Final 1.PDF · Web viewPatients in borderline heart failure cannot tolerate these salt loads) Lowers serum potassium (this may be desirable at times, as in hyperkalemia, but in cardiac

ST. JOSEPH HEALTH CENTER

PRE-HOSPITAL CARE

&

PROCEDURES MANUAL

Updated January 5, 2005

PRE-HOSPITAL MEDICAL PROTOCOL FOR ALL UNITSOPERATING UNDER THE MEDICAL AUTHORITY OF

ST. JOSEPH HEALTH CENTERWARREN, OH 44484

MISSION STATEMENT: TO PROVIDE THE HIGHEST QUALITY PRE-HOSPITAL CARE TO THE CITIZENS OF TRUMBULL COUNTY AND SURROUNDING AREAS THROUGH SOUND MEDICAL DIRECTION, QUALITY EDUCATION, INNOVATION, AND CONTINUOUS PERFORMANCE IMPROVEMENT PROGRAMS

MEDICAL DIRECTOR, EMS

KATHRYN BULGRIN, D.O.

The contents of this document will be revised periodically as indicated by changing patient care and other medical standards. Revisions and modifications will be distributed to all pre-hospital units

operating under medical authority of the Medical Director.

EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 2

This pre-hospital medical protocol is for use ONLY by Emergency Medical Service squads operating under medical authority of St. Joseph Health Center and Dr. Kathryn Bulgrin, D.O.

MEDICAL AUTHORITY. Emergency Medical Technicians operating under this medical authority are required to follow this protocol unless an intervening physician licensed to practice medicine in the State of Ohio (M.D. or D.O.) accepts full responsibility for deviation from the provisions of this document and accompanies the patient to the receiving hospital. No squad or personnel of any particular squad is permitted to practice medicine beyond the scope of practice of their level of training as defined by the Department of Public Safety, Division of Emergency Medical Services, State of Ohio.

ALS ACTIVATION AND INTERCEPT. For any patient with serious illness and/or potentially life-threatening situations (chest pain/suspected myocardial infarction, respiratory distress, hypoglycemia, altered mental status, and/or other potentially life-threatening situations), all EMT-Basic and EMT-Intermediate units should immediately request assistance from the nearest ACLS (Paramedic) unit UNLESS the transport time is less than the rendezvous time with the Paramedic unit. EMT-Basic and EMT-Intermediate units' intervention on the patient's behalf should not exceed the scope of their practice and training.

All Emergency Medical Service units operating under the medical authority of St. Joseph Health Center are reminded that this protocol is for use in the pre-hospital setting only. This includes patient transports from:

Home to hospitalAccident scene to hospital

Extended care facility to hospital

Any other type of transport, i.e., inter-facility transport of critical care patients or inter-facility transport of any other type of patient is the responsibility of the sending facility, the respective physician, and the transporting agency. St. Joseph Health Center, including any of its signing physicians, WILL NOT accept liability or responsibility for these types of transports.

_______________________________Kathryn Bulgrin, D.O.

HMHP St. Joseph Health CenterEMS Director

State of Ohio, County of TrumbullSworn to and subscribed to before me

On this _____ day of ______________________, 20 ___.

_______________________________Notary Public


ST. JOSEPH HEALTH CENTEREMERGENCY MEDICAL SERVICES

COLOR-CODED KEY TO PATIENT CARE GUIDELINES

All patient care algorithms are color coded to denote procedures which may be performed by each level of certification.

EMT-Basics. EMT-Basics may perform any procedures in blue.

EMT-Intermediate. EMT-Intermediates may perform all of the EMT-Basics procedures, as well as those color coded green.

EMT-Paramedics. Paramedics may perform all of the EMT-Basic and EMT-Intermediate procedures, as well as those color coded red.

Any boxed procedures require on-line medical control direction

Higher levels of certification will perform lower level evaluations and procedures when interpreting the algorithms. No EMT is permitted to perform any procedures beyond his level of certification.


TABLE OF CONTENTS

I. ADULT PROTOCOLS

Abdominal Pain...................................................................................................... xxAllergic Reactions.................................................................................................. xxAltered Level of Consciousness............................................................................. xxAnaphylactic Shock (See Shock)Burns....................................................................................................................... xxCardiac Emergencies.............................................................................................. xx

- Angina/Chest Pain.................................................................................... xx- Arrest........................................................................................................ xx

- Asystole........................................................................................ xx- PEA.............................................................................................. xx- Ventricular Fibrillation................................................................. xx

- Arrhythmias.............................................................................................. xx- Bradycardia.................................................................................. xx- Tachycardias................................................................................. xx

Childbirth................................................................................................................ xxDiabetic Emergencies............................................................................................. xxEye Injuries............................................................................................................. xxGlasgow Coma Scale / Revised Trauma Score...................................................... xxHeat Exposure......................................................................................................... xxHypertension Management .................................................................................... xxHypothermia / Frostbite.......................................................................................... xxNear-Drowning / Drowning.................................................................................... xxOverdose / Poisoning.............................................................................................. xxRespiratory Emergencies........................................................................................ xx

- Airway Obstruction.................................................................................. xx- Asymmetric Breath Sounds...................................................................... xx- Rales/Pulmonary Edema.......................................................................... xx- Wheezing.................................................................................................. xx

Seizures................................................................................................................... xxShock....................................................................................................................... xx

- Anaphylactic............................................................................................. xx- Cardiogenic / Neurogenic / Septic / Hypovolemic................................... xx

Stroke...................................................................................................................... xxThrombolytic Screening Checklist......................................................................... xxTrauma Arrest......................................................................................................... xxTrauma Emergencies.............................................................................................. xxTrauma Triage........................................................................................................ xx

II. PEDIATRIC PROTOCOLS

Altered Level of Consciousness............................................................................. xxArrhythmias ........................................................................................................... xx

- Bradycardia.............................................................................................. xx


- Narrow complex tachycardia................................................................... xx- Wide complex tachycardia....................................................................... xx

Cardiac Arrest......................................................................................................... xx- Ventricular Fibrillation / Pulseless V-Tachycardia.................................. xx- Asystole / PEA......................................................................................... xx

Child Abuse / Neglect............................................................................................ xxFluid and Drug Administration.............................................................................. xxMedications – Reference Dosages.......................................................................... xxNewborn Resuscitation........................................................................................... xxRespiratory Distress................................................................................................ xx

- Upper Airway Obstruction....................................................................... xx- Wheezing.................................................................................................. xx

Seizures................................................................................................................... xxShock...................................................................................................................... xx

- Anaphylactic............................................................................................. xx- Cardiogenic / Neurogenic / Septic / Hypovolemic................................... xx

Vital Signs – Normal............................................................................................... xx

III. MEDICAL PROCEDURES

Automatic External Defibrillator (AED)................................................................ xxAirway and Breathing:........................................................................................... xx

- Oxygen Therapy....................................................................................... xx- Pulse Oximetry......................................................................................... xx- Endotracheal Intubation........................................................................... xx- Chest Decompression............................................................................... xx- Cricothyrotomy........................................................................................ xx

Alternative Medication Routes............................................................................... xxAssisting with Medication Administration............................................................. xxC-Spine Immobilization.......................................................................................... xxConscious Sedation................................................................................................. xxExternal Pacemaker................................................................................................ xxHeimlich Maneuver................................................................................................ xxInterosseus Infusions............................................................................................... xxIntravenous Therapy................................................................................................ xxPain Management.................................................................................................... xx Patient Assessment.................................................................................................. xx

IV. PHARMACEUTICAL PROTOCOL

Activated Charcoal (Actidose)............................................................................... xxAdenocard (adenosine)........................................................................................... xxAlbuterol (Proventil / Ventolin)............................................................................. xxAmiodarone (Cordarone)........................................................................................ xxAspirin.................................................................................................................... xxAtropine Sulfate as Antidote for Poisonings.......................................................... xxAtropine Sulfate as Cardiac Agent......................................................................... xx


Benadryl (diphenhydramine HCL)......................................................................... xxCordarone (amiodarone)......................................................................................... xxDextrose 50% (D50) and 25% (D25)..................................................................... xxDiazepam (Valium)................................................................................................ xxDiphenhydramine (Benadryl)................................................................................. xxDopamine HCL...................................................................................................... xxEpinephrine (Adrenalin) (1:1000 and 1:10,000).................................................... xxFurosemide (Lasix)................................................................................................. xxGlucagon................................................................................................................. xxIsuprel .................................................................................................................... xxKetorolac (Toradol)................................................................................................ xxLasix (Furosemide)................................................................................................. xxLidocaine (Xylocaine) 2% and 1%......................................................................... xxMagnesium Sulfate................................................................................................. xxMidazolam (Versed)............................................................................................... xxMorphine Sulfate.................................................................................................... xxNarcan (Naloxone).................................................................................................. xxNitroglycerin (Nitrostat)......................................................................................... xxOxygen (O2)........................................................................................................... xxPediatric Medications – Common Dosages............................................................ xxProcainamide (Pronestyl)........................................................................................ xxProventil (Albuterol / Ventolin).............................................................................. xxSodium Bicarbonate 8.4% & 4.2%......................................................................... xxSolu-Medrol............................................................................................................ xxThiamin HCL (Vitamin B-1/Biamine)................................................................... xxToradol (Ketorolac)................................................................................................ xxValium (Diazepam)................................................................................................. xxVentolin (Albuterol / Proventil).............................................................................. xxVersed (midazolam) ............................................................................................... xxXylocaine (Lidocaine)............................................................................................ xx

V. ADMINISTRATIVE PROTOCOLS

Aeromedical Transport........................................................................................... xxCommunications / When to Call Medical Control................................................. xxCoroner Death Notification.................................................................................... xxDead on Arrival (DOA).......................................................................................... xxDo Not Resuscitate (DNR) Guidelines & Forms................................................... xxDrug Box Exchange Guidelines............................................................................. xxLinen Replacement................................................................................................. xxObtaining Individual Protocol................................................................................ xxPatient Refusal or Withdrawal of Consent............................................................. xxPhysician at the Scene............................................................................................ xxRestraint Policy....................................................................................................... xxTermination of Resuscitation Efforts...................................................................... xxTransfer Refusal...................................................................................................... xx


GENERAL PATIENT ASSESSMENT

1. ASSURE SCENE SAFETY

2. UNIVERSAL PRECAUTIONS SHALL BE OBSERVED TO PREVENT CONTACT WITH BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS

3. INITIAL ASSESSMENT (Including ABCs) This assessment is to discover and treat immediately life-threatening conditions.

a) Airway Open airway if needed Medical – head tilt chin lift Trauma – jaw thrust Look for airway obstructions: vomit, bleeding, facial trauma, etc. Identify and correct any existing or potential airway obstruction or problems Consider oxygen therapy at this time Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA)

b) Breathing Check adequacy of ventilation – should be done by quickly observing chest

rise/fall, approximate rate and listening to patient talk Expose chest and observe chest wall movement Consider oxygen therapy at this time

c) Circulation Palpate for pulse Radial pulse not present indicates systolic blood pressure < 80 mmHg Carotid pulse not present indicates systolic blood pressure < 60 mmHg Note skin temperature, color, and condition Note capillary refill in children Identify and treat life-threatening conditions or injuries and control bleeding, as

needed

d) Disability: Determine Level of Consciousness by:

A – Alert V – Responds to Voice P – Responds to Pain U – Unresponsive Check pupils for size and reaction time

Form a General Impression of the Patient (age, sex, injury or illness, and immediate environment)

4. FOCUSED HISTORY AND PHYSICAL EXAM This section will identify any additional injuries or conditions that may also be life threatening. Re-evaluate the mechanism of injury (trauma) or nature of illness (medical).EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 8

a) Trauma patients with significant mechanism of injury should be assessed as follows :

Rapid head-to-toe assessment (inspect, palpate, and auscultate) Assess baseline vital signs to include:

a. Respirationsb. Pulsec. Skin color, temperature, and conditiond. Pupilse. Blood pressure

Obtain SAMPLE HistorySigns and SymptomsAllergiesMedications (prescribed and over-the-counter)Pertinent past medical historyLast oral intakeEvents prior to injury

Provide interventions (bandaging, splinting, boarding)

b) Trauma patients without significant mechanism of injury should be assessed as follows :

Focused assessment (focuses primarily on injury site, rather than head to toe) Assess baseline vital signs (as listed above) Obtain SAMPLE history (as listed above)

c) Medical patients who are unresponsive should be assessed as follows: Rapid head-to-toe assessment Assess baseline vital signs (as listed above) Obtain SAMPLE history (as listed above)

d) Medical patients who are responsive should be assessed as follows: Assess patient's complaints (OPQRST)::

Onset (When and how did the symptoms begin?)Provocation (What makes the symptoms worse?)Quality (How would you describe the pain?)Radiation (Where do you feel the pain?)Severity (How bad is the pain?)Time (How long have you had the symptoms?)

Obtain a SAMPLE history (see above) Focused assessment (Assessment of specific complaint areas unless general "I

don't feel well," which would require head-to-toe exam) Assess baseline vital signs

5. ONGOING ASSESSMENT

Reassess interventions.


I. ADULT PROTOCOLS


ABDOMINAL PAIN

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. Obtain relevant history (Onset, Provokes, Quality, Radiation,

Severity, Time, Interventions, Associated Symptoms, Allergies, Medications, Past Med/Surg History, Last Meal)5. Perform complete assessment6. Check blood sugar level (if < 80 or > 400, refer to Diabetic Emergency Protocol)7. Place patient in position of comfort8. Give nothing by mouth

EMT-Intermed: 9. Reassess patient10.Obtain IV access – normal saline at TKO11. 250-500 cc bolus IV normal saline for hypotension (may repeat bolus x 2 as needed for hypotension)

EMT-Paramedic: 12. Reassess patient13. Apply cardiac monitor and treat per ACLS protocol


ALLERGIC REACTIONS

Mild Reaction: Rash, Itching, and/or SwellingModerate Reaction: Wheezing and/or LightheadednessSevere Reaction (Anaphylaxis): Respiratory Distress, Hypotension, and/or Decreased Responsiveness

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. Obtain relevant history (Onset, Possible Exposures/New Medications, Allergies, Associated Symptoms, Interventions, Past Medical History)5. Perform complete assessment6. Assist patient in administering their own EPI-pen and/or albuterol MDI as indicated by symptoms or history7. Place patient in position of comfort

EMT-Intermed: 8. Reassess patient (monitor airway & respiratory status closely)9. Obtain IV access – normal saline at TKO10. 250-500 cc bolus IV normal saline for hypotension (may repeat bolus x 2 as needed for hypotension)11. Benadryl 25-50 mg IM or 25 mg IV slow over 3 minutes12. Albuterol aerosol 2.5 mg prn for wheezing (may repeat x 2)13. Epinephrine (1:1000) 0.3 mg SQ for severe reactions/anaphylaxis 14. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 15. Reassess patient (monitor airway & respiratory status closely)16. Consider Solu-Medrol 125 mg IV 17. Apply cardiac monitor and treat per ACLS protocol18. Intubate as indicated

19. Dopamine 5 mcg/kg/min titrated up to 20 mcg/kg/min in symptomatic patient with SBP < 90 mmHg


ALTERED LEVEL OF CONSCIOUSNESS

EMT-Basic: 1. Confirm ALS en route.2. Secure airway and consider cervical spine injury3. Administer 100% oxygen by NRB mask (assist ventilation with BVM with oral or nasal airway if indicated)4. Apply pulse oximeter (if available)5. Obtain relevant history (Onset, Circumstances, Past Medical History-DM, Seizure, Drug Abuse, Head Injury, Medications, Recent Illness, Associated Symptoms, and Allergies)6. Thrombolytic Screening (for stroke patients)7. Perform complete assessment8. Document Glasgow Coma Scale9. Check blood glucose of diabetic patients (If < 80 and patient alert, give oral glucose 1 tube)10. Place patient in position of comfort

EMT-Intermed: 11. Reassess patient12. Obtain IV access – normal saline at TKO13. D50 1 amp IV if blood sugar < 80 or not obtainable (or Glucagon 1 mg IM)14. 250-500 cc bolus IV normal saline for hypotension (may repeat bolus x 2 as needed for hypotension)15. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 16. Reassess patient (manage airway)17. Apply cardiac monitor and treat per ACLS protocol18. Narcan 0.5-2 mg IV/ET for decreased responsiveness, respiratory depression, or suspicion of narcotic overdose (consider patient restraint prior to administration). May repeat dose19. Consider thiamine 100 mg IV/IM (especially with alcohol history)20. Intubate patient if indicated for airway protection/

ventilation (if no response to Narcan and/or D50)


ANAPHYLACTIC SHOCK

EMT-Basic: 1. Confirm ALS en route.2. Administer oxygen 100% NRB mask (prepare to assist ventilation) 3. Apply pulse oximeter (if available)4. Obtain relevant history (Onset, Possible Exposures/New Medications, Allergies, Associated Symptoms, Interventions, Past Medical History)5. Perform complete assessment6. Assist patient in administering their own EPI-pen as

indicated7. Place patient in position of comfort8. Transport immediately with ALS intercept

EMT-Intermed: 9. Reassess patient (monitor airway & respiratory status closely)10. Obtain IV access – normal saline at TKO 11. Epinephrine (1:1000) 0.3 mg SQ (may repeat in 15 minutes if no improvement)12. 250-500 cc bolus IV normal saline for hypotension (may repeat bolus x 2 as needed for hypotension)13. Benadryl 25-50 mg IM or 25 mg IV slow over 3 minutes14. Albuterol aerosol 2.5 mg prn for wheezing (may repeat x 2)15. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 16. Reassess patient (monitor airway & respiratory status closely)17. Consider epinephrine (1:10,000) 0.5 mg IV push for significant hypotension/shock (if SBP < 90)18. Apply cardiac monitor and treat per ACLS protocol19. Solu-Medrol 125 mg IV 20. Intubate as indicated



BURNS

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Ensure scene safety3. Remove patient from heat, flame, electrical, and chemical exposure (protective wear/Hazmat Services with chemical or radiation contamination)4. Secure airway and consider cervical spine injury5. Administer 100% oxygen by NRB mask (assist ventilation with BVM with oral or nasal airway if indicated)6. Assess for inhalation burns (Suspect if patient is found in a closed, smoky environment and/or has burns to the face, neck, singed nasal hairs, cough and/or stridor, or soot in the sputum)7. Apply pulse oximeter (if available)8. Obtain relevant history (Circumstances, Past Medical History, Injury, and Medications)9. Determine type, extent, and seriousness of burn (see below)10. Stop burning process, remove clothing, and cool skin (flush, stop cooling process if shivering) 11. Decontaminate chemical burns with irrigation12. Look for entrance and exit wounds with electrical burns and consider other traumatic injuries13. Cover wounds with dry sterile dressing14. Perform complete assessment

EMT-Intermed: 15. Reassess patient16. Obtain IV access (do not delay transport for IV access)17. 250-500 cc bolus IV normal saline (may repeat bolus x 2 as needed for hypotension)18. Intubate as indicated (Certified EMT-I only. Early intubation warranted with signs of inhalation injury)

EMT-Paramedic: 19. Reassess patient (manage airway)20. Intubate as indicated (early intubation warranted with signs of inhalation injury)21. Apply cardiac monitor and treat per ACLS protocol (monitor for dysrhythmia, particularly with electrical burn)22. Consider Pain Management (See Pain Management Protocol)

- Morphine sulfate 2-5 mg IV for pain, may repeat once (Do not administer if SBP < 100 mmHg)

- Toradol 30 mg IV for pain (Use ONLY in atraumatic burn patients. See precautions)


EXTENT AND SERIOUSNESS OF BURN INJURIES

a) Rule of Nines

b) 1% body surface area is equal to the surface of the palm of the patient's hand.

c) Seriousness of Burns

MINOR MODERATE CRITICAL 1st degree < 70% 1st degree > 70% 2nd degree > 30% 2nd degree < 10% *2nd degree 10-30% 3rd degree > 2%*3rd degree < 2% Any burns with trauma

Any burns with head, Face, feet, genitalia

* Only if hands, face, feet, or genitalia are not involved


CARDIAC EMERGENCIES: ANGINA/CHEST PAIN

EMT-Basic: 1. Confirm ALS en route.2. Assess ABCs, vital signs, and responsiveness3. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress4. Apply pulse oximeter 5. Obtain relevant history (Onset, Radiation, Associated Symptoms, Past Medical History, Allergies, and Medications)6. May assist patient in taking their own nitroglycerin as prescribed if indicated (Hold if SBP < 100)7. Transport immediately with ALS intercept 8. Thrombolytic screening9. Complete assessment10. May give two (2) 81-mg baby ASA (only orange flavor) or one (1) adult ASA to patient suspected of having cardiac- related chest pain

EMT-Intermed: 11. Reassess patient (ABCs)12. Obtain IV access x 2 – normal saline at TKO (Do not delay transport)13. Nitroglycerin sublingual 0.4 mg, 1 every 5 minutes to a

maximum dose of 3 (hold if SBP < 100)14. Normal saline 250-500 cc IV bolus for hypotension. May repeat bolus x 2 as needed.15. May apply cardiac monitor and run a rhythm strip if ALS unit en route (may NOT interpret rhythm)

EMT-Paramedic: 16. Reassess patient17. Apply cardiac monitor and treat per ACLS protocol 18. Morphine sulfate 2-5 mg IV for significant chest pain (Hold if SBP < 100)

19. Dopamine 5 mcg/kg/min and titrate to 20 mg/kg/min for symptomatic hypotension to maintain SBP > 90


CARDIAC EMERGENCIES: ARREST

EMT-Basic: 1. Confirm ALS en route.2. Assess ABCs and responsiveness (confirmed arrest)3. Apply automated external defibrillator (AED) and follow prompts as per AED protocol4. Administer oxygen 100% bag valve mask with oral or nasopharyngeal airway (auscultate for bilateral breath sounds with ventilations)5. Initiate CPR 6. Gather history as available from family/bystanders

EMT-Intermed: 7. Reassess patient (ABCs and continue CPR)8. Obtain IV access – normal saline at TKO9. Intubate for definitive airway as indicated (Certified EMT-I only)10.May apply cardiac monitor if ALS en route (may not interpret rhythm)

EMT-Paramedic: 11. Reassess patient12. Quick look with defibrillator pads and treat rhythm per ACLS protocol (see Arrest Rhythm Protocols below)13. Intubate for definitive airway as indicated

(SEE SPECIFIC ARREST PROTOCOLS ON THE FOLLOWING PAGES)


ARREST RHYTHM PROTOCOLS

ASYSTOLE:

1. Quick look-asystole2. Continue CPR 3. Consider immediate transcutaneous pacing (set heart rate at 100 bpm, start at 200 MA (may titrate down after capture), and check for mechanical capture (feel for pulse)) 4. Epinephrine (1:10,000) 1 mg IV push or double dose via ET tube. May repeat dose every 3-5 minutes5. Atropine 1 mg IV push or double dose via ET tube (max 0.04 mg/kg). Repeat dose every 3-5 minutes (limit 3 doses)6. Consider Sodium bicarbonate 1 mEq/kg IV7. Re-evaluate 8. If no response, consider Termination of Resuscitation Protocol and contact Medical Control

PEA:

1. Quick look-PEA, continue CPR 2. Attempt to identify treatable underlying causes:

Condition TreatmentHypovolemia Give fluid bolus (1 liter NS open)Hypoxia Adequate airway managementHydrogen Ions (acidosis) Consider sodium bicarbHyperkalemia Consider sodium bicarbHypothermia Aggressively warm patientTension Pneumothorax Chest decompressionTricyclic Overdose Consider sodium bicarb

3. Epinephrine (1:10,000) 1 mg IV push or 2 mg via ET tube. Repeat every 3-5 minutes4. Atropine 1 mg IV push or double dose via ET tube (if PEA rate is slow). Repeat every 3-5 minutes (limit 3 doses)5. Normal saline 1 liter open6. Consider sodium bicarbonate 1 mEq/kg IV7. Re-evaluate

8. If no response, consider Termination of Resuscitation Protocol and contact Medical Control


V-FIB/PULSELESS V-TACH:

1. Quick look-V-fib/pulseless V-Tach2. Immediate defibrillation 200 J, 300 J, 360 J3. Initiate CPR4. Intubate as indicated5. Epinephrine (1:10,000) 1 mg IV push or 2 mg via ET tube every 3-5 min6. Defibrillate 360 J after each dose7. Antiarrhythmic therapy (administer only 1 antiarrhythmic agent)

- Amiodarone 300 mg IV push over 3 minutes, may repeat 150-mg IV push dose in 10 minutes OR- Lidocaine 1 mg/kg IV push or via ET tube, may repeat once in 5 minutes (if rhythm converts, hang drip at 2-4 mg/min) OR- Procainamide 20 mg/min IV infusion (Caution: Hold if hypotension or QRS widening > 50%. Max total dose 17 mg/kg.)

