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Pridemark Protocols

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									               PRIDEMARK PARAMEDIC SERVICES

                                            &

                        DENVER METROPOLITAN

                      PREHOSPITAL PROTOCOLS




                  These protocols are effective January 31st, 2008




       These protocols are considered property of the Denver Metro EMS Medical Directors and
        Pridemark Paramedic Services, LLC. as well as contributors listed below. They may be
         utilized and edited by others as long as the Denver Metro EMS Medical Directors and
        Pridemark Paramedic Services are credited. We also ask to be notified at: Pridemark
                       Paramedic Services 6385 W. 52nd Ave. Arvada, CO 80002




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                                        Introduction
At first glance, these protocols appear a bit unusual. They are in that they are a hybrid of
the Denver Metro Protocols that the majority of agencies in our area utilize, Boulder
County Protocols and the Pridemark Protocols.

By allowing the documents to compliment each other, this allows us to practice at the
regional standard as set by the Denver Metro EMS Medical Directors as well as utilize
the protocols that we have developed in house that are specific to the needs of Pridemark.

If you have practiced in the Metro area before coming to Pridemark, much of what you
have utilized still apply, however, you will find some differences in ways that hopefully
will make your job easier.

This document is separated into different sections addressing different items. There are
no page numbers—this is by design to allow easy introduction / retirement of protocols
so the entire book doesn’t need to be printed.

Pridemark specific protocols are noted by a Pridemark Logo in the header area of the
page. In the event of discrepancies or conflicts between the Pridemark and Denver Metro
Protocols, Pridemark protocols are to be followed.

Please remember that it is impossible to write a protocol or guideline to cover every
eventuality. Use good judgment, always act in the patient’s best interest and document
well. Help is only a phone call away.




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  PRIDEMARK PREHOSPITAL PROTOCOL MANUAL ACKNOWLEDGEMENT OF
          RECEIPT AND PROVIDER PRACTICE EXPECTATIONS


The completed information below verifies that the Pridemark Prehospital Protocol
Manual has been received and that the recipient accepts the responsibility for knowing
and practicing as an EMT and/or paramedic in accordance with these protocols.


______________________________________________________________
Name of Recipient (please print)               Date Received


______________________________________________________________
Signature of Recipient                         Date


___________________________________________
Agency




For office and administrative use only:


Protocol Examination Results:
(90% or higher required to pass on all tests)

Mapping and Radios:
______________________________________________________________________
Combination Analgesia:
______________________________________________________________________
Cardiology:
______________________________________________________________________
Operations:
______________________________________________________________________
Final Protocol Test:
______________________________________________________________________
Notes:
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________




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                               ACKNOWLEDGEMENTS
This version of the Denver Metro Emergency Medical Services Medical Directors
protocols has been produced based on previous protocols produced by the following.

                   The Denver Metropolitan Physician Advisor Group
F. Keith Battan, M.D.                         Mark Kozlowski, M.D.
Christopher Colwell, M.D.                     Donald Massey, D.O.
James Cusick, M.D.                            David McArdle, M.D.
Eugene Eby, M.D.                              Gilbert Pineda, M.D.
James Hogan, M.D.                             John Riccio, M.D.
Benjamin Honigman, M.D.                       Ray Rossi, M.D.
Arthur Kanowitz, M.D.                         W. Peter Vellman, M.D.
Ron Keller, M.D.

Special thanks and recognition to:

Mike Armacost, MS, EMT-P                      Wilson Lindquist
Eric Bettinger, EMT-P                         Rick Lindsey, EMT-P
Michael Bilo, EMT-P                           Robert Marlin, EMT-P
Marilyn Bourn, RN, MSN, EMT-P                 Kathy Mayer, RN, MSN
Colleen Bruntz                                Bill Mayfield, RN
Thomas Candlin, III, EMT-P                    Ron McCuiston
Jami Mari Cavos                               Lee Meyer, B.S., EMT-P
Anne Clouatre, MHS, EMT-P                     David Patterson, EMT-P
Jim Cloud                                     Randy Pennington, EMT-P
Tracy Collins, RN                             Scott Phillips, EMT-P
Ray Coniglio, RN                              Lorna Prutzman
Brian Daley, EMT-P                            Ron Quaife, RN, EMT-P
David Day, EMT-P                              Joe Rockwell, EMT-P
Jean Distretti                                David Sanko, BA, EMT-P
Jeff Fletcher, BS, EMT-P                      Mike Shabkie, EMT-P
Douglas Frosh, BS, EMT-P                      Bill Spialek, EMT-P
John Glenn, EMT-P                             Tracy Thomas, EMT-P
Craig Gravitz, RN, EMT-P                      Thomas Tkach, EMT-P
Garet Hickman, EMT-P                          Ted Hockenberry, EMT-P
Carol Hurdelbrink, RN                         Patricia Tritt, RN, MS
Carol Jenks                                   Ted Vargas
Jacob Johnson, EMT-P                          Sam Walters
Kathee Johnson                                Danny Willcox, EMT-P
Timothy Keane, EMT-P                          Jean Zambrano, EMT-P

These protocols have been developed specifically for the Denver metropolitan
community. They represent consensus amongst all of the Denver metropolitan EMS
agency Medical Directors. The protocols express a commitment to a consistent
approach to quality patient care.




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The process that has been initiated in the construction of this revised set of metro-wide
protocols will remain in place. The authors will continue to edit and revise the protocols
    Dedicated to Carol J. Shanaberger, Esq., EMT-P. May her memory be eternal.



                              Acknowledgments
The process behind managing protocols is a daunting one in that the document is truly
living. What may be standard-of-care today could possibly be extinct as early as
tomorrow. Many people have spent hundreds of hours on protocol development and
maintenance. The following people are thanked in the first version of the Pridemark
Protocols:
                          Christina Crumpecker, EMT-Paramedic
                              Arthur Kanowitz, MD FACEP
                             Jeff Flasschoen, EMT-Paramedic

along with the Protocol Development committee:
             Tori Ainlay, EMT                          Chris Naig, EMT-Paramedic
      Bruce Amdahl, EMT-Paramedic                       Thomas F. Pedigo, PA-C
     Chantel Benish, EMT-Paramedic                     David Pace, EMT-Paramedic
    Matthew Bergland, EMT-Paramedic
        Ray Bondi, EMT-Paramedic
      Jamie Bosten, EMT-Paramedic
  Christopher Carleton, EMT-Paramedic
Alice “Twink” Dalton, RN EMT-Paramedic
             Julia Davis, EMT
    Eammonn Dolan, EMT-Paramedic
     Bryan DeWolfe, EMT-Paramedic
     Cameron Duran, EMT-Paramedic
             Sarah Duran, EMT
          Simon Edwards, PA-C
        Pam Evans, EMT-Paramedic
     David Fending, EMT-Paramedic
       Wes Filener, EMT-Paramedic
       Chris Galton, EMT-Paramedic
     Faith Goodrich, EMT-Paramedic
     Robert Greenlee, EMT-Paramedic
      Terry Halford, EMT-Paramedic
    Bryan Handwork, EMT-Paramedic
     Chris Hendricks, EMT-Paramedic
     Hollis Hopkins, EMT-Paramedic
     Megan Huffman, EMT-Paramedic
     Scott Kittredge, EMT-Paramedic
     Steve Koniezny, EMT-Paramedic
       Pam Howes, EMT-Paramedic
      Paul Johnson, EMT-Paramedic
     Brendan Kelly, EMT_Paramedic
    William H. Kraft, EMT-Paramedic
     Chris Mulberry, EMT-Paramedic
       Melissa Lunt, EMT-Paramedic



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                                   Table of Contents
   I.   Introduction
  II.   Confidentiality / HIPAA
 III.   Consent
 IV.    Physician on scene
  V.    DNR/ Advanced Directives

Protocol         Protocol Title                        Last Revision Date
Number
1000             Airway
                V.                                                     Airway




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4012            Coma
4013            Seizure
4014            Syncope
4020            Allergies & Anaphylaxis
4030            Abdominal (including GI/GU)
4031            Vomiting
4040            Poisoning & Overdose
4050            Environmental
4051            High Altitude
4052            Drowning/Near Drowning
4053            Cold Emergencies
4054            Heat Emergencies
4055            Bites & Stings/ Snake Bites
4056            Snake Bites
4060            Shock-Medical
4070            Psychiatric/ Behavioral Emergencies
4080            Obstetrics/ Gynecological Emergencies
4090            Excited Delirium

5000            Trauma
5010            Trauma Arrest
5020            Amputations
5030            Head Trauma
5040            Face & Neck Trauma
5050            Spinal Trauma
5055            Selective Spinal Immobilization
5060            Chest Injury
5070            Abdominal Trauma
5080            Extremity Injuries
5090            Burns
5100            Taser
5200            Boulder Specific Trauma Activation Criteria
SOP             Tourniquet Procedure                          Located with SOP’s

6000            General Guidelines for Pediatrics
6010            Infant and Child Resuscitation
6020            Sudden Infant Death Syndrome
6030            Pediatric Dehydration
6040            Pediatric Respiratory Distress
6050            Pediatric Seizures
7000            Pharmacology. Medication Administration
7010            Medication Administration
7020            Medication Administration (Parental)
7030            Medications
                Adenosine (Adenocard)
                Albuterol Sulfate (Proventil, Ventolin)
                Amiadorone (Cordarone)
                Aspirin
                Atropine Sulfate
                Diltiazem (Cardizem)
                Dextrose



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                Diazepam (Valium)
                Diphenhydramine (Benadryl)
                Dopamine (Intropin)
                Epinephrine (Adrenalin)
                Epinephrine Auto-Injector (Epi-pen, Epi-pen Jr.)
                Fentanyl
                Furosemide (Lasix)
                Glucagon
                Haloperidol (Haldol)
                Ipratropium Bromide (Atrovent)
                IV Solutions
                Lidocaine 2% Solution
                Lidocaine Gel (Xylocaine)
                Magnesium Sulfate
                Mark I Nerve Agent Antidote Kit
                Metered Dose Inhaler (MDI)
                Methylprednisolone (Solu-Medrol)
                Midazolam (Versed)
                Morphine Sulfate
                Naloxone (Narcan)
                Nitroglycerine (Nitrostat, Nitroquick, etc.)
                Ondansetron (Zofran)
                Oral Glucose (Glutose, Insta-Glucose)
                Oxygen
                Phenylephrine (Intranasal)
                Promethazine (Phenergan)
                Racemic Epinephrine (Vaponephrine)
                Sodium Bicarbonate
                Topical Ophthalmic Anesthetics

                Interfacility Transfer
                Formulary Protocols
                Antibiotics
                Heparin Drip
                Nitro Drip
8000            System Specific Medical Procedures &
                Operations Guidelines

Procedures      Bandaging
Procedures      Capnography
Procedures      Cardioversion
Procedures      Combination Analgesia
Procedures      Continuous Positive Airway Pressure (CPAP)
Procedures      Field Drawn Blood Samples
Procedures      Blood Draw for Law Enforcement
Procedures      Percutaneous Cricothyrotomy
Procedures      Pneumatic Anti-Shock Garment (PASG)
Procedures      Restraints
Procedures      Splinting: Axial
Procedures      Splinting: Extremity
Procedures      Tension Pneumothorax: Needle Decompression



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Procedures     Transcutaneous Cardiac Pacing
Procedures     Transport of the Handcuffed Patient
Procedures     Vascular Access Devices
Procedures     Venous Access Technique-General Principle
Procedures     Venous Access Technique-Saline Lock
Procedures     Vascular Access Technique-External Jugular
               Vein
Procedures     Venous Access Technique-Extremity
Procedures     Venous Access Technique-Intraosseous
               Infusion
Assessment     Assessment/ MOI
Assessment     History
Assessment     Documentation
Assessment     Commonly Accepted Abbreviations
Operations     Combined Advanced Directives
Operations     Communication
Operations     Destination Policy
Operation      Destination Policy: Divert
Operations     Incident Command System
Operations     START Triage
Operations     Hazardous Materials / WMD
Operations     Infectious Diseases
Operations     Non-Transport of Patients
Operations     Non-Transport of Patients: Refusals
Operations     Non-Transport of Patients: Field
               Pronouncements
Miscellaneous Lab Values
Miscellaneous 12-Lead EKG Landmarks & Infarct Patterns
9000          Pridemark Paramedic Services
              Clinical SOP’s
SOP            BLS Transport
SOP            Certification Requirement
SOP            QA/QI Guidelines
SOP            Protocol Violations
SOP            Narcotic Storage and Administration
SOP            FI Process
SOP            Paramedic School Sponsorship
SOP            Firefighter or Emergency Event Rehab
SOP            Pridemark TB Screening Policy/Procedure
SOP            Disposition of ETOH Patients




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                                    INTRODUCTION

The following PROTOCOLS define the rules of medical care by EMS Providers. These
protocols delineate the expected practice, actions and procedures of EMS providers in
the field. They have been developed in conjunction with and are sanctioned by the
Denver Metro EMS Medical Directors (DMEMSMD). Deviation from the protocols is
occasionally necessary due to the vast array of complex clinical presentations. It should
always be done with the patient’s best interest in mind and backed with documentable
and defendable clinical reasoning and judgment.

When protocol variance occurs it should be approached in a logical and knowledgeable
manner, done in the best interests of the patient, and well documented. In essence it
should be done “in good faith.” Deviation from standing order protocols should be done
with the support of online medical control and/or reported to the agency’s Medical
Director for offline medical control and review.

The prehospital protocols are categorized in accordance with the National Standard
curriculum and further broken down by sub-categories within a section.

Advanced procedures are those techniques that require physician direction in teaching,
skill maintenance, and use. Some procedures are suitable for a standing order while
others are categorized as a direct order that requires base contact. A number of
treatment, medication, procedure, and operational guidelines protocols require base
contact for specific circumstances. A list of protocols that require base contact can be
found in the appendix.

Please remember that protocols define process; people provide care.

PROTOCOL KEY

The following symbols denote assessments and treatments that are limited to a certain
level of prehospital provider:

                      EMT with IV certification
              IV


               P      Paramedic


                      Advanced Practice Paramedic

The following symbol denotes assessments and treatments that are specific to
prehospital pediatric care.

                      Pediatric Care




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                                     CONFIDENTIALITY
   A. The patient-physician relationship, the patient-registered nurse relationship, and
      the patient-EMT relationship are recognized as privileged. This means that the
      physician, nurse, or EMT may not testify as to confidential communications
      unless:
      • the patient consents or
      • the disclosure is allowable by law (such as Medical Board or Nursing Board
          proceedings, or civil litigation in which the patient's medical condition is in
          issue)
   B. The patient's medical information must be kept confidential by the prehospital
      provider as private information in medical care. The patient likely has an
      expectation of privacy and trusts that personal, medical information will not be
      disclosed by medical personnel to any person not directly involved in the patient's
      medical treatment.
   Exceptions
   A. The patient is not entitled to confidentiality of information that does not pertain to
      the medical treatment, medical condition, or is unnecessary for diagnosis or
      treatment.
   B. The patient is not entitled to confidentiality for disclosures made publicly.
   C. The patient is not entitled to confidentiality with regard to evidence of a crime.
   Additional Considerations
   A. Any disclosure of medical information should not be made or allowed unless
      necessary for the treatment, evaluation or diagnosis of the patient.
   B. Any disclosures made by any person, medical personnel, the patient, or law
      enforcement should be treated as limited disclosures and not authorizing further
      disclosures to any other person.
   C. Any discussions of prehospital care by and between the receiving hospital, the
      crew members in attendance, or at in-services or audits are done strictly for
      educational purposes. Further disclosures are not authorized.
   D. Radio communications should not include disclosure of patient names.
   E. This procedure does not preclude or supersede your agency’s HIPAA policy and
      procedures.




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                                       CONSENT
   General Principles: Adults
   A. An adult in the State of Colorado is 18 years of age or older.
   B. Every adult is presumed capable of making medical treatment decisions. This
      includes the right to make "bad" decisions that the prehospital provider believes
      are not in the best interests of the patient.
   C. A person is deemed to have decision-making capacity if he/she has the ability to
      provide informed consent, i.e., the patient:
           1. Understands the nature of the illness/injury or risk of injury/illness;
           2. Understands the possible consequences of delaying treatment/refusing
               transport; and
           3. Given the risks and options, the patient voluntarily refuses or accepts
               treatment/transport.
   D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient
      may refuse medical treatment (IVs, oxygen, medications), but you should try to
      inform the patient of the need for therapies, offer again, and treat to the extent
      possible.
   E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient
      from refusing treatment. Refer to letter C above.
   F. Implied Consent: An unconscious adult is presumed to consent to treatment for
      life-threatening injuries/illnesses.
   G. Involuntary Consent: In rare circumstances, consent may be authorized by a
      person other than the patient (such as a court order [guardianship], from a peace
      officer for prisoners in custody or detention, and persons under a mental health
      hold or commitment who are a danger to themselves or others or are gravely
      disabled).
   Procedure: Adults
   A. Consent may be inferred by the patient's actions or by express statements. If
      you are not sure that you have consent, clarify with the patient or CONTACT
      BASE. This may include consent for treatment decisions or transport/destination
      decisions.
   B. Determining whether or not a patient has decision-making capacity to consent or
      refuse medical treatment in the prehospital setting can be very difficult. Every
      effort should be made to determine if the patient has decision-making capacity,
      as defined above under C.
   C. For patients who do not have decision-making capacity, CONTACT BASE.
   D. If the patient lacks decision-making capacity and the patient's life or health is in
      danger, and there is no reasonable ability to obtain the patient's consent,
      proceed with transport and treatment of life-threatening injuries/illnesses. If you
      are not sure how to proceed, CONTACT BASE.
   E. For patients who refuse medical treatment.
   F. If you are unsure whether or not a situation of involuntary consent applies,
      CONTACT BASE.




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   General Principles: Minors
   A. A parent, including a parent who is a minor, may consent to medical or
      emergency treatment of his/her child. There are exceptions:
          1. Neither the child nor the parent may refuse medical treatment on religious
              grounds if the child is in imminent danger as a result of not receiving
              medical treatment, or when the child is in a life-threatening situation, or
              when the condition will result in serious handicap or disability.
          2. The consent of a parent is not necessary to authorize hospital or
              emergency health care when an EMT-P in good faith relies on a minor's
              consent, if the minor is at least 15 years of age and emancipated or
              married.
          3. Minors may seek treatment for abortion, drug addiction, and venereal
              disease without consent of parents. Minors > 15 years may seek
              treatment for mental health.
   B. When in doubt, your actions should be guided by what is in the minor's best
      interests and base contact.
   Procedure: Minors
   A. A parent or legal guardian may provide consent to or refuse treatment in a non-
      life-threatening situation.
   B. When the parent is not present to consent or refuse:
           1. If a minor has an injury or illness, but not a life-threatening medical
               emergency, you should attempt to contact the parent(s) or legal guardian.
               If this cannot be done promptly, transport.
           2. If the child does not need transport, they can be left at the scene in the
               custody of a responsible adult (e.g., teacher, social worker, grandparent).
               It should only be in very rare circumstances that a child of any age be left
               at the scene if the parent is not also present.
           3. If the minor has a life-threatening injury or illness, transport and treat per
               protocols. If the parent objects to treatment, CONTACT BASE
               immediately and treat to the extent allowable, and notify police to respond
               and assist.




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                   PHYSICIAN AT THE SCENE/MEDICAL DIRECTION
   Purpose
   A. To provide guidelines for prehospital personnel who encounter a physician at the
      scene of an emergency
   General Principles
   A. The prehospital provider has a duty to respond to an emergency, initiate
      treatment, and conduct an assessment of the patient to the extent possible.
   B. A physician who voluntarily offers or renders medical assistance at an
      emergency scene is generally considered a "Good Samaritan." However, once a
      physician initiates treatment, he/she may feel a physician-patient relationship has
      been established.
   C. Good patient care should be the focus of any interaction between prehospital
      care providers and the physician.
   Procedure
   See algorithm.
   Special notes
   A. Every situation may be different, based on the physician, the scene, and the
      condition of the patient.
   B. CONTACT BASE when any question(s) arise.

               NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMTs

THANK YOU FOR OFFERING YOUR ASSISTANCE.

The prehospital personnel at the scene of this emergency operate under standard
policies, procedures, and protocols developed by their physician advisor. The drugs
carried and procedures allowed are restricted by law and written protocols.

After identifying yourself by name as a physician licensed in the State of Colorado and
providing identification, you may be asked to assist in one of the following manners:

   1. Offer your assistance or suggestions, but the prehospital care providers will
      remain under the medical control of their base physician or
   2. With the assistance of the prehospital care providers, talk directly to the base
      physician and offer to direct patient care and accompany the patient to the
      receiving hospital. Prehospital care providers are required to obtain an order
      directly from the base physician for this to occur.

  THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.


Medical Director                            Agency




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             PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM

                       EMT arrives on scene




                     EMS attempts patient care




 Physician reports on patient.        Physician wants to help or is
  Relinquishes patient care.          involved in patient care and will
                                      not relinquish patient care




  Provide care per protocol            Prehospital provider identifies
                                          self and level of training




                 Physician wishes to just help                                  Physician requests or performs
                             out                                                     care inappropriate or
                                                                                  inconsistent with protocols




                 Provide general instructions                                    Prehospital care provider shares
                and utilize physician assistance                                 Physician at the Scene/Medical
                                                                                  Direction note with physician.
                                                                                    Advise physician of your
                                                                                     responsibility to patient




                                                              Physician does not relinquish                Physician complies
                                                               patient and continues care
                                                               inconsistent with protocols




                                                                 Contact base physician             Continue per patient protocol




                                                                 Follow base physician’s
                                                                        direction



                           Document patient care on run report.
           Document difficulties or problems on the unusual circumstance report.




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          RESUSCITATION AND FIELD PRONOUNCEMENT GUIDELINES
   Purpose
   A. To provide guidelines for resuscitation and field pronouncement of patients in
      cardiac arrest in the prehospital setting
   General Principles
   A. Agency policy determines base contact requirements for patients for whom
      resuscitative efforts are being withheld.
   B. All patients found pulseless and apneic are to be resuscitated, except patients
      found in any of the following conditions:
      1. Decapitation or
      2. Decomposition or
      3. Third degree burns over more than 90% of the total body surface area or
      4. Dependent lividity or rigor mortis or
      5. A valid CPR directive present with the patient or
      6. Evidence of massive blunt head, chest, or abdominal trauma
   Special Considerations in Resuscitation Decisions:
   A. All cases described below require contact with a base physician to approve
      termination of treatment.
      1. Blunt Trauma: Resuscitative efforts may be withheld or terminated in patients
          found apneic and pulseless with:
              a. Blunt trauma to the head, neck or torso; and
              b. No spontaneous pulse or respirations following appropriate medical
                 interventions, which include, for example: ensuring a patent airway or
                 chest decompression. (The majority of injuries sustained by these
                 patients are not compatible with life. "Appropriate" interventions will
                 vary and should be dictated by guidance from the base.)
      2. Penetrating Trauma:
              a. Research data shows that a significant number of victims of
                 penetrating trauma to the neck or torso, who are found without signs
                 of life, may be successfully resuscitated. Therefore, resuscitation and
                 rapid transport to a trauma facility should be initiated on all patients
                 found in full arrest secondary to penetrating trauma. Exceptions may
                 exist in the following circumstance:
                        i. Patients found pulseless and apneic with penetrating trauma if
                           the provision of ALS (EMT-Intermediate or EMT-Paramedic or
                           emergency department) has been unavailable for at least 10
                           minutes from the time EMS personnel initiate on-scene
                           assessment. (Some of the injuries sustained by these patients
                           may be compatible with life. "Appropriate" interventions will
                           vary and should be dictated by guidance from the base
                           physician.)
                       ii. However, if there is any doubt about duration of the arrest,
                           then resuscitation and rapid transport should be initiated.
      3. Medical Patients (i.e., no evidence of trauma and presumed medical arrest)
          should receive resuscitative treatment until there is:




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               a. No return of spontaneous pulse or respirations during 15 minutes of
                   CPR (after successful intubation and medications) and no reversible
                   causes have been identified; or
               b. Continuous asystole for at least 10 minutes in the adult patient, and
                   30 minutes in a pediatric patient (after successful intubation and
                   medications), and no reversible causes have been identified
               c. The following patients found pulseless and apneic warrant
                   resuscitation efforts beyond 30 minutes and should be transported:
                        i. Hypothermic; or
                       ii. Drowning with submersion less than 60 minutes (with
                           hypothermia); or
                      iii. Pregnant and estimated to be 20 weeks or later in gestation
       4. After pronouncement, do not alter condition in any way or remove equipment
          (lines, tubes, etc.) as the patient is now a potential coroner’s case.
   Advance Medical Directives
   A. There are several types of advance medical directives (documents in which a
      patient identifies the treatment to be withheld in the event the patient is unable to
      communicate or participate in medical treatment decisions).
   B. Do not resuscitate (DNR) orders are generally intended to be written by a
      physician for a patient whose medical condition is such that commencement of
      resuscitation efforts would be futile.
   C. A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires
      a patient to have a terminal condition, as certified in the patient's hospital chart by
      two physicians. For the document to become operative, the patient must be
      unresponsive because of a terminal condition for a period of seven days.
   D. Other types of advance directives may be a "Durable Medical Power of Attorney,"
      or "Health Care Proxy" (the CPR Directive is covered separately. Each of these
      documents can be very complex and require careful review and verification of
      validity and application to the patient's existing circumstances. Therefore, the
      consensus is that resuscitation should be initiated until a physician can review
      the document or field personnel can discuss the patient’s situation with the base
      physician.
   E. Resuscitation may be withheld from or terminated for a patient who has a valid,
      written do not resuscitate order or other advance medical directive.
      1. The document is clear, unequivocally to the prehospital provider that CPR,
           intubation and defibrillation are refused by the patient or by the patient's
           attending physician who has signed the document; and
      2. Base physician has approved of withholding or ceasing resuscitative efforts;
           and
      3. There is no apparent indication of suicidal gesture or intent by the patient.
   F. If there is disagreement at the scene about what should be done, the base
      should be contacted immediately for guidance.
   G. Prehospital providers presented with equivocal DNR orders or advance medical
      directives should proceed with resuscitation and establish base contact for
      guidance on treatment and transport.
      1. If the directive document is long and detailed, then it is probably more
           reasonable for resuscitation to be initiated and the patient to be transported
           so that the base physician can review the document and possibly contact the
           patient's attending physician.



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      2. The duration of the resuscitation should be guided by the same factors of any
          medical cardiac arrest.
   H. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the
      event family or an attending physician directs resuscitation be ceased, the
      prehospital provider should immediately CONTACT BASE. The prehospital
      provider should accept verbal orders to cease resuscitation only from the base
      physician.
   I. There may be times in which the prehospital provider feels compelled to perform
      or continue resuscitation, such as a hostile scene environment, family members
      adamant that "everything be done," or other highly emotional or volatile
      situations. In such circumstances, the prehospital provider should attempt to
      confer with the base for direction and if this is not possible, the prehospital
      provider must use his or her best judgment in deciding what is reasonable and
      appropriate, including transport, based on the clinical and environmental
      conditions, and establish base contact as soon as possible.

   Additional Considerations:
   A. Mass casualty incidents are not covered in detail by these guidelines. (See
      Colorado State Unified Disaster Tag and Triage System: A Guide to MCI).
   B. These guidelines apply to both adult and pediatric patients.
   C. If the situation appears to be a potential crime scene, EMS providers should
      disturb the scene as little as possible.
   D. ALS personnel should document asystole for 10 seconds in at least two leads
      prior to withholding or terminating resuscitative efforts. However, base
      physicians and prehospital providers must use discretion when considering the
      need for a rhythm strip (i.e., monitor strips are not necessary in patients found
      decapitated, decomposed or with dependent lividity or rigor mortis).
   E. Mechanism for disposition of bodies by means other than EMS providers and
      vehicles should be prospectively established in each county or locale.
      1. In all cases of unattended deaths occurring outside of a medical facility, the
           coroner should be contacted immediately.
      2. Patients with valid DNR orders or advance medical directives should receive
           medical treatment and supportive or comfort care prior to cardiac arrest.




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                                         1000
                                 AIRWAY & VENTILATION
                                  GENERAL PRINCIPLES

The following protocols are recommended as a guide for approaching difficult medical
and trauma airway problems. They assume that the responder is skilled in the various
procedures, and will need to be modified according to training level. Advanced
procedures should only be attempted if simpler ones fail and if the technician is qualified.
Individual cases may require modification of these protocols.

All patients require continuous monitoring of their airways to ensure airway patency.
Wherever the term "Monitor airway" is used throughout these protocols, the following
elements shall be utilized:
    • Position of the patient's head
    • Need for airway adjuncts
    • Need for oropharyngeal suctioning;
    • Need for Advanced Life Support airway management techniques
    • Use of Pulse Oximetry (SpO2), if available
    • Use of secondary form of Endotracheal Tube confirmation (Example: End Tidal
        Capnography (ETCO2). Secondary confirmation devices are not a substitute for
        primary confirmation techniques that rely upon direct visualization and
        auscultation, but serve as an additional method of documenting proper
        endotracheal tube placement.


   Definitions
Respiratory distress – Signs and symptoms may include increased respiratory effort,
peripheral cyanosis, tachypnea, accessory muscle use, anxiety and adventitious lung
sounds upon auscultation.

Respiratory insufficiency/failure – signs and symptoms include the above with central
cyanosis and insufficient air exchange, tiring, and inability to speak in complete
sentences.

Pediatric respiratory distress is characterized by increased respiratory effort with
peripheral cyanosis, i.e. anxiety, tachypnea, nasal flaring and intercostal retractions.

Respiratory failure in a child is characterized by ineffective respiratory effort with central
cyanosis, i.e. agitation or lethargy, severe dyspnea or labored breathing, bobbing or
grunting, and marked intercostal and parasternal retractions.

Use appropriate airway adjuncts as indicated – These are devices that are approved for
the level of the provider and by the agency’s Medical Director.

NOTE: Bradycardia is an ominous sign that indicates hypoxic cardiac arrest may be
imminent




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METHODS OF OPENING THE AIRWAY

HEAD TILT-CHIN LIFT:
Technique: From beside head, place one hand on forehead. Grasp lower edge of
             chin with fingers of other hand and lift chin forward. Teeth may come
             together.
Indications: Medical patient. May require less neck extension than head tilt. Useful
             with dentures. May be used without head tilt in trauma victims.

JAW THRUST:
Technique: Position yourself above patient. Place fingers of each hand under angle
             of jaw, just below ears. Lift jaw, using forearms to maintain head
             alignment.
Indications: Trauma victim or medical patient, where neck extension is not possible.
             Another rescuer must do BVM ventilation, and this is a fatiguing method.
             May be used with dentures in place.

Providers are reminded that aggressive treatment is indicated for better outcomes.




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                                            1010
                                      OBSTRUCTED AIRWAY
         Indications
         A. Complete or partial obstruction of the airway due to a foreign body.
         B. Complete or partial obstruction due to airway swelling from anaphylaxis, croup,
            or epiglottitis.
         C. Patient with unknown illness or injury who cannot be ventilated after procedures
            of previous protocol: Opening the Airway.
         Precautions
         A. Perform chest thrusts only in visibly pregnant patients, obese patients, and in
            infants.
         B. Patients with partial airway obstruction can be very uncomfortable and
            vociferous. Abdominal or chest thrusts will not be effective and may cause injury
            to the patient who is still breathing. Be ready to intervene promptly if arrest
            occurs.
         C. Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts
            may not be effective until the patient becomes relaxed after the seizure is over.

         Technique
         A. COMPLETE AIRWAY OBSTRUCTION:
            1. Open airway using head tilt-chin lift or jaw thrust.
            2. Attempt to ventilate using BVM ventilations or mouth to mask.
            3. If unable to ventilate, reposition airway and reattempt ventilations.

            4. If airway remains obstructed, visualize with laryngoscope and remove any
IN
               obvious foreign body.

            5. If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts.
            6. Reposition the airway and reattempt to ventilate.

            7. Consider percutaneous cricothyrotomy if obstruction is above the cords
P              unrelieved or unusable to ventilate adequately with bag-valve. See Appendix
               for more information.

            8. When obstruction is relieved:
                 a. Keep patient on side, sweeping airway to remove debris.
                 b. Administer high flow oxygen via reservoir mask.
                 c. Assess adequacy of ventilation, and support as needed.
                 d. Suction aggressively.
                 e. Restrain if combative
     .
         B. PARTIAL AIRWAY OBSTRUCTION:
            1. Have patient assume most comfortable position.
            2. Administer high flow oxygen by non-rebreather mask.
            3. Attempt suctioning of upper airway.
            4. If patient is unable to move air, confused, or otherwise deteriorating, visualize
               airway, remove foreign body or perform abdominal thrusts as noted above.



     Go to Table of Contents
   Complications
   A. Hypoxic brain damage and death from unrecognized or unrelieved obstruction.
   B. Trauma to ribs, lung, liver and spleen from chest or abdominal thrusts
      (particularly when forces are not evenly distributed).
   C. Vomiting and aspiration after relief of obstruction.
   D. Creation of complete obstruction after blind incorrect finger probing.
   E. Tonsillar or pharyngeal laceration from over vigorous finger sweep.




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                                        1020
                         CLEARING AND SUCTIONING THE AIRWAY
        Indications
        A. To remove foreign material that can be removed by a suction device.
        B. To remove excess secretions or pulmonary edema fluid in upper airway or lungs
           (with endotracheal tube in place).
        C. To remove meconium or amniotic fluid in mouth, nose and oropharynx of
           newborn
        Technique
        A. Turn patient on side if possible, to facilitate clearance.
        B. Open airway and inspect for visible foreign material.
        C. Remove large or obvious foreign matter with gloved hands. Use padded tongue
           blade or oropharyngeal airway (do not pry) to keep airway open. Sweep finger
           across posterior pharynx and clear material out of mouth.
        D. Suction of oropharynx:
           1. Attach tonsil tip (or use open end for large amounts of debris).
           2. Ventilate and oxygenate the patient as needed prior to the procedure.
           3. Insert tip into oropharynx under direct vision, with sweeping motion.
           4. Continue intermittent suction interspersed with active oxygenation by mask or
               cannula. Use positive pressure ventilation if needed.

        E. Catheter suction of endotracheal tube:
IN         1. Hyperventilate patient prior to any suctioning attempts.
           2. Put on sterile gloves.
           3. When catheter tip has been gently advanced as far as possible, apply suction
              and withdraw catheter slowly.
              NOTE: Suctioning should only done with a sterile catheter.
           4. Rinse catheter tip in sterile water or saline.
           5. Administer oxygen appropriately following suctioning.

        F. Suction of the newborn:
           1. Use neonatal suctioning device.
           2. As soon as infant's head has delivered, insert suction tip into the mouth and
              back to oropharynx.
           3. Apply suction while slowly withdrawing catheter from the mouth.
           4. Insert catheter tip into each nostril and back to posterior pharynx.
           5. Apply suction while slowly withdrawing catheter from each nostril.
           6. As soon as infant has delivered, repeat process.

IN      G. Suction trachea under direct vision with laryngoscope if there is evidence of
           meconium aspiration.
        Complications
        A. Hypoxia due to excessive suctioning time without adequate ventilation between
           attempts.
        B. Persistent obstruction due to inadequate tubing size for removal of debris.
        C. Lung injury from aspiration of stomach contents due to inadequate suctioning.
        D. Asphyxia due to recurrent obstruction if airway is not monitored after initial
           suctioning.
        E. Conversion of partial to complete obstruction by attempts at airway clearance.
        F. Trauma to the posterior pharynx from forced use of equipment.


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   G. Vomiting and aspiration from stimulation of gag reflex.
   H. Induction of cardio-respiratory arrest from Vagal Nerve stimulation.
   Side Effects and Special Notes
   A. Complications may be caused both by inadequate and overly vigorous
      suctioning. Technique and choice of equipment are very important. Choose
      equipment with enough power to suction large amounts rapidly to allow time for
      ventilation.
   B. Proper airway clearance can make the difference between a patient who survives
      and one who dies. Airway obstruction is one of the most common treatable
      causes of prehospital death.




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                                       1030
                              ASSISTING VENTILATION
   Indications
   A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory
      depression.
   B. To apply positive pressure ventilation in patients with pulmonary edema and
      severe fatigue.
   C. To ventilate patients in respiratory arrest.
   Precautions
   A. Two people are often required to obtain an adequate mask fit and also ventilate.
   B. Assisted ventilation will not hurt a patient, and should be used whenever the
      breathing pattern seems shallow, slow, or otherwise abnormal. Do not be afraid
      to be aggressive about assisting ventilation, even in patients who do not require
      or will not tolerate intubation.
   C. Early intubation may be of benefit for patients who continue to bleed or vomit.
   Technique
   A. Open the airway. Check for ventilation.
   B. Administer ventilations. If unsuccessful, go to Airway Obstruction protocol.
   C. Check pulse. If absent, go to Cardiac Arrest protocol.
   D. Attach oxygen to BVM.
   E. Position yourself above patient's head, continue to hold airway position, seat
      mask firmly on face, and begin assisted ventilation.
   F. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust
      mask fit as needed.
   G. If patient resumes spontaneous respirations, continue to administer supplemental
      oxygen. Intermittent assistance with ventilation may still be needed.
   H. Continuous monitoring of pulse oximetry is required.
   I. Use Capnography, if available.
   Complications
   A. Continued aspiration of blood, vomitus, and other upper airway debris
   B. Inadequate ventilations due to poor seal between patient's mouth and ventilatory
      device
   C. Gastric distention, possibly causing vomiting
   D. Trauma to the upper airway from forcible use of airways
   E. Pneumothorax




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                                           1040
IN   P                             OROTRACHEAL INTUBATION
         Indications
         A. In most cases orotracheal intubation provides definitive control of the airway. Its
            purposes include:
            1. Actively ventilating the patient
            2. Delivering high concentrations of oxygen
            3. Suctioning secretions and maintaining airway patency
            4. Preventing aspiration of gastric contents, upper airway secretions, or
                bleeding
            5. Preventing gastric distention due to assisted ventilation
            6. Administering positive pressure when extra fluid is present in alveoli
            7. Allowing more effective CPR
            8. Administering drugs during resuscitation for absorption through the lungs as a
                last resort.
         Precautions
         A. Do not use intubation as the initial method of managing the airway in an arrest.
            Oxygenation prior to intubation should be accomplished with pocket mask or
            BVM as needed.
         B. Appropriate intubation precautions should be taken in the trauma patient.
            Nasotracheal intubation is preferred in the breathing patient. Oral intubation with
            in-line cervical immobilization is the best alternative for a trauma patient requiring
            definitive airway control.
         C. Never lever the laryngoscope against the teeth. The jaw should be lifted with
            direct upward traction by the laryngoscope.
         D. Prepare suction beforehand. Vomiting is particularly common when the
            esophagus is intubated.
         E. Intubation should take no more than 20 seconds to complete: do not lose track
            of time. If visualization is difficult, stop and re-ventilate before trying again.
         F. Orotracheal intubation can be accomplished in trauma victims if an assistant
            maintains stabilization and keeps the neck in neutral position. Careful
            visualization with the laryngoscope is needed, and McGill forceps may be helpful
            in guiding the ET tube.
         G. If the patient presents with a difficult airway or difficulties are expected then use
            of OTHER AIRWAY DEVICES may be preferable to intubation.
         Technique
         A. Use BSI including gloves, mask, eye protection. Assemble the equipment while
            continuing ventilation:
            1. Choose tube size (see table on next page). Use the largest tube available.
            2. Introduce the stylette and be sure it stops ½” short of the tube’s end.
            3. Assemble laryngoscope and check light.
            4. Connect and check suction.
         B. Position patient: neck flexed forward, head extended back. Back of head should
            be level with or higher than back of shoulders.
         C. Give a minimum of 4 good ventilations before starting procedure.
         D. Have an assistant apply gentle cricothyroid pressure to prevent aspiration and to
            assist in visualization of vocal cords.
         E. Gently insert laryngoscope to right of midline. Move it to midline, pushing tongue
            to left and out of view.


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   F. Lift straight up on blade (no levering) to expose posterior pharynx.
   G. Identify epiglottis: tip of curved blade should sit in vallecula (in front of epiglottis);
      straight blade should slip over epiglottis.
   H. With gentle further traction to straighten the airway, identify trachea from
      arytenoid cartilages and vocal cords.
   I. Insert tube from right side of mouth, along blade into trachea under direct vision.
   J. Advance tube so cuff is 1-1½" beyond cords. Inflate cuff with 5-10 ml of air,
      clamp if necessary to secure against leaks.
   K. Ventilate and watch for chest rise. Listen for breath sounds over stomach
      (should not be heard), lungs and axillae.
   L. Note proper tube position and secure tube with tape or ties.
   M. Re-auscultate over stomach and both sides of chest whenever patient is moved.
   N. End tidal CO2 colormetric devices can be used for initial tube confirmation
      however, IT IS REQUIRED TO CONFIRM TUBE PLACEMENT WITH
      CAPNOGRAPHY.
   See Protocol: Capnography
   O. Accurate documentation includes indications for intubation as well as measures
      taken for tube verification.
   P. If patient is in cardiac arrest for medical reasons then use of a ResQPod device
      is required.
   Complications
   A. Esophageal intubation: particularly common when tube not visualized as it
      passes through cords. The greatest danger is in not recognizing the error.
      Auscultation over stomach during trial ventilations should reveal air gurgling
      through gastric contents with esophageal placement. Also make sure patient's
      color improves as it should when ventilating.
   B. Intubation of right main stem bronchus: be sure to listen to chest bilaterally.
   C. Upper airway trauma due to excess force with laryngoscope or to traumatic tube
      placement
   D. Vomiting and aspiration during traumatic intubation or intubation of patient with
      intact gag reflex
   E. Hypoxia due to prolonged intubation attempt
   F. Cervical spine fracture in patients with arthritis and poor cervical mobility
   G. Cervical cord damage in trauma victims with unrecognized spine injury
   H. Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of
      airway
   I. Induction of pneumothorax, either from traumatic insertion, forceful bagging, or
      aggravation of underlying pneumothorax




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         OROTRACHEAL TUBE SIZE
              AGE           ENDOTRACHEAL TUBE
              Preemie       2.5 - 3.0 uncuffed
              Newborn       3.0-3.5 uncuffed
              6 mos.        3.5 uncuffed
              18 mos.       4.0 uncuffed
              3 yrs.        4.5 uncuffed
              5 yrs.        5.0 uncuffed
              8 yrs.        6.0 cuffed
              15 yrs.       6.5-7.0 cuffed
              Adult         7.0-9.0 cuffed

 Note: The pediatric Broselow™ tape is the most accurate predictor of tube
 size.




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                                         1050
P                               NASOTRACHEAL INTUBATION
       Indications
       A. Same function as orotracheal intubation in patients greater than 12 years of age
       B. Used in the breathing patient requiring intubation
       C. Asthma or pulmonary edema with respiratory failure, where intubation may need
          to be achieved in a sitting position
       Precautions
       A. Head must be exactly in midline for successful intubation.
       B. Have suction ready. Vomiting can occur, as with any stimulation of the airway.
       C. Often nares are asymmetrical and one side is much easier to intubate. Avoid
          inducing bilateral nasal hemorrhage by forcing a nasotracheal tube on multiple
          attempts.
       D. The use of nasotracheal intubation should be discouraged in patients with
          significant nasal or craniofacial trauma.
       E. Blind nasotracheal intubation is a very gentle technique. In the field, the secret of
          blind intubation is perfect positioning and patience.
       F. Only absolute contraindication is apnea

       G. Should not be attempted in children under 12 years of age
       Technique
       A. Choose correct ET tube size (usually 7 mm tube in adult). Limitation is nasal
          canal diameter.
       B. Position patient with head in midline, neutral position (cervical collar may be in
          place, or assistant may provide cervical stabilization in trauma patients).
       C. Administer Phenylephrine nasal drops, 1 – 2 gtts, in both nostrils.
       D. Assist ventilations prior to procedure if spontaneous respirations are inadequate.
       E. Lubricate ET tube with Xylocaine jelly or other water-soluble lubricant.
       F. With gentle steady pressure, advance the tube through the nose to the posterior
          pharynx. Use right or largest nostril. Abandon procedure if significant resistance
          is encountered.
       G. Keeping the curve of the tube exactly in midline, continue advancing slowly.
       H. There will be a slight resistance just before entering trachea. Wait for an
          inspiratory effort before final advance into trachea. Patient may also cough or
          buck just before breath.
       I. Continue advancing until air is exchanging through the tube.
       J. Advance about 1 inch further, then inflate cuff.
       K. Ventilate and auscultate chest and abdomen for proper tube placement.
       L. Note proper tube position and tape securely.
       M. Apply Capnography for continuous end tidal CO2 monitoring
       Complications
       A. Same as orotracheal intubation. In addition:
          1. Further craniofacial injury particularly in patients presenting with facial trauma
          2. Nasal bleeding caused by tube trauma.
          3. Vomiting and aspiration in the patient with intact gag reflex.




    Go to Table of Contents
                                            1060
                                 END-TIDAL CO2 MONITORING
IN   P
         Indications
         A. All intubated patients require continuous end-tidal CO2 monitoring device and
            although end-tidal colorimetric devices can be used for initial confirmation,
            Capnography must still be used. Colorimetric devices are not standard of
            care for prolonged monitoring of intubated patients.
         B. Continuous end-tidal CO2 monitors are to be used to monitor patients requiring a
            mechanical ventilator during transportation. The monitor is used to determine if
            an endotracheal tube has become displaced or to detect the disruption of the
            ventilator circuit.
         See Protocol: Capnography
         Precautions
         A. Caution should be exercised to ensure that the clinical picture matches the
            colorimetric end-tidal CO2 detector reading.
         Technique - Colorimetric End-tidal CO2 Detectors
         A. The colorimetric end-tidal CO2 detector should be placed in-line between the
            endotracheal tube and the BVM immediately after the endotracheal tube is
            passed.
         B. Proper tube placement is confirmed by a color change in the colorimetric device,
            indicating the elevated concentrations of CO2 expected in the trachea. Elevated
            concentrations of CO2 are not expected in the esophagus.
         Complications
         A. Contamination with blood and secretions may render colorimetric end-tidal CO2
            detectors ineffective.
         B. Device may be ineffective or inaccurate in patients without spontaneous
            circulation.
         Note
         A. Adhere to the expiration dates on these devices.
         B. Follow manufacturers instructions for appropriate ranges and color indications.




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                                         1070
                              PERCUTANEOUS CRICOTHYROTOMY
P
       Introduction
       A. Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be
          used only in extraordinary circumstances as defined below. The reason for
          performing this procedure must be documented and submitted for review to the
          physician advisor or designee within 24 hours. Percutaneous cricothyrotomy is
          to be performed only by paramedics trained in the procedure.
       Indications
       A. When a life threatening condition exists and advanced airway management is
          indicated, and you are unable to establish airway by other means.
       Precautions
       A. Bleeding is possible, even with correct technique. Straying from the midline is
          very dangerous and likely to cause hemorrhage from the carotid or jugular
          vessels, or their branches.
       Technique
       A. Using aseptic technique (Betadine/alcohol wipes) cleanse the area.
       B. Position the patient in a supine position, with in-line spinal immobilization if
          indicated.
       C. At this time the scalpel included with the kit may be used to make a ¼ inch
          vertical incision through the skin, over the cricothyroid membrane.
       D. Using the prepackaged set, insert the needle or over-the-needle-catheter through
          the cricothyroid membrane in a caudal direction at a 45-degree angle.
       E. If using an over-the-needle-catheter, remove the syringe and needle. Otherwise
          remove the syringe.
       F. Insert the guidewire through the catheter or needle.
       G. Remove the catheter or needle over the wire.
       H. Slide the dilator and tracheostomy tube onto the wire into the neck incision.
       I. Push the dilator through the cricothyroid membrane with a twisting motion, and
          insert the tracheostomy tube into the trachea.
       J. Remove the dilator and wire, leaving the tracheostomy tube in place.
       K. Ventilate with BVM and 100% oxygen.
       L. Confirm tube placement is successful. (Chest rise and fall, breath sounds,
          secondary confirmation device). Observe for subcutaneous air, indicating
          tracheal injury or improper placement.
       M. Secure tube with ties.
       N. Transport to appropriate facility.




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                                        1080
                               OTHER AIRWAY DEVICES
Introduction
Dual lumen airway device(s) are to be used as a rescue when
endotracheal intubation is not preferable, possible and/or BLS
methods have proven unsuccessful. These devices have external
insertion depth marks, an anatomically shaped proximal cuff to seal
the nasopharynx and oropharynx, and a distal cuff to seal the
esophagus and to help minimize the possibility of gastric insufflation.
The second channel, or gastric access lumen, allows the ability to
pass a French suction catheter (18 f for adults) into the stomach.
Depending on the device, the airways may be sized or limited to
patients between 4’8” and 6 ft in height.

Indications
1. Cardiac arrest
2. Difficult airway cases where endotracheal intubation is not possible
and BLS methods are unsatisfactory or unsuccessful.
Contraindications/Precautions
      1. Responsive patients with an intact gag reflex
      2. Known esophageal disease
      3. Known ingestion of caustic substances
      4. Respiratory burns


King LT-D
   1. Choose correct size, based on patient height.
   2. Test cuff and inflation system for leaks by injecting the maximum recommended
      volume of air into the cuffs. Remove all air from both cuffs prior to insertion.
   3. Apply lubricant to the beveled distal tip and posterior aspect of the tube, taking
      care to avoid introduction of lubricant in or near the ventilatory openings.
   4. Pre-oxygenate, if possible.
   5. Position the head. The ideal head position is the "sniffing position". However, it
      may also be inserted with the head in a neutral position.
   6. With the dominant hand holding the King device at the connector. With non-
      dominant hand, hold mouth open and apply chin lift.
   7. With the device rotated laterally 45-90o such that the blue orientation line is
      touching the corner of the mouth, introduce tip into mouth and advance behind
      base of tongue.
   8. As tube tip basses under tongue, rotate tube back to midline (blue orientation line
      faces chin).
   9. Without exerting excessive force, advance tube until base of connector is aligned
      with teeth or gums.
   10. Using syringe, inflate both cuffs, using the recommended amount of air for the
       device (size 3 = 50 ml, size 4 = 70 ml, size 5 = 80 ml).
   11. Attach EtCO2 monitor to ventilation port.
   12. While gently ventilating with a BVM, withdraw until ventilation is optimized.


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   13. Attach ResQPod to ventilation port
   14. Confirm proper position by auscultation, chest movement and verification of CO2
       by EtCO2 monitor.
           a. Depth markings are provided at the proximal end of the King LT-D.
              These refer to the distance from the distal ventilatory opening. When
              properly placed, with the distal tip and cuff in the upper esophagus, and
              the ventilatory openings aligned with the opening to the larynx, the depth
              markings give an indication of the distance, in centimeters, from the vocal
              cords to the teeth.
   15. Secure King device to patient using tape or other accepted means. A bite block
       can also be used, if desired.
Complications and Special Notes
Because of the relative lack of complications and the ability to place
this airway without interruption of CPR, it should be considered a
primary airway device in cardiac arrest.
The King LT-D Airway is to be used in unconscious, apneic patients or
those unconscious patients who are spontaneously breathing but
without a gag reflex,
If the patient regains consciousness or develops a gag reflex, prepare
suction, immediately deflate all cuffs and remove the device.
Patients that do not fall within the height ranges of the device will
instead require intubation. DO NOT USE THIS DEVICE IF THE
PATIENT IS NOT OF ADEQUATE HEIGHT.




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                                       1081
                           ResQPod (Circulatory Enhancer)

The ResQPOD circulatory Enhancer provides a small but important
amount of resistance when breathing through the device. This
resistance increases blood flow back to the heart, so that on the next
chest compression, more blood is circulated out of the heart, through
the coronary arteries and the rest of the body. This device can be
used during assisted ventilation to improve circulation.
 Indications
Assisted ventilations for patients with an advanced airway during
cardiac arrest (ET tube or King Airway)
 Contraindications/Precautions
Conscious patients
Known dilated cardiomyopathy
Known pulmonary hypertension and/or aortic stenosis
Chest trauma

Technique
   1. Once the patient is endotracheally intubated, attach the EtCO2 device to the ET
      tube then attach the bottom of the ResQPOD directly to the top of the EtCO2
      device.
   2. Be sure all pieces fit as tightly together as possible, ensuring that the airway
      adjunct has not become dislodged.
   3. Attach the BVM to the top of the ResQPOD and begin ventilating, using the
      EtCO2 values to direct your rate of ventilations.

 Complications and Special Notes
The device has a timing assist light, that when switched to the "On"
position may serve as a guide to administering ventilations at a rate of
ten (10) per minute.
The ResQPOD is for single patient use only.
The ResQPOD may be used with other airway adjuncts, such as
rescue airways (King LT-D).




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                                      2000
                                 CARDIAC ARREST
                                GENERAL PRINCIPLES
   Specific Information Needed
   A. History of arrest: onset, preceding symptoms, bystander CPR, other treatment,
      duration of arrest
   B. Past history: medical/surgical history, medications, allergies
   C. Surroundings: environmental conditions, evidence of drug ingestion, trauma,
      other unusual presentations
   Document Specific Objective Findings
   A.   Absence of consciousness
   B.   Agonal or no respirations
   C.   Absence of pulse
   D.   Signs of trauma, blood loss
   E.   Skin temperature
   General Treatment Guidelines
   A. Assure unobstructed airway
   B. Request ALS assistance if not already on scene or responding.
   C. Refer to appropriate protocol
      1. Automated External Defibrillator (AED) – protocol 2010
      2. Witnessed/Unwitnessed Adult Cardiac Arrest – protocol 2020
      3. Trauma Arrest - protocol 5010
      4. Pediatric Arrest - protocol 6020
   Special Notes
   A. Survival from cardiac arrest is related to the time to BOTH BLS and ALS
      treatment. Don't forget CPR in the rush for advanced equipment. A call for back-
      up should be initiated promptly by any BLS unit. Likewise, standing order
      administration of the first steps in treatment is recommended to minimize time
      delays to ALS.
   B. Large peripheral veins (antecubital or external jugular) are preferred IV sites in
      cardiac arrest. IO access should be considered if first attempt peripheral access
      is unsuccessful. Additional lines can be started later in the arrest and IO access
      is preferred to ET drug administration.
   C. Quick-look paddles-or Combi-Pads are preferred for initial rhythm check. Be
      sure machine is set to record from whichever mode is in use.
   D. Be sure to recheck for pulselessness and unresponsiveness upon arrival, even if
      CPR is in progress. This will avoid needless and dangerous treatment of
      "collapsed" patients who are inaccurately diagnosed initially, or who have
      spontaneous return of cardiac function after an arrhythmia or vasovagal episode.
   E. After conversion to another rhythm, providers should switch to the appropriate
      protocol for continued and ongoing treatment.
   F. Good high quality CPR with minimal interruption is shown to improve survival
      more than any procedure or drug administration. Be sure it is being done
      correctly. Avoid hyperventilation.
   G. If appropriate, OTHER AIRWAY DEVICES like the King airway should be
      considered first line to avoid delay in securing the airway while minimizing
      interruptions to compressions.
   H. The ResQPod device should be used in arrest when appropriate.



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                                   2010
                     AUTOMATED EXTERNAL DEFIBRILLATOR
   Indications
   A. Patient must be unconscious, pulseless and apneic.
   Precautions
   A. A patient who is talking is not pulseless.
   B. AEDs may be utilized for pediatric arrests if pediatric-sized defibrillator pads are
      available and compatible with the machine.
   C. Do not use on trauma patients.
   D. Dry the chest well if wet.
   E. Remove any transdermal patches to avoid igniting a Nitroglycerin patch.
   F. If an airway obstruction exists, clear the airway before using AED.
   G. Protect rescuers: “Clear” the patient, use only in safe and dry environment.
   H. May not be able to use in a moving vehicle.
   Technique
   A. Follow manufacturer directions for AED operation. In absence of specific
      operational instructions, the following technique is used.
      1. Determine unresponsiveness.
      2. Open airway, check for breathing, give a breath if no respirations.
      3. Determine pulselessness.
      4. Apply AED according to manufacturer’s guidelines.
      5. Turn the AED on and follow its instructions.
      6. Assure all rescue personnel are “Clear” and not touching the patient or
          stretcher.
      7. Whenever “no shock advised” or following a delivered shock, check patient’s
          pulse. If no pulse, begin CPR and reanalyze every 2 minutes.
      8. Use appropriate airway adjuncts to secure airway. If there is a pulse, check
          breathing and assist as needed.
      9. Once the AED is applied, necessary steps should begin immediately to
          transport the patient to the hospital or rendezvous with an advanced life
          support ambulance.
      10. Shocks may be continued during transport, as long as indicated.
      11. After 2 minutes of CPR, check pulse again. If no pulse, repeat steps to
          analyze and defibrillate as long as shocks are indicated.
   Special Notes
   A. A rescuer may be shocked if one forgets to clear the area, or leans against metal
      stretcher or patient during procedure.
   B. Expired AED patches can cause arching of electricity or inadequate shock.
   C. Do not delay this procedure by performing other procedures first, such as airway
      adjuncts and IV access.
   D. In presumed hypothermic patients, institute hypothermia protocol and contact
      base.




Go to Table of Contents
                              2020
  VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA

                                                 Unwitnessed                               * Witnessed
                                          Adult (>12) Cardiac Arrest



                                        2 Minutes of Compressions (80-                V-Fib or Pulseless V-Tach
                                                   100/min)
                                               No interruptions
                                               **IV, Epi, Airway                          Defibrillate 1x at
                                                                                            Max Joules



      Asystole/PEA/NSA*                    V-Fib or Pulseless V-Tach                              ROSC


     ACLS/BCLS Algorithm                   Defibrillation x 1 Max joules                  ACLS/BCLS Algorithm



      Asystole/PEA/NSA*                    V-Fib or Pulseless V-Tach                              ROSC


     ACLS/BCLS Algorithm                Compressions 2 minutes without                    ACLS/BCLS Algorithm
                                                   pauses
                                              **IV, Epi, Airway

                                           Defibrillation x 1 Max joules


      Asystole/PEA/NSA*                    V-Fib or Pulseless V-Tach                              ROSC


     ACLS/BCLS Algorithm                Compressions 2 minutes without                    ACLS/BCLS Algorithm
                                                   pauses
                                              **IV, Epi, Airway

                                           Defibrillation x 1 Max joules



      Asystole/PEA/NSA*                    V-Fib or Pulseless V-Tach                              ROSC


     ACLS/BCLS Algorithm                ACLS/BCLS V-Fib / Pulseless V-                    ACLS/BCLS Algorithm
                                              Tach Algorithm



                   Must be medical, normothermic arrest
                   Must be from primary respiratory mechanism
                   NSA* - no shock advised on AED

                   * Witnessed by provider with defibrillator immediately available
                   ** If possible without interrupting compressions
                   ** Ventilation rate should be 8-10 per minute


Go to Table of Contents
                                      2020
                          VENTRICULAR FIBRILLATION
                     PULSELESS VENTRICULAR TACHYCARDIA
        (Continued from 2020 – Unwitnessed/Witnessed Adult Cardiac Arrest)

   1.   Administer Amiodarone 300 mg IV bolus for refractory VF/VT.
   2.   Defibrillate at maximum joule setting. (Pridemark: 360 Joules)
   3.   Consider Magnesium Sulfate, 2 gm IV bolus
   4.   Defibrillate at maximum joule setting.
   5.   Consider transport options.

