Field Operations Guide - emslc.orgemslc.org/documents/2015EMSLCProtocols.pdf · Field Operations Guide ... f e r e n c e 2 Aspirin 3 Atropine 4 Calcium Chloride ... 20 Lasix 21 Levalbuterol

Field Operations GuideEmergency Medical Services of LeFlore County

Innovative. Dynamic. Skilled.

Revision: 2.5Latest Revision: 10.01.2014

By: Anthony Stankewitz, NRP and Dr. Justin Fairless, DO, NRP

Reviewed annually for medical, procedural, policy, and protocol updates.

Reviewed By:

Full Content Review

Justin W. Fairless, D.O., NRPEMSLC Medical Director

Anthony Stankewitz, NRPEMSLC, Clinical Manager

David Grovdahl, NRPEMSLC, Director

Keith Lickly, NRPEMSLC, Operations Manager

EMS of LeFlore County

Receipt of Protocols Memorandum

Date: October 2014

To: EMS of LeFlore County Paramedics and EMTs

From: David Grovdahl, NRP, Executive DirectorJustin Fairless, DO, NRP, Medical Director

Attached, please find a copy of the treatment Protocols for Paramedics, Advanced EMTs,EMTs, and EMRs Please discard any other protocols you may have. You are asked to reviewthe protocols in their entirety. If you have any questions, please contact the EMS Office.

These protocols are written to the “Prudent EMT” level. Protocols written at this levelassume core knowledge of EMS principles being mastered. A “prudent EMT” knows whenthey need to ask their physician advisor or training officer about a concept or procedure,which is unfamiliar or unclear. It is also the EMTs responsibility to maintain requiredcontinuing education.

Lastly, Protocol revision is a dynamic and continual process that needs your support. If younotice errors, whether they are grammatical or content based, please contact the EMSDirector so they can be corrected.

Thank You.

Name: _________________________________ Date: ________________________

INTRODUCTION TO PREHOSPITAL CARE

The Medical Director has approved these standing orders. Oklahoma Statute requires thatEMT’s provide care through standing orders or verbal communications under the direction ofa physician. These protocols constitute the standing orders of Justin W. Fairless, DO, NRP,the Medical Control Physician (Medical Director).

These standing orders are designed for exclusive use by qualified Emergency MedicalTechnicians. EMTs will use only those parts of the protocols which are within thescope of practice for their level of training, as defined by Oklahoma Statutes, andin accordance with Agency policy.

This format recognizes that pre-hospital care is part of a continuum of care, which beginswith access to the system and ends with the return of the patient to our community. Nophase of this continuum can function ideally without communication between all the steps ofthe system. A seamless transfer of care between providers is the goal. Please remember tocontact the receiving hospital as soon as possible in every acute situation.Few patients will fall under a single protocol. More often than not, multiple protocols will becombined to provide patient care. Complete documentation of the physical examination andcare rendered is required. These protocols shall serve as the written guideline for patientcare.

Remember the Prime Directive:

RELY ON YOUR BEST JUDGEMENT - TREAT THE PATIENT NOT THE PROTOCOL!!

These protocols represent a dynamic medical system and it is hoped that all providers willcontinue to be actively involved in their formulation and revision. Questions regarding thedevelopment, revision and implementation of these protocols should be directed to the EMSExecutive Director and/or Medical Director.

______________________________Justin W. Fairless, DO, NRPMedical Director

https://trust.docusign.com

ALSBLS

PROTOCOLTable of Contents

EMSOf

LeFlore Co.

EMS of LeFlore CountyEMS Medical Control Authority

Ge

ne

ral

1 Abdominal Pain & Nausea

2 ACLS: Bradycardia

3 ACLS: Pulseless Arrest

4 ACLS: Tachycardia with Pulses

5 Acute Pulmonary Edema & Congestive Heart Failure

6 AICD Inappropriate Discharge

7 Allergies & Anaphylaxis

8 Altered Mental Status & Unresponsive

9 BLS CPR & AED

10 Burns

11 Chest Pain: Non-STEMI

12 Chest Pain: STEMI

13 Death in the Field

14 Hypertension

15 Hyperthermia

16 Hypoglycemia

17 Hypotension & Shock

18 Hypothermia

19 Induced Hypothermia for Post Cardiac Arrest

20 Overdose & Poisoning

21 Pain Management

22 Psychiatric & Behavioral

23 Rapid Sequence Intubation

24 Respiratory Distress

25 Sedation

26 Seizure

27 Sepsis

28 Stroke

29 Syncope

30 Universal Patient Care

Trau

ma

1 Abdominal Trauma

2 Amputation

3 Chest Trauma

4 Eye Trauma

5 Facial Trauma

6 General Trauma Management

7 Head Injury & Traumatic Brain Injury

8 Hemorrhagic Shock

9 Orthopedic Trauma

10 Spinal Cord Trauma

Pe

di 1 Croup & Epiglottitis

2 PALS: Bradycardia

3 PALS: Pulseless Arrest

4 PALS: Tachycardia with Pulses5 Rapid Sequence Intubation

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6 Seizure

O B1 Child Birth

2 Eclampsia

3 Vaginal Bleeding

Pro

ced

ure

s

1 12 Lead EKG

2 AED

3 Capnography

4 Cardioversion

5 Defibrillation

6 Escharotomy

7 Gastric Tube

8 Hemostatic Agents

9 KingLt Airway

10 Needle Thoracostomy

11 Non-Invassive Positive Pressure Ventilation(CPAP/BiPAP)

12 Refusal of Care

13 Restraints

14 Selective Spinal Immobilization

15 Surgical Airway

16 Taser Discharge & Removal

17 Tourniquet

18 Vascular Access

Re

fere

nce

1 ACLS: H’s& T’s

2 APGAR Score

3 Burn Chart

4 Glasgow Coma Score

5 Hixson Chart

6 LA Pre-Hospital Stroke Screen

7 Metric Conversions

8 Pediatric Trauma Score

9 Phone Numbers

1 Amiodarone

Me

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Re

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2 Aspirin

3 Atropine

4 Calcium Chloride

5 Decadron (Dexamethasone)

6 Dextrose 50%

7 Diltiazem (Cardizem)

8 Diphehydramine (Benadryl)

9 Dopamine

10 Epinephrine 1:1,000

11 Epinephrine 1:10,000

12 Etomidate

13 Fentanyl

14 Glucagon

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15 Glucose-Oral

16 Ipatropium Bromide (Atrovent)

17 Keppra

18 Ketamine

19 Labetalol

20 Lasix

21 Levalbuterol (Xopenex)

22 Lidocaine

23 Magnesium Sulfate

24 Methylprednisolone (Solu-Medrol)

25 Midazolam (Versed)

26 Morphine Sulfate

27 Naloxone (Narcan)

28 Nitroglycerin

29 Ondasetron (Zofran)

30 Pitocin

31 Rocuronium

33 Succinylcholine

34 Sodium Bicarbonate

35 Vasopressin

36 Vecuronium

Dri

p

s

D1 Epinephrine Drip

D2 Dopamine

D3 Nitroglycerin

D4 Lidocaine

D5 Levophed (NorEpi)

ALSBLS

PROTOCOLAbdominal Pain & Nausea

General1


EMR

1. Follow Universal Patient Care Protocol.2. Keep Patient NPO-Nothing by mouth.3. Perform a detailed abdominal exam.4. Assess distal pulses for possible vascular emergency (i.e. aortic dissection.)5. Assess vital signs frequently.6. Allow the patient to assume the position of comfort.

EMR

EMT

7. Apply oxygen using the appropriate rate/device based on patient condition.8. Consider cardiac involvement-perform EKG, request ALS.9. If systolic BP<90mmHg:

a. See Hypotension Protocol.b. Provide Rapid Transport.c. Assess vital signs frequently.d. Request ALS backup.

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11. If severe pain refer to Pain Management protocol12. If severe nausea consider ondansetron (Zofran) 4mg IV/IO for adults, 0.15mg/kg IV/IO for pediatric

patients to a max of 4mg, may repeat once if no significant relief in 5 minutes.13. May administer ondansetron (Zofran) 4mg ODT PO (adult) if not actively vomiting and/or if IV/IO is

not available.

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PROTOCOL

ACLSBradycardia

General2


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1. Follow Universal Patient Care Protocol.2. Maintain airway-assist with ventilations as needed.3. Apply oxygen if hypoxic.4. Attach monitor/defibrillator when appropriate.5. Establish IV/IO access.6. Perform 12-Lead EKG

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7. Consider and rule out H’s and T’s.

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Assess appropriateness of clinical condition.Heart rate typically <50 if bradyarrythmia.

Identify and treat underlying cause

Main patent airway; assist breathing as necessary.

Apply oxygen if hypoxic.

Identify rhythm, monitor vital signs often.

Persistent Bradyarrhythmia causing:

Hypotension?

Acute altered mental status?

Signs of shock?

Ischemic chest discomfort?

Acute heart failure?

Monitor and observe.

Consider: AtropineOR

Consider: Dopamine or Epinephrine InfusionOR

Consider: Transcutaneous Pacing

YES

NO

Dose/Details:

Atropine: 0.5mg bolusIV/IOrepeat PRN, max 3mg.

Dopamine IV Drip:2-20mcg/kg/min. (seedrug reference)

Epinephrine IV Drip:2-10mcg/min. (see drugrefrence)

ALSBLS

PROTOCOLACLS Pulseless Arrest

General3


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1. Remove Shirt, PlaceAutoPulse within 1 min.

Provide Continuouscompressions prior to

Autopulse Placement (rateof 100-120 bpm).

2. Apply Monitor.

VF/Pulseless VT: SHOCK200J

Vascular Access; Proximalhumerus IO access is the first-

line vascular access site in adultcardiac arrest (over IV or tibia).

Epi. 1mg every 3-5 minutesIV/IO.

Narcan 2mg IV/IO

Assess CBG

VF/Pulseless VT refractory toshock:

1st Round: Amiodarone300mg

2nd Round: Amiodarone150mg

3rd Round: Mag Sulfate 2g.

Consider KINGLT Airway withCapnography.

If advanced airway placement deferreduntil after ROSC, use OPA and BVM

during arrest. Endotracheal intubationmay be performed post-arrest with

Capnography.

Consider NG or OG placement.

Consider ResQpod.

Doses/Details:

Consider 40u Vassopressin to replace the first orsecond dose of epi.

Capnography and ResQpod required for anyadvanced airway in pulseless patients.

Consider 1g Calcium Chloride for dialysis patients,and Calcium Channel Blocker overdose.

Consider H’s and T’s, treat reversible causes.

Consider obtaining second line (IV/IO) after ROSC.

Maximum interruption in chest compressions <10 seconds.

After 3 rounds with no clinical improvement,consider contacting medical control for possibletermination of the resuscitation

Also Consider: 50mEq Sodium Bicarbonate IV/IO for

hyperkalemia (dialysis patients), tricyclicantidepressant (TCA) overdose, or pre-existing metabolic acidosis.

Consider Glucagon 3mg IV/IO for betablocker overdose. May administer lowerdose if total of 3mg is unavailable.

ALSBLS

PROTOCOLACLS Tachycardia with Pulse

General4


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Tachycardia

Stable:

Consider Vagal Mauvers

AFib with RVR: Cardizem20mg IV. May repeat bolus in

5 minutes or if recurrent.

Avoid if hypotensive.

Caution in elderly patients.

SVT: Adenosine 12mg RapidIV, repeat once at 12mg IV.

VT with pulse: Amiodarone150mg IV/IO over 10 min.

Unstable:

SynchronizedCardioversion

AFib with RVR 120-200j.

SVT 50-100J

VT with pulse: 100j

ALSBLS

PROTOCOL

Acute Pulmonary Edema & CongestiveHeart Failure

General5


EMR

1. Follow Universal Patient Care Protocol.2. Apply Oxygen if hypoxic.3. Detailed assessment including lung sounds, JVD, peripheral edema, GCS, & history.4. Closely monitor respirations; if patient becomes fatigued it may be necessary to assist/control

ventilations.

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5. Consider Albuterol 2.5mg via nebulizer only for patients with significant bronchospasm/wheezing. EMT

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6. Establish IV access.7. If systolic BP<100mmHG with severe signs and symptoms of respiratory distress and hypotension

contact medical control for the appropriate amount of NS and rate.8. If systolic BP>100mmHG with severe signs and symptoms of respiratory distress give nitroglycerin

(NTG) 0.4mg SL.a. NTG SL is contraindicated for patients whose systolic BP<100.b. Relay to medical control if the patient has been taking medications for erectile dysfunction

in the past 24 hours.c. Administer NTG every five minutes for a total of three. Reassess BP between each NTG

administration.9. If the patient is in respiratory distress with the presence of rales, rhonci, wheezes, or decreased

lung sounds initiate CPAP or BiPAP.10. Consider 12-Lead EKG, transmit if available.

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11. If symptoms persist and systolic BP>100mmHG:a. Consider Lasix 0.5-1mg/kg IV up to 100mg.

12. If symptoms persist and systolic BP>100mmHG consider Nitroglycerin IV drip:a. Start at 5mcg/min.b. Increase by 5-10mcg every 2-5 minutes as BP allows.c. Contraindicated if the patient has been taking medication for erectile dysfunction in the last

24 hours. May consider NTG Paste 1” ACW if IV NTG unavailable.13. If symptoms persist and the patient becomes unstable or lethargic, consider Rapid Sequence

Intubation.

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ALSBLS

PROTOCOLAICD Inappropriate Discharge

General6


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1. Follow Universal Patient Care Protocol.2. Apply Cardiac Monitor.3. Placing patient on their left side may decrease the risk of inappropriate AICD shocks.4. Apply oxygen if hypoxic.5. Establish IV/IO.6. Perform 12-Lead EKG, transmit to hospital if available.7. If patient reports any chest pain, syncope, or near syncope follow appropriate protocol.

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8. If the patient reported a single or multiple AICD discharges with no preceding cardiac-relatedsymptoms; consider Ativan 0.5-1mg IV for anxiety.

9. If the patient’s AICD discharges while the cardiac rhythm is being monitored and it can bedetermined that the patient was not in a shockable rhythm.:

a. If systolic BP is >100mmHG:i. Reconfirm that AICD is inappropriately firing and there is no evidence of a shockable

rhythm.ii. If inappropriately firing, place cardiac magnet over AICD and secure.

b. If systolic BP<100mmHG and clinically unstable.i. Therapy pads should ideally be place anterior and posterior position.ii. Reconfirm that the AICD is inappropriately firing and that there is no evidence of a

shockable rhythm.iii. If inappropriate firing, place the cardiac magnet and secure.

c. If treatable dysrhythmia occurs see the appropriate ACLS protocol.d. If patient presents with shockable rhythm after the magnet is secure; remove the magnet

from the patient’s chest and the AICD should discharge within 15 seconds or provideexternal cardioversion/defibrillation as needed.

10. If the AICD is firing inappropriately refer to the sedation protocol.11. Refer to the ACLS Tachycardia with a Pulse Protocol and treat accordingly with appropriate

medications per the underlying rhythm.

Note:a. Not all AICD’s can be disabled via a cardiac magnet, continue above pharmacological

treatments if inappropriate AICD firing continues after the cardiac magnet’s placement.b. Some manufacturer’s AICD’s may temporarily beep or emit and audible alert whent the

cardiac magnet is in place and the device is disabled.c. Placing a cardiac magnet may temporarily disable the shock-therapy functions; however the

device’s pacing functions will continue.

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ALSBLS

PROTOCOLAllergies and Anaphylaxis

General7


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and /or using adjuncts as needed.3. If anaphylaxis is result of a bee sting and the stinger is still present gently remove/scrape away and

apply a cold pack to the site as needed.

EMR

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4. If systolic BP<90mmHG or airway compromise consider anaphylaxis.a. (MC only) Epi-Pen Adult IM in the lateral thigh.b. (MC only) Epi-Pen Jr. IM in the lateral thigh.

