https://powerdms.com/link/IDS/document/?id=12332


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If all of the above fail, consider needle cricothyrotomy. Use 12 or 14 gauge

needles.

Start IV with NS TKO.

B. Altered Mental Status

Altered Mental Status with History of Diabetes Mellitus (Hypoglycemia)


2. Check blood sugar level.

3. Start IV/IO with NS, titrate to vital signs.

4. If blood sugar is less than 70 and / or signs & symptoms are present which are

consistent with hypoglycemia:

Ensure patent IV with a 20ml flush of NS.

Administer D10 (D10 = 25 Grams of Dextrose in 250 mL premixed bag)

If D10 is not available then

Administer 12.5 – 25 grams (25-50 ml) of D50W IV push, followed by 10ml NS

flush.

Recheck blood sugar. Consider repeating if blood sugar remains less than 70.

Altered Mental Status, Excluding Exposure



3. Start IV with NS, titrate to vital signs.

4. If blood sugar is less than 70 and/or signs & symptoms are present which are

consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol.

5. If narcotic overdose suspected (GCS <13, pin point pupils, and/or respiratory

depression), administer Narcan, 0.4 mg to 2.0 mg IV/IM/IO/IN, repeat as indicated.

6. Note: If the patient is not an imminent safety concern consider Physical

Restraint Procedures.

7. Ketamine if patient is an (Imminent safety concern)

8. RASS SCORE +2, +3, or +4 (document in your report before Ketamine

administration and 5 min after administration of Ketamine, and once again upon

ED arrival)

Adult – 250 mg IM (16 y/o and older)

May repeat once (250 mg) in 5 minutes if needed (Max 500 mg)

Pediatric – 150 mg IM (12 y/o – 16 y/o)

May repeat once (150 mg) in 5 minutes if needed (Max 300 mg)


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9. Obtain 12 Lead ECG

10. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated)

11. If the patient is not calm after 10 minutes:

Administer Versed 5 mg IM / IN

Administer Versed 2 mg IV (as needed every 5 minutes x 3 doses up to 6

mg max dose)

12. If patient is sedative apply nasal cannula and monitor CO2

13. Documentation

Ensure statements of self-harm, harm to others are reported to Law

Enforcement and document in the patient care report.

RASS SCALE:

Pearls

Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro

Crew / responders safety is the main priority.

Any patient who is handcuffed or restrained by Law Enforcement and transported

by EMS must be accompanied by law enforcement in the ambulance of follow

immediately behind the ambulance.

Consider sedatives (Ketamine or benzodiazepine) for patients with other

presumed substance abuse. While benzodiazepines may be indicated for patients

with alcohol intoxication, consider that alcohol and benzodiazepines together may

lead to respiratory depression


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All patients who receive either physical or chemical restraint must be continuously

observed by ALS personnel on scene or immediately upon their arrival. Consider

bringing extra personnel during transport.

If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc >

500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS

is greater than .12 seconds consider administering Sodium bicarbonate (1mEq /

kg). Consult medical control if appropriate.

Be sure to consider all possible medical/trauma causes for behavior

(hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.)

Do not irritate the patient with a prolonged exam.

Do not overlook the possibility of associated domestic violence or child abuse.

If patient is suspected of agitated delirium suffers cardiac arrest, consider a

fluid bolus and Sodium Bicarbonate early

Do not position or transport any restrained patient is such a way that could impact

the patient's respiratory or circulatory status.

Documentation

o Ensure statements of self-harm, harm to others are reported to Law

Enforcement and document in the patient care report.

o Document RASS Score before Ketamine administration, 5 minutes after

administration and upon ED arrival.

Altered Mental Status associated with anxiety, agitation, confusion, hallucinations, bizarre behavior, combative, violent, delusional thoughts, paranoia, hyper aggression tachycardia, increased strength, hyperthermia –

C. Excited Delirium

1. Ketamine

RASS SCORE +2, +3, or +4 (document in your report before Ketamine

administration and 5 min after administration of Ketamine, and once again upon

ED arrival)

Adult 250 mg IM (16 y/o and above)

May repeat x 1 dose in 5 minutes if needed (Max 500mg)

Pediatric 150 mg (12 y/o – 16 y/o)

May repeat x1 dose in 5 minutes if needed (Max 300mg)

2. If patient is not calm after 10 minutes:

a. Versed 5 mg IM/IN

b. Versed 2 mg IV (as needed every 5 min X3 doses up to 10 mg max)


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3. IV Access - NS 1,000 mL Bolus May repeat 500 mL bolus x2

a. Maximum 2 Liters

4. Glucose Check – Refer to hypoglycemia protocol

5. Temperature measurement and cooling measures as needed

6. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated)

7. 12 Lead ECG procedure

a. Cardiac monitor

8. Sodium Bicarbonate 1mEq/kg IV / IO if patient has S/S of cardiac arrhythmias or

presents in cardiac arrest.

9. Monitor and reassess frequently.

10. If patient is sedated apply nasal cannula and monitor CO2

11. Document RASS score before Ketamine administration, 5 minutes after

administration and on ED arrival.

Pearls

Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro

Crew / responders safety is the main priority.


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Any patient who is handcuffed or restrained by Law Enforcement and transported

by EMS must be accompanied by law enforcement in the ambulance of follow

immediately behind the ambulance.

Consider sedatives (Ketamine or benzodiazepine) for patients with other

presumed substance abuse. While benzodiazepines may be indicated for patients

with alcohol intoxication, consider that alcohol and benzodiazepines together may

lead to respiratory depression

All patients who receive either physical or chemical restraint must be continuously

observed by ALS personnel on scene or immediately upon their arrival. Consider

bringing extra personnel during transport.

If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc >

500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS

is greater than .12 seconds consider administering Sodium bicarbonate (1mEq /

kg). Consult medical control if appropriate.

Be sure to consider all possible medical/trauma causes for behavior

(hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.)

Do not irritate the patient with a prolonged exam.

Do not overlook the possibility of associated domestic violence or child abuse.

If patient is suspected of agitated delirium suffers cardiac arrest, consider a

fluid bolus and Sodium Bicarbonate early

Do not position or transport any restrained patient is such a way that could impact

the patient's respiratory or circulatory status.

Excited Delirium Syndrome:

o Medical emergency: Combination of delirium, psychomotor agitation,

anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre

behavior, insensitivity to pain, hyperthermia and increased strength.

Potentially life-threatening and associated with use of physical control

measures, including physical restraints and Tasers. Most commonly seen

in male subjects with a history of serious mental illness and /or acute or

chronic drug abuse, particularly stimulant drugs such as cocaine, crack

cocaine, methamphetamine, amphetamines or similar agents. Alcohol

withdrawal or head trauma may also contribute to the condition.

Documentation Ensure statements of self-harm, harm to others are reported to Law Enforcement and document in the patient care report. RASS Score before and after Ketamine administration.

D. Seizure Disorder


2. Protect patient from further injury, DO NOT restrain or force bite block.



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5. If blood sugar is less than 70 and/or signs & symptoms are present which are

consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol.

6. For recurrent seizures, consider one of the following:

Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intra-

nasal (may repeat in 5 minutes at half the dose).

7. If narcotic overdose suspected, consider Narcan 0.4 mg to 2.0 mg IV push or 0.4

– 2.0 mg intranasal or other route as accessible, repeat as indicated.

E. Difficulty Breathing

Acute Allergic Reactions / Anaphylaxis (Difficulty Breathing in the presence of

urticaria, wheezing and/or contact with a known allergen)

BP <70 Systolic




Epinephrine 0.1 - 0.2 mg (1:10,000) IV/IO OR If intubated, 0.2 - 0.4 mg

(1:10,000) ET (Dose is doubled for ET route).

Repeat every 5-10 minutes depending on vital signs and respiratory status.

DuoNeb by nebulizer, may repeat as necessary. Consider BVM aerosol setup;

do not wait for IV access.

Benadryl 50 mg slow IV push over 1 - 3 minutes.

BP >70 Systolic

1. Airway, oxygen, monitor, intervene when needed.


Epinephrine 0.3 – 0.5 (1:1,000) IM. Repeat in 5 minutes as necessary.

NOTE: Epinephrine has no contraindication in acute anaphylaxis.

DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary.