8. Defibrillate 360 J after each dose9. Consider sodium bicarbonate 1 mEq/kg IV10. Re-evaluate

11. If no response, consider Termination of Resuscitation Protocol and contact Medical Control


CARDIAC EMERGENCIES: ARRHYTHMIAS

EMT-Basic: 1. Confirm ALS en route.2. Assess ABCs and responsiveness (Confirmed pulse and spontaneous respirations)3. Administer oxygen 100% NRB mask or assist with bag valve mask with oral or nasopharyngeal airway as indicated (auscultate for bilateral breath sounds with ventilations)4. Apply pulse oximeter 5. Assess patient (General appearance, responsiveness, ABCs)6. Obtain relevant history (Onset, Circumstances, Past Medical History, and Medications)7. Transport immediately unless ALS within 5 minutes

EMT-Intermed: 8. Reassess patient (ABCs)9. Obtain IV access – normal saline at TKO10. Transport immediately unless ALS within 5 minutes11. Intubate for definitive airway as indicated (Certified EMT-I only)12. May apply cardiac monitor and run a rhythm strip (may NOT interpret rhythm)

EMT-Paramedic: 13. Reassess patient14. Apply cardiac monitor and treat per ACLS protocol (see Arrhythmia Protocols below)15. Intubate for definitive airway as indicated

(SEE SPECIFIC ARRHYTHMIA PROTOCOLS ON FOLLOWING PAGE)


ARRHYTHMIA PROTOCOLS

BRADYCARDIA:1. Asymptomatic patient:

- Continue cardiac monitoring and oxygen- Transport with frequent reevaluation

2. Symptomatic patient: (with chest pain, dyspnea, decreased LOC, SBP < 80, and/or pulmonary congestion):

- Continue cardiac monitoring and oxygen- Atropine 1 mg IV push, may repeat q 3-5 min up to 3 doses (Caution: With 2nd degree type 2 and 3rd degree heart blocks, prepare for external pacing) - Consider external pacing (May sedate patient with Versed 2 mg IV prior to pacing if SBP >100 (see Conscious Sedation protocol). Set heart rate at 70 bpm, start at 20 MA, increase MA by 20 until mechanical capture)

- Dopamine 5 mcg/kg/min titrate to 20 mcg/kg/min prn to maintain SBP > 90

- Transport with frequent re-evaluations

NARROW COMPLEX TACHYCARDIA (SVT heart rate > 150):1. Unstable patient: (altered LOC, poor perfusion, hypotension, shortness of breath, chest pain, shock)

- Continue cardiac monitoring and oxygen- May attempt Adenosine 6 mg IV push with immediate 10-20 cc NS flush prior to cardioversion (ONLY if IV access readily available) - Immediate synchronized cardioversion 50 J, 100 J, 200 J, 300 J, 360 J

2. Stable patient: (alert, oriented, good perfusion):- Continue cardiac monitoring and oxygen- Vagal maneuvers (avoid carotid massage in elderly)- Adenosine 6 mg rapid IV push with immediate 10-20 cc NS flush. - If no change, adenosine 12-mg rapid IV push with flush. Repeat if no response in 1-2 minutes.- If patient remains stable, observe and transport.- If patient becomes unstable, immediate synchronized cardioversion

WIDE COMPLEX TACHYCARDIA (with a pulse):1. Unstable patient: (altered LOC, poor perfusion, hypotension, shortness of breath, chest pain, shock)

- Continue cardiac monitoring and oxygen- Immediate synchronized cardioversion 100 J, 200 J, 300 J, 360 J- Antiarrhythmic therapy (administer only 1 antiarrhythmic agent)

- Amiodarone 150 mg IV push over 3 min. May repeat in 10 min if unchanged. OR- Lidocaine 1 mg/kg IV push. May repeat 0.75 mg/kg IV push q 5 min (max 3 mg/kg. If rhythm converts, hang drip at 2-4 mg/min)

2. Stable patient: (alert, oriented, good perfusion):- Continue cardiac monitoring and oxygen- Antiarrhythmic therapy (administer only 1 antiarrhythmic agent) - Amiodarone 150 mg IV push over 3 minutes. May repeat in 10 min if unchanged OR - Lidocaine 1 mg/kg IV push. May repeat 0.75 mg/kg IV push q 5 min

(max 3 mg/kg. If rhythm converts, hang drip at 2-4 mg/min)- If patient remains stable, monitor and transport.- If patient becomes unstable, immediate synchronized cardioversion


CHILDBIRTH

EMT-Basic: 1. Confirm ALS en route.2. Administer oxygen 100% NRB mask 3. Complete assessment4. Obtain history (Last menstrual period, due date, complications, prenatal care, onset/frequency of contractions, number of pregnancies/live children, medical history)5. Visual inspection of the perineal area should only be done when contractions are less than 5 minutes apart and/or there is bleeding or fluid discharge

- If no crowning, transport patient in the left lateral position with frequent reassessment- If crowning present, prepare to assist and facilitate

delivery (See possible complications below)6. EMT should NOT place a gloved hand inside the vagina except in the case of breach delivery with entrapped head or prolapsed umbilical cord7. During delivery, apply gentle pressure with a flat hand on the baby's head to prevent explosive delivery8. Upon delivery, suction baby's mouth and then nose with bulb syringe, clamp and cut umbilical cord, and warm and dry baby. (See Neonatal Resuscitation below if problems)9. Assess mother and child. Note APGAR scores at 1 and 5 minutes. (See chart below for APGAR scoring)10.Transport mother and child (car seat if available)

EMT-Intermed: 11. Reassess patient, assist with delivery if needed

12. Obtain IV access – normal saline at TKO13. 250-500 cc bolus IV normal saline for hypotension (may repeat bolus x 2 as needed for hypotension)

EMT-Paramedic: 14. Reassess patient, assist with delivery if needed


POTENTIAL COMPLICATIONS OF CHILDBIRTH

Excessive Bleeding : 1. Pre-delivery transport on left side 2. Post-delivery transport emergent in shock position3. If placenta delivered, may perform uterine massage in attempt to slow bleeding 4. Obtain IV access x 25. NS 500 cc bolus IV for hypotension, repeat as indicated (See Shock Protocol)

Cord Around Neck : 1. Loosen cord and remove from neck 2. If unable to loosen cord, clamp in 2 places and cut3. Complete delivery sequence

Prolapsed Cord : 1. Transport immediately with hips elevated and knees to chest. 2. Insert fingers in birth canal to relieve pressure on the cord 3. DO NOT attempt to push the cord back

Breech Presentation : 1. If body delivered and head remaining in canal, support child's body and insert two

fingers into the canal to create an air passage at the nasal area of the child's face by pushing the vaginal canal away from the child's face until delivery complete

APGAR SCORE

Sign 0 Points 1 Point 2 PointsA Activity (Muscle Tone) Absent Arms and Legs Flexed Active MovementP Pulse Absent Below 100 bpm Above 100 bpmG Grimace (Reflex Irritability) No Response Grimace Sneeze, cough, pulls awayA Appearance (Skin Color) Blue-gray, pale all Normal, except for Normal over entire bodyR Respiration Absent Slow, irregular Good, crying

NEONATAL RESUSCITATION

CONSIDER: 1. Hypovolemia. Give fluid bolus 10 cc/kg NS2. Hypoglycemia (blood sugar < 40 mg/dL). Give D10, 1 cc/kg IV/IO bolus (make D10 by diluting D50 4:1 with NS) 3. Suspected narcotic dependence: Give Narcan 0.1 mg/kg IV/IO every 3 minutes


Neonatal ResuscitationDry, Warm, Position, Tactile Stimulation, Suction

Mouth then Nose. Call for ALS back-up. Administer O2 as needed.

Apnea/Gasping, HR <100 or central cyanosis

Ventilate with BVM @ 40-60/min

HR <60 after 30 sec BVM

Chest compressions @ 120/min - 3:11/3 to 1/2 chest depth

2 thumb encircle chest or 2 fingersALS available & HR

<60Intubate

Epinephrine (1:10,000)0.01-0.03 mg/kg

IV/IO/ETq 3-5 min

DIABETIC EMERGENCIES

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. Obtain relevant history (Onset, Provokes, Quality, Radiation,

Severity, Time, Interventions, Associated Symptoms, Allergies, Medications, Past Med/Surg History, Last Meal)5. Perform complete assessment6. Check blood glucose (If < 80 mg/dl and patient alert, give 1 tube oral glucose)7. Repeat blood glucose after therapy

EMT-Intermed: 8. Reassess patient9. Obtain IV access – normal saline at TKO10. If blood sugar < 80 or altered LOC, give D50 1 amp IV

push or Glucagon 1 mg IM (if no IV access available)11. If blood sugar > 400, give normal saline 250-500 cc IV bolus (Use caution with history of renal failure or CHF)

EMT-Paramedic: 12. Reassess patient13. Apply cardiac monitor and treat per ACLS protocol14. If blood sugar normalized and altered LOC persists, see Altered Level of Consciousness Protocol

EYE INJURIESEMT-Basic: 1. Keep patient calm

2. Remove contact lenses if possible (have patient remove if alert)3. Obtain history (when, where, how)4. Treat traumatic eye injuries:

- Penetrating- Do not remove object- Secure in place- Cover other eye as well (if patient can tolerate)

- Non-Penetrating- For dust/dirt, flush with water- For blunt trauma, avoid pressure to eye, apply sterile wet dressing, and transport sitting upright (unless other traumatic injury)

5. For chemical eye injuries/burns, flush with water for a minimum of 20 minutes (determine type of chemical)6. Treat nontraumatic eye injuries:

- Obtain relevant history (history of strokes, glaucoma, other eye problems)- For acute unilateral vision loss, transport patient flat


HEAT EXPOSURE

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. Move patient to cool environment and remove any tight clothing5. Obtain relevant history (Onset, Provokes, Quality, Radiation,

Severity, Time, Interventions, Associated Symptoms, Allergies, Medications, Past Med/Surg History, Last Meal)6. Perform complete assessment (reassess vital signs and mental status every 10 minutes) 7. Determine type of exposure:

- Heat stroke (Most serious. Temperature often 105+. Skin usually hot and dry. Often altered LOC and/or seizure.)- Heat exhaustion (Associated with dehydration with

overexertion. Core temperature usually below 105. Possible syncope with orthostatic hypotension. Skin pale and moist)- Heat cramps (Due to dehydration, overexertion, and electrolyte abnormalities. Skin moist with muscle cramps)

8. Administer oral fluids if patient alert and without nausea9. Cool with mist or cool wet sheets or air conditioning.10. For heat stroke/exhaustion, apply cold packs to axilla, groin, and neck (cease if shivering)

EMT-Intermed: 11. Reassess patient12.Obtain IV access13. 250-500 cc bolus IV normal saline (may repeat bolus x 2 as needed for hypotension)14. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 15. Reassess patient16. Apply cardiac monitor and treat per ACLS protocol17. Intubate as indicated18. Treat seizures as per Seizure Protocol


HYPERTENSION MANAGEMENT (Paramedics Only)

“High Blood Pressure” is rarely a chief complaint, but instead more commonly a physical finding.

WHEN NOT TO TREAT:

Transient HTN : May be seen at times of stress, with pain and anxiety in these situations treatment of the underlying cause of the HTN is most appropriate (respiratory distress: aerosol, anxiety: assurance, pain: pain management) and NOT antihypertensive therapy.

Chronic HTN : Many patients have long standing uncontrolled HTN without symptoms, rapid reduction of BP in these cases may due more harm then benefit and thus should NOT be initiated.

Stroke : HTN is a normal physiologic response in stroke patients and is the bodies attempt to improve blood flow to the stroked area. BP should NOT be treated in these patients.(exception: DBP>120)

WHEN TO TREAT:

Symptomatic patients with 2 consecutively elevated DBP > 110 measured 3-5minutes apart. (symptoms of HTN: chest pain, shortness of breath, headache, blurry vision, fatigue, nausea)

Stroke patients with a DBP >120

Aortic Dissection : (severe tearing back or chest pain) if suspected, BP control should be more aggressive to prevent worsening of the dissection. Treat for DBP > 90

TREATMENT:

Nitroglycerin SL 0.4mg q5 minutes up to 3 doses

GOAL OF TREATMENT ( not normalization of BP) :

To lower DBP:

< 110mmHg in symptomatic patients <120mmHg in stroke patients < 90mmHg in suspected aortic dissection


HYPOTHERMIA / FROSTBITENote: Resuscitation efforts should continue until patient's body temperature has normalized

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Secure airway and consider cervical spine precaution3. Administer warmed humidified oxygen by NRB mask or BVM4. Apply pulse oximeter (if available)5. Move patient to warm environment6. Remove any wet clothing and cover with blankets7. Obtain history as possible (Length of exposure, unconsciousness, drug or alcohol ingestion)8. Complete assessment (vital signs, mental status, temperature, evidence of local injury/frostbite)9. Check blood sugar (Hypothermia often results in hypoglycemia. If < 80 and patient alert, may give oral glucose)10. For hypothermia with arrest:

- CPR and transport unless AED or ALS available in < 5 min - Apply AED if available (see protocol)

11. For hypothermia without arrest:- Check pulse for a full 60 seconds- Do NOT initiate CPR if there is ANY pulse present (no matter how bradycardic). - Avoid adjunctive airways- Avoid rough handling (may cause dysrhythmia)- May initiate external re-warming with heated oxygen, blankets, and warm packs to trunk, neck, and groin- Do not allow conscious patients to ambulate or move about

12. For local hypothermia (frostbite):- Protect injured areas from pressure, trauma, or friction- Remove all coverings- Do not allow limb to thaw if there is chance of refreeze- Local re-warming in the field is RARELY indicated

EMT-Intermed: 13. Reassess patient14. Obtain IV access15. 250 cc bolus IV normal saline, warmed if available (may repeat bolus as needed for hypotension)16. D50 1 amp IV or Glucagon 1 mg IM for blood sugar < 8017. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 18. Reassess patient19. Apply cardiac monitor and treat per ACLS protocol

- Maximum defibrillations 3 (200 J, 300 J, 360 J)- One round of ACLS medications may be attempted- Continue CPR

20. Intubate as indicated


NEAR DROWNING/DROWNING

EMT-Basic: 1. Confirm ALS en route2. C-spine precautions (stabilize prior to removing patient from water)3. Assess airway, breathing, circulation (ABCs)4. Oxygen 100% NRB mask (assist with BVM as needed)5. Suction airway as needed (be prepared to manage emesis)6. Apply pulse oximeter (if available)7. Obtain history as possible (Temperature of water, length of submersion, mechanism of injury, drug or alcohol involved)8. Remove wet clothing9. Assess patient (signs of head injury/trauma, respiratory distress/rales, skin perfusion, etc.) 10. If hypothermic, see Hypothermia Protocol

EMT-Intermed: 11. Reassess patient12. Airway management/intubate as indicated (EMT-I certified)13. Obtain IV access (do not delay transport) NS at TKO

EMT-Paramedic: 14 Reassess patient15. Intubate as indicated16. Apply cardiac monitor and treat per ACLS


OVERDOSE/POISONING

EMT-Basic: 1. Confirm ALS en route, as indicated.2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. If altered level of consciousness, check blood sugar (If < 80 and patient is alert, give oral glucose 1 tube)5. Obtain relevant history (Onset, Type of Drug/Poison, Amount and Route of Exposure, Psychiatric/Suicidal History, Severity, Time, Interventions, Associated Symptoms, Allergies, Medications, and Past Med/Surgical History)6. Bring any pill bottles from the scene7. Perform complete assessment (reassess vital signs and mental status every 15 minutes) 8. Contact Poison Control Center at 1-800-872-5111

EMT-Intermed: 9. Reassess patient10. Obtain IV access normal saline TKO11. D50 1 amp IV if blood sugar < 80 (or Glucagon 1 mg IM)12. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 13 Reassess patient14. Narcan 0.5-2 mg IV/ET for decreased responsiveness, respiratory depression, or suspicion of narcotic overdose in a patient with altered level of consciousness (consider patient restraint prior to administration)15. Apply cardiac monitor and treat per ACLS protocol16. Intubate as indicated


RESPIRATORY EMERGENCIES: AIRWAY OBSTRUCTION

EMT-Basic: 1. Confirm ALS en route.2. Assess airway

- Choking patient able to speak/coughing:- Reassure, allow patient to attempt clearing airway by self

- Choking patient unable to speak:- Heimlich maneuver (conscious patient)- Abdominal thrusts (unconscious patient)

- Non-choking patient:- Consider underlying cause and treat appropriately (anaphylactic reaction, infection, compressing tumors, etc.)

3. Open airway (consider C-spine precautions) and check for foreign body (suction airway, blind finger sweep in adults)4. Attempt to ventilate

- No air movement- Reposition and reattempt

- Still no air movement after reposition and attempt- Continue abdominal thrusts/ventilation (5/2) and foreign body checks- Transport ASAP unless ALS < 5 minutes

- Air movement around obstruction- Continue BVM ventilation with 100% O2 and transport

5. If obstruction cleared:- Administer 100% O2 NRB mask- Apply pulse oximeter- Complete assessment (focus on breath sounds)- Obtain history- Transport

EMT-Intermed: 6. Reassess patient7. If obstruction cleared, obtain IV access normal saline TKO8. If obstruction persists, continue efforts to clear airway and transport ASAP unless ALS < 5 minutes

EMT-Paramedic: 9. Laryngoscopy with Magill forceps (attempt to remove foreign body) if obstruction persists

10. Cricothyrotomy if obstruction persists (see procedure)

11. If obstruction cleared, apply cardiac monitor and treat per ACLS


RESPIRATORY EMERGENCIES: ASYMMETRIC BREATH SOUNDS

(See Following Flowchart)

EMT-Basic: 1. Confirm ALS en route.2. Administer 100% O2 by NRB mask (be prepared to assist ventilations. Caution: Use low-flow O2 with mild COPD exacerbation)3. Apply pulse oximeter (if available)4. Obtain relevant history if possible (Onset, duration, past medical history, associated symptoms, allergies, medications) 5. Assess patient -- general appearance, vitals, heart sounds, JVD, skin, breath sounds6. Transport ASAP with ALS intercept

EMT-Intermed: 7. Reassess patient 8. Obtain IV access NS at TKO (do not delay transport)9. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 10. Reassess patient11. Needle decompression if suspected tension pneumothorax (hypotension, tracheal deviation, worsening distress) Contact Medical Control if not PTLS or BTLS Certified

12. Apply cardiac monitor and treat per ACLS protocol13. Intubate as indicated


RESPIRATORY EMERGENCIES: RALES/PULMONARY EDEMA


EMT-Basic: 1. Confirm ALS en route.2. Administer 100% O2 by NRB mask (be prepared to assist ventilations. Caution: Use low-flow O2 with mild COPD exacerbation)3. Apply pulse oximeter (if available)4. Obtain relevant history if possible (Onset, duration, past medical history, associated symptoms, allergies, medications) 5. Assess patient -- general appearance, vitals, heart sounds, JVD, leg edema, skin, breath sounds6. Position patient upright on cot7. Transport with ALS intercept

EMT-Intermed: 8. Reassess patient 9. Obtain IV access10. Nitroglycerin sublingual, 1 every 5 minutes (HOLD if SBP < 100)11. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 12. Reassess patient13. Apply cardiac monitor and treat per ACLS protocol14. Lasix 40-80 mg IV (HOLD if SBP < 100)15. Morphine sulfate 2-5 mg IV (HOLD if SBP < 100)16. Intubate as indicated (Consider Versed 2 mg IV for conscious sedation prior to intubation if SBP > 100. See

Conscious Sedation Protocol)



RESPIRATORY EMERGENCIES: WHEEZING


EMT-Basic: 1. Confirm ALS en route.2. Administer 100% O2 by NRB mask (be prepared to assist ventilations. Caution: Use low-flow O2 with mild COPD exacerbation)3. Apply pulse oximeter (if available)4. Obtain relevant history if possible (Onset, duration, past medical history, associated symptoms, allergies, medications) 5. Assess patient -- general appearance, vitals, heart sounds, JVD, skin, breath sounds 6. May assist patient with prescribed medications:

- Albuterol MDI 2 puffs- EPI-pen SQ for severe allergic reactions

7. Transport with ALS intercept

EMT-Intermed: 8. Obtain IV access normal saline TKO9. Reassess patient -- general appearance, vitals, heart sounds, JVD, skin, breath sounds 10. Epinephrine (1:1000) 0.3 mg SQ (for severe asthma or suspected anaphylaxis ONLY. Use caution if elderly or cardiac history – contact Medical Control, consider Glucagon 1 mg IV as an alternative)11. Albuterol aerosol 2.5 mg prn, may repeat x 212. Normal saline 250 cc bolus IV13. Benadryl 25-50 mg IV/IM (for suspected allergic reaction)14. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 15. Reassess patient16. Apply cardiac monitor and treat per ACLS protocol17. Consider Solu-Medrol 125 mg IV18. Intubate as indicated



RESPIRATORY DISTRESSSPONTANEOUS BREATHING

EMT-B EMT-I EMT-P

OPEN AIRWAY PROVIDE O2 NRB/BVM

OBTAIN HISTORY & MEDICATIONS

CONTACT MEDICAL CONTROL

CLEAR LUNG SOUNDS TREAT UNDERLYING CAUSE (MI, PE, etc.)

TRANSPORT

ASSESS PATIENT PULSE OXIMETER LUNG SOUNDS

ABNORMAL LUNG SOUNDS

IV NS, TKO, MONITOR EKG

DECREASED SOUNDS WITH

WHEEZES

RALESPULMONARY EDEMA ASSYMMETRICAL

ANAPHYLAXISASSIST WITH

AUTO-INJECTOR EPINEPHRINE

EPINEPHRINE (1:1000) 0.3mg SQ

(CAUTION)

ASTHMA / COPDASSIST WITH

INHALER

PROVENTIL AEROSOL 2.5 mg (3cc) O2 at 8L/min

NITROGLYCERIN 0.4 mg q5 min SL

KEEP SBP >100

DETERMINE AND TREAT CAUSE

LASIX 40-80 mgSLOW IVP

MORPHINE2-5 mg IV

CONSIDER EPINEPHRINE

(1:1000) 0.3mg SQOR GLUCAGON

TENSION PNEUMOTHORAX

PLEURAL DECOMPRESSION

ALBUTEROL AEROSOL 2.5 mg

andBENADRYL 25-50

mg IM/IVand

SOLU-MEDROL 125 mg IV

NORMAL SALINE 500 cc BOLUS IF HYPOTENSIVE

TRANSPORT

CONSIDER SOLU-MEDROL125 mg IV

SEIZURES

EMT-Basic: 1. Confirm ALS en route.2. Seizure precautions (protect patient from self-injury)3. Consider C-spine precautions4. Administer oxygen 100% NRB mask5. Suction airway as needed6. Apply pulse oximeter (if available)7. Obtain relevant history as possible (Onset, history/frequency of seizures, drug abuse, medications/medication changes, duration of seizure activity, postictal state, head injury)8. Perform complete assessment9. Check blood glucose (If < 80 or > 400, refer to Diabetic Emergency Protocol)10. Transport with ALS intercept

EMT-Intermed: 11. Reassess patient12. Obtain IV access – normal saline at TKO (do not delay transport)13. D50 1 amp IV or Glucagon 1 mg IM for <8014. Valium 2-10 mg IV for status epilepticus. May repeat dose if seizure does not subside (IV route should be administered slowly, no faster than 5 mg/min)15. Normal saline 250-500 cc bolus for hypotension16. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 17. Reassess patient18. Apply cardiac monitor and treat per ACLS protocol19. Valium 2-10 mg IV/rectal for status epilepticus. May repeat dose if seizure does not subside (IV route should be administered slowly, no faster than 5 mg/min)20. Consider Versed 2 mg IV for persistent seizures (hold if SBP < 100)21. Intubate as indicated


SHOCK: CARDIOGENIC, NEUROGENIC, SEPTIC, OR HYPOVOLEMIC

EMT-Basic: 1. Confirm ALS en route2. Administer oxygen 100% NRB mask (prepare to assist ventilation) 3. Apply pulse oximeter (if available)4. Obtain relevant history 5. Attempt to identify underlying cause:

- Hypovolemic (bleeding, dehydration)- Cardiogenic (MI, CHF, tamponade, tension pneumothorax) - Neurogenic (spinal injury with vasodilation)- Septic (infection with vasodilation)

6. Perform complete assessment7. Place patient in Trendelenburg position or elevate legs8. Transport ASAP with ALS intercept

EMT-Intermed: 9. Reassess patient 10. Obtain IV access11. 250-500 cc bolus IV normal saline for hypotension (may repeat boluses as needed for hypotension. HOLD if any signs of pulmonary edema or rales) 12. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 13. Reassess patient 14. Apply cardiac monitor and treat per ACLS protocol15. Continue volume resuscitation with normal saline boluses to maintain SBP > 90 (HOLD if pulmonary edema or rales develop)16. Intubate as indicated

17. Dopamine 5 mcg/kg/min titrated up to 20 mcg/kg/min in symptomatic patient with SBP < 90 mmHg (AVOID with hypovolemic shock)


STROKE

EMT-Basic: 1. Confirm ALS en route2. Administer oxygen 2 liters nasal cannula or higher concentrations as indicated with shock or respiratory distress3. Apply pulse oximeter (if available)4. Obtain relevant history as possible (Onset, Circumstances, Past Medical History-DM, Seizure, Drug Abuse, Head Injury, Medications, Recent Illness, Associated Symptoms, and Allergies)5. Thrombolytic Screening6. Determine Glasgow Coma Score7. Perform complete assessment8. Check blood glucose of diabetic patients (If < 80 and patient alert, give oral glucose 1 tube)9. Place patient in position of comfort10.Call receiving hospital immediately if onset < 3 hours

EMT-Intermed: 11. Reassess patient12. Obtain IV access – NS at TKO (do not delay transport)13. D50 1 amp IV or Glucagon 1 mg IM if blood sugar < 8014. Intubate as indicated (decreasing level of consciousness, loss of gag reflex. See Altered Level of Consciousness Protocol. Certified EMT-I only. )

EMT-Paramedic: 15. Reassess patient 16. Apply cardiac monitor and treat per ACLS protocol17. Intubate as indicated (decreasing level of consciousness, loss of gag reflex (see Altered Level of Consciousness Protocol))



Inclusion Criteria: (Must answer YES to all criteria) YES NO

1. Male or female, age 18-80 years2. Suspected ischemic stroke, with onset of symptoms less than 3 hours. Suspected MI with onset of symptoms less than 6 hours3. Measurable deficit on F.A.S.T. Screening Exam (if CVA suspected)

Exclusion Criteria: (Must answer NO to all criteria) YES NO

1. Stroke or head trauma in previous 3 months2. History of intracranial hemorrhage that may increase risk of recurrent hemorrhage3. Major surgery or other serious trauma in previous fourteen (14) days4. Gastrointestinal or genitourinary bleeding in previous twenty one days5. Arterial puncture at a noncompressible site in previous seven days6. Lumbar puncture in previous seven days7. Pregnant or lactating8. Rapidly improving symptoms9. Seizure at stroke onset10. Symptoms suggestive of subarachnoid hemorrhage (sudden severe headache, stiff neck, or recurrent nausea and vomiting)11. Blood glucose less than 60 or greater than 400 mg/dl12. Low platelet count by history13. On Warfarin Sodium (Coumadin), Heparin, or Lovenox14. History of intracranial neoplasm, AV malformation, cerebral or abdominal aneurisms

THROMBOLYTIC SCREEN CHECKLIST

EMS Service: __________________________________ Date: ___________________

Name: _________________________________________________ Age: __________

Time of onset of symptoms: ______________________ a.m./p.m.