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5. Assess lung sounds, if bilateral wheezes are present or diminished/absent lung sounds considernebulizer treatments:

a. Patients >12 years Albuterol 2.5mg with Atrovent 0.5mg via nebulizer.b. Patients<12 years Albuterol 2.5mg via nebulizer.

6. Consider IV access.7. Administer albuterol treatments as needed.8. Consider the use of epinephrine for patients in severe distress with no improvement after

treatment:a. Adult: Epinephrine 0.5mg 1:1,000IM, may be repeated every 20 minutes up to 3 doses.b. Pedi: Epinephrine 0.01mg/kg IM up to 0.5mg, may be repeated every 20 minutes up to

three doses.

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9. Consider IV Epinephrine for refractory anaphylaxis:a. Adult: Epinephrine 0.5mg IV (SLOW over 3 minutes)b. Pedi: Epinephrine 0.01mg/kg IV, max dose 0.5mg (SLOW over 3 minutes)

10. Consider Benadryl 25-50mg IV/IO. Pedi = refer to Broslow Tape.11. Consider Decadron (dexamethasone) 0.6mg/kg, 10mg max dose, may give IM if no vascular access is

available.a. May administer Solu-Medrol if Decadron unavailable:

i. Adult: 125mg IV/IO, may give IM if no vascular access.ii. Pediatric: 2mg/kg IV/IO, max dose 125mg.

12. If severe stridor present despite interventions consider Racemic Epinephrine 0.5–0.75ml of a 2.25%solution in 2.0 ml normal saline.

13. If severe difficulty breathing persists without favorable response to above treatments orcompromised airway consider facilitated intubation or rapid sequence intubation.

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ALSBLS

PROTOCOLAltered Mental Status / Unresponsive

General8

EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using airway adjuncts as needed.3. Apply oxygen if the patient is hypoxic.4. Implement C-Spine precautions if indicated.5. Keep patient warm.6. Perform a detailed patient assessment and review of medical history.7. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (APNEIC/AGONAL BREATHING) CONSIDER:

a. Adult: Naloxone 2mg IN, may repeat once.b. Pediatric: 0.5mg IN, may repeat once.

8. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (SHALLOW/INEFFECTIVE BREATHING ORUNRESPONSIVE) CONSIDER:

a. Adult/Pediatric: Naloxone 0.5mg IN9. Use Naloxone to restore effective breathing and airway maintenance only. Avoid excessive dosing

(precipitates withdraws).

EMR

EMT

10. If systolic BP <90mmHg see Shock Protocol.11. Apply cardiac monitor and perform EKG.12. If blood glucose <60mg/dl move to Hypoglycemia Protocol.13. Recheck blood glucose in 5 minutes following treatment, if glucose remains <60mg/dl contact

medical control.14. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (APNEIC/AGONAL BREATHING) CONSIDER:



a. Adult/Pediatric: Naloxone 0.5mg IN16. Use Naloxone to restore effective breathing and airway maintenance only. Avoid excessive dosing


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17. Establish IV/IO.18. If blood glucose <60mg/dl consider:

a. Adult: Dextrose 50% 12.5-25g IV/IOb. Recheck blood glucose in 5 minutes following treatment, if glucose remains <60mg/dl

repeat the Dextrose and reassess in 5 minutes.19. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (APNEIC/AGONAL BREATHING) CONSIDER:

a. Adult: Naloxone 2mg IN/IV/IO, may repeat once.b. Pediatric: 0.5mg IN/IV/IO, may repeat once.


a. Adult/Pediatric: Naloxone 0.5mg IN/IV/IO21. Use Naloxone to restore effective breathing and airway maintenance only. Avoid excessive dosing


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PROTOCOL

BLSCPR and AED

General9


EMR

1. Follow Universal Patient Care Protocol.2. Manually open the airway, consider c-spine precautions as needed, using oral/nasal airway as

needed with supplemental oxygen.3. If not breathing provide two ventilations, each lasting one second with enough volume to see the

chest start to rise.4. Perform a carotid pulse check for no longer than 10 seconds.

a. If a definite pulse is present begin rescue breathing:i. Give 1 breath over 1 second every 6 seconds.ii. Recheck pulse every 2 minutes.

b. If no definite pulse is present continue to follow this protocol.5. Start CPR – Chest compressions are the number one priority.

a. Begin 2 minutes of continuous chest compressionsb. Perform continuous chest compressions at a rate of 100 per minute and provide ventilations

over 1 second every 6 seconds.c. Switch compressors every 2 minutes.d. Allow the chest to completely recoil, do not lean/rest on the patient’s chest.e. Do no interrupt chest compressions for any reason greater than 10 second.

6. Attach AED when available.a. If a witnessed cardiac arrest or with bystander CPR in progress analyze immediately.b. If unwitnessed arrest or no bystander CPR provide 2 minutes of CPR prior to analyzing.c. Follow AED’s instructions even if they deviate from this protocol, administer shocks at the

AED’s recommended intervals.d. Ideally, AED analysis should occur every 2 minutes of CPR.e. If AED allows for a shock immediately resume CPR after energy is delivered without a pulse

check, continue CPR until directed by the AED.

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7. Insert Supraglottic airway without interruption in chest compressions.8. Ventilate at 8-10 breaths per minute.

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9. Establish IV/IO access NS TKO enroute to the receiving facility. Humeral IO access preferred over IVor tibia.

10. Rule out H’s and T’s (see reference).11. Insert supraglottic airway without interruption in chest compression12. May attempt endotracheal intubation, if supraglottic airway is contraindicated, only if able to

perform without interrupting chest compressions.

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ALSBLS

PROTOCOLBurns

General10


EMR

1. Follow Universal Patient Care Protocol.

2. Ensure scene safety prior to entry.

3. Stop the burning process:

a. Thermal burns:i. Carefully remove involved clothing and jewelry.ii. Flood burned area with normal saline/sterile water (water may be used if sterile

fluids are not available) only if flames or smoldering is present and monitor closelyfor signs of hypothermia.

b. Chemical Burns:i. Consider the need for HAZMAT.ii. With a gloved hand carefully brush off (take care not to contaminate yourself) and

dilute/irrigate, if indicated, exposed area with copious amount of saline/sterilewater (water may be used if sterile fluids are not available).

c. Electrical Burns:i. Make sure the patient has been removed from the electrical source prior to making

contact.ii. Suspect internal injuries.

iii. Observe for entry and exit wounds.4. If the patient is in respiratory distress administer oxygen, ventilate and control airway as needed.5. Monitor closely for signs of shock, see Hypotension& Shock Protocol.6. Consider carbon monoxide if the victim was in an enclosed space, see Overdose Protocol.7. Evaluate the severity and percentage of body surface area burned.

a. Refer to the rule of nines in the reference section.8. Dress burns loosely with dry, sterile dressings-never tightly wrap a burn, especially with

circumferential burns. Burn gel dressings may be used if burn area is 2% or smaller. (The palm ofthe patient’s hand is approx. 1%.)

9. Prevent unnecessary cooling and watch for signs of hypothermia.

EMR

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10. Continue to closely monitor airway and respiratory effort.11. Determine if burn is a critical burn and consider air transport directly to Burn Center.12. Consider Albuterol 2.5mg nebulized for respiratory distress.

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a. 4x(pt weight in kg)x(%BSA burned)/2/16=fluid over first hour.

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PROTOCOLBurns

General10


DESTINATION DECISION MAKING:

CONSIDER HEMS UTILIZATION.

ADULT:1. Burns >10% (2

ndand 3

rddegree) TBSA or significant burns involving face, airway, hands, feet, genitalia, circumferential

burns (2nd

and 3rd

degree) transport to Hillcrest Medical Center.2. ANY burn associated with Priority 1 or Priority 2 trauma, transport to Saint Francis Hospital (odd calendar days 0700-0700 if

unassigned). Saint John Medical Center (even calendar days 0700-0700 if unassigned).3. Burns <10% (2

ndand 3

rddegree) not meeting criteria above, transport to nearest facility as appropriate.

PEDIATRIC (age 16 and under):1. Burns >30% (2

ndand 3

rddegree) TBSA or significant burns involving face, neck, airway, hands, feet, genitalia, circumferential

burns (2nd

and 3rd

degree), transport to Hillcrest Medical Center.2. ANY burn associated with Priority 1 or Priority 2 trauma, transport to Saint Francis Hospital or Hillcrest Medical Center.3. Burns 10-30% (2

ndand 3

rddegree) TBSA not meeting criteria above, transport to Saint Francis Hospital or Hillcrest Medical

Center.4. Burns <10% (2

ndand 3

rddegree) TBSA not meeting criteria above, transport to nearest facility as appropriate.

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16. In the presence of facial, neck, or possible airway burns; RSI early.17. If unable to intubate consider surgical cricothyrotomy.18. If there is significant eschar covering the chest in a way that prevents chest rise and impedes

adequate ventilation, perform a chest escharotomy. (see procedure)

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PROTOCOL

Chest PainNon-STEMI/Unstable Angina

General11


EMR

1. Follow Universal Patient Care Protocol.2. Complete a review of medical history including OPQRST pain assessment.

EMR

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3. Apply oxygen if hypoxic.4. Obtain EKG within 10 min. of patient contact, transmit to hospital if equipped.5. Consider Aspirin 324mg PO. (81mg chewable baby ASA x4)6. Assist patient with NTG SL if it has been prescribed to them and is in date and their SBP>100.

Contraindicated in patients who have taken erectile dysfunction medication in the last 24 hours.Administer every 5 minutes up to 3 doses as long as BP is maintained.

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7. Consider vascular access.8. Consider NTG 0.4mg SL for chest pain.

a. SBP>100b. No erectile medications in the last 24 hours.c. Administer every 5 minutes up to three times. Monitor BP.

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9. Interpret EKG, if STEMI, transmit EKG with 15 minutes of patient contact then refer to STEMIprotocol.

10. Consider Morphine for pain control.11. Consider IV Nitroglycerin at 5mcg/min increase by 5 mcg every 5 minutes until pain free. Monitor

BP closely. May also consider Nitroglycerin Paste 1” to ACW instead of IV.12. If nausea refer to nausea protocol.

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PROTOCOL

Chest PainSTEMI

General12


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1. Consider Aspirin 324mg PO (81mg baby Aspirin x4).2. EKG Rules:

a. II, III, AVF: Inferiorb. V1, V2: Septalc. V3, V4: Anteriord. V5, V6: Laterale. Must be 1mm of elevation in 2 or more contiguous leads to call STEMI alert. (Exception:

LBBB and Ventricular Paced Rhythm)f. If LBBB or ventricular paced rhythm, refer to Sgarbossa Criteria.

3. Transmit EKG within 15 minutes, notify receiving facility and confirm that they have received EKG.4. Repeat 12L EKG every 10 minutes.5. Consider vascular access x2.6. Consider Fentanyl for pain management.7. Consider NS boluses for inferior wall MIs.8. Use NTG with caution in inferior wall MIs.9. Consider IV NTG 5mcg/min, increase by 5mcg/min every 5 min. until pain free.10. Consider Lovenox for Lovenox eligible patients: (See Lovenox screen)

a. Less than 75 years old:i. 30mg IV single bolus plus 1mg/kg and 1mg/kg SQ. (SQ max dose 100mg)

b. Greater than 75 years old:i. 0.75mg/kg SC (No initial IV bolus)ii. SC dose not to exceed 75mg.

c. Hypersensitivity to Lovenox, Heparin, pork products; severe thrombocytopenia;uncontrolled bleeding; pregnant or breast feeding mothers.

11. May consider NTG Paste 1” ACW if IV NTG unavailable.12. Sgarbossa Criteria: (STEMI Diagnosis in LBBB or ventricular paced rhythm)

a. ST elevation >1mm in leads with a positive QRS complex (concordance in ST deviation.b. ST depression >1mm in V1-V3 (concordance with ST deviation)c. ST elevation >5mm in leads with a negative QRS complex (inappropriate disconcordance ST

deviation)

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ALSBLS

PROTOCOLDeath in the Field

General13

EMS of Leflore CountyEMS Medical Control Authority

ALL

Withholding Life Support Measures:1. Life support may be withheld if any of the following exists:

a. Patient qualifies for DNR status (with one of the following):i. Do Not Resuscitate Order Form signed by the patient, Medical Power of Attorney, or

Physician.ii. Any bracelet with the wording “Do Not Resuscitate Order” with at least the name

and address of the patient (on the patient).b. Decapitation.c. Rigor Mortis (exception: Severe Hypothermia).d. Dependent lividity: venous pooling in dependent body parts.e. Trauma incompatible with life.

2. All hypothermic patients (whom are not completely frozen), electrocution/lightning strike, anddrowning victims should receive resuscitation measures and be transported.

3. Attach cardiac monitor and confirm asystole in present in multiple leads.4. Contact medical control. (Mandatory for all patients regardless of situation.)5. After medical control has pronounced the patient:

a. Note the time the patient was pronounced and by which physician.b. Cover the body with a sheet.c. Contact the appropriate authorities.d. Secure the scene-do not remove personal property from the body, disturb the scene, or

leave the body unattended.e. If not already present request law enforcement and the medical examiner.f. Assess the need for pastoral services for family and friends.g. Complete detailed scene report and assessment.

6. Relinquish scene control to law enforcement, coroner, or medical examiner.

Discontinuing Life Support Measures:1. Follow appropriate protocols for treatment.2. If the patient is in a viable rhythm or has positive response to treatment

a. Continue resuscitation as needed.b. Transport ASAP.

3. Contact medical control and consult regarding the termination of efforts.

ALL

ALSBLS

PROTOCOLHypertension

General14


EMR

1. Follow Universal Patient Care Protocol.2. Confirm hypertension by manual BP:

a. Systolic BP >220b. Diastolic BP >130c. Symptoms of organ compromise (CHF, pulmonary edema, chest pain, changes in mental

status, etc.)

EMR

EMT

3. Consider the most likely cause:a. If CHF or cardiac origin, follow the Acute Pulmonary Edema Protocol.b. If head trauma, follow Head Trauma Protocol.

EMT

AEM

T 4. Consider IV access with saline lock, do not infuse fluids unless directed by medical control. AEM

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5. Consider the most likely cause:a. If CHF or cardiac origin, follow the Acute Pulmonary Edema Protocol.b. If head trauma, follow Head Trauma Protocol.c. Consider Ativan 1mg IV for hypertension secondary to anxiety.d. If severely altered mental status AND hypertensive crisis as defined above consider:

i. Labetalol 20mg IV/IO slowly over two minutes.1. Discontinue if heart rate <60.2. Contraindicated in a second degree AV type II block or patients with cocaine

related chest pain/MI.3. Use with caution with patients in CHF and the elderly.

ii. SLOWLY decrease BP by 25% over 30-60 minutesiii. Target BP below 190mmHg systolic and 110mmHg diastolic.

Guidelines for Treating Hypertension in Stroke patients:1. Pre-Hospital (Scene Calls): Do not treat HTN in Acute Stroke.2. Interfaciltiy (Post CT): Only treat HTN in Acute Ischemic Stroke receiving TPA or Any Acute

Hemorrhage Stoke (Intracerebral Hemorrhage).

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PROTOCOLHyperthermia

General15


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using airway adjuncts as needed.3. Apply oxygen if hypoxic.4. Move patient to a cool environment.5. Perform and detailed assessment and review of medical history.6. If the patient is alert and can follow commands to take oral fluid without airway compromise give

oral fluids such as Gatorade or water.7. If shock is present, see Hypotension Protocol.8. Anticipate potential for seizures.9. Assess and document GCS.

EMR

EMT

10. Transport ASAP.11. Assess core temperature and if temperature above 104f:

a. Implement rapid cooling measures (fan patient, apply moist towels, apply ice, etc…)b. Guard against shivering.

