EMT EMT Basic
J EMT-Johnson
EN EMT-Enhanced
EMT Enhanced
I/P Intermediate or Paramedic
P Paramedic Only
MC Medical Command
Universal Patient Care Protocol
Scene Safety/ Personal Protective Equipment
Primary Survey
Initial interventions as needed
y
Pulse oximetry
Supplemental O2
Obtain and document
Vital signs
SAMPLE history
Pain assessment
OPQRST (medical)
DCAP BTLS (trauma)
Cardiac monitor/ 12 Lead ECG
Appropriate Protocol/Consider Differential Diagnoses
If no protocol applies or condition is unknown, consult medical
command
Transport per guidelines
Pearls:
•Complete vital signs should be taken every 5 min for critical and 15 min for non-critical pts.
•Complete vitals include a minimum of HR, RR, and BP.
•On scene times should be limited to 15 minutes for medical, 10 minutes for trauma.
•Do not delay oxygen therapy to obtain pulse oximetry reading.
Do
*if available
Abdominal Pain
History Physical Differential
•Age •Pain Diagnoses
•Past medical/ surgical history •Tenderness •Trauma
•Medications •Nausea/ vomiting •Pregnancy
•Onset •Diarrhea •Pneumonia
•Palliation/.provocation •Dysuria/hematuria •Pulmonary embolism
•Quality
Q lit C
•Constipation
ti ti (hepatitis,
•Liver (hepatitis CHF)
•Radiation •Vaginal bleeding/discharge •Peptic ulcer disease
•Severity •Pregnancy •Gastritis
•Time •Fever •Gallbladder
•Fever •Headache •Myocardial Infarction
•Last meal eaten •Malaise •Pancreatitis
•Last bowel movement/emesis •Kidney stone
•Menstrual history •Addominal aneurysm
•Appendicitis
•Bladder/ prostate
•Pelvic inflammatory
•Ovarian cyst
•Spleen enlargement
•Diverticulitis
•Bowel obstruction
•Gastroenteritis
Pearls:
•Acute, undiagnosed abdominal pain should not receive analgesics in the field
without medical command
Abdominal Pain
B Universal Care Protocol B
EN IV access, bolus up to 1 liter NS EN
I/P Initiate cardiac monitor and pulse oximetry I/P
B Consider 12 Lead ECG B
I/P For persistent nausea and vomiting, consider Zofran 4 mg IV, may repeat in 10 I/P
minutes
Alcohol Related Emergencies
History Physical Differential
Diagnoses
Hypoglycemia
Traumatic injury
Universal Care Protocol
B Monitor for respiratory depression B
B If seizures occur, refer to the Neurological/Seizure Protocol B
EN Infuse 1 liter NS over 1 hour, then 150 ml/hr EN
EN Treat suspected hypglycemia EN
I/P Initiate cardiac monitor and pulse oximetry I/P
I/P For severe agitation, tachycardia, or halluciniations, consider diazepam I/P
(Valium) 5 mg IV or midazolam (Versed) 5 mg IM, may repeat either in 10
minutes
Cardiac Arrest: General Management
History Physical Differential
•Events leading to arrest •Unresponsive Diagnoses
•Estimated down time •Apneic •Medical vs. trauma
•Past medical history •Pulseless •V-fib/pulseless v-tach
•Medications •Asystole
•Terminal illness? •PEA
Si f i /li idit
•Signs of rigor/lividity
•DNR
B Universal Care Protocol B
B Criteria for Death/ No Resuscitation? B
B CPR B
Interrupt compressions only as per AED prompt or every 2 minutes (5 cycles
of CPR)
B AED B
Apply immediately if witnessed or bystander CPR in progress
Use after 2 minutes of CPR when unwitnessed
I/P Assess Rhythm (do not use AED mode), I/P
R f t appropriate protocol/algorithm
Refer to i t t l/ l ith
B Airway Management B
Ventilate no more than 10/min (1 breath every 6-8 seconds)
Pearls:
Change compressors every 2 minutes.
Allow full chest recoil.
Check femoral/carotid pulse to verify effective CPR.