Benadryl 50 mg IM OR slow IVP over 1 - 3 minutes

3. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay

medications while waiting for IV access.

Asthma/COPD (Difficulty breathing in the presence of wheezing with history of

asthma, chronic bronchitis, emphysema, or irritant exposure)

1. Airway, oxygen, monitor, intervene when needed, CPAP if BP > 90 systolic.


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DuoNeb by nebulizer, may repeat x1.

If the nebulizer treatments are ineffective:

Magnesium Sulfate 2 Grams IV/IO diluted in 10 ml NS, slow push over 10

minutes.

Epinephrine 0.3 - 0.5 mg (1:1,000) IM OR 0.1 – 0.2 mg (1:10,000) IV (IV dose

used in severe asthma with impending arrest, only.)

NOTE: Do NOT administer epinephrine if the patient has chest pain, is being

treated for angina, has a history of coronary artery disease, or AMI.



F. Exposure

Hypothermia (Lowered Skin Temperature with Altered Mental Status)

1. Remove wet clothing, protect against heat loss and wind chill.

2. Avoid rough movement and excess activity.

3. Maintain horizontal position.

4. Monitor temperature, if possible.

5. Monitor cardiac rhythm.

If Pulse/Breathing Present

1. Oxygenate with warm oxygen (if available).

2. Start IV with NS TKO, use warm IV fluid (if available).

If Pulse/Breathing Absent

1. Start CPR.

2. If VF/VT, defibrillate X 1.

3. Continue CPR if pulseless and apneic.

4. Ventilate with warm oxygen (if available).

5. Start IV with NS TKO, use warm IV fluid (if available).

NOTE: Medications are not indicated in extreme hypothermia.

Transport considerations:

Adult patients with extreme hypothermia and no signs or suspicion of trauma,

transport to catchment area hospital.


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Pediatric patients with extreme hypothermia and no signs or suspicion of

trauma, transport to Children’s Hospital.

Hyperthermia (Elevated Skin Temperature with Altered Mental Status)

1. Remove from environment and wrap with moist sheets.

Replace moist sheets frequently.

Increase airflow to improve evaporation and convection.



G. Hypovolemic Shock (Hypotension in the Absence of Trauma)

Shock is present when pulse greater than 120 and systolic BP less than 90 mmHg in a

previously normotensive patient or systolic drops 40-50 mmHg in a previously

hypertensive patient, especially if accompanied by pale, clammy skin and decreased level

of consciousness.


2. Start 1 or 2 large bore IVs, NS and titrate to vital signs, up to 2 liters.

3. Consider Epinephrine drip at 2-10 mcg / min

H. Poisons

Consider calling Poison Control Center

Omaha area-------------------------402-955-5555

Outside of Omaha area---------1-800-222-1222

I. Nerve Agents

See Procedure D


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J. Overdose/Toxic Ingestion


2. Check blood sugar level is less than 70, follow hypoglycemia protocol.


4. If altered mental status, respiratory depression and/or pin point pupils consider

Narcan, 0.4 mg to 2.0 mg IV push or 0.4 – 2.0 mg intranasal, repeat as necessary.

5. If patient demonstrates one of the following:

Prolonged or widening of QRS ( > 120ms).

Ventricular dysrhythmias.

Hypotension unresponsive to fluid challenge of 500 ml NS.

Seizure with no previous history of seizures.

Administer 1mEq/Kg Sodium Bicarbonate slow IV push.

6. Treat dysrhythmias according to protocol guidelines.

7. Combative patients see Physical and/or Altered Mental Status Protocols

K. Toxic Inhalation

1. Remove from exposure.

2. Airway, oxygen, monitor, consider CPAP.

3. If wheezing and/or signs of bronchoconstriction:

DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary.


5. If CO poisoning, treat with high flow oxygen, 15LPM via non-rebreather mask.

6. If only CO poisoning is suspected and no inhalation injury, assess for the presence

of any of the following and transport directly to Nebraska Medicine for possible

hyperbaric chamber treatment:

Chest pain.

Headache in pregnant patient.

Altered LOC or history of unconsciousness.

Dizziness.

Seizures.

Unsteady gait or difficulty speaking.


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L. Cyanide Poisoning (see Procedure ‘F’)

1. Assess and treat Airway, Breathing, and Circulation.

2. Start (2) IV’s with NS, titrate to vital signs.

3. Administer Cyanokit if known or suspected cyanide poisoning in persons exposed

to smoke from a fire in closed spaces and in victims with soot around the mouth,

nose, and oropharynx with a depressed mental status, systolic blood pressure <

90, seizure activity or who are unresponsive.

Adult Dose (19 years and older):

5 Grams of Cyanokit (hydroxocobalamin) in 200 mL 0.9% sodium chloride IV

infusion over 15 minutes

15 drop IV tubing – 200 gtts/min or 3 drops / sec (nearly wide-open).

Check in 7 minutes and ½ the antidote should be infused.

Pediatric Dose: Contact medical control at the receiving hospital.

4. Follow ACLS guidelines if the patient in pulseless, apneic and unresponsive –

establish and use a second IV / IO site for all other medications.

5. Notify PSS and EMS B/C when used.

**DO NOT DELAY TRANSPORT FOR CYANOKIT ADMINISTRATION

**Monitor blood pressure as the patient could have significant increases.

M. Stroke


2. Check blood sugar level is less than 70 follow hypoglycemia protocol.

3. Start IV with NS en route to hospital. Do NOT delay transport. Titrate to vital signs

if BP is < 90 systolic.

4. Perform, document and report results of the Cincinnati Prehospital Stroke Scale

(see Procedure B) to receiving facility.

5. Obtain history – if possible, determine onset time of signs and symptoms from

patient and / or bystanders – report to receiving facility for possible activation of

hospital stroke team.

6. Code 3 Stroke Transport if:

Signs/symptoms have recently developed (onset within last 3 hours).

Signs/symptoms are progressing.

Unstable vital signs.


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N. Behavioral Emergencies

1. A patient with a behavioral emergency should be transported to the catchment

hospital for medical clearance and psychiatric evaluation.

2. Patients who are rational and present no risk to OFD personnel or to themselves

may be transported to hospital of choice.

3. Patients who pose a risk to themselves or OFD personnel (See Refer to Altered

Mental Status Protocol)

ALWAYS consider a medical etiology for a behavioral emergency.

O. Nausea and/or Vomiting

1. Follow appropriate protocol for the patient’s condition.


3. Administer Zofran (ondansetron), single dose only.

For adult patients < 250 lbs., give 4 mg IV, slow push 2-5 minutes, or SL

For adult patients > 250 lbs., give 8 mg IV, slow push 2-5 minutes, or SL

For pediatrics age 1 or older, give 0.15 mg/kg IV, slow IV push, max of 4 mg.

OBSTETRICS - GYNECOLOGY

A. Imminent Delivery with History of Pregnancy, a Palpable Uterus and

Contractions


2. Consider IV with NS, titrate vital signs. If possible, start IV’s in forearms.

3. If not crowning (no signs & symptoms of imminent delivery), transport patient in

position of comfort, usually on left side.

4. If crowning present, prepare mother for delivery.

5. Allow placenta to deliver naturally. DO NOT forcibly extract. If mother allows, put

baby to breast. Massage fundus. Transport all tissue passed with patient to

receiving facility.

B. Neonatal Care

General Care Given Newborn, Full-Term or Premature

1. Suction nose with bulb syringe.

2. Keep baby warm and dry, keep at same level as vagina.

3. Stimulate to breathe.

4. Maintain airway and apply blow-by oxygen as necessary.


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5. Assess APGAR score at 1 minute and 5 minutes. (See Appendix)

6. Within 1 - 2 minutes, double clamp cord 6 - 12 inches from baby and cut.

7. Continue supportive care as needed.

If spontaneous respirations absent or inadequate, or pulse rate below 60:

Ventilate with bag-valve-mask at a rate of 40 - 60/minute with ROOM AIR.

If pulse remains less than 60, despite positive pressure ventilation, intubate and

ventilate with 5 L/min oxygen.

If pulse remains less than 60 after intubation OR drops below 60 at any time,

start chest compressions.

Compression to ventilation ratio is: 3:1 (90 compressions and 30

ventilations per minute).

If no change after this point, Administer Epinephrine:

0.01 – 0.03 mg / kg IV / IO, (1:10,000).