EMT

AEM

T 12. If the patient is not alert and/or if temperature is greater than 104f, establish IV access NS TKO. AEM

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13. Follow above treatments. Pa

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PROTOCOLHypoglycemia

General16


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilation and/or using airway adjuncts as needed.3. Apply oxygen if hypoxic.4. Watch for signs of hypothermia.

EMR

EMT

5. Assess blood glucose, <60mg/dl consider oral glucose.a. Oral Glucose 15g if patient is responsive and can follow commands to take oral medication

without airway compromise, may repeat as needed to maintain adequate blood glucose.6. Recheck blood glucose in 5 minutes following treatment, if glucose remains <60mg/dl contact

medical control.

EMT

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7. Establish IV/IO.8. If blood glucose <60mg/dl consider:

a. Adult: Dextrose 50% 12.5-25g IV/IO9. Recheck blood glucose in 5 minutes following treatment, if glucose remains <60mg/dl repeat the

Dextrose and reassess in 5 minutes.

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10. If blood glucose <60mg/dl consider:a. Child: Dextrose 50%: 0.25-0.5ml/kgb. Infant: Dextrose 25%: 0.25-0.5mg/kgc. Neonate: Dextrose 10%: 0.25-0.5mg/kg

11. Consider D5W maintenance drip titrated to maintain a blood glucose >60.12. Glucagon 1mg IM if unable to rapidly establish IV/IO access.

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PROTOCOLHypotension & Shock

General17


EMR

1. Follow Universal Patient Care Protocol.2. Apply oxygen if patient is hypoxic.3. Keep patient warm if cold, cool if warm.

EMR

EMT

4. If Hypovolemic Shock is suspected:a. Control any external bleeding, see Trauma Protocols as needed.

5. If Cardiogenic Shock is suspected, see Pulmonary Edema Protocol.

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6. If Hypovolemic Shock is suspected with systolic BP <90mmHg:a. Establish large-bore IV NS bilaterally or proximal Humerus IO.

7. If sepsis is suspected, refer to the Sepsis Protocol.8. When Hypovolemic and Septic Shock are suspected, administer NS fluid boluses:

a. Adult: Up to 30ml/kg NS if no contraindications present.b. Child: 20ml/kg NS, may repeat for a total of 3 boluses.c. Infant: 10ml/kg NS, may repeat for a total of 3 blouses.

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9. For adults with hemorrhagic shock with need for massive blood transfusion see Trauma Protocol10. Consider Dopamine 2-20mcg/kg/min IV/IO (see drug reference).

a. Contraindicated for suspected sepsis and those with sustained tachycardia.b. Preferred for patients who are bradycardic.

11. Consider Epinephrine 2-10mcg/min IV/IO (see drug reference).12. Consider Levophed 0.5-30mcg/min IV/IO (see drug reference).

a. Preferred for patients with suspected sepsis.

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ALSBLS

PROTOCOLHypothermia

General18


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using airway adjuncts as needed.3. Apply oxygen if hypoxic.4. Passive rewarming (remove wet clothes, move to warm environment, etc).5. Prevent heat loss/wind exposure.6. Maintain a horizontal patient position.7. Avoid rough patient movements.8. Consider assessing the patient’s blood glucose in diabetic patients and in moderate to severe cases

of hypothermia.9. If no pulse, follow BLS CPR & AED Protocol.

EMR

EMT

10. Monitor core temperature:a. 34-36c or 93.2-96.8f-Mild Hypothermia

i. Passive rewarming.ii. Active external rewarming (electrical/chemical warming devices, heat packs, etc).

b. 30-34c or 86-93.2f-Moderate Hypothermiai. Passive rewarming.ii. Active external rewarming (electrical/chemical warming devices, heat packs, etc) of

the trunk only, do not rewarm limbs.c. <30c or 86f-Severe Hypothermia

i. Request ALS.ii. Passive rewarming.

iii. Cautious active external rewarming (electrical/chemical warming devices, heatpacks, etc.) of trunk only (do not warm extremities or limbs).

11. Consider monitoring cardiac rhythm.12. Notify receiving hospital ASAP in cases of moderate to severe hypothermia.

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T 13. Consider IV access and warm NS TKO in moderate and severe cases of hypothermia. AEM

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ALSBLS

PROTOCOL

Induced Hypothermiafor Post Cardiac Arrest

General19


EMR

Inclusion Criteria:1. Patient has a ROSC post cardiac arrest and is in a perfusing rhythm within 50 min of initial arrest.2. Etiology of cardiac arrest was not related to trauma.3. Patient has no speech, no eye opening, or purposeful movement to painful stimuli.4. Systolic BP >90. (with or without the use of pressors)5. Advanced airway in place and the patients is being mechanically ventilated.6. Initial temperature >95f.7. ETCO2 >20.8. Patient age > 18 years.9. Patient is not known to be pregnant.10. No indication of a reversible cause for coma (overdose, stroke, hypoglycemia)11. No known history of bleeding or clotting disorders.12. No known intracranial event.13. No major surgery within 72 hours.14. No DNR.15. Receiving hospital must be able to continue Hypothermia treatment.

If the patient meets ALL of the inclusion criteria continue with the protocol.

EMR

EMT

Procedure:1. Manage any life threatening problems first. (CAB’s)2. Insure that the patient meets all inclusion criteria.3. Obtain a baseline temperature.4. Expose the patient.5. Draw rainbow of blood tubes for lab testing6. Apply ice packs to the axilla, groin, neck, and head.

EMT

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7. Start cold NS (4º Celsius (39º Fahrenheit) bolus of 30ml/kg over 30-60min through peripheral IV or IO.(AEMT Level)8. Record temperatures q 15 min. If temperature drops below 91f, discontinue cooling. If temperature isabove 91f, continue cooling measures to target temperature of 33º Celsius (92º F).

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9. If patient begins to shiver consider Versed 5mg or Ativan 2mg IV/IO. If patient continues to shiverconsider Vecuronium 0.15mg/kg IV/IO, then refer to the continued sedation protocol.10. Record VS, ETCO2, temp., and rhythm q 15 min.11. Perform EKG q 15 min.12. If patient’s systolic BP becomes less than 90 refer to hypotension protocol.13. CALL HOSPITAL ASAP.

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ALSBLS

PROTOCOLOverdose and Poisoning

General20


EMR

1. Confirm scene safety prior to EMS entry2. Follow Universal Patient Care Protocol3. Maintain airway - consider assisting ventilations and/or using oral/nasal/advanced airway as needed4. If safely possible, bring the source of poising with the patient to the receiving hospital5. If internal overdose/poisoning determine what was ingested, at what time, what amount, and past history6. If external poisoning remove contaminated clothing, brush away excess substances, and flush contaminated skin

and eyes with copious amounts of water/normal saline if indicated – DO NOT flush phosphorus, sodium metal,phenol, or acids

7. Assess level of consciousness/GCS, if decreased LOC follow Altered Mental Status protocol8. Assess pupillary response

a. Constricted/pinpoint – narcotics, opiates, phenothiazines, cholinergicsb. Dilated – tricyclics, anticholinergics, cocaine

9. Monitor airway closely and prepare for seizure, decreased LOC, confusion, vomiting, and/or cardiovascular collapse10. If hypotension is present (systolic BP ≤ 90 mmHg) see Hypotension/Shock protocol. 11. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (APNEIC/AGONAL BREATHING) CONSIDER:


12. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (SHALLOW/INEFFECTIVE BREATHING OR UNRESPONSIVE) CONSIDER:a. Adult/Pediatric: Naloxone 0.5mg IN

13. Use Naloxone to restore effective breathing and airway maintenance only. Avoid excessive dosing (precipitateswithdraws).

EMR

EMT

14. Apply Oxygen using the appropriate rate/device based on patient condition15. If suspected carbon monoxide poisoning immediately remove from environment and apply high flow oxygen vianon-rebreather mask

a. Signs/Symptoms – headache, dyspnea, fatigue, nausea, vomiting, confusion, ataxia, seizure, syncope,respiratory arrest, incontinence, irritabilityb. Pulse oximetry cannot distinguish oxygen from carbon monoxide, DO NOT rely on pulse oximetry

16. If suspected cyanide poisoning immediately remove from environment and apply high flow oxygen via non-rebreather mask

a. DO NOT rely on pulse oximetry, blood may be oxygen enriched, but cells cannot receive the oxygenb. Prepare for seizure, nausea/vomiting, respiratory depression, and cardiac addressc. Notify receiving facility of possible cyanide overdose

17. If suspected organophosphate poisoning immediately remove from environment, decontaminate, and apply highflow oxygen via non-rebreather mask

a. Common organophosphates are insecticides/fertilizersb. Observe for SLUDGE: salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis

18. Consider applying cardiac monitor if abnormal pulse.

EMT

ALSBLS

PROTOCOLOverdose and Poisoning

General20


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19. Establish IV NS TKO,20. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (APNEIC/AGONAL BREATHING) CONSIDER:

a. Adult: Naloxone 2mg IN/IV/IO, may repeat once.b. Pediatric: 0.5mg IN/IV/IO, may repeat once.

19. IF SUSPECTED NARCOTIC/OPIATE OVERDOSE (SHALLOW/INEFFECTIVE BREATHING OR UNRESPONSIVE) CONSIDER:a. Adult/Pediatric: Naloxone 0.5mg IN/IV/IO

20. Use Naloxone to restore effective breathing and airway maintenance only. Avoid excessive dosing (precipitateswithdraws).

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21. If suspected organophosphate poisoning administer atropine 2 mg IV/IO slowly (adult) or 0.05mg/kg IV/IO(pediatric), repeat every 3-5 minutes until symptoms (bronchorrhea, bradycardia, bronchospasm) resolve.22. If suspected beta blocker overdose consider:

a. Adult: Glucagon 1-2 mg IV/IO Pediatric: Glucagon 0.05 to 0.1 mg/kg IV/IOb. For symptomatic bradycardia see ACLS/PALS Bradycardia protocol

23. If suspected calcium channel blocker overdose considera. Glucagon 1-2 mg IV/IOb. Calcium Chloride 10 mg/kg IV/IO

24. If suspected tricyclic antidepressant overdose consider the following:a. Signs/Symptoms – wide QRS, tachycardia, ventricular arrhythmias, decreased LOC, seizures, cardiovascularcollapseb. Consider Sodium Bicarbonate 50 mEq IV/IO (adult), 1mEq/kg (pediatric, max dose 50 mEq), repeat asneeded every 5-10minutes.

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PROTOCOLPain Management

General21


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1. Follow Universal Patient Care Protocol.2. Apply oxygen if hypoxic.3. Establish Vascular access.4. Observe Indications for pain management:

a. Musculoskeletal Injury with obvious bony deformity, or deformity indicating hip or femurfracture. Use of pain medication to allow immobile patients who would otherwise not beable to be moved by EMS personnel due to morbid obesity, but may be able to assist withmovement if treated for severe back pain, may be done with medical control.

b. Burnsc. Abdominal Paind. Chest Paine. Multisystem Trauma

5. Observe CONTRAINDICATIONS:a. Pregnant greater than 20 weeks. (Medical Control Consultation Required)b. History of allergy to desired analgesic.c. Signs or symptoms of shock. (Exception: Ketamine)d. Hypotension (Exception: Ketamine)

6. Consider Zofran 4mg IV/IO prior to giving analgesia.7. Consider: (escalate per the patient’s pain and response to lesser medications)

a. Fentanyl 1mcg/kg, 100mcg max push dose, IV/IO up to 200mcg.b. Morphine 0.05mg/kg IV/IO (max single dose 5mg, max total dose 15mg).c. Ketamine 0.25mg/kg IV/IO one dose. (Preferred if patient is hypotensive)

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ALSBLS

PROTOCOLPsychiatric / Behavioral

General22


EMR

1. Confirm scene safety prior to EMS entry.2. Do not let the patient come between you and the exit.3. Carefully remove any dangerous objects.4. Follow Universal Patient Care Protocol.5. Remain calm and attempt verbal de-escalation if possible prior to using physical restraint.6. If it is necessary and can be performed safely physically restrain the patient:

a. Place in supine position –closely monitor respiratory effort and airway.b. Only soft-style restrains are permitted, hard restraints, including handcuffs, are not

permitted. Ask the officer to assist you in placing soft restraints.c. Handcuffs may be permitted if an officer rides with you.d. DO NOT place patient in the prone position for any length of time.e. Continuously evaluate for signs of potential airway compromise.f. Assess/document CMS distal to restraints before and after application as well as every 15

minutes.7. Obtain history and search for potential causes of change in behavior, hypoglycemia, hypoxia,

hypotension, head injury; anticholinergic poisoning, stroke, illicit drugs, alcohol use, and alcoholwithdraw.

8. If the patient feels warm to the touch implement mild cooling methods.9. If the patient is suicidal alert law enforcement and do not leave the patient alone at any time-

document any suicide related comments the patient makes.

EMR

EMT

10. Follow above treatments. EMT

AEM

T 11. Consider vascular access, NS TKO. AEM

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12. If all attempts were made to verbally de-escalate the behavior and physical restraints wereattempted and the patient remains a threat to self/others consider chemical restraint:

a. Consider Ketamine 4mg/kg IM (max dose 400mg IM) or Ketamine 2mg/kg IV/IO (max dose200mg). PLUS Versed 5mg IM/IV/IO/IN, if ineffective, go to b.

b. Perform a., if ineffective: Consider Ativan 1-2mg IV/IO/IM or Versed 2-5mg IV/IO/IN/IM.c. If (a) and (b) are ineffective, contact medical control.d. Contact Medical Control prior to administering chemical restraints in pediatric patients.

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ALSBLS

PROTOCOLRapid Sequence Intubation

General23

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1. Follow Universal Patient Care Protocol.2. Maintain airway-assisting ventilations and using adjuncts as needed.3. If unable to manually ventilate the patient using a BVM, do not proceed with RSI if the patient has adequate

oxygenation.4. Observe indications:

a. Acute or impending respiratory failure with intact gag reflex.b. Multiple system traumas where the airway is not protected.c. Unconsciousness.d. Intractable seizures.e. Head trauma with a GCS <9f. Critical burns with suspected inhalation injury.

5. Perform an airway assessment to determine if the patient may be a difficult intubation.6. Pre-oxygenate the patient with 100% oxygen.7. Establish IV/IO access.8. Monitor heart rate and SpO2 during procedure.9. If patient is bradycardic consider 0.5mg Atropine IV/IO.10. If the patient has suffered a traumatic injury and/or increased intracranial pressure/bleed is suspected

consider Fentanyl 1mcg/kg IV/IO. Preferably at least 3 minutes prior to intubation.11. Consider sedation or induction.

a. Consider Etomidate 0.3mg/kg IV/IOi. Contraindicated for patients with suspected sepsis.

b. Consider Ketamine 2mg/kg IV/IO (preferred if bronchospasms are present).i. Avoid Ketamine if increased ICP is suspected.

c. Consider Versed 0.1-0.3mg/kg IV/IO.i. Contraindicated in hypotension.

12. Consider paralytic Succinylcholine 1.5mg/kg IV/IO (off-line paralytic).a. Do not administer succinylcholine if patient or family history of malignant hyperthermia is noted.b. Caution if suspected rhabdomyolysis or hyperkalemia.c. Caution if penetrating eye injury.d. Caution in severe burns or crush injuries that are more than 24 hours old.e. Use with caution if history of renal insufficiency/failure.

13. If Succinylcholine is contraindicated, contact medical control for the use Rocuronium 1mg/kg IV/IO for RSIprocedure.

14. Do not ventilate patient with BVM unless hypoxic, due to risk of aspiration. Pre-Oxygenate with NRB (usenasal ETCO2 to monitor ventilation).