Cardiac Arrest: Asystole / Pulseless Electrical Activity
History: Physical: Differential:
•Past medical history •Pulseless •Medical vs. trauma
•Medications •Apneic •Hypoxia
•Events leading to arrest •No electrical activity on ECG •Hypo-/Hyperkalemia
•End stage renal disease •No ascultate heart tones •Drug overdose
•Estimated down time •Acidosis
S t d hypothermia
•Suspected h th i H th
•Hypothermiai
•Suspected overdose •Device error
•DNR
B General Cardiac Arrest protocol B
EN Establish IV or IO Access and NS infusion EN
I/P Confirm asystole in more than one lead I/P
I/P Administer Vasopressin 40 units (one time dose) I/P
g p p
Begin epinephrine after 3-5 minutes
I/P 1 mg Epinephrine (1:10,000) IV/IO I/P
Or 2 mg ETT every 3-5 minutes up to three doses
I/P Atropine 1 mg IV/IO every 3-5 minutes up to 3 doses I/P
I/P Consider and treat for reversible causes as above I/P
MC Contact medical command for termination of efforts after establishing secure MC
airway, IV/IO access, administering initial medications, and treating for
reversible causes
Pearls:
•Vasopressin should be adminstered only one time in place of either the first or
second epinephrine dose.
Cardiac: Atrial Fibrillation/Flutter
History Physical Differential
•Medications • HR >150/min Diagnoses
Aminophylline, Q S
•QRS 90 mmHG.
For patients who have not responded to TCP and atropine, consider
dopamine (Intropin) 5 to 20 mcg/kg/min to maintain BP of 90 mmHg.
MC Midazolam (Versed) 2-5 mg IV during TCP. MC
Cardiac: Chest Pain/ Suspected Myocardial Event
History Physical Differential
•Age •Chest Pain Diagnoses
•Medications (pain, pressure, aching,
( Trauma vs.
•Trauma vs medical
•Use of Viagra, Cialis, Levitra tightness) •Angina vs. MI
•Past medical history •Location •Pericarditis
•Recent physical exertion (substernal, epigastric, arm, •Pulmonary embolism
•Onset
Onset jaw, neck, shoulder) •Asthma/ COPD
•Palliation/Provocation •Pale, diaphoretic •Pneumothorax
•Quality •Dyspnea •Aortic dissection or
•Radiation •Nausea, vomiting aneurysm
•Severity •Reflux or hiatal
hernia
•Time
•Esophageal spasm
•Pleuritic pain
•Cocaine overdose
Pearls:
Metoprolol should generally be avoided in Interior and Inferior-Posterior STEMI’s (II, III, and AVL).
Metoprolol should be avoided if cocaine or methamphetamine use is known or suspected.
Avoid NTG if use of Viagra, Cialis, or Levitra use within the past 24 hours, contact medical command.
Inferior MI’s are preload dependent and may not tolerate NTG well, use IV fluids as needed.
Diabetics, females, and geriatric patients often present with atypical chest pain or generalized complaints.
Cardiac: Chest Pain/ Suspected Myocardial Event
B Universal Care Protocol B
B Transmit 12 Lead ECG, Consult Medical Command for possible STEMI alert B
B Aspirin 162 mg (2 baby aspirin) chewed. B
EN Establish IV access EN
B Nitroglycerin 0.4 mg every 5 minutes as needed. No maximum, keep BP B
>100 mmHg.
•EMT-B’s should assist patient with prescribed NTG only, max 3 doses.
•EMT-J’s should administer only if patient has taken NTG in past, max 3
doses.
J Apply 1 inch 2% Nitropaste (15 mg) topically keeping BP >100 mmHg. J
I/P For vomiting, consider Zofran 4 mg IV repeated in 10 minutes if needed./ I/P
I/P Consider morphine sulfate 2 mg slow IV. May be repeated every 5-10 I/P
100mmHg
minutes to a max of 6mg keeping BP >100mmHg
I/P Refer to hypotension and dysrhythmia protocols as indicated I/P
I/P Consider fluid bolus for Inferior (II, II, and AVF) STEMI’s I/P
I/P Metoprolol 5mg slow IVP if Anterior (V3, V4), Antero-spetal (V1, V2, V3, V4), I/P
Antero lateral (V3, V4, V5, V6, I,
or Antero-lateral (V3 V4 V5 V6 I AVL) STEMI . May be repeated in 15
minutes to a max dose of 15 mg.