Special notes
   A. Per AHA guidelines CPR should be performed immediately after each
      defibrillation attempt for two minutes prior to performing rhythm checks.
   B. Torsade de pointes is a rare and special form of ventricular-tachycardia.
      Consider treating with Magnesium sulfate.
   C. The initiation of IV or airway treatments should not delay defibrillation.
   D. After conversion from VF/VT, consider Amiodarone 150 mg IV bolus infusion
      over 10 minutes.




Return to Table of Contents
                                                2030
                                              ASYSTOLE
IN
          A.   Begin Basic Life Support measures, including CPR
          B.   Establish airway.
          C.   Establish IV/IO access
          D.   Begin cardiac monitoring. Confirm asystole in at least two leads.
          E.   Consider transcutaneous pacing.

     CB
          F. Administer epinephrine 1.0 mg, (1 ml of a 1:10,000 solution) IV bolus. If no
IN
             change, repeat every 3-5 minutes.
          G. Administer atropine 1.0 mg, IV bolus. If no change, repeat every 3-5 minutes, not
             to exceed 3.0 mg.
          H. Administer sodium bicarbonate 1.0 mEq/kg, IV bolus. This should be considered
             only in prolonged cardiac arrest situations.
          I. Contact base for transport options.


          Special notes
          A. Patients who convert from a viable rhythm into asystole should have
             transcutaneous pacing initiated immediately. However, pacing should be
             withheld from those patients who present in asystole.
          B. The effectiveness of transcutaneous pacing is directly related to the speed with
             which this therapy is initiated.
          C. When asystole is diagnosed, check the integrity of the leads and electrode
             patches and confirm this interpretation in at least two leads.

          D. In pediatric patients, after ABCs have been initiated, ventilate, consider an IV
             fluid bolus of normal saline 20 ml/kg, reassess, consider epinephrine.




     Go to Table of Contents
                                      2040
                        PULSELESS ELECTRICAL ACTIVITY (PEA)
             INITIATE SUPPORTIVE MEASURES:
IN
             - ABCs

             - CPR

             - Endotracheal intubation

             - Establish venous access


IN   CB      CONSIDER POSSIBLE CAUSES:                TREATMENT:

             Hypovolemia                              IV fluid bolus (20 ml/kg normal saline)

             Tension pneumothorax                     Chest decompression (per protocol)

             Hypoxia                                  Ensure airway patency

             Acidosis                                 Ventilation

             Cardiac tamponade                        IV fluid bolus (20 ml/kg normal saline)

             Hypothermia                              see 4063 Hypothermia protocol

             Pulmonary embolism

             Myocardial infarction

             Drug overdose

             Hyperkalemia                             Sodium bicarbonate


             EPINEPHRINE (1:10,000)
                                                      Pediatric doses: First dose: 0.01
                                                      mg/kg IV/IO/ET (0.1 ml/kg of 1:10,000
             1.0 mg IV/IO push, repeat every 3 – 5
                                                      solution); Subsequent doses: 0.01
             minutes
                                                      mg/kg, IV/IO/ET (0.1 ml/kg of
                                                      1:10,000 solution


             ATROPINE for BRADYCARDIA
             1.0 mg IV/IO push, repeat every 3-5      Pediatric dose: refer to Length Based
             minutes, not to exceed 3.0 mg            Measurement tool

             INITIATE TRANSPORT
     Special notes
        A. Standing orders should expedite care - not prolong scene time. Rapid transport
           is still the goal.
        B. In pediatric patients, ventilate, consider fluid bolus, reassess, consider
           epinephrine.


     Go to Table of Contents
                                     2050
IN            ARRHYTHMIAS: GENERAL CONSIDERATIONS AND TREATMENT
        Specific Information Needed
        A. Present symptoms: sudden or gradual onset, palpitations
        B. Associated symptoms: chest pain, dizziness or fainting, trouble breathing,
           abdominal pain, fever
        C. Prior history: arrhythmias, cardiac disease, exercise level, pacemaker
        D. Current medications, particularly cardiac
        Specific Objective Findings
        A. Vital signs
        B. Signs of poor cardiac output:
               1. Altered level of consciousness
               2. Outward appearance of shock: cool/clammy skin, pallor, diaphoresis
               3. Systolic blood pressure < 90 mmHg
        C. Signs of cardiac failure (increased back-up pressure):
               1. Neck vein distention
               2. Lung congestion, rales
               3. Peripheral edema: sign of chronic failure, not acute
        D. Signs of hypoxia: marked respiratory distress, cyanosis, tachycardia
        Advanced treatment, general
        A. Administer oxygen, position of comfort.
        B. Establish venous access.
        C. Evaluate the patient. Is the patient perfusing adequately or are there signs of
           inadequate perfusion?
        D. Apply cardiac monitor and evaluate arrhythmia.
               1. Is there a pulse corresponding to monitor rhythm?
               2. Rate: tachycardia, bradycardia, normal?
               3. Are the ventricular complexes wide or narrow?
               4. What is the relation between atrial activity (P waves) and ventricular
                    activity?
               5. Is the arrhythmia potentially dangerous to the patient?
        E. Document the arrhythmia by rhythm strip and 12 lead EKG if available.
        F. Treat if needed according to pulse rate, perfusion status, risk of deterioration or
           as directed by base physician.
        G. Document results of treatment (or lack thereof) by checking pulse and recording
           change on paper tape.
        H. Transport patient. Monitor condition enroute.




     Go to Table of Contents
   Specific Precautions
   A. Treat the patient, not the arrhythmia! If the patient is perfusing adequately, he
      does not need emergency treatment. This is true of bradyarrhythmias as well as
      tachyarrhythmias. What is normal for one person may be fatal to another.
   B. Documentation of arrhythmias is extremely important. Field treatment of an
      arrhythmia may be life saving, but long-term treatment requires knowing what the
      problem was.
   C. Correct arrhythmia diagnosis based only on monitor strip recordings is difficult
      and often not possible. Treatment must be based on observable parameters:
      rate, patient condition and distance from the hospital.
   D. Dangerous rhythms are those which do not necessarily cause poor perfusion, but
      are likely to deteriorate. They require recognition and treatment to prevent
      degeneration to mechanically significant arrhythmias. Some of these dangerous
      rhythms include ventricular tachycardia and Mobitz II 2nd degree block.
   E. Cardiac arrest and life-threatening arrhythmias can be treated in the field, and
      show the benefits of "stabilization before transfer" in prehospital care. The
      patient is better off when the duration of arrest or poor perfusion is minimized.

   F. Drug dosages vary in the pediatric and elderly populations.




Return to Table of Contents
                                      2060
                    PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
IN
        A. The treatment of PVCs is rarely, if ever, indicated in the prehospital setting.
        B. Patients with PVCs and active chest pain should have their pain treated
           aggressively with oxygen, Aspirin, nitrates, and pain medications.
        C. Prophylactic use of Amiodarone is contraindicated.




     Go to Table of Contents
                                                  2070
IN                                  BRADYCARDIA WITH PULSE
     Patients who are asymptomatic with normal blood pressure do not need treatment of
     bradycardia in the field, they require transport.
                                   Initiate Supportive Measures:
                                         • Airway management
                                        • Initiate oxygen therapy
                                      • Establish venous access


                                 Is the patient conscious, alert and
                                  without signs of poor perfusion?



                      Yes                                              No
                                                          (Intermediates contact base)



                Initiate transport                                  Atropine
                                                                 0.5-1.0 mg IV
                                                                     bolus
                                                               Evaluate response




            Systolic BP >90                     Heart rate normal                       Persistent
                mmHg                          Systolic BP <90 mmHg                  hemodynamically
                                                                                   unstable bradycardia


                                              Fluid bolus up to 250 cc                  Atropine
            Initiate transport                       maximum                       0.5-1.0 mg IV push
                                                                                   Evaluate response


                                           Initiate transport and contact
                                            base to consider dopamine                  Consider
                                           or epinephrine administration        Transcutaneous pacing,
                                                                                      if available


                                                                                  Initiate transport and
                                                                                contact base to consider
                                                                                dopamine or epinephrine
                                                                                      administration


        Special notes
        A. Do not delay Transcutaneous Pacing while awaiting IV access or for Atropine to
           take effect if the patient is showing signs of poor perfusion.



     Go to Table of Contents
   B. When pacing, verify mechanical capture and patient tolerance. Administer
      Midazolam or Diazepam per protocol, if conscious, after initial pacing.
   C. Differentiate premature ventricular beats from escape beats, which are wide
      complexes occurring late after preceding beat as a lower pacemaker cell takes
      over. Escape beats are beneficial to the patient and should be treated by
      increasing the underlying rate and conduction; not by suppressing the escape
      beats.

   D. In pediatric patients, bradycardia is most often a sign of hypoxia. After therapy
      for the ABCs has been initiated, hyperventilate, give fluid bolus, reassess, and
      consider epinephrine. Epinephrine should be the first medication utilized.




Return to Table of Contents
                                      2080
                      NARROW COMPLEX TACHYCARDIA WITH PULSE
IN
                                      Initiate Supportive Measures:
                                             •  Airway management
                                           •   Initiate oxygen therapy
                             •   Establish venous access (If unable and patient is
                           hemodynamically unstable, move to synchronized cardioversion)



                   Is the patient conscious, alert and without signs of poor perfusion?



                        Yes                                                    No
            (Intermediates contact base)

          Attempt Valsalva’s maneuver                      Refer to Synchronized Cardioversion
                                                                Protocol (paramedic only)


                Initiate Transport                                    Initiate Transport


       Administer Adenosine 6 mg, rapid IV                              Contact Base
      bolus followed by 20 ml Normal Saline
                      Flush

      If no change, administer Adenosine 12
        mg, rapid IV bolus followed by 20 ml
                Normal Saline Flush


                  Contact Base


        Special notes
        A. Valsalva’s Maneuver
           1. This is any action that causes the patient to bear down against the closed
               glottis.
           2. Carotid sinus massage, orbital pressure or stimulation of mammalian diving
               reflex is Not Permitted.
        B. A narrow, QRS complex is less than 0.12 seconds in duration.
        C. Tachycardia is most likely a secondary problem when the pulse is less than 150
           in an adult. Treat hypoxia, hypovolemia, pain, and other problems first.
        D. Adenosine is not effective in treating atrial fibrillation, which is an irregular
           rhythm.
        E. Adenosine must be administered over 1-3 seconds and followed by a rapid 20ml
           saline flush. A proximal vein and port are preferred.
        F. Pridemark specific: Consider Cardizem for A-Fib >150



     Go to Table of Contents
   G. If the patient takes theophylline or xanthine derivatives, higher doses of
      adenosine may be needed.




Return to Table of Contents
                                          2081
IN                        WIDE COMPLEX TACHYCARDIA WITH PULSE

                                         Initiate Supportive Measures:
                                               • Airway management
                                             • Initiate oxygen therapy
                               •    Establish venous access (If unable and patient
                                        is hemodynamically unstable, move to
                                               synchronized cardioversion)


                                   Is the patient conscious, alert and without
                                            signs of poor perfusion?



                         Yes                                                      No



                  Initiate transport                             Refer to synchronized cardioversion
                                                                      protocol (paramedic only)




       Contact Base for consideration of one of                            Initiate transport
             the following medications:
                      • Adenosine
                     • Amiodarone
           • Magnesium (paramedics only)




        Special notes
        A. A wide QRS complex is defined as a complex with a width of 0.12 seconds or
           greater.
        B. A wide complex tachycardia is usually ventricular in origin but may, on occasion,
           be a supraventricular rhythm with aberrant conduction.
        C. Consider Midazolam or Diazepam for cardioversion in conscious patients.
        D. Immediate cardioversion is rarely needed for heart rates < 150.




     Go to Table of Contents
                                                2090
                                             CHEST PAIN
          Specific Information Needed
          A. Symptoms: Patient of either gender, more than 20 years old, with any of the
             following chief complaints:
                  1. Suspected Acute Coronary Syndrome
                        a. Pressure, tightness, heaviness in chest
                        b. Chest pain radiating into neck, jaw, shoulders, back, one or both
                             arms
                        c. Indigestion or heartburn, nausea and/or vomiting
                        d. Persistent shortness of breath
                        e. Weakness/dizziness/lightheadedness/loss of consciousness
                        f. No pain or discomfort; however, patient may experience painless
                             syncope, change in mental status, or dyspnea.
                        g. Cocaine or other stimulant drug use
                  2. Respiratory
                        a. Acute onset of shortness of breath
                        b. Wheezing
          Document Specific Objective Findings
          A. Vital signs
          B. General appearance: color, apprehension, sweating
          C. Signs of heart failure: neck vein distention, peripheral edema, respiratory
             distress
          D. Lung exam by auscultation: rales, wheezes or decreased sounds
          E. Chest wall tenderness, abdominal tenderness
          Treatment
          A. Reassure and place patient at rest, position of comfort.
          B. Administer oxygen.
          C. If patient’s history suggests a potential cardiac origin to the chest pain:
             1. Administer 4 chewable aspirin tablets, 324mg total, if patient is able to
                 swallow

IV           2. Establish venous access.

IN           3. Monitor cardiac rhythm and obtain 12 lead EKG if available. If patient has
                1mm ST elevation in two or more contiguous leads, notify receiving hospital
                for CARDIAC ALERT.

          D. Administer nitroglycerin, 0.4mg SL if BP > 100 systolic. Repeat every 5 min until
             pain is relieved or systolic BP drops < 100.

IN   CB   E. If pain persists after third nitroglycerin, administer morphine sulfate or Fentanyl
             for patients with no alteration of mental status and systolic BP > 100.
          F. Consider base contact for additional nitroglycerin and/or morphine sulfate or
             Fentanyl if pain persists.




      Go to Table of Contents
   Specific Precautions
   A. “All chest pain should be considered cardiac in origin until proven otherwise” but
      remember, there are many causes for chest pain. Consider pulmonary
      embolism, pneumonia, aortic aneurysm, pneumothorax.
   B. Consider Normal Saline fluid challenge or vasopressor if hypotensive. Beware of
      IV fluid overload in the potential cardiac patient. Document breath sounds.
   C. Patients taking medication for erectile dysfunction should not be given
      nitroglycerin.




Return to Table of Contents
                                        2095
                                    CARDIAC ALERT

Cardiac Alert:

   A. Cardiac alert is a program that is designed to mobilize cardiac catheterization
   staff and have them awaiting the arrival of EMS. This reduces the door to
   catheterization times and improves overall patient outcomes. By reducing time until
   reperfusion, less damage occurs in the myocardium and reduces mortality
   significantly.

   B. Most hospitals in the metro and Boulder County area recognize cardiac alert with
   the notable exceptions of Denver Health Medical Center and Boulder Foothills.

Criteria

      1. Pt presenting with active chest pain or discomfort consistent with acute coronary
         syndrome.
      2. Pt is between the ages of 35 and 80
      3. 1mm ST segment elevation in 2 or more anatomically contiguous leads See 12-
         Lead ECG Patterns protocol
      4. Consider MD consultation if transport time is greater than 10 minutes.
Exclusions

         1.    Paced Rhythm
         2.    Left Bundle Branch Block
Procedure
         1.  Assess patient for all criteria listed above
         2.  Ensure that none of the exclusionary criteria exists
         3.  Contact dispatch IMMEDIATELY and inform them that you have a cardiac
             alert and where your intended transport destination is.
          4. Transport emergently and notify the receiving hospital while transporting
             via normal means (Bio-phone) and inform them of patient condition and
             that the patient is a cardiac alert.
          5. Attempt to include all of the following in your report
                    i. Patient Age
                   ii. Patient Sex
                  iii. PMHx
                 iv. Elevated Leads
                   v. Cardiologist (if any)
                 vi. ETA
                 vii.
Special Considerations
          1. If a patient does not meet all cardiac alert criteria it does not mean that
             transport cannot be done emergently.
          2. Cardiac Alert is a procedure and not a condition.




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                                               2100
                                           HYPERTENSION
          Specific Information Needed
          A. History of hypertension and current medications
          B. New symptoms: dizziness, nausea, confusion, visual impairment, paresthesia,
             weakness
          C. Drug use: phenylpropanolamine (found in a wide variety of over-the-counter
             weight-loss products), amphetamines, cocaine or other stimulant drug use
          D. Other symptoms: chest pain, breathing difficulty, abdominal/back pain, severe
             headache
          Specific Objective Findings
          A. Evidence of encephalopathy: confusion, seizures, coma, vomiting
          B. Presence of associated findings: pulmonary edema, neurologic signs, neck
             stiffness, unequal peripheral pulses
          Treatment
          A.   Administer oxygen.
          B.   Place patient in position of comfort.
          C.   Monitor vital signs.
          D.   Treat chest pain, pulmonary edema or seizure activity per protocol.
          E.   Establish venous access.

IN   CB   F. If diastolic blood pressure remains above 130 mmHg on repeated readings and
             patient has symptoms of encephalopathy without evidence of CVA or head injury,
             CONTACT BASE to consider:
             1. Nitroglycerin, 0.4 mg SL.
             2. Morphine sulfate, 4.0 mg slow IV bolus, with repeat boluses of 2.0 mg slow IV
                  up to a maximum of 10 mg.

          G. Monitor cardiac rhythm. Obtain 12 lead ECG, if available.
          H. Monitor vital signs and mental status during transport.
          Specific Precautions
          A. Secondary hypertension (high BP in response to stress or pain) is commonly
             seen in the field. It does not require field treatment, and may not even mean the
             patient has chronic hypertension requiring ongoing treatment.
          B. Hypertensive encephalopathy is rare, but can be treated with nitroglycerin or
             morphine. Hypertension is more common in association with other problems
             (pulmonary edema, seizures, chest pain, coma, or altered mental states). It
             should be managed by treating the primary problem.
          C. Diastolic pressures and mean arterial pressures are much more important in
             determining danger of severe hypertension than is systolic pressure. These are
             poorly measured in the field. The diagnosis of "malignant" hypertension is not
             based on numerical levels, but rather on microscopic changes in blood vessels
             and damage to organs, which place this disease beyond the scope of prehospital
             care.




      Return to Table of Contents
   D. Hypertension is seen in severe head injury and intracranial bleeding, and is
      thought to be a protective response that increases perfusion to the brain.
      Treatment should be directed at the intracranial process, not the blood pressure.




Return to Table of Contents
                                      3010
                              RESPIRATORY DISTRESS
   Specific Information Needed
   A. History: acute change or injury, slow deterioration
   B. Past history: chronic lung or heart problems or known diagnosis, medications,
      home oxygen, past allergic reactions, recent surgery, tobacco abuse
   C. Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia
   Document Specific Objective Findings
   A.   Vital signs
   B.   Oxygenation: level of consciousness, cyanosis
   C.   Respiratory effort: accessory muscle use, forward position, pursed lips
   D.   Neurologic signs: slurred speech, impaired consciousness, evidence of
        drug/alcohol ingestion
   E.   Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest wall
        movements, inspiratory stridor
   F.   Signs of congestive failure: neck vein distention in upright position, rales,
        peripheral edema
   G.   Breath sounds: clear, decreased, rales, wheezing, or rhonchi
   H.   Hives, upper airway edema
   I.   Evidence of trauma: crepitation of neck or chest, bruising, steering wheel
        damage, penetrating wounds
   Treatment
   A. Put patient in position of comfort, usually upright.
   B. Identify and treat upper airway obstruction if present (e.g. suctioning, NPA/OPA,
      CPAP, endotracheal intubation, etc.).
   C. Administer high flow oxygen.
   D. Prepare to assist ventilations if patient fatigues or develops altered mentation, or
      if respiratory arrest occurs.
   E. If diagnosis unclear, place patient in position of comfort, and administer oxygen,
      transport.
   F. Assess and consider treatment for other problems if respiratory distress is severe
      and patient does not respond to proper positioning and administration of oxygen.
   G. Establish venous access.
   H. Monitor cardiac rhythm.
   Specific Precautions
   A. Don't overdiagnose "psychogenic" in the field. Your patient could have a
      pulmonary embolus or other serious problem; give him/her the benefit of the
      doubt. Treatment with oxygen will not harm the “hyperventilator”, and it will keep
      you from underestimating the problem.
   B. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma").
      Pulmonary embolus is an uncommon cause of wheezing




Go to Table of Contents
                                                 3020
                                                ASTHMA
          Specific Objective Findings
          A.   Vital signs
          B.   Oxygenation: level of consciousness, cyanosis
          C.   Respiratory effort: accessory muscle use, forward position, pursed lips
          D.   Breath sounds: clear, decreased, wheezing, or rhonchi
          Treatment
          A. Put patient in position of comfort, usually upright.
          B. Administer high flow oxygen.
          C. Use appropriate airway adjuncts as indicated.
          D. Assess and consider treatment for other problems if respiratory distress is severe
             and patient does not respond to proper positioning and administration of oxygen.
          E. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI
             protocol. EMT’s must contact base.

IV        F. Establish venous access.

IN        G. Monitor cardiac rhythm

          H.   Administer Albuterol Sulfate. Consider adding Ipratropium.
IN   CB
          I.   Use continuous nebulization of Albuterol Sulfate for respiratory distress.
          J.   Consider Epinephrine, 0.3 mg SQ/IM (0.3 ml of 1:1,000 solution).
          K.   Consider Methylprednisolone, 125 mg IV.

P         L. Consider Magnesium Sulfate, 2.0 gm, IV bolus, over 2 minutes
          Specific Precautions
          A. Prepare to assist ventilations if patient fatigues or develops altered mentation, or
             if respiratory arrest occurs.
          B. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma").
             Pulmonary embolus is an uncommon cause of wheezing.
          C. If available, utilize pulse oximetry and capnography.




      Go to Table of Contents
                                         3030
                         CHRONIC OBSTRUCTIVE PULMONARY DISEASE


          Specific Objective Findings
          A.   Vital signs
          B.   Oxygenation: level of consciousness, cyanosis
          C.   Respiratory effort: accessory muscle use, forward position, pursed lips
          D.   Breaths sounds: clear, decreased, rales, wheezing, or rhonchi
          Treatment
          A. Place patient in position of comfort, usually upright
          B. Identify and treat upper airway obstruction of present (suctioning,
             nasopharyngeal airway, endotracheal intubation, etc.).
          C. Administer high flow oxygen.
          D. Use appropriate airway adjuncts as indicated.
          E. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI
             protocol. EMT’s must contact base.

IN        F. Monitor cardiac rhythm. Perform 12-lead, if available.
          G. Assess and consider treatment if respiratory distress is severe and patient does
             not respond to proper positioning and administration of oxygen.

          H. Administer Albuterol Sulfate. Consider adding Ipratropium.
IN   CB
          I. Use continuous nebulization of Albuterol Sulfate for respiratory distress.
          J. Consider Methylprednisolone, 125mg IV bolus.

P         K. CONTACT BASE for Magnesium Sulfate, 2 gms IV over 2 minutes.
          Specific Precautions
          A. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma").
             Pulmonary embolus is an uncommon cause of wheezing.
          B. Some COPD patients rely on a hypoxic drive for ventilatory support. Never
             withhold oxygen for fear of decreasing this hypoxic drive.
          C. If available, utilize pulse oximetry and capnography.




     Go to Table of Contents
                                       3040
                                PULMONARY EMBOLISM
   Specific Information Needed
   A. History: diabetes, chronic lung disease, congestive heart failure (CHF).
   B. Past history: sedentary life style, surgery or recent fractures, pregnancy, oral
      contraceptives, atrial fibrillation.
   C. Associated symptoms: anxiety, dyspnea, chest pain, tachycardia, JVD


   Document Specific Objective Findings
   A. Vital signs
   B. Oxygenation: level of consciousness, anxiety
   C. Respiratory effort: dyspnea, tachypnea, shortness of breath
   D. Neurologic signs: impaired consciousness, syncope
   E. Objective findings: distended neck veins, chest splinting, hypotension,
      tachycardia.
   F. Breath sounds: clear, decreased, rales, wheezing, or rhonchi
   Treatment
   A.   Put patient in position of comfort, usually upright.
   B.   Identify and treat upper airway obstruction if present
   C.   Administer high flow oxygen
   D.   Assist ventilation if necessary
   E.   If available, utilize pulse oximetry and capnography.
   Special Precautions
   A. Because prehospital care is primarily supportive and diagnosis difficult;
      understanding the contributing factors is paramount.
   B. A pulmonary embolism should be considered with any person who has an
      unexplained cardiorespiratory problem.




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                                              3050
                                        PULMONARY EDEMA
          Specific Objective Findings
          A. Vital signs
          B. Oxygenation: level of consciousness, cyanosis
          C. Respiratory effort: accessory muscle use, forward position, pursed lips
          D. Signs of congestive failure: Neck vein distention in the upright position, rales,
             peripheral edema.
          E. Breath sounds: clear, decreased, rales, wheezing, or rhonchi.
          Treatment
          A. Place patient in position of comfort, usually upright.
             1. Sit patient up, legs dangling if possible.
          B. Administer high flow oxygen.
          C. Consider CPAP
          D. Assist ventilations with pocket mask or bag valve mask if necessary.
          E. Establish venous access.
          F. Monitor cardiac rhythm. Perform 12-lead, if available.

IN   CB   G. Consider:
             1. Nitroglycerin 0.4mg SL
             2. Morphine Sulfate, initial dose up to 4mg, then 2mg increments up to a total
                dose of 10mg.

P              3. Lasix, 20-80mg slow IV push.
               4. If available, consider CPAP.
          Specific Precautions
          A. If diagnosis is unclear, place patient in position of comfort, administer oxygen,
             and transport.
          B. Wheezing in older persons may be due to pulmonary edema (“cardiac asthma”).
             Pulmonary embolus is an uncommon cause of wheezing.
          C. Prepare to assist ventilations if patient fatigues or develops altered mentation, or
             if respiratory arrest occurs.
          D. If available, utilize pulse oximetry and capnography.




     Go to Table of Contents
                                        3060
                                  HYPERVENTILATION
   Specific Information Needed
   A. History: anxiety provoking episode, acute change or injury
   B. Past history: panic attack, anxiety attack, chronic lung or heart problems or
      known diagnosis, medications, home oxygen, past allergic reactions, recent
      surgery, tobacco use,
   C. Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia,
      carpal pedal spasm, cerebrovascular constriction resulting in headache,
      dizziness or euphoria.
   Document Specific Objective Findings
   A.   Vital signs
   B.   Oxygenation: level of consciousness, cyanosis
   C.   Respiratory effort: accessory muscle use, forward position, pursed lips.
   D.   Neurologic signs: slurred speech, impaired consciousness, evidence of
        drug/alcohol ingestion.
   E.   Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest wall
        movements, inspiratory stridor.
   F.   Signs of congestive failure: neck vein distention in upright position, rales,
        peripheral edema.
   G.   Breath sounds: clear, decreased, rales, wheezing, or rhonchi.
   H.   Hives, upper airway edema
   I.   Evidence of trauma: crepitation of neck or chest, bruising, steering wheel
        damage, penetrating wounds.
   Treatment
   A.   Put patient in position of comfort, usually upright.
   B.   Identify and treat upper airway obstruction if present.
   C.   Administer high flow oxygen.
   D.   Use appropriate airway adjuncts as indicated.
   E.   Assess and consider treatment for the following problems
        1. Coaching of breathing pattern and ventilations.
        2. Calming of anxiety and stress inducing factors.
        3. Suspicion that the symptoms are indicative of other illness, disorder or
           overdose, patient should be transported.
   Specific Precautions
   A. Don’t over-diagnose “psychogenic” in the field. Your patient could have a
      pulmonary embolus or other serious problem; give him/her the benefit of the
      doubt. Treatment with oxygen will not harm the “hyperventilator”, and it will keep
      you from underestimating the problem.
   B. Utilize pulse oximetry and Capnography, if available.




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                                    3070
                          SPONTANEOUS PNEUMOTHORAX
   Specific Information Needed
   A. History: acute change or injury, slow deterioration
   B. Past history: chronic lung or heart problems, medications, home oxygen, past
      allergic reactions, recent surgery, tobacco use
   C. Associated symptoms: chest pain
   Document Specific Objective Findings
   A. Vitals signs
   B. Oxygenation: level of consciousness, cyanosis
   C. Respiratory effort: accessory muscle use, shortness of breath, tachypnea,
      decreased breath sounds on affected side
   D. Neurologic signs: impaired consciousness, evidence of drug/alcohol ingestion
   E. Signs of upper airway obstruction: exaggerated chest wall movements
   F. Breath sounds: clear, decreased, rales, wheezing, or rhonchi
   G. Assess for evidence of trauma: crepitation of neck or chest, bruising, steering
      wheel damage, penetrating wounds
   H. Other signs and symptoms: sudden onset of chest pain, diaphoresis, pallor,
      subcutaneous emphysema.
   Treatment
   A. Put patient in position of comfort, usually upright.
   B. Identify and treat upper airway obstruction if present
   C. Administer high flow oxygen.
   D. Use appropriate airway adjuncts as indicated.
   E. Assess and consider treatment for severe cases: airway, ventilatory and
      circulatory support.
   F. If a tension pneumothorax develops, follow “Tension Pneumothorax” protocol.
   Special Precautions
   A. May occur in apparently healthy persons; often men between 20 and 40 years of
      age, which are tall and thin.
   B. May occur in patients with COPD, patients with AIDS and pneumonia, history of
      Marfan’s Syndrome, drug abusers.
   C. Utilize pulse oximetry and capnography if available.




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                                                3080
                                             PNEUMONIA
          Specific Information Needed
          A. History: acute change or injury, slow deterioration, general malaise.
          B. Past history: chronic lung or heart problems or known diagnosis, medications,
             home oxygen, past allergic reactions, recent surgery, tobacco abuse
          C. Associated symptoms: chest pain, productive cough, fever, sputum production.
          Treatment
          A. Place patient in position of comfort, usually upright.
          B. Identify and treat upper airway obstruction if present (suctioning, nasopharyngeal
             airway, endotracheal intubation, etc.).
          C. Administer high flow oxygen.
          D. Assist ventilation if necessary.
          E. Assess and consider treatment if respiratory distress is severe and patient does
             not respond to proper positioning and administration of oxygen.

IN   CB      1. Administer Albuterol Sulfate 2.5 mg nebulization.
          Special Precautions
          A. Pneumonia can be caused by bacterial, viral, or fungal infection; these diseases
             may spread by droplets or contact with infected persons. Utilize appropriate
             Body Substance Isolation (BSI) precautions.
          B. If diagnosis is unclear, place patient in position of comfort, administer oxygen,
             and transport.
          C. Prepare to assist ventilations if patient fatigues or develops altered mentation, or
             if respiratory arrest occurs.
          D. If available, consider pulse oximetry and capnography.




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                                      4000
                              MEDICAL EMERGENCIES

The following are protocols for various medical emergencies. Treatment for each may
be unique but there are similar things to consider when treating all medical patients.

   A. Ensure the scene is safe and wear the appropriate protective equipment for
      proper body substance isolation.
   B. Obtain clues from the scene to help create a picture of the nature of the illness.
   C. Determine if your patient is physiologically stable or unstable. Certain
      assessment findings may help determine this, including:
      1. Any airway obstruction that is limiting ventilation.
      2. The patient is unable to maintain or protect their airway.
      3. Not breathing or breathing inadequately.
      4. Absent or diminished breath sounds.
      5. Working hard to breathe and use of accessory chest muscles with retractions.
      6. Absent or weak peripheral or central pulses.
      7. H th8/chehat too fequason t, too sfol, oider1( thing out taregns of )( as. )]Tc -0.0009 Tc 0 TJ1.639
                                        uout of thphere(Abseillnscle)5(s)se awhof (mo4(Arvedrwa)thpiohe
      2. 3.3.evalue pthiof tbody systems affetre ses2.2.
      2. reiesIe someoteeat(scsssclelly)5eslar (mentwitnass d ay )]TJ000009 Tc 0 TJ1.639 -1.153 Td
      3. ahow lothii5hlasre ses. 3. eeth6oiderraionuma6(d (f thiconsure of tentmouth, lipsble )6(ay )]Tc 0 T
      1. Repeat all previous assessments for any change.
      2. Reassess vital signs.
      3. Evaluate the effectiveness of any interventions.
   J. It is always appropriate to err on the side of caution. If you feel the patient is
      unstable, aggressively treat and transport rapidly to the appropriate facility.




Return to Table of Contents
                                    4010
                          NEUROLOGICAL EMERGENCIES




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                                              4011
                                           STROKE/CVA
        Indication
        A. For patients presenting with an acute episode of neurological deficits without any
           evidence of trauma as the causative agent.
        Specific Information Needed
        A. Symptoms:
              1. Altered level of consciousness
              2. Impaired speech
              3. Unilateral weakness / hemiparesis
              4. Facial asymmetry / facial droop
              5. Headache
              6. Poor coordination or balance
              7. Vision changes
              8. Seizure activity
              9. Previous CVA / TIA
              10. Chest Pain
              11. Last time “without symptoms”
        Document Specific Objective Findings
        A. Vital signs and complete history including patient medications
        B. General appearance: color, apprehension, sweating
        C. Cincinnati Prehospital Stroke Scale (CPSS)
           1. Face – facial droop present
           2. Arm – upper extremity arm drift present (arms extended, palms up)
           3. Speech – inability to speak a simple sentence
           4. Time – time of onset of symptoms / last time without symptoms
        D. Complete Neurologic Exam
IV
        E. Determine Blood Glucose level
IN
        F. Monitor cardiac rhythm. Perform 12-lead EKG, if available.
        Treatment
        A.   Reassure and place patient with head slightly elevated (<30 degrees)
        B.   Administer oxygen.
        C.   NPO
        D.   Transport to appropriate facility
        E.   Contact receiving facility early with symptoms and objective findings

        F. Establish venous access (proximal18 gauge or larger is preferred)
        G. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose
           reading <60 and if clinically indicated.
        Special Precautions
        A. Treatment of hypertension in the setting of CVA / TIA is not indicated in the
           prehospital setting.


     Go to Table of Contents
                                        4012
                    COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT
          Specific Information Needed
          A. Present history: duration of illness, onset and progression of present state
             illness; preceding symptoms such as headaches, seizures, confusion, or trauma.
          B. Past history: previous medical or psychiatric problems
          C. Medications: use, misuse, or abuse
          D. Surroundings: check for pill bottles or syringes and bring with patient. Note odor
             in house.
          Specific Objective Findings
          A.   Safety of rescuer. Check for gases or other toxins.
          B.   Vital signs
          C.   Level of consciousness and neurological status
          D.   Signs of trauma
          E.   Breath odor
          F.   Needle tracks
          G.   Medical alert tag
          Treatment
          A. Use appropriate airway adjuncts as indicated
          B. Administer oxygen.
          C. If patient a known diabetic and can swallow administer one full tube of oral
             glucose per protocol.

IV
          D. Establish venous access and fluid bolus as indicated.
          E. Draw appropriate blood tubes. Test blood glucose level
          F. Administer Dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose
             reading <60 and/or if clinically indicated.

          G. Administer Naloxone up to 2 mg IV, IN, IM or IO if clinically indicated.
IN   CB
          H. If venous access is unsuccessful and unable to administer dextrose, administer
             Glucagon 1 mg IM.
          I. Monitor cardiac rhythm.

          J. Transport in lateral recumbent position. (If trauma suspected, transport supine
             with cervical collar and backboard; logroll as necessary.)
          K. Monitor vitals during transport.
          Specific Precautions
          A. Be particularly attentive to airway. Difficulty with secretions, vomiting, and
             inadequate tidal volume are common.
          B. Hypoglycemia may present as a focal neurological deficit or coma (stroke like
             picture).
          C. Coma in the diabetic may be due to hypoglycemia or to hyperglycemia (diabetic
             ketoacidosis). Dextrose should be given IV Bolus to all unconscious diabetics,
             as well as patients with coma of unknown origin unless a blood glucose reading
             in the high range is obtained. The treatment may be life saving in hypoglycemic


      Go to Table of Contents
      patient, and will do no harm in the normal or hyperglycemic patient. Do not give
      oral sugar to an unconscious patient.
   D. Stroke patients may be alert but unable to respond (aphasic); therefore,
      communicate with the patient and explain what you are doing. Avoid
      inappropriate comments.
   E. Naloxone is useful in any potential narcotic overdose, but be sure the airway and
      the patient are controlled before giving naloxone to a known drug addict. The
      acute withdrawal precipitated in an addict may result in violent combativeness.




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                                                 4013
                                              SEIZURES
          Specific Information Needed
          A. Seizure history: onset, time interval, previous seizures, type of seizure
          B. Medical history: especially head trauma, diabetes, headaches, drugs, alcohol,
             medications, compliance with anticonvulsants, pregnancy
          Document Specific Objective Findings
          A.   Vital signs
          B.   Description of seizure activity
          C.   Level of consciousness
          D.   Head and mouth trauma
          E.   Incontinence
          F.   Air temperature; patient temperature
          G.   Skin color and moisture
          Treatment
          A. Ensure airway patency. Nasopharyngeal airways are useful.
              NOTE: Don’t force anything between the teeth.
          B. Administer oxygen.
          C. Suction as needed.
          D. Protect patient from injury.
          E. Check pulse immediately after seizure stops.
          F. Keep patient on side.

IV        G. Establish venous access.
          H. Draw appropriate blood tube; test for blood glucose if available.
          I. Administer Dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose
             <60 and if clinically indicated.
          J. Administer Naloxone up to 2 mg IV or IN (may also be given IM or IO by EMT-
             Intermediate or paramedic) if clinically indicated.
             1. If EMT-IV, contact base for consideration of administration of Naloxone as
                 described above

IN   CB   K. Administer Diazepam 1-10 mg slow IV push for status epilepticus.

          L. If venous access unsuccessful after two attempts, administer Midazolam 1-5 mg
P
             IM or IN.

IN   CB   M. If venous access is unsuccessful and unable to administer dextrose, administer
             Glucagon 1 mg, IM.
          N. Monitor cardiac rhythm.

          O. Keep in lateral recumbent position for transport.
          P. Monitor vitals.
          Specific Precautions




      Go to Table of Contents
       A. Move hazardous materials away from patient. Restrain the patient only if needed
          to prevent injury. Protect patient's head.
       B. Trauma to tongue is unlikely to cause serious problems, however, trauma to
          teeth may. Attempts to force an airway into the patient's mouth can completely
          obstruct airway. Do not use bite sticks or jaw screws.
       C. Seizure can be due to lack of glucose or oxygen to the brain, as well as to the
          irritable focus we associate with epilepsy. Hypoxia from transient arrhythmia or
          cardiac arrest (particularly in younger patients) may cause seizure and should be
          treated promptly. Don't forget to always check for pulse once a seizure
          terminates.
       D. Hypoxic seizures can also result when the tongue obstructs the airway in the
          supine position, or when overly helpful bystanders prop the patient up or
          improperly elevate the head.
       E. Alcohol related seizures are common, but cannot be differentiated from other
          causes of seizure in the field. Assessment in the intoxicated patient should still
          include consideration of hypoglycemia and all other potential causes. Field
          management is as for any seizure.
       F. Seizures may be due to arrhythmias or stroke. It is important to look for and
          recognize arrhythmias in the field since they may be the cause of the seizure.
       G. Medical personnel are often called to assist epileptics who seize in public. If
          patient clears completely, is taking his/her medications, has his/her own
          physician, and is experiencing his/her usual frequency of seizures, transport may
          be unnecessary. Consult your base physician.
       H. Diazepam has a tendency to decrease respiratory effort, therefore be prepared to
          assist ventilations.
       I. Seizures in pregnant patients (or even those who are postpartum) may be the
          presenting sign of eclampsia or toxemia of pregnancy.

           1. Seizures in those patients will respond better to administration of magnesium
P
              sulfate.




    Return to Table of Contents
                                               4014
                                             SYNCOPE
        Specific Information Needed
        A. History of the event: onset, duration, seizure activity, precipitating factors. Was
           the patient sitting, standing, or lying? Pregnant?
        B. Past history: medications, diseases, prior syncope
        C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain,
           headache, palpitations
        Specific Objective Findings
        A.   Vital signs
        B.   Neurological status: level of consciousness, residual neurological deficit
        C.   Signs of trauma to the head or mouth or incontinence
        D.   Neck stiffness
        Treatment
        A. Place patient in position of comfort: do not sit patient up prematurely; supine or
           lateral positioning if not completely alert
        B. Monitor vital signs and level of consciousness closely for changes or recurrence.

        C. Establish venous access and administer Normal Saline if indicated.
IV      D. Consider hypoglycemia. If signs of hypoglycemia are present (clinical indications
           and blood glucose<60):
           1. Establish venous access.
           2. Draw appropriate blood tubes.
           3. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus.

IN           4. If venous access is unsuccessful and unable to administer dextrose,
                administer glucagon 1 mg IM.

        E. If vital signs unstable or age > 40 years:
           1. Administer oxygen.
           2. Keep patient supine, elevate legs 10-12 inches.

IV           3. Establish venous access.

IN           4. Monitor cardiac rhythm. Consider 12-lead EKG if available.
        Specific Precautions
        A. Syncope is by definition a transient state of unconsciousness from which the
           patient has recovered. If the patient is still unconscious, treat as coma. If the
           patient is confused, treat according to Coma/Altered Mental Status/Neurologic
           Deficit protocol.
        B. Most syncope is vasovagal, with dizziness progressing to syncope over several
           minutes. Recumbent position should be sufficient to restore vital signs and level
           of consciousness to normal.
        C. Syncope that occurs without warning or while in a recumbent position is
           potentially serious and often caused by an arrhythmia.


     Go to Table of Contents
   D. Patients with syncope, even though apparently normal, should be transported. In
      middle-aged or elderly patients, syncope can be due to a number of potentially
      serious problems. The most important of these to monitor and recognize are
      arrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm.
   E. Any elderly patient with syncope and back pain should be considered to
      have a ruptured abdominal aortic aneurysm until proven otherwise.
   F. In children 1-4 years of age breath-holding spells associated with heightened
      emotional states can cause syncopal-like events. Children may be pallid or
      cyanotic and seizures can occur. No specific treatment is indicated for these
      events. Consult base station if questions.




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                                              4020
                                      ALLERGY/ANAPHYLAXIS
          Specific Information Needed
          A. History: current sequence of events, exposure to allergens (bee stings, drugs,
             nuts, seafood most common), prior allergic reactions.
          B. Current symptoms: itching, wheezing, respiratory distress, nausea, weakness,
             rash, anxiety, swelling.
          C. Medications, past medical history.
          Specific Objective Findings
          A.   Vital signs, level of consciousness
          B.   Respirations: wheezing, upper airway noise, effort
          C.   Mouth: tongue and airway swelling
          D.   Skin: hives, swelling, flushing
          Treatment
          A. Ensure airway patency. Early endotracheal intubation may be advisable before
             swelling becomes severe. Suction as needed. Prepare to assist ventilations.
          B. Position of comfort (upright if respiratory distress predominates; supine if shock
             prominent)
          C. Administer oxygen as indicated.
          D. Remove the mechanism of injection if still present (stinger, needle, etc). Do not
             squeeze venom sac; rather, scrape with straight edge.
          E. Remove any clothing or other items which may contain the allergen, for example
             if a person was horse back riding, clothing may still contain the allergen.

          F. If signs of severe generalized reaction present establish venous access.
IV
          G. Consider Epi-Pen if available (EMT-B must contact base).

IN        H. Monitor cardiac rhythm.

IN   CB   I. Administer diphenhydramine 50 mg IV or IM (IO if already established) as
             indicated.
          J. For objective findings of respiratory distress such as stridor, wheezing, hypoxia,
             tachypnea or angioedema, Epinephrine 0.3 mg of 1:1000 SQ/IM is indicated.
          K. For signs of shock (BP < 90) or altered mental status:
             1. Fluid bolus of Normal Saline at 20 ml/kg
             2. Administer epinephrine, 0.1 mg 1:10,000 IV followed by epinephrine 1.0 mg
                 mixed in 250 ml Normal Saline infusion started at: 2mcg/min. Titrate to
                 desired effects including signs of improved perfusion or a systolic blood
                 pressure greater than 90 mmHg.
          Specific Precautions
          A. Allergic reactions can take multiple forms. Early consult with base physician is
             encouraged.
          B. Anxiety, tremor, palpitations, tachycardia, and headache are not uncommon with
             administration of epinephrine. These may be particularly severe with IV
             administration. In children, epinephrine may induce vomiting.


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   C. Angina, MI, or dysrhythmias may be precipitated.
   D. Use caution in the administration of epinephrine in cardiac patients or the elderly.
   E. Two forms of epinephrine are carried as part of paramedic equipment. The
      standard ampules of aqueous epinephrine contain a 1:1000 dilution appropriate
      for SQ or IM injection. IV epinephrine should be given in a 1:10,000 dilution. Use
      the 1:10,000 premix for IV dosing to avoid mistakes. Be sure you are giving
      the proper dilution to your patient, and give slowly.
   F. Before treating anaphylaxis, be sure your patient has objective signs as well as
      subjective symptoms and history. Hyperventilators will occasionally think they are
      having an allergic reaction. Epinephrine will just aggravate their anxiety.
   G. Lethal edema may be localized to the tongue, uvula, or other parts of the upper
      airway. Examine closely, and be prepared for early intubation before swelling
      precludes this intervention.




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                                               4030
                                           ABDOMINAL PAIN
          Specific Information Needed
          A. Pain: nature (crampy or constant), duration, location; radiation to back, groin,
             chest, shoulder
          B. Associated symptoms: nausea, vomiting (bloody or coffee ground), diarrhea,
             constipation, black or tarry stools, urinary difficulties, menstrual history, fever
          C. Past history: previous trauma, abnormal ingestions, medications, known
             diseases, surgery
          Document Specific Objective Findings
          A.   Vital signs
          B.   General appearance: restless, quiet, sweaty, pale
          C.   Abdomen: tenderness, guarding, distention, rigidity, pulsatile mass
          D.   Emesis, stool, or urine, describe, amount
          E.   Check for equality of pulses.
          Treatment
          A. Place patient in position of comfort
          B. Give nothing by mouth
          C. If BP <90 mmHg systolic and signs of hypovolemic shock:
             1. Administer oxygen.

             2. Establish venous access with 2 large bore lines. Consider Normal Saline
IV
                bolus of 20 ml/kg.
             3. Consider transport to a trauma center based upon destination protocol.
          D. Establish venous access even if vital signs normal.

          E. Cardiac monitor and 12 lead EKG (if available) for upper abdomen pain.
IN
          F. Consider pain medication for hemodynamically stable patients with transport
IN   CB
             times >10 minutes
             Fentanyl 1-2 mcg/kg IV bolus to a cumulative dose of less than 200 mcg.

          G. Monitor vitals during transport.
          H. For patients who are nauseated or vomiting consider antiemetic administration.
          Specific Precautions
          A. The most important diagnoses to consider are those associated with catastrophic
             internal bleeding: ruptured aneurysm, liver, spleen, ectopic pregnancy, etc.
             Since the bleeding is not apparent, you must think of the volume depletion and
             monitor patient closely to recognize shock. If a patient presents in shock,
             consider transport to a trauma center where appropriate surgical consultation is
             readily available.
          B. Elderly patients may have significant hypovolemic shock with systolic blood
             pressures above 90 mmHg. With signs of hypovolemia, treat with fluids.
          C. Upper abdomen and lower chest pain may reflect thoracic pathology such as
             myocardial infarction, etc. Massive fluid resuscitation may be contraindicated.


     Go to Table of Contents
                                              4031
                                            VOMITING
        Document Specific Objective Findings
        A.   Frequency, duration of vomiting
        B.   Presence of blood or bile in vomitus
        C.   Associated symptoms: abdominal pain, weakness, confusion
        D.   Medication ingestion
        E.   Past medical history: diabetes, cardiac disease, abdominal problems, alcoholism
        F.   Vital signs
        G.   Color of vomitus: presence of blood
        H.   Abdomen: tenderness, guarding, rigidity, distention
        I.   Signs of dehydration: poor skin turgor, dry mucous membranes, confusion
        Treatment
        A. Position patient: left lateral recumbent if vomiting; otherwise, supine.
        B. Administer oxygen.
        C. Nothing by mouth

IV      D. If BP < 90 mmHg systolic and signs of hypovolemic shock or for signs of poor
           perfusion in pediatric patients:
           1. Elevate legs 10-12 inches.
           2. Establish venous access.
           3. Normal Saline bolus of 20 ml/kg

P       E. For patients who are nauseated or vomiting consider antiemetic administration.
              a. Ondansetron (Zofran) 4mg IV/IM
              b. Promethazine (Phenergan) 12.5mg IV
        Specific Precautions
        A. Vomiting may be a symptom of a more serious problem. The most serious
           causes are GI bleed or other intra-abdominal catastrophe. A rare cardiac patient
           may also present with vomiting as the predominant symptom.
        B. Consider drug overdose; a patient who does not call the ambulance for
           medication ingestion may call later when GI symptoms become severe.
        C. The vast majority of persons with vomiting have become sick over days, not
           minutes. Treat appropriately.
        D. Dehydration may be particularly severe in children with simple vomiting. IVs may
           be very difficult to start, particularly with infants.




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                                             4040
                                    POISONS AND OVERDOSES
          Specific Information Needed
          A. Type of ingestion: What, when, and how much was ingested? Bring the poison,
             the container, description of emesis, all medications and everything questionable
             in the area with the patient to the Emergency Department.
          B. Reason for exposure: think of child neglect, depression, etc.
          C. Symptoms: respiratory distress, sleepiness, nausea, agitation or decreased level
             of consciousness
          D. Past history: medications, diseases, psychiatric
          E. Action taken by bystanders: induced emesis? "antidote" given?
          Document Specific Objective Findings
          A.   Vital signs
          B.   Airway: patency and adequacy of ventilation
          C.   Level of consciousness and neurologic status: check frequently.
          D.   Breath odor, increased salivation, oral burns
          E.   Skin: sweating, cyanosis
          F.   Systemic signs: vomitus, arrhythmias, lung sounds
          Treatment
          A. Use appropriate airway adjuncts as indicated.
          B. Administer oxygen.
          C. Support patient on side and protect airway.

          D. Establish venous access.
IV        E. Test for blood glucose level, if available.
          F. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose
             <60 and if clinically indicated.
          G. Administer naloxone up to 2 mg IV or IN (may also be administered IM or IO) in
             patients with decreased respiratory effort and observe patient for improved
             ventilations.
     CB
          H. If venous access is unsuccessful and unable to administer dextrose, administer
IN
             glucagon 1 mg, IM.
          I. Monitor cardiac rhythm.
          J. Administration of sodium bicarbonate may be necessary with signs of a widened
               QRS or ventricular arrhythmias after excessive tricyclic antidepressant(s)
               ingestion. Administration of diazepam 1-10 mg slow IV bolus may be necessary
               in suspected stimulant use or abuse (cocaine, Ecstasy, etc.)

          Specific Precautions
          A. There are few specific "antidotes." Product labels and home kits can be
             misleading and dangerous. Watch the ABCs: these are important.
          B. Do not neutralize acids with alkalis. Do not neutralize alkalis with acids. These
             "treatments" cause heat releasing chemical reactions that can further injure the
             GI tract.
          C. Inhalation poisoning is particularly dangerous to rescuers. Recognize an
             environment with ongoing contamination and extricate rapidly.


      Go to Table of Contents
   D. Organophosphate exposure may require massive doses of atropine.
   E. For personal exposure to nerve agents refer to Mark I auto-injector protocol.

 Rocky Mountain Poison Center #: 303-739-1123 (local) or 1-800-332-3073 (statewide)
               Nationwide Poison Control Access#: 1-800-222-1222
            Poison Control Phone for Hearing Impaired: 303-739-1127
                          CHEMTREC: 1-800-424-9300




Return to Table of Contents
                                     4050
                          ENVIRONMENTAL EMERGENCIES




Go to Table of Contents
                                             4051
                                    HIGH ALTITUDE ILLNESS
        Specific Information Needed
        A. Presenting symptoms generally fall into two categories:
           1. Acute mountain sickness (AMS) - headache, sleeplessness, anorexia,
              nausea, fatigue.
           2. High-altitude pulmonary edema (HAPE) - breathlessness, cough, headache,
              trouble breathing, confusion, fatigue, nausea
           3. High-altitude Cerebral Edema (HACE) – ataxia, headache, confusion, stroke
              like picture with focal deficits, seizure and coma
        B. Current and highest altitude, time at this altitude, duration of ascent
        C. Medical problems, medications, previous experience at altitude
        Document Specific Objective Findings
        A. Vital signs
        B. Mental status: confusion, lack of coordination, coma
        C. Lungs: respiratory rate, distress, rales, sputum (bloody or frothy)
        Treatment
        A. Put patient at rest in position of comfort.
        B. Administer oxygen.
        C. Suction as needed. Assist ventilation if patient has cyanosis, confusion, and
           poor respiratory effort.
        D. For Pulmonary Edema consider Continuous Positive Airway Pressure (CPAP)
           and if the patient fails to respond consider intubation.

IV      E. Establish venous access if conditions permit
        Specific Precautions
        A. Recognition of the problem is the most critical part of treating high altitude illness.
           While in the mountains, recognize symptoms which are out of proportion to those
           being experienced by the rest of the party: fatigue, or trouble breathing
           (particularly at rest).
        B. The mainstay of treatment is descent from altitude. Even a loss of 1,000 - 1,500
           feet makes enough difference in the oxygen content of air that symptoms may be
           relieved or stop progressing. Oxygen administration can also relieve symptoms
           and may allow more time for orderly evacuation.
        C. In addition to the more common pulmonary edema, cerebral edema may occur,
           with confusion and a stroke-like picture with focal deficits. Treatment is the
           same.
        D. Acute mountain sickness, the mild form of illness during altitude adaptation,
           consists of fatigue, headache, and poor sleeping, without severe CNS or
           respiratory symptoms. Treatment is rest. This increases the body's time to
           acclimatize. Descend if symptoms progress, or ataxia present.
        E. Commercial airlines pressurize cabins to a level equivalent to about 5,000 -
           8,000 feet.
        F. Patients at risk for high altitude illness for whatever reason may be taking
           Diamox (acetazolamide). Diamox may be useful in preventing some altitude


     Go to Table of Contents
       illness because of direct effects on acid-base balance. Diuretics are not useful,
       however, in treating high altitude pulmonary edema, because the cause is
       excess capillary leakage of fluid, rather than increased venous pressure.




Return to Table of Contents
                                         4052
                                DROWNING/NEAR-DROWNING
        Specific Information Needed
        A. How long patient was submerged?
        B. Degree of contamination, water temperature?
        C. Diving accident? Water depth?
        Specific Objective Findings
        A. Vital signs
        B. Neurologic status: monitor on a continuing basis.
        C. Lung exam: rales or signs of pulmonary edema, respiratory distress
        Treatment
        A. Clear upper airway of vomitus or large debris.
        B. Start CPR if needed.
        C. Stabilize neck prior to removing patient from water if any suggestion of neck
           injury.
        D. Suction as needed.
        E. Administer oxygen.
        F. If patient not awake and alert:
           1. Assist ventilation if necessary.
IV
            2. Establish venous access

            3. Consider use of Continuous Positive Airway Pressure (CPAP)

IN          4. Intubate when indicated and apply positive pressure ventilation.
            5. Monitor cardiac rhythm during transport; treat arrhythmias per protocol.

        G. Transport patient, even if normal by initial assessment.
        Specific Precautions
        A. Be prepared for vomiting. Patients should be secured on spineboard when
           indicated for log-rolling to protect the neck and manage the airway.
        B. All near-drownings should be transported. Even if patients initially appear fine,
           they can deteriorate. Monitor closely. Pulmonary edema often occurs due to
           aspiration, hypoxia, and other factors. It may not be evident for several hours
           after near-drowning.
        C. Beware of neck injuries - they often go unrecognized. Collar and backboard
           straps can be applied in the water.
        D. If patient is hypothermic, defibrillation and pharmacologic therapy may be
           unsuccessful until the patient is rewarmed. Prolonged CPR may be needed.
        E. Under current ACLS standards, Heimlich maneuver is not indicated.




     Go to Table of Contents
                                            4053
                                  HYPOTHERMIA AND FROSTBITE
          Specific Information Needed
          A.   Length of exposure
          B.   Air temperature, water temperature, winds, patient wet?
          C.   History and timing of changes in mental status
          D.   Drugs: alcohol, tranquilizers, anticonvulsants, others
          E.   Medical problems: diabetes, epilepsy, alcoholism, etc.
          F.   With local injury: history of thawing/refreezing?
          Specific Objective Findings
          A. Vital signs, mental status, shivering. (Prolonged observation for 1-2 min. may be
             necessary to detect pulse, respirations.)
          B. Skin temperature (estimated); also note current temperature of environment
          C. Evidence of local injury: blanching, blistering, erythema of extremities, ears,
             nose
          D. Cardiac rhythm
          Treatment
          A. Generalized:
             1. CPR, if no pulse
             2. Administer oxygen. Assist with bag-valve-mask as needed.
             3. Use appropriate airway adjunct only to protect airway or in absence of
                organized cardiac electrical activity.
             4. Avoid unnecessary suctioning or airway manipulation.
             5. Remove wet or constrictive clothes from patient. Wrap in blankets and
                protect from wind exposure. Increase ambient temperature in ambulance.
             6. Attempt defibrillation, if appropriate, up to 3 shocks.

               7. Establish venous access. Solution should be warmed if possible. Do not
IV                start IV until patient is moved to transport vehicle.

IN             8. Monitor cardiac rhythm.

               9. No more than one round of ACLS drugs should be administered to a
IN   CB           hypothermic patient in the prehospital setting.

          B. Local (frostbite):
             1. Remove wet or constricting clothing. Keep skin dry and protected from wind.
             2. Do not allow the limb to thaw if there is a chance that limb may refreeze
                before evacuation is complete, or if patient must walk to transportation.
             3. Rewarm minor "frostnip" areas by placing in axilla or against trunk under
                clothing.
             4. Dress injured areas lightly in clean cloth to protect from pressure, trauma or
                friction. Do not rub. Do not break blisters.
             5. Maintain core temperature by keeping patient warm with blankets, warm
                fluids, etc.
             6. Transport with frostbitten areas supported and elevated if feasible.