15. Consider using BURP technique.16. Intubate, see procedure guide.17. Confirm placement:

a. Auscultate lung sounds and epigastrium.b. ET capnography waveform concurrent with ventilations, monitor continuously.

18. If ET tube placement cannot be placed/confirmed in 60 seconds place a KingLT airway.19. If no airway can be established ventilate patient with BVM.20. If patient can no longer be ventilated with BVM consider cricothyrotomy. (see procedures)21. Refer to the Sedation Protocol for post intubation sedation and paralyzation as needed.22. Reassess tube placement frequently.23. Keep patient warm.24. Upon arrival to the ED have the physician confirm placement before moving the patient off the cot, and sign

the ePCR that the tube was in place upon arrival at the ED.

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ALSBLS

PROTOCOLRespiratory Distress

General24

EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway, consider ventilations and adjuncts as needed.

EMR

EMT

3. Apply oxygen using the appropriate rate/device based on patient condition.a. If lung sounds are clear and equal, monitor, and transport.b. If lung sounds are unilateral, consider pneumothorax, see Chest Trauma Protocol.

i. If lung sounds decreased or wheezes, consider Albuterol 2.5mg nebulized.ii. Consider EPI PEN or EPI PEN Jr. for severe distress AND suspected allergic reaction

or asthma.c. If lung sounds have rales/crackles and are unilateral, consider possibility of pneumonia:

i. Productive cough, fever, chills?ii. Consider Albuterol 2.5mg nebulized.

d. If Lung sounds have rales/crackles bilaterally, consider CHF, see Acute Pulmonary EdemaProtocol.

e. If lung sounds have rales/crackles unilaterally consider pneumonia.4. If systolic BP<90mmHg see hypotension and shock protocol, request ALS.

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5. Assess lung sounds, if bilateral wheezes are present or diminished/absent lung sounds consider:a. >12years old: Albuterol 2.5mg with Atrovent 500mcg nebulized.b. <12years old: Albuterol 2.5mg nebulized.

6. Consider vascular access.7. If patient becomes unstable consider epinephrine 0.5mg IM.

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8. If patient is maintaining adequate ventilation:a. Choose Xopenex 1.25mg in 3ml NS or Albuterol 2.5mgb. Mix with Atrovent 500mcg nebulized.

9. For severe bronchoconstriction consider Racemic Epinephrine 0.5–0.75ml of a 2.25% solution in 2.0ml normal saline.

10. Consider Magnesium Sulfate 2g in 250ml NS over 20minutesif severe or refractory bronchospasm orwheezing.

11. Consider Decadron (Dexamethasone) if any inspiratory stridor is present: Adult and pediatric:0.6mg/kg IV/IO (max 10mg), may give IM if no access) OR Solu-Medrol (if expiratory wheezingonly—NO inspiratory stridor).

12. If patient has normal mental status, SBP>90, less than adequate ventilation, or has pulmonaryedema:

a. Consider CPAP or BiPAP with nebulized treatments.13. If patient continues to deteriorate: use Ketamine for induction. (See RSI Protocol)

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PROTOCOLSedation

General25


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1. Monitor vital signs every 1-3 minutes.2. Monitor respiratory and airway status constantly.3. Use lowest effective dose.4. Consider Zofran 4mg IV/IO prior to sedation.5. Treat sedation, paralysis, and analgesia as three separate issues.6. Continuous waveform capnography (ETCO2) must be in place prior to sedation.

Procedural Sedation: (elective cardioversion, pacing, etc…)Consider:

1. Ketamine:a. Adult/Pediatric Dose: 1mg/kg IV/IO (max 150mg), repeat up to 4mg.

2. Versed: (may be used in conjunction with Fentanyl if ineffective alone.)a. Adult Dose: 0.5-2.5mg IV/IO, repeat up to 10mg.b. Pediatric Dose: 0.05-0.2mg/kg IV/IO, titrate to desired effect (max dose 10mg)

3. Fentanyl: (consider as an adjunct analgesic when Versed is used.)a. Adult Dose: 25-50mcg IV/IO every 5 minutes.b. Pediatric Dose: 1-2mcg/kg slow IV/IO.

Induction for Intubation: (see RSI protocol)Consider:

1. Etomidate: (contraindicated in the presence of suspected sepsis)a. Adult / Pediatric: 0.3mg/kg IV/IO, max dose 0.6mg/kg.

2. Versed: (contraindicated in the presence of hypotension)a. Adult: 0.1-0.3mg/kg IV/IO.b. Pediatric: Refer to Broselow Tape.

3. Ketamine: (avoid if suspected increased ICP)a. Adult/Pediatric: 2mg/kg IV/IO (max 200mg).

Post Intubation: (ETCO2 must be used to confirm tube placement before continuing in this protocol).1. Consider: Ketamine 2mg/kg IV/IO for adult and pediatric. (If not used for induction.)2. Consider: Versed 3-5mg IV/IO every 10-15 minutes up to 20mg. (pedi = consult Broselow Tape).3. Consider Ativan 1-2mg IV/IO every 10-15 minutes up to 4mg. (pedi = consult Broselow Tape.)

Paralytic:1. Consider: Vecuronium 5-10mg IV/IO. (pedi = consult Broselow Tape)

Analgesia:1. Consider: Fentanyl 1mcg/kg 1mcg/kg IV/IO every 5-10 minutes (up to 200mg for adult and

pediatric).2. Consider: Morphine 2-5mg IV/IO for adult every 10-15 minutes (up to 20mg—avoid in pediatric

patients and in hypotensive).

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PROTOCOLSeizure

General26


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using adjuncts as needed.3. Apply oxygen if hypoxic.4. Protect the patient from injury before and after the seizure, do not restrain the patient or place

anything in the mouth during seizure.5. Consider nasal airway during seizure.6. Implement C-spine precaution as needed.7. Place patient in the lateral recumbent position.8. Note history of seizures, motor activity, during the seizure, duration of seizure, and duration of

postictal phase.9. May assist patient in using Vagus Nerve Stimulator once every 3-5 minutes, up to 3 times.

EMR

EMT

10. Assess blood glucose, if <60-refer to Hypoglycemia protocol. EMT

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12. If pregnant in the third trimester consider eclampsia, refer to eclampsia protocol.13. If seizure is in progress, patient reports an aura, or patient is unresponsive and petite mal seizure is

suspected consider:a. Versed 5mg IV/IO/IM/IN, may repeat once in 5 minutes.b. Ativan 2mg IV/IO, may repeat once in 10 minutes.

14. If seizure persists after 2 doses of benzodiazepines, consider Keppra 500mg IV (infuse in 100ml NSover 15 min.)

15. If seizure persists after Keppra infusion complete, CONTACT MEDICAL CONTROL.

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PROTOCOLSepsis

General27


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1. For a sepsis alert to be activated, patient must be 18 years old or greater, not pregnant, and meetthe following three general criteria:

a. Physical signs of SIRS.b. History consistent with infection.c. Signs of hypoperfusion or hypotension.

2. Patient must meet two of the following criteria:a. Temperature greater than 38C (100.4F) or lower than 36C (96F)b. Pulse greater than 90.c. Respiratory rate greater than 20.d. Suspected or documented infection.

ANDHypoperfusion as manifest by one of the following:

e. Systolic BP less than 90.f. MAP less than 65.g. Lactate level greater than 4mmol/L

3. Treatment:a. Administer oxygen to maintain an oxygen saturation >94% and capnography between 35-

45mmHg.b. Establish IV access with two large-bore catheters and draw labs.

i. Baseline blood values will be important.ii. Administer IV fluid boluses (30cc/kg), rapid infusion.

c. Reassess after infusing 500ml increments.i. Blood pressure.ii. Breath sounds.

iii. Levophed 2-4mcg/min titrated to maintain systolic pressure of 90.d. Reassess patient on a regular basis. Document appropriately the following:

i. Vital signs-Auscultated BP.ii. Breath sounds.

iii. Capnography.iv. Pulse Oximetry.v. Blood Sugar.

vi. Monitor cardiac rhythm.e. If RSI is required, Ketamine is the preferred induction agent. Etomidate is contraindicated in

sepsis.

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PROTOCOLStroke

General28


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or airway adjuncts as needed.3. Apply oxygen if hypoxic.4. Perform detailed patient assessment and review medical history.5. Assess blood glucose, if <60 go to hypoglycemia protocol.6. Last known well time <6 hours.

EMR

EMT

7. Perform LAPSS, if positive ACTIVATE CODE STROKE and transport immediately.8. Transport with head elevated at 45 degrees if possible.9. Consider cardiac monitor.

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11. Perform 12-Lead EKG.12. If the patient is pre-hospital (scene call), DO NOT treat hypertension.13. Complete screening for fibrinolytics (TPA), notify hospital early of code stroke.

a. Last known well time <3 hours (Extended Window TPA < 4.5 hours).b. Last known well time <6 hours (interventional radiology).

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Destination Decision Making:1. LKWT <3 hours, Transport to Sparks Hospital or Mercy Hospital in Fort Smith, AR. Call “CODE STROKE” early during transport.

a. Patient is a candidate for TPA.2. LKWT >3 hours, but <6 hours, transport to Sparks (Fort Smith).

a. Patient is a candidate for extended TPA or thrombectomy.

ALSBLS

PROTOCOLSyncope

General29


EMR

1. Follow Universal Patient Care Protocol.2. Implement C-Spine precautions if mechanism of injury is consistent with C-Spine injury3. Apply oxygen if hypoxic.4. If the patient remains unresponsive, see altered mental status protocol and consider overdose,

diabetic, heat related, etc.5. Assess mental status and calculate GCS.6. Assess blood glucose if <60 go to hypoglycemia protocol.7. Perform detailed assessment and review medical history.8. Perform LAPSS, if positive go to stroke protocol.

EMR

EMT

9. Follow above treatments.10. If the patient has chest discomfort, see chest pain protocol.11. Consider cardiac monitor.

EMT

AEM

T

12. If the patient remains unresponsive or feels “light headed” or “dizzy” or remains hypotensive,administer NS fluid bolus:

a. Adult: 500cc NS, repeat as needed to maintain systolic >90.b. Pediatric: 20cc/kg NS, repeat for a total of 3 times.c. Infant: 10cc/kg NS, repeat for a total of 3 times.

AEM

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13. Observe for cardiac arrhythmias. Para

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ALSBLS

PROTOCOLUniversal Patient Care

General30


ALL

1. Confirm scene safety prior to EMS entry.a. Contact law enforcement, fire, or HAZMAT as needed.b. Do not expose self or crew to the scene until it has been secured and is safe to enter.

2. Don the appropriate body substance isolation (gloves, eye protection, respiratory protection, etc.).3. Perform primary survey:

a. Airway and C-spine precautions.i. Manually maintain airway via head tilt, chin lift or modified jaw thrust.ii. Oral/nasal suction as needed.

iii. Manually maintain c-spine immobilization and transfer to a long spine board usinginline spinal immobilization if indicated.

b. Breathing:i. Consider assisting ventilations as needed.ii. Apply oxygen if hypoxic.

iii. Perform a detailed lung sound assessment.iv. Note respiratory rate/depth, work of breathing, skin color, cap refill, patient

position, SpO2, etc.c. Circulation:

i. Note rate and quality.ii. Obtain venous access (if qualified).

iii. Apply AED when required.d. Disability:

i. Assess pupils and pupillary responses.ii. Assess GCS/RTS.

iii. Assess blood glucose.iv. Note respiratory rate and pattern.v. Assess CMS in all extremities.

vi. Perform the LAPSS.vii. Attempt to mitigate hypo/hyperthermia.

e. Expose the patient for detailed assessment.4. Perform a detailed assessment:

a. Vital signs (pulse, respirations, BP, SpO2, LOC, blood glucose, etc.)b. Perform a detailed head to toe exam.c. Review patient’s medical history, allergies, medications, etc.

5. Monitor:a. ABC’sb. Consider cardiac and SpO2 monitor.

6. Refer to the appropriate protocol based on the patient assessment and history.7. Contact medical control as indicated by the specific protocols or if a question or complication arises.

ALL

ALSBLS

PROTOCOLAbdominal Trauma

Trauma1


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway – consider assisting ventilations and/or using adjuncts as needed.3. Protect C-Spine.4. Apply oxygen if patient is hypoxic.5. Monitor closely for shock, see hypotension protocol.6. Perform a detailed abdominal assessment and consider underlying anatomy.7. If penetrating abdominal injury – note entrance/exit wounds and direction, injury instrument

size/shape/caliber and distance from muzzle.8. If abdominal injury resulting from an MVA – Note details of vehicle/scene, steering wheel,

associated fatalities, etc.9. If evisceration injury:

a. Do not reduce or attempt to replace abdominal contents.b. Cover exposed tissues with a most sterile dressing and cover with an occlusive dressing.

10. Calculate Glasgow Coma Score (see reference).

EMR

EMT

11. Load & Go – On scene goal < 10 minutes and notify receiving facility with trauma alert.12. Expose the injury – if significant mechanism of injury cut/remove all clothing to allow for a complete

assessment.13. Perform a complete head-to-toe trauma assessment and reassess as needed.14. Frequent Vital Signs.15. Keep patient warm.16. Consider applying cardiac monitor.

EMT

AEM

T 17. Establish large-bore IV access NS TKO bilaterally. AEM

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18. Consider nasogastric tube placement, place tube orally if facial or head trauma is present.19. Consider RSI if indicated, per RSI protocol20. Consider pain and nausea management, as per applicable protocols.21. Administer Tranexamic Acid, if indicated, per hemorrhagic shock protocol.

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ALSBLS

PROTOCOLAmputation

Trauma2


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilation and adjuncts as needed.3. Protect C-Spine.4. Apply oxygen if patient is hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. Frequent vital sign assessment.7. Calculate Glasgow Coma Score.8. If active bleeding is present, control bleeding with direct pressure and/or pressure points-if bleeding

persists, consider tourniquet application.9. Cover the amputated part with a sterile dressing moistened with normal saline and place in a plastic

bag, place the plastic bag on ice (do not freeze or soak in saline) and transport amputated part withpatient.

EMR

EMT

10. Load & Go-Transport ASAP (On scene goal <10 minutes) and notify receiving facility of trauma alert.11. Expose the patient-if significant mechanism of injury cut/remove all clothing to allow for a complete

assessment.12. Perform a complete head-to-toe trauma assessment.13. Frequent vital signs.14. Keep patient warm.15. Consider applying cardiac monitor.

EMT

AEM

T 16. Establish large-bore IV access NS TKO bilaterally.17. When shock is suspected administer fluid bolus up to 3 times:

a. Adult: 500ml NS or LR.b. Pediatric: 20ml/kg NS or LR

AEM

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18. If patient is in pain, refer to pain management protocol.19. Administer Tranexamic Acid, if indicated, per hemorrhagic shock protocol.

Para

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ALSBLS

PROTOCOLChest Trauma

Trauma3


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine injury is suspected or as dictated by mechanism of injury.4. Apply oxygen if hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. Detailed chest assessment and consider underlying anatomy.7. If a sucking chest wound is present:

a. Apply an occlusive dressing secured on 3 sides.b. Monitor closely for signs of tension pneumothorax.c. It may be necessary to periodically “BURP” the wound if signs of tension pneumothorax are

present or a change in respiratory effort is observed or reported.8. Perform detailed lung sound assessment-if absent or diminished suspect tension pneumothorax.9. If a flail segment is suspected, stabilize the area with gentile pressure. It may be necessary to assist

ventilations with positive pressure ventilation.10. Calculate Glasgow Coma Score (see reference).

EMR

EMT

11. Load & Go-Transport ASAP (on scene goal <10 minutes) and notify receiving facility with a traumaalert.

12. Expose the injury. If significant mechanism of injury cut/remove all clothing to allow for a completeassessment.

13. Perform a complete head-to-toe assessment and reassess as needed.14. Frequent vital signs.15. Keep patient warm.16. Consider applying cardiac monitor.