Cardiac: Narrow Complex Tachycardia- Paroxysmal SVT
History Physical Differential
•Medications •HR >150 Diagnoses
Aminophylline •QRS 103
For heat exhaustion PO water if patient can tolerate If temp >103°, cool with B
wet towels or fans until temp reaches 100°.
B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs B
to groin and axillae) unitl core temp is 100 mmHg.
Environmental: Hypothermia
History Physical Differential
•Past medical history •Cold, clammy Diagnoses
•Medications •Shivering •Sepsis
•Exposure to environment, even •Altered mental status •Environmental
in normal temperatures •Extremity pain or sensory exposure
•Exposure to extreme cold abnormality •Hypoglycemia
•Extremes of age •Bradycardia CNS
•CNS dysfunction
•Drug use •Hypotension Stroke
•Infections/ sepsis Head injury
•Length of exposure/wetness Spinal cord injury
Pearls:
P l
Avoid rough handling.
Maintain supine position.
Warm fluids as close to 109° as possible by placing on heater or hot packs. Do not microwave.
Avoid intubation if possible in the severely hypothermic patient.
urban hypothermia abuse.
Consider “urban hypothermia” with high association of poverty or drug//alcohol abuse
Environmental: Hypothermia
B Universal Care Protocol B
B Obtain accurate core body temperature. B
B Confirm pulselessness for 30-45 seconds B
B Refer to CPR and AED protocol if needed. B
B Remove wet garments. B
.Protect from further heat loss.
Apply heat packs if body temperature 86°-93°
EN Airway management EN
EN IV or IO access EN
NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.
I/P Modify ACLS algorithms: I/P
Temp > 86°, give IV meds as indicated as longer intervals.
Temp 90 mmHg
I/P Dopamine 5-20 mcg/kg/min to maintain BP >90 mmHg if no response to IV I/P
therapy or if CHF is present.
Pearls:
Hypovolemia must be corrected prior to dopamine infusion.
Identify and manage underlying cause.
Consider drug side effects or overdose.
General Medical: Severe Allergic Reaction
History Physical Differential
•Onset and location •Itching or hives Diagnoses
•Insect bite or sting •Coughing or wheezing •Rash only
•Food allergy/exposure •Chest or throat constriction •Anaphylaxis
•New clothing, soap, detergent •Difficulty swallowing •Shock
•Past history of reactions •Hypotension or shock •Angioedema
•Past medical hi t
P t di l history •Edema
Ed •Aspiration/ airway
•Medication history •Vomiting obstruction
•Vasovagal event
•Asthma or COPD
•CHF
General Medical: Severe Allergic Reaction
B Universal Care Protocol B
B Remove from source of exposure. B
B Apply ice packs to localized area. B
B Administer epinephrine (1:1000) 0.3 mg SQ. B
p j ,
•EMT-B’s should assist with prescribed auto injector for severe hives,
respirator distress, and/or shock if >8 years or >30 kg..
J Albuterol 2.5 mg nebulized for wheezing/ bronchospasm. J
EN NS 500 mL bolus, repeated up to 1 liter for hypotension. EN
J Diphenhydramine reactions
Diphenh dramine 25 mg IM/IV for mild to moderate reactions, 50 mg IM/IV for J
severe reactions. May repeat once in 10 min.
•EMT-J’s should administer 50 mg IM.
EN Methylprednisolone 125 mg IV over 1 minute for severe hives or difficulty EN
breathing.
I/P Cardiac and pulse oximetry monitor. I/P
MC Epinephrine (1:10, 000) 0.5 – 1 mg IV over 5 minutes in dire circumstances. MC
MC Dopamine 5-20 mcg/kg/min to maintan BP >90 mmHg MC
MC Epinephrine 2-10 mcg/min to maintain BP >90 mmHg MC
Neurological: Altered Level of Consciousness
History Physical Differential
•Known diabetic •Change in baseline mental Diagnoses
•Drugs or paraphernalia status •Head trauma
•Past medical history •Bizarre behavior •Stroke
•Medications •Cool, diaphoretic skin •Seizure
•History of trauma (hypoglycemia) •Tumor
Ch
•Change in condition
i diti Warm,dry
•Warm,dry skin, signs of •Infection
dehydration (hyperglycemia) •Cardiac
•Fruity breath odor •Thyroid
•Kussmaul respirations •Shock
•Diabetes
•Toxicologic
•Acidosis/alkalosis
•Exposure
•Hypoxia
•Electrolyte
abnormality
•Psychiatric disorder
Pearls:
Medications are a common cause of altered mental status.
