ambulance protocols by WWJe6RN

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									EMS
Protocols
EMS Protocols

Revised 2/23/2011
                                                               EMS Protocols 2009

Index

PART I: GENERAL GUIDELINES…………………………………………….5

PART II. ADULT CARDIAC EMERGENCIES……………………………….8

      Standing Orders for All Cardiac Problems………………………………….8
      Chest Pain – Suggestive of Ischemia………………………………………..9
      Suspected Pulmonary Edema…………………………………………..…..11
      Cardiogenic Shock/Pump Failure…..............................................................13
      Stable Tachycardia’s………………………………………………….…....14
      Unstable Tachycardia’s……………………………………………….…....15
      Ventricular Fibrillation and Pulseless Ventricular tachycardia……….…....16
      Asystole………………………………………………………………….…18
      Pulseless Electrical Activity (PEA)…………………………………….…..20

PART III. ADULT MEDICAL EMERGENCIES

      Shock, Non-Traumatic………………………………………………….….22
      Abdominal Pain………………………………………………………….…23
      Allergic Reaction / Anaphylaxis……………………………………….…..24
      Respiratory Distress…………………………………………………….….26
      Seizures………………………………………………………………….…28
      Altered mental Status / Unconsciousness……………………………….….29
      Symptomatic Known Diabetic………………………………………….….30
      Drug Overdose / Accidental Poisoning…………………………………….31
      Suspected CVA / TIA……………………………………………………...32
      Suspected carbon Monoxide Poisoning……………………………………33
      Severe Nausea / Vomiting or Diarrhea…………………………………….34

PART IV. TRAUMATIC EMERGENCIES…………………………………..35

      Standing Orders for ALL Traumatic Emergencies………………………...35
      General Trauma / Traumatic Shock…………………………………….….36
      Isolated Head and Spine Injuries…………………………………………..38
      Amputations…………………………………………………………….….40
      Extremity Fractures / Dislocations………………………………………....41



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PART V. OTHER EMERGENCIES…………………………………………...42

      Hypothermia………………………………………………………………..42
      Hyperthermia……………………………………………………………….45
      Chemical Eye Injury………………………………………………………..46
      Burns……………………………………………………………………….47
      Behavioral Emergencies……………………………………………………49

PART VI. OBSTETRIC / GYNECOLOGICAL EMERGENCIES………….50

      Normal Labor and Delivery………………………………………………..50
      Obstetric Complications……………………………………………………52

PART VII. PEDIATRIC MEDICAL EMERGENCIES………………………53

      General Guidelines…………………………………………………………53
      Pediatric Airway Management……………………………………………..54
      Pediatric circulatory Management…………………………………………55
      Pediatric MAST Guidelines………………………………………………..55
      Newborn Emergencies……………………………………………………..56
      Standing Orders for ALL Newborn Emergencies………………………….56
      Basic Skills………………………………………………………………....56
      Advanced Skills…………………………………………………………….56
      Pediatric Asthma Attack…………………………………………………....58
      Pediatric Airway Obstructions / Foreign Body…………………………….60
      Pediatric Status Seizures…………………………………………………...61
      Pediatric Anaphylaxis……………………………………………………...62
      Pediatric Drug Ingestion or Overdose………………………………….…..64
      Pediatric Unconscious – Unknown Etiology………………………………65
      Pediatric Symptomatic Known Diabetic…………………………………...66
      Pediatric Shock……………………………………………………………..68

PART VIII. PEDIATRIC CARDIAC EMERGENCIES……………………..69

      Pediatric Bradycardia………………………………………………………69
      Pediatric tachycardia with Adequate Perfusion…………………………….71
      Pediatric Tachycardia with Poor Perfusion (Pulse Present)………………..72
      Pediatric Pulses Arrest –VT/VF……………………………………………73
      Pediatric Pulseless Arrest – (Asystole / PEA)……………………………...75
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                                                EMS Protocols 2009
PART IX. APPENDICES TO EMS PROTOCOLS………………………………76


      ALS Procedures……………………………………………………..……...76
      ALS Medications (required)……………………………………….….…....76
      ALS Medications (Optional)……………………………………..…..(OPEN)
      Appendix A – Endotracheal & Nasotracheal Intubation………………...…79
      Appendix D- Peripheral IV Access……………………………………...…80
      Appendix E – Intraosseous Access……………………………………..….82
      Appendix F- Cardioversion……………………………………………..…88
      Appendix G- Cardiac Defibrillation……………………………………..…89
      Appendix H- Transcutaneous/External Cardiac Pacing…………………....92
      Appendix I – Pain Management…………………………………………....93
      Appendix K- Medications……………………………………………….…95
      Activated Charcoal………………………………………………………....95
      Albuterol……………………………………………………………………96
      Albuterol – Patient Assisted Inhalers………………………………………97
      Aspirin……………………………………………………………………...98
      Atropine…………………………………………………………………….99
      Dextrose…………………………………………………………………..100
      Epinephrine……………………………………………………………….101
      Epinephrine – Patient Assisted Auto-Injector…………………………….102
      Glucagon………………………………………………………………….103
      Glucose – Patient assisted Medication……………………………………104
      Lidocaine Hydrochloride………………………………………………….105
      Morphine Sulfate…………………………………………………………106
      Narcan…………………………………………………………………….107
      Nitroglycerine, Tablets – Patient Assisted Medications………………….108
      Nitroglycerin……………………………………………………………...109
      Appendix – L Laryngeal Mask Airway (LMA) Insertion …………….110
      Appendix – I Mucosol Atomization Device (MAD) Naloxone (Narcan) ..111
      Appendix – K Taser Deployment & Barb Removal ……………………...112




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PART I: GENERAL GUIDELINES
A.     Incident Response:         Upon notification of emergency medical incidents, the Fire
Department dispatches and responds with Ambulance, Squad or Engine companies fully staffed
and equipped for initial care and/or basic life support for patients. This agency has mandated it
absolutely necessary to staff our EMS units with at least two EMT’s, one being and EMT-I

B.     Ambulance Service: Ambulance service for Sunset city, will include one Type I
ambulance located at 85 West 1800 North, Sunset City Utah. They will response from
pager/radio response.

C.      Aero-Medical Evacuation: Evacuation of patients by means of air, or air-ambulance
(i.e. Life-Flight, Air-Med, etc.) should be coordinated through the fire department on-scene
commander, and other responding agencies. A call for standby or actual flight shall be deemed
appropriate by the highest medical authority on scene and coordinated through the dispatch
center. Criteria include, but are not limited to the following;
        -Lengthy extrication
        -Severity of injury needs critical care team
        -Any type of pediatric
        -Any type of Neonatal
        -Any type of Respiratory
        -LVAD or artificial Heart
        -Hoist/Search and rescue ops
        -Possible stroke
        -Burns

D.     Communications: Communication is established between responding units and the
dispatch center by Emergency Medical Dispatch (EMD) certified operators and a state-of-the-art
telecommunications console capable of patching to any local agency frequency, including
statewide emergency channels. The “Priority Dispatch” card system is used to prioritize certain
response codes Alpha through Omega depending on the nature and severity of an incident.
Personnel on responding apparatus are also equipped with landline-enabled handheld radios
and/or cellular phones for access to live, on-line Medical Control (Davis Hospital-Layton)
Physicians or Nurses.




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E.     Infection Control:

1) Personal Protective Equipment (PPE) i.e. gloves, goggles, mask and gowns will be used
   when it is reasonably anticipated that workers will come in contact with blood or other
   potentially infectious materials. PPE is maintained in all SFD units.

2) All tools and equipment will be cleaned with 1:100 (10%) bleach to water solution when
   contaminated by any body fluids. Commercially available cleaners may be used as well. All
   equipment shall be allowed to air dry at least 20 min, prior to being placed back into
   service.

3) Disposable resuscitation bags and pocket masks are located in all SFD units.
   If an occupational exposure does occur, the employee is advised to seek medical attention
   for testing no longer than 24-48 hours after the exposure.



INITIAL CARE
STIPULATIONS:

A. These protocols are designed for use by Sunset Fire Department personnel only, as guidelines
   for the implementation of emergency care in the pre-hospital setting. All personnel utilized
   as a rescue team member are as a minimum certified to the CPR level of care and often
   consist of at least two EMTs, both CPR and AED trained. These protocols will be in effect
   until they are revised or rescinded.

B. The individual treatment protocols are provided to allow SFD response teams to institute
   lifesaving and routine pre-hospital care until radio and/or direct contact can be established
   with medical control or incoming ALS units. Communications should be attempted as soon
   as possible, but may be delayed if doing so would endanger the patient’s welfare. Always err
   on the side of quality patient care.

C. Procedures will only be performed by individuals who have been trained and verified in
   those particular skills. Any procedure not directly covered in the following protocols will not
   be performed except under exceptional circumstances and only after discussion and approval
   of on-scene ALS providers or local Medical Control

D. Remember: courtesy to the Patient, the patient family and other emergency care personnel is
   of utmost importance.

E. BEMS approved SFD EMS incident report form must be completed on all patients. Specific
   prehospital care information must also be recorded on all patient contacts as part of the
   System data collection program.



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F. This document is to be used as consultive material in striving for optimal patient care. It is
   recognized that specific procedures or treatments may be modified depending on the
   circumstances of a particular case. Also, a medical control physician, when consulted, will
   either concur or further evaluate the EMT’s clinical findings and suggest and alternate
   diagnosis and treatment.

G. In all circumstances, physicians have latitude in the care they give and may deviate from
   these Medical Protocols if it is felt such deviation is in the best interest of the patient.

H. Nothing in these protocols shall be interpreted as to limit the range of treatment modalities
   available to medical control physicians to utilize, other than the modulated and the
   medications used must be consistent with the SFD EMT’s training.

I. All patient interaction and communications between responders, agencies, and hospitals is
   considered protected health information and shall be guarded as outlined in the Health
   Insurance Portability and Accountability Act of 1996 (HIPPA).




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                                                                 EMS Protocols 2009

Part II: Adult Cardiac Emergencies

Treatment protocols for cardiac emergencies are based on Bureau of Emergency
Medical Services approved emergency cardiovascular care standards.

Standing Orders for All Cardiac Problems

EMT Basic:
1) Make a rapid determination of the patient’s level of conscious and insure the patient has a
   patent airway, adequate breathing, and proper circulation

2) Talk to patient and reassure to decrease anxiety. Place at rest on stretcher with head elevated
   30-40 degrees or in position of comfort.

3) Elicit patient history, i.e., chief complaint, SAMPLE history (especially prior cardiac history)
   OPQRST specific to chief complaint pacemaker or automatic implantable cardiac
   defibrillation (ICD).

4) Begin oxygen therapy. Administer via Non-Rebreather Mask (NRB) at 10-15L/min.

5) Perform the following expeditiously:

       a. Obtain vital signs including SPO2 and estimate the patient’s weight.
       b. Perform appropriate physical exam including skin condition, lung auscultation,
          observation for jugular vein distention (JVD), and dependent edema.

EMT Intermediate:
6) Establish IV access using Normal Saline or Lactated Ringers and obtain blood tubes. Run to
   keep vein open (TKO). If IV cannot be started after two attempts, begin transport.

7) When medical control is indicated, establish ASAP.

8) If the patient’s condition is determined to be unstable, transport the patient to the closest
   emergency room.

9) During transport reassess patient’s vitals and level of consciousness every 5 min, for unstable
   patients, every 10 min. for stable patients.




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                           CHEST PAIN – Suggestive of Ischemia


Patients with any of the following chief complaints or presenting problems should be treated as a
suspected MI unless ordered otherwise. If in doubt, contact physician and discuss case:
    Chest pain or pressure in any patient over age 30
    Syncopal episode in any patient over age 50 (without suspicion of stroke)
    Atypical cardiac pain, i.e., shoulder, arm, or jaw pain in absence of chest pain
       (especially in patient with past cardiac history)
    Acute onset fatigue, SOB or diaphoresis in patient with past cardiac history (especially
       elderly)
    Unexplained respiratory distress


             Standing Orders                             Medical Control Options
EMT Basic:
1) ABC’s, correct life – threatening
   complications
2) Position patient to maintain airway. Use
   Positive pressure ventilator assist as
   needed
3) Obtain baseline vitals, including SPO2,
    Temperature & Glascow score
4) Administer 02 via NRB
5) Obtain SAMPLE history.
6) Assess for associated sign/symptoms
                                                 7) In the absence of EMT-I or EMT-P contact
                                                    Base hospital for permission to administer
                                                    Patient assisted Nitroglycerin
EMT Intermediate
8) For any suspected MI, even in absence of
     Chest pain, administer Aspirin 160 to 325
     Mg PO if no history of allergy
9) Establish IV access & blood tubes. If
    Patient has been loaded in the ambulance
    Without IV access, begin transport
     Promptly with IV and all other
    Interventions performed en route
10) For cardiac pain, administer nitroglycerin
    0.4 mg SL tablet or one metered dose
    Spray if patient’s systolic BP ≥ 110
    (Consult with medical control physician if
    SBP < 100). Check BP immediately prior
    To and after administration.

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                                                           EMS Protocols 2009
11) If no relief and patient’s SBP ≥ 100, may
    Repeat Nitro every five minutes. Recheck
    BP before and after administration.
12) Contact receiving ED prior to arrival and
    Communicate the following pertinent
    Patient information & interventions
    Including:

    a)   Patient age/sex
    b)   Vital signs
    c)   Pain – OPQRST & response to Nitro
    d)   Medications administered and response
         seen
    e)   Hx recent surgery or trauma
    f)   Hx bleeding problems
    g)   CNS disease
    h)   Previous lytic therapy
    i)   Pregnancy
    j)   Results of 12-lead EKG if available

13) Expedite transport to appropriate facility
    Frequently monitor serial vitals as outlined
    In standing orders
14) If pain persists after 3 Nitro and SBP ≥       ** EMT Intermediate providers require
    100, may give Morphine 2-10mg IV                   medical control approval before
    Titrated to obtain pain relief. (Use caution       administration of Morphine**
    In presence of COPD)
15) If Respiratory Depression or Hypotension
occurs, after administration of Morphine,
ventilate patient as necessary and administer
Narcan 0.4 – 2mg in accordance with
Appendix – I. Notify Medical Control.
Transport Immediately




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                             SUSPECTED PULMONARY EDEMA


  Condition characterized by Tachypnea, labored respirations, anxiety and agitation, fatigue,
 rales, JVD, possible peripheral edema, frothy sputum and/or cyanosis. Condition attributed to
   cardiac pump problem versus heart rate problem, volume problem or respiratory disease.

                Standing Orders                           Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threatening
   Complications.
2) Position patient to maintain airway. Keep
   Head elevated at all times.
3) Obtain baseline vitals, including SPO2
   Temperature & Glascow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history.
6) Assess for associated signs/symptoms
EMT Intermediate:
7) Establish IV access and blood tubes.
8) For severe distress and/or ineffective
   Ventilation intubate immediately. Confirm
   Tube placement by exams plus
   Confirmation device (End-tidal CO2
   Detection device, Endotracheal tube
   Locator or Capnographer).

9) Give Nitroglycerin 0.4 mg SL tablet or 1
   Metered dose spray if systolic BP – 140
   Or greater. (Consult with medical control
   Physician if SBP < 140 and check BP
   Immediately prior to and after each nitro
   Administration.)

      a) 3 minutes after initial dose repeat
         Nitroglycerin 0.4 mg SL or 1 metered
         Dose spray if patient still has sign of
         Pulmonary edema and systolic BP
         140 or greater.

       b) 5 minutes after second dose repeat
          nitroglycerin 0.4 mg SL or 1 metered
          dose spray if patient still has signs of
          pulmonary edema and systolic BP 140
         or greater
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11) Give Aspirin 160 – 325 mg PO if no
    History of allergy or regular Aspirin
    Consumption.
12) Contact medical control physician for
    Further orders
                                            13) Consider Morphine 2 - 4 mg IV
14) Transport Immediately




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                                                  EMS Protocols 2009


                       CARDIOGENIC Shock / Pump Failure


         Standing Orders                       Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threatening
   Complications.
2) Position patient to maintain airway
3) Obtain baseline vitals, including SPO2
    Temperature & Glascow score.
4) Administer 02 via NRB
5) Obtain SAMPLE history
6) assess for associated sign/symptoms: \
   (decreasing LOC, skin condition, chest
   Pain, shortness of breath, edema).
EMT Intermediate:
7) Establish IV access & obtain blood tubes
8) Contact medical control physician for
    Orders.
9) Transport Immediately




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                                                         EMS Protocols 2009

                                  Stable Tachycardia’s


         Standing Orders                           Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threatening
   Complications.
2) position patient to maintain airway
3) Obtain baseline vitals, including SPO2
   Temperature & Glascow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history
6) Assess for associated signs/symptoms
EMT Intermediate:
7) Establish IV access & obtain blood tubes.
8) Evaluate for serious signs or symptoms
   (shortness of breath, chest pain, dyspnea
   On exertion, altered mental status,
   Pulmonary edema, rales, rhonchi,
   Hypotension, orthostasis, JVD, peripheral
   Edema, and/or ischemic ECG changes). If
   Present refer to unstable tachycardia
   Protocols.
9) Contact Medical control
10) Transport Immediately




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                                                      EMS Protocols 2009

                                 Unstable Tachycardia’s


    These are patients who appear in extremis with altered mental status, poor
 perfusion, respiratory distress, hypertension and not simply complaining of chest
                           pain/pressure or mild dyspnea.

         Standing Orders                          Medical Control Options
EMT Basic:
1) establish ABC’s, correct life-threatening
   Complications
2) Position patient to maintain airway
3) Obtain baseline vitals, including SPO2
   Temperature & Glascow score
4) Administer 02 via NRB.
5) Obtain SAMPLE History
6) Assess for associated sign/symptoms
EMT Intermediate:
7) establish IV access & obtain blood tubes
8) Contact Medical Control
9) Transport immediately




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                                                         EMS Protocols 2009

               Ventricular Fibrillation and Pulseless Ventricular Tachycardia



         Standing Orders                              Medical Control Options
EMT Basic:
1) Establish ABC’s confirm cardiac arrest
   (unresponsive, Pulseless, apenic).
2) Start Time Hack (P.A.R, check)
3) Continue/Institute CPR for 5 cycles at        **IN CARDIAC ARREST WITNESSED B
   30:2 ratios. Ventilate via BVM, F.R.O.P         EMS, PROCEED IMMEDIATELY TO
   w/ OPA, LMA & 100% O2                                 DEFIBRILLATION**
4) Attach AED and analyze rhythm. If shock
   Advised follow Automatic Defibrillator
   Protocol. (Appendix G)
5) Obtain SAMPLE history: (events
   Precipitating arrest & estimated arrest
   Time).
6) Assess for associated signs/symptoms
    And/ or trauma.
EMT Intermediate:
7) Establish IV access & obtain blood tubes
8) Assess and confirm Pulseless VT/VF
    Defibrillate once at 360 J monophasic or
    Equivalent biphasic per manufactures
    Recommendation. Immediately resume
    CPR for 5 cycles/2 minutes
9) If not already established obtain IV access
    w/tubes
10) Administer Epinephrine 1 mg every 3-5
    Min. DO NOT INTERRUPT CPR
11) After 5 cycles/2 minutes of CPR reassess
    For shockable rhythm. Defibrillate once at
    360J monophasic or equivalent biphasic
    Per manufacturer’s recommendation.
    Immediately resume CPR for 5 cycles/2
    minutes
12) Consider Lidocaine 1 to 1.5mg/kg IV. May
    Repeat Lidocaine .5 to .75mg/kg in 3-5
    Min. (max dose 3mg/kg). OR consider
    Amiodorone 300mg/IV once, then follow
    Up dose 150mg IV once for refractory VT.
13) Secure airway with ET intubation. Confirm
    Tube placement by exam plus confirmation
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   Device.

14) If unable to secure airway via ET
    Intubation, keep LMA/Combitube.
15) Consider treatable causes for cardiac arrest.
16) Contact medical control
17) transport immediately
18) ON SCENE TIME SHOULD NOT
EXCEED 1O MIN TOTAL




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                                                Asystole


         Standing Orders                                   Medical Control Options
EMT: Basic
1) rapid scene survey: Is there any evidence
   That resuscitation should not be attempted
    (e.g., DNR orders, conditions
    Incompatible with life) START TIME
    HACK (P.A.R. CHECK)
2) Establish ABC’s, confirm cardiac arrest
   (unresponsive, Pulseless, apenic)
3) continue/institute CPR for 5 cycles/2
   Minutes at 30:2 ratios. Ventilate via BVM
   W/OPA, LMA at 100% O2.
4) Attach AED and analyze rhythm. If shock
   Advised follow Automatic Defibrillator
   Protocol. (Appendix G)
5) Obtain SAMPLE history: (events
   Precipitating arrest & estimated arrest
   Time).
6) Assess for associated signs/symptoms
   And/or trauma
EMT Intermediate
7) Establish IV access & obtain blood tubes.
8) Secure airway with ET intubation. Confirm
    Tube placement by exam plus confirmation
    Device (End-tidal Carbon Dioxide
    Detection device, Endotracheal tube
    Locator or Capnographer).
9) If unable to secure airway via ET
    Intubation, consider staying with the LMA.
10) During course of arrest consider treatable
    Causes for cardiac arrest.
11). Do not interrupt CPR for > 10 seconds
12) Assess and confirm Asystole
13) If not already established obtain IV access
    w/tubes.
14) Administer Epinephrine 1:10,000 1 mg
    IV, repeat q 3-5 min.
15) Administer Atropine 1 mg IV, repeat every
    3-5 min (max dose 3 mg)
16) Contact medical control
17) Transport Immediately
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18) ON SCENE TIME NO MORE THAN
10 MIN




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                          Pulseless Electrical Activity (PEA)

         Standing Orders                           Medical Control Options
EMT Basic:
1) Rapid Scene survey: Is there any evidence
   That resuscitation should not be attempted
   (e.g., DNR orders, conditions incompatible
   With life). START TIME HACK
   P.A.R check)
2) Establish ABC’s confirm cardiac arrest
   (unresponsive, Pulseless, apenic).
3) Continue/Institute CPR for 5 cycles of 30:2
   Compressions to Ventilations. Ventilate
   Via BVM w/OPA, LMA at 100% O2
4) Attach AED and analyze rhythm. If shock
   Advised follow AUTO DEFIBRILATOR
   Protocol. (Appendix G)
5) Obtain SAMPLE history: (Events
   Precipitation arrest & estimated arrest
   Time).
6) Assess for associated signs/symptoms
   And/ or trauma.
EMT Intermediate
7) Secure airway with ET intubation. Confirm
    Tube placement by exam plus confirmation
    Device.
8) If unable to secure airway via ET
    Intubation, consider placement of rescue
   Airway (Combitube/LMA). Confirm
   Placement by exam plus confirmation
   device
9) During course of arrest consider treatable
    Causes for cardiac arrest (e.g. H’s & T’s)
    Treat according to protocols if present:

      Hypovolemia-fluids, MAST (if
       Available)
     Hypoxia-ventilation and oxygenation
     Hypothermia-careful handling &
       Passive re-warming (see Hypothermia
       Protocol)
     Hypoglycemia- D50 or Glucagon
10) Do not interrupt COR > 10 seconds.

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                                               EMS Protocols 2009
11) Assess and confirm rhythm as PEA
    (rhythm on monitor without detectable
     Pulse)
12) If not already established, obtain IV
    Access w/tubes. Consider bilateral large
    Bore lines and fluid challenge.
13) Administer Epinephrine 1:10,000 1mg,
    Repeat every 3-5 min.
14) If PEA rate is slow (<60 bpm) administer
    Atropine 1 mg, repeat every 3-5 min (up
    To total of 3mg)
15) Contact medical control physician for
    Further orders.
16) ON SCENE GOAL, 10 MIN TOTAL




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                                 SHOCK, NON - TRAUMATIC


 Consider acute presentation of anaphylaxis, overdose, acute aortic aneurysm, or
                             myocardial infarction.

         Standing Orders                                  Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threading
   complications
2) Position patient to maintain airway
3) Obtain baseline vitals, including SPO2,
   Temperature & Glascow score.
4) Administer O2 via NRB 15LPM
5) Obtain SAMPLE history
6) Assess for associated symptoms.
7) If SBP < 90, consider placing patient in        DO NOT INFLATE WITHOUT VERBAL
    MAST (if available).                                       ORDERS.
8) Begin transport immediately.
EMT Intermediate:
9) apply cardiac monitor & monitor rhythm.
10) Start NS/LR IV en route. Consider bilateral
    Large bore lines. Administer 300-500 cc
    Bolus.
11) Reassess vitals, shock & respiratory status.
12) Contact a medical control physician for
    Further orders
                                                   13) Consider further volume loading for
                                                       Hypotension.
                                                   14) Consider inflation of MAST w/SBP < 80
                                                       (if available).
                                                   15) If hypotension persists, consider
                                                        Administration of Epinephrine (2-10
                                                        Mcg/kg/min)




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                                      Abdominal Pain


 Definition: pain occurring in the area between the chest and pelvis; it is usually a
signal that something is wrong with one of the organs within the abdominal cavity.


         Standing Orders                                 Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threatening
   complications
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
    Temperature & Glascow score.
4) Administer O2 via NRB 15 LPM
5) Obtain SAMPLE history: (OPQRST of
    Pain, posture of patient, skin, distention
    Rigidity, tenderness, guarding, pulsatile
    Masses, & bowel sounds).
6) Assess for associated symptoms:
   (Nausea/vomiting, change in bowel &
   Urinary habits, menstrual history, fever)
7) If SBP < 90 place patient MAST pants (if
   Available).
8) Begin transport immediately
EMT Intermediate
9) Apply cardiac monitor &,monitor rhythm
10) Start NS/LR IV en route. Consider bilateral
    Large bore lines.
11) Contact a medical control physician for
    Further orders.
                                                  12) Consider volume loading (300-500 cc’s
                                                      NS/LR) for hypotension.
                                                  13) Consider inflation of MAST w/SBP <
                                                      80 (if available)




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                              Allergic Reaction / Anaphylaxis


  Description: an abnormal and individual hypersensitivity to substances that are
  ordinarily harmless. Anaphylaxis is an exaggerated reaction to these substances
                               that can lead shock.


EMT Basic:
1) Establish ABC’s, correct life-threatening
   Complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2
   Temperature & Glasgow score.
4) Administer O2 via NRB 15 LPM
5) Obtain SAMPLE History: (Known
   Exposure to bee stings, drugs, nuts,
   Seafood. Prior allergic reactions).
6) Assess for associated symptoms: (itching
   Wheezing, respiratory distress, N/V
   Chest tightness, headache, cough,
   Weakness, facial swelling, Urticaria,
   Flushing, swollen tongue/airway).
7) Degree of allergic reaction:

       Mild – local swelling itching
       Moderate – hives, wheezing
       Severe - respiratory distress, systolic
        BP < 90
8) remove injection mechanism if still
    Present and visible. Consider ice pack at
    Sting or injection site.
9) Place patient in position of comfort.
10) In absence of EMT-I or EMT-P may
    Administer one adult EpiPen IM if
    Patient was exposed to commonly
    Recognized allergen and has respiratory
    Distress OR systolic BP < 90
EMT Intermediate:
11) May administer Epinephrine 0.3 to 0.5mg
    1:1000 IM or one adult EpiPen IM if
    Patient was exposed to commonly
    Recognized allergen and has respiratory
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     Distress OR systolic BP < 90

                                                     ** Anxiety, tremors, palpitations,
                                                 Tachycardia, and headache are common
                                                  after administration of Epinephrine **
12) Start IV NS/LR, large bore. Consider rapid
    Infusion of 1000cc’s of NS or LR. Obtain
    Blood specimen if possible.
13) Attach cardiac monitor
14) Transport immediately




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                                    Respiratory Distress

         Standing Orders                                  Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life-threatening
    Complications.
2) Position patient to maintain airway &
    Position of comfort. Usually sitting upright
    (45 -90 degrees w/feet dropped).
3) Obtain baseline vitals, including SPO2
    Temperature & Glascow score
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (Accessory
muscle use, tripod/positioning, drooling,
pursed lips, retractions, nasal flaring, one/two
word dyspnea, orthopnea, peripheral edema,
JVD, acute/slow onset, recent surgery &/or bed
rest, recent trauma &/or long bone fractures,
intubation history).
6) Assess for associated signs/symptoms:
(Chest pain/discomfort, productive cough,
fever).
                                                   7) In the absence of EMTI or EMTP contact
                                                   base hospital for permission to administer
                                                   patient assisted medication Inhaler
EMT Intermediate:
8) If patient breathing:
a) Establish IV NS/LR, TKO. Obtain blood
tubes.
b) Move patient to ambulance and begin
transport.
c) En route to hospital, may give nebulized
Albuterol 2.5 mg mixed w/0.5mg Atrovent.
May immediately repeat neb of Albuterol 2.5
mg if no relief.
d) Contact a medical control physician for
patients with continued moderate to severe
respiratory distress after two nebs.
10) If patient in full cardiopulmonary
arrest:
a) Treat according to cardiac arrest protocols
for rhythm. Contact a medical control
physician after first dose of epinephrine.

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b) Ventilate at rate of 8-10/min.




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                                            Seizures

         Standing Orders                                 Medical Control Options
EMT: Basic
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
5) Administer O2 via NRB
6) Obtain SAMPLE history: (Number of
seizures, type seizure (grand mal, petite mal,
Jacksonian, focal), frequency, incontinence,
tongue biting, cyanosis, postictal state,
previous head trauma, congenital defects).
7) Assess for associated signs/symptoms:
(Nucal rigidity, fever).
8) Determine blood glucose.
                                                  9) In the absence of EMTI or EMTP contact
                                                  base hospital for permission to administer
                                                  patient assisted medication – Oral Glucose
EMT Intermediate:
10) Establish IV access and obtain blood tubes.
Secure IV site well due to seizure activity.
11) Treat hypoglycemia as directed in
protocols.
A) If blood glucose <60, may give 50 ml
D50W IV.
b) If IV access difficult or impossible, may
give Glucagon 1 mg IM/SQ.
12) Monitor patient airway and breathing
status. Be prepared to assist respirations.
13) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
14) Contact medical control. Report
assessment findings, treatment, and request
further orders if necessary.
15) Transport to appropriate facility.




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                       Altered Mental Status/ Unconsciousness

         Standing Orders                                Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (LOC prior to
unconsciousness, patient surroundings, seizure
activity).
6) Assess for associated signs/symptoms:
(Incontinence, breath odor, signs of trauma).
7) Determine blood glucose.
8) In the absence of EMTI or EMTP
administer patient assisted medication – Oral
Glucose
EMT Intermediate:
9) Establish IV access and obtain blood tubes.
10) Treat hypoglycemia per protocols.
a) If blood glucose <60, may give 50 ml D50W
IV.
11) If suspected narcotics overdose, consider
up to 2 mg Narcan IV/IM. May repeat every 35
min up to 10mg.
12) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
13) Consider nasotracheal or ET intubation in
patient that remains unconscious with a)
decreased/absent gag reflex b) Glasgow < 8 c)
impending respiratory arrest.
14) Confirm ET tube placement by exam plus
confirmation device (EndTidal Carbon Dioxide
Detection Device, Endotracheal Tube Locator,
or Capnographer).
15) Immobilize on backboard prior to transport
unless trauma can definitely be ruled out.
16) Contact a medical control physician for
orders.
                                                 17) Give or repeat 50 ml D50W IV as


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                              Symptomatic Known Diabetic


         Standing Orders                                  Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (Insulin
dependency, last oral intake, skin condition,
LOC).
6) Assess for associated signs/symptoms.
7) In the absence of EMTI or EMTP
administer patient assisted medication – Oral
Glucose.
EMT Intermediate:
8) Establish IV access and obtain blood tubes.
9) Determine blood glucose level:
a) If low and patient is conscious, give sugar,
50 ml of D50W or 80 Gm of oral glucose if
patient is able to swallow.
b) If patient unable to take oral fluids due to
altered level of consciousness: i) Give 50 ml
D50W IV. ii) May give glucagon 1 mg IM/SQ
if IV access difficult or impossible.
c) If blood sugar level is elevated, establish
second IV line, large bore, administer fluid
bolus of 5001000cc’s while transporting.
10) Repeat blood glucose level.
11) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
12) Contact medical control physician for: a)
patients with poor response to glucose
                                                  13) Consider transport of all patients who are
                                                  on oral prescribed hypoglycemic agents and/or
                                                  insulin pumps.




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                         Drug Overdose/ Accidental Poisoning


         Standing Orders                                 Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications. Tricyclic overdoses requiring
ventilatory support should be hyperventilated
at the high end of normal respiratory rates.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (Type of
substance/medication, time of
ingestion/exposure, amount ingested).
6) Assess for associated signs/symptoms:
(pupil reaction/size, needle track marks,)
EMT Intermediate:
7) Establish IV access and obtain blood tubes.
8) For any patient with respiratory rate <8, or
history, or physical findings consistent with
narcotics overdose assist ventilation and may
give up to 2 mg Narcan IV/IM.
                                                  9) Consider additional Narcan up to 10 mg.
                                                  10) Consider administration of Activated
                                                  Charcoal 1 g/kg PO.
11) Consider nasotracheal or ET intubation in
patient that remains unconscious with a)
decreased/absent gag reflex b) Glasgow < 8 c)
impending respiratory arrest
12) Confirm ET tube placement by exam plus
confirmation device (EndTidal Carbon Dioxide
Detection Device, Endotracheal Tube Locator,
or Capnographer).
13) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
14) Transport Immediately




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                                   Suspected CVA/TIA


         Standing Orders                         Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (Time of onset,
noted deficits).
6) Assess for associated signs/symptoms.
EMT Intermediate:
7) Establish IV access and obtain blood tubes.
8) Check blood sugar and treat if indicated.
9) Perform neurological tests (Cincinnati
Prehospital Stroke Scale, includes difficulty
speaking, arm weakness, facial droop).
10) Establish time of onset of symptoms and
notify receiving hospital of suspected stroke
patient. Expedite transport.
11) If patient is a potential candidate for
reperfusion therapy, consider diversion if
difference in transport times to requested
hospital vs. closest hospital is > 30 minutes.
Consider Helicopter.
12) Apply cardiac monitor and interpret
rhythm. Obtain 12lead ECG if practical.




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                       Suspected Carbon Monoxide Poisoning


   Definition: Elevated blood levels of carbon monoxide as a result of breathing
  contaminated carbon monoxide gas. Consider carbon monoxide exposure in any
  patient who is exposed to smoke or auto exhaust – especially in enclosed spaces,
                often caused by faulty furnace or fireplace chimneys.


         Standing Orders                          Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score. (Beware: pulse
oximetry is unreliable finding in setting of
acute poisoning). USE RAD 57 DEVICE
4) Immediately administer high flow O2 via
NRB.
5) Obtain SAMPLE history.
6) Assess for associated signs/symptoms:
(Headache, hoarseness, SOB, coughing,
substernal discomfort, N/V, skin condition).
EMT Intermediate:
7) Establish IV access and obtain blood tubes.
8) Apply cardiac monitor and interpret/monitor
cardiac rhythm.
9) Contact a medical control physician to
consider need for hyperbaric oxygen therapy.
10) Transport Immediate




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                          Severe Nausea/Vomiting or Diarrhea

         Standing Orders                         Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score. Perform
orthostatic vitals.
4) Administer O2 via nasal cannula.
5) Obtain SAMPLE history: (Frequency &
duration of N/V/D, signs/symptoms of
dehydration, presence of blood in vomitus
and/or stool, skin condition).
6) Assess for associated signs/symptoms:
(Abdominal pain, fever).
EMT Intermediate:
7) Establish IV access & obtain blood tubes.
8) If signs/symptoms of shock present consider
fluid bolus of 300-500cc’s.
9) If patient has severe nausea or vomiting,
Zofran 4mg IV/IM
10) Contact a medical control physician for
further medication orders if needed.




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PART IV. TRAUMATIC EMERGENCIES
Standing Orders for All Traumatic Emergencies

1) Begin oxygen therapy as early as possible in all traumatic emergencies.


2) Insert oral or nasal airway in all unconscious patients. May ET intubate, if authorized,
in patients with severe respiratory distress and/or ineffective ventilation or Glasgow
Coma Score <8.
3) Except in unusual circumstances, spine immobilization will be performed if a trauma
patient:
  a) complains of pain in the spinal area;
  b) has experienced head trauma or a mechanism of injury that may be associated with
  spinal column injury, including penetrating injury to the neck or trunk, and have
  any of the following findings:
           i) altered level of consciousness or Hx of loss of consciousness;
           ii) any abnormal neurological findings;
           iii) evidence of alcohol or other drug ingestion;
           iv) multiple facial lacerations or maxillofacial injuries or evidence of
          scalp hemorrhage or hematoma.

 4)        All intravenous lines, whether started on standing orders or physician’s verbal
           orders, should be started in transit to the hospital. (The only exception is when
           there is an unavoidable delay moving the patient from the scene, i.e., trapped in
           auto, etc.) IV fluids should be hung whenever IV access is established for trauma.

  5) The Military AntiShock Trousers (MAST) may be considered during treatment (if
  available).
  6) Consider pain management per protocol. See Appendix I.
  7) Under no circumstances should transport of critical trauma patients be delayed for
  detailed physical examination and/or treatment of nonlife threatening injuries. Set
  priorities and expedite transport.
  8) Attempt to notify the receiving hospital as soon as possible when transporting a
  critical trauma patient.

  9) Transport of trauma patients will be as directed in BEMS Prehospital Trauma
  Transport Protocol.


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                            General Trauma/Traumatic Shock

         Standing Orders                            Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Administer O2 via NRB.
6) Obtain SAMPLE history.
7) Assess for associated symptoms.
EMT Intermediate:
8) Establish IV access and obtain blood tubes.
Start bilateral, large bore, IV lines of NS/LR
while en route on any patient with severe
trauma. If SBP <90, run wide open until BP
reaches 90, then TKO.
9) Airway Trauma:
  a) Observe for tracheal deviation,
subcutaneous emphysema, crepitus,
hoarseness, and stridor.
  b) Consider nasotracheal or ET intubation in
patient that remains unconscious with
    i) Decreased/absent gag reflex.
    ii) Glasgow < 8.
    iii) Impending respiratory arrest.
10) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
11) Chest Trauma:
  a) Observe for cyanosis, tachypnea, apnea,
retractions, paradoxical movement,
asymmetrical chest wall, sucking wounds, air
leaks and/or SQ air, crepitus, tracheal position.
  b) Occlude sucking chest wounds with 3
sided occlusive dressing or commercially
designed chest seal.
  c) Splint unstable rib fractures.
  f) Stabilize impaled objects with bulky

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dressings.

12) Abdominal Trauma:
  a) Observe for pain/tenderness, Kehr’s sign,
and guarding, rigidity, distension, and bowel
sounds, bruising.
  b) Consider application of military antishock     Inflate MAST (if available) per
trousers (if available) on any patient with             medical control orders.
significant trauma:
   i) Do not inflate without verbal orders if
patient has chest injury or penetrating injury of
neck.
   ii) Consider inflation if evidence of intra-
abdominal and/or pelvic hemorrhage.
    iii) Consider inflation for uncontrolled
external hemorrhage that can be controlled if
systolic BP less than 90.
    iv) Consider inflation in attempting
resuscitation of a traumatic arrest.
  c) Stabilize impaled objects with bulky
dressings.
  d) Cover open wounds with moistened sterile
dressings.
  e) Cover eviscerated organs with moistened
sterile dressings. Do not replace organs.
  13) Expedite Transport to appropriate
facility. Consider flying patient to trauma
facility via helicopter.




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                            Isolated Head and Spine Injuries



         Standing Orders                           Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow/RTS scores.
5) Administer O2 via NRB.
6) Obtain SAMPLE history. (MOI, helmet
usage, LOC/KO’d, resp. rate & pattern, pupil
deviation).
7) Assess for associated symptoms. (Posturing
– decorticate/decerebrate, incontinence,
priapism, Battle’s sign, Raccoon eyes, CSF
drainage, numbness & tingling in extremities).
EMT Intermediate:
8) If patient unconscious, start IV NS/LR and
run TKO if BP > 90. If BP < 90, treat per
Traumatic Shock protocol.
9) If time permits, determine blood glucose
and treat hypoglycemia per protocol.
10) Consider ET intubation in patient that
remains unconscious with
   a) decreased/absent gag reflex
   b) Glasgow < 8
   c) Impending respiratory arrest
11) Confirm ET tube placement by exam plus
confirmation device (EndTidal Carbon Dioxide
Detection Device, Endotracheal Tube Locator,
or Capnographer).
12) If showing signs/symptoms of neurological
deterioration (changing pupil size, rising BP,
slowing pulse, posturing, decreasing GCS)
consider mild hyperventilation at a rate of 2030
bpm. a) If capnographer is available maintain
ETCO2 @ 3235 (Adults) or 3034 (Peds)
13) Apply cardiac monitor and interpret
rhythm.
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14) If BP drops below 100mmHg with
signs/symptoms of shock look for other
sources of hypotension and treat accordingly.
15) Monitor spine injury patients closely for
neurogenic shock and/or respiratory problems.
16) Expedite Transport to appropriate facility.
Consider flying patient to trauma facility via
helicopter.




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                                          Amputations

         Standing Orders                                  Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Administer O2 via NRB.
6) Obtain SAMPLE history.
7) Assess for associated symptoms.
8) Care for Patient as follows:
  a) Control hemorrhage and cover stump with
sterile dressing saturated with saline.
  b) Treat as per protocol for General
Trauma/Traumatic Shock.
  c) Do not spend excessive time looking for
amputated part if patient unstable.
9) Care for Amputated Part as
follows:
  a) Wrap part in sterile gauze.
  b) Moisten with saline.
  c) Place in plastic bag.
  d) Place on ice, if available, or cold packs (do
not freeze).
EMT Intermediate
10) Establish IV access and obtain blood tubes.
11) Consider pain management according to            ** EMT Intermediate providers require
Pain Management Protocol, Appendix I.                    medical control approval before
                                                         administration of Morphine**
12) Transport to appropriate facility.




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                             Extremity Fractures/Dislocations

         Standing Orders                          Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Apply cervical/spinal immobilization as
appropriate.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB as needed.
5) Obtain SAMPLE history.
6) Assess for associated symptoms: (Crepitus,
deformity, open wounds,).
7) Apply sterile dressing to open
fractures/wounds.
8) Check for pulse and sensation distal to
injury.
9) Splint appropriately. Apply traction splints
according to BEMS TTP’s.
  a) Check pulse and sensation before and after
splinting.
  b) Select appropriate splint, splint joints
above and below injury site.
10) Elevate injured limb if possible.
11) Apply cold packs to injury site, if
available.
                                                  12) Contact medical control if distal pulses are
                                                  absent, delayed capillary refill, or no distal
                                                  sensation.
EMT Intermediate
13) Establish IV access and obtain blood tubes.
14) Consider pain management according to           ** EMT Intermediate providers require
Pain Management Protocol, Appendix I.                   medical control approval before
                                                        administration of Morphine**
15) Transport to appropriate facility.
                                                  16) For prolonged transport situations, consult
                                                      with medical control to assess need for
                                                       immediate joint/fracture reduction.




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PART V. OTHER EMERGENCIES

                                           Hypothermia

               Standing Orders                           Medical Control Options
Standing orders for all hypothermic patients:
  • Remove wet garments.

    • Protect against further heat loss and wind
      chill (use blankets and insulating
       equipment).

    • Maintain horizontal position. • Avoid
      rough movement and excess activity.

    • Assess responsiveness, breathing and
      Pulse
.
  • Do pulse check for 30-45 seconds (clinical
    signs of death may be misleading).
Definitions:
  • Passive Rewarming
       -Remove from cold -Insulate from
        Further cold

    • Active External Rewarming
        -Apply warm blankets
        -Apply hot packs -Warmed air

    • Active Internal Rewarming
        -Administer warmed IV fluids -Hospital
          interventions (lavage)
Pulse and breathing present:
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature using hypothermia thermometer &
Glascow score.
5) Administer O2 via NRB.
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6) Obtain SAMPLE history.

7) Assess for associated symptoms: (lack of
coordination, confusion, lethargy, coma,
shivering).
8) Begin gentle transport immediately.
EMT Intermediate:
9) Establish IV access w/warm IV fluids and
obtain blood tubes while enroute.
10) Apply cardiac monitor and
interpret/monitor cardiac rhythm.
11) Handle patient very gently – Cardiac
irritability can lead to Vfib.
12) Rewarming:
  a) Mild Hypothermia (temperature ≥ 92º F or
  if patient is shivering) – Passive rewarming,
  active external rewarming.

  b) Moderate hypothermia (temperature ≥ 86º
  F to < 92º F or if patient is shivering) –
  Passive rewarming, active external
  rewarming to truncal areas only (neck,
  armpits, groin).

  c) Severe hypothermia (temperature < 86º F)
  – transport for active internal rewarming.
13) Frostbite:
  a) Manipulation of frostbitten tissues should
  be avoided. Trauma to frostbitten tissues
  furthers tissue loss. Do not rub affected area,
  protect from further cold/trauma, cover
  w/clean, dry dressings.
For pulseless patients with severe
hypothermia, with or without
organized ECG rhythm:
EMT Basic:
14) Establish ABC’s, correct life threatening
complications.
15) Begin CPR.
16) Beginning rewarming procedures as
outlined above.
EMT Intermediate:
17) Establish IV access if possible and infuse
warm IV fluids.
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18) If intubation is indicated, intubate gently to
prevent inducing Vfib.
19) For VF/VT, defibrillate up to 3 times
(energy rates as prescribed by current AHA
ACLS guidelines; e.g. 200 J, 200 to 300 J, 360
J, or equivalent biphasic). Withhold drugs and
further shocks and transport immediately.
20) Warm packs should not be used.
                                                     21) May consider cardiac arrest drugs and
                                                     defibrillation but they are usually not effective
                                                     until hypothermia is corrected.
                                                     22) Do not pronounce patient dead until all
                                                     efforts of rewarming are complete.




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                                        Hyperthermia


Definition: A severe life threatening condition usually associated with a core body
temperature above 41C/106F. It is characterized by neurological symptoms such
 as loss of consciousness or agitation and other systemic hyperpyretic symptoms.


         Standing Orders                               Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Administer O2 via NRB.
6) Obtain SAMPLE history:
(length/type/duration of exposure, fluid
intake).
7) Assess for associated symptoms: (sweating,
flushed/hot skin, tachycardia, and bizarre
behavior).
8) Begin cooling measures. Remove from heat
source, remove clothing, and apply cool packs,
if available, to head and truncal areas. Suspend
cooling measures if shivering occurs.
EMT Intermediate
9) If patient confused or unconscious, start IV
NS/LR. May infuse up to 300 ml without
further orders.
10) Apply cardiac monitor. Interpret EKG
rhythm.
11) Expedite transport to appropriate facility.




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                                   Chemical Eye Injuries


         Standing Orders                            Medical Control Options
EMT Basic/Intermediate
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Administer O2 via NRB.
6) Obtain SAMPLE history: (chemical or
irritant).
7) Assess for associated signs/symptoms
8) Immediately and continuously flush the
affected eye(s) with normal saline solution for
a minimum of 20 minutes, continuing en route
to hospital.
9) Transport to appropriate facility.




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                                             Burns


     Definition: Injury to tissues caused by contact with thermal heat, chemicals,
                            electricity, lightning or radiation.


         Standing Orders                             Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score
5) Administer O2 via NRB.
6) Obtain SAMPLE history: (time of burn,
patient in closed space w/smoke and/or steam,
electrical contact, loss of consciousness,
accompanying explosion/toxic fumes).
7) Assess for associated symptoms:
(respiratory distress, cough, hoarseness, singed
nasal or facial hair, soot or erythema of mouth,
associated trauma).
8) Estimate depth and percent of body surface
area (BSA) burned using rule of nines.
EMT Intermediate:
9) If less than 20% of body surface, apply
sterile dressings and saturate with cool water.
Do not allow any burn patient to become
chilled and shiver.
10) More than 20% of body surface remove
any non adherent burned clothing and cover
patient with sterile sheet. Do not cool down
with water (exception: presence of smoldering
clothes, articles or material adhering to skin
that would continue burning process, i.e., hot
tar, etc.).
11) Establish bilateral, large bore, IV lines.
Begin fluid administration and calculate
infusion amounts using Parkland formula.
%BSA (2o & 3o) x Wt. Kg / 4 = ml/hr 1st hr.
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12) Consider pain management per protocol.          ** EMT Intermediate providers require
See Appendix I.                                         medical control approval before
                                                        administration of Morphine**
13) In the presence of inhalation injury with
the potential or actual airway compromise,
perform early endotracheal intubation. If
patient unable to tolerate, consider nasotracheal
intubation
14) Begin rapid transport and contact a medical
control physician for further orders and
destination decision.
15) Consider direct transport to burn center for
major burns via helicopter:

 a) 2nd and 3rd degree burns > 10% BSA in
    patients under 10 or over 50 yrs. of age.

  b) 2nd and 3rd degree burns > 20% BSA in
     other age groups.

  c) 2nd and 3rd degree burns with serious
     threat to functional or cosmetic
     impairment that involve face, hands, feet,
     gentile, perineum and major joints.

   d) Circumferential burns to chest and/or
      extremities.

   e) Burns with concurrent trauma.

   f) Electrical burns (including lightening)

   g) Inhalation injury w/burns

   h) Burn injury in patients with serious
      chronic medical conditions.




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                                  Behavioral Emergencies


         Standing Orders                           Medical Control Options
EMT Basic/Intermediate:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Apply cervical/spinal immobilization as
appropriate.
4) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Administer O2 if indicated.
6) Obtain SAMPLE history.
7) Assess for associated symptoms.
8) Assess need for physical restraints.

  a) Indicated for patient and/or caregiver
     safety.

  b) Document indications, time limits, type of
     restraints used, etc…

  c) Request immediate assistance from PD in
     all cases involving restraint.




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PART VI. OBSTETRIC/GYNECOLOGICAL
EMERGENCIES
                               Normal Labor and Delivery

         Standing Orders                           Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
3) Administer O2 via nasal cannula. If delivery
is imminent switch to NRB.
4) Obtain SAMPLE history: (due date, # of
previous pregnancies, known complications,
loss of mucous plug &/or rupture of amniotic
sac, contractions (how long & how far apart),
urge to push, preeclampsia, prenatal care).
5) Assess for associated symptoms: (bleeding,
swelling of face/extremities).
6) Perform physical exam. Observe for:

   a) Vaginal bleeding/fluid; color & odor.

   b) Crowning c) Abnormal presentation (foot,
       arm, buttocks, cord).
7) Document duration, intensity, and time
between contractions.
8) If no imminent delivery, transport patient in
position of comfort, usually on left side.
9) If question of imminent delivery, observe
briefly, then transport unless delivery in
progress. Be prepared to stop ambulance if
delivery occurs en route.
10) If delivery in progress or imminent assist
delivery as outlined below.
11) Transport immediately for previous
cesarean section, multiple births, abnormal
presentation, excessive bleeding.
EMT Intermediate
If delivery in progress:
12) Establish IV line and obtain blood tubes.
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13) Assist delivery using clean or sterile
technique. Apply gentle pressure to perineum.
14) Guide and control head, do not retard or
hurry delivery.
15) Suction mouth then nose with bulb syringe
upon delivery of head. See Pediatric Protocols
Newborn Emergencies.
16) Suction again after delivery, stimulate by
drying.
17) Double clamp and cut cord 810 in. from
infant.
18) Observe infant. Complete 1 min. APGAR.

  a) If color poor, child limp, or poor vitals
     signs (APGAR<7) proceed with neonatal
     resuscitation.

   b) If child pink, crying and moving well
     (APGAR 810) dry completely, wrap to
      conserve heat, and give to mother to
      nurse.

   c) Refer to Newborn Emergency Protocols
      as indicated.
19) Transport; do not wait for or attempt
delivery of placenta.
20) Closely observe infant for distress and
perform 5 minute APGAR scores of infant.
21) Observe mother for excessive postpartum
bleeding. If bleeding is excessive: a) Massage
uterus gently.
                                                 22) Add 10-20 units to 500cc’s NS/LR and
                                                 titrate to uterine tonus and/or cessation of
                                                 bleeding OR administer 10 units IM.




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                                   Obstetric Complications

         Standing Orders                             Medical Control Options
EMT Intermediate:
1) Administer O2 via NRB if not already
applied
2) Transport immediately for:

  a) prepartum or postpartum hemorrhage

    (moderate heavy),

  b) limb/breech presentation,

  c) prolapsed umbilical cord,

  d) known multiple fetuses,

  e) previous cesarean section.

  f) blunt or penetrating trauma to abdomen.
3) If not already established gain IV access en
route.
4) For hypotension, position patient on left
side.
5) For postpartum hemorrhage:

   a) Massage uterus gently.

  b) Fluid bolus of 500-1000cc’s NS/LR.
6) For prolapsed umbilical cord:

   a) Place mother in knee chest position or
      Trendelenburg.

   b) Insert sterile gloved finger(s) into vagina
      and hold presenting part off cord.

   c) Do not apply pressure to umbilical cord.
7) For infant distress see Pediatric Protocols -
Newborn Emergencies.
8) Contact a medical control physician for
further orders for any complication.

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PART VII. PEDIATRIC MEDICAL
EMERGENCIES

General Guidelines
1)      Age limits for pediatric and adult medical protocols must be flexible. For age less than 13
years, pediatric orders should always apply. Between ages 13 and 18, judgment should be used,
although the pediatric orders will usually apply. It is recognized that the exact age of a patient is
not always known.

2)      Patient Consent and Refusal: Consent or refusal of treatment/transport of minors (less
than 18 years) must be given by the child’s parent or legal guardian. Although less desirable,
consent or refusal may be given by a responsible adult (over age 18) caretaker if the parent has
deliberately left the minor in the care of this adult, and the adult is competent and capable. If
unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor,
a medical control physician should be consulted. (Also, see Adult Protocols).

3)     Parents should be allowed to stay with children during evaluation and transport, if
appropriate. The parent’s lap is usually the best place for the examination of a stable patient.

Pediatric Reference Chart
                 Wt      Wt.                               IV Catheter   Laryngoscope     Tracheal
  Age                             HR     RR      SBP
               (Kgs.)   (Lbs.)                                 (G)       Blade Size       Tube Size

                                                                                          Term Infant
Newborn         35       611     80180   4060     70          2224       01 straight
                                                                                          3.03.5

                                                                                          3.5
6 Months        69      1220     80180   2436   90 ± 30       2224       1 straight
                                                                                          uncuffed

                                                                                          4.0
 1 Year        1011     2124     80180   2230   95 ± 30       2024       1 straight
                                                                                          uncuffed

                                                                                          4.5
 2 Years       1214     2531     80180   2026   100 ± 20      1822       2 straight
                                                                                          uncuffed

                                                                         2 straight or    5.0
 4 Years       1518     3240     75150   2026   100 ± 25      1822
                                                                         curved           uncuffed

                                                                         2 straight or    5.5
 6 Years       1922     4148     70150   2024   100 ± 15      1820
                                                                         curved           uncuffed

                                                                         23 straight or
 8 Years       2430     4966     60125   1822   105 ± 15      1820                        6.0 cuffed
                                                                         curved

                                                                         3 straight or
10 Years       3144     6796     60125   1822   110 ± 20      1620                        6.5 cuffed
                                                                         curved

                                                                         3 straight or
12 Years       4549     97109    60125   1622   115 ± 20      1620                        6.5 cuffed
                                                                         curved

                                                                         3 straight or
14 Years        50+     110+     60125   1420   115 ± 20      1620                        6.5 cuffed
                                                                         curved

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Pediatric Airway Management
1)      Do not hyperextend the neck in newborns and infants, as airways are smaller, softer, and
easier to obstruct or collapse. Respiratory reserve is small; minor insults such as improper
positioning, vomitus or airway narrowing each lead to major problems.

2)       Consider oral and/or nasal airways of appropriate size for all unconscious patients

3)       For spontaneously breathing patients in shock, high flow oxygen should be given by
partial rebreathing mask.

4)       If epiglottitis is a possibility, do not attempt to visualize the throat or pharynx. However,
if a patient with an airway obstruction has a respiratory or cardiac arrest, the airway may be
visualized with a laryngoscope to rule out a foreign body.

5)       Endotracheal intubation shall be performed only by trained paramedics and in accordance
with the information and protocol contained in Appendix A and consistent with other protocols
in this document.

6)     Transtracheal needle ventilation for patients that cannot be ventilated by any other means
may be performed by paramedics. This intervention shall be performed in accordance with the
information and protocols contained in Appendix B.

7)     Endotracheal Tube Locator: ETTL devices utilize anatomical differences between the
trachea and the esophagus to verify proper endotracheal tube placement. ETTLs do not rely on
chemical reaction to detect the presence or absence of EndTidal carbon dioxide and may be used
in conjunction with an EndTidal CO2 detector device to confirm tube placement.

8)      EndTidal CO2 monitoring: An EndTidal carbon dioxide (CO2) detector may be used to
accomplish confirmation of endotracheal tube placement and is most reliable in patients with
spontaneous circulation. This device may not be able to detect CO2 in cardiac arrest patients due
to extremely low blood flow to the lungs.

9)      Pulse oximetry: A pulse oximeter may be used for any patient with suspected hypoxemia,
in respiratory distress, or whenever sedating medications are administered. Obtaining a normal
pulse oximetry reading does not negate the need for oxygen therapy as specified in these
protocols.




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Pediatric Circulatory Management
1)      Circulatory reserve is small in children. The loss of one unit of blood is sufficient to
account for severe shock or death in an infant. Conversely 500 ml of unnecessary fluid can result
in acute pulmonary edema. The only fluid that should be infused in pediatric patients are isotonic
fluids.

         Do not inflate without verbal order if patient has chest injury or penetrating injury to
         the neck;

2)        For trauma and shock of other etiology, start IV’s en route

3)     Use minidrip IV infusion sets for nontraumatic emergencies and macrodrip sets for
trauma or hypotensive patients.

4)      Fluid replacement: 20cc/kg over 515 minutes. Monitor vitals, repeat fluid bolus as needed
to rehydrate and maintain vitals. May require 60100 cc/kg during the first hour. Check B/P,
pulse, and respirations (avoid pulmonary edema) capillary refill, and level of consciousness
frequently.

5)     If IV access cannot be established at the scene in two attempts for patients with non-
traumatic problems, begin transport to the hospital. There should be no delay at the scene for IV
attempts on children with trauma or in shock these IV’s should be started during transport

6)       Intraosseous infusion is a procedure used in children under the age of seven years in
critical condition when IV access is unobtainable. This procedure must be performed in
accordance with the information and protocol contained in Appendix E.

Pediatric MAST Guidelines

Place patient in appropriate size pneumatic compression trousers (MAST) (uninflated) whenever
symptoms of shock are present, i.e., cool skin, poor capillary refill, tachycardia, etc.

         Do not inflate without verbal order if patient has chest injury or penetrating injury to the
         neck;

         For other patients with traumatic shock, inflate MAST if SBP is less than lower limit for
         age (see below) after obtaining permission from Medical Control.

Age Systolic BP Lower Limit
6 mos. 70
 2 years 80
4 years 80
6 years 80
8 years 85

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10 years & older 90

Patient Size:

•        >100 lbs: use adult pneumatic compression trousers
•        40100 lbs: use pediatric MAST

Precautions:

•       Use the lowest effective pressure when inflating MAST
•       Do not apply the abdominal compartment above midabdomen on any pediatric patient.
•       Monitor adequacy of ventilation carefully whenever the abdominal compartment is
inflated.
•       Prepare to suction vomitus when abdominal compartment is inflated.


Newborn Emergencies Standing Orders for All

Newborn Emergencies

1) In all situations, minimize heat loss

    a) Dry the newborn well

    b) Increase environment temperature.

    c) Use warmed IV solutions, warmed blankets, swaddler and cover infants head if patient is
       stable.

2) Suction infant:

    a) During delivery suction mouth and oropharynx first, and then nose on perineum, before
       delivery of shoulders.

     b) If meconium is present at birth, suction the mouth and oropharynx first, then the nose,
        gently, but as completely as possible, prior to ventilating. If meconium is thick, utilize 2.5
        ET tube as suction catheter w/meconium aspirator to suction appropriately. Repeat
        procedure until no further meconium remains.

     c) Monitor heart cease suctioning if heart rate <80 (monitor apical pulse with stethoscope).

3) Provide physical stimulation if respirations are present but depressed. Suction and position for
   optimal airway. DO NOT hyperextend the neck.

4) Assist ventilation if respirations are absent, minimal or heart rate < 100. Suction and position

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   for optimal airway. DO NOT hyperextend the neck.

5) Perform chest compressions if apical heart rate is <80 /minute despite assisted/adequate
   ventilation.

6) Transport early. Contact a medical control physician as soon as possible after birth. Attempt
   to maintain body temperature and assure optimal ventilation and oxygenation.




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                                  Pediatric Asthma Attack

         Standing Orders                                  Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway &
position of comfort. Usually sitting upright
(45-90 degrees w/feet dropped).
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (accessory muscle
use, tripod/positioning, drooling, pursed lips,
retractions, nasal flaring, one/two word
dyspnea, orthopnea, JVD, intubation history,).
6) Assess for associated signs/symptoms.
EMT Intermediate
If patient breathing:
7) Move patient to ambulance and begin
transport.
8) En route to hospital, may give nebulized
Albuterol 2.5mg w/0.25mg Atrovent added to
3ml saline. May repeat neb of Albuterol 2.5
mg.
9) Establish IV access NS/LR, TKO.
10) Contact medical control for patients with
continued moderate to severe respiratory
distress after two nebs.
11) Consider oral/nasal intubation.
                                                   12) Consider Epinephrine 0.01mg/kg 1:1000
                                                   (0.01 cc/kg) IM. Maximum dose = 0.3 cc
                                                   Epinephrine (to be used prehospital only if
                                                   condition severe).
If patient in respiratory arrest:
13) Insert oral airway and begin positive
pressure ventilation. Ventilate with short insp:
long exp ratio at rate of 8-10/min.
14) Intubate as soon as possible. Confirm ET
tube placement by exam plus confirmation
device (EndTidal Carbon Dioxide Detection
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Device, Endotracheal Tube Locator, or
Capnographer).
15) If ET intubated give inline nebulized
albuterol 2.5 mg w/0.25mg Atrovent added to
3ml saline. May repeat neb of albuterol 2.5 mg.

16) Attach cardiac monitor and interpret
rhythm.
17) Expedite transport.
18) Contact medical control.
                                                  19) If not already given, consider Epinephrine
                                                  0.01 mg/kg 1:1000 (0.01 cc/kg) IM. Maximum
                                                  dose = 0.3 cc Epinephrine.
                                                  20) If patient ET intubated and becomes
                                                  agitated from increased level of consciousness:
                                                  a) Consider Versed 0.1 mg/kg IV/IO.




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                       Pediatric Airway Obstruction/Foreign Body

         Standing Orders                            Medical Control Options
EMT Basic:
1) If the patient is making efforts to clear the
airway without success, you may assist with
careful back blows (infants only); chest or
gentle abdominal compressions (per BCLS
Protocols) avoid abdominal compressions in
infants less than one year old. Synchronize
with patient’s cough.
2) If the patient has lost consciousness, attempt
to open the airway (use moderate extension
and jaw lift) and ventilate. Reposition and
attempt ventilation again if necessary. If
unsuccessful, perform standard obstructed
airway maneuvers for infant or child, as
appropriate. Position an infant with the head
dependent during back blows and chest
compressions.
EMT Intermediate:
3) If unable to remove by any method, attempt
to blow obstruction past the trachea with
mouth to mask ventilation. Attempt
endotracheal intubation if indicated. .
4) Avoid prolonged scene time with continued
attempts at removal of persistent foreign body.
5) Contact a medical control physician
promptly for further orders if necessary.




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                                  Pediatric Status Seizures

         Standing Orders                               Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB.
5) Apply cervical/spinal immobilization as
appropriate
6) Obtain SAMPLE history: (time of onset,
duration, history of previous seizures, type of
seizure activity)
7) Assess for associated symptoms: (Fever,
bitten tongue, incontinence, postictal state,
evidence of trauma)
EMT Intermediate:
8) Determine blood glucose and treat
hypoglycemia per protocol.
9) Establish IV access and obtain blood tubes
if possible.
10) Contact a medical control physician for
further orders if necessary.
11) Transport immediately




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                                   Pediatric Anaphylaxis


         Standing Orders                            Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway. Assist
respirations with BVM if necessary.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB or assisted BVM.
5) Obtain SAMPLE history: (Known exposure
to bee stings, drugs, nuts, seafood. Prior
allergic reactions).
6) Assess for associated symptoms. (Itching,
wheezing, respiratory distress, N/V, chest
tightness, headache, cough, weakness, facial
swelling, Urticaria, flushing, swollen
tongue/airway).
7) Degree of allergic reaction:

   a) Mild – local swelling, itching

   b) Moderate – hives, wheezing

   c) Severe – respiratory distress, systolic BP
      < 90.
8) Remove injection mechanism if still present
and visible. Consider ice pack at sting or
injection site.
9) Place patient in position of comfort.
10) In the absence of EMTI or EMTP may
administer one Epi Pen (Pediatric) if patient
was exposed to commonly recognized allergen
and has respiratory distress or is hypotensive.
EMT Intermediate:
11) Determine blood glucose and treat
hypoglycemia per protocol.
12) Establish IV access and obtain blood tubes
if possible.
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13) May administer epinephrine 1:1000 0.01
mg/kg (0.01cc/kg) IM up to 0.3cc if patient
was exposed to commonly recognized allergen
and has respiratory distress or hypotension.

14) For severe respiratory distress or
ineffective ventilation consider oral/nasal
intubation.
15) Confirm ET tube placement by exam plus
confirmation device (EndTidal Carbon Dioxide
Detection Device, Endotracheal Tube Locator,
or Capnographer).
17) Contact medical control for additional
orders.
                                                18) Consider fluid bolus of 20 cc/kg.
20) Expedite transport to closest appropriate
facility.




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                         Pediatric Drug Ingestion or Overdose

         Standing Orders                          Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications. Tricyclic overdoses requiring
ventilatory support should be hyperventilated
at the high end of normal respiratory rates.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (Type of
substance/medication, time of
ingestion/exposure, amount ingested).
6) Assess for associated signs/symptoms:
(pupil reaction/size, powder/residue to lips,)
EMT Intermediate:
7) For all significant overdoses, obtain IV
access and obtain blood tubes.
8) If child unconscious and blood glucose <60
mg/dl, consider D50W 1 cc/kg IV up to 50 cc
for patients four years or older. For patients
three years or younger, use D25W, 2 cc/kg.
9) Consider Narcan 0.1 mg/kg IM or IV up to 2
mg.
10) Apply cardiac monitor observe rhythm,
especially in suspected tricyclic overdoses.
11) Transport Immediately




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                      Pediatric Unconscious Unknown Etiology

         Standing Orders                         Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Immobilize spine if trauma is possible.
4) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
5) Administer O2 via NRB.
6) Obtain SAMPLE history: (LOC prior to
unconsciousness, patient surroundings, seizure
activity).
7) Assess for associated signs/symptoms:
(Incontinence, breath odor, signs of trauma)
EMT Intermediate:
8) Obtain IV access & blood tubes. Transport
early if no IV site available.
9) Determine blood glucose. If blood glucose
<60 mg/dl, may give D50W, 1 cc/kg IV up to
50 cc to patients four years or older. For
patients three years or younger, use D25W, 2
cc/kg.
10) Consider Narcan 0.1 mg/kg IM or IV up to
2 mg.
11) Contact a medical control physician.




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                           Pediatric Symptomatic Known Diabetic


         Standing Orders                            Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history: (insulin
dependency, last oral intake, skin condition,
LOC).
6) Assess for associated signs/symptoms.
(incontinence, breath odor, signs of trauma).
7) If patient is conscious, cooperative, and able
to swallow effectively, give oral glucose
therapy.
EMT Intermediate:
8) If patient unable to take oral fluids due to
altered level of consciousness:

  a) Obtain IV access and obtain blood tubes.

  b) Determine blood glucose. If <60 mg/dl,
     may give D50W, 1 cc/kg up to 50 cc to
     patients four years or older. For patients
     three years or younger, use D25W, 2cc/kg
     IV.

   c) May give glucagon 0.25 1 mg IM if IV
      access difficult or impossible.
9) Position in Trendelenburg if hypotensive.
10) Obtain IV access and obtain blood tubes. If
unable to obtain peripheral IV consider IO
placement according to Appendix E.
11) Administer fluid bolus of 20cc/kg NS/LR.
Reassess vital signs. Administer additional
fluid boluses until signs/symptoms of shock
reverse.
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12) Determine blood glucose. Give D50W, 1
cc/kg up to 50 cc to patients four years or
older. For patients three years or younger, use
D25W, 2 cc/kg IV.

13) Apply cardiac monitor and interpret
rhythm.
14) For all other hemorrhagic and non-
Hemorrhagic conditions begin transport and
contact medical control while enroute for
additional orders.
15) Expedite transport.




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                                      Pediatric Shock

         Standing Orders                            Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Immobilize head & spine if trauma
suspected.
4) Obtain baseline vitals, including SPO2,
temperature & Glasgow score.
5) Administer O2 via NRB
6) Obtain SAMPLE history: (fever,
nausea/vomiting/diarrhea, # of “wet” diapers,
fluid intact, nursing habits, recent trauma, ).
7) Assess for associated signs/symptoms: (cool
skin, poor capillary refill, tachycardia, weak
peripheral pulses, low B/P, altered mental
status).
EMT Intermediate:
8) Begin transport prior to any other ALS
intervention.
9) Position in Trendelenburg if hypotensive.
10) Obtain IV access and obtain blood tubes. If
unable to obtain peripheral IV consider IO
placement according to Appendix E.
11) Administer fluid bolus of 20cc/kg NS/LR.
Reassess vital signs. Administer additional
fluid boluses until signs/symptoms of shock
reverse.
12) Determine blood glucose. Give D50W, 1
cc/kg up to 50 cc to patients four years or
older. For patients three years or younger, use
D25W, 2 cc/kg IV.
13) Apply cardiac monitor and interpret
rhythm.
14) For all other hemorrhagic and non
hemorrhagic conditions, begin transport and
contact medical control while enroute for
additional orders.
15) Expedite transport.


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PART VIII. PEDIATRIC CARDIAC
EMERGENCIES

                                  Pediatric Bradycardia

         Standing Orders                           Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
5) Obtain SAMPLE history.
6) Assess for associated signs/symptoms. (poor
perfusion, hypotension, respiratory difficulty,
altered level of consciousness).
EMT Intermediate:
7) Establish IV access & obtain blood tubes.
Consider need to fluid bolus (20cc/kg).
8) Assess and support ABCs as needed and
attach monitor/defibrillator.
9) If cardio respiratory compromise: (poor
perfusion, hypotension, respiratory difficulty,
altered level of consciousness).
a) Begin chest compressions 15:2 ratio
b) Intubate, confirm placement and assure
adequate oxygenation and ventilation.
c) If despite oxygenation and ventilation heart
rate <60 bpm in infant or child and poor
systemic perfusion:
i) Give Epinephrine IV/IO: 0.01 mg/kg
(1:10,000, 0.1 mL/kg), ET: 0.1 mg/kg (1:1000,
0.1 mL/kg). May repeat every 3 to 5 minutes at
same dose.
ii) Atropine 0.02 mg/kg (minimum dose: 0.1
mg) may repeat once
iii) Contact Medical Control for orders to
consider cardiac pacing, see Appendix H.
d) If pulseless arrest develops see appropriate
protocol.
e) Consider treatable causes (H’s & T’s)

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10) If no cardio respiratory compromise:
a) Support ABCs, observe and transport.
11) Transport immediately.




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                   Pediatric Tachycardia with Adequate Perfusion


         Standing Orders                                 Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history.
6) Assess for associated signs/symptoms. (poor
perfusion, hypotension, respiratory difficulty,
altered level of consciousness).
EMT Intermediate:
7) Establish IV access & obtain blood tubes.
Consider need to fluid bolus (20cc/kg).
8) Assess and support ABCs as needed and
attach monitor/defibrillator. Evaluate rhythm:
9) Probable ventricular tachycardia QRS
duration wide for age (approximately > 0.08
sec)
                                                  a) Consider Lidocaine 1mg/kg IV bolus (wide
                                                  complex only)
10) Probable supraventricular tachycardia QRS      *Infant Heart Rate > 220 bpm* *Child Heart
duration normal for age (approximately ≤ 0.08                    Rate > 180 bpm*
sec)
a) Obtain 12lead ECG if available.
11) Probable sinus tachycardia QRS duration        *Infant Heart Rate < 220 bpm* *Child Heart
normal for age (approximately ≤ 0.08 sec)                        Rate < 180 bpm*
a) Consider NS/LR bolus 20 cc/kg IV/IO.




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               Pediatric Tachycardia with Poor Perfusion (Pulse Present)

         Standing Orders                          Medical Control Options
EMT Basic:
1) Establish ABC’s, correct life threatening
complications.
2) Position patient to maintain airway.
3) Obtain baseline vitals, including SPO2,
temperature & Glascow score.
4) Administer O2 via NRB.
5) Obtain SAMPLE history.
6) Assess for associated signs/symptoms. (poor
perfusion, hypotension, respiratory difficulty,
altered level of consciousness).
EMT Intermediate:
7) Establish IV access & obtain blood tubes.
Consider need to fluid bolus (20cc/kg).
8) Assess and support ABCs as needed and
attach monitor/defibrillator. Evaluate rhythm:
9) Probable ventricular tachycardia QRS
duration wide for age (approximately > 0.08
sec)
10) Probable supraventricular tachycardia QRS
duration normal for age (approximately ≤ 0.08
sec)
11) Probable sinus tachycardia QRS duration
normal for age (approximately ≤ 0.08 sec)
a) Consider NS/LR bolus 20 mL/kg IV/IO
b) Continue to assess and support ABCs,
monitor, and provide oxygen and ventilation as
necessary.




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                             Pediatric Pulseless Arrest – VT/VF


         Standing Orders                                   Medical Control Options
EMT Basic:
1) Establish ABC’s, confirm cardiac arrest.
(unresponsive, pulseless, apenic).
2) Attach pediatric AED and analyze rhythm.
If shock advised follow Automatic
Defibrillator Protocol (May use adult AED for
children over 8 yrs of age).
3) Continue/Institute CPR. Give 5 cycles of
CPR 15:2. Ventilate via BVM w/OPA & 100%
O2.
4) Obtain SAMPLE history: (events
precipitating arrest & estimated arrest time.
5) Assess for associated signs/symptoms
and/or trauma. (H’s & T’s)
EMT Intermediate
6) If not already done, attach
monitor/defibrillator. Evaluate rhythm:
a) Assess and confirm Pulseless VT/VF then
defibrillate up to 3 times, if necessary (energy
rates as prescribed by current AHA ACLS
guidelines; e.g., 2 J/kg, 4 J/kg, 4 J/kg).
Immediately resume CPR for 5 cycles
b) Reassess rhythm, if defibrillation results in a
change in rhythm proceed to the appropriate
protocol. If rhythm remains unchanged or
recurs continue this protocol.
7) Establish IV access & obtain blood tubes. If
unable to establish IV access after (2)
peripheral attempts, establish IO access.
8) Transport early if no readily accessible
IV/IO access.
10) Administer Epinephrine IV/IO: 0.01 mg/kg           Note: Refer to pediatric reference e.g.,
q. 35 min. (1:10,000; 0.1 mL/kg). ET:                Broselow Tape, if assistance is needed with
0.1mg/kg (1:1000; 0.1 mL/kg) Do Not                    drug dosage calculations for pediatric
Interrupt CPR                                                         patients.
11) Defibrillate (energy rates as prescribed by
current AHA ACLS guidelines e.g., 4 J/kg)
within 30-60 seconds.
a) Pattern should be CPR drug shock (repeat)

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b) Immediately resume CPR for 5 cycles

12) Administer Lidocaine 1 mg/kg bolus
IV/IO.
13) Defibrillate (energy rates as prescribed by
current AHA ACLS guidelines e.g. 4 J/kg)
after each drug dose, within 30-60 seconds.
Immediately resume CPR for 5 cycles
                                                  14) If no response, consider termination of
                                                  resuscitative efforts.




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                      Pediatric Pulseless Arrest (Asystole/PEA)


         Standing Orders                                   Medical Control Options
EMT Basic:
1) Establish ABC’s, confirm cardiac arrest.
(unresponsive, pulseless, apenic).
2) Attach pediatric AED and analyze rhythm.
If shock advised follow Automatic
Defibrillator Protocol (May use adult AED for
children over 8 yrs of age).
3) Continue/Institute CPR. Give 5 cycles of
CPR 15:2. Ventilate via BVM w/OPA & 100%
O2.
4) Obtain SAMPLE history: (events
precipitating arrest & estimated “down time”).
5) Assess for associated signs/symptoms
and/or trauma.
EMT Intermediate:
6) Secure airway; confirm tube placement,
effective ventilation and oxygenation.
7) Assess and confirm rhythm as Asystole or
PEA in (2) leads.
8) Obtain IV access. If IV not possible, attempt
IO access (if authorized). Transport early if no
readily accessible IV/IO access.
9) If PEA, review the most frequent causes and
treat according to protocol if present: a)
Hypovolemia – fluids, MAST (if available) b)
Hypoxia – hyperventilate c) Hypothermia – re-
warming (see Hypothermia protocol).
10) Administer Epinephrine IV/IO: 0.01 mg/kg           Note: Refer to pediatric reference e.g.,
every 35 min. (1:10,000; 0.1 mL/kg). ET:            Broselow Tape, if assistance is needed with
0.1mg/kg (1:1000; 0.1 mL/kg) Do Not                drug dosage calculations for pediatric patients.
Interrupt CPR
11) Assess for rhythm change(s) and treat
accordingly or continue CPR- EPI - CPR
12) Contact medical control physician for
further orders.
                                                     13) If no response, consider termination of
                                                                 resuscitative efforts.



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PART IX. APPENDICES TO THE EMS
PROTOCOLS
ALS Procedures


•        All BLS procedures (including oral and nasal airway insertion and MAST application)
•        ECG monitoring/interpretation
•        Defibrillation
•        Synchronized cardioversion
•        Endotracheal suctioning
•        Administration of specified drugs by: IV push technique, IM and SC injection, oral and
•         sublingual administration, inhalation (includes nebulization
•        Blood glucose measurement
•        Uterine massage
•        Transcutaneous pacing
•        Endotracheal intubation
•        Administration of specified drugs via endotracheal tube
•        Intraosseous infusion of IV fluids and drugs (adult and pediatric)
•        Administration of specified drugs by: IV push technique, IM and SC injection, oral and
•        sublingual administration, inhalation (includes nebulization)
•        Measurement of O2 saturation by pulse oximetry
•        12 lead EKGs
•        Nasogastric tube insertion

ALS Medications (required)

•        Albuterol (Proventil, Ventolin) premixed for nebulization 2.5 mg
•        Aspirin (ASA)
•        Atropine
•        Dextrose 50% / Dextrose 25%
•        Epinephrine 1:1000 and 1:10,000
•        Glucagon
•        Lidocaine hydrochloride
•        Morphine Sulfate
•        Naloxone (Narcan)
•        Nitroglycerin tablets or spray 0.4 mg (grains 1/150)




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Appendix A Endotracheal & Nasotracheal Intubation

Candidates:

The following categories of patients, both adult and pediatric, are potential candidates for
endotracheal (ET) intubation in the Davis County EMS System:

•      Cardiac arrest (nontraumatic)
•      Traumatic cardiac arrest
•      Respiratory arrest
       Patients with decreased level of consciousness (i.e., Glasgow Coma Score < 8) trauma
and nontrauma
       Conscious patients with respiratory distress who are unable to ventilate adequately -
trauma and nontrauma

Equipment:

•        Endotracheal tubes various sizes (3 to 9) with soft high volume, low pressure cuffs

•      Laryngoscope with adult and pediatric straight and curved blades and spare batteries and
bulbs
•      McGill forceps
•      Bag/valve/mask apparatus capable of delivering 100% oxygen with pediatric and adult
masks
•      10 cc syringe
•      1” adhesive tape, cloth tracheal tape, or commercially designed securing device, for
securing tube
•      Stylette for endotracheal tube
•      Oral and nasal airways of pediatric and adult sizes
•      Good suction with both tonsilar suction and suction catheters available
•      Intubation monitoring device (bulb, syringe, or capnographer)

Procedure – Oral Intubation:

1)      Maintain airway and ventilation prior to intubation with oral airway and positive pressure
ventilation.

2)    Assemble equipment; select appropriate size tube and blade; check operation of key
elements, including suction equipment. Put on personal protective equipment.

3)      Position patient supine with head in “sniffing” position. If cervical spine injury suspected,
have second person maintain neutral position with inline manual stabilization and performs
Sellick’s maneuver throughout procedure. Remove all potential airway obstructions.

4)     Hyperventilate patient with Bag Valve Mask (BVM) with 100% O2 for a minimum of 3
minutes before attempting intubation. Hyperventilation should be repeated for a minimum of one
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minute anytime 30 seconds without ventilation has elapsed for an intubation attempt.

5)      Holding the laryngoscope blade in the left hand, insert it into the right side of the mouth.
Advance the blade along the curvature of the tongue, moving the tongue to the left, out of the
field of view.

6)        Lift the laryngoscope straight up and slightly towards the patient’s feet to expose and
visualize the epiglottis and vocal cords. Do not pry back on the blade. With a straight blade, the
blade is inserted so the tip lifts the bottom edge of the epiglottis. With a curved blade, the blade
tip is inserted into the vallecula just above the epiglottis, indirectly raising the epiglottis when
lifted. It may be necessary to slowly withdraw the blade until the epiglottis and vocal cords come
into view. Suction as needed for visibility. If unable to view identifiable structures, have assistant
place slight downward pressure on the patient’s cricoid cartilage (Sellick’s maneuver).

7)     Stop and ventilate the patient if more than 30 seconds has elapsed for the intubation
attempt.

8)      While directly visualizing the vocal cords, pass the tip of the ET tube between the cords
until the proximal end of tube cuff is ½1 inch beyond.

9)      Manually secure position of the ET tube while removing the laryngoscope, then the
stylet.

10)     Inflate the cuff with 5-10 ml of air and check the pilot balloon. Suction the tube and
oropharynx as needed.

11)     Continue to manually stabilize the tube and ventilate the patient with 100% O2 with a
bag valve device.

12)       Immediately assess tube placement by auscultating breath sounds bilaterally then
auscultating over the epigastrium. A second method to verify tube placement is required and may
include use of an EndTidal CO2 detector, an endotracheal tube detector device, an aspirator
syringe, or revisualization of the cords and ET tube. Remove or reposition tube as necessary.

13)      If proper tube placement is confirmed, hyperventilate the patient for at least three
minutes.

14)       Mark tube depth and stabilize the ET tube with tape or other device. Repeat lung
auscultation to check position of the tube after taping procedure is completed. The patient should
also be reassessed for proper tube position after any significant movement of the patient (onto
the stretcher, down stairs, into the ambulance, etc.)




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Procedure – Nasal Intubation:

1)       Steps 1 - 4 as above.

2)      Inspect nostrils for visible obstructions and select the larger or least obstructed. Insert the
lubricated ET tube and advance through the nostrils and along the floor of the nasal passage
through the nasopharynx. If resistance is encountered, gently retry to advance the ET tube. If
resistance persists, abandon the attempt.

3)      As the ET tube approaches the glottic opening, pause to listen for exhaled air coming
from the proximal end of the ET tube. Pass the ET tube through the glottic opening during
inhalation. If no air movement is heard at the end of the tube, withdraw the ET tube until air
movement is heard, and reattempt passage into the trachea.

4)       Steps 11-15 as above.

Complications:

•       Esophageal intubation
•       Intubation of right mainstem bronchus
•       Upper airway trauma due to excess force with laryngoscope or to traumatic tube
placement
•       Vomiting and aspiration during traumatic intubation or intubation of patient with intact
gag reflex.
•       Hypoxia due to prolonged intubation attempt
•       Cervical cord damage in trauma victim with unrecognized spine injury
•       Dental trauma
•       Tension pneumothorax




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Appendix D – Peripheral IV Access


Candidates:

Adult and pediatric patients determined to need fluid administration for volume expansion or as a
route for medication administration.

Equipment:

•        Assorted over the needle catheters
•        IV fluid, Normal saline (NS) or Lactated ringers (LR)
•        IV tubing (Select Set, microdrip, or blood set
•        IV extension tubing
•        Alcohol Wipes
•        Bioclusive dressing and tape

Procedure:

1)     Apply tourniquet proximal to proposed site. Alternatively, use blood pressure cuff blown
up to 40 mm Hz.

2)       Clean insertion site with alcohol prep

3)       Hold vein in place by apply gentle traction on vein distal to point of entry.

4)     Puncture the skin with the bevel of the needle upward, about 0.5 to 1 cm from the vein
and enter the vein from the side or from above.

5)       Note blood return and advance the catheter either over or through the needle (depending
on tip).

6)       Release tourniquet.

7)       Remove needle and connect tubing. Immediately dispose of needle in sharps container.

8)      Open IV tubing clamp full to check flow and placement, then slow rate to TKO or as
directed.

9)      Secure tubing with tape, making sure of at least one 180 degree turn in the taped tubing to
be sure any traction on the tubing is not transmitted to the cannula itself.

10) Anchor with arm board or splint as needed to minimize chance of losing line with
movement.

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Complications:

•        Infiltration with formation of hematoma and pain at insertion site
•        Infection (phlebitis)
•        Thrombosis
•        Catheter shear and pulmonary embolus
•        Cannulation of artery

Considerations:

•       Antecubital veins are useful access sites for patients in shock, but if possible, avoid areas
near joints (or splint well)
•       Start distally and, if successive attempts are necessary, you will be able to make
additional proximal attempts on the same vein without extravasating IV fluid.




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Appendix E – Intraosseous Access

Pediatric Intraosseous

Candidates:

Children who are less than 8 years old for whom IV access is unobtainable. The child must be in
cardiopulmonary arrest, impending arrest or in critical condition characterized by evidence of
clinical shock and unresponsiveness to verbal stimuli. Intraosseous infusion may be instituted
after two IV attempts have been unsuccessful or if no peripheral veins are readily apparent or
obtainable or if peripheral attempts take longer than 90 seconds.

Contraindications:

•        Recently fractured bone at the site;
•        Cellulitis, infection, osteomyelitis, trauma, or burns at site;
•        Previous intraosseous attempt in same bone;
•        If history known, bone disorders such as osteogenesis imperfecta and osteopetrosis;

Equipment

•        Arm board
•        Tape or Kerlix
•        Needle (15g & 18g IO needles)
•        Alcohol wipe
•        Betadine
•        IV set up with tubing and fluid (Volutrol or Metriset)
•        Syringe 35 cc

Procedure:

1)      Prepare equipment: NS/LR IV solution and IV administration set (Volutrol or Metriset),
intraosseous needle, 10 ml syringe filled with normal saline, skin prep materials, protective eye
wear, mask and gloves;

2)       Position patient; support the child’s leg and externally rotate to expose medial aspect of
leg;

3)      Select site: Palpate the proximal tibia to find the tibial tuberosity, and then locate a point
on the flat aspect of the tibia 1-2 finger lengths (child’s) or 1-2 cm below the tuberosity.

4)       Put on gloves and prep site as for IV start.

5)      Using the selected device, angle the needle at approximately 90 degrees off surface away
from the growth plate of the selected bone and insert the needle with firm downward pressure
using a twisting or screwing motion to penetrate the skin and subcutaneous tissues, then the
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periosteum and bone cortex. Expect moderate resistance. Entrance into the medullary cavity will
be heralded by a “pop” or a sudden loss of resistance. Only 24 mm insertion depth necessary.

6)      Manually stabilize needle. Remove the stylet from the needle and aspirate with a 10 ml
syringe filled with NS/LR. Marrow, which appears as dark old blood, may or may not aspirate
into the syringe. Inject entire contents of aspirate and NS/LR into the bone marrow. If marrow
cannot be aspirated but fluid flushes easily without evidence of swelling, the needle can be
considered properly placed. Lastly, the IO needle should stand, unsupported if in the intraosseous
space

7)      If initial attempt fails, may make one additional attempt on other tibia using new needle.
Transport immediately if second attempt unsuccessful. Physician verbal orders must be obtained
for further attempts.

8)      Attach IV tubing and infuse IV solution full flow. Observe for continuous, free flow of
IV fluid without significant subcutaneous infiltration (characterized by swelling and redness)
around intraosseous site.

9)      Secure needle. If appropriate to device, screw down the needle depth guard until it is
flush to the skin. Dress site and tape needle securely in place using a gauze dressing for support,
as necessary.

10) Set drip rates for fluid as you would for any peripheral IV. Flow rates of up to 1200 ml/hr
can be achieved with pressure infusion. All medications designated for IV use can be
administered by the intraosseous route.

11) Medical Control contact should be established following initiation of intraosseous infusion.


Complications:

•        Infiltration at insertion site if improperly inserted
•        Slow infusion from clotting of marrow
•        Osteomyelitis & Infection
•        Fracture




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Adult Intraosseous – F.A.S.T. I Device

Candidates:

•      Patients in critical need of vascular access for volume replacement or medication
administration and
•      Delay in obtaining or unable to obtain vascular access via peripheral IV techniques after
2 attempts and
•      Decreased level of consciousness (GCS < 6 with no purposeful movement) due to
medical or traumatic insult or injury.

Contraindications:

•       Weight < 110 lbs. (50 kg) or pathological small size patient
•       Previous sternotomy
•       Suspected fractured manubrium/sternum or significant tissue/vascular damage at
insertion site
•       Obvious congenital sternal malformations
•       Severe osteoporosis or other bone softening conditions
•       Very small sternum

Procedure:

•       Assemble and prepare equipment
•       Prep the site with Betadine and clean with alcohol using sterile
•       Locate the sternal notch with your finger and apply the patch using your finger as a guide
•       Verify the patch is over the Target Zone, midline of the manubrium and inferior to (5/8”
or 1.5cm below) the suprasternal notch
•       Remove the sharp protector from the device and position the Introducer in the target zone
perpendicular to the skin/manubrium
•       Push the Introducer with increasing force until a distinct release of the Introducer handle
is heard and felt
•       Remove the Introducer and dispose of it properly
•       Connect the Infusion Tube to the male connector on the patch
•       Aspirate with a syringe for free flow of marrow
•       Attach female connector to IV set and begin to run fluids
•       Check for infiltration
•       Apply protector dome to site
•       Insure Remover Package remains with the patient (unopened) and is forwarded to the ED
along with removal instructions. Suggest attaching to patient.
•       Accurately document the procedure on patient care report, including justification for
using the device
•       Removal of the device is to be performed by a physician




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Complications

    •       Improper insertion site (for use in adult manubrium only)
    •       Insufficient depth of needle insertion
    •       Infiltration/Extravasations (soft tissue infusion from penetration of the
    posterior wall)
    •       Infection at insertion site


Additional Considerations

•       If drip rate is slow, flush with 10cc normal saline. If slow drip continues, consider
inflating BP cuff on bag to 300mm/Hg
•       For bleeding around the site, apply pressure around the catheter
•       All medications and blood or blood products that are given via the IV route may be given
IO.
•       Device may be left in place for up to 24 hours
•       In cases on non penetration on the first attempt at insertion, a second attempt with a new
device can be made.

F.A.S.T. I Removal Procedure

•      Stop IV flow
•      Remove the plastic dome
•      Disconnect the infusion line under the dome
•      Gently align the infusion tube perpendicular to the manubrium
•      Insert the removal tool into the infusion tube
•      Locate the infusion port (needle) by gently probing the port with the removal tool
threaded tip
•      Proper position and alignment is ascertained when a grating feeling is palpated
•      Snugly tighten the removal tool onto the infusion port
•      Extract firmly with the removal tool handle, pulling perpendicular to the manubrium.
•      Remove the patch
•      Place pressure to the exit site – sterile dressing

Make sure that the infusion port and infusion tube are removed completely

•       The EZIOTM may be attempted only on the critically ill or injured adult patient when IV
fluids and/or medications must be immediately administered to prevent the patient’s death.
•       It is not to be used when routine IV access is unsuccessful or difficult to establish.