Signature ______________________________________________ Date/Time _______________________

4. Continue treatment per protocol, obtain 12-lead ECG (if possible) if MI suspected

1. Insert 18-gauge IV catheter with 0.9% NaCl @ TKO rate (mark missed IV sites)2. Administer no IM injections3. Notify E.D. If possible Thrombolytifc candidate and suspected diagnosis

TRAUMA ARREST

Note: Resuscitation should not be attempted in cardiac arrest patients where resuscitation efforts will be ineffective/hopeless, such as with hemicorporectomy, decapitation, or total body burns, nor in patients with obvious, massive/severe blunt trauma who are without vital signs, pupillary response, or an organized or shockable cardiac rhythm (asystole) at the scene.

Patients in cardiac arrest with deep penetrating cranial injuries and patients with penetrating cranial or truncal wounds associated with asystole and a transport time of more than 15 minutes to a definitive care facility are unlikely to benefit from resuscitation efforts. Such efforts should be initiated ONLY if there are no other victims in need of care that would be more likely to benefit from intervention.

Extensive, time-consuming care of trauma victims in the field is usually not warranted. Unless the patient is trapped, they should be en route to a medical facility WITHIN 10 MINUTES after arrival of the ambulance on the scene.

EMT-Basic: 1. Cervical spine immobilization2. Ventilate with 100% oxygen BVM with oral/nasal airway adjunct (avoid nasal airway with facial trauma)3. Suction airway as needed4. CPR5. Control major bleeding6. Fully immobilize and transport immediately

EMT-Intermed: 7. Obtain large-bore IV access x 2 (16G-18G/largest possible, do not delay transport)

8. Continue CPR during transport9. Intubate with C-spine precautions (Certified EMT-I only)

EMT-Paramedic: 10. Intubate patient with C-spine precautions11. Apply cardiac monitor and treat per ACLS protocol12. Continue CPR during transport

13. If no signs of life after 10 minutes, contact Medical Control for possible termination of resuscitative efforts


TRAUMA EMERGENCIES

(See Flowchart and Field Triage Decision Scheme on Following Pages)

EMT-Basic: 1. Confirm ALS en route2. Assure scene safety3. Determine mechanism of injury, number of patients, and request additional help as needed4. Rapid trauma assessment and triage (DCAP-BTLS = Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling)

- Establish life threats/chief complaints- Assess airway and initiate appropriate therapies- Assess circulation and control major bleeding- Obtain vital signs- General impression of patient's condition- Prioritize for transport

5. C-spine immobilization6. Airway management as indicated with 100% O27. Obtain brief history (allergies, medications, past medical/ surgical history, last meal, events surrounding injury)8. Transport immediately9. Detailed physical and ongoing assessment during transport 10.Control bleeding11. Splint fractures with distal neurovascular exam

EMT-Intermed: 12. Reassess patient13. Obtain IV access – NS at TKO (do not delay transport)14. Normal saline 500 cc bolus for hypotension, repeat bolus as needed to maintain SBP > 9015. Intubate as indicated (Certified EMT-I only)

16. Contact Medical Control for permission to administer morphine for pain control if indicated.

EMT-Paramedic: 17. Reassess patient 18. Apply cardiac monitor and treat per ACLS protocol19. Intubate as indicated20. Treat any life threats as appropriate21. Pain management (See Pain Management Protocol)

- Morphine sulfate 2-5 mg IV (drug of choice in trauma patients) for severe pain (HOLD if SBP < 100). May repeat dose if indicated.

- Consider Toradol with focal extremity injuries ONLY (see Pain Management Protocol)



TRAUMA EMERGENCIES

URGENT PATIENTS

RAPID TRAUMA ASSESSMENT (DCAP-BTLS)

TRANSPORT IMMEDIATELY (CONTACT MEDICAL CONTROL)

DURING TRANSPORT, DETAILED ASSESSMENT/MANAGEMENT OF SPECIFIC INJURIES

IV ACCESS X2 WITH NS TO MAINTAIN SBP > 90

EMT-B EMT-I EMT-P

SCENE SIZE-UP -- SAFETY, MECHANISM OF INJURY, NUMBER OF PATIENTS, IDENTIFY THE NEED FOR AND SUMMON ADDITIONAL RESOURCES.

INITIAL ASSESSMENT -- DETERMINE LIFE-THREATS, PRIORITIZE PATIENTS FOR TRANSPORT, ASSESS AND MANAGE AIRWAY, CIRCULATION, BLEEDING,

AND CONTROL C-SPINEINTUBATE PATIENT WITH C-SPINE CONTROL

DECOMPRESS TENSION PNEUMOTHORAX/SURGICAL CRICOTHYROTOMY

NON-URGENT PATIENTS

FOCUSED ASSESSMENT/ MANAGEMENT OF INJURED AREAS (DCAP-BTLS)

TRANSPORT AND CONTACT MEDICAL CONTROL

CHEST ABDOMINAL HEAD EXTREMITY

EVALUATE BREATH SOUNDS

PNEUMO/HEMO THORAX

(POSITION ON INJURED SIDE AND ELEVATE

HEAD)

FLAIL CHEST(STABILIZE)

OPEN CHEST WOUND

(NON-POROUS 3-SIDED DRESSING)

EVISCERATION (SURROUND

ORGANS WITH MOIST DRESSING

AND ELEVATE KNEES)

BLUNT INJURY(TREAT

HYPOVOLEMIA)

PENETRATING INJURY

(SECURE OBJECT: DO NOT REMOVE)

EVALUATE NEURO (GLASGOW COMA

SCORE)

ELEVATE HEAD WITH C-SPINE PROTECTION

HYPER- OXYGENATE

(IF SUSPECTED HERNIATION)

SPLINTING(EVALUATE

CIRCULATION & NEURO BEFORE,

DURING, & AFTER)

AMPUTATION (CONTROL BLEEDING)

(TRANSPORT PART COOL & DRY)

PAIN CONTROL(PER PROTOCOL)

EMS Protocol – St. Joseph Health Center – Updated February 13, 2005

YES

Glasgow Coma Scale (see following page).......................................... < 14 orSystolic blood pressure......................................................................... < 90 orRespiratory rate..................................................................................... < 10 or > 29Revised Trauma Score (see following page)........................................ < 11

Measure vital signs and level of consciousness

FIELD TRIAGE DECISIONS SCHEME

YES NO

Take to trauma center; alert trauma team.Steps 1 and 2 triage attempts identify the most seriously injured patients in the field. In a trauma system, these patients would preferentially be transported to the highest level of care within the system.

Step One

Step Two

Assess anatomy of injury

Step Three

NOYES

Take to trauma center; alert trauma team.Steps 1 and 2 triage attempts identify the most seriously injured patients in the field. In a trauma system, these patients would preferentially be transported to the highest level of care within the system.

Evaluate for evidence of mechanism of injury and high-energy impact

Step Four

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

Flail chest Combination trauma with burnsTwo or more proximal long-bone fractures

NO

Age < 5 or > 55Cardiac disease, respiratory diseaseInsulin-dependent diabetes, cirrhosis, or morbid obesityPatient with bleeding disorder or patient on anticoagulants

NOYES

43

Pelvic fractures Open and depressed skull fracture Paralysis Amputation proximal to wrist and ankle Major burns

• Ejection from automobile• Death in same passenger compartment• Extrication time > 20 minutes

• Falls > 20 feet• Rollover

• High-speed auto crash Initial speed > 40 mphMajor auto deformity > 20 inchesIntrusion into passenger compartment > 12 inches

• Auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact• Pedestrian thrown or run over• Motorcycle crash > 20 mph or with separation of rider from bicycle

Contact medical direction and consider transport to a trauma centerConsider trauma team alert

Reevaluate with medical direction

Contact medical direction and consider transport to trauma centerConsider trauma team alert

• Pregnancy • Immunosuppressed

patients

ADULT GLASGOW COMA SCOREEye Opening Verbal Response Motor Response

4-Spontaneous 5-Oriented & converses 6-Obeys verbal commands

3-To verbal Commands 4-Disoriented & converses 5-Localizes pain

2-To pain 3-Inappropriate words 4-Withdraws from pain

1-No response 2-Inconprehensible sounds 3-Decorticate to pain

1-No response 2-Decerebate to pain

1-No response

INFANT GLASGOW COMA SCOREEye Opening Verbal Response Motor Response

4-Spontaneous 5-Coos, babbles 6-Spontaneous

3-To speech 4-Irritable cries 5-Localizes pain

2-To pain 3-Cries to pain 4-Withdraws from pain

1-No Response 2-Moans, grunts 3-Flexion

1-No response 2-Extension

1-No response

A Score between 13 and 15 may indicate a mild head injury A score between 9 and 12 may indicate a moderate head injury

A score of 8 or less indicate a severe head injury (Endotracheal intubation is indicated)

REVISED TRAUMA SCORE

Glasgow Coma Score (GCS) Systolic Blood Pressure Respiratory Rate

4=(13-15) 4=(>89) 4=(10-29)

3=(9-12) 3=(76-89) 3=(>29)

2=(6-8) 2=(50-75) 2=(6-9)

1=(4-5) 1=(1-49) 1=(1-5)

0=(3) 0=(0) 0=(0)


II. PEDIATRIC PROTOCOLS


NORMAL PEDIATRIC VITAL SIGNS

Age Pulse Resp SBP* (70 + 2 x Age)Newborn 126-160 30-60 60-70Up to 1 yo 100-140 30-60 70-801 to 3 yo 100-140 20-40 76-904 to 6 yo 80-120 20-30 80-1007 to 9 yo 80-120 16-24 84-11010 to 12 yo 60-100 16-20 90-120

* Blood pressure is a late and unreliable indicator of shock in children

INFANT GLASGOW COMA SCORE

Eye Opening Verbal Response Motor Response

4-Spontaneous 5-Coos, babbles 6-Spontaneous

3-To speech 4-Irritable cries 5-Localizes pain

2-To pain 3-Cries to pain 4-Withdraws from pain

1-No Response 2-Moans, grunts 3-Flexion

1-No response 2-Extension

1-No response

A Score between 13 and 15 may indicate a mild head injury A score between 9 and 12 may indicate a moderate head injury

A score of 8 or less indicate a severe head injury (Endotracheal intubation is indicated)


QUICK-REFERENCE FOR COMMON PEDIATRIC MEDICATIONS AND DOSAGES

(See Complete Medication Protocols for Indications, Contraindications, Side Effects/Warnings, Administration, and Dosages)

Medication Dose Route RemarksAcetaminophen (Tylenol)

10 mg/kg PO Useful for musculoskeletal pain and fever control

Activated charcoal 1 gm/kg PO Do not give to child with altered level of consciousnessAdenosine 0.1 mg/kg IV, IO Indicated for SVT. First dose 6 mg, second dose 6 mg. Max

dose 12 mgAlbuterol 2.5 mg Aerosol Indicated for wheezing as per protocolAmiodarone 5 mg/kg IV, IO Over 20-60 minutes, max 15 mg/kg per day. For shock-

refractory pulseless VT/VF: 5 mg/kg rapid IV/IOAtropine 0.02 mg/kg IV, IO,

ETMinimum dose 0.1 mg; max dose for child 0.5 mg; max dose for adolescent 1.0 mg; may repeat x1; also useful before intubating children < 5 years old, blocks bradycardia due to vagal nerve stimulation

Dextrose 25% 2 mL/kg IV, IO Try to obtain bedside glucose level before administering – administer if blood glucose < 80; dilute 50% 1:1 with sterile water; consult Medical Control if infant < 1 month as solution may need to be further diluted.

Diazepam (Valium) 0.2-0.3 mg/kg

IV Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max dose 10 mg

Diazepam (Valium) 0.5 mg/kg Rectal Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max dose 10 mg

Diphenhydramine (Benadryl)

1 mg/kg IV Useful in allergic reactions and anaphylaxis. Max dose 50 mg

Epinephrine (1:10,000)

0.1 mL/kg (0.01 mg/kg)

IV, IO Commonly used in cardiac arrest rhythms as first dose. Increase second dose 10 X (may use 1:1,000 solution)

Epinephrine (1:1,000) 0.1 mL/kg (0.1 mg/kg)

ET, IV, IO

Commonly used in cardiac arrest rhythms. Use for all ET doses, and second and subsequent IV/IO doses. The ET route has limited absorption, use IV/IO route whenever possible

Epinephrine (1:1,000) 0.01 mL/kg SubQ Used for anaphylaxis. Max dose is 0.3 mLLidocaine 1 mg/kg IV, IO,

ETCan repeat once. If successful, start continuous infusion at 20-50 mg/kg/min. Also useful before intubating for cerebral protection and decreases airway reactivity

Morphine 0.1 mg/kg IV/IM Useful for moderate pain. May cause respiratory depression. Hypotension and reflex bradycardia may develop from histamine release

Midazolam (Versed) 0.1 mg/kg IV/IO/IM Indicated for uncontrolled seizure activity; anticipate respiratory depression. Useful to facilitate advanced airway management in combative patients

Naloxone (Narcan) 0.1 mg/kg IV,IO,ET Useful for unknown unconscious, known narcotic overdosesProcainamide 15 mg/kg IV Over 30-60 minutes. Alternative treatment for recurrent or

refractory VT, SVTIV = Intravenous ET = Endotracheal IO = Intraosseous IM = Intramuscular

Refer to Broselow Pediatric Emergency tape for length-based drug treatment when unsure of weight, age, or drug dosage


PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS

EMT-Basic: 1. Confirm ALS en route2. Secure airway and consider cervical spine injury3. Administer 100% oxygen by NRB mask (assist ventilation with BVM if indicated at 20 bpm)4. Apply pulse oximeter (if available)5. Obtain relevant history (Onset, Circumstances, Past Medical History-DM, Seizure, Drug Abuse, Head Injury, Medications, Recent Illness, Associated Symptoms, and Allergies)6. Perform complete assessment7. Document Glasgow Coma Scale8. Check blood glucose (If < 70 and patient alert, give oral glucose 1 tube – must have gag reflex)9. Place patient in position of comfort10. Transport immediately unless ALS < 5 minutes

EMT-Intermed: 11. Reassess patient (manage airway)12. Obtain IV access – normal saline at TKO (do not delay transport)13. D25 2 mL/kg IV bolus if blood sugar < 70 or not obtainable

(or Glucagon 0.5 mg IM ONLY for children > 20 kg)14. 20 cc/kg bolus IV normal saline for any of the following: Unresponsive, appears dry, tachycardic, hypotensive, poor capillary refill, or blood sugar > 400 mg/dL (may repeat bolus once as indicated)15. Intubate patient as indicated (Certified EMT-I only)

EMT-Paramedic: 16. Reassess patient (manage airway)17. Apply cardiac monitor and treat per ACLS protocol18. Consider Narcan 0.1 mg/kg IV/IO/ET (Max dose 2 mg. for patients with normal blood sugar, impaired respirations, and no response to fluid bolus, or if any suspicion of narcotic overdose. Also consider patient restraint.)19. Intubate patient if indicated for airway protection/

ventilation (if no response to Narcan and/or D25)


PEDIATRIC ARRHYTHMIAS

Arrhythmia in children is more frequently a result of airway compromise/poor oxygenation than of cardiac origin. Initial therapy should always consist of proper ventilation and oxygenation.

Arrhythmias in children should be treated ONLY if the arrhythmia compromises cardiac output or has potential for degenerating into a rhythm that compromises cardiac output.

EMT-Basic: 1. Confirm ALS en route2. Open and manage airway 100% O2 by NRB mask (Assist ventilations with BVM if respiratory rate is slow, fast, or there

are any signs of hypoxia)3. Apply pulse oximeter 4. Assess circulation. Start CPR if signs of decreased cardiac output and heart rate < 60 that is not improving with oxygenation. Signs of decreased cardiac output include:

- Poor perfusion- Hypotension- Decreased LOC- Respiratory difficulty- Pulmonary congestion

5. Assess patient (General appearance, responsiveness, vital signs, perfusion, and lung sounds)6. Obtain relevant history (Onset, circumstances, past medical history, and medications)7. Transport immediately unless ALS < 5 minutes

EMT-Intermed: 8. Reassess patient (manage airway)9. Intubate as indicated (Certified EMT-I only)10. Obtain IV/IO access – normal saline at TKO (do not delay transport)11. May apply cardiac monitor and run a rhythm strip (may NOT interpret rhythm)12. Transport immediately unless ALS unit < 5 minutes

EMT-Paramedic: 13. Reassess patient14. Apply cardiac monitor and treat per PALS protocol (see specific Arrhythmia Protocols below)15. Intubate for definitive airway as indicated

(SEE SPECIFIC ARRHYTHMIA PROTOCOLS ON FOLLOWING PAGES)EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 49

PEDIATRIC ARRHYTHMIA PROTOCOLS

BRADYCARDIA:

- Asymptomatic patient (Alert, good pulse, good perfusion, no distress):1. Continue cardiac monitoring and oxygenation2. Transport with frequent reevaluation

- Symptomatic patient (Heart rate < 60 and poor perfusion, respiratory difficulty, decreased LOC, and/or pulmonary congestion):

1. Assure adequate oxygenation prior to further treatment2. Begin CPR if no improvement with oxygenation (heart rate < 60, poor perfusion, unstable)3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO or epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) diluted in 3-5 cc normal saline via ET tube. Repeat every 3-5 minutes as needed4. Atropine 0.02 mg/kg (minimum dose 0.1 mg) IV/IO or atropine 0.04 mg/kg via ET tube. May repeat once in 3-5 minutes5. Transport and contact Medical Control for possible pediatric pacing

NARROW COMPLEX TACHYCARDIA:

Note: Consider normal pulse for age, possible hypovolemia, and any history of Wolff-Parkinson-White (transport immediately if history of WPW)

- Unstable patient: (Altered LOC, poor perfusion, hypotension, difficulty breathing, shock)

1. Prepare for immediate synchronized cardioversion2. May attempt adenosine 0.1 mg/kg (max 6 mg) rapid IV/IO bolus with immediate 5-10 cc NS flush (if IV access readily available). May repeat adenosine 0.2-mg/kg dose (max 12 mg) in 1-2 minutes

3. Consider sedation with Versed 0.1 mg/kg slow IV/IO (max 2 mg) prior to cardioversion if time permits (see Conscious Sedation Protocol)4. Synchronized cardioversion 1J/kg, 2J/kg, 2J/kg

- Stable patient: (alert, oriented, good perfusion):1. Transport immediately with continued monitoring2. Consider vagal maneuvers (ice pack to face, blowing through straw)3. If at any time patient becomes unstable, immediate synchronized


cardioversion


WIDE COMPLEX TACHYCARDIA (with a pulse):

- Unstable patient: (altered LOC, poor perfusion, hypotension, difficulty breathing, CHF)

1. Prepare for immediate synchronized cardioversion 2. Consider sedation with Versed 0.1 mg/kg slow IV/IO (max 2 mg) if time permits. (See Conscious Sedation Protocol)

3. Synchronized cardioversion 1J/kg, 2J/kg, 2J/kg4. Administer antiarrhythmic (administer only 1 antiarrhythmic agent)

- Amiodarone 5 mg/kg IV/IO over 20-60 minutes OR - Lidocaine 1.0 mg/kg IV push (no response in 5 minutes, repeat at 0.5 mg/kg. Max 3 mg/kg) If rhythm converts, continue lidocaine 0.5 mg/kg IV every 20 minutes OR- Procainamide 15 mg/kg IV/IO over 30-60 minutes

5. Repeat synchronized cardioversion at 2J/kg

- Stable patient: (alert, oriented, good perfusion):1. Administer antiarrhythmic (administer only 1 antiarrhythmic agent)

- Amiodarone 5 mg/kg IV/IO over 20-60 minutes OR - Lidocaine 1.0 mg/kg IV push (no response in 5 minutes, repeat at 0.5 mg/kg. Max 3 mg/kg) If rhythm converts, continue lidocaine 0.5 mg/kg IV every 20 minutes OR- Procainamide 15 mg/kg IV/IO over 30-60 minutes

2. If patient remains stable, monitor and transport.3. If at any time patient becomes unstable, immediate synchronized cardioversion


PEDIATRIC CARDIAC ARREST

Cardiac arrest in children is primarily a result of airway compromise/poor oxygenation. Initial therapy should always consist of proper ventilation and oxygenation.

Transport immediately if excessive hemorrhage or hypothermia associated with the arrest.

EMT-Basic: 1. Confirm ALS en route2. Open airway 100% O2 BVM ventilation3. Assess circulation (confirmed arrest)4. Initiate CPR5. Apply automated external defibrillator (AED) if available

and follow prompts (For children 8 years old only. See AED Protocol)6. Transport immediately unless ALS < 5 minutes

EMT-Intermed: 7. Reassess patient and manage airway8. Intubate patient as indicated (Certified EMT-I only)9. Obtain IV/IO access – normal saline at TKO (do not delay transport)10.May apply cardiac monitor if ALS en route (May not interpret rhythm)

EMT-Paramedic: 11. Reassess patient and manage airway12. Intubate as indicated13. Apply cardiac monitor and treat per PALS protocol

(SEE SPECIFIC ARREST PROTOCOLS ON FOLLOWING PAGES)


PEDIATRIC ARREST PROTOCOLS

ASYSTOLE/PEA:

1. Confirm asystole in 2 different leads and continue CPR2. Consider treatable causes:

Condition TreatmentHypovolemia Give 20 cc/kg NS bolusHypoxia Adequate airway managementHydrogen Ions (acidosis) Consider sodium bicarb 1 mEq/kgHyperkalemia Consider sodium bicarb 1 mEq/kgHypothermia Aggressively warm patientTension Pneumothorax Chest decompressionTricyclic Overdose Consider sodium bicarb 1 mEq/kgHypoglycemia Give D25, 2 mL/kg bolus

3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO every 3-5 minutes or epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) in 3-5 cc NS via ET tube4. Normal saline 20 cc/kg IV/IO bolus5. Check blood sugar. If < 70, give D25, 2 mL/kg IV/IO6. Sodium bicarbonate 1 mEq/kg IV/IO7. Continue CPR and transport

V-FIB/PULSELESS V-TACH:

1. Immediate defibrillation 2J/kg, 4J/kg, 4J/kg2. If no response, resume CPR3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO every 3-5 minutes or epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) in 3-5 cc NS via ET tube4. Defibrillate at 4J/kg approximately 1 minute after each dose5. Consider antiarrhythmic (administer only 1 antiarrhythmic agent)

- Amiodarone 5 mg/kg IV/IO over 2-3 minutes. May repeat 2.5-mg/kg dose in 10 minutes OR- Lidocaine 1 mg/kg bolus IV/IO. May repeat 0.5-mg/kg dose every 5 minutes up to 3-mg/kg total

6. Defibrillate at 4J/kg approximately 1 minute after each dose7. Continue CPR and transport


CHILD ABUSE / NEGLECT

GENERAL CONSIDERATIONS: Child abuse/neglect are widespread enough that nearly all EMTs and Paramedics will see these problems at some time. The first step in recognizing abuse or neglect is to accept that they exist and to learn the signs and symptoms.