Blood l t be helpful but d
Bl d glucose meters may b h l f l b t used cautiously, particularly if values are b d li
ti l ti l l l borderline.
Intubated patients should not receive naloxone unless in cardiac arrest.
Naloxone may be administered IM up to 1.6 mg (2 mL) per injection site.
Neurological: Altered Level of Consciousness
B Universal Care Protocol B
B Instant Glucose 15 grams. B
B Spinal immobilization if indicated. B
B 12 Lead ECG. B
EN Establish IV access. EN
EN Dextrose 50%grams slow IVP. EN
J Glucagon 1mg IM if no IV access. May be repeated in 10 minutes. J
J 08 overdose
Naloxone 0.8 mg IM or slow IVP for suspected narcotic overdose. J
EN For hyperglycemia (BS >400mg/dl), infuse I liter NS over 30-60 minutes, EN
followed by NS at 250 mL/hr.
I/P Cardiac and pulse oximetry monitors. I/P
Neurological: Seizures
History Physical Differential
•Reported/witnessed seizure •Altered mental status Diagnoses
activity •Sleepiness • Head trauma
•Previous seizure history •Incontinence •Tumor
•Medic alert information •Observed seizure activity •Metabolic, hepatic, or
•Seizure medications •Evidence of trauma renal failure
•History of trauma U
•Unconsiousness
i Hypoxia
•Hypoxia
•History of diabetes •Electrolyte imbalance
•History of pregnancy •Medication non-
compliance
•Infection/ fever
Al h l ithd
•Alcohol withdrawall
•Eclampsia
•Stroke
•Hyperthermia
•Hypoglycemia
yp g y
Pearls:
Care during the post-ictal phase should be supportive or precautionary only.
Status epilepticus is defined as 2 or more successive seizures without recovery; it is a true
emergency.
Grand mal (generalized) seizures: loss of consciousness, incontinence, and tongue trauma.
Focal (petit mal) seizures: effect only one part of body, usually not associated with loss of
consciousness.
Jacksonian seizure: start as focal seizure then become generalized.
Neurological: Seizures
B Universal Care Protocol B
B Protect patient. Do not attempt to restrain. B
EN Establish IV access. EN
EN Dextrose 50%grams slow IVP. EN
J Glucagon 1mg IM if no IV access. May be repeated in 10 minutes. J
I/P Cardiac and pulse oximetry monitors. I/P
I/P Diazepam 5mg IVP. I/P
I/P Midazolam 5 mg IM if no IV access. I/P
I/P If patient is pregnant, refer to OB/GYN Eclamptic Seizure protocol I/P
Neurological: Stroke/CVA
History Physical Differential
•Previous CVA or TIA •Altered mental status Diagnoses
•Previous cardiac or vascular •Weakness/ paralysis •TIA
surgery •Blindness or other sensory •Seizure
•Diabetes loss •Hypoglycemia
•Hypertension •Aphasia •Thrombotic or
•Coronary artery disease •Syncope embolic stroke
•Atrial fibrillation •Vertigo/dizziness •Hemorrhagic stroke
•Mediations (blood thinners) •Vomiting •Tumor
•History of trauma •Headache •Trauma
•Seizures
•Change in
Pearls:
Obtain and document onset of symptoms, medications, and contact information for medical
decision maker.
p g (Coumadin) or other anitcoagulants.
Determine whether or not the patient is taking warafin ( ) g
Neurological: Stroke/CVA
B Universal Care Protocol B
B Focused neurological exam. Cincinnati Prehospital Stroke Scale. Repeat B
every 15 minutes.
B Instant glucose 15 grams for suspected hypoglycemia. B
B ECG.
12 Lead ECG B
EN Establish IV access. EN
EN Dextrose 50% 25 grams IV for suspected hypoglycemia. EN
J Glucagon 1 mg IM if no IV access and suspected hypoglycemia. J
I/P Cardiac and pulse oximetry monitors. I/P
MC For onset of symptoms 100 mmHg EN
EN 1 inch nitropaste if BP >100 EN
B 12 Lead EKG, proceed to Chest Pain protocol if STEMI is determined B
I/P Morphine 2-4 mg slow IV push if BP >100mmHg I/P
I/P Consider dopamine 2 to 20 mcg/kg/min I/P
Pearls:
All h i is t th
•All wheezing i not asthma.