Repeat every 3 – 5 minutes.

For ET administration, give 0.1 mg / kg, (1:1,000)

Fluid Bolus at 10 cc / kg

C. Meconium Stained Fluid

1. Use a suction catheter or infant bulb syringe to clear mouth and nose.

2. If meconium present, intubate with #3.0 ET tube, suction the tube as the tube is

pulled out, re-intubate with a new tube each time until CLEAR (consider use of

Meconium Aspirator).

3. Once clear, re-intubate and ventilate, maintain a patent airway and provide oxygen

at no greater than 5 L/min.

D. Childbirth Complications

Prolapsed cord, breech presentation, limb presentation, significant hemorrhage,

decreased fetal heart rate.

1. Airway, oxygen, monitor, start 1 or 2 IVs with NS and titrate to vital signs.

2. If prolapsed cord, place patient on back and elevate the hips or consider knee-

chest position. Place two fingers of a gloved hand in vagina to raise the presenting

part of the infant off the cord. Check cord for pulsations and avoid compressing

the cord. Continue during transport. Apply warm, moist sterile dressings to the

exposed cord to maintain temperature.

3. If breech delivery and unable to deliver head, place gloved hand in the vagina with

palm towards the infant’s face. Form a “V” with the index and middle fingers on


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either side of infant's mouth and nose and push the vaginal wall away from the

infant’s face. If necessary, continue during transport.

4. If arm or leg presentation, place patient on back and elevate hips or consider knee-

chest position, transport immediately.

5. If significant hemorrhage, place dressings to monitor bleeding and elevate hips.

E. Postpartum Hemorrhage


2. Massage the fundus of the uterus and put baby to breast.

3. Start IV with NS and titrate to vital signs.

F. Hypertensive Disorders of Pregnancy

Toxemia of Pregnancy/Eclampsia - Toxemia is characterized by hypertension and diffuse edema

1. Airway, oxygen, monitor, position patient on her left side.

2. Start 2 IVs with NS TKO.

3. Consider blood sugar check if blood sugar is <70 follow hypoglycemia protocol.

4. Administer Medications if patient has eclampsia (actively seizing):

Magnesium Sulfate (50%) 5 grams in 50 cc D5W with a minidrip setting.

Infusion must be over a minimum of 5 minutes.

If patient has pre-eclampsia (headache, confusion, visual disturbances, chest pain,

dyspnea or history of recent seizure prior to medic unit arrival), consider

Magnesium Sulfate at the above dose.

If still seizing after 5 minutes, repeat Magnesium Sulfate at half dose.

Magnesium Sulfate (50%) 2.5 grams in 50 cc D5W with a minidrip setting.

Infuse over a minimum of 5 minutes.

5. For continued seizures, consider:

Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intra-

nasal (may repeat in 5 minutes at half the dose).

G. Vaginal Bleeding


2. Start IV NS and titrate to vital signs.


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PEDIATRICS

A. General Guidelines

This protocol acknowledges that age limits for pediatric patients should be flexible and

that the exact age of a patient is not always known. Between the ages of 13 and 16, OFD

personnel should use his / her own judgment in making medical care decisions. OFD

personnel always have the option of contacting medical control directly for assistance in

decision making.

See General Operations section (Refusal of Care) for patient consent and refusal

guidelines.

Parents / caregivers should be allowed to stay with children during assessment and

transport, if appropriate.

OFD personnel shall transport all size-appropriate pediatric patients using the Pedi Mate.

OFD personnel are strongly encouraged to use current length based resuscitation tapes

and guidelines for dosage and equipment recommendations for pediatric patients.

If specific protocol not found in Pediatric Section, OFD personnel should follow

appropriate Adult Protocol, adjusting all medications and interventions to pediatric

dosages and guidelines.

B. Airway Management and Oxygen Therapy

OFD personnel should administer high flow oxygen by mask as needed. If patient will not

tolerate mask, use high flow blow-by oxygen.

Do not hyperextend the neck in newborns and infants.

Avoid hyper-oxygenating newborns and infants after resuscitation. Keep O2 saturation >

94% once ROSC is achieved in a previously pulseless patient.

Consider appropriately sized oral airway for all unconscious patients.

When ventilation is needed, use appropriately sized bag valve mask device.

Endotracheal intubation is allowed, but is not necessary when ventilations are effectively

maintained with BVM.


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C. IV Therapy

For pediatric trauma patients and for all types of shock, attempt IVs enroute. Do not delay

scene time to establish an IV with a code 3 pediatric trauma patient.

For pediatric patients that are in critical or unstable condition, establish an intraosseous

(IO) infusion if difficult or unable to establish an IV.

D. Pediatric Cardiac Arrest

General Guidelines

1. If respirations are absent or inadequate, begin assisted ventilations using the

appropriately sized bag-valve-mask with 100% oxygen.

2. Begin chest compressions if:

No pulse.

Bradycardia (< 60 beats/min) is causing severe cardiorespiratory compromise

as evidenced by poor perfusion, hypotension, respiratory difficulty or altered

mental status.

3. Apply ECG monitor and follow standing orders as indicated using protocol

guidelines or Broselow tape.

4. Use Zoll Pediatric pads for patients up to 55 pounds (25kg).

5. A patient that is over 8 years old or over 55 pounds (weight over age) should be

treated as an adult with respect to electrical therapy. A patient that has signs of

puberty (breast development or under arm hair) should be treated as an adult with

respect to electrical therapy.

6. Consider drug overdose and/or hypoglycemia as precipitating factors in

cardiopulmonary arrest. Treat confirmed hypoglycemia with glucose. Dosing

guidelines based on patient age:

If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push).

For patients three (3) years or younger, Administer Dextrose 25% 2-4 ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with NS or sterile water, which will result in D25W).

7. If BVM ventilation is effective, do not delay scene time to establish ET intubation

E. Pediatric Cardiac Arrest: V-Fib / Pulseless Ventricular Tachycardia

1. UNWITNESSED arrest, perform 5 cycles (2 minutes) of CPR.

WITNESSED arrest, shock X 1 at 2 joules per kilogram (2 J / kg).

2. Immediate CPR after defibrillation for 2 minutes.


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3. Shock # 2 at 4 J / kg.

4. Immediate CPR after defibrillation for 2 minutes.

5. Repeat shocks at 4 J / kg; continue with 2 minutes of CPR between each shock.

6. Consider endotracheal intubation at any time with minimal interruption to CPR.

Ventilate with BVM (15 compressions to 2 ventilations) until ET tube

established, then ventilate 8 to 10 times per minute with continuous

compressions.

7. Deliver chest compressions at > 100 per minute.

8. Establish IV or IO at any time without interrupting CPR.


Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes

OR

0.1 mg / kg (1:1,000) ET every 3 to 5 minutes.

Amiodarone 5 mg / kg IV or IO

If Torsades de Pointes:

Magnesium Sulfate 25 - 50 mg/kg to a Max of 2 Grams IV / IO slow IV push

(over 5 minutes).

F. Pediatric Cardiac Arrest: Asystole / PEA

1. Perform 5 cycles (2 minutes) of CPR.

2. Confirm rhythm is asystole or PEA.

Ventilate with BVM (15 compressions to 2 ventilations) until ET tube

established, then ventilate 8 to 10 times per minute with continuous

compressions.

3. Deliver chest compressions at > 100 per minute.

4. Establish IV or IO at any time without interrupting CPR.

5. Consider endotracheal intubation at any time with minimal interruption to CPR.



OR

0.1 mg / kg (1:1,000) ET every 3 to 5 minute.

7. Consider treatable causes in the field:

Hypovolemia, administer fluid boluses at 20 ml / kg. May repeat 2 more times,

as needed.


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Tension Pneumothorax, consider needle decompression.

Infants up to 1 year use 18 ga needle

1 year and older use 14-16 ga needle

Hypothermia, provide warming measures.

Acidosis or Tricyclic Overdose, administer sodium bicarbonate 1 mEq / kg IV

or IO.

Hypoglycemia,

If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push).


G. Pediatric General Cardiac Dysrhythmia

In general, pediatric patients do not have cardiac dysrhythmias due to cardiac disease.

Most often, the cause of dysrhythmias in pediatrics is due to an airway/ventilation or

volume condition. For pediatric patients with signs & symptoms of poor perfusion, clear &

maintain the airway, provide BVM ventilations and fluid resuscitation (20 ml / kg) as

needed.