EMT

AEM


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18. If a tension pneumothorax is suspected, perform a needle decompression of the chest, seeprocedures.

19. If respiratory compromise present consider RSI.20. Administer Tranexamic Acid, if indicated, per hemorrhagic shock protocol.21. If pneumothorax or hemothorax suspected, consider HEMS activation for chest tube (tube

thoracostomy) placement. Do not delay needle decompression (needle thoracostomy) whileawaiting HEMS arrival.

22. Refer to pain management protocol.

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ALSBLS

PROTOCOLEye Trauma

Trauma4


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine injury is suspected or as dictated by mechanism of injury.4. Apply oxygen if hypoxic.5. Perform detailed eye assessment.6. If a small foreign body is present consider flushing eye gently with 500-1000ml’s of NS.7. If an impaled object is present:

a. Do not attempt to remove.b. Stabilize the object and dress the affected eye(s).c. Patch the unaffected eye taking care not to apply pressure to the eye.d. Offer reassurance and discourage the patient from making any eye movement.

8. If a chemical burn is present flush the affected eye(s) for 5-20 minutes with sterile NS. If alkaline orlye exposure is the cause of the chemical burn, try to continuously irrigate the eye while enroute tothe receiving facility.

9. If blunt trauma is present, assess for blow out fracture of the orbit, hyphema, and symptoms ofretinal detachment.

10. Calculate Glasgow Coma Score (see reference).

EMR

EMT

11. Transport ASAP and notify receiving facility with a trauma alert. EMT

AEM

T 12. Follow above treatments. AEM

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13. Refer to pain management protocol. PA

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IC

ALSBLS

PROTOCOLFacial Trauma

Trauma5


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine if injury is suspected or as dictated by mechanism of injury.4. Apply oxygen if hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. If external bleeding is present, apply direct pressure/use pressure points if necessary and dress

wounds.7. If broken/missing teeth:

a. Remove dislodged teeth from the mouth and collect dislodged teeth from the scene.b. Pick up dislodge teeth by the crown (protect the root) and place in milk or normal saline

(milk preferred).8. If nose injury is present apply pressure and cold pack to the nose.9. If suspected fractured mandible:

a. Apply stabilize the mandible with bandages.b. DO NOT compromise the airway.

10. If suspected fracture of the maxilla, maintain the airway and apply ice.11. Calculate Glasgow Coma Score (see reference).

EMR

EMT

12. Load & Go-transport ASAP (on scene goal <10 minutes) and notify receiving facility of trauma alert.13. Continuously monitor airway.14. Expose the injury-if significant MOI, remove all of the patients clothing to assess for injuries.15. Perform a complete head-to-toe assessment.16. Frequent vital signs.17. Keep patient warm.18. Consider applying the cardiac monitor.

EMT

AEM


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20. If respiratory compromise exists-consider RSI. If orotracheal intubation is unable to be performedconsider cricothyrotomy.

21. Refer to pain management protocol.

Pa

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ALSBLS

PROTOCOLGeneral Trauma Management

Trauma6


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine if injury is suspected or as dictated by mechanism if injury.4. Apply oxygen if hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. Control active external bleeding with direct pressure, if bleeding persists consider tourniquet and

application of Celox hemostatic agent per the Hemorrhagic Protocol.7. Calculate Glasgow Coma Score (see reference).8. Keep patient warm.9. Refer to specific trauma protocol.

EMR

EMT

10. Load & Go-transport ASAP (on scene goal <10 minutes) and notify receiving facility with a traumaalert.

11. Constantly monitor airway.12. Perform a complete head-to-toe trauma assessment and reassess as needed.13. Frequent vital signs.14. Keep patient warm.15. Consider applying the cardiac monitor.

EMTA

EMT 16. Establish large-bore IV access NS TKO bilaterally. A

EMT

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17. If respiratory compromise is present, consider RSI.18. Administer Tranexamic Acid, if indicated, per hemorrhagic shock protocol.

Para

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Destination Decision Making:-Any priority 1 or 2 trauma patient should be transported to a Level I or Level II Trauma Center unless in active cardiacarrest or failed airway. CONSIDER HELICOPTER TRANSPORT FOR LEVEL I and II PATIENTS.-If the patient is being transported to Tulsa and is unassigned (no requested hospital), then follow the Tulsa Area TraumaPlan (0700-0700):Adult: Even Days: St. John, Odd Days: St. Francis Pediatric: Everyday: St. Francis-Area Level I and II Trauma Centers: St. John (Tulsa), St. Francis (Tulsa), St. Joseph-Mercy (Hot Springs), WashingtonRegional (Fayetteville), UAMS (Little Rock).-Area Pediatric Trauma Centers (age 16 or less): St. Francis (Tulsa), UAMS (Little Rock).

ALSBLS

PROTOCOLHead Trauma & TBI

Trauma7


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine if injury is suspected or as dictated by mechanism of injury.4. Apply oxygen if hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. Calculate Glasgow Coma Score (see reference).

EMR

EMT

7. Load & Go-transport ASAP (on scene goal <10 minutes).a. Notify receiving facility with a trauma alert.b. Every head-injured patient who has had a period of unconsciousness should be evaluated at

the hospital.8. Expose the injury-if significant mechanism of injury cut/remove all clothing to allow for a complete

assessment.9. Perform a complete head-to-toe assessment and reassess as needed.10. Frequent vital signs.11. Keep the patient warm.12. Consider applying the cardiac monitor.13. Keep head of the cot at 45 degrees if the patient is not on a backboard.

EMT

AEM


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15. Consider intubation if mental status is not adequate.16. Maintain systolic BP above 90.17. Refer to pain management protocol.

Para

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ALSBLS

PROTOCOLHemorrhagic Shock

Trauma8


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using airway adjuncts as needed.

EMR

EMT

3. Control External Hemorrhage aggressively and immediately upon discovery.4. Apply an approved tourniquet (CAT) to extremities with uncontrolled hemorrhage. Apply to the

most proximal part of the extremity as possible. Record time of application and do no remove pre-hospital without Medical Control approval.

5. For areas not amendable to tourniquets, use approved hemostatic gauze (Celox or Quick ClotCombat Gauze) with pressure dressing. Celox hemostatic gauze may be used in conjunction withtourniquets, but tourniquet is the first line intervention for uncontrolled arterial extremityhemorrhage.

EMTA

EMT 6. Administer 1L NS and 1L LR IV/IO. A

EMT

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If the patient is experiencing signs or symptoms of hemorrhagic shock that may need blood transfusions:7. Consider Tranexamic Acid 1g in 100ml NS IV/IO PB over 10 minutes.

a. ONLY FOR PATIENTS THAT ARE TRANSPORTED DIRECTLY TO SAINT FRANCIS, SAINT JOHN, OROU MEDICAL CENTER.

Pa

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ALSBLS

PROTOCOLOrthopedic Trauma

Trauma9


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and adjuncts as needed.3. Protect C-Spine if injury is suspected or as dictated by mechanism of injury.4. Apply oxygen if hypoxic.5. Monitor closely for shock, see Hypotension & Shock Protocol.6. Calculate GCS.7. Control external bleeding with direct pressure, if bleeding persists consider tourniquets and Celox

hemostatic dressing.8. Check distal circulation, motor, and sensation (CMS) and mark the site where the pulse can be felt.

a. If circulation is not present and a dislocation is suspected, consider reduction/realignmentof the joint one time, if unsuccessful contact medical control. DO NOT REDUCE ELBOWS.

9. Expose and immobilize the injury by splinting the joint above and below the injury in the positionfound/position of comfort (with the exception of compromised CMS, see above).

10. If a mid-shift femur fracture is a suspected without injury to pelvis, knee, lower leg, or ankle applytraction splint.

11. If an open fracture is present, stabilize and dress with a dry sterile dressing.12. Reassess CMS after splinting the injury and while transporting.13. Apply ice and elevate to the patient’s position of comfort.

EMR

EMT

14. Load & Go-Transport ASAP (on scene goal <10 minutes) and notify receiving facility of trauma alert.15. Expose the injury if significant MOI is present cut/remove all clothing to allow for a complete

assessment.16. Perform a complete head-to-toe assessment and reassess as needed.17. Continue CMS checks distal to the suspected fracture.18. Frequent vital signs

EMT

AEM


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20. If patient is in pain, refer to pain management protocol.21. If major joint dislocation and pulseless extremity (reduction indicated as above), refer to sedation

protocol for procedural sedation.

Pa

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ALSBLS

PROTOCOLSpinal Cord Injury

Trauma10


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or adjuncts as needed.3. Protect C-Spine with full spinal immobilization.4. Perform a detailed neurological assessment.5. Observe closely for signs of shock, refer to Hypotension & Shock Protocol.

EMR

EMT

6. Repeat neurologic assessment frequently.7. If paralysis is present, notify the receiving facility.8. Keep patient warm, provide supportive care.9. Closely monitor vital signs.

EMT

AEM


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11. Perform above treatments. Pa

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ALSBLS

PROTOCOLCroup & Epiglottitis

Pediatric1


EMR

1. Follow Universal Patient Care Protocols.2. Approach the patient in a calm reassuring fashion-anxiety is likely to exacerbate the condition.3. Consider blow by oxygen.4. Allow the child to adopt a position of comfort.5. Be prepared to assist/control ventilations with BVM.6. Determine croup vs. epiglottitis:

a. Croup: 6mo-3yr, gradual onset, worse at night, “seal bark cough”, leaning forward tobreath, and retractions.

b. Epiglottitis: >2yrs, Rapid onset, signs/symptoms, stridor, hoarse voice, fever, nasal flaring,restlessness, drooling, and wants to sit up.

EMR

EMT

7. Monitor closely. EMT

AEM

T 8. Avoid agitation of the child; do not attempt vascular access unless child is unstable. AEM

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9. For Croup consider Racemic Epinephrine 0.5–0.75ml of a 2.25% solution in 2.0 ml normal saline vianebulizer.

10. If patient shows signs of respiratory compromise consider RSI after medical control consultation, orif respiratory arrest is imminent. Prepare for difficult airway.

11. Consider Dexamethasone 0.6mg/kg IV/IO (may give IM if no vascular access).

Pa

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ALSBLS

PROTOCOL

PALSBradycardia

Pediatric2


Par

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1. Identify and treat reversible causes (H’s and T’s).2. Maintain airway.3. Apply oxygen if hypoxic.4. Apply cardiac monitor and identify rhythm. Monitor vital signs.5. Consider vascular access.6. If HR<60 despite oxygenation and ventilation, start compressions if patient is <12 months of age.7. If bradycardia persists:

a. Consider epinephrine 0.01mg/kg IV/IO repeat every 3-5 minutes.b. Consider atropine 0.02mg/kg IV/IO repeat once, min dose 0.1mg and max dose 0.5mg.

8. If cardiac arrest occurs, go to PALS Pulseless Arrest Algorithm.

Pa

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ALSBLS

PROTOCOL

PALSPulseless Arrest

Pediatric3


AEM

T 1. Consider vascular access. Intraosseous vascular access is first-line in cardiac arrest. May useproximal humerus if landmarks are palpable. Alternatively may use proximal tibia or distal femur.Distal tibia is a last resort.

AEM

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1. Start CPR.

2. Apply Monitor.

VF/Pulseless VT:SHOCK 1st: 2J/kg

2nd: 4j/kg

3rd and subsequent:

10J/kg

Vascular Access:

Epi. 0.1mg/kg every 3-5minutes

Narcan 0.1mg/kg

Assess CBG

VF/Pulseless VT refractoryto shock:

1st Round: Amiodarone5mg/kg

2nd Round: Amiodarone5mg/kg

Consider KINGLT Airwaywith Capnography.

Consider NG or OGplacement.

Consider ResQpod.

Doses/Details:

Consider 40u Vassopressin to replace the first orsecond dose of epi.

Capnography and ResQpod required for anyadvanced airway in pulseless patients.

Consider H’s and T’s, treat reversible causes.

After 3 rounds with no clinical improvement,consider contacting medical control for possibletermination of the resuscitation.

ALSBLS

PROTOCOL

PALSTachycardia

Pediatric4


AEM

T 1. Consider vascular access. AEM

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Evaluate QRS Width:

QRS <0.09:o Sinus Tach: Infants: <220/min, children: <180/min.

Consider NS bolus.o SVT: Infants: >220/min, children: >180/min.

Consider vagal maneuvers. Consider Adenosine 0.1mg/kg up to 6mg repeat once at 0.2mg/kg IV, IO up to 12mg.

Wide complex tachycardia: Consider vagal mannuvers. Consider Adenosine 0.1mg/kg up to 6mg repeat once at 0.2mg/kg IV, IO up to 12mg. Obtain EKG, assess axis for possible VT. If VT consider Amiodarone 5mg/kg over 20 minutes IV, IO.

o If patient becomes unstable: Synchonize cardiovert. 0.5-1j/kg, increase to 2j/kg for second and subsequent.

Refer to Sedation Protocol if cardioversion being performed and time permits. Ketamine is thepreferred procedural sedation agent in pediatrics.

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ALSBLS

PROTOCOLRapid Sequence Intubation

Pediatric5

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1. Follow Universal Patient Care Protocol.2. Maintain airway-assisting ventilations and using adjuncts as needed.3. If unable to manually ventilate the patient using a BVM, do not proceed with RSI if the patient has adequate

oxygenation.4. Observe indications:

a. Acute or impending respiratory failure with intact gag reflex.b. Multiple system trauma where the airway is not protected.c. Unconsciousness.d. Intractable seizures.e. Head trauma with GCS < 9.f. Critical burns with suspected inhalation injury.

5. Perform an airway assessment to determine if the patient may be a difficult intubation.6. Perform EKG, evaluate for hyperkalemia.7. Pre-oxygenate the patient with 100% oxygen.8. Establish IV/IO access.9. Monitor heart rate and SpO2 during procedure.10. If patient is bradycardic go to PALS Bradycardia Protocol.11. If the patient has suffered a traumatic injury and/or increased intracranial pressure/bleed is suspected

consider Fentanyl 1-2mcg/kg IV/IO. Preferably at least 3 minutes prior to intubation.12. Consider sedation or induction.

a. Etomidate 0.3mg/kg IV/IO up to 20mg or Versed 0.2-0.3mg/kg IV/IO.

i. Contraindicated in suspected sepsis.b. Ketamine 2mg/kg IV/IO (preferred in bronchospasm)

i. Avoid Ketamine if increased ICP is suspected.c. Versed 0.2-0.3/kg IV/IO

i. Contraindicated in the presence of hypotension.13. Consider paralytic Succinycholine 2mg/kg IV/IO.

a. Do not administer succinylcholine if patient or family history of malignant hyperthermia is noted.b. Caution if suspected rhabdomyolysis or hyperkalemia.c. Caution if penetrating eye injury.d. Caution in severe burns or crush injuries that are more than 24 hours old.e. Use with caution if history of renal insufficiency/failure.

14. If Succinylcholine is contraindicated, contact Medical Control for the use of Rocuronium.15. Do not ventilate with BVM unless hypoxic, die to risk of aspiration. Pre-oxygenate with NRB (use nasal ETCO2

to monitor ventilation).16. Consider using BURP technique.17. Intubate, see procedure guide.18. Confirm placement:

a. Auscultate lung sounds and epigastrium.b. ET capnography waveform concurrent with ventilations, monitor continuously.

19. If ET tube placement cannot be placed/confirmed in 60 seconds place a KingLT airway.20. If no airway can be established ventilate patient with BVM.21. If patient can no longer be ventilated with BVM consider cricothyrotomy. (see procedures)22. Refer to the Sedation Protocol as needed.23. Reassess tube placement frequently.24. Keep patient warm.

25. Upon arrival to the ED have the physician confirm placement before moving the patient off the cot, and signthe ePCR that the tube was in place upon arrival at the ED.