•Lasix is not a first line drug.
•Allow position of comfort.
•Use of nitropaste may be preferable to SL NTG if hypotension is likely to occur.
•Avoid NTG with use of Viagra, Cialis, or Levitra within past 24 hours.
Respiratory Distress—COPD/Bronchospasm
History Physical Differential Diagnoses
Tobacco use Air hunger Asthma
COPD/Emphysema/ Diaphoresis Anaphylaxis
Chronic Bronchitis Retractions Aspiration
Asthma Accessory muscle use COPD
Sudden weather change Tripoding Pneumonia
Home O2 Cyanosis Pulmonary Embolism
Prescribed MDI Clubbed fingernails Pneumothorax
Prescribed steroids Barrel Chest Cardiac (MI or CHF)
Prescribed bronchodilators JVD Hyperventilaton
Wheezes Inhaled toxin (carbon
Silent chest monoxide, etc)
B General Respiratory Distress Protocol B
B Assist with prescribed MDI, may repeat in 5 min B
J Albuterol 2.5 mg/Atrovent 500 mcg neb J
EN Consider Solumedrol 125 mg SLOW IV push EN
MC Consider Epi 0.3 mg 1:1000 SQ for severe cases MC
MC Consider Epi 1:10, 000 IV for dire circumstances only MC
Pearls:
Contact
•Contact medical command before administering epi to patients who are > 50 years, have cardiac history, or if
heart rate is >150.
•Silent chest is a sign of impending respiratory arrest.
Respiratory Distress– Pneumonia
History Physical Differential Diagnoses
Decreased oral intake Fever Asthma
Chills Productive cough Aspiration
Exertional dyspnea Chest Pain Cardiac (CHF. MI)
General illness Nausea/vomiting COPD
Altered mental status Tachycardia Septic Shock
Prescribed or OTC Tachypnea Pulmonary effusion
medications Rales or decreased breath
sounds
Hypotension (sepsis,
dehydration)
Poor skin turgor
B General R
G l Respiratory Di t
i t Protocol
Distress P t l B
J Consider CPAP Protocol J
J Albuterol 2.5 mg/ Atrovent 500 mcg neb J
EN Consider IV bolus if clinical signs of dehydration are present EN
Toxicology: Poisoning/ Overdose
History Physical Differential Diagnoses
•Ingestion of toxic •Altered mental status •Tricyclic antidepressants
substance •Hypotension •Acetaminophen
•Route and quantity of •Decrease respiratory rate •Depressants
ingestion •Tachycardia •Stimulants
•Time of ingestion •Dysrhythmias •Anticholinergics
R (suicide, id t)
•Reason ( i id accident) •Seizures •Cardiac medications
•Available meds near •Solvents, cleaning agents
patient
•Insecticides
•Past medical history (organophosphates)
•Medications
Pearls:
Intubated patients should not receive naloxone unless in cardiac arrest.
Tachycardia is not a contraindication to atropine adminstration.
Poison control should be consulted on all complex toxicology at 434-924-5543 or 1-800-451-1428.
Aeromedical resources will not transport contaminated patients.
Any patient with a QRS >100 msecs should receive sodium bicarbonate.
Toxicology: Poisoning/ Overdose
B Universal Care Protocol B
J Identify substance and assure decontamination. J
J Flush skin/membranes with appropriate solution if indicated. J
EN IV access. EN
J Naloxone 0.8 mg IV or IM for suspected narcotic overdose with respiratory J
depression.
EN Diphenhydramine 1 mg/kg slow iVP for dystonic reaction secondary to EN
phenothiazine ingestion (max dose of 50 mg).
I/P For Symptomatic Tricyclic Antidepressant Overdose: I/P
( if QRS >0.12 msecs, hypotension, or dysrhythmia)
•Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes
I/P For Symptomatic Calcium Channel Blocker Overdose: I/P
(if bradycardic, QRS >0.12 msecs, heart block, hypotension, lethargy,
slurred speech, nausea, vomiting)
•Calcium chloride 20 mg/kg slow IVP over 10 minutes
•Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.
I/P For Symptomatic Organophosphate Poisoning: I/P
(secretions, bronchospasm, seizures, bradycardia)
•Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased
secretions.
Trauma: Amputation
History Physical Differential Diagnoses
•Mechanism of injury •Deformity •Complete amputation
•Time of injury •Diminished pulse, •Incomplete amputation
•Wound contaminatior capillary refill
•Medical history
•Medications
B Universal Care Protocol B
B Spinal Immobilization. B
B Apply direct pressure to control hemorrhage. Avoid tourniquet if possible. B
B If incomplete amputation, splint entire digit or limb in physiological B
position.
B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, B
place on ice/water mix.
EN IV Acess. EN
NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.
I/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to I/P
i
severe pain.
Pearls:
Tourniquets should be used with the smallest amount of pressure over the widest area.
Never freeze the part by placing directly on ice.
Trauma: Burns
History Physical Differential Diagnoses
•Type of exposure •Burns, pain,
•Burns pain swelling •Superficial
•Inhalation injury •Dizziness •Partial thickness
•Time of injury •Loss of consciousness •Full thickness
•Past medical history •Hypotension •Chemical
•Medications •Airway compromise •Thermal
•Other trauma •Singed facial or nasal hair •Electrical
•Loss of consciousness •Hoarseness/wheezing •Radiation
•Tetanus status
Pearls:
In electrical burns, search for additional traumatic injury.
In thermal burns, assess for carbon monoxide exposure.
Remove jewelry and nonadherent clothing.
Avoid establishing IV distal to extremity burn.
Trauma: Burns
B Universal Care Protocol B
B Apply dry sterile dressings. B
B Spinal immobilization if indicated. B
B Irrigate chemical burn with water if water is appropriate to chemical. B
chemical,
If powdered chemical brush off off.
B Splint fractures after apply dressing. B
EN Advanced airway management EN
EN IV Acess. EN
NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.
Administer 300 mL/hr for electrical burns if no risk of CHF
I/P Cardiac and pulse oximetry monitors. I/P
I/P M hi sulfate up t 10 mg slow IVP with BP >90mmHg f moderate t
Morphine lf t to l ith 90 H for d t to I/P
severe pain.
Trauma: CNS Injuries
History Physical Differential Diagnoses
Time of injury •Pain swelling bleeding
•Pain, swelling, •Skull fracture
Mechanism of injury •Altered mental status •Brain injury
Loss of consciousness •Unconsciousness •Epidural hematoma
Bleeding •Respiratory •Subdural hematoma
Medical history distress/failure •Subarachnoid
Medications •Vomiting hemorrhage
Evidence of multi-trauma •Significant mechanism of •Spinal injury
Helmet use or damage injury •Abuse
B Universal Care Protocol B
B Spinal immobilization if indicated. B
B Elevate head of stretcher 30° if not hypotensive. B
B Maintain patient warmth. B
EN Advanced airway management EN
EN IV Acess. EN
NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.
I/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to I/P
pain.
severe pain
Pearls:
GCS should be assessed and documented.
pupil,
Hyperventilation (10 breaths over normal ventilation) only if evidence of herniation (blown pupil
posturing, or bradycardia.
Intracranial pressure may cause hypertension, bradycardia, and altered respiratory rate.
Haloperidol should not be administered to these patients.
Trauma: General Management
History Physical Differential Diagnoses
•Time and mechanism of •Pain,
•Pain swelling •Chest
injury •Deformity, lesions, Tension pneumothorax
•Damage to structure or bleeding Flail chest
vehicle •Altered mental status Pericardial tamponade
•Location in structure or •Hypotension Open chest wound
vehicle •Arrest Hemothorax
•Others injured or dead
•Intra-abdominal bleed
•Speed and details of MVC
•Pelvis/ femur fracture
•Restraints/ protective
devices •Spinal fracture/cord injury
•Past medical history •Head injury
•Medications •Extremity trauma
•HEENT trauma
•Hypothermia
Pearls:
GCS should be assessed and documented.
Trauma: General Management
B Universal Care Protocol B
B Spinal immobilization if indicated. B
B Notify MedCom if possible trauma alert (red or yellow category): B
Advise mechanism of injury, age and sex of patient, sites of injury, vital if
available, ETA.
B For evisceration, cover with moist sterile dressing then with plastic. B
Do not push organs back into abdominal cavity.