PROCEDURES:

1. Initiate treatment as necessary for situation using established protocols.

2. If possible, remove child from scene, transporting to hospital even if there is no medical reason for transport.

3. If parents refuse permission to transport, notify law enforcement for appropriate disposition. Do not jeopardize your safety. If patient is in immediate danger, let law enforcement handle scene.

4. Advise parents to go to hospital. Avoid accusation as this may delay transport. The adult with child may not be the abuser.

5. Carefully document findings and report to physicians at the hospital. An EMT must also report or assure that actual or suspected child abuse/neglect is reported to the local law enforcement agency or the Children's Services Board.


PEDIATRIC FLUID AND DRUG ADMINISTRATION

EMT-Intermed:

Peripheral venous access lines will be the first route for fluid and drug administration for any life or limb threatening emergency situation.

Normal saline will be the fluid of choice for all resuscitative measures. Unless there are compelling factors, no more than two attempts at peripheral

access should be made in a pediatric patient. In a life threatening situation where venous access appears futile and the

child's condition is unstable, intraosseous access should be established immediately following airway stabilization.

Contraindications to intraosseous access include recently fractured bone, known bone disorder, and unsuccessful prior attempt. Relative contraindications include cellulitis or infected burn at site (see IO procedure)

EMT-Paramedic:

When peripheral IV or IO access is not available for administering medications:

Endotracheal tube route may be used for lidocaine, atropine, Narcan, and epinephrine.

Intramuscular (IM) route may be used for Versed, morphine, and Toradol. Rectal route may be used for Valium (diazepam).


PEDIATRIC RESPIRATORY DISTRESS: UPPER AIRWAY OBSTRUCTION

TOTAL OBSTRUCTION/FOREIGN BODY:

EMT-Basic: 1. ALS en route2. Manual clearing ONLY if foreign body is visible (no blind finger sweep)3. Back blows and chest thrusts if < 1 year old4. Abdominal or chest thrusts if > 1 year old5. If airway cannot be cleared in < 60 seconds, transport immediately (do not take history, do not perform further physical assessment)

EMT-Intermed: 6. Continue attempts to clear airway

EMT-Paramedic: 7. Continue attempts to clear airway8. May attempt laryngoscopy and McGill forceps if complete obstruction with history of foreign body in an unconscious patient9. Cricothyrotomy as indicated (see procedure protocol)

PARTIAL OBSTRUCTION:

EMT-Basic: 1. ALS en route2. Do NOT agitate child. Do NOT examine throat. 3. 100% oxygen by NRB or blow-by as tolerated4. Obtain brief history (allergies, medications, past medical history, events surrounding incident)5. Assess general appearance6. Allow child to assume position of comfort, allow parent to be with/hold child7. Transport immediately with ALS intercept

EMT-Intermed: 8. Reassess9. Do NOT start IV unless child in arrest (do not agitate)10. Do NOT attempt invasive airway unless child in arrest11. Transport immediately


PEDIATRIC RESPIRATORY DISTRESS: WHEEZING

EMT-Basic: 1. ALS en route2. Rapid assessment (general appearance, ABCs)3. 100% oxygen NRB (BVM assist with ventilation as indicated)4. Allow position of comfort5. Obtain relevant history as possible (history of asthma, allergic reaction, illness)6. May assist with prescribed EPI-pen if allergic reaction is

suspected7. May assist with albuterol MDI if prescribed8. Transport immediately with ALS intercept

EMT-Intermed: 9. Reassess (attention ABCs)10. Do not start IV/agitate child (unless unresponsive)11. Epinephrine 0.01 mg/kg (1:1000) subcutaneous (max dose 0.3 mg) for severe wheezing/distress ONLY12. Albuterol aerosol 1.25-2.5 mg with oxygen prn (May repeat twice as needed)13. Benadryl 1 mg/kg IM/IV/IO for suspected allergic reactions14. Consider intubation (ONLY if child unresponsive)15. Transport with ALS intercept

EMT-Paramedic: 16. Reassess (airway management)17. Consider intubation (ONLY if child unresponsive)18. Apply cardiac monitor and treat per PALS19. Consider Solu-Medrol 2 mg/kg IV/IM/IO20. Transport immediately


PEDIATRIC SEIZURES

EMT-Basic: 1. Confirm ALS en route2. Seizure precautions (protect patient from self-injury)3. Consider C-spine precautions4. Administer oxygen 100% NRB mask5. Suction airway as needed6. Apply pulse oximeter (if available)7. Obtain relevant history as possible (Onset, history/frequency of seizures, drug abuse, medications/medication changes, duration of seizure activity, postictal state, head injury)8. Perform complete assessment9. Check blood glucose (If < 60 or > 300, refer to Diabetic Emergency Protocol)10. Transport with ALS intercept

EMT-Intermed: 11. Reassess patient12. Obtain IV access – normal saline at TKO (do not delay transport)13. D25 2 ml/kg IV bolus if blood sugar <60 or not obtainable (or give Glucagon 0.5 mg IM ONLY for children > 20 kg)14. Valium 0.2 mg/kg slow IV over 3 minutes (max 5 mg) for status epilepticus. May repeat dose if seizure does not subside.15. Normal saline 10 cc/kg bolus for hypotension or if blood sugar > 30016. Intubate as indicated (Certified EMT-I only)

EMT-Paramedic: 17. Reassess patient18. Valium 0.2 mg/kg slow IV over 3 minutes (max 5 mg) or 0.5 mg/kg rectal (max 10 mg) for status epilepticus. May repeat dose if seizure does not subside.19. Apply cardiac monitor and treat per PALS protocol 20. Intubate as indicated


PEDIATRIC SHOCK

EMT-Basic: 1. Confirm ALS en route2. Administer oxygen 100% NRB mask (prepare to assist ventilation) 3. Apply pulse oximeter (if available)4. Obtain relevant history (Onset, Possible Exposures/New Medications, Allergies, Associated Symptoms, Interventions, Past Medical History)5. Perform rapid assessment (pulse and respirations) TACHYCARDIA IS OFTEN THE FIRST SIGN OF SHOCK

IN CHILDREN. DO NOT DEPEND ON BLOOD PRESSURE6. Place patient in position of comfort7. Transport immediately with ALS intercept

EMT-Intermed: 8. Reassess patient (attention ABCs)9. Obtain IV access (do not delay transport)10. Normal saline 20 cc/kg IV bolus if signs of hypoperfusion or dehydration are present (may repeat bolus twice as indicated)11. Epinephrine 0.01 mg/kg SQ (1:1000) (max 0.3 mg) for allergic/anaphylactic shock ONLY (bee sting, insect bite)12. Intubate as indicated (Certified EMT-I only)13. Transport immediately with ALS intercept

EMT-Paramedic: 14. Reassess patient (monitor ABCs closely)15. Identify type of shock and treat accordingly:

Anaphylactic Shock 1. Epinephrine 0.01 mg/kg SQ (1:1000) (max 0.3 mg) 2. Benadryl 1 mg/kg IM/IV (max 25 mg) 3. Albuterol aerosol 1.25-2.5 mg with O2 prn

Hypovolemic, Septic, or Neurogenic Shock 1. Normal saline 20 cc/kg bolus. May repeat x 2 2. Check blood sugar. If < 60 mg/dl, give:

- D25 2 ml/kg IV/IO bolus OR - Glucagon 0.5 mg IM ONLY for children > 20 kg)

16. Apply cardiac monitor and treat per PALS protocol17. Intubate as indicated


III. MEDICAL PROCEDURES


AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)

The automatic external defibrillator should be used on any patient meeting the following criteria: unconscious, pulseless, and breathless regardless of the cause. Current information available on medical policies and practices does not differentiate between ventricular fibrillation as a result of a medical condition or resulting from a traumatic injury. The instrument is programmed to determine a shockable rhythm. If questions arise, follow written protocol and contact Medical Control ASAP.

A) Patient Assessment

1. Check patient responsiveness2. Primary exam (ABCs)

B) Request ACLS Back-up (Basic and Intermediate Squads)

C) Initiation of B.L.S.

D) Use of A.E.D.

1. Patient Criteria. Patient must be 8 years old or older and:a) Pulselessb) Breathlessc) Unconscious

2. Begin Basic Life Support Proceduresa) Open and maintain clear airwayb) Support ventilation with appropriate equipmentc) Begin CPRd) Set up A.E.D.

1) Properly place defibrillator pads on patient2) Connect pads to A.E.D. unit if not already done3) Turn A.E.D. unit on4) Follow audio/visual prompts (directions) given by A.E.D. unit

e) If second rescuer is available, have him/her secure airway, support ventilation with appropriate equipment and begin CPR (chest compressions).

E) Transportation

1. If ACLS unit more than 10 minutes away or delayed, consider transportation of patient if:a) Nine (9) electrical shocks have been delivered to the patientb) Three (3) consecutive messages that no shock is indicated have been delivered

2. Meet ACLS unit rather than waiting extended amount of time for ACLS unit to arrive:a) Continue Basic Life/Advanced Life Support measuresb) If patient requires defibrillation during transport, stop the transporting unit for the A.E.D. to properly analyze and deliver electrical shock to patient


AIRWAY AND BREATHING

1. SECURE AIRWAY

2. ADMINISTER OXYGEN THERAPY

a) All patients should be evaluated for the administration of high-flow oxygen (NRB at 12-15 lpm). If the patient does not tolerate the NRB, give low-flow oxygen via nasal cannula at 1-6 lpm.

b) Special consideration should be given to the COPD patient when administering oxygen:1. If exhibiting mild respiratory distress, should receive low-flow oxygen via nasal cannula2. If exhibiting moderate to severe respiratory distress and shows signs of hypoxia,

administer high-flow oxygen via NRB

c) Any patient unresponsive to low-flow oxygen administration should receive high-flow oxygen.

3. CONTINUOUS PULSE OXIMETRY

NEVER BASE ANY TREATMENT OR OXYGEN THERAPY SOLELY ON THE READING FROM THE PULSE OXIMETER

a) Place the monitor near the patient where it can be readily seen.

b) Place with sensor against fingernail. If evidence of nail polish is present, remove it or reposition the sensor until the display changes and confirms that proper sensing has been established.

c) Make sure that the sensor has been connected to both the monitor and the patient and turn the switch to the "on" position.

d) Treat hypoxia appropriately with the proper delivering device and liter flow.

e) Considerations in overall patient condition: 1. Temperature of extremities2. Anemic conditions3. Carbon monoxide exposure

4. RAPID ASSESSMENT

5. TREAT IDENTIFIED CAUSE


ENDOTRACHEAL INTUBATION

Indications: Victim with respiratory arrest and/or insufficiency to achieve complete control over their airway (loss of gag reflex, hypoventilation, persistent airway compromise despite basic maneuvers) should be intubated. Oral-tracheal intubation is the preferred technique for placement of an endotracheal tube in all patients.

Benefits: It protects the airway from aspiration of foreign material, allows for intermittent positive pressure ventilation to be achieved with 100% oxygen, makes the trachea and the respiratory tract available for suctioning, and also eliminates the problem of gastric distention.

Risks/Complications: Esophageal intubation, tracheal rupture, right mainstem bronchus intubation, broken teeth, laryngospasms, trauma to the oral-pharynx, and trauma or puncture of trachea due to misplacement of stylet

Procedure for performing a endotracheal intubation is as follows:

a) Preoxygenate with 100% O2 BVMb) Prepare and check equipmentc) Put victim's head in sniffing position (C-spine precautions as indicated)d) Suction the mouth and the pharynx as needede) Visualize the epiglottis and vocal cordsf) Select the proper size tube and insert with the right hand, starting at the corner of the mouth down into the trachea, past the vocal cords approximately 2 inches (Intubation

attempt should not take longer than 30 seconds. If delays, reoxygenate with 100% O2 BVM prior to each re-attempt. Children < 8 years old should have an uncuffed tube)

GUIDE FOR TUBE SIZING

Neonate.......... 3mm (id) 18-24 months..... 5-6mm (id)3-12 months..... 4-5mm (id) 2-4 years........... 6mm (id)12-18 months....5mm (id) 4-7 years........... 6-7mm (id)Most adults....... 8mm (id) 7-10 years......... 7mm (id)

g) Remove laryngoscope and stylet (if used), holding the tube securely. Ventilate and confirm placement.

- Check for breath sounds with 5-point auscultation bilateral anterior and lateral chest and epigastrium- Mist/condensation in tube- CO2 detector change (if available)- Increasing pulse oximeter

IF ANY CONCERN OR QUESTION OF PROPER TUBE PLACEMENT, TUBE SHOULD BE REMOVED AND BVM VENTILATION CONTINUED.

h) If breath sounds heard, inflate tube's cuff with 4-6cc of air and secure the tube. i) Verify lung sounds/tube placement each time patient moved or every 10 minutes. j) Document the intubation by noting the following:

1. Number of attempts2. Person(s) making attempts3. Size of tube used4. Lung sounds before and after intubation, and time of each check5. Measurement on tube at lips of patient when lung sounds are present6. Any complications


COMBI-TUBE PROTOCOL

(MAY ONLY BE PERFORMED BY PARAMEDICS & EMT-INTERMEDIATES WITH INTUBATION CERTIFICATION)

Indications: The patient is unconscious and unable to protect own airway; no apparent gag reflex. Cardiorespiratory/respiratory (pulse present) arrest.

Contraindications:1. Patients under 70 pounds and under 5 feet tall2. Responsive patients with an intact gag reflex3. Patients with known esophageal disease4. Patients who have ingested caustic substances5. Known or suspected foreign body obstruction of the larynx or trachea6. Presence of tracheostomy

Procedure for using Combi-tube in the pre-hospital setting is as follows:

a) The first priority is to defibrillate the patient in cases of ventricular fibrillation. The AED should be applied first, using conventional airway management, following the AED protocolb) The Combi-tube should be placed during the one minute of CPR between sets of AED analyses (this may somewhat delay subsequent AED analyses)c) Hyperventilate the patient prior to Combi-tube insertion for 10-15 seconds using either a BVM or mouth-to-mask device with supplemental oxygend) Insertion – done quickly between ventilation:

1. Except in cases of suspected cervical spine injury, hyper-extend the head and neck2. In cases of suspected cervical spine injury, C-spine precautions will be taken at all times3. Patent airway and ventilation should already have been established by other basic methods4. In the supine patient, insert the thumb of a gloved hand into the patient's mouth, grasping the tongue and lower jaw between the thumb and index finger, and lift upward

CAUTION: WHEN FACIAL TRAUMA HAS RESULTED IN SHARP, BROKEN TEETH OR DENTURES, REMOVE DENTURES AND EXERCISE EXTREME CAUTION WHEN PASSING THE COMBI-TUBE INTO THE MOUTH TO PREVENT THE CUFF FROM TEARING

5. With the other hand, hold the Combi-tube with the curve in the same direction as the curve of the pharynx. Insert the tip into the mouth and advance carefully until the printed ring is aligned with the teeth

CAUTION: DO NOT FORCE. IF THE TUBE DOES NOT ADVANCE EASILY, REDIRECT IT OR WITHDRAW AND REINSERT. HAVE SUCTION AVAILABLE AND READY WHENEVER WITHDRAWING TUBE.


6. If the Combi-tube is not successfully placed within 30 seconds, remove the device and hyperventilate the patient for 30 seconds using basic methods, as described in

c) above, before re-attempting insertion

e) Inflation of Combi-tube:

1. Inflate line 1, blue pilot balloon leading the pharyngeal cuff, with 100 ml of air using the 140-ml(cc) syringe (This may cause the Combi-tube to move slightly from the patient's mouth)2. Inflate line 2, white pilot balloon leading the distal cuff, with approximately 15 ml of air using the 20-ml(cc) syringe

f) Ventilation:

1. Begin ventilation through the longer blue (distal) tube. Watch for chest rise. If auscultation of breath sounds is positive, and auscultation of gastric air sounds is negative, continue ventilation2. If no chest rise, negative lung sounds, and/or positive gastric air sounds with ventilation through the distal tube, begin ventilation through the shorter clear (proximal) tube. Confirm ventilation with chest rise, presence of auscultated lung sounds, and absence of gastric air sounds3. If there is no chest rise or positive lung sounds through either tube, remove the device, hyperventilate the patient 20-30 seconds as described in c) above, and repeat the insertion/inflation/ventilation procedures4. Continue to ventilate the patient through the tube which resulted in lung sounds using a BVM or a manually-triggered oxygen delivery value5. REASSESS TUBE PLACEMENT FOLLOWING EVERY PATIENT MOVEMENT.

g) If two consecutive attempts at intermediate airway placement fail to result in a proper placement and ventilation, do not attempt placement again. Ventilate the patient using basic methods and equipment.

h) Removal of Combi-tube (at direction of Medical Control, or when attempting re- insertion, or if the patient awakens) Remove Combi-tube as follows:

1. Have suction ready2. Deflate blue tube3. Deflate white tube4. Remove Combi-tube5. Be prepared for vomiting

NOTE ON SUCTIONING THROUGH THE COMBI-TUBE: When suctioning the patient through the Combi-tube, always introduce the suction catheter through tube #2 (white). Because the Combi-tube will always be in the esophagus, most through-the-tube suctioning will be gastric suctioning and will result in decreased gastric distention. In the event that the Combi-tube is in the trachea, suctioning of the patient's airway will result.

CONTINUE CPR AND VENTILATION AS APPROPRIATE DURING TRANSPORT, AND CONTACT MEDICAL CONTROL FOR DIRECTION


NOTE: PARAMEDICS ATTEMPTING NEEDLE DECOMPRESSION OR CRICOTHYROTOMY MUST BE CURRENTLY CERTIFIED IN PRE-HOSPITAL TRAUMA LIFE SUPPORT (PTLS) OR BASIC

TRAUMA LIFE SUPPORT (BTLS), OTHERWISE CONTACT MEDICAL CONTROL

NEEDLE DECOMPRESSION(Paramedics Only)

Chest decompression should be performed via needle thoracentesis immediately following the identification of a tension pneumothorax.

The procedure should be performed as follows:1. Prep site if time permits.2. Insert large gauge angiocath (16G or 14G) attached to a syringe with the plunger pushed fully in.3. Locate the second intercostal space in the mid-clavicular line on the affected side.4. Insert the needle and catheter OVER the rib and into the thorax.5. Pull back on the syringe plunger to confirm the presence of air in the pleural space6. Remove the syringe and advance the catheter.7. Continuously re-assess the patient's respiratory status.

CRICOTHYROTOMY(Paramedics Only)

Indications: Unable to provide adequate oxygenation and unable to intubate by another route. This may be seen with cervical spine injuries, maxillofacial trauma, laryngeal trauma, and oropharyngeal obstruction (infectious swelling, allergic reaction, inhalation burns, foreign body, and mass lesions).

Risks/Complications: Bleeding, infection, voice change, persistent stoma, obstructive problems, misplacement of the airway.

NEEDLE CRICOTHYROTOMY PROCEDURE:1. Identify cricothyroid membrane (small depression immediately inferior to the thyroid cartilage

and superior to the cricoid cartilage).2. Prep the area with antiseptic solution.3. Insert 14G angiocath connected to a syringe at a 45-degree angle caudally (aim towards the feet)

through the cricothyroid membrane while pulling back on the syringe plunger. Entrance of air into the syringe indicates the needle is in the trachea.

4. Advance the catheter over the needle into the trachea.5. Begin ventilating with a positive pressure device. Watch for chest rise, release pressure, and

allow passive exhalation.

SURGICAL CRICOTHYROTOMY PROCEDURE:1. Identify cricothyroid membrane (small depression immediately inferior to the thyroid cartilage

and superior to the cricoid cartilage).2. Prep the area with antiseptic solution.3. Make a 2-3 cm vertical skin incision over the cricothyroid membrane. Once the membrane is

exposed, make a 1.5-cm horizontal incision through the membrane into the trachea (maintain a slight caudal direction with the blade to avoid vocal cord damage).

4. Use forceps to spread open the membrane (may use the blunt end of the scalpel and twist to open the membrane if time does not allow for proper equipment).

5. Insert appropriate sized ET tube (6mm), advance caudally 3-4 cm, and inflate cuff.6. Confirm tube placement (auscultate breath sounds, monitor pulse oximetry, and CO2 detector (if

available)).7. Secure tube in place.EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 67

ALTERNATIVE MEDICATION ROUTES

Endotracheal route of administration is not considered to be the preferred route for drugs, but can be considered when intravenous or interosseous access cannot be established.

The following drugs are permitted to be administered via the endotracheal tube:

Narcan Atropine Epinephrine Lidocaine

No drug, other than those listed on this page, can be administered via the endotracheal tube route. If in question, contact Medical Control

A previously established surgical tracheal opening may also be used in place of the endotracheal tube.

Medications should be administered at two (2) times the IV dosage and diluted with 10 ml of saline or sterile water before administration.

PROCEDURE:

1. Remove needle from syringe2. Hyperventilate patient and make sure ET tube and airway are clear of mucous3. Disconnect ventilation device from tube and squirt medication rapidly into tube4. Reconnect ventilation device and rapidly ventilate patient to assure passage of medication down tube and airway

SPECIAL NOTE: DO NOT TAKE LONGER THAN 15 SECONDS TO ADMINISTER MEDICATION IN ORDER TO PREVENT HYPOXIA OF THE PATIENT


ASSISTING WITH MEDICATION ADMINISTRATION

First responders and Basic EMTs may assist patients in taking their medications under certain conditions. These conditions are as follows:

The medication must be prescribed for the patient currently being treated. The medication container must bear the name of the patient being treated

The medication must not be expired

Medications in unmarked containers (pill boxes, etc.), containers that do not bear the patient's name, or containers where the patient's name is altered should not be administered

First responders may ONLY assist a patient in taking medication that has been prescribed for the patient being treated.

An EMT-Basic may additionally administer:

Four (4) 81-mg chewable baby aspirin (total of 324 mg)

DUE TO COMMON ALLERGIES, USE ONLY ORANGE FLAVORED CHEWABLE BABY ASPIRIN

One (1) adult aspirin (325 mg) to patient suspected of having cardiac-related chest pain or discomfort.


CERVICAL SPINE (C-SPINE) IMMOBILIZATION

IMPORTANT

A complete assessment of the patient's C-spine MUST be done. Lack of verbal complaint of neck and/or back pain is not sufficient reason for eliminating cervical spine and spinal immobilization:

Full C-Spine immobilization MUST include: C-Collar (appropriate size for patient) Backboard with straps at shoulders, hips, lower legs Head immobilization blocks or other CIM device

GUIDELINES:

Apply cervical collar/immobilize if:

1. Any complaint of neck pain, back pain, or pain on palpation of same areas with a history of recent trauma (watch patient's face for grimace)

2. Knowledge or suspicion of ethanol/drugs on board

3. History of loss of consciousness or altered level of consciousness related to injury

4. Any co-existing distracting injury or pain (for example, head, chest, abdomen, long bone fracture)

5. Any patient with a mechanism of injury worrisome for cervical spine injury, including:

Falls Blow to the head Ejection from motor vehicle Severe deformity of motor vehicle or extrication required Struck by motor vehicle with speed greater than 20 mph Near-drowning patient Death of another person in same vehicle


CONSCIOUS SEDATION(Paramedics Only)

Monitoring of Patients During Conscious Sedation:

1. Place the patient on a cardiac monitor If the patient becomes hypotensive, administer a fluid bolus per protocol

2. Closely monitor patient's respiratory effort and effectiveness If the patient's respiratory effort or effectiveness decreases significantly, or if

the patient becomes apneic, immediately begin ventilatory assistance Consider intubating the patient

3. Monitor patient's O2 saturation via pulse oximetry

Conscious Sedation for Patients to be Cardioverted:

1. Secure and protect patient's airway2. Administer oxygen as is appropriate for the patient's condition3. Establish IV 0.9% NaCl (normal saline) and run at TKO4. Administer 2 mg of Versed IV push as an initial dose to induce amnesia

(Do NOT give if SBP < 100) May repeat dose once in 5 minutes as needed. Pediatric Versed 0.1 mg/kg slow IV/IO (max 2 mg IV/IO)

5. Contact Medical Control for any additional dosages

Adjunct to Intubation for Conscious Patients:

1. Secure and protect patient's airway2. Administer oxygen as is appropriate for the patient's condition3. Establish IV 0.9% NaCl (normal saline) and run at TKO4. Administer 2 mg of Versed IV push as an initial dose

(Do NOT give if SBP < 100) May repeat dose once in 5 minutes as needed. Pediatric Versed 0.1 mg/kg slow IV/IO.