Most pediatric arrhythmia guidelines follow the adult protocols. OFD personnel should

refer to a pediatric reference guide (length based pediatric tape) if assistance is needed

with drug dosages for pediatric patients.

Stable Pediatric Patient –

If tolerating the rhythm, monitor and provide supportive care without medications or

electrical intervention.

Unstable Pediatric Patient –

Treatments are based on the patient’s condition and how rapidly a medication may be

delivered versus how rapidly an electrical therapy can be performed.

H. Bradycardia (HR <60 / min)

Bradycardia with signs and symptoms of poor perfusion

1. Airway, oxygen and monitor.

2. Establish an IV or IO of NS.

3. If unstable (poor perfusion, hypotensive, respiratory distress, altered mental

status), start chest compressions and assure airway and oxygen with BVM and/or

endotracheal intubation.


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OR

0.1 mg / kg (1:1,000) ET every 3 to 5 minutes.

Atropine 0.02 mg / kg IV or IO (minimum atropine dose is 0.1 mg).

Consider reversible causes (H’s and T’s)

Administer Epinephrine Drip:

Begin infusion at 0.1 - 1mcg / min

Pulse and BP should be monitored every 2-5 minutes.

Goal of resuscitation:

HR > 60 (80 for neonates/infants)

Systolic BP > 70 + (age in years x2)

Improving mental status

Improving capillary refill

5. Consider Transcutaneous Pacing (TCP)

If possible, pre-medicate with Versed 0.1 mg / kg IV/IO to a maximum dose of

2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg

I. Monomorphic Ventricular Tachycardia with a Pulse and Poor Perfusion

1. Airway, oxygen and monitor.


3. Administer Medications: If patient appears to be critically unstable go straight to

Synchronized Cardioversion.

Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is

6 mg). May repeat once in 2 – 3 minutes at double the dose (max dose 12 mg).

Amiodarone 5 mg / kg SLOW IV / IO over 60 minutes.

4. Consider Synchronized Cardioversion

Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose

of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg

Synchronized Cardioversion #1 at 0.5 – 1 joule / kg

Synchronized Cardioversion #2 at 2 joules / kg.

J. SVT with signs and symptoms of poor perfusion

1. Airway, oxygen and monitor. If patient appears to be critically unstable, go straight

to Synchronized Cardioversion.



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3. Vagal maneuvers, if patient is old enough to understand commands.

4. Administer fluid bolus at 20 ml / kg, repeat bolus as needed, up to a total of 3 times,

to increase perfusion. If patient has history of SVT, adenosine should not be

delayed for multiple fluid boluses.


Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is

6 mg). May repeat once in 2 – 3 minutes at double the dose (max dose 12

mg).

6. Consider Synchronized Cardioversion

Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose

of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg

Synchronized Cardioversion #1 at 0.5 – 1 joule / kg.

Synchronized Cardioversion #2 at 2 joules / kg.

K. Difficulty Breathing

Asthma, Bronchiolitis (Difficulty Breathing in the presence of wheezing)

1. Airway, oxygen, monitor, maintain position of comfort.

2. If patient in respiratory arrest, begin ventilations with a BVM, consider endotracheal

intubation.


DuoNeb by nebulizer, immediately. May repeat as necessary.

For patients in severe respiratory distress or the nebulizer treatment is ineffective:

Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3mg. Repeat

Epinephrine in 5 minutes, if necessary.

4. If unconscious, consider Bag-In nebulizer setup for DuoNeb.



Acute Allergic Reaction/Anaphylaxis (Difficulty Breathing in the presence of urticaria, wheezing and/or contact with a known allergen)


If patient in respiratory arrest, begin ventilations with a BVM, consider

endotracheal intubation.

2. Administer Medications immediately:

Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3 mg.

OR


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0.01 mg / kg (1:10,000) IV/IO (in severe anaphylaxis w/ imminent

arrest).

May repeat epinephrine in 3 - 5 minutes if necessary and/or start epinephrine

infusion at 0.1 – 1 mcg/kg/min.

DuoNeb by nebulizer, may repeat as necessary.

Benadryl 1 mg / kg IM or slow IV/IO push (over 1 - 3 min), maximum dosage of

50 mg.

3. IV of NS if not started already, titrate to vital signs.

Croup and Epiglottitis (Difficulty Breathing in the presence of stridor and history of illness)


2. Maintain patient in position of comfort, try to keep patient calm.

3. If unconscious, position supine and ventilate with BVM.

4. Consider early and rapid transport.

5. For suspected croup, administer medications:

Nebulized Epinephrine 0.5 ml / kg of 1:1000 solution (may dilute in 3 ml saline).

Maximum dose for patients < 4 years old is 2.5 ml per dose.

Maximum dose for patients > 4 years old is 5.0 ml per dose.

If unable to give epi nebulizer treatment, consider Epinephrine 0.01 mg/kg

(1:1,000) IM (maximum of 0.3 – 0.5 ml).

6. Consider IV of NS TKO.

Choking

1. Attempt to relieve obstruction according to the American Heart Association Foreign

Body Airway Obstruction (FBAO) guidelines.

2. If above maneuvers are unsuccessful, attempt to visualize obstruction with

laryngoscope and remove with Magill forceps.

3. Administer oxygen, monitor.

4. If all of the above fail, consider needle cricothyrotomy, 12 – 14 gauge for children,

16 – 18 gauge for infants or the largest catheter that will fit into the airway /

cricothyroid space.

5. Start IV with NS TKO enroute.

L. Seizures - recurrent or prolonged


2. Protect patient from further injury, DO NOT restrain.


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If blood sugar less than 70:

If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push).


For continued seizures, consider one of the following:

Versed 0.05 mg / kg slow IV/IO push up to a maximum dose of 2.5 mg, may

be repeated with authorization from receiving hospital.

If no IV access, Versed 0.05 mg / kg IM to a maximum dose of 2.5 mg,

OR

0.2 mg / kg (max of 5 mg) intranasal (max of 1 ml per nostril). If

given via nasal route, may be repeated at half-dose with

authorization from receiving hospital.

OR

If no IV/IO access, Valium 0.5 mg / kg rectally, may repeat to a maximum

dose of 10 mg.

If narcotic overdose suspected:

Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary.

M. Altered Mental Status





If blood sugar less than 70:

If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push).



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If narcotic overdose suspected:

1. Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary.


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PROCEDURE A - RAPID SEQUENCE INTUBATION

Indications

1. Altered mental status with airway compromise.

2. Head injuries with signs of increased ICP (GCS < 8), but combativeness or

agitation threatens the airway, spinal cord stability, and/or patient and crew safety.

3. Conscious but unable to maintain airway.

4. Severe respiratory distress with hypoxia / cyanosis, impending respiratory failure.

NOTES:

High flow oxygen should be applied. If the patient has inadequate

ventilations, ventilate with BVM @ 12 – 16 / minute with 100% oxygen.

Maintain cricoid pressure during entire intubation until tube placement is

confirmed by O2 saturations, physical exam and CO2.

DO NOT PERFORM IN TRANSPORT. Stop vehicle to initiate RSI.

Pre-medication Considerations

1. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg)

to the pediatric patient due to potential bradycardia (any patient under 4 years of

age).

2. Sedation

Versed (Midazolam)

Adults: 2 - 5 mg IV (may repeat every 5 minutes to a total dose of 10 mg) OR

5 – 10 mg intranasal, repeat at half-dose in 5 minutes. Max of 1 cc

per nostril.

Peds: 0.1 mg / kg IV or IO OR 0.4 mg / kg intranasal, max of 10 mg. Max

of 1 cc per nostril.

3. Paralyzing Agent

Succinylcholine

Adults: 1.5 mg / kg IV or IO

Peds: 1.5 mg / kg IV or IO

(DO NOT REPEAT Succinylcholine)

Procedure

1. Establish IV/IO access.

2. BVM (12-16 / min for adults, 14-20 / min for pediatrics) to preoxygenate the patient

for approximately 2 minutes if necessary. If patient has adequate ventilations

before RSI procedure, ventilations with BVM are not required prior to intubation.


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3. Maintain cricoid pressure at all times.