      Go to Table of Contents
   Specific Precautions
   A. HYPOTHERMIA:
      1. Shivering does not occur below 90˚ Fahrenheit. Below this the patient may
         not even feel cold, and occasionally will even undress and appear
         vasodilated.
      2. The heart is most likely to fibrillate below 85-88˚ Fahrenheit. Defibrillation
         should be attempted with no more than 3 shocks. Prolonged CPR may be
         necessary until the temperature is above this level.
      3. ALS drugs should be used sparingly, since peripheral vasoconstriction may
         prevent entry into central circulation until temperature is restored. At that
         time, a large bolus of unwanted drugs may be infused into the heart.
      4. Bradycardias are normal and should not be treated.
      5. If patient has organized monitor rhythm, CPR is currently felt to be
         unnecessary. In general, even very slow rates are probably sufficient for
         metabolic demands. CPR is indicated for asystole and ventricular fibrillation.
      6. Patients who appear dead after prolonged exposure to cold air or water
         should not be pronounced "dead" until they have been rewarmed. Full
         recovery from hypothermia with undetectable vital signs, severe bradycardia,
         and even periods of cardiac arrest has been reported.
      7. Rewarming should be accomplished with careful monitoring in a hospital
         setting, whenever possible.
      8. Consider other reasons for altered mental status.
   B. FROSTBITE:
      1. Thawing is extremely painful and should be done under controlled conditions,
         preferably in the hospital. Careful monitoring, pain medication, prolonged
         rewarming, and sterile handling are required.
      2. It is clear that rewarming followed by refreezing is far more injurious to
         tissues than delay in rewarming or walking on a frozen extremity to reach
         help. Do not rewarm prematurely. Indications for field rewarming are almost
         nonexistent.
      3. Warming with heaters or stoves, rubbing with snow, drinking alcohol and
         other methods of stimulating the circulation are dangerous and should not be
         used.




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                                              4054
                                          HYPERTHERMIA
          Specific Information Needed
          A. Patient age, activity level
          B. Medications: depressants, tranquilizers, alcohol, etc.
          C. Associated symptoms: cramps, headache, orthostatic symptoms, nausea,
             weakness
          Specific Objective Findings
          A. Vital signs: temperature; usually 104 degrees Fahrenheit or greater (if
             thermometer available)
          B. Mental status: confusion, coma, seizures, psychosis
          C. Skin flushed and warm to hot: with or without sweating
          D. Air temperature and humidity; patient dress
          Treatment
          A.   Use appropriate airway adjuncts as indicated.
          B.   Remove clothing.
          C.   Administer oxygen.
          D.   Cool with water-soaked sheets.

IV
          E. Establish venous access:
             1. TKO if vital signs stable
             2. IV fluid bolus of 20 ml/kg if signs of hypovolemia.

          F. Treat seizures with diazepam 1-10 mg slow IV push.
IN   CB

          G. If unable to obtain venous access after two attempts administer midazolam 1-5
P            mg IM.

          H. Monitor cardiac rhythm.
      .
          Specific Precautions
          A. Heat stroke is a medical emergency. It is distinguished by altered level of
             consciousness. Sweating may still be present, especially in exercise-induced
             heat stroke. The other persons at risk for heat stroke are the elderly and persons
             on medications which impair the body's ability to regulate heat.
          B. Differentiate heat stroke from heat exhaustion (hypovolemia of more gradual
             onset) and heat cramps (abdominal or leg cramps). Be aware that heat
             exhaustion can progress to heat stroke.
          C. Do not let cooling in the field delay your transport. Cool patient as possible
             while en route.
          D. Do not use ice water or cold water to cool patients, as these may induce
             vasoconstriction.




      Go to Table of Contents
                                        4055
                                  BITES AND STINGS
   Specific Information Needed
   A. Type of animal or insect.
   B. Time of exposure.
   C. Symptoms:
      1. Local: pain, stinging
      2. Generalized: dizziness, weakness, itching, trouble breathing, muscle cramps
   D. History of previous exposures, allergic reactions
   Specific Objective Findings
   A. Identification of spider, bee, marine animal if possible
   B. Local signs: erythema, swelling, heat in area of bite
   C. Systemic signs: hives, wheezing, respiratory distress, abnormal vital signs
   Treatment
   A. SNAKES: See Snake Bites.
   B. SPIDERS:
      1. Ice for comfort
      2. Bring in spider, if captured and contained or if dead, for accurate
         identification, if possible.
      3. Transport for observation if systemic signs and symptoms present.
   C. BEES AND WASPS:
      1. Remove sting mechanism. Do not squeeze venom sac if this remains on
         stinger, rather, scrape with straight edge.
      2. Observe patient for signs of systemic allergic reaction. Treatment per the
         Allergy/Anaphylaxis protocol and transport rapidly if needed
      3. Transport all patients with systemic symptoms or history of systemic
         symptoms from prior bites.
   Specific Precautions
   A. For all types of bites and stings, the goal of prehospital care is to prevent further
      inoculation and to treat allergic reactions.
   B. Allergy kits consist of injectable epinephrine and oral antihistamine, and are
      prescribed for persons with known systemic allergic reactions. Prehospital care
      personnel need not contact the resource hospital before assisting the patient with
      their own medication.
   C. About 60% of patients who have experienced a generalized reaction to a bite or
      sting in the past will have a similar or more severe reaction upon reinoculation.
      Thus, although it is not inevitable, this group of patients must be considered at
      high risk for anaphylaxis. In addition, a small group of patients will have
      anaphylaxis as a "first" reaction.
   D. Time since envenomation is important. Anaphylaxis rarely develops more than
      60 minutes after inoculation.




Go to Table of Contents
                                        4056
                                     SNAKE BITES
   Specific Information Needed
   A.   Appearance of snake (e.g. rattle, color, banding)
   B.   Time of bite
   C.   Prior first-aid by patient or friends
   D.   Symptoms: local pain and swelling, peculiar or metallic taste sensations. Severe
        envenomations may result in hypotension, coma, and bleeding.
   Specific Objective Findings
   A. Bite wound: location, configuration (1, 2, or 3 fang marks; entire jaw imprint,
      none)
   B. Snake identification: look for elliptical pupils, thermal pit and rattle
   C. Signs of envenomation: spreading numbness and tingling from the site, local
      edema and pain, ecchymosis, bleeding, hypotension. Mark time and extent of
      erythema and edema with pen.
   Treatment
   A. Remove patient and rescuers from area of snake to avoid further injury.
   B. Remove rings or other bands which may become tight with local swelling.
   C. Immobilize bitten part at heart level.
   D. Minimize venom absorption by keeping bite area still and patient quiet.
   E. Transport promptly for definitive observation and treatment.
   F. Do not use ice or refrigerants.
   G. For all suspected envenomations establish venous access and administer
      oxygen.
   H. Monitor vital signs, cardiac rhythm, and swelling.
   Specific Precautions
   A. The prairie rattlesnake is native to the Denver metro region. If the snake is dead,
      bring it in for examination. Do not jeopardize fellow rescuers by attempting to
      "round it up." Be careful: a dead snake may still reflexively bite and
      envenomate. Do not pick up with hands, even if dead. Use a shovel or stick.
   B. At least 25% of poisonous snake strikes do not result in envenomation.
      Conversely, the initial appearance of the bite may not reflect the severity of
      envenomation.
   C. Fang marks are characteristic of pit viper bites, such as from the rattlesnake,
      water moccasin, or copperhead, which are native to North America. Jaw prints
      (without fangs) are more characteristic of nonvenomous species.
   D. Ice can cause serious tissue damage. Never use!
   E. Exotic poisonous snakes, such as those found in zoos, have different signs and
      symptoms than those of pit vipers.




Go to Table of Contents
                                             4060
                                        SHOCK: MEDICAL
        Specific Information Needed
        A. Onset: gradual or sudden; precipitating cause or event
        B. Associated symptoms: itching, peripheral or facial edema, thirst, weakness,
           respiratory distress, abdominal or chest pain, dizziness on standing
        C. History: allergies, medications, blood in vomitus or stools, significant medical
           diseases, history of recent trauma, last menstrual period, vaginal bleeding, fever
        Specific Objective Findings
        A. Vital signs: pulse > 120 (occasionally < 50); Systolic BP < 90 mmHg
        B. Mental status: apathy, confusion, restlessness, combativeness
        C. Skin: flushed, pale, sweaty, cool or warm, hives, or other rash
        D. Signs of trauma
        E. Signs of cardiogenic shock: jugular venous distention in upright position, rales,
           peripheral edema
        F. In children <8 years old, 2 or more of the following signs: tachycardic for age,
           diminished capillary refill, thready pulses, cool extremities, poor color, altered
           mental status, diminished respiratory effort
        Treatment
        A. Administer oxygen.
        B. Cover patient to avoid excess heat loss. Do not over bundle.
        C. Assess for cardiogenic cause:

             1. If pulse is > 150 treat tachyarrhythmia according to protocol.
IN
             2. If pulse is < 60 treat bradyarrhythmia according to protocol.
             3. If distended neck veins, chest pain, or other evidence of cardiac cause:
                     a. Position of comfort
                     b. Be prepared to assist ventilations or initiate CPR.
                     c. Evaluate for possible tension pneumothorax

IV                  d. Establish venous access.

IN                  e. Monitor cardiac rhythm.

P       D. Consider dopamine.

        E. Transport rapidly for definitive diagnosis and treatment.
        F. If no evidence of cardiogenic cause, institute general treatment measures:
           1. Place patient supine, elevate legs 10-12 inches. (If respiratory distress
               results, leave patient in position of comfort.)

             2. Establish venous access.
IV           3. Administer IV Fluid bolus of normal saline.

        G. Assess and treat for specific cause, such as anaphylaxis, if this can be
           determined.



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   H. Monitor vital signs, cardiac rhythm, and level of consciousness during transport.
   Specific Precautions
   A. Shock in a cardiac patient may be caused by hypovolemia; however, contact
      should be made with base prior to administering fluid boluses.
   B. Mixed forms of shock are treated as hypovolemia, but the other factors
      contributing to the low perfusion should be considered. Neurogenic shock is
      caused by relative hypovolemia as blood vessels lose tone, either from spinal
      cord trauma, drug overdose, or sepsis. Cardiac depressant factors can also be
      involved. Anaphylaxis is a mixed form of shock with hypovolemic, neurogenic,
      and cardiac depressant components. Epinephrine is used in addition to fluid
      load.
   C. Cardiogenic shock from various causes is difficult to treat even in a hospital
      setting. Rapid transport is recommended.

 SHOCK: MEDICAL
 Mechanism/Causes                     Differential/Symptoms
 HYPOVOLEMIA
 Dehydration                          suggestive illness
 Vomiting, diarrhea
 Diabetes with hyperglycemia          Diabetes; acute illness, increased urine or blood
                                      loss, thirst, fever
 Ectopic pregnancy                    female, 12-50 years, abdominal pain
 GI bleed                             bloody vomitus, black or red stool
 Ruptured abdominal aneurysm          severe back/abdomen pain, age, history of high
                                      blood pressure
 Vaginal bleeding                     suggestive history, miscarriage, abortion or
                                      delivery
 Intra-abdominal bleeding             minor trauma; abdominal, back, or shoulder pain
 CARDIOGENIC
 Arrhythmia                           palpitations
 Pericardial tamponade                chest area cancer, blunt or penetrating trauma
 Tension pneumothorax                 respiratory distress, COPD, trauma
 Myocardial failure                   chest pain, history of congestive failure
 Pulmonary embolus                    sudden respiratory distress, chest pain, SOB
 MIXED
 Sepsis symptoms                      fever, elderly, urinary symptoms
 Drug overdose                        suggestive history
 Anaphylaxis                          SOB, itching, mouth swelling, dizziness, exposure
                                      to allergen




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                                                4070
                                       PSYCHIATRIC/BEHAVIORAL
            Specific Information Needed
            A. Obtain history of current event, inquire about recent crisis, toxic exposure, drugs,
               alcohol, emotional trauma, suicidal or homicidal ideation
            B. Obtain past history; inquire about previous psychiatric and medical problems,
               medications.
            Specific Objective Findings
            A.   Evaluate vital signs.
            B.   Note medic alert tags, odor to breath.
            C.   Determine ability to relate to reality.
            D.   Note hallucinations and behavior.
            Treatment
            A. Attempt to establish rapport.
            B. Assure airway.
            C. Restrain if necessary.
            D. Chemical restraint if needed
                    a. Midazolam (Versed)
                    b. Diphenhydramine 50mg as a synergist (not stand alone treatment)
                                OR
                    c. Diazepam 1-10mg slow IVP
                    d. DO NOT USE BOTH VERSED AND DIAZEPAM ON THE SAME
                        PATIENT
            E. Monitor vital signs.
            F. If altered mental status or unstable vital signs:
               1. Administer oxygen.
               2. Establish venous access.
IV             3. Draw appropriate blood tubes.
               4. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood
                    glucose <60 and if clinically indicated.
IN             5. Administer naloxone up to 2 mg IV or IN (may also be administered IM or IO)
CB                  in patients with decreased respiratory effort and observe patient for improved
                    ventilations. (EMT-IV can only give naloxone IV or IN)
               6. If EMT-IV, contact base for consideration of administration of Naloxone as
                    described above
               7. If venous access is unsuccessful and unable to administer dextrose,
                    administer Glucagon 1 mg, IM.

                 8. Consider Diazepam 1-10 mg slow IV bolus for stimulant use.

            Specific Precautions
            A. Psychiatric patients often have an organic basis for mental disturbances.
     P         Beware of hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion.
            B. If emergency treatment is unnecessary, do as little as possible except to
               reassure while transporting. Try not to violate the patient's personal space.




         Go to Table of Contents
   C. If the situation appears threatening, consider a show of force involving police
      before attempting to restrain.
   D. Beware of weapons. These patients can become very violent.

   E. The paramedic may initiate a Mental Health Hold only with the permission and
      online contact with the BASE PHYSICIAN.




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                                        4080
                         OBSTETRICS/GYNECOLICAL EMERGENCIES
        Specific Information Needed
        A. Symptoms: pain, cramping, passage of clots or tissue, dizziness, weakness; if
           pregnant, inquire about swelling of face and extremities, urge to push,
           contractions (regularity and timing), ruptured membranes, fever
        B. Obtain menstrual history: last normal menstrual period, duration of period,
           amount of flow, birth control method
        C. If pregnant, inquire about due date, prior problems with pregnancy.
        D. Past and present history of hypertension (preeclampsia/eclampsia)
        E. Past history: bleeding problems, pregnancies, medications, allergies
        Specific Objective Findings
        A. Vital signs and orthostatic changes
        B. Evidence of blood loss, clots or tissue fragments; bring tissue to the ED
        C. Signs of hypovolemic shock, altered mental status, hypotension, tachycardia,
           sweating, pallor
        D. Fever
        E. If pregnant, observe for contractions and relaxation of uterus. Where privacy is
           possible, examine perineum by observation only for:
           1. Vaginal bleeding or fluid (note color)
           2. Crowning (check during contraction)
           3. Abnormal presentation (i.e. foot, arm, face, or cord)
        Treatment
        A. If patient is bleeding vaginally (moderate to heavy):
           1. Administer oxygen.
           2. If hypotensive and pregnant, position onto left side.

            3. Establish venous access.
IV          4. If hypotensive, give IV fluid bolus of normal saline, further fluids as directed
               and consider a second line.

        B. If patient is delivering:
           1. Use clean or sterile technique.
           2. Administer oxygen.
           3. Guide and control but do not retard or hurry the delivery.
           4. Suction the mouth (not throat) then nose with a bulb syringe.
           5. Protect the infant from fall and temperature loss; wipe off amniotic fluid and
               wrap in a clean or sterile blanket, check vital signs, provide CPR as indicated.
           6. Clamp the umbilical cord in two places approximately 8-10" from the infant.
           7. Cut the cord between the clamps.

IV          8. Establish venous access in mother and monitor vital signs.

            9. Do not wait for or attempt delivery of placenta before transporting. If placenta
               delivers spontaneously bring it to the hospital.




     Go to Table of Contents
        C. If patient is bleeding in the postpartum period (within 24 hours of delivery):
           1. Massage uterus and have mother nurse infant to aid in uterine contractions.
           2. Administer oxygen.

IV          3. Establish venous access.
        Specific Precautions
        A. If patient is in late pregnancy and there is crowning or other indication of
           imminent delivery, deliver or transport. Be prepared to stop ambulance for
           delivery while enroute.
        B. Amount of vaginal bleeding is difficult to estimate. Try to get an estimate of
           number of saturated pads in previous 6 hours.
        C. Transport immediately any pregnant patient with an abnormal presenting part or
           vaginal bleeding.
        D. A patient in shock from vaginal bleeding should be treated like any other patient
           with hypovolemic shock.
        E. If patient is pregnant, bring in any tissue that was passed. Laboratory analysis
           may be important in determining status of pregnancy.
        F. Always consider pregnancy as a cause of vaginal bleeding. The history may
           contain inaccuracies, denial, or wishful thinking.
        G. If the patient is pregnant, ask if she feels as though she is delivering. Particularly
           with prior deliveries, most mothers will know.
        H. The primary enemy of newborns is hypothermia, which can occur within minutes
           due to increased evaporative heat loss resulting from the infant's large body
           surface area and the presence of amniotic fluid.
        I. Record an APGAR score with vital signs, at one and five minutes.
IN
        J. Consider early tracheal suctioning after delivery of the infant with evidence of
           meconium.

     APGAR Score


     Sign                       0                1                           2

     Muscle tone (Activity)     Limp             Some flexion                Active, good flexion
     Pulse                      Absent           <100/min                    =100/min
     Reflex irritability*       No response      Some grimace or             Cough, cry or sneeze
     (Grimace)                                   avoidance
     Color (Appearance)         Blue, pale       Pink body, blue             Pink
                                                 hands/feet
     Respirations               Absent           Slow, irregular,            Crying, rhythmic, effective
                                                 ineffective

     *Nasal or oral suction catheter stimulus




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                                         4090
                                   EXCITED DELIRIUM

Purpose
       Excited Delirium is a potentially lethal medical condition that often presents itself
as a law enforcement issue. This protocol is to guide EMS interaction with persons who
present with excited delirium.

General Principles
         Excited Delirium seems to be a commonality in patients suffering cardiac arrest
after struggling with law enforcement, EMS or hospital staff. Patients who seem to be
prone to Excited Delirium generally fall into one of three categories.
         1. Those suffering from psychiatric illness, eg., schizophrenia or bipolar disorder
         2. Illicit substance users, especially stimulant drugs such as cocaine and
            methamphetamine, and chronic alcohol abusers
         3. A combination of mental illness and substance abuse
The patient presents with bizarre, violent behavior that usually leads them to be
contacted by law enforcement. There are often acts of aggression against persons or
property, with particular affinity to shiny, inanimate objects and may include breaking
glass. They are further found to be paranoid, often shout incoherently; They don’t seem
to be able to effectively communicate. They appear to be impervious to pain. As a result,
traditional methods of gaining compliance using pain are often ineffective. Often they
demonstrate superhuman strength and can battle multiple people for long periods of
time. They are almost always hyperthermic. These patients tend to disrobe and are often
found fully unclothed. Patients seem to follow a pattern that culminates in full cardiac
arrest preceded by a period of calm, listlessness that may be mistaken as compliance.
When patients progress to full arrest, they are most times refractory to treatment.

Procedure
      1. Be aware of the signs and symptoms of Excited Delirium
      2. Be prepared for the patient to have a full cardiac arrest, particularly if they
           suddenly become calm.
      3. Consider Midazolam (Versed) or Diazepam (Valium) for chemical restraint.
      4. If at all possible, keep the patient supine while attempting to control them
      5. Keep in mind that these patients will not respond to pain
      6. As soon as it is feasible, begin continuous monitoring of vital signs, EKG,
           SpO2, and ETCO2
      7. There is conjecture that hypoventilation is ultimately what causes the cardiac
           arrest so be prepared to assist in ventilations in patients who suddenly
           become calm even though they have a patent airway.
Special Notes
   1. While these patients will generally declare themselves, it is imperative that they
      are transported by Advanced Life Support.
   2. Law enforcement may request that the patient go to jail but responders must
      reinforce that this is a significant medical problem that requires ALS transport.
   3. It is not uncommon for these patients to have been exposed to a Conducted
      Energy Weapon such as a Taser, multiple times.
   4. Current reports are showing possible links that Taser use in conjunction with
      excited delirium increases mortality.
See Protocol: Taser


Go to Table of Contents
                                      5000
                           MULTIPLE TRAUMA OVERVIEW
   Specific Information Needed
   A. Mechanism of injury:
      1. Cause, precipitating factors, weapons used
      2. Trajectories and forces involved
      3. For vehicular trauma:
           a. Specific description of mechanism such as auto vs. pole, rollover,
                broadside, high speed
           b. Condition of vehicle including windshield, steering wheel, compartment
                intrusion, condition of dashboard/firewall/pedals, type and use of
                seatbelts, supplemental restraint system (e.g. airbag) deployment
      4. Helmet use; motorcycle, bicycle, skiing, snowboarding, skateboarding,
           rollerblading
   B. Patient complaints.
   C. Initial position and level of consciousness of patient.
   D. Patient movement, treatment since injury
   E. Other factors such as drugs, alcohol, medications, diseases, pregnancy
   Specific Objective Findings
   A. Scene evaluation:
      1. Note potential hazard to rescuers and patient.
      2. Identify number of patients; organize triage operations if appropriate
      3. Observe position of patient, surroundings, probable mechanism, and vehicle
          condition.
   B. Patient evaluation: see treatment below
   Treatment
   A. Initial assessment in multiple trauma is performed at the same time as treatment.
   B. Airway with spinal precautions and immobilization
   C. Breathing
   D. Circulation, with control of major bleeding
   E. Transport decision
      1. If patient unstable, transport immediately. Treat enroute.
      2. If patient stable, assess for potentially life-threatening injuries and treat
           accordingly.
   F. Monitor vital signs, neurologic status and cardiac rhythm enroute.
   G. CONTACT BASE.
   Specific Precautions
   A. Assessment and management of trauma in the field has changed considerably in
      the past 5 years. There are patients who cannot tolerate a full assessment before
      life saving intervention is needed. Likewise, splinting, bandaging, and, often, the
      focused history and physical examination are procedures that may need to be
      bypassed in the critical patient. Time and the treatment available in a trauma
      center are critical elements in resuscitation. Therefore, with severely injured
      patients, it is most appropriate to rapidly transport (“load and go”) the patient




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        rather than using extended stabilization or the old "grab and run," with no trauma
        stabilization or care rendered.
   B.   Critical injuries involve:
        1. Difficulty with respiration.
        2. Difficulty with circulation (hypoperfusion a.k.a. shock).
        3. Decreased level of consciousness.
        4. Any trauma patient with one or more of these above conditions is a "load and
             go," with treatment occurring enroute.
   C.   Even in the noncritical patient with significant injury, "stabilization in the field"
        does not occur. With major injuries, the very most you can do is to buy time. If
        the initial bolus of fluids results in improved vitals, do not become complacent.
        This patient frequently needs blood and an operating room to truly "stabilize" the
        traumatic process. Rapid transport is still the highest priority.
   D.   Serial vital signs and observations of respiratory, circulatory and neurologic
        status prior to arrival are critical.
   E.   The trauma patient is the greatest risk to the rescuer for exposure to "bodily
        fluids." Use all appropriate body substance isolation precautions.




Return to Table of Contents
                                             5010
                                        TRAUMA ARREST
        Specific Information Needed
        A. Time of arrest
        B. Mechanism: blunt vs. penetrating
        C. Signs of irreversible death (decapitation, dependent lividity, etc.)
        Specific Objective Findings
        A. Vital signs
        B. Evidence of massive external blood loss
        C. Evidence of massive blunt head, thorax or abdominal trauma
        Treatment
        A. Blunt trauma arrest:
           1. Initiate basic life support
           2. Use appropriate airway adjuncts as indicated. Administer oxygen.
           3. If no vital signs or other signs of life present after above treatments, consider
              field pronouncement.
           4. If pulse returns with above treatment, treat per protocol and transport rapidly
              to a Level I or II trauma center.
           5. CONTACT BASE.
        B. Penetrating trauma arrest:
           6. Initiate basic life support
           1. Use appropriate airway adjuncts as indicated. Administer oxygen
           2. Begin rapid transport.
           3. CONTACT BASE to report patient status.

            4. Establish venous access, administer IV fluid bolus of normal saline.
IV
            5. If cardiac activity returns with above treatment, treat arrhythmias per
               protocols.
            6. Consider field pronouncement (See Resuscitation and Field Pronouncement)
               Guidelines for the following:
               a. Signs of irreversible death
               b. ALS has been unavailable for at least 20 minutes from the time EMS
                    personnel initiate on-scene assessment and there is no return of vital
                    signs or signs of life
        Specific Precautions
        A. Victims of blunt trauma arrest without vital signs at the scene after initiation of
           ALS have a mortality rate of nearly 100%.
        B. Trauma arrests secondary to penetrating truncal injuries can be resuscitated and
           saved. There is a higher rate of survival in victims of low velocity penetrating
           injuries versus victims of high velocity injuries.




     Go to Table of Contents
                                              5020
                                           AMPUTATIONS
        Specific Information Needed
     History: time and mechanism of amputation; care for severed part prior to rescuer
     arrival
     Past history: medications, bleeding disorders, medical problems
        Specific Objective Findings
        A.   Vital signs
        B.   Other injuries
        C.   Blood loss at scene
        D.   Structural attachments in partial amputations if identifiable
        Treatment
        A.   Manage airway and breathing
        B.   Resuscitate and treat other more urgent injuries.
        C.   Control hemorrhage with direct pressure, elevation.
        D.   If hypotension or signs of shock:

             1. Establish venous access.
IV
             2. Fluid bolus: normal saline
             3. CONTACT BASE.

        E. Patient: gently cover stump with sterile dressing. Saturate with sterile saline.
           Cover with dry dressing. Elevate.
        F. Severed part: wrap in sterile gauze, preserving all amputated material. Moisten
           with sterile saline. Place in watertight container (specimen cup, plastic bag, etc).
           Place container in cooler with ice (do not freeze).
        G. CONTACT BASE for optimal transport destination.
        Specific Precautions
        A. Partial amputations should be dressed and splinted in alignment with extremity to
           ensure optimum blood flow. Avoid torsion in handling and splinting.
        B. Do not use dry ice to preserve severed part.
        C. Control all bleeding by direct pressure only to preserve tissues. The most
           profuse bleeding may occur in partial amputations, where cut vessel ends cannot
           retract to stop bleeding. Never clamp bleeding vessels.
        D. Many factors enter into the decision to attempt replantation (age, location,
           condition of tissues, other options). A decision regarding treatment cannot be
           made until the patient and part have been examined by a physician and may not
           be made at the primary care hospital. Try to help the family and patient
           understand this, and don't falsely elevate hopes.




     Go to Table of Contents
                                              5030
                                          HEAD TRAUMA
        Specific Information Needed
        A. History: mechanism of injury, estimate of force involved; helmet use.
        B. History since injury: loss of consciousness (duration), change in level of
           consciousness, memory loss for events before and after trauma, movement
           (spontaneous or moved by bystanders), seizure activity
        C. Past history: medications (esp. insulin), medical problems, seizure history,
           alcohol or drug use
        Specific Objective Findings
        A. Vital signs (note respiratory pattern and rate)
        B. Neurologic assessment: Glasgow Coma Score
        C. External evidence of trauma: contusions, abrasions, lacerations, drainage from
           nose, ears
        Treatment
        A. Assess airway and breathing; treat life threatening conditions. Use assistant to
           provide in-line cervical immobilization when indicated, while managing respiratory
           difficulty.
        B. Administer oxygen.
        C. Control hemorrhage. Stop scalp bleeding with direct pressure. Continued
           pressure may be needed.
        D. TRANSPORT RAPIDLY if patient has multiple injuries, or unstable neurologic,
           respiratory or circulatory status.
        E. Obtain initial vital signs, neurologic assessment.
        F. If unconscious:
           1. Assist ventilations.
           2. Consider airway adjuncts
           3. Ventilate at 10 breaths per minute for adults (15 breaths for children, 20
                breaths for infants).
           4. If signs of cerebral herniation are present, hyperventilate at 20 bpm for adults
                (30 bpm for children, 35 bpm for infants).
           5. CONTACT BASE.
        G. Immobilize cervical, thoracic and lumbosacral spine when indicated.
        H. If signs of hypovolemic shock are present, initiate treatment en route:

             1. Establish venous access.
IV           2. Fluid bolus of normal saline.

             3. Look carefully for possible sources of bleeding (abdomen, pelvis, chest).
             4. CONTACT BASE.
        I.   If patient stable:

IV           1. Establish venous access.

             2. Complete detailed assessment.
             3. Splint fractures and dress wounds if time permits.



     Go to Table of Contents
   J. Monitor and record airway, vital signs, and level of consciousness repeatedly at
      scene and during transport. Status changes are important.
   Specific Precautions
   A. When head injury patients deteriorate, check first for airway, oxygenation and
      blood pressure. These are the most common causes of "neurologic"
      deterioration. If the patient has tachycardia or hypotension, evaluate for
      hypovolemia from associated injuries.
   B. Secondary brain injury and adverse outcomes can occur in brain-injured patients
      who exhibit hypotension and/or hypoxia. Early aggressive treatment of
      hypotension and administration of high flow oxygen may prevent further injury.
   C. The most important information you provide for the base physician is level of
      consciousness and its changes. Is the patient stable, deteriorating or improving?
   D. Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent
      cause of death in head injury.
   E. Hypoventilation aggravates cerebral edema.
   F. Scalp lacerations can cause profuse bleeding, and are difficult to define and
      control in the field. If direct local pressure is insufficient to control the bleeding,
      evacuate any large clots from flaps and large lacerations with sterile gauze, and
      use direct hand pressure to provide hemostasis. If the underlying skull is
      unstable, pressure should be applied to the periphery of the laceration over intact
      bone.
   G. Routine prophylactic hyperventilation should be avoided. It has been shown to be
      detrimental to cerebral blood flow and patient outcome. Hyperventilation in the
      field for head trauma is indicated only when signs of cerebral herniation such as
      extensor posturing or pupillary abnormalities (asymmetric or bilaterally fixed and
      dilated pupils) are present after correcting hypotension and/or hypoxemia.




Return to Table of Contents
                                             5040
                                    FACE AND NECK TRAUMA
        Specific Information Needed
        A. Mechanism of injury: impact to steering wheel, windshield, or other objects;
           clothesline type injury to face or neck; blunt object to head, face, or neck
        B. Management before arrival by bystanders, first responders
        C. Patient complaints: areas of pain; trouble with vision, hearing; neck pain; dental
           occlusion, tooth loss; short of breath
        D. Past medical history: medications, medical illnesses
        Specific Objective Findings
        A. Vital signs
        B. Airway: jaw or tongue instability, loose teeth, vomitus or blood in airway, other
           evidence of impairment or obstruction
        C. Neck: tenderness, crepitation, hoarseness, bruising, swelling, stridor
        D. Blood or drainage from ears, nose
        E. Level of consciousness, evidence of head trauma
        F. Injury to eye: lid laceration, blood anterior to pupil, abnormal pupil, abnormal
           globe position
        Treatment
        A. Control airway with cervical spine immobilization if indicated:
           1. Open airway using jaw thrust, keeping neck in alignment with in-line cervical
              immobilization.
           2. Use finger sweep to remove oral foreign bodies.
           3. Suction blood and other debris.
           4. Stabilize tongue and mandible with chin lift. Manual traction of the tongue
              may be necessary to keep posterior pharynx open as needed.
           5. Note evidence of laryngeal injury and transport immediately if signs present.
           6. If bleeding is severe, attempt to manage with suctioning, oral airway, and
              bag-valve-mask.
           7. Support breathing as needed.
           8. Use appropriate airway adjuncts as indicated.

IN          9.   If intubation cannot be performed due to severe facial injury, attempt to
                 manage with suctioning and bag-valve-mask.
P
            10. If necessary, consider percutaneous cricothyrotomy

        B. Administer oxygen.
        C. Control hemorrhage, check pulse and circulation.

        D. Establish venous access:
IV         1. TKO if stable
           2. With signs of hypovolemia:
              a. Fluid bolus of normal saline; CONTACT BASE.




     Go to Table of Contents
   E. Cover injured eyes with protective shield or cup; avoid pressure or direct contact
      to eye.
   F. Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing
      to avoid contamination.
   G. Bring avulsed teeth with you. Keep moist in saline soaked gauze.
   H. Monitor airway closely during transport for development of obstruction or
      respiratory distress. Suction and treat as needed.
   Specific Precautions
   A. Fracture of the larynx should be suspected in patients with respiratory distress,
      abnormal voice, and history of direct blow to neck from steering wheel, rope,
      fence wire, etc. Both intubation and percutaneous cricothyrotomy may be
      unsuccessful in the patient with a fractured larynx, and attempts may result in
      increased injury. Transport rapidly for definitive treatment if you suspect this
      potentially lethal injury. Do not attempt intubation or percutaneous
      cricothyrotomy unless the patient is in severe respiratory distress. Bag-valve-
      mask ventilation is preferred.
   B. Airway obstruction is the primary cause of death in persons sustaining head and
      face trauma. Meticulous attention to suctioning and basic airway maneuvers
      may be the most important treatment rendered.
   C. Remember that the apex of the lung extends into the lower neck and may be
      injured in penetrating injuries of the lower neck, resulting in pneumothorax or
      hemothorax.
   D. Do not be concerned with contact lens removal in the field.
   E. When midface fractures are suspected, nasotracheal intubation is
      contraindicated.
   F. No nasotracheal intubation under age 12.




Return to Table of Contents
                                             5050
                                        SPINAL TRAUMA
        Specific Information Needed
        A. Mechanism of injury and forces involved: be suspicious with falls, decelerations,
           diving accidents and motor vehicle accidents.
        B. Past medical problems and medications
        Specific Objective Findings
        A. Vital signs, including neurological assessment
        B. Level of sensory and motor deficit; presence of any evidence of neurological
           function below level of injury
        C. Physical exam, with careful attention to organs or limbs which may not have
           sensation
        Treatment
        A. Assess airway and breathing; treat life threatening difficulties. Use controlled
           ventilation for high cervical cord injury associated with abdominal breathing. Use
           assistant to provide in-line cervical immobilization while managing ABCs.
        B. Administer oxygen.
        C. Control hemorrhage.
        D. Immobilize cervical, thoracic and lumbosacral spine as indicated.
        E. Obtain and record vital signs and neurologic assessment before and after
           immobilization.

IV      F. Establish venous access. If signs of hypovolemia: fluid bolus of Normal Saline,
           CONTACT BASE

        G. Monitor airway, vitals, and neurologic status frequently at scene and during
           transport.
        Specific Precautions
        A. Be prepared to turn entire board on side if patient vomits (patient must be
           secured to spine board or scoop stretcher).
        B. Neurogenic shock is likely with significant spinal cord injury. If present, elevate
           legs 10-12 inches. Ensure adequate respirations.
        C. If hypotension is unresponsive to simple measures, it is likely due to other
           injuries. Neurological deficits make other injuries hard to evaluate. Cord injury
           above the level of T-8 makes the abdominal examination unreliable.
        D. Spinal immobilization in patients with penetrating trauma should be accomplished
           only when neurological deficit or impaled foreign body is present.
        E. It is important from a clinical and medical legal perspective to record neurological
           assessment before and after spinal immobilization.




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                                        5055
                          SELECTIVE SPINAL IMMOBILIZATION
The purpose of this protocol is to minimize unnecessary application of
spinal precautions in trauma or potential trauma patients.
Selective Spinal Immobilization may only be performed by EMTs or
Paramedics trained in this procedure, and approved by their medical
director.
1. Patients who meet the following criteria may be excluded from spinal precautions. All
   other patients must be placed in spinal immobilization
2. This protocol is for the patient over the age of 12 and under the age of 60

Assessment - Mental Status, Speech and History
      1. There is no complaint of neck or back tenderness or pain elicited either while
         obtaining a history or from the physical exam.
      2. The patient is reliable
      3. There is no significant language barrier
      4. There is no history or appearance of drug or alcohol ingestion.
      5. The patient is alert and oriented to person, place, time and event.
      6. The history and exam exclude mental retardation, senility, Alzheimer's disease,
         stroke, significant closed head injury, anoxia or hypovolemia.
      7. There is no distracting social or emotional situation in which the patient cannot
         focus on his/her physical condition.
      8. There is no potentially distracting injury such as a painful extremity or
         abdominal injury.
Assessment - Physical
If at any time, pain or discomfort occurs as a result of the exam, stop the assessment
and immobilize the patient.
1. Palpate down the spinal cord including the occipital notch at the top and the sacrum at
the bottom.
2. Have the patient shrug their shoulders against resistance.
3. Have the patient turn their head against resistance.
4. Test for motor strength, weakness, numbness, tingling, focal deficits or other
paresthesias or discomfort by having the patient move each joint against resistance and
compare to the opposite side. Be methodical.
   1.   Have the patient spread their fingers against your resistance
   2.   Have the patient squeeze your hands
   3.   Have the patient flex wrist against your resistance
   4.   Have the patient extend wrist against your resistance
   1.   Have the patient flex their elbow against your resistance
   2.   Have the patient extend their elbow against your resistance
   3.   Have the patient flex their hip
   4.   Have the patient extend their knee
   5.   Have the patient flex their knee
   6.   Have the patient dorsiflex their ankle
   7.   Have the patient plantar flex their ankle


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If there is notable weakness, determine if the weakness if unilateral or bilateral.

Special Considerations
Do not use in the elderly over the age of 60. Arthritic spinal rigidity
and osteoporosis can result in increased risk of injury even with minor
mechanism such as a ground level fall. There is a high degree of
peripheral neuropathy in the elderly, therefore complaints of pain are
unreliable.
Being ambulatory does not exclude spinal immobilization.
If the patient does not meet these criteria for exclusion, spinal
immobilization should be applied. It is inappropriate to walk a patient to
the ambulance and have them lie down on a board.
Immobilization devices, once applied, may require re-adjustment while
maintaining alignment, but shall not be removed.
Once applied, immobilization devices shall only be removed by the
receiving facility physician.
A patient may refuse any treatment being rendered at any time. If a
patient is refusing spinal precautions, the risks involved must be
relayed and the proper documentation of the patients condition and
associated risks must be documented on a patient care report or
refusal form that the patient signs.
Patients immobilized on devices are prone to losing body heat. Keep
the patient warm.




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                                              5060
                                          CHEST INJURY
        Specific Information Needed
        A. Patient complaints: chest pain type (pleuritic, positional, location sharp, dull, etc.)
           respiratory distress, neck pain, other areas of injury.
        B. Mechanism: amount of force involved (particularly deceleration), speed of impact,
           seatbelt use/type, airbag.
        C. Penetrating trauma: size of object, caliber of bullet, trajectory, distance from
           patient.
        D. Past medical history: medications, prior medical problems.
        Specific Objective Findings
        A. Observe: wounds, air leaks, chest wall movement, neck veins
        B. Palpate: tenderness, crepitation, tracheal position, tenderness on sternal
           compression, pulse pressure
        C. Auscultate: breath sounds, heart sounds (quality)
        D. Surroundings: vehicle, steering wheel condition, dashboard.
        Treatment
        A. Clear and open airway. Immobilize cervical spine, if indicated.
        B. Use appropriate airway adjuncts as indicated.
        C. Assist breathing if patient is apneic or respirations depressed.
        D. Administer oxygen.
        E. If penetrating injury present, transport rapidly with further stabilization en route.
        F. For open chest wound with air leak, use Vaseline type gauze or occlusive
           dressing taped on three sides only, to allow air to escape but not enter the chest.
        G. Observe chest for paradoxical movements.
        H. Obtain baseline vital signs, neurologic assessment.
           1. If the patient is in shock transport rapidly to a trauma center and CONTACT
               BASE.
IV           2. If neck veins flat and patient in shock, transport rapidly and treat hypovolemia
                en route:
                    a. Establish venous access.
                    b. Fluid bolus: normal saline
IN                  c. Monitor cardiac rhythm.

             3. If patient in shock with neck veins distended, also transport rapidly, and
                consider:
                    a. Tension pneumothorax if respiratory status markedly deteriorating
                        with clinical findings of pneumothorax:
                              i. Release occlusive dressings on open chest wounds.
P
                            ii. Needle decompression; CONTACT BASE for orders

                    b. Pericardial tamponade, if suggested by clinical findings (distant heart
                       sounds, narrow pulse pressure):



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                             i. Establish venous access.
IV                          ii. Fluid bolus: normal saline

                    c. Cardiac contusion with typical ischemic chest pain or severe chest
IN                     wall contusion:
                            i. Monitor cardiac rhythm.

             4. If patient stable without signs or symptoms of shock:
                    a. Complete focused assessment.
                    b. If significant injury suspected:

IV                          i. Establish venous access.
IN
                            ii. Monitor cardiac rhythm en route.
        I. Immobilize impaled objects in place with dressings to prevent movement. Large
           objects may require manual stabilization during transport.
        J. Monitor and record vital signs, and level of consciousness every five minutes with
           significant injury.
        Specific Precautions
        A. Chest trauma is treated with difficulty in the field and prolonged treatment before
           transport is not indicated if significant injury is suspected. If patient is critical,
           transport rapidly and avoid treatment of nonemergent problems at the scene.
           Penetrating injury particularly should receive immediate transport with minimal
           intervention in the field.
        B. Consider medical causes of respiratory distress such as asthma, pulmonary
           edema or COPD that have either caused trauma or been aggravated by it.
        C. Chest injuries sufficient to cause respiratory distress are commonly associated
           with significant blood loss. Consider hypovolemia.
        D. Myocardial contusion can occur, particularly with sudden deceleration injury, as
           from a steering wheel. Pain is similar to myocardial infarct pain. Monitor the
           patient and treat arrhythmias as in a medical patient, but think first of hypoxia and
           hypovolemia as potential causes of arrhythmias.
        E. Check the back for injuries, especially the patient in shock, where a cause is not
           evident (check the back, axillary region and base of neck).
        F. Significant intrathoracic injuries can exist without external signs of injury.




     Return to Table of Contents
                                             5070
                                       ABDOMINAL TRAUMA
        Specific Information Needed
        A. Patient complaints
        B. For penetrating trauma: weapon, trajectory
        C. For auto: condition of steering wheel, dash, vehicle; speed, patient trajectory;
           seatbelts in use, airbag deployment
        D. Past history: medical problems, medications, pregnancy, drugs, alcohol
        Specific Objective Findings
        A. Observe: distention, bruising, entrance/exit wounds
        B. Palpate: areas of tenderness, guarding; pelvis stability to lateral and suprapubic
           compression
        Treatment
        A. Stabilize life threatening airway and circulatory problems first.
        B. Administer oxygen.
        C. Observe carefully for signs of blood loss. If signs of shock:
           1. Rapid transport

            2. Establish venous access. Consider second IV using large bore catheter.
IV
            3. Administer fluid bolus of normal saline if clinically indicated; further fluids as
               directed.
            4. CONTACT BASE.

        D. For penetrating injuries: cover wounds and eviscerations with moist saline gauze
           to prevent further contamination and drying. Do not attempt to replace.
        E. Monitor vital signs during transport.
        Special precautions
        A. The extent of abdominal injury is difficult to assess in the field. Be very
           suspicious; with significant blunt trauma, injuries to multiple organs are the rule.
        B. Patients with spinal cord injury, altered sensorium due to drugs or alcohol, head
           injury or significant distracting injuries (i.e. long bone fractures) may not complain
           of tenderness and may lack guarding in the face of significant intra abdominal
           injury.
        C. Seatbelts, steering wheels, and other blunt objects may cause occult intra
           abdominal injury that is not apparent until several hours after the trauma. You
           must consider forces involved to properly assess and treat a trauma victim.
        D. In children, significant intra-abdominal injury, which may lead to shock, may be
           present without any external signs of injury, such as abrasions or hematomas.
        E. The pregnant patient deserves special attention during transport. Transport the
           patient on her side or angle backboard to prevent Supine Hypotension Syndrome
           from uterine compression of the inferior vena cava.




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                                              5080
                                        EXTREMITY INJURIES
          Specific Information Needed
          A. Mechanism of injury: direction of forces, if known
          B. Areas of pain, swelling or limited movement
          C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations,
             movement of patient
          D. Past medical history: medications, medical illnesses
          Specific Objective Findings
          A. Vital signs
          B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone
             fragments, loss of function, guarding
          C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation
          D. Note estimated blood loss at scene.
          Treatment
          A. Treat airway, breathing, and circulation as first priorities.
          B. Immobilize cervical spine when appropriate.
          C. Examine for additional injuries to head, face, chest, and abdomen; treat those
             problems with higher priority first.
          D. If patient unstable, transport rapidly, treating life threatening problems en route.
             Splint patient to minimize fracture movement by securing to long board.
          E. If patient stable, or isolated extremity injury exists:
             1. Check and record distal pulses and sensation prior to immobilization of
                 injured extremity.
             2. Apply sterile dressing to open fractures. Note carefully wounds that appear
                 to communicate with bone.
             3. Splint areas of tenderness or deformity: apply gentle traction throughout
                 treatment and try to immobilize the joint above and below the injury in the
                 splint.
             4. Realign angulated fractures by applying gentle axial traction if indicated:
             5. To restore circulation distally
             6. To immobilize adequately, i.e., realign femur fracture
             7. Check and record distal pulses and sensation after reduction and splinting.
             8. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries
                 allow.
             9. Monitor circulation (pulse and skin temperature), sensation, and motor
                 function distal to site of injury during transport.

IV           10. Establish venous access.

             11. Consider Morphine Sulfate 2-10 mg, IV bolus for pain control
IN   CB          OR
                 Consider Fentanyl, 1-2 mcg/kg, slow IV bolus for pain control.




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   Special precautions
   A. Patients with multiple injuries have a limited capacity to recognize areas which
      have been injured. A patient with a femur fracture may be unable to recognize
      that he has other areas of pain. Be particularly aware of missing injuries
      proximal to the obvious ones (e.g., a hip dislocation with a femur fracture, or a
      humerus fracture with a forearm fracture).
   B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels
      or leave cooling for hospital setting.
   C. Do not attempt to realign angulated fractures in the field unless circulation is
      compromised. Splint in the position of comfort.
   D. Injuries around joints may become more painful and circulation may be lost with
      attempted realignment. If this occurs, stabilize the limb in the position of most
      comfort with the best distal circulation.




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                                                 5090
                                                BURNS
          Specific Information Needed
          A. History of injury: time elapsed since burn. Was patient in a closed space with
             steam or smoke? Electrical contact? Loss of consciousness? Accompanying
             explosion, toxic fumes, other possible trauma?
          B. Past history: prior cardiac or pulmonary disease, medications?
          Specific Objective Findings
          A. Vital signs
          B. Extent of burns: description or diagram of areas involved
          C. Depth of burns: superficial - erythema only; partial or full thickness - blistered or
             charred areas. Estimate size of burn. Use Rule of Nines or area of one patient
             palm = 1% burn.
          D. Evidence of carbon monoxide poisoning or other toxic inhalation: altered mental
             state, headache, vomiting, seizure, coma
          E. Evidence of inhalation burns: respiratory distress, cough, hoarseness, singed
             nasal or facial hair, soot erythema of mouth, carbonaceous sputum
          F. Entrance and exit wounds for electrical burns
          G. Associated trauma
          Treatment
          A. THERMAL BURNS:
             1. Remove clothing which is smoldering or which is non-adherent to the patient.
             2. Administer oxygen if indications from history or physical of respiratory burns,
                toxic inhalation, or significant flame or smoke exposure.
             3. Assess and treat for associated trauma (blast or fall).
             4. Consider cervical spine injury.
             5. Remove rings, bracelets, and other constricting items.
             6. If burn is moderate-to-severe (over 15% of body surface area), cover wounds
                with dry clean dressings to avoid hypothermia. Preheat ambulance to
                maximum temperature to prevent hypothermia during transport.
             7. Use cool, wet dressings in smaller burns (less than 15%) for patient comfort.

IV           8. Establish venous access in non-burned extremity when possible.
IN   CB
             9. Consider morphine sulfate 2-10 mg, IV bolus for pain relief.
             10. If IV access is delayed consider Nebulized or IN (MAD device) Fentanyl

             11. Transport, monitoring vital signs.
             12. Observe for airway distress

IN               a. Be prepared to intubate.

          NOTE:      Patients older than 12 years of age, with isolated second degree or third
          degree burns greater than 20% body surface area, consider direct transport to the
          University Hospital Emergency Department.




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        Patients 12 years of age and younger, with isolated second degree or third degree
        burns greater than 20% body surface area, consider direct transport to the Children's
        Hospital Emergency Department.

        Patients in immediate need of airway management should be transported to the
        nearest Emergency Department.

        B. INHALATION INJURY:
           1. Administer 100% oxygen during transport.

IN          2. Be prepared to intubate or assist if respirations inadequate.
            3. Monitor cardiac rhythm.

        C. CHEMICAL BURNS:
           1. Protect rescuer from contamination. Wear appropriate gloves and clothing.
           2. Remove all clothing and any solid chemical that might provide continuing
              contamination.
           3. Assess and treat for associated injuries.
           4. Decontaminate patient using running water for 15 min. prior to transport if
              patient stable.
           5. Check eyes for exposure and rinse with free-flowing water for 15 min.
           6. Evaluate for systemic symptoms that might be caused by chemical
              contamination. CONTACT BASE for possible treatment.
           7. Remove rings, bracelets, constricting bands.
           8. Wrap burned area in clean, dry cloths for transport. Keep patient as warm as
              possible after decontamination.

        D. ELECTRICAL INJURY:
           1. Protect rescuers from continued live electric wires.
           2. Separate victim from electrical source when area safe for rescuers.
           3. Initiate CPR as needed, monitor cardiac rhythm and treat arrhythmias per
              protocols.
           4. Prolonged respiratory support may be needed.
           5. Immobilize cervical spine when appropriate, assess for other injuries.

IV          6. Establish venous access.
        Specific Precautions
        A. Leave blisters intact when possible.
        B. Suspect airway burns in any facial burns or burns received in closed places.
           Edema may become severe, but not be immediately apparent. Avoid
           unnecessary trauma to the airway. Humidified oxygen is preferred if available.
        C. Assume carbon monoxide poisoning in all closed space burns. Treatment is
           100% oxygen continued for several hours. In addition, other toxic products of
           combustion are more commonly encountered than realized.
        D. CONTACT BASE for special instructions if other toxic inhalations are suspected.
           Consider suicide attempt as cause of burn, and child abuse in pediatric burns.
        E. Lightning injuries can cause ventricular asystole and prolonged respiratory arrest.
           Prompt, continuous respiratory assistance (sometimes for hours to days) can
           result in full recovery.



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   F. Field decontamination of chemical exposures has been shown to significantly
      reduce extent of burn. Gross decontamination should occur prior to transport.
      Notify hospital immediately to mobilize internal resources.
   G. EMS personnel should not participate in decontamination unless trained and
      equipped to do so.
   H. In patients with severe burns, their ability to prevent heat loss is
      significantly compromised. The time of transport may be enough to cause
      hypothermia. Keep the ambulance as warm as possible during transport
      despite discomfort to EMS personnel.
   I. Isolated carbon monoxide poisoning should be taken to a hyperbaric oxygen
      chamber. Multiple trauma patients with suspected carbon monoxide poisoning
      should be taken to the appropriate trauma center.




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                                         5100
                                   TASER PROTOCOL

I.   Purpose
     To provide guidelines in handling patient who has been subjected to a Taser

General Principles
   The Taser is a popular conducted electronic control weapon primarily used by law
      enforcement as a less-than-lethal device
   A Taser can be used as a contact device (touch-Taser) but is primarily used as a
      distance weapon where it can fire probes up to 25 feet and engage an assailant
   A controlled, pulsed electrical current is delivered that cause muscles in between the
      probes to spasm uncontrollably
      This is quite painful, and incapacitating
Special Considerations
      1. Think safety—subjects who have been Tasered can still remain a threat
      2. A thorough history and physical exam should be completed
      3. All patients for whom a Taser has been utilized on shall be transported.
      4. Patients with suspected stimulant use that have been tasered should have
      continuous cardiac monitoring.

Procedure Taser Probe Removal
              1. Taser probes imbedded anywhere above the clavicles, or in the nipple
              or genitalia If found in this area, leave in place and transport
              2. On most Taser probes there is a groove that runs along the side that
              has the barb on it. Gently place counter pressure on each side of the
              probe downward and perpendicular to the groove with one hand, then
              firmly tug on the probe straight back.
              3. Law enforcement may keep the probes as evidence. Otherwise treat
              the probe as any other contaminated sharp and dispose of appropriately.
              4. Document the contact appropriately
See Protocol: Excited Delirium




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                                            5200
                   Boulder Specific Trauma Activation Guidelines
Full Trauma Activation
  1. GCS < 10 with trauma
  2. Systolic BP < 90 and/or Pulse > 120
  3. Respirations <10 or >29 or requiring intubation
  4. Pediatric Criteria
          a. Tachycardia with 2 or more signs of poor perfusion
          b. BP lower limits for age (70 + 2 x age)
  5. Flail chest
  6. Multiple system traumatic blunt injury associated with suspected pelvic or long
       bone fractures or altered mental status
  7. Burns > 15% in adults and 10% in children AND associated trauma or
       hemodynamically unstable or with inhalation injury
  8. Suspected spinal injuries with neuro deficits
  9. Amputation proximal to wrist or ankle
  10. Penetrating trauma to Head, Neck, Chest, Abdomen, or Groin
  11. Deterioration from Stable
  12. Field Request for Activation
Limited Activation
  1.      Hemodynamically stable patient without respiratory distress, but potential for
          deterioration
  2.      High energy transfer situations
          a. Intrusion into passenger compartment > 12 inches
          b. Auto vs. pedestrian, auto vs. bike, struck > 20 mph or thrown > 15 ft or
              run over
          c. MCC or ATV crash with separation of rider from vehicle
          d. Death in same vehicle OR Ejection from vehicle
          e. Unrestrained in rollover OR Extrication > 20 minutes
          f. Blast injury OR Crush injury
          g. Extrication > 20 minutes
  3.      Stable electrical injury including lightning strikes
  4.      Fall greater than 15 feet. Pediatric 2x height
  5.      Pregnancy greater than 20 weeks, with mechanism
  6.      Field Request for Activation

Special Considerations:
   1. Extremes of age < 5 and > 55 y/o
   2. Medical illness (COPD, CHF, renal failure, diabetes, HTN, etc.)
   3. Presence of intoxicants
Special Notes:
1. The hospital shall be notified as soon as possible of a Trauma Activation.
2. A Trauma activation request will include: age, brief physiologic data and MOI.
3. Full Trauma Activation is based on physiological criteria while Limited Trauma
Activation is based on mechanism of injury.
4. A Full Trauma Activation will activate a surgeon who will evaluate the patient.
5. A Limited Trauma Activation will be met by the Emergency Physician who will then
evaluate the patient.




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                                     6000
                       GENERAL GUIDELINES FOR PEDIATRICS

Pediatric patients, for the purpose of the protocols, defined as age < 12 years, have
unique anatomy, physiology, and developmental needs that affect prehospital care as
well as hospital care. Because children make up a small percentage of total calls and
few pediatric calls are critically ill or injured, it is important to stay attuned to these
differences to provide good care. Therefore, CONTACT BASE early for guidance when
treating pediatric patients with significant complaints, including abnormalities of vital
signs. Pediatric emergencies are usually not preceded by chronic disease. If
recognition of compromise occurs early, and intervention is swift and effective, the child
will often be restored to full health.

The following should be kept in mind during the care of children in the prehospital
setting:
    A. Airways are smaller, softer, and easier to obstruct or collapse.
    B. Respiratory reserves are small. A minor insult like improper position, vomiting, or
         airway narrowing can result in major deficits in ventilation and oxygenation.
    C. Circulatory reserves are also small. The loss of as little as one unit of blood can
         produce severe shock in an infant. Conversely, it is difficult to fluid overload
         children. You can be confident that good hands-on circulation assessment will
         accurately determine fluid needs.
    D. Assessment of the pediatric patient can be accurately done using your
         knowledge of the anatomy and physiology specific to infants and children.
    E. Listen to the parents' assessment of the patient's problem. They often can detect
         small changes in their child's condition. This is particularly true if the patient has
         chronic disease.
    F. The proper equipment is very important when dealing with the pediatric patient.
         A complete selection of pediatric airway management equipment, IV catheters,
         cervical collars, and drugs has been mandated by the state. This equipment
         should be stored separately to minimize confusion.
    G. When following these protocols, the age groups used are:
                 1. INFANTS:            birth to one year
                 2. TODDLERS:           one through five years
                 3. SCHOOL AGE: six through fourteen years

 NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP

 AGE                     PULSE                   RESPIRATIONS             BLOOD PRESSURE
                         Average/minute          breaths/minute           systolic in mm Hg
 Newborn                 150                     40-60                    60-80
 6 mo                    140                     25-40                    65-105
 1 yr                    135                     20-30                    70-110
 3 yr                    110                     20-30                    76-116
 5 yr                    100                     20-30                    80-120
 8 yr                    90                      12-25                    86-126
 12 yr                   80                      12-25                    95-120




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                                            6010
                               INFANT AND CHILD RESUSCITATION
        Specific Information Needed
        A. Time since the child was last in good health
        B. History of any recent illness or injury
        C. Past medical history
        Specific physical findings
        A. General appearance: LOC, muscle tone, color
        B. Airway: obstruction, stridor, drooling, cough
        C. Breathing: respiratory rate, skin color (cyanosis late sign), chest wall symmetry
           and depth of movement, work of breathing (grunting, nasal flaring, retractions),
           wheezing.
        D. Circulation: heart rate, peripheral pulses, capillary filling time, skin color,
           extremity skin temperature.
        E. Level of consciousness, pupil size and reaction to light.
        F. Physical assessment.
        G. Respiratory distress is a critical situation that can be made worse with prolonged
           scene times.
        H. Any child with or suspected apnea episode should be transported.
        Treatment
        A. Airway/Breathing:
           1. Manage airway. Effective airway management is by far the most critical
               aspect of treatment. Bag-mask ventilation may be as good as and in some
               cases superior to endotracheal intubation for EMS treatment.
           2. Administer oxygen via blow-by, non-rebreather mask, or bag-mask
               ventilation.
           3. If apneic, ventilate with a BVM, intubate as indicated, ventilation rate per AHA
               BLS protocols. Ensure adequate chest rise and fall (tidal volumes), and air
               entry.

            4. Note the drugs that are appropriate for endotracheal administration
IN             (naloxone, epinephrine, atropine). (mnemonic: N.E.A. – naloxone,
               epinephrine, atropine). Endotracheal administration of any medication should
               be considered LAST RESORT.

        B. Circulation:
           1. Initiate CPR if indicated.

IN         2. Monitor cardiac rhythm.
           3. Establish peripheral venous access.
           4. If unable to establish a peripheral IV after 1 attempt, establish an
              intraosseous infusion. If unable to see good peripheral vein, go straight to IO
              infusion.
           5. If any signs of poor perfusion, infuse a 20 cc/kg of normal saline fluid bolus.
              CONTACT BASE if you feel perfusion is compromised on reassessment.
        C. Medications:



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       1. Stabilizing the airway and supporting respiration are the mainstays of
          treatment. Specific treatment should be focused on the etiology of the arrest.
       2. Arrhythmias are treated as noted in Arrhythmia Algorithms.
       3. Hypoglycemia is common in younger children. If the child has altered mental
          status, either administer dextrose (1-8 years should receive 2 ml/kg of a 25%
          solution IV; <1 year should receive 5 ml/kg of 10% solution) or rule out
          hypoglycemia with a bedside blood sugar check. Hypoglycemia in pediatrics
          is commonly defined as a blood sugar <40.
   Specific Precautions
   A. The most successful pediatric resuscitations occur before a full cardiopulmonary
      arrest. Assess pediatric patients carefully and assist with airway, breathing, and
      circulatory problems before the arrest occurs, to improve the outcome in pediatric
      patients.
   B. Pediatric arrests are most likely to be primary respiratory events. The rescuer's
      primary attention must be directed to securing the airway and providing good
      ventilation before specific treatment of cardiac rhythm. Any cardiac rhythm can
      spontaneously convert to sinus rhythm in a well-ventilated child.
   C. Oxygen and epinephrine are the mainstays of pediatric resuscitations. Atropine
      and sodium bicarbonate are not first line drugs in pediatrics.
   D. Cardiopulmonary arrest from trauma is treated with airway management, rapid
      transport, CPR and fluid administration en route.
   E. Recommendations for obstructed airway are abdominal thrusts over the age of
      one year. Infants less than one year old should be treated with back blows and
      chest thrusts. Early laryngoscopy should be used in an attempt to visualize and
      remove upper airway obstructions.
   F. If a child 1 year of age or older is in cardiac arrest, an AED may be used,
      preferably one with pediatric capabilities.
   G. Use of a length-based emergency tape (LBET) such as the Broselow™ tape is
      highly accurate and allows for rapid drug and fluid doses and correct equipment
      size and use. LBET use should be routine for any pediatric emergency.




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                                        6020
                    POSSIBLE SUDDEN INFANT DEATH SYNDROME (SIDS)
        Specific Information Needed
        A. History: position in which the child was found, condition of the bed, last time the
           child was seen well, seizure activity, trauma, possibility of ingestion
        B. Associated symptoms: history of fever, respiratory symptoms, infection, vomiting,
           diarrhea, other signs of infections
        C. Past medical history: prematurity, chronic illness
        Specific physical findings
        A.   ABCs
        B.   Neurologic: level of consciousness, responsiveness, muscle activity and tone
        C.   Skin: signs of trauma
        D.   Dependent lividity or early rigor mortis.
        E.   Body temperature.
        Treatment
        A.   Initiate or continue resuscitation based on field pronouncement protocol.
        B.   Use appropriate airway adjuncts as indicated.
        C.   Ventilate with 100% oxygen; suction as needed.
        D.   Support cardiac output as indicated by:
             1. CPR
             2. External chest compressions
             3. Establish venous access.

             4. Pediatric ALS as indicated
IN
             5. Monitor cardiac rhythm

        E. CONTACT BASE for field pronouncement if appropriate.
        F. Support the parents and siblings.
        Special Considerations
        A. Activate appropriate support for the family if the patient is pronounced dead in
            the field. Police, County Social Services, and the SIDS support line should be
            contacted.
        B. Automatic External Defibrillator (AED) should be used in patients >1 year old.
        C. Avoid premature assessments.
        D. The cause of SIDS is unknown. Cases occur between one month and one year
            of age. All cases are mandatory coroner cases.
        E. Consider possible NAT (non-accidental trauma, child abuse) and pass on any
            concerns to receiving facility personnel.
        F. For family support and community education, family members may welcome the
            following contact information:
     The Colorado SIDS Program, 6825 East Tennessee Ave., Suite 300, Denver, CO 80224
      Local#: 303-320-7771 or toll-free#: 1-888-285-7437; Web: http://www.coloradosids.org




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                                              6030
                                     PEDIATRIC DEHYDRATION
        Specific Information Needed
        A. History: onset and progression of symptoms, frequency of vomiting and
           diarrhea, urine output, oral intake, recent trauma, possible drug ingestion
        B. Past medical history
        Document Specific physical findings
        A. General appearance: LOC, muscle tone, color
        B. ABCs and vital signs
        C. Skin: warmth of distal extremities, color, skin turgor, capillary fill time (should be
           less than 2 seconds), pulses
        D. Mucous membranes: wetness of mouth, presence of tears
        E. Musculoskeletal: evaluate for trauma
        F. The signs of dehydration are:
           1. EARLY - tachycardia and tachypnea for age, decreased LOC, capillary filling
               time longer than two seconds, cool skin, mucous membranes dry, sunken
               eyes and fontanelle;
           2. LATE - loss of skin turgor, diminished pulses, and shock
        Treatment
        A.   Use appropriate airway adjuncts as indicated.
        B.   Administer oxygen
        C.   Breathing: ventilation as indicated
        D.   Circulation:
             1. Establish pulse rate and capillary refill time

IV
             2.   Establish peripheral venous access.
             3.   Consider fluid bolus of normal saline 20cc/kg.
             4.   Do not delay transport for IV attempts.
             5.   The patient with simple dehydration is not a candidate for intraosseous
                  infusion, CONTACT BASE for approval of IO if shock is present.
        Specific Precautions
        A. Assessment of dehydration is primarily by physical exam. Vital signs may be
           abnormal, but they are nonspecific.
        B. Determination of tachycardia or hypotension is based on age.
        C. Monitor carefully for signs of decreased tissue perfusion (shock). Early
           (compensated) shock is present if capillary fill time is greater than 2 seconds,
           and there are poor pulses, muscle tone and color, and/or are normotensive.
           Decompensated shock is present if systolic BP is <normal for age, have a
           decreased mental status and/or have weak or absent central pulses.




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                                            6040
                               PEDIATRIC RESPIRATORY DISTRESS
          Specific Information Needed
          A. History: sudden or gradual onset of symptoms, cough, fever, sore throat,
             hoarseness
          B. History of potential foreign body aspiration or trauma
          C. Past medical history
          D. Current medication use
          Specific Objective Findings
          A. Airway: look for respiratory distress during inspiration, listen for abnormal
             breathing sounds such as stridor, cough (croup-like?), and wheezing, feel for air
             movement, crepitation, and tracheal deviation (late finding).
          B. Breathing: respiratory rate and effort, chest wall movement/adequacy of tidal
             volume, color, use of accessory muscles, retractions, nasal flaring, head
             bobbing, or grunting
          C. Respiratory sounds by auscultation of chest: wheezing, rales, decreased
             (unilateral?), prolonged inspiratory (croup) or expiratory (wheezing) phases.
          D. Mental status: AVPU
          E. General appearance: leaning forward or drooling (suggests upper airway
             obstruction), skin color and temperature, muscle tone.
          Treatment
          A. Administer high-flow oxygen by blow-by or non-rebreather mask.
          B. As long as the child is adequately ventilating and has adequate mentation, avoid
             agitating the patient. Keep the patient in his position of comfort.
          C. If the child is not ventilating adequately, assist with a BVM.
          D. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI
             protocol. EMT’s must contact base.

          E. In the rare case that the child cannot be ventilated with a BVM device:
IN           1. Reposition airway. Consider oral airway if patient unconscious.
             2. If still unable to ventilate, visualize the airway with a laryngoscope. Remove
                 any foreign object with Magill forceps.
             3. If nothing is seen, orally intubate the patient.
          F. Consider intubation only if unable to provide ventilatory support with a BVM and
             oral airway.
          G. Assess and consider treatment for the following problems if respiratory distress is
             severe and the patient does not respond to proper positioning and administration
             of high flow oxygen.

IN   CB      1. Croup or Epiglottitis:
                a. Allow patient to remain in position of comfort if alert.
                b. Consider administering nebulized racemic epinephrine 0.5 ml or L-
                   epinephrine, 5 mg (5.0 ml of a 1:1000 solution) (under 10 kg use 0.5
                   ml/kg of a 1:1000 solution) via nebulizer if croup is likely and there is
                   respiratory distress.
             2. Asthma:



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               a. Administer albuterol sulfate, one unit dose bottle by nebulizer. Consider
                  adding Ipratropium (0.5 mg/2.5ml) for patients over 2 years of age.
               b. Use continuous nebulization of Albuterol sulfate for respiratory distress.
               c. Consider Epinephrine 0.01 mg/kg (0.01 ml/kg of a 1:1000 solution),
                  SQ/IM.

        H. If diagnosis is unclear, transport patient with 100% oxygen, reassess frequently
           and be prepared to manage the patient's airway.
        Specific Precautions
        A. Children with croup, epiglottitis, or laryngeal edema usually have respiratory
           arrest due to exhaustion. Most children can still be ventilated with a BVM.
        B. Children with severe asthma may not exhibit wheezing. The patients will have
           prolonged expiratory phases and may appear listless, agitated, or unresponsive.
        C. Respiratory distress is a critical situation that can be made worse with prolonged
           scene times.
        D. Cyanosis is a late sign in pediatric hypoxia. Provide 100% oxygen for any child in
           distress.
        E. Consider the differential assessment for each finding:
           1. Stridor: foreign body, croup, epiglottitis or other bacterial upper airway
               infection, larynx trauma, etc
           2. Wheezing: foreign body, asthma, bronchiolitis, hydrocarbon exposure, etc
           3. Respiratory distress: pneumothorax, foreign body, pneumonia, shock, CHF,
               etc

IN
        F. Any child with a witnessed or suspected apnea episode should be transported.
        G. Intubation of the infant is most easily accomplished with an infant-sized straight
           laryngoscope blade.
        H. Do not intubate unless you can visualize the ETT going through the cords. If you
           are unable to intubate the trachea quickly, withdraw, re-oxygenate with BVM, and
           try again. No harm will result to the child if you keep the patient well oxygenated
           and don't traumatize the airway with intubation attempts. Transporting while
           using BVM only is acceptable and may be preferable in many circumstances.




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                                               6050
                                        PEDIATRIC SEIZURES
          Specific Information Needed
          A. History: preceding activity level, onset and duration of seizure, description of
             seizure activity, fever, color change, recent illness, head trauma, possibility of
             ingestion, cardiac symptoms.
          B. Past history: previous seizures, current medications, chronic illness
          Specific Objective Findings
          A. Airway: look for respiratory distress, listen for abnormal breathing sounds, feel for
             air movement, crepitus.
          B. Breathing: respiratory rate and effort, chest wall movement (adequacy of tidal
             volume), use of accessory muscles, retractions.
          C. Circulation: heart rate, pulse, capillary filling time, skin color, blood pressure
          D. Neurologic: mental status, muscle tone, focal findings, post-ictal period,
             incontinence. Note improvement or deterioration in mental status with time.
          E. Musculoskeletal: note any associated injuries.
          Treatment
          A. Airway: Maintain patent airway by BLS maneuvers. Suction as needed.
             Administer high concentration oxygen.
          B. Breathing: Assist ventilation as needed. (rarely necessary)
          C. If child is in status epilepticus:

IN   CB      1. Attempt peripheral venous access x1. If successful, administer diazepam 0.3
                mg/kg, IV/IO bolus, slowly, over 2 minutes OR 0.5 mg/kg rectally up to a
                maximum of 10 mg OR administer diazepam, 0.5 mg/kg rectally, not to
                exceed 10 mg.
             2. If unable to start peripheral IV:
                a. for ages 8 and under, administer diazepam, 0.5 mg/kg rectally, not to
                    exceed 10 mg.

P
                b. for ages 9 and above, administer midazolam 0.1 mg/kg IM, not to exceed
                   10 mg.
             2. Determine blood glucose level and draw appropriate blood tubes if possible.

             3. If hypoglycemic, give dextrose (1-8 years should receive 2 ml/kg of a 25%
IV                solution IV; <1 year should receive 5 ml/kg of 10% solution).
             4. If seizures continue, CONTACT BASE.
          D. If the child has stopped seizing and is postictal, transport while continuing to
             monitor vital signs and neurological condition. Continue to provide supplemental
             oxygen.

IN        E. If child is febrile initiate passive cooling measures.




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   Specific Precautions
   A. Febrile seizures occur in normal children between 6 months and 6 years. Such
      seizures are usually short, lasting less than 5 minutes, generalized, and usually
      do not require anti-seizure drug therapy.
   B. Do not force anything between the teeth.
   C. Consider hypoglycemia as a cause for non-traumatic seizure.
   D. Breath-holding spells in toddlers can resemble seizures, but are not a true
      seizure.
   E. Most airways of seizing children can be managed with BLS measures. Intubation
      is only necessary if there is prolonged apnea from diazepam or from the seizure
      activity itself.




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                                 7010
                 STANDARD DRUG ADMINISTRATION PROTOCOL

   A. The following protocol should be followed with the administration of any pre-
      hospital medication.
      1. Perform initial patient assessment.
      2. Administer supplemental oxygen.
      3. Obtain vital signs.
      4. Assess the need for medication.
      5. Ensure medication to be delivered is prescribed to the patient.
      6. Contact on-line medical control for an order to administer medication.
      7. Administer the medication.
      8. Reassess the vital signs and patient condition after 1-2 minutes.
      9. If the patient’s condition persists or worsens, re-contact the base station for
          additional guidance.
      10. Complete your patient care record with full documentation of the patient’s
          symptoms, the patient assessment, the patient vital signs, the time and the
          amount of the drug given, and the effect the medication had on the patient’s
          condition.
   B. The above steps should be performed while initiating patient transportation. The
      administration of field medication should not delay patient transportation.
   C. ALL PATIENTS RECEIVING PATIENT ASSISTED DRUG ADMINISTRATION
      SHOULD BE TRANSPORTED TO THE HOSPITAL.




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                                   7020
                  MEDICATION ADMINISTRATION (PARENTERAL)

   Indications
   A. Illness or injury which requires medication to improve or maintain the patient's
      condition

   Precautions
   A. Use BSI.
   B. Certain medications can be administered via one route only, others via several.
      If you are uncertain about the drug you are giving - check with base.
   C. Make certain that the medication you want to give is the one in your hand.
      Always double check medication and dose before administration.
   D. IM and SQ routes are unpredictable: medications are absorbed erratically via
      these routes and may not be absorbed at all if the patient is seriously ill and
      severely vasoconstricted. The IV route should be used almost exclusively in the
      field. If an IV cannot be started, the endotracheal route is the best alternative.

   Technique
   A. Use syringe just large enough to hold appropriate quantity of medication (or use
      prefilled syringe).
   B. Attach large gauge needle to syringe.
   C. Break ampule (use filtered needle, when available) or cleanse multi-dose vial
      with alcohol (the latter is less desirable for field use).
   D. Using sterile technique, draw medication into syringe.
   E. Change needles to small gauge for IM or SQ.

   Endotracheal Technique (LAST RESORT)
   A. Prepare medication to be given, and set next to patient being ventilated.
   B. Ventilate fully and rapidly 4-5 times prior to disconnecting the bag from the
      endotracheal tube.
   C. Check medication in hand. Confirm medication, dose, amount, and expiration
      date.
   D. Higher doses are required when administering drugs endotracheally
   E. Dilute medication with 10 ml of normal saline, unless using prefilled syringes.
   F. Administer medication.
   G. Connect the bag and ventilate rapidly an additional 4-5 times.
   H. Disconnect the bag and administer the remaining half of medication into the
      endotracheal tube.
   I. Again connect the self-inflating bag and ventilate rapidly 4-5 times before
      resuming the recommended ventilation rate according to the age and condition of
      patient.
   J. Record medication given, dose, amount, and time.

   Intraosseous Technique
   A. Prepare medication to be administered.
   B. Check medication in hand. Confirm medication, dose, amount, and expiration
       date.
   C. Wipe port site with alcohol.
   D. Inject into port on intraosseous line, or
   E. Remove needle from syringe and inject directly into intraosseous needle.


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   F. Record medication given, dose, amount, and time.

   Intramuscular Technique (for ages 8 or greater only)
   A. Prepare medication to be administered.
   B. Check medication in hand. Confirm medication, dose, amount, and expiration
       date.
   C. Prep area of skin with alcohol or Betadine wipe.
   D. Inject 22 g/1½" needle into desired muscular site (deltoid, gluteus, or vastus
       lateralis) at 90˚ angle. Aspirate to ensure needle is not in blood vessel.
   E. Inject medication slowly into muscular site.
   F. Withdraw needle and observe for any bleeding or swelling. Apply sterile dressing
       to injection site.
   G. Record medication given, dose, amount, and time.

   Intravenous Push (IVP) Technique
   A. Use needle appropriate for viscosity of fluid injected.
   B. Wipe IV tubing injection site with alcohol.
   C. Check medication in hand. Confirm medication, dose, amount, and expiration
       date.
   D. Eject air from syringe.
   E. Insert needle into injection site.
   F. Pinch IV tubing closed between bag and needle.
   G. Inject at a rate appropriate for medication.
   H. Withdraw needle and release tubing to restore flow.
   I. Record medication given, dose, amount, and time.
   J. Give 20 cc saline fluid flush after giving any drugs.

   Nebulization Technique
   A. Use hand-held nebulizer with mouthpiece (or mask for patient unable to hold
      mouthpiece).
   B. Check medication in hand. Confirm medication, dose, amount, and expiration
      date.
   C. Draw up dose of medication in syringe or dropper; inject into nebulizer.
   D. Attach to oxygen tubing and set at 6-8 L/min (sufficient to produce good
      vaporization).
   E. Administer for approximately 5 minutes, until solution is gone from chamber.
   F. Record medication given, dose, amount, and time.

   Rectal Technique
   A. Technique One
      1. Use a tuberculin syringe (without needle) lubricated with a water-soluble,
          lubricating jelly.
      2. Check medication in hand. Confirm medication, dose, and expiration date.
      3. Insert needleless syringe into rectum completely to end of syringe (4-5cm).
      4. Inject the medication and withdraw the syringe. No flushing is necessary.
   B. Technique Two
      1. Lubricate with a water-soluble lubricating jelly and insert a feeding tube 4-5
          cm into the rectum.
      2. Attach a syringe containing the appropriate dose of the medication to be
          given and instill.



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   3. Remove the syringe from the tube, draw up 1 cc of air, reattach the syringe to
      the tube, and instill the air to clear the tube of medication. Then withdraw the
      feeding tube from the rectum.

Subcutaneous Injection Technique
A. Use 25 g needle, 5/8" length for most subcutaneous injections.
B. Check medication in hand. Confirm medication, dose, amount, and expiration
   date.
C. Select injection site (usually jrm misctr todeltoid)(. )]TJEMC /P <</MCID119 >>BDC 0.001 Tc -0.0001
       time. This may include the dilution of a medication to facilitate a slow
       administration.




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ADENOSINE (ADENOCARD)

Description
Adenosine is primarily formed from the breakdown product of adenosine triphosphate
(ATP). Both compounds are found in every cell of the human body and have a wide
range of metabolic roles. Adenosine slows tachycardias associated with the AV node via
modulation of the autonomic nervous system without causing negative inotropic effects.
It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease
chronotropic and dromotropic activity. Adenosine is the drug of choice for paroxysmal
supraventricular tachycardia (PSVT).

Onset & Duration
Onset: almost immediate
Duration: 10 sec

Indications
Conversion of PSVT to sinus rhythm

Contraindications
Second- or third-degree AV block
Sick sinus syndrome
Hypersensitivity to adenosine

Adverse Reactions
Facial flushing
Lightheadedness
Paresthesia
Headache
Diaphoresis
Palpitations
Chest pain
Hypotension
Nausea
Metallic taste
Shortness of breath

Drug Interactions
Methylxanthines (for example, caffeine and theophylline) antagonize the action of
adenosine. Dipyridamole potentiates the effect of adenosine; reduction of adenosine
dose may be required. Carbamazepine may potentiate the AV-nodal blocking effect of
adenosine.

Dosage and Administration
Adult:
   6.0 mg IV bolus, rapidly, followed by a Normal Saline flush.
   Observe EKG monitor for 1-2 minutes for evidence of cardioversion.
   If there is no evidence of cardioversion, administer Adenosine 12 mg, IV bolus,
   rapidly, followed by a Normal Saline flush.
   Observe EKG monitor for 1-2 minutes for evidence of cardioversion.
   Contact medical control for further considerations
   NOTE: Total maximum dose should not exceed 18 mg.


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Pediatric:
   0.1 mg/kg, IV or IO bolus, rapidly, followed by Normal Saline flush.
   If SVT persists, a second dose may be given using 0.2 mg/kg IV or IO bolus,
   followed by Normal Saline flush
   If this fails to convert the dysrhythmia, Adenosine may be repeated at 0.2 mg/kg, IV
   or IO bolus, rapidly, followed by Normal Saline flush.

Protocol
Narrow Complex Tachycardia

Special Considerations
May produce bronchoconstriction in patients with asthma or bronchopulmonary disease.
At the time of conversion asystole or new rhythms may result. These generally last a few
seconds without intervention
Adenosine is not effective in atrial flutter or fibrillation
Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome.
Concomitant use of dipyridamole (Persantine) enhances the effects of adenosine.
Smaller doses may be required.
Caffeine and theophylline antagonize adenosine's effects. Larger doses may be
required.
A 12-lead EKG should be performed and documented, when available.




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ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)

Description
Albuterol is a sympathomimetic that is selective for beta-2 adrenergic receptors. It
relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating
adrenergic receptors of the sympathetic nervous system.

Onset & Duration
Onset: 5-15 min. after inhalation
Duration: 3-4 hr after inhalation

Indications
Relief of bronchospasm in patients with reversible obstructive airway disease
Prevention of exercise-induced bronchospasm

Contraindications
Prior hypersensitivity reaction to albuterol
Cardiac dysrhythmias associated with tachycardia
Tachycardia caused by digitalis intoxication

Adverse Reactions
Tachycardia
Restlessness
Anxiety
Headache
Dizziness
Nausea
Palpitations
Hypertension
Dysrhythmias

Drug Interactions
Sympathomimetics may exacerbate adverse cardiovascular effects. Antidepressants
may potentiate the effects on the vasculature. Beta blockers may antagonize albuterol.
Albuterol may potentiate diuretic-induced hypokalemia.

How Supplied
MDI: 90 mcg/metered spray (17-g canister with 200 inhalations)
Prediluted nebulized solution: 2.5 mg in 3 ml NS (0.083%)

Dosage and Administration
Bronchial asthma
Adult:
   Albuterol sulfate solution 0.083% 2.5mg (one unit dose bottle of 3.0 ml), by nebulizer,
   at a flow rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes.
Pediatric:
   Albuterol sulfate 0.083% 2.5mg (one unit dose bottle of 3.0 ml), by nebulizer, at a
   flow rate (6-8 lpm) that will deliver the solution over 5-15 minutes.

Protocol
Asthma


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Chronic Obstructive Pulmonary Disease
Pneumonia
Pediatric Respiratory Distress

Special Considerations
May precipitate angina pectoris and dysrhythmias
Should be used with caution in patients with diabetes mellitus, hyperthyroidism, prostatic
hypertrophy, or seizure disorder




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AMIODARONE (CORDARONE)

Description
Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset.
The dominant effect is prolongation of the action potential duration and the refractory
period.

Indications
Ventricular Fibrillation
Ventricular Tachycardia without a pulse
Wide complex tachycardia refractory to cardioversion

Precautions
Wide complex irregular tachycardia
Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose
NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms

Contraindications
Wolff-Parkinson-White Syndrome (relative contraindication)
Pulmonary congestion
Cardiogenic shock

Adverse Reactions
Severe hypotension
Profound bradycardia

Dosage and Administration
Adult:
Cardiac Arrest
   300 mg IV bolus. Repeat once 150 mg IV bolus in 3-5 minutes. CONTACT BASE
   for additional doses.
   After successful defibrillation, 150 mg IV bolus infusion over 10 minutes
Wide Complex tachycardia
   150 mg IV bolus infusion over 10 minutes.
Pediatric:
Cardiac Arrest
   5mg/kg IV over 3-5 minutes. CONTACT BASE for additional doses.

Protocol
Ventricular Fibrillation/Ventricular Tachycardia without a pulse
Wide complex tachycardia refractory to cardioversion

Special Considerations
A 12-lead EKG should be performed and documented, when available.




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ASPIRIN (ASA)

Description
In low doses, aspirin inhibits blood clotting, specifically the formation of thromboxane A2,
a platelet aggregating, vasoconstricting prostaglandin.
Platelet aggregation has been implicated in the pathogenesis of atherosclerosis
contributing to the acute episodes of transient ischemic attacks, unstable angina, and
acute myocardial infarction. This has been linked to anginal episodes. Unstable angina
is precipitated by a sudden fall in coronary blood flow.
Aspirin has been shown to be beneficial in decreasing sudden cardiac death and
myocardial infarction in patients with unstable angina. It has also been shown to be of
added benefit in maintaining vessel patency after thrombolytic therapy

Indications
Patients with chest pain that may be related to cardiac origin.

Contraindications
Patients with an active gastrointestinal bleed
Patients with an allergy to aspirin

Adverse Reactions
Wheezing, Tinnitus, GI Upset, GI bleeding

How Supplied
Chewable tablets 81mg

Dosage and Administration
Aspirin should be given to conscious patients who can voluntary chew and swallow.
Dose is four (4) 81 mg tablets for a total of 324mg.

Protocol
Premature Ventricular Contractions (PVCs)
Chest Pain

Special Considerations
Aspirin should not be given for analgesia, i.e. head or body aches.
Patients on coumadin may be given aspirin




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ATROPINE SULFATE

Description
Atropine is a parasympathetic or cholinergic blocking agent. As such, it has the following
effects:
    • Increases heart rate (by blocking vagal influences)
    • Increases conduction through A V node
    • Reduces motility and tone of GI tract
    • Reduces action and tone of urinary bladder (may cause urinary retention)
    • Dilates pupils
Note: This drug blocks cholinergic (vagal) influences already present. If there is little
         cholinergic stimulation present, effects will be minimal.

Indications
Asystole and idoventricular cardiac arrests
Hemodynamically unstable bradycardias
To improve conduction in 2nd and 3rd degree heart block or in pacemaker failure
Organophosphate poisoning

Precautions
Should not be used without medical control direction for stable bradycardias
Closed angle glaucoma

Adverse Reactions
Headache
Dry mouth
Nausea
Dizziness
Tachycardia
Palpitations

Dosage and Administration
Cardiac Arrest
Adult:
   1.0 mg IV/IO rapid bolus. Repeat every 3-5 minutes, not to exceed 3.0 mg.
Pediatric:
   Refer to Length Based Measurement tool.
Hemodynamically Unstable Bradycardia
Adult:
   0.5 – 1.0 mg IV/IO rapid bolus. Repeat if needed at 3-5 minute intervals to a dose of
   3 mg. (Stop at ventricular rate which provides adequate mentation and B/P.)
Pediatric:
   0.02 mg/kg, IV/IO bolus. Minimum dose is 0.1 mg.
Acute Organophosphate Exposure
Adult:
   2mg IV/IO every 5 min. until secretions dry
Pediatric:
   0.05 to 0.2mg/kg every 5 min. until secretions dry

Protocol



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Asystole
Bradycardia with a pulse
Poisoning/Overdose
Infant and Child Resuscitation

Special Considerations
   • Atropine causes pupil dilation, even in cardiac arrest settings.
   • Endotracheal administration should be used only as a last resort.
   • If given ET, dosing is x2 normal dosing with a max ET dose of 6mg.




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Diltiazem (Cardizem)

Description

Diltiazem is an Antiarrhythmic / Calcium Channel Blocker. As such it has the following
effects:
     • Slows conduction through the AV node.
     • Vasodilation
     • Decreases rate of ventricular response
     • Decreases myocardial oxygen demand

Indications
To control rapid ventricular rates (>150 bpm) associated with atrial fibrillation and atrial
flutter.

Rapid narrow complex PSVT, unresponsive to adenosine.

Contraindications
Known hypersensitivity to diltiazem
Hypotension
Pulmonary congestion
Wide-complex tachycardia
Conduction disturbances: WPW, sick sinus syndrome, AV block

Precautions
Concurrent use with Midazolam may require decreased dose
Use with caution in patients on oral / IV beta-blockers

Adverse Reactions
Nausea and vomiting, hypotension, and dizziness

Dosage and Administration
     1. Initial dose: Bolus 0.25 mg / kg (typically 20 mg) IV over 2 minutes
     2. Second dose in 15 minutes if inadequate response to initial dose:
     3. Bolus 0.35 mg / kg (typically 25 mg) IV over 2 minutes
     4. All dosing in the physiologically elderly pt. should be reduced 50%.

Protocol
Narrow complex tachycardia

Special Considerations
   • Patients with rapid atrial fibrillation who are unstable (BP < 80 and altered mental
      status or signs of ischemia) should be cardioverted. If cardioversion is
      unsuccessful then diltiazem can be considered.
   • Patients with chronic atrial fibrillation run the risk of embolization with sudden
      cessation of the rhythm by cardioversion. Therefore, in the semi-unstable patient
      with chronic atrial fibrillation and now with a rapid ventricular response, slowing of
      the rate with diltiazem is preferred so that cardioversion can be done after the
      patient is anticoagulated.




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   •   The use of calcium channel blockers in patients with rapid atrial fibrillation
       secondary to accessory conduction pathways (WPW) can potentially accelerate
       conduction through the accessory pathway causing a fatal dysrhythmia. This
       effect is primary found with verapamil and not diltiazem.
   •   Stable patients with rapid atrial fibrillation and short transport times should be
       transported to the ED, where calcium channel blocker therapy can be initiated.




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DEXTROSE 50%

Description
Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop
in blood sugar level will result in disturbances of normal metabolism, manifested
clinically as a decrease in mental status, sweating and tachycardia. Further decreases
in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is
regulated by insulin, which stimulates storage of excess glucose from the blood stream,
and glucagon, which mobilizes stored glucose into the blood stream.

Indications
   • Hypoglycemic states (i.e., insulin shock in the diabetic)
   • The unconscious patient with an unknown history. Any patient with focal or
       partial neurologic deficit or altered state of consciousness, which may be due to
       hypoglycemia
   • Non-traumatic seizure patients who show no improvement in post-ictal state
   • Patients in status epilepticus not responsive to Valium
   • Blood glucose test < 60 if clinically indicated
   • Poisons and Overdoses protocol
   • In children with alcohol exposure, suspected sepsis, hypoperfusion or altered
       mental status

Precautions
Patients presenting with signs of CVA, unless presenting with a significantly low blood
glucose.
Dextrose can exacerbate Wernicke’s encephalopathy and Korsakoff’’s Psychosis found
primarily in the chronic ETOH abuse patient.

Dosage and Administration
Adult:
   25 gm (50 ml of a 50% solution), IV bolus or Rectal.
Pediatric:
   1-8 years: 2-4 ml/kg of a 25% solution IV or Rectal.
   <1 year: 2-4 ml/kg of a 10% solution IV or Rectal.
NOTE: Oral glucose can be used for conscious patients able to swallow.

Protocol
Altered Mental Status
Seizures
Syncope
Poisoning/Overdose
Psychiatric/Behavioral
Infant and Child Resuscitation
Pediatric Seizures

Special Considerations
Draw blood sample before administration if possible.


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Use glucometer before administration.
Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to
ensure route patency.
Dextrose should be diluted 1:1 with normal saline (to create D25W) for patient 8 years
and younger




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DIAZEPAM (VALIUM)

Description
Diazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle relaxant through
effects on the central nervous system

Indications
Status epilepticus
Drug-induced hyperadrenergic states manifested by tachycardia and hypertension (i.e.,
cocaine, amphetamine overdose)
Combative patients from head injury or from suspected stimulant abuse (i.e.: cocaine,
PCP, ecstasy, amphetamines)
Severe musculoskeletal back spasms

Precautions
Patients under the influence of alcohol

Adverse Reactions
Drowsiness
Dizziness
Respiratory depression
Fatigue
Ataxia
Paradoxical excitement or stimulation may occur

Dosage and Administration

A. Adult
   1. Status Seizures
      a. Initial dose: 1-10 mg IV or IM
      b. Repeat dose: 1-10 mg IV or IM
   2. Hyperadrenergic States/ Severe Musculoskeletal Spasm/
      Combative Patients/Sedation
      a. Initial dose 1-10 mg IV or IM
      b. Repeat dose 1-5 mg IV or IM
   3. Combination Analgesia
                  a. 1-5 mg IV over 2 minutes for spasm and/or anxiety.
                  b. Repeat Dose 1-2 mg IV over 2 minutes.

B. PEDIATRIC DOSAGES
     Status Seizures
     a. Initial dose 0.2 mg/kg IV/IM OR 0.50 mg/kg rectal
     b. Repeat dose 0.2 mg/kg IV/IM OR 0.50 mg/kg rectal

Protocol
Seizures
Combination Analgesia
Poisoning/Overdose
Hyperthermia
Psychiatric/Behavioral
Pediatric Seizures


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Head trauma

Special Considerations
Since diazepam can cause respiratory depression and/or hypotension, the patient
should be monitored closely (vitals signs, cardiac monitor, pulse oximeter). Very rarely,
cardiac arrest can occur.
Patients receiving diazepam should be placed on oxygen.
Do not give unless the patient is actively seizing.
Diazepam should be used with caution in any patient under the influence of alcohol.




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DIPHENHYDRAMINE (BENADRYL)

Description
Diphenhydramine blocks action of histamine released from cells during an allergic
reaction. Direct CNS effects, which may be stimulant or, more commonly, depressant,
depending on individual variation. Also has anticholinergic, antiparkinsonian effects,
which is used to treat acute dystonic reactions to antipsychotic drugs (Haldol, Thorazine,
Compazine, etc.) These reactions include oculogyric crisis, acute torticollis, and facial
grimacing.

Indications
Moderate allergic reactions
Second line for anaphylaxis and severe allergic reactions
Control extrapyramidal effects
Synergist to other medications in Combative Patient

Precautions
Lower respiratory diseases such as asthma or COPD
Narrow-angle glaucoma
Bladder obstruction

Side effects
Dose-related drowsiness
Dilated pupils
Dry mouth and throat
Flushing
May potentiate with alcohol usage

Drug Interactions
CNS depressants and alcohol may have additive effects.
MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.

Dosage and Administration
Adults: 25-50 mg, IV bolus, or IM if vascular access has not been obtained
<8 years: 1-2 mg/kg slow IV bolus/IM (not to exceed 50 mg)

Protocol
Restraint
Allergic Reaction




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DOPAMINE (INTROPIN)

Description
Dopamine is chemically related to epinephrine and norepinephrine. It acts primarily on
alpha-1 and beta-1 adrenergic receptors, increasing systemic vascular resistance and
exerting a positive inotropic effect on the heart. In addition, the actions of this drug on
dopaminergic receptors dilate renal and splanchnic vasculature, maintaining blood flow.
Dopamine is commonly used to treat hypotension associated with cardiogenic shock.

Indications
Symptomatic hypotension from causes other than hypovolemia

Contraindications
Patients with hypovolemia
Cardiogenic Shock secondary to Arrhythmia prior to treatment of the arrhythmia

Adverse Reactions
Dose-related tachydysrhythmias
Hypertension
Increased myocardial oxygen demand

Dosage and Administration
     Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of
     1600 mcg/ml.
     Actions of dopamine are dose dependent:
            1. <5 mcg/kg/min Dilates renal/mesenteric vessels with no effect on
                  heart rate or blood pressure
            2. 5-10 mcg/kg/min Mild effect on cardiac output and peripheral
                  vasoconstriction leading to slight increase in blood pressure
            3. 10-20 mcg/kg/min Increased heart rate, cardiac output, and peripheral
                  vasoconstriction leading to increased blood pressure
            4. >20 mcg/kg/min Diffuse vasoconstriction leading to increased blood
                  pressure, however, major decrease in renal and mesenteric blood
                  flow

   Adults: 5-20 mcg/kg/min
   Pediatrics:
          5-20 mcg/kg/min CONTACT BASE EXCEPT IN CASES OF CARDIAC
          ARREST


Protocol
Shock: Medical

Special Considerations
   • Dopamine is better administered using an infusion pump to ensure accurate
      dosing
   • May become ineffective is added to solutions containing alkaloids
   • At low doses, decreased blood pressure may occur due to peripheral
      vasodilatation. Increasing infusion rate will correct this.



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   •   Tissue extravasation at the IV site can cause skin sloughing due to
       vasoconstriction. Be sure to make Emergency Department personnel aware if
       there has been any extravasation of dopamine-containing solutions, so that
       proper treatment can be instituted.
   •   Can cause hypertensive crisis in susceptible individuals
   •   Certain antidepressants potentiate the effects of this drug.

INTRAVENOUS DRIP RATES FOR DOPAMINE

Concentration: 1600 mcg/ml

                          Dose
                                                             (mcg/kg/min)
            Weight    5          10      15        20
                                                             microdrips/min
            50        10         20      30        40

            60        10         25      35        45

            70        15         25      40        50

            80        15         30      45        60

            90        15         35      50        70

            100       20         35      55        75

            110       20         40      60        85




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EPINEPHRINE (ADRENALIN)

Description
Epinephrine stimulates alpha, beta-1, and beta-2 adrenergic receptors in dose-related
fashion.

Indications
Bronchial asthma
Acute allergic reaction
Bradycardia
Cardiac arrest
Airway obstruction secondary to croup or epiglottitis

Adverse Reactions
Headache
Nausea
Vomiting
Anxiety
Tremors
Palpitations
May precipitate angina

Drug Interactions
May be deactivated by alkaline solutions (sodium bicarbonate, furosemide).

Dosage and Administration
Adult:
Cardiac Arrest
   1.0 mg (10 ml of a 1:10,000 solution), IV/IO bolus. Repeat every 3-5 minutes.
Bradycardia refractory to other interventions:
   1.0 mg in 250 ml of Normal Saline. Infuse at 2 mcg/min until desired BP of 90 mmHg
   systolic.
Asthma:
   0.3 mg (0.3 ml of a 1:1,000 solution), SQ/IM.
Moderate to Severe Allergic Reaction:
   0.3 mg (0.3 ml of a 1:1,000 solution), SQ/IM.
Anaphylactic Reaction:
   0.1 mg (1 ml of a 1:10,000 solution), IV followed by 1.0 mg in 250 ml of Normal
   Saline infused at 2 mcg/min until desired BP of 90 mmHg systolic
Pediatric:
   Cardiac arrest:
   First dose: 0.01 mg/kg IV/IO/ET (0.1 ml/kg of 1:10,000 solution)
   Subsequent doses: 0.01 mg/kg, IV/IO/ET (0.1 ml/kg of 1:10,000 solution)
Bradycardia
   0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO
Moderate to Severe Allergic Reactions
   0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM/SQ
Anaphylaxis
   0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO
Asthma
   0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM/SQ


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Life threatening airway obstruction suspected secondary to croup or epiglottitis
    In the absence of racemic epinephrine, plain L-epinephrine can be used. The dose is
    5 mg (5.0 ml of 1:1000 solution of L-epinephrine, undiluted, nebulized). In smaller
    infants, weighing <10 kg, the recommended dose is 0.5 ml/kg of 1:1000 L-
    epinephrine.

Protocol
Asystole
Bradycardia with a pulse
Asthma
Allergy/Anaphylaxis
Infant and Child Resuscitation
Pediatric Respiratory Distress
Pediatric Anaphylactic Reaction

Special Considerations
Syncope has occurred after epinephrine administration to asthmatic children.
May increase myocardial oxygen demand.
IV doses may be given through ET tube at 2 times the IV dose. Endotracheal
administration is a LAST RESORT.




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EPINEPHRINE AUTO-INJECTOR (Adrenaline, Epi-Pen and Epi-Pen Jr.)

Pharmacology and Actions
Cardiovascular
   1. Increased heart rate
   2. Increased blood pressure
   3. Arterial vasoconstriction
   4. Increased myocardial contractile force
   5. Increased myocardial oxygen consumption
   6. Increased myocardial automaticity and irritability
Pulmonary
   1. Potent bronchodilator

Indications
   1. The patient has a history consistent with allergic reaction and exhibits any one of
       the following:
       a. Respiratory distress/airway compromise with tongue swelling or stridor.
       b. Signs and symptoms of hypoperfusion (shock)
   2. Patient has his/her own physician prescribed Epinephrine Auto-Injector.

Precautions
   1. Increased myocardial oxygen consumption can precipitate angina or myocardial
      infarction in patients with coronary artery disease.
   2. Use with caution in patients with hypertension or known coronary artery disease.

Administration
  1. The initial dosage for adult: one Epinephrine Auto-Injector (0.3 mg.)
  2. The initial dosage for pediatric: one pediatric Epinephrine Auto-Injector (0.15
      mg.)
  3. Follow the standard drug administration protocol.
  4. Contact on-line medical control for an order to administer if EMT-I or Basic
  5. Standing order for Paramedics
  6. Administer a single dose of Epinephrine Auto-Injector.
  7. In a patient with hypoperfusion, early venous access should be anticipated.
  8. Dispose of Auto-Injector in a biohazard container.
  9. Reassess patient’s vital signs and condition 1-2 minutes after administration.

Side Effects and Special Notes
   1. Experienced side effects include increased heart rate, pallor, dizziness, chest
       pain, nausea, vomiting, excitabilty, anxiousness, headache, hypertension.
   2. Only a single auto-injector should be utilized. Should the patient’s condition
       persist or worsen, contact the base station for additional orders.




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FENTANYL

Description
Used as an analgesic and sedative. Does not cause histamine release.

Onset & Duration
Onset: Within 5 minutes, with a peak effect within 30 minutes
Duration: 90 minutes

Indications
Pain management of extremity injuries; to be given only in the absence of any evidence
of head, chest or abdominal injuries
Management of pain secondary to selected medical problems (abdominal pain, back
pain, Chest Pain, kidney stones)
Burns

Contraindications
Hypersensitivity to opiates
Hypotension

Side Effects
Can cause significant respiratory depression and hypotension especially when used in
combination with other sedatives such as alcohol or benzodiazepines.
Can increase intracranial pressure
Chest wall rigidity has been reported with rapid administration that is unaffected by
narcan administration.
Pediatric patients may develop apnea without manifesting significant mental status
changes

Dosage and Administration
Adult:
   The initial adult dose is 1-2 mcg / kg, SLOW IV bolus.

Pediatric (<12 years):
   Initial dose is 1-2mcg / kg, SLOW IV bolus.
   Contact base for any single or cumulative dose > 3 mcg/kg (not to exceed 100 mcg)

Combination Analgesia:
             0.5 – 1.0 mcg/kg IV over two minutes
             Repeat dose at 0.5 -1.0 mcg/kg over two minutes

           Initial pain management : In certain circumstances it is appropriate to give
                fentanyl via MAD device or nebulizer to initiate pain control. In the
                hospice patient where no IV access is required, fentanyl may be
                Nebulized. In the pediatric population it may be beneficial to initiate pain
                control so IV access can be obtained more readily. In the pediatric
                population MAD device administration should be the preferred route but
                nebulization is acceptable. Once administered, every reasonable attempt
                should be made to gain IV access




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          Special Notes:.Fentanyl should be given SLOWLY (over 2 min.) to prevent a
             sudden onset of chest wall rigidity. This can be accomplished by diluting it
             in a syringe or 50 ml bag and running it in over time.

          Use with caution in patients with headache. If the headache is associated
             with a clinical picture of CVA extra precaution should taken or the drug
             withheld.


NOTE: Continuous pulse oximetry is necessary. Frequent evaluation of the
patient’s vital signs is also necessary. Emergency resuscitative equipment must
be immediately available

Protocol
Abdominal Pain
Combination Analgesia
Extremity Injuries




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FUROSEMIDE (LASIX)

Description
Rapid acting, potent diuretic; inhibits re-absorption of Sodium Chloride. It is also a
venous dilator that decreases preload

Indications
Cardiogenic Pulmonary Edema

Contraindications
Pregnancy
Known hypersensitivity
Dehydration or shock

Side Effects
Hypotension
Headache
Dizziness
Hypovolemia
Nausea
Vomiting

Adverse Reactions
Rapid administration may cause auditory problems including tinnitus and hearing loss

Special Notes
Digitalis toxicity may be potentiated by the potassium depletion that can result from
furosemide administration.
Drug may be deactivated by exposure to light

Dosage and Administration
20-80 mg, IV bolus. Patients not on Lasix should receive 20 mg. Patients compliant with
Lasix should receive higher doses in the 40-80 mg range

Protocol
Pulmonary Edema




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GLUCAGON

Description
Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon
also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and
colon.

Onset & Duration
Onset: Within 1 min.
Duration: 3-6 min.

Indications
Altered level of consciousness where hypoglycemia is suspected and IV access is
unavailable.
May be used for beta-blocker overdose.

Contraindications
Hypersensitivity
Use with caution in patients with a history of cardiovascular disease, renal disease,
pheochromocytoma or insulinoma

Side Effects
Tachycardia
Headache
Nausea and vomiting

Dosage and Administration
Adult:
   Hypoglycemia 1.0 mg, IM
   Beta Blocker/Calcium Channel overdose 2.0 – 5.0mg IV bolus
Pediatric:
   Hypoglycemia 0.1 mg/kg IM. Maximum dose 1.0 mg
   Beta Blocker/Calcium Channel overdose 2.0 mg IV bolus

Protocol
Altered Mental Status
Seizures
Syncope
Poisoning/Overdose
Psychiatric/Behavioral




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HALOPERIDOL (HALDOL)

Description
Haloperidol is a butyrophenone in the therapeutic class of antipsychotic medications.
Haloperidol produces a dopaminergic blockade, a mild alpha-adrenergic blockade, and
causes peripheral vasodilation. Its major actions are sedation and tranquilization.

Onset & Duration
Onset: Within 10 minutes after IM administration. Peak effect within 30 minutes
Duration: 2-4 hours (may be longer in some individuals)

Indications
Acts as a chemical restraint in patients that require transport and are behaving in a
manner that poses a threat to their own well-being or others.

Contraindications
Suspected myocardial infarction
Systolic BP of less than 100 mmHg or the absence of a radial pulse
Signs of sedation, respiratory or CNS depression
Known Parkinson’s Disease
Known pregnancy
History of severe liver or cardiac disease
Under 8 years of age

Precautions
   A. Haldol may cause hypotension, tachycardia, and prolongation of the QT interval.
   B. When administering this IM medication, paramedic must put patient on cardiac
      monitor and establish an IV as soon as possible.
   C. Due to the vasodilatory effect, haloperidol can cause a transient hypotension that
      is usually self-limiting and can be treated effectively with position and fluids.
      Haloperidol has also been known to cause tachycardia, which usually does not
      require pharmacologic intervention.
   D. Should profound hypotension occur that is unresponsive to positioning and fluid
      therapy and vasopressors are required, epinephrine should not be used since
      haloperidol may block its vasopressor activity and paradoxically further lower the
      blood pressure. Haldol may also decrease the effectiveness of dopamine.
   E. Some patients may experience unpleasant sensations manifested as
      restlessness, hyperactivity, or anxiety following haloperidol administration.
   F. Extra-pyramidal reactions have been noted hours to days after treatment, usually
      presenting as spasm of the muscles of the tongue, face, neck, and back. This
      may be treated with diphenhydramine.
   G. Rare instances of neuroleptic malignant syndrome (very high fever, muscular
      rigidity) have been known to occur after the use of haloperidol.

Dosage and Administration
Standing order:
   5 - 10 mg, IM
   May be followed with Diphenhydramine 25 – 50 mg, IV or IM
   Base contact must be made for additional doses (consider if no effects within 10
   minutes)



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Special Considerations
   A. Although extra-pyramidal reactions are infrequent and usually present after the
      prehospital phase, be prepared to administer 50 mg diphenhydramine IVP/IM.
   B. Hypotension and tachycardia secondary to haloperidol are usually self-limiting
      and hypotension is correctable through recumbent positioning and fluid
      administration. Be aware of other causes of these conditions, especially in
      relation to a patient that is the victim of trauma.
   C. The action of haloperidol potentiates the effect of sedative/tranquilizer type
      medications and is relatively contraindicated in the presence of these types of
      medications. In this setting, be prepared for respiratory depression, apnea,
      muscular rigidity, and hypotension.
   D. Patients 65 and older will respond more readily to haloperidol, and a reduced
IPRATROPIUM BROMIDE (ATROVENT)

Description
Used as a bronchodilator that dries respiratory tract secretions.

Onset & Duration
Onset: 5-15 min. after inhalation
Duration: 6-8 hr after inhalation

Indications
Bronchospasm related to asthma, chronic bronchitis, or emphysema

Contraindications
Hypersensitivity reaction to this drug or atropine or soy or peanuts

Adverse Reactions
Palpitations
Dizziness
Anxiety
Tremors
Headache
Nervousness
Dry mouth

Precautions
Should not be used as the primary agent for treatment of bronchospasm.
Use with caution in patients with coronary artery disease.
Vital signs, and EKG must be monitored

How Supplied
Premixed Container: 0.5 mg in 2.5ml NS

Dosage and Administration
Bronchial asthma
Adult and Pediatrics over 2 years of age:
   A. Mild / Moderate Bronchospasm:
       1. Ipratropium may be used in combination with albuterol as described below if
          patient is unresponsive to initial albuterol nebulization treatment.
   B. Severe Bronchospasm:
       1. Place one premixed vial of ipratropium (0.5 mg/2.5 ml) along with albuterol in
          a nebulizer and administer via oxygen-powered nebulizer to create a fine
          mist. If patient requires further treatment, continuous nebulization of plain
          albuterol should be utilized

Protocol
Asthma
Chronic Obstructive Pulmonary Disease
Pediatric Respiratory Distress

Special Considerations
Can cause paradoxical bronchospasm. Discontinue treatment if this occurs.


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IV SOLUTIONS

Pharmacology and Actions
Initiation of all IVs in the field in these protocols utilizes normal saline (NS). The
standard IV drip rate will be TKO unless a fluid bolus or fluid challenge is required.

TKO FLUID RATE
Indications
Prophylactic IV
Drug administration

Administration
TKO = 5-10 drops/min. or saline lock.

FLUID REPLACEMENT/BOLUS
Indications
Hemorrhagic shock, volume depletion (dehydration, burns, severe vomiting)
Shock caused by increased vascular space (neurogenic shock)

Precautions
   A. In hemorrhagic shock, volume expansion with blood is the treatment of choice.
      Normal saline will temporarily expand intravascular volume and "buy time," but
      does decrease oxygen-carrying capacity, and is insufficient in severe shock.
      Because of this, rapid transport is still necessary to treat severely hypovolemic
      patients who need blood and possibly surgical intervention.
   B. Volume overload is a constant danger, particularly in cardiac patients. Keep a
      close eye on your IV rate during transport. For this reason, a fluid challenge (see
      below) is more appropriate in cardiac patients.

Administration
20 ml/kg NS through large bore cannula, as rapidly as possible.

FLUID CHALLENGE
Indications
Hypotension felt to be secondary to cardiac cause (i.e. acute MI, pericardial tamponade,
cardiogenic shock)

Administration
250-500 ml rapidly through a large bore cannula, then reassess the patient.

Side Effects and Special Notes
   A. Flow rate through a 14g cannula is twice the rate through an 18g cannula, and
       volume administration in trauma patients can be accomplished more rapidly. If
       the patient has poor veins, a smaller bore is better than no IV at all, in some
       instances.
   B. IVs in an unstable trauma patient should be placed enroute, and may be left to
       the hospital setting for short transports. Do not delay transport in critical patients
       for IV attempts.
   C. If you are unable to start in two attempts, another qualified attendant may try, or
       you may leave the IVs for the hospital.



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   D. If IV access is required but volume expansion is not, consider starting a saline
      lock.
   E. 1 ml/min = 60 microdrops/min = 15 regular drops/min.




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LIDOCAINE 2% SOLUTION

Description
Used as a local anesthetic to reduce somatic pain during intraosseous fluid
administration.

Indications
Given following intraosseous insertion to patients over 8 years of age

Contraindications
Allergy to lidocaine or novacaine


Side Effects
Seizures
Drowsiness
Tachycardia
Bradycardia
Confusion
Hypotension

Precautions
Lidocaine is metabolized in the liver; elderly patients and those with liver disease or poor
liver perfusion secondary to shock or congestive heart failure are more likely to
experience side effect

Dosage and Administration
0.5 mg/kg IO bolus, slowly, maximum dose is 50 mg

Protocol
Intraosseous Administration

Special Notes
Diazepam should be available if seizures manifest
NOT to be used for treatment of cardiac events




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Lidocaine (Xylocaine) Gel


Description
Used as a local anesthetic and lubricant to minimize discomfort and trauma during
airway insertion.

Indications
Prior to nasal pharangeal airway placement
Prior to nasal intubation

Contraindications
Allergy to lidocaine, xylocaine, or novacaine

Side Effects
When administered to nares side effects are uncommon and minimal

Precautions and Special Notes
Use with caution in patients with a heart rate <50 on in the presence of high degree AV
block. In Atrial fibrillation patients it may cause ventricular acceleration.
Should not be used to treat cardiac events.

Dosage and Administration
Administration can be accomplished in two ways:
       1. Apply gel directly to airway
       2. Insert gel directly in nare prior to airway insertion
As the medication is used to facilitate a procedure, the dose should be the amount
required to adequately lubricate the airway device. In nearly all cases this will not exceed
one container.

Protocol
Nasotracheal Intubation




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MAGNESIUM SULFATE

Description
Magnesium sulfate reduces striated muscle contractions and blocks peripheral
neuromuscular transmission by reducing acetylcholine release at the myoneural
junction. In cardiac patients, it stabilizes the potassium pump, correcting repolarization.
It also shortens the Q-T interval in the presence of ventricular arrhythmias due to drug
toxicity or electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in
acute bronchospasm due to asthma or other bronchospastic diseases. For best results,
it should be used after normal field inhalation therapy has been attempted.
For obstetric cases, it controls seizures by blocking neuromuscular transmission. Also
lowers blood pressure and decreases cerebral vasospasm

Indications
   A. Cardiac: Refractory VF and pulseless VT (after amiodarone) Cardiac arrest from
       suspected torsade de pointes Wide complex tachycardia with pulse and without
       poor perfusion
   B. Respiratory: Acute bronchospasm unresponsive to continuous inhaled beta-
       agonists, ipratropium, and epinephrine.
   C. Obstetrics: Pregnancy > 20 weeks with signs and symptoms of pre-eclampsia,
       defined as:
       1. Blood pressure > 180 mmHg systolic or > 120 mmHg diastolic with altered
           mental status or
       2. Seizures (eclampsia)

Precautions
Heart block
Decrease in respiratory or cardiac functions
Use with caution in patients on digitalis

Adverse Reactions
Reduced heart rate
Circulatory collapse
Respiratory depression

Dosage and Administration
Cardiac Arrest (refractory VF/VT; Torsades de Pointes)
   2 gm, IV bolus.
Wide complex tachycardia with a pulse and poor perfusion
   2.0 gm, IV bolus, over 2 minutes
Acute bronchospasm
   2.0 gm, IV bolus, over 2 minutes
Seizure activity associated with pregnancy:
   Mix 6.0 gm, IV drip, diluted in 50 ml of Normal Saline (0.9 NS), over 15-30 minutes.
   If no IV access can be obtained, IM injection of 4g in each buttock (8g total)

Protocol
Ventricular Fibrillation/Pulseless Ventricular Tachycardia
Asthma
Chronic Obstructive Pulmonary Disease
Obstetric Complications


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Special Considerations
Principal side effect is respiratory depression
NOT to be used in pediatric patients




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MARK I NERVE AGENT ANTIDOTE KIT

Description
Nerve agents can enter the body by inhalation, ingestion, and through skin. These
agents are absorbed rapidly and can produce injury or death within minutes. The Mark I
Nerve Agent Antidote Kit consists of two auto-injectors for self and/or buddy
administration. One injector contains atropine and another which contains pralidoxime
chloride (2-PAM)




Indications
Suspected nerve agent exposure accompanied with signs and symptoms of nerve agent
poisoning

Injection Sites
Outer thigh – mid-lateral thigh (preferred site)
Buttocks – upper lateral quadrant of buttock (gluteal) in thin individuals

Procedure
   A. Utilize appropriate safety precautions including BSI
   B. Remove atropine injector (smaller of the two). Once removed, it is now active.
      Use caution not to self-inject.
   C. Hold securely in one hand and place against injection site on patient.
   D. Firmly apply constant pressure against site for at least 10 seconds.
   E. Repeat using the 2-PAM injector.
   F. Contact receiving hospital to set up appropriate decontamination facilities.

Dosage and Administration
Atropine injector contains 2 mg
2-PAM injector contains 600 mg
No more than three (3) sets of antidote should be administered.

Protocol
WMD exposure

Special Considerations
Within 5-10 minutes after administration, tachycardia and dry mouth may occur. This
indicates the antidote is working and that you should not need another injection

Usage Instructions




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1. Hold the set of auto-injectors with the non-dominant hand and by the plastic clip.
2. Grasp the atropine injector
3. Remove the atropine injector with the thumb and first two fingers.




4. Repeat using the 2-PAM injector




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METERED DOSE INHALER

Medication Name
Generic: albuterol, isoetharine, metaproternol
Trade: Proventil, Ventolin, Bronchosol, Alupent, Metaprel

Pharmacology and Actions
   A. These medications are all bronchodilators. These medications have a rapid onset
       of action and duration between 2 and 4 hours. All of these agents will have
       cardiovascular side effects, including increasing heart rate and increasing blood
       pressure.
Indications
   A. Wheezing due to bronchial asthma, COPD, or bronchospasm related to an
       allergic reaction.
   B. Patient has chief complaint of shortness of breath and has a history of bronchial
       asthma or COPD.
   C. Patient has a physician prescribed bronchial inhaler.

Note: The bronchodilator must be prescribed for this patient. If in doubt, contact medical
control. No over-the–counter medications should be administered.

Precautions
   A. If the patient is not breathing adequately on his/her own, the treatment of choice
      is ventilation.
   B. The patient in need of a metered dose inhaler for wheezing should also be on
      supplemental oxygen.

Administration
  A. Follow the steps in the standard drug administration protocol.
  B. Administer supplemental oxygen.
  C. Confirm prescription identification.
  D. Ascertain how many times the patient has used the inhaler.
  E. Contact on-line medical control for an order to administer.
  F. Shake the inhaler vigorously.
  G. Have the patient place the actuator two finger breadths away from his/her
      mouth.(If the patient has a spacer, use it.) The patient should begin to inhale
      deeply as he/she can.
  H. Depress the canister shortly after inhalation has begun. Have the patient hold
      his/her breath as long as comfortably possible, then exhale. This should be
      repeated to accomplish the two puffs.
  I. In the event of a prolonged transport and the patient is not getting better, contact
      base station for additional orders.

Side Effects and Special Notes
Some common side effects which may be experienced include, hypertension, chest
pain, increased heart rate, nervousness, tremors, nausea, vomiting and sore throat.