5. Contact Medical Control for any additional dosages


EXTERNAL PACEMAKER

DO NOT DELAY OTHER THERAPIES SUCH AS AIRWAY CONTROL, MEDICATION, OR CPR TO INSTITUTE EXTERNAL PACING

INDICATIONS:

An external pacemaker may be used to treat patients with bradycardia (or other conditions at the discretion of the on-line Medical Control physician

External pacemakers are indicated as the first line of therapy associated with second degree heart block Mobitz II and third degree heart block when a pulse is present

External pacing may also be indicated for the treatment of sinus bradycardia or ventricular rhythms < 60 bpm unresponsive to atropine if the patient is symptomatic with chest pain, shortness of breath, or hypotension when a pulse is present

APPLICATION:

For conscious patients with bradycardia, set the rate at 70 bpm and current at 20 mA initially. Increase the amperage by 20 mA every 10 seconds until capture is obtained

For unconscious patients with bradycardia, set the rate at 100 bpm and 200 mA (after capture, may titrate down to maintain the lowest voltage maintaining capture)

Once electrical capture is obtained, check for mechanical capture (a pulse)

On-line Medical Control consultation is indicated for all pediatric patients prior to using an external pacemaker

Remove nitroglycerin patches prior to using an external pacemaker


HEIMLICH MANEUVER

CONSCIOUS, NON-OBESE, ACCESSIBLE ADULT VICTIM. A choking victim can't speak or breathe and needs your help immediately. Never slap the victim's back, as this may make matters worse. Follow these steps to help an adult choking victim:

1. From behind, wrap your arms around the victim's waist.2. Make a fist and place the thumb side of your fist against the victim's upper abdomen, below the ribcage and above the navel.3. Grasp your fist with your other hand and press into their upper abdomen with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands.4. Repeat until object is expelled.5. Transport for evaluation immediately after rescue.

UNCONSCIOUS ADULT VICTIM OR WHEN RESCUER CANNOT REACH AROUND VICTIM.

1. Place the victim on his/her back and, facing the victim, kneel astride their hips. 2. With one of your hands on top of the other, place the heel of your bottom hand on the

upper abdomen below the rib cage and above the navel.3. Use your body weight to press into the victim's upper abdomen with a quick upward thrust. Repeat until the object is expelled.4. If the victim has not recovered, proceed with CPR.5. Transport for evaluation immediately after rescue.

INFANT VICTIM. Never slap the victim's back, as this may make matters worse. Follow these steps to help a choking infant:

1. Lay the child down, face up, on a firm surface and kneel or stand at the victim's feet, or hold infant on your lap facing away from you.

2. Place the middle and index fingers of both of your hands below the victim's rib cage and above their navel. 3. Press into the victim's upper abdomen with a quick upward thrust; do not squeeze the rib cage. Be very gentle. 4. Repeat until object is expelled.5. Transport for evaluation immediately after rescue.


INTEROSSEOUS INFUSION

INDICATIONS: To establish parenteral means to administer fluids, blood products and parenteral medications,

and to draw blood (except for CBCs) May be used in any instance that an IV route would be appropriate Its use should be considered after two IV attempts have failed or if no peripheral IV sites are

found This procedure is indicated primarily in children

CONTRAINDICATIONS: Osteomyelitis or cellulitis over the proposed site Fracture at or above the proposed site Previous IO attempt at the proposed site

RISKS: Subcutaneous infiltration Osteomyelitis Subcutaneous infections Growth plate damage

PROCEDURE:

1. Prepare as for a surgical procedure, using sterile technique

2. Attempt to have feet in flexed position against board or sandbag

3. The preferred site is the proximal anteromedial tibia, 1-3 cm below the tibial tuberosity. Secondary site is the distal femur, midline, 3 cm above condyle

4. With a steady push and/or rotary motion, push needle through subcutaneous tissue and bone until a drop or pop is felt

5. Once the needle has reached the bone marrow, saline should be injected via syringe to clear needle and then aspiration should be attempted. The infusion should flow freely without evidence of subcutaneous infiltration

6. The needle should feel firm in position and stand upright without support

7. Infusion via this route is the same as venous access without limit to rate of administration, drugs pushed, or fluid type infused

8. After removing needle (for successful or unsuccessful attempt), apply pressure to area for five minutes and apply dressing to area


INTRAVENOUS THERAPY

GUIDELINES: Intravenous cannulation is restricted to the following sites:

Dorsum of the hands, wrists, forearm, and antecubital fossa Long saphenous vein at the medial malleolus

(antecubital vein is the site of first choice during cardiac arrests and trauma) Trauma fluid resuscitation: Bolus of 20 ml/kg NS infused using a macrodrip set via a large-bore

angiocatheter (14-18G) Rapid infusion, reassessment, repeat bolus as indicated (should be initiated while en route to the medical facility, excluding cases of entrapment or difficult extrication)

A TKO or KVO infusion rate for non-resuscitation situations is set at 10 ml/hr (1 drop every 6 seconds when using a macrodrip administration set)

Utilize the saline-lock for intravenous cannulation when appropriate (refer to protocols)

GENERAL CONSIDERATIONS: IVs will be started by the EMT-Intermediate and/or the Paramedic ONLY IV placement must NOT delay transport of any critical patient Generally, no more than two (2) attempts or more than five (5) minutes should be spent

attempting an IV. If unable to initiate an IV line, transport patient and notify hospital that IV was not able to be started

Blood draws for hospital laboratory testing will not be required under this protocol

IV SOLUTION:0.9% sodium chloride will be the only fluid used in the pre-hospital setting under this protocol.

MECHANICS FOR STARTING A PERIPHERAL IV:1. Prepare equipment2. The initial attempt should be the dorsum of the hand. Further attempts should proceed to the forearm (antecubital fossa for cardiac arrests/trauma/critical patients)3. Apply tourniquet4. Cleanse site with alcohol5. First attempt at insertion on an adult patient should be:

a) 16G IV catheter for trauma patientsb) 18G IV catheter for medical patients

6. Puncture the skin with the bevel of the needle upward. Note blood return and advance catheter into the vein7. Attach IV tubing8. Secure IV using appropriate measures to insure stability of the line9. Check for signs of infiltration10. Adjust flow rate

Document All IV Attempts Document all IV Medications Administered1. Time IV was started/attempted 1. Name of medication2. Size of catheter or needle used 2. Dosage given3. Location of IV site 3. Time given4. Type and amount of solution infused 4. Initial of EMT who administered medication5. Initial of EMT who attempted/started IV


PAIN MANAGEMENT(Paramedics Only)

Pain management in the pre-hospital setting should be limited to patients with moderate to severe pain. Paramedic must always consider the type of pain, the patient's overall condition, allergies, co-existing medical conditions, and drug contraindications when deciding if pain management is appropriate and which pain medication should be administered.

Guidelines as to which medication is most appropriate for specific situations are outlined below. (refer to pharmacologic protocol for complete drug information)

Morphine 2-5mg IV, may repeat dose once as needed (HOLD if SBP<100) for:

Flank Pain Trauma patient Burns Chest pain/angina

Toradol 30 mg IV or 60 mg IM (<60 y/o), 15 mg IV or 30 mg IM (>60 y/o) for:

Focal extremity injury Burns Low back pain/strains (without trauma)

*NEVER use Toradol in trauma patient*NEVER use Toradol in patient with history of ulcers/GI bleeding*NEVER use Toradol in patients on anticoagulation therapy (Coumadin, Lovenox)*NEVER use Toradol in patient who may be Pregnant

DO NOT TREAT THE FOLLOWING WITH PAIN MANAGEMENT IN THE FIELD:

Headaches (Toradol increases risk of bleeding, morphine may induce sedation/AMS obscuring exam)

Abdominal Pains (Toradol increases risk of bleeding, morphine may obscure good abdominal exam)

Eye Pains (Toradol increases risk of bleeding, morphine increases eye pressure) Mild/Nonemergent Pain Syndromes (i.e., dental pain, body aches, chronic pain)

IF IN DOUBT, CONTACT MEDICAL CONTROL FOR DIRECTION. *EMT-INTERMEDIATES MAY CONTACT MEDICAL CONTROL FOR PERMISSION TO ADMINISTER

MORPHINE FOR TRAUMA PATIENTS


IV. PHARMACEUTICAL PROTOCOLS


USE OF PHARMACOLOGICAL AGENTS

EXTREMELY IMPORTANT

More than 7,000 people die each year due to medication mistakes. There are an ever-increasing number of over-the-counter-drugs, prescription drugs, and elicit drugs available to the public. When we are called to render aid to people in a healthcare crisis, we are placed in a position of making what could be a life or death decision. For this reason, today's EMT, especially Paramedics who may administer a number of medications while operating under the medical authority of St. Joseph Health Center, need to keep their knowledge of medications up-to-date.

The drug boxes carried in the EMS unit contain a number of medications. Before administering any medication, the Paramedic should know:

- What is the drug being used?- What class or category is this drug in?- Does the patient have an allergy to this drug?- What is the safe and effective dosage?- What are its indications (Why are you using it)?- What are its contraindications (Why or when would you NOT use it)?- What are its effects (What does it do, and how does it act)?- What are its adverse effects (Will it harm the patient and in what ways)?- What are its side effects (Will the patient sense heat, cold, nausea, etc.)?- What is the date on the medication container/is the drug outdated?- Is the fluid you are using clear or cloudy?

USE OF A MEDICATION SIMPLY BECAUSE IT IS IN THE PROTOCOL IS NOT AN ACCEPTABLE STANDARD OF MEDICAL CARE. WHEN THERE ARE QUESTIONS ABOUT MEDICATION ADMINISTRATION, CONSULT

WITH THE MEDICAL CONTROL AT THE RECEIVING HOSPITAL


ACTIVATED CHARCOAL (ACTIDOSE)

CONTACT POISON CONTROL OR ON-LINE MEDICAL CONTROL PRIOR TO ADMINISTRATION OF ACTIVATED CHARCOAL

THERAPEUTIC EFFECTS:Activated charcoal binds and absorbs ingested toxins present in the gastrointestinal tract. Once bound to the activated charcoal, the combined complex is excreted from the body

INDICATIONS: Ingested poisons and medication overdoses

CONTRAINDICATIONS: Activated charcoal should not be administered to the patient who has, or has the potential for, an

altered level of consciousness unless administered by NG tube and the airway protected by an ET tube

Avoid use in cyanide, methanol, organophosphate toxicity, and/or caustic ingestion

SIDE EFFECTS:Gastrointestinal: Nausea, vomiting, abdominal cramping/bloating, and constipation (black stools)

HOW SUPPLIED AND ADMINISTERED:25 g bottle

ADULT DOSAGE:1 gm/kg (average 50-75 gm) PO of activated charcoal mixed with a glass of water to form a slurry

PEDIATRIC DOSAGE:1 gm/kg PO of activated charcoal mixed with a glass of water to form a slurry


ADENOCARD (ADENOSINE)

THERAPEUTIC EFFECTS:Adenosine slows conduction time and can interrupt the re-entry pathways through the AV node, and is the drug of choice to restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT). The half life is estimated to be less than 20 seconds. In controlled clinical trials, 92% of patients with PSVT were converted after a bolus dose of 12 mg. It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity. Adenosine can be used diagnostically for stable, wide-complex tachycardias of unknown type after two doses of lidocaine. It is not effective in converting rhythms other than PVST, such as atrial flutter, atrial fibrillation, or ventricular tachycardia.

INDICATIONS: Conversion of PSVT to sinus rhythm

CONTRAINDICATIONS: Second or third degree AV block (except in patients with a functioning artificial pacemaker) Sick-sinus syndrome (except in patients with a functioning artificial pacemaker) Hypersensitivity to adenosine

SIDE EFFECTS:Central Nervous System: Lightheadedness, dizziness, paresthesia, tingling, numbnessCardiovascular: Hypotension, sweating, palpitations, chest pain, headacheGastrointestinal: Nausea, tightness in throat, metallic tasteRespiratory: Shortness of breathSkin: Facial flushing

HOW SUPPLIED AND ADMINISTERED:6 mg/2 ml and 12 mg/4 ml vials or prefilled syringes

ADULT DOSAGE:Initial Dose: 6 mg rapid IVP (over 1-3 sec) immediately followed with 20 cc rapid saline flushRepeat Dose: If not response after 1-2 min, administer 12 mg rapid IVP (over 1-3 sec) immediately followed with 20 cc saline flush

PEDIATRIC DOSAGE:Initial Dose: 0.1 mg/kg rapid IVP followed with a 10 cc saline flush (max 6 mg)Repeat Dose: If not response after 1-2 min, administer 0.2 mg/kg rapid IVP followed with 10 cc saline flush (max 12 mg)


ALBUTEROL (PROVENTIL / VENTOLIN)

THERAPEUTIC EFFECTS:Primarily is a beta-2 sympathomimetic that produces bronchodilatation/dilates smooth muscle. Because of its greater specificity for beta-2 adrenergic receptors, it produces fewer cardiovascular side effects and more prolonged bronchodilatation than Isuprel. Onset is within 15 minutes; peaks in 60-90 minutes. Therapeutic effects may be active up to 5 hours.

INDICATIONS: Nebulized albuterol is indicated for relief of bronchospasm in patients with reversible

obstructive airway disease, including asthma Shortness of breath caused by bronchoconstriction May help transiently decrease potassium levels in patients with hyperkalemia

CONTRAINDICATIONS: Allergy to drug/hypersensitivity Excessive prior use of beta stimulants Shortness of breath not from bronchoconstriction

WARNINGS / PRECAUTIONS: Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and

diabetes Epinephrine should not be used at the same time as albuterol; however, either may be used

subsequent to a failure of the other Beta-blockers and albuterol will inhibit each other

SIDE EFFECTS:Central Nervous System: Nervousness, weakness, tremor, headache, insomnia, dizzinessCardiovascular: Increased heart rate, angina, hypertension, tachycardiaGastrointestinal: Drying of oropharynx, nausea, vomiting, unusual taste

HOW SUPPLIED AND ADMINISTERED:3 ml unit dose (2.5 mg vial albuterol sulfate/3 ml)

ADULT DOSAGE:Initial Dose: 2.5 mg in N/S via aerosol device with oxygen at 8 liters per minute

PEDIATRIC DOSAGE:If >1 year or >10 kg: Add 2.5 mg of albuterol mixed in 3 ml of NS (0.083%) to nebulizer and flow oxygen at 6-8 liters/min for 5-15 minutes

If <1 year or <10 kg: Add 1.25 mg of albuterol mixed in 1.5 ml of NS (0.083%) to nebulizer and flow oxygen at 3 liters/min for 5-15 minutes


AMIODARONE (CORDARONE)

THERAPEUTIC EFFECTS:Amiodarone blocks sodium channels at rapid pacing frequencies and exerts a noncompetitive antisympathetic action. One of its main effects, with prolonged administration, is to lengthen the cardiac action potential. Amiodarone also blocks myocardial potassium channels, which contributes to slowing of conduction and prolongation of refractoriness. The antisympathetic action and the blocking of calcium and potassium channels are responsible for its effect on slowing conduction and prolongation of refractoriness in the atrioventricular (AV) node. Its vasodilatory action can decrease cardiac workload and consequently myocardial oxygen consumption.

INDICATIONS: Indicated for the treatment and prophylaxis of frequently recurring ventricular fibrillation and

hemodynamically unstable ventricular tachycardia in patient refractory to other therapy Amiodarone may also be used to treat supraventricular tachycardia

CONTRAINDICATIONS: Contraindicated in severe sinus-node dysfunction, causing marked sinus bradycardia; second

and third-degree atrioventricular block; and when episodes of bradycardia, have caused syncope Contraindicated in patients with a known hypersensitivity to the drug Contraindicated in patients with cardiogenic shock

WARNINGS / PRECAUTIONS:May worsen existing, or precipitate new, dysrhythmias, including torsades de pointes and VF. Using with beta-blocking agents could increase the risk of hypotension and bradycardia. Amiodarone inhibits atrioventricular conduction and decreases myocardial contractility, increasing the risk of AV block with verapamil or diltiazem, or of hypotension with any calcium channel blocker. Use with caution in pregnancy and with nursing mothers.

SIDE EFFECTS:Cardiovascular: Hypotension is the most common adverse effect seen with amiodarone IV. May precipitate if combined in the same IV line with sodium bicarbonate. Also,

bradycardia, congestive heart failure, cardiac arrest, ventricular tachycardiaGastrointestinal: NauseaSystemic: Fever, abnormal liver function

HOW SUPPLIED AND ADMINISTERED:150 mg/3 ml vial

ADULT DOSAGE:Recurring VF and pulseless VT: 300 mg peripheral IV push rapid infusion

Stable VT with pulse and SVT (adequately perfusing): Amiodarone 150 mg IV in 50 ml D5W over first 10 minutes (15 mg/min to minimize the potential for hypotension) for monomorphic ventricular tachycardia patients with AMI if the VT is not accompanied by hypotension or altered mental status. May repeat every 10 minutes prn.

PEDIATRIC DOSAGE:VF and pulseless VT: 5 mg/kg IV/IO push

Stable VT with pulse and SVT (adequately perfusing): Amiodarone 5 mg/kg in 50 ml D5W IV/IO over 20 minutes


ASPIRIN

THERAPEUTIC EFFECTS:Aspirin is an analgesic, anti-inflammatory, and anti-pyretic, which also appears to cause an inhibition of synthesis and release of prostaglandins. Aspirin also blocks formation of thromboxane A-2, which causes platelets to aggregate and arteries to constrict, therefore aspirin inhibits vasoconstriction and decreases the likelihood of thrombosis, preventing blood clot formation specifically in the coronary arteries. It also reduces overall mortality from acute myocardial infarction.

INDICATIONS: Cardiac-related chest pain Chest pain consistent with acute myocardial infarction following the administration of

nitroglycerin to prevent further clotting

CONTRAINDICATIONS: Active GI ulceration or bleeding Hemophilia, active bleeding (i.e., blood in stools or melena), or other bleeding disorders Pregnancy Trauma Aspirin hypersensitivity/known allergy (e.g., asthma) Children under 2 years of age Chicken pox or flu symptoms in children or teenagers (Reye's Syndrome)

SIDE EFFECTS:Cardiovascular: With hypersensitivity, tightness in chestGastrointestinal: GI bleeds, nausea, vomiting, heartburn, blood loss, gastritis, esophagitis, and

stomach painGenitourinary: Nephropathy, renal function abnormalitiesHematologic: Blood loss and inhibition of platelet aggregation have been reportedHypersensitivity: Anaphylaxis, tightness in chest, urticaria, angioedema, bronchospasmOther: Hepatotoxicity, anaphylaxisOTIC: Tinnitus, hearing lossRespiratory: With hypersensitivity, bronchospasm and anaphylaxisSkin: With hypersensitivity, urticaria/hives and angioedema

HOW SUPPLIED AND ADMINISTERED:81 mg tablets for oral use or 325-mg coated tablets

ADULT DOSAGE:160-325 mg chewable upon onset of cardiac signs or symptoms (high doses may interfere with the benefits of aspirin)

PEDIATRIC DOSAGE:DO NOT USE. Caution is advised with use of the drug in children and adolescents with viral illnesses due to the possible association with an increased risk of Reye's syndrome


ATROPINE SULFATE AS ANTIDOTE FOR POISONINGS

THERAPEUTIC EFFECTS:Atropine is a potent parasympathetic blocker that binds to acetylcholine receptors, thus diminishing the actions of acetylcholine

INDICATIONS: Anticholinesterase syndrome poisoning such as organophosphate (e.g., parathion, malathion,

rid-a-bug) and carbamate (Baygon, Sevin, and many common roach and ant sprays). Signs of organophosphate poisoning are:

Salivation, Lacrimation, Urination, Defecation, GI Distress, Emesis, pinpoint pupils, bradycardia, and excessive sweating

CONTRAINDICATIONS:None when used in the management of severe organophosphate poisoning

WARNINGS / PRECAUTIONS: It is important that the patient be adequately oxygenated and ventilated prior to using atropine, as atropine may precipitate ventricular fibrillation in a poorly oxygenated patient. Even after atropine is administered, the patient may require intubation and aggressive ventilatory support

SIDE EFFECTS:Victims of organophosphate poisoning can tolerate large doses (1000 mg) of atropine. Signs of atropinization are the end point of treatment.

Cardiovascular: Tachycardia, headache, flushing of skinEyes: Pupil dilation, blurred visionGastrointestinal: Dry mouth, thirst

HOW SUPPLIED AND ADMINISTERED:Prefilled syringes containing 1 mg in 10 ml. Autoinjector 2 mg. For organophosphate poisoning, a combination of IV and IM administration is commonly used.

ADULT DOSAGE:2 mg IM and 1 mg IV (0.03 mg/kg IV), repeat every 5-10 minutes until atropinization with decreased secretions occurs

PEDIATRIC DOSAGE:0.05 mg/kg (max 3 mg) IV, repeat every 5-10 minutes until atropinization occurs


ATROPINE SULFATE AS CARDIAC AGENT

THERAPEUTIC EFFECTS:Atropine is a potent anticholinergic (parasympathetic blocker) that by blocking parasympathetic (vagal) action on the heart, increases the rate of discharge by the sinus node, enhances conduction through the AV junction, and accelerates the heart rate, thereby improving cardiac output. In addition, by speeding up a slow heart to a normal rate, atropine reduces the chances of ectopic activity in the ventricles and thus of ventricular fibrillation. Atropine is most effective in reversing bradycardia due to increased parasympathetic tone or to morphine; it is less effective in treating bradycardias due to actual damage to the AV or SA node.

INDICATIONS: Sinus bradycardia when accompanied by hemodynamic compromise (SBP < 90 mmHg,

confusion, frequent PVCs, pale and cold clammy skin) In infants, bradycardia of less than 80 bpm should be treated even if BP is normal In some cases of asystole to remove any type of heart block Symptomatic second-degree and third-degree AV heart blocks when accompanied by

bradycardia (consider external pacing)

CONTRAINDICATIONS: Atrial flutter or atrial fibrillation where there is a rapid ventricular response Glaucoma – narrow angle Use with caution in myocardial infarction

WARNINGS / PRECAUTIONS: Too small of a dose (<0.5 mg) or if normal dose pushed too slowly, may initially cause heart rate to decrease. Antihistamines and antidepressants potentiate atropine. A maximum dose of 0.04 mg/kg should not be exceeded. Excessive doses may precipitate ventricular tachycardia or fibrillation

SIDE EFFECTS:Cardiovascular: Increased heart rate, may worsen ischemia or increase area of infarction, ventricular fibrillation, ventricular tachycardia, angina, flushing of skinCentral Nervous System: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and headacheEyes: Worsened pre-existing glaucomaGastrointestinal: Dry mouth, thirst, difficulty swallowingGenitourinary: Urinary retention

HOW SUPPLIED AND ADMINISTERED:Prefilled syringes containing 1 mg in 10 ml. In the field, atropine is usually given intravenously for bradycardia. In resuscitation from cardiac arrest, if an intravenous route cannot be established, atropine may be given through the endotracheal tube

ADULT DOSAGE:Bradycardias: 0.5-1 mg IV, or 1-2 mg ET diluted in 10 ml NS, may repeat every 5 minutes until

improved/desired heart rate is achieved or total of 0.04 mg/kg or 3 mg is reachedAsystole: 1 mg IV or 2 mg ET diluted in 10 ml NS, repeat every 5 minutes if asystole persists

to a total dose of 0.4 mg/kg or 3 mg

PEDIATRIC DOSAGE:0.02 mg/kg IV, IO, or ET diluted in 10 ml NS. In pediatric bradycardia, 0.02 mg/kg dose may be repeated 1 time. Minimum dose is 0.1 mg, maximum single dose is 0.5 mg in a child, and maximum total dose is 1 mg in a child and 2 mg in an adolescent. EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 85

DEXTROSE 50% (D50) and 25% (D25)THERAPEUTIC EFFECTS:A monosaccharide, which provides calories for metabolic needs, spares body proteins and loss of electrolytes. Readily excreted by kidneys, acting transiently as an osmotic diuretic. Restores circulating blood sugar levels to normal in states of hypoglycemia. Hypertonic solution.

INDICATIONS: Hypoglycemia (blood sugar < 70 with Glucometer in symptomatic patients) Coma caused by hypoglycemia or of unknown origin Status epilepticus of uncertain cause Some cases of refractory cardiac arrest

CONTRAINDICATIONS: Presumed intracranial or intraspinal hemorrhage Cerebral ischemia (i.e., cardiac arrest, stroke) DTs with dehydration Blood glucose level > 80 mg/dl

WARNINGS / PRECAUTIONS: May cause Wernicke-Korsakoff syndrome in acute alcohol intoxication – usually this is prevented by prior administration of thiamine 100 mg IM or IV. Perform a glucose test (if possible) and draw a blood sample (red top tube) prior to administering dextrose.

SIDE EFFECTS:Central Nervous System: D50 may precipitate severe neurologic symptoms in alcoholics (For this

reason, when given to an alcoholic, should be accompanied by thiamine, 100 mg IV and 100 mg IM, which will prevent this neurologic syndrome)

Cardiovascular: Thrombosis, sclerosing if given in peripheral veinLocal: Tissue irritation or necrosis if infiltrates (should therefore be given only

through a good, rapidly flowing IV line)Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia

HOW SUPPLIED AND ADMINISTERED:Prefilled syringes and vials containing 10 ml of 25% dextrose (= 2.5 g of dextrose) or 50 ml of 50% dextrose (= 25 g of dextrose). Administered intravenously through a free-flowing IV line, preferably in a large vein. If possible, draw blood for serum glucose determinations before administering the dextrose.

ADULT DOSAGE (> 8 years of age and over 50 pounds):50 ml of 50% dextrose (25 g) solution as bolus IV. If conscious, glucose may be given orally (25 g)

PEDIATRIC DOSAGE:D50: 1 ml/kg of a 50% solution (25 g) IV in children > 50 poundsD25: 2 ml/kg slow IV of a 25% solution in children < 50 pounds (D25 is made by diluting D50 with equal volume (1:1 solution) of saline or sterile water) Newborn dose: 5 ml/kg IV of 10% solution (dilute D50 4:1 with NS)


DIAZEPAM (VALIUM)

THERAPEUTIC EFFECTS:A member of the benzodiazepine family, Diazepam depresses the limbic system, thalamus, and hypothalamus, resulting in calming and amnesic effects. It is also a muscle relaxant.

INDICATIONS: Status epilepticus Premedication prior to cardioversion Agitation due to acute alcohol withdrawal Short-term relief of acute anxiety Eclampsia Seizures associated with hyperthermia Cocaine intoxication Severe muscle spasm due to acute back strain

CONTRAINDICATIONS: Acute alcohol intoxication Pregnancy (except for control of seizures associated with status epilepticus or eclampsia) Neonates

WARNINGS / PRECAUTIONS: Do not mix Diazepam with any other solutions or drugs. When injecting IV, administer slowly through the IV tubing as close as possible to the vein

insertion to prevent precipitation with the IV fluid Do not administer into small veins such as those on dorsum of the hand – causes local irritation

and possibly venous thrombosis in small veins

SIDE EFFECTS:Central Nervous System: Confusion, muscular weakness, blurred vision, drowsiness, respiratory

depression, respiratory arrest, slurred speechCardiovascular: Bradycardia, hypotension, and cardiovascular collapseGastrointestinal: Nausea, vomiting, abdominal discomfort, hiccupsOther: Potentiates MAOs, barbiturates, tricyclics, and phenothiazines. Potentiated by Cimetidine, ETOH, and other CNS depressants

HOW SUPPLIED AND ADMINISTERED:Prefilled syringes containing 10 mg/2 ml

ADULT DOSAGE:2-10 mg IV, IM, or rectal. IV route should be administered slowly – no faster than 5 mg/min

PEDIATRIC DOSAGE:Status epilepticus 0.1-0.2 mg/kg (max 5 mg) IV route should be administered slowly – no faster than 1 mg/min.

For patients < 2 years of age and IV access has not been obtained, administer Valium rectally. Draw up 0.5 mg/kg of Valium in tuberculin syringe. Lubricate end of syringe (without needle) and insert into rectum past sphincter, 1-2 inches (often done most easily with child recumbent). The total does should not exceed 5 mg.


DIPHENHYDRAMINE HCL (BENADRYL)

THERAPEUTIC EFFECTS:Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Diphenhydramine prevents, but does not reverse histamine-mediated responses, particularly histamine effects on the smooth muscle of the bronchial airways, gastrointestinal tract, uterus, and blood vessels.

INDICATIONS: Allergy symptoms, anaphylaxis (as an adjunct to epinephrine) Sedation of violent patient Dystonic reactions from phenothiazine overdose (e.g., Haldol, Compazine, Thorazine, and

Stelazine)

CONTRAINDICATIONS:Diphenhydramine is not to be used in newborn or premature infants or in nursing mothers. Diphenhydramine is also not to be used in patients with lower respiratory tract symptoms, including asthma

WARNINGS / PRECAUTIONS: In infants and children especially, antihistamines in overdose may cause hallucinations,

convulsions, or death As in adults, antihistamines may diminish mental alertness in children In young children, may produce excitation Diphenhydramine has additive effects with alcohol and other CNS depressants Antihistamines are more likely to cause dizziness, sedation, and hypotension in the elderly (60

years or older) patient

SIDE EFFECTS:Central Nervous System: Drowsiness, confusion, insomnia, headache, vertigo (all especially in the

elderly)Cardiovascular: Palpitations, tachycardia, PVCs, and hypotensionRespiratory: Thickening of bronchial secretions, tightness of the chest, wheezing,

nasal stuffinessGastrointestinal: Nausea, vomiting, diarrhea, dry mouth, and constipationGenitourinary: Dysuria, urinary retention

HOW SUPPLIED AND ADMINISTERED:50 mg diphenhydramine HCL in 1 ml ampules

ADULT DOSAGE:25-50 mg IV or deep IM.

PEDIATRIC DOSAGE:1 mg/kg IV or IM (max 50 mg). Dilute with 9 ml NS to equal 50 mg/10 ml.


DOPAMINE HCL

THERAPEUTIC EFFECTS:Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the sympathetic nervous system. It exerts an inotropic effect on the myocardium, resulting in an increased cardiac output. Dopamine produces less increase in myocardial oxygen consumption than does isoproterenol and its use is usually not associated with a tachyrhythmia. Dopamine dilates renal and mesenteric blood vessels at low doses that may not increase heart rate or blood pressure. Therapeutic doses have predominant beta adrenergic receptor stimulating actions that result in increases in cardiac output without marked increases in pulmonary occlusive pressure. At high doses, Dopamine has alpha receptor stimulating actions that result in peripheral vasoconstriction and marked increases in pulmonary occlusive pressure.

INDICATIONS: To treat shock Correct hemodynamic imbalances Improve perfusion to vital organs Increase cardia output

CONTRAINDICATIONS:Dopamine should not be used in patients with pheochromocytoma or hypovolemic shock.

WARNINGS / PRECAUTIONS: Do not administer Dopamine in the presence of uncorrected tachyarrhythmias or ventricular

fibrillation Do not add Dopamine to any alkaline dilatant solution since the drug is inactivated in alkaline

solution Patients who have been treated with monoamine oxidase (MAO) inhibitors will require

substantially reduced dosages (MAO inhibitors include furazolidone (Furoxone), isocarboxazid (Marplan), pargyline hydrochloride (Eutonyl), pargyline hydrochloride with methyclothiazide (Eutron), phenelzine sulfate (Nardil), procarbazine hydrochloride (Matulane), tranylcypromine sulfate (Parnate))

SIDE EFFECTS:Central Nervous System: HeadacheCardiovascular: Ectopic beats, tachycardia, anginal pain, palpitations, hypotensionGastrointestinal: Nausea, vomitingRespiratory: DyspneaLocal: Necrosis and tissue sloughing with extravasationSkin: Piloerection

HOW SUPPLIED AND ADMINISTERED:10 ml ampules containing 400 mg

ADULT DOSAGE:Begin infusion at 5 mcg/kg/min (400 mg in 250 ml D5W – concentration 1600 mcg/ml) and titrate to effect. Dosages of over 20 mcg/kg/min have been required occasionally to obtain desired effect


EPINEPHRINE (ADRENALIN) (1:1000) AND (1:10,000)

THERAPEUTIC EFFECTS:Epinephrine is a sympathomimetic, which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate, and an increase in the force of cardiac contraction. Subcutaneous dose lasts 5-15 minutes.

In cardiac arrest, may restore electric activity in asystole; increases myocardial contractility; and decreases the threshold for defibrillation – all through its actions as a beta sympathetic agent

In addition, the alpha effects of epinephrine, causing vasoconstriction, elevate the perfusion pressure and may thus improve coronary blood flow during external cardiac compressions.

In anaphylaxis, acts as a bronchodilator (beta effect) and helps maintain blood pressure (alpha effect)

INDICATIONS (1:1000): Severe acute asthma attacks in pediatric or adult (age < 45) patients Anaphylaxis (life-threatening symptoms) Angioneurotic edema Cardiac arrest (may consider high-dose epinephrine)

INDICATIONS (1:10,000): Asystole Ventricular fibrillation unresponsive to defibrillation PEA Anaphylaxis with hypotension (life-threatening symptoms) Cardiac arrest Pediatric bradycardia (before atropine) Pediatric hypotension in patients with circulatory instability

CONTRAINDICATIONS: Hyperthyroidism Hypertension Angina Cerebral arteriosclerosis in asthma Should not be given to elderly or debilitated patients with underlying cardiovascular disease. No contraindications in anaphylactic shock or cardiac arrest

WARNINGS / PRECAUTIONS: Epinephrine 1:1000 should not be given intravenously in adults Causes hyperglycemia Epinephrine is inactivated by alkaline solutions – never mix with sodium bicarbonate. Do not mix isoproterenol and epinephrine – results in exaggerated response. Action of catecholamines is depressed by acidosis – attention to ventilation and circulation is

essential Antidepressants potentiate the effects of epinephrine


HOW SUPPLIED AND ADMINISTERED:Ampules containing 1 mg in 1 ml (1:1000 solution) Prefilled syringes containing 1 mg in 10 ml (1:10,000 solution)

SIDE EFFECTS:Central Nervous System: Anxiety, headache, cerebral hemorrhageCardiovascular: Tachycardia, ventricular dysrhythmias (particularly in asthmatic with

preexisting heart disease), hypertension, angina, palpitations, ectopic beats, elevation of blood pressure (which may not be desirable if the patient is already hypertensive)

Gastrointestinal: Nausea and vomiting

ADULT DOSAGE:Anaphylactic Reaction: 0.3 mg (0.3 ml of (1:1000) subcutaneously (upper arm/hip). May be (mild=SQ, shock=IV) repeated in 15 minutes on another extremity as needed. (mild)

0.5 mg (1:10,000) IV push (shock) (1:1000 solution should NOT be given IV)

Asthma (moderate to severe): 0.3 mg (1:1000) subcutaneously

Cardiac arrest: 1.0 mg (1:10,000) IV every 3-5 minutes. OR 2 mg (1:1000) diluted with 10 ml NS via ET tube during ventilation

PEDIATRIC DOSAGE:Anaphylactic Reaction: 0.01 mg/kg (1:1000) up to 0.3 mg subcutaneously. May be repeated in (mild=SQ, shock=IV) 15 minutes on another extremity as needed. (mild)

0.01 mg/kg (1:10,000) solution IV/IO push (shock) (1:1000 solution should NOT be given IV)

Pediatric Cardiac Arrest: 0.01 mg/kg (1:10,000) epinephrine IV/IO every 3-5 minutes OR

0.1 mg/kg (1:1000) solution via ET tube

Newborn Cardiac Arrest: 0.02 mg/kg (1:10,000) every 5 minutes by IV/IO

Bradycardia: 0.01 mg/kg (1:10,000) every 3 minutes by IV/IO


FUROSEMIDE (LASIX)

THERAPEUTIC EFFECTS:Furosemide is a sulfonamide derivative and potent diuretic which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules, as well as in the Loop of Henle. With IV administration, onset of diuresis of large volumes of urine is within 5 minutes; peaks in 30 minutes; and has a duration of 2 hours, thus is useful in ridding the body of excess fluid in conditions such as congestive heart failure (CHF).

Furosemide may be useful in long-range transports of patients in marked heart failure (especially catheterized patients) where there is a need to begin definitive therapy before the patient arrives at the hospital.

INDICATIONS: Congestive heart failure (to reverse fluid overload) Pulmonary edema (to reverse fluid overload) Hypertension Cerebral edema

CONTRAINDICATIONS: Anuria Should not be given to pregnant women Hypokalemia may be suspected in a patient who has been on chronic diuretic therapy or whose

EKG shows prominent P waves, diminished T waves, and the presence of U waves. Use in patients allergic to sulfa drugs is relatively contraindicated (if previous reaction to sulfa

drug was minor, consideration should be given to risks versus benefit to the patient)

WARNINGS / PRECAUTIONS: Furosemide should be protected from light Dehydration and electrolyte imbalance can result from excessive dosages Rapid diuresis can lead to hypotension and thromboembolic episodes

SIDE EFFECTS:Central Nervous System: Dizziness, tinnitus, hearing loss, headache, blurred vision, weaknessCardiovascular: Hypotension, cardiac dysrhythmias with potassium depletionGastrointestinal: Nausea, vomiting, anorexiaMusculoskeletal: Muscle crampingSkin: Pruritus, urticariaOther: Potassium depletion (with attendant cardiac dysrhythmias), dehydration

HOW SUPPLIED AND ADMINISTERED:Pre-filled syringes of 10 ml in a concentration of 10 mg/ml. In the field, furosemide is given intravenously.

ADULT DOSAGE:40 mg IV SLOWLY (injected over 1-2 min).

PEDIATRIC DOSAGE:0.5-1.0 mg/kg IV SLOWLY over 1-2 minutes.


GLUCAGON

THERAPEUTIC EFFECTS:Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose levels. Glucagon also relaxes the smooth muscle of the GI tract. It is helpful in hypoglycemia only if the liver glycogen is available. Because glucagon is of little or no help in states of starvation, adrenal insufficiency, or chronic hypoglycemia, glucose should be considered for the treatment of hypoglycemia.

INDICATIONS: For the treatment of hypoglycemia when an IV cannot be established, IV Dextrose is not

available, or is contraindicated Anaphylaxis Possibly effective in symptomatic beta blocker overdose

CONTRAINDICATIONS: Since glucagon is a protein, hypersensitivity is a possibility Contraindicated in patients with pheochromocytoma

WARNINGS / PRECAUTIONS: Glucagon should be administered with caution in patients with a history of insulinoma and/or pheochromocytoma.

SIDE EFFECTS:Allergic Reactions: Generalized allergic reactions, including urticaria, respiratory distress,

and hypotension have been reported in patients who receive glucagon by injection

Gastrointestinal: Glucagon is relatively free of adverse reactions except for occasional nausea and vomiting, which may also occur with hypoglycemia

HOW SUPPLIED AND ADMINISTERED:Rubber-stoppered vials of 1 mg glucagon (dry powder) with 1 ml of diluting solution to reconstitute.

Glucagon is compatible with dextrose solutions, but precipitates may form in solutions of sodium chloride, potassium chloride, or calcium chloride.

ADULT DOSAGE:In hypoglycemia, 1.0 mg IM injection. Response is usually seen in 5-20 minutes. If response is delayed, dose may be repeated 1 to 2 times.

PEDIATRIC DOSAGE:In hypoglycemia for children weighing > 20 kg, 0.5-1.0 mg IM. Response is usually seen in 5-20 minutes. If response is delayed, dose may be repeated 1 to 2 times.


LIDOCAINE (XYLOCAINE) 2% and 1%

THERAPEUTIC EFFECTS:Suppresses ventricular ectopic activity automatically by decreasing the excitability of the heart muscle and the cardiac conduction system, thereby raising the ventricular fibrillation threshold.

INDICATIONS:Lidocaine is the drug of first choice: To suppress premature ventricular contractions (PVCs) in the appropriate setting (PVCs > 6 per

minute, R on T phenomenon, multifocal, or in bursts of 2 or more in a row) To prevent recurrence of ventricular fibrillation after electric conversion To treat ventricular tachycardia To suppress reflex rise in ICP during intubation

CONTRAINDICATIONS: If PVCs occur in conjunction with sinus bradycardia, the bradycardia should be treated first Known history of allergy to lidocaine or local anesthetics (e.g., Novocain) Second-degree heart block, Mobitz II; complete AV block, third-degree AV heart block; and

Stokes-Adams syndrome Sinus bradycardia or sinus arrest Idioventricular rhythm Ventricular dysrhythmias associated with tricyclic antidepressant overdose

WARNINGS / PRECAUTIONS: Lidocaine is metabolized in the liver. Maintenance dosage should be decreased by half in patients with liver disease and low cardiac output states (e.g., acute MI, shock, congestive heart failure, patient older than 70 years old)

SIDE EFFECTS:Central Nervous System: Seizures, blurred vision, tinnitus, euphoria, muscle twitching,

convulsions, tremors. May cause numbness, drowsiness, or confusion when given in high doses, especially to the elderly or patients in heart failure.

Cardiovascular: Fall in cardiac output and blood pressure may occur due to the decreasing force of cardiac contractions, as well as decreasing peripheral resistance. Rarely toxic levels will cause hypotension, widening of QRS complex, bradycardia, and/or cardiac arrest.

Respiratory: At toxic levels, can cause respiratory depression and/or arrest.

HOW SUPPLIED AND ADMINISTERED:Ampules and prefilled syringes: 2% = 100 mg in 5 ml (20 mg/ml) for bolus injection. Given by IV bolus. If an IV route cannot be established, lidocaine may be given via catheter through an ET tube.

ADULT DOSAGE (Use 2%):1.0 mg/kg IV push, followed by 50 mg bolus every 20 minutes1 mg/kg IV push prior to intubation of head-injured patientReduce the dosage by half (both bolus and infusion) for patients in congestive heart failure or shock and for patients over 70 years old.

PEDIATRIC DOSAGE (Use 1%):V-Fib: 1 mg/kg IVP, IOP, or ETEMS Protocol – St. Joseph Health Center – Updated February 13, 2005 94

MAGNESIUM SULFATE

THERAPEUTIC EFFECTS:Magnesium is an important cofactor for enzymatic reactions and plays an important role in neurochemical transmission and muscular excitability. Magnesium prevents or controls convulsions and seizures associated with eclampsia by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse. Magnesium is said to have a depressant effect on the central nervous system, but it does not affect the mother, fetus, or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilation. Since magnesium sulfate affects impulse formation and conduction time in myocardium, it thereby reduces incidence of dysrhythmias associated with hypomagnesemia or prolonged QT interval.

INDICATIONS: Parenteral anticonvulsant for the prevention and control of seizures in severe toxemia of

pregnancy Suspected hypomagnesemic state (e.g., chronic alcoholism and chronic use of diuretics) Ventricular Fibrillation/Pulseless VT:

Third-lined antiarrhythmic (after amiodarone and lidocaine) in shockable cardiac arrests with refractory ventricular fibrillation/pulseless VT

Give early if suspected Torsades de Pointes pattern (a rare variation of ventricular tachycardia). Suspect Torsades in a patient in VF/pulseless, VT, or in wide complex tachycardia with classic Torsades pattern. Conditions of patients at risk to develop Torsades include:

Toxic levels of certain antidysrhythmics, including procainamide (Pronestyl) and Quinidine.

Toxic levels of certain psychotropic drugs, including tricyclic antidepressants and some phenothiazines

Exposure to organophosphate insecticides Cerebrovascular disease, including strokes Electrolyte disorders, including hypokalemia, hypomagnesemia,

hypocalcemia Hypothyroidism Coronary artery disease, including AMI, left ventricular failure Pacemaker malfunction

CONTRAINDICATIONS: Kidney failure Heart block Respiratory depression Shock May interfere with effect of neuromuscular blocking agents and calcium

WARNINGS / PRECAUTIONS: Because magnesium is removed from the body solely by the kidneys, the drug should be used

with caution in patients with renal impairment. Intravenous use of magnesium sulfate should not be given to mothers with toxemia of

pregnancy during the two hours immediately preceding delivery. Magnesium sulfate injection USP 50% must be diluted to a concentration of 20% or less prior to EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 95

infusion Since magnesium sulfate affects neuromuscular transmission in the body, it must be given

carefully and monitored closely in the patient with a pulse In non-arrest patients, magnesium toxicity may cause hypotension, bradycardia, and/or

respiratory arrest Early warning that magnesium sulfate toxicity is developing is decrease in reflexes measured at

patella (knee jerk), antecubital area, or heel, and respiratory depression Monitoring magnesium serum levels and the patient's clinical status is essential to avoid

consequences of overdose in toxemia Calcium chloride should be immediately available to counteract the potential hazards of

magnesium intoxication in eclampsia

SIDE EFFECTS:Adverse effects of magnesium sulfate IV are usually the result of magnesium intoxication. Signs of hypermagnesemia include:

Central Nervous System: CNS depression, flaccid paralysis, depression of reflexes, sweatingCardiovascular: Depression of cardiac function, hypotension, circulatory collapse,

hypothermia, bradycardia, respiratory arrest, flushing, sensation of body warmth

THE ABOVE SYMPTOMS CAN PRECEDE FATAL PARALYSIS

HOW SUPPLIED AND ADMINISTERED:Vials containing 10% in 20 ml

ADULT DOSAGE:Ventricular Fibrillation/Pulseless VT: 1.0 g IV push over 1 minute. Electrical defibrillation is then

attempted againEclamptic Seizures: 1 g/min IV push until seizure stops. Maximum dose is 4 gTorsades de Pointes: 1-2 g (mixed in 50 ml of D5W & administered over 1-2

min). If Torsades is refractory or reoccurs, repeat dose in 3 minutes

PEDIATRIC DOSAGE:Not indicated


MORPHINE SULFATE

THERAPEUTIC EFFECTS:Morphine's primary use as a narcotic analgesic which depresses the central nervous system and suppresses pain via binding at opioid receptors of the brain. It increases venous capacitance, decreases venous return, and produces mild peripheral vasodilation. Morphine also decreases myocardial oxygen demand, and helps to allay the anxiety associated with pulmonary edema.

INDICATIONS: Pain from acute myocardial infarction Anxiety associated with pulmonary edema in congestive heart failure Pain associated with isolated extremity fracture, renal colic, or burns

CONTRAINDICATIONS: Marked hypotension or volume depletion (if hypotension occurs, keep the patient flat and do not

give any more of the drug) Respiratory depression, except that caused by pulmonary edema, where the drug may be used if

ventilatory support is provided Pain due to trauma or acute abdomen (except isolated extremity trauma or burns) Head trauma Acute alcoholism Acute asthma Known hypersensitivity to morphine sulfate

WARNINGS / PRECAUTIONS: Morphine is detoxified by the liver; it is potentiated by alcohol, antihistamines, barbiturates, sedatives, and beta blockers

SIDE EFFECTS:Central Nervous System: Euphoria, drowsiness, pupillary constriction, respiratory arrest or

respiratory depression (this effect can be reversed with naloxone) Cardiovascular: Increased vagal tone leading to bradycardia (this effect can be reversed

with atropine), hypotension (most likely in volume depleted patients)Gastrointestinal: Decreases gastric motility, nausea, vomitingGenitourinary: Urinary retentionRespiratory: Bronchoconstriction, decreased cough reflex

HOW SUPPLIED AND ADMINISTERED:Prefilled (Tubex) syringes containing 10 mg. Given by titrated IV injection. If hypotension occurs, keep the patient flat, and do not give more of the drug. Watch for respiratory depression.

ADULT DOSAGE:2-5 mg by slow IV push every 5-30 minutes until the desired therapeutic effect is achieved. Do not exceed 10 mg in the field. Can also be given IM.

PEDIATRIC DOSAGE:0.1-0.2 mg/kg IV slowly (maximum single dose 4 mg)Infant: 0.05-0.1 mg/kg IV slowly


NARCAN (NALOXONE)

THERAPEUTIC EFFECTS:Antidote for narcotic agents that reverses the action of all narcotic drugs, although large doses are required to reverse the effects of a Darvon overdose. Naloxone will reverse stupor, coma, respiratory distress, etc. when these are due to narcotic overdose. The mechanism of action is not fully understood. It appears that naloxone antagonizes the effects of opiates by competing at same receptor sites. When given IV, the action is apparent within two (2) minutes. IM or subcutaneous administration is slightly less rapid.

INDICATIONS: Indicated for complete or partial reversal of narcotic overdose, depression, and respiratory

depression or coma secondary to narcotics or related drugs: Heroin Demerol (meperidine) Codeine Morphine Methadone Lomotil Paregoric Darvocet Dilaudid (hydromorphone) Pentazocine (Talwin) Darvon (propoxyphene) Percodan Fentanyl (Sublimaze) (Known on the street as "white china")

CONTRAINDICATIONS:Contraindicated in patients known to be hypersensitive to it

WARNINGS / PRECAUTIONS: Naloxone should be administered VERY SLOWLY, using improvement of respiratory status as

an end point Naloxone should be administered cautiously to persons, including newborns of dependent

mothers, who are known or suspected to be physically dependent on opiates – may precipitate an acute abstinence syndrome

May need to repeat naloxone since duration of action of some narcotics may exceed that of naloxone

Naloxone is not effective against a respiratory depression due to non-opiate drugs. Use caution during administration, as patient may become violent as level of consciousness

increases

SIDE EFFECTS:Central Nervous System: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear

production, sweating, seizures secondary to withdrawalCardiovascular: Too rapid administration may precipitate ventricular dysrhythmias,

pulmonary edema and sudden death in rare cases, hypertension, hypotension, ventricular tachycardia, ventricular fibrillation

Gastrointestinal: Too rapid administration may precipitate projectile vomiting, nauseaOther: Administration to people who are physically dependent on narcotics may

cause an acute withdrawal syndromeEMS Protocol – St. Joseph Health Center – Updated February 13, 2005 98

HOW SUPPLIED AND ADMINISTERED:2 mg in 2 ml prefilled syringe. In the field, given by VERY SLOW IV injection. As soon as there is improvement in the respirations, stop giving the drug. It is preferable that the patient NOT wake up fully in the field, as these patients may be violent when brought abruptly out of coma. Use respirations as a guide.