4. If trauma, maintain spinal immobilization (per trauma protocol).

5. Obtain & record vital signs (BP, Pulse, Respirations, O2 saturations and ECG).

6. Prepare equipment and medications.

7. Pre-medicate with Versed.

8. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg)

to the pediatric patient due to potential bradycardia (any patient under 4 years of

age).

9. Administer Succinylcholine 1.5 mg / kg rapid IV push (100 mg for 70 kg adult

patient).

Once fasciculations stop (approximately 30 seconds), with cricoid pressure continued,

intubate.

Confirm endotracheal tube placement by:

Attaching the EtCO2 monitor and verify CO2 production by waveform or mmHg.

Observing for chest rise and fall.

Verifying the presence of bilateral lung sounds and the absence of epigastric

sounds by auscultation with a stethoscope.

Confirming improvement in saturations by pulse oximetry.

Once ET tube confirmed, inflate the ET tube cuff. Release cricoid pressure and secure

the tube in place.

Apply c-collar, repeat vital signs and O2 sats.

NOTE: Failed intubation should be followed by BVM ventilation, then placement of the

King Airway.

Contraindications (for the procedure):

Inability to ventilate with BVM

Examples: lodged foreign body, severe maxillofacial injury tracheo-bronchial

injury (fractured larynx)

Body habitus (physical exam reveals potential difficult intubation)

Examples: large tongue, no neck, and morbid obesity


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Contraindications (for succinylcholine):

Known hyperkalemia (peaked T-waves), renal failure.

Burns greater than 8 hours old.

History of chronic paraplegia or quadriplegia

History of muscular dystrophy, ALS, multiple sclerosis or myasthenia gravis.

History of malignant hyperthermia or pseudo cholinesterase deficiency.

Open eye injury.

If patient goes into cardiac arrest after administration of Succinylcholine, defibrillate if V-

FIB or pulseless V-TACH, then:

Administer Sodium Bicarbonate for presumed hyperkalemia

Adults: 1 mEq / kg IV push

Peds: 1 mEq / kg IV push

Follow protocol for cardiac arrest and dysrhythmia management


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PROCEDURE B – CINCINNATI PREHOSPITAL STROKE SCALE

Facial Droop (have patient show teeth or smile):

Normal – both sides of face move equally well.

Abnormal – one side of face does not move as well as the other side.

Arm Drift (patient closes eyes and holds both arms out):

Normal – both arms move the same or both arms do not move at all (other findings, such as pronator grip, may be helpful).

Abnormal – one arms does not move or one arms drifts down compared with the other.

Speech (have the patient say “you can’t teach an old dog new tricks”):

Normal – patient uses correct words with no slurring.

Abnormal – patient slurs words, uses inappropriate words, or is unable to speak.


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PROCEDURE C - PRE-HOSPITAL SPINAL INJURY ASSESSMENT AND TREATMENT (CERVICAL SPINE IMMOBILIZATION CONSIDERATIONS)

NOTE: Maintain manual c-spine immobilization until evaluation is complete.

Evaluate for the presence of any of the following:

Multi-system trauma.

Any loss of consciousness.

Altered mental status.

Significant injury above the clavicles (i.e. head/neck wounds).

Presence of a distracting injury (i.e. fractured femur).

Presence or suspicion of alcohol or drug use.

Presence of language/communication barrier.

Ask patient if any presence of neck pain.

If negative findings to all listed above, proceed with the following focused physical exam:

Test for motor/sensory function.

Finger abduction/adduction.

Finger/hand extension.

Foot plantar flexion.

Foot/great toe dorsiflexion.

Light touch sensation to hands and feet.

Palpate spine for tenderness.

Pre-Hospital Spinal Injury Assessment and Treatment – (continued):

If all findings negative for potential injury, ask patient to:

Flex and extend the head up and down.

Rotate the head to the right and left.

Tilt the head to the right and left.

If the paramedic assesses any criteria above to be positive findings OR if the patient has

any complaints of neck pain, pain on palpation, neurological deficit, positive mechanism

of injury or is unreliable, the paramedic will immobilize patient to back board.

NOTE: For patient to be reliable, he/she must be calm, cooperative, and alert and have

no suspicion of alcohol or drug use.


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If the paramedic assesses that all criteria above to be negative findings, spinal

immobilization is not indicated.

It is advised to document the following:

Absence/presence of complaints of pain.

Neck pain to direct palpation.

Neck pain to motion.

Injury above the clavicles.

Neurologic abnormality.

Obvious injury.

Patient reliability.


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PROCEDURE D – NERVE AGENT / ORGANOPHOSPHATE POISONING – MARK 1 / DUODOTE KITS (ADULT), VALIUM AUTO-INJECTORS (ADULT) AND ATROPEN AUTO-INJECTOR (PEDIATRIC)

Purpose: To establish guidelines concerning the local EMS response to a WMD

(Weapons of Mass Destruction) event and to provide local EMS providers with access to

pharmaceutical resources and guidance on the use of auto-injectors (Mark I Kits,

DuoDote, Diazepam and pediatric AtroPens).

EMS providers are reminded to:

1. Consider scene safety and first responder safety as primary goal.

2. Consider implementing local protocol for mass casualty incidents and/or

requesting the opening of the county EOC (Emergency Operations Center) in the

event of a mass casualty incident to assist in assembling treatment resources and

facilitating the transportation of large numbers of patients.

3. Contact the Nebraska Regional Poison Center for immediate assistance at 1-800-

222-1222.

Until the Douglas County EOC Medical Table is activated and opened, the Poison

Center will serve as the point of contact for local first responders and hospitals to

access the stockpiles distributed throughout the community. DuoDotes and Mark

1 Kits are available on most area rescue squads for self-administration, in small

cache supplies at several local fire departments, in other local stockpiles and in

federally supplied assets in the Omaha Metropolitan Medical Response System

(OMMRS) area for treatment of victims of nerve agent exposures.

The requesting agency will be responsible for providing the transportation of the

product to the scene locally. This may often be delegated to the 911 Center by pre-

established protocol. The Nebraska State Patrol may serve as the medium for

movement across jurisdictions that do not already have established plans or when

movement of product must come from other assets across the state.

Mark I Kit: For adult patients and pediatrics over 84 lbs. (38 kg)

1. Atropine auto-injector (2 mg total dose per injection)

2. Pralidoxime chloride auto-injector (600 mg total dose per injection)

DuoDote: For adult patients and pediatrics over 84 lbs. (38 kg)

1. *Atropine (2.1 mg total dose per injection)

2. *Pralidoxime chloride (600 mg total dose per injection)

* DuoDote is a newer version of the Mark 1 Kit and contains the same medications

and doses as the Mark 1 Kit. The only difference is the DuoDote contains both

atropine and pralidoxime chloride in a single auto-injector for IM injection.


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AtroPen: For pediatric patients up to 84 lbs. (38 kg)

Atropine auto-injector (0.5 mg total dose per injection)

Diazepam (Valium): For adult patients

Diazepam auto-injector (10 mg total dose per injection)

Nerve Agents: A classification of potential WMD chemical agents that might be used in

a terrorist attack. Examples include Tabun, Sarin, Soman and VX.

Organophosphates: Insecticides such as Malathion, Diazinon and Parathion

Nerve Agent or Organophosphate Poisoning Signs/Symptoms by Severity:

Mild Constricted (pinpoint) pupils, excessive sweating, tearing, drooling,

runny nose/nasal secretions, mild chest tightness, mild shortness of

breath, chest tightness

Moderate Severe chest tightness, wheezing, profuse airway secretions,

respiratory distress, muscle weakness, vomiting, abdominal cramps

and diarrhea

Severe Unconsciousness, coma, seizures, no muscle tone (flaccid

paralysis), cyanosis, respiratory failure, apnea

Authorization for Use

The auto-injectors are authorized for use by the local Physician Medical Directors for the

departments that have received them and for use by personnel who have received

adequate training (by the Physician Medical Director or designee) on the recognition and

treatment of nerve and/or organophosphate agent exposure in the event of a chemical

release. In the case of a nerve agent incident, it would be specific to the disaster setting.

Organophosphate exposure may be treated as an isolated case with the Mark 1 kits or

DuoDotes.

Pediatric strength atropine (AtroPen 0.5 mg) and diazepam auto-injectors are to be

distributed only to paramedic staffed rescue squads.

