Morrow County EMS Patient Care Protocol

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					                       Morrow County EMS




                     Patient Care Protocol
                                         Effective Date: January 1, 2011
                                                                                        Authorized for use by
                                                                                    Emergency Care Providers
                                                                                       Under the authority of
                                              Dr. Mark Seher DO , Medical Director
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                       Page 1
Dr. Mark Seher DO, Medical Director.
Medical Director Statement
The following document presents the protocols for the provision of out of hospital care by all
levels of emergency medical care providers. These have been written with the knowledge that
every situation is different, but that certain basic guidelines must be adhered to in order to
best standardize the care of our patients. Pre-hospital emergency medicine is an art and not
an exact science; hopefully this protocol will allow pre-hospital providers and members of the
emergency department to work together for the benefit of our patients.

This protocol contains colored text and must be printed in color. All protocol drug doses
specified in RED are for an ADULT patient. When a drug dose is calculated as dose/kg,
doses are pre-calculated for 50 kg, 75 kg, and 100 kg patients using a micro drop or 60
drop set. These doses appear in parentheses after the standard dose and are printed in
GREEN. Specific pediatric guidelines are provided where necessary and/or appropriate and
are printed in BLUE.

As the current EMS Medical Director, I have reviewed and approved these protocols for use.


_____________________________________________
Dr Mark Seher, DO
EMS Medical Director




STATE OF OHIO
COUNTY OF Morrow                  SS:

The undersigned hereby affirms that the statements made in the foregoing affidavit are true,
under penalty or perjury.

Subscribed and affirmed to before me this _________ day of                          , 2010,
By




                                                                    Notary Public


My Commission Expires: _____________________________________




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 2
Dr. Mark Seher DO, Medical Director.
Table of Contents
Medical Director Statement .................................................................................................. 2
Table of Contents................................................................................................................ 3
Preamble ............................................................................................................................ 8
Section I – Patient Assessment .................................................................................... 14
Patient Assessment Guidelines ........................................................................................... 14
Initial Assessment ............................................................................................................. 15
Focused History and Physical Exam .................................................................................... 16
Rapid Assessment ............................................................................................................. 17
Detailed Assessment ......................................................................................................... 18
Ongoing Assessment ......................................................................................................... 18
SECTION II – Transport Guidelines ............................................................................. 19
Air-Medical Transport Guidelines ........................................................................................ 19
Load and Go Guidelines ..................................................................................................... 20
SECTION III – Trauma / Multi-System Injuries ......................................................... 21
Traumatic Arrest ............................................................................................................... 21
Thoracic Trauma ............................................................................................................... 22
Head Trauma.................................................................................................................... 23
Musculoskeletal / Extremity Trauma ................................................................................... 25
Splinting Suggestions for Specific Orthopedic Injuries .......................................................... 26
Avulsion & Amputation ...................................................................................................... 27
Ocular Emergencies .......................................................................................................... 29
Crushing Injury & Crush Syndrome .................................................................................... 31
Animal / Reptile Bites & Insect Stings ................................................................................. 33
Sexual Assault .................................................................................................................. 34
SECTION IV – Environmental Emergencies ................................................................. 35
Burns ............................................................................................................................... 35
Hypothermia ..................................................................................................................... 37
Heat Related Illness / Hyperthermia / Temperature Instability ............................................. 38
SECTION V – Cardiac Emergencies .............................................................................. 39
CPR Critical Concepts ........................................................................................................ 39
Arrhythmia Guidelines ....................................................................................................... 40
Pulseless Non-Breathing (PNB) Guidelines .......................................................................... 41
Ventricular Fibrillation / Pulseless Ventricular Tachycardia.................................................... 43
Asystole / Pulseless Electrical Activity (PEA) ........................................................................ 45
Bradycardia ...................................................................................................................... 47
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                             Page 3
Dr. Mark Seher DO, Medical Director.
Ventricular Tachycardia with Pulses .................................................................................... 49
Symptomatic PVCs ............................................................................................................ 50
Supraventricular Tachycardia ............................................................................................. 51
Known WPW & Wide Complex Atrial Fibrillation .................................................................. 53
Chest Pain ........................................................................................................................ 55
CHF / Pulmonary Edema.................................................................................................... 57
SECTION VI – Respiratory Emergencies ...................................................................... 58
Asthma............................................................................................................................. 58
COPD ............................................................................................................................... 59
Upper Airway Distress in Pediatrics .................................................................................... 60
Spontaneous Pneumothorax .............................................................................................. 61
Pulmonary Embolism ......................................................................................................... 62
SECTION VII – Medical Emergencies ........................................................................... 63
Decreased / Altered Level of Consciousness........................................................................ 63
Stroke / CVA ..................................................................................................................... 64
Hypoglycemia / Hyperglycemia .......................................................................................... 65
Hypotension - Non-Traumatic, Symptomatic ....................................................................... 67
Hypertension .................................................................................................................... 67
Seizures ........................................................................................................................... 68
Overdose .......................................................................................................................... 69
Common Overdose Medications ......................................................................................... 70
Allergic Reaction, Anaphylaxis, Dystonic Reaction................................................................ 71
Pain Management ............................................................................................................. 73
Behavioral Emergency & Patient Restraint .......................................................................... 75
SECTION VIII – Toxic Exposures / Haz-Mat ............................................................... 76
Carbon Monoxide Poisoning ............................................................................................... 76
Hazardous Materials & Toxic Exposure ............................................................................... 77
Exposure to Nerve Agents / Organophosphates .................................................................. 78
SECTION IX – Obstetrical / Gynecological Emergencies ............................................ 80
Obstetrical Emergencies - During Pregnancy ....................................................................... 80
Obstetrical Emergencies – Delivery .................................................................................... 81
Special Delivery Situations ................................................................................................. 82
SECTION X – Procedures .............................................................................................. 84
Oxygen, Airway & Ventilation ............................................................................................. 84
OPA – Oropharyngeal Airway ............................................................................................. 86
NPA – Nasopharyngeal Airway ........................................................................................... 87
Orotracheal Intubation ...................................................................................................... 88

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                            Page 4
Dr. Mark Seher DO, Medical Director.
Nasotracheal Intubation .................................................................................................... 90
Combitube ........................................................................... Error! Bookmark not defined.
LMA – Laryngeal Mask Airway ............................................... Error! Bookmark not defined.
RSI – Rapid Sequence Intubation ....................................................................................... 95
CPAP – Continuous Positive Airway Pressure ....................................................................... 98
Retrograde Intubation ..................................................................................................... 100
Cricothyroidotomy ........................................................................................................... 102
Suctioning ...................................................................................................................... 104
Needle Decompression .................................................................................................... 105
Pulse Oximetry ............................................................................................................... 106
Pulse CO-Oximetry .......................................................................................................... 107
Colorimetric End Tidal CO2 Monitoring .............................................................................. 108
IV Access ....................................................................................................................... 109
Intraosseous Access ........................................................................................................ 110
Central Venous Line Access ............................................................................................. 112
IN – Intranasal Atomizer ................................................................................................. 113
NG – Nasogastric Tube .................................................................................................... 114
PASG – Pneumatic Anti-Shock Garment ............................................................................ 115
Taser Probe Removal ...................................................................................................... 116
Spinal Immobilization – Appropriate Omission ................................................................... 117
Helmet Removal ............................................................................................................. 118
AED ............................................................................................................................... 120
12-Lead Monitoring ......................................................................................................... 122
12-Lead – Monitor Lead Placement .................................................................................. 123
Auto-Injector .................................................................................................................. 125
SECTION XI – Appendices .......................................................................................... 126
Adult vs. Pediatric Glasgow Coma Scoring ........................................................................ 126
Normal Pediatric Vital Signs ............................................................................................. 126
Differential Causes of Chest Pain and Dyspnea ................................................................. 127
Universal Precautions ...................................................................................................... 129
Trauma Triage Protocol ................................................................................................... 133
Special Situations ............................................................................................................ 135
Patient Refusal................................................................................................................ 139
Terminating and/or Withholding Resuscitation Efforts........................................................ 143
DNR – Do-Not-Resuscitate ............................................................................................... 145
Safe Harbor .................................................................................................................... 147
CCW – Patients with Concealed Carry Weapons ................................................................ 151

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                            Page 5
Dr. Mark Seher DO, Medical Director.
SECTION XII – Medical Abbreviations ....................................................................... 159
SECTION XIII – MEDICATIONS .................................................................................. 163
Acetaminophen (Tylenol) ................................................................................................. 163
Activated Charcoal .......................................................................................................... 164
Adenosine (Adenocard) ................................................................................................... 165
Albuterol Sulfate (Proventil) ............................................................................................. 166
Amiodarone (Cordarone) ................................................................................................. 167
Aspirin............................................................................................................................ 168
Atropine Sulfate .............................................................................................................. 169
Calcium Chloride .................................................................. Error! Bookmark not defined.
Dextrose 25% / 50% (D25 / D50) ...................................................................................... 170
Diazepam (Valium) .......................................................................................................... 171
Diltiazem (Cardizem) ....................................................................................................... 172
Diphenhydramine (Benadryl) ........................................................................................... 173
Dopamine (Intropin) ....................................................................................................... 174
Epinephrine .................................................................................................................... 176
Etomidate (Amidate) ....................................................................................................... 178
Fentanyl (Sublimaze)....................................................................................................... 179
Furosemide (Lasix).......................................................................................................... 180
Glucagon ........................................................................................................................ 181
Glutose (Oral Glucose) .................................................................................................... 182
Haloperidol (Haldol) ............................................................. Error! Bookmark not defined.
Ipratropium (Atrovent) .................................................................................................... 183
Lidocaine (Xylocaine) ...................................................................................................... 184
Lidocaine Jelly 2% (Xylocaine Jelly 2%) ........................................................................... 185
Magnesium Sulfate .......................................................................................................... 186
Methylprednisolone (Solu-Medrol) .................................................................................... 187
Midazolam (Versed) ........................................................................................................ 188
Morphine Sulfate ............................................................................................................. 189
Naloxone (Narcan) .......................................................................................................... 190
Nitroglycerin (Nitrostat) ................................................................................................... 191
Ondansetron (Zofran) ..................................................................................................... 192
Oxymetazoline HCl (Afrin) ............................................................................................... 193
Oxygen (O2) ................................................................................................................... 194
Racemic Epinephrine (Vaponephrin) ................................................................................. 195
Sodium Bicarbonate (NaHCO3) ........................................................................................ 196
Sodium Thiosulfate ......................................................................................................... 197

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                            Page 6
Dr. Mark Seher DO, Medical Director.
Succinylcholine (Anectine) ............................................................................................... 198
Tetracaine (Pontocaine) .................................................................................................. 199
Vasopressin (Pitressin) .................................................................................................... 200
Vecuronium (Norcuron)……………………………………………………….………………………………………199
SECTION XIV – Index ................................................................................................. 200




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                     Page 7
Dr. Mark Seher DO, Medical Director.
Preamble
Summary
These Patient Care Guidelines (PCGs) explain the policies, procedures and standing medical
orders for treating the ill and injured in the out-of-hospital setting.
These Patient Care Guidelines (PCGs) are the result of the combination of nationally
recognized guidelines, local medical practice, and input from the Medical Director and
participants from the protocol development team. Nationally recognized resources include, but
are not limited to: Basic Life Support (CPR), Advanced Cardiac Life Support (ACLS/ACLS-EP)
AHA or equivalent, Pediatric Advanced Life Support (PALS), Pediatric Education for Pre-hospital
Providers (PEPP), Pediatric Trauma Life Support (PTLS), Neonatal Resuscitation Program
(NRP), Neonatal Advanced Life Support (NALS), Advanced Medical Life Support (AMLS), Basic
Trauma Life Support (BTLS), Pre-Hospital Trauma Life Support (PHTLS), Advanced Burn Life
Support (ABLS), and Geriatric Training for Emergency Medical Services (GEMS).
Emergency medical personnel are encouraged to use the guidance and algorithms of these
resources to supplement the PCGs in their daily practice. If contradiction occurs, however,
these PCGs will supersede any other algorithm. Alternative courses of action may be utilized
when appropriate, following standard medical control, deviation, and documentation
guidelines.
No procedures, techniques, or drugs will be used without the proper equipment or beyond the
training or capabilities of the Pre-hospital personnel. Treatment guidelines are separated into
EMT - Basic, EMT-Basic, EMT-Intermediate, and Paramedic. It is the understanding that EMS
providers will provide care up to and including the care specified by their current certification
level.
Nothing in this protocol may be used without specific pre-approval of the Medical Director for
the local department or agency. Items enclosed in braces { } are at the option of the
Department and the Medical Director.
Authority
The Medical Director has the authority to ensure that the medical objectives and mission of all
emergency medical personnel are achieved. Individual patient care protocols, procedures and
standing orders have been reviewed, approved and authorized for immediate implication by
the Medical Director.
Applicability
These PCGs apply specifically to personnel operating under the Medical Direction of Dr. Eric
Hansen. Patients with Ohio DNR status shall receive treatments in accordance with these
PCGs but within the limits of the DNR actions.
Interim Changes
Interim changes to these plans are not official unless they are authenticated by the Medical
Director. Users will destroy interim changes on their expiration (or revision) date unless
sooner superseded or rescinded. These PCGs shall remain effective until changed by the
appropriate Medical Authority.
Intent
It is the intent of these PCGs to give emergency medical personnel written guidelines to
manage a wide variety of common medical, trauma and psychiatric emergencies. Personnel

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 8
Dr. Mark Seher DO, Medical Director.
must always make thorough situational and patient assessments and specific treatment plans
based on those case-by-case findings. While this document cannot cover every possible
variation of disease or injury encountered in the field, it should provide a foundation for the
acute care of the majority of patients seen. When deviation from these PCGs or
implementation of special procedures is thought to be in the best interest of the patient, every
effort must me made to contact the receiving Medical Control Physician, if possible. The
reason for this deviation, the attempts to contact Medical Control, and any orders received
from the receiving facility physician must be documented in the PCR.
Color Coding
 All protocol drug doses specified in RED are for an ADULT patient.
 When a drug dose is calculated as dose/kg, doses are pre-calculated for 50 kg, 75 kg,
    and 100 kg patients using a micro drop or 60 drop set. These doses appear in
    parentheses after the standard dose and are printed in GREEN.
 Specific pediatric guidelines are provided where necessary and/or appropriate and are
    printed in BLUE.
 For purposes of medication doses and other protocol specifics, pediatric patients are
    defined as patients < 12 years old and adults are patients > 12 years old.
Patient Definition
“Patient: an individual requesting or potentially needing medical evaluation or treatment.”
The relationship between provider and patient is established either by telephone, radio, or
personal contact. This definition reflects more of an ethical principle than anything else. In the
case of a mass casualty incident, everyone is a potential patient until proven otherwise. This
principle holds true for every incident, regardless of size or magnitude. It is every provider’s
responsibility to make certain that all effected individuals are offered the opportunity for
evaluation, treatment, and/or transport.
Personal Protective Equipment (PPE)
Each and every protocol should be considered to have, as its first directive, a mandate to
maintain universal blood and body fluid precautions and scene safety to the emergency care
providers of the department.
Transfer of Care Responsibility & Delegation
When transferring a patient to another health care provider whether in the pre-hospital
environment to another crew or agency, or to a receiving facility, emergency medical
personnel releasing the patient should provide the receiving health care provider with
complete patient information to include:
 Past Medical History.
 History of Present Illness or Episode.
 Overview of Patient Assessment.
 Treatment Rendered by Personnel.
 Any Other Pertinent Information.
Transfer of care should only be made to a healthcare provider, or a healthcare team, whose
level of training is equivalent to or greater than that of the personnel transferring the care.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 9
Dr. Mark Seher DO, Medical Director.
Patients with Pre-Existing Medical Devices or Drug Administration
The number and type of pre-existing Medical Devices and/or Drug Administrations (MDDA)
currently or potentially encountered by EMS personnel in the community setting is extensive
and may change frequently. As a guideline for EMS personnel, current pre-existing MDDAs
may include, but not limited too; ventilatory adjuncts (CPAP, BiPAP), continuous or
intermittent IV medication infusions (analgesics, antibiotics, chemotherapeutic agents,
vasopressors, cardiac drugs), and nontraditional out-of-hospital drug infusion routes
(subcutaneous infusaports, central venous access lines, direct subcutaneous infusions, self-
contained implanted pumps).
EMS personnel confronted with a prehospital patient with a preexisting physician-ordered
medical device or drug administration not covered in their respective scope of practice should
provide usual care and transportation while maintaining the pre-existing MDDA, if applicable.
There is no expectation that EMS personnel will initiate, adjust, or discontinue the pre-existing
MDDA. EMS personnel will maintain and continue care so that the patient can be transported.
EMS personnel are expected to follow the appropriate sections of this protocol regarding the
overall evaluation, treatment, and transportation of this type of prehospital patient. Concerns
or questions regarding real-time events associated with a preexisting MDDA should be directed
to the relevant Medical Control Physician. Concerns or questions regarding previous,
recurrent, or future pre-hospital transportations with a pre-existing MDDA should be directed
to the appropriate EMS Medical Director and legal counsel.
Emergency Operations Declaration
During the course of a major medical incident, emergency medical personnel may be asked to
administer medications that are not listed on their drug license, and/or addressed in these
PCGs. These medications may also be requested to be administered at locations which are not
an incident location listed on the agency’s drug license; however, during the course of an
emergency, this shall be authorized. These medications will be administered only after an
“Emergency” has been declared by the Health Commissioner or Emergency Management
Agency having jurisdiction and, these providers will be working under the direction of that
agency until they deem the “Emergency” to be over. Prior to administration, the EMS
providers will be given guidance with information related to the medication, such as
indications, dosage and side effects. This operation will only take place upon declaration of an
“Emergency”; otherwise these PCGs will be followed.
    Ohio Administrative Code: 4765-6-03 “Additional services in a declared emergency”
    (A) In the event of an emergency declared by the (governor) that affects the public's
    health, a EMT - Basic, EMT-basic, EMT-intermediate, or EMT-paramedic, certified in
    accordance with section 4765.30 of the Revised Code and Chapter 4765-8 of the
    Administrative Code, may perform immunizations and administer drugs or dangerous
    drugs, in relation to the emergency, provided the EMT - Basic or EMT is under physician
    medical direction and has received appropriate training regarding the administration of
    such immunizations and/or drugs.
    Effective 09/01/2005
Patient Advocacy
Patient care and safety shall be the primary focus of all emergency health care providers. Any
request for urgent or emergency medical care shall be honored as long as the request is legal
and ethical. Patients deserve to be informed, when possible, of all decisions affecting their

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 10
Dr. Mark Seher DO, Medical Director.
care and transport. Competent adults have the legal right to accept or refuse treatment
and/or transport recommendations. Immediate family members should be considered an
extension of the patient in notification and scene management. Family members should be
treated with dignity and respect, and should be equally supported in their role as the patient’s
advocate.
Patient Confidentiality
All information obtained during the course of treating and transporting a patient is confidential.
This includes the patient’s name, condition, hospital of transport, or any medical information.
Providers have an ethical responsibility to handle all information and documentation regarding
a patient with a high degree of confidentiality. Patient information is only to be shared with
those individuals who are part of the continuity of patient care. Patient records should not be
provided to law enforcement agencies or other non-medical public safety entities that are not
part of the patient care continuum.
Once a patient record has been completed, it is considered a medical record and, therefore, is
confidential. Every effort should be made to ensure that the patient record will not be left
unattended, open for public view, or stored haphazardly in a way which will compromise the
confidentiality of the patient and the record’s contents. Similarly, it is our responsibility to not
discuss patient care issues with anyone other than those medical professionals involved in that
patient’s care.
Child Abuse/Neglect
1. In cases of suspected abuse/neglect of a child:
     a. Document all physically and emotionally abusive signs and symptoms.
     b. Make every attempt to transport the patient.
     c. Contact Children Services, this may be done after care of the patient is handed off to
        another provider.
     d. Never assume that when you pass information to the hospital that they will report it.
        Either make the report yourself or in conjunction with the hospital staff.
     e. Document the time and who contacted on the patient care report.
     f. If there is suspected abuse/neglect and you believe that the patient’s safety is in
        imminent danger, and the patient or their care provider refuses transportation, request
        law enforcement and do not leave the scene until they arrive. Be tactful.
2. Abuse - Any injury inflicted upon a child by other than accidental means.
3. Neglect - Any child that is abandoned by their parent or guardian, or whose parent or
     guardian refuses to provide that child with proper necessary subsistence, education,
     medical, surgical or other necessary care for his/her health, moral or well being.
Elderly Abuse/Neglect
1. In cases of suspected abuse/neglect of an adult:
     a. Document all physically and emotionally abusive signs and symptoms.
     b. Make every attempt to transport the patient.
     c. Contact Adult Protective Services through Job and Family Services, this may be done
        after care of the patient is handed off to another provider.
     d. Never assume that when you pass information to the hospital that they will report it.
        Either make the report yourself or in conjunction with the hospital staff.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.           Page 11
Dr. Mark Seher DO, Medical Director.
    e. Document the time and who contacted on the patient care report.
    f. If there is suspected abuse/neglect and you believe that the patient’s safety is in
         imminent danger, and the patient or their care provider refuses transportation, request
         law enforcement and do not leave the scene until they arrive. Be tactful.
2. Abuse - Any injury inflicted upon an adult by other than accidental means which was
    inflicted by a spouse, child or other person responsible for that adult’s care.
3. Neglect - Any person that is abandoned by their custodian or whose custodian refuses to
    provide that person with proper necessary subsistence, education, medical, surgical or
    other necessary care for his/her health, moral or well being.
Nondiscrimination Statement
Emergency medical personnel shall serve as the patient’s advocate, and will provide prompt
urgent or emergency response, treatment and transport upon request, and shall have no
regard to race, color, religion, gender, national origin, age, disability, disease, marital status,
sexual orientation or any other factor.
Documentation
All patient contacts shall be appropriately documented using the appropriate patient care
reporting system. All patient care documentation is encouraged to be completed in an
organized fashion. C.H.A.R.T. format can assist in your narratives:
            C.H.A.R.T.
            Chief complaint
            History
            Assessment
            Rx (treatment)
            Transport
Selected Principles of Writing Narrative Comments
 Try to be chronological, including care prior to arrival of the ambulance.
 Include pertinent negatives.
 Describe, don't conclude, e.g., "pt. involved in accident" is much less informative than "pt.
    driver of car that hit truck head on at high speed".
 Record important observations about the scene, e.g., presence or absence of a gun, pill
    bottles, suicide note, etc.
 Only use approved abbreviations.
 Include changes in patient's condition after treatment or while en route.
 Identify the source of information when it is not the patient, especially when the
    information is of a sensitive nature.
 Check spelling and grammar. There are many references available.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 12
Dr. Mark Seher DO, Medical Director.
Professionalism
The following paragraphs were taken from Bledsoe’s “Paramedic Emergency Care Second
Edition,” and establish the foundation that all providers (volunteer or career) should strive for
and maintain.
    “Professionalism describes the conduct or qualities that characterize a practitioner in a
    particular field or occupation. Health care professionals promote quality patient care
    and take pride in their profession. They earn the respect and confidence of team
    members by performing their duties to the best of their abilities and by exhibiting a
    high level of respect for their profession. Attaining professionalism is not easy. It
    requires an understanding of what distinguishes the professional from the non-
    professional. To develop this skill, keep the following points in mind. Professionals
    place the patient first; non-professionals place their egos first. Professionals practice
    their skills to the point of mastery, and then keep practicing them to improve and
    remain sharp. Non-professionals do not believe their skills will fade and see no reason
    to constantly strive for improvement. Professionals understand the importance of
    response times; non-professionals get to an accident when it’s convenient.
    Professionals take refresher courses seriously, because they know they have forgotten
    a lot and because they are eager for new information. Non-professionals believe they
    don’t need training sessions and dislike being required to attend them. Professionals
    critically review their performance, always seeking a way to improve. Non-professionals
    look to protect themselves, to hide inadequacies, and to place blame on others.
    Professionals check out their equipment prior to the emergency response. Non-
    professionals hope that everything will work, supplies will be in place, batteries will be
    charged, and oxygen levels will be adequate. Maintaining professionalism requires
    effort. But, the result of that effort - the admiration and respect of one’s peers - is the
    highest compliment a person can receive.”
Being a professional has nothing to do with pay or rank or the level of certification that you
hold. It is the goal that every member of our Practice, from EMT - Basic to the Medical
Director, constantly strives for to remain a comprehensive, clinically sophisticated, and
compassionate EMS System.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 13
Dr. Mark Seher DO, Medical Director.
Section I – Patient Assessment
Patient Assessment Guidelines
Patient Assessment Tools
AVPU – Used to assess Level of Consciousness.
 A – Alert – eyes open.
 V – Responds to verbal stimuli.
 P – Responds only to painful stimuli.
 U – Unresponsive to verbal or painful stimuli.
OPQRST-ASPN – History tool for medical patients.
 O – Onset, when did pain/problem begin?
 P – Provocation, what makes pain/problem worse or better?
 Q – Quality, describe the pain/problem.
 R – Region/Radiation, where is pain/problem and does it radiate anywhere?
 S – Severity, rate pain on scale of 0 – 10.
 T – Time when pain/problem.
 AS – Associated Symptoms, any other pain/problems?
 PN – Pertinent Negatives, are likely associated symptoms absent?
SAMPLE – History tool for trauma patients.
 S – Signs/Symptoms
 A – Allergies
 M – Medications
 P – Past medical history
 L – Last oral intake
 E – Events preceding the incident
DCAP-BLS-TIC – Assessment method for signs/symptoms of injury.
 D – Deformity
 C – Contusions
 A – Abrasions
 P – Penetrations
 B – Burns
 L – Lacerations
 S – Swelling
 T – Tenderness
 I – Instability
 C – Crepitus




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 14
Dr. Mark Seher DO, Medical Director.
Scene Size Up
 Consider appropriate level of universal precautions. Assess the scene for dangers to the
    rescuers.
 Consider the number of patients, and mechanism of injury / nature of the illness. Request
    additional help if necessary.
Baseline Vital Signs
In most cases obtain and record a set of baseline vital signs as soon as practical. Standard
vital signs include:
 Heart /pulse rate
 Blood pressure
 Respiratory rate
 Pulse Oximeter reading when available
 Temperature when appropriate
EMT – Intermediate, EMT – Paramedic
   When indicated, initiate an IV of 0.9% Sodium Chloride at keep open rate, except as
    otherwise noted, see IV Procedure.
   Apply an EKG monitor for all cardiac patients (including 12-lead, see 12-Lead Procedure),
    multiple trauma patients and those receiving ACLS procedures or medications.

Initial Assessment
Begin an Airway, Breathing, Circulation approach to the patient to form a general impression
and establish the presence of a life threatening injury or illness. Obtain and record the chief
complaint of the patient.
1. Quickly assess level of consciousness using the AVPU method.
2. Assess the airway, maintaining C-Spine if indicated. Treat accordingly:
   a. Responsive - no intervention needed, proceed to step 3.
   b. Unresponsive - use the appropriate medical or trauma maneuver to open the airway.
   c. Airway remains partially or totally obstructed, continue attempts to clear the airway
   d. Use full C-Spine precautions if mechanism of injury and cervical spine involvement is
      unknown. When in doubt, immobilize.
      i) C-collar, LBB with straps x 3, CID, KED (or similar devices).
      ii) If female patient is pregnant (second or third trimester), tilt backboard on left side.
3. Assess adequacy of breathing:
   a. Observe chest rise and fall, listen to breath sounds anteriorly, posteriorly and
      peripherally.
   b. Observe for signs of distress - use of secondary muscles, cyanosis.
   c. Count the respiratory rate and obtain pulse oximeter reading (SpO2) if available.
   d. If breathing adequate - go to step 4.
   e. If breathing is inadequate and patient is unresponsive - assist breathing with BVM and
      100% O2, see Oxygen, Airway & Ventilation Guidelines.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 15
Dr. Mark Seher DO, Medical Director.
    f. If breathing is inadequate and patient is responsive - administer oxygen, see Oxygen,
       Airway & Ventilation Guidelines.
4. Assess the circulation/perfusion:
    a. Assess rate and quality of pulses - peripheral and central pulses.
       i) Palpable pulses indicating approximate systolic blood pressure (BP):
           (1) Carotid = Systolic BP of 60
           (2) Femoral = Systolic BP of 70
           (3) Radial = Systolic BP of 80
    b. Stop any active bleeding, assess skin color, temperature, and obtain blood pressure.
    c. If there is no palpable pulse or rate is too slow to maintain cerebral blood flow, perform
       basic life support according to the current guidelines.
    d. If bleeding is present - manage bleeding.
    e. Apply EKG monitor, when appropriate, especially for suspected cardiac problems and
       patients with a change in their level of consciousness.
5. Identify priority patients:
    a. Priority patients include those with compromises in airway, level of consciousness,
       breathing, and circulation. These are not easily remedied with basic intervention. Go to
       Rapid Assessment.
    b. If identified as a non priority medical or trauma patient, go to Non-Priority Medical
       and Trauma Patients.
6. Baseline vital signs should be obtained and recorded as soon as practical:
    a. Standard vital signs include: heart rate, respiratory rate, blood pressure, and pulse
       oximetry reading when available.
    b. Repeat and re-record vital signs every 5 to 15 minutes and after interventions.
7. Make a transport decision:
    a. Consider air-medical transport when necessary.
8. Talk with patient’s relatives and/or bystanders and gather additional pertinent information.
9. Place the patient in their position of comfort unless contraindicated by patient condition.
10. Always attempt to minimize patient exertion.

Focused History and Physical Exam
Non-Priority Medical and Trauma Patients
1. If the patient is unresponsive, go to Rapid Assessment.
2. Gather the patient’s history of present illness/injury using the OPQRST-ASNP or SAMPLE
    method if possible.
3. Assess the affected body part/system based on Chief Complaint:
  a. If indicated at any time, go to Rapid Assessment.
4. Provide treatment and interventions based on the signs and symptoms following these
    PCGs.
5. Continue with Detailed Assessment as appropriate.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 16
Dr. Mark Seher DO, Medical Director.
Rapid Assessment
Priority Medical and Trauma Patients
Perform a Rapid Assessment on all priority transport patients after the Initial Assessment.
Manually control the spinal column for patients with a mechanism of injury or nature of illness
consistent with the possibility of spinal cord injury and after the rapid assessment provide full
spinal immobilization.
Assess for any signs of DCAP-BLS TIC:
1. Head, Ears, Eyes, Nose, Throat:
   a. Head: for signs of trauma.
   b. Ears: look for blood, CSF or foreign bodies.
   c. Pupils: symmetric & responsive to light.
   d. Nose: injury, blood or CSF.
   e. Throat: bleeding or obstruction.
   f. Neck: pain, stiffness or injury, JVD, obvious injury, employs cervical spine precautions.
2. Chest and Abdomen:
   a. Chest: signs of blunt or penetrating trauma, bleeding, symmetrical chest wall
        movement, pain upon palpation or other visible injury.
   b. Breath Sounds: present in all lung fields, abnormal sounds (wheezing, rales, rhonchi, or
        diminished).
3. Abdomen: blunt or penetrating injury, pain, tenderness, rigidity, or guarding.
   a. Bowel sounds: present or absent.
   b. Pelvis: stability, history of trauma.
4. Extremities and Back:
   a. Extremities: lower and upper extremities.
   b. PMS: Assess for presence of pulse, sensation, and motor function, edema, signs of poor
        perfusion.
   c. Back: visible signs of injury or pain. Patients with possible spinal injury, assess during
        log roll.
5. Neurological Survey:
   a. Pupils: equality & reactive to light.
   b. LOC: AVPU
6. Past Medical History:
   a. SAMPLE
7. Exposure: Expose the patient, keeping modesty in mind. Keep patient warm.
8. Obtain Baseline Vital Signs.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 17
Dr. Mark Seher DO, Medical Director.
Detailed Assessment
Package multiple body system trauma patients using a properly fitting cervical collar, spinal
immobilization device and /or long back board, at least 3 patient immobilization straps and an
acceptable cervical immobilization device. Complete a detailed examination of the patient in
route to the hospital as needed or as time permits. Utilize a “head to toe” approach similar to
the Rapid Assessment (except slow and detailed). Assess for DCAP-BTLS (5-10 minutes).

Ongoing Assessment
Repeat Initial Assessment and obtain vital signs every 5 minutes for priority patients and every
15 minutes for non-priority patients or as often as practical during transport. Reassess all
interventions performed.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 18
Dr. Mark Seher DO, Medical Director.
SECTION II – Transport Guidelines
Following your current certification:
1. Transportation to the hospital shall be offered to any patient that request transport for
    their complaint.
2. Perform Initial, Focused, Detailed, and On-going assessments including a past medical
    history of every patient transported.
3. When possible, bring the patient’s medications to the hospital with the patient. Include all
    over-the-counter and non-prescription medications, including supplements and herbal
    remedies.
4. Transport the patient as comfortably as possible following appropriate protocols.
5. Advise receiving facility as soon as possible of patient status and all changes in condition
    via radio and/or telephone.
6. EMT-Basic and EMT-Intermediates are expected to transport immediately, unless an ALS
    unit is en route and has an ETA of less than 5 minutes.
7. All patients with abnormal vital signs or with potential deterioration in vital signs should be
    transported to an appropriate medical facility. In most cases, this will imply transport of
    the patient to the closest medical facility with an emergency department.
8. Patients with vital signs within normal limits and patients that are not in imminent danger
    that require transport may be taken to the patient’s facility of choice provided that it is
    within a reasonable transport time and will not result in undue stress to the EMS system.
    Generally, the crew should honor the patient’s wishes when it is acceptable under the
    conditions of this protocol.
9. Transportation should be provided by an ALS unit, if available for:
    a. Recent complaint of chest discomfort/pain.
    b. Abnormal difficulty in breathing.
    c. Any need for cardiac monitoring.
10. Transportation must be provided and patient cannot refuse when they appear impaired
    (See Patient Refusal Guidelines).
11. Trauma Transports – see Trauma Triage Protocol.

Air – Medical Transport Guidelines
The decision to access an air medical response will generally be made by the first arriving EMS
vehicle. The EMS unit should advise Fire Control for the need of the medical helicopter. In
general air medical services should be restricted for only special situations:
 When the speed of transport will make a significant difference in patient outcome.
 When the smoothness of the ride will affect patient outcome.
 When the scene is not accessible by ground vehicle.
 When there will be a decrease in the transport time of 10 minutes or greater by using a
   helicopter.
 Significantly injured trauma patients.
 Hypothermic patients in cardiopulmonary arrest.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 19
Dr. Mark Seher DO, Medical Director.
    Carbon monoxide exposures with cardiac dysrhythmias, chest pain, altered mental status,
     or cardiopulmonary arrest may be transferred to a specific facility for hyperbaric oxygen
     therapy.
    Pediatric multiple trauma with extended transport times.

Load and Go Guidelines
1.   Airway obstruction uncorrectable in the field.
2.   Traumatic cardiopulmonary arrest.
3.   Uncontrolled arterial bleeding.
4.   Severe signs of shock.
5.   Major chest injury (i.e., tension pneumothorax, pericardial tamponade, massive
     hemothorax, sucking chest wound, penetrating wounds with shock, flail chest).
6.   Bilateral femur fractures and/or unstable pelvis.
7.   Head injury with decreasing level of consciousness and/or unilateral dilated pupil.
8.   Symptomatic pregnancy.
9.   The only field treatments to be instituted prior to transport are as follows:
     a. Airway management with C-Spine control, 100% O2. Maintain ETCO2 at 25 to 40
         mmHg for intubated patients.
     b. Chest wound management (i.e., tension pneumothorax, sucking chest wound, flail
         chest stabilization).
     c. Basic CPR in cases of trauma arrest.
     d. IV’s (if placed during extrication or during transport), C-Collar and backboard (when
         appropriate), and cardiac monitor.
     e. First round ACLS medications.
     f. PASG Trousers (for unstable pelvic and femur fractures ONLY).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.      Page 20
Dr. Mark Seher DO, Medical Director.
SECTION III – Trauma / Multi - System Injuries
Traumatic Arrest
Traumatic arrests are load and go situations (See Load and Go Guidelines). Constantly
reassess ABCDEs and consider causes for arrest and potential interventions. Loss of airway
and hypovolemic shock is by far the most common causes of traumatic arrest. Assess for
mechanism of injury to determine additional rapid interventions needed, (i.e. with thoracic
mechanism – consider tension pneumothorax, cardiac tamponade). See separate protocols for
procedure details.
EMT – Basic
1. Start CPR and follow PNB Guidelines:
   a. Maintain airway and initiate high flow oxygen.
   b. Assume spinal injury and treat accordingly.
2. Place advanced airway (maintaining cervical spine precautions):
   a. Assess breathing and success of advanced airway – intervene PRN.
3. Contact designated hospital ASAP and initiate transport without delay unless resuscitation
   is deemed futile or an ALS unit is en route and has an ETA of less than 5 minutes.
4. If decision to transport is made, choose closest Emergency Department regardless of
   trauma status, and inform the ER of patient’s condition as early as possible enroute.
EMT – Intermediate
5. Place two large bore IV's and give wide open warmed NS via blood tubing:
   a. If IV cannot be established consider IO (see IO procedure).
6. Apply cardiac monitor following PNB and appropriate arrhythmia guidelines.
Paramedic
7. Suspected Pericardial Tamponade:
   a. Do not delay transport!




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 21
Dr. Mark Seher DO, Medical Director.
Thoracic Trauma
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. Open chest wounds:
   a. Cover sucking wound with a non-porous dressing (Vaseline gauze, jelled defibrillator
       pad, cellophane) taped over three sides.
   b. Reassess adequacy of ventilation.
   c. If ventilation is inadequate, consider positive pressure ventilation via BVM. Monitor
       closely for development of tension pneumothorax.
3. Flail Chest (paradoxical movement of portion of chest wall):
   a. Stabilize flail segment with bulky dressing and tape if possible.
   b. Reassess adequacy of ventilation.
   c. Assisted positive pressure ventilations using a BVM may be indicated and may also
       serve as an “internal splinting” of the flail segment due to lung expansion.
4. Simple Pneumothorax:
   a. Treatment is supportive.
   b. Monitor for development of tension pneumothorax particularly if positive pressure
       ventilation is used.
5. Impaled foreign objects:
   a. Do not remove.
   b. Stabilize object with bulky dressing and transport.
6. Control external bleeding.
7. Apply pulse oximeter.
8. Consider air-medical transport when necessary.
EMT – Intermediate
9. Place two large bore IV's and give wide open warmed NS via blood tubing:
    a. If IV cannot be established consider IO (see IO procedure).
10. Apply cardiac monitor.
11. Open (Sucking) Chest Wound:
    a. Cover wound with “Aschermann Chest Seal” or equivalent. Reassess adequacy of
       ventilation. Monitor closely for development of tension pneumothorax.
Paramedic
12. Tension Pneumothorax (See Needle Decompression Procedure).
13. Suspected Pericardial Tamponade or Myocardial Contusion:
    a. Anticipate hypotension and dysrhythmias. Treat accordingly.



EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 22
Dr. Mark Seher DO, Medical Director.
Head Trauma
Hyperventilation and EtCO2 Levels: Prophylactic hyperventilation for head injury is no
longer recommended. Cerebral herniation syndrome is the only situation in which
hyperventilation (rate of 20 per minute) is still indicated.
An increase in the level of CO2 (hypoventilation) promotes cerebral vasodilation and increased
swelling, while lowering the level of CO2 (hyperventilation) promotes cerebral vasoconstriction
and cerebral ischemia. Hyperventilation causes a significant decrease in cerebral perfusion
from vasoconstriction, which results in cerebral hypoxia. Thus, both hyperventilation and
hypoventilation cause cerebral hypoxia and increase mortality.
The one time you may hyperventilate is cerebral herniation syndrome. In cerebral herniation,
there is a sudden rise in intracranial pressure, portions of the brain may be forced downward,
applying great pressure on the brainstem. This is a life-threatening situation characterized by a
decreased LOC that rapidly progresses to coma, dilation of the pupil and an outward-
downward deviation of the eye on the side of the injury, paralysis of the arm and leg on the
side opposite the injury, or decerebrate posturing. When this is occurring, the vital signs
frequently reveal increased blood pressure and bradycardia. The patient may soon cease all
movement, stop breathing, and die. If these signs are developing in a head injury patient,
cerebral herniation is imminent and aggressive therapy is needed. Hyperventilation will
decrease ICP. In this situation, the danger of immediate herniation outweighs the risk of
ischemia.
Continually assess Level of Consciousness (AVPU/Glasgow Coma Scale), pupil response as well
as the ABCs, disability and Vital Signs. Examine head for presence of lacerations, depressions,
swelling Battle Sign, Cerebrospinal Fluid (CSF) from ears/nose, and foreign (impaled) objects.
Determine presence or absence of significant neurologic signs and symptoms: motor function,
sensory      function,   reflex   responses,      visual   inspection,  bradycardia,    priapism,
hypotension/hypertension, loss of sweating or shivering and loss of bladder/bowel control.
Anticipate neurogenic shock, secondary to a spinal cord injury, and be prepared to support
vital signs.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury and treat accordingly.
2. Ventilate apneic or hypoventilating patients with BVM. Ventilation rates (breaths per
   minute-bpm):
   a. 10 bpm for adults (every 6 seconds)
   b. 20 bpm for children (every 3 seconds)
   c. 25 bpm for infants (every 2.5 seconds)
3. Unconscious or unresponsive patients that exhibit the following signs; dilated unreactive
   pupils, asymmetric pupils, nonresponsive to painful stimuli, displaying extensor posturing,
   then hyperventilate at these rates:
   a. 20 bpm for adults (every 3 seconds)
   b. 30 bpm for children (every 2 seconds)
   c. 35 bpm for infants (every 1.7 seconds)
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 23
Dr. Mark Seher DO, Medical Director.
4. Anticipate seizures. If seizures develop, see Seizure Guidelines.
5. Apply pulse oximeter.
6. Consider air-medical transport when necessary.
EMT – Intermediate
7. Establish IV of 0.9% NS at an infusion rate to maintain a systolic blood pressure above:
   a. 13 years to adult > 90 mm Hg
   b. 6-12 years > 80 mm Hg
   c. 2-5 years > 75 mm Hg
   d. 0-1 years > 65 mm Hg
8. If signs and symptoms of hypovolemia or neurogenic shock are present, rapid IV fluid
   bolus as per Multiple Trauma General Guidelines.
9. Apply cardiac monitor.
EMT – Paramedic
10. If Glasgow Coma Score (GCS) < 9 or decreased by > 2 points, orally intubate patient
    {preferably by RSI}.
Pediatric Specifics
   Administer a 20 ml/kg bolus - repeat x 2.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 24
Dr. Mark Seher DO, Medical Director.
Musculoskeletal / Extremity Trauma
The patient who requires a load and go approach can have musculoskeletal/extremity trauma
adequately immobilized by careful packaging on the long backboard. You can then do some
additional splinting in the vehicle en route to the hospital as time and the patient’s condition
permits.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic
1. Maintain airway and initiate oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. Control external bleeding:
   a. Open wounds should be covered with a sterile dressing before you apply splints.
3. Manually immobilize above and below injury site:
   a. Assess PMS (pulse, motor, and sensation). Compare PMS to uninjured limb.
   b. If PMS impaired, reposition. Apply gentle distal aligning traction. If you feel resistance
      or increase patient discomfort, stop! Only attempt alignment one time.
   c. Reassess PMS every 5 to 10 minutes.
4. Apply appropriate splinting device:
   a. Document PMS pre and post splinting.
5. Apply Pulse Oximeter.
6. Consider air-medical transport when necessary.
EMT – Intermediate
7. Initiate IV NS.
Paramedic
8. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
       25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
       minutes. Max cumulative dose 10 mg.
9. Apply cardiac monitor.
10. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
       repeat once. Max cumulative dose 8 mg.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 25
Dr. Mark Seher DO, Medical Director.
Splinting Suggestions for Specific Orthopedic Injuries
     Site               Injury                          Suggested Immobilization
 Clavicle             Fracture            Sling and swath
 Shoulder             Dislocation         Splint in position found with pillow, sling and swath
 Humerus              Fracture            Short board splint & sling and swath
 Elbow                Fracture            Splint in position found
 Elbow                Dislocation         Splint in position found
 Forearm              Fracture            Rigid splint and sling
 Wrist                Fracture            Splint in position found
 Hand                 Fracture            Splint in position of function
 Finger               Fracture            Malleable padded splint in position of function
 Pelvis               Fracture            *PASG or Sam Sling & long board
 Hip                  Fracture            Blanket between legs & secure injured leg to uninjured
                                          leg or KED, backboard, Vacuum splint
 Hip                  Dislocation         Long board with leg supported with pillow, Vacuum
                                          splint
 Femur                Fracture            *Sager splint, *PASG
 Knee                 Fracture            Splint in position found
 Knee                 Dislocation         Splint in position found unless instructed to reduce.
 Tibia/fibula         Fracture            Vacuum splint, Air splint, padded board splint
 Ankle                Fracture            Pillow splint or air splint, Vacuum splint
 Ankle                Dislocation         Pillow splint or air splint, Vacuum splint
 Toe                  Fracture            Tape to adjacent toe
*PASG, Sager or other Traction splints are EMT procedures only.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                  Page 26
Dr. Mark Seher DO, Medical Director.
Avulsion & Amputation
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. Control bleeding and splint.
3. Amputated Body Parts and/or Tissue:
   a. Rinse part(s) with NS.
   b. Wrap tissue in sterile gauze moistened with NS.
   c. Place tissue into plastic bag or container.
   d. Place bag / container into separate container filled with ice.
       i) Do not allow tissue to come into direct contact with ice.
4. Tooth Avulsion:
   a. Handle tooth by chewing surface only. Avoid touching the root.
   b. Rinse with water. Do not scrub, dry, or wrap tooth in tissue or cloth.
   c. Place tooth in container of (in order of preference):
       i) Patient’s Saliva
       ii) Milk
       iii) Normal Saline
       iv) Water
5. If incomplete avulsion, do not remove. Attempt to clean with gross irrigation and sterile
   dressing.
6. Apply pulse oximeter.
7. All retrievable tissue should be transported (do not delay transport for tissue retrieval).
8. Consider air-medical transport when necessary.
EMT – Intermediate
9. Initiate IV NS.
Paramedic
10. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
       25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
       minutes. Max cumulative dose 10 mg.
11. Apply cardiac monitor.
12. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
       repeat once. Max cumulative dose 8 mg.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.      Page 27
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 28
Dr. Mark Seher DO, Medical Director.
Ocular Emergencies
When possible determine type of chemical involved first. Always obtain name and, if possible,
the Material Safety Data Sheet (MSDS), or ask that name or MSDS be brought to the hospital
as soon as possible. Knowing the pH of the chemical is crucial information for the ER.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic
1. Initiate oxygen.
2. Chemical Injury / Exposure:
   a. The eye should be flushed with copious amounts of water or Saline. Irrigate for a
       minimum of 20 minutes, starting as soon as possible, and continue until the pain is
       relieved. Any delay may result in serious damage to the eye.
3. Penetrating Injuries:
   a. Stabilize impaled objects, apply metal eye shield if possible. Cover both eyes.
4. Open Eye Injuries or Torn Eyelid:
   a. Apply sterile dressing soaked in normal saline. Cover both eyes.
5. Apply pulse oximeter.
6. Transport patient supine if possible.
EMT – Intermediate
7. Initiate IV NS.
8. Consider the use of a nasal cannula and IV tubing for irrigation.
9. Apply cardiac monitor.
Paramedic
10. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
        25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg.
11. In cases where eyes may need irrigation, and other appropriate situation with significant
    eye pain, administer Tetracaine (Pontocaine) - 2 drops in the affected eye or eyes
    prior to irrigation:
    a. Ideally, it should be placed in the eye prior to irrigation, but must not delay the
        irrigation.
    b. Tetracaine (Pontocaine) must not be used if there is a possibility of penetrating
        trauma to the eye.
12. Chemical Injury / Exposure:
    a. Consider Morgan Lens for irrigation after administration of Tetracaine (Pontocaine).
13. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
        repeat once. Max cumulative dose 8 mg.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 29
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.
   Tetracaine (Pontocaine) - 2 drops in the affected eye or eyes prior to irrigation.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 30
Dr. Mark Seher DO, Medical Director.
Crushing Injury & Crush Syndrome
If patient has been trapped/pinned for longer than 20 to 30 minutes, and exhibits
signs/symptoms of relevant mechanism of injury to suspect crushing injury:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
**PRIOR TO EXTRICATION**
EMT – Basic
1. Refer to General Trauma and Specific Trauma Protocols if applicable.
2. Coordinate time of release with rescue personnel.
3. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
4. Anticipate crush syndrome and cardiac arrest at time of, or immediately after, extrication.
5. Contact receiving hospital of patient’s injuries early.
6. Apply pulse oximeter.
7. PASG are contraindicated in crushing injury patients.
8. Consider air-medical transport when necessary.
EMT – Intermediate
9. Initiate at least one large bore IV NS.
10. Apply cardiac monitor.
Paramedic
11. Mix Sodium Bicarbonate - 1 amp per liter of NS solution IV/IO. Infuse 1500ml/hr
    until extrication, THEN administer 1.0 to 1.5 liter bolus of mixture IV/IO right before
    extrication.
**AFTER EXTRICATION**
EMT – Intermediate
12. Continue aggressive fluid resuscitation with NS and TRANSPORT IMMEDIATELY!
13. Watch the patient and monitor closely for:
    a. Widened QRS complexes – 0.12 seconds or greater.
    b. Presence of PVC’s.
    c. Ventricular Tachycardia/V-Fib/Idioventricular rhythms.
    d. Cardiovascular compromise and/or cardiac arrest.
Paramedic
14. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
       25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
       minutes. Max cumulative dose 10 mg.
15. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
       repeat once. Max cumulative dose 8 mg.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 31
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 32
Dr. Mark Seher DO, Medical Director.
Animal / Reptile Bites & Insect Stings
Obtain identifying information of the animal, insect or reptile, including size, color, markings,
shape of the head, location of the event, how it happened, and if the predator was captured.
Notify animal control and law enforcement if appropriate. Mark margins of wounds, swelling,
and/or redness with pen. If stinger is present, attempt to remove.
Watch for signs & symptoms of anaphylaxis, and treat according to Anaphylaxis Guidelines.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic

1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. If appropriate, immobilize affected limb.
3. Minimize patient exertion.
EMT – Basic
4. Apply pulse oximeter.
EMT – Intermediate
5. Initiate IV NS:
   a. Titrate IV fluids to maintain a systolic BP > 90 mmHg.
6. Apply cardiac monitor.
Paramedic
7. If patient severely anxious or in severe pain, consider pain control if systolic BP > 90
   mmHg:
   a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
       25 mcg increments. Max cumulative dose 150 mcg. - OR -
   b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
       minutes. Max cumulative dose 10 mg.
8. In addition to pain control consider:
   a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
       repeat once. Max cumulative dose 8 mg.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 33
Dr. Mark Seher DO, Medical Director.
Sexual Assault
The terms sexual assault and sexual abuse refer to any act of sexual contact or conduct
performed upon one person by another, and without mutual consent, or with an inability of
the victim to give consent due to age, mental or physical incapacity. This protocol should also
be used for other forms of sexual assault (sex crimes perpetrated against adults), and sexual
abuse (sex crimes perpetrated against children and adolescents).
Patient confidentiality is a priority. Providing care to sexual assault patients requires special
sensitivity. Social, cultural, and religious practices may cause patients additional stress if they
are concerned about discriminatory treatment as they are seeking support.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic / EMT – Intermediate / Paramedic
1. Documentation:
       a. Chief complaint (do not use alleged, probable, or possible):
               i. If the patient volunteers information, ascertain all body areas violated in the
                  assault.
              ii. Use patient’s quotes using only the exact statements given. Do not
                  paraphrase.
       b. Time, date and place of the assault.
       c. All marks or evidence of trauma.
       d. Other significant physical findings.
       e. Medical history, including possibility of pregnancy.
       f. All treatment given.
2. Physical Exam:
       a. Explain all procedures to be performed before undertaking them.
       b. Limit the physical exam to any details you can visually obtain without causing any
          further emotional distress to the patient.
3. If the victim is still wearing the clothing worn during the assault, suggest she he/she take
   other clothing with him/her to be worn home:
       a. If the patient changed clothes after the assault, clothing must be brought along to
          the hospital in a paper bag:
               i. Plastic bags trap moisture and promote mildew, which destroys vital
                  evidence.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 34
Dr. Mark Seher DO, Medical Director.
SECTION IV – Environmental Emergencies
Burns
Even if the patient appears to be breathing well, watch carefully any signs of burn injury to the
mouth/nose or potential for airway edema from inhalation injury (carbonaceous sputum,
hoarse voice, stridor, etc). Refer to General Trauma and Specific Trauma Protocols when
applicable. The following "Major Burn" patients should be transported to closest most
appropriate facility:
    Burns associated with other significant traumatic injuries or significant co-morbidities.
    Burns involving complex body areas (hands, feet, face, genitalia).
    Second and third degree burns involving greater than 15% BSA.
    All significant chemical or electrical burns.
    All significant pediatric burns.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. Cool acute burns (including chemical burns) if <10% BSA using profuse irrigation (sterile
   water is best – or sterile saline). Once cooled, cover the burns with sterile, dry dressings.
3. Prevent hypothermia - keep patient treatment area warm, use warm blankets.
4. Apply pulse oximeter.
5. Consider air-medical transport when necessary.
EMT – Intermediate
6. Apply cardiac monitor.
7. Place IV's and administer IV fluids according to general trauma guidelines for all major
   burns – 2 liters NS initially for adults.
8. If patient is exhibiting any signs of bronchospasm or inhalation injury administer Albuterol
   (Proventil) - 2.5 mg (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg
   of Ipratropium (Atrovent):
   a. Albuterol ONLY may be given by continuous administration.
Paramedic
9. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
        25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg.
10. Even if the patient appears to be breathing well, consider advanced airway if patient has
    any signs of burn injury to the mouth/nose or potential for airway edema from inhalation
    injury (carbonaceous sputum, hoarse voice, stridor, etc.) – see {RSI} Protocol.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 35
Dr. Mark Seher DO, Medical Director.
11. If a closed space fire victim, suspect cyanide toxicity in anyone who has a decreased level
    of consciousness and is not responding to O2, consider:
    a. Administer Sodium Thiosulfate - 12.5 grams IV/IO over ten minutes. Mixing
        suggestion; inject 12.5 grams into a 50 ml bag of NS (gives 100 ml total).
        Administer 10 ml/minute. One time dose.
12. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
        repeat once. Max cumulative dose 8 mg.
Pediatric Specifics
   Administer a 20 ml/kg bolus - repeat x 2.
   Albuterol Sulfate (Proventil) - 2.5 mg (diluted in 3 ml NS) nebulized. May be
    given by continuous administration.
   Ipratropium (Atrovent) - NOT recommended for pre-hospital use in children.
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.
   Sodium Thiosulfate - 8 grams IV/IO over ten minutes. Mixing suggestion; inject
    8 grams (32 ml) into 50 ml bag of NS (gives 82 ml total). Administer 8
    ml/minute. One time dose.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 36
Dr. Mark Seher DO, Medical Director.
Hypothermia
Pulse and respiratory rates will be slow, breathing will be shallow, and peripheral
vasoconstriction will make pulses difficult to feel. For these reasons assess for breathing and
then for a pulse to confirm respiratory arrest, pulseless cardiac arrest, or bradycardia profound
enough to require CPR.
Handle gently avoiding rough movements. Maintain horizontal position. Do not allow
conscious patients to ambulate or move about.
Remember the general rule that a patient isn’t dead, until they are WARM and dead.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
2. Prevent further heat loss with warm blankets. Remove wet clothing if applicable.
3. Apply heat packs to neck, axillae and groin.
4. If possible measure body core temperature.
5. If PNB and body core temperature ≥ 93° F follow usual PNB / Trauma Protocols as
   indicated by the circumstances.
6. If PNB and body core temperature < 86° F:
   a. Withhold AED shocks.
7. Begin passive rewarming:
   a. Turn heat up as warm as possible.
8. Consider air-medical transport when necessary.
EMT – Intermediate
9. Initiate IV NS using warmed IV fluids.
10. Apply cardiac monitor:
    a. If extremely cold, it may be impossible to record the cardiac rhythm using adhesive
        electrodes.
11. If patient is PNB and body core temperature is < 93° F but > 86° F:
    a. Defibrillation x 1 and intubation can be attempted.
12. If PNB and body core temperature < 86° F:
    a. Withhold defibrillation attempts. The fibrillating myocardium at this temp is unlikely to
        respond. Shocks can resume whenever the core temperature is > 86°.
Paramedic
13. If patient is PNB and body core temperature is < 93° F but > 86° F:
    a. Attempt one round of ACLS medications. Double normal time intervals for medications
14. If PNB and body core temperature < 86° F:
    a. Withhold IV medications.



EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 37
Dr. Mark Seher DO, Medical Director.
Heat Related Illness / Hyperthermia / Temperature Instability
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
2.    Move patient to cool environment.
3.    Apply cold packs to neck, axillae and groin.
4.    If possible, measure body core temperature.
5.    Initiate oxygen.
6.    Be prepared for seizures, see (Seizure Guidelines).
7.    Apply pulse oximeter.
EMT – Intermediate
8. Initiate IV NS.
9. Apply cardiac monitor.
Paramedic
10. Treat arrhythmias according to specific protocols.
Pediatric Specifics
    In febrile pediatric patients, remove excess clothing.
    Obtain patient’s temperature (rectal preferable) if available in patients under 2
     years old.
    If temperature > 100.8° F, administer Children’s Acetaminophen (Tylenol) - 15
     mg/kg PO.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 38
Dr. Mark Seher DO, Medical Director.
SECTION V – Cardiac Emergencies
CPR Critical Concepts
1.     If no indication of DNRCC or DNRCC-Arrest proceed with resuscitation.
2.     Follow current American Heart Association guidelines.
3.     Good quality CPR improves chances of survival.
4.     If victim is not on a hard surface, place a back board or other rigid surface between the
       victim and the bed or move victim to the floor.
5.     Minimize interruptions in chest compressions to 10 seconds or less.
6.     Push hard, push fast; compress at a rate of 100 compressions per minute with depth
       of 1½ - 2 inches.
7.     Allow full chest recoil after each compression.
8.     Consider rotating compressors every 2 minutes with rhythm analysis.
9.     Perform a pulse check – preferably during rhythm analysis – only if an organized rhythm
       is present (EMT-I & EMT-P).
10.    If unwitnessed arrest or response time greater than 4 to 5 minutes:
       a. Perform 5 cycles or 2 minutes of CPR before using AED or manual
            defibrillator.
       b. Attach Bag Mask Valve to high flow oxygen when available.
11.    Compression to ventilation ratio without advanced airway – 30:2.
12.    Compression to ventilation ratio with advanced airway – approximately 1 breath every 6
       to 8 seconds (8 to 10 breaths per minute) without attempting to synchronize breaths
       between compressions.
13.    If there is no response to an adequate trial of ALS on the scene, termination of
       resuscitation should be considered. (See Terminating or Withholding of Resuscitation
       protocol).
14.    Patients exhibiting deemed “inappropriate for resuscitative efforts” (See Terminating or
       Withholding of Resuscitation Guidelines) will not have resuscitation initiated.
Pediatric Specifics
     Compression depth - 1/3 to 1/2 depth of chest.
     1 rescuer 30:2, 2 rescuers 15:2.
     If pulse is < 60 bpm with signs of poor perfusion, start CPR.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 39
Dr. Mark Seher DO, Medical Director.
Arrhythmia Guidelines
In the treatment of cardiac arrhythmias, current American Heart Association guidelines were
referred to for protocol development.
Consider Differential Diagnosis in search for treatment of reversible causes:
       Hypovolemia                               Toxins
       Hypoxia                                   Tamponade, cardiac
       Hydrogen ion (acidosis)                   Tension pneumothorax
       Hypo-/hyperkalemia                        Thrombosis (coronary or pulmonary)
       Hypoglycemia                              Trauma
       Hypothermia
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1.   Maintain airway and initiate high flow oxygen.
2.   Make patient comfortable and provide reassurance.
3.   Evaluate patient's general appearance and relevant history of condition.
4.   Apply pulse oximeter.
5.   Establish early communications with receiving hospital and advise of patient condition.
EMT – Intermediate
6. Apply cardiac monitor.
7. Initiate IV NS.
Paramedic
8. Obtain 12-lead EKG, (see 12 Lead Guideline).
9. Treat arrhythmias according to specific protocols.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 40
Dr. Mark Seher DO, Medical Director.
Pulseless Non-Breathing (PNB) Guidelines
Paramedics are expected to provide resuscitation at the scene. You should not consider
transporting PNB patients before completing an adequate trial of BLS and ACLS interventions.
Consider Differential Diagnosis in search for treatment of reversible causes:
       Hypovolemia                                Toxins
       Hypoxia                                    Tamponade, cardiac
       Hydrogen ion (acidosis)                    Tension pneumothorax
       Hypo-/hyperkalemia                         Thrombosis (coronary or pulmonary)
       Hypoglycemia                               Trauma
       Hypothermia
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Follow CPR Critical Concepts and activate ALS.
2. Maintain airway and initiate high flow oxygen.
   a. Assume spinal injury, if indicated, and treat accordingly.
3. Use Automated External Defibrillator (AED) if available (See AED Guidelines).
4. Establish early communication with receiving facility advising of cardiac arrest.
5. Consider advanced airway following appropriate procedures.
   a. If unable to secure an advanced airway, basic airway maneuvers with BVM,
      nasopharyngeal airway adjunct, oropharyngeal airway adjunct, combi-tube, or LMA is
      acceptable.
   b. Minimize interruptions in chest compressions to 10 seconds or less.
EMT – Intermediate
6. Apply cardiac monitor.
7. If Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia:
   a. Defibrillate with 200 joules biphasic or 360 joules monophasic.
       i) Continue CPR while defibrillator is charging if charging takes > 10 seconds.
   b. Newer defibrillators using biphasic technology require lower energy doses and self-
       regulate the appropriate electrical energy delivered. When not specified, or when a
       different device (other than those normally used by emergency medical personnel), or if
       device deployment changes after publication of the PCGs, all protocols assume energy
       levels as set by the manufacturer recommendations for the device.
8. Immediately resume CPR after the shock starting with chest compressions for 5 cycles
   (about 2 minutes), then recheck rhythm:
   a. If a nonshockable rhythm is present and the rhythm is organized (complexes appear
       regular and narrow), try to palpate a pulse (not exceeding 10 seconds) if no pulse
       resume CPR.
   b. Continue CPR/defibrillation sequence for persistent VF/VT.
9. Initiate IV/IO NS, run wide open.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.      Page 41
Dr. Mark Seher DO, Medical Director.
Paramedic
10. Go to appropriate arrhythmia protocol or other protocol based on suspected etiology of the
    arrest.
11. When IV/IO access is available, give medications during CPR:
    a. ET absorption of drugs is poor, for this reason IV/IO route is preferred.
    b. Approved medications should only be administered via ET when an IV/IO cannot be
       established (after at least two failed IV/IO attempts), dose is 2 to 2 ½ times the typical
       IV/IO dose.
Pediatric Specifics
   Defibrillate 2 J/kg repeat at 4 J/kg.
   Compression depth - 1/3 to 1/2 depth of chest.
   1 rescuer 30:2, 2 rescuers 15:2.
   If pulse is < 60 bpm with signs of poor perfusion, start CPR.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 42
Dr. Mark Seher DO, Medical Director.
Ventricular Fibrillation / Pulseless Ventricular Tachycardia
Paramedic
Paramedics are expected to provide resuscitation at the scene. You should not consider
transporting PNB patients before completing an adequate trial of BLS and ACLS interventions.
Record a Lead II ECG strip before, during and after defibrillation attempts.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
1. Vasopressor Agents:
    a. Vasopressin (Pitressin) - 40 units IV/IO. One time dose to replace 1st or 2nd
       dose of Epinephrine. - OR -
    b. Epinephrine - 1 mg IV/IO (1:10,000) OR 2 - 2.5 mg ETT (1:1,000) diluted in
       10 ml NS, if unable to start an IV/IO. May repeat every 3 to 5 minutes. No max dose.
2. After a total of 2 or 3 shocks, separated by cycles of CPR and administration of a
    vasopressor, consider the use an Antiarrhythmic.
3. Antiarrhythmic Agents:
    a. Amiodarone (Cordarone) - 300 mg IV/IO. May repeat 150 mg IV/IO once in 3
       to 5 minutes.
    b. If rhythm converts to a perfusing rhythm, hang a maintenance infusion. Infuse 1
       mg/min. Mixing suggestion; inject 100 mg into 100 ml bag of NS. Initiate
       infusion with a 60 gtt set. - OR -
    c. Lidocaine (Xylocaine) - 1 to 1.5 mg/kg IV/IO. May repeat half of original dose
       every 3 to 5 minutes PRN. Max cumulative dose 3 mg/kg.
       i) If rhythm converts to a perfusing rhythm, hang a maintenance drip. Premix of
           2 grams in 500 ml infuse at 2 to 4 mg/min IV/IO (30 to 60 gtts/min).
4. For Torsades de points consider:
    a. Magnesium Sulfate - 2 grams slow IV/IO over 5 minutes. Premix available in
       50 mL NS.
5. If prolonged resuscitation with effective ventilation unresponsive to drug and electrical
    therapies, diabetic ketoacidosis, tricyclic antidepressant or aspirin overdose, consider:
    a. Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100
       mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
6. If chronic dialysis patient and/or suspected hyperkalemia, consider:
    a. Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100
       mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
7. Insert {NG} tube PRN.
Pediatric Specifics
   Defibrillate 2 J/kg repeat at 4 J/kg.
   Vasopressin (Pitressin) is NOT INDICATED in pediatrics!
   Epinephrine - 0.01 mg/kg (1:10,000) IV/IO OR 0.1 mg/kg (1:1,000) via ETT if
    unable to start an IV/IO. May repeat every 3 to 5 minutes:
    o Maximum single dose 1 mg.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 43
Dr. Mark Seher DO, Medical Director.
    o No maximum cumulative done.
   Amiodarone (Cordarone) - 5 mg/kg IV/IO bolus (max first dose 300 mg). May
    repeat 2.5 mg/kg IV/IO (max second dose 150 mg) once in 3 to 5 minutes.
   Lidocaine - 1 mg/kg IV/IO (max single dose 100 mg). May repeat half of
    original dose every 3 to 5 minutes PRN. Max cumulative dose 3 mg/kg:
    o If rhythm converts to a perfusing rhythm, hang a Lidocaine (Xylocaine) drip.
       Mixing suggestion; inject 100 mg in 500 ml bag of NS (200 mcg/ml). Initiate
       infusion at 20 to 50 mcg/kg/min IV/IO (see chart).
   Magnesium Sulfate - 25 mg/kg IV/IO over 10 minutes (max dose 2 grams).
   Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (same as adults). May repeat
    0.5mEq/kg IV/IO every 10 minutes PRN.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 44
Dr. Mark Seher DO, Medical Director.
Asystole / Pulseless Electrical Activity (PEA)
Paramedic
Paramedics are expected to provide resuscitation at the scene. You should not consider
transporting PNB patients before completing an adequate trial of BLS and ACLS interventions.
After recognizing the rhythm of Asystole or PEA, implement the appropriate interventions
outlined in CPR Critical Concepts. Confirm Asystole in two leads.
Consider Differential Diagnosis in search for treatment of reversible causes:
       Hypovolemia                                  Toxins
       Hypoxia                                      Tamponade, cardiac
       Hydrogen ion (acidosis)                      Tension pneumothorax
       Hypo-/hyperkalemia                           Thrombosis (coronary or pulmonary)
       Hypoglycemia                                 Trauma
       Hypothermia
Continually reassess ABCDEs and keep reassessing and intervening as needed.
1. Vasopressor Agents:
    a. Vasopressin (Pitressin) - 40 units IV/IO. One time dose to replace 1st or 2nd
       dose of Epinephrine. - OR -
    b. Epinephrine - 1 mg IV/IO (1:10,000) OR 2 - 2.5 mg ETT (1:1,000) diluted in
       10 ml NS, if unable to start an IV/IO. May repeat every 3 to 5 minutes. No max dose.
2. For Asystole or slow PEA rate administer:
    a. Atropine - 1 mg IV/IO. May repeat every 3 to 5 minutes. Max cumulative dose 3
       mg.
3. For history of diabetes consider:
    a. Dextrose 25 grams 50% solution IV/IO. May repeat as necessary.
4. If prolonged resuscitation with effective ventilation unresponsive to drug and electrical
    therapies, diabetic ketoacidosis, tricyclic antidepressant or aspirin overdose, consider:
    a. Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100
       mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
5. If chronic dialysis patient and/or suspected hyperkalemia, consider:
    a. Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100
       mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
6. Insert {NG} tube PRN.
7. Determine if patient is appropriate for termination of resuscitative efforts (See Terminating
    or Withholding of Resuscitation protocol).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 45
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Vasopressin (Pitressin) NOT indicated in pediatrics!
   Epinephrine - 0.01 mg/kg (1:10,000) IV/IO OR 0.1 mg/kg (1:1,000) via ETT if
    unable to start an IV/IO. May repeat every 3 to 5 minutes:
    o Maximum single dose 1 mg.
    o No maximum cumulative done.
   Atropine Sulfate NOT indicated in pediatric Asystole.
   Dextrose - 2 cc/kg of a 25% solution IV/IO (mix D50 with equal parts NS). May
    repeat as necessary.
   Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (same as adults). May repeat
    0.5 mEq/kg IV/IO every 10 minutes PRN.
   Calcium Chloride - 25 mg/kg slow IV/IO (max single dose 500 mg).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 46
Dr. Mark Seher DO, Medical Director.
 Bradycardia
After recognizing the rhythm of Bradycardia, implement the appropriate interventions outlined
in Arrhythmia Guidelines.
Heart rate < 60 bpm and inadequate for clinical condition.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Intermediate
STABLE
1. Consider fluid bolus of 250 - 500 ml NS.
Paramedic
2. For 2˚ AV Block type II or 3˚ AV Block, prepare patient for transcutaneous pacing (TCP) by
    applying external pacer pads. If signs/symptoms develop, initiate transcutaneous pacing.
3. Atropine - 0.5 mg IV/IO. May repeat every 5 minutes until desired heart rate is
    achieved. Max cumulative dose 3 mg:
    a. If Atropine ineffective, begin transcutaneous pacing.
UNSTABLE
If patient develops signs/symptoms of altered level of consciousness, hypotension, ongoing
chest pain, other signs of shock, or shortness of breath:
4. Prepare for transcutaneous pacing:
    a. TCP at a set heart rate of 80 bpm, titrate amplitude to mechanical capture.
    b. If time permits, sedate with Midazolam (Versed) - 2 mg slow IV/IO. May repeat in
       5 minutes. Max cumulative dose 10 mg.
    c. Consider pain control if systolic BP > 90 mmHg:
       i) Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes
            in 25 mcg increments. Max cumulative dose 150 mcg. - OR -
       ii) Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
            minutes. Max cumulative dose 10 mg.
    d. In addition to pain control consider:
       i) Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
            repeat once. Max cumulative dose 8 mg.
5. While awaiting pacer or if pacing ineffective consider:
    a. Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14
       gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed
       20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable
       (1600 mcg/ml), see chart. - OR -




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 47
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   If pulse is < 60 bpm with signs of poor perfusion, start CPR.
   Administer a 20 ml/kg bolus - repeat x 2.
   Atropine - 0.02 mg/kg IV/IO. May repeat once:
    o Minimum single dose 0.1 mg.
    o Maximum single dose 0.5 mg.
    o Maximum cumulative dose 1 mg.
   Epinephrine: Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5
    minutes as needed until desired heart rate is achieved:
    o Maximum single dose 1 mg.
   Epinephrine: Persistent 0.1 - 1 mcg/kg/min IV/IO. Mixing suggestion; inject 1
    mg (1:1,000) into 500 ml bag NS. Titrate until desired heart rate is achieved.
   Midazolam (Versed) - 0.05 mg/kg IV/IO (max single dose 2 mg). May repeat in
    5 minutes. Max cumulative dose 10 mg.
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.
   Dopamine - 5 to 20 mcg/kg/min IV/IO (same as adults). Titrate to maintain
    systolic BP > 90 mmHg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 48
Dr. Mark Seher DO, Medical Director.
Ventricular Tachycardia with Pulses
After recognizing the rhythm of Wide Complex Tachycardia, implement the appropriate
interventions outlined in Arrhythmia Guidelines.
Record a Lead II ECG strip before, during and after conversion attempt.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
Paramedic
STABLE
1. Attempt Valsalva maneuver.
2. If patient is asymptomatic and/or stable, consider an anti-arrhythmic:
    a. Amiodarone (Cordarone) - 150 mg over 10 minutes IV/IO. Mixing suggestion;
        inject 150 mg into 50 ml bag of NS. Initiate infusion with a 60 gtt set. Infuse 50
        ml over 10 minutes (15 mg/min).
        i) If rhythm converts to a perfusing rhythm, hang an Amiodarone maintenance
            infusion. Infuse 1 mg/min. Mixing suggestion; inject 100 mg into 100 ml bag
            of NS. Initiate infusion with a 60 gtt set.
3. For Torsades de points consider:
    a. Magnesium Sulfate - 2 grams IV/IO over 5 minutes. Premix available in 50
        mL NS.
4. If rhythm converts, observe for recurrence.
UNSTABLE
If patient develops signs/symptoms of altered level of consciousness, hypotension, ongoing
chest pain, other signs of shock, or shortness of breath:
5. Prepare for synchronized cardioversion.
6. If time permits, sedate with Midazolam (Versed) - 2 mg slow IV/IO. May repeat in 5
    minutes. Max cumulative dose 10 mg.
7. Consider pain control if systolic BP > 90 mmHg:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
        25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg.
8. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
        repeat once. Max cumulative dose 8 mg.
9. Begin synchronized cardioversion:
                                 If                                                 Sequence*
      Stable monomorphic VT                                       100 to 200 J, 300 J, 360 J
      Polymorphic VT (irregular form and                          Treat as VF with high-energy shock
      rate) and unstable                                          (defibrillation doses)
      *Consult the device manufacturer for specific recommendations for Biphasic

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                      Page 49
Dr. Mark Seher DO, Medical Director.
    a. Repeat if necessary using above guidelines.
    b. Make sure you press the sync button after each cardioversion.
Pediatric Specifics
STABLE:
 Amiodarone (Cordarone) - 5 mg/kg IV/IO over 20 minutes (max single dose
  150 mg).
 Magnesium Sulfate - 25 mg/kg IV/IO over 10 minutes (max dose 2 grams).
UNSTABLE:
 Synchronized cardioversion at 0.5 to 1 J/kg: if not effective, increase to 2 J/kg.
 If time permits, sedate with Midazolam (Versed) - 0.05 mg/kg IV/IO (max
  single dose 2 mg). May repeat in 5 minutes. Max cumulative dose 10 mg:
     o Sedation in children is relatively contraindicated if they have eaten solid
        food in the past 4 hours. It should be obvious that life threatening
        situations override this concern.
 Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
  repeat once in 5 minutes.
 Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
  repeat once in 5 minutes.
 Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
  dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
  cumulative dose 8 mg.

Symptomatic PVCs
1. Asymptomatic PVC's do not require specific intervention(s).
2. If PVC's are CLEARLY symptomatic (i.e. altered mental status, syncope, systolic BP <90
   mmHg, signs of acute MI, etc.) OR are occurring in sustained runs of ventricular
   tachycardia, are multiform, or occur with R on T phenomena, then refer to the Ventricular
   Tachycardia with Pulses Guideline.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.    Page 50
Dr. Mark Seher DO, Medical Director.
Supraventricular Tachycardia
After recognizing the rhythm of Narrow Complex Tachycardia, implement the appropriate
interventions outlined in Arrhythmia Guidelines.
Heart rate >150 bpm and inadequate for clinical condition.
Record a Lead II ECG strip before, during and after conversion attempt.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
Paramedic
STABLE
1. Attempt vagal maneuvers.
2. Administer Adenosine (Adenocard) - 6 mg rapid IV followed by 20 ml NS bolus. May
    repeat twice every 2 minutes if no response as 12 mg rapid IV/IO. Max cumulative dose
    30 mg.
3. If refractory to Adenosine with adequate blood pressure, atrial fibrillation or atrial flutter
    with rapid ventricular response (RVR): administer Diltiazem (Cardizem) - 0.25 mg/kg
    IV/IO (12.5 mg 19 mg 25 mg) over 2 minutes. May repeat 0.35 mg/kg IV/IO (18
    mg, 25 mg, 35 mg) over 2 minutes in 15 minutes if heart rate remains > 110 bpm.
4. If rhythm converts, observe for recurrence.
UNSTABLE
If patient develops signs/symptoms of altered level of consciousness, hypotension, ongoing
chest pain, other signs of shock, or shortness of breath:
5. Prepare for synchronized cardioversion:
    a. If time permits, sedate with Midazolam (Versed) - 2 mg slow IV/IO. May repeat in
       5 minutes. Max cumulative dose 10 mg.
    b. Consider pain control if systolic BP > 90 mmHg:
       i) Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes
            in 25 mcg increments. Max cumulative dose 150 mcg. - OR -
       ii) Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
            minutes. Max cumulative dose 10 mg.
    c. In addition to pain control consider:
       i) Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
            repeat once. Max cumulative dose 8 mg.
6. Begin synchronized cardioversion:
                                 If                                                        Sequence*
                      Atrial fibrillation                                           100 to 200 J, 300 J, 360 J
                    SVT or Atrial flutter                                      50J, 100 J, 200 J, 300 J, 360 J
                 *Consult the device manufacturer for specific recommendations for Biphasic




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                Page 51
Dr. Mark Seher DO, Medical Director.
    a. Repeat if necessary using above guidelines.
    b. Make sure you press the sync button after each cardioversion.


Pediatric Specifics
SVT RATES
     o Infants: ≥ 220 bpm
     o Children: ≥ 180 bpm
STABLE
 Adenosine (Adenocard) - 0.1 mg/kg rapid IV/IO followed by a 20 ml NS bolus
  (max first dose 6 mg). May repeat twice every 2 minutes if no response as 0.2
  mg/kg IV/IO (max second/third dose of 12 mg). Max cumulative dose 30 mg.
 Diltiazem (Cardizem) NOT indicated in children.
UNSTABLE
 Synchronized cardioversion at 0.5 to 1 J/kg: if not effective, increase to 2 J/kg.
 If time permits, sedate with Midazolam (Versed) - 0.05 mg/kg IV/IO (max
  single dose 2 mg). May repeat in 5 minutes. Max cumulative dose 10 mg:
     o Sedation in children is relatively contraindicated if they have eaten solid
         food in the past 4 hours. It should be obvious that life threatening
         situations override this concern.
 Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
  repeat once in 5 minutes.
 Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
  repeat once in 5 minutes.
 Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
  dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
  cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 52
Dr. Mark Seher DO, Medical Director.
Known WPW & Wide Complex Atrial Fibrillation
This dysrhythmia itself can be VERY difficult to identify and treat properly. Furthermore, most
anti-arrhythmic medications, and rate control or A-V node blocking agents, such as Adenosine
and Diltiazem (Cardizem), are contraindicated and potentially dangerous in this dysrhythmia.
Therefore, the intelligent pre-hospital approach is supportive care for "stable" patients with
rapid transport – and synchronized cardioversion for unstable patients.
Record a Lead II ECG strip before, during and after conversion attempt.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
Paramedic
STABLE
1. Administer Amiodarone (Cordarone) - 150 mg over 10 minutes IV/IO. Mixing
    suggestion; inject 150 mg into 50 ml bag of NS. Initiate infusion with a 60 gtt set.
    Infuse 50 ml over 10 minutes (15 mg/min):
    a. If rhythm converts to a perfusing rhythm, hang an Amiodarone maintenance infusion.
       Infuse 1 mg/min. Mixing suggestion; inject 100 mg into 100 ml bag of NS.
       Initiate infusion with a 60 gtt set.
UNSTABLE
If patient develops signs/symptoms of altered level of consciousness, hypotension, ongoing
chest pain, other signs of shock, or shortness of breath:
2. Prepare for synchronized cardioversion:
    a. If time permits, sedate with Midazolam (Versed) - 2 mg slow IV/IO. May repeat in
       5 minutes. Max cumulative dose 10 mg.
    b. Consider pain control if systolic BP > 90 mmHg:
       i) Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes
            in 25 mcg increments. Max cumulative dose 150 mcg. - OR -
       ii) Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
            minutes. Max cumulative dose 10 mg.
    c. In addition to pain control consider:
       i) Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
            repeat once. Max cumulative dose 8 mg.
3. Begin synchronized cardioversion:
      WPW / Atrial fibrillation                                   100 to 200 J, 300 J, 360 J
      *Consult the device manufacturer for specific recommendations for Biphasic
    a. Repeat if necessary using above guidelines.
    b. Make sure you press the sync button after each cardioversion.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.              Page 53
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
STABLE
 Amiodarone (Cordarone) - 5 mg/kg IV/IO over 20 minutes (max single dose
  150 mg).

UNSTABLE
 Synchronized cardioversion at 0.5 to 1 J/kg: if not effective, increase to 2 J/kg.
 If time permits, sedate with Midazolam (Versed) - 0.05 mg/kg IV/IO (max
  single dose 2 mg). May repeat in 5 minutes. Max cumulative dose 10 mg:
     o Sedation in children is relatively contraindicated if they have eaten solid
        food in the past 4 hours. It should be obvious that life threatening
        situations override this concern.
 Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
  repeat once in 5 minutes.
 Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
  repeat once in 5 minutes.
 Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
  dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
  cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 54
Dr. Mark Seher DO, Medical Director.
Chest Pain
Elderly patients, diabetics and women are more likely to experience symptoms, especially their
chest pain, in an atypical fashion, presenting as vague weakness, SOB, arm, back or jaw
discomfort, etc. Ask patient about allergies. Verify that patient has not taken any PDE5
inhibitors within the past 48 hours (such as Viagra, Levitra, or Cialis) which are known to
exacerbate the hypotensive effects of nitrates.
If high index of suspicion chest pain is cardiac in nature (see Differential Causes of Chest Pain
and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basics
1. Maintain airway and initiate high flow oxygen.
2. If patient condition permits, obtain a severity of chest pain value (1 to 10 scale).
3. Minimize patient exertion.
4. Apply pulse oximeter.
5. Assist patient with administering Aspirin 324 mg PO (chewable). Patient MUST CHEW
   the aspirin.
6. If systolic BP > 90 mmHg:
   a. Nitroglycerine (Nitrostat) - 0.4 mg SL (tablet or spray). May repeat in 3-5 minutes
       x 2. EMT-B’s may not administer Nitroglycerin to a patient for whom it is not
         currently prescribed.
     b. Recheck vital signs and reassess pain with Pain Scale after each Nitroglycerine
        (Nitrostat) and intervention.
EMT – Intermediate
7. Initiate IV NS.
8. Apply cardiac monitor.
9. If systolic BP > 90 mmHg:
   a. Nitroglycerine (Nitrostat) - 0.4 mg SL (tablet or spray). May repeat in 3-5 minutes
       x 2.
   b. Recheck vital signs and reassess pain with Pain Scale after each Nitroglycerine
       (Nitrostat) and intervention.
Paramedic
10. If no relief after Nitroglycerine (Nitrostat), and BP > 90 mmHg administer:
    a. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg. - OR -
    b. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
        25 mcg increments. Max cumulative dose 150 mcg.
11. If patient's systolic BP drops < 90 mmHg after administration of Nitroglycerine AND
    lungs are clear, administer 250 ml IV fluid challenge of NS. May repeat PRN.
Paramedic (cont.)

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 55
Dr. Mark Seher DO, Medical Director.
12. Obtain 12-Lead ECG for all chest pain patients prior to Nitroglycerine (Nitrostat)
    administration if possible (see 12 Lead Procedure).
    a. In cases of RIGHT SIDED MI (confirmed in lead V4R on 12-Lead ECG):
        i) Withhold nitrates and administer 250 ml IV fluid challenge of NS. Repeat every
            5 to 8 minutes PRN to maintain systolic BP > 90 mmHg, assuring absence of rales.
        ii) Use caution with low doses of Morphine Sulfate, and watch closely for
            cardiovascular compromise associated with right sided MI.
13. Treat any arrhythmias per appropriate Arrhythmia Guideline.
14. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
        repeat once. Max cumulative dose 8 mg:
        i) It is prudent to administer Zofran in cases of inferior wall, posterior wall, and right
            sided AMIs to prevent vagal stimulation and the resultant bradycardia associated
            with these AMI patterns.
15. If systolic BP < 90 mmHg consider:
    a. Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14
        gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed
        20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable
        (1600 mcg/ml), see chart.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 56
Dr. Mark Seher DO, Medical Director.
CHF / Pulmonary Edema
Look for and note cyanosis, clammy skin, absence of fever, coughing, wheezing, labored
breathing, diaphoreses, rales in bilateral lower lung fields, tachypnea, apprehension, and
inability to talk.
If high index of suspicion difficulty breathing is CHF/Pulmonary Edema in nature (see
Differential Causes of Chest Pain and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1.   Maintain airway and initiate high flow oxygen.
2.   Place patient sitting position.
3.   Minimize patient exertion.
4.   Apply pulse oximeter.
5.   If indicated consider CPAP (see CPAP Guideline)
EMT – Intermediate
6. Initiate IV NS.
7. Apply cardiac monitor.
8. If BP is > 90 mmHg:
   a. Administer Nitroglycerine (Nitrostat) - 0.4 mg SL (tablet or spray). May repeat in
       3-5 minutes x 2.
Paramedic
9. If systolic BP maintains > 90 mmHg, consider Nitroglycerine (Nitrostat) - 0.4 mg SL
    (tablet or spray). May repeat in 3-5 minutes x 2
10. If BP is > 90 mmHg:
    a. Furosemide (Lasix) - 40 mg slow IV/IO OR double patient’s oral dose. Max
        dose 80 mg.
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg:
        i) Morphine Sulfate has been shown in some studies to be harmful in CHF.
            Use only as a 3rd line treatment.
11. Consider 12-Lead ECG (see 12 Lead Procedure).
12. Treat any arrhythmias per appropriate Arrhythmia Guideline.
13. If systolic BP < 90 mmHg consider:
    a. Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14
        gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed
        20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable
        (1600 mcg/ml), see chart.
14. Consider advanced airway {RSI} if patient deteriorates despite these efforts.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 57
Dr. Mark Seher DO, Medical Director.
SECTION VI – Respiratory Emergencies
Asthma
If high index of suspicion difficulty breathing is Asthma in nature (see Differential Causes of
Chest Pain and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1.   Maintain airway and initiate high flow oxygen.
2.   Place patient sitting position.
3.   Minimize patient exertion.
4.   Apply pulse oximeter.
5.   Assist with bronchodilator administration:
     a. EMT-Bs may not administer metered dose inhalers to a patient for whom it is
         not currently prescribed.
EMT – Intermediate
6. Initiate IV NS.
7. Apply cardiac monitor.
8. If patient is exhibiting signs of bronchospasm administer Albuterol (Proventil) - 2.5 mg
   (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg of Ipratropium
   (Atrovent):
   a. Albuterol ONLY may be given by continuous administration.
9. If in status asthmaticus, administer Epinephrine - 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3
   - 0.5 ml). May repeat every 15 minutes as needed.
Paramedic
10. Consider {CPAP} (see CPAP guidelines).
11. If in status asthmaticus, administer Methylprednisolone (Solu-Medrol) - 125 mg slow
    IV/IO.
12. Consider advanced airway {RSI} if patient deteriorates despite these efforts.
Pediatric Specifics
    Albuterol Sulfate (Proventil) - 2.5 mg (diluted in 3 ml NS) nebulized. May be
     given by continuous administration.
    Ipratropium (Atrovent) - NOT recommended for pre-hospital use in children.
    If in status asthmaticus:
         o Epinephrine - 0.01 mg/kg SQ/IM 0f 1:1,000 (0.01ml/kg). May repeat
            every 15 minutes as needed:
               o Maximum single dose 0.5 mg.
         o Methylprednisolone (Solu-Medrol) - 2 mg/kg IV/IO (max dose 80 mg).
    CPAP is NOT indicated in pediatric patient’s age < 12 yo.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 58
Dr. Mark Seher DO, Medical Director.
COPD
If high index of suspicion difficulty breathing is COPD in nature (see Differential Causes of
Chest Pain and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1.   Maintain airway and initiate high flow oxygen.
2.   Place patient sitting position.
3.   Minimize patient exertion.
4.   Apply pulse oximeter.
5.   Assist with bronchodilator administration:
     a. EMT-Bs may not administer metered dose inhalers to a patient for whom it is
         not currently prescribed.
EMT – Intermediate
6. Initiate IV NS.
7. Apply cardiac monitor.
8. If patient is exhibiting signs of bronchospasm administer Albuterol (Proventil) - 2.5 mg
   (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg of Ipratropium
   (Atrovent):
   a. Albuterol ONLY may be given by continuous administration.
Paramedic
9. Consider {CPAP} (see CPAP guidelines).
10. If in severe distress, administer Methylprednisolone (Solu-Medrol) - 125 mg slow
    IV/IO.
11. Consider advanced airway {RSI} if patient deteriorates despite these efforts.
Pediatric Specifics
    CPAP is NOT indicated in pediatric patient’s age < 12 yo.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 59
Dr. Mark Seher DO, Medical Director.
Upper Airway Distress in Pediatrics
If high index of suspicion difficulty breathing is Upper Airway Distress in nature (see
Differential Diagnosis of Airway Distress in Pediatrics Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basics
1. Maintain airway and initiate high flow oxygen:
   a. Consider blow-by.
2. Keep patient with the caregiver if possible. Encourage caregiver to hold patient upright.
3. Minimize patient exertion.
4. Apply pulse oximeter.
EMT – Intermediate
5. Do not initiate IV or invasive airway procedure unless patient lapses into respiratory failure.
Paramedic
6. For suspected croup administer Racemic Epinephrine (Vaponephrin) - 2.25% (0.5
   ml) mixed with 3 ml of NS nebulized. May repeat every 15 minutes PRN.

Differential Diagnosis of Airway Distress in Pediatrics:
                          Epiglottitis                      Croup                   Bronchiolitis        Asthma
Site of     Above vocal cords                       Below vocal cords                Bronchioles      Lower airways,
Obstruction                                                                                             bronchioles
Cause                 Bacterial infection              Viral infection                  Viral              Varies
Age Range             Usually older child            Younger child (6               Up To 2 Years           Any
                        (> 2 yo) can                   mo – 3 yo)                      Of Age
                      occur @ any age.
Onset                 Sudden (6-24 hrs)                 24 – 72 hrs                    Sudden           Sudden to
                                                                                                        prolonged
Toxicity              Very ill, high fever          Mild – moderate,                   Mild To        Typically not ill
                                                        low fever                      Severe
Drooling                     Common                      Infrequent                    Absent           Infrequent
Cough                           Rare                    “Barking” or                 Early Sign     Early sign, typically
                                                         “Seal-like”                                 before wheezing




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                    Page 60
Dr. Mark Seher DO, Medical Director.
Spontaneous Pneumothorax
If high index of suspicion difficulty breathing is Spontaneous Pneumothorax in nature (see
Differential Causes of Chest Pain and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen.
2. Minimize patient exertion.
3. Apply pulse oximeter.
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
Paramedic
6. The patient’s status can quickly change into Tension Pneumothorax. Monitor carefully (see
   Needle Decompression Procedure).
7. Consider 12-Lead ECG (see 12 Lead Procedure).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.    Page 61
Dr. Mark Seher DO, Medical Director.
Pulmonary Embolism
If high index of suspicion difficulty breathing is Pulmonary Embolism in nature (see Differential
Causes of Chest Pain and Dyspnea Chart) then:
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen.
2. Minimize patient exertion.
3. Apply pulse oximeter.
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
Paramedic
6. Consider pain control if systolic BP > 90 mmHg:
   a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
       25 mcg increments. Max cumulative dose 150 mcg. - OR -
   b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
       minutes. Max cumulative dose 10 mg.
7. In addition to pain control consider:
   a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
       repeat once. Max cumulative dose 8 mg.
8. Consider 12-Lead ECG (see 12 Lead Procedure).
9. Consider advanced airway {RSI} if patient deteriorates.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 62
Dr. Mark Seher DO, Medical Director.
SECTION VII – Medical Emergencies
Decreased / Altered Level of Consciousness
Consider differential diagnosis: hypoglycemia, stroke, traumatic head injury, MI, respiratory
arrest, drugs. Follow appropriate guidelines based on suspected etiology of the decreased
LOC. Always immobilize C-spine for unconscious patients with an unknown mechanism of
injury.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen.
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Pulse oximeter.
3. Check capillary blood glucose (if < 60 mg/dl or > 400 mg/dl, see Hypo-/Hyperglycemia
   Guideline).
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
6. If high index of suspicion for narcotic overdose, see Overdose Guideline.
Paramedic
7. Treat any arrhythmias per appropriate Arrhythmia Guideline.
Pediatric Specifics
   If hypoglycemic (blood sugar < 60 mg/dl) or hyperglycemic (≥ 300 mg/dl) see
    Hypo-/Hyperglycemia Protocol.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 63
Dr. Mark Seher DO, Medical Director.
Stroke / CVA
If you suspect that the patient is having a stroke (symptoms such as one sided facial drooping,
one sided extremity weakness/paralysis, or a positive Cincinnati Stroke Scale are present),
lowering systolic blood pressure may be harmful.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Minimize patient exertion.
3. Apply pulse oximeter.
4. Check capillary blood glucose (if < 60 mg/dl or > 400 mg/dl, see Hypo-/Hyperglycemia
   Guideline).
5. Perform and record Pre-Hospital Stroke Screen:
   a. Attempt to pinpoint the specific time at which the patient’s symptoms began, and
      Document It.
6. Establish early communication with receiving facility advising of suspected stroke.
EMT – Intermediate
7. Initiate IV NS.
8. Apply cardiac monitor.
Paramedic
9. Consider 12-Lead ECG (see 12 Lead Procedure).
10. Consider advanced airway {RSI} if patient deteriorates.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 64
Dr. Mark Seher DO, Medical Director.
Hypoglycemia / Hyperglycemia
“Treat-and-refuse” may be considered for diabetic patients with a well documented medical
history who have received the treatment outlined below and meet ALL of the following
criteria:
 Blood glucose is now > 60 mg/dl.
 Patient agrees to eat a meal, and is able to do so.
 Patient will be in the company of a responsible adult who will stay with him/her for at least
    12 hours or can ensure that somebody else does.
 Patient agrees to contact their primary health care provider within 24 hours.
 Patient has the capability of measuring their own blood sugar and adjusting their
    medications (i.e. insulin) accordingly.
 There are no other acute medical issues involved (i.e. suspected stroke, MI, trauma, drugs,
    alcohol, serious infection, etc.).
 A signed “non-transport” refusal form MUST still be obtained.
 Thoroughly document all of the above criteria on your patient care report.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Check blood glucose level. If initial blood glucose is < 60 mg/dl:
   a. If patient is able to swallow and easily protect their own airway, give Glutose - 15 g
      (one tube) PO.
   b. Recheck blood glucose in 5 - 10 minutes. If blood glucose remains < 60 mg/dl:
      i) Repeat Glutose - 15 g (one tube) PO once.
EMT – Intermediate
3. Initiate IV NS.
4. Check blood glucose level. If initial blood glucose is < 60 mg/dl:
   a. Administer Dextrose - 25 grams 50% solution IV/IO. May repeat as necessary.
5. Apply cardiac monitor.
Paramedic
6. If unable to start an IV - administer Glucagon - 1 mg IM or SQ.

Hyperglycemia
EMT – Intermediate
7. If hyperglycemic with a blood sugar > 400 mg/dl, administer 250 ml bolus of IV NS -
   except with cardiac patients.
8. “Treat-and-refuse” is NOT an option.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 65
Dr. Mark Seher DO, Medical Director.
Paramedic
9. Hypoglycemic patient with altered LOC and insulin pump in place:
   a. Care is directed at treating hypoglycemia first, then stopping administration of insulin!
   b. Turn off insulin pump if able.
   c. If no one familiar with the device is available to assist, disconnect pump from patient
      by:
      i) Using quick-release where tubing enters dressing on patient’s skin. - OR -
      ii) Completely removing the dressing, thereby removing the subcutaneous needle and
          catheter from under patient’s skin.
Pediatric Specifics
Hypoglycemic (blood sugar < 60 mg/dl):
 Glutose - 7.5 g (1/2 tube) PO. May repeat once in 5 - 10 minutes.
 Dextrose - 2 cc/kg of a 25% solution IV/IO (mix D50 with equal parts NS). May
  repeat as necessary.
 Glucagon - 0.03 mg/kg IM or SQ (max dose 1 mg).
Hyperglycemia - blood sugar (≥ 300 mg/dl):
 IV fluid bolus (20 ml/kg) of NS.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 66
Dr. Mark Seher DO, Medical Director.
Hypotension – Non - Traumatic, Symptomatic
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Place patient in Trendelenburg position, if possible.
3. Keep Patient warm.
4. Minimize patient exertion.
5. Apply pulse oximeter.
EMT – Intermediate
6. Initiate IV NS:
   a. Consider starting two IV lines.
7. If systolic BP < 90 mmHg AND if breath sounds are clear infuse 250 ml of NS. May
   repeat to maintain systolic BP > 90 mmHg.
8. Apply cardiac monitor.
Paramedic
9. Treat any arrhythmias per appropriate Arrhythmia Guideline.
10. If systolic BP < 90 mmHg consider:
    a. Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14
        gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed
        20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable
        (1600 mcg/ml), see chart.
Pediatric Specifics
   Administer a 20 ml/kg bolus - repeat x 2.
   Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (same as adults).
    Titrate to maintain systolic BP > 90 mmHg.

Hypertension
In most cases, hypertension (HTN) is a symptom rather than the primary disease. Always
consider other causes of symptoms but do not delay transport. Rapidly lowering diastolic BP
may cause brain injury.
If pregnant, and patient is greater than 20 weeks gestation, place on left side, and transport
to her obstetrical facility of choice. Be cautious of seizure or abruption. Transport with head
slightly elevated.
If you suspect that the patient is having a stroke (symptoms such as one sided facial drooping,
one sided extremity weakness/paralysis, or a positive Pre-Hospital Stroke Screen), lowering
systolic blood pressure may be harmful.



EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 67
Dr. Mark Seher DO, Medical Director.
Seizures
Obtain history from family members or bystanders.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Apply pulse oximeter.
3. Check capillary blood glucose (if < 60 mg/dl or > 400 mg/dl, see Hypo-/Hyperglycemia
   Guideline).
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
Paramedic
6. If repeated or continuing seizure activity, administer Diazepam (Valium) - 5 to 20 mg
   IV/IO, in 5 mg increments. Push slowly (2 to 5 mg/min). Max cumulative dose 20
   mg.
7. If repeated or continuing seizure activity and if unable to establish IV:
   a. Consider Midazolam (Versed) - 2 mg atomized IN. May repeat in 5 minutes. Max
       cumulative dose 10 mg. - OR -
   b. Consider Diazepam (Valium) - 0.2 mg/kg PR.
8. If patient pregnant and may have eclampsia, administer Magnesium Sulfate - 2 to 4
   grams IV/IO over 5-10 minutes. Premix available of 2 grams in 50 mL NS.
   a. Consider eclampsia up to 1 month post-partum.
Pediatric Specifics
   Consider Fever / Temperature Instability as cause, see Hyperthermia protocol.
   Check capillary blood glucose (if < 60 mg/dl or > 300 mg/dl, see Hypo/Hyper-
    glycemia Guideline).
   If repeated or continuing seizure activity, administer Diazepam (Valium) - 0.2
    mg/kg IV push slowly. Max dose 10 mg.
   If repeated or continuing seizure activity and if unable to establish IV:
        o Midazolam (Versed) - 0.2 mg/kg atomized IN. May repeat in 5 minutes.
          Max cumulative dose 10 mg. - OR -
        o Consider Diazepam Rectal dose 0.5 mg/kg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 68
Dr. Mark Seher DO, Medical Director.
Overdose
Medications: Gather type, dose, time and route of exposure, how consumed, and take
bottles with you.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. Check capillary blood glucose (if < 60 mg/dl or > 400 mg/dl, see Hypo-/Hyperglycemia
   guideline).
3. Apply pulse oximeter.
EMT – Intermediate
4. Initiate IV NS:
   a. Maintain systolic BP > 90 mmHg.
   b. Infuse 500 ml IV NS wide open. May be repeated PRN.
5. Apply cardiac monitor.
6. If blood glucose ≥ 60 mg/dl and high suspicion for narcotic overdose:
   a. Administer Naloxone (Narcan) – 0.4 to 2 mg IV, IM, SQ, IO, or IN. May repeat in
       2 to 3 minutes. Titrate to effect.
Paramedic
7. If ingested overdose, initiate {NG} PRN:
   a. Administer Activated Charcoal 1 gm/kg NG (minimum dose 30 grams).
8. If suspected tricyclic antidepressant overdose and QRS begins to widen > 0.12 seconds:
   a. Administer Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (50 mEq, 75 mEq,
       100 mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN. - OR-
   b. If coma, seizures, wide QRS, or dysrhythmias develop 2 mEq/kg IV (100 mEq, 150
       mEq, 200 mEq). May repeat every 3 to 5 minutes PRN.
9. If systolic BP < 90 mmHg consider:
   a. Dopamine (Intropin) infusion - 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14
       gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed
       20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable
       (1600 mcg/ml), see chart.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 69
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Fluid bolus Administer a 20 ml/kg bolus - repeat x 2.
   If blood glucose ≥ 60 mg/dl and high suspicion for narcotic overdose:
        o Administer Naloxone (Narcan) - 0.1 mg/kg IV, IM, SQ, IO, or IN. May
          repeat in 2 to 3 minutes. Max single dose 2 mg. Titrate to effect.
   Activated Charcoal - 1 gm/kg NG (minimum dose 30 grams) same as adults.
   Calcium Chloride - 25 mg/kg slow IV/IO (max single dose 500 mg).
   Sodium Bicarbonate (NaHCO3) - 1 mEq/kg IV/IO (same as adults). May repeat
    0.5 mEq/kg IV/IO every 10 minutes PRN.
   Dopamine - 5 to 20 mcg/kg/min IV/IO (same as adults). Titrate to maintain
    systolic BP > 90 mmHg.

Common Overdose Medications
Includes but is not limited too:
Benzodiazepines
Alprazolam, Xanax, Bromazepam, Lexotan, Chlordiazepoxide, Librium, Clonazepam, Klonopin,
Clorazepate, Tranxene, Diazepam, Valium, Flunitrazepam, Rohypnol, Estazolam, ProSom,
Flurazepam, Dalmane, Halazepam, Paxipam, Loprazolam, Dormonoct, Lorazepam, Ativan,
Midazolam, Versed, Hypnovel, Dormicum, Nitrazepam, Mogadon, Oxazepam, Serax,
Quazepam, Doral, Temazepam, Restoril, Triazolam, Halcion
Tricyclic and Tetracyclic Antidepressants
Doxepin, Adapin, Sinequan, Clomipramine, Anafranil, Amoxipine, Asendin, Nortiptyline,
Aventyl, Pamelor, Amitriptyline, Elavil, Endep, Limbitrol, Triavil, Perphenazine, Etrafon,
Imipramine, Janamine, Tofranil, Maprotiline, Ludiomil, Desipramine, Norpramin, Pertofrane,
Trimipramine, Surmontil, Protriptyline, Vivactil
Non-Cyclic Antidepressants
Trazodone, Desyrel, Paroxetine, Paxil, Fluoxetine, Prozac, Sertraline, Zoloft
Calcium Channel Blocking Agents
Adalat, Nifedipine, Procardia, Cardene SR, Nicardipine, Cardene, Cardizem, Diltiazem, Dilacor
XR, Tiazac, Dynacirc, Isradipine, Plendil XR, Felodipine, Nitrendipine, Bepridil, Vascor,
Nisoldipine, Sular, Nimotop, Nimodipine, Amlodipin, Norvasc, Verapamil, Verelan, Isoptin,
Calan, Covera




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.     Page 70
Dr. Mark Seher DO, Medical Director.
Allergic Reaction, Anaphylaxis, Dystonic Reaction
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. If severe allergic reaction, assist patient in administering their own prescribed Epi-Pen if
   available:
   a. EMT-Bs may not administer an Epi-Pen to a patient for whom it is not
         currently prescribed.
3. Minimize patient exertion.
4. Apply pulse oximeter.
5. If patient develops wheezing, assist with bronchodilator administration:
   a. EMT-Bs may not administer metered dose inhalers to a patient for whom it is
         not currently prescribed.
EMT – Intermediate
6. Initiate IV NS.
7. If patient is exhibiting signs of bronchospasm administer Albuterol (Proventil) - 2.5 mg
    (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg of Ipratropium
    (Atrovent):
    a. Albuterol ONLY may be given by continuous administration.
8. Apply cardiac monitor.
9. If reaction is localized, systolic BP is > 90 mmHg, no respiratory difficulty and no symptoms
    of airway edema administer Diphenhydramine (Benadryl) - 25 to 50 mg IV/IO/IM.
10. If reaction is systemic, respiratory difficulty and/or symptoms of airway edema, and BP >
    90 mmHg:
    a. Administer Epinephrine - 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml):
        i) If systolic BP remains > 90 mmHg and no improvement after 15 minutes may repeat
            Epinephrine 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml) using a different
            injection site.
    b. Administer Diphenhydramine (Benadryl) - 25 to 50 mg IV/IO/IM.
11. If systolic BP < 90 mmHg, infuse 250 ml NS. May repeat bolus PRN.
Paramedic
12. If reaction is severe and unable to start an IV/IO:
    a. Consider Epinephrine - 0.5 mg IV/IO of 1:10,000. May repeat every 3 - 5 minutes as
        needed.
    b. Administer Methylprednisolone (Solu-Medrol) - 125 mg slow IV/IO.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 71
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Diphenhydramine (Benadryl) - 1 mg/kg IV/IO/IM (max single dose 50 mg).
   Epinephrine - 0.01 mg/kg SQ/IM of 1:1,000 (0.01 ml/kg). May repeat every 15
    minutes as needed:
       o Maximum single dose 0.5 mg.
   Epinephrine - Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5
    minutes as needed:
       o Maximum single dose 1 mg.
   Administer IV NS fluid bolus at 20 ml/kg, may repeat x 2.
   Methylprednisolone (Solu-Medrol) - 2 mg/kg IV/IO (max dose 80 mg).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 72
Dr. Mark Seher DO, Medical Director.
Pain Management
Consider use of this protocol for patients with sickle cell crisis, flank pain consistent with renal
colic, back pain from strains, and those patients with isolated extremity injuries that are not
due to multi-system trauma or falls from substantial heights.
Do not use this protocol in patients with pain due to cardiac or stroke episodes or those with
other significant issues or complicating factors (i.e. multisystem illness, drug or alcohol
intoxication, etc).
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen:
   a. Assume spinal injury, if indicated, and treat accordingly.
   b. Be prepared assist ventilations with oral or nasal airway and BVM.
2. For extremity injuries, splint and control bleeding as needed.
3. Apply pulse oximeter.
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
Paramedic
6. If systolic BP >90 mmHg consider:
    a. Fentanyl (Sublimaze) - 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in
        25 mcg increments. Max cumulative dose 150 mcg. - OR -
    b. Morphine Sulfate - 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5
        minutes. Max cumulative dose 10 mg.
7. If hypotension (systolic BP < 90 mmHg) occurs following administration of pain medication,
    infuse 250 ml NS. May repeat bolus PRN.
8. If respiratory depression occurs following administration of above pain medications,
    administer Naloxone (Narcan) - 0.4 to 2 mg IV/IO. May repeat in 2 to 3 minutes.
    Titrate to effect:
    a. Be alert to the need for advanced airway management {RSI} if necessary.
9.
10. In addition to pain control consider:
    a. Ondansetron (Zofran) - 4 mg undiluted, IM or slow IV/IO for nausea. May
        repeat once. Max cumulative dose 8 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.           Page 73
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Fentanyl (Sublimaze) - 2 mcg/kg slow IV/IO (max single dose 25 mcg). May
    repeat once in 5 minutes.
   Morphine Sulfate - 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May
    repeat once in 5 minutes.
   Ondansetron (Zofran) - If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single
    dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max
    cumulative dose 8 mg.
   If hypotension occurs following administration of pain medication, infuse IV NS
    fluid bolus at 20 ml/kg, may repeat x 2.
   If respiratory depression occurs following administration of the above pain
    medications, give Naloxone (Narcan) - 0.1 mg/kg IV/IO. May repeat in 2 to 3
    minutes. Max single dose 2 mg. Titrate to effect.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 74
Dr. Mark Seher DO, Medical Director.
Behavioral Emergency & Patient Restraint
Definition of a “Behavioral Emergency”: When the patient acts abnormally in a way that is
unacceptable or intolerable to the patient, family, or community.
Behavioral changes may be due to psychological, emotional, or physical conditions.
Psychological causes include depression, mania, paranoia, suicida, and environmental
changes. Physical causes may include excessive heat or cold, lack of oxygen, lack of blood
flow to the brain, head injuries, stroke, alcohol or drug abuse, high or low blood sugar,
metabolic disorders, and neurologic disease.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic / EMT – Intermediate
1. Make the scene safe. Law enforcement should be used as needed to determine scene
   safety.
2. Never turn your back on the patient. Never leave the patient alone, unless for your safety.
3. Encourage the patient to talk. Listen carefully.
4. Be confident. Be respectful. Be calm. Be honest.
5. Explain all movements and procedures.
6. Provide interventions for possible medical causes.
USE OF RESTRAINT - Patient Restraint May Be Used Under The Following
Conditions:
1. It is understood that the use of restraint is a "last resort" measure to ensure safe transport.
   All efforts should be made to avoid this AND must be PROPERLY DOCUMENTED.
2. Consult with law enforcement. Law enforcement should perform physical restraint if
   possible.
3. After patient is physically restrained, use wide leather or cloth restraints to immobilize.
4. The Reasoning For Restraint, Either Physical Or Chemical, Must Be Sufficiently
   Documented On The Patient Care Report.
5. Patients may ONLY be restrained face up on the cot.
6. The patient MUST be fully conscious and protecting his/her airway with stable vital signs
   prior to physical restraint.
7. Physical restraints MAY NOT BE USED in situations where the combative behavior of the
   patient is due to severe trauma, burns, pain, or any life threatening medical condition (i.e.
   asthma, COPD, anaphylaxis, hypoglycemia, etc). In such cases the underlying condition
   resulting in the patient's behavior must be addressed. If interventions to address the
   underlying condition cannot ensure safe transport, then soft physical restraints may be
   applied. This must be painstakingly documented.
Paramedic
8. Chemical restraint may be used if necessary, especially in the case of drug/illegal
   substance overdoses, only as a last resort:
   a. Administer Midazolam (Versed) - 2 mg IV/IO for patients with presumed substance
      abuse. May repeat in 5 minutes. Max cumulative dose 10 mg.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 75
Dr. Mark Seher DO, Medical Director.
SECTION VIII – Toxic Exposures / Haz - Mat
Carbon Monoxide Poisoning
Always insure the safety of you and your crew. If you suspect CO poisoning remove yourself,
your crew, and the patient immediately. Do not attempt to enter a home if this is suspected
prior to your arrival. Wait for FD ventilation or have patients come out to you. Assess patient
carefully for other injuries associated with carbon monoxide poisoning (burns, trauma, and
overdose) and follow appropriate Guidelines.
Remember Pulse Oximetry Is Unreliable In Carbon Monoxide Poisoning!
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Maintain airway and initiate high flow oxygen.
2. Minimize patient exertion.
3. {Pulse CO-Oximetry}. RAD 57.
EMT – Intermediate
4. Initiate IV NS.
5. Apply cardiac monitor.
Paramedic
6. Consider advanced airway {RSI} if patient deteriorates.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 76
Dr. Mark Seher DO, Medical Director.
Hazardous Materials & Toxic Exposure
In an event where there is a possible toxic exposure and/or hazmat incident, report to incident
command and stage until patients are decontaminated. NEVER enter the “Warm” or “Hot” zone under
any circumstance!
When possible determine type of chemical involved first. Always obtain name and, if possible, the
Material Safety Data Sheet (MSDS), or ask that name or MSDS be brought to the hospital as soon as
possible.
Skin Exposure: Remove clothing, brush dry chemicals, and flood skin with copious amounts
of water.
Fire Victims: Evaluate for airway obstructions secondary to thermal injury!
Contact Poison Control via one of the following (in this order, Poison Center’s preference):
 Call the National Call Center at 800-222-1222.
 Call the Children’s Hospital ECC at 614-722-6868.
EMT – Basic / EMT – Intermediate / Paramedic
  Do not accept responsibility for a patient’s care until the contaminated patient has
   completed the on-scene decontamination process, as determined by appropriate Decon
   Officer. Patients should be decontaminated to the point where only “Universal Precautions”
   will need to be worn by the EMS personnel:
   o All patients received from Decon should be properly packaged.
 Notify receiving hospital(s) of patient or possible patients as soon as possible into an
   incident.
 Initial patient care should take place in the treatment area to limit possible vehicle
   contamination.
 During transport, ventilation system should be turned on and the driver’s compartment
   should be separated from the patient compartment as best can be achieved.
Treatment:
1. Evaluate the patient to determine if injuries and/or complaints are chemical or health
   related. Treat in accordance with the appropriate patient care guideline.
2. Continually reassess ABCDEs and keep reassessing and intervening as needed.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 77
Dr. Mark Seher DO, Medical Director.
Exposure to Nerve Agents / Organophosphates (WMD)
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT – Basic / EMT – Intermediate / Paramedic
1. If the potential exists for exposure to chemical agents that affect the nervous system:
   a. Protect SELF AND CREW above all else, with personal protective equipment.
   b. Protect victim from further exposure:
       i) Remove from source and identify agent if possible:
            (1) Weaponized nerve agents included Sarin (gb), Soman (gd), Tabun (ga), and VX.
       ii) Remove only outer clothing if exposed to vapors.
       iii) Remove all clothing and decontaminate if liquid exposure.
       iv) Follow gross decontamination procedure per hazmat protocol.
2. Identify signs & symptoms that raise your index of suspicion indicating possible exposure
   to nerve agents or organophosphates (SLUDGEM):
   a. S – Salivation / L – Lacrimation / U – Urination / D – Defecation / G – Gastrointestinal
       Upset / E – Emesis / M – Muscle Twitching / Miosis (pinpoint pupils).
3. Nerve Agent or Organophosphate exposure:
   a. If patient has a mild to moderate exposure, with symptoms to include: SLUDGEM,
       agitation and respiratory depression, administer one (1) Mark-1 Kit - IM Auto-
       injector if available:
       i) Mark-1 Kit Auto-injector consists of:
            (1) Atropine (AtroPen) - 2 mg in 0.7 ml.
            (2) Pralidoxime Chloride (Protopam Chloride, 2PAM) - 600 mg in 2 ml.
   b. If symptoms continue in 5 to 8 minutes, administer one (1) additional Mark-1 Kit -
       IM Auto-injector.
   c. If patient has a severe exposure, with symptoms to include: SLUDGEM, agitation and
       respiratory depression PLUS seizure, administer a third Mark-1 Kit - IM Auto-
       injector.
   d. If Mark-1 Kits unavailable:
       i) Atropine - 2 mg IV/IO. May repeat every 5 minutes until a decrease in
            secretions is observed. No max dose.
   e. In addition, administer Diazepam (Valium) - 5 to 20 mg IV/IO, in 5 mg
       increments. Push slowly (2 to 5 mg/min). Max cumulative dose 20 mg:
       i) Diazepam (Valium) - Rectal dose 0.2 mg/kg, if unable to start IV.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.      Page 78
Dr. Mark Seher DO, Medical Director.
4. All levels of providers that have been trained to do so are permitted to administer nerve
   agent antidotes:
         Ohio Administrative Code: 4765-6-03 “Additional services in a declared emergency”
         (B) A EMT - Basic, EMT-basic, EMT-intermediate, or EMT-paramedic, certified in
         accordance with section 4765.30 of the Revised Code and Chapter 4765-8 of the
         Administrative Code, may administer drugs or dangerous drugs contained within a
         nerve agent antidote auto-injector kit, including a MARK-1 kit, in response to
         suspected or known exposure to a nerve or organophosphate agent provided the
         EMT - Basic or EMT is under physician medical direction and has received
         appropriate training regarding the administration of such drugs within the nerve
         agent antidote auto-injector kit.
         Effective 09/01/2005
5. Transport patients as quickly as possible, notifying receiving hospitals as early as possible
   so they may prepare for fine decontamination procedures.
Pediatric Specifics
   If Mark-1 Kits unavailable:
       o Atropine - 0.02 mg/kg IV/IO. May repeat every 5 minutes until a decrease
          in secretions is observed. No max dose.
       o Atropine - 0.05 mg/kg IM, if unable to start an IV.
   Diazepam (Valium) - 0.2 mg/kg IV/IO push slowly. Max dose 10 mg:
       o Diazepam (Valium) - Rectal dose 0.5 mg/kg, if unable to start IV.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 79
Dr. Mark Seher DO, Medical Director.
SECTION IX – Obstetrical / Gynecological Emergencies
Obstetrical Emergencies - During Pregnancy
Continually reassess ABCDEs and keep reassessing and intervening as needed.
EMT - Basic
1. Initiate oxygen.
VAGINAL BLEEDING DURING PREGNANCY, ABRUPTION OR PLACENTA PREVIA
2. Apply external vaginal pads.
GESTATIONAL HYPERTENSION, PRE-ECLAMPSIA
Signs & Symptoms: Edema, Excessive Weight Gain, Headaches, Right Upper Epigastric Pain,
Visual Disturbances, Apprehension, Systolic BP > 140 mmHg, Pale, Diastolic > 110 mmHg.
3. Be prepared for seizures.
4. Transport immediately to appropriate facility with patient rolled on left side:
   a. Bring any fetal tissues to hospital.
EMT – Intermediate
5. Initiate IV NS:
   a. Maintain systolic BP > 90 mmHg, infuse 250 ml NS. May repeat bolus PRN.
6. Apply cardiac monitor.
Paramedic
ECLAMPSIA, SEIZURE DURING PREGNANCY (Consider up to 1 month post-partum)
7. Magnesium Sulfate - 2 to 4 grams IV/IO over 5-10 minutes. Premix available of
   2 grams in 50 mL NS.
8. Diazepam (Valium) - 5 to 20 mg IV/IO, in 5 mg increments. Push slowly (2 to 5
   mg/min). Max cumulative dose 20 mg:
   a. Diazepam - 0.2 mg/kg PR, if unable to start IV.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 80
Dr. Mark Seher DO, Medical Director.
Obstetrical Emergencies – Delivery
  Attempt to attain sanitary environment.
  Focused history and physical exam, however, do not perform pelvic exam.
  Develop and implement treatment plan based on assessment findings, resources, and
   training.
Continually reassess ABCDEs and keep reassessing and intervening as needed.
NORMAL DELIVERY PROCEDURES
EMT - Basic
1. Initiate oxygen.
2. Attempt to prevent explosive delivery:
   a. As delivery occurs, suction mouth, then nose.
   b. If membrane is still intact as head delivers:
       i) Instruct the mother to stop pushing.
       ii) Gently tear open membrane and immediately suction mouth, then nose.
   c. Keep newborn warm and dry.
   d. Keep newborn at level of vagina until cord is cut.
   e. Once cord pulsations cease:
       i) Place one clamp six (6) inches away from baby.
       ii) Place second clamp nine (9) inches away from baby.
       iii) Cut cord between the clamps.
   f. Allow infant to nurse:
       i) In multiple births, do not allow babies to nurse until all have been delivered.
   g. APGAR score at 1 minute and again at 5 minutes:

                      Signs                          -0-                             -1-              -2-
    A             Appearance                      Blue, Pale        Body Pink, Extremities Blue Completely Pink
    P                  Pulse                        Absent                   Slow Or < 100           > 100
               Grimace (Reflex
    G                                          No Response                          Grimace      Cough Or Sneeze
                  Irritability)
    A      Activity (Muscle Tone)                    Limp          Some Flexion Of Extremities    Active Motion
    R        Respiration (Effort)                   Absent                   Slow, Irregular      Good, Crying
3. Apply pulse oximeter.
4. Unless delivery is imminent, transport immediately to appropriate facility.
EMT – Intermediate/Paramedic
5. Initiate IV NS:
   a. Maintain systolic BP > 90 mmHg, infuse 250 ml NS. May repeat bolus PRN.
6. Apply cardiac monitor.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                            Page 81
Dr. Mark Seher DO, Medical Director.
Special Delivery Situations
SIGNIFICANT HEMORRHAGE FOLLOWING DELIVERY OR DELAYED PLACENTA
DELIVERY
      Unless multiple births are anticipated, begin fundal massage.
NUCHAL CORD
      Attempt to slip cord over the head.
      If cord is too tight to remove, immediately clamp in two places and cut between
       clamps.
PROLAPSED CORD OR LIMB PRESENTATION
      With maintaining a pulsatile cord as the objective, two fingers of gloved hand into
       vagina to raise presenting portion of newborn off the cord.
      If possible, place mother in Trendelenburg position. Otherwise, knee-chest.
      Keep cord moistened with sterile saline.
      Continue to keep pressure off cord throughout transport.
MECONIUM DELIVERY
      Deliver infant per “normal delivery” protocol.
      If meconium is noted, suction mouth, nose, & posterior pharynx with bulb syringe
       AFTER deliver of the head but BEFORE deliver of the shoulders.
      If the Infant is VIGOROUS (Strong Respiratory Effort, Good Muscle Tone, Heart Rate
       > 100 bpm) - Continue with APGAR & stimulation.
             Paramedic - If the Infant is DEPRESSED (Poor Respiratory Effort, Decreased
       Muscle Tone, Heart Rate < 100bpm) - Delay drying & stimulation, suction trachea
       before taking other resuscitative steps, examine with laryngoscope and suction x 3,
       intubate trachea on 3rd tracheal suction. Aggressively resuscitate the infant to the
       extent necessary.
BREECH PRESENTATION
      Position mother with her buttocks at edge of bed, legs flexed.
      Support body as it delivers.
      As the head passes the pubis, apply gentle upward pressure until the mouth appears
       over the perineum. Immediately suction mouth, then nose.
      If head does not deliver, but newborn is attempting to breath, place gloved hand
       into the vagina, palm toward newborn’s face, forming a “V” with the index and
       middle finger on either side of the nose. Push the vaginal wall from the face.
       Maintain position throughout transport.
SHOULDER DYSTOCIA
      Position mother with buttocks off the edge of the bed and thighs flexed upward as
       much as possible.
      Apply firm, open hand pressure above the symphysis pubis.
      If delivery does not occur, maintain airway patency as best as possible, immediately
       transport.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 82
Dr. Mark Seher DO, Medical Director.
STILLBORN/ABORTION
      All products of conception should be carefully collected and transported with the
       mother to the hospital.
      Anything other than transport should be coordinated with on-line medical
       consultation and/or law enforcement.
UTERINE INVERSION
      Make one attempt to put the uterus back into the vaginal vault. Using the palm of
       the hand, push the fundus of the inverted uterus toward the vagina.             If
       unsuccessful, cover uterus with moistened sterile gauze.
SEIZURES
      If mother is in active seizures, see Seizure Guideline.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 83
Dr. Mark Seher DO, Medical Director.
 SECTION X – Procedures
Oxygen, Airway & Ventilation
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 All patients protecting their own airway should be given oxygen unless they have only
  isolated extremity injury and no other co-morbidities.
CONTRAINDICATIONS
 None
EQUIPMENT
   Oxygen cylinder with regulator                                        OPA/NPA
   Oxygen delivery device
PREPARATION
 Ensure that the cylinder has oxygen in it.
 Ensure that the regulator is securely fastened and not leaking.
 Attach the delivery device to the regulator and begin oxygen flow.
 Set the flow rate (fill NRB reservoir prior to placing on patient).
PROCEDURE Oxygen Administration - Stable and spontaneously breathing patients.
1. Explain the procedure to the patient.
2. Place the delivery device on the patient and adjust to patient’s comfort:
   a. Nasal cannula - 2 to 6 lpm.
   b. Non-rebreather mask - 10 to 15 lpm (flow sufficient to keep the bag from collapsing
       during inhalation) for severe trauma, very distressed cardiac, respiratory distress, and
       other patients who appear to need high flow O2.
3. Monitor patient’s respiratory effort carefully.
4. EMT’s use pulse oximeter to measure oxygen saturation - record readings.
PROCEDURE Ventilation Guidelines - Unstable or deteriorating patients.
1. When breathing is inadequate but an advanced airway is not (yet) needed, assist the
   patient's ventilations at 8 to 10 breaths per minute:
   a. Pocket mask with supplemental oxygen at 10 to 15 lpm. - OR -
   b. Flow-Restricted Oxygen Powered Ventilation Device. - OR -
   c. Bag-valve mask with 100% oxygen.
2. Manually open the airway:
   a. Use modified jaw thrust if suspected c-spine injury.
3. Use simple airway adjuncts (i.e. oral or nasal airways) PRN:
   a. Never use an oral airway in a patient with an intact gag reflex.
4. If pulseless and not intubated - ventilate twice after every 30th compression:
   a. Place advanced airway:
       i) Never remove Combitube or LMA in the field if it is providing an adequate airway.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 84
Dr. Mark Seher DO, Medical Director.
5. If pulseless and intubated: ventilate patient 8 to 10 times per minute.
Pediatric Considerations
   Ventilate children at least once every 3 seconds.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 85
Dr. Mark Seher DO, Medical Director.
OPA – Oropharyngeal Airway
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Unconscious patient without a gag reflex.
CONTRAINDICATIONS
 Patient with a gag reflex.
EQUIPMENT
   Oropharyngeal airway (various sizes)                                  Tongue depressor
   Suction                                                               BVM with Oxygen supply
PREPARATION
 Measure airway from corner of mouth to the earlobe or center of lips to angle of the jaw.
PROCEDURE
1. Check for lack of gag reflex using tongue depressor.
2. Assess the need for suctioning.
3. Insert the airway with the tip pointing toward the roof of the mouth, rotate the airway 180
   degrees as the tip reaches the soft palate so as to displace the tongue anteriorly.
4. If properly inserted the flange of the airway should be seated against the lips.
5. Ventilate PRN.
Pediatric Considerations
   Use tongue depressor to assist with the placement.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                   Page 86
Dr. Mark Seher DO, Medical Director.
NPA – Nasopharyngeal Airway
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Patient with a decreased LOC and sonorous respirations that will not accept an OPA.
CONTRAINDICATIONS
 Patient with maxillary or nasal trauma or suspected skull fracture.
 Resistance encountered during insertion.
EQUIPMENT
   Nasopharyngeal airway (various sizes)                                 Water soluble lubricant.
   BVM with Oxygen supply
PREPARATION
 Measure airway from tip of nose to the earlobe.
 NPA should be slightly smaller diameter than patient’s nostril.
 Lubricate airway.
PROCEDURE
1. Insert the airway with the bevel toward the septum and the curve downward, toward the
   feet.
2. If properly inserted the flange of the airway should be seated against the nose.
3. Ventilate PRN.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                     Page 87
Dr. Mark Seher DO, Medical Director.
Orotracheal Intubation
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 EMT-B – Adult PNB.
 EMT-I – Adult PNB, adult apneic.
 Paramedic – PNB, apneic, and breathing patients unable to protect their own airway:
  o Consider {RSI} for patients who are in extreme respiratory distress and are
      decompensating.
 Patients with suspected cervical spine injury should be approached with caution. A two
  rescuer in-line cervical stabilization technique should be utilized.
CONTRAINDICATIONS - Relative for RSI authorized Paramedics.
 Trismus
 Gag reflex.
EQUIPMENT
   BVM with Oxygen supply                                                OPA/NPA
   Stethoscope                                                           Laryngoscope handle / blades
   Endo-Tracheal Tube (variety of sizes)                                 Stylet
   10 ml Syringe                                                         Suction
   Secondary Confirmation Device                                         Commercial tube-securing device
   Water soluble lubricant or Lidocaine
    Jelly 2% (Xylocaine)
 PREPARATION
 Assemble and check required equipment.
PROCEDURE
1. Using basic manual and adjunctive maneuvers open the airway and pre-oxygenate with
   100% oxygen prior to any intubation attempt.
2. The intubation attempt should be no longer than 10 seconds. If so, the attempt should be
   stopped and the patient should be re-oxygenated with 100% oxygen:
   a. If endotracheal intubation is unsuccessful after three attempts at visualization total, not
      per provider, insert a Combitube or LMA:
      i) Visualization is defined as any advanced airway device, either a laryngoscope or an
          endotracheal tube, entering the patient’s mouth in an attempt to secure the airway.
3. Perform intubation:
   a. Apply gentle cricoid pressure until intubation is successfully completed.
4. Ventilate with the BVM using 100% oxygen.
5. EMS personnel are required to use both a Primary and at least one appropriate Secondary
   Method of tube placement confirmation (as defined below) on every intubation:
   a. If there is any doubt as to proper tube placement, resume ventilation with the BVM
      using 100% oxygen before re-attempting.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                            Page 88
Dr. Mark Seher DO, Medical Director.
    b. Secondary Confirmation can help prevent esophageal intubation, but they can't identify
       placement in a mainstem bronchus. That requires Physical Assessment, including depth
       of the tube, and auscultation.
Primary Confirmation Method                                           Secondary Confirmation Methods
 Visualization of tube passing between the                            {End Tidal Carbon Dioxide Monitor} -
   vocal cords.                                                          electronic waveform EtCO2 may be used
 Physical Assessment – auscultate                                       for all intubations.
   epigastrium, anterior chest, midaxillary                            {End Tidal Carbon Dioxide Detector} -
   areas, then epigastrium again.                                        colorimetric EtCO2 is limited to patients
 Observing rise and fall of the chest wall.                             with pulses.
 Condensation in the tube.                                            {Esophageal Detection Device (EDD)} -
                                                                         may be used with any intubation.
6. Secure tube with a commercially manufactured, tracheal tube holder:
   a. C-Collar may be used to help assure tube security.
   b. Keeping the ETT at the 20 -22 cm mark at the teeth will prevent inserting the ETT too
      far, greatly reducing the chances of a right mainstem bronchi intubations.
7. Reverify tube placement each time patient is moved using Primary and Secondary
   methods.
8. An airway Q.A. form MUST be completed on ALL advanced airway attempts (ET,
   Combitube, LMA, or Cricothyrotomy) regardless of success.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                             Page 89
Dr. Mark Seher DO, Medical Director.
Nasotracheal Intubation
Paramedic
INDICATIONS
 Breathing patients unable to protect their own airway.
 Possible spinal injury. A two rescuer in-line cervical stabilization technique should be
  utilized.
 Fractured jaw, oral injuries, or recent oral surgery.
 Significant angioedema (facial and airway swelling).
 Obesity
 Arthritis, preventing placement in the sniffing position.
CONTRAINDICATIONS
 Suspected nasal fractures.
 Suspected basilar skull fractures.
 Significantly deviated nasal septum or other nasal obstruction.
 Cardiac or respiratory arrest.
EQUIPMENT
   BVM with Oxygen supply                                                OPA/NPA
   Stethoscope                                                           BAAM
   10 ml Syringe                                                         Suction
   Secondary Confirmation Device                                         Water soluble lubricant or Lidocaine
   Endotracheal tubes of various sizes                                    Jelly 2% (Xylocaine)
    (ENDOTROL type)
PREPARATION
 Assemble and check required equipment.
 Inspect the nose and select the larger nostril as your passageway.
 Oxymetazoline HCL (Afrin) may be used to lessen risk of epistaxis - 2 to 3 sprays in
   each nostril 1 to 2 minutes prior to intubating.
PROCEDURE
1. Using basic manual and adjunctive maneuvers open the airway and pre-oxygenate with
   100% oxygen prior to any intubation attempt.
2. The intubation attempt should be no longer than 10 seconds. If so, the attempt should be
   stopped and the patient should be re-oxygenated with 100% oxygen:
   a. If nasotracheal intubation is unsuccessful after three attempts total, not per provider,
      insert a Combitube or LMA.
   b. Lidocaine Jelly 2% (Xylocaine) may be used as an anesthetic as needed.
3. Perform intubation:
   a. Hold tube in dominant hand, place thumb against 15mm connector and index finger in
      ring-loop.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                            Page 90
Dr. Mark Seher DO, Medical Director.
   b. Insert tube into the selected nostril, advance tube gradually, anterior to posterior,
      avoiding superior movement which will be met with resistance and could cause injury.
   c. As the tube enters the pharynx, listen for breathing and pull on the tip control ring loop
      to turn the tube anterior towards the trachea.
   d. When the patient takes a breath, advance the tube into the trachea.
4. Ventilate with the BVM using 100% oxygen.
5. EMS personnel are required to use both a Primary and at least one appropriate Secondary
   Method of tube placement confirmation (as defined below) on every intubation:
   a. If there is any doubt as to proper tube placement, resume ventilation with the BVM
      using 100% oxygen before re-attempting.
   b. When a Nasotracheal tube is correctly placed, there is often only an inch or so between
      the nose and the ET adapter. A tube that is 22 cm at the nose is unlikely to reach the
      glottis.
   c. Secondary Confirmation can help prevent esophageal intubation, but they can't identify
      placement in a mainstem bronchus. That requires Physical Assessment, including depth
      of the tube, and auscultation.
Primary Confirmation Method                                           Secondary Confirmation Methods
 Physical Assessment – auscultate                                     {End Tidal Carbon Dioxide Monitor} -
   epigastrium, anterior chest, midaxillary                              electronic waveform EtCO2 may be used
   areas, then epigastrium again.                                        for all intubations.
 Observing rise and fall of the chest wall.                           {End Tidal Carbon Dioxide Detector} -
 Condensation in the tube.                                              colorimetric EtCO2 is limited to patients
                                                                         with pulses.
                                                                       {Esophageal Detection Device (EDD)} -
                                                                         may be used with any intubation.
6. Secure tube:
   d. C-Collar may be used to help assure tube security.
7. Reverify tube placement each time patient is moved using Primary and Secondary
   methods.
8. An airway Q.A. form MUST be completed on ALL advanced airway attempts (ET,
   Combitube, LMA, or Cricothyrotomy) regardless of success.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                            Page 91
Dr. Mark Seher DO, Medical Director.
King Airway
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Emergency airway control in absence of other effective methods.
CONTRAINDICATIONS
 Patients under 4 feet tall.
 Patients with an intact gag reflex.
 Patients with known esophageal pathology.
 Patients who have ingested caustic substances.
 Central airway obstruction.
EQUIPMENT
   BVM with Oxygen supply.                                               Stethoscope
   King Airway                                                           Secondary Confirmation Device
   100 ml Syringe
   Suction                                                               Water soluble lubricant.
PREPARATION
 Determine size to be used:
 Test cuff integrity by inflating each cuff with the prescribed volume of air.
 Lubricate with water soluble lubricant to facilitate insertion.
PROCEDURE
  A. Use BSI including gloves, mask, and eye protection. Assemble the equipment while
    continuing ventilations.
      1. Choose the correct tube size based on the patient’s height. (See chart)
         a. 4 to 5 feet tall = size 3
         b. 5 to 6 feet tall = size 4
         c. > than 6 feet tall = size 5
      2. Check inflatable cuffs for leaks.
      3. Apply water soluble lubrication to the tip.
      4. Prepare and turn on suction.
  B. Apply chin lift and introduce the King airway in to the corner of the mouth.
  C. Advance tip under the base of the tongue while rotating the tube back to midline.
  D. Without excessive force, advance the tube until the base of the connector is aligned
    with the patient’s teeth or gums.
  E. Inflate cuff based on tube size.
      1. Size 3 = 50 ml
      2. Size 4 = 70 ml
      3. Size 5 = 80 ml
  F. Attach the BVM. While gently bagging slowly withdraw the tube until ventilation is easy
    to administer a large tidal volume with minimal airway pressure.
  G. Adjust cuff inflation, if necessary, to obtain an airway seal at peak ventilation pressure.
  H. Assess for proper tube placement.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                          Page 92
Dr. Mark Seher DO, Medical Director.
         1.    Assess breath sounds.
         2.    Assure chest rise and fall
         3.    ALS Providers attach patient to continuous end tidal CO2 monitoring.
         4.    Continue to reassess that tube is properly placed and that patient ventilation is easy
              and free flowing with chest rise and adequate breath sounds.
         5. If at anytime the provider is unsure of proper placement – deflate cuff,
           remove and use BVM for ventilation.

Notes

A       The key to insertion is to get the distal tip of the King airway around the corner in the
        posterior pharynx under the base of the tongue. A chin lift along with the lateral
        approach has been shown to help facilitate tube placement.
        1. Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue to
           the anterior to allow easy advancement of the King tube into the proper position.
        2. Insertion can also be accomplished using a midline approach by applying a chin lift
           and sliding the distal tip along the palate and into position in the hypopharynx. In
           this instance, head extension may also be helpful.
B   It is important to maintain the tube midline after it is advanced around the corner in the
    posterior pharynx. Keeping the tip at the midline assures the distal tip is properly placed in
    the hypopharynx/upper esophagus.
C   Depth of insertion is key to proper tube placement.
        3. With deeper initial insertion only withdrawal is required to accomplish a patent
           airway. A shallow inflation requires cuff deflation to advance the tube deeper.
        4. As the tube is withdrawn the proximal opening will be the first align with the
           laryngeal inlet. Since the proximal opening is closest to the proximal cuff there is less
           chance of airway obstruction.
        5. Withdrawal of the airway with the cuffs inflated results in retraction of tissues away
           from the laryngeal opening encouraging a more patent airway.
D   During ventilation the epiglottis or other tissue can be drawn into the distal ventilatory
    opening resulting in obstruction. Advancing the tube 1-2 cm or initiating deeper placement
    normally eliminates the obstruction.
E   Ensure the cuff is not over inflated. Cuff pressure should be adjusted to 60 cmH2O or until
    air does not leak around the cuff at peak inspiratory pressure.
F   Medications cannot be administered directly through this airway.
G       To remove the King airway:
        6. Suction above the cuff in the oral cavity if indicated.
        7. Fully deflate both cuffs before removal
        8. Remove the tube when the gag reflex has returned.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.              Page 93
Dr. Mark Seher DO, Medical Director.
SPECIAL NOTES
 The King Airway is NOT to be used as a route for drug administration in the absence of an
  endotracheal tube.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 94
Dr. Mark Seher DO, Medical Director.
RSI – Rapid Sequence Intubation
Paramedic
INDICATIONS
 Deteriorating patient in severe respiratory distress.
 Patient in shock or impending shock state with loss of ability to breathe and/or protect their
   airway.
 Patient with severely altered mental status.
 “Life threatening” situations, in the Paramedic’s judgment, mandating immediate
   placement of an advanced airway, AND the likelihood of successful placement of an
   advanced airway without RSI must be considered "low".
CONTRAINDICATIONS
 Paramedics not authorized by their department and the Medical Director.
 RSI should not be undertaken if the environment or positioning of the patient is not
   optimum.
 See RSI drug contraindications (Versed, Lidocaine, Etomidate, Succinylcholine, Vecuronium)
 Avoid RSI if patient will be difficult to bag valve mask ventilate or anticipate difficult
   intubation.
EQUIPMENT
 BVM with Oxygen supply                          OPA/NPA
 Patent and secure IV                            Laryngoscope handle / blades
 Endo-Tracheal Tube (variety of sizes)           Stylet
 10 ml Syringe                                   Suction
 Secondary Confirmation Device                   Commercial tube-securing device
 RSI Medications                                 Water soluble lubricant
 Rescue airway devices                           Pulse oximeter
                                                  ET Capnography (required for ALL RSI
                                                    patients)
PREPARATION
 Assemble, check and have ready ALL required equipment. Have all RSI medications
   prepared and drawn up before RSI is performed. (this will increase chances of successful
   intubation)
 Assure patient is in a controlled environment (e.g. preferably, inside the truck; however,
   adequate airway maintenance should not be delayed in an effort to get to the truck).
 Evaluate for possible difficult airway (Mallampati chart)
 Ensure functioning IV access and have suction on hand.
PROCEDURE
1. Using basic manual and adjunctive maneuvers open the airway and pre-oxygenate with
   100% oxygen via NRB mask prior to any intubation attempt, avoid BVM ventilation:
   a. Do not aggressively ventilate the spontaneously breathing patient unless SPO2 is below
       92%.
   b. Apply pulse oximeter and heart monitor.
   c. Push medications one right after another but SLOWLY to reach maximum ideal effects .


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.        Page 95
Dr. Mark Seher DO, Medical Director.
2. Prior to Etomidate administration and if systolic BP is>90 give 2mg Midazolam (Versed)
   IV, IO
3. If head injury suspected, administer Lidocaine (Xylocaine) 1 - 1.5 mg/kg IV/IO
   SLOWLY
4. Administer defasciculating dose of Vecuronium (Norcuron) 0.01 mg/kg IV, IO
5. Administer Etomidate (Amidate) - 0.3 mg/kg IV/IO (over 30-60 seconds)
6. Wait 1 to 2 minutes for sedation to begin to take effect.
7. Administer Succinylcholine (Anectine) - 1.5 mg/kg IV, IO (Succinylcholine can be
   omitted if Etomidate delivers proper sedation conditions for intubation.)
8. Apply gentle cricoid pressure until endotracheal intubation is completed. Intubate orally
   once adequate sedation has taken affect.
   9. Ventilate with the BVM using 100% oxygen.
   10. Verify ET placement with all below and document the following:
   a. Auscultation (bilateral breath sounds)
   b. Visualization of ET tube passing through the cords
   c. EID (Esophageal bulb)
   d. Easy cap CO2 detector
   e. ET CO2 Capnograghy
   f. Negative gastric sounds
   g. Rise/fall of chest
       (ET tube placement must be verified after every move of patient)
   11. If evidence of combativeness and after ET Tube placement is verified consider use
       Vecuronium (Norcuron) 0.1mg/kg IV, IO (use of capnography is required)
   12. If Vecuronium is used and if systolic BP is>90 keep patient sedated with subsequent
       doses of Midazolam (Versed) 1- 2.5 mg slow IV/IO throughout transport. Watch
       for signs of increased heart rate and increased BP. Max cumulative dose 10 mg.
   13. IF AIRWAY MANAGEMENT BY ENDOTRACHEAL INTUBATION IS UNSUCCESSFUL:
   a. If intubation attempt is longer than 10 seconds and SpO2 drops below 92%, the
       attempt should be stopped and the patient should be gently re-oxygenated with 100%
       oxygen via NRB and gentle cricoid pressure before reattempting.
   b. If endotracheal intubation is unsuccessful after three attempts at visualization total, not
       per provider, insert a King Airway.
       i) Visualization is defined as any advanced airway device, either a laryngoscope or an
           endotracheal tube, entering the patient’s mouth in an attempt to secure the airway.
   c. If King airway is contraindicated or unable after two attempts consider agent reversal or
       surgical airway (See Cricothyrotomy Procedure):
   14. An airway Q.A. MUST be completed on ALL advanced airway attempts (ET, Combitube,
       LMA, or Cricothyrotomy) regardless of success.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 96
Dr. Mark Seher DO, Medical Director.
Pediatric Specifics
   Peds ETT size = (16+age) ÷ 4 - have 0.5 larger and smaller sizes available.
   Atropine - 0.02 mg/kg IV/IO (< 8 years old):
        o Minimum single dose is 0.1 mg.
        o Maximum cumulative dose 1 mg.
   Lidocaine (Xylocaine) - 1 mg/kg IV/IO (max single dose 100 mg).
   Etomidate (Amidate) children < over 10 y/o - 0.3 mg/kg IV/IO. One time dose.
   If Etomidate not effective or child is under 10 y/o use Midazolam (Versed) - 0.2
    mg/kg IV/IO May repeat in 5 minutes. Max cumulative dose of 2 mg (monitor for
    hypotension)
   Succinylcholine (Anectine) children > (over 10 y/o) – 1.5 mg/kg IV, IO
   If evidence of combativeness and after ET Tube placement is verified consider use
    Vecuronium (Norcuron) 0.1mg/kg IV, IO (use of capnography is required)
   If Vecuronium is used and if systolic BP is>90 keep patient sedated with subsequent
    doses of Midazolam (Versed) 0.05 mg/kg IV/IO throughout transport. Watch for
    signs of increased heart rate and increased BP. Max cumulative dose 2 mg.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 97
Dr. Mark Seher DO, Medical Director.
CPAP – Continuous Positive Airway Pressure
All Levels
INDICATIONS
 Patients with signs and symptoms of CHF, COPD, pulmonary edema, or asthma who are
  awake and oriented, have the ability to maintain an open airway (GCS > 10), and have a
  systolic BP > 90 mmHg, with one or more of the following:
  o Severe and/or sudden onset of shortness of breath.
  o Orthopnea (Difficulty breathing except in upright position).
  o Rales or coarse wheezing.
  o Verbal impairment (inability to speak in complete sentences).
 Any two or more of the following:
  o Retractions or accessory muscle use.
  o Respiratory rate > 30 per minute.
  o Pulse oximetry < 92% on high flow oxygen.
CONTRAINDICATIONS - Absolute contraindications
 Respiratory or cardiac arrest.
 Agonal respirations.
 Severely depressed level of consciousness.
 Suspicion or indication of pneumothorax.
 Inability to maintain patent airway.
 Major trauma, especially head trauma with increased intracranial pressure.
 Facial trauma.
 Patient has a tracheostomy.
 CPAP is NOT indicated in pediatric patient’s age < 12 yo.
CONTRAINDICATIONS - Relative contraindications
 History of pulmonary fibrosis.
 Decreased level of consciousness, or inability to follow simple commands.
 Claustrophobia.
EQUIPMENT
   CPAP ventilation device                                               Pulse oximetry
   Oxygen supply                                                         Stethoscope
PREPARATION
 Assemble and check required equipment.
 Ensure indication for use and rule out contraindications.
 Explain the procedure to the patient (it will take reassurance for the patient to tolerate
  procedure), and place them in an upright or sitting position.
 Ensure adequate oxygen supply to CPAP ventilation device.


EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.           Page 98
Dr. Mark Seher DO, Medical Director.
PROCEDURE
1. Place patient on continuous pulse oximetry.
2. Place the delivery device over the mouth and nose.
3. Secure the mask with provided straps and continue to reassure the patient.
4. Start procedure at 5.0 cmH20 pressure.
5. Check for air leaks from the mask.
6. Due to changes in preload and afterload of the cardiovascular system during CPAP therapy,
    a complete set of vital signs needs to be obtained every 5 minutes.
7. Titrate CPAP pressure to effect and never increase above 12 cmH20.
8. Continue to coach patient to keep mask in place.
9. If respiratory status deteriorates, remove device and consider BVM ventilations or
    placement of an advanced airway.
10. Depending on patients underlying problem (CHF, Pulmonary Edema, COPD, Asthma),
    follow appropriate protocol with medication interventions as well.
SPECIAL NOTES
 Contact receiving emergency department as early as possible so that they can be prepared
    for the patient.
Pediatric Specifics
   CPAP is NOT indicated in pediatric patient’s age < 12 yo.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.    Page 99
Dr. Mark Seher DO, Medical Director.
{Retrograde Intubation}
Paramedic
INDICATIONS
 When definitive airway control is required and less invasive methods have failed.
CONTRAINDICATIONS
 Availability of less invasive means of airway control and the inability to open the mouth.
EQUIPMENT
   BVM with Oxygen supply                                      Suction
   Retrograde Intubation Kit                                   10 ml Syringes
   If kit unavailable:                                         Commercial tube-securing device
    o 80 cm spring J-tip guidewire                              Hemostat
   18-14 gauge IV catheter                                     Magill forceps
   Endo-Tracheal Tube (variety of                              Secondary Confirmation Device
    sizes)                                                      Alcohol or ChloraPrep
PREPARATION
 Assemble and check required equipment:
   o Add small amount of saline to syringe and attached to IV catheter.
 Identify cricothyroid membrane and cleanse skin overlying the cricothyroid membrane.
PROCEDURE
1. Using basic manual and adjunctive maneuvers open the airway and pre-oxygenate with
   100% oxygen prior to any intubation attempt.
2. Introduce IV catheter (bevel up) through lower half of cricothyroid membrane directed
   slightly cephalad into the trachea.
3. Aspirate air to confirm needle tip position, observing air bubbles in syringe.
4. Remove syringe and needle.
5. Advance the “J” end of guidewire through catheter sheath until the tip of the guidewire can
   be retrieved through the mouth. When visible, grasp with Magill forceps.
6. Remove IV catheter sheath from neck. Secure the end of the guidewire at the puncture
   site with a hemostat to prevent it from being pulled into trachea.
7. Thread oral end of guidewire through Murphy’s Eye (outside to inside) on appropriate sized
   ET tube:
   o Passing wire through Murphy’s Eye allows end of tube to pass beyond the point at
       which the wire enters the larynx.
8. Pass ET tube over the guidewire until resistance is met:
   o If resistance is met at the epiglottis, rotate the tube 90 degrees in counter clockwise
       direction. This allows tip of tube to slide under epiglottis. Then rotate tube back 90
       degrees to allow bevel to pass through the cords.
9. When satisfied that the tube has entered the trachea, stabilize tube and pull guidewire out
   through the mouth.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                  Page 100
Dr. Mark Seher DO, Medical Director.
10. Advance farther into the trachea and inflate balloon cuff on ET tube.
11. Auscultate breath sounds and confirm placement.
12. Secondary Confirmation Device.
Primary Confirmation Method                                           Secondary Confirmation Methods
 Physical Assessment – auscultate                                     {End Tidal Carbon Dioxide Monitor} -
   epigastrium, anterior chest, midaxillary                              electronic waveform EtCO2 may be used
   areas, then epigastrium again.                                        for all intubations.
 Observing rise and fall of the chest wall.                           {End Tidal Carbon Dioxide Detector} -
 Condensation in the tube.                                              colorimetric EtCO2 is limited to patients
                                                                         with pulses.
                                                                       {Esophageal Detection Device (EDD)} -
                                                                         may be used with any intubation.
13. Secure tube with a commercially manufactured, tracheal tube holder.
14. C-Collar may be used to help assure tube security:
    a. Advise receiving facility that retrograde procedure was utilized to secure airway.
15. Reverify tube placement each time patient is moved using Primary and Secondary
    methods.
16. An airway Q.A. form MUST be completed on ALL advanced airway attempts (ET,
    Combitube, LMA, or Cricothyrotomy) regardless of success.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                            Page 101
Dr. Mark Seher DO, Medical Director.
{Cricothyroidotomy}
Paramedic
INDICATION
 When all other airway management measures have failed and the patient needs an airway
  immediately:
  o Surgical cricothyroidotomy or {suitable device} for adults.
  o Needle cricothyroidotomy for pediatric patients.
 Inability to control the airway by other methods, particularly when time is a critical factor in
  securing the airway in a critically ill or injured patient.
 Impacted foreign bodies.
 Severe facial trauma or oropharyngeal hemorrhage.
 Severe laryngeal trauma.
 Laryngeal spasm.
 Burns of the face and/or upper airway precluding intubation.
 Pharyngeal hematoma usually secondary to cervical fractures.
CONTRAINDICATIONS
 Another airway management technique working effectively.
EQUIPMENT
   BVM with Oxygen supply                                                Alcohol or ChoraPrep
   Stethoscope                                                           Scalpel
   Endo-Tracheal Tube (variety of sizes)                                 Suction
   10 ml Syringe                                                         Tape
   Secondary Confirmation Device                                         3.0 - 3.5 mm ET tube adaptor
   10 or 14 gauge IV catheter
PREPARATION
 Locate the cricoid membrane between the thyroid cartilage and the cricoid cartilage.
 Quickly prep the site with Alcohol or ChoraPrep.
PROCEDURE - To Perform A Surgical Cricothyrotomy (Adults)
1. Using a sterile scalpel, make a 3 to 4 cm vertical incision through the skin over the cricoid
   membrane.
2. Visualize the cricoid membrane and use the scalpel to cut a 1 cm puncture through the
   membrane.
3. Enlarge the puncture with an inducer and place a size #5 or #6 ET tube caudally thru the
   incision.
4. Ventilate with the BVM using 100% oxygen.
5. EMS personnel are required to use both a Primary and at least one appropriate Secondary
   Method of tube placement confirmation (as defined in orotracheal intubation) on every
   intubation.
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                         Page 102
Dr. Mark Seher DO, Medical Director.
6. Secondary Confirmation can help prevent esophageal intubation, but they can't identify
   placement in a mainstem bronchus. That requires Physical Assessment, including depth of
   the tube, and auscultation.
7. Secure the tube.
8. An airway Q.A. form MUST be completed on ALL advanced airway attempts (ET,
   Combitube, LMA, or Cricothyrotomy) regardless of success.
Pediatric Specifics
PROCEDURE - Needle Cricothyrotomy (Pediatric Patients)
1. Using a 10 or 14 gauge IV catheter with a syringe attached, puncture the skin in
   the midline over the cricoid membrane.
2. Once through the membrane, advance the IV catheter at a 45 angle a few more
   millimeters caudally. Aspirate with a syringe while advancing. Aspiration of air
   and/or the sensation of a “pop” signify entry into the trachea.
3. Advance the catheter over the needle.
4. Remove the needle.
5. Recheck placement by aspirating with the syringe.
6. Secure the catheter with tape.
7. Attach a 3.0 - 3.5 mm ET tube adaptor to the catheter.
8. Ventilate with the BVM using 100% oxygen.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 103
Dr. Mark Seher DO, Medical Director.
Suctioning
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Presence of blood, secretions, or emesis in the nose or mouth causing respiratory distress
  or airway compromise.
CONTRAINDICATIONS
 Patient able to control airway without assistance.
EQUIPMENT
   Manual or mechanical suction unit                                     Suction tubing
   Sterile saline (for clearing a clogged                                Rigid or flexible suction catheters
    catheter)
PREPARATION
 Attach catheter to tubing.
 Attach tubing to suction unit.
 Check for operation of the suction unit and adequacy of suction.
 Pre-measure soft suction catheters for insertion depth:
   o Nose – from tip to earlobe.
   o Mouth – from corner of mouth to earlobe.
   o Endotracheal – from end of tube to earlobe to supraclavicular notch.
PROCEDURE - Nose or Mouth
1. Insert soft suction catheter to pre-determined depth or rigid catheter no further than you
   are able to observe.
2. Suction while withdrawing the catheter:
   a. Limit suction to 10 seconds.
3. Suction until airway is clear.
PROCEDURE - Endotracheal (Paramedic)
1. Insert appropriate suction catheter down the endotracheal tube to pre-determined depth:
   a. Use sterile technique to avoid contaminating the pulmonary system.
2. Apply suction while withdrawing the catheter:
   a. Limit suction to 10 seconds.
3. Place 3ml of sterile saline down the endotracheal tube to loosen thick secretions PRN.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                Page 104
Dr. Mark Seher DO, Medical Director.
Needle Decompression
Paramedic
INDICATIONS
 Tension pneumothorax.
CONTRAINDICATIONS
 None in the setting of a Tension Pneumothorax.
EQUIPMENT
   BVM with Oxygen supply                                                Large bore needle ≥14 (16g-18g peds)
   Stethoscope                                                           30ml to 50ml syringe
   Alcohol or ChoraPrep
PREPARATION
 Assemble and check required equipment.
 Expose entire chest and clean site vigorously with Alcohol or ChoraPrep.
 Prepare large bore needle catheter, 14 gauge or larger (16 to 18 gauge for children)
   with 30ml to 50ml syringe attached.
PROCEDURE
1. Insert catheter in mid-clavicular line, on affected side into second or third intercostal space.
2. Enter at the rib and slide OVER it. The needle should be “walked” upward on the rib until
   it slides off the upper edge and penetrates into the pleural space.
3. If air is under tension, it will exit under pressure. Leave needle in place.
4. If no air is obtained, remove needle and catheter, cover site with dressing, and inform
   receiving facility of attempt.
5. Continuously reassess adequacy of ventilation.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                         Page 105
Dr. Mark Seher DO, Medical Director.
Pulse Oximetry
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 All patients.
 Pulse oximetry measures the oxygen saturation of the red blood cells (SpO2%).
CONTRAINDICATIONS
 Carbon Monoxide poisoning.
 Cyanide poisoning.
 Peripheral vasoconstriction.
EQUIPMENT
   Pulse Oximeter                                                       Appropriate Pulse Oximeter sensor
PREPARATION
 Never base any treatment or oxygen therapy solely on the reading from the pulse
   oximeter.
 Remove nail polish if necessary.
 Select Sensor:
      o Finger Clip Sensors - Older pediatric and adult patients. Insert finger (preferably the
          patient’s index finger) completely into sensor, keeping fingernail side facing the
          sensor top. The thumb should not be used in the finger clip.
      o Flex Sensor - Pediatric and adult patients. Place the light emitter portion on the
          finger/toe-nail side and the detector of the side opposite of the nail, making sure to
          align the emitter and detector through the tissue.
      o Infant and Neonatal Sensors - The infant sensor is designed for
          application on the big toe of infants > 2 kilograms. The neonatal sensor is
          designed for application on the foot of infants < 2 kilograms.
PROCEDURE
1. Apply sensor.
2. Try to obtain oxygen saturation on room air prior to applying supplemental oxygen:
      96 – 100% SpO2                 Maintain airway & O2 support                   NC – 2 to 6 lpm
      90 – 95% SpO2                  Maintain airway & increase O2                  NRB – 10 to 15 lpm
                                     support
      85 – 89% SpO2                  Assist ventilation with BVM                    BVM – 100% O2
      Below 85% SpO2                 Ventilate with BVM                             BVM – 100% O2, consider
                                                                                    intubation
SPECIAL NOTES
 Never withhold oxygen from patients that need it (ex. COPD patients).




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                             Page 106
Dr. Mark Seher DO, Medical Director.
Pulse CO-Oximetry
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Suspected Carbon Monoxide poisoning.
 Pulse oximetry measures the oxygen saturation of the red blood cells, (SpO2%).
 Pulse CO-oximetry measures the carboxyhemoglobin saturation (SpCO).
CONTRAINDICATIONS
 Peripheral vasoconstriction.
 Elevated levels of Carboxyhemoglobin (COHb) may lead to inaccurate SpO2 readings.
 Elevated levels of Methemoglobin (MetHb) will lead to inaccurate SpO2 and SpCO readings.
EQUIPMENT
   Pulse CO-Oximeter                                                    Appropriate Pulse CO-Oximeter sensor
PREPARATION
 Never base any treatment or oxygen therapy solely on the reading from the pulse
   oximeter.
 Remove nail polish if necessary.
 Select Sensor – Only use sensors capable of reading SpO2 and SpCO.
PROCEDURE
1. Apply sensor.
2. Try to obtain oxygen saturation on room air prior to applying supplemental oxygen:
96 – 100% SpO2             Maintain airway & O2 support                             NC – 2 to 6 lpm
90 – 95% SpO2              Maintain        airway       &     increase       O2 NRB – 10 to 15 lpm
                           support
85 – 89% SpO2              Assist ventilation with BVM                              BVM – 100% O2
Below            85% Ventilate with BVM                                             BVM – 100% O2, consider intubation
SpO2
3. Treat elevated SpCO levels using appropriate guidelines.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                               Page 107
Dr. Mark Seher DO, Medical Director.
Colorimetric End Tidal CO2 Monitoring
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 To assure placement of the endotracheal tube into the trachea after intubation.
CONTRAINDICATIONS
 Not used for non-intubated patients.
EQUIPMENT
   Nellcor “Easy Cap” device on adults                                   “Pedi-Cap” devices on children under
   Appropriate airway adjuncts                                            30 lbs.
PREPARATION
 Remove the detector from package (Do not remove the caps until ready to attach device).
 Remove the caps immediately before use and shake device to introduce room air.
 Match initial color of the indicator to the purple color labeled “CHECK” on the product
   dome. If the purple indicator color is not the same or darker, do not use.
PROCEDURE
1. Insert endotracheal tube (Inflate cuff if tube is equipped with one).
2. Firmly attach the detector between the endotracheal tube and the BVM.
3. Ventilate patient with six breaths of moderate tidal volume (may be done quickly).
   Interpreting result with less than six breaths can yield false results.
4. Compare color of indicator on full end-expiration to color chart on product dome.
5. If initial intubation attempts fail, the detector can be used for re-intubation on the same
   patient provided the indicator color still matches the “CHECK” color stand on product dome.
6. The detector may only be left in place during ventilation to assist in monitoring tube
   placement for approximately 15 minutes.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                        Page 108
Dr. Mark Seher DO, Medical Director.
IV Access
EMT – Intermediate / Paramedic
INDICATIONS
 Signs or symptoms which indicate the possibility or potential for a life-threatening cardiac,
  respiratory or neurological or traumatic condition or if there is an anticipated use for IV
  medications.
 Saline wells are acceptable in stable patients when the need for a drug route is anticipated,
  but the need for fluid replacement is not expected.
CONTRAINDICATIONS
 None in the emergent setting.
EQUIPMENT
   Tourniquet                                                            Alcohol or ChloraPrep
   Over the needle IV catheters (22g-14g)                                IV site occlusive dressing
   Tape                                                                  IV tubing or saline lock
   Normal Saline IV solution
PREPARATION
 Attach IV tubing to Normal Saline solution and flush tubing.
 Apply tourniquet.
 Select and clean site.
 PROCEDURE
1. Cannulate the vein.
2. Remove the needle, release the tourniquet.
3. Flush IV catheter using preload saline syringe or IV fluid bag.
4. Secure the tubing with tape and apply an occlusive dressing over the site.
5. All IV infusions are to be run at TKO unless specified by the appropriate guideline.
6. Discard sharps.
7. Document location, size of needle, number of attempts and amount of fluid infused.
8. Start a second IV line when appropriate.
SPECIAL NOTES
 Use trauma (blood) tubing if there are any factors which indicate the potential for
   hypovolemic shock. Use a large bore IV catheter (16 gauge or larger) if possible.
 After drugs have been administered, flush saline well with 5 to 10 ml of normal saline.
 Use a pressure infusion for fluid resuscitation in the adult hypovolemic patient.
Pediatric Specifics
   For fluid resuscitation use 20 ml/kg bolus - repeat x 2 PRN.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                       Page 109
Dr. Mark Seher DO, Medical Director.
Intraosseous Access
EMT – Intermediate / Paramedic
INDICATIONS
 IV fluids or medications are needed and a peripheral IV cannot be established in 2
   attempts or 90 seconds AND exhibit 1 or more of the following:
   o Altered mental status.
   o Severe respiratory compromise.
   o Hemodynamic instability (systolic BP < 90 mmHg).
 May be considered PRIOR to IV attempts in the following situations:
   o Cardiac arrest (medical or traumatic).
   o Profound hypovolemia with altered mental status.
   o Emergent needs for IV, but veins are not readily accessible.
CONTRAINDICATIONS
 Fracture of the tibia or femur (consider alternate tibia).
 Previous orthopedic procedure (knee replacement).
 IO within past 24 hrs.
 Pre-existing medical condition: tumor near site, peripheral vascular disease, cellulitis at the
   site.
 Inability to locate landmarks (significant edema or excessive tissue at insertion site).
 EQUIPMENT
   IO needle or Easy IO                                                  Alcohol or ChloraPrep
   Tape                                                                  IV Tubing
   Normal Saline IV solution (1000ml)                                    Lidocaine (Xylocaine) - 20 to 50 mg
                                                                           IO
   10 ml syringe for aspiration                                          Extension tubing
   Stopcock                                                              Large syringe for boluses
PREPARATION
 Locate insertion site and cleanse using aseptic technique:
      o Adult - Find the medial malleolus. Move from one to two finger breadths above the
         medial malleolus and locate the flat expanse medial to the anterior tibial crest.
      o Pediatric – Locate the tibial tuberosity. Move 1 to 2 finger breadths below
         the tibial tuberosity and find the flat expanse medial to the anterior tibial
         crest.
 Attach extension tubing to stopcock, stopcock to IV tubing, and IV tubing to Normal Saline
  solution and flush.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                         Page 110
Dr. Mark Seher DO, Medical Director.
PROCEDURE
1. Perform the puncture. Holding the needle perpendicular to the puncture site, insert it with
   twisting motion until you feel a decrease in resistance or a “pop.” When this occurs, the
   needle is in the medullary canal. Do not advance it any further. Generally, you will need
   to insert the needle only 2 to 4 mm for entry.
2. Remove the trocar and attach the syringe. Slowly pull back the plunger to attempt
   aspiration into the syringe. Easy aspiration of bone marrow and blood confirms correct
   medullary placement.
3. Once you have confirmed placement, rotate the plastic disk toward the skin to secure the
   needle.
4. Remove the syringe and attach the prepared administration tubing and solution. Set the
   appropriate flow rate.
5. Secure the IO needle as if securing an impaled object by surrounding it with bulky
   dressings and taping them securely in place.
6. After establishing IO access, you must periodically flush the IO needle to keep it patent.
7. Consider Lidocaine (Xylocaine) - 20 to 50 mg IO for pain control in conscious patients.
SPECIAL NOTES
 All medications indicated in the PCGs to be administered via IV may also be administered
   via Intraosseous (IO).
 If available Adult Intraosseous (IO) devices, including but are not limited to: EZ-IO, may be
   used.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.       Page 111
Dr. Mark Seher DO, Medical Director.
{Central Venous Line Access}
Paramedic
INDICATIONS
 Some patients have a Central Venous Line established from an extended illness. Lines can
   have anywhere from 1 to 3 ports attached (Single, Double, or Triple Lumen). The ports
   are color coded along with the location marked (proximal, medial, and distal). The “distal”
   is the preferred port to use. Lines can be located at one of three sites, (Subclavian,
   Internal Jugular, or Femoral). All locations are appropriate for our use. All ports can be
   accessed with different meds at the same time.
Hickman/Broviac Catheter
 Hickman/Broviac Catheters are color coded. Blue is Venous, and Red is Arterial. Only
   access the Blue port.
CONTRAINDICATIONS
 If unable to aspirate blood from the port.
EQUIPMENT
   10 ml syringe                                                         Alcohol or ChloraPrep
   Normal Saline IV solution (1000ml)                                    IV Tubing
PREPARATION
 Prepare the site, clean each port with alcohol prep.
PROCEDURE
1. Aspirate 10 ml of blood from the desired port.
2. If unable to aspirate blood, attempt to gently flush with saline. If no resistance is met with
   flush, attempt to aspirate blood again:
   a. If still unsuccessful, do NOT use that port.
3. After successfully aspirating blood, flush port with 10 ml Normal Saline.
4. Connect IV fluids to port or push IV medication.
SPECIAL NOTES
 If treatment is discontinued in any of the ports, flush with 10 ml NS and clamp.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                  Page 112
Dr. Mark Seher DO, Medical Director.
IN – Intranasal Atomizer
EMT – Intermediate / Paramedic
INDICATIONS
 In the absence of an established IV, intranasal is the next quickest route offering the
  highest level of bio-availability of drug being administered.
   Midazolam (Versed) -Paramedic - Sedation prior to cardioversion, {RSI}, or Seizures.
 Naloxone (Narcan) -EMT – Intermediate - High index of suspicion for narcotic
  overdose or to reverse respiratory depression and CNS sedation from narcotics (Fentanyl,
  Morphine, etc).
CONTRAINDICATIONS
 None in the emergent setting.
EQUIPMENT
   Mucosal Atomization Device (MAD)                                      1 or 3 ml syringe
   Desired medication
PREPARATION
 Visually inspect nostrils, choosing the largest, or the one with least obstruction.
 Using a 1 or 3 ml syringe, draw up the required amount of desired medication.
 Expel all air from syringe.
 Affix the Mucosal Atomization Device (MAD) to the syringe.
PROCEDURE
1. Insert the MAD 1½ cm into the chosen nostril.
2. Timing the respirations, depress plunger rapidly upon patient fully exhaling and before
   inhalation.
Midazolam (Versed) -Paramedic-
3. - Adults and Peds: 0.2 mg/kg atomized IN if unable to start an IV. May repeat in
   5 minutes. Max cumulative dose 10 mg.
4. Naloxone (Narcan):- EMT – Intermediate
   a. Adult: 0.4 to 2 mg IN. May repeat every 2 to 3 minutes. Titrate to effect.
   b. Peds: 0.1 mg/kg IN. May repeat every 2 to 3 minutes. Max single dose 2
      mg. Titrate to effect.
SPECIAL NOTES
 Do not exceed 1cc per nostril. When dose is greater than volume of 1 ml, administer ½ of
   the dose in each nostril.
 MAD is reusable on the same patient, dispose after each patient.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.              Page 113
Dr. Mark Seher DO, Medical Director.
NG – Nasogastric Tube
Paramedic
INDICATIONS
 Cardiopulmonary arrest with gastric distention.
 Ingested drug overdose.
CONTRAINDICATIONS
 Suspected basilar skill fracture (battle’s sign, raccoon eyes, bleeding from nose).
 Significant facial fractures.
 Ingestion of corrosive, acidic or other tissue destructive substance.
EQUIPMENT
   NG tubes of various sizes                                             Toomey syringe
   Water soluble lubricant or Lidocaine Jelly                            Desired medication
    2% (Xylocaine)                                                        Tape
   Stethoscope                                                           Suction
PREPARATION
 If conscious, explain procedure to patient.
 Prepare the patient’s head in a neutral position while preoxygenating.
 Determine the length of NG tube insertion by measuring from the epigastrium to the angle
   of jaw, then to the tip of the nares.
 Lubricate the distal tip of the NG tube:
   o Arrest - Water soluble lubricant.
   o Ingested over dose - Lidocaine Jelly 2% (Xylocaine) to control gagging.
 Look at the nose for deformity or obstruction and determine the best side, usually the
   right.
PROCEDURE
1. Gently insert the tube into nares. Advance tube gently. If the patient is awake, encourage
   swallowing to facilitate the tube’s passage. Do not force the tube if increasing resistance is
   encountered.
2. Advance to the predetermined mark on the tube.
3. Confirm placement by injecting 30 to 50 ml of air while listening to the epigastric region for
   air sounds.
4. Apply LOW suction to the tube, and note gastric contents that pass through the tube.
5. Secure the tube in place.
SPECIAL NOTES
 Inability to speak that develops after NG tube placement indicates malposition of the tube
   through the vocal cords and into the trachea. If this occurs, you must remove the tube.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.               Page 114
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PASG – Pneumatic Anti-Shock Garment
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Bilateral femur fractures (may be used in conjunction with traction devices).
 Pelvic fractures with hypotension.
CONTRAINDICATIONS
 Pulmonary edema.
 Cardiogenic shock.
 Penetrating trauma to torso.
CONTRAINDICATIONS - Relative (Do not inflate abdominal section)
 3rd trimester pregnancy.
 Pediatric patient under 10 y/o.
 Uncontrolled bleeding above diaphragm.
EQUIPMENT
   PASG/MAST                                                             LBB
PREPARATION
 Complete patient assessment including baseline vitals.
 Remove clothing and assess areas of the body that will lie beneath the garment.
PROCEDURE
1. Secure the garment around patient:
   a. Upper portion of the abdominal segment is positioned just below the rib margin.
2. Attach inflation tubing and open stopcocks.
3. Inflate slowly until the garment is firm while maintaining distal circulation:
   a. Inflation options:
       i) All three compartments simultaneously.
       ii) One compartment at a time beginning with leg compartments
           (1) NEVER inflate abdominal section first or alone.
4. Close stopcocks.
SPECIAL NOTES
 Deflation in the field should not be performed unless pulmonary edema develops.
 The use of PASG is continuously being evaluated throughout the Nation. Currently, the
   recommended use for PASG is limited to the above indications.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 115
Dr. Mark Seher DO, Medical Director.
Taser Probe Removal
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Imbedded Taser probe.
CONTRAINDICATIONS - Do not remove probes if they become lodged in:
 Eye
 Face
 Neck
 Ear
 Breast
 Groin
 Deeply imbedded elsewhere.
EQUIPMENT
   Wound care supplies                                                   Taser spent cartridge
PREPARATION
 Remember, the probes are bio-hazards.
 Assure scene and crew safety.
 Evaluate patient for injuries maintaining a high index of suspicion for fall trauma and
   substance abuse.
PROCEDURE
1. Snap wires 3 – 4 inches above probe.
2. If probe removal is contraindicated:
   a. Immobilize probe, treat, and transport.
3. Probe removal:
   a. Secure area around probe with gloved hand.
   b. Firmly grasp probe with other gloved hand.
   c. Remove probe with one pull.
4. Once probe removed:
   a. Visually confirm that the barb is still attached to the probe, document on patient care
       report:
       i) If barb is not on probe, patient must be transported.
   b. Place the spent probe, point down, into the spent cartridge. Holding the spent
       cartridge in your gloved hand, remove the glove, leaving the cartridge inside the
       inverted glove.
   c. Turn over to law enforcement for evidence.
   d. Cleanse area with ChoraPrep or alcohol swab.
   e. Place band aid over wound.



EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                  Page 116
Dr. Mark Seher DO, Medical Director.
Spinal Immobilization – Appropriate Omission
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Patients with traumatic mechanism of injuries may have spinal immobilization omitted if
   ALL of the following conditions apply.
CONTRAINDICATIONS
 If ANY of the following conditions do not apply.
EQUIPMENT - N/A
PREPARATION - N/A
PROCEDURE
1. Assess the patient and the MOI for the following conditions:
   a. They are conscious, cooperative are able to communicate and can cooperate with the
      physical exam.
   b. There is no mechanism for severe injury, for example:
      i) Ejection from vehicle.
      ii) Death of another occupant.
      iii) Fall greater than 20 feet.
   c. Have no history of new or temporary neurological deficit:
      i) Numbness or weakness in any extremity.
   d. Have no evidence of intoxication or other altering substance.
   e. Have no evidence of a concentration-distracting injury:
      i) Long bone fractures.
      ii) Burns
   f. Have no back or neck pain, or tenderness upon palpation to the cervical spine.
   g. Have no language barrier or difficulty communicating with the paramedic conducting
      the physical examination.
2. Negative findings of all the above conditions must be clearly documented on the PCR.
SPECIAL NOTES
 If the patient has a positive finding at any time during this procedure, stop and proceed
   with complete spinal immobilization.
 Any time the paramedic feels the patient needs spinal immobilization despite these
   guidelines, immobilization is always warranted.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 117
Dr. Mark Seher DO, Medical Director.
Helmet Removal
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Helmet does not immobilize the patient’s head within.
 Cannot securely immobilize helmet to LBB.
 Helmet prevents airway care.
 Helmet prevents assessment of anticipated injuries.
 There are, or anticipated, airway or breathing problems.
 Helmet removal will not cause further injuries.
CONTRAINDICATIONS
 Do not remove football helmet if it fits and the airway is maintainable with the helmet in
  place.
EQUIPMENT
   C-collar                                                              LBB with CID and straps
   Padding
PREPARATION
 Assemble C-spine immobilization equipment.
 Perform a primary survey if possible. Also, if the situation permits, ascertain if the victim
   has the ability to move their extremities.
 Keep the cervical spine in the neutral position as much as possible.
PROCEDURE Motorcycle, Bicycle or other non-football type head protective device.
1. The in-charge rescuer should designate a trained rescuer (Rescuer II) to manually control
   the cervical spine. The in-charge rescuer should kneel beside the patient and remove the
   chin strap device. A third rescuer should prepare padding for use to keep the spine in a
   neutral position.
2. The in-charge rescuer should then take control of the cervical spine from a side position to
   the patent. Rescuer II should then relinquish control of the cervical spine to the in-charge
   rescuer. Rescuer II should remove the helmet by spreading the sides of the helmet and
   removing the helmet using caution not to manipulate the cervical spine. (Use caution not
   to pinch the nose when removing) The in-charge rescuer should be prepared to hold the
   head as when the helmet is removed, there will be an increase in weight. The pad should
   be inserted under the patient’s head and cervical spine control should then be maintained
   by Rescuer II. The in-charge rescuer should then resume the primary survey, further
   assessment and interventions.
PROCEDURE - Football Helmets
1. If the football helmet fits and the airway is maintainable with the helmet in place, do not
   remove the helmet.         Immobilize manually and complete the primary survey.            If
   transportation is necessary, the cervical spine should be immobilized with the helmet and
   shoulder pads in place. A CID, towels, or blanket rolls may be used to immobilize the head
   on a back board. The face mask may be removed.

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2. If the football helmet does not fit correctly or the airway is not maintainable with the
   helmet in place:
   a. The in-charge rescuer should designate a trained rescuer (Rescuer II) to manually
       control the cervical spine. The in-charge rescuer should kneel beside the patient and
       remove the chin strap, ear pads, and remove the face mask retainers if not already
       done. A third rescuer should prepare padding for use to keep the spine in a neutral
       position.
   b. The in-charge rescuer should then take control of the cervical spine from a side position
       to the patient. Rescuer II should then relinquish control of the cervical spine to the in-
       charge rescuer.
   c. Rescuer II should remove the helmet by spreading the sides of the helmet and
       removing the helmet not to manipulate the cervical spine. The in-charge rescuer
       should be prepared to hold the head as when the helmet is removed, there will be an
       increase in weight. The pad should be inserted under the patient’s head and cervical
       spine control should then be maintained by Rescuer II.
   d. If shoulder pads need to be removed, the helmet should be removed prior to the
       shoulder pads. When removing shoulder pads, remove the straps and lift on side of the
       pads prior to log-rolling. Then after rolling the patient on their side, finish removing the
       shoulder pads. A CID pad or a 1” pad may be sufficient to maintain neutral alignment
       of the cervical spine.
   e. Immobilize on a long back board using a cervical collar, straps, and a cervical
       immobilization device. Continue the assessment.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 119
Dr. Mark Seher DO, Medical Director.
 AED
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Unresponsive patient that is pulseless and apneic.
CONTRAINDICATIONS
 Unable to clear contact with the patient (standing water, confined space, etc).
CONTRAINDICATIONS - RELATIVE
 Currently there is not enough evidence to recommend for or against use on infants <1 year
  of age.
EQUIPMENT
   AED                                                                   Electrode Pads
   Razor                                                                 Towel
PREPARATION
 Follow Adult CPR Critical Concepts and activate ALS.
 Attach electrode pads to the patient’s bare chest:
  o Choose correct pads (adult vs. child) for size and age of victim. Use child pad or child
      system for children <8 years of age, if available.
  o Do not use child pad or child system for patients 8 years of age or older.
  o Place on electrode pad on the upper-right side of the bare chest to the right of the
      breastbone, directly below the collarbone.
  o Place the other electrode pad to the left of the nipple, a few inches below the left arm
      pit.
 Hairy Chest – AED prompts “check pads” or “check electrodes”:
  o If pads stick to hair instead of skin, press down firmly on each pad.
  o AED continues to prompt “check pads” or “check electrodes,” quickly pull of pads. This
      will remove a lot of hair.
  o If a lot of hair remains, shave the area.
  o Put on new set of pads.
 Water:
  o Do not use AED in water. Remove patient from water.
  o Quickly wipe chest before attaching electrodes.
  o If patient is lying in snow or small puddle, you may use AED.
 Implanted Defibrillators and Pacemakers:
  o Place AED pad at least 1 inch to side of the implanted device.
 Transdermal Medication Patches:
  o Remove the patch and wipe the area clean.
 Attach cables to AED if needed.



EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.           Page 120
Dr. Mark Seher DO, Medical Director.
PROCEDURE
1. POWER ON the AED.
2. Allow the AED to ANALYZE the patient’s rhythm:
   a. Always clear the victim during analysis.
   b. Some AEDs will tell you to push a button to allow the AED to begin analyzing; others
       will do that automatically. The AED may take about 5 to 15 seconds to analyze.
   c. Verify no patient contact/movement during ANALYZE period.
3. If SHOCK advised:
   a. Clear victim verifying no patient contact.
   b. Deliver shock.
   c. Immediately resume CPR after the shock starting with chest compressions:
       i) Do not delay CPR to check the patient’s pulse even if displayed rhythm looks
           “normal”.
   d. After 5 cycles (about 2 minutes) of CPR, the AED will prompt to repeat analyze
       sequence.
4. If NO SHOCK Advised:
   c. Immediately resume CPR starting with chest compressions. Do not delay CPR to check
       the patient’s pulse even if a displayed rhythm looks “normal”.
   d. After 2 minutes of CPR, the AED will prompt to repeat analyze sequence.
5. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of
   less than 5 minutes to the scene:
   a. You may leave AED attached while transporting.
   b. Never ANALYZE while moving victim. Bring cot or vehicle to a complete stop, then
       reanalyze.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 121
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12-Lead Monitoring
Paramedic
INDICATIONS
 Any patient who, in the opinion of the Paramedic, has the potential for or is exhibiting
  symptoms of an acute myocardial event will have a 12-lead ECG performed and
  transmitted into the ED.          All patients with chest pain, shortness of breath,
  unconsciousness, suspected CVA, or with a cardiac history will receive a 12-lead ECG
  during prehospital treatment (if equipment is available).
CONTRAINDICATIONS
 Trauma patients unless a suspected cardiac incident caused the event. Do not delay
  transport in order to obtain a 12-lead ECG. Three (3) lead ECG is monitoring of choice for
  trauma patients.
EQUIPMENT
   12-Lead capable monitor                                              Electrodes
   Razor                                                                Transmission method, if available
PREPARATION
 Whenever possible attempt to obtain 12-lead ECG with the patient in the supine position.
   If the patient does not tolerate this position, place them in a semi-reclined or sitting
   position.
 Prep skin as necessary:
   o Cleanse with alcohol.
   o Dry with towel if diaphoretic.
   o Shave body hair.
PROCEDURE
1. Apply electrodes according to the chart below:
   a. Leave the electrodes in place so that ED personnel can confirm the lead placement if
       necessary.
   b. On female patients always place leads V3-V6 under the breast rather than on the
       breast.
   c. Never use the nipples as a reference point for electrode location as the nipple location
       may vary widely from patient to patient.
2. Connect the cables to the monitor as per manufactures specifications. Then connect the
   appropriate leads to the corresponding electrodes.
3. Obtain the 12-lead ECG while the patient is not moving if possible. Ask the patient to
   remain as still as possible for approximately 10 seconds while the monitor is capturing the
   rhythm and providing pertinent information about the rhythm. DO NOT rely solely on the
   monitor interpretation of the rhythm.
4. Inform the receiving facility that a 12-lead ECG has been obtained and also specify it in
   your documentation. Transmit 12-lead ECGs with ST segment elevation (STEMI) to the
   receiving hospital (if equipment is available):

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                             Page 122
Dr. Mark Seher DO, Medical Director.
  a. If unable to transmit, early notification of the receiving hospital is essential.
  b. Be sure to provide a copy of the ECG for the physician to review upon arrival.
SPECIAL NOTES
 The 2005 American Heart Association Guidelines for CPR and ECC strongly recommend
  EMS systems transmit diagnostic-quality 12-lead Eggs to the emergency department to
  shorten the time to treatment and decrease mortality rates.
 Obtain the 12-lead ECG as early as possible in the patient care cycle.
 A normal ECG does not definitely rule out an MI nor should it be justification for no
  transport of a patient.
 The Cardiac Cath Lab is not currently staffed 24/7 at Marion General Hospital. Early
  notification and transmission facilitates early team notification to assemble and prepare for
  incoming patient.
 Print or copy enough ECGs needed to attach to each page of the PCR.

12-Lead – Monitor Lead Placement
Lead Positive              Negative         Heart                                   Lead Positive         Electrode Heart
     Electrode             Electrode        Surface                                      Position                     Surface
     Position              Position         Viewed                                                                    Viewed
 I   Left Arm              Right Arm        Lateral                                 AVR   Right Arm                   None
II   Left Leg              Right Arm        Inferior                                AVL   Left Arm                    Lateral
III  Left Leg              Left Arm         Inferior                                AVF   Left Leg                    Inferior
                                                                                    V1    Right side of sternum, Septum
                                                                                          4th intercostal space
                                                                                    V2    Left side of sternum, Septum
                                                                                          4th intercostal space
                                                                                    V3    Midway between V2 & V4 Anterior
                                                                                    V4    Left midclavicular line, Anterior
                                                                                          5th intercostal space
                                                                                    V5    Left anterior axillary line Lateral
                                                                                          at same level as V4
                                                                                    V6    Left midaxillary line at    Lateral
                                                                                          Same level as V4




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                   Page 123
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EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.   Page 124
Dr. Mark Seher DO, Medical Director.
Auto-Injector
EMT – Basic / EMT – Intermediate / Paramedic
INDICATIONS
 Epi-Pen – as stated in Allergic Reaction, Anaphylaxis, Dystonic Reaction Guideline.
 Mark 1 Kit – As stated in Exposure to Nerve Agents / Organophosphates Guideline.
CONTRAINDICATIONS
 As stated in the appropriate PCGs.
EQUIPMENT
   Auto-Injector                                                         Sharps container
PREPARATION
 Check medication for expiration date.
 Have Sharps container nearby.
PROCEDURE
1. Provide oxygen and /or ventilatory assistance as needed.
2. Administer by placing the auto-injector on the patient’s lateral thigh (not necessary to
   remove clothing); push the injector firmly against the site.
3. Hold the injector against the site for ten (10) seconds.
4. Dispose of injector in the sharps container.
5. Record time and site of injection.
SPECIAL NOTES
 Follow the appropriate PCGs for additional treatments.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.             Page 125
Dr. Mark Seher DO, Medical Director.
SECTION XI – Appendices
Adult vs. Pediatric Glasgow Coma Scoring
                                                   Adult                            Infant

                                 Spontaneous                           Spontaneous                    4
                           Eye   To Voice                              To Voice                       3
                         Opening To Pain                               To Pain                        2
                                 None                                  None                           1

                                 Oriented                              Coos, babbles                  5
                                 Confused                              Irritable cry, Inconsolable    4
                         Verbal
                                 Inappropriate                         Cries to Pain                  3
                        Response
                                 Garbled Speech                        Moans to Pain                  2
                                 None                                  None                           1

                                 Obeys Commands                        Normal Movements               6
                                 Localizes Pain                        Withdraws to touch             5
                         Motor Withdraws to Pain                       Withdraws to pain              4
                        Response Flexion                               Flexion                        3
                                 Extension                             Extension                      2
                                 Flaccid                               Flaccid                        1

Normal Pediatric Vital Signs
                  Age                    Pulse         Respiration                      Blood Pressure
               Newborn                120 - 160            30 - 60                     Systolic = 60 - 70
               < 1 year               120 - 140            30 - 50
              1 - 2 years             100 - 140            30 - 40                  Systolic = 70 + (2 x age)
              3 - 5 years             100 - 120            20 - 30                   Diastolic = 2/3 systolic
             6 - 10 years              80 - 100            16 - 20




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                               Page 126
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Differential Causes of Chest Pain and Dyspnea
               CAUSES                                    SYMPTOMS                        PHYSICAL SIGNS
Acute Myocardial                               Sudden onset pain
Infarction (AMI)                               (midsternal or epigastric);
Risk factors for coronary                      radiation to arms, neck or           Diaphoresis, dyspnea,
artery disease (CAD) include:                  jaw; descriptors – burning,          hypotension, crackles,
diabetes, hypertension,                        crushing, pressure,                  arrhythmias. Initial ECG may
smoking, obesity, elevated                     squeezing, occasionally sharp        not show ST segment
cholesterol, family history,                   or stabbing; usually not             changes typical of AMI.
and cocaine use.                               relieved by nitro; anxiety;
                                               nausea, dizziness.
Aortic Dissection                              Sudden onset pain described
Risk factor: underlying                        as “tearing or cutting”; most        Hypotension; difference in
hypertension.                                  intense at onset; typically          upper extremity pulse,
                                               radiates straight to back,           arrhythmias.
                                               flank, or arm.
Pulmonary Embolism (PE)
                                                                                    Dyspnea, tachypnea,
Risk factors include:
                                                                                    coughing up blood, hypoxia,
immobility, recent surgery,                    Sudden onset of pleuritic
                                                                                    crackles, chest wall
deep venous thrombosis                         pain; usually worsens with
                                                                                    tenderness, syncope,
(DVT), smoking, cancer, birth                  deep inspiration.
                                                                                    arrhythmias; warm reddened,
control pills (BCP), and
                                                                                    tender lower extremity.
pregnancy.
Cardiac Tamponade                                            Beck’s triad: distended neck
                                                             veins, hypotension, muffled
Risk factors include:                                        heart sounds; dyspnea,
                                Chest pain may or may not be
pericarditis, chest trauma, and                              tachycardia, tachypnea,
                                present.
cancer.                                                      narrowed pulse pressure,
                                                             pulsus paradoxus, pericardial
                                                             friction rub.
Tension Pneumothorax                                         Severe respiratory distress;
Risk factors include: COPD,                                  neck vein distention, tracheal
                                Sudden onset pleuritic pain;
lung CA, chest trauma, heavy                                 deviation, diminished breath
                                usually worsens with deep
lifting, and tall thin young                                 sounds on one side; hypoxia;
                                inspiration.
men.                                                         possible hypotension; drum
                                                             like quality on percussion.
Pericarditis                    Gradual onset; steady,
Risk factors include: cancer,   burning, retrosternal pain,
renal failure or other          may radiate to back, neck
inflammatory conditions.        scapula, or jaw; usually     Friction rub that varies with
                                worsens with deep            heart beat; possible fever;
                                inspiration; worse when      may have ST segment
                                supine.                      changes similar to AMI.




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Foreign Body                                   Sudden onset while eating;
Risk factor: stroke.                           foreign body sensation in            Possible visible foreign body.
                                               throat.
Anaphylaxis                                    Sudden onset after ingesting
                                               food, medication, or insect          Itchy rash, wheezing,
                                               bite/sting; nausea, abdominal        hypotension.
                                               cramps.
Asthma                                         Sudden onset dyspnea with            Cough, wheezing, eventual
                                               exertion, chest tightness.           prolongation of expirations.
COPD                                           Gradual onset; dyspnea
                                                                                    Thin with barrel chest;
                                               interferes with normal
                                                                                    wheezing, sputum, productive
                                               activities; improvement after
                                                                                    cough.
                                               coughing.
Pneumonia                                                                           Fever, tachycardia,
                                               Gradual onset of chills,             tachypnea, crackles, rhonchi,
                                               pleuritic chest pain.                decreased breath sounds in
                                                                                    affected lung areas.
Congestive Heart Failure      Gradual onset; dyspnea at
(CHF)                         rest, when lying flat, or at                          Rales, occasionally wheezing,
Risk factors include:         night; dyspnea that interferes                        ankle edema; enlarged liver,
hypertension and previous MI. with normal activities;                               jugular vein distention.
                              improves when upright.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                           Page 128
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Universal Precautions
Providers SHALL use Universal Precautions as outlined
Adherence to infection control principles is the responsibility of each Provider. All EMS
Providers must be aware of well-known infectious agents (Hepatitis B, influenza, MRSA, etc.),
as well as emerging new pathogens (Avian Flu, SARS, etc.) that present challenges to
medicine and risks to Providers. A personal commitment to employing basic infection control
measures on every single incident will provide the simplest and best protection against
infectious diseases. Make it a habit!
Basic Protection Guidelines and Immunizations
The infection “triad” requires a portal of entry, an adequate amount of the infectious agent,
and a susceptible host (the Provider) in order for a person to actually become infected.
Through the engineering of safer equipment and the use of Personal Protective Equipment
(PPE), we can prevent portals of entry and reduce the amount of materials to which you may
be exposed.
Although it sounds simplistic and obvious, individuals that are well nourished, rested, and
physically fit have immune systems that are more responsive and better prepared to mount an
effective fight against invading pathogens. Taking care of ourselves decreases our long-term
morbidity and allows us to recover more quickly should we become infected.
In any health care environment, Providers can expect to be routinely exposed to infectious
agents. Immunizations are an extremely important weapon against infection from many of the
more common agents. Keeping current on appropriate immunizations protects you, protects
patients from becoming infected by you, and decreases overall disease transmission (a
concept in public health known as herd immunity). As always, you should consult with your
regular physician regarding your health care and immunization status. For healthcare workers,
the currently available recommended immunizations (or documented immunity) include:
     Hepatitis B, Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, or Pertussis.
     Influenza (seasonal)
     Hepatitis A (particularly for Providers routinely involved in water rescue operations).
Attention to ongoing hand washing, especially during the cold and flu season, is very
important. Contact with contaminated surfaces provides a ready way for you to become
infected and for you to infect others. Hands should be washed after each patient contact,
gloves should be changed and all equipment cleaned. In addition, gloves should be changed
between patient contacts while on multiple patient scenes. Waterless, alcohol-based hand
cleaners are an acceptable alternative to soap and water provided there is no gross organic
material present. To be effective, hand washing with soap and water needs to be performed
for a minimum of twenty (20) seconds, using a vigorous rubbing together of all surfaces of
lathered hands followed by thorough rinsing under a stream of water. As soap and water are
not typically available at the scene, a waterless hand wash/wipe should be used before
boarding the vehicle. Upon return to the station, all Providers should wash their hands with
soap and water.
Additionally, it is important to conduct a self-check of your skin (particularly hands and
exposed surfaces) prior to any potential patient contact. Identify scrapes, wounds, or other
non-intact surfaces and cover all open and scabbed wounds with bandages. The integrity of

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any bandages should be monitored during your shift to ensure the continuation of their
protection.
Personal Protective Equipment (PPE)
PPE is designed to stop the transmission chain of an infectious agent by preventing potentially
infectious microorganisms from contaminating a Provider’s skin, mucous membrane, or
clothing, and subsequently being transmitted to others. While PPE reduces the risk, it does not
completely eliminate the possibility of infection, and is only effective if chosen and used
correctly.
Remember, PPE should always be readily available, not just carried in the vehicle for those
“surprise” circumstances where the possibility of exposure exists. In addition, wishing you had
your PPE available AFTER an exposure is a terrible place to put yourself.
There are instances that the selection of appropriate PPE should be obvious and regarded by
all Providers as standard practice. These include:
     Anytime patient contact is made, gloves are to be worn. The EMS System has adopted
        the use of latex free materials whenever possible and certainly in all cases where a
        patient or Provider suffers from latex sensitivity.
     During any type of airway management procedure, or other situation that fluid splash
        contact with the Provider’s face is a possibility, the protection of mucous membrane is
        crucial. Effective mucous membrane protection may be afforded by use of the
        combination eye shield and mask apparatus, or N95 mask in conjunction with approved
        eyewear (goggles or safety glasses with side shields).
     Whenever the possibility exists that a patient’s bodily fluids could be splashed onto a
        Provider, gowns should be utilized.
There are times when the selection of proper PPE, especially respiratory protection, is not so
obvious and must be made based on how a disease is spread. In these situations, the difficulty
in determining the appropriate level of protection is that a truly informed decision usually can’t
be made until a patient assessment is completed and/or a history is obtained.
By then, it’s too late! For that reason, a patient exhibiting any of the following signs or
symptoms should be a signal to Providers, that in addition to gloves and possibly a gown;
some level of respiratory protection is required:
     Productive cough (with or without blood).
     Fever and chills with coughing.
     Night sweats.
     Dramatic (> 10%) unexplained weight loss.
     Fatigue (in the presence of other symptoms).
     Hemoptysis (coughing up blood).
     Nuchal rigidity (stiff neck).
     Chest and upper torso rash.
     A recent history of travel out of the continental United States.
     Patients with high risk for a positive history of TB exposure (i.e. nursing home patients).
In determining the type of respiratory protection needed, remember that only the N95 mask
will afford protection against diseases spread via airborne particles (i.e., tuberculosis), while
the combination eye shield and mask apparatus is appropriate protection against disease
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spread through larger droplets (i.e., meningitis). In either case, protection is only afforded if
the mask is worn, and worn properly:
     For a patient exhibiting signs and/or symptoms of a disease spread via airborne
        particles, the N95 mask should be donned prior to entering an enclosed area that the
        patient may have contaminated
     When caring for a patient with signs and symptoms of a disease spread through larger
        droplets, the N95 mask or combination eye shield and mask should be donned as soon
        as possible, and worn anytime the Provider is within five (5) feet of the patient.
     When airborne or droplet precautions are appropriate, the additional step of placing a
        non-rebreather mask with supplemental oxygen on the patient should be employed.
        This will limit the amount of aerosolized agent emitted. You may also consider placing a
        disposable surgical mask to all persons suspected of having a respiratory infection. In
        N95 mask should never be used on a patient as it could inhibit his or her respiratory
        function.
     If the patient needs to expectorate, every attempt to should be made to capture the
        sputum in a tissue or gauze, and dispose of properly.
     When in doubt, maximal rather than minimal PPE should be selected.
Sharps Hazards
     The greatest risk for an occupational exposure to blood occurs with the use of needles
        and other sharp utensils. The most common occupational blood exposure occurs when
        needles are recapped. Needles that have contact with human tissue SHALL not be
        recapped, resheathed, bent, broken, or separated from disposable syringes.
     Used needles and other sharps shall be disposed of in approved sharps containers.
     Providers should ensure that no sharp is used in a manner inconsistent with its intended
        purpose or attempt to circumvent the safety features of the device.
Cleaning and Disinfection of Equipment and Work Areas
Remember how important it is to keep all medical equipment clean and free from infectious
agents. The essential part of cleaning and disinfecting equipment is ensuring the removal of all
accumulated organic material. Failure to remove organic material provides a continuing
breeding ground for organisms. After removal, disinfection can take place.
Be thorough with your cleaning and consider using your PPE eyewear if you need to do heavy
cleaning that may result in splashing. Remember to clean any surface that your gloved hand
may have contacted. After applying your disinfectant, permit the equipment to air dry. Wiping
dry the wet disinfected surface will negate the effects of the agent and render it useless. Upon
completion of the cleaning, make sure you wash your hands.
Exposure Follow-up
The purpose of PPE and always using sound infection control practices is to reduce or
eliminate the potential for infection. On occasion, a Provider is exposed to blood, bodily fluids,
or airborne particles, and appropriate action must be taken. Many of these actions are time-
dependent so it’s important to initiate the reporting and follow up process as soon as possible.
Besides adherence to sound infection control practices, the most important thing you can do
to ensure your health and well-being is to educate yourself. Become knowledgeable about
infectious diseases and the exposure reporting and follow-up process for your Department.
Knowledge of the process specific to your Department ensures the right people are notified in

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a timely manner should post exposure testing, follow-up, and documentation be required.
Following are general guidelines to be followed should you experience, or suspect that you
have experienced, an exposure to blood or other infectious material:
     Withdraw from patient care as soon as it is appropriate. This is usually at the
       completion of care but may need to occur sooner in some cases.
     Take self-care steps and cleanse the wound (or irrigate the membranes) with the
       appropriate solution immediately after any exposure to a patient’s bodily fluids. Don’t
       attempt to “milk” any needle stick injuries. This is not useful in removing source patient
       material.
Exposures require immediate intervention. Report any suspected exposure to communicable
diseases to the appropriate designated individual in your Department as quickly as possible.
Questions and consultation regarding post exposure actions should be immediately directed to
the Provider’s Infection Control Officer. Consultation may reveal that medical evaluation of the
exposure, testing, follow-up, and/or additional documentation is necessary. In the case of a
blood exposure due to needle stick (or other sharps), spray to mucous membrane, or patient
blood contacting non-intact skin, the Provider should immediately travel, or be transported to,
the closest appropriate facility for evaluation, preferably where the patient was transported.




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Trauma Triage Protocol
                               OHIO’S DEFINITION OF TRAUMA
An injured patient who you think is at significant risk for loss of life or limb, or significant,
permanent disfigurement or disability; and the injury is caused by blunt or penetrating injury,
exposure to electromagnetic, chemical, or radioactive energy, drowning, suffocation, or
strangulation, or a deficit or excess of heat.
EMS should use the following criteria to help identify patients that fit the above
description of a trauma patient.
     FIELD TRAUMA TRIAGE CRITERIA: PHYSIOLOGIC – ADULT AND PEDIATRIC
                    Adult - ≥ 16 years                                              Pediatric - < 16 years
 Neuro                                                                 Neuro
  GCS ≤ 13                                                             GCS ≤ 13
  LOC > 5 minutes                                                      LOC > 5 minutes
  Decreased LOC at the scene/transport                                 Decreased LOC at the scene/transport
  Failure to localize pain (motor GCS ≤ 4)                             Failure to localize pain (motor GCS ≤ 4)
 Respiratory                                                           Respiratory
  Respiratory rate < 10 or > 29                                        Evidence of respiratory distress or failure;
  Requires endotracheal intubation; BVM; or                              one or more of the following signs;
    other invasive airway support                                         Stridor, Grunting, Retractions, Cyanosis,
                                                                          Hoarseness, Difficulty speaking.
  Suspicion of or requires relief of tension
    pneumothorax                                                        Requires endotracheal intubation; BVM; or
                                                                          other invasive airway support
 Circulatory
                                                                       Circulatory
  Pulse > 120 with suspicion of hemorrhagic
    shock                                                               Evidence of poor perfusion: one or more
                                                                          of the following signs; Weak distal pulse,
  SBP < 90 or no radial pulse w/ carotid
                                                                          Pallor, Cyanosis, Delayed capillary refill,
    pulse present with suspicion of
                                                                          Tachycardia
    hemorrhagic shock
 ***All known pregnant trauma patients, regardless of age, should go to an adult trauma
 center capable of obstetrical care***
                  FIELD TRAUMA TRIAGE CRITERIA: ANATOMIC – ALL AGES
   Penetrating trauma to the head, neck, or torso.
   Significant, penetrating trauma to extremities proximal to the knee or elbow with evidence
    of neurovascular compromise.
   Injuries to the head, neck, or torso where the following physical findings are present:
            (i)     Visible crush injury.
            (ii)    Abdominal tenderness, distention, or seat belt sign.
            (iii)   Pelvis fracture.
            (iv)    Flail chest.
   Injuries to the extremities where the following physical findings are present:

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            (i)   Amputations proximal to the wrist or ankle.
            (ii)  Visible crush injury.
            (iii) Fractures of two or more proximal long bones.
            (iv)  Evidence of neurovascular compromise.
   Signs or symptoms of spinal cord injury.
   Second degree or third degree burns greater than ten per cent total surface area, or other
    significant burns involving the face, feet, hands, genitalia, or airway.
   Profound environmental hypothermia.
SOURCES OF FORCES WARRANTING HIGH INDEX OF SUSPICION FOR MAJOR INJURY
When any of these mechanisms of injury are present, the index of suspicion should be
heightened and correlated with anatomic and physiologic criteria. The EMT should consider
additional mechanisms as identifies in training curriculum.
 Fatality in same vehicle                    Rollover
 Ejected OR thrown from vehicle              Auto-pedestrian impact > 20 mph OR thrown >
 Seat belt restraint use and high               15 feet
   impact collision                           Motorcycle, ATV, OR Bicycle crash with
 Intrusion of the passenger                     potentially significant injury
   compartment > 12 inches                    Falls > 20 feet
   PRE-EXISTING CONDITIONS / “COMORBIDS” WARRANTING HIGH INDEX OF
                              SUSPICION FOR MAJOR INJURY
 Age < 5 OR > 55 years                       Immunosuppression
 Bleeding Disorder OR use of                 Insulin-dependent diabetes
   Anticoagulants                             Morbid Obesity
 Cardiac Disease OR Respiratory              Pregnancy
   Disease                                    Cirrhosis
              EXCEