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Rhode Island Emergency Medical Services Statewide EMS ProtocolsOctober 2016Rhode Island Department of Health
Trauma - Environmental - Toxicological ProtocolsSection 4
Trauma – Environmental – Toxicological Protocols
General Changes and Additions• This is a new section in the EMS
protocols• This section has 24 protocols
Trauma – Environmental – Toxicological Protocols
New Protocol Previous ProtocolPrevious
Protocol Section
04.01A Multiple Trauma - Adult 5.1 TraumaTraumatic Emergencies
04.01P Multiple Trauma - Pediatric 5.1 TraumaTraumatic Emergencies
4.02 Head Trauma - Traumatic Brain Injury 5.1 TraumaTraumatic Emergencies
4.03 Spinal Motion Restriction Precautions New – not in previous versions
4.04 External Hemorrhage Control New – not in previous versions
4.05 Extremity and Musculoskeletal Injuries New – not in previous versions
4.06 Traumatic Cardiac Arrest New – not in previous versions
04.07A Thermal - Burn Injury - Adult 5.2 BurnsTraumatic Emergencies
04.07P Thermal - Burn Injury - Pediatric 5.2 BurnsTraumatic Emergencies
4.08 Chemical and Electrical - Burn Injury 5.2 BurnsTraumatic Emergencies
4.09 Crush Injury New – not in previous versions
4.1 Dental Trauma and Emergencies New – not in previous versions
4.11 Ocular Trauma and Emergencies New – not in previous versions
Trauma – Environmental – Toxicological Protocols
New Protocol Previous ProtocolPrevious
Protocol Section
4.12 Heat Related Illness 3.5 Heat Stroke 3.4 Heat Cramps and Heat Exhaustion
Environmental Emergencies
04.13A Hypothermia and Localized Cold Injury - Adult
3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia
Environmental Emergencies
04.13P Hypothermia and Localized Cold Injury - Pediatric
3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia
Environmental Emergencies
4.14 Submersion - Near Drowning 3.3 DrowningEnvironmental Emergencies
4.15 Diving Emergencies New – not in previous versions
4.16 Marine Envenomation New – not in previous versions
4.17 Bites - Stings - Envenomation New – not in previous versions04.18A Toxicological Emergencies - General - Adult 3.6 Poisoning and Overdose
Environmental Emergencies
04.18P Toxicological Emergencies - General - Pediatric 3.6 Poisoning and Overdose
Environmental Emergencies
4.19 Toxicological Emergencies – Nerve Agent or Organophosphate Toxicity New – not in previous versions
4.20 Carbon Monoxide Exposure New – not in previous versions
4.21 Blast Injury - Incident New – not in previous versions
4.22 Radiation Incident New – not in previous versions
4.01 Adult Multiple TraumaProtocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides standing
orders for adult patient with blunt or penetrating trauma.
• This protocol is divided into different levels of care.ALL Providers Levels
• Routine Patient Care• Manage life threatening injuries• Treat as per appropriate protocols• Vented chest seal device• Stabilize impaled Objects• Stabilize pelvis as indicated• Normothermia• Limit on scene time to ≤ 10 min• If indicated (≥45 mins to Trauma Center) follow
HEMS Protocol • Transport to Level 1 Trauma CenterParamedic• Perform needle thoracostomy for suspected
tension pneumothorax
4.01 Pediatric Multiple Trauma
Protocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides standing
orders for pediatric patient with blunt or penetrating trauma.
• This protocol is divided into different levels of care.ALL Provider Levels
• Routine Patient Care• Manage life threatening injuries• Treat as per appropriate protocols• Vented chest seal device over open penetrating
torso injury• Stabilize impaled objects• Stabilize pelvis as indicated• Maintain normothermia• Limit in scene time to ≤ 10 min• If indicated (≥45 mins to Trauma Center) follow
HEMS Protocol • Transport to Level 1 Trauma CenterParamedic• Perform needle thoracostomy for suspected
tension pneumothorax
4.02 Head Trauma - Traumatic Brain Injury (TBI)
Protocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides
standing orders for adult patient with a history or clinical evidence of blunt or penetrating head trauma. In addition, patients who fell and take anticoagulant/antiplatelet medications.
• This protocol is divided into different levels of care.ALL Providers Levels
• Routine patient care• Baseline neurologic examination • Evaluate for increased intracranial
pressure, manage as indicated per 2.01 Acute Neurologic Event with Evidence of Increased ICP
• Provide airway management• Ventilate • Perform blood glucose analysis if AMS• TransportAdvanced EMT Cardiac and Paramedic• Manage hypotension as per the age
appropriate General Shock and Hypotension Protocol.
4.03 Spinal Motion Restriction Precautions
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders
for patients experiencing a mechanism of injury with risk for spinal injury.
• This protocol is for all levels of care.ALL Providers Levels• If criteria met, apply
spinal motion restriction precautions
• If criteria is not met, use the algorithm
• Apply cervical collar, supine on cot, secure with belts
• Self-extrication allowed• Ambulatory patients may
sit, then lie on cot• Scoop and flexible devices
to move patients• Long spine boards for
extrication and movement• Position patient supine on
cot, secure with belts• Manage as per Patient
Comfort protocol • Immobilize patients with
penetrating trauma only if deficit
Pediatric Patients • TRANSPORT IN PEDIATRIC RESTRAINT SYSTEM• Apply padding to cervical collar • Avoid movement• Move from car seat to stretcher ONLY if criteria are
met
4.04 External Hemorrhage Control
ALL Providers Levels• Routine Patient Care• Apply direct pressure• Liberal use of a tourniquet to achieve
hemostasis• Hemostatic agent dressings and devices
as needed• Use of a junctional tourniquet• If involving a dialysis fistula/shunt, use
digital pressure, if tourniquet application is necessary, apply PROXIMALY as far from the fistula as possible
• Manage as per the age appropriate Hemorrhagic Shock Protocol
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients with external hemorrhage.
• This protocol is for all levels of care.
4.05 Extremity Trauma and Musculoskeletal Trauma
ALL Provider Levels• Routine Patient Care• Manage as per appropriate protocol• Remove rings, bracelets, other
constricting items• Care for amputated parts• Splint joint above and below possible
fracture• Traction for isolated midshaft femoral
fractures• Splint dislocations and angulated
fractures in place unless distal circulation is compromised
• Binder for pelvic fractures
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients with musculoskeletal injury/complaint.
• This protocol is divided into different levels of care.
Paramedics• CEFAZOLIN 2 mg IV/IO for open
fractures/ amputations/grossly contaminated wounds
• CEFAZOLIN is contraindicated if history of PCN or cephalosporin allergy
4.06 Traumatic Cardiac Arrest
ALL Providers Levels• Routine Patient Care• IMMEDIATELY INITIATE CPR• Consider medical etiology• Control external hemorrhage• Binder for suspected pelvic fracture• Transport to Level 1 Trauma Center if
<15 minutes
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients in cardiopulmonary arrest with presumed traumatic etiology.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• LACTATED RINGER’s 1L IV/IO Adult• LACTATED RINGER’s 20 ml/kg Pediatric
Paramedic• LACTATED RINGER’s 1L IV/IO Adult• LACTATED RINGER’s 20 ml/kg Pediatric• Perform needle thoracostomy if
suspected tension pneumothorax
4.07 Adult Thermal Burn Injury
ALL Provider Levels• Routine Patient Care• Assess
burn/concomitant injury severity using Rule of Nines.
• Minor burn management
• Serious or critical burns management and transport to Burn Center
Protocol Summary • Previously protocol 5.2 Burn.• This protocol recognizes and provides standing
orders for patients with minor burn, serious burn and critical burn.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• Analgesia, IV for
minor burns• IVFs for serious or
critical burns and transport to Burn CenterParamedic
• Analgesia, IV for minor burns• IVFs, airway management for serious or critical
burns and transport to Burn Center
ALL Providers Levels• Routine Patient Care• Assess
burn/concomitant injury severity using Rule of Nines.