Guidelines for Use

The decision to use the Mark I kit or DuoDote is based on signs and symptoms of the

patient, regardless if the patient is an EMS provider, firefighter or a civilian. The goal of

using the auto-injectors is directed at relieving respiratory distress and alleviating

seizures. The suspicion or identified presence of a nerve agent is not sufficient reason on

its own to warrant the administration of the medication.


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EMS providers/firefighters may self-administer the Mark 1 kit or DuoDote. The pre-

measured doses in the auto-injectors are generally safe for most adults suffering from a

nerve agent or organophosphate exposure.

Paramedics are reminded to review the indications for use and to only treat victims with

an auto-injector that are exhibiting signs and symptoms from a nerve agent or

organophosphate exposure.

Mark 1 Kit / DuoDote Dosage Guidelines for Adults

Each Mark 1 Kit contains two auto-injectors: Atropine 2 mg and Pralidoxime Chloride 600

mg. Each DuoDote contains the same medications in a single auto-injector. Dosing is

based on signs & symptoms.

For MILD signs & symptoms, administer one Mark 1 Kit OR one DuoDote.

For MODERATE signs & symptoms, administer two Mark 1 Kits OR two DuoDotes.

For SEVERE signs & symptoms, administer three Mark 1 Kits OR three DuoDotes.

Diazepam (Valium) Dosage Guidelines for Adults

Each Valium auto-injector contains Diazepam 10 mg

For SEIZURES and/or SEVERE signs & symptoms, administer one Valium auto-injector

May repeat every 5 – 10 minutes as needed

AtroPen Dosage Guidelines for Children

Each AtroPen auto-injector contains Atropine 0.5 mg

Dosing is weight based:

13 to 40 lbs. (6-18 kg), administer one AtroPen, repeat every 5-10 mins

as needed

41 to 62 lbs. (19-28 kg), administer two AtroPens, repeat every 5-10

mins as needed

63 to 84 lbs. (29-38 kg), administer three AtroPens, repeat every 5-10

mins as needed

Greater than 84 lbs. (>38 kg), administer one Mark 1 Kit OR one

DuoDote, repeat every 5-10 mins as needed

Mark 1 Kit Injection Procedure

1. Remove the Mark I kit from the protective foam case.


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2. With the non-dominant hand, hold the kit so that the larger injector is on top and

position the kit at eye level.

3. With the other hand, check the injection site (outer thigh or buttocks) for buttons or

objects in the pocket, which may interfere with the injections.

4. Grasp the small (green tipped) injector (atropine) with your thumb and first two

fingers.

5. Pull the injector out of the clip with a smooth motion.

6. Hold the injector like a pen, between your thumb and first two fingers.

7. Position the green tip of the auto injector against the injection site (thigh or

buttocks).

8. Apply firm even pressure (not a jabbing motion) to the injector until it pushes the

needle in to the site. Hold the injector firmly in place for at least 10 seconds.

9. Carefully remove the auto injector and place it into a sharps container. In an

emergency, and no sharps container available, bend the used needle over, or blunt

the end to avoid any accidental needle sticks.

10. Pull the 2-PAM auto injector (larger, black tipped one) out of the clip and inject

using the same procedure outlined above.

11. Document the number of auto injectors administered on the patient care report, on

the triage tag or attached the used injector(s) to the patient.

DuoDote Injection Procedure

1. Remove the DuoDote from the plastic pouch.

2. Place the DuoDote in your dominant hand. Firmly grasp the center of the DuoDote

with the green tip pointing down. Do not touch the green tip.

3. With your other hand, pull off the gray safety release. The DuoDote is now ready

to be administered.

4. Make sure pockets at the injection site are empty.

5. Firmly push the green tip straight down against the outer thigh. Continue to firmly

push until you feel the auto-injector trigger.

6. Hold the DuoDote in place for 10 seconds.

7. Remove the auto-injector from the thigh and look at the green tip. If the needle is

visible, the drug has been administered.

8. If the needle is not visible, check to be sure that the gray safety release has been

removed and repeat the procedure.

9. Place the auto-injector in a sharps container.

10. Document the number of auto injectors administered on the patient care report, on

the triage tag or attached the used injector(s) to the patient.


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PROCEDURE E – 12 LEAD ECG

Indications

1. Chest pain / discomfort (signs / symptoms suggestive of MI), any suspected

cardiac event.

2. Cardiac dysrhythmias.

3. Patient presents with cardiac signs / symptoms including but not limited to:

HR greater than 150.

HR less than 50.

Epigastric pain, unless there is other evidence indicating a GI bleed.

Thoracic back pain without trauma.

Diaphoresis not explained by fever or other environmental factors.

Shortness of breath or dyspnea with clear lung sounds.

Syncope without seizure or obvious blood loss.

PVCs unchanged by oxygen and/or PVCs greater than 6 / minute.

CHF / Pulmonary edema.

Tricyclic overdose.

All overdoses with abnormal rhythms.

4. Patients with the following chief complaints should be treated as suspected AMI:

Chest pain or pressure in a patient > 25 years old.

Syncopal episode in any patient > 25 years old.

Unexplained respiratory distress.

Atypical upper body pain (shoulder, arm or jaw pain) in the absence of chest

pain, especially with past medical history of cardiac problems, irregular pulse,

diabetes, or female and elderly patients.

Consider in young adult patients with a history of cocaine or methamphetamine

use.

Contraindications

1. Treat all life-threatening conditions (A B Cs, Dysrhythmias) prior to obtaining 12-

Lead.

2. Do NOT allow 12-Lead to delay transport of a critically ill patient.


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Patient Preparation

1. Protect patient modesty.

2. Area where leads applied should be clear of items that may cause artifact (clothing,

jewelry, etc.).

3. Skin should be clean and dry.

4. Shave chest hair as needed.

12 Lead ECG Placement

Limb Leads: RA right arm, upper arm or upper chest near the shoulder LA left arm, upper arm or upper chest near the shoulder RL right leg or lower abdominal quadrant near the hip LL left leg or lower abdominal quadrant near the hip

Chest Leads: V1 4th intercostal space, right sternal border V2 4th intercostal space, left sternal border V4 5th intercostal space, left mid-clavicular line V3 placed between V2 and V4 V5 5th intercostal space, anterior axillary line V6 5th intercostal space, mid-axillary line

Procedures

1. Acquire 12 Lead ECG when indicated per protocol.

2. Identify rhythm and treat THE PATIENT per protocol.

3. Transmit 12 Lead ECG to receiving hospital as soon as possible.

4. Transport Code 3 STEMI to receiving hospital (closest hospital with functioning

Cath Lab capability).

5. Radio report to receiving hospital should include your interpretation, treatment, and

notification that 12 Lead ECG has been transmitted.

6. If STEMI, inform receiving hospital that you are enroute with a STEMI Alert.

Remember: A 12 Lead ECG is only a diagnostic tool.

TREAT THE PATIENT, NOT THE MONITOR

*An MI may present with a normal ECG, maintain a high index of suspicion, especially

with diabetics, elderly, and female patients.


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PROCEDURE F – CYANIDE POISONING AND CYANOKIT

Rationale:

Smoke inhalation is the most common cause of mortality due to fires of all sources. For

decades it had been suggested that carbon monoxide is the most common cause of death

due to smoke inhalation. However, recent research suggests that cyanide exposure may

contribute to fire mortality. Cyanide is produced in every type of fire, residential,

commercial, regardless of the known presence of hazardous materials of chemical

process.

Cyanide has an affinity for all body tissues and can be considered a primary gas of

incapacitation for anyone attempting to escape a smoke charged environment. Cyanide’s

primary action is to block cellular respiration. Cyanide impairs the body’s ability to use

oxygen required for normal respiration. Tissues with the greatest oxygen requirements

(brain and heart) are the most affected by acute exposure. At the cellular level the body

switches from aerobic metabolism to an anaerobic metabolism in an attempt to

compensate –resulting in production of toxic waste (lactic acid), which contributes further

to metabolic derangements. Death typically results from central respiratory arrest.

Carbon monoxide poisoning and cyanide poisoning can be clinically indistinguishable in

the pre-hospital setting. The classis signs and symptoms include (cherry red skin, bitter

almond odor on the skin and/or breath, profound cyanosis) are insensitive indicators of

exposure. Cyanide exposure should be considered in any person (firefighter or civilian)

exposed to smoke within a confined compartment with the following signs and symptoms:

altered mental status, seizures, or who are unresponsive.