B Maintain patient warmth. B
EN Acess.
IV Acess EN
NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.
EN Needle Decompression Procedure if indicated EN
I/P Cardiac and pulse oximetry monitors. I/P
Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to
severe pain from isolated distal extremity fracture/ dislocation
MC Consider cessation of efforts for patients in traumatic cardiac arrest. MC
Pediatrics: General Management of Cardiac Arrest or Pre-Arrest
History Physical Differential Diagnoses
•Time of arrest •Unresponsive •Respiratory failure
•Medical history •Pulseless Foreign body
•Medications •Apneic Secretions
•Possibility of foreign body Infection
•Suspected abuse •Hypovolemia
•SIDS •Congenital heart disease
•Trauma
•Tension pneumothorax
•Toxin or medication
•Hypoglycemia
•Acidosis
Pearls:
If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.
IV medications should be followed by a 10 mL bolus NS.
ETT doses are less desirable, flush with 2-3 mL NS.
ETT placement should be reconfirmed everytime the patient is moved or for change of status.
Continuous ETCO2 is mandatory in intubated patient.
distention.
Consider orogastric tube for abdominal distention
Use length-based resuscitation tape.
.
Pediatrics: General Management of Cardiac Arrest or Pre-Arrest
B Universal Care Protocol B
B Check adequacy of CPR. B
Perform chest compressions if HR persistently 220, child rate >180)
Consider vagal maneuvers if stable
MC Adenosine 0.1 mg.kg rapid IV/IO max initial dose 6 mg, may repeat one MC
g
time at twice the first dose to a max of 12 mg.
MC Synchronized cardioversion 0.5 to 1 j/kg may increase to 2 j/kg if MC
ineffective
MC Consider midazolam 0.1 mg/kg IV/IO max single dose 2 mg. MC
Do not delay cardioversion.
Pediatrics: Ventricular Fibrillation/ Pulseless VT
History Physical Differential Diagnoses
B Universal Care Protocol B
B General Management of Cardiac Arrest Protocol B
B AED protocol using pediatric pads if possible B
I/P Attempt defibrillation at 2 j/kg I/P
I/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mg I/P
Or
Epinephrine ET (1:1000) 0.1 mg/kg
*For newborns 0 08
Confirm QRS >0.08 msec I/P
I/P If unstable, sychronized cardioversion 0.5 to 1 j/kg, I/P
may increase to 2 j/kg if ineffective.
MC Consider amiodarone 5 mg/kg IV/IO over 10 to 20 minutes MC
MC C id
Consider midazolam 0 1 mg/kg IV/IO
id l 0.1 /k IV/IO. MC
Do not delay cardioversion.
Pearls:
patient.
VT is uncommon in the pediatric patient
The ventricular rate may vary from near normal to near 400 bpm.
Slow rates may be well tolerated.
The majority of children who develop VT have underlying structural heart disease or prolonged QT syndrome.
IV medications should be followed by a 10 mL bolus NS.
Pediatrics: Hyperthermia
History Physical Differential
Diagnoses
B Universal Care Protocol B
B Obtain accurate core body temperature. B
B Move to cooler environment, remove excess clothing, protect from further B
heat i
h t gains.
B For heat exhaustion, PO water if patient can tolerate. If temp >103°, cool with B
wet towels or fans until temp reaches 100°.
B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs B
8 years, Dextrose 50% 1mL/kg IV or IO.
•Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV or IO.
•Neonates 8 years, Dextrose 50% 1mL/kg IV or IO.
•Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV or IO.
g
•Neonates 0.10 msecs, hypotension, or dysrhythmia)
•Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes
I/P For Symptomatic Calcium Channel Blocker Overdose: I/P
(if bradycardic, QRS >0.12 msecs, heart block, hypotension, lethargy,
slurred speech, nausea, vomiting)
•Calcium chloride 10 mg/kg slow IVP over 10 minutes
•Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.
I/P For Symptomatic Organophosphate Poisoning: I/P
(secretions, bronchospasm, seizures, bradycardia)
•Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased
secretions.