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ALSBLS

PROTOCOLSeizure

Pediatric6


EMR

1. Follow Universal Patient Care Protocol.2. Maintain airway-consider assisting ventilations and/or using adjuncts as needed.3. Apply oxygen if hypoxic.4. Protect the patient from injury before and after the seizure, do not restrain the patient or place

anything in the mouth during seizure.5. Consider nasal airway during seizure.6. Implement C-spine precaution as needed.7. Place patient in the lateral recumbent position.8. Note history of seizures, motor activity, during the seizure, duration of seizure, and duration of

postictal phase.9. May assist patient in using Vagus Nerve Stimulator once every 3-5 minutes, up to 3 times.

EMR

EMT

10. Assess blood glucose, if <60-refer to Hypoglycemia protocol. EMT

AEM

T 11. Establish IV/IO. AEM

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12. If pregnant in the third trimester consider eclampsia, refer to eclampsia protocol.13. If seizure is in progress, patient reports and aura, or patient is unresponsive and petite mal seizure is

suspected consider:a. Versed 0.15mg/kg IV/IO/IM/IN, 5mg max dose, 10mg total; may repeat once in 5 minutes.b. Ativan: 0.05-0.1mg/kg IV/IO, max dose 2mg max single dose, 4mg total dose, may repeat

once in 10 minutes.14. If age 16 or greater and seizures persist, see Adult Seizure Protocol for Keppra dosing. If age less

than 16, CONTACT MEDICAL CONTROL.

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ALSBLS

PROTOCOLChildbirth

Obstetrics1

EMR

1. Follow Universal Patient Care Protocol. EMR

EMT

2. Obtain pertinent history: number of previous births, prenatal care, possibility of multiple births, previous c-sections, frequency of contractions, etc.

3. If the patient does not appear to be in active labor, no crowning present.a. Place patient on her left side.

4. If the patient is having bleeding/pain, not labor, see hypotension & shock protocol, or Vaginal Bleedingprotocol.

a. Monitor Vital Signs.b. Discontinue following this protocol.

5. If active labor and abnormal presentation contact medical control.a. Foot, hand, or cord presentation: No field delivery—Elevate mother’s hips or Trendelenburg.

Prevent cord compression with a gloved hand to maintain a pulsating cord. Keep cord moist usingsaline solution.

b. Buttocks/Breech: Support legs & trunk. If the baby’s head does not deliver and the baby begins tobreath, place a gloved hand in the vagina and form a v-shape with your first 2 fingers to hold vaginalwall from the baby’s face.

i. Arms before head: lower the infant’s body to assist with the head in passing.ii. As hairline appears, raise body by ankles upwards.

iii. Bulb suction baby’s mouth first then nose.6. If delayed labor with the baby attempting to breath:

a. DO NOT pull on the baby.b. Form a v-shape with your first 2 fingers to hold the vaginal wall from the baby’s face.

7. If active labor and normal presentation:a. Control delivery with gentle pressure to prevent explosive delivery.b. Support head while it rotates.c. Bulb suction baby’s mouth first then nosed. Guide the head upward to deliver the lower shoulder, then downward to deliver the upper shoulder.e. Control the delivery of the trunk and legs.

8. If the cord is around the baby’s neck (nuchals cord):a. Attempt to slip the cord over the head & shoulders or If the cord is too tight, place clamps on the

cord 2” apart and cut the cord.9. Keep newborn at the level of vagina until cord is clamped and cut.

10. Once cord pulsations cease, clamp the cord 8” from the naval with clamps 2” apart and cut the cord.

11. Briskly dry infant, keep warm, cover head. Note time of birth and obtain a 1 and 5 minute APGAR score (seereference).

12. Refer to neonate resuscitation protocol as needed. Massage fundus gently; allow baby to feed to promoteplacental delivery.

13. Do not pull cord and note time of placental delivery. Do not discard placenta.

EMT

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14. If mother’s bleeding >250ml post labor:a. Obtain vascular access.b. See hypotension and shock protocol.c. Intermittently massage the fundus gently; unless multiple births are anticipated.

15. If patient is in active labor, consider vascular access NS TKO.

AEM

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ALSBLS

PROTOCOLChildbirth

Obstetrics1

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16. For severe bleeding following placental delivery, consider 40units Pitocin IM (20u in each hip). (seemedication reference).

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ALSBLS

PROTOCOLEclampsia & Pre-Eclampsia

Obstetrics2


EMR

1. Follow Universal Patient Care Protocol.2. Apply oxygen if patient is hypoxic.3. Consider signs and symptoms of pre-eclampsia & eclampsia:

a. Pregnant mother in her 3rd trimester >28 weeks.b. Hypertension typically greater than 140/90.c. Extremity edema and/or blurred vision.d. Headache and/or excessive weight gain.e. Dizzinessf. Confusiong. Epigastric pain (RUQ pain often indicates impeding seizure).

4. Maintain a calm and quiet environment; make attempts to minimize excessive noise, lighting, andstimulation in order to decrease the risk of seizure.

5. Assess blood glucose.6. Place in left lateral recumbent position.

EMR

EMT

7. Consider applying cardiac monitor. EMT

AEM


TP

aram

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9. If systolic BP greater than 140 systolic or 90 diastolic and patient appears agitated and at risk forseizures, contact medical control.

10. If seizures are present, see Seizure Protocol and administer 4g Magnesium Sulfate IV/IO over 20minutes, then 2g in 250ml NS IV / 1 hour.

a. Monitor for signs of adverse reaction: hypotension, pulmonary edema, respiratorycompromise).

Pa

rame

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ALSBLS

PROTOCOLVaginal Bleeding

Obstetrics3


EMR

1. Follow Universal Patient Care Protocol.2. If bleeding is postpartum, refer to child birth protocol.3. Apply oxygen if patient is hypoxic.4. If systolic BP<90mmHg, see Hypotension and Shock Protocol:

a. Request ALS.b. Elevate the patient’s legs.

5. Keep patient warm.6. Consider the possibility of pregnancy and establish when the last menstrual period was, how many

times the patient has been pregnant and how many live births she has delivered.7. If the possibility of assault exists maintain chain of evidence, preserve clothing, and if possible, have

a female caregiver in the patient care area.8. Preserve any tissue fragments.9. Apply bulky dressing to the external genitalia, do not pack the vagina.

EMR

EMT

10. Follow above treatments. EMT

AEM


TP

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ALSBLS

PROTOCOL12-Lead EKG

Procedure1


1. If patient is unstable, definitive treatment is the priority. If the patient is stable or stabilizedafter treatment, perform a 12-lead ECG.

2. Prepare ECG monitor and pre-cordial lead cables.3. Enter patient demographic data.4. Expose the chest and prep as necessary. Modesty should be considered.5. Apply chest leads and limb leads as follows:

RA----right arm

LA----left arm

RL----right leg

LL----left leg

V1----4th intercostal space at right sternal border

V2----4th intercostal space at left sternal border

V3----Directly between V2 and V4

V4----5th intercostal space at midclavicular line

V5----Level with V4 at the left anterior axillary line

V6----Level with V5 at the left midaxillary line6. Instruct patient to remain still.7. Press the 12 lead acquisition button on the monitor.8. If the monitor detects a problem, such as loose leads, bad connection, noisy data, the monitor

will alarm.9. Once acquired, transmit to the appropriate receiving facility.10. Contact the receiving facility to notify them of the patient and the incoming 12-lead.11. Monitor and reassess the patient enroute and continue treatment protocol.12. Attach a copy of the 12-lead with the patient’s record at the hospital.13. Document the procedure and time on the PCR.

Paramedic Level Care:1. Review and interpret EKG, treat per applicable protocols.2. Document the EKG and rhythm interpretation in PCR.

ALSBLS

PROTOCOLAED

Procedure2


Indications:1. Pulseless patients with no normal breathing.2. Adult—onset of puberty.3. Child—pre-puberty.4. Infant—first year of life.

Procedure:1. If more than one rescuer is available, one should provide uninterrupted chest compressions

while the AED is being prepared by the other. If unwitnessed arrest, perform 2 minutes of CPRprior to analyzing.

2. Apply pads per manufacturer recommendations. Place one inch away from medical implants.3. Remove any medication patches on the chest and wipe off any residue.4. If pads touch due to the patient’s small size, utilize anterior / posterior placement.5. Turn on AED.6. Follow instructions from AED, clear during analyzing and defibrillation.7. Immediately following a shock, resume CPR with chest compressions.8. Analyze rhythm every two minutes.9. Check for a pulse every 5 minutes.10. If “no shock advised” perform two minutes of CPR and reanalyze the rhythm.

11. Interrupt CPR for no longer than 10 seconds at any time.

ALSBLS

PROTOCOLCapnography

Procedure3


Indications:1. Should be considered for all patients with altered mental status, Chest Pain, Toxic Ingestion, or Head

Injury.2. Required if an advanced airway is in place and/or for procedural sedation.

Procedures:1. Select type: Nasal cannula or ET capnography.2. Connect to monitor.3. Connect to patient.4. Keep in place throughout transport.5. All capnometry and capnography readings should be recorded in the PCR.6. High capnometry=acidosis.7. Low capnometry=alkalosis.8. In patients with a pulse: capnometry between 35-45 is considered normal.9. In cardiac arrest patients: capnometry between 10-15 is a sign on viability while a level of <10 is a sign of

the patient being unsalvageable.10. Wave Forms:

a. Bronchospasm: “shark fin”, uneven alveolar emptying.b. Inadequate sedation: “notches” in waveform.c. Gradual Increase in EtCO2: Hypoventilation.d. Gradual Decrease in EtCO2: Hyperventilation.e. Elevated Baseline: Air trapping (COPD, asthma)

ALSBLS

PROTOCOLCardioversion

Procedure4


Pa

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1. Continuously monitor patients status and rhythm.2. Place therapy pads on patient.3. If this is an elective cardioversion, consider the Sedation Protocol.4. Narrow Regular:

a. Press sync, insure that the monitor is synced.b. Start at 50j and increase in a stepwise fashion.

5. Narrow Irregular:a. Press sync, insure that the monitor is synced.b. Start at 120 and increase in a stepwise fashion.

6. Wide Irregular:a. Go to defibrillation procedure.b. Shock at 200j.

7. If patient loses a pulse at any time start CPR and move to pulseless protocol.

Param

ed

ic

ALSBLS

PROTOCOLDefibrillation

Procedure5


Indications:1. As indicated by protocol for patients in shockable rhythms.

Procedure:1. Use the dial to select the appropriate energy dose.2. Press the charge button, continue CPR while the machine charges.3. After the machine is charged, press the shock button.4. Immediately after shock, continue CPR starting with compressions.

ALSBLS

PROTOCOLEscharotomy

Procedure6


Indications:Patients with circumferential burns to the thorax which can limit chest excursion and

compromise ventilations. It is imperative that an escharotomy is performed to restore mobility to thechest wall and ensure adequate ventilations. It is not recommended unless absolutely and immediatelynecessary to prevent loss of life.

Equipment:1. Scalpel2. Sterile Dressings3. Sterile 4x4 gauze pads

Procedure:1. Prepare your equipment2. Administer sedation and pain medications.3. Maintain aseptic technique.4. Determine a well-defined incision pattern. The incision should be of sufficient depth for an

obvious release in pressure on the skin and for fat to bulge through the incision.5. Make an incision on the mid-axillary lines bilaterally.6. If necessary continue to incise across the base of the chest at the level of the diaphragm.

ALSBLS

PROTOCOLGastric Tube Placement

Procedure7


Indications:1. Gastric Decompression.

Procedure:1. Estimate insertion length by superimposing the tube over the body from the nose to the

stomach.2. Flex the neck if not contraindicated to facilitate esophageal passage.3. Liberally lubricate the distal end of the tune and pass through the patient’s nostril along the

floor of the nasal passage. Do not orient the tip upward into the turbinate’s. This increases thedifficulty of the insertion and may cause bleeding. Alternatively, the tube may be passedthrough the gastric lumen of the King LTS-D airway for patients in whom this device is beingutilized.

4. In the setting of an unconscious, intubated patient or a patient with facial trauma, oral insertionof the tube may be considered or preferred and may be facilitated with laryngoscopy.

5. Continue to advance until the appropriate depth is reached.6. Confirm placement by injecting 20ml of air and auscultating for the swish or bubbling of the air

over the stomach, additionally, aspirate gastric contents to confirm proper placement.7. Secure the tube.8. Decompress the stomach of air and food either by connecting the tube to suction or manually

aspirating with the large syringe.9. Document the procedure, time, and result on/with the patient care report.

ALSBLS

PROTOCOLHemostatic Agents

Procedure8


Indications:1. Serious hemorrhage that cannot be controlled by other means.

Procedure:1. Use sterile gauze pads to wipe away all excess blood inside the wound.2. Manually insert Celox hemostatic gauze by pushing into wound with gloved finger until cavity is

filled.3. Apply direct pressure to the wound for 5 minutes.4. Apply dressing and bandage.

ALSBLS

PROTOCOLKing LT Airway

Procedure9


Indications:1. Cardiac arrest where initial BLS airway management has been completed per protocol or

sufficient personnel are present to perform without interruption of other cardiac arrest care.2. Non-cardiac arrest patient without a gag reflex for whom at least one failed intubation attempt

has occurred or the King can be placed more rapidly or with less interruption to care.3. Appropriate intubation is impossible due to patient access or difficult airway anatomy.

Procedure:1. Prepare, position, and oxygenate the patient.2. Choose appropriate size airway based off of height of the patient.3. Check the cuffs for proper inflation and deflation.4. Place a lubricated 18fr NG tube in the gastric lumen of the airway beneath the BVM connector,

advancing it to ¼” past the distal opening. (King LTS-D only)5. Apply head tilt chin lift and introduce device to the corner of the mouth.6. Advance tip between tongue and hard palate rotating tube midline.7. Without excessive force, advance tube until base of connector aligns with teeth or gums.8. If a paramedic is present, they should advance the NG tube at this time, otherwise this should

be deferred until paramedic’s arrival. In either case, confirmation of placement shouldultimately occur per the NG tube procedure.

9. Inflate the cuff per the recommended amount.10. Apply BVM and ventilate, pulling back slowly on the King until good chest rise is noted.11. If necessary, add air to cuff to maintain seal.12. Apply ETCO2 and resQpod as needed.13. Record confirmation in PCR.

ALSBLS

PROTOCOLNeedle Thoracostomy

Procedure10


Par

ame

dic

Indications:1. Suspected Tension Pneumothorax.

Procedure:1. Assemble equipment.

a. 2” 14ga needle or preferably Turkel Thoracentesis Needle.b. Alcohol or betadinec. Dressing and tape

2. Identify landmarks:a. Insert the needle in the mid-claviclular line at the second intercostal space

just above the third rib.3. Prep the area with alcohol or betadine.4. Insert needle over the top of the rib until you feel a give in resistance, advance

catheter and remove needle.5. A small puff of air may be heard escaping the catheter.6. Reassess breath sounds and patient condition.7. Secure catheter with tape.8. Remember, the patient may need to have both sides of the chest decompressed

do to bilateral pneumothoraxes.9. Pediatric consideration:

a. Use an 18 or 20ga needle in the mid-clavicular line above the 3rd rib.10. If necessary, a second needle decompression can be performed just anterior to the

mid-axillary line at the 4th intercostal space, just above the 4th rib. This isrecommended if the first decompression is unsuccessful, or in the event that ahemothorax is suspected.

Pa

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ALSBLS

PROTOCOLNon-Invasive Positive Pressure

Ventilation (NIPPV)CPAP/BiPAP

Procedure11


Indications:1. Dyspnea associated with CHF, COPD, Pneumonia, Asthma, Anaphylaxis, Near-Drowning, or unknown

cause with inadequate ventilation as a component of the patient’s respiratory distress.2. Invasive airway management indicated, but patient is in DNI status (“Do Not Intuate Order”); Written

order by a physician or DNR/DNI paperwork signed by patient and /or medical power of attorney.