Cyanokit Administration Procedure

Indications: Known or suspected cyanide poisoning – suspect cyanide poisoning in

persons exposed to smoke from a fire in closed spaces and in victims with

soot around the mouth, nose with an altered mental status, seizure activity

or unresponsive.

A. Toxic Inhalation (Smoke Inhalation) – exposure to an enclosed smoke filled environment.

1. Remove from exposure.

2. Assess and treat Airway, Breathing, and Circulation.

3. Start (2) IV with NS, titrate to vital signs.

4. Follow appropriate ACLS Guidelines for dysrhythmia treatment and or Cardiac

Arrest treatment.

5. Administer the following - Cyanokit: Adult Dose (19 years and older)

5 Grams of Cyanokit (hydroxocobalamin) in 200 mL 0.9% sodium chloride

IV infusion over 15 minutes using the provided 15 gtt set.


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Mixing Procedure:

1. Reconstitute: Add 200 mL of 0.9% Sodium Chloride to vial using sterile rapid

transfer spike.

a. Fill to line on the Cyanokit (hydroxocobalamin) bottle.

b. Vial must be in an upright position.

2. Mix solution: Rock or rotate vial for 60 seconds to mix solution. DO NOT SHAKE

**Visually inspect solution prior to administration. If the solution is not dark

red or if particulate matter is seen, do not administer solution.

3. Infuse Vial: Use the supplied vented 15 drop set to infuse over 15 minutes.

a. 15 drop IV tubing – 200 gtts / min or 3 drops / sec

b. Drip set will be run nearly wide open, check in 7 minutes and re-evaluate

drips / minute (1/2 of the solution should be infused)

4. All other IV medications shall be given using a second IV / IO site.

5. Cyanokit (hydroxocobalamin) may be repeated at 5 Grams / 200 mL if no changes

in patient. Infusion rates vary depending on severity if signs/symptoms (15 minutes

to 2 hours). (Follow the above steps for administration).

Contraindications:

Allergy to hydroxocobalamin – otherwise none in a lifesaving attempt

Side Effects:

Elevation in blood pressure – maximum levels towards the end of the

infusion. (blood pressure tend to return to normal values within 4 hours post –

infusion) Substantial increases may occur following administration

Allergic Reaction – Signs of serious allergic reaction include chest tightness,

dyspnea, swelling, hives, itching, or rash.

Erythema – redness of the skin (may last up to 2 wks)

Chromaturia – Urine discoloration (may last up to 5 wks)

Rash – acne type of rash may appear anywhere from 7 – 28 days post

infusion

Throat tightness, dry throat

Headache, dizziness

Injection site irritation


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Incompatibility:

Physical incompatibility (particle formation) and chemical incompatibility were observed

with the mixture of hydroxocobalamin in solution with selected drugs that are frequently

used in resuscitation efforts.

Hydroxocobalamin is also chemical incompatible with other cyanide antidotes (sodium

thiosulfate, sodium nitrite and ascorbic acid).

Simultaneous administration of whole blood and blood products through the same IV is

not recommended, however, administration in a separate IV line is acceptable –preferably

in collateral extremities if peripheral lines are being used.

Location and Storage of Cyanokit:

Prior to reconstitution – Store at 77 degree F (59 – 86O F recommended)

Once reconstituted it is stable for up to 6 hours at temperatures below 104 F.

Location of Cyanokits:

Currently at least one (1) and up to two (2) Cyanokits are located in each OFD Battalion

Chief vehicle & in Supervisor 1 Vehicle. One additional (spare) kit will be placed on R-30

as available. The number is dictated by the number of kits available to OFD by OMMRS.

Cyanokits are stored in a clear Sterlite Container in the backseat of each BC vehicle and

on R-30.

Restocking of the Cyanokit and Notification of Use:

EMS, OMMRS, and the CDC are collectively working together on replacement funding

for the purchase of additional Cyanokits as well as maintain our current stock. In the

meantime, it is vitally important to document Cyanokit usage for continued support.

Tracking and documentation is required. Immediately notify the PSS upon use of a

Cyanokit (402) 660 - 1060. The PSS shall be responsible for the following:

Notify the Nebraska Poison Control Center (PCC) at 800 -222 -1222 or (402)

955-5555

Redistribution amongst the Suppression BC vehicles if necessary until extra

Cyanokits are obtained.

Contact the OFD IDCO by email informing them that a Cyanokit needs to be

replaced.

Each Cyanokit will have a label specifically stating these instructions to ensure the PSS

is notified and in turn satisfy data collection.


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PROCEDURE G - TRAUMA SCORING AND GCS

TRIAGE & MANAGEMENT OF THE INJURED PATIENT

REVISED TRAUMA SCORE (ADULT) GLASGOW COMA SCALE

Glasgow Coma Scale Value Eye Opening Value

13 - 15 4 Spontaneous 4 9 – 12 3 To Voice 3 6 – 8 2 To Pain 2 4 – 5 1 None 1

3 0

Respiratory Rate Value Verbal Response Value

10 – 29 4 Oriented 5 >29 3 Words or Phrases 4 6 – 9 2 Incomprehensible 3 1 – 5 1 Grunts or Moans 2 None 0 None 1

Systolic Blood Pressure Value Motor Response Value

>89 4 Obeys Commands 6 76 - 89 3 Localizes Pain 5 50 - 75 2 Withdraws (Pain) 4 1 - 49 1 Flexion (Pain) 3 None 0 Extension (Pain) 2

None 1

Score 0 – 12 Score 3 – 15

Score < or = 11, transport to the Trauma Center

Score < or = 13, transport to the Trauma Center


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PEDIATRIC TRAUMA SCORE

Component Score Weight > 20 kg (44 pounds) +2 10 – 20 kg (22 – 44 pounds) +1 < 10 kg (22 pounds) -1 Airway Patent 1 +2 Maintainable2 +1 Unmaintainable3 -1 Systolic BP > 90 mmHg +2 50 – 90 mmHg +1 < 50 mmHg -1 Pulses Radial +2 Carotid +1 Non-palpable -1 CNS Awake +2 Responds to voice, pain or temporary loss of consciousness noted +1 Unresponsive -1 Fractures None +2 Closed or suspected +1 Multiple closed or open -1 Wounds None +2 Minor * +1 Major, penetrating or burns ** -1

(Possible Scoring of - 6 to + 12, decreases with severity of condition) 9 – 12 Minor Trauma 6 – 8 Potentially life-threatening 0 – 5 Life threatening < 0 Usually fatal Score of 9 or less, transport to the Trauma Center Key 1 No assistance required. 2 Protected by patient, but requires continuous monitoring for changes, may require

positioning. 3 Requires airway adjuncts NPA, OPA and ET or suctioning. * Abrasions, minor lacerations, burns < 10% and not involving hands, face, feet or

genitalia. ** Penetrating, major avulsions, lacerations, burns > 10% or involving hands, face, feet or

genitalia.


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PROCEDURE H – EPINEPHRINE DRIP

Administration Guidelines

Mix 1mg of Epinephrine (1:1,000) in 250 mL bag of NS or D5W

Begin infusion at 2 - 10 mcg / min

Pulse and BP should be monitored every 2-5 minutes.