INDICATIONS

•        Adult patients (Greater than 35 kg or 16 years of age) who:



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a. Need IV fluids or medications and a peripheral IV cannot be established in 2 attempts or 90
seconds AND exhibit 1 or more of the following:

         i. An altered mental status (GCS of 8 or less)
         ii. Respiratory compromise (SpO2 < 80% after appropriate oxygen therapy, respiratory
              rate < 10/min or > 40/min)
         iii. Hemodynamic instability (Systolic BP < 90mmHg)

b. EZIO may be considered PRIOR to peripheral IV attempts in the following situations:

         i. Cardiac arrest (medical or traumatic)
         ii. Profound hypovolemia with alteration of mental status

CONTRAINDICATIONS

•        Fracture of the tibia or femur (consider alternate tibia)
•        Previous orthopedic procedures (IO within 24 hours, knee replacement, consider alternate
tibia)
•        Preexisting medical condition involving that extremity
•        Infection at insertion site (consider alternate tibia)
•        Inability to locate landmarks (significant edema)
•        Excessive tissue at insertion site (obesity)

CONSIDERATIONS

Flow rates:
    • Due to the anatomy of the intraosseous space, flow rates will be slower than those
    achieved with IV catheters.
    • Initially infuse a rapid bolus of 10mL of normal saline.
    • Use a pressure bag to ensure continuous infusion.
Pain:
        Insertion of the VidacareTM EZ-IOTM in conscious patients causes mild to moderate
discomfort but is usually no more painful than a large IV.
        IO infusion can cause severe discomfort for conscious patients
        Prior to IO flush on alert patients, SLOWLY administer 40mg (or2mLs) 2% IV
Lidocaine through the EZ-IOTM hub.

PROCEDURE

If the patient is conscious, advise them of the EMERGENT NEED for this procedure and obtain
consent.

•        Locate and cleanse insertion site using aseptic technique.
•        Prepare the EZIO driver and needle set.
•        Stabilize leg.
•        Insert EZIO needle set. (Consider insertion complete when less resistance is encountered
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from driver)

•        Remove EZIO driver from needle set while stabilizing catheter hub.

INDICATIONS

•       Remove stylet from needle set and dispose in sharps container.
•       Confirm placement (Aspiration of marrow, stands w/o support, ease of flushing)
•       If the patient is conscious, administer 40mg (2mLs) 2% Lidocaine IO and wait 15
seconds.
•       Bolus the EZIO catheter with 10ml of normal saline.
        Connect the IV tubing
• Place a pressure bag on solution being infused and adjust the flow rate, as desired
• Monitor EZIO site and patient condition & Document use of EZIO in the patient care report.




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Appendix F Cardioversion

Candidates:

Used only in emergency situations when there is a rapid rhythm associated with inadequate
cardiac output and signs of poor perfusion (confusion, unconsciousness/coma, angina, systolic
BP < 100mmHg, dyspnea)

•        Ventricular Tachycardia with pulses
•        Supraventricular Tachycardia
•        Unknown wide complex tachycardia

Equipment:


•        Cardiac monitor with defibrillator
•        Defibrillation/pacing pads or defibrillation gel

Procedure:

1) If practical, start IV prior to procedure 2) IV Versed may be used if time permits in conscious
patients prior to cardioversion 3) Attach defibrillation pads and extremity leads. Select lead that
gives upright QRS complex.
         (usually Lead II)

4) Press synchronizer button
5) Set energy level according to ACLS protocols
6) Press charge button
7) Verbalize “clear” and visually ensure that the patient area is clear
8) When completed charged, hold shock button until defibrillator delivers counter shock.
9) If the rhythm remains unchanged, increase energy levels according to ACLS and continue at
the direction of medical control.
10) If the rhythm cardioverts into or progresses to ventricular fibrillation, immediately increase
the energy to 200j and defibrillate without synchronization of the monitor. Follow appropriate
ACLS protocols.

•        Ventricular fibrillation and asystole occur rarely
•        Muscle pain and cramps in the conscious patient




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Appendix G Cardiac Defibrillation

Manual Defibrillation Candidates

Patients found in cardiac arrest and determined to be in ventricular fibrillation (Vfib) or
ventricular tachycardia (Vtach) without pulses.

Equipment:
•     Cardiac monitor/defibrillator
•     Defibrillation pads/electrode gel

Procedure:

1) Establish ABC’s, continue/begin CPR
2) Place defibrillation pads on patient’s chest or place electrode gel on paddles and place on
3) Determine rhythm to be ventricular fibrillation or unstable ventricular tachycardia
4) Select energy level at 200j and press charge button
5) Recheck rhythm; confirm shockable rhythm, and “clear” area

6) Press shock button and deliver defibrillation attempt
7) Watch for evidence that shock was delivered (Muscle contractions)

8) Assess for pulses and reassess rhythm after each defibrillation attempt

9) If VF/VT persists, increase joule setting, and immediately defibrillate again according to
    protocols and ACLS recommendations.

Complications:

•       Rescuer defibrillation may occur if you forget to “clear” the area or lean against metal
stretcher or patient during the procedure

•        Skin burns from poor contact with defibrillation pads/paddles

Automatic External Defibrillator (AED) Candidates:

Patients found in cardiac arrest and determined to be in ventricular fibrillation (Vfib) or
ventricular tachycardia (Vtach) without pulses. Only those patients receiving CPR will be
attached to the AED. The AED is to be used in all patients in cardiac arrest who are viable
enough to receive CPR other than children under 9 yrs old or 25 kg, or cardiac arrest caused by
trauma.



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Equipment:

•        Automatic External Defibrillator (AED) Monophasic or biphasic
•        Defibrillation/pacing pads


Procedure:

1) With body substance isolation (BSI) precautions donned, establish unresponsiveness, stop
CPR, and check for spontaneous pulses and spontaneous respirations

2) Resume/begin CPR

3) Attach defibrillation pads to patient and turn on defibrillator

4) Stop CPR, “clear” the patient and analyze rhythm

5) If defibrillator advises shock a) “clear” patient, visualize that no one is touching the patient b)
deliver shock at 360j (or biphasic equivalent)

6) Resume/begin CPR

7) After 2 min CPR reanalyze rhythm

8) If machine advises shock, deliver second shock at 360j (or biphasic equivalent) after
“clearing” patient 9) Resume/begin CPR a) After 2 min CPR reanalyze rhythm

9)) If machine advises shock, deliver third shock at 360j (or biphasic equivalent) after “clearing”
patient 11) Resume/begin CPR

10) If pulses return, manage patient’s airway and breathing appropriately. Transport
immediately.

11) If no pulse, resume CPR for two minutes then repeat defibrillation at 360j (or biphasic
equivalent).

12) If, after any rhythm analysis, the defibrillator advises no shock, check carotid pulses a) if
pulses are present, manage patient’s airway and breathing appropriately. Transport immediately.
b) if no pulses are present, resume CPR for two minutes then repeat analysis of rhythm.

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13) Only six shocks are allowed. Should the patient not convert, transport immediately

14) Should the patient lose pulses or fibrillate during transport to the hospital following a
successful defibrillation, begin CPR. Pull the ambulance to the side of the road and turn off the
motor. Analyze rhythm and deliver up to two additional sets of three stacked shocks according to
protocols and/or medical control. Following defibrillation continue transport.




Internal Cardiac Defibrillator (ICD) General Guidelines:

1)       Treat a patient with an implantable cardiac defibrillator (ICD) like any other patient.

2)      If ICD discharges while you are touching the patient, you may feel a slight sensation. It
will not harm you.

3)      Do not wait for the device to fire in the presence of VT or VF. Begin CPR and
defibrillate with external paddles/pads as necessary. This will not harm the device.

4)      ICD’s are implanted under the skin in the left lower abdominal area or left upper chest
just below the clavicle.

5)      Patients with and ICD will carry a wallet card or Medic Alert bracelet with important
data regarding cutoff rate.

6)       ICD’s will deliver the first shock within 10-30 seconds after recognizing the arrhythmia.

7)       Subsequent shocks will be delivered every 10-30 seconds

8)     An ICD will generally only shock 45 times (depending on model), and requires 35
seconds of nonVT/VF rhythm, including asystole, to reset itself.




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Appendix H Transcutaneous/External Cardiac Pacing

Candidates:


Adult and pediatric patients with bradycardia who are clinically unstable, unconscious or
unresponsive to atropine. Adult and pediatric patients in asystole. Must be done immediately in
resuscitation sequence if considered.

Equipment:
•     Cardiac monitor/defibrillator capable of external pacing
•     Defibrillation/pacing pads
•     Procedure:

1)     Place chest leads, if not already done, in Lead II position, attach to pacing machine and
obtain hard copy recording of patient’s baseline rhythm. Adjust gain to obtain tall QRS
complexes.

2)       Apply pacing electrodes to chest, to left of sternum and on left posterior chest wall.

3)      Connect to pacing machine. In females, place the precordial electrode under the breast
but not over the diaphragm. If authorized to pace pediatric patients, use pediatric pacing
electrodes for patients < 15 kg.

4)    Set pacing rate to 80 or 1020 higher than the patient’s intrinsic heart rate. If patient has no
QRS complexes, set rate at 80.

5)      Set milliamp setting at zero. Turn pacer power on and observe the pacing artifact on the
ECG to assure it is well positioned during diastole. Slowly increase the milliamp setting while
observing the ECG and feeling for a pulse to determine if capture is achieved (usually at a setting
of between 40 to 80 mA). A pulse oximeter, if available, may be helpful to monitor the patient’s
pulse. Once capture is obtained, set milliamp setting 10% higher. If capture cannot be obtained,
try moving the precordial pacing electrode around to a more effective location.

6)      Contact a medical control physician if orders are needed for sedation for the \conscious
patient. Muscle fasciculations will typically be seen at about 50 mA and the patient will
experience pain at levels above about 4050 mA.

7)      Obtain an ECG tracing of the patient’s paced rhythm. Closely monitor the patient’s ECG,
pulse and, if applicable, pulse oximeter during packaging and transport to assure pacing capture
if maintained.




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Appendix I – Pain Management

Adult Pain Management:

To provide relief of pain when indicated. This protocol is NOT to be used in cases where the
patient:

•        has systolic blood pressure less than or equal to 90,
•        has pain determined to be cardiac in origin (see chest pain protocol page),
•        is in active labor.
•        patient has sustained a head injury.

                                         Pain Management

                Standing Orders                               Medical Control Options
1. Assess pain on 010 scale.
2. Inform patient that pain is an important
diagnostic parameter and the goal of this
protocol is to relieve suffering not totally
eliminate pain.
3. Administer Morphine Sulfate 210 mg IV/IM
(Maximum total dose 10 mg) or Fentanyl 50-            ** EMT Intermediate providers require
100mcg IV/IM                                              medical control approval before
                                                          administration of Morphine**
4. Reassess pain scale and titrate additional
doses of pain medication as needed to
maximum dosage as above.
5. Monitor vital signs. If respiratory depression
or hypotension occurs after administration of
narcotics ventilate patient as necessary and
administer Narcan 0.4 2 mg IV. Notify a
medical control physician.
6. Contact medical control physician for orders
if: a. patient has SBP ≤ 90, b. if further pain
medication is required.
                                                    7. Consider additional pain medication as
                                                    appropriate.




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Pediatric Pain Management:


To provide relief of pain when indicated for pediatric patients. This protocol is NOT to be used
in cases where the patient:

•        is hypotensive (i.e. clinical signs of poor perfusion, capillary refill >2 seconds),
•        complains of abdominal pain,
•        has sustained a head injury,
•        has pain determined to be cardiac in origin,



                                  Pediatric Pain Management


               Standing Orders                                Medical Control Options
1. Assess pain on 010 scale if possible.
2. Inform patient and/or guardians that pain is
an important diagnostic parameter and the goal
of this protocol is to relieve suffering, not
totally eliminate pain.
3. Administer Morphine Sulfate x 1 at 0.1              ** EMT Intermediate providers require
mg/kg IV/IM (up to maximum dose of 5 mg)                    medical control approval before
                                                             administration of Morphine**
                                                     Note: Refer to pediatric reference e.g.,
                                                     Broselow Tape, if assistance is needed with
                                                     pediatric vital signs or drug dosage
                                                     calculations.
4. Monitor vital signs. If respiratory depression
or hypotension occurs after administration of
Morphine, ventilate patient as necessary and
administer Narcan 0.01 mg/kg IV (up to a
maximum dose of 0.4 mg). Notify a medical
control physician.
5. Contact a medical control physician for
orders if: a. patient is hypotensive, b. head
injured, c. complains of abdominal pain, d.
further pain medication is required.
                                                     6. Consider initial or additional pain
                                                     medication as appropriate.




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Appendix K – Medications

Medication profiles given in this section are for guidance and informational purposes only. This
section is not intended to provide specific orders for patient care. See specific protocols for
approved system practice.


Activated Charcoal

Generic Name:        Activated Charcoal
Trade Name:          SuperChar, InstaChar, Actidose, LiquiChar
Classification:      Absorbent/Antidote
                     Absorbs poison compounds to its surface, which reduces the
Action/Kinetics:
                     poisons
                     absorption by the body. Very effective in binding ASA,
                     amphetamines,
                     Strychnine, Dilation, Theophyline and Phenobarbital.
                     Poisoning and oral overdose in a conscious patient with an
Indications:
                     intact gag reflex

                     • Special consideration of patients with decreased level of
Contraindication
                     consciousness.
                     • Of no value in poisoning due to methanol, acids/alkalis, iron
                     tablets or lithium.
                     • Cyanide poisoning
                     • Should not be given before ipecac.
Adverse Effects:     Nausea/vomiting. Diarrhea. Black stools.
                     Premixed in water, frequently available in plastic bottle
How supplied:
                     containing 12.5 grams of activated charcoal
                     .
                     1 gram/kg for adults and children. Usual adult dose 2550g.
Dosage:
                     Usual pediatric dose 12.525g
                     .
Precautions:         None




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Albuterol

Generic Name:       Albuterol Sulfate Inhalation Solution, 0.083%

Trade Name:         Ventolin, Proventil

Classification:     Bronchodilators

Action/Kinetics:    Relaxes bronchial, uterine, and vascular smooth muscle
                    Stimulating beta2-adrenergic receptors.

Indications:        Indicated for the relief of bronchospasm in patients two years of age and

                    older with reversible obstructive airway disease and acute attacks of

                    bronchospasm.

Contraindications: Hypersensitivity to the drug

Adverse Effects:    Tachycardia, hypertension, bronchospasm, bronchitis, nasal congestion,

                    tremors, dizziness, nervousness, headache, and sleeplessness.

How Supplied:        Unit dose plastic vial containing Albuterol sulfate inhalation solution

                     0.083%, 2.5mg/3ml.

                      Usual dose for adults and children weighing at least 15 kg is one vial 2.5

                      mg of Albuterol administered by nebulization. Inhalation solution will

                      be delivered over approximately 5 to 15 minutes.

Precautions:          Used with caution in patients with cardiovascular disorders, especially

                      coronary insufficiency, cardiac arrhythmias and hypertension. MAO

                      inhibitors, tricyclic antidepressants, may potentiate action on CV

                      system. Propranolol, and other beta blockers inhibit the effect of

                      Albuterol.




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Albuterol – Patient Assisted

Generic Name: Albuterol Sulfate Inhalation Solution, 0.083%

Trade Name: Ventolin, Proventil, Bronkosol, Bronkometer, Alupent, Metaprel

Classification: Bronchodilators

Action/Kinetics: Beta agonist bronchodilator dilates bronchioles reducing airway resistance.

Indications:
          o    Patient exhibits signs and symptoms of respiratory emergency
          o    Patient has physician prescribed handheld inhaler
          o    Medical control gives specific authorization for use.
          o    Patient is unable to use device (not alert, responsive)
          o    Inhaler is not prescribed for patient
          o    No permission has been given by medical control.
          o    Patient has already taken maximum prescribed dose prior to EMS arrival.

Adverse Effects: Tachycardia, hypertension, bronchospasm, bronchitis, nasal congestion,
                 tremors, dizziness, nervousness, headache, and sleeplessness.


How Supplied: Handheld metered dose inhaler. Dosage: Number of inhalations dependant on
              Medical control orders.


Precautions:    Used with caution in patients with cardiovascular disorders, especially coronary
                insufficiency, cardiac arrhythmia’s and hypertension. MAO inhibitors, tricyclic
                antidepressants may potentiate action on CV system. Propranolol, and other
                beta blockers inhibit the effect of albuterol




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Aspirin (ASA)

Generic Nam             Acetylsalicylic acid

Trade Name:             Aspirin ASA, Ecotrin,

Classification:         Antiplatelet effect, non narcotic analgesic, antipyretic

Action/Kinetics To       reduce risk of death and/or nonfatal MI in patients with a previous MI or
                         unstable angina pectoris. Impedes clotting by blocking prostaglandin
                         which prevents formation of the platelet aggregating substance
                        tromboxane
                   .

DOSE:                   Dose for cardiac patients fitting criteria, even if absence of chest pains, is
                        160 - 325mg.

Indications:            Aspirin given orally if patient has no history of allergy.

Contraindications: Hypersensitivity to drug. Patients with active ulcer disease.

Adverse Effects:       Bleeding gums, signs of GI bleeding, and petechiae. Aspirin will increase
                       Bleeding time.




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Atropine
Generic Name:        Atropine Sulfate

Trade Name:           Atropine

Classification:      Antiarrhythmic, anticholinergic, antidote, cardiac stimulant

                     Anticholinergic that inhibits acetylcholine at the
Action/Kinetics:     parasympathetic neuroeffector junction, blocking vagal effects
                     on the SA and AV nodes; this enhances conduction through the
                     AV node and speeds heart rate, increases heart contractility,
                     improves automaticity, and dilates peripheral vessels.

 Indications:         Treatment of symptomatic sinus bradycardia, second and third
                      degree heart block, or ventricular asystole. Second drug for
                      asystole or PEA. Antidote in organophosphate poisoning.