ADULT DOSAGE:Initial Dose: 0.5-2 mg. Administer this solution VERY SLOWLY via IV, IM, or ET while monitoring the rate and depth of the patient's respirations. If there is no response to the full dose of naloxone, it may be repeated in 5 minutes in the same fashion. Give larger dose if overdose with synthetic narcotics (e.g., Talwin, Darvocet, Fentanyl). If no response after 10 mg, suspect overdose with a non-narcotic drug.

PEDIATRIC DOSAGE:Newborn Dose: 0.1 mg/kg (narcotic dependent with decreased respiration) IV, IM, IO, or ET. 0.1 mg/kg every 3 minutes until respiration is improved (not to exceed 2 mg)


NITROGLYCERIN (NITROSTAT)

THERAPEUTIC EFFECTS:The primary pharmacologic effect of nitroglycerin on the cardiovascular system is relaxation of vascular smooth muscle, hence vasodilatation. Nitroglycerin provides relief of pain in angina, probably dilating coronary arteries and thereby increasing blood flow through them, as well as by decreasing myocardial oxygen demand. Through its vasodilatation action on peripheral vessels, nitroglycerin promotes pooling of the blood in the systemic circulation and decreases the resistance against which the heart has to pump (the afterload); these effects may be useful in treating congestive heart failure.

INDICATIONS: To relieve chest pain or discomfort associated with suspected AMI or angina pectoris Hypertensive crisis To treat selected cases of pulmonary edema with hypertension or due to left heart failure

CONTRAINDICATIONS: Use with caution in presumed right ventricular myocardial infarction Increased intracranial pressure Systolic blood pressure < 100 mmHg Patients who have used Viagra in the past 24 hours Children under 12 years old

WARNINGS / PRECAUTIONS: Use with caution in presumed right ventricular myocardial infarction Because of an easily developed tolerance, patients on chronic nitrate therapy may require larger

doses of nitroglycerin during acute anginal episodes. Alcohol will accentuate vasodilating and hypotensive effects Nitroglycerin tablets are inactivated by light, air, and moisture; must be kept in amber glass

containers with tight-fitting lids. Do not leave cotton in container. Once opened, nitroglycerin has a shelf life of 3 months. Nitrospray has as shelf life of 1-2 years. Do not shake Nitrolingual spray. Advise patient not to inhale spray.

All patients being treated with nitroglycerin should be asked about possible use of the medication Viagra within the past 24 hours (recent cases have shown that the use of Viagra within a 24-hour time frame from the use of nitroglycerin may cause irreversible hypotension and, in a patient with coronary artery disease, can precipitate angina or an MI)

IF PATIENT HAS TAKEN VIAGRA WITHIN PAST 24 HOURS, RECORD VITAL SIGNS, & CONTACT ON-LINE MEDICAL CONTROL FOR FURTHER DIRECTION

SIDE EFFECTS:Central Nervous System: Transient throbbing headache, dizziness, flushing, nausea, weakness, and

vomitingCardiovascular: Hypotension, reflex tachycardia, angina or MI in patient with coronary

artery disease who has taken Viagra in past 24 hours

HOW SUPPLIED AND ADMINISTERED:Many forms, including ointment, spray, tablets, sustained release capsules. For use in the field, tablets or spray of 0.4 mg metered dose strength are preferred. Give sublingually (under tongue). The patient should be semi-sitting or recumbent. Monitor BP and be prepared for hypotension.

ADULT DOSAGE:One 0.4-mg tablet or spray 1 puff under the tongue. For chest pain, may repeat every 5 minutes as long as SBP > 90 mm/Hg (maximum 1.2 mg or 3 doses)EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 100

OXYGEN (O2)

THERAPEUTIC EFFECTS:Reverses the deleterious effects of hypoxemia on the brain, heart, and other vital organs.

INDICATIONS:Any condition in which global or local hypoxemia may be present: Cardiac or respiratory arrest (given with artificial ventilation) Dyspnea or respiratory distress from any cause Chest pain Shock Coma from any cause Chest trauma Near-drowning Pulmonary edema Toxic inhalations (smoke, chemicals, carbon monoxide) Acute asthmatic attack Acute decompensation of COPD Stroke Head injury Repeated seizures Any patient in critical condition

CONTRAINDICATIONS:None

WARNINGS / PRECAUTIONS: May depress respirations in rare patients with chronic obstructive pulmonary disease. This is NOT a contraindication to its use, but simply means that such patients must be watched closely and assisted to breathe if the respiratory rate declines.

SIDE EFFECTS:None when given for short periods to adults (less than 24 hours)

HOW SUPPLIED AND ADMINISTERED:As a compressed gas in cylinders of varying sizes. Administered by inhalation from a dosage mask, nasal cannula, endotracheal tube, etc. A patent airway and adequate ventilation must be ensured.

ADULT DOSAGE:Depends on the condition being treated. For cardiac arrest and other critical conditions, 100% oxygen should be given as soon as possible.


PROCAINAMIDE (PRONESTYL)

THERAPEUTIC EFFECTS:Procainamide reduces the automaticity of various pacemaker sites in the heart and slows intraventricular conduction, which makes it effective in suppressing ventricular ectopy.

INDICATIONS:PVCs, ventricular tachycardia, and ventricular fibrillation that are refractory to lidocaine

CONTRAINDICATIONS:Patients with severe conduction system disturbances, especially second- and third-degree heart blocks

WARNINGS / PRECAUTIONS: Patients with PVCs in conjunction with bradycardia should first be treated with atropine or

pacing to correct bradycardia prior to administration of procainamide. Constantly monitor blood pressure and QRS width during administration

SIDE EFFECTS:Central Nervous System: Drowsiness, seizures, confusionCardiovascular: Hypotension, bradycardia, heart blocks, cardiac arrestGastrointestinal: Nausea, vomitingRespiratory: Respiratory arrest

ADULT DOSAGE:Mix 1000 mg in 100 ml of D5W and, using a macrodrip (10 gtts/ml) set, run at 20-30 gtts/min to administer 20-30 mg/min until one of the following criteria is met:

1. Dysrhythmia is suppressed2. Systolic BP drops 10 mmHg or more3. QRS widens by 50% of its original width4. A total of 17 mg/kg (or 1.2 g) has been administered

If dysrhythmia is suppressed by procainamide, start maintenance infusion at 1-4 mg/min (15-60 gtt/min)


SODIUM BICARBONATE

THERAPEUTIC EFFECTS:Neutralizes excess acids (usually lactic acid) to form a weak, volatile acid that is broken down into CO2 and H2O, which helps return the blood towards a physiologic pH, in which normal metabolic processes and sympathomimetic agents (such as epinephrine) work more effectively. Sodium bicarbonate is effective only when administered with adequate ventilation and oxygenation. Alkalizing agent used to buffer acids present in the body during and after severe hypoxia.

INDICATIONS: To treat metabolic acidosis due to:

Salicylate (aspirin) overdose - Barbiturate overdose Cardiac arrest - Tricyclic antidepressant overdose Hyperkalemia - Severe ketoacidosis Shock - Physostigmine toxicity Methanol toxicity - Ethylene glycol toxicity

To treat hyperkalemia To promote the excretion of some types of drugs taken in overdose

CONTRAINDICATIONS:Congestive heart failure; alkalotic states

WARNINGS / PRECAUTIONS: Excessive bicarbonate therapy inhibits the release of oxygen Bicarbonate does not improve the ability to defibrillate May inactivate simultaneously administered catecholamines Will precipitate if mixed with calcium chloride Patients in borderline heart failure cannot tolerate salt loads of this magnitude Sodium bicarbonate administration transiently raises the arterial carbon dioxide level, and thus

its administration must be accompanied by adequate ventilation Do not give bicarbonate in the same syringe with epinephrine or calcium.

SIDE EFFECTS: Metabolic alkalosis Hypernatremia Cerebral acidosis Sodium and H2O retention, which can cause CHF (Increases the vascular volume because

sodium bicarbonate has the same effect as other salt-containing infusions. Three 50-ml syringes of sodium bicarbonate (1 mEq/ml) contain approximately the same amount of salt as 1 liter of normal saline. Patients in borderline heart failure cannot tolerate these salt loads)

Lowers serum potassium (this may be desirable at times, as in hyperkalemia, but in cardiac patients, if the potassium falls too low, dysrhythmias may occur. This is especially likely in patients taking diuretics)

Raises arterial carbon dioxide level (thus must be accompanied by adequate ventilation)

HOW SUPPLIED AND ADMINISTERED:Vials and prefilled syringes of 50 ml, containing 1 mEq/ml. Given by IV bolus injection. Administration should be guided by arterial blood gasses and pH, when available. Do not give bicarbonate in the same syringe with epinephrine or calcium.


ADULT DOSAGE:Cardiac Arrest: 1 mEq/kg IV (8.4%) after the first minutes of CPR. Repeat with 0.5 mEq/kg every

10 minutes. Acidosis should be prevented with adequate ventilation.. Do not give bicarbonate in the same syringe with epinephrine or calcium. For other conditions,

as ordered by physician.

PEDIATRIC DOSAGE:Cardiac Arrest: 1 mEq/kg IV (8.4%) diluted with NS, Repeat with 0.5 mEq/kg every 10 minutesInfants: 0.5 mEq/kg IV (4.2% diluted with NS) slowly. May repeat in 10 minutes. For

other conditions, as ordered by physician.


SOLU-MEDROL

THERAPEUTIC EFFECTS:Solu-Medrol is a potent, synthetic anti-inflammatory steroid that decreases inflammatory response and reduces edema in many tissues

INDICATIONS: Severe anaphylactic and hypersensitivity/allergic reactions Acute asthma attacks Bronchospasm associated with COPD exacerbation that does not respond to other treatments Acute spinal cord injury

CONTRAINDICATIONS: Known hypersensitivity Patients with systemic fungal infections Premature infants/neonates Spinal cord injuries more than eight (8) hours old

WARNINGS / PRECAUTIONS: Steroids have been shown to have little effect on cerebral edema associated with head trauma

and are not recommended in the prehospital setting for this reason. Corticosteroids should be avoided in burn or smoke inhalation patients with wheezing because

studies have shown an increased risk of infection and mortality

SIDE EFFECTS:Side effects are commonly seen with prolonged administration, but rarely seen with single doses:

Central Nervous System: Seizures, vertigo, headacheCardiovascular: Fluid retention, hypertension, hypotension, dysrhythmias, CHF,

electrolyte imbalanceGastrointestinal: Nausea, vomiting, GI bleeding, abdominal distentionMultisystemic: Anaphylactic reactionSkin: Urticaria

HOW SUPPLIED AND ADMINISTERED:125-mg vials

ADULT DOSAGE:For asthma/associated bronchospasm , COPD, or severe allergic reactions: 125 mg IV

PEDIATRIC DOSAGE:For asthma/associated bronchospasm or severe allergic reaction: 2 mg/kg IV (maximum 125 mg)


THIAMINE HCL (VITAMIN B-1/BIAMINE)

THERAPEUTIC EFFECTS:Thiamine is a water-soluble vitamin and member of the B-complex group that functions as an essential co-enzyme in carbohydrate metabolism. Thiamine provides the appropriate thiamine levels to allow glucose to be utilized in sufficient amounts, thus reversing cellular hypoglycemia secondary to thiamine deficiency

INDICATIONS: Given along with administration of Dextrose 50% to prevent Wernicke and/or Korsakoff

Syndrome as seen in acute alcohol intoxication. Coma or seizure of unknown etiology, especially if alcohol use suspected Suspected alcohol intoxication Suspected poor nutrition Delirium Tremens

CONTRAINDICATIONS:Contraindicated in patients with a history of sensitivity to thiamine

SIDE EFFECTS:Central Nervous System: Weakness, restlessness, sweating, feelings of warmth, tightness of throatCardiovascular: Angioneurotic edema, cardiovascular collapse, slight fall in blood

pressure following rapid IV administration, Gastrointestinal: NauseaMultisystemic: AnaphylaxisRespiratory: Pulmonary edemaSkin: Cyanosis, urticaria, pruritus (itching)

HOW SUPPLIED AND ADMINISTERED:100 mg/cc ampule

ADULT DOSAGE:100 mg IV or IM

PEDIATRIC DOSAGE:10-25 mg (rarely used) IV/IO


TORADOL (KETOROLAC)

THERAPEUTIC EFFECTS:Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) that also exhibits peripherally acting, non-narcotic analgesic activity by inhibiting prostaglandin synthesis. Onset is within 10 minutes and lasts 2-6 hours.

INDICATIONS: Short-term management of moderate to severe pain

CONTRAINDICATIONS: Hypersensitivity to the drug Contraindicated in pregnancy labor and delivery because may adversely affect fetal circulation

and inhibit uterine contractions, thus increasing the risk of uterine hemorrhage Patients with history of asthma Patients with allergies to aspirin or other non-steroidal anti-inflammatory drugs Bleeding disorders Renal failure Hypotension Patient on Coumadin/anticoagulant therapy (increased bleeding time)

WARNINGS / PRECAUTIONS: Use with caution and reduced doses when administering to elderly patients

SIDE EFFECTS:Central Nervous System: Headache, sedationCardiovascular: Hypertension, hypotension, Gastrointestinal: NauseaHematologic: Bleeding disordersMultisystemic: Anaphylaxis from hypersensitivity, edemaSkin: Rash

HOW SUPPLIED AND ADMINISTERED:15 mg or 30 mg in 1 ml60 mg in 2 ml

ADULT DOSAGE:30-60 mg IM or 30 mg IV over 1 minuteOver 65 or Renal Impaired: 15 mg IV over 1 minute

PEDIATRIC DOSAGE:Not recommended


VERSED (MIDAZOLAM)

THERAPEUTIC EFFECTS:Midazolam is a short-acting benzodiazepine central nervous system depressant that produces sedation and lack of recall.

INDICATIONS: Conscious sedation as an adjunct to cardioversion and intubation Severe agitation or anxiety states Premedication prior to external transthoracic pacing

CONTRAINDICATIONS: Known hypersensitivity to the drug History of glaucoma Signs or symptoms of shock Renal failure Ethanol intoxication Coma Pregnancy

WARNINGS / PRECAUTIONS: Midazolam does not protect against increase in intracranial pressure and bradycardia associated with intubation attempts. Emergency resuscitative equipment should be readily available, as respiratory depression is more common with Midazolam than with any other benzodiazepines

SIDE EFFECTS:Central Nervous System: Retrograde amnesia, euphoria, altered mental status, dizziness, prolonged

emergence from anesthesia, drowsiness, confusionCardiovascular: PVCs, bradycardia, tachycardia, nodal rhythms, hypotensionGastrointestinal: Nausea, vomiting, hiccups, coughingLocal: Pain, burning, swelling, redness at injection siteRespiratory: Respiratory depression or arrest, laryngospasm, bronchospasm, dyspnea

HOW SUPPLIED AND ADMINISTERED:Tubex containing 5 mg/2 mL prefilled syringe

ADULT DOSAGE:2 mg slow IVP

PEDIATRIC DOSAGE:0.1 mg/kg slow IV push to a maximum dose of 2 mg



V. ADMINISTRATIVE PROTOCOLS


AEROMEDICAL TRANSPORT

Rotor wing air medical services may be requested directly to the scene by:

(a) An on-scene EMS organization(b) hospitals and healthcare facilities

A request for rotor wing air medical service response may be initiated when one or more of the following conditions exist:

(a) The patient's airway, breathing, or hemorrhage/circulation can not be controlled by conventional means and the estimated arrival time of the air medical service is less than the time required for ground transport to the nearest hospital.

OR

(b) Air transport to a medical facility/the most appropriate trauma center will occur in a shorter time than ground transport to a medical facility/the most appropriate trauma center.

(i) Time estimation should be made from the time the patient is ready for transport to arrival at the medical facility/the most appropriate trauma center. This should include aircraft response to the scene.

Destinations:

(a) An appropriate medical facility/the most appropriate trauma center based upon, but not limited to the following factors...

(i) Time to definitive care(ii) Capabilities of receiving hospitals(iii) Patient wishes and family continuity(iv) Maximizing utilization of resources


COMMUNICATIONS / WHEN TO CALL MEDICAL CONTROL

A member of the prehospital care team must contact Medical Control at the earliest time conducive to good patient care. This may be a brief early notification or "heads up." It may mean that the hospital is contacted from the scene if assistance is needed in the patient's immediate care or permission is required for part of the patient care deemed necessary by the paramedic or EMT in charge.

When possible, the member of the team most knowledgeable about the patient should be the one calling in the report. Although all EMTs and paramedics have been trained to give a full, complete report, this is often not necessary and may interfere with the physician's duties in the Emergency Department. Reports should be as complete but concise as possible to allow the physician to understand the patient's condition. It is not an insult for the physician to ask questions after the report is given. This is often more efficient than giving a thorough report consisting mostly of irrelevant information.

If multiple victims are present on the scene, it is advisable to contact Medical Control with a preliminary report. This should be an overview of the scene, including the number of victims, seriousness of the injuries, estimated on-scene and transport times to the control hospital or possible other nearby facilities. This allows preparation for receiving the victims and facilitates good patient care.

When calling in a report, it should begin by identification of the squad calling, and the level of care which is able to be provided to the patient (i.e., basic, advanced or medic), and the nature of the call (who you need to talk with, physician or nurse) as follows:

CODE THREE PATIENTS TYPES OF CODE THREE PATIENTS MOST SERIOUSLY ILL OR INJURED: ACCORDING TO TRIAGE PRIORITY:

1. Type of squad: Basic, intermediate, paramedic. - Airway and/or breathing difficulty2. Age and sex of patient. - Cardiac Arrest3. Type of situation: Injury and/or illness - Circulation difficulty (bleeding/shock)4. Specific complaint: Short and to-the-point - Open chest and abdominal injury (i.e., chest pain, skull fracture) - Complicated childbirth5. Mechanism: MVA / MCA / fall - Chest pain6. Vital signs: B/P / Pulse / Resp. / LOC / EKG - Unconsciousness7. Patient care: Airway management, - Severe head injury circulatory support, drug therapy - Severe burns8. General impression: Stable / unstable - Severe poisoning9. ETA to medical facility - Status epilepticus

- Altered LOC- Multiple fractures


CODE TWO PATIENTS TYPES OF CODE TWO PATIENTSSIGNIFICANTLY ILL OR INJURED, BUT STABLE : ACCORDING TO TRIAGE PRIORITY:

1. Type of squad: Basic, intermediate, paramedic - C-spine injury2. Age and sex of patient - Acute ABD pain3. Type of situation: Injury and/or illness - Moderate burns4. Specific complaint: Short and to-the-point - Normal childbirth (i.e., 10% 2nd degree burn to leg) - Violent and/or combative patient5. Mechanism: MVA / MCA / fall - Psychiatric6. Vital signs: B/P / Pulse / Resp. / LOC / EKG7. ETA to medical facility

CODE ONE PATIENTS TYPES OF CODE ONE PATIENTS MINOR ILLNESSES OR INJURIES : ACCORDING TO TRIAGE PRIORITY:

1. Type of squad: Basic, intermediate, paramedic - Minor injuries2. Age and sex of patient - Minor illness3. Type of situation: Injury and/or illness4. Specific complaint: Short and to-the-point (i.e., ABD pain for the last two weeks)


CORONER DEATH NOTIFICATION

As required by law, all unexplained or unnatural deaths must be reported to the Coroner's office.

An unnatural death is any death that is not the direct result of a natural, medically-recognized disease process. Any death where an outside intervening influence, either directly or indirectly, is contributory to the individual's demise, or accelerates and exacerbates an underlying disease process to such a degree as to cause death, would fall into the category of unnatural death.

A cause of death is etiologically specific. Any injury or disease process, however brief or prolonged, which initiates a dependent and related sequence of events ultimately responsible for the individual's demise, is the cause of death.

There are five manners of death: Natural, Homicide, Suicide, Accident and Undetermined. The manner of death, simply put, is the circumstances in which the cause of death took place. Autopsy alone cannot determine the manner of death. The manner of death is based upon all available knowledge of a particular case, including the terminal events, scene investigation, police report, and social and medical background information.

A mechanism of death is not etiologically specific, but any pathophysiological derangement that is incompatible with life and should not be confused with a cause of death. Ventricular fibrillation or hypoxia are mechanisms of death; however they can occur in advanced arteriosclerotic coronary artery disease, low voltage electrocution, or homicidal strangulation.

The Trumbull County Coroner's Office is staffed 24 hours a day, 365 days a year. To report a death, call (330) 675-2516 promptly after a death. A Forensic Investigator will request the following information. Even if you do not have all the information, that should not inhibit you from making notification. On the basis of this information, the decision will be made whether or not the death falls under the jurisdiction of the Coroner and you will be advised accordingly.

1. Name, age, race, and sex of the decedent.2. Address and location of the decedent.3. Telephone number and location of the next of kin.4. The time of death and who made the pronouncement.5. If the individual was transported, who made the transport?6. A brief narrative of the circumstances surrounding the death.7. Where the decedent was found and by whom, if known.8. When the decedent was last seen alive and by whom, if known.9. Any past medical history.10. Current medications, if known.11. The name and telephone number of the attending physician, if known.


DEAD ON ARRIVAL (DOA)

When a DOA is encountered, the squad members should avoid disturbing the scene or the body as much as possible, unless it is necessary to do so in order to care for and assist other victims. Once it is determined that the victim is in fact dead, the squad members should move as rapidly as possible to transfer responsibility or management of the scene to the Police Department and/or Coroner's Office. It is the squad member's responsibility to notify the Coroner's Office directly at (330) 675-2516 or to ensure that the Coroner's Office has been notified by a police officer on the scene.

A determination that the victim is dead rests with the squad members. Any of the following may be used as guidelines to support the determination that a victim is deceased:

1. There is an injury which is incompatible with life (i.e., decapitated, burned beyond recognition)

2. The victim shows signs of decomposition, rigor mortis, or extremely dependent lividity.

3. If the patient is an adult with an unwitnessed cardiac arrest, has a history of an absence of vital signs for greater than 20 minutes, and is found in asystole, not secondary to hypothermia or cold water drowning.

4. If there are valid DNR orders, see Do Not Resuscitate Protocol.

5. If the patient has a history of terminal disease, the family refuses resuscitation, and permission to pronounce the patient dead is given by Medical Control.

CAUTION: IF ANY DOUBT EXISTS THAT THE VICTIM IS DEAD AT THE TIME OF ARRIVAL OF THE SQUAD, RESUSCITATIVE MEASURE SHOULD BE INSTITUTED IMMEDIATELY. WHENEVER RESUSCITATIVE MEASURES ARE INSTITUTED, THEY MUST BE CONTINUED UNTIL ARRIVAL AT A HOSPITAL, UNTIL A PHYSICIAN HAS PRONOUNCED THE VICTIM DEAD, OR A VALID DNR IS PRONOUNCED.


DO NOT RESUSCITATE (DNR) GUIDELINES & FORMS

Pre-hospital (out of hospital) providers are frequently called to care for patients who are known to have incurable or terminal illnesses. These guidelines are designed to help EMS providers and Medical Control physicians determine how, when, and to what level of resuscitation a patient desires or requires. Many patients and/or their families have consciously altered their consent for treatment, made out a Living Will, or entered into Hospice Care agreements.

NOTE: LIVING WILL OR DURABLE POWER OF ATTORNEY DOES NOT MEAN DNR

DNR orders are defined to withhold CPR and Advanced Life Support from patients suffering from terminal illness, but a DNR order may be written with specific guidelines, such as Comfort Care only or Full Medical Management with "checklist" treatment modalities (e.g., medications, blood products, tube feedings.) implemented only if noted. Prehospital providers and Medical Control physicians must be sensitive to, and involved with, the administration of palliative and supportive care interventions, such as to make the patient comfortable, relieve pain, and allay the patient's/family's fear and apprehension.

NOTE: DNR ORDERS DO NOT MEAN "DO NOT TREAT"

A DNR/Comfort Care patient may revoke their status at any time by either direct communication with the prehospital provider or by a private physician directed verbally or in writing by the patient, guardian, or family when the patient cannot communicate with the EMS provider.

The DNRCC must be properly completed by a physician or nurse, legible with all appropriate signatures included, witnessed, and dated within two (2) years. If written by a nurse and not countersigned by a physician, the order must include the patient's name, state that it is a verbal or telephone order, the order must be less than two (2) weeks old, and the patient must be a nursing home or Hospice patient.

If there is no written order, but a physician requests the patient be made DNR, the physician should directly contact Medical Control.