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METHYLPREDNISOLONE (SOLU-MEDROL)

Description
Methylprednisolone is a synthetic steroid that suppresses acute and chronic
inflammation and may alter the immune response. In addition, it potentiates vascular
smooth muscle relaxation by beta-adrenergic agonists and may alter airway
hyperactivity. An additional newer use is for reduction of posttraumatic spinal cord
edema.

Indications
Anaphylaxis
Severe asthma
COPD

Contraindications
Hypersensitivity

Adverse Reactions
Gastrointestinal bleeding
Hypertension

Dosage and Administration
Adult: 125 mg, IV bolus, slowly, over 2 minutes
Pediatric: 2 mg/kg, IV bolus, slowly, over 2 minutes

Protocol
Asthma
Chronic Obstructive Pulmonary Disease

Special Considerations
   • Must be reconstituted and used immediately
   • Be aware that the effect of methylprednisolone is generally delayed for several
      hours. Although it is worthwhile to administer methylprednisolone early in the
      treatment of a patient with severe respiratory distress or anaphylaxis you may not
      see any effect from the drug for several hours.
   • Methylprednisolone is not considered a first line drug. Initial effects can be seen
      at about 20 minutes but the medication effect will not peak for about 2 hours. Be
      sure to attend to the patient’s primary treatment priorities (i.e. airway, ventilation,
      beta-agonist neublization) first. If primary treatment priorities have been
      completed and there is time while in route to the hospital, then
      methylprednisolone can be administered. Do not delay transport to administer
      this drug
   • Use in Pregnancy: Since adequate human reproduction studies have not been
      done with this medication, the use of this drug in pregnancy or with nursing
      mothers requires that the possible benefits of the drug be weighed against the
      potential hazards to the mother and the embryo or fetus.




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MIDAZOLAM (VERSED)

Description
Midazolam HCl is a water-soluble benzodiazepine that may be administered for sedation
to relieve apprehension or impair memory. It is also used as an anti-convulsant.

Indications
Sedation for cardioversion or transcutaneous pacing (TCP)
Status Epilepticus in adults; as an IM benzodiazepine when two IV attempts have been
unsuccessful. If an IV is obtained, then diazepam should be used. combination
analgesia, combative patients, and severe anxiety states.

Contraindications
Hypersensitivity to benzodiazepines
Acute narrow angle glaucoma

Adverse Reactions
Significant hypotension
Significant respiratory depression
Apnea
Amnesia

Drug Interactions
Sedative effect of midazolam may be heightened by associated use of barbiturates,
alcohol, CNS depressants, or narcotics.

Dosage and Administration
C. ADULT DOSAGES
   1. Combination Analgesia
              1-2 mg IV after Fentanyl or Morphine administration
   2. Status Epilepticus
              2.5 mg IV/ 5 mg IM or IN (MAD Device)
   3. Combative Patient
              2.5 mg IV / 5 mg IM
   4. Severe Anxiety State
              0.5 - 1 mg IV/IM

Special Considerations
Midazolam should be given slowly. This may be accomplished in different ways.
   1. The appropriate dose my be diluted in a 10cc syringe with normal saline and pushed
      slowly over 2 minutes.
   2. The appropriate dose may be placed in a 50cc bag of normal saline and administered over
      2 minutes via a microdrip administration set.
   3. The appropriate dose may be administered Intra Nasally via the MAD device in Status
      Seizure




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D. PEDIATRIC DOSAGES
   1. Combination Analgesia
      a. 0.05 mg/kg IV
      b. Maximum dose 2 mg
   2. Status Epilepticus
      a. 0.10 mg/kg IV/IM/IO/IN
      b. Maximum dose 2 mg


Protocol
Bradycardia with a pulse
Combination Analgesia
Wide Complex Tachycardia
Seizures
Hyperthermia
Pediatric Seizures
Combination Analgesia

Special Considerations
Provide continuous monitoring of respiratory and cardiac function.
Have resuscitation equipment and medication readily at hand.
Consider lower doses for elderly patients
MORPHINE SULFATE

Description
Morphine sulfate is a natural opium alkaloid that increases peripheral venous
capacitance and decreases venous return. It promotes analgesia, euphoria, and
respiratory and physical depression. Morphine sulfate is a schedule II drug.

Onset & Duration
Onset: Immediate
Duration: 2-7 hr

Indications
Chest pain of a likely cardiac origin
Severe burns
Cardiogenic pulmonary edema
Isolated extremity injuries
Pain management

Contraindications
Hypersensitivity
Hypovolemia
Hypotension (relative)
Head injury or undiagnosed abdominal pain

Side effects
Hypotension
Nausea and/or vomiting
Vasodilation (Tachycardia or bradycardia)
Respiratory depression

Dosage and Administration
Adult:
Cardiac Chest Pain
    Initial dose 1 – 4 mg. Repeat doses of 2.0 mg, up to 10 mg. IV only
Injuries / Burns
    Initial dose 0.1 mg/kg slow IV/IM/IN, up to 10 mg.

Pediatric:
   0.1-0.2 mg/kg, IV/IM SLOWLY. Maximum single dose is 5.0 mg.

Protocol
Chest pain
Hypertension
Pulmonary Edema
Abdominal Pain
Extremity Injuries
Burns



Special Considerations


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IV is the preferred route for all indications. IM or IN should only be used for pain if an IV
cannot be obtained and should NOT be used for cardiac indications.
Vital signs, including pulse oximetry and EKG when available, should be monitored
regularly
Naloxone and resuscitation equipment should be readily available




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NALOXONE (NARCAN)
Seizures
Poisoning/Overdose
Psychiatric/Behavioral
Infant and Child Resuscitation
Pediatric Altered Mental Status

Special Considerations
Patients receiving Naloxone must be transported to a hospital
If dose is given endotracheally, double the dose. This should be an absolute last resort.
Give with extreme caution prior to administering endotracheally as the patient may
awake violently and the endotracheal tube placement may be displaced.




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NITROGLYCERINE (NITROSTAT, NITROQUICK, etc)

Description
It was originally believed that nitrates and nitrites dilated coronary blood vessels, thereby
increasing blood flow to the heart. It is now believed that atherosclerosis limits coronary
dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and
veins in the periphery. The resulting reduction in preload and to a lesser extent in
afterload decreases the work load of the heart and lowers myocardial oxygen demand.
Nitroglycerin is very lipid soluble and is thought to enter the body from the Gl tract
through the lymphatics rather than the portal blood.

Onset & Duration
Onset: 1-3 min.
Duration: 20-30 min.

Indications
Angina
Chest, arm, or neck pain caused by coronary ischemia
Patients with 12-lead evidence of acute MI, with or without chest pain
Control of hypertension in angina, acute MI, or hypertensive encephalopathy without
evidence of CVA
Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac preload
and afterload

Contraindications
Blood Pressure under 90 mmHg

Precautions
Hypersensitivity
Use with caution in patients with EKG evidence of right ventricular infarction
Hypotension
Patients taking erectile dysfunction drugs should not receive nitroglycerine in any form

Adverse Reactions
Transient headache
Postural syncope
Hypotension
Nausea and vomiting
Flushing
Dizziness
Burning under the tongue

Dosage and Administration
   • 0.4 mg (1/150 gr) sublingually or spray, every 5 minutes. Vital signs must be re-
     assessed after each administration.
   • Nitropaste 1 inch (if available)

Protocol
Premature Ventricular Contractions (PVCs)
Chest Pain
Hypertension


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Pulmonary Edema

Special Considerations
Susceptibility to hypotension in older adults increases.
Nitroglycerin loses potency when exposed to light or heat.
Must be kept in airtight, dark containers.
Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective
in relieving chest pain caused by esophageal spasm




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ODANSETRON (ZOFRAN)

Description
Odansetron is a selective 5-HT3 receptor agonist. Mechanism of action has not been
fully characterized. It is not certain whether odansetron’s antiemetic action is mediated
centrally, peripherally, or in both sites.

Indications
Nausea with concern for potential vomiting
Vomiting

Contraindications
Patients with a known hypersensitivity to odansetron.

Precautions
Odansetron is listed as a category B with regard to use in pregnancy.

Dosage and Administration
Adult:
  4 mg undiluted SLOW IV push over 2 to 5 minutes or IM. Repeat dose 4mg.
   CONTACT BASE for cumulative dose above 8mg.
Pediatric (1 to 12 years of age):
   under 40 kg: 0.1 mg/kg SLOW IV push over 2 to 5 minutes or IM or SL**
   over 40 kg: 4 mg SLOW IV push over 2 to 5 minutes or IM or SL**
   **(For SL administration, the IV solution may be used, simply remove the
   needle and administer under the tongue)

Protocol
Antiemetic situations




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ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE)

Description
Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop
in blood sugar level will result in disturbance of normal metabolism, manifested clinically
as decrease in mental status, sweating, and tachycardia. Further decreases in blood
sugar may result in coma, seizures, and cardiac arrhythmia. Serum glucose is regulated
by insulin, which stimulates storage of excess glucose from the body's blood stream, and
glucagon, which mobilizes stored glucose into the blood stream. The oral glucose paste
is rapidly absorbed into the oral mucosa, thus elevating the body's blood glucose level.

Indications
Hypoglycemia
Altered Mental Status with a history of (hypoglycemia) diabetes

Contraindications
Inability to swallow
Patient who may experience an airway obstruction from administration

Administration
The dosage of oral glucose is one full tube.
Follow the standard drug administration protocol.
Squeeze a small portion of the tube (approximately 1/3) into the patient's mouth between
the cheek and gum. Or, utilizing a tongue depressor, deposit a small portion of the tube
(approximately 1/3) onto the tongue depressor and slide it into the patient's mouth
between the cheek and gum. Repeat the procedure until one full tube of glucose has
been administered.
Reassess the vital signs and the patient's condition

Protocol
Altered Mental Status

Special Notes
There are few, if any, side effects with this medication.
Be aware of possible airway obstruction. Have suction available.




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OXYGEN

Description
Oxygen added to the inspired air increases the amount of oxygen in the blood, and
thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell
damage and death. Breathing, in most people, is regulated by small changes in the
acid-base balance and CO2 levels. It takes relatively large decreases in oxygen
concentration to stimulate respiration.

Indications
Suspected hypoxemia or respiratory distress from any cause
Acute chest or abdominal pain
Hypotensive states from any cause
Trauma
All acutely ill patients
Any suspected carbon monoxide poisoning
Pregnant females

Precautions
   • If the patient is not breathing adequately, the treatment of choice is assisted
      ventilation, not just oxygen.
   • A small percentage of patients with chronic lung disease breathe because they
      are hypoxic. Administration of oxygen will inhibit their respiratory drive. Do not
      withhold oxygen because of this possibility. Be prepared to assist
      ventilations if needed.
   • When pulse oximetry is available, titrate Sa O2 to 90% or greater. This may take
      some time. Be patient within reason.
   • In the COPD patient: increase oxygen in increments of 2 liters/minute every 2 3
      minutes until improvement is noted (color improvement or increase in mental
      status).

Administration
Flow                  LPM dosage                    Indications
Low Flow              1-2 LPM                       Minor medical / trauma
Moderate Flow         3-9 LPM                       Moderate medical / trauma
High Flow             10-15 LPM                     Severe medical / trauma

Special Notes
Restlessness may be an ominous sign of hypoxia.
Some people become more agitated when a nasal cannula is applied, particularly when
it is not needed. Acquiesce to your patient if it is reasonable.
Nasal prongs work equally well on nose and mouth breathers, except babies.
Non humidified oxygen is drying and irritating to mucous membranes.
Oxygen toxicity is not a hazard of short term use.
Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen,
use a single patient use device.
During long transports for high altitude illness, reduce oxygen flow from high to low, to
conserve oxygen.




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                                 OXYGEN FLOW RATES
             METHOD                   FLOW RATE                OXYGEN INSPIRED AIR
                                                                    (approximate)
 Room Air                                                    21%
 Nasal Cannula                       1 LPM                   24%
                                     2 LPM                   28%
                                     6 LPM                   44%
 Simple Face Mask                    8 - 10 LPM              40-60%
 Non-rebreather Mask                 10 LPM                  90%
 Mouth to Mask                       10 LPM                  80%
                                     15 LPM                  50%
 Bag/Valve/Mask (BVM)                Room Air                21%
                                     12 LPM                  40%
 Bag/Valve/Mask with Reservoir       10-15 LPM               90-100%
 OXYGEN -powered breathing           hand-regulated          100%
 device
 NOTE:
 Most hypoxic patients will feel more comfortable with an increase of inspired oxygen from
 21% to 24%.




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PHENYLEPHRINE (INTRANASAL)

Description
Used for topical nasal administration, phenylephrine primarily exhibits alpha adrenergic
stimulation. This stimulation can produce moderate to marked vasoconstriction and
subsequent nasal decongestion.

Indications
Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa
Pain related to middle ear congestion or infection
Epistaxis without hypertension

Contraindications
Known Hypersensitivity

Precautions
Avoid administration into the eyes, as it will cause dilation of the pupils

Dosage and Administration
Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation
In epistaxis moisten gauze and place in affected nare

Side Effects
Headache, dizziness, insomnia, sedation, hypertension, mydriasis

Protocol
Nasotracheal Intubation




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PROMETHAZINE (PHENERGAN)

Description
Promethazine is a first-generation H1 receptor antagonist antihistamine and antiemetic
medication which acts centrally and has sedative properties. It is related to the
phenothiazine family and may cause extrapyramidal and anticholinergic symptoms.

Indications
Nausea with concern for potential vomiting
Vomiting

Contraindications
Patients in a comatose state
CNS depression from alcohol or drug usage
Pediatric patients 2 years old or younger

Precautions
Promethazine does not eliminate the need to monitor the airway.
Respiratory depression may occur if the patient has used alcohol or drugs.
Extrapyramidal effects are more likely to manifest in pediatric patients with acute illness
or dehydration

Side Effects
Hypotension if administered too quickly. Give Normal Saline to reverse the hypotension.
Extrapyramidal effects. Give Benadryl 25 mg to reverse these effects.
Dry mouth
Dilated pupils
Incontinence/Constipation

Dosage and Administration
Adult: 12.5 mg, IV bolus slowly over 1-2 minutes.
        Consider 6.25mg dosing for patients that have:
        1. Consumed alcohol
        2. Been given narcotic analgesics
        3. Present with signs/symptoms of CHI
Pediatric (3-8 years of age): 0.25 mg/kg IV bolus slowly or IM.
Geridatric: 6.25mg Slow IVP

FOR REPEAT DOSES consider use of Ondansetron (Zofran) or a repeat dose of
6.25mg after 15 min.

Protocol
Nausea/Vomiting




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RACEMIC EPINEPHRINE (VAPONEPHRINE)

Description
Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for use by oral
inhalation only. Effects are those of epinephrine. Inhalation causes local effects on the
upper airway as well as systemic effects from absorption. Vasoconstriction may reduce
swelling in the upper airway, and beta effects on bronchial smooth muscle may relieve
bronchospasm.

Onset & Duration
Onset: 1-5 minutes
Duration: 1-3 hours

Indications
Life threatening airway obstruction suspected secondary to croup or epiglottitis
Laryingeal Edema

Side Effects
Tachycardia
Anxiety
Palpitations

Dosage and Administration
Do NOT delay transport to begin administration
0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml saline, via
nebulizer at 6-8 LPM to create a fine mist
If racemic epinephrine is not available plain L-epinephrine may be used:
Place 5 mg (5.0 ml of a 1:1,000 solution) undiluted in a nebulizer at 6-8 LPM to create a
fine mist
For infants <10 kg, the recommended dose is 0.5 mg/kg undiluted (0.5 ml/kg of 1:1,000
solution) of L-epinephrine.

Protocol
Pediatric Respiratory Distress

Special Considerations
Always try to utilize the parents help as the mask may frighten children
Is heat and photo-sensitive and needs to be protected from heat and light sources
Do not confuse the side effects with respiratory failure or imminent respiratory arrest.
If respiratory arrest occurs, it is usually due to patient fatigue or laryngeal spasm.
Complete obstruction is not usually present. Ventilate the patient, administer oxygen,
and transport rapidly. If you can ventilate and oxygenate the patient adequately with
mouth-to-mask, pocket mask, or BVM, intubation is best left to a specialist in a controlled
setting
Try to differentiate croup from epiglottitis by history. Cough is usually present in croup.
Do not use a tongue blade to examine the back of the throat. The diagnosis is
frequently difficult in the field, but a critical patient deserves a trial of racemic epinephrine
during transport. Although used as specific therapy for croup, it may also buy some time
in patients with epiglottitis




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SODIUM BICARBONATE

Description
Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body.
Acids are increased when body tissues become hypoxic due to cardiac or respiratory
arrest.

Indications
Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures
Consider in patients with prolonged cardiac arrest.
Consider in dialysis patients with cardiac arrest (presumed secondary to hyperkalemia)

Contraindications
Metabolic and respiratory alkalosis
Hypocalcemia
Hypokalemia

Adverse Reactions
Metabolic alkalosis
Hyperosmolarity may occur, causing cerebral impairment

Drug Interactions
May precipitate in calcium solutions.
Alkalinization of urine may increase half-lives of certain drugs.
Vasopressors may be deactivated.

Dosage and Administration
   A. STANDING ORDER in cardiac arrest
   B. CONTACT BASE for all other indications.
   C. Solutions:
      1. Adult / Pediatric: 8.4% = 1.0 mEq/ml
      2. Neonatal: 4.2% = 0.5 mEq/ml
         a. (Either prepackaged or adult solution diluted 1:1 with sterile NS or water)
   D. For cardiac arrest / Tricyclic Overdose:
      1. Adult: 1 mEq/kg (1 ml/kg)
      2. Pediatric: 1 mEq/kg (1 ml/kg)
      3. Neonatal: 1 mEq/kg (2 ml/kg)

Protocol
Asystole
Poisoning/Overdose

Special Considerations
   • Sodium bicarbonate administration increases CO2 which rapidly enters cells,
      causing a paradoxical intracellular acidosis.
   • Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This
      increases intravascular volume, which increases the workload of the
      heartSodium bicarbonate's lack of proven efficacy and its numerous adverse
      effects have lead to the reconsideration of its role in cardiac resuscitation.
      Effective ventilation and circulation of blood during CPR are the most effective
      treatments for acidemia associated with cardiac arrest


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   •   Administration of sodium bicarbonate has not been proven to facilitate ventricular
       defibrillation or to increase survival in cardiac arrest. Metabolic acidosis lowers
       the threshold for the induction of ventricular fibrillation, but has no effect on
       defibrillation threshold.
   •   The inhibition effect of metabolic acidosis on the actions of catecholamines has
       not been demonstrated at the pH levels encountered during cardiac arrest.
   •   Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field
       treatment is rarely indicated.
   •   Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest
       due to suspected hyperkalemia.




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TOPICAL OPHTHALMIC ANESTHETICS (TETRACAINE)

Description
Used for topical administration as a pain reliever for eye irritation. Only proparacaine
and tetracaine are approved for use.

Indications
Used to provide topical ophthalmic anesthesia during transport of patients with actual or
potential serious eye injuries that present with a "foreign body sensation"

Contraindications
Known allergy to local anesthetics (Novacaine, Lidocaine, Xylocaine, etc.)
Eyelid lacerations
Global lacerations or rupture
Discoloration of medication

Precautions
Occasional burning/stinging can occur when initially applied, although this is usually
transient

Dosage and Administration
Instill two drops into affected eye. Repeat only with Base Contact and physician consult

Protocol
Eye injury

Special Considerations
This is single patient use. Unused portions are to be discarded and only new bottles are
to be used.
Do not administer until patient consents to transport and transport has begun
Topical ophthalmic anesthetics should never be given to a patient for self-administration




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                                                              Inter-Facility Drug Protocol

Antibiotics

Description
Due to the vast number of antibiotics available, it is not practical to develop a written
protocol for every antibiotic. Therefore, this protocol shall serve as a general guide to
the inter-facility maintenance of antibiotic drips.

Indications
Treatment and prevention of Bacterial Infections

Contra-Indications:
Hypersensitivity

Precautions:


Adverse Reactions
Allergic or Anaphylactic reactions


Dosage and Administration
   • The Paramedic shall consult drug reference guide for proper dosage and
     administration information.



Protocol
  1. For inter-facility transport only when initiated by a sending facility.
  2. Must be maintained on an IV pump
  3. Paramedic must familiarize him/herself with proper dosage and administration
     information utilizing appropriate drug guide or manufacturer information as well as
     general information regarding the particular antibiotic.
  4. The Paramedic shall consult with Nursing staff or Medical control to obtain any
     specific instructions for transport.
  5. Signs and Symptoms of anaphylaxis should be watched for at all times.
  6. Treatment of allergic or anaphlaxtic reactions shall be per normal ALS protocol.
  7. In the event of allergic or anaphlaxtic reaction the antibiotic shall be stopped and
     disconnected from the patient, and medical control should be advised.




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Reference Material:


                                         Antibiotics[6]



    Generic Name           Brand Names        Common Uses            Possible Side Effects



                                       Aminoglycosides



Amikacin                  Amikin           Infections caused by
                                           Gram-negative
                                           bacteria, such as
Gentamicin                Garamycin
                                           Escherichia coli and
Kanamycin                 Kantrex                                        Hearing loss
                                           Klebsiella particularly
Neomycin                                   Pseudomonas                   Vertigo
                                           aeruginosa. Effective
Netilmicin                Netromycin       against Aerobic               Kidney damage
Streptomycin                               bacteria (not
                                           obligate/facultative
Tobramycin                Nebcin           anaerobes).
Paromomycin               Humatin
                                         Ansamycins
Geldanamycin                               Experimental, as
Herbimycin                                 antitumor antibiotics

                                        Carbacephem
Loracarbef                Lorabid
                                        Carbapenems
Ertapenem                 Invanz           Bactericidal for both
                                           Gram-positive and             Gastrointestinal
Doripenem                 Finibax
                                           Gram-negative             upset and diarrhea
Imipenem/Cilastatin       Primaxin         organisms via
                                           inhibition of cell wall       Nausea
                                           synthesis and
                                           therefore useful for          Seizures
                                           empiric broad-                Headache
Meropenem                 Merrem           spectrum antibacterial
                                           coverage. (Note               Rash and Allergic
                                           MRSA resistance to
                                                                     reactions
                                           this class.)
                               Cephalosporins (First generation)
Cefadroxil                Duricef
                                                                         Gastrointestinal
Cefazolin                 Ancef
                                                                     upset and diarrhea
Cefalotin or Cefalothin   Keflin
Cefalexin                 Keflex                                         Nausea (if alcohol



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                                                                    taken concurrently)
                                                                        Allergic reactions
                         Cephalosporins (Second generation)
Cefaclor              Ceclor
                                                                        Gastrointestinal
Cefamandole           Mandole
                                                                    upset and diarrhea
Cefoxitin             Mefoxin
                                                                        Nausea (if alcohol
Cefprozil             Cefzil
                                                                    taken concurrently)
Cefuroxime            Ceftin, Zinnat
                                                                        Allergic reactions
                          Cephalosporins (Third generation)
Cefixime              Suprax
Cefdinir              Omnicef
Cefditoren            Spectracef
Cefoperazone          Cefobid                                           Gastrointestinal
Cefotaxime            Claforan                                      upset and diarrhea
Cefpodoxime                                                             Nausea (if alcohol
Ceftazidime           Fortaz                                        taken concurrently)
Ceftibuten            Cedax                                             Allergic reactions
Ceftizoxime
Ceftriaxone           Rocephin
Cefdinir
                          Cephalosporins (Fourth generation)

                                                                        Gastrointestinal
                                                                    upset and diarrhea
Cefepime              Maxipime                                          Nausea (if alcohol
                                                                    taken concurrently)
                                                                        Allergic reactions
                                       Glycopeptides
Teicoplanin
Vancomycin            Vancocin
                                        Macrolides
                      Zithromax,          Streptococcal
Azithromycin          Sumamed,            infections, syphilis,         Nausea, vomiting,
                      Zitrocin            respiratory infections,   and diarrhea (especially
                                          mycoplasmal
Clarithromycin        Biaxin                                        at higher doses)
                                          infections, Lyme
Dirithromycin                             disease                       Jaundice
Erythromycin




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Roxithromycin
Troleandomycin
                                                                Visual Disturbance, LIVER
                                                                TOXICITY. This medication's
                                                                approval in the U.S. was
                                                                controversial, and one doctor
                                                                went to jail in followup
                                                                attempts to ascertain its
                                                                safety because she falsified
Telithromycin         Ketek            Pneumonia
                                                                the results of her part of the
                                                                testing precisely because it
                                                                seemed to cause liver
                                                                problems, including liver
                                                                failure, to a greater extent
                                                                than would be expected of a
                                                                common-use antibiotic.[7]
                                       Antimetabolite,
Spectinomycin
                                       Anticancer
                                    Monobactams
Aztreonam
                                      Penicillins
Amoxicillin           Novamox
Ampicillin
Azlocillin
Carbenicillin                                                           Gastrointestinal
Cloxacillin                            Wide range of                upset and diarrhea
Dicloxacillin                          infections; penicillin
                                                                        Allergy with serious
                                       used for streptococcal
Flucloxacillin                         infections, syphilis,        anaphylactic reactions
Mezlocillin                            and Lyme disease
                                                                        Brain and kidney
Nafcillin
                                                                    damage (rare)
Penicillin
Piperacillin
Ticarcillin
                                     Polypeptides
Bacitracin                             Eye, ear or bladder
                                       infections; usually
Colistin
                                       applied directly to the Kidney and nerve damage
                                       eye or inhaled into     (when given by injection)
Polymyxin B                            the lungs; rarely given
                                       by injection
                                     Quinolones
                      Ciproxin,      Urinary tract              Nausea (rare), tendinosis
Ciprofloxacin
                      CiploxESTECINA infections, bacterial      (rare)
                                     prostatitis,
Enoxacin




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Gatifloxacin              Tequin            community-acquired
                                            pneumonia, bacterial
Levofloxacin              Levaquin
                                            diarrhea,
Lomefloxacin                                mycoplasmal
Moxifloxacin              Avelox            infections, gonorrhea

Norfloxacin               NOROXIN
Ofloxacin                 Ocuflox
Trovafloxacin             Trovan
                                          Sulfonamides
Mafenide
                                                                         Nausea, vomiting,
Prontosil (archaic)
Sulfacetamide                                                        and diarrhea

Sulfamethizole                                                           Allergy (including
                                            Urinary tract
Sulfanilimide (archaic)                     infections (except       skin rashes)
                                            sulfacetamide and
Sulfasalazine                               mafenide); mafenide          Crystals in urine
Sulfisoxazole                               is used topically for        Kidney failure
                                            burns
Trimethoprim
                                                                         Decrease in white
Trimethoprim-
Sulfamethoxazole (Co-                                                blood cell count
                          Bactrim
trimoxazole) (TMP-                                                       Sensitivity to sunlight
SMX)
                                          Tetracyclines
Demeclocycline
                                                                         Gastrointestinal
Doxycycline               Vibramycin
                                                                     upset
Minocycline               Minocin           Syphilis, chlamydial
                                                                         Sensitivity to sunlight
Oxytetracycline           Terracin          infections, Lyme
                                            disease,                     Staining of teeth
                                            mycoplasmal
                                            infections, acne         (especially in children)
                                            rickettsial infections       Potential toxicity to
Tetracycline              Sumycin
                                                                     mother and fetus during
                                                                     pregnancy
                                             Others
                                            Spirochaetal
Arsphenamine              Salvarsan
                                            infections (obsolete)
Chloramphenicol           Chloromycetin
                                            acne infections,
Clindamycin               Cleocin           prophylaxis before
                                            surgery
                                            acne infections,
Lincomycin                                  prophylaxis before
                                            surgery




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Ethambutol                              Antituberculosis
Fosfomycin
Fusidic acid             Fucidin
Furazolidone
Isoniazid                               Antituberculosis
Linezolid                Zyvox
Metronidazole            Flagyl         Giardia
Mupirocin                Bactroban
                         Macrodantin,
Nitrofurantoin
                         Macrobid
Platensimycin
Pyrazinamide                            Antituberculosis
Quinupristin/Dalfopristin Syncercid
                                        Binds to the β subunit
                                        of "RNA polymerase"
                                        to inhibit transcription Reddish-orange sweat, tears,
Rifampin or Rifampicin
                                        of mostly "Gram-         and urine
                                        positive" and
                                        "mycobacteria"
Tinidazole




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Heparin                                                  Inter-Facility Drug Protocol

Description
Heparin is an anticoagulant (blood thinner)

Indications
Treatment and prevention of blood clots often associated in treatment of:
   • Acute Coronary Syndrome
   • Pulmonary Embolus
   • Pre-Operatively
   • A-Fib
   • DVT

Contraindications
  • Known Hypersensitivity
  • Active Bleeding Disorder


Precaution for Patients with:
   • Liver Disease
   • Menstrual period
   • Hypertension
   • GI Problems
   • Endocarditis

Side Effects
   • Bleeding
   • Bruising
   • Allergic Reaction

Dosage and Administration
   • The following is provided for information and reference purposes only.
   • Traditional regimen calls for Bolus dose followed by maintenance infusion.
   • Normal Bolus 50-100 units/kg (70units/Kg average)
   • Normal Infusion 15-25 units/kg/hr (Typically around 20ml/hr)

Protocol
   1. For inter-facility transport only when initiated by a sending facility.
   2. Heparin infusions must be maintained on an IV pump at all times during transport
      at facility initiated maintenance dosage.
   3. Heparin dosage may not be titrated in the interfacility environment.
   4. Heparin Bolus may not be given.
   5. Heparin infusion should be stopped if life threatening bleeding develops. (CVA,
      GI Bleed, etc.)
   6. If infusion is stopped, medical control or the receiving facility should be consulted
      for further instructions and consultation.


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                                                               Inter-Facility Drug Protocol
Nitroglycerin Drip

Description
It was originally believed that nitrates and nitrites dilated coronary blood vessels, thereby
increasing blood flow to the heart. It is now believed that atherosclerosis limits coronary
dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and
veins in the periphery. The resulting reduction in preload and to a lesser extent in
afterload decreases the work load of the heart and lowers myocardial oxygen demand.
Nitroglycerin is very lipid soluble and is thought to enter the body from the Gl tract
through the lymphatics rather than the portal blood.


Indications
Angina
Chest, arm, or neck pain caused by coronary ischemia
Patients with 12-lead evidence of acute MI, with or without chest pain
Control of hypertension in angina, acute MI, or hypertensive encephalopathy without
evidence of CVA
Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac preload
and afterload

Contra-Indications:
Hypersensitivity
Hypotension
Patients taking erectile dysfunction drugs should not receive nitroglycerine in any form

Precautions:
Use caution in patients with Right Ventricular Infarct patterns.

Adverse Reactions
Transient headache
Postural syncope
Hypotension
Nausea and vomiting
Flushing
Dizziness
Burning under the tongue

Dosage and Administration
   • Continue Nitroglycerin drip at the rate begun at the transferring hospital
   • Refer to dosing chart below based on 25mg or 50mg Nitro in 250ml solution.
   • Be advised that varying concentrations for Ntiroglycerin exist, please refer
     to facility specific concentration guidelines
   • Typical dosing starts a 5-10mcg/min (typically 3-6ml/hr)
   • Typical titration increases or decreases in 5-10mcg increments q 5-10 minutes
     titrated to cessation of pain and Systolic BP >90




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Protocol
   1. For inter-facility transport only when initiated by a sending facility.
   2. Nitro infusions must be maintained on an IV pump at all times during transport.
   3. Blood Pressure Monitoring must be maintained on q 5-10 minute intervals
      depending on stability of patient. (q 5 when titrating, q 10 if stable)
   4. Maintain continuous EKG and Pulse Oximetry monitoring
   5. Nitro Dosage may be titrated downward in 5mcg increments at 5-10 minute
      intervals to maintain systolic BP >90 or according to facility specific transfer
      orders.
   6. If systolic BP drops below 90 a 250ml fluid challenge of NS should be given in
      addition to lowering titration.
   7. If systolic remains below 90 after 250ml fluid challenge and decreasing titration,
      Nitro drip should be stopped and medical control contacted for further
      instructions.
   8. Maximum drip rate should not exceed 200mcg/min
   9. Nitroglycerin requires non-polyvinyl tubing and glass or maxide IV bag as Nitro
      bonds to certain plastics which can alter dosing accuracy.

Nitro Concentration    Ml per Hour            Nitro Concentration    ML per Hour
25mg/250ml                                    50mg/250ml
5mcg                   3ml                    5mcg                   1.5ml
10mcg                  6ml                    10mcg                  3ml
15mcg                  9ml                    15mcg                  4.5ml
20mcg                  12ml                   20mcg                  6ml
25mcg                  15ml                   25mcg                  7.5ml
30mcg                  18ml                   30mcg                  9ml
35mcg                  21ml                   35mcg                  10.5ml
40mcg                  24ml                   40mcg                  12ml
45mcg                  27ml                   45mcg                  13.5ml
50mcg                  30ml                   50mcg                  15ml
55mcg                  33ml                   55mcg                  16.5ml




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                                       BANDAGING
   Indications
   A. To stop external bleeding by application of direct and continuous pressure to
      wound site
   B. To protect patient from contamination to lacerations, abrasions, burns
   Precautions
   A. Although external skin wounds may be dramatic, they are rarely a high
      management priority in the trauma victim.
   B. Do not use circumferential dressings around neck. Continued swelling may block
      airway.
   Technique
   A.   Use BSI.
   B.   Control hemorrhage with direct pressure, using sterile dressing.
   C.   Assess patient fully and treat all injuries by priority once assessment is complete.
   D.   Remove gross dirt and contamination from wound: clothing (if easily removable),
        dirt, gasoline, acids, or alkalis. Use copious irrigating saline or tap water for
        chemical contamination.
   E.   Evaluate wound for depth, presence of fracture in wound, foreign body, or
        evidence of injury to deep structures. Note distal motor, sensory, and circulatory
        function prior to applying dressings.
   F.   Apply sterile dressing to wound surface. Touch outer side of dressing only.
   G.   Wrap dressing with clean gauze or cloth bandages applied just tightly enough to
        hold dressing securely (if no splint applied).
   H.   Assess wound for evidence of continued bleeding.
   I.   Check distal pulses, color, capillary refill, and sensation after bandage applied.
   J.   Continue to apply direct hand pressure over dressing, or use air splint if bleeding
        not controlled with bandage alone.
   K.   For deep or gaping muscle wounds in which bleeding cannot be controlled with
        direct pressure, pack the wound with sterile gauze than reapply a sterile dressing
        with pressure.
   Complications
   A. Loss of distal circulation from bandage applied too tightly around extremity; for
      this reason, do not use elastic bandages or apply bandages too tightly.
   B. Airway obstruction due to tight neck bandages.
   C. Restriction of breathing from circumferential chest wound splinting
   D. Continued bleeding no longer visible under dressings. (This is particularly
      common with scalp wounds that continue to lose large amounts of unnoticed
      blood.)
   E. Inadequate hemostasis: some wounds require continuous direct manual
      pressure to stop bleeding.




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                               AIRWAY MANAGEMENT
                                  CAPNOGRAPHY

E. Indications
   1. All intubated patients REQUIRE continuous end-tidal CO2 monitoring to assess:
      a. Proper initial placement of the endotracheal tube and continued airway
           patency.
      b. Inadvertent displacement of the endotracheal tube.
      c. Effectiveness of cardiopulmonary resuscitation
      d. Patients requiring mechanical ventilation during transportation. The monitor is
           used to determine if the endotracheal tube has become displaced or to detect
           the disruption of the ventilator circuit
   2. Patients receiving procedural sedation and analgesia (PSA) require continuous
      monitoring for hypoventilation.
   3. Patients with evidence of hypoventilation for any reason (pain management,
      ingestion, seizure, CNS disorders, etc) should receive continuous end-tidal CO2
      monitoring.
   4. Patients with bronchospasm or CHF should receive continuous end-tidal CO2
      monitoring.

F. Precautions
   1. Caution should be exercised to ensure that the clinical picture matches the end-
      tidal CO2 reading.
   2. Determination of patient status should always involve a combination of end-tidal
      CO2 readings, pulse oximetry readings and clinical signs.

G. Technique - End-tidal CO2 Monitor – Lifepak 12
   1. Attach the CO2 sensor in-
      line between the
      endotracheal tube and
      the BVM or mechanical
      ventilator.


   2. Open the CO2 tubing
      connector door and
      connect the Microstream
      CO2 FilterLine tubing by
      turning the tubing clockwise.




   3. Press ON
   4. Verify EtCO2 monitor display is on.
   5. Display CO2 waveform on channel 2 or 3.
   6. (Typically displayed on channel 3, although
      shown here on channel 2)
   7. Pridemark preselected lead group #2 is II, III,
      CO2


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H. Evaluate the capnograph waveform and numerical value.
   1. It is important to evaluate both the numerical value (capnometry) and the
      waveform (capnography). Evaluating the numerical value alone may lead to
      erroneous interpretations. There are multiple sita etations i whichg the numerical
       value isnor waveform isabnormca,e sgnifytinganh ore
      ormcaity. .




                                      Cardiac Output   EtCO2
                                            (L)        (mmHg)
                                            2           20
                                            3           28
                                            4           32
                                            5           36




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               By monitoring the EtCO2 value during cardiopulmonary resuscitation,
               efficacy of CPR in relation to cardiac output can be indirectly determined.
               EtCO2 can be used as a feedback mechanism to optimize chest
               compressions during CPR.




       f.   If the shape of the capnogram appears abnormal it indicates an underlying
            physiologic abnormal suggestive of different clinical pictures. The following
            quick-reference with example waveforms can be used to help identify
            underlying clinical disorders:

            Bronchospasm




        Bronchospasm with hypoventilation




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CARDIOVERSION ALGORITHM (Patient is not in cardiac arrest)
Tachycardia:
With serious signs and symptoms related to the tachycardia


If ventricular rate is > 150 beats/min., prepare for IMMEDIATE CARDIOVERSION. May
give brief trial of medications based on specific arrhythmia algorithms. Immediate
cardioversion is generally not needed for rates < 150 beats/min.


Check
● Ensure adequate oxygenation
● Section Device
● IV Line
● Intubation equipment

Premedicate with midazolam whenever possible

Synchronized
Cardioversion

VT                                       Adult Dose                   Pediatric Dose
PSVT                                      100j, 200j                  .05j/kg, 1.0j/kg
Atrial fibrillation                       300j, 360j                  1.5j/kg, 2.0j/kg
Atrial flutter



    Precautions
    A. Precautions for defibrillation apply. Protect rescuers!
    B. A patient who is talking to you is probably perfusing adequately.
    C. If the defibrillator does not discharge on "synch" with tachycardia, turn off "synch"
       button and refire. The waves may not have enough amplitude to trigger the
       "synch" mechanism.
    D. If sinus rhythm is achieved, even transiently, with cardioversion, subsequent
       cardioversion at a higher energy setting will be of no additional value. Leave the
       setting the same; consider correction of hypoxia, acidosis, etc. to hold the
       conversion.
    E. If the patient is pulseless, begin CPR and treat as cardiac arrest, even if the
       electrical rhythm appears organized.
    F. People with chronic atrial fibrillation are very difficult to convert, and their atrial
       fibrillation is not usually the cause of their decompensation. If you get a history of
       "irregular heartbeat," look elsewhere for the problem.
    G. Sinus tachycardia rarely exceeds 150 beats/min. in adults (220 beats/min. in
       children < 8 years old), and does not require cardioversion. Treat the underlying
       cause.




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   H. Do not be overly concerned about the dysrhythmias that normally occur in the
      few minutes following successful cardioversion. These usually respond to time
      and adequate oxygenation, and should only be treated if they persist.
   I. Biphasic monitors require different energy doses.




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Combination Analgesia

A. Introduction
   1. The appropriate management of anxiety, spasm and pain is an important
       component of comprehensive emergency medical care.
   2. The American College of Emergency Physicians state that proactively
       addressing pain and anxiety will improve quality of care and patient satisfaction
       by minimizing patient suffering.
   3. Frequently it is necessary to combine a narcotic (analgesic) and a
       benzodiazepine (anxiolytic) to provide adequate control of pain in combination
       with anxiety and/or spasm.
   4. Since combining a benzodiazepine and narcotic in the field is typically used for
       treatment of pain in combination with anxiety and/or spasm and not to facilitate a
       procedure the term Combination Analgesia will be used.
   5. This protocol will address the use of combination narcotic and benzodiazepine
       for combination analgesia. See Pain Management protocol for issues related to
       patients who receive analgesia for pain management without sedatives.
       Additionally, see Diazepam and Midazolam guidelines for treatment of anxiety
       and spasm in the absence of pain.
   6. Combination Analgesia describes a level of sedation that reduces the degree of
       anxiety, spasm, pain or awareness a patient may experience during a pain illness
       or injury. The patient retains their ability to maintain a patent airway
       independently and continuously. They maintain their protective reflexes and their
       ability to respond appropriately to physical stimulation and/or verbal command
       and are easily aroused.
   7. Combination Analgesia can only be performed by ALS providers who have met
       the following requirements:
       a. Completed training in the procedure and have met competency requirements
           leading to certification.
       b. Remain current through continuing education and semiannual skills check-
           offs.
       c. Only paramedics certified in combination analgesia can perform this
           procedure.

B. Indication
   Combination Analgesia is indicated for conditions that require pain management in
   combination with anxiety and/or spasm management (i.e. shoulder / hip dislocations,
   severe back spasms, etc).

I.   Precautions
     1. Patients with cardiopulmonary disorders, multiple trauma, head trauma, or who
        have ingested a central nervous system depressant such as alcohol are at
        increased risk of complications from this procedure and require a high level of
        vigilance.
     2. Elderly patients (>65) tend to be more sensitive and therefore should always
        receive the low end of the dose range. Administration should be slow and titration
        with additional doses should be given with extreme care.

J. Technique
   1. Equipment:



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       a.   Cardiac monitor / defibrillator
       b.   Pulse oximeter
       c.   Capnography
       d.   Oxygen
       e.   Advanced airway management equipment
       f.   Suction equipment
       g.   IV Equipment
       h.   Reversal agent: Naloxone

K. Preparation:
      a. Place the patient on a cardiac monitor.
      b. Place the patient on oxygen
      c. Place the patient on a pulse oximeter
      d. Place the patient on capnography
      e. Insert an intravenous line.
      f. Make sure airway equipment, suction and reversal agent are available and
         ready.

L. Pre-procedure assessment:
      a. Complete an appropriate history and physical examination:
          i. Focused exam of heart, lungs and airway evaluation
          ii. Vital signs including oxygen saturation
          iii. Level of consciousness / Mental status exam
          iv. Pain Scale Evaluation
          v. Determine patient’s NPO status:
               (a) If patient has not been NPO for 6-8 hours for solids and 2-3 hours for
                   liquids, the risk of the procedure and necessary or anticipated benefit
                   of the procedure must be weighed.
          vi. Obtain Consent:
               (a) Inform the patient of the risks and benefits of using combination
                   analgesia.
               (b) If the patient is able to give informed consent after being advised of
                   the risks and benefits document said consent in narrative.
M. Combination Analgesia Procedure:
      The following parameters will be continuously monitored during Combination
      Analgesia.
      a. Responsiveness to commands
      b. Capnography
      c. Oxygen saturation
      d. Heart rate
      e. Respiratory rate
      f. Blood pressure
      g. Heart rhythm
      h. Pain Scale Evaluation

N. Drug administration
   1. A key to minimizing complications in Combination Analgesia is the slow titration
      of drugs to the desired effect.
   2. The combined use of opioids and benzodiazepines increases the risk of
      respiratory depression



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   3. When both a benzodiazepine and an opioid are used, the opioid, which
       possesses the greatest risk for respiratory depression, should be given first and
       the benzodiazepine dose titrated.
   4. Administer Fentanyl 0.5 – 1.0 mcg/kg IV over two minutes
   5. Then administer Midazolam 1-2 mg IV over 2 minutes for anxiety or administer
       Valium 1-5 mg IV over 2 minutes for spasm and/or anxiety.
   6. Titrate additional drugs to desired effect:
   7. If the patient needs additional sedation, use repeat doses of 1 mg IV Midazolam
       or 1-2mg IV Valium.
   8. If the patient needs additional pain control, use repeat doses of 0.5 – 1 mcg/kg IV
       Fentanyl
   9. Fentanyl, Midazolam & Diazepam should be given slowly. This may be
       accomplished in several ways. (1) The appropriate dose may be diluted in a 10cc
       syringe with normal saline and then push slowly over 2 minutes.          (2) The
       appropriate dose may be placed in a 50cc bag of normal saline and administered
       over 2 minutes via a microdrip administration set.
   10. Carry-out procedure and/or transport with continuous monitoring
   11. If patient has significant respiratory depression or hemodynamic instability,
       consider reversal agent.
       a. Reversal agents
           vii. Naloxone - An agent used for reversal of narcotics (opioids). Duration of
                 action is approximately 30 minutes, which may be shorter than the clinical
                 effect of the agonist agent it is reversing. Use with caution. May
                 precipitate withdrawal in patients dependent on narcotic agents
           viii. Dose: Administer 2 mg IV, Repeat as needed
O. Documentation
   1. The procedure shall be documented in the patient care report
   2. The opiod should be documented as administered for pain management
   3. The benzodiazepine should be documented as administered for anxiety and/or
       spasm management.
   4. Each of these medications is given to treat a separate condition, the fact that
       they are being used in combination only add’s to the risk of the the combination
       therapy. Therefore, it is important to document the administration of these
       medications for the individual purpose for which they were administered.
   5. The following information should be documented in the PCR
       a. Equipment Checklist
       b. Pre-Procedure Assessment
       c. History and Physical Examination
       d. Reason for the use of combination analgesia
       e. Vital Signs and Mental Status (before, during, and post administration)
       f. Informed Consent
       g. Medications used
       h. Response to medications (Pain Scale Evaluation)
       i. Any complications or side effects noted during combination analgesia
       j. Patient condition when turned over to the receiving facility

P. Quality Management
   1. An audit will be performed on any case in which the patient receives Combination
      Analgesia
   2. Any case where there is a complication from the procedure will be referred to the
      Medical Director within 24 hours.


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   3. Any case that is noted to be out-of-protocol will be referred to the Medical
      Director within 24 hours.
Q. Complications
   1. Altered consciousness, sedation, dizziness and euphoria
   2. Respiratory depression
   3. Hypotension, bradycardia
   4. Nausea and vomiting
   5. Allergic reactions and anaphylaxis
   6. Bronchospasm




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   Continuous Positive Airway Pressure (CPAP)
   Indications
   A. For consideration in moderate to severe respiratory distress secondary to
      asthma/reactive airway disease, near drowning, COPD, CHF, acute pulmonary
      edema or pneumonia who present with any of the following:
      1. Pulse oximetry < 88% not improving with standard therapy.
      2. ETCO2 > 50mmHg
      3. Accessory muscle use / retractions
      4. Respiratory rate > 25
      5. Wheezes, rales, rhonchi
      6. Signs of fatigue
   Contraindications
   A.   Age <12
   B.   Cardiac or respiratory arrest
   C.   Agonal respirations
   D.   Inability to maintain patent airway
   E.   Hypotensive, systolic BP (< 90mmHg)
   F.   Major trauma (face, neck, chest/abdomen, pneumothorax)
   G.   Nausea/vomiting
   H.   Inability to sit upright
   I.   Upper GI bleeding
   J.   Suspected pneumothorax
   K.   Unresponsive to speech, and/or unable to follow commands
   Procedure
   A. Treat patients underlying condition according to appropriate protocol
   B. Ensure full monitoring in place (EKG, SpO2 ) (ETCO2 if available)
   C. Document breath sounds, ensure no signs or symptoms of pneumothorax
   D. Document adequate BP (>90mmHg)
   E. Have patient sitting up
   F. Carefully explain procedure to patient
   G. Place head strap over occipitoparietal area
   H. Gently hold the delivery device to the patient’s mouth and nose
   I. Attach the straps, loosely at first, gradually tightening as the patient tolerates.
      Proceed with tightening the straps until air leaks are eliminated.
   J. Progressively increase the pressure to a max of 10 cmH2O (see attached chart
      for reference). There is better tolerance with gradual progression of pressure.
   K. Repeat and record vital signs every 5min
   Considerations and Special Notes
A. Success is highly dependent upon patient tolerance, and EMT-P ability to coach
   1. Instruct patient to breath in through nose and exhale through mouth as long as
      possible
B. Deterioration on CPAP ⇒ mechanical ventilation/intubation
   1. Deterioration of mental status
   2. Increase of the EtCO2
   3. Decline of SpO2


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   4. Progressive fatigue
C. Monitor closely for development of pneumothorax and or hypotension
D. Patients should be closely monitored with SpO2, EKG, BP (ETCO2 if available)
E. Monitor patients closely for vomiting and or gastric distention
F. Inline nebulization may be used with CPAP and is required if the procedure is being
   done to treat bronchospasm.
G. Chemical and physical restraints should never be used to facilitate this procedure

           The following charts are for reference and represent flow rates and information
           pertaining to the Boussignac CPAP System. They are guidelines only and other
           devices necessitate following manufacturer and Medical Director guidelines.

The chart below gives the approximate CPAP/ PEEP in cmH2O based on the flow of O2.

             Flow (LPM)                                       CPAP / PEEP (cmH2O)

                 10                                                   2.5 - 3.0
                 15                                                   4.5 - 5.0
                 20                                                   7.0 - 8.0
                 25                                                  8.5 - 10.0
                > 25                                                    > 10


                             Minutes of Oxygen by Cylinder Size

                                      All based on full 2200 PSI Cylinders


      Flow              D Cylinder                  E Cylinder                      M Cylinder
     (LPM)             EMS Portable                EMS Portable                   EMS Ambulances

      5                    70                           123                            703
      6                    58                           102                            598
      8                    44                            77                            498
      10                   35                            61                            374
      12                   29                            51                            299
      15                   23                            41                            199
      20                   16                            29                            175
      25                   14                            23                            140




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FIELD DRAWN BLOOD SAMPLES
   Indications
   A. Patients receiving an IV in the field and who, in the judgment of the field
      providers, will need blood tests in the emergency department
   B. Patients receiving IV dextrose in the field
   C. Patients that may have been exposed to carbon monoxide
   Precautions
   A. Use BSI.
   B. Proper identification of the patient and the specimen(s) is mandatory.
   C. Improper technique in obtaining the specimen will result in inaccurate or invalid
      test results. This wastes critical time and defeats the purpose of drawing
      specimens in the field.
   Technique
   A. After initiating an IV and removing the needle, attach the Vacutainer holder to the
      hub of the IV catheter. (This is accomplished using the Luer adaptor attached to
      the Vacutainer holder.)
   B. Fill all the desired blood tubes in appropriate order per system requirements.
   C. Tubes containing anticoagulant should be inverted gently back and forth at least
      ten times to insure adequate mixing of blood with the substance in the tube. Do
      not shake the tube as this could cause hemolysis, which could interfere with test
      results.
   D. The tubes should be placed in a small biohazard bag. The bag should be labeled
      with the patient's name and time of draw, and taped to the patient's IV bag. The
      tubes may also be handed directly to the nurse attending the patient.
   Side Effects and Special Notes
   A. Any discrepancy in identification must be reported immediately to the emergency
      department charge nurse.

   B. Pediatrics receiving an IV should have at least a speckled red tube and lavender
      top tube drawn. The red top may be filled only halfway and the lavender only 1/4
      of the way to do the needed tests. If available, red and lavender pediatric tubes
      may be used.

   C. The blue top tube must be filled exactly, according to the vacuum.
   D. Blood samples should be drawn prior to the administration of IV fluid, in order to
      provide a better and less dilute sample for potential “donor” patients.




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IV    BLOOD DRAW FOR LAW ENFORCEMENT
        Purpose
        A. To meet all requirements of the Board of Health rules relating to chemical tests
           for alcohol determination
        Indications
        A. Request of the law enforcement officer, and
        B. Agency authorization
        Precautions
        A. Blood samples shall be collected only in an appropriate clinical or public safety
           facility and in the presence of the officer.
        B. In no event shall the collection of blood samples interfere with the provision of
           essential medical care.
        C. Do not use alcohol or phenolic solutions as a skin antiseptic.
        Technique
        A.   Assure the patient’s consent to the procedure.
        B.   Utilize blood draw supplies provided by the law enforcement agency.
        C.   Use BSI.
        D.   Apply tourniquet proximal to the proposed site.
        E.   Scrub the insertion site with non-alcohol prep provided in blood draw kit.
        F.   Put on disposable medical gloves prior to venipuncture.
        G.   Hold vein in place by applying gentle traction on the vein distal to the point of
             entry.
        H.   Puncture the skin and the vein with the bevel of the needle upward.
        I.   Once in the vein, collect the sample directly into the sterile blood tubes provided
             by the officer.
        J.   Remove tourniquet.
        K.   Remove the needle from the vein and hold pressure to stop any bleeding.
        L.   Give the blood sample to the officer.
        M.   Sign any paper work required by the officer.
        N.   Ensure all seals and samples are labeled accurately and completely as failure to
             do so can result in case dismissal and other legal complications
        O.   Obtain Officer’s name, Patient name, and if possible SSN and DOB and
             document on the patient care report.
        P.   Dispose of contaminated needles appropriately.




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P                         PERCUTANEOUS CRICOTHYROTOMY
    Introduction
    A. Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be
       used only in extraordinary circumstances as defined below. The reason for
       performing this procedure must be documented and submitted for review to the
       physician advisor or designee within 24 hours. Percutaneous cricothyrotomy is
       to be performed only by paramedics trained in the procedure.
    Indications
    A. When a life threatening condition exists and advanced airway management is
       indicated, and you are unable to establish airway by other means.
    Precautions
    A. Bleeding is possible, even with correct technique. Straying from the midline is
       very dangerous and likely to cause hemorrhage from the carotid or jugular
       vessels, or their branches.
    Technique
    A. Using aseptic technique (Betadine/alcohol wipes) cleanse the area.
    B. Position the patient in a supine position, with in-line spinal immobilization if
       indicated.
    C. At this time the scalpel included with the kit may be used to make a ¼ inch
       vertical incision through the skin, over the cricothyroid membrane.
    D. Using the prepackaged set, insert the needle or over-the-needle-catheter through
       the cricothyroid membrane in a caudal direction at a 45-degree angle.
    E. If using an over-the-needle-catheter, remove the syringe and needle. Otherwise
       remove the syringe.
    F. Insert the guidewire through the catheter or needle.
    G. Remove the catheter or needle over the wire.
    H. Slide the dilator and tracheostomy tube onto the wire into the neck incision.
    I. Push the dilator through the cricothyroid membrane with a twisting motion, and
       insert the tracheostomy tube into the trachea.
    J. Remove the dilator and wire, leaving the tracheostomy tube in place.
    K. Ventilate with BVM and 100% oxygen.
    L. Confirm tube placement is successful. (Chest rise and fall, breath sounds,
       secondary confirmation device). Observe for subcutaneous air, indicating
       tracheal injury or improper placement.
    M. Secure tube with ties.
    N. Transport to appropriate facility.




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PNEUMATIC ANTI SHOCK GARMENT (PASG-formerly MAST)
   Indications
The Denver Metropolitan EMS Medical Directors Group does not recommend the use of
this device in the field for the management of shock.




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RESTRAINTS
   Indications
   A. Use of physical restraint on patients is permissible if the patient poses a danger
      to himself or to others. Only reasonable force is allowable, i.e., the minimum
      amount of force necessary to control the patient and prevent harm to the patient
      or others. CONTACT BASE for physician direction if there is uncertainty as to
      whether or not the use of restraints is warranted to transport the unwilling or
      uncooperative patient.
   B. Restraints are to be applied to patients only in limited circumstances:
      1. A patient whose medical or mental condition warrants immediate ambulance
          transport and who is exhibiting behavior that the prehospital provider feels
          may or will endanger the patient or others
      2. The prehospital provider reasonably believes the patient's life or health is in
          danger and that delay in treatment and transport would further endanger the
          patient's life or health, and there is no reasonable opportunity to obtain the
          necessary consent to provide treatment or obtain informed refusal.
      3. The patient is being transported under the direction of a mental health hold,
          security hold, or police custody.
   Precautions
   A. Restraints shall be used only when necessary to prevent a patient from seriously
      injuring themselves or others (including the ambulance crew), and only if safe
      transportation and treatment of the patient cannot be done without restraints.
      They may not be used as punishment, or for the convenience of the crew.
   B. Any attempt to restrain a patient involves risk to the patient and the prehospital
      provider. Efforts to restrain a patient should only be done with adequate
      assistance present.
   C. Be sure to evaluate the patient adequately to determine the medical condition,
      mental status and decisional capacity of the patient. The hostile, angry, unwilling
      patient with decision-making capacity may refuse treatment.
   D. Be sure that restraints are in good condition (will not break and will not injure the
      patient).
   E. Do not use "hobble" restraints and do not restrain patient in the prone position.
   F. Ensure that patient has been searched for weapons.
   Technique
   A. Determine that the patient's medical or mental condition warrants ambulance
      transport to the hospital and that the patient lacks decision-making capacity, or
      there is basis for police custody or a mental health hold to be instituted.
   B. Treat the patient with respect. Attempts to verbally calm the patient should be
      done prior to the use of restraints. To the extent possible, explain what is being
      done and why.
   C. Have all equipment and personnel ready (restraints, suction, a means to
      promptly remove restraints, and adequate number of personnel).
   D. Use assistance such that, if possible, one rescuer handles each limb and one
      manages the head or supervises the application of restraints.
   E. Consider the patient's strength and range of motion in the need for and method
      of applying restraints.



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       F. Apply restraints to the extent necessary to subdue the patient. Do not use
          restraints to punish the patient.
       G. After application of restraints, check all limbs for circulation. During the time that
          a patient is in restraints, an assessment of the patient's condition including
          assessment of the patients airway, circulation and vital signs shall be made at
          least every fifteen minutes, but more frequently if conditions warrant.
       H. During transport and pending the arrival at the hospital, the patient shall be kept
          under constant supervision.
       I. The run report shall include: attempts at verbal persuasion to calm patient;
          description of the facts justifying use of restraints; the type of restraints; a
          description of the steps taken to assure that the patient's needs, comfort and
          safety were properly cared for; the condition of the patient during restraint,
          including reevaluations during transport; and the condition of the patient on
          arrival at the hospital.
       J. Removal of restraints should be done with sufficient manpower and caution for
          protection of the patient and healthcare providers.
       K. Utilize police assistance if necessary and if possible.
       L. Handcuffs or other "hard restraints" are not to be applied by prehospital
          providers. If police apply handcuffs, the officer should be requested to stay with
          the patient and ride in the ambulance during transport.
       M. The use of chemical restraints is limited to the use of Haloperidol, Versed and
          Benadryl. If used, cardiac monitoring and intravenous access should be
          performed as soon as possible.
       Complications
       A. Aspiration can occur, particularly if the patient is supine. It is the responsibility of
          the attendant to continually monitor the patient's airway.
       B. Nerve injury can result from hard restraints.
       C. Do not overlook the medical causes for combativeness, such as hypoxia,
          hypoglycemia, stroke, hyperthermia, hypothermia, or drug ingestion.