• Minor burn management
• Serious or critical burns transport to Burn Center
Protocol Summary • Previously protocol 5.2 Burn.• This protocol recognizes and provides standing
orders for pediatric patients with minor burn, serious burn and critical burn injuries.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• Analgesia for minor
burns• Consider IV• IVFs for serious or
critical burnsParamedic• Analgesia for minor burns• Consider IV• IVFs for serious or critical burns• Airway management
4.07 Pediatric Thermal Burn Injury
4.08 Chemical and Electrical Burn Injury
ALL Providers Levels• Routine Patient Care• Assess chemical source, utilize HAZMAT
resources as needed • Assess electrical source• Assess burn/concomitant injury severity• Decontaminate most chemical burns with liquid• Brush off powdered chemicals• Treat Hydrofluoric Acid burns with calcium gel• Remove non-adherent clothing/rings/constricting
items• Manage per the age the appropriate Thermal
Burn Protocol and Trauma related protocols. • Transport to Adult Burn Center
Protocol Summary • Previously protocol 5.2 Burn.• This protocol recognizes and provides standing
orders for patients with partial or full thickness burn injury resulting from contact with a chemical agent or energized electrical source.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• Initiate cardiac monitoring
Paramedic• Consider IV CALCIUM if hydrofluoric acid and
hypocalcemia.• Consider nebulized CALCIUM if HF inhalation
4.09 Crush Injury
ALL Providers Levels• Routine Patient Care• Manage as per Trauma Protocols/Shock
Protocols/Hypothermia or Localized Cold Injury Protocols
• Remove constricting items• REQUEST ALS response• Analgesia as needed per Patient Comfort Protocol • Transport
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing
orders for patients with extremity/body crush, entrapped and crushed under heavy load for > 30 min.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• IV NS with SODIUM BICARBONATE during extrication• Manage Cardiac Arrest per appropriate protocol (s)• If ECG suggests hyperkalemia or cardiac arrest occurs,
contact MEDICAL CONTROL for administration of CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO
• Albuterol for suspected hyperkalemiaParamedic• Consider IV NS with SODIUM BICARBONATE during
extrication • Manage Cardiac Arrest per appropriate protocol(s)• ECG suggestive of hyperkalemia or if cardiac arrest
occurs, CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO
• Albuterol for suspected hyperkalemia
4.10 Dental Trauma and Emergencies
ALL Provider Levels• Routine Patient Care• Consider possible cardiac etiology• Manage bleeding with direct pressure
during multisystem trauma treatment• Control dental related bleeding with
rolled gauze direct pressure• Put avulsed teeth in saline, milk, or
commercial solution. Do NOT scrub or cleanse.
• Provide analgesia as indicated per the Patient Comfort Protocol
• Transport
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients with tooth pain or dental injury.
• This protocol is for all levels of care.
4.11 Ocular Trauma and Emergencies
ALL Providers Levels• Routine Patient Care• Assess visual acuity• Obtain history• Rigid shield over penetrating ocular injuries• Immobilize impaled objects and patch BOTH eyes• Assess EOM for blunt traumatic injuries, elevate
HOB, patch• Moist saline over traumatic enucleation • Irrigate chemical eye injuries with water or
LACTATED RINGER’S
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing
orders for patients with ocular complaint or injury.• This protocol is divided into different levels of care.
Advanced EMT Cardiac• ONDANSETRON for penetrating ocular injuries
Paramedic• ONDANSETRON for penetrating ocular injuries• TETRACAINE or PROPARACAINE for ocular flash
burns or chemical eye injuries• Irrigate with LACTATED RINGER’S utilizing a Morgan
lens• Use pH to guide irrigation
4.12 Heat Related Illness
ALL Provider Levels• Routine Patient Care• Measure body temperature• Begin passive cooling• Oral rehydration for heat cramps• Active cooling for heat exhaustion and
heat stroke• Transport
Protocol Summary • Previously protocols 3.4 Heat Cramps
and Heat Exhaustion and 3.5 Heat Stroke.
• This protocol recognizes and provides standing orders for patients with heat cramps, heat exhaustion and heat stroke.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac and Paramedic• IV NS for heat exhaustion and heat
stroke
4.13 Adult Hypothermia and Localized Cold Injury
ALL Providers Levels• Routine Patient Care• Provide airway management• Check pulse 60 seconds if unresponsive• Assess mental status and treat as
indicated• Determine body temperature
• ≥ 34 – 35°C external rewarming• < 34 – 35°C warmed humidified air or
oxygen if available• Avoid refreezing if localized cold
thermal injury
Protocol Summary • Previously protocols 3.1 Cold Exposure
Frost Bite and 3.2 Cold Exposure Hypothermia in Environmental Emergencies.
• This protocol recognizes and provides standing orders for adult patients with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite).
• This protocol is divided into different levels of care.
Advanced EMT Cardiac and Paramedic• For patients with a core temperature <
34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 500 ml IV/IO boluses.
4.13 Pediatric Hypothermia and Localized Cold Injury
ALL Providers Levels• Routine Patient Care• Provide airway management• Check pulse for 60 seconds if
unresponsive• Assess mental status and treat as
indicated• Determine body temperature
• ≥ 34 – 35°C external rewarming• < 34 – 35°C warmed humidified air or
oxygen if available• Avoid refreezing localized cold thermal
injury
Protocol Summary • Previously protocol 3.1 Cold Exposure
Frost Bite 3.2 Cold Exposure Hypothermia in Environmental Emergencies.
• This protocol recognizes and provides standing orders for pediatric with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite).
• This protocol is divided into different levels of care.
Advanced EMT Cardiac and Paramedic• For patients with a core temperature <
34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 20 ml/kg IV/IO boluses
4.14 Submersion – Near Drowning
ALL Providers Levels• Routine Patient Care• Apply Spinal Motion Restriction
Precautions• Manage Cardiac Arrest even after
prolonged immersion in cold water• Manage Hypothermia and Local Cold
Injury as indicated.• Remove wet clothing, dry and warm the
patient.• Provide Airway Management and
Altered Mental Status as indicated.• Manage per the age appropriate
Respiratory Distress Protocol if indicated• Monitor and reassess the patient.• Transport
Protocol Summary • Previously protocol 3.3 Drowning.• This protocol recognizes and provides
standing orders for patients submersed in water regardless of depth.
• This protocol is for all levels of care.
4.15 Diving Emergencies
ALL Provider Levels• Routine Patient Care• Consult Diver’s Alert
Network (DAN)• Analgesia for ear or sinus
squeeze• Oxygen and
recompression Treatment at HBO Facility for
• Pulmonary Overpressure syndrome
• Arterial gas embolism
• Decompression sickness type I and II
• Nitrogen narcosis
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing
orders for patients with ear squeeze/sinus squeeze, pulmonary overpressure syndrome, arterial gas embolism, decompression sickness type I and II, Nitrogen Narcosis.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac and Paramedics• OXYMETAXOLINE or PSEUDOEPHEDRINE for ear or sinus squeeze – Patient
Comfort Protocol• IV NS for decompression sickness type II
4.16 Marine Envenomation
ALL Providers Levels• Routine Patient Care• Manage allergic or anaphylactic
reactions• Regional Center for Poison Control and
Prevention 800-222-1222• Sting Ray, Lionfish or Urchin/Starfish
related injuries• Immobilize injury and object, or remove barb
if small• Jellyfish or Man o’ War related injuries
• Lift away tentacles• Irrigate with vinegar or sea water NOT fresh
water or ice• Treat pain as per the age appropriate
Patient Comfort Protocol
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients exposed to marine organisms with intense localized pain, nausea/vomiting, allergic reaction or anaphylactic reaction.
• This protocol is divided into different levels of care.
Paramedic• Manage severe muscle spasm with
CALCIUM IV
4.17 Bite - Stings - Envenomation
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients with bee or wasp sting, spider, snake, feline, canine, or human bite.
• This protocol is divided into different levels of care.
Paramedic• Manage severe muscle spasm with
MIDAZOLAM
ALL Providers Levels• Routine Patient Care• Manage allergic or anaphylactic
reactions• Consider Regional Center for Poison
Control and Prevention 800-222-1222• Spider bites and bee or wasp stings
• Elevate, ice, remove constricting jewelry• Snake bites
• Immobilize, elevate, remove constricting jewelry
• NO ICE• Feline, Canine or Human bites
• Wound care• Immobilize• Contact animal control
4.18 Adult Toxicological Emergencies
ALL Provider Levels• Routine Patient Care• Recognition symptoms
(toxidromes)• OPIOID OVERDOSE
• NALOXONE UNTIL ADEQUATE VENTILATION
• FOLLOW THE RECOVERY COACH ALGORITHM
• CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL
• ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE manage per appropriate protocol
Protocol Summary • Previous protocol 3.6 Poisoning and
Overdose.• This protocol recognizes and provides
standing orders for patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• NALOXONE for Opioid Overdose until
adequate ventilation• SODIUM BICARBONATE for suspected
antidepressant or other sodium channel blocking agent toxicity
• GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity
• HYDROXYCOBALAMIN for suspected Cyanide toxicity
• MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity
• Treat seizures
Paramedic• INTRALIPID or NOREPINEPHRINE for
antidepressant or other sodium channel blocking agent toxicity
• GLUCAGON, CALCIUM or INTRALIPID for beta blocker or calcium channel blocker toxicity
• SODIUM THIOSULFATE for Cyanide toxicity
• ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide exposure
• MIDAZOLAM or LORAZEPEM for sympathomimetic/stimulant toxicity
• DIPHENHYDRAMINE for dystonic reactions
• INTRALIPID for lipid-soluble toxicity cardiac arrest / hemodynamic compromise
2.17 Obstetrical Delivery4.18 Pediatric Toxicological Emergencies
ALL Provider Levels• Routine Patient Care• Recognition symptoms
(toxidromes)• OPIOID OVERDOSE
• NALOXONE UNTIL ADEQUATE VENTILATION
• FOLLOW THE RECOVERY COACH ALGORITHM
• CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL
• ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE
• DuoDote
Protocol Summary • Previous protocol 3.6 Poisoning
and Overdose.• This protocol recognizes and
provides standing orders for pediatric patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• NALOXONE for Opioid Overdose until adequate
ventilation• SODIUM BICARBONATE for suspected
antidepressant or other sodium channel blocking agent toxicity
• GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity
• HYDROXYCOBALAMIN for suspected Cyanide toxicity
• MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity
• Treat seizures
Paramedic• INTRALIPID or NOREPINEPHRINE for antidepressant or other
sodium channel blocking agent toxicity• GLUCAGON, CALCIUM or INTRALIPID for beta blocker or
calcium channel blocker toxicity• SODIUM THIOSULFATE for Cyanide toxicity • ATROPINE / PRALIDOXIME for organophosphate nerve agent
or insecticide exposure• MIDAZOLAM or LORAZEPEM for
sympathomimetic/stimulant toxicity unless < 5kg• DIPHENHYDRAMINE for dystonic reactions unless < 5 kg• INTRALIPID for lipid-soluble toxicity cardiac arrest /
hemodynamic compromise
2.17 Obstetrical Delivery4.19 Nerve Agent or Organophosphate Toxicity
ALL Provider Levels• Routine Patient Care• PPE• DuoDote
• Adult• Pediatric
Protocol Summary • New Protocol • This protocol recognizes and provides standing orders for patient with
suspected or know exposure to a nerve or organophosphate agent with salivation, lacrimation, urination, defecation, GI distress, emesis [SLUDGE], muscle twitching, seizures, respiratory arrest), bradycardia, bronchorrhea, and/or bronchospasm.
• This protocol is divided into different levels of care.
Advanced EMT Cardiac• Manage Seizures as per the age appropriate Seizure Protocol
Paramedic• Manage Seizure as per the age appropriate Seizure Protocol• ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide
exposure
4.20 Carbon Monoxide
ALL Providers Levels• Routine Patient Care• OXYGEN• Treat as outlined in table
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing
orders for patients involved in fire or in a confined space/poorly ventilated area with potential for the presence of carbon monoxide (combustion of carbon containing fuels or inadequate ventilation of natural gas).
• This protocol is divided into different levels of care.
Advanced EMT Cardiac and Paramedic• Cardiac monitoring and multi-lead ECG
4.21 Blast Injury - Incident
ALL Providers Levels• Routine Patient Care• Ensure scene safety.• Determine nature of incident, nature of device,
nature of environment, potential for threat of particalization of hazardous materials and distance from blast.
• Quantify and triage patients per the Multiple Patient Incident Protocol(s) as indicated.
• Manage patient as indicated per age appropriate Trauma and Burn Protocols, Crush Injury Protocol, Radiation Incident Protocol.
• Transport
Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing
orders for Blast explosion occurring in an open space (conventional blast) or enclosed/confined space (vehicle, building, bus, train).
• This protocol is divided into different levels of care.
4.22 Radiation Incident
ALL Providers Levels• Routine Patient Care• Ensure scene safety.• If the incident involves a blast, also
manage per Blast Incident and Injury Protocol.
• Determine need for additional resources, exposure type, quantification of exposure, quantify and triage patients as per the Multiple Patient Incident Protocol as indicated.
• Flush contact areas with NORMAL SALINE for 15 minutes.
• If present, manage burn injuries as per age appropriate Burn Protocol(s).
• Identify and manage any secondary injuries as per appropriate Trauma Protocols.
• Transport
Protocol Summary • This is a new protocol. • This protocol recognizes and provides
standing orders for patients with radiation burn or exposure to radiation.
• This protocol is for all levels of care.
Continue on to RI EMS Protocol Education ModulesSection 5