1. DNR Comfort Care – The protocol is activated immediately when a valid "DNR Comfort Care" order is issued and/or upon identification of the person as a "DNR Comfort Care" patient. (See following state Comfort Care protocol)

2. DNR Comfort Care Arrest – The protocol is implemented in the event of cardiac or respiratory arrest. Prior to cardiac or respiratory arrest, a DNR Comfort Care Arrest patient may receive all necessary care and treatment appropriate to the patient's needs (See following state Comfort Care protocol)

3. DNR Identification – The following items are approved as DNRCC Identification A valid DNR/Support Care document is present or the order is documented on the "DNRCC

Identification Form" (See following form) A Living Will authorizes the withholding or withdrawal of CPR


The patient, guardian, or family refuses care The patient is wearing a DNR/Comfort Care bracelet/ID or a transparent hospital bracelet

with an insert bearing the statewide Comfort Code logo, or their wallet contains a card bearing the statewide Comfort Care logo

NOTE: IT IS IMPERATIVE THAT THE ORIGINAL DNR/COMFORT CARE ORDER (OR A COPY) ACCOMPANY THE PATIENT WHEREVER THE PATIENT GOES

4. Interaction with the Patient, Family, and Bystanders – The patient always may request resuscitation, even if he or she is a DNRCC patient and the protocol has been activated. The request for resuscitation amounts to a revocation of DNRCC status

If family or bystanders request or demand resuscitation for a person for whom the DNRCC Protocol has been activated, do not proceed with resuscitation. Provide comfort measures as outlined on the form

5. A DNRCC Order for a Patient Shall be Considered Current: – UNLESS discontinued by the patient's attending physician/CNP/CNS, or revoked by the patient. EMS personnel are not required to research whether a DNRCC order that appears to be current has been discontinued

6. EMS Personnel who Receive a Verbal DNR Order from a Physician, CNP, or CNS, Must Verify the Identify of the Person Issuing the Order: Personal knowledge of the physician, CNP, or CNS List of practitioners with other identifying information A return telephone call to verify information provided

Contact Medical Control

7. Relationship of DNRCC with Living Wills and Durable Powers of Attorney for Healthcare A Living Will Supersedes a Durable Power of Attorney (DPOA) for healthcare A Living Will with a DNRCC identification that is added supersedes the DPOA for

healthcare A Living Will supersedes a DNRCC order that is inconsistent with the Living Will


❏ DNRCC (If this box is checked the DNR Comfort Care Protocol is activated immediately.)

❏ DNRCC—Arrest (If this box is checked, the DNR Comfort Care Protocol is implemented in the event of a cardiac arrest or a respiratory arrest.)

Patient Name:_________________________________________________________________________Address:______________________________________________________________________________City________________________________________ State_______________ Zip___________________

Birthdate____________________________ Gender ❏ M ❏ F Signature_____________________________________________________ (optional)

Certification of DNR Comfort Care Status (to be completed by the physician)*

(Check only one box) ❏ Do-Not-Resuscitate Order—My signature below constitutes and confirms a formal order to emergency medical services and other health care personnel that the person identified above is to be treated under the State of Ohio DNR Protocol. I affirm that this order is not contrary to reasonable medical standards or, to the best of my knowledge, contrary to the wishes of the person or of another person who is lawfully authorized to make informed medical decisions on the person’s behalf. I also affirm that I have documented the grounds for this order in the person's medical record.

❏ Living Will (Declaration) and Qualifying Condition—The person identified above has a valid Ohio Living will (declaration) and has been certified by two physicians in accordance with Ohio law as being terminal or in a permanent unconscious state, or both.

Printed name of physician*:_____________________________________________________________ Signature____________________________________ Date___________________________________ Address:_____________________________________________ Phone__________________________ City/State______________________________________________ Zip___________________________

* A DNR order may be issued by a certified nurse practitioner or clinical nurse specialist when authorized by section 2133.211 of the Ohio Revised CodeEMS Protocol – St. Joseph Health Center – Updated February 13, 2005 118

After the State of Ohio DNR Protocol has been activated for a specific DNR Comfort Care patient, the Protocol specifies that emergency medical services and other health care workers are to do the following:


WILL: Suction the airway Administer oxygen Position for comfort Splint or immobilize Control bleeding Provide pain medication Provide emotional support Contact other appropriate health care

providers such as Hospice, home health, attending physician/CNS/CNP


WILL NOT: Administer chest compressions Insert artificial airway Administer resuscitative drugs Defibrillate or cardiovert Provide respiratory assistance

(other than that listed above) Initiative resuscitative IV Initiate cardiac monitoring

If you have responded to an emergency situation by initiating any of the WILL NOT actions prior to confirming that the DNR Comfort Care Protocol should be activated, discontinue them when you activate the Protocol. You may continue respiratory assistance, IV medications, etc., that have been part of the patient’s ongoing course of treatment for an underlying disease.

DRUG BOX EXCHANGE GUIDELINES

To insure the effective efficient management of the Drug Box Exchange Program, there is a common agreement between St. Joseph Health Center and Trumbull Memorial Hospital that they will follow these guidelines as closely as possible without compromising patient care standards.

I. RESERVE SUPPLY Each hospital shall keep on hand in the Emergency Department a sufficient number of loaded Exchange Boxes for Paramedic Squads to reduce turnaround time for EMS units. Each hospital shall maintain an accurate log that includes the date, squad name, M Box number coming in, M Box number going out, lock number going out, and signatures of both pre-hospital and E.D. personnel.

NOTE: DRUG BOXES SHOULD ONLY BE SIGNED OUT BY PARAMEDICS(since all boxes contain medications and narcotics)

II. EXCHANGING WITH PARTICIPATING SQUADS This program is designed to encourage all EMS squads who function under both St. Joseph Health Center protocols and Trumbull County protocols to participate in this program.

III. EXCHANGING WITH NON-PARTICIPATING SQUADS Squads choosing not to participate in the Box Exchange Program will still be allowed to exchange with individual hospitals items of medication only, but must go to the hospital pharmacy to do so. Squads wishing to


participate in the program should contact the EMS Coordinator or such designee at each institution.

NO EXCHANGE BOXES SHOULD BE OPENED IN THE EMERGENCY DEPARTMENT TO RE-SUPPLY SQUADS

IV. BASE HOSPITAL Each squad participating in the Box Exchange Program will be assigned a "Base Hospital" which will serve as their support unit. The squads shall be divided into groups based on their geographic location (departments and/or private companies with multiple locations will use their main station as the criteria for base hospital selection). Squads will make the final choice in cases where a question may arise concerning a Base Hospital (i.e., department and/or private provider is located on a geographic boundary that allows either hospital to service the squad). The purpose of the Base Hospital is to be the resource unit for a particular squad where they will return if any questions arise, not as the sole medical command.

V. SQUAD RESPONSIBILITY Should abuse of the equipment take place, the responsible squad will be required to pay for replacement equipment. Each EMS squad participating in the program will be required to do the following:

1. Deposit a non-refundable $25.00 fee and sign for each exchange box received2. Use the boxes with care and respect so as not to subject them to abuse3. Report any defects in material or workmanship of the exchange boxes to the Base Hospital so proper documentation and adjustment can be made4. If any department requests withdrawal from the Drug Box Exchange Program, the drug box in their possession shall be returned at the time of receipt of their letter of forfeiture, and the box will be inventoried


OBTAINING INDIVIDUAL PROTOCOL

Provide medical command with appropriate documentation of qualifications:

- Letter of recommendation from employer- Copy of state of Ohio EMT card- Copy of current BLS certification- Copy of current ACLS certification (EMT-P ONLY)- Copy of current PALS certification (EMT-P ONLY)- Copy of current PHTLS/BTLS certification (EMT-P ONLY)

It is understood that PALS and BTLS certifications have not previously been mandated in Trumbull county. Thus, a 6-month grace period for obtaining these certifications will be granted to actively practicing paramedics transitioning to the medical direction of St. Joseph Health Center. Following this grace period, it is expected for paramedics to have obtained, and to continue to maintain, their certifications in order to practice under St. Joseph Health Center protocol.

Successful Completion of Protocol Testing: Written Protocol Test: A passing score will be 85% or higher Procedural skills lab/testing: All personnel must attend and demonstrate understanding

and indications for procedures

Candidates who do not successfully pass either the written or procedural testing, will be permitted to re-test not sooner than 21 days after the initial attempt. Candidates will be given no greater than 2 re-testing opportunities per year.

Demonstrate Clinical Ability Through Successful Supervised Participation in the Field as a "Third Person":

Candidates must submit documentation of each run, as well as written approval from the supervising preceptor:

EMT-Basics – must complete a minimum of 5 supervised runs and assessments

EMT-Intermediates – must complete a minimum of 10 supervised runs and assessments; and a minimum of 5 successful IVs in the field

EMT-Paramedics – must complete a minimum of 10 ALS supervised runs and assessments; and must complete a minimum of 5 successful IVs in the field

The supervising preceptor will be an EMT of greater or equal certification to the candidate. Preceptors must be actively practicing Medics with a minimum of 2 years of current experience in good standing. All preceptors must be approved by the Medical Director.

Receiving Final Protocol:


Protocol will be issued on a probationary status to Medics fully completing and submitting the documentation listed above. The probationary period will last for a minimum of one (1) month, or the time necessary for the completion of a minimum of 10 runs. During this probationary period, all runs will be reviewed. At the completion of this probationary period, a decision will be made by the Medical Director to either approve full protocol, extend probation, hold protocol pending counsel/further education, or deny protocol.

Maintaining Individual Protocol:

1. Maintaining Certifications: All Medics will be expected to keep their state certifications (BLS, ACLS, PALS, PTLS/BTLS) for their practicing level, as well as their license, up to date.

2. Continuing Medical Education (CME): Emergency medicine is a dynamic field, and it is important for all of us to keep up-to-date on the current information and to refresh our understanding of complex medical issues. For this reason, it will be mandated that all EMTs provide documentation annually to medical command demonstrating their active involvement in continuing education. (CME may be obtained from any certified source):

a. EMT-Basics must submit……………….4 hours CME annuallyb. EMT-Intermediates must submit………..8 hours CME annuallyc. EMT-Paramedics must submit………….16 hours CME annually

3. Special Labs. Individual may be required to attend specific educational or procedural labs if significant deficiencies in their performance are identified

Revoking/Suspending Individual Protocol:

Any individual's protocol may be revoked or suspended at any time at the discretion of the Medical Director. Reinstatement of revoked/suspended protocol may be offered, requirements for which will be determined on an individual basis. Automatic suspension of protocol will occur if any Medic fails to comply with the criteria set forth for maintaining protocol, including current certifications and annual CME.

Reinstatement of Protocol:

EMS personnel who previously held protocol under the direction of St. Joseph Health Center and have left in “Good Standing” may reinstate as instructed below:

- Return <6 months: Automatically reinstated- Return >6 months but <24 months: May reactivate by passing the

protocol/procedures testing.- Return >24 months: Will be required to complete the entire “Obtaining

Protocol” process.

Obtaining and Maintaining Departmental Protocol:

- Departmental Protocol will be issued and renewed annually once all criteria are met.

- Monthly run reports must be submitted to the St. Joseph Health Center Medical Directory for quality assurance purposes

- Annual documentation is to be sent to the St. Joseph Health Center EMS office:


a) Current drug license b) Current roster c) Drug box maintenance fees paid up to date.

Departments not in compliance with the above criteria, will have their protocol suspended, and will not be able to practice under the medical authority of the Medical Director.

Obtaining/Maintaining EMT-Intermediate Intubation Certification:

EMT-Intermediate providers wishing to obtain intubation privileges must fully demonstrate their competence to provide successful endotracheal intubation, both in the hospital and in the field. (Obtain form from St. Joseph Health Center EMS office): Step I : Candidates must first complete a minimum of 5 in-hospital intubations under the supervision of a physician. Signed approval must be obtained from the supervising physician prior to proceeding to Step II.

Step II: Candidates must complete 3 field intubations under the direct supervision of an approved paramedic supervisor. (May NOT attempt any field intubations until hospital approval Step I has been successfully completed). EMT-Intermediates should submit the signed approval form documenting intubations to the Medical Director for final approval and official intubation certification/privileges. An updated protocol card will be issued.

Step III (Maintaining Certification): Certification is to be renewed annually:

Two (2) documented in-field/ER intubations performed throughout the year – automatically renewed

Less than two (2) intubations performed during the year – repeat supervised hospital intubations for renewal

If intubation certification has lapsed by > 1 year – repeat entire certification process


LINEN REPLACEMENT

Linens soiled and used in the pre-hospital setting may present a significant public health issue. Therefore, all participating EMS squads, both public and private, will:

1. Remove all soiled and used linens from their respective transport vehicles after each patient transport is completed. Each receiving hospital will designate an appropriate container as a receptacle for the deposit of soiled linen used by participating EMS squads in the pre-hospital setting during transport to the receiving hospital; and

2. Obtain from the receiving hospital such linen replacement consistent with that used during the patient transport, but not more than:

A. Two (2) bed sheetsB. One (1) pillow caseC. One (1) bath blanketD. One (1) towelE. One (1) washcloth

IF ANY OF THE LINENS ARE NOT USED, THE SQUAD WILL NOT SEEK AND WILL NOT RECEIVE A REPLACEMENT FOR THE UNUSED ITEM

Hospitals in the Region 10 area of Ashtabula, Columbiana, Mahoning, and Trumbull counties have collectively pledged to continue the practice of replacing linen supplies used by pre-hospital units because there are no facilities in the entire four-county area equipped to deal with biohazard linen except the receiving hospitals. Abandonment of this practice would leave EMS squads without a proper means to handle linen needs.

THIS PROCESS WILL BE IDENTICAL AT ALL RECEIVING HOSPITALS FOR ALL PARTICIPATING EMS SQUADS. NO MEMBER SQUAD OR RECEIVING HOSPITAL WILL BE GRANTED ANY EXCEPTIONS, VARIANCES, OR OTHER WAIVERS


PATIENT REFUSAL OR WITHDRAWAL OF CONSENT

GENERAL STATEMENT: Competent adult patients have the right to give consent for, or refuse, any or all treatments. EMS should attempt to obtain vital signs on all patients. Competent adult patients also have the right to give consent for, or refuse, ambulance transport.

When waiting to obtain lawful consent from the person authorized to make such consent would present a serious risk of death, serious impairment of health, or would prolong severe pain or suffering of the patient, treatment may be undertaken to avoid those risks without consent.

IN NO EVENT SHOULD LEGAL CONSENT PROCEDURES BE ALLOWED TO DELAY IMMEDIATELY REQUIRED TREATMENT

I. ADULTS

1. Refusal. If a patient wishes to refuse either treatment, examination, or transportation, the EMT will complete a Patient Refusal Checklist (see following pages). The patient:

a) Must be advised of benefits of treatment & transport, as well as specific risks of refusal.

b) Must be able to relate to EMT in his or her own words what these risks and benefits are.

c) Will be provided with a Refusal Information Sheet (see following pages). A copy of this

Refusal Information Sheet or the refusal section of the checklist will be signed by the patient, dated, and both will be kept with the patient's file.

2. Withdrawal. A competent patient may withdraw consent for treatment at any time. Prior to discontinuing or withdrawing treatment, the EMT shall determine if the patient is competent:

a) Mental Competence – Decision Making Ability. A person is mentally competent if he:

1. Is capable of understanding the nature & consequences of the proposed treatment.

2. Has sufficient emotional control, judgment, discretion to manage his own affairs.

Ascertaining that the patient is oriented, has an understanding of what happened, and may possibly happen if treated or not treated, and a plan of action -- such as whom he will call for transportation home – should be adequate for these determinations.

b) Impairment. Patients may be considered incompetent to refuse care and/or transportation when they appear impaired. Patients who appear impaired include:

- Suicidal patients - Patients impaired by illicit drugs

- Patients impaired by alcohol - Patients impaired by prescription or

- Patients impaired by medical conditions nonprescription drugs

II. PEDIATRIC

1. A critically ill or injured child should be treated and transported immediately.2. In non-emergency cases involving minors, consent should be obtained from the parent or legal guardian prior to undertaking any treatment. All children must be evaluated for acuity of illness, regardless of obtaining parental consent.


EMS PATIENT REFUSAL CHECKLIST

1. ASSESSMENT OF PATIENT (CIRCLE APPROPRIATE RESPONSE)

ALCOHOL / DRUGS INGESTION PER HISTORY OR EXAM YES NOALTERED LEVEL OF CONSCIOUSNES YES NOHEAD INJURY YES NOORIENTED TO: PERSON PLACE TIME SITUATION

2. MEDICAL CONTROL

CONTACTED VIA: PHONE RADIO TIME ___________UNABLE TO CONTACT MEDICAL CONTROL PHYSICIAN: ___________________If Medical Control not able to be contacted, explain in comments section of checklist

ORDERS:

INDICATED TREATMENT / TRANSPORT MAY BE REFUSED BY PATIENT USE REASONABLE FORCE / RESTRAINT TO PROVIDE TREATMENT USE REASONABLE FORCE AND / OR RESTRAINT TO TRANSPORTOTHER: ___________________________________________________________________________

3. PATIENT ADVISED (CIRCLE APPROPRIATE RESPONSE)

MEDICAL TREATMENT / EVALUATION NEEDED YES NO AMBULANCE TRANSPORT NEEDED YES NO FURTHER HARM MAY RESULT WITHOUT MEDICAL YES NO

TREATMENT OR EVALUATION TRANSPORT BY MEANS OTHER THAN AMBULANCE COULD YES NO

BE HAZARDOUS IN LIGHT OF THE PATIENT'S PRESENT ILLNESSOR INJURY

4. DISPOSITION

REFUSED ALL EMS SERVICES REFUSED TRANSPORT, ACCEPTED FIELD TREATMENT REFUSED FIELD TREATMENT, ACCEPTED TRANSPORT RELEASED IN CARE OR CUSTODY OF SELF RELEASED IN CUSTODY OF LAW ENFORCEMENT AGENCY

AGENCY: ________________________________OFFICER: ________________________________

RELEASED IN CARE OR CUSTODY OF RELATIVE OR FRIENDNAME: ___________________________________RELATION: _______________________________

5. COMMENTS: ______________________________________________________________________________________________________________________________________________

EMT SIGNATURE __________________________ DATE: _____________ TIME: _________


PHYSICIAN AT THE SCENE

GOOD SAMARITAN PHYSICIAN:

This is a physician with no previous relationship to the patient who is not the patient's private physician, but is offering assistance in caring for the patient. The following criteria must be met for the physician to assume any responsibility for the care of the patient:

1. Medical Control must be informed and give approval

2. The physician must have proof they are a physician. They should be able to show you their medical license. Notation of physician name, address, and certification numbers must be documented on the run report

3. The physician must be willing to assume responsibility for the patient until relieved by another physician, usually at the emergency department

4. The physician must not require the EMT to perform any procedures or institute any treatment that would vary from protocol and/or procedure

If the physician is not willing or able to comply with all of the above requirements, his assistance must be courteously declined

PHYSICIAN IN HIS/HER OFFICE OR URGENT CARE CENTER:

1. EMS should perform its duties as usual under the supervision of Medical Control or by protocol

2. The physician may elect to treat the patient in his office

3. The EMT should not provide any treatment under the physician's direction that varies from protocol. If asked, the EMT should decline until contact is made with Medical Control

4. Once the patient has been transferred into the squad, the patient's care comes under Medical Control


RESTRAINT POLICY

GENERAL GUIDELINES:

1. Soft restraints are to be used only when necessary in situations where the patient is potentially violent and may be of danger to themselves or others. EMS providers must remember that aggressive violent behavior may be a symptom of medical conditions such as, but not limited to:

a) Head traumab) Alcohol/drug related problemsc) Metabolic disorders (i.e., hypoglycemia, hypoxia, etc.)d) Psychiatric/stress related disorders

2. Patient health care management remains the responsibility of the EMS provider. The method of restraint shall not restrict the adequate monitoring of vital signs, ability to protect the patient's airway, compromise peripheral neurovascular status or otherwise prevent appropriate and necessary therapeutic measures. It is recognized that evaluation of many patient parameters requires patient cooperation and thus may be difficult or impossible.

3. All restraints should have the ability to be quickly released, if necessary.

4. Restraints applied by law enforcement (i.e., handcuffs) require a law enforcement officer to remain available to adjust restraints as necessary for the patient's safety. This policy is not intended to negate the need for law enforcement personnel to use appropriate restrain equipment to establish scene control.

5. Patient shall not be transported in a face down prone position to ensure adequate respiratory and circulatory monitoring and management.

6. Restrained extremities should be monitored for color, nerve and motor function, pulse quality, and capillary refill at the time of application and every 15 minutes hereafter.

7. After addressing and/or treating metabolic causes of aggressive or violent behavior, administration of a benzodiazepine and/or Haldol as a chemical restraint should be considered.

8. Restraint documentation on the EMS report shall include:

a) Reason for restraintb) Agency responsible for restraint application (i.e., EMS, police)c) Documentation of cardio-respiratory status and peripheral neurovascular status


TERMINATION OF RESUSCITATION EFFORTS (IN NON-TRAUMATIC CARDIAC ARREST)

Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of ACLS (see below) when the patient's survivability is questionable.

1. Adequate Trial of ACLSAn adequate trial of ACLS according to the Journal of American Medical Association's guidelines occurs when:

a) Adequate BCLS has been provided for a reasonable amount of time;b) Endotracheal intubation has been successfully accomplished;c) Intravenous access has been achieved and rhythm-appropriate medications and countershocks for V-Fib have been administered according to protocol; andc) Persistent asystole or agonal electrocardiographic patterns are present and no reversible causes are identified

2. Immediate Transporation to the Emergency DepartmentThe patient WILL BE be transported to the emergency department when:

a) The patient is an adult that exhibits signs or symptoms of hypothermia or drug overdoseb) The patient is a childc) ACLS cannot be provided in a timely mannerd) Endotracheal intubatione) Cardiac defibrillationf) Cardiac medication administration, org) Intravenous catheterization, when there is copious pulmonary edema or aspirated material emanating from the endotracheal tubeh) The BLS service can enter the emergency department faster than prehospital ACLS can be initiated

3. Transporation to the Emergency Department After On-Scene ACLSa) There is a stable pulseb) Persistent ventricular tachycardia or coarse ventricular fibrillation (> 1 cm amplitude)

4. Termination of Resuscitation Efforts

Paramedics WILL CONTACT Medical Control to terminate resuscitation efforts in the field when:

a) There is no return of circulation (spontaneous pulse > 60 bpm) after 20 minutes of ACLSb) Presenting rhythm is asystole and persists unaffected by 2-3 doses of epinephrine and atropine accompanied by ACLSc) Adult cardiopulmonary arrest (not associated with trauma, body temperature aberration,

respiratory etiology, or drug overdose)d) Absence of persistent, recurring, or refractory V-Fib/tachycardia or any continuous neurological activity (e.g., spontaneous respirations, eye opening, or motor response)

Upon termination of life support efforts, the body is to be transported to the Medical Control facility with all IVs and ETT in place for pronouncement. Documentation should be completed and forwarded to Medical Control within 48 hours of the run.EMS Protocol – St. Joseph Health Center – Updated February 13, 2005 131

TERMINATION OF RESUSCITATION EFFORTS (IN TRAUMA PATIENT CARDIAC ARREST)

Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of ACLS (previous page) when the patient's survivability is questionable.

1. No Signs of Lifea) Trauma patient has no vital signs and no signs of life when there is no cardiac, respiratory, or neurologic function:

1. No palpable pulse2. No blood pressure3. No respiratory effort4. No swallowing, eye, or extremity movement5. No pupillary activity

b) Trauma patients with no signs of life at the scene or in transport have virtually no chance of survival, even when no signs of life are restricted to no pulse, respirations, or pupil reactivity.c) Trauma patient survival is negligible when there is cardiac arrest and asystole or idioventricular rhythmd) Trauma patients with prehospital cardiac arrest for more than 5-10 minutes rarely survive

2. Protocol Guidelinesa) The 10-minute time period begins as soon as a BLS/ALS provider recognizes that the patient has no signs of lifeb) Patients with no signs of life upon BLS/ALS arrival

1. When possible, immediately check the cardiac rhythm2. If asystole is present, terminate all support; handled by Coroner at this point3. If asystole is absent or the rhythm is unknown:

I. Initiate BLS/ALS as soon as possible; promptly establish the most appropriate airway & transport to nearest emergency departmentII. If there is no return of any signs of life within 10 minutes of BLS/ALS, obtain Medical Control and recommend the termination of resuscitation efforts; transport body to emergency departmentIII.When the patient access prevents the administration of BLS/ALS, all support is terminated if there is no sign of life witnessed for 10 minutes; handled by CoronerIV. If there is return of any signs of life, immediately transport the patient to the nearest emergency department

c) Patients deteriorating to conditions as set forth in 1a above after BLS/ALS arrival:1. If the patient can be delivered to the emergency department within 10 minutes, initiate BLS/ALS and immediately transport the patient2. If the patient cannot be delivered to the emergency department within 10 minutes, follow items under 2b3 above

CONTACT MEDICAL CONTROL FOR PERMISSIONTO TERMINATE RESUSCITATION EFFORTS

Upon termination of life support efforts, the body is to be transported to the Medical Control facility with all IVs and ETT in place for pronouncement. Documentation should be completed and forwarded to Medical Control within 48 hours of the run.


Documents

Final 1.PDF · Web viewPatients in borderline heart failure cannot tolerate these salt loads) Lowers serum potassium (this may be desirable at times, as in hyperkalemia, but in cardiac