P      D. Contraindications, precautions, and Special Considerations regarding the use of
          chemical restraints are found in the appropriate drug protocol, i.e. Haloperidol.
          Versed, and Benadryl




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SPLINTING: AXIAL
   Indications
   A. Pain, swelling, or deformity of spine which may be due to fracture, dislocation, or
      ligamentous instability.
   B. Neurologic deficit that might be due to spine injury.
   C. Prevention of neurologic deficit or further deficit in patients with suspected spine
      injury or instability.
   D. In all trauma victims who are unconscious or with impaired consciousness due to
      head injury or drug ingestion, to protect against damage or further damage in
      patients where injury to the spine cannot be ruled out by accurate exam or
      history.
   Precautions
   A. All patients with significant head trauma should be immobilized because of the
      potential for unrecognized coexistent neck trauma.
   B. Perform and document complete neurologic exam prior to moving the patient.
      Reassess and document finding after splinting is completed and after each set of
      vital signs (i.e. – every 5 minutes for a critical patient and every 15 minutes for a
      non-emergent patient).
   Cervical Splinting Technique
   A. Perform cervical splinting immediately following initial assessment (if indicated).
      If necessary, use assistant to maintain cervical stabilization while completing
      initial assessment.
   B. Use two people to apply splint if at all possible.
   C. Do not use excessive force to straighten. Gently restore normal alignment.
   D. Advise patient of procedure and purpose before and during application.
   E. Immobilize the cervical spine with a semi-rigid collar of appropriate size for age.
   F. Pad behind head in adults to maintain an anatomically neutral position.
   G. Use long/short spine board or orthopedic scoop to support patient as situation
      dictates.
   H. Use tape and/or straps to secure patient effectively and allow turning as a unit for
      airway control.
   I. Continue to monitor airway and effectiveness of immobilization.

   J. Board with an appropriate size collar is preferred to KED in pediatric patients.


   Spine Immobilization Technique
   A. Splint cervical spine concurrent with the initial assessment. Document neurologic
      findings.
   B. Complete detailed assessment and splint fractures prior to movement of patient
      when possible.
   C. Document neurologic findings.
   D. In a sitting patient, use short board or Kendrick Extrication Device (KED) may be
      beneficial for extrication:
      1. Slide short board or KED behind patient.
      2. Apply thigh straps snugly as close to groin as possible.
      3. Apply shoulder or chest straps.
      4. Use padding as needed to keep neck (in cervical collar) in a neutral position.



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          a. For pediatrics, use padding as needed to prevent misalignment.

      5. Secure head to board.
   E. Use long backboard or full body vacuum splint for supine patients.
      1. For sitting patients, after short board or KED is applied:
         a. Logroll or lift patient as a unit to board. Apply continuous cervical
             stabilization during movement. One person should protect neck in collar.
             Do not use force to straighten spine.
         b. Release leg straps if short board or KED was used.
         c. Use padding as needed behind knees to support a neutral axis under
             small of back, neck and knees.
         d. Use towel rolls or commercially available cervical immobilization device
             and tape to secure neck immobilization.
         e. Apply straps or tape to secure chest, thighs, and lower legs to allow
             turning as a unit in case of vomiting or airway difficulty.
   F. Reassess patient status, particularly airway and neurologic findings frequently.
   Complications
   A. Vomiting is common in head/spine-injured patients. Your splinting must be good
      enough to allow turning of the patient for airway protection but must not impede
      breathing efforts.
   B. It is easy to miss injuries below the level of a neurological deficit. Look carefully
      for abdominal and chest injuries, pelvic fractures, and extremity injuries without
      symptoms. With loss of sensation below T-8, there will be no guarding, rebound
      pain, or tenderness to alert you to internal abdominal injuries.
   C. Pelvis fractures are difficult to diagnose in the field. Suspected pelvis injury can
      be immobilized by use of the long board during spine immobilization with a
      circumferential “pelvic wrap” or by use of a full body vacuum splint.
   Side Effects and Special Notes
   A. Patients with helmets and shoulder pads (Football, Lacrosse, Hockey)
      1. When immobilization is indicated for football players with shoulder pads and
          helmets, it should be accomplished with the helmet and pads in place.
      2. The only indications for removal of a football helmet during immobilization
          are:
          a. Airway management cannot be accomplished without removal.
          b. Bleeding cannot be controlled without removal.
          c. The helmet does not provide adequate control of the head.
      3. If the helmet is removed, the provider(s) should ensure adequate padding is
          in place behind the head to allow for neutral alignment.
      4. If the patient is immobilized with helmet and pads in place, the
          facemask/shield must be removed prior to transport.
      5. Lacrosse and hockey shoulder pads may not provide enough padding to
          prevent hyperflexion. The helmet may need to be removed and head padded
          or padding may be placed under the shoulders to accomplish neutral
          alignment.
      6. EMS responders should utilize the tools and expertise that the athletic
          trainers at the scene can provide.
      7. A “flat lift” with the backboard introduced from the patients feet is preferred to
          a standard roll when the patient has shoulder pads.
      8. It is recommended that EMS practice these procedures and become familiar
          with athletic training staff tools and policies frequently.



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       9. As always, neurologic exam must be done and documented reflecting status
          before and after the procedure.

   B. Patient with motorcycle, ATV, racing helmets
      1. Patients with these types of helmets should usually have them removed early
          in the assessment to allow immediate access to the airway, face and
          posterior skull.
      2. Two providers are required to perform this procedure. One to control the
          head and maintain in-line stabilization and one to manipulate and remove the
          helmet.
      3. As always, neurologic exam must be done and documented reflecting status
          before and after the procedure.

   C. Axial immobilization should be initiated any time it is indicated. However, the
      procedure is not without complications. Research indicates that axial
      immobilization may cause back pain, muscle spasm, pressure sores,
      claustrophobia or restricted breathing efforts. As such, routine prophylactic axial
      immobilization may not be indicated in a patient who meets all the following
      criteria:
      1. Is conscious, awake, and oriented to person, place and time (Glasgow Coma
           Score = 15) and has no pre-existing mental impairment which might hinder
           cognitive function (i.e. psychological disorder or mental retardation) and does
           not complain of neck pain.
      2. No language barrier exists which might hinder the assessment process.
      3. Did not experience a loss of consciousness (either documented or
           suspected).
      4. The mechanism of injury does not warrant activation of a trauma team.
      5. Upon physical exam, there is no evidence of tenderness, deformity, or spasm
           in the neck, back or paraspinal region.
      6. There is no evidence of peripheral sensory or motor deficit or impairment (i.e.
           paresthesia, “peripheral tingling”, or decreased motor function following
           incident).
      7. There are no complaints or evidence of visual disturbances such as diplopia
           or blurred vision.
      8. There is no evidence of an unstable or staggered gait.
      9. There is no evidence that suggests the use of prescribed CNS depressants,
           analgesics, ETOH, or other mind-altering substances.
      10. The patient has no pre-existing neck, back or neurologic injury.
      11. There are no distracting injuries present which might mask an underlying
           neurologic or spinal injury.
      12. Once a patient has been immobilized by a first responder, the patient may not
           have a cervical collar or other immobilization device removed by subsequent
           responders. Patient must be transported to a healthcare facility. CONTACT
           BASE if questions and/or clearance is desired.

       See Also Protocol: Selective C-spine Immobilization




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SPLINTING: EXTREMITY
   Indications
   A. Pain, tenderness, swelling, or deformity in extremity which may be due to fracture
      or dislocation
   B. In an unstable extremity injury: to reduce pain; limit bleeding at the site of injury;
      and prevent further injury to soft tissues, blood vessels or nerves
   Precautions
   A. Critically injured trauma victims should not be delayed in transport by lengthy
      evaluation of possible non-critical extremity injuries. Prevention of further
      damage may be accomplished by securing the patient to a spine board when
      other injuries demand prompt hospital treatment.
   B. The patient with altered level of consciousness from head injury or drug/alcohol
      influences should be carefully examined and conservatively treated, because his
      ability to recognize pain and injury is impaired.
   C. Make sure the obvious injury is also the only one. It is particularly easy to miss
      fractures proximal to the most visible one.
   D. In a stable patient where no environmental hazard exists, splinting should be
      done prior to moving the patient.
   Extremity Splinting Technique
   A. Check pulse and sensation distally prior to movement or splinting.
   B. Remove bracelets, watches, or other constricting bands prior to splint application.
   C. Identify and dress open wounds. Note wounds that contain exposed bone or are
      near fracture sites and may communicate with a fracture.
   D. To minimize pain and soft tissue damage, avoid sudden or unnecessary
      movement of fracture site.
   E. Choose splint to immobilize joint above and below injury. Pad rigid splints to
      prevent pressure injury to extremity.
   F. Apply gentle continuous traction to extremity and support to fracture site during
      splinting operation.
   G. Reduce angulated fractures (if no pulses), including open fractures, with gentle
      axial traction as needed to immobilize properly.
   H. Check distal pulses and sensation after reduction splinting. Realign gently if
      adequate circulation and sensation is lost.
   Traction Splinting Technique (for suspected femur fractures):
   A. Use two persons for splint application procedure.
   B. Remove sock and shoe and check for distal pulse and sensation (unless you
      cannot protect exposed foot from weather; then just ask patient about sensation
      and observe movement).
   C. Identify and dress open wounds, and note exposed bone or wounds overlying
      fractures and potential communicating wounds.
   D. Measure splint length prior to application.
   E. Apply gentle axial traction with support to calf and fracture site, reducing
      angulation of open fractures as necessary for secure traction.




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        F. Position ischial pad under buttocks, up against bony prominence (ischial
           tuberosity). Empty pockets if necessary for patient comfort and appropriate
           splinting.
        G. Secure groin strap carefully.
        H. Maintain continuous traction and support to fracture site throughout procedure.
        I. Adjust support straps to appropriate positions under leg.
        J. Apply ankle hitch and tighten traction until patient experiences improved comfort.
           (Movement at the fracture site will cause some pain, but if traction continues to
           cause increased pain, do not proceed. Splint and support leg in position of most
           comfort.)
        K. Secure support straps after traction properly adjusted.
        L. Recheck distal pulses and sensation.
        Complications
        A.   Circulatory compromise from excessive constriction of limb
        B.   Continued bleeding not visible under splint
        C.   Pressure damage to skin and nerves from inadequate padding
        D.   Delayed treatment of life-threatening injuries due to prolonged splinting
             procedures
        Side Effects and Special Notes
        A. Traction splints should only be used if the leg can be straightened easily and
           patient is comfortable with the traction device on. Particularly with injuries about
           the hip and knee, forced application of traction device can cause increased pain
           and damage. If this occurs, do not use traction device, but support in position of
           most comfort and best neurovascular status.
        B. When in doubt and the patient is stable, splint. Do not be deceived by absence
           of deformity or disability. Fractured limbs often retain some ability to function.
        C. Splinting body parts together can be a very effective way of immobilizing: arm-to-
           trunk or leg-to-leg. Padding will increase comfort. This method can be very
           useful in children when traction devices and pre-made splints do not fit.

IN      D. Consider pain management prior to splinting as needed.




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P   TENSION PNEUMOTHORAX DECOMPRESSION
       Indications
       A. Tension pneumothorax is rare, but when present may rapidly lead to death and
          must be treated promptly.
       B. Nontension pneumothorax is relatively common, is not immediately life
          threatening, and should not be treated in the field.
       C. Treatment of tension pneumothorax is not difficult, although complications of the
          procedure can be severe, but diagnosis must be accurate and is not always
          easy.
       D. The following signs are significant. Signs of pneumothorax as well as signs of
          tension must be present before treatment is undertaken:
          1. Simple Pneumothorax:
              a. Respiratory distress - mild to severe
              b. Chest pain
              c. Decreased or absent breath sounds on affected side to auscultation of
                  chest
              d. Subcutaneous crepitation, and
          2. Signs of Tension:
              a. Progressive respiratory distress (severe)
              b. Tympanitic percussion note on affected side
              c. Hyperexpanded chest on affected side
              d. Tracheal shift away from affected side
              e. Distended neck veins
              f. Shock – low BP
              g. If patient is intubated, increasing difficulty in bagging
       Precautions
       A. Accurate diagnosis is paramount. Note that simple pneumothorax has one set of
          signs and tension pneumothorax has an additional set of signs.
       B. Tension pneumothorax is a rare condition, but can occur both with trauma and
          spontaneously. It can also occur as a complication of CPR.
       Technique
       A. Decompress using one of the following techniques:
           1. Needle:
              a. Expose entire chest. Clean chest vigorously with alcohol, Betadine, or
                 soap.
              b. Insert an angiocath (14g or larger in adult; 18g in children) with syringe
                 attached, in the 4th or 5th intercostal space, midaxillary line (horizontal
                 "nipple line" in children). Alternatively, the angiocath may be inserted
                 between the 2nd and 3rd intercostal space, midclavicular line.
              c. Hit the rib, then slide above it.
              d. If air is under tension, barrel will pull easily and "pop" out the back.
                 Remove syringe, advance catheter and remove needle.
              e. Only one attempt to be done per side.
       Complications
       A. Complications include:


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       1. Creation of pneumothorax if none existed previously
       2. Laceration of lung
       3. Laceration of blood vessels: slide above rib (intercostal vessels run in grove
          under each rib)
       4. Severe pain: if you're doing this in the field, patient should be sick enough
          not to require anesthesia, but they'll let you know when you go through
          pleura. Don't let that deter you - move briskly on.
       5. Infection: clean rapidly but vigorously. Use sterile gloves, if possible.
   Side Effects and Special Notes
   A. Sudden onset of chest pain and shortness of breath in a normal individual may
      also be caused by a pneumothorax (particularly in patients with COPD or
      asthma). These can also progress to a "tension" state.
   B. Tension pneumothorax can be precipitated by occlusion of an open chest wound
      with a dressing. If, after dressing an open chest wound, the patient deteriorates,
      remove the dressing.




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P   TRANSCUTANEOUS CARDIAC PACING
       Indications
       A. Use cardiac pacing only when there is insufficient cardiac rate to maintain
          adequate perfusion, and rate is unaffected by atropine and adequate oxygen and
          ventilation.
       B. Symptomatic bradyarrhythmias (includes A-V block)
       C. P.E.A. (Pulseless Electrical Activity) with bradycardia
       D. Patients who convert from a viable rhythm into asystole
       Precautions
       A.   Capture can be difficult in some patients.
       B.   Patient may experience discomfort; consider midazolam.
       C.   Use the same precautions as with defibrillation.
       D.   Patients in atrial fibrillation may require higher energy settings for capture than
            others.
       Technique
       A. Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left
          posterior.
       B. Turn pacer unit on.
       C. Select pacing rate at 80 beats per minute (BPM)
       D. If the patient is awake, consider the use of sedation
       E. Start pacing unit.
       F. Confirm that pacer senses intrinsic cardiac activity by adjusting ECG size. If not,
          pacer may discharge on an existing complex.
       G. Set initial current to 40 mAmps.
       H. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps
          (usually captures around 100 mAmps).
       I. If there is capture, check for pulses.
       J. If there are no pulses with capture, consider a fluid challenge or dopamine.
       K. If no capture occurs with maximum output, discontinue pacing and resume
          ACLS.
       Complications
       A. Ventricular fibrillation and ventricular tachycardia are rare complications, but
          follow appropriate protocols if either occur.
       B. Pacing is rarely indicated in patients under the age of 12 years.
       C. Muscle tremors may complicate evaluation of pulses.
       D. Pacing may cause diaphragmatic stimulation.
       E. CPR is safe during pacing. A mild shock may be felt if direct active electrode
          contact is made.




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TRANSPORT OF THE HANDCUFFED PATIENT
   Indications
The patient is being transported under police custody and has already been placed in
handcuffs by a police officer.
   Precautions
Any attempt to restrain a patient involves risks to the patient and the prehospital
provider. Efforts to restrain a patient should only be done with adequate assistance
present.
At no time should the patient be placed in a prone position for a prolonged time at the
scene or during transport to the hospital.
Ensure that patient has been searched for weapons.
   Technique
   A. For the patient who does not require spinal immobilization or transport in a
      supine position:
      1. Maintain restraint via the handcuffs.
      2. Escort the patient to the bench seat inside the ambulance.
      3. Secure the patient in a sitting position with the seat belt.
      4. Treatment and transport should be done with the patient remaining in the
         handcuffs.
      5. Request that the officer stay with the patient and ride in the ambulance during
         transport. Ultimately, we are not responsible for the hold on this patient.
   B. For the patient who requires transport with spinal immobilization or in a supine
      position and is found in standing or sitting position:
      1. Ensure that you have adequate assistance available to maintain restraint of
         the patient.
      2. Secure the patient's cervical spine with a cervical collar if indicated.
      3. Assign one individual to support the patient's head.
      4. Bring the stretcher, with backboard or scoop if indicated, to the patient.
      5. Have the patient sit down on the stretcher and secure each arm with Kerlix
         before having the officer remove the handcuffs.
      6. Lie the patient down on the stretcher in a supine position.
      7. Secure one arm of the patient to the scoop or backboard with the handcuffs.
         If further restraint is required, use Kerlix or Velcro cuffs to restrain other
         extremities.
   C. For the patient who requires transport with spinal immobilization or in a supine
      position and is found in a prone position:
      1. Ensure that you have adequate assistance available to maintain restraint of
         the patient.
      2. Secure the patient's cervical spine with a cervical collar if indicated.
      3. Assign one individual to support the patient's head.
      4. Secure each arm and both legs with Kerlix prior to having the officer remove
         the handcuffs.
      5. Roll the patient onto a backboard or scoop.
      6. Place the stretcher next to the patient and lift the patient onto the stretcher.




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       7. Secure one arm of the patient to the scoop or backboard with handcuffs. If
          further restraint is required, use Kerlix or Velcro cuffs to restrain other
          extremities.

Note: If the patient remains combative after physical restraints, consider the use of
      chemical restraint.




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P   VASCULAR ACCESS DEVICES
       Specific Information Needed:
       A. Obtain pertinent medical history if possible.
       B. Obtain any information possible regarding the type of Vascular Access Device
          (VAD), number of lumens, purpose of the VAD, etc.
       Indications
       A. To obtain rapid venous access for the critical patient when peripheral access
          cannot be obtained.
       Precautions
       A. Obtain information and assistance from family members or home health
          professionals who are familiar with the device.
       B. Discontinue any intermittent or continuous infusion pumps.
       C. Assure placement and patency of the VAD prior to infusing any fluids or
          medications.
       D. Flush the catheter completely with sterile normal saline.
       E. Use aseptic technique.
       Central Venous Catheters or PICC Lines
       A. Attempt peripheral or external jugular access first unless patient or patient's
          family insist on the direct usage of VAD.
       B. Identify the location and type of VAD (i.e. central venous catheter, peripheral
          inserted central catheter).
       C. Utilize knowledgeable family members, significant others or home visiting nurse if
          available.
       D. Discontinue and/or disconnect any pumps or medications.
       E. Clamp the VAD closed to prevent air embolus.
       F. If multiple lumen, identify the lumen to be used.
       G. Utilize aseptic technique.
       H. Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad.
       I. Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive
          blood return. Obtain blood samples if necessary. Then flush the line with
          solution.
       J. Insert the needle (attached to a medication syringe or IV tubing) and infuse
          medications or fluids.
       K. Secure the IV tubing.
       L. Reassess the infusion site.
       M. Reassess patient condition.
       Implanted Ports
       A. Attempt peripheral or external jugular access first unless patient or patient's
          family insist on the direct usage of the VAD.
       B. Identify the location and type of VAD (e.g. implanted port).
       C. Utilize knowledgeable family members, significant others or home visiting nurse if
          available.
       D. Discontinue and/or disconnect any pumps or medications.
       E. Carefully palpate the location of the implanted port.


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   F. If multiple ports, identify the port to be used.
   G. Using sterile technique, prep the site with alcohol and/or povidone-iodine pad.
      Wipe from the center outward three times in a circular motion.
   H. Using a sterile gloved hand, press the skin firmly around the edges of the port.
   I. Using a syringe filled with solution, insert the needle perpendicular to the skin.
   J. Aspirate slowly for blood return, then flush the port prior to infusion. When
      aspirating blood from a VAD, use a syringe that is 10cc or less to avoid
      complications.
   K. Secure the IV tubing.
   L. Reassess the infusion site.
   M. Reassess the patient.
   Complications
   A. Patients with VADs are very susceptible to site infection or sepsis. Use sterile
      techniques at all times.
   B. Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected,
      do not utilize the lumen.
   C. Rarely, a catheter will migrate. The symptoms may include the following:
      1. burning with infusion
      2. site bleeding
      3. shortness of breath
      4. chest pain
      5. tachycardia
      6. hypotension
   D. If a catheter migration is suspected, do not use the VAD and treat the patient
      according to symptoms.
   E. Catheters are durable but may leak or be torn. Extravasation of fluids or
      medications occurs and may cause burning and tissue damage. Clamp the
      catheter and do not use.
   F. Air embolism may occur if the VAD is not clamped in between infusions. Avoid
      this by properly clamping the catheter and preventing air from entering the
      system.




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IV   VENOUS ACCESS TECHNIQUE - GENERAL PRINCIPLES
        Indications
        A. Administer fluids for volume expansion
        B. Administer drugs
        Precautions
        A. Do not start IVs distal to a fracture site or through skin damage with more than
           erythema or superficial abrasion.
        B. Due to the uncontrolled environment in which prehospital IVs are started, take
           extra care to use sterile technique.
        C. Due to the high complication rate associated with prehospital IV therapy, use
           good judgment when deciding which patients should receive an IV.
        Technique
        A.   Connect tubing to IV solution bag.
        B.   Fill drip chamber one-half full by squeezing.
        C.   Tear sufficient tape to anchor IV in place.
        D.   Use BSI.

        E. For pediatric patients consider applying an arm board or splint prior to
           venipuncture.

        F. Scrub insertion site with alcohol or iodine pads.
        G. Don't palpate, unless necessary, after prep.
        H. Perform venipuncture or enter bone marrow as described in the specific
           techniques described in this protocol.
        I. After the catheter is in place, remove the needle or stylette, draw bloods when
           possible and connect tubing.
        J. Open full to check flow and placement, then slow to TKO rate unless otherwise
           indicated or ordered.
        K. Secure tubing with tape, making sure of at least one 180-degree turn in the
           tubing when taping to be sure any traction on the tubing is not transmitted to the
           cannula itself.
        L. Anchor with arm board or splint as needed to minimize chance of losing line with
           movement.
        M. Recheck to be sure IV rate is as desired.
        Complications
        A. Pyrogenic reactions due to contaminated fluids become evident in about 30 min
           after starting the IV. Patient will develop fever, chills, nausea, vomiting,
           headache, backache, or general malaise. If observed, stop and remove IV
           immediately. Save the solution so it may be cultured.
        B. Local: hematoma formation, infection, thrombosis, phlebitis. Note: the
           incidence of phlebitis is particularly high in the leg. Avoid use of lower extremity
           if possible.
        C. Systemic: sepsis, pulmonary embolus, catheter fragment embolus, fiber
           embolus from solution in IV




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   Side Effects and Special Notes
   A. Antecubital veins are useful access sites for patients in shock, but if possible,
      avoid areas near joints (or splint well!).
   B. The point between the junction of two veins is more stable and often easier to
      use.
   C. Start distally, and if successive attempts are necessary, you will be able to make
      more proximal attempts on the same vein without extravasating IV fluid.
   D. Venipuncture has little morbidity; however, the excess fluids inadvertently run in
      when nobody is watching can be fatal!
   E. The most difficult problem associated with IV insertion is knowing when to try and
      when to stop trying. Valuable time is often wasted attempting IVs when a critical
      patient requires blood. IV solutions may "buy time," but they frequently lose time
      instead. In critical patients do not delay transport while attempting IV insertion at
      the scene. IVs may be placed en route.
   F. For the purpose of this protocol, peripheral IV will be defined as extremity or
      external jugular vein.




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IV   VENOUS ACCESS TECHNIQUE - SALINE LOCK (Buff Cap)
        Indications
        A. Prophylactic IV access
        B. Drug administration
        Precautions
        A. Consider the patient, and whether a running IV or a buff cap is needed.
        B. For any buff cap established in the prehospital setting, the attendant is
           responsible for showing the buff cap to the receiving nurse.
        Technique
        A.   Assemble the necessary equipment.
        B.   Prefill the saline lock with sodium chloride.
        C.   Proceed with the technique for extremity IVs.
        D.   Remove the needle from the catheter and insert the saline lock.
        E.   Flush the saline lock with 2-5 ml of sodium chloride.
        Contraindications
        A. Any catheter placed in the external jugular vein
        B. Any patient who is in need of fluid or is hypotensive
        C. The cardiac arrest patient




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IN   P   VENOUS ACCESS TECHNIQUE - EXTERNAL JUGULAR VEIN
            Indications
            A. Inability to secure extremity IV access
            Technique
            A. Position the patient: supine, head down (this may not be necessary or desirable
               if congestive heart failure or respiratory distress present). Turn patient's head
               opposite side of procedure.
            B. Align the cannula in the direction of the vein, with the point aimed toward the
               ipsilateral shoulder (on the same side).
            C. "Tourniquet" the vein lightly with one finger above the clavicle and apply traction
               to the skin above the angle of the jaw.
            D. Make puncture midway between the angle of the jaw and the midclavicular line,
               "tourniqueting" the vein lightly with one finger above the clavicle.
            E. Puncture the skin with the bevel of the needle upward; enter the vein either from
               the side or from above.
            F. Note blood return and advance the catheter over the needle and remove
               tourniquet.




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IV   VENOUS ACCESS TECHNIQUE - EXTREMITY
        Technique
        A. Apply tourniquet proximal to proposed site to venous return only.
        B. Hold vein in place by applying gentle traction on vein distal to point of entry.
        C. Puncture the skin (with the bevel of the needle upward) about 0.5 to 1 cm from
           the vein and enter the vein either from the side or from above.
        D. Note blood return and advance the catheter over the needle and remove
           tourniquet.




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IN   VENOUS ACCESS TECHNIQUE - INTRAOSSEOUS INFUSION
        Indications (Must meet all criteria)
        A. Rescue or primary vascular access device when peripheral IV access not
           obtainable (see vascular access protocol)
        B. Patient with critical illness. Critical illness is defined as:
               1. Cardiopulmonary arrest
               2. Impending arrest
               3. Profound shock with hypotension (SBP<80) and poor perfusion
               4. Utilization of IO access for all other patients requires base station contact
        C. Adults IOs can be used in children age > 8 years old or weight > 40 kg
        D. May be considered prior to peripheral IV attempts in patients without identifiable
           peripheral vein
        Technique
        A. Site of choice – tibial plateau - one finger breadth below the tuberosity on the
           anteromedial surface
        B. Clean skin with povidone-iodine.
        C. Place intraosseous needle perpendicular to the bone.
        D. Follow manufacturer’s guidelines specific to the device being used for insertion.
        E. Entrance into the bone marrow is indicated by a sudden loss of resistance.
        F. Even if properly placed, the needle will not be secure. The needle must be
           secured and the IV tubing taped. The IO needle should be stabilized at all times.
           A person should be assigned to monitor the IV at the scene and en route to the
           hospital.
        G. Only one intraosseous attempt is to be done in each tibia.
        H. Puncture site should be covered with a dressing and notify hospital staff of all
           insertion sites/attempts.
        Complications
        A. Bone fracture (pushing too hard while not twisting the needle enough)
        B. Infection
        Contraindications
        A.   Fractures
        B.   Cellulitis
        C.   Osteogenesis imperfecta
        D.   Total knee replacement
        Side Effects and Special Notes
        A. Some authorities recommend aspiration of marrow fluid or tissue to confirm
           needle location. This is not recommended for field procedures, as it
           increases the risk of plugging the needle.
        B. Expect flow rates to be slower than peripheral IV’s. Pressure bags may be
           needed. Any drug or IV fluid may be infused.
        C. Prior to IO insertion, consider rectal administration of benzodiazepines in patients
           8 and under with status epilepticus. Consider IM midazolam for ages 9 and
           above for patients in status epilepticus.




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   D. Some manufacturers recommend the use of lidocaine for the treatment of pain
      associated with fluid administration. Check with your manufacturer and Medical
      Director for further guidance.




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                              PREHOSPITAL PATIENT ASSESSMENT
                               PATIENT ASSESSMENT ALGORITHM
                                                                      Scene Size-Up
                                                                          BSI


                                                        Safe Scene                       Unsafe Scene


                                                                                        Control Scene
                                                                                         Move Patient
                                                                                        Correct Hazard
                                                     Initial Assessment




                   TRAUMA PATIENT                                                     MEDICAL PATIENT




                   Focused History and                                                Focused History and
                     Physical Exam                                                      Physical Exam

                Evaluate Mechanism of
                     Injury (MOI)
                                                                          Responsive                     Unresponsive


    Significant MOI               No Significant MOI
                                                                     SAMPLE History                      Rapid Medical
                                                                                                          Assessment
                                  Focused Trauma
     Rapid Trauma              Assessment for Specific
      Assessment                       Injury                       Focused Medical
                                                                 Assessment for specific            Baseline Vital Signs
                                                                       complaint
  Baseline Vital Signs           Baseline Vital Signs

                                                                   Baseline Vital Signs                 SAMPLE History
    SAMPLE History                 SAMPLE History

                                                                          Transport                         Transport
       Transport                         Transport

 Detailed Physical Exam                                          Components of Detailed            Detailed Physical Exam
                               Components of Detailed                   Exam
                                  Physical Exam




                                 Ongoing Assessment



                                   Communication


                                    Documentation




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                                    SCENE SIZE UP

   A. Recognize environmental hazards to rescuers, and secure area for treatment.
      Implement body substance isolation (BSI).
   B. Make sure you and your partner are safe. Also make sure the patient and
      bystanders are safe. Move the patients and bystanders to safe area if needed.
   C. Recognize hazard for patient, and protect from further injury.
   D. Identify number of patients. Initiate a triage system if appropriate.
   E. Observe position of patient, mechanism of injury, surroundings.
   F. Identify self.
   G. Initiate communications if hospital resources require mobilization; call for backup
      if needed.




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                                      INITIAL ASSESSMENT

        A. Form a general impression of the patient (sick/not sick; hurt/not hurt)
        B. Determine the chief complaint/apparent life threats
        C. Assess mental status (AVPU)
               • A----Alert
               • V----Responsive to verbal stimulus
               • P----Responsive to painful stimulus
               • U----Unresponsive
        D. Briefly note body position and extremity movement.
        E. Airway:
           1. Observe the mouth and upper airway for air movement.
           2. Open airway if needed: use head tilt chin lift in medical patients; chin lift
               (without head tilt) or jaw thrust in trauma victims.
           3. Protect cervical spine from movement in appropriate trauma victims. Use
               assistant to provide continuous manual stabilization.
           4. Look for evidence of upper airway problems, such as vomitus, bleeding, facial
               trauma.
           5. Clear upper airway of mechanical obstruction with finger sweep or suction, as
               needed.
        F. Breathing:
               1. Expose chest and observe chest wall movement.
               2. Note respiratory rate (qualitative), noise, and effort.
               3. Auscultate for breath sounds.
               4. Treat respiratory arrest with:
                   a. Pocket mask or bag-valve-mask for initial ventilatory control.
                   b. Check pulse and begin CPR if no pulse.
IN                 c. Intubate after initial ventilation if necessary.

               5. Assess for partial or complete obstruction.
               6. If respiratory rate < 12/min or breathing appears inadequate:
                  a. Assist respirations with pocket mask or BVM; administer supplemental
                       oxygen.
IN                 b. Consider tracheal intubation to secure airway if necessary.

                  c. Transport rapidly.
              7. Observe skin color, mentation for signs of hypoxia.
              8. Administer oxygen if signs of hypoxia
              9. Look for life threatening respiratory problems and briefly stabilize:
                  a. Open or sucking chest wound: seal.
                  b. Large flail segment: stabilize.
                  c. Tension pneumothorax: transport rapidly and decompress chest.
        G. Circulation:
              1. Pulse
                  a. Palpate for pulse: radial pulse presence implies BP>80 systolic;
                     carotid or femoral pulse presence implies BP>60-70. If the patient is
                     pulseless and apneic, begin CPR




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              b. Note pulse quality (strong, weak) and general rate (slow, fast,
                 moderate).

              c. Check capillary refill time in fingertips: 2 sec. is normal. Pediatric
                 patients only.

         2. Major Bleeding
              a. Control hemorrhage by direct pressure with clean dressing to wound.
                  (If needed, use elevation, pressure points; tourniquet if appropriate)
   H. Identify Priority of Patients
         1. If evidence of medical shock or severe hypovolemia, obtain baseline vital
              signs immediately and begin treatment according to protocols: medical
              and trauma.
   Special notes
   A. Initial assessment may take 30 seconds or less in a medical patient or victim of
      minor trauma. In the severely traumatized patient, however, assessment and
      treatment of life threatening injuries evaluated in the initial assessment may
      require rapid intervention, with treatment and further assessment en route to the
      hospital.
   B. In the awake patient, the initial assessment may be completed by your initial
      greeting to the patient. This may make it clear that the ABCs are stable and
      emergency intervention is not required before completing assessment.
   C. Neck should be immobilized and secured during airway assessment or
      immediately following initial assessment if indicated.
   D. Vital signs should be obtained during the focused and detailed assessment. If
      immediate intervention for profound shock or hypoventilation is required, this may
      need to be initiated before numerical vital signs are taken.




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                              FOCUSED ASSESSMENT
   MEDICAL
A focused medical assessment is done on all conscious medical patients. In awake
patients, this may consist only of identifying yourself and noting the patient’s
responsiveness and general appearance. The formal detailed assessment may not need
to be done on patients with a specific complaint, such as “chest pain”. Assessment must
be no less thorough, but it may be limited to the body systems that are pertinent to the
presenting problem.
Based on the information obtained from the initial assessment, perform either a rapid or
focused medical assessment, and a detailed exam.
   Focused-Responsive
   A. Assess history of present illness
         • O---Onset                 (When it first began?)
         • P---Provocation           (What brings it on or makes it better or worse?)
         • Q---Quality               (On scale of 1-10, rate the pain)
         • R---Radiation             (Does pain go anywhere & where is the pain?)
         • S---Severity              (Compare pain to before, is it worse or same?)
         • T---Time                  (How long does the pain last, how long did it last
                                     before, what helped before for relief?)
   B. Obtain SAMPLE Information:
         • S---Signs and Symptoms, chief complaint
         • A--- Allergies
         • M---Medications
         • P--- Pertinent Medical History
         • L--- Last oral intake, Last menstrual period
         • E--- Events leading to illness
   C. Perform a focused Medical Assessment
      1. Chief Compliant
      2. Signs
      3. Symptoms
   D. Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature
      and color.
   E. Based on the exam findings, initiate proper intervention.
   F. Make transport decision.
   G. Perform detailed physical exam
   H. Transport as soon as possible.
   I. Perform Ongoing Assessment




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History
History of Present Illness (HPI)
An essential part of history taking. A proper history can give the provider all the
essential information necessary to diagnose the problem.

Chief Complaint - This is what the patient tells you, in his/her own words, is wrong.

O-P-Q-R-S-T (need to know)
Onset
Provocation
Quality
Radiation
Severity
Time

R-O-A-D-Q-A-L (nice to know, helpful in chest pains)
Radiation
Onset
Aggravating/Alleviating Factors
Duration
Quality
Associated problems
Location

Types of Pain
Focal - Pain that is located in one area and does not travel or move.
Radiating - Pain that originates in one spot and travels away from the focal point.
Diffuse - Pain that can be localized.

S-A-M-P-L-E History
Signs and symptoms
Allergies
Medications
Past history
Last meal eaten
Events leading to incident

Vital Signs
There are four vital signs that are recorded in the field. They are:
Pulse (Heart Rate)
Respiratory Rate
Blood Pressure
Skin Condition




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                                       TRAUMA

   A. Focused-No Significant
      1. The Focused Assessment is performed on the Specific Injury Site.
      2. As you inspect and palpate specific injury, look and feel for the following
         examples of injuries or signs of injury:
            • D---Deformity
            • C---Contusions/Crepitation
            • A---Abrasions
            • P---Punctures/Penetrations/Paradoxical Movement
            • B---Burns
            • T---Tenderness
            • L---Lacerations
            • S---Swelling
      3. Assess baseline vital signs: blood pressure, pulse, respirations, skin
         temperature, and color
      4. Assess SAMPLE history:
            • S--- Signs and Symptoms, chief complaint
            • A--- Allergies.
            • M--- Medications
            • P--- Pertinent past medical history
            • L--- Last oral intake, last menstrual period
            • E--- Events leading to injury, illness
      5. Based on the exam findings, initiate proper intervention
      6. Transport as soon as possible.
      7. Perform Detailed Assessment
      8. Perform Ongoing Assessment




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                                RAPID ASSESSMENT
   MEDICAL-Unresponsive
   A. Perform a rapid assessment of the specific area of complaint
      1. Position the patient to protect the airway
      2. Assess the head
      3. Assess the neck
      4. Assess the chest
      5. Assess the abdomen
      6. Assess the pelvis
      7. Assess the extremities
      8. Assess the posterior body
   B. Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature
      and color
   C. Obtain SAMPLE Information:
         • S---Signs and Symptoms, chief complaint
         • A---Allergies
         • M---Medications
         • P---Pertinent medical history
         • L---Last oral intake, Last menstrual period
         • E---Events leading to illness
   D. Based on the exam findings, initiate proper interventions
   E. Transport as soon as possible
   F. Perform Detailed Assessment
   G. Perform ongoing assessment




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                                       TRAUMA

   A. Perform a rapid trauma assessment on patients with significant mechanism of
      injury (MOI) to determine life-threatening injuries. The rapid trauma assessment
      should be performed on responsive and unresponsive patients alike. An integral
      part of this assessment is evaluation using the simple mnemonic "DCAP-BTLS".
      For each area of the body, you should quickly look for Deformities, Contusions,
      Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and
      Swelling. In the responsive patient, symptoms should be sought before and
      during the trauma assessment.
      1. Continue spinal immobilization.
      2. Reconsider transport decision.
      3. Assess mental status:
               • A----Alert
               • V----Verbal
               • P----Painful
               • U----Unresponsive
   B. As you inspect and palpate, look and feel for the following examples of injuries or
      signs of injury:
               • D----Deformity
               • C----Contusions/Crepitation
               • A----Abrasions
               • P----Punctures/Penetrations/Paradoxical Movement
               • B----Burns
               • T----Tenderness
               • L----Lacerations
               • S----Swelling
   C. Assess the Head; inspect and palpate for injuries of signs of injury (DCAP BTLS)
   D. Assess the Neck; inspect and palpate for injuries of signs of injury (DCAP BTLS)
   E. Assess the Chest; inspect and palpate for inures of signs of injury (DCAP BTLS)
   F. Assess the Abdomen; inspect and palpate for injuries of signs of injury (DCAP
      BTLS)
   G. Assess the Pelvis; inspect and palpate for injuries of signs of injury (DCAP BTLS)
   H. Assess the Extremities; inspect and palpate for injuries of signs of injury (DCAP
      BTLS)
   I. Roll patient with spinal precautions and assess posterior body; inspect and
      palpate for injuries or signs of injury (DCAP BTLS)
   J. Assess baseline vital signs: Blood pressure, Pulse, Respirations, Skin
      Temperature, and Color
   K. Assess SAMPLE history:
               • S---Signs and Symptoms, chief complaint
               • A---Allergies
               • M---Medications
               • P---Pertinent Medical History
               • L---Last oral intake, LMP
               • E---Events leading to illness
   L. Based on the exam findings, initiate proper intervention
   M. Transport as soon as possible
   N. Perform ongoing assessment



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ALGORITHM: TRAUMA
                          PEDIATRIC PATIENT ASSESSMENT

Children can be examined easily from head to toe, but lack of understanding by the
patient, poor cooperation, and fright often limit the ability to assess completely in the
field. Children often cannot verbalize what is bothering them, so it is important to do a
systematic survey which covers areas that the patient may not be able to tell you about.
Any observations about spontaneous movements of the patient and areas that the child
protects are very important. In the patient with a medical problem, the more limited set of
observations listed below should pick up potentially serious problems.

   A. General
      1. Level of alertness, eye contact, attention to surroundings.
      2. Muscle tone: normal or increased, weak or flaccid.
      3. Responsiveness to parents, caregivers; Is patient playful or irritable?
   B. Head
      1. Signs of Trauma
      2. Fontanelle, if open: abnormal depression or bulging
   C. Face
      1. Pupils: size, symmetry, reaction to light.
      2. Hydration: brightness of eyes; Is child making tears? Is mouth moist?
   D. Neck: note stiffness
   E. Chest
      1. Note presence of stridor, retractions (depressions between ribs on
          inspiration) or increased respiratory effort.
      2. Ausculate the chest:
          a. Breath sounds: symmetrical, rales or wheezing?
          b. Heart: rate, rhythm
   F. Abdomen: distension, rigidity, bruising, tenderness.
   G. Extremities
          a. Brachial Pulse
          b. Signs of Trauma
          c. Muscle tone: symmetry of movement
          d. Skin temperature and color, capillary refill
          e. Areas of tenderness, guarding or limited movement
   H. Neurologic Exam




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                           SPECIAL ASSESSMENT NOTES

   A. Do not let the gathering of information distract from management of life-
      threatening problems.
   B. Appropriate questioning can provide valuable information while establishing
      authority, competence, and rapport with patient. Questions should be objective
      and should not “lead” the patient.
   C. Two types of information are used to assess medical or trauma conditions.
      Subjective information is related by the patient in taking a history, and describes
      symptoms. The physical exam provides signs or objective information that may
      or may not correlate with the patient’s symptoms.
   D. In medical situations, history is commonly obtained before or during physical
      assessment. In trauma cases, it may be simultaneous or following the detailed
      assessment. An assistant is often used for gathering information from family or
      bystanders.
   E. In trauma cases, carefully examine all areas where the patient complains of pain,
      but realize that the patient’s capacity to feel pain is usually limited to one or two
      areas- even if more areas are injured! That is why a systematic survey is
      important even in an awake patient.
   F. Use bystanders to confirm information obtained from the patient and to provide
      facts when the patient cannot. History from the scene is invaluable.
   G. Over-the-counter medications including aspirin, homeopathic remedies, and
      herbal supplements are frequently overlooked by patient and rescuer, but may be
      important to emergency problems. Birth control pills are also frequently
      overlooked so be sure to ask.
   H. Confidentiality is mandatory. Patients are in need and vulnerable, they deserve
      respect, kindness and discretion.
   I. Complete legible documentation is critical to convey the information above.
   J. Be systematic. If you jump from one obvious injury to another, the subtle injury
      that is most dangerous to the patient is easily missed.
   K. If the patient has any significant airway or circulatory deterioration, these
      problems must be addressed immediately. Otherwise, complete the assessment
      before you begin to address the problems that have been identified.
   L. Obtain and record two or more sets of vital signs and neurologic observations. A
      patient cannot be called “stable" without at least two sets of vital signs giving
      similar normal readings. Serial vital signs are an important parameter of the
      patient’s physiologic status. Vital signs should be repeated frequently, at least
      every 15 minutes in stable patients and at least every 5 minutes in unstable
      patients.




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                                DETAILED ASSESSMENT

Detailed assessment is the systematic assessment of the entire patient. It should be
performed after:

       a) Initial assessment
       b) Stabilization and initial treatment of life threatening airway, breathing, or
          circulatory difficulties
       c) Cervical immobilization as needed

The purpose of the detailed assessment is to uncover problems which are not life-
threatening, but which could be injurious or could become life threatening to the patient.

   A. Initial vital signs
   B. Head and Face:
      1. Observe for deformities, asymmetry, bleeding.
      2. Palpate for deformities, tenderness, crepitation.
      3. Recheck airway for potential obstruction: dentures, bleeding, loose or avulsed
           teeth, vomitus, abnormal tooth position from mandible fracture, absent gag
           reflex.
      4. Eyes: pupils (equal or unequal, responsiveness to light), foreign bodies,
           contact lenses
      5. Nose: deformity, bleeding, discharge.
      6. Ears: bleeding, discharge, bruising behind ears
   C. Neck:
      1. Recheck for deformity or tenderness if not already immobilized.
      2. Observe for wounds, neck vein distention, use of neck muscles for
           respiration, altered voice, and medical alert tags.
      3. Palpate for crepitation, tracheal shift.
   D. Chest:
      1. Observe for wounds, chest wall movement, and accessory muscle use.
      2. Palpate for tenderness, wounds, fractures, crepitation, unequal rise of chest.
      3. Have patient take deep breath: observe for pain, symmetry, air leak from
           wounds.
      4. Auscultate chest for rales, wheezes, rhonchi, or decreased breath sounds.
   E. Abdomen
      1. Observe for wounds, bruising, distention.
      2. Palpate all 4 quadrants for tenderness, rigidity.
      3. Consider orthostatic vital signs for volume status.
   F. Pelvis
      1. Palpate and compress lateral pelvic rims, symphysis pubis, for tenderness or
           instability.
   G. Shoulders/Upper Extremities
      1. Observe for angulation, protruding bone ends, symmetry.
      2. Palpate for tenderness, crepitation.
      3. Note distal pulses, color, medical alert tags.
      4. Check sensation.
      5. Test for weakness if no obvious fracture present (have patient squeeze your
           hands).
      6. If no obvious fracture, gently move arms to check overall function.
   H. Lower Extremities


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        1. Observe for angulation, protruding bone ends, symmetry.
        2. Palpate for tenderness, crepitation.
        3. Note distal pulses, color.
        4. Check sensation.
        5. Test for weakness if no obvious fracture present (have patient push feet
           against your hands and pull back against your hands).
        6. If no obvious fracture, gently move legs to check overall function.
   I.   Back
        1. Immobilize if any suspicion of back injury. To the extent immobilization
           allows, palpate for wounds, fractures, tenderness.
        2. Recheck motor and sensory function as appropriate.




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                              ONGOING ASSESSMENT

   A. Repeat initial assessment for a stable patient, repeat and record every 15
      minutes. For an unstable patient, repeat and record at a minimum every 5
      minutes.
      1. Reassess mental status.
      2. Maintain an open airway.
      3. Monitor breathing for rate and quality.
      4. Reassess pulse for rate and quality.
      5. Monitor skin color and temperature.
      6. Reassess and record vital signs.
   B. Repeat focused assessment regarding patient complaint or injuries.
   C. Check interventions:
      1. Assure adequacy of oxygen delivery/artificial ventilation.
      2. Assure management of bleeding.
      3. Assure adequacy of other interventions.




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                             NEUROLOGIC ASSESSMENT

Management of patients with head injury or neurologic illness depends on careful
assessment of neurologic function. Changes are particularly important. The first
observations of neurologic status in the field provide the basis for monitoring sequential
changes. Therefore, it is important that the first responder accurately observes and
records neurologic assessment, using measures which will be followed throughout the
patient's hospital course.

   A. Vital Signs: observe particularly for adequacy of ventilations; depth, frequency,
      and regularity of respirations.
   B. Level of consciousness:

                                                        Glasgow Coma Score
        Eye opening:         None                                  1
                             To pain                               2
                             To speech                             3
                             Spontaneously                         4
        Best verbal          None                                  1
        response:            Garbled sounds                        2
                             Inappropriate words                   3
                             Disoriented sentences                 4
                             Oriented                              5
        Best motor           None                                  1
        response:            Abnormal extension                    2
                             Abnormal flexion                      3
                             Withdrawal to pain                    4
                             Localizes pain                        5
                             Obeys commands                        6
               Score = Sum of scores in 3 categories: (15 points possible)

   C. Eyes:
      1. Direction of gaze, extraocular movement.
      2. Size and reactivity of pupils.
   D. Movement: observe whether all four extremities move equally well.
   E. Sensation (if patient awake): observe for absent, abnormal, or normal sensation
      at different levels if cord injury is suspected.
   Special Notes
   A. The Glasgow Coma Scale (GCS) used above has gained acceptance as one
      method of scoring and monitoring patients with head injury. It is readily learned,
      has little observer to observer variability, and accurately reflects cerebral
      function. Always record specific responses rather than just the score (sum of
      observations). In areas where numerical assignment of scores is not a formal
      procedure, the observations of the GCS still provide an excellent basis for field
      neurologic assessment. Note also that the other parameters listed must be
      observed to assess fully the neurologically impaired patient.
   B. Use your written report to follow and document changes in neurologic findings.
   C. At a minimum, gross motor function must be documented before and after
      moving a patient with suspected spinal injury.


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   D. Sensory deficit levels should be marked gently on the patient's skin with a pen to
      help identify any changes.
   E. Note what stimulus is being used when recording responses. Applied noxious
      stimuli must be adequate to the task but not excessive. Initial mild stimuli can
      include light pinch, dull pinprick, or light sternal rub. If these are unsuccessful at
      eliciting a pain response, pressure with a dull object to base of nailbed, stronger
      pinch (particularly in axilla), or sternal rub will be necessary to demonstrate the
      patient's best motor response.
   F. When responses are not symmetrical, use motor response of the best side for
      scoring GCS and note asymmetry as part of neurologic evaluation.
   G. Use of restraints or intubation of patient will make some observations less
      accurate. Be sure to note on chart if circumstances do not permit full verbal or
      motor evaluation.
   H. Remember that a patient who is totally without response will have a score
      of 3, not 0.

   I.   In small children, the GCS may be difficult or impossible to evaluate. Use an age-
        appropriate neurological assessment for small children. Children who are alert
        and appropriate should focus their eyes and follow your actions, respond to
        parents or caregivers, and use language and behavior appropriate to their age
        level. In addition, they should have normal muscle tone and a normal cry.
        Several observers should attempt to elicit a "best verbal response," to avoid over
        or underestimation of level of consciousness.




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                       PATIENT ASSESSMENT GUIDELINES
                      APPROACH TO DIFFICULT ASSESSMENTS

A. Background and Philosophy
   1. Common difficulties that the care provider encounters are communication barriers. The
      care provider frequently depends on effective communications in dealing with patient
      evaluations and treatment.
   2. Communication means more than the simple spoken word. Communication is the
      collaboration of ideas between individuals based on body position, affect, gestures,
      sounds, and sensory input. Communication occurs when the care provider palpates the
      fractured extremity and the patient moans in response to pain. Communication occurs
      when the care provider enters the patient’s residence and the patient’s body language
      suggests hostility. Communication also occurs when the care provider asks a question
      that evokes fear in the patient, creating a response of denial.
   3. The Approach to Difficult Assessments Protocol separates the communication barrier
      into five main categories, with suggestions to assist the care provider in overcoming
      communication difficulties specific to each category. Suggestions have been separated
      into “Reactive” strategies, which may be used by a care provider when confronted with a
      current communication barrier, and “Proactive” strategies, which the care provider may
      utilize to prepare for future potential communication barriers. The five communication
      barrier categories are as follows:

        a. Category 1: The patient’s language is foreign to the care provider (sign language,
           foreign nationality, etc.):

Reactive troubleshooting techniques:

            Quickly attempt to locate an interpreter. Bilingual family members are ideal.
               Almost without exclusion, children can be very effective as interpreters.
               Situations where there are no immediate family members or bystanders
               are more challenging and require creativity on the part of the care
               provider. Look for pictures of family members in the immediate vicinity,
               point to the picture, and make a gesture of talking on the phone.

            Pay close attention to gestures, sounds, and body language. Try to use
               gestures similar to those of the patient in order to clarify meaning. The
               care provider can generally obtain an idea of the nature of the complaint.

            Consider using a pocket handbook for foreign language medical questions
               (not highly recommended as the patient usually responds in a language
               that you do not understand, causing further frustration). However, the
               care provider can show patients a list of symptoms that are translated into
               their primary language and have them point out their complaints. This
               method may allow the care provider to develop a general impression of
               the patient’s condition.

Proactive troubleshooting techniques:




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            Consider enrolling in language classes if there is a predominate language in
               your response area that you know little about.

            Attempt to discover different personnel in the company who know different
                languages and utilize them as translational and educational resources.
            There are telephone hotlines available in several areas that assist medical
                personnel in interpretation of foreign languages. Care providers should
                research their area for number listings of this type of hotline.

        b. Category 2: The patient has experienced an acute impairment in his/her ability
           to communicate or the patient has a chronic sensory deficit that hinders
           communication (acute visual disturbances, acute hearing impairment, inability to
           speak, etc.):

Reactive troubleshooting techniques:

            Attempt to establish an alternative means of communication. For example,
                the patient with Broca’s aphasia may not be able to speak to you, but can
                understand what you are saying. Establish a hand-squeeze or an eye-
                blinking system of communication.

            Be patient. Impairment to the patient’s normal means of communication can
               be incredibly frustrating to the patient. Assuming that the patient cannot
               understand what you say because they cannot respond is a false
               assumption in many cases.

Proactive troubleshooting techniques:

            The care provider should practice establishing alternative means of
               communication with their fellow employee, family members, etc.

            Research pathology that causes impairment of communication. For example,
               understanding different types of aphasia may help in developing
               alternative means of communication.

       c. Category 3: There is a cognitive barrier between the patient and the care
            provider that hinders communication (the patient does not understand your
            terminology, etc.):
Reactive troubleshooting techniques:

            Physically position yourself at a level equal to the patient. Your body position
               alone can help you to communicate more effectively.

            Attempt to use phrases that the patient will understand. For example, when
                assessing the pediatric patient for mental status, the patient may
                understand “Pokemon,” but may not understand “visual disturbance.”

            The care provider should consider the use of props or objects that the patient
               can understand.

Proactive troubleshooting techniques:


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            The care provider can prepare for interaction with patients by taking classes
               on communication.
            The care provider can expand on their skills in breaking down cognitive
               barriers by teaching different topics to people with different levels of
               understanding of, or experience with, the subject matter.

       d. Category 4: There is an affective barrier between the patient and the care
           provider that hinders communication (the patient is angry, upset, or frustrated
           about your intrusion into his/her life, is distancing himself/herself from the care
           provider, etc.):
Reactive Troubleshooting Techniques:

            For the patient with a high need for control and/or authority: Avoid the
               creation of conflict. Validate your patients’ input by repeating their
               statements back to them. Validate your patients’ complaints—repeating
               back their complaints establishes that you are listening to their concerns
               and allows your patients to clarify any misinterpretation, adding to their
               trust in you as their care provider. Utilize your partner’s input during
               conflict. Attempt to get the patient’s family member/s to agree with you,
               they can assist in convincing the patient of the need for treatment.
               Attempt to identify and address the anxiety-causing agent.

            For the patient that does not want to participate in assessment and/or
               treatment: Positively reinforce participatory behavior that the patient
               exhibits (your body language and dialog should reflect your appreciation
               of the patient assisting you or cooperating with assessment and
               treatment). Reassure the patient of your intentions. Attempt to find
               common ground for initiating dialog (this should segue into dialog about
               the patient’s condition). Do not perform procedures on patients without
               telling them first—even if the procedure is necessary, the patient has the
               right to refuse treatment.

            For the patient with an adversarial attitude toward the care provider: Attempt
               to find common ground with the patient. Identify and point out the similar
               intentions that you share with the patient. This technique should be
               performed in a discerning fashion because it can be perceived as
               condescending. For example, if the patient tells you that he/she wishes to
               harm him/herself and you tell the patient, “I understand that you are
               hurting and I want to get you help as well,” the patient may assume your
               response is condescending. Be careful to avoid adding your own
               interpretation to the patient’s statements. By repeating patients’ words
               back to them, you allow them to reflect and help to establish trust. As a
               last resort, attempt to resolve the conflict by taking authority of the
               situation (for example, with the hostile or violent patient).

       e. Category 5: The patient is a poor historian, does not have a clearly defined
           complaint, and/or continually sidetracks the dialog.
Troubleshooting techniques:




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            Establish a basic approach for every conscious patient. Consider the
                 following questions: “Why were emergency services activated? Why
                 were we called?”
            If there is no clear reason given, consider “What is bothering you? What is
                 bothering you the most?” If no clear reason is given, consider “What is
                 different about right now compared to what is normal?”

            If the care provider is still unable to establish a clearly defined complaint,
                 consider questioning the patient on a linear body systems approach.
                 Start with the head and make your way down through the rest of the body
                 systems until a complaint is established. Once a clearly defined
                 complaint is established, consider using that as a chief complaint until an
                 additional complaint arises.
            The care provider needs to discern a careful balance between pressing the
                 patient for specific critical information and listening to the patient’s version
                 of their complaints and concerns. The patients that continually sidetrack
                 the dialog need to be given direction in the dialog. As the patient gives
                 you the information that you need, validate the patient by repeating that
                 information and carefully move the direction of the dialog to the next
                 question. If the care provider too quickly or forcefully directs the
                 conversation, trust may be broken and the sidetracking behavior may
                 increase.

B. Special Considerations
   1. Although the Approach to Difficult Assessments Protocol is based on experience and
      research, it should only be used as a guideline, not as a rule. There are many different
      approaches to dealing with difficult assessment situations and there are many different
      situations that are not practical to include in this protocol. Inevitably, the care provider
      will have to incorporate the assessment tools that are most effective for him/herself when
      approaching difficult patient assessments.
   2. The fundamental key to mastering difficult patient assessment is awareness and
      effectiveness in communication skills.




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PATIENT CARE REPORT REQUIREMENTS
   General Principles
   A. The prehospital report is an integral component of patient care, quality
      improvement and professional responsibility.
   B. The prehospital report must be legible.
   C. Vital information should also be immediately communicated to the Emergency
      Department (ED) staff for efficient and safe transfer of care.
   D. A legible copy of the prehospital report should be given to the ED staff at the time
      of transport to the ED. If this is not possible, the report or a facsimile copy must
      be received in the ED within 24 hours from the time of transport.
   Procedure
   A. All prehospital run reports must include the information noted in the EMS Division
      policy statement.
   B. Additional considerations and information to be included to the extent pertinent.
      1. The physical examination should include assessment findings:
          a. Head, Ears, Eyes, Nose and Throat (HEENT), including mentation, skin
              color and condition, and trauma
          b. Neck
          c. Chest
          d. Abdomen
          e. Pelvis
          f. Back
          g. Extremities
          h. Neurologic status
          i. Cardiovascular status
          j. Respiratory status
      2. Treatment rendered should be detailed, including:
          a. The reason or assessment findings that were the basis of the treatment,
              procedure or medication
          b. The effects (including lack of effect)
          c. Treatment rendered prior to your arrival or by others
          d. Medication administration should include time(s) and dose(s).
      3. Facility contact information:
          a. Name of physician and facility
          b. Orders requested or denied
          c. Time of contact
      4. Additional documentation should be included, where pertinent to particular
          protocols; for example:
          a. Resuscitations in the field should document time and effects of all
              procedures and medications, and time of pronouncement or termination
              of resuscitation.
          b. Refusals of transport should include documentation of mental status,
              decision-making capacity, warnings given and condition of patient at
              termination of contact.
          c. Copies of EKG tracings should be affixed to copies of run reports left with
              the hospital.
          d. The mechanism of injury in trauma should be descriptive, not general.