Contraindications:1. Apnea or any indication for invasive airway management.2. Altered mental status with inability to tolerate mask.3. Comatose or obtunded state.4. High risk of aspiration/impaired gag reflex.5. Impending or active vomiting.6. Facial/Head Trauma.

Procedure: (BiPAP is preferred. Use CPAP if BiPAP unavailable)1. Activate device, initial settings of 5cmH2O (CPAP), 10cmH2O/5cmH2O (IPAP/EPAP = BiPAP).2. Explain procedure to the patient.3. Place nasal cannula capnography.4. Hold or let patient hold mask up to their face to orient themselves with it.5. After patient is comfortable, attach mask to patients face to prevent air leaks.6. CPAP: Increase PEEP levelin increments of 2cmH2O up to 15cm H2O.7. BiPAP:

a. Increase IPAP level in increments of 5cmH2O up to 25cmH2O.b. Increase EPAP level in increments of 2cmH2O up to 15cmH2O.

8. Constantly evaluate patient.9. Consider in-line nebulized treatments for all patients on CPAP/BiPAP.10. Encourage patient in the use of CPAP/BiPAP.11. If patient becomes unstable, remove CPAP/BiPAP immediately, ventilate, and consider RSI.

ALSBLS

PROTOCOLRefusal of Care

Procedure12


EMR

1. Follow Universal Patient Care Protocol.2. Assess mental status, history of illness, MOI.3. If at any time the patient consents to treatment and transfer proceed to the

appropriate protocol.4. Determine if the patient is alert and oriented to person, place, time, and event.5. If the patient is not alert, complete a detailed assessment, transport is indicated.

EMR

EMT

6. If the patient refuses care and is alert complete a patient care report and have thepatient sign the refusal documentation.

a. Inform the patient and/or responsible parties of the potentialconsequences of their decision to refuse treatment and/or transport.

b. Ensure that the patient understands these consequences.c. If medical control is contacted and determines the patient requires further

assessment and treatment in the ED, report this to the patient. If thepatient continues to refuse transport and/or treatment, the refusal shouldbe written showing that it was against medical advice.

d. Present the refusal documentation to the patient in the presence of awitness:

i. Ideally the witness should not be affiliated with EMS and shouldsign the release documentation stating that they acted as awitness.

ii. If the patient refuses to sign release documentation, document therefusal to sign and obtain 2 witness signatures if possible.

e. When possible, leave the patient in the care of family, friend, caregiver, orlegal guardian.

f. Give the patient EMSLC refusal discharge instructions.g. Inform patient that if need arises to call back as soon as possible.

EMT

AEM

T 7. Follow above treatments. AEM

TP

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ram

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ALSBLS

PROTOCOLRestraints

Procedure13


Indications:1. Any patient who may harm himself, herself, or others may be gently restrained to prevent injury

to the patient or crew. This restraint must be humane in manner and used only as a last resort.Other means to prevent injury to the patient or crew must be attempted first. These effortscould include reality orientation, distracting techniques, or other less restrictive therapeuticmeans. Physical or chemical restraint should be a last resort technique.

Procedure:1. Attempt less restrictive means of managing the patient.2. Request law enforcement.3. Ensure that there are sufficient personnel available to physically restrain the patient safely.4. Restrain the patient in a lateral or supine position. No devices such as backboards, splints, or

other devices will be on top of the patient. The patient will never be restrained in the proneposition.

5. The patient must be under constant observation by the EMS crew at all times. This includesdirect visualization of the patient as well as cardiac and pulse oximetry monitoring.

6. The extremities that are restrained will have a circulation check at least every 15 minutes. Thefirst of these checks should occur as soon after placement of the restrains as possible. ThisMUST be documented in PCR.

7. Documentation on PCR should include the reason for use of restraints, type of restraint, andtime restraints were placed.

8. If the above actions are unsuccessful, or if the patient is resisting the restraints, considerSedation Protocol.

9. If a patient is restrained by law enforcement personnel , an officer must accompany the patientto the hospital in the transporting EMS vehicle.

ALSBLS

PROTOCOLSelective Spinal Immobilization

Procedure14


Indications:1. Patients who had suffered trauma where spinal injury is a consideration should be immobilized

with c-collar, CSID, Spider straps, and LSB using in-line immobilization.2. If none of the following are present selective spinal immobilization may be considered:

a. Loss of or possible loss of consciousness.b. Midline neck or back pain/tenderness/stiffness/deformities upon palpation.c. Abnormal neurologic exam including; numbness, tingling, or unusual sensations in the

patient’s extremities.d. Altered mental status from any cause including illicit drugs or alcohol.e. Any significant distracting injuries or multisystem/blunt trauma.f. Less than 8 years old.

3. Consider the MOI and the general health and age of the patient.4. If no contraindications/exclusions exist the patient may be transported in a position of comfort

without spinal precautions at the discretion of the provider.5. If any doubt exists—apply spinal precautions.

Ambulatory at the scene or interfacility transfer:1. Apply rigid cervical collar.2. Sit the patient in a position of comfort on the cot.

No c-collar required if the patient is an interfacility transfer with previous radiographic (x-ray, CT, MRI)clearance of the c-spine by physician. A DOCUMENTED radiology report AND CD or FILM copy mustaccompany the patient. If the documented report AND CD/FILM are not available, the patient is NOTconsidered cleared by the physician and a c-collar should be used on an interfacility transfer patient orambulatory scene patient (c-collar only).

Penetrating trauma with no evidence of neck/spine injury:Use of spinal immobilization has been shown to cause more harm that benefit in patients withpenetrating trauma. Avoid use of backboard and c-collar in patients with penetrating trauma (GSW,impalement, stabbing) unless obvious neurologic deficits or spinal column injury. The above criteria donot apply to penetrating trauma unless concomitant blunt trauma has occurred.

Contact Medical Control for c-spine clearance that does not meet above protocol, as needed.

Spinal Immobilization:

EMT and greater Level of Care:Indications:1. Patients with significant MOI, complaining of neck or back pain and tenderness, decreased ROM,numbness or tingling in an extremity, CMS deficits, altered mental status, or multisystem trauma.Procedure:1. Maintain manual stabilization of the c-spine.2. Assess CMS.3. Apply appropriately sized c-collar.

ALSBLS

PROTOCOLSelective Spinal Immobilization

Procedure14


4. Place the patient on the spine board using log roll or long axis pull.5. Secure the patient using “spider straps”, torso first, then legs.6. Secure CSID to board.7. Pad all voids.8. Reassess CMS often.

Avoid use of backboards in patients whom are interfacility transfer, have received isolated penetratingtrauma with no neurologic deficits, or who are ambulatory at the scene.

ALSBLS

PROTOCOLSurgical Airway

Procedure16


Indications:1. If no other means of airway control is successful.2. CONTACT MEDICAL CONTROL IF AGE <8.

Procedure:1. Assemble additional personnel.2. Locate cricothyroid membrane at the inferior portion of the thyroid cartilage (with head in

neutral position, membrane is approximately 3 finger widths above the sternal notch).3. Have assistant hold skin taunt over membrane and locate the midline.4. Prep area with betadine if possible.5. Make a 2-3cm vertical incision over the membrane.6. Expose the membrane and make a lateral cut through it.7. Insert the bougie stick to the level of the carina8. Use scalpel to make the incision large enough for a 6.0 ETT.9. Introduce ETT over the bougie stick and inflate cuff.10. Confirm placement with ETCO2 and bilateral lung sounds.11. Secure tube and bandage area.

ALSBLS

PROTOCOLTaser Discharge and Removal

Procedure17


Paramedic Level of Care:

Indications:1. Patient with uncomplicated electrical weapon probes embedded subcutaneously in non-

sensitive areas of skin.2. Taser probes are barbed metal projectiles that may embed themselves up to 13mm into the

skin.Procedure:

1. Ensure wires are disconnected form the weapon.2. Stabilize skin around the probe.3. Grasp and remove probe in a single quick motion.4. Wipe around with antiseptic wipe and apply dressing.5. Do not remove probes embedded in the face, head, bone, or genitalia.6. Perform 12-lead EKG.

ALSBLS

PROTOCOLTourniquet

Procedure18


Indications:1. Uncontrolled bleeding secondary to failure of direct pressure.2. Life threatening extremity hemorrhage.

Procedure:1. Place tourniquet proximal to wound.2. Tighten per manufacturer instructions until hemorrhage stops and/or distal pulses in affected

extremity disappear.3. Tighten tourniquet until bleeding is controlled.4. Note time of tourniquet application and communicate this to receiving care providers.5. Dress wounds.6. May place second tourniquet immediately proximal to first tourniquet if pulses remain present

and hemorrhage continues.

ALSBLS

PROTOCOLVascular Access

Procedure19


Indications:1. Any patient who requires medications or fluid resuscitation.2. Patients who are unstable or may become unstable.

Procedure:1. Identify need for access.2. Choose access type:

a. IV: Preferred (unless cardiac arrest):i. Apply Tourniquet, select appropriate site.ii. Cleanse the area with alcohol or approved substitute.

iii. Select appropriate equipment and perform venipuncture.iv. Connect the catheter to a saline lock and flush to confirm placement.

b. IO:i. Locate appropriate area

1. Adult: Humerus (preferred), proximal tibia, distal tibia (last resort).2. Child: Proximal Humerus (if landmarks palpable), proximal tibia, distal

femur, distal tibia (last resort).ii. Apply appropriate size needle. Once contact with bone is made at least one

black line should be visible above the skin. Use Yellow needle for humeralinsertion.

iii. Place needle through skin to site.iv. Press firmly and engage button.v. Insert needle at least 5mm.

vi. Confirm with aspiration and flush.vii. Use Hixson Chart in reference section for IO anesthetic.

c. EJ: Least Preferred:i. Locate appropriate location.ii. Cleanse area.

iii. Perform venipuncture, be especially careful to prevent air embolism.iv. Connect catheter to saline lock.v. IV pressure bag required for all IO infusions / fluids.

ALSBLS

PROTOCOLACLS H’s & T’s

Reference1


Hypovolemia ToxinsHypoxia Tamponade

Hyper/Hypokalemia Tension PneumothoraxHypoglycemia ThrombosisHypothermia Trauma

Hydrogen Ions (acidosis)

ALSBLS

PROTOCOLAPGAR Score

Reference2


Sign 0 1 2 Explanation

Skin Color Cyanotic all over Acrocyanosis No cyanosis Appearance

Heart Rate Absent <100 >100 Pulse

Reflex Irritability No response tostimulation

Grimace/feeblecry when

stimulated

Cry or pull awaywhen stimulated

Grimace

Muscle Tone None Some Flexion Flexed arms andlegs that resist

extension.

Activity

Breathing Absent Weak, irregular,gasping

Strong, lusty cry Respiration

Record APGAR scores at one and five minutes post delivery.

ALSBLS

PROTOCOLBurn Chart

Reference3


ALSBLS

PROTOCOLGlasgow Coma Score

Reference4


EYES OPEN BEST MOTOR RESPONSE BEST VERBAL RESPONSE

Spontaneously—4 Obeys verbal orders—6 Oriented, conversant—5

To command—3 Localizes painful stimuli—5 Disoriented, conversant—4

To pain—2 Withdraws—4 Inappropriate words—3

No response—1 Painful stimulus, flexion—3 Inappropriate sounds—2

Painful stimulus, extension—2 No Response—1

No Response--1

ALSBLS

PROTOCOLHixson Chart

Reference5


ALSBLS

PROTOCOLLA Pre-Hospital Stroke Screen

Reference6


Screening Criteria Yes No

4. Age over 45 years ____ ____

5. No prior history of seizure disorder ____ ____

6. New onset of neurologic symptoms in last 24 hours ____ ____

7. Patient was ambulatory at baseline (prior to event) ____ ____

8. Blood glucose between 60 and 400 ____ ____

9. Exam: look for obvious asymmetry:

Normal Right Left

Facial smile / grimace: __Droop __Droop

Grip: __Weak Grip

__No Grip

__Weak Grip

__No Grip

Arm weakness: __Drifts Down

__Falls Rapidly

__Drifts Down

__Falls Rapidly

Based on exam, patient has only unilateral (and not bilateral) weakness: __Yes __No

10. If Yes (or unknown) to all items above LAPSS screening criteria met: __Yes __No

11. If LAPSS criteria for stroke met, call receiving hospital with “CODE STROKE”, if not then return to theappropriate treatment protocol. (Note: the patient may still be experiencing a stroke if even if LAPSScriteria are not met.)

*NOTE: “CODE STROKE” should not be called if time of symptom onset is greater than 6 hours ago. However,worsening or new symptoms should start the clock again. Err on the side of calling a “CODE STROKE” if in doubt.

ALSBLS

PROTOCOLMetric Conversions

Reference7


Weight

lbs kg lbs kg

396 180 132 60

375 170 121 55

352 160 110 50

330 150 99 45

308 140 88 40

286 130 77 35

264 120 66 30

242 110 55 25

220 100 44 20

209 95 33 15

198 90 22 10

187 85 15 7

176 80 11 5

165 75 7.5 3.5

154 70 5 2.3

143 65 3 1.4

Temperature

F C F C

106 41.1 91 32.8

105 40.6 92 33.3

104 40 91 32.8

103 39.4 90 32.2

102 38.9 89 31.7

101 38.3 88 31.1

100 37.8 87 30.6

99 37.2 86 30

98.6 37 85 29.4

98 36.7 84 28.9

97 36.1 83 28.3

96 35.6 82 27.8

95 35 81 27.2

94 34.4 80 26.7

93 33.9 75 23.8

92 33.3 70 21.1

Weight1/150gr = 0.4mg

1/100gr = 0.6mg

1/65gr = 1mg

1gr = 65mg

15gr = 1gm

1gm = 1000mg

1oz. = 28gm

2.2lbs = 1kg

Lab ValuesCalcium 4.5-5.5 mEq/L

Hematocrit M: 40-50% F: 37-47%

Hemoglobin M: 14-18% F: 12-16%

pH 7.35-7.45

Platelets 150,000-350,000/cu mm

Sodium 136-147 mEq/L

BUN 6-23%

Creatine 0.7-1.4%

ALSBLS

PROTOCOLPediatric Trauma Score

Reference8


LEVEL OF CONSCIOUSNESS – PEDIATRIC GLASGOW COMA SCALE: (GCS range: 3 to 15)

EYE Opening Verbal Response Motor Response

Spontaneous 4 Spontaneous Oriented 5 Coos, babbles Obeys commands 6 Normal, spontaneous

To voice 3 To speech Confused 4 Irritable, cries Localizes pain 5 Withdraws to touch

To pain 2 To pain Inappropriate 3 Cries to pain Withdraws to pain 4 Withdraws to pain

None 1 None Incomprehensible 2 Moans to pain Flexion to pain 3 Abnormal flexion

None 1 None Extension to pain 2 Abnormalextension

None 1 None

Eye opening = _____ Verbal = _____ Motor =____TOTAL = ____________/ 15

Pediatric Trauma Score (PTS) +2 +1 -1

Weight > 20 kg (44 lbs.) 10-20 kg (22-44 lbs.) < 10 kg (22 lbs.)

Airway Patent Maintainable Unmaintainable

Systolic B/P> 90 mm Hg 50-90 mm Hg < 50 mm Hg

CNS Awake + LOC Unresponsive

Fractures None Closed or suspected Multiple closed or open

Wounds None Minor Major, penetrating or burns

ALSBLS

PROTOCOLPhone Numbers

Reference9


EMSL

C

Co

nta

ctIn

fo.