Pediatric: Amputation
History Physical Differential Diagnoses
•Mechanism of injury •Deformity •Complete amputation
•Time of injury •Diminished pulse, •Incomplete amputation
•Wound contaminatior capillary refill
•Medical history
•Medications
B Universal Care Protocol B
B Spinal Immobilization. B
B Apply direct pressure to control hemorrhage. Avoid tourniquet if possible. B
B If incomplete amputation, splint entire digit or limb in physiological B
position.
B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, B
place on ice/water mix.
EN IV Access. EN
NS 20 mL/ kg bolus.
I/P Morphine sulfate up to 0.1 mg/kg slow IV/IO/IM. Max dose 10 mg. I/P
Pearls:
Tourniquets should be used with the smallest amount of pressure over the widest area.
Never freeze the part by placing directly on ice.
Pediatric: Burns
History Physical Differential Diagnoses
•Type of exposure •Burns, pain, swelling •Superficial
Inhalation
•Inhalation injury Dizziness
•Dizziness Partial
•Partial thickness
•Time of injury •Loss of consciousness •Full thickness
•Past medical history •Hypotension •Chemical
•Other trauma •Airway compromise •Thermal
•Medications •Singed facial or nasal hair •Electrical
•Loss of consciousness •Hoarseness/wheezing •Radiation
•Tetanus status
B Universal Care Protocol B
B y y g
Apply dry sterile dressings. B
MC Consult medical command regarding cooling procedures. MC
B Spinal immobilization if indicated. B
B Irrigate chemical burn with water if water is appropriate to chemical. B
chemical,
If powdered chemical brush off off.
B Splint fractures after apply dressing. B
EN Advanced airway management EN
EN IV or IO Acess. EN
L/k b l t t L/k
NS 20 mL/kg bolus, may repeat up to 40 mL/kg.
I/P Cardiac and pulse oximetry monitors. I/P
I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe I/P
pain.
Pearls:
In electrical burns, search for additional traumatic injury.
In thermal burns, assess for carbon monoxide exposure.
Remove jewelry and nonadherent clothing.
Avoid establishing IV distal to extremity burn.
Trauma: CNS Injuries
History Physical Differential Diagnosis
Time of injury •Pain swelling bleeding
•Pain, swelling, • Skull fracture
Mechanism of injury •Altered mental status •Brain injury
Loss of consciousness •Unconsciousness •Epidural hematoma
Bleeding •Respiratory •Subdural hematoma
Medical history distress/failure •Subarachnoid
Medications •Vomiting hemorrhage
Evidence of multi-trauma •Significant mechanism of •Spinal injury
Helmet use or damage injury •Abuse
B Universal Care Protocol B
B Spinal immobilization if indicated. B
B Elevate head of stretcher 30° if not hypotensive. B
B Maintain patient warmth. B
EN Advanced airway management EN
EN IV or IO access EN
NS 20 mL/kg bolus, may repeat up to 40 mL/kg.
Pearls:
GCS should be assessed and documented.
Pediatric: General Trauma Management
History Physical •Chest
•Time and mechanism of •Pain,
•Pain swelling Tension pneumothorax
injury •Deformity, lesions, Flail chest
•Damage to structure or bleeding Pericardial tamponade
vehicle •Altered mental status Open chest wound
•Location in structure or •Hypotension Hemothorax
vehicle •Arrest •Intra-abdominal bleed
•Others injured or dead
•Pelvis/ femur fracture
•Speed and details of MVC
•Spinal fracture/cord injury
•Restraints/ protective
devices •Head injury
•Past medical history •Extremity trauma
•Medications •HEENT trauma
•Hypothermia
Pearls:
GCS should be assessed and documented.
Preservation body heat is paramount.
Pediatric: General Trauma Management
B Universal Care Protocol B
B Spinal immobilization if indicated. B
B Notify MedCom if possible trauma alert (red or yellow category): B
Advise mechanism of injury, age and sex of patient, sites of injury, vital if
available ETA
available, ETA.
B For evisceration, cover with moist sterile dressing then with plastic. B
Do not push organs back into abdominal cavity.
B Maintain patient warmth. B
EN IV or IO access. EN
NS 20 mL/kg bolus, may repeat up to 40 mL/kg.
EN Needle Decompression Procedure if indicated EN
I/P Cardiac and pulse oximetry monitors. I/P
I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe I/P
pain from isolated distal extremity fracture/ dislocation. Max dose 10 mg.
MC Consider cessation of efforts for patients in traumatic cardiac arrest. MC