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       5. The prehospital provider who authors the report must include his/her name
          and signature on the report.




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                           Pridemark Paramedic Services
                          Patient Care Report Requirement

A. Purpose

In addition to the specific requirements of the Denver Metro Protocols, Pridemark
Paramedic Services has a higher expectation of PCR (Patient Care Report) requirements.
These requirement are designed to assure smooth continuity of care. This Process shall
outline Pridemark specific requirements.

B. Process

   1. A paper PCR shall be left at the receiving hospital facility for all patients
      transported prior to departure from the unit. If utilizing electronic documentation,
      this may be accomplished by syncing the completed PCR thus faxing it to the
      unit.
   2. In the event you are unable to leave a complete PCR either by electronic or
      written means you shall complete and leave a PPCR (Preliminary Patient Care
      Report) as approved by the Foothills RETAC or Draft Patient Care Report from
      the TPCR Toughbook.
   3. If you choose to leave a Draft PCR from the Toughbook, it must contain at a
      minimum the same information the PPCR requires.
   4. If leaving a PPCR or Draft be sure to keep a copy of that record for utilization
      later when you complete your full report.

C. General Principles

    1. The final and complete patient care report shall serve as the complete medical
       record.
    2. Draft or Preliminary reports are done to facilitate smooth continuity of care and
       as a courtesy to the receiving facility. They may contain partial or incomplete
       data.
    3. These are provided at the request of the Foothills RETAC and participating
       hospital facilities with the full knowledge that these are preliminary or draft
       documents.




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          REQUIRED RECORDS ON TREATMENT AND TRANSPORTATION

            Policy Statement of the Colorado Dept. of Health EMS Division:

          REQUIRED RECORDS ON TREATMENT AND TRANSPORTATION
          OF PATIENTS FOR PREHOSPITAL CARE EMS ORGANIZATIONS

Section 9.2 of the EMS Rules specifies that each ambulance service shall maintain
records of the treatment and transportation of all patients cared for. Such records shall
include all information determined by the Department of Health to be essential for the
maintenance of adequate minimum records on a patient's condition and medical care
provided. In addition, these records shall be preserved by the ambulance service for a
period of three (3) years.

In compliance with Section 9.2, the Emergency Medical Services Division of the
Department of Health has established the foregoing policy that specifies the essential
information to be recorded and preserved for each patient cared for by an ambulance
service.

The Emergency Medical Services Division of the Colorado Department of Health hereby
determines that the following information shall be recorded and preserved by each
Prehospital care EMS service in the State on each patient cared for:

   A. Patient name, if known, as complete as possible and ideally including full first
      and last name.
   B. Patient residential address, if known, as complete as possible (to allow medical
      or public health follow up, if needed).
   C. Patient sex (both for purposes of identification and to facilitate diagnosis and
      treatment).
   D. Patient age, as accurate as possible (both for purposes of identification and to
      facilitate diagnosis and treatment).
   E. Patient location at time of response and apparent cause of the injury or nature of
      illness (to assist in subsequent diagnosis and treatment).
   F. Patient condition at time of response, including a preliminary assessment of the
      patient based on vital signs, apparent symptoms, and known medical history.
   G. Patient vital signs at time emergency medical care is begun, to include
      respiratory rate, pulse rate, blood pressure, level of consciousness, and pupil
      size and reaction to light. Subsequent vital signs shall be recorded at least every
      15 minutes when either treatment or transport time exceed 15 minutes.
   H. Known patient history related to the apparent illness or injury, including allergies
      and medications. If it is determined that the patient is on medication of any kind,
      the prescribing physician should be identified, if possible, so he/she may be
      contacted for confirmation, consultation, or actual care of the patient.
   I. Treatment rendered to the patient at the scene and during transport, in sufficient
      detail to permit the receiving facility (i.e., hospital, clinic, etc.), physician advisor,
      and any other reviewing physician or nurse to determine the nature and extent of
      treatment rendered.
   J. Patient's apparent condition upon delivery to the receiving facility, and any
      pertinent comments regarding changes in the patient's condition during transport
      (to assist the receiving physician in diagnosis and treatment).



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   K. Identity and location of the receiving facility and signature or other indication of
      the physician or nurse receiving the patient and assuming responsibility for the
      care of the patient.
   L. Full name and level of training and certification or licensure of each member of
      the EMS crew caring for the patient.
   M. Times of dispatch and departure to the emergency scene, time of arrival at the
      scene, time of departure from the scene, and time of arrival at the receiving
      facility.
   N. Indication of whether emergency lights and siren were used enroute to the scene
      and/or during transport.

In all cases, a copy of the patient care report should be delivered to the receiving facility
along with the patient.




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COMMONLY ACCEPTED ABBREVIATIONS FOR FIELD USE

a             before
AAA           abdominal aortic aneurysm
A&O x         alert and oriented times
abd           abdomen
AB            abortion
ABC           airway, breathing, circulation
ACLS          Advanced Cardiac Life Support
adm           admission
ALS           Advanced Life Support
am            morning
AMA           against medical advice
AMS           altered mental status
amp(s)        ampule(s)
ant           anterior
asa           aspirin
ASCVD         arteriosclerotic cardiovascular disease
ASHD          arteriosclerotic heart disease
asys          asystole
ATLS          Advanced Trauma Life Support
A&P           anterior and posterior
a&p           auscultation and percussion
≈             approximately
@             at
BBB           Bundle Branch Block
BCLS          Basic Cardiac Life Support
BLS           Basic Life Support
bil           bilateral
BM            bowel movement
BP            blood pressure
BS            breath sounds
BVM           bag, valve, mask
c             with
C             Centigrade
Ca            cancer
Ca++          calcium
CABG          coronary artery bypass graft(s)
CAD           coronary artery disease
cath          catheter, catheterization
CBC           complete blood count
cc            cubic centimeter
CC            chief complaint
CCU           coronary care unit
CHF           congestive heart failure
CHI           closed head injury
circ          circulation



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cm            centimeter
CMS           circulation, movement, sensation
CNS           central nervous system
CO            carbon monoxide
c/o           complaining of/complaint of
CO2           carbon dioxide
              change
COPD          chronic obstructive pulmonary disease
COR-0         cardiopulmonary arrest
C-spine       cervical spine
C-section     cesarean section
CSF           cerebrospinal fluid
CSM           carotid sinus massage
CVA           cerebral vascular accident
CVP           central venous pressure
CPR           cardiopulmonary resuscitation
d/c           discharge/discontinue
D&C           dilatation and curettage
detox         detoxification
D5W           dextrose 5% in water
D50W          dextrose 50% in water
DOA           dead on arrival
DOB           date of birth
DOE           dyspnea on exertion
DOS           dead on-scene
Dr.           doctor
drsg/dsg      dressing
DT            delirium tremens
Dx            diagnosis
↓             decrease
ea            each
ED            emergency department
ECG/EKG       electrocardiogram
EENT          eye, ear, nose, throat
EMS           emergency medical services
ENT           ear, nose, throat
EOA           esophageal obturator airway
EOM           extraocular movement
et            and
ET            endotracheal
ETT           endotracheal tube
ETA           estimated time of arrival
etc           and so forth
ETOH          alcohol (ethyl)
exam          examination
=             equal
F             Fahrenheit


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FB            foreign body
FD            fire department
fl            fluid
Fx            fracture
♀             female
1o            first degree/primary
GB            gallbladder
GC            gonorrhea or gonococcus
GCS           Glasgow coma scale
GI            gastrointestinal
g             gram
GPA           gravida, para, abort
gr            grain
GSW           gunshot wound
gtt(s)        drop(s)
GU            genitourinary
GYN           gynecology
→             going to/leading to
>             greater than
h/hr          hour
HA            headache
HACE          high-altitude cerebral edema
HAPE          high-altitude pulmonary edema
HAZMAT        hazardous materials (incident)
HB            heart block
HBV           hepatitis B virus
Hct           hematocrit
HEENT         head, eyes, ears, nose, throat
Hg            mercury
Hgb           hemoglobin
HIV           human immunodeficiency virus
H&P           history and physical
HR            heart rate
ht            height
Hx            history
hypo-         low
H2O           water
ICS           intercostal space
ICU           intensive care unit
I&D           incision and drainage
IM            intramuscular
inf           inferior
int           internal
IV            intravenous
↑             increase
J             Joule(s)
JVD           jugular venous distention



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K+            potassium
KVO/ TKO      keep vein open / to keep open
L/l           liter
L             left
lac           laceration
lat           lateral
LBBB          left bundle branch block
lb            pound
lg            large
LLL           left lower lobe
LLQ           left lower quadrant
LMP           last menstrual period
LOC           loss of consciousness
L-spine       lumbar spine
LUL           left upper lobe
LUQ           left upper quadrant
<             less than
O    /\       lying
♂             Male
MAE           moves all extremities
MAST          medical antishock trousers, military antishock trousers
mcg           microgram
MCL           midclavicular line, modified chest lead
med(s)        medication(s)
mEq           milliequivalent
Mg            magnesium
mg/mgm        milligram
MI            myocardial infarction
misc          miscellaneous
ml            milliliter
mm            millimeter
MOE x         movement of extremities times
MS/MSO4       morphine sulfate
MVA           motor vehicle accident
              male
N/A           not applicable
NaCl/NS       normal saline
NaHCO3        sodium bicarbonate
NC            nasal cannula
neg           negative
NKA           no known allergies
noc/noct      night
NPO           nothing by mouth
NSR           normal sinus rhythm
NTG           nitroglycerin
N/V/D         nausea and vomiting and diarrhea



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∅             none
O2            oxygen
OB            obstetrics
occ           occasional
O.D.          right eye (oculus dexter)
OD            overdose
OJ            orange juice
ophth         ophthalmology
OPP           organophosphate poisoning
OR            operating room
Ortho         orthopedics
O.S.          left eye (oculus sinister)
O.U.          both eyes (oculus uterque)
oz            ounce
P             after
PAC           premature atrial contraction
PASG          pneumatic antishock garment
PAT           paroxysmal atrial tachycardia
path          pathology
PD            police department
PE            physical examination/pulmonary edema/pulmonary
              embolus
peds          pediatrics
per           by or through
PERL          pupils equal and react to light
PERLA         pupils equal and react to light and accommodation
PID           pelvic inflammatory disease
PND           paroxysmal nocturnal dyspnea
po            by mouth
pos/ö/+       positive
post          posterior
POV           privately owned vehicle
PSVT          paroxysmal supraventricular tachycardia
psych         psychiatric
pt            patient
PTA           prior to arrival
PVC           premature ventricular contractions
Ψ             psychiatric
q             every
®             right
RBBB          right bundle branch block
RBC           red blood cell
resp          respirations
RHD           rheumatic heart disease/right hand dominant
RLQ           right lower quadrant
R/O           rule out
ROM           range of motion



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ROS           review of systems
RUQ           right upper quadrant
Rx            take, treatment
s             without
SAB           spontaneous abortion
SC/sub q      subcutaneous
SL            sublingual
SOB           shortness of breath
sol           solution
sm            small
stat          at once
sup           superior
Sx            sign/symptom
surg          surgery
SVT           supraventricular tachycardia
synch         synchronous
2o            second degree/secondary
TAB           therapeutic abortion
TB            tuberculosis
tbsp          tablespoon
temp          temperature
TIA           transient ischemic attack
tid           three times a day
TKO           to keep open
TLC           tender loving care, total lung capacity
TM            tympanic membranes
tol           tolerated
tsp           teaspoon
Tx            treatment
∴             therefore
3o            third degree, tertiary
U/A           upon arrival
uncons        unconscious
unk           unknown
URI           upper respiratory infection
uro           urology
UTI           urinary tract infection
≠             not equal/unequal
vag           vaginal
VD            venereal disease
VF            ventricular fibrillation
via           by way of
vol           volume
V/S           vital signs
VT            ventricular tachycardia
WAP           wandering atrial pacemaker
WBC           white blood cell



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wc            wheelchair
WNL           within normal limits
WPW           Wolff-Parkinson-White Syndrome
wt            weight
x             times
y/o           year(s) old
yr            year(s)




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COMBINED ADVANCE DIRECTIVES AND CPR DIRECTIVE
   ADVANCE MEDICAL DIRECTIVES
   A. There are several types of advance medical directives (documents in which a
      patient identified the treatment to be withheld in the event the patient is unable to
      communicate or participate in medical treatment decisions).
      1. Do not resuscitate (DNR) orders are generally intended to be written by a
          physician for a patient whose medical condition is such that commencement
          of resuscitation efforts would be futile.
      2. A Colorado living will ("Declaration as to Medical or Surgical Treatment")
          requires a patient to have a terminal condition, as certified in the patient's
          hospital chart by two physicians. For the document to become operative, the
          patient must be unresponsive because of a terminal condition for a period of
          seven days. In most cases, these do not impact prehospital care, but
          become effective in the in hospital setting.
      3. "Durable Medical Power of Attorney" or "Health Care Proxy" are documents
          which can be very complex and require careful review and verification of
          validity, and application to the patient's existing circumstances. Therefore,
          the consensus is that resuscitation should be initiated until a physician can
          review the document or field personnel can discuss the patient’s situation
          with the base physician.
      4. The Colorado CPR Directive is a specific situation under Colorado law that
          provides for CPR to be withheld or withdrawn.
   B. Resuscitation may be withheld from or terminated for a patient who has a valid,
      written do not resuscitate order or other advanced medical directive only if:
      1. The documentation is clear, unequivocally to the prehospital provider that
          CPR, intubation and defibrillation are refused by the patient or by the patient's
          attending physician who has signed the document, and
      2. Base physician has approved of withholding or ceasing resuscitative efforts,
          and
      3. There is no apparent indication of suicidal gesture or intent by the patient.
      4. If there is disagreement at the scene about what should be done, the base
          should be contacted immediately for guidance.
      5. Prehospital providers presented with equivocal DNR orders or advance
          medical directives should proceed with resuscitation and establish base
          contact for guidance on treatment and transport.
          a. If the directive document is long and detailed, then it is probably more
              reasonable for resuscitation to be initiated and the patient to be
              transported so that the base physician can review the document and
              possibly contact the patient's attending physician.
          b. The duration of the resuscitation should be guided by the same factors of
              any medical cardiac arrest.
   C. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the
      event family or an attending physician directs resuscitation be ceased, the
      prehospital provider should immediately CONTACT BASE. The prehospital
      provider should accept verbal orders to cease resuscitation only from the base
      physician.
   D. There may be times in which the prehospital provider feels compelled to perform
      or continue resuscitation, such as hostile scene environment, family members
      adamant that "everything be done", or other highly emotional or volatile



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       situations. In such circumstances, the prehospital provider should attempt to
       confer with the base for direction and if this is not possible, the prehospital
       provider must use his or her best judgment in deciding what is reasonable and
       appropriate, including transport, based on the clinical and environmental
       conditions, and established base contact as soon as possible. Documentation of
       these events must be explicit.
   CPR DIRECTIVE PROTOCOL
General Principles
  A. This protocol is for the prehospital management of the statutory "CPR Directive,"
      which refers to a specifically identifiable, numbered form that is printed on
      security paper. The form must be signed by the patient or the patient's
      authorized agent. The form must also be signed by the patient's attending
      physician.
  B. In addition to the written CPR Directive form, the patient or authorized agent may
      obtain a CPR Directive necklace or bracelet to be worn by the patient. This
      bracelet or necklace will have imprinted on it the same number as the form.
  C. CPR shall be withheld or terminated if the original CPR Directive form is readily
      accessible with an original signature, or if the necklace or bracelet is worn by the
      patient.
  D. A CPR Directive may be implemented for a minor only after a physician issues a
      "Do Not Resuscitate" order and the parents of the minor (if married and living
      together), custodial parent, or legal guardian execute(s) a CPR Directive for the
      minor.
  E. A CPR Directive does not only apply to patients in full cardiac arrest, but should
      also be honored by withholding resuscitation in patients who are seriously ill or
      near arrest.
   Procedure
   A. Upon finding a patient with a CPR Directive (form, bracelet, or necklace):
      1. Perform initial patient assessment.
      2. Verify that the CPR Directive form is one of the original copies (it should be
         light blue color below the title portion of document) and is unaltered (not
         defaced or altered physically in some way).
      3. Verify that the information on the form or, if present, on the back of necklace
         or bracelet, appears to be appropriate for the patient (look at race, sex, date
         of birth, eye and hair color). If possible, try to verify identity of patient by an
         additional source (e.g., family member, driver's license or other readily
         available sources).
      4. Upon verification of the CPR Directive, withhold CPR. If CPR has been
         started, it should be stopped.
      5. If there is any question of the validity of the document or the identity of the
         patient, initiate full resuscitation measures and contact the base for guidance.
         Be sure to inform the base of the CPR Directive form, bracelet, or necklace,
         and the condition and history of the patient.
      6. Complete documentation, including attaching a copy of monitor strips on
         each copy of the run report (EMT-P or EMT-I). Additional required
         documentation is listed in section K below.
      7. Provide appropriate emotional support to family if possible.



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      8. If the death occurs outside of a health care facility or if tissue donation has
          been declared, then the coroner is to be immediately contacted. If the
          declarant has indicated on the CPR Directives form a desire to donate any
          tissues, appropriate authorities should be notified.
      9. The following resuscitation measures are to be withdrawn or withheld from a
          person who has a valid CPR Directive:
      10. CPR and chest compressions
      11. Endotracheal intubation or other advanced airway management
      12. Artificial ventilation
      13. Defibrillation
      14. Cardiac resuscitation measures and medications.
   B. The following interventions may be administered or provided:
      1. Assist in maintenance of airway (non-advanced airway management, such as
          positioning)
      2. Suctioning
      3. Oxygen
      4. Pain medication
      5. Control bleeding
   C. In addition to the standard documentation, the following information should be
      documented when possible by the prehospital provider on the run report:
      1. Patient's status (e.g. condition found, medical history obtained)
      2. Type of "CPR Directive" found (document, bracelet or necklace)
      3. CPR Directive number
      4. Name of attending physician, if known
      5. Special circumstances which justify initiating resuscitation if this was done
          despite the presence of the CPR Directive
      6. Monitor strips in at least two leads (EMT-P and EMT-I)
   Additional Considerations
   A. The patient may revoke the CPR Directive at any time by oral expression of
      revocation or by destruction of the CPR Directive form, bracelet or necklace. If a
      guardian, agent or proxy decision-maker executed the CPR Directive, then the
      guardian, agent or proxy decision-maker may revoke the CPR Directive.
   B. CPR is to be initiated if the original CPR Directive form, necklace or bracelet is
      not readily available, (i.e., being worn by or physically present with the patient).
      The bracelet or necklace is only available to the patient after the form has been
      properly executed. Removal of the bracelet or necklace may be construed as
      revocation. Therefore, if the bracelet or necklace is readily accessible but not on
      the patient, any question as to whether or not the Directive has been revoked
      should result in resuscitation until the situation is clarified. Consult with base if
      you have questions about terminating CPR and transport. If not in full arrest,
      patients with CPR Directives may still be transported to provide comfort
      measures.
   C. In the absence of the existence of a CPR Directive, a person's consent to CPR
      shall be presumed. The statutorily authorized CPR Directive is only one manner
      for a patient to document resuscitation preferences. Other "Do Not Resuscitate"
      forms and advance directives may be honored but base contact is required.
   D. Under Colorado Law, refraining from performing CPR, when there is a CPR
      Directive, does not constitute assisting a suicide, and caregivers who honor a
      CPR Directive by withholding CPR are protected from legal liability.



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COMMUNICATION

   A. The purpose of contacting the receiving hospital is to provide enough data to
      allow the Emergency Department staff to decide what preparations they will need
      to make for the patient. In addition, a base physician may direct appropriate
      treatment to be administered en route.
   B. Radio contact should only include essential, relevant information. Remember,
      the Emergency Department staff may be busy and radio time is valuable.
   C. First, always identify agency, unit, person, and the reason for contact such as a
      treatment orders/requests, notification, and/or consultation.
   Procedure for Notification to Receiving Facility
   A. Report the following, to the extent pertinent, to the receiving facility:
      1. Transport status or code
      2. Chief complaint
      3. Age and gender of patient
      4. General status and course of events, stable, improving, deteriorating
      5. Past medical history, only if pertinent
      6. State of consciousness
      7. Vital signs
      8. Pertinent localized findings
      9. Treatment in progress
      10. Estimated time of arrival
   Procedure for Requests for Treatment Orders
   A. Only a physician may provide authorization to a paramedic to perform a
      procedure or administer a medication pursuant to these protocols. The
      paramedic should be clear and concise in requesting that a physician be
      available for consultation or orders.
   B. Request to talk to a physician to obtain an order.
   C. Identify yourself to the physician and state the order you are requesting.
   D. Provide pertinent information that is the basis of the request, such as:
      1. Enroute (emergent or non-emergent, estimated time to destination hospital)
          or on scene
      2. Chief complaint
      3. Course of events, stable, improving, deteriorating
      4. Past medical history, only if pertinent
      5. General status
      6. State of consciousness
      7. Vital signs
      8. Pertinent localized findings
      9. Treatment in progress
      10. Order requested, stating dosage and route to be given
      11. All allergies the patient has
   E. In the event a request is for a field pronouncement, the report should include
      information about the responses to resuscitation efforts, mechanism, and
      duration of resuscitation efforts. If the pronouncement is made, state the time.
   F. Communication with a physician at the base is appropriate if you are not sure
      whether or not a treatment, procedure or destination is appropriate for a patient.



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      BASE CONTACT should be considered as a consultation, not just as a source of
      authorization for medications and procedures.
   G. Requests for orders should be made to a hospital's recorded line whenever
      possible.




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DESTINATION POLICY
   Purpose
   A. To provide a set of guidelines to help ensure proper disposition of the various
      patients encountered in the field.
   Philosophy
   A. Critical patients with a special medical need should be taken to the nearest
      facility that can best provide for that need.
   B. Critical patients without a special need (i.e., cardiopulmonary arrest) should be
      taken to the closest emergency department.
   C. All other patients should have their request accommodated, consistent with the
      ability of that system to meet that request.
   Special Needs
   A. Burns
      1. Patients older than 12 years of age, with second degree or third degree burns
         greater than 20% body surface area, should be transported directly to the
         University Hospital emergency department. Patients 12 years of age and
         younger, with second degree or third degree burns greater than 20% body
         surface area, should be transported directly to The Children's Hospital
         emergency department.
      2. Special Considerations. Complications of airway compromise or
         cardiovascular instability, require transport to the nearest appropriate
         emergency department. Burns associated with multi-system trauma should
         be transported according to the State of Colorado Trauma Triage Algorithm
         and RETAC rules.
   B. Trauma
      1. The destination of trauma patients should always be in accordance with the
         Colorado Department of Health approved Rules and Regulations and RETAC
         rules.
   C. Psychiatric patients
      1. Patients placed on a Mental Health Hold (MHH) by the Denver Police
         Department or Mental Health Corporation of Denver shall be transported to
         DHMC.
      2. Patients placed on a MHH by other police departments or other state licensed
         providers shall be taken to the nearest emergency department.
      3. Patients with psychiatric problems not on an MHH shall be taken to the
         closest hospital.
      4. Patients with psychiatric problems who have an acute medical or traumatic
         concern shall be treated according to the appropriate medical or trauma
         protocol.
      5. MHH may be placed by a state-certified EMT-P under the auspices of the
         receiving physician.
   D. Obstetric/Gynecologic
      1. For patients in uncomplicated labor:
         a. Delivery not imminent:
            i.   If the patient has a private obstetrician or gynecologist, then follow the
                 patient's request for destination, when possible.



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          b. If the patient has no private physician, then follow the patient's request for
             destination (if expressed), or transport to the closest hospital.
       2. Imminent delivery
          a. If the patient has a private obstetrician/care giver, then follow the patient's
             request for destination, when appropriate. If the requested facility does
             not meet these time constraints and the patient still requests the facility,
             CONSULT BASE physician.
          b. If the patient has no private physician, then transport to the closest
             appropriate hospital.




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DIVERT POLICY
(modified with permission from document created by Art Kanowitz, Pridemark Paramedic
Services)

   Purpose
   A. To provide a standard approach to ambulance diversion that is practical for field
      use.
   B. To facilitate unobstructed access to hospital emergency departments for
      ambulance patients
   C. To allow for optimal destination policies in keeping with general EMS principles
      and Colorado State Trauma System Rules and Regulations.
   General Principles
   A. EMSystem, an internet-based tracking system, is used to manage diverts in the
      Denver Metro region.
   B. The State Trauma Triage Algorithms should be followed.
   C. The only time an ambulance can be diverted from a hospital is when that hospital
      is posted on EMSystem as being on official divert (RED) status. As of December
      15, 2001, Emergency Department divert is the only category recognized in the
      Denver Metro region.
   D. Overriding factors: the following are appropriate reasons for a paramedic to
      override ED divert and, therefore, deliver a patient to an emergency department
      that is on ED divert:
      1. Cardiopulmonary arrest
      2. Imminent cardiopulmonary arrest
      3. Unmanageable airway emergencies
      4. Unstable “Level I” trauma patients for Level I and Level II trauma centers
   E. Prehospital personnel should honor advisory categories, when possible,
      considering patient’s condition, travel time, and weather. Patients with specific
      problems that fall under an advisory category should be transported to a hospital
      not on that specific advisory when feasible.
   F. There are several categories that are considered advisory (yellow) alert
      categories. These categories are informational only and should alert field
      personnel that a hospital listed as being on an advisory alert may not be able to
      optimally care for a patient that falls under that advisory category.
   G. The following are advisory (yellow) categories:
      1. ICU (Intensive Care Unit)
      2. OB (Obstetrics)
      3. Psych (Psychiatric)
      4. Trauma (Trauma Services)
      5. Operating Room (OR)
   H. Zone saturation is when all hospitals in that zone are on ED Divert.
   I. A Zone Master is a hospital contact that is responsible for determining hospital
      destinations when the zone is saturated.
   J. When an ambulance is transporting a patient that the paramedic feels cannot go
      outside the zone due to patient acuity or other concerns, the paramedic should
      contact the Zone Master and request a destination assignment.
   K. In general, patients contacted within a zone should be transported to an
      appropriate facility within the zone. Patients may be transported out of the




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            primary zone at the paramedic’s discretion, if it is in the patient’s best interest or
            if the transport to an appropriate facility is shorter.
         L. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact
            phone numbers listed in the following table.


ZONE              HOSPITALS                    ZONE MASTER                     ZONE MASTER
                                                                               PHONE NUMBER

Zone 1            North Suburban               St. Anthony’s Central           303-595-6135
                  St. Anthony’s North
NORTH/            St. Anthony’s Central
NORTHWEST         Lutheran


Zone 2            Swedish                      Swedish                         303-788-6911
SOUTH             Porter
                  Littleton
                  Sky Ridge


Zone 3            University                   Aurora AND University*
EAST              Rose                                                         303-695-2946 - Aurora
                  Aurora                       ALTERNATE every
                  Parker                       QUARTER:
                                                                               720-848-5120 -
                                               1st and 3rd quarter –           University
                                               Aurora

                                               2nd and 4th quarter -
                                               University

                                               (*Zonemaster date rollover
                                               occurs at midnight on the
                                               first day of each quarter.)


Zone 4            Denver Health                Denver Health                   303-436-8100
MIDTOWN           St. Joseph/Kaiser
                  Presbyterian-St. Luke’s




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           ATAC ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM

COLORADO STATEWIDE TRAUMA SYSTEM AREA TRAUMA ADVISORY COUNCILS
ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM

The Denver Metro EMS Medical Directors now recommends the use of local RETAC
rules for this protocol.




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 COLORADO STATEWIDE TRAUMA SYSTEM
 PEDIATRIC PREHOSPITAL TRAUMA TRIAGE ALGORITHM
Triage and transport requirements for pediatric (< 12 years old*) trauma patients

The Denver Metro EMS Medical Directors now recommends the use of local RETAC
rules for this protocol.


See also: Boulder Specific Trauma Activation Protocol




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HAZARDOUS MATERIALS (HAZMAT)
   Indications
   A. Responding to reported and/or known hazardous materials incident
   B. Vapor clouds, fire, smoke, leaking substances, frost lines on cylinders, sick
      personnel, dead or distressed animals and noxious odors are present on or near
      scene.
   Precautions
   A. Senses are one of the best ways to detect chemicals, particularly the sense of
      smell. If you smell something you are too close.
   B. A safe approach to the scene is the first element of any EMS response. Unless
      you arrive safely at the site, you will not be able to perform your duties.
   C. Observe the site from a distance using binoculars, if possible, before you get too
      close. Look for danger signs such as vapor clouds, fire and smoke, placards,
      shape of vehicle or container, leaking substances, frost lines on cylinders, injured
      personnel, and dead or distressed animals. These are key clues to warn you not
      to get too close. Remember that you want to be part of the solution, not part of
      the problem.
   D. If the fire department is already on the scene, report in to the incident
      commander. If you are first on the scene and a hazardous material is
      suspected, request a hazardous materials team response. Keep yourself and
      your unit at a safe distance. This usually requires your unit to leave the scene,
      leaving patients and bystanders in a hazardous situation. Your safety comes
      first. Seek a location uphill and upwind from the incident.
   E. EMS personnel should not be participating in patient decontamination unless
      trained and equipped to do so in a safe manner.
   Procedure
   A. Your safety is the highest priority. EMS operations should be established in the
      cold zone. You should report to the incident commander.
   B. Position your vehicle to make a hasty retreat. This may require you to leave the
      scene to seek safety.
   C. The hazardous materials team should perform the initial assessment, treatment,
      and decontamination. Decontaminated patients should then be brought to the
      EMS unit.
   D. Once the situation has been assessed, notify the receiving hospital of the
      following information:
      1. Location of the incident
      2. Name of chemicals/products involved
      3. Number of injured and contaminated
      4. Extent of the injuries/contamination
      5. Extent that the patients will be decontaminated in the field
      6. Your estimated time of arrival
      7. Other pertinent information that is available
   E. Patient treatment is usually based on signs and symptoms. Specific patient
      treatment should be based on information obtained from BASE CONTACT.




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HELICOPTER TRANSPORT

   A. Air transport is a useful adjunct to the EMS System. The risks and benefits of the
      helicopter transport should be carefully weighed, especially when flying into a
      less than optimal landing zone. Benefits of helicopter transport should be
      considered when:
      1. Rapid transport is desired. An obvious beneficiary of air transport is the rural
          trauma victim requiring rapid transport to the trauma center.
      2. Multiple victims require multiple unit response/transport.
      3. Extrication is complicated by difficult access requiring prolonged scene time.
      4. Advanced life support is not available by ground within a reasonable time
          period.
   B. In order to effect the most expedient use of ground and air ambulance resources,
      the following guidelines should be considered:
      1. The helicopter should be placed on standby when responding to a scene
          which may include any of the elements listed in section A.
      2. The helicopter should be dispatched when it is the most appropriate means of
          transport.
      3. In order to save time, the helicopter should be contacted through your own
          dispatched.
      4. Please note that an accurate ETA will not be available until the helicopter is
          actually airborne. Consider alternative flight services or ground transport if the
          helicopter is not immediately available.
      5. Generally speaking, the helicopter will stand-down only when so requested
          by the agency initiating the original response. Do not forget to stand down or
          cancel the helicopter if it is not required.
      6. Public safety officers should be informed of the impending arrival of the
          helicopter.
      7. Patient care in the field is a team response. State statutes dictate that
          ultimate responsibility rests with highest trained medical person on the scene.
          In this regard, the flight nurse assumes responsibility only for the patients
          turned over to him/her by the attending EMS personnel, unless the flight
          nurse is the first EMS person on the scene.




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INFECTIOUS and COMMUNICABLE DISEASES

   A. Field personnel occasionally come into contact with infectious and communicable
      diseases. It is important that a protocol is followed so that the appropriate
      persons are notified. Not all diseases require immediate treatment; however,
      early awareness will assist those involved to take any necessary precautions and
      actions.
   B. Contamination by infectious and communicable diseases may be minor or
      serious. Field personnel should take precautions to avoid unnecessary exposure.
      When dealing with a suspected contagious patient, attempt to avoid direct
      contact with the patient's blood, sputum, emesis, urine, feces, or respiratory and
      lesion secretions. The provider should wear disposable latex or vinyl gloves and
      any other appropriate BSI. Routine practice of good hand washing and
      equipment cleaning may help decrease the incidence of contamination.
   C. The following guidelines have been provided for reference. Follow your
      individual agency infectious and communicable disease exposure policy and
      procedure.
      1. All healthcare personnel should always practice good hygiene before, during
          and after delivering patient care. Each patient contact should be considered
          to be a potential source of infection.
      2. Persons with significant exposure must report the incident to the designated
          Infection Control Officer of his/her agency. All personnel should be advised to
          consult with their private physician as well.
      3. Agency policy, developed in conjunction with the Physician Advisor, will
          dictate procedure with regard to screening, follow-up testing, prophylaxis
          and/or treatment.
      4. Exposed prehospital care personnel may be counseled and treated according
          to established guidelines.
      5. Refer to the following website resource for information on diseases, means
          and methods of exposure, exposure risks, and recommended precautions,
          actions, and treatment: www.cdc.gov




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INTERHOSPITAL TRANSFER

   A. Interhospital patient transfers are commonly initiated when definitive diagnostic
      or therapeutic needs of a patient are beyond the capacity of transferring hospital.
      In these cases the patient may be unstable, and medical treatment must be
      continued and possibly even initiated en route. Likewise, patients being
      transferred for diagnostic or therapeutic purposes may be stable but on
      continuous pharmacological or ventilatory therapy. It is imperative that such
      therapies be continued or interruptions in care planned to minimize risk to the
      patient. These guidelines encourage orderly transfer of patients with appropriate
      continuity of care.
   B. All patients should be stabilized, if possible, before transfer.
   C. Attending EMT or paramedic should receive a summary of the patient’s
      condition, current treatment, possible complications and other pertinent medical
      information.
   D. Treatment orders should be given to the attending EMT or paramedic. These
      orders should be either in writing or by direct verbal order from the doctor who is
      initiating the transfer.
   E. Any unstable or potentially unstable patients must have at least one IV in place.
      Orders for IV fluid and rate should be provided.
   F. Transfer papers (summary, lab work, x-rays, etc.) should be given to the
      attending EMT or paramedic, rather than the family or friends.
   G. The attending EMT or paramedic should confirm that the receiving hospital and
      physician have been notified prior to initiation of transfer.
   H. The personnel used to transfer a patient should be appropriate to the treatment
      needed or anticipated during transfer. EMT-Bs who are not IV approved should
      not attend patients who have or may require IV therapy. Paramedics should be
      utilized if any advanced resuscitation or treatment is anticipated. In specialized
      fields not ordinarily handled by paramedics (i.e. high risk obstetrics, high risk
      newborns) an appropriately trained person should accompany the patient.
   I. The equipment used to transfer a patient should be appropriate to the treatment
      being provided. Example: IV medications being delivered by an IV pump should
      be either maintained on an IV pump during the transfer, discontinued, or the IV
      tubing be appropriate to the manual control. In order to maintain these standards,
      it may be appropriate for the receiving hospital to send an ambulance with more
      specifically trained personnel to transfer the patient. This is particularly true in the
      case of newborns, but has also been shown to be effective in the treatment of
      other critically ill or injured patients




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MENTAL HEALTH HOLDS (MHH)
   Indications
   A. Any person who appears to be:
      1. mentally ill and
      2. an imminent danger to others or to him/herself or
      3. gravely disabled
   Procedure
   A.   Restrain if necessary.
   B.   Call receiving facility for the physician to place MHH.
   C.   Transport to Emergency Department.
   D.   Provide appropriate documentation of events so 72-hour MHH can be filled out
        by the physician at the receiving facility.
   General Principles
   A. The paramedic may initiate an MHH only with the permission and online contact
      with the receiving physician.
   B. The law allows only physicians, trained nurses, and peace officers to place MHH.
   C. Paramedics may act as the field representative of the physician when the above
      protocol is followed.




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NON-TRANSPORT OF PATIENTS
   General Principles
   A. A patient who has decision-making capacity may refuse treatment, examination
      or transport.
   B. A person has decision-making capacity sufficient to refuse treatment/transport if
      he/she:
      1. Understands the nature of the illness/injury or risk of injury/illness; and
      2. Understands the possible consequences of refusing treatment/refusing
           transport; and
      3. Given the risks and options, the patient voluntarily refuses
           treatment/transport.
   C. The prehospital provider is responsible for deciding if the patient's refusal is
      informed and voluntary. The prehospital provider should consider the nature of
      the incident, potential mechanism, obvious actions of the patient, as well as the
      verbal statements of the patient. The prehospital provider is responsible for a
      reasonable assessment of the patient to determine if there is an injury/illness or
      reason for transport or treatment. Only then is a patient's refusal an informed
      refusal. Do not attempt to diagnose, do assess carefully.
   D. Remember: it is your assessment and advice to the patient, and proper
      documentation of it, that are most important in the non-transport.
   Procedure for Non-Transports (See Non-Transport/Refusal of Care Algorithm
   following)
   A. If the patient is 18 years of age or older, has no demonstrable illness or injury,
      has no mechanism of injury, demonstrates competency (as defined in the
      “Consent” portion of this section), and did not initiate the call for help, then base
      contact is not required.
   B. For the patient who has only an isolated soft tissue injury and has decision-
      making capacity, treatment and transport should be offered. If the patient
      refuses, then warn the patient of the risks of non-transport and delay in
      treatment. Agency policy determines base contact requirement.
   C. Patients with medical conditions/injuries that may recur or deteriorate, or may
      render the patient unable to seek medical care, should be carefully evaluated
      and warned to not delay in obtaining medical treatment. High-risk areas in EMS
      are head injury, chest pain, abdominal pain, "flu" like symptoms, alcohol-related
      illnesses, or injuries.
   D. For the patient refusing transport/treatment:
      1. Assess patient to the extent possible. Look for objective causes of
           injuries/illnesses that may impair decision-making. Evaluate
           mechanism/history, scene and potential for unseen injuries/illnesses. Do not
           diagnose.
      2. Inform patient of findings, possible injuries or illnesses that warrant treatment
           and transport, and of the risks of non-transport, delaying treatment, and non-
           physician examination.
      3. If the patient still refuses treatment/transport, then determine the patient's
           ability to understand the immediate medical situation and need for treatment.
           Questions asked might include:
           a. Why don't you want to go to the hospital?
           b. What other means of transport do you have?


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             c. What will you do if you get sick again?
             d. What are the risks I just explained to you about delaying treatment?
   E.   If the patient still refuses transport, CONTACT BASE.
   F.   The base physician may:
        1. Agree or determine that the patient's decision-making capacity is impaired
             and instruct transport of the patient.
             a. The patient may be transported under the basis of a medical emergency
                 (i.e., patient is incapacitated and unable to consent.)
             b. The patient may be transported under the basis of a mental health
                 emergency. Police should be requested to place the patient under a
                 Mental Health Hold. Appropriate paperwork, such as the Mental Health
                 Hold, must accompany the patient.
        2. Agree or determine that the patient has decision-making capacity, in which
             case:
             a. The patient may refuse treatment and transport but must be advised of
                 the risks of non-transport (informed refusal).
             b. The prehospital provider must warn the patient that non-transport is
                 against medical advice (AMA).
             c. The patient should be urged to seek medical attention and transport.
   G.   For the patient who refuses treatment and transport (against medical advice),
        providing the patient with clear instructions and warnings is imperative. Use of an
        Information Sheet is recommended.
   H.   Minors: CONTACT BASE any time a minor under the age of 18 is not left in the
        custody of the parents.
   I.   The following must be documented for every patient examined, offered and
        refused treatment/transport (in addition to EMS Division guidelines):
        1. All assessment findings
        2. Description of mechanism or scene factors (damage, environment, etc.)
        3. Description of mental status and decision-making capacity
        4. Vital signs, unless the patient refused
        5. Patient's response to warning about risks of non-transport/non-treatment
        6. Base physician's advice
        7. Patient's condition at termination of patient contact, such as “ambulatory”,
             “with family”
   J.   The "AMA" (refusal) patient should be provided with an Information Sheet.
        Obtaining a patient's signature on a run report or release form is encouraged
        because signing may be evidence of the patient's decisional capacity and
        physical stability. However, do not have a patient sign a release or waiver that
        you do not understand, and do not expect that a signature relieves you of
        responsibility for a reasonable assessment or treatment of the patient.
   K.   The role of base contact is to assist in determining or verifying the patient's ability
        or inability to make medical treatment decisions and assist when transport should
        be done. It is imperative that an accurate, concise report be given for the
        physician to give good advice.
   L.   Have all AMA forms co-signed by a witness. The witness should not be an
        employee of the responding agency.




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                    NON-TRANSPORT/REFUSAL OF CARE ALGORITHM
                         (See Non-Transport of Patients protocol)

                        Determine mental status and extent and history of
                                  injury, mechanism or illness




    Pt is alert, oriented and has decision-          Injury or illness or has impaired decision-
                 making capacity                                    making capacity




 • No apparent                Limited injury          Pt refuses consent or offer of treatment
   injury/illness            consistent with                       and transport
 • No complaints               mechanism
 • No significant
   history                                                         Contact Base
 • No MOI
                          Offer treatment and
                               transport
                                                     Base physician            Base physician
                                                   determines pt does        determines pt does
                                                     have decision-           not have decision
                                                    making capacity           making capacity.
                             Pt still refuses                                (Treatment/transpo
  18 years or older                                                               rt may be
 and did not call for                                                         authorized under
                                                    Warn pt of risks of
        help                                                                    MHH, ATH or
                                                          non-
                                                   treatment/transport       implied consent if a
                                                     against medical               medical
                                                         advice               emergency exists
  Pt does not want          Refer to agency
        help                    policy
                                                       Document              Transport: request
                                                      appropriately           MHH or police if
                                                                               necessary for
                                                                                assistance
   Advise pt and              Base contact
    document                                                                     Document
   appropriately                                                                appropriately




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TRIAGE: MULTIPLE PATIENT ASSESSMENT
REFER TO: THE COLORADO STATE UNIFIED DISASTER TAG AND TRIAGE
SYSTEM - A GUIDE TO MCI (multiple/mass causality incident)
   Definition
   A. MCI: The combination of numbers and types of injuries that goes beyond the
      capability of an entity's normal response.
   B. Triage: From French - means to sort, sift, or pick out; specifically, the sorting of
      and allocation of treatment to patients.
   Indications
   A. Medical emergency involving more than one patient, interaction between different
      agencies, and the need to make choices regarding treatment.
   Procedure
   A. Park vehicle in safe location.
   B. Contact appropriate command personnel and follow instructions.
   C. If assigned to triage, do initial assessment of scene; proceed only when safe to
      rescuer.
   D. Rapidly estimate number of victims and severity of injuries. Do not provide
      extensive treatment.
   E. Establish communications and request necessary assistance as per department
      or agency procedure; this may include contacting the appropriate hospital and
      providing initial estimate of number and types of injuries.
   F. Designate or ensure designation of:
      1. The Incident Command System (ICS) depending on the size of the event and
          the number of agencies involved (see Diagram A - Incident Command
          System)
      2. Medical command: follow departmental and jurisdictional procedures.
      3. Medical Triage Team:
          a. Categorize patients after brief assessment using the Simple Triage and
              Rapid Treatment START) system (see Diagram B - START Algorithm).
          b. Update categorizations and provide transport to stabilization area as able.
          c. Initiate medical stabilization to patients awaiting transport after triage
              duties completed.
      4. Transport Team (if necessary):
          a. Transport patients in order of priority from field to stabilization area.
          b. Establish venous access or perform other stabilization procedures as
              needed in support of triage team.
          c. If ongoing assessment, categorization, and transport are to be required,
              organize the area into an appropriate Triage/MCI format (see Appendix
              Section F, Triage/MCI Templates; diagrams C-1, C-2, and C-3)
   Precautions
   A. Identification of medical charge personnel is extremely important and often
      overlooked. Use vests, hats, or other labeled equipment consistent with
      departmental or agency procedures.
   B. Location of stabilization area is very important. It should fulfill the following
      criteria as much as possible:


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       1.   Away from objective dangers of scene
       2.   Close enough for access from scene for stretchers
       3.   Accessible by multiple rescue vehicles, both in and out
       4.   Near communications and other command personnel for coordination of
            evacuation
   C. If triage tags are part of departmental or agency procedures, attach triage tags to
      patient, not clothing.
   D. Triage assessment and management differs from single patient assessment.
      Certain problems recur in major disasters, and should be avoided:
      1. Do not use up ambulance space initially transporting class III (green) patients
            before more serious injuries have been transported (red and yellow).
      2. Do not delay transport to treat patients at the scene.
      3. Reassess patients when able and communicate any changes to the medical
            command and transport officers.
      4. Disaster scenes require discipline within the team. Be sure that the
            leadership and individual roles are well identified. It is important that
            individuals fulfill their roles as members of the team and in turn give up those
            roles appropriately as personnel and officers arrive to the MCI scene.
   Special notes
   A. The Incident Command Structure developed and disseminated by the National
      Interagency Incident Management System (NIIMS) and Federal Emergency
      Management Agency (FEMA) provides an excellent overall approach to disaster
      management. The structure is designed to allow flexibility and local differences,
      as well as incorporation of different training levels (physician, nurse, paramedic,
      EMT-B) within Medical Control at the scene. It is important that individuals are
      aware of the command structure and follow instructions. (see ICS Flow chart
      below).
   B. Multiple trauma patients with no vital signs upon arrival of rescue personnel have
      a very poor chance of survival even if they are the only victim. If there are
      additional victims with any signs of life, attention will be better spent with the
      living.




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 INCIDENT COMMAND SYSTEM
* Command system with group and branch divisions based on functions

                                       Incident Commander




                                             Operations




          Branch                              Medical                          Branch
         (i.e. fire)                          Branch                  (i.e. law enforcement)




   Triage Officer                Treatment                      Transport                Logistics
                                   Officer                       Officer                  Officer

                                                                 Deputy
                                                                Transport
   Triage Group                Area Leaders
                                                                 Officer

                                                                  Clerk




     Leader                 Leader                 Leader                    Leader
     Group 0               Group I                Group II                  Group III
   (Black tags)           (Red tags)            (Yellow tags)             (Green Tags)




    Area Staff            Area Staff             Area Staff                 Area Staff




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START TRIAGE FLOWCHART

                                Respirations



                No                                             Yes



            Reposition                          >30 / minute         <30 / minute
             Airway



       No                 Yes                    Immediate            Assess
                                                  Red Tag            Perfusion


     Non-            Immediate
  Salvageable         Red Tag
   Black Tag


                                        Capillary refill >2             Capillary refill <2
                                          seconds OR                      seconds OR
                                        No palpable radial            palpable radial pulse
                                              pulse


                                               Immediate                Assess Mental
                                                Red Tag                    Status




                                       Fails to follow simple           Able to follow simple
                                            commands                        commands




                                               Immediate                      Delayed
                                                Red Tag                      Yellow Tag

Remember – Patients that can initially ambulate with or without assistance are GREEN
tags. Constant reassessment is necessary and there should be no hesitation in up-
triaging when necessary.




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CRITICAL CARE TRANSPORT UTILIZATION GUIDELINES
Revised: January 22, 2008


   Purpose
   A. To effectively triage and process any request for service in which Critical Care
      Transport (CCT) may be utilized.
   Policy
   A. The Communications Center employees will utilize the standard operating
      procedures to process CCT requests and appropriate utilization of CCTs and
      ALS resources to manage acute patients. A request of services within the scope
      of an Advanced Life Support paramedic-staffed ambulance will be scheduled as
      a non-CCT transport unless specifically requested by the transferring physician.
      This policy is included as a reference for clarity and support in decision making
      for Denver Metro paramedics and other non-CCT staff.
   Definition
   A. CCT: Transport of a patient whose clinical needs in transport exceed those
      procedures and medications included in the acts allowed for paramedics, and for
      whom additional care providers are required (RN, RT, etc.).
   Procedure
       Mandatory Critical Care Utilization
       The following situations will result in utilization of a Critical Care Transport:
   Patient Origin/Destination
   A. Intensive care unit (ICU) to ICU or Cardiac Care unit (CCU) unless the following
      criteria are met:
      1. Patient on a psychiatric hold in an ICU, with medical clearance completed
           (versus mental health clearance)
      2. Patients in ICU because of non-ICU overflow or telemetry bed overflow status
           at the referring or receiving facility
   B. CCU or ICU to Cardiac Cath Lab unless the following criteria are met:
      1. Patients with acute myocardial infarctions 36 hours out or greater from
           admission who have no ongoing chest pain, malignant arrhythmias, or
           cardiovascular instability (non-emergent cath only).
      2. Patients with Acute Coronary Syndrome who have been ruled out for
           myocardial infarction after 12 hours or more. They should have no ongoing
           chest pain, malignant arrhythmias, or cardiovascular instability (non-emergent
           cath only).
   Monitoring/Equipment/Medication Needs
   A. Transports requiring intra-aortic balloon pump
   B. Transports requiring invasive treatment modalities including:
      1. Non-standard airway management, requiring conscious sedation and/or
         anesthetic agents




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      2. Intensive care monitoring (condition in which clinical presentation in or is at
          risk of being unstable, including: intracranial monitoring devices, arterial lines,
          Swan-Ganz catheters, etc).
   C. Patients requiring medications and infusions not approved by the Denver Metro
      Protocols.
   D. Patients on vasoactive infusions initiated or adjusted within two hours of
      transport. (“2-hour rule”)
   E. Patients requiring fetal monitoring/high risk OB patients
   Instability
   A. Multi-Systems trauma patient < 24 hours post-injury with a potential for
      hemodynamic instability as determined by the transferring physician
   B. Patients with known cardio-thoracic compromise (e.g., AAA, dissecting
      aneurysms)
   C. Hemodynamically unstable patient.
   D. Any other patient whom the sending facility indicates is clinically unstable (a
      physician or registered nurse must authorize the use of the CCT)
   Exceptions
   A. Patients may be sent by paramedic ambulance if, in the opinion of the
      transferring physician, time consideration outweighs the need for RN presence if
      the following criteria are met:
      1. Critical Care Transport Services are not available in a reasonable response
          time.
      2. There is no nurse available from the sending facility to accompany the
          transport.
      3. The transport requirements are not outside of the acts allowed for
          paramedics, or the medications specified by the Denver Metro Protocols.
      4. The sending facility will provide additional resources when possible including
          other staff, IV pumps, etc.
   Medications
   A. The following is a complete list of medications that the Pridemark Protocols
      authorize Colorado State Paramedics to administer and maintain pursuant to the
      scope of practice under Rule 500 Acts Allowed for the State of Colorado.
   B. Denver Metro Protocol Pharmacy List:
      1. Adenosine (Adenocard)
      2. Albuterol Sulfate
      3. Antibiotics
      4. Amiodarone
      5. Aspirin (ASA)
      6. Atropine
      7. Dextrose 50%
      8. Diazepam (Valium)
      9. Diphenhydramine (Benadryl)
      10. Dopamine (Intropin)
      11. Epinephrine
      12. Fentanyl
      13. Furosemide (Lasix)



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       14. Glucagon
       15. Haloperidol (Haldol)
       16. Heparin
       17. Ipratropium Bromide (Atrovent)
       18. IV Solutions
       19. Magnesium Sulfate
       20. Methylprednisolone (Solu-Medrol)
       21. Metoclopramide (Reglan)
       22. Midazolam (Versed)
       23. Morphine Sulfate
       24. Naloxone (Narcan)
       25. Nitroglycerin
       26. Ondansetron (Zofran)
       27. Oral Glucose (Glutose, Insta-Glucose)
       28. Oxygen
       29. Phenylephrine (Intranasal)
       30. Promethazine (Phenergan)
       31. Racemic Epinephrine (Vaponephrine)
       32. Sodium Bicarbonate
       33. Topical Ophthalmic Anesthetics

   C. Maintenance IV Infusions
   D. IV Solutions
      1. 0.9% Normal Saline
      2. Lactated Ringers
      3. D5W
      4. Any combination of the above solutions
   E. Vasoactive Drips
      1. Dopamine (2-hour rule)
      2. Epinephrine (2-hour rule)
      Medications or infusions not included in this section will most likely require CCT
      transfer or, at a minimum, an EMS physician consult and approval.


The Communications Specialist should use the CCT vs ALS Transport Algorithm to assist in the
determination of the Level of Care:




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                                                              CCT vs ALS Transport Algorithm


     Has the PHYSCIAN REQUESTED that the patient                yes [ ]
                                                                            CCT
                be transported by CCT.
                           No [ ]
     Intensive Care Setting to antoher Intensive Setting        yes [ ]
                                                                            CCT
       ICU to ICU, PICU to NICU, SICU to CICU, etc.
                           No [ ]
  Is the patient being transport from an ICU to a procedure     yes [ ]
                                                                            CCT
                and then returning to the ICU?
                           No [ ]
     Will the patient have any medication drips running         yes [ ]   List Medications: __________________________________________
                       during transport?                                  _________________________________________________________
                                                                          _________________________________________________________
                                                                          _________________________________________________________
                           No [ ]
                                                                          _________________________________________________________


Will the patient have any special equipment needs?
   ___ Intra-aortic balloon pump
   ___ Chest tube to drainage                                   yes [ ]                yes [ ]        Are any of these medications outside
                                                                            CCT
   ___ Arterial Line                                                                                 of the (BME / Metro Protocols defined)
   ___ Invasive Pressure Monitoring (Arterial, ICP, CVP)                                            paramedic scope of practice? (See Back)




                           No [ ]

           If any question whether CCT Vs ALS                                      Date:                      Time:
      Call Director of Clinical Medicien 720-641-4093
                                                                                   Patient Name:
                           No [ ]
                                                                                   Run Number:              Ordering MD:
                      ALS Ambulance
                                                                                   Assigned Unit:           Receiving MD:



 All patients requiring CCT transport should be referred to Flight for Life of Colorado unless
 another service is specifically requested by the caller.




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Appendix F TRIAGE/MCI TEMPLATES

Simple Triage Template




                                        OMCI




                                     Triage Area


         Green                                                  Black



                          Yellow                      Red




                                                            Landing
                                                             Zone



                                   Ingress / Egress




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Moderate Triage Template



                             OMCI




         Green                                 Black




                           Triage Area




                 Yellow                  Red


                             Supply


                                             Landing
                                              Zone
                            Ingress /
                             Egress



                                         Staging




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Complex Triage Template




                              OMCI
    Bus                                             Coroner


          Green                                 Black




                            Triage Area




                   Yellow                 Red


                              Supply
                                              Landing Zone



                  Egress      Ingress     Egress




                  Staging                 Staging




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PEDIATRIC PATIENT ASSESSMENT

Children can be examined easily from head to toe, but lack of understanding by the
patient, poor cooperation, and fright often limit the ability to assess completely in the
field. Children often cannot verbalize what is bothering them, so it is important to do a
systematic survey which covers areas that the patient may not be able to tell you about.
Any observations about spontaneous movements of the patient and areas that the child
protects are very important. In the patient with a medical problem, the more limited set of
observations listed below should pick up potentially serious problems.