Facility Number

EMSLC MEDICAL DIRECTORDr. Justin Fairless, DO, NRP 918-995-0906EMSLC Business Office 918-647-9270

EMSLC Dispatch 918-647-5480

Public Relations ManagerCiera Crank, NRP

918-916-5935

Clinical ManagerAnthony Stankewitz, NRP

479-831-9882

Operations ManagerKeith Lickly, NRP

918-649-4691

EMSLC DirectorDavid Grovdahl

918-647-5922

Medic 1 Cell 918-649-4886

Medic 2 Cell 918-649-7176

Medic 3 Cell 918-649-4375

Medic 4 Cell 918-649-5628

Medic 5 Cell 918-649-5124

Medic 6 Cell 918-413-7875

Loca

lFac

iliti

es

CNIH 918-567-7000

EOMC ER 918-635-3282

Haskell County Hosp. (Stigler) 918-967-4682

Mena Regional Hospital 479-243-2237

Mercy Fort Smith 479-314-6000

Sequoyah County Hosp. (Sallisaw) 918-774-1100

McAlester Regional Hosp. 918-426-1800

Muskogee VA 918-577-3591

Sparks Hospital 479-441-4000

Tuls

a

Hillcrest Hospital 918-599-4000

Oklahoma Surgical Hospital 918-477-5000

OSU Medical Center 918-599-1000

Saint Francis 918-494-2200

Saint Johns 918-744-2345

Southcrest Hospital 918-294-4000

Southwestern Regional Medical Center 918-286-5000

OK

C

Integris Baptist Medical Center 405-949-6026

Oklahoma Heart Hospital 405-608-3800

OU Medical Center 405-271-4700

Saint Anthony 405-685-6671

ALSBLS

ReferenceMedication References Medications


Amiodarone 1Adult: VF/Pulseless VT: 300mg IV push, repeat 150mg IV push.

VT with pulse: 150mg IV over 10 minutes.

Pediatric: VF/pulseless VT: 5mg/kg IV over 5 minutes.VT with pulse: 5mg/kg IV over

Contraindications/Cautions: Avoid in patient with heart blocks, profound bradycardia.DO NOT rapid bolus in patients with a pulse.

Aspirin 2Adult: Chest pain/stable arrhythmia: 324mg PO (81mg baby Aspirin x4)

Pediatric: Not recommended.

Contraindications/Cautions: Avoid in patient with stomach ulcers or bleeding disorders.

Atropine 3Adult: Anticholinergic (reverse organophosphate): 2mg every 3 minutes until

symptom reversal (bronchospasm, bradycardia, bronchorrhea).Symptomatic Bradycardia: 0.5mg IV, IO every 5 minutes up to 3mg.

Pediatric: Bradycardia: 0.02mg/kg IV, IO max 1mg per dose. Repeat every 3-5minutes.

Contraindications/Cautions: Avoid in patient with heart blocks, profound bradycardia.DO NOT rapid bolus in patients with a pulse.

Calcium Chloride 4Adult: For dialysis patients in cardiac arrest consider and calcium channel

blocker overdose: 0.5-1g IV, IO.

Pediatric: Severe Hyperkalemia (T waves greater than half the size of the QRS, orlong QT segment in symptomatic patients.): 20mg/kg IV, IO slowly.

Contraindications/Cautions: DIGOXIN USE, Known hypercalcemia (i.e. Multiple Myeloma)

DecadronDexamethasone

5

Adult: Inspiratory Stridor: 0.6mg/kg.

Pediatric: Non-depolarizing paralytic: 0.1mg/kg max of 10mg.

Contraindications/Cautions:

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Dextrose 50% 6Adult: Hypoglycemia: 12.5-25g IV, IO.

Pediatric: Cut to D25: 6.25-12.5g IV, IO. Use Broselow tape for dosing.

Contraindications/Cautions: Hyperglycemia

Diltiazem (Cardizem) 7Adult: Symptomatic AFib with RVR: 20mg IV over 2 minutes, repeat one time for

recurrence.Refractory SVT secondary to adenosine.


Contraindications/Cautions: SBP<100mmHG.

Diphenhydramine(Benadryl)

8

Adult: Allergic reaction: 25-50mg IM, IV, IO.Dystonic reaction: 25-50mg IM, IV, IO.Consider for Nausea refractory to Zofran.

Pediatric: Allergic reaction: 1mg/kg IV, IO, IM up to 50mg.Dystonic reaction: 1mg/kg IV, IO, IM up to 50mg.

Contraindications/Cautions: May cause drowsiness.

Dopamine 9Adult: Hypotension: 2-20mcg/kg/min IV, IO titrate for a systolic BP of 90.

Pediatric: Hypotension: 2-20mcg/kg/min IV, IO titrate for a systolic BP of 90.

Contraindications/Cautions: Sepsis, Septic Shock, Sustained HR >130bpm.

Epinephrine 1:1000 10Adult: Anaphylactic Shock/Respiratory Distress: 0.5mg IM (if age<50 years)

0.5mg IM (if age>50 years)Nebulized: 2mg (2ml) mixed with 1ml NS.

Pediatric: Anaphylactic Shock/Respiratory Distress: 0.01mg /kg IM (max 0.5mg).Nebulized: 2mg (2ml) mixed with 1ml of NS.

Contraindications/Cautions: May cause reflex tachycardia, HTN, Palpitations, anxiety, etc.

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Epinephrine 1:10,000 11Adult: Cardiac Arrest: 1mg IV/IO every 3-5 minutes.

Anaphylaxis: 0.1mg IV/IO repeat every 3-5 minutes until responseobserved.Hypotension: 2-20mcg/min IV/IO. (see drip table__)

Pediatric: Cardiac Arrest: 0.01mg/kg IV, IO every 3-5 minutes. (Use Broslow tape)

Contraindications/Cautions: May cause reflex tachycardia, HTN, palpitations, anxiety, etc.

Etomidate 12Adult: Induction: 20-40mg IV, IO.

Pediatric: Induction: 0.3mg/kg IV/IO up to 20mg.

Contraindications/Cautions: May cause myoclonic reactions. Contraindicated in Sepsis and SepticShock.

Fentanyl 13Adult: Pain Management: 50-100mcg IM, IV, IO up to 200mcg.

Induction: 100mcg IV, IO up to 200mcg.

Pediatric: 1mcg/kg IM, IV, IO. Max 50mcg per bolus, repeat as needed. Max total of200mcg.

Contraindications/Cautions: May cause hypotension.

Glucagon 14Adult: Hypoglycemia: 1mg IM

Bronchodilator: 1-2mg IV, IO.Betablocker / Ca. Channel Blocker OD: 1-3mg IV.

Pediatric: Hypoglycemia: 0.1mg/kg IM.

Contraindications/Cautions: Avoid in severe hyperglycemia and DKA.

Glucose-Oral 15Adult: Hypoglycemia: 15g PO.

Pediatric: Hypoglycemia: 15g PO.

Contraindications/Cautions: Patient must be in control of their airway and be able to swallow.

Ipatropium Bromide(Atrovent)

16

Adult: Bronchospasm: 500mcg nebulized.

Pediatric: Bronchospasm: 500mcg nebulized.

Contraindications/Cautions: Soy/peanut allergies are a contraindication.

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Keppra 17Adult: Status Epilepticus Refractory to benzodiazepines x2 doses: 500mg IV over

15 min.

Contraindications/Cautions: DO NOT USE IF AGE <16 without Medical Control order.

Ketamine 18Adult: Sedation for Procedures: 1mg/kg IV/IO (max 150mg)

Sedation RSI/Post Intubation: 2mg/kg IV/IO. (max 200mg)


Contraindications/Cautions: Avoid if known increased ICP (relative contraindication).

Labetalol 19Adult: Hypertension 10-20mg IV, IO slow.


Contraindications/Cautions: Heart blocks, asthma, CHF, bradycardia, and cardiogenic shock.

Lasix 20Adult: CHF: 1mg/kg up to 100mg IV slow.


Contraindications/Cautions: Soy/peanut allergies are a contraindication.

Levalbuterol(Xopenex)

21

Adult: Bronchospasm: 1.25mg in 3ml NS nebulized continuously up to 3 doses.Preferred over Albuterol in Bronchospasm with sustained tachycardia.

Pediatric: Bronchospasm: 0.31-0.63mg in 3ml NS nebulized continuously up to 3doses.


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Lidocaine 22Adult: IO anesthetic: Refer to Hixson Lidocaine Chart. Initial adult dose: 40mg

SLOW IOP.

Arrhythmia unresponsive to Amiodarone: 1-1.5mg/kg bolus, repeat halfthe bolus dose one time.

Pediatric: IO anesthetic: Refer to Hixson Chart.


Magnesium Sulfate 23Adult: Respiratory Distress: 2g IV, IO over 20 minutes repeat once.

VF/VT Characteristic of torsades de pointes: 2g IV, IO repeat once.

Pre/Eclampsia: 4 grams IV, IO over 20 minutes repeat once.

Pediatric: Respiratory distress: 40mg/kg over 30 minutes. Repeat once.

Contraindications/Cautions: Administer slowly.

Methylprednisolone(Solu-Medrol)

24

Adult: Allergic reaction/inflammatory respiratory distress: 125mg IV, IO, IM.

Pediatric: Allergic reaction/inflammatory respiratory distress: 2mg/kg IV, IO, IM.


Midazolam(Versed)

25

Adult: Procedural Sedation 2-5mg IV, IO slow up to 20mg.

Sedation for RSI 5-10mg IV, IO up to 20mg.

Seizure: 5mg IV, IO, IM repeat once in 3 minute.

Chemical Restraint: 5mg IV, IO, IN, IM up to 20mg.

Pediatric: Seizure: 0.15mg IV, IO, IN, IM repeat in 3 minutes.

Sedation for RSI: 0.3mg/kg IV/IO

Contraindications/Cautions: Sedative, respiratory compromise. Avoid in hypotensive patients.

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Morphine Sulfate 26Adult: Pain Management: 5-10mg up to 20mg.

Pediatric: Pain Management: 0.1mg/kg IV, IO single bolus up to 5mg. up to 20mgtotal.

Contraindications/Cautions: Hypotension, respiratory compromise.

Naloxone(Narcan)

27

Adult: Cardiac Arrest: 2-4mg IV, IO.Opiate overdose: 0.5mg every 5 minutes IV, IO, IN, IM.

Pediatric: Cardiac Arrest: 0.1mg/kg IV, IO, IN, IM repeat up to 3 times.Opiate Overdose: 0.1mg/kg IV, IO, IN, IM.

Contraindications/Cautions: Administer slowly, use lowest effective dose, consider antiemetic.Caution in opiate dependent patients.

Nitroglycerin 28Adult: Chest Pain: 0.4mg SL every 5 minutes x3 or until pain free.

Chest Pain/CHF: 5mcg/min drip, increase by 5 mcg’s every 5 minutes oruntil pain free. Or NTG 1” to ACW.


Contraindications/Cautions: Do not administer if SBP<100. If drip is being used and BP falls, give fluidboluses.

Ondansetron(Zofran)

29

Adult: Nausea/Vomiting: 4mg IV, IO every 5 minutes up to 8mg.

Pediatric: Nausea/Vomiting: 0.15mg/kg IV, IO max 4mg every 5 minutes up to 2doses.


Pitocin 30Adult: Post Delivery Hemorrhage: 20u in 1L NS 30-60gtts/min.


Contraindications/Cautions: Multiple deliveries.Do not administer before delivery of the placenta.

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Rocuronium 31Adult: Non-depolarizing paralytic: 1mg/kg IV, IO max of 10mg, may repeat dose

once.

Pediatric: Non-depolarizing paralytic: 1mg/kg max of 10mg.


Succinylcholine 32Adult: Depolarizing Neuromuscular Blockade: 1-1.5mg/kg IV, IO.

Pediatric: Depolarizing Neuromuscular Blockade: 2mg/kg IV, IO

Contraindications/Cautions: Family HX of malignant hyperthermia.Rhabdomyolysis or hyperkalemia.Penetrating eye injuries.Crush injuries or severe burns more than 24 hours old.All contraindications are relative and not absolute.

Sodium Bicarbonate 33Adult: Acidosis post cardiac arrest: 50mEq IV, IO.

Crush syndrome: 1mEq/kg IV, IO.

TCA overdose: 50mEq bolus, then 100mEq in 1L NS at 200ml/hr.

Pediatric: Acidosis post cardiac arrest: 1mEq/kg IV, IO.

Crush syndrome: 1mEq/kg IV, IO.


Transexamic Acid(TXA)

34

Adult: Anti-Fibrinolytic: 1g IVPB/IOPB over 10 minutes


Contraindications/Cautions: Non-hemorrhagic shock.Non-traumatic hemorrhagic shock.Hemorrhagic shock stabilized with other hemostatic agents/measures.

Vasopressin 35Adult: Cardiac arrest to replace the first or second dose of epinephrine: 40u IV,

IO.



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Vecuronium 36Adult: Non-depolarizing paralytic: 0.1mg/kg IV, IO max of 10mg, may repeat

dose once.



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Epinephrine Drip Drip 1

Mix:2mg Epinephrine 1:1,000 in 1000ml.

Yield:2mcg/ml

Pump 60gtts setDose ml / hr. gtts./30sec gtts./15sec

2 mcg/min 60 30 153 mcg/min 90 45 22.54 mcg/min 120 60 305 mcg/min 150 75 37.56 mcg/min 180 90 457 mcg/min 210 105 52.58 mcg/min 240 120 609 mcg/min 270 135 67.5

10 mcg/min 300 150 75

Or: mix 1ml of 1:10,000 in 9ml of flush. Yield is 10mcg/ml.

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Dopamine Drip Drip 2

Mix:

800mg in 500ml OR 400mg in 250ml

Yield:1600 mcg / ml

Patient weight in Kg.

Mcg/kg/min 30 40 50 60 70 80 90 100 110

2 2 3 4 5 6 7 8 9 8

5 6 8 9 11 13 15 17 19 21

8 9 12 15 18 21 24 27 30 33

10 11 15 19 23 26 30 34 38 42

12 14 18 22 27 32 36 40 45 50

15 17 23 28 34 39 45 51 56 61

18 20 27 34 40 47 54 61 68 74

20 22 30 38 45 53 60 68 75 83gtts/min AND ml/hr.

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Nitroglycerine Drip Drip 3

Mix:50mg in 250ml D5W

Yield:5mcg/1.5ml

Dose: ml/hr. OR gtts/min

5mcg/min 1.5

10mcg/min 3

15mcg/min 4.5

20mcg/min 6

25mcg/min 7.5

30mcg/min 9

35mcg/min 10.5

40mcg/min 12

45mcg/min 13.5

50mcg/min 1555mcg/min 16.5

60mcg/min 18

65mcg/min 19.5

70mcg/min 21

Dose: Ml/hr OR gtts/min

75mcg/min 22.5

80mcg/min 24

85mcg/min 25.5

90mcg/min 27

95mcg/min 28.5

100mcg/min 30

105mcg/min 31.5

110mcg/min 33

115mcg/min 34.5

120mcg/min 36125mcg/min 37.5

130mcg/min 39

135mcg/min 40.5

140mcg/min 42

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Lidocaine Drip Drip 4

Mix:2g in 500ml

Yield:4mg/ml

Dose: ml/hr AND gtts/min.1mg/min. 15

2mg/min. 30

3mg/min. 45

4mg/min. 60

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Levophed Drip Drip 4

Mix:8mg in 250ml.

Yield:32mcg/ml

Mcg/min ML/HR

2 3.8

3 6

4 6

7 13

8 15

9 17

10 19

11 21

12 23

13 24

14 26

15 28

16 30

18 34

20 38

Documents

Field Operations Guide - emslc.orgemslc.org/documents/2015EMSLCProtocols.pdf · Field Operations Guide ... f e r e n c e 2 Aspirin 3 Atropine 4 Calcium Chloride ... 20 Lasix 21 Levalbuterol