Contraindications:    Hypersensitivity to the drug, unstable cardiovascular
                      status, myocardial ischemia, glaucoma, and COPD



 Adverse Effects:      Postural hypotension, Blurred vision, dryness of the mouth, GI
                       reflux, nausea, vomiting, tachyarrhythmias, and urinary
                       retention. May also cause ventricular tachycardia or ventricular
                       fibrillation.
  How
  Supplied:            0.1mg/ml total of 10ml to equal 1mg of atropine.



  Dosage:               Adult: For bradycardia, 0.5mg to 1mg. IV every three to five
                        minutes as needed, up to a total of 3mg. In asystole give 1mg.
                        IV; repeat every 3 to 5 minutes up to a total of 0.04 mg/kg.

                        Peds: Give 0.02 mg/kg or 0.2 cc/kg IV/IO/ET up to 5cc for
                        child or 10cc for adolescent (minimum dose 0.1mg or 1cc). May
                        be repeated once in 5 minutes.

  Precautions:          Use with caution in presence of myocardial ischemia and
                        hypoxia. Avoid in hypothermic bradycardia. Usually not
                        effective in second degree block type II and third degree
                        blocks with wide QRS complexes. Antacids decrease
                        absorption of med.
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  Dextrose
  Generic Name:                  D-glucose or glucose


Trade Name:                      Dextrose

Classification:                  Nutritional (carbohydrate)


Action/Kinetics                  Dextrose and water provide calories and increases blood
                                 glucose concentrations.


Indications:         •        Diabetics who are unable to take oral fluids due to
                              altered level of consciousness and low blood glucose.
                     •        Unknown, unconsciousness


Contraindications:       Delirium tremens with hydration, diabetic coma while blood
                         sugar is excessive, intracranial or intraspinal hemorrhage.



Adverse Effects:         Pulmonary edema, exacerbated hypertension, heart failure,
                         Hyperglycemia, (during infusion), hyperosmolar syndrome
                         (mental confusion, loss of consciousness), hypokalemia,
                         reactive hypoglycemia (after infusion).


 How                      50 ml prefilled syringe of D50W IV
 Supplied:



                          Adult dose: one prefilled syringe of 50ml D50W IV—may
                          repeat as appropriate.
 Dosage:
                          Pediatric dose: Give D50W, 1cc/kg up to 50 cc to patients four
                          years and older with a blood glucose <60 mg/dl. For patients
                          three years and younger, use D25W, 2cc/kg IV.

  Precautions:             Use with caution in patients with cardiac or pulmonary disease,
                           hypertension, renal insufficiency, urinary obstruction, or
                           hypovolemia. Avoid extravasation may cause tissue sloughing,
                           necrosis, and phlebitis.


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    Epinephrine
    Generic Name:       Epinephrine Hydrochloride
    Trade Name:         Adrenalin
    Classification:     Cardiac stimulant, bronchodilator, antiallergic, and vasopressor
     Action/Kinetics:   Stimulates alpha and beta-adrenergic receptors within the
                        sympathetic nervous system. A potent cardiac stimulant, it
                        strengthens the myocardial contraction (positive inotropic effect)
                        and increases cardiac rate (positive chronotropic effect).
                        Increases myocardial and cerebral blood flow during CPR.
     Indications:       Cardiac arrest: VF, pulseless VT, asystole, pulseless electrical
                        activity. Anaphylaxis, severe allergic reactions, and profound
                        bradycardia or hypotension after other drugs tried maybe used
                        as a gtt.
Contraindications:      Patients with angle closure glaucoma, shock (other than
                        anaphylactic shock), organic brain damage, cardiac dilation,
                        coronary insufficiency, cerebral arteriosclerosis or labor and
                        delivery. Do not use to treat overdose of adrenergic blocking
                        agents.
 Adverse Effects        Nervousness, tremor, headache, agitation, dizziness, weakness,
                        cerebral hemorrhage, palpitations, hypertension, tachycardia,
                        anginal pain, nausea and vomiting, and dyspnea.
                        Prefilled syringe 0.1mg/ml (1:10,000), total of 10cc = 1 mg.-
                        vial 1 mg/ml (1:1,000) total of 1 cc
     How Supplied:
                        Adult
     Dosage:            Cardiac arrest: 1 mg (10 ml of 1:10,000 solution) administered
                        every 35 minutes during resuscitation. Tracheal route: 2 mg.
                        diluted in saline. Anaphylaxis: 0.3 mg (1, 1000) SC
                        Pediatric
                        Cardiac arrest: (1:10,000) Give 0.1mg/kg or 0.1 cc/kg up to
                        10cc. Tracheal route: (1:1000) Give 0.1 mg/kg or 0.1 cc/kg up to
                        10cc. Anaphylaxis: (1:1000) 0.01 mg/kg (0.01 cc/kg) SC or IM
                        up to 0.3 cc if patient was exposed to commonly recognized
                        allergen and has respiratory distress or hypotension.
                        High doses do not improve survival or neurologic outcome and
                        may contribute to post resuscitation myocardial dysfunction.
     Precautions:
                        Raising blood pressure and increasing heart rate may cause
                        myocardial ischemia, angina and increased myocardial oxygen
                        demand. Higher doses maybe required to treat poison/drug
                        induced shock. The effects of the drug maybe potentiated by
                        tricyclic antidepressants.

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Epinephrine –              Patient Assisted Auto Injector
Generic Name:             Epinephrine
Trade Name:           Adrenalin, EpiPen
Classification:       Cardiac stimulant, bronchodilator


Action/Kinetics
                      •         Dilates bronchioles
                      •         Constricts blood vessels


Indications:          Patient meets all of the following criteria:
                      •       Patient exhibits signs of a severe allergic reaction, including
                              either respiratory distress or shock (hypoperfusion)
                      •       Medication is prescribed for this patient by a physician
                      •       Medical control gives specific authorization for its use.


 Contraindications:        None when used in a life threatening situation

  Adverse Effects         Increased heart rate, pallor, dizziness, chest pain, headache, nausea/vomiting,
                          excitability, anxiety



                            Liquid administered by an auto injector (an automatically injectable needle and
   How Supplied:            syringe system).
                            Adult
   Dosage:                  One adult auto injector (.3mg)
                            Pediatric
                            One infant/child auto injector (.15mg)

  Precautions:              If patients condition continues to worsen (decreasing mental
                            status, increasing breathing difficulty, decreasing blood pressure)
                            obtain medical direction to administer additional dose of
                            epinephrine, treat for shock (hypoperfusion) and prepare to
                            initiate basic life support measures (CPR, AED)
                            If patient’s condition improves, provide oxygen and treat for shock.

                            Transport immediately. Request ALS response early if not
                            initially dispatched. Continually monitor patient’s airway,
                            breathing, and circulatory status.

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 Glucagon
 Generic Name:         Glucagon
 Trade Name:           GlucaGen
 Classification:       Antihypoglycemic, antidote, and diagnostic agent
Action/Kinetics:       Induces liver glycogen breakdown, releasing glucose from
                       the liver. Blood glucose is raised within 10 minutes. Has a
                       half-life of 8 to 18 minutes.


Indications:           Treatment of severe hypoglycemia, Helpful in reversing adverse beta blockade of
                       beta-adrenergic blocking agents and calcium channel blockers.




Contraindications:    known hypersensitivity to drug, and in patients with pheochromocytoma or with
                      insulinoma (tumor of pancreas).



Adverse Effects      Hyperglycemia (excessive dosage), nausea and vomiting hypersensitivity reactions
                     (anaphylaxis, dyspnea, hypotension, rash), increased blood pressure, and pulse; this
                     maybe greater in patients taking beta blockers.


How Supplied:        One vial containing 1 mg. (1 IU) powder and one vial
                     containing 1/ml of sterile water to be reconstituted.


Dosage:
                     Give 1 mg. IM, after reconstituting powder and sterile water,
                     for symptomatic diabetic patient whose IV access has been
                     difficult. For beta-blocker overdose also give 1 mg. IV.

Precautions:          Give with caution to patients that have low levels of releasable glucose (e.g.,
                      adrenal insufficiency, chronic hypoglycemia, and prolonged fasting). Potentiates
                      oral anticoagulants. Depletes glycogen stores especially in children and
                      adolescents.




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Glucose –               Patient Assisted Medication
Generic Name:           Glucose, oral Glucose,
Trade Name:             Instaglucose
Classification:         Carbohydrate Increases
 Action/Kinetics        blood sugar levels
 Indications:           Patient meets all of the following criteria:
                        •      Altered mental status
                        •      Known history of diabetes mellitus
                        •      Unconsciousness

Contraindications:      Known diabetic who has not taken insulin for days
                        Patient who is unable to swallow
Adverse Effects         None when given properly. May be aspirated by
                        the patient without gag reflex.


How Supplied: Dosage:   Gel, in toothpaste type tube

Dosage:                 Administer one tube between the patients cheek and gums

Precautions:            None. Monitor patient for improvements in mental status




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Lidocaine Hydrochloride
Generic Name:             Lidocaine Hydrochloride
Trade Name:               Xylocaine
Classification:           Antiarryhthmic
Action/Kinetics:          Decreases ventricular excitability without depressing the force of ventricular
                          contractions by increasing the stimulation threshold of the ventricle during diastole.
                          Onset of action should occur within 2 minutes and last approximately 10 to 20
                          minutes. Metabolized in the liver and excreted in the urine.

Indications:              Cardiac arrest from VF/VT (class II B) Stable VT, wide complex tachycardia’s of
                          uncertain type, wide complex PSVT (class IIB). Used to stabilize patients converted
                          from VT/VF. Occasionally used in control of symptomatic criteria PVC’s.

Contraindications:        Hypersensivity to the drug. Stokes Adams syndrome, WolffParkinsonWhite
                          syndrome, severe degrees of SA, AV, or intraventricular block (when no
                          pacemaker is present.).

Adverse Effects           Anaphylaxis, bradycardia, hypotension, cardiovascular collapse, seizures,
                          malignant hyperthermia, respiratory depression, tremors, lightheadedness,
                          confusion, tinnitus, blurred or double vision, and vomiting

How Supplied:             5 ml prefilled syringe (100 mg. total)


Dosage:                   Adult: V tach Lidocaine 100 mg. (1.01.5 mg/kg) IV over two minutes. Use ½
                          dose, i.e., 50 mg. if patient is over age 70 or if CHF or hepatic failure present.
                          Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes; maximum total dose: 3 mg/kg.

                           Cardiac arrest from VF/VT Lidocaine 100 mg. (1.5 mg/kg) may repeat lidocaine
                           100mg. IV or 200 mg. ET followed by defib. Drip – 2gm/500cc’s administered
                           14mg/min. Always preceded by a bolus.

                           Peds: Cardiac Arrest – 1mg/kg
                           IV/ET/IO Drip – 120mg/100cc’s at 1-
                           2.5cc’s/kg/hr IV
 Precautions:             Do not administer with sinus bradycardia, second or third degree AV blocks and
                          idioventricular rhythms.

                          Prophylactic use in AMI patients is not recommended. Discontinue infusion
                          immediately if signs of toxicity develop. Elderly clients who have hepatic or
                          renal disease or who weigh less than 45.5 kg. Should be watched closely for
                          adverse side effects. Toxicity can occur due to reduced metabolism of lidocaine.



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Morphine        Sulfate
Generic Name:             Morphine Sulfate
Trade Name:               Morphine Sulfate (names may vary if preservative free)
Classification            Narcotic analgesic, pulmonary edema An opium derivative, narcotic analgesic,
                          which is a CNS depressant.
Actions/Kinetics:         Induces sleep and inhibits perception of pain by binding to opiate
                           receptors, decreasing sodium permeability, and inhibiting transmission of pain
                          pulses.
                          Causes peripheral vasodilatation, thereby decreasing venous blood return to the
                          heart.
                           Relieves pulmonary congestion, and lowers myocardial oxygen need. Detoxified in
                           the liver and excreted in the urine. Onset 23 minutes peak 30 minutes, and duration is
                           36 hours.
 Indications:              Analgesic of choice in pain associated with myocardial infarction that is
                           unresponsive to nitrates. Treatment of acute pulmonary edema associated with left
                           ventricular failure, (if blood pressure is adequate). Used for sedation, to decrease
                           anxiety and facilitate induction of anesthesia. Used for management of pain in
                           trauma, kidney stones, etc…
 Contraindications:        Hypersensitivity to opiates, acute bronchial asthma, heart failure secondary to
                           lung disease, upper airway obstruction, acute alcoholism, convulsive states, and
                           paralytic ileus.

 Adverse Effects            Seizures (with large doses), hypotension, bradycardia, cardiac arrest, or may see
                            tachycardia, and hypertension. Nausea and vomiting, rash, itching, urine retention,
                            respiratory depression and arrest, hypothermia, and increased intracranial pressure
                            may also been seen.
How Supplied:               Vial 10 mg/ml =1ml or 10mg/1ml prefilled syringe


 Dosage:                    For persistent pain, give Morphine sulfate 2-10 mg IV titrated to obtain pain relief.
                            (Use caution in presence of COPD).
                             Pediatric dose: 0.10.2mg/kg IV/IM
 Precautions:               Causes hypotension in volume depleted patients. Administer slowly and titrate to effect.
                            May cause apnea in asthmatic patients. May also cause increase ventricular response
                            rate in presence of supraventricular tachycardias. Use with caution in the elderly, head
                            injuries with increased intracranial pressure, COPD, severe hepatic or renal disease,




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    Narcan:
    Generic Name          Naloxone Hydrochloride
    Trade Name:           Narcan
    Classification       Narcotic (opioid) antagonist, Antidote


   Actions/Kinetics       Overcomes effects of narcotic overdose including respiratory depression, sedation, and
                          hypotension. It does not have any narcotic effect itself. It exhibits essentially no
                          pharmacologic activity. Diagnostic agent in unconsciousness of unknown origin. Onset of
                          action is within 2 minutes. Duration of action is dependent on dose and route of
                          administration


   Indications:           Indicated for complete or partial reversal of known or suspected narcotic induced
                          respiratory depression and overdose. Antidote for natural and synthetic narcotics.



Contraindications:        Hypersensitivity to the drug.




                                    .
Adverse Effects           May see VF, tachycardia, hypertension, nausea, vomiting, and diaphoresis, in
                          higher doses. Tremors and withdrawal symptoms in narcotic dependent patients.


 How Supplied:            2mg/2cc’s preloaded syringe



 Dosage:                  Adult dose: If suspected narcotic overdose consider 2 mg Narcan IV. For physical
                                                                    IV.
                          findings consistent with narcotics overdose, may give 2 mg. Narcan
                          Pediatric dose: .01 mg/kg IV/IM




Precautions:          May precipitate acute withdrawal symptoms in narcotic addicts. Effects of drug may not
                      outlast effects of narcotics. Use with caution in patients with cardiac disease or those
                      receiving cardio toxic drugs. It is ineffective against respiratory depression caused by
                      barbiturates, anesthetics, other non narcotic agents, or pathologic conditions.

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Nitroglycerin, Tablets – Patient Assisted Medications
Generic Name:                Nitroglycerin
Trade Name:                  Nitro stat
Classification               Antianginal, coronary vasodilator, antihypertensive



Actions/Kinetics             Primary action is relaxation of the vascular smooth muscle and dilatation of peripheral
                             arteries and veins. Although venous effects predominate, nitro produces dilation of both
                             arterial and venous beds. Promotes peripheral pooling of blood and decreases venous return
                             to the heart, reducing left ventricular pressure (preload). Arteriolar relaxation reduces
                             systemic vascular resistance and arterial pressure (afterload). Also increases blood flow
                             through the collateral coronary vessels. Onset: 12 minutes Duration: 35 minutes. Patient must
                             meet all of the following criteria


 Indications:            •         The patient complains of chest pain
                         •         The patient has a history of heart problems
                         •         The patients physician has prescribed nitroglycerin
                         •         The systolic blood pressure is greater than 100 systolic
                         •         Medical control gives specific authorization for its use.


 Contraindications:
                             • The patient has hypotension, or a systolic blood pressure below 100
                             .
                             •      The patient has a head injury
                             •      The patient is an infant/child
                             •      The patient has already taken the maximum prescribed dose
 Adverse Effects             Headache, transient episodes of lightheadedness related to blood pressure changes,
                             hypotension, syncope, crescendo angina, rebound hypertension, and anaphylactoid reactions.
                             Abd pain and vomiting may also be seen.


  How Supplied:
                             Tablets 0.4mg S.L. (1/150).


   Dosage:                   One tablet S.L. 0.4 mg (gr. 1/150). May repeat same dosage for chest pain patient
                             every 5 minutes x 3 if SBP remains 110 or greater if medical control gives
                             authorization.

                             If patient is wearing a nitroglycerine patch or paste, an additional administration may
  Precautions:
                             not be appropriate.
                             If patient is taking prescribed Viagra, consult medical control regarding nitro
                             administration.
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Nitroglycerin
Generic Name:          Nitroglycerin


Trade Name:            Nitrostat


Classification         Antianginal, coronary vasodilator, antihypertensive


Actions/Kinetics        Primary action is relaxation of the vascular smooth muscle and dilatation of peripheral arteries
                        and veins. Although venous effects predominate, nitro produces dilation of both arterial and
                        venous beds. Promotes peripheral pooling of blood and decreases venous return to the heart,
                        reducing left ventricular pressure (preload). Arteriolar relaxation reduces systemic vascular
                        resistance and arterial pressure (afterload). Also increases blood flow through the collateral
                        coronary vessels. Onset: 12 minutes Duration: 35 minutes.




 Indications:           •         Control of pain associated with angina pectoris/myocardial infarction.
                        •         Relief of pulmonary edema caused by leftsided heart failure.


 Contraindications: •              The patient has hypotension, or a systolic blood pressure below 100
                    •              The patient has a head injury
                    •              The patient has already taken the maximum prescribed dose

 Adverse Effects            Headache, transient episodes of lightheadedness related to blood pressure changes,
                            hypotension, syncope, crescendo angina, rebound hypertension, and anaphylactoid reactions.
                            Abd pain and vomiting may also be seen.


 How Supplied:
                            Tablets 0.4mg S.L. (1/150).


 Dosage:                    One tablet S.L. 0.4 mg (gr. 1/150). May repeat same dosage for chest pain patient every 5
                            minutes x 3 if SBP remains 100 or greater if medical control gives authorization.


 Precautions:               If patient is wearing a nitroglycerine patch or paste, an additional administration may
                            not be appropriate.
                             If patient is taking prescribed Viagra, consult medical control regarding nitro
                             administration.
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Appendix – L Laryngeal Mask Airway (LMA) Insertion

Purpose: The purpose of this Appendix is to provide a guideline for the placement of a
Laryngeal Mask Airway as a primary airway when endoctracheal intubation is not available and /
or not desired.

Indication: To secure an airway with a non-invasive device in a patient with no gag reflex. May
also be used to secure an airway when tracheal intubation is not desired or has failed.

Contraindication:
      1. Responsive patient with an intact gag reflex
      2. Patients under the minimum weight indicated on the LMA device.
      3. Patients with obvious risk of regurgitation / pulmonary aspiration
      4. Patients with significant inhalations burns.

Procedure:
      1. Identify that the patient is unresponsive and without gag reflex. The airway needs to be
         Protected and tracheal intubation is not available and/or not desired.
      2. Select the appropriate size LMA based on patients approx. weight kg:

                a. Size 3:                    Small Adult 30-50kg
                b. Size 4:                    Adult 50-70kg
                c. Size 5:                    Large Adult 70>

         3.Test cuff and lubricate the posterior surface area of the cuff only with water soluble
            jelly
         4. Maintain cervical immobilization (if indicated) and lift tongue and jaw upward with
            One hand.
         5. Verify there are no obvious obstructions (OPA, etc) or foreign matter in the mouth that
            Could occlude the airway.
         6. Insert the LMA until resistance is felt while holding LMA, in alignment with the
            septum of the nose.
         7. Inflate cuff with syringe provided.
         8. Attach BVM and confirm effective ventilation, monitor, SPO2 and/0r CO2
            Performance, secure LMA placement and continuously monitor LMA performance
         9. If unable to achieve adequate ventilation using the LMA, deflate cuff, remove
            Device, and attempt again. If unable to ventilate, deflate cuff, remove device, and
            Attempt bag mask valve ventilation, consider obstructed airway maneuvers (if not
            Yet performed).

Standing Orders & Other Information: Standing orders allow placement of the LMA device in
patients who would otherwise require an OPA by trained EMT’s.




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Appendix – I Mucosol Atomization Device (MAD) Naloxone (Narcan) Application

Purpose :
Mucosol Atomization device as a primary method of administration the drug Naloxone (Narcan)
to patients suspected of opiate intoxication related comas.

Indications:
First line application to treat known narcotic overdose or coma suspected to be related to narcotic
overdose.

Contraindications
      1. Obvious blockage of nasal passages due to trauma, secretions, blood, etc
      2. Obvious indicators of chronic nasal related disease, obstructing the nasal passages.

Procedure:
      1. Drawing up solution (1mg/ml):
                   A.      Inspect nostrils for mucus, blood or other problems which inhibit
                           Absorption.
                   B.      Draw up 2mg of 1mg/ml Naloxone (Narcan) into the 3ml
                           Atomizing syringe.
                   C.      Holding the syringe vertical. Un-thread the needle form the syringe
                   D.      Attach the atomizer device to the luer thread of the syringe and
                           Aspirate residual air form the syringe.
                   E.      Give ½ of the syringe volume in each nostril (1mg/ml)
                   F.      Monitor patient closely while administering medication

         2. Using pre-loaded 2,ml syringe )1mg/ml):
                        A.     Inspect nostrils for mucus, blood or other problems which inhibit
                               Absorption.
                        B.     Assemble the 2ml pre-loaded syringe and remove the luer cover.
                        C.     Attach the atomizer device to the luer thread of the 2ml pre-loaded
                               Syringe and aspirate any residual air form the syringe.
                        D.     Give ½ of the syringe volume in each nostril (1mg/ml)
                        E.     Monitor patient closely while administering medication

Standing Orders & Other Information: Standing orders allow the use of the MAD as a first line
application tool for delivering Naloxone (Narcan) as indicated in the applicable protocols prior to
contacting medical control.




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Appendix – J TraumaDEX (Microporous Polysaccharide)

Purpose
The purpose of this Appendix is provide a guideline for the placement and use of TraumaDex as
part of primary bleeding control that will aid in providing rapid hemostasis for the patients with
moderate or perfuse bleeding.

Indications:
       1.    TraumaDex is to be used as a topical application to control and manage a wound
             With moderate or severe bleeding.
       2.    TraumaDex can be used for actively bleeding wounds.

Contraindications:
      1.     Known allergies to starch products
      2.     TraumaDex is contraindicated for sucking chest wounds.
      3.     TraumaDex is contraindicated for open brain Injuries.
      4.     TraumaDex is contraindicated for open fractures with exposed bone.

Procedure:
      1.        Attempt to control bleeding with direct pressure, elevation, and pressure points
                While preparing TraumaDex.
         2.     Open the package and remove the bellows applicator, twist and bend the nozzle to
                Remove the cover.
         3.     Remove excess blood from the wound using sterile gauze.
         4.     Quickly identify the source of the bleeding, again remove any excess blood, and
                Then thoroughly cover the source and the wound bed with TraumaDex powder.
         5.     Immediately reapply guaze to the wound and maintain direct pressure to the
                Source of bleeding.

         6.     Wound coverage:
                       A.      2.0 grams applicator providers up to 4 square inches of wound
                               Coverage.
                       B.      5.0 grams applicator provides up to 10 square inches of wound
                               Coverage.
         7.     If bleeding is not controlled with one application, TraumaDex may be reapplied
                Once using steps 1-5.
         8.     continue use of direct pressure, elevation, and pressure points as needed after
                TraumaDex has been applied.
         9.     Nosebleeds: Note: Must Have Medical Control Approval!
                A.     Control nosebleed with direct pressure while preparing TraumaDex
                B.     Contact the receiving hospital with report and request use of TraumaDex
                C.     Have patient blow their nose to remove excess blood and loose clots.
                D.     Have patient tilt their head back and apply TraumaDex (2.0 grams) into
                       Bleeding nostril.
                E.     Provide direct pressure to nostril as needed to control bleeding.

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Pediatric Considerations:
TraumaDex can be used on all pediatrics.

Standing Orders & Other Information: Standing orders allow for the application of TraumaDex
by trained EMT’s as indicated by this protocol prior to contacting medical control. Receiving
facilities must be notified after any application of TraumaDex prior to transfer of patient care.

Note: The receiving facility must authorize the use of TraumaDex for the use on
nosebleeds.

Additional Notes:

         1.     TraumaDex is bioinert, there is no risk of disease transmission, immune or
                Allergic responses

         2.     TraumaDex is a medical device not a medication, patients cannot overdose on
                TraumaDex.

         3.     TraumaDex is extremely stable and does not require any special storage
                Conditions.
         4.     TraumaDex should be kept dry before applying to the wound.




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Appendix – K Taser Deployment & Barb Removal

Purpose:
The purpose of this Appendix is to provide a guideline for all EMT personnel to follow when
assisting other public safety entities with treatment of patient(s) after “Drive Stun” & “Probe
deployment with probe penetration of the skin” events.

Indication:
In compliance with other agencies “Use of Force” Policies and/or equivalent procedures. Most
agencies who utilize the Taser – X26 or equivalent non-lethal force weapon, require EMS
personnel perform the following on all persons subjected to either “Drive Stun” and/or Probe
deployment with probe penetration of the skin”

                   A basic patient assessment.
                   Removal of probes if they have penetrated the patient’s skin.

Contraindications:
Probes shall not be removed from the patient if the following conditions exists:
    Probes are embedded in the soft tissue areas, such as the neck, face, groin, and female
      breasts.

                    These probes are to be bandaged in-place and the patient transported to the
                    Hospital Emergency Department via applicable transportation.

Procedure:
“Drive Stun” Application:
    Upon arrival make contact with Officer who deployed the non-lethal device for simple
       report (location of Drive Stun etc.). Be sure to ascertain any information indicating
       potential secondary injuries.
    Once cleared to approach the patient, perform a head-to-toe assessment. This should
       include the following: ABC’s – Work of Breathing, Respiratory Rate, SPO2 reading,
       Heart Rate, Blood Pressure, AVPU, DCAPBTLS, PMS, SAMPLE History, if possible,
       expose and inspect the drive stun site.
    Consider additional airway management, cervical & spinal immobilization, and care of
       potential secondary injuries when applicable.
    Communicate findings and treatment game plan with the arresting officer.
    Contact the Hospital for report & advise of disposition & game plan.

                    a.     Non-Transport – Releasing to Police Department
                    b.     Transport – Via Ambulance or Police to Emergency Department.

        Documentation should include a copy of the: “Sunset City Police Department – Taser
         Use Report Form”.



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“Probe deployment with probe penetration of the skin” Applications:

        Upon arrival make contact with Officer who deployed the non-lethal device for a simple
         report – (location of probes etc.). Be sure to ascertain any information indicating potential
         secondary injuries.
        Once cleared to approach the patient, perform a head-to-toe assessment.
        This should include the following: ABC’s – Work of Breathing, Respiratory rate, SPO2
         reading, Heart Rate, Blood Pressure, AVPU, DCAPBTLS, PMS, SAMPLE History,
         expose and inspect the penetrating probe site(s)
        Consider additional airway management, cervical & spinal immobilization, and care of
         secondary injuries when applicable.
        Ensure probes are not within the contra-indicated area listed.
        Remove probes as follows:
             o Ensure both conductor leads are disconnected by the arresting officer.
             o Apply gentle traction to the surrounding surface area of the probe with one hand
                 while holding the probe with the other hand.
             o Locate the barb indicator on the side of the probe
             o With one swift in and out motion, remove the probe while using the barb indicator
                 as a guide.
             o Assess the wound site before applying dressing.
             o Place probes inside the container provided by the arresting officer
        Communicate findings and treatment game plan with the arresting officer.
        Contact Hospital for report & advise of disposition & game plan:

         1.     Non-Transport – Releasing to Police Department
         2.     Transport – Via Ambulance or Police to Emergency Department.
         3.     Special Considerations – Probes located within the contra – indicated area(s)

        Document should include a copy of the: “Sunset City Police Department – (Taser Use
         Report Form”.

Standing Orders & Other Information: Standing orders allow trained EMT personnel to remove
the probes as indicated within this protocol prior to contacting medical control.

Note: This Appendix is intended for treatment and removal of non-lethal probes only. All
other impaled related injuries should be treated according to Davis County EMS Protocols.




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Appendix – L USE OF RESTRAINTS

                         ALWAYS USE UNIVERSAL PRECAUTIONS


PURPOSE

To provide guidelines on the use of restraints in the field, or during transport, for patients who
   are violent, or potentially violent, or who may harm themselves or others.

PRINCIPLES

The safety of the patient, community and responding personnel is of paramount concern.

Restraints are to be used only in situations where the patient is violent and is exhibiting behavior
   that is dangerous to self or others.

Prehospital personnel must consider that aggressive or violent behavior may be a symptom of
   underlying medical conditions.

The responsibility for patient health care management care rests with the highest medical
   authority on scene. Therefore, prehospital personnel shall determine medical intervention and
   patient destination.

Authority for scene management shall be vested in law enforcement.

The method of restraint used shall allow for adequate monitoring of vital signs and shall not
   restrict the ability to protect the patient’s airway nor compromise neurological or vascular
   status.

Restraints applied by law enforcement require the officer’s continued presence to remove or
   adjust the restraints for patient safety.

This policy is not intended to negate the need for law enforcement personnel to use appropriate
   restraint equipment that is approved by their respective agency to establish scene
   management control.


PROCEDURES

The following procedures should guide prehospital personnel in the application of restraints and
   the monitoring of a restrained patient:

Restraint equipment, applied by prehospital personnel, must be soft restraints (i.e. Kerlix, Velcro
   or seatbelt type). Both methods must allow for quick release.

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The following forms of restraint shall NOT be used by prehospital personnel:

Hard plastic ties or any restraint device requiring a key to remove.

Sandwiching patients between backboards, scoop-stretchers, or flat, as a restraint.

Restraining a patient’s hands and feet behind the patient, i.e. hog-tying.

Methods or other materials applied in a manner that could cause respiratory, vascular or
   neurological compromise.

Restraint equipment applied by law enforcement (handcuffs, plastic ties, or hobble restraints)
   must provide sufficient slack in the restraint device to allow the patient to straighten the
   abdomen and chest and to take full tidal volume breaths



UNCONSCIOUS Patients

If indicated, performance of Basic Life Support protocols, Defibrillation, and Spinal
     Immobilization protocols supersede and precede initiation of Restraint protocols

If artificial ventilation is required and Intubation cannot immediately be performed, implement
    "Crotch Restraint" of the Unconscious Patient's Wrists Immediately AFTER Initiating Bag-
    Valve-Mask Ventilations.

If artificial ventilation is required and Intubation CAN immediately be performed, implement
    "Crotch Restraint" of the Unconscious Patient's Wrists DURING or Immediately AFTER
    Intubation.

If artificial ventilation is NOT required, implement "Crotch Restraint" of the Unconscious
    Patient's Wrists Immediately AFTER Initiating supplemental oxygenation – BEFORE
    initiating IV access and/or transportation.


           CROTCH RESTRAINT:

Crotch Restraint may be initiated on EITHER the right or left side of the patient. For instruction
   purposes only, this protocol will begin with the RIGHT side.

         Place the middle of a Gauze Strap at the medial (inside) aspect of the patient's right upper
             leg (at the right side of the patient's "crotch" or "groin").

         Tie a half-knot at the lateral (outside) aspect of the right leg. Tighten the half-knot so that
             the Gauze Strap "tails" are of equal length, and the restraint is tight, but does not
             impede circulation to the leg.
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         Tie another half-knot to create a full-knot that locks the Right Crotch Restraint in place,
             and prevents it from becoming tighter.

         Place the posterior (back) of the Right wrist AT the Right Crotch Restraint knot.

         Tie a half-knot at the front (anterior) of the patient's right wrist. Tighten the half-knot so
             that the wrist restraint is snug enough not to slip off of the patient's wrist, but not so
             tight that it impedes circulation to the hand.

         Tie another half-knot to create a full-knot that locks the Right Wrist Restraint in place,
             and prevents it from becoming tighter or looser.

         Repeat the above steps on the patient's Left side with a second Gauze Strap.

Because the patient is unconscious, the Shoulder/Chest Restraint Belt and Lower Body Restraint
Belt may not be required. If the patient does not regain consciousness subsequent to treatment,
"standard" application of wheeled stretcher safety belts is all that will be required for
transportation to the emergency department.

If the patient regains consciousness subsequent to treatment, and becomes resistively
Confused or Violently Confused, implement the correspondingly-appropriate restraint protocol.
If the patient regains consciousness subsequent to treatment, becomes alert and well-oriented,
and is unresistive to treatment/transport, counsel the patient regarding the necessity of allowing
the soft restraints to remain in place until arrival at the emergency department, for safety reasons.

"A COOPERATIVE patient will COOPERATE with restraints

If the patient complains of discomfort, adjust the restraints as necessary, without diminishing
their effectiveness and safety. Increase the patient's comfort by ensuring that the patient is warm
enough, cool enough, and the like. Adjust the patient's position (head elevation) to increase the
patient's comfort.

         CONFUSED TRAUMA PATIENTS With a Mechanism Of Injury
               REQUIRING SPINAL IMMOBILIZATION:
Provide Spinal Immobilization in the "Normal" Manner.
    If – at any time – the patient becomes Strongly Resistive to normal spinal immobilization
   procedures, they should be treated according to the "STRONGLY RESISTIVE or
   COMBATIVE PATIENT RESTRAINT" protocol.

Restrain ONE Wrist If possible, restraint the wrist of an UNINJURED arm to a T-anchor
  point ABOVE The Patient's Head.

The other arm will be used for blood pressure measurement and IV access, and remain

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    unrestrained. By anchoring the restrained wrist above the patient's head, the patient's ability
    to inappropriately remove his IV (without intervention) is minimized.

If the nature of an arm injury prohibits blood pressure measurement and/or IV access being
     safely accomplished using the "injured" arm: "Splint" and Restrain the Injured Arm at the
     patient's side, leaving the Uninjured Arm free of restraint.

Have your Partner MANUALLY Restrain the Unrestrained Arm, while you perform blood
  pressure measurement and IV access. After these procedures are accomplished, discontinue
  manual restraint and transport.

    Restrain BOTH Wrists ONLY if
           The patient becomes strongly Resistive to continued care, and begins to "strike
              out" with the unrestrained arm, in an effort to push-away care providers.

                The patient's attempts to bring the unrestrained arm above his head and
                   inappropriately remove his IV are PERSISTENT.

                The patient PERSISTENTLY utilizes the unrestrained hand to attempt removal
                   of other restraints.

         If required, restrain the Second Wrist at the Patient's Side.




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                VIOLENTLY RESISTIVE or COMBATIVE PATIENT RESTRAINT


STEPS FOR ACCOMPLISHING SUPINE TOTAL-BODY-RESTRAINT

Upon arrival, if the patient is restrained in a prone position
  (hobbled or not), IMMEDIATELY roll the patient
  OFF of his stomach!!!

Once on his side, if the patient is UNCONSCIOUS and in hobble restraints, remove the hobble
  (the tie that binds the wrists to the ankles)
  and the handcuffs, and assess for respiratory or cardiopulmonary arrest.

If Rescue Breathing is indicated, implement it while others are removing ALL restraint devices.

While providing appropriate resuscitation measures,
  have the patient restrained SUPINELY to a LBB. (long back board)

If the side-positioned, restrained patient is CONSCIOUS (still combative, OR NOT),
    mechanical restraints (handcuffs, ankle shackles – even hobble restraint) may REMAIN IN
    PLACE as long as the patient is maintained on his SIDE!

Keep the restrained, conscious, patient on his side until a "sufficient number of people" are
   available to control the patient during alternative restraint replacement.

At least FIVE PEOPLE are required to accomplish the safe transfer of significantly violent
    individuals from law enforcement restraint to MEDICAL restraint: one person to control
    each limb/major joint, and one person to apply alternative restraints.

Bring a LONG BACK BOARD to the Side of the Patient.

Put the law-enforcement-restrained patient on the Long Back Board, ON HIS SIDE, and
   prepare to transfer him to LBB restraint. Position all responders around the patient and LBB
   to ensure optimal control of the individual when law enforcement restraints are gradually
   removed.




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REFERENCES:

US Department of Transportation (US DOT) National Standard Curriculum for the Emergency
Medical Technician, (1994)

US Department of Transportation, N.S.C. for Emergency First Responder, (1996)

Utah State Teaching and Testing Protocols (TTP’s)

Davis County Pre-Hospital Care & Treatment Protocols, (2009)




  We have reviewed these protocols and have found them acceptable for use by the Sunset
                        Fire Department as of the date indicated.



         ____________________________               __________________________
         Kevin, Gardner, MD                         Neil Coker, Fire Chief
         Medical Control Physician                  Sunset Fire Department



         ____________________________
         James Weston, EMS Program Mngr
         Sunset Fire Department

                                   Signed 1st April 2009




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