   A. General:
      1. Level of alertness, eye contact, attention to surroundings
      2. Muscle tone: normal, increased, or weak and flaccid
      3. Responsiveness to parents, caregivers; is the patient playful or irritable?
   B. Head:
      1. Signs of trauma
      2. Fontanelle, if open: abnormal depression or bulging
   C. Face:
      1. Pupils: size, symmetry, reaction to light
      2. Hydration: brightness of eyes; is child making tears? Is the mouth moist?
   D. Neck: note stiffness.
   E. Chest:
      1. Note presence of stridor, retractions (depressions between ribs on
          inspiration) or increased respiratory effort.
      2. Auscultate the chest:
      3. Breath sounds: symmetrical, rales, wheezing?
      4. Heart: rate, rhythm
   F. Abdomen: distention, rigidity, bruising, tenderness
   G. Extremities:
      1. Brachial pulse
      2. Signs of trauma
      3. Muscle tone, symmetry of movement
      4. Skin temperature and color, capillary refill
      5. Areas of tenderness, guarding or limited movement
   H. Neurologic exam

      NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP
      AGE         PULSE       RESPIRATIONS    BLOOD PRESSURE
                  avg./min.   breaths/min.
      Premature   140         40-60           40-60
      Newborn     150         40-60           60-80
      6 mo        140         25-40           65-105
      1 yr        135         20-30           70-110
      3 yr        110         20-30           80-110
      5 yr        100         20-30           80-110
      8 yr         90         12-25           90-115




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                                LAB VALUES

HEMATOLOGY - Red Blood Cells
RBC (Male)                   4.2 - 5.6 M/µL
RBC (Female)                 3.8 - 5.1 M/µL
RBC (Child)                  3.5 - 5.0 M/µL

HEMATOLOGY - White Blood Cells
WBC (Male)                    3.8 - 11.0 K / mm3
WBC (Female)                  3.8 - 11.0 K / mm3
WBC (Child)                   5.0 - 10.0 K / mm3

HEMOGLOBIN
Hgb (Male)                      14 - 18 g/dL
Hgb (Female)                    11 - 16 g/dL
Hgb (Child)                     10 - 14 g/dL
Hgb (Newborn)                   15 - 25 g/dL

HEMATOCRIT
Hct (Male)                      39 - 54%
Hct (Female)                    34 - 47%
Hct (Child)                     30 - 42%
MCV                             78 - 98 fL
MCH                             27 - 35 pg
MCHC                            31 - 37%
neutrophils                     50 - 81%
bands                           1 - 5%
lymphocytes                     14 - 44%
monocytes                       2 - 6%
eosinophils                     1 - 5%
basophils                       0 - 1%

CARDIAC MARKERS
troponin I                      0 - 0.1 ng/ml (onset: 4-6 hrs, peak:
                                12-24 hrs, return to normal: 4-7 days)
troponin T                      0 - 0.2 ng/ml (onset: 3-4 hrs, peak:
                                10-24 hrs, return to normal: 10-14 days)
myoglobin (Male)                10 - 95 ng/ml (onset: 1-3 hrs, peak:
                                6-10 hrs, return to normal: 12-24 hrs)
myoglobin (Female)              10 - 65 ng/ml (onset: 1-3 hrs, peak:
                                6-10 hrs, return to normal: 12-24 hrs)

GENERAL CHEMISTRY
acetone                         0.3 - 2.0 mg%
albumin                         3.5 - 5.0 gm/dL
alkaline phosphatase            32 - 110 U/L
anion gap                       5 - 16 mEq/L
ammonia                         11 - 35 µmol/L
amylase                         50 - 150 U/dL
AST,SGOT (Male)                 7 - 21 U/L
AST,SGOT (Female)               6 - 18 U/L


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bilirubin, direct             0.0 - 0.4 mg/dL
bilirubin, indirect           total minus direct
bilirubin, total              0.2 - 1.4 mg/dL
BUN                           6 - 23 mg/dL
calcium (total)               8 - 11 mg/dL
carbon dioxide                21 - 34 mEq/L
carbon monoxide               symptoms at greater than or equal to 10%
                              saturation
chloride                      96 - 112 mEq/L
creatine (Male)               0.2 - 0.6 mg/dL
creatine (Female)             0.6 - 1.0 mg/dL
creatinine                    0.6 - 1.5 mg/dL
ethanol                       0 mg%; Coma:
                              greater than or equal to 400 - 500 mg%
folic acid                    2.0 - 21 ng/mL
glucose                       65 - 99 mg/dL
                              (diuresis greater than or equal to 180 mg/dL)
HDL (Male)                    25 - 65 mg/dL
HDL (Female)                  38 - 94 mg/dL
iron                          52 - 169 µg/dL
iron binding capacity         246 - 455 µg/dL
lactic acid                   0.4 - 2.3 mEq/L
lactate                       0.3 - 2.3 mEq/L
lipase                        10 - 140 U/L
magnesium                     1.5 - 2.5 mg/dL
osmolarity                    276 - 295 mOsm/kg
parathyroid hormone           12 - 68 pg/mL
phosphorus                    2.2 - 4.8 mg/dL
potassium                     3.5 - 5.5 mEq/L
SGPT                          8 - 32 U/L
sodium                        135 - 148 mEq/L
T3                            0.8 - 1.1 µg/dL
thyroglobulin                 less than 55 ng/mL
thyroxine (T4) (total)        5 - 13 µg/dL
total protein                 5 - 9 gm/dL
TSH                           Less than 9 µU/mL
urea nitrogen                 8 - 25 mg/dL
uric acid (Male)              3.5 - 7.7 mg/dL
uric acid (Female)            2.5 - 6.6 mg/dL

LIPID PANEL (Adult)
cholesterol (total)           Less than 200 mg/dL desirable
cholesterol (HDL)             30 - 75 mg/dL
cholesterol (LDL)             Less than 130 mg/dL desirable
triglycerides (Male)          Greater than 40 - 170 mg/dL
triglycerides (Female)        Greater than 35 - 135 mg/dL

URINE
color                         Straw
specific gravity              1.003 - 1.040
pH                            4.6 - 8.0


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Na                                    10 - 40 mEq/L
K                                     Less than 8 mEq/L
C1                                    Less than 8 mEq/L
protein                               1 - 15 mg/dL
osmolality                            80 - 1300 mOsm/L

24 HOUR URINE
amylase                               250 - 1100 IU / 24 hr
calcium                               100 - 250 mg / 24 hr
chloride                              110 - 250 mEq / 24 hr
creatinine                            1 - 2 g / 24 hr
creatine clearance (Male)             100 - 140 mL / min
creatine clearance (Male)             16 - 26 mg / kg / 24 hr
creatine clearance (Female)           80 - 130 mL / min
creatine clearance (Female)           10 - 20 mg / kg / 24 hr
magnesium                             6 - 9 mEq / 24 hr
osmolality                            450 - 900 mOsm / kg
phosphorus                            0.9 - 1.3 g / 24 hr
potassium                             35 - 85 mEq / 24 hr
protein                               0 - 150 mg / 24 hr
sodium                                30 - 280 mEq / 24 hr
urea nitrogen                         10 - 22 gm / 24 hr
uric acid                             240 - 755 mg / 24 hr

COAGULATION
ACT                                   90 - 130 seconds
APTT                                  21 - 35 seconds
platelets                             140,000 - 450,000 /ml
plasminogen                           62 - 130%
PT                                    10 - 14 seconds
PTT                                   32 - 45 seconds
FSP                                   Less than 10 µg/dL
fibrinogen                            160 - 450 mg/dL
bleeding time                         3 - 7 minutes
thrombin time                         11 - 15 seconds

CEREBRAL SPINAL FLUID
appearance                            clear
glucose                               40 - 85 mg/dL
osmolality                            290 - 298 mOsm/L
pressure                              70 - 180 mm/H2O
protein                               15 - 45 mg/dL
total cell count                      0 - 5 cells
WBCs                                  0 - 6 / µL

HEMODYNAMIC PARAMETERS
cardiac index                         2.5 - 4.2 L / min / m2
cardiac output                        4 - 8 LPM
left ventricular stroke work index    40 - 70 g / m2 / beat
right ventricular stroke work index   7 - 12 g / m2 / beat
mean arterial pressure                70 - 105 mm Hg


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pulmonary vascular resistance          155 - 255 dynes / sec / cm to the negative 5
pulmonary vascular resistance index 255 - 285 dynes / sec / cm to the negative 5
stroke volume                          60 - 100 mL / beat
stroke volume index                    40 - 85 mL / m2 / beat
systemic vascular resistance           900 - 1600 dynes / sec / cm to the negative 5
systemic vascular resistance index 1970 - 2390 dynes / sec / cm to the negative 5
systolic arterial pressure             90 - 140 mm Hg
diastolic arterial pressure            60 - 90 mm Hg
central venous pressure                2 - 6 mm Hg; 2.5 - 12 cm H2O
ejection fraction                      60 - 75%
left arterial pressure                 4 - 12 mm Hg
right atrial pressure                  4 - 6 mm Hg
pulmonary artery systolic              15 - 30 mm Hg
pulmonary artery diastolic             5 - 15 mm Hg
pulmonary artery pressure              10 - 20 mm Hg
pulmonary artery wedge pressure 4 - 12 mm Hg
pulmonary artery end diastolic pressure        8 - 10 mm Hg
right ventricular end diastolic pressure       0 - 8 mm Hg

NEUROLOGICAL VALUES
cerebral perfusion pressure          70 - 90 mm Hg
intracranial pressure                5 - 15 mm Hg or 5 - 10 cm H2O

ARTERIAL VALUES
pH                                   7.35 - 7.45
PaCO2                                35 - 45 mm Hg
HCO3                                 22 - 26 mEq/L
O2 saturation                        96 - 100%
PaO2                                 85 - 100 mm Hg
BE                                   -2 to +2 mmol/L

VENOUS VALUES
pH                                   7.31 - 7.41
PaCO2                                41 - 51 mm Hg
HCO3                                 22 - 29 mEq/L
O2 saturation                        60 - 85%
PaO2                                 30 - 40 mm Hg
BE                                   0 to +4 mmol/L




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12 LEAD EKG LANDMARKS & INFARCT PATTERNS




RA = Right Arm                                         V1 - 4th ICS, R sternal border
LA = Left Arm                                          V2 - 4th ICS, L sternal border
RL = Right Leg                                         V3 - Midway between V2 and V4
LL = Left Leg                                          V4 - 5th ICS, Left MCL
                                                       V5 - Follow V4 in a straight line to
                                                       the anterior axillary line.
                                                       V6 - Follow V4 and V5 to mid- axillary
                                                       line.

Locations of Infarcts

Inferior wall                 II, III, aVF
Anterior wall                 V1, V2, V3, V4, V5, V6
    Anteroseptal              V1, V2, V3, V4
    Anterolateral             V3, V4, V5, V6
Lateral wall                  I, aVL, V5, V6




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                         Clinical Division
                   Standard Operating Procedure
Effective Date: February 01, 2008                 Approval:
DOCM_______HR_______

Policy: BLS Transport Utilization
Objective: To provide clear standards for the proper utilization of BLS
ambulances to transport patients in the 911 system.

Scope: Clinical Director, Clinical Manager, Team Leaders, Field
Instructors, Paramedics, EMT-Basics
 
Procedure: 
 
    1. A Pridemark paramedic will respond to all 911 calls as the primary responder
       and perform a full ALS examination to determine the type of care that is
       required. Certain vital signs will be disqualifiers for BLS transport.
           a. Blood Pressure below 100 systolic
           b. A heart rate in excess of 108/min.
           c. A respiratory rate in excess of 30
           d. Altered mental status of unknown etiology
                    i. AMS due to dementia is acceptable as long as it is not below
                       patient baseline
                   ii. AMS due to alcohol is acceptable as long as the patient is not
                       obtunded or in need of airway support. A good benchmark would
                       be the ability to ambulate with minimal assistance.
                  iii. Co-ingestion of drugs and alcohol is a disqualifier for BLS
           e. Poor skin signs
    2. If the patient is determined to need ALS monitoring, ALS procedures, or has the
       potential for deterioration, a Paramedic will attend during transport to the
       hospital. If ALS treatment is initiated by the Paramedic, then transport will be
       continued by ALS.
    3. ALS transport of patients that have been excluded from BLS care can be handled
       in one of two ways:
           a. If the responding Paramedic is a member of an ALS ambulance, they will
              continue to take the patient in their ambulance and initiate transport.
           b. If the responding Paramedic responded on a supervisor vehicle, the
              paramedic can assume the attendant role in the BLS ambulance which is
              possible because all vehicles are equipped as standard ALS units.
    4. All attendants from BLS units that can be utilized in the 911 system will have
       successfully completed a field instruction program. This will ensure that they
       will be able to provide care at the same level as an EMT working on a standard
       Pridemark ALS unit.


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    5. If during transport the patient deteriorates and develops vital signs that exceed
       the initial transport criteria, Base Contact will be initiated and ALS will be called
       in to complete transport if appropriate.
    6. Use of the BLS transport model will be restricted to urban areas within 15
       minutes or less transport time to a hospital and per individual contract
       requirements.




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                            Clinical Division
                     Standard Operating Procedure
Effective Date: January 31, 2008             Approval: DOCM_______HR_______

Policy: Controlled Substances
Objective: To clearly identify the process and responsibilities for storage,
administration, and restocking of controlled substances as required by
state and federal law

Scope: Clinical Director, Clinical Manager, Team Leaders, Field
Instructors, EMT-Paramedics

Procedure:

General Principles
Controlled substances, drugs that come under the jurisdiction of the Federal Controlled
Substances Act of 1970, are drugs that have a high risk for misuse or abuse by patients,
professionals, and the public. The Drug Enforcement Administration (DEA) administers
The Federal Controlled Substances Act. Because of the high potential for abuse,
controlled substances have special requirements for ordering, receiving, storing, and
administering. Very strict security and record-keeping is mandatory. The Clinical Director
is responsible for overseeing the entire process and ensuring that security remains high.
Anytime there is a suspected breech in security, the Director of Clinical Medicine must
be notified immediately. A thorough investigation is mandatory. If criminal activity is
suspected, law enforcement officials and the DEA must be notified immediately.
Pridemark Paramedic Services/Medical Director must maintain a current DEA license.
The DEA license is registered under Pridemark Paramedic Services with the Medical
Director also listed on the license and shall be held by the Director of Clinical Medicine.

Procedure
Ordering Controlled Substances
Schedule II Controlled Substances
Include Fentanyl and Morphine
Schedule II Substances must be ordered on an Official US DEA Order Form (DEA-222).
The order must be entered on the DEA-222 Tracking Record and a copy of the DEA-222
form must be kept on file and tracked. Include on the tracking record the Form 222 #, the
order form #, the item ordered, quantity ordered, date ordered, date received, and
quantity received.
Schedule IV Controlled Substances
Include Valium (Diazepam), and Versed (Midazolam)
Schedule IV Substances may be ordered directly from the supplier without an Official US
DEA Order Form.
Invoices must be kept on file and tracked.
Storing Controlled Substances
All controlled substances must be handled with the highest security.
All controlled substances will be placed in the Clinical Director’s safe immediately upon
receipt.

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All controlled substances coming into or going out of the Clinical Director’s safe must be
logged on the Clinical Director’s Narcotic Log. The safe count must be reconciled with
every transaction.
The flow of controlled substances shall be as follows:
The Clinical Director will initially secure all controlled substances.
                         a) Controlled substances will then be distributed to the
                         appropriate divisions as needed to replace used stock.
Controlled substances shall be kept in the Team Leaders’ safe. All controlled substances
coming into or going out of the Team Leaders’ safe must be logged. The safe count
must be reconciled with every transaction.
             iv. Using Controlled Substances during the shift:
                 a. At the beginning of the shift, the paramedic or RN shall access the
                     controlled substances cabinet and sign out an intact box.
                 b. At the end of the shift, or during the shift if call volume requires, the
                     box is returned to the cabinet with the appropriate documentation if
                     substances have been used and the box appropriately handled. A
                     witness must verify the procedure.
                 c. Should a narcotic box be used or unsealed, it shall be placed in the
                     lower locker cabinet with proper documentation rubber banded around
                     box.
             v. The sealed controlled substances boxes must be kept in a locked cabinet
                 in each ambulance. Each ALS provider shall be issued a combination
                 lock which can be custom coded for this purpose. This code shall not be
                 shared with others.
        e. Tamper controls
             i. The controlled substance box should remain in the heat-sealed plastic
                 until use, and the plastic unique lock should remain attached to the box.
             ii. Each individual controlled substance container, vial or pre-load, also has
                 a tamper seal. As soon as the tamper has been broken, the entire
                 contents of the container should be drawn up and prepared for use.
                 a) Should no controlled substance be given, the medication should be
                     wasted and properly documented with a witness signature. Said
                     witness may be EMT partner.
                 b) Should a container be discovered with the tamper seal missing, the
                     Team Leader shall be notified as soon as possible and the container
                     not used.
                     i) An IR regarding the circumstances surrounding the missing
                         tamper shall be filed.
Administration of Controlled Substances
Controlled substances must be administered according to Pridemark Protocols, Policies,
and Procedures.
The only time that a controlled substance may be administered out of compliance with
the protocols is when a direct order is given from a base hospital physician (see
Operational Guidelines—Base Physician Consultation).
Any time a paramedic administers a controlled substance, the paramedic must complete
a Patient Care Record and a “Controlled Substance Storage and Administration
Record.”
Documentation of Controlled Substance Usage
All controlled substance usage shall be documented in the PCR. The controlled
substance may be documented using either the generic or trade name. Initials or
abbreviations should not be used.
A Controlled Substance Storage and Administration Record (SAR) shall also be filled out
for every usage or waste.
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The original SAR should be attached to the narc box with a rubber band and placed with
the box in the lower locked cabinet for Team Leader restock.
Exchange of Controlled Substances
After any usage or waste, the box and documentation shall either be turned in directly to
the Team Leader, or returned to the controlled substances cabinet.
The Team Leader will restock used controlled substances by turning over all Patient
Care Records/Administration Record Forms to the Director of Clinical Medicine once per
month. The Director of Clinical Medicine will also keep records of all controlled
substances used and related information to include:
Date Replaced
Substance
Trip Number
Patient Name
Patient Date of Birth
Dosage Administered
Dosage Wasted
Administered By
Employee Number
Serial Number




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                                     EMT
                              Field Instruction
                                  Program
Purpose: To outline the field orientation process in an effort to create an
effective and consistent training program for new Pridemark EMT’s.

Scope: Team Leaders, Field Instructors, & EMT’s



Description: The EMT Field Instruction program shall consist of five stages.
The following is merely a guide and may at the discretion of the Clinical Manager
or Administration be custom tailored to meet individual employee or operational
needs.

                                     Phase I:
                               Classroom Orientation
                                     Phase II:
                                    Third Rides
                                     Phase III:
                                    Para-transit
                                     Phase IV:
                                    Operations
                                     Phase V:
                                      Medical



Details:

Phase I: Phase I shall consist of general classroom orientation to Pridemark.
This includes but is not limited to Human Resource policies, benefits, and
mandatory new employee training. It shall also include system specific training in
mapping, radios, and paperwork. Phase I will be managed and administered by
the Human Resources Staff, in coordination with the Directors of Operations,
Risk, Customer Service, and Clinical Managers.

Phase II: Phase II shall consist of 3rd rides with Pridemark Paramedic EMT’s.
This phase in intended to introduce the new employee to Pridemark Para-transit
operations and prepare them for Phase III where they will operate as the sole
crew member on Para-transit. During Phase II, the new employee shall be
oriented on radio operations, mechanical wheel chair lift usage, securing
patients, mapping, and general Para-transit operations and expectations. The


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new EMT should also be oriented on all patient care equipment and van
inventory.

Phase III: While working independently on Para-transit, the new EMT should
focus on mastering general operational aspects of working at Pridemark to
prepare them for future BLS and eventually ALS roles. Specifically, the new
EMT should learn the system specific street rotations, mapping, hospital and
SNF locations around the district, radio etiquette, and general operational
expectations such as proper care of vehicles and equipment. Questions and
help during this phase should be solicited from peers, Team Leaders, Field
Instructors, and management as needed.

It is expectation that time on Para-transit will allow the new EMT to learn partially
thru the example of others, and partially thru self study. Some self initiative and
motivation are required during this phase to be successful. Historically, the best
EMT’s and Medics in the company have started in Para-transit. Most all will tell
you that it was a valuable learning opportunity.

At regular intervals thru out the year, which shall be available by going to the
education calendar on line at www.Pridemark.net Pridemark shall offer EMT FI
testing. This testing process shall serve to rank EMT’s for entry into the BLS and
ALS systems and further Field Instruction. The testing will be based on much of
what is expected during Phase III. A prerequisite to this testing shall also be the
completion of an approved IV therapy course. Basic EKG class is also strongly
recommended.

It is the goal that people transition from Para-transit to BLS only after going thru
Field Instruction with an EMT FI. However, at times, operational needs may
necessitate moving people sooner. In such cases every attempt will be made to
FI EMT’s as soon as possible. It may at times also be necessary to place people
in FI out of ranking order, as may be necessary to facilitate scheduling or
operational needs of the company or individual employees who may not be able
to participate in FI due to schedule conflicts, etc.

Phase IV: Once selected and placed into Field Instruction with an EMT or
Paramedic Field Instructor you will be given one week to complete phase IV.
Phase IV shall introduce the aspects of scene management and operations.
Additional time may be granted at the discretion of the Clinical Manager and
Operations.

During this phase emphasis shall be placed on the following:
   • Customer Service & Communication (Pt’s, Fire, Hospital, everyone we
      meet)
   • Scene Management & Safety
   • Driving & Vehicle operations
   • Radio Operation & Etiquette
   • Mapping and Routing
   • Working as a team
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   •   Observation of how the EMT functions in ALS
   •   Protocol Review

Phase V: Phase V shall focus on your Medical roles as an EMT with Pridemark
and build on what was learned in Phase IV. This phase shall be completed
within one week. Additional time may be granted at the discretion of Clinical
Management and Operations.

During this phase emphasis shall be placed on the following skills:
   • Assessment of the BLS and ALS patient.
   • Obtaining accurate Vital Signs
   • Developing BLS treatment plans
   • IV Therapy (Canulation, proper priming of various IV tubing such as Micro,
      Macro, Blood tubing, & Buretrols, and knowing when each is appropriate)
   • Monitor usage (4 & 12 lead EKG placement)
   • Documentation of Patient Care

The EMT will successfully pass this phase and be cleared for ALS with the
approval of the Field Instructor or Clinical Manager and successful completion of
the Final EMT Protocol test. The Field Instructor will then complete the
recommendation for action form and return it to the Clinical Manager for
processing.

While the EMT is now clear to work in the BLS and ALS system, this does not
guarantee scheduling in the BLS or ALS system. Scheduling shall be based
solely on operational needs and policy.




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                         Clinical Division
                   Standard Operating Procedure
Effective Date: January 31, 2008         Approval: DOCM_______HR_______

Policy: Paramedic FI Process
Objective: To clearly identify the training process for Paramedics to
function independently in the Pridemark system.

Scope: Clinical Director, Clinical Manager, Team Leaders, Field
Instructors, EMT-Paramedics



Description: The Paramedic Field Instruction program shall consist of five
stages. The following is merely a guide and may at the discretion of the Clinical
Manager or Administration be custom tailored to meet individual employee or
operational needs.

                                     Phase I:
                              Classroom Orientation
                                     Phase II:
                                     3rd Rides
                                     Phase III:
                                      Medical
                                     Phase IV:
                                Driving/Operations
                                     Phase V:
                              Independent Probation




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Details:

Phase I: Phase I shall consist of general classroom orientation to Pridemark.
This includes but is not limited to Human Resource policies, benefits, and
mandatory new employee training. Phase I will be managed and administered
by the Human Resources Staff, in coordination with the Directors of Operations,
Risk, Customer Service, and Clinical Managers.

Phase II: Phase II shall consist of 3rd rides with Pridemark Paramedic Field
Instructors. This phase in intended to introduce the new employee to Pridemark
operations and prepare them for Phase III where they will operate as the 2nd crew
member on a two person ambulance (2 UP). During Phase II, the new employee
shall be oriented on radio operations and mapping. The new Paramedic should
also be oriented on all patient care equipment and ambulance inventory.

During this phase the new Paramedic should successfully pass the mapping and
radio test. The new Paramedic should also be proficient in map reading. While
not being expected to know the entire district at this point, it is expected they be
able to locate calls and provide effective verbal navigation cues to the partner
driving. This phase is also designed to evaluate the new employees learning
style and develop and effective plan for 2 Up Field Instruction.

The new Paramedic shall also attend on all Calls. However, the goal of this
phase is to prepare for 2 up Field Instruction. Fine tuning of Medicine shall be
the goal of Phase 3. During phase 2 we merely want to assure that the new
Paramedic is competent to practice medicine under indirect supervision. The
focus should be on global type medical issues, for instance the things we won’t
be able to observe in the two up phase.

Phase III: Phase 3 is the medical phase. The Probationary Paramedic will be
tasked with attending to all patient care (ALS & BLS) and developing treatment
plans. Such treatment plans shall be verbally discussed with the Field Instructor
and agreed upon prior to departure from the scene. Changes enroot should be
verbally discussed with the FI and/or medical control and appropriate changes
made as needed to the original care plan. All trips should be constructively
critiqued after the call.

Phase 3 shall also serve to allow the new Paramedic to learn the geography of
the district, locations and best routes to all hospitals served. It shall be the
discretion of the FI as to whether or not to allow driving to calls and around the
district. The new Paramedics learning style should be taken into account when
making this decision. The new Paramedic should also work on mapping,
developing skills to find the quickest route to calls and facilities.

During this phase the new Paramedic shall successfully complete the Cardiology,
and Procedural Sedation tests.



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*The new Paramedic, being Colorado State Certified, shall be presumed to be
capable of attending any and all patients during this phase unless the Paramedic
consistently performs to the contrary, in which case consultation with the Clinical
Manager is advised.



Phase IV: Phase 4 shall concentrate on driving and Pridemark operations.
During this phase the new Paramedic should be able to safely and effectively
navigate to and from calls. Additionally, the Field Instructor should attempt to
function at the BLS level to simulate what the new Paramedic can expect once
cleared. During this portion, the new Medic shall attend on all ALS calls and
determine which calls are appropriate to delegate to the FI acting in a BLS role.
The FI shall continue to critique each call after it’s conclusion to assure continued
learning and evolution in the program.

The new Paramedic should successfully complete the operations and final
protocol test during this Phase.

Phase V: The new Paramedic is cleared for independent duty. The new
Paramedic shall continue to be considered in orientation until the completion of
the 90 day probationary Period. During this phase the new Paramedic will
undergo 100% chart review via the Clinical Manager, be assigned self study
modules and also participate and present at M&M’s.

The 90 day probationary period may be extended at the discretion of Human
Resources and Administration if needed. The new Paramedic may also be
partnered with an EMT FI if additional operational orientation is needed.




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                               Target Timeline:

In an effort to set motivational goals for the new Paramedic, the following
timelines shall be used as targets to complete each phase. For the purpose of
these timelines each new Paramedic shall be placed in one of three categories.

                              New Paramedic
Any Paramedic with less than one year experience running as a Paramedic in a
                                911 system.

                        New Company Paramedic
Any new Paramedic who was working for Pridemark full-time as an EMT prior to
  completion of Paramedic School. These individuals should have at least 6
 months experience with Pridemark to fall into this category or be ALS cleared.

                         Experienced Paramedic
Any Paramedic with more than one year experience running as a Paramedic in a
                               911 System.



Phase I Timeline:
     New Medic:             5Days
     Company Medic:         5Days
     Experienced Paramedic: 5Days

Phase II Timeline:
     New Medic:             4 Weeks
     Company Medic:         4 Week
     Experienced Paramedic: 2 Weeks

Phase III Timeline:
     New Medic:             8 Weeks
     Company Medic:         6-8 Weeks
     Experienced Paramedic: 3 Weeks

Phase IV Timeline:
     New Medic:             2 Weeks
     Company Medic:         1 Week
     Experienced Paramedic: 1-2 Weeks

Phase V Timeline:
     New Medic:             Completion of 90 Days
     Company Medic:         Completion of 90 Days
     Experienced Paramedic: Completion of 90 Days




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                         Clinical Division
                   Standard Operating Procedure
Effective Date: August 29, 2007           Approval: DOCM_______HR_______

Policy: Certifications
Objective: To clearly identify the process and responsibilities of
employees as it relates to the obtaining, maintaining, and tracking of all
required certifications.

Scope: Clinical Director, Clinical Manager, Team Leaders, Field
Instructors, RN’s, EMT-Paramedics, EMT-Basics

Procedure:

   A. It is the responsibility of all clinical employees’ (EMT-B, EMT-I, EMT-P,
      RN’s) to maintain all required certifications.
           a. Required Certifications/license:
                    i. State EMT-B, I, Paramedic, or RN License
                   ii. NREMT (EMT’s and Medics only) certification with 12
                       months of hire date
                  iii. CPR (AHA or ASHI)
                  iv. ACLS ( AHA or ASHI) for RN’s and Paramedics
                   v. PALS or PEPP for RN’s and Paramedics with 6 months of
                       hire
                  vi. NIMS ICS 100,200, 300, 400, 700, & 800 as appropriate for
                       position. ICS 100 & 700 are required at a minimum for all
                       clinical employees
   B. Two copies (front and back) of all required certifications shall be provided
      to the Clinical Director.
           a. The Clinical Director shall provide one copy to the Communication
               Center for entry into CAD.
           b. The Clinical Director shall maintain the other copy for placement in
               the employees’ clinical file.
           c. To avoid lapses, all certifications shall be turned in prior to the
               expiration date to allow adequate time for entry into CAD. 1 week
               minimum
   C. All clinical employees seeking continuing education and in house
      certifications must have a current Clinical Education Application on file.
      (Available from Clinical Manager)
   D. Employees seeking assistance with re-certification shall abide and agree
      with the following:
           a. As a courtesy, Pridemark Paramedics will assist employees who
               participate in our Clinical Education Program with re-certification of
               State and National Registry certifications. Such assistance shall be
               limited to providing guidance on the application process, providing
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             copies of CE records, and signing of required documents for re-
             certification should the employee meet the requirements.
         b. All such requests for assistance with recertification must be made
             in writing or via email to the Director of Clinical Medicine well in
             advance of expiration dates. In general, it can take three months to
             process some re-certifications for in state candidates and in some
             cases longer from the date the application is submitted to the state.
                   i. Applicants shall allow one month for processing of requested
                      assistance and preparation of applications for submittal.
                  ii. Once the above is processed, applicants shall be
                      responsible for submittal of certification applications to the
                      State or National Registry.
                 iii. In summary, as a general rule of thumb all requests for re-
                      certification should be submitted four months prior to
                      expiration.
                          1. Example: If your National Registry expires March
                              31st, 2008, you should request assistance from the
                              Director by December 1st, 2007 and they will have
                              their portion of your application completed by
                              December 31st, and returned to you to deliver.
         c. Employees seeking such assistance shall obtain at least 50% of CE
             in house by PPS.
                   i. The Clinical Division shall offer regular monthly CE and
                      annual re-certification classes in BLS, ACLS and PALS or
                      PEPP
                  ii. Such CE shall be posted on www.Pridemark.net on the
                      education calendar.
                 iii. Application and RSVP may be required for certain courses.
         d. Pridemark Paramedics shall assume no responsibility for lapses in
             certifications and any assistance provided is done strictly as a
             courtesy. Ultimately, the responsibility of maintaining required
             certification is that of the employee.
         e. Pridemark Paramedic Services has no control over issues related
             to the States handling or processing of certification applications. At
             times, the state may take longer than the above timelines to
             process applications.
   E. The Clinical Manager shall maintain an accurate record of all in house
      continuing education and maintain such records for a minimum of four
      years in an electronic data base.
         a. To obtain copies of CE records, individuals should make a request
             in writing or via email to the Clinical Manager and allow up to two
             weeks processing time.
   F. When attending any in house continuing education, employees must sign
      a continuing education roster.
         a. The Clinical Manager shall enter rosters in a data base within one
             week or receipt.



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          b. All rosters along with copies of course outlines must be kept on file
             for a minimum of four years. This is in addition to the data base
             records.
          c. Certificates of Completion for individual courses shall be provided
             on specific request only.




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                                   Clinical Division
                             Standard Operating Procedure

Effective Date: January 31, 2008              Approval: DOCM_______HR_______

Policy: Quality Improvement Guidelines

Objective: To establish guidelines for the routine evaluation of patient care in an
effort to monitor and improve patient care.

Scope: Medical Director, Director of Clinical Medicine, Clinical Manager, Team
Leaders, Field Instructors, EMT-Paramedics, EMT-Basics

Procedure:

   A. General Principles
         a. The Quality Improvement (QI) process is designed to be a constructive
            process.
         b. The QI process is the ultimate responsibility of the Medical Director.
         c. The Medical Director will work in cooperation with the Director of Clinical
            Medicine.
         d. The process shall include objective and quantitative tools to track overall
            quality of patient care.
         e. The process shall generate monthly reports
         f. The QI process is a tiered collaborative system that shall include peer
            review, management review, and Medical Director review. It shall also
            allow for care provider feedback and loop closure.
         g. The Medical Director shall have physical and Electronic Access to all
            Patient Care Reports (PCR).

   B. Process
           a. All patient care shall be documented according to Documentation
              Requirements.
           b. Documentation shall be reviewed for general compliance by the Clinical
              Managers.
           c. The Clinical Managers will distribute all PCR’s to the Field Instructor
              group and/or Medical Director for review.
           d. These PCR’s will be distributed via electronic means on flash drives.
           e. Each Field Instructor shall be given a flash drive for rotational use, and
              each Field Instructor shall be assigned set individuals to monitor on a
              continual basis. The purpose of this assignment is to allow the FI’s the
              ability to watch for patterns that may develop with individuals.
           f. Field Instructors shall review all assigned PCR’s for compliance with
              Pridemark Protocols and overall quality of patient care and
              documentation.
           g. The Field Instructors should follow up directly with individuals on a face to
              face basis to provide positive as well as any corrective feedback on
              routine QA/QI matters. This should be a constructive process and allow
              for two way communication that enables professional growth and
              education. This shall not be a disciplinary role.
           h. If the Field Instructor notes patterns of deficiencies with an individual or
              out of the ordinary protocol violations, the Field Instructor shall report said
              cases to the Clinical Manager for further follow up.
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          i. The Field Instructors should report all level I-IV protocol violations to the
             Clinical Manager for tracking and possible follow up.
          j. The Clinical Managers shall track all Level I-IV protocol violations for
             quarterly review.
          k. The Clinical Mangers shall report all Level III-IV violations to the Director
             of Clinical Medicine as soon as practical.
          l. The Director of Clinical Medicine shall review all Level III-IV violations
             with the Medical Director as soon as Practical.
          m. All Protocol violations will be evaluated on a quarterly basis to review the
             need for additional education of protocol changes.

       C. The following procedures or events shall be reported to the Director of
       Clinical Medicine within 24 hours via email and telephone. The Director shall
       then consult with the Medical Director regarding these cases as soon as
       possible.

          a.   Cricothyroidotomy
          b.   Chest Decompression
          c.   Esophageal Intubation
          d.   Medication errors
          e.   Iatrogenic events
          f.   Pediatric Cardiac Arrest
          g.   Major MCI’s or cases that draw media attention

       D. The following qualitative reviews shall be performed on a quarterly basis.

          a. Intubation success rates
          b. IV success rates
          c. Matrix Report
             (a) A random sampling of 50 ALS trip reports from each division shall be
                 reviewed by a minimum of 3 Field Instructors. These charts shall
                 contain no identifying information regarding the patient or crew
                 involved.
             (b) These trips shall be placed in one of two categories (Agree with care)
                 or (Disagree with Care) Majority rule will apply to decide which final
                 category chart shall be placed in.
             (c) The Clinical Manager shall facilitate this process and provide the
                 Director of Clinical Medicine a % of Agree with Care and Disagree
                 with Care breakdowns.
             (d) The Director of Clinical Medicine will compare the reports from all
                 divisions and provide the Medical Directors, CEO and BOD with the
                 findings.
             (e) This tool will be used to monitor overall quality of care over long
                 periods.




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                                    Clinical Division
                              Standard Operating Procedure

Effective Date: January 31, 2008             Approval: DOCM_______HR_______

Policy: Out of Protocol Incidents

Objective: To provide guidelines for situations when out-of-protocol incidents
occur related to Pridemark Protocols, Policies, and Procedures.

Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, EMT-
Paramedics, EMT-Basics.

II. General Principles
Adherence to medical and procedural protocols is paramount to providing optimal patient
care. Initial education and ongoing training help to ensure the knowledge of, and
therefore compliance with, protocols. Our Quality Management Program, Quality Audit
System and Field Evaluation and Training Program are designed to ensure compliance
with the protocols.
There are four levels of Out-of-Protocol Incidents:
Level I Out-of-Protocol Incident: Out-of-protocol incidents that are determined to be
appropriate and are cleared by a physician order and appropriate documentation
Level II Out-of-Protocol Incident: Out-of-protocol incidents that are determined to be
appropriate however it is not cleared by a physician order but appropriate documentation
as to why there was not physician order is included in the Patient Care Record
Level III Out-of-Protocol Incident: Out-of-protocol incident that is determined to be
inappropriate medical care or the omission of appropriate medical care but is non-life-
threatening
Level IV Out-of-Protocol Incident: Out-of-protocol incident that is determined to be
inappropriate medical care or the omission of appropriate medical care and is potentially
life-threatening

Procedure
Anytime field personnel are aware they have operated out-of-protocol, they must fill out
an Incident Report documenting their out-of-protocol incident and the reasons for going
out-of-protocol. The Clinical Manager will review these and route these to the Director of
Clinical Medicine as appropriate.
Out-of-protocol incidents will be monitored via the Quality Management Program/Quality
Audit System and by feedback from hospital or field personnel. In those cases where an
out-of-protocol incident is discovered via the Quality Management Program, the
individuals involved will be asked to write an Incident Report to describe their reasoning
for going out-of-protocol.
The out-of-protocol level will be determined and disposition, including education,
trending, and/or discipline will be handled according to the level.
   dleddiy
Level I Out-of-Protocol
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      ucatiiy is iedicete




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there was not physician order is included in the Patient Care Record) will be handled in
the following manner:
The case will be discussed with the personnel involved and appropriate education will be
given.
The out-of-protocol incident will be trended.
No discipline is indicated.

Level III Out-of-Protocol (out-of-protocol incident that is determined to be inappropriate
medical care or the omission of appropriate medical care but is non-life-threatening) will
be handled in the following manner:
           The case will be handled via the standard quality management process,
           however, must be reported to the Director of Clinical Medicine and Clinical
           Manager. Appropriate education and trending are necessary to ensure
           personnel learn from the situation and repeat episodes are minimized.
           Discipline will be handled on a case by case basis but may include
           suspension and/or termination depending on severity and/or history of similar
           violations at the discretion of the Director of Clinical Medicine in consultation
           with the Director of Operations, Human Resources, and Medical Director.

Level IV Out-of-Protocol (out-of-protocol incident that is determined to be inappropriate
medical care or the omission of appropriate medical care and is potentially life-
threatening) will be handled in the following manner:
           The case will be referred to the Director of Clinical Medicine who will meet
           with the personnel involved. Appropriate education and follow up evaluation
           prior to return to duty is necessary to ensure personnel learn from the
           situation and repeat episodes are minimized. Discipline will be handled on a
           case by case basis but may include suspension and/or termination depending
           on severity and/or history of similar violations at the discretion of the Director
           of Clinical Medicine in consultation with the Director of Operations, Human
           Resources, and Medical Director.




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                          Clinical Division
                    Standard Operating Procedure
Effective Date: January 31, 2008             Approval: DOCM_______HR_______

Policy: Paramedic School Sponsorship
Objective: To provide guidelines for the sponsorship and recommendation
of Pridemark EMT-Basics to attend Paramedic School.

Scope: Clinical Director, Director of Operations, Clinical Manager, Human
Resources, Team Leaders, EMT-Basics.

Process:
I.  General Principles
       A. Pridemark Paramedic Services, when possible, will sponsor 2 EMT-Basics
       per division per year to attend Paramedic School.
       B. Sponsorship shall allow the individual to be eligible for financial
       reimbursement, remain eligible for certain benefits without loosing seniority, and
       scheduling assistance to continue working on a limited basis or take time off to
       attend school without loss of seniority.
                1. Sponsored employees shall be responsible for full payment of health
                insurance premiums while in school should they choose to continue
                coverage.
                2. Such payments shall be for the full premium amount (both employee
                and company contribution)
                3. Full payment shall be made the first of each month to remain on
                benefits.
       C. Financial tuition reimbursement shall be paid in two installments at one year
       intervals following successful completion of Paramedic school and Pridemark
       Paramedic Field Instruction. To be eligible, the sponsored employee must
       maintain uninterrupted full time status for two years following graduation. Current
       total reimbursement is $5000, paid as above in $2500 installments.
       D. This program is intended to encourage continued full time employment with
       Pridemark Paramedic Services after completion of paramedic school. It is also
       the intent of this program to encourage all EMT-Basics to attend Paramedic
       School.
       E. Those individuals not eligible for sponsorship may qualify for
       recommendation.
       F. Recommendation shall allow the employee to obtain written recommendation
       as may be required for certain Paramedic programs. However, recommendation
       does not guarantee a Paramedic Position will be available upon graduation, not
       does it guarantee the maintenance of seniority or assistance with scheduling.
II. Sponsorship Process
       A. Bi-Annually, two sponsorship positions will be posted utilizing the internal job
       posting process.
       B. Minimum preferred qualifications will include:
                1. One year of experience in ALS system
                2. Team Leader and employee recommendation letter
                3. IV & EKG certification
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        C. The selection process will consist of: (Selection will be based on a
        combination of the below process as well job performance. Seniority will only be
        taken in to account in the event of a tie.)
                1. Panel Interview Process consisting of representatives from:
                       a) Operations
                       b) Clinical Department
                       c) Team Leader Group
                2. Written Test
                3. Practical Test
III. Recommendation Process
        A. Submit written request via email to the Director of Clinical Medicine.
                1. You should submit your request at a minimum of two weeks prior to
                when it is needed.
                2. Enclose the below items and verification with your letter.
        B. Obtain a letter of recommendation from your Team Leader as well as one
        other employee whom you have worked with.
        C. Have one year experience on an ALS ambulance, or one year experience as
        an EMT with Pridemark.




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                              Firefighter Rehab Protocol

Purpose of Firefighter Rehab:
To ensure that the physical and mental condition of personnel operating at a scene of an
emergency or training exercise does not deteriorate to a point that affects the safety of
each member or that jeopardizes the safety and integrity of the operation.

PPS Role:
PPS plays an important role in the rehab process. When an incident occurs – (fire,
hazmat, or clandestine lab breakdown), FD may depend on us to staff and/or operate a
rehab unit for them. To enable us to smoothly integrate with FD and maintain coverage
for the county, the following policies will be followed:

Rehab Group Establishment:
Staff officers will establish a rehab group at any time during an emergency response.
Conditions that will be considered will include: climatic or environmental conditions that
result in heat stress index above 90*F or wind chill index below 10*.

The rehab group has a rehab officer (RO) who is appointed by the Incident Commander
(IC). The RO may be PPS personnel or a firefighter. If you are asked to be the RO, call
the TL to come and take over for you. You will then staff the rehab group.

The RO is in communication with IC and PPS to request additional EMS personnel,
ambulances, request periodic relief for EMS stand-by/rehab crew and other resources as
deemed necessary. RO will obtain forms, equipment and supplies form the IC vehicle.
Those supplies include: Thermometer, fluids and nourishment. Forms and examples are
included in this protocol.

Responsibilities of the RO:
   • Obtain rehab materials from the command vehicle
   • Establish a rehab area and location
   • Check in companies as they arrive, check out companies as they leave rehab
   • Be in communication with the IC and PPS to request additional EMS personnel,
       ambulances, and other resources as deemed necessary by the situation
   • Return completed EIRR and Company Check In/Out sheets to IC
Selecting a rehab site: It should…
   • Be far enough away from the scene that personnel may safely remove their
       turnout gear and SCBA
   • Provide protection form the environment
   • Be free of exhaust fumes
   • Be large enough to accommodate multiple crews
   • Be easily accessible by EMS units
   • Allow prompt entry back into the emergency operation
Resources: Supplies for the rehab include the following:
   • Fluids (water, sport drinks, etc.)
   • Nourishment (broth, soup, granola bars, energy bars, fruit, etc.)
   • Medical supplies (thermometers, IV fluids, etc.)
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    •   Other (awnings, fans, tarps, smoke ejectors, dry clothing, blankets, towels, traffic
        cones, barrier tape, etc.)
Responsibilities of rehab staff:
    • Report to IC or RO on arrival
    • Obtain Emergency Incident Rehab Report (EIRR) from RO
    • Receive incoming crews for rehab, obtain initial and repeat VS
    • Provide hydration and nourishment for crews as required
    • Request additional supplies from RO
    • Notify RO if a firefighter needs transport to a hospital
Guidelines:
Preventive hydration – a critical factor in the prevention of heat injury is the management
of water and electrolytes. Water must be replaced during exercise periods and at
emergency incidents. During heat stress, the member should consume at least one
quart of water per hour. A re-hydration solution should be a 50/50 mix of sport drink and
water given at a temp of about 40*F. Avoid both carbonated and caffeinated beverages
because they interfere with the body’s water conservation mechanisms.

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                            Tuberculosis Screening Policy Overview

Introduction
Who to Test
 Targeted tuberculin testing for latent TB infection (LTBI) is a strategic component of tuberculosis
(TB) control for purposes of identifying persons at high risk for latent TB infection (LTBI) or TB
disease who would benefit from treatment. Targeted tuberculin testing should be conducted only
among groups at high risk and discouraged in those at low risk. Public Health agencies in
Colorado can only provide targeted testing as TB Program resources allow, or if the agency has
alternate funding resources. All testing activities should include a plan for follow-up care of
persons with LTBI or disease and periodic program evaluation.

A local chief medical health officer may conduct required targeted screening programs of
populations who are at increased risk of developing tuberculosis or having LTBI, as defined by
the Centers for Disease Control and Prevention, and offer treatment as appropriate. Such
screening programs shall not be implemented without the prior approval of the local board of
health, state board of health and the state chief medical health officer.

The Mantoux tuberculin skin test (TST), intradermal injection of purified protein derivative
(PPD) is the standard method of identifying persons infected with Mycobacterium tuberculosis
(MTB). Multiple puncture tests (MPTs), such as the Tine test, should not be used. The MPTs
are not reliable because the amount of tuberculin injected intradermally cannot be precisely
controlled. TB skin testing is both safe and reliable throughout the course of pregnancy and
during breastfeeding.

If previous TST results cannot be provided (measured in mm, not “positive” or “negative”), repeat
the test unless there was a severe reaction (e.g. blistering, ulceration, or necrosis) at the
previous site of injection. TB skin retesting should NOT be done if there is appropriate
documentation of a previous positive TST and/or previous treatment for LTBI or active TB.

In general, high-risk groups that should be tested for TB infection include:
    • persons with HIV infection/AIDS
    • recent close contacts to persons with infectious pulmonary TB disease
    • persons with fibrotic lesions on chest x-ray consistent with healed TB
    • persons who inject drugs or use other high risk substances, such as crack cocaine, and
       alcoholics
    • persons with medical conditions which increase the risk of TB disease
    • residents and employees of high risk congregate settings such as correctional
       institutions, long-term residential care facilities (nursing homes, mental institutions, etc.),
       hospitals and other health care facilities, and homeless shelters.
    • health care workers and volunteers who serve high risk clients who undergo
       employment screening and cannot provide documentation of a previous TST or
       information about appropriate follow-up for a “positive” skin test
    • mycobacteriology laboratory personnel
    • foreign-born persons who have arrived within five years from countries that have a high
       TB incidence or prevalence (most countries in Africa, Asia, Latin America, Eastern
       Europe, and Russia)
    • children less than 4 years of age, or children and adolescents exposed to adults in high
       risk categories adult contacts to children with TB infection
    • persons with a history of inadequately treated TB




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                               Pridemark TB Testing Overview

Protocol Overview

        1. All Pridemark Employees must provide proof of TB testing within 6 months of their
           annual performance evaluation.
        2. All new employees must provide proof of TB testing within 12 months prior to
           employment and submit to TB testing at time of hire.
        3. Any employee that has not had a test within a 12 month period must submit to a 2
           stage test.
        4. Any employee with a history of previous positive TB test must provide records of the
           treatment and be willing to submit to a risk assessment screening and if indicated, an
           additional chest x-ray. (see flow chart at the end of this section)
        5. Employees with a history of BCG vaccination must also be skin tested and if positive,
           referred to employee health for follow up. Subsequent to the initial employee health
           referral, risk assessments must be done on an annual basis 6 months prior to
           performance evaluation.
        6. Any employee that has a positive skin test must submit to appropriate treatment as
           deemed necessary by our occupational health provider.
        7. Pregnancy does not exempt employees from testing.
        8. Failure to comply with these standards poses an unacceptable risk to our patients
           and the public at large and may result in suspension from duty or other disciplinary
           action.

How to Apply the Tuberculin Skin Test

1. Administer the tuberculin skin test using the Mantoux technique; intradermal injection of
purified protein derivative (PPD). NOTE: Some PPD vial stoppers contain 41.6% latex, which
could pose a concern for those with latex allergy. For those persons who have a latex allergy,
use vials without latex stoppers or remove the stopper prior to drawing up PPD.

Mantoux test procedure

    1. Equipment needed: gloves, sharps container, PPD tuberculin (Tubersol or Aplisol),
       tuberculin syringe and safety needle, and alcohol pads. NOTE: Opened PPD tuberculin
       vials must be dated and discarded after 30 days. Also see package insert for
       appropriate storage information.

    2. Obtain written consent as per agency requirements

    3. Follow infection control procedures, including the use of gloves and a sharps container.

    4. Clean the injection site, the upper, outer, lateral aspect of the left forearm 1-2 inches
       below the antecubital fossa, with an alcohol pad or alternative skin cleanser (for those
       allergic to alcohol). The left forearm is the standard site for TB skin testing.

    5. Using a disposable safety needle and syringe, inject 0.1 ml of PPD tuberculin containing
       5 TU between the layers of the skin (intradermally) with the needle bevel facing upward.

    6. The injection should produce a discrete, pale elevation of the skin (a wheal) 6-10
       millimeters (mm) in diameter. NOTE: Repeat the test on the opposite arm or the same
       arm, 3 inches from the original site, if a 6-10 mm wheal is not produced.

    7. Document location of injection, time and date of injection, dose, name of person who
       administered the test, name and manufacturer of tuberculin product used, lot number,
       expiration date, and the reason for testing.

How to Read/Measure/Record Test Results
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        9. Read the tuberculin skin test 48 to 72 hours after the injection.

        10. If the individual fails to show up for the scheduled reading, positive reactions may still
            be measurable up to one week after testing.

        11. If the results appear negative and more than 72 hours have passed, the test should
            be repeated. It can be repeated immediately, or after 1 week if two-step testing is
            required (see page 12, “Two Step Tuberculin Skin Testing”).

        12. TST results should be read by designated, trained personnel. Do not accept self-
            reading of TST results.

        13. Measure the tuberculin skin test site crosswise to the axis of the forearm.

        14. Measure only induration (swelling that can be felt) around the site of the injection. Do
            NOT measure erythema (redness). A tuberculin skin test with erythema but no
            induration is non-reactive.

        15. Record the test result in mm, not as “positive” or “negative.” An exact reading in mm
            may be necessary to interpret whether conversions occur on a subsequent test.
            Record a tuberculin skin test with no induration as “0 mm.”

        16. Adverse reactions to a TST (e.g. blistering, ulcerations, necrosis) should be reported
            to the Food and Drug Administration’s Med Watch Program at 1-800-FDA-1088 or via
            the Internet at www.fda.gov/medwatch.

         17. All licensed hospitals and nursing home facilities must maintain a register of the TST
             results of health care workers in their facility, including physicians and physician
             extenders who are not employees of the facility but provide care to or have face-to-
             face contact with patients in the facility. The facility must maintain such TST results
             as confidential.
In addition:
    For persons previously skin tested, an increase in induration of 10 mm within a 2-year period
    is classified as a conversion to positive.

    1. False negative reactions may be due to:
           a. Anergy (see “Anergy Testing”)
           b. Recent TB infection (within the past 10 weeks)
           c. Very young age (< 6 months of age-because their immune systems are not fully
               developed)
           d. Overwhelming TB disease
           e. Live virus vaccination (see below)
           f. Some viral infections (measles, mumps, chickenpox, and HIV)
           g. Corticosteroids and other immunosuppressive agents at doses of 2 mg/kg/day or
               greater for 2 or more weeks
    2. False positive reactions may be due to:
           a. Non-tuberculous mycobacteria
           b. BCG vaccination
           c. Local latex allergic reactions
           d. Vaccination with live viruses (e.g. Measles, Mumps, Rubella, Varicella, Oral
               Polio, and Yellow Fever) may also interfere with TST reactivity and cause false
               negative reactions.

Two-Step Tuberculin Skin Testing (Booster
Phenomenon)
Introduction


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Delayed type hypersensitivity (a skin test reaction) may wane over the years in some people who
are infected with TB. When these people are skin tested many years after infection, they may
have a negative reaction. However, this negative skin test may stimulate (boost) their ability to
react to tuberculin, causing a positive reaction to subsequent tests. This boosted reaction may be
interpreted as new infection. Two-step testing is used to establish a true baseline skin test.

Thus, it is recommended that a baseline two-step tuberculin skin test be performed on workers in
health care facilities, correctional institutions and jails, long term care facilities for the elderly,
homeless shelters, drug treatment centers, residents of long-term care facilities, and other adults
who will be re-tested periodically. Two-step tuberculin skin testing should be performed on these
individuals who cannot document a history of a negative tuberculin skin test within the past year.

Protocol:
   1. Apply the tuberculin skin test.
   2. If the initial skin test is positive, consider person infected and refer to “What to do After
      Interpreting the Skin Test.”
   3. If the initial tuberculin skin test is negative: It should be repeated within 1-3 weeks using
      the same dose and strength of tuberculin.
   4. An individual who can provide documentation of a TST by the Mantoux technique within
      the preceding year should have an initial skin test performed, and should be managed
      on the basis of that result. There is no need for a second test because the earlier test is,
      in effect, the first of a two-step test.
   5. If the second test is negative, the individual is classified as uninfected and retested at
      routine intervals (two-step testing is not required for subsequent tests unless one or more
      years have elapsed since the last test).
   6. If the second test is positive, consider person infected and refer to “What to do After
      Interpreting the Skin Test”.

BCG (Bacillus Calmette-Guerin) Vaccines

BCG vaccines are live vaccines derived from a strain of Mycobacterium bovis (M. bovis).
Because their effectiveness in preventing infectious forms of TB is uncertain, they are not
recommended as a TB control strategy in the U.S. except under rare circumstances (see below).
They are, however, used commonly in other countries.

Tuberculin Skin Testing of an Individual with a History of BCG
Vaccination

1. A history of BCG vaccination is not a contraindication to tuberculin skin testing if the person is
at risk of exposure to TB.

2. A false positive reaction may occur in persons vaccinated with BCG. However, tuberculin
reactivity caused by BCG vaccination wanes with time and is unlikely to persist > 10 years.
3. A diagnosis of LTBI and the use of therapy should be considered for any BCG-vaccinated
person who has a TST reaction of >10 mm induration, especially if:

•   the vaccinated person is exposed continually to populations in which the prevalence of TB is
    high (e.g., some health care workers, employees and volunteers at homeless shelters, and
    workers at drug-treatment centers)
•   the vaccinated person was born or has resided in a country in which the prevalence of TB is
    high; or
•   the vaccinated person is a contact of another person who has infectious TB, particularly if the
    infectious person has transmitted TB to others




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                                 Tourniquet Procedure
   Indications
   A tourniquet should be used to control potentially fatal hemorrhagic extremity
   wounds only after other means of stopping blood loss have failed.
   Precautions
       1. A tourniquet applied incorrectly can increase blood loss and lead to death or
          loss of limb.
       2. Applying a tourniquet can cause nerve and tissue damage whether applied
          correctly or not.
       3. Use on appropriate patients only is of utmost importance.
       4. Damage is unlikely if the tourniquet is removed within an hour. Low risk to
          tissue is acceptable over death secondary to hypovolemic shock.
       5. A commercially made tourniquet is the standard of care as improvised
          tourniquets can increase the risk of harm.


   Technique
       1. Use BSI.
       2. Attempt to control hemorrhage using direct pressure, elevation and indirect
          pressure on pressure points prior to considering the application of a
          tourniquet.
       3. If unable to control hemorrhage using above means, apply a tourniquet using
          the steps below:
                  •   Cut away any clothing so that the tourniquet will be clearly visible.
                      The tourniquet should NEVER be obscured by clothing or
                      bandages.
                  •   Apply tourniquet proximal to the wound and not across any joints.
                  •   Tighten tourniquet until bleeding stops. **Note: Applying a
                      tourniquet loosely will only increase blood loss by inhibiting
                      venous return.
                  •   Mark the time and date of application on the patient’s skin next to
                      the tourniquet. Use a permanent marker.
                  •   Keep tourniquet on for full duration of transport. A correctly placed
                      tourniquet should only removed by the receiving hospital.



   Complications
The possibility of the loss of limb, permanent circulatory, and/or neurological damage to
the extremity is very real and should be weighed against the risk of loss of life.




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                        Therapeutic Induced Hypothermia (TIH)


   Overview:

   For several decades out of hospital cardiac arrest survival rates have
   remained stagnant despite numerous changes in pre-hospital care. Research
   published in the New England Journal of Medicine in 2002 as well as the
   ILCOR statement in 2003 now show strong statistical evidence that
   therapeutic cooling of medical patients of non-hemorrhagic cardiac arrest is
   beneficial increasing neurologically intact patient survival rates by 16-23%.
   Inclusion Criteria

       1. Cardiac arrest secondary to suspected medical causes with no
          evidence of traumatic or hemorrhagic causes.
       2. Age >16
       3. Initial temperature >34c.
   Exclusion Criteria

       1. Traumatic or hemorrhagic arrest
       2. Pregnancy
       3. Lack of an advanced airway

   Protocol:


       1. Patients who meet criteria should receive all traditional treatments as
           per existing cardiac arrest protocols & AHA guidelines.
           Implementation of the TIH protocol should not delay other therapies.
       2. Assure and verify advanced airway (ET tube)
       3. Establish two large bore IV’s or IO
       4. Remove clothing
       5. Obtain temperature if possible
       6. Infuse cooled 2-4deg. Celcius saline 40ml/kg rapid IV push with Infuser
           if available as soon as inclusion criteria are met. (80 kg patient =
           3200ml’s)
       7. Upon ROSC
               a. MIDAZOLAM (VERSED) 2mg prn, q. 5minute intervals to
                   control any shivering
               b. Maintain hemodynamic stability per current protocols
                        i. Consider Dopamine/Epi drips
                       ii. Consider Cordarone
       8. Transport to nearest medical facility that supports continuation of TIH
           and interventional cardiology.
       9. Target patient temperature is 32-34 deg. Celsius
       10. Document in PCR to include meeting inclusion criteria


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                                     ETOH Disposition Policy

Overview
The purpose of this policy is to give field crews a guideline to help them ensure for the proper
disposition of calls involving intoxicated parties.

The term intoxicated does not simply mean that an individual has had some alcohol at some point
in the last 24 hours. Tolerance levels differ by age, body type, underlying medical conditions, food
intake, and the amount ingested over time. There are set blood alcohol levels that have proven to
impair judgment and reaction time and are generally accepted by the legal system to determine
the level of intoxication. A blood alcohol level of .05% is considered to be impaired under
Colorado law and .08% is enough for a DUI conviction. In the pre-hospital setting we are not privy
to these types of tests and therefore must make our decision based on clinical assessment and
the use of sound judgment. The point at which a person can be taken against their wishes is
when they have become “Incapacitated by Alcohol”. The legal definition of this condition is
defined as:

C.R.S. 25-1-302 (9) “Incapacitated by alcohol”: means that a person, as a result of the use of
alcohol, is unconscious or has his judgment otherwise impaired that he is incapable of realizing
and making a rational decision with respect to his need for treatment or is unable to take care of
his basic personal needs or safety or lacks sufficient understanding or capacity to make or
communicate rational decisions concerning his person.

Some basic assessment clues for determining the level of intoxication:
Nystagmus
Ataxia (loss of muscle coordination/balance)
Odor of alcohol
Slurred Speech
Irrational behavior
Loud boisterous speech

Understand that apart from the odor of alcohol finding, all of the assessment clues can have a
metabolic cause. Some causes can include hypoglycemia, CVA, hypoxia, hyper/hypothermia,
and hypo-perfusion. ETOH intoxication should be a diagnosis of exclusion in which you are left
with no other reasonable diagnosis.

Protocol
If a patient is found to have ingested alcohol but is not intoxicated, the normal disposition rules
apply. The patient is able to consent to, or refuse treatment or transport.

If a patient is found to be intoxicated there are two possible dispositions:
     1. Transport to closest appropriate hospital
     2. Turn custody of patient over to someone for transport to a detox facility*
*Note- Transport to a detox facility will only be done by Pridemark units if the call originates from
an emergency department. We DO NOT transport directly to these facilities from the field.

If a patient is determined to be intoxicated and has any of the following the disposition should be
transport to the closest appropriate ED:
     1. Visible signs of injury
     2. Involvement with high energy transfer event (accident, fall 2x height, assault, etc.)
     3. Abnormal vital signs (BP <90 >180, pulse rates <60 or >100, abnormal ecg, abnormal
          pulse ox, etc.)
     4. New complaints of pain
     5. New onset of illness
     6. Complaint of exacerbation of current underlying medical condition (COPD worse than
          usual, old back problems hurting more than usual, etc.)
     7. Unable to stand or walk with minimal assistance
     8. Obtunded
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    9. Co-ingestion of Rx medication or recreational drugs
    10. Psychiatric component (mania, suicidal ideation, hallucinations, etc)

In the absence of these findings in association with the determination that the patient is
intoxicated, the patient may be released for transport to a detox facility like Denver CARES,
Arapahoe House, or the ARC in Boulder. Most often the police are asked to transport patients to
these facilities. If the police cannot or will not transport the patient to a detox facility, the
Pridemark unit will initiate transport to the closest appropriate medical facility. BLS may perform
these transports provided the patient has been cleared by ALS (and only when appropriate for
system status). Outright release of patients that have been determined to be intoxicated is not
appropriate.




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