Goal is to maintain systolic BP at > 90 mmHg.

mcg /min drips (gtt / min)

1 15 gtt / min 2 30 gtt / min 3 45 gtt / min 4 60 gtt / min 5 75 gtt / min 6 90 gtt / min 7 105 gtt / min 8 120 gtt / min 9 135 gtt / min 10 150 gtt / min

Note: 1mg of Epi 1:1,000 = 1000 mcg = 4 mcg = 4 mcg = 60 drops using (mini drip) 250 mL bag 250 mL 1 mL


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APPENDIX A- OMAHA FIRE DEPARTMENT EMS ABBREVIATIONS

Letter A

ā before AMI acute myocardial infarction

AAA abdominal aortic aneurysm amio. amiodarone, cordarone

ABC airway, breathing, circulation AMPLE allergies, medications, past medical history, last oral intake, event preceding incident

abd abdomen AMS altered mental status

a/c antecubital amt amount

ACLS advanced cardiac life support ant. anterior

A.D. right ear (auris dexter) APAP acetaminophen

ADD attention deficit disorder APGAR appearance, pulse, grimace, activity, respirations

AED automated external defibrillator A.S. left ear (auris sinister)

A-fib atrial fibrillation ASA aspirin

AHA American heart association A.T. atrial tachycardia

AIDS acquired immunodeficiency syndrome ATV all-terrain vehicle

AKA above knee amputation AU both ears

ALS advanced life support, amyotrophic lateral sclerosis (ALS), "Lou Gehrig's disease

AV atrio-ventricular (reference to heart blocks)

AMA against medical advice AVPU alert, verbal, pain, unresponsive (mental status eval)

amb ambulatory ax axillary

Letter B

B.A. blood alcohol BKA below knee amputation

bb back board BM bowel movement

BBB bundle branch block BOT reeves portable stretcher (big orange thing)

BCP birth control pill BP blood pressure

Bergan Bergan Mercy hospital bpm beats per minute

Bicarb sodium bicarbonate BS breath sounds, blood sugar

bid twice a day BSA body surface area

bilat bilateral BSI body substance isolation

BLS basic life support BVM bag-valve mask

Letter C

c ̅ with CO carbon monoxide

Ca++ calcium CO2 carbon dioxide

CA cancer c/o complains of

CABG coronary artery bypass graft COPD chronic obstructive pulmonary disease

CAD coronary artery disease CP chest pain, cerebral palsy

CAO conscious alert CPAP continuous positive airway pressure

C/C chief complaint CPR cardiopulmonary arrest

cc cubic centimeter cric. cricoid

CHB complete heart block C-spine cervical spine


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CHF congestive heart failure CSF cerebrospinal fluid

CISD critical incident stress debriefing CSM circulation, sensory, motor

CISM critical incident stress management CUMC CHI Alegent Creighton Health

cm centimeter CVA cerebrovascular accident (stroke)

CNS central nervous system

Letter D

D5W 5% dextrose in water DOA dead on arrival

D25 25% dextrose in water drsg dressing

D50 50% dextrose in water d/t due to

d/c discontinue DT’s delirium tremors

DCAP-BTLS deformities, contusions, abrasions, puncture/penetration, burns, tenderness, lacerations, swelling

DUMBELS diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm, bronchorrhea; emesis; excess lacrimation; and salivation)

DKA diabetic ketoacidosis DuoNeb 3.0 mg Albuterol & 0.5 mg Ipratropium in 3 ml by nebulizer

dL deciliter DVT deep vein thrombosis

DM diabetes mellitus Dx diagnosis

DNR do not resuscitate

Letter E

EBL estimated blood loss ENT ears, nose, throat

ECG (EKG) electrocardiogram Epi epinephrine

ED emergency department est. estimated

EDC estimated date of confinement (due date-pregnancy)

ET(T) endotracheal (tube)

EJ external jugular ETA estimated time of arrival

EMS emergency medical services ETOH alcohol

EMT emergency medical technician eval evaluate

EMT-P emergency medical technician-paramedic

Letter F

FA forearm fib fibrillation

FB foreign body FRMS fire record management system

FD fire department fx fracture

ft foot

Letter G

G or gm gram GSW gun shot wound

GCS Glasgow coma scale Gtt(s) drop(s)

GERD gastro-esophageal disease GU genitourinary

GI gastro-intestinal GYN gynecology

Letter H

h, hr hour HIV human immunodeficiency virus

HA headache H2O water

HBV hepatitis B virus HOH hard of hearing

HCPA Health Care Power of Attorney HR heart rate


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HCO3 bicarbonate ht height

HEENT head, eyes, ears, nose, throat HTN hypertension (high blood pressure)

HEPA high efficiency particulate arresting Hx history

Letter I

IC incident command ICP intra-cranial pressure

IM intramuscular IDDM insulin dependent diabetes mellitus

IMM Immanuel hospital inf inferior

IN Intranasal IVP intra-venous push (IV-push)

IO intraosseous IVPB intra-venous piggy back

IV intravenous

Letter J

J joules (electrical measure) JVD jugular vein distention

Letter K

K+ potassium kg kilogram

Letter L

(L) left LBBB left bundle branch block

L. liter LLQ left lower quadrant

L1-L5 lumbar veterbrae lpm liters per minute

LA left arm LMP last menstrual period

lb pound LOC level of consciousness

lac laceration lsb long spine board (backboard)

lat lateral LUQ left upper quadrant

lg large LV left ventricle

lido lidocaine LVH left ventricular hypertrophy

Letter M

m meter min minute

MCI multiple casualty incident Min minimal

mag magnesium (sulfate) 50% mL milliliter

max maximum mm millimeter

mcg micrograms mmHg millimeters of mercury

MDI metered dose inhaler MMR measles, mumps, rubella

meds medications MOI mechanism of injury

mEq milliequivilant MRSA methicillin resistant staphylococcus aureus

mg milligram MS multiple sclerosis or morphine sulfate

Mg magnesium MVA motor vehicle accident

MgSO4 magnesium sulfate MVP mitral valve prolapse

MI myocardial infarction

Letter N

N-95 hepa mask NKDA no known drug allergies

Na+ Sodium NMC Nebraska Medicine

N/A not applicable NOI nature of illness

NAHCO3 sodium bicarbonate npo nothing by mouth

NC nasal cannula NPA nasopharyngeal airway

neb nebulizer NR non-rebreather mask


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neg negative NS normal saline

neuro neurologic NSR normal sinus rhythm

NG nasogastric NTG nitroglycerin

NH nursing home n/v nausea and vomiting

NKA no known allergies n/v/d nausea/vomiting and diarrhea

Letter O

O/A on arrival OPD Omaha police department

O2 oxygen OPA oropharangeal airway

O2 sat oxygen saturation by pulse oximetry OPQRST onset, provocation, quality, radiation, severity, time (pain assessment)

OB obstetrics OTC over the counter

OBS organic brain syndrome O.U. both eyes

O.D. right eye (oculus dexter) oz ounce

od overdose

Letter P

P pulse pnd paroxysmal nocturnal dyspnea

p after PNS peripheral nervous system

PAC premature atrial contraction POC position of comfort

PALS pediatric advanced life support Po by mouth

PAT paroxysmal atrial tachycardia post. Posterior

PCR patient care report Pov private owned auto

PE pulmonary embolism PPE personal protective equipment

PEA pulseless electrical activity PR per rectum

PEARL pupils equal & reactive to light Prn as needed

pedi pediatric PSS paramedic shift supervisor

PHTLS pre-hospital trauma life support SVT supraventricular tachycardia

PI personal injury pt. patient

PJC premature junctional contraction PTA prior to arrival

pm afternoon p/u pick up

PMH past medical history PVC premature ventricular contraction

Letter Q

q every

Letter R

(R) right r/o rule out

RBBB right bundle branch block ROM range of motion

re regarding RR respiratory rate

reg regular RSI rapid sequence induction (intubation)

RLQ right lower quadrant RUQ right upper quadrant

RMS record management system (OFD documentation program)

Rx prescription, treatment

Letter S

s ̅ with SOB shortness of breath

SAMPLE signs/symptoms, allergies, medications, pertinent past history,

SOP standard operating procedure


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last oral intake, events preceding injury/illness

sec. second SQ subcutaneous

SIDS sudden infant death syndrome s/s signs and symptoms

SL sublingual STEMI st elevation MI

SLUDGE salivations, lacrimation, urination, defication, GI distress, emesis

SVT supraventricular tachycardia

sm small Sx symptom

SOAP subjective, objective, assessment plan Sz seizure

Letter T

T temperature TIA transient ischemia attack

T1-T12 thoracic spine tib/fib tibia and fibula

TB tuberculosis TKO to keep open

TCA tricyclic antidepressant trach tracheal, tracheostomy

TCC trauma center candidate Tx treatment

TCP transcutaneous pacing

Letter U

ud unit dose URI upper respiratory infection

unk unknown UTI urinary tract infection

UR unresponsive

Letter V

vag. vaginal VS vital signs

VF ventricular fibrillation VT ventricular tachycardia

VRE vanocomycin-resistant enteroccocci

Letter W

w/c wheel chair WMD weapons of mass destruction

W&D warm and dry WPW wolff-parkinson-white syndrome

WNL within normal limits w/o without

wt weight

Letters X Y Z

x times y/o year-old

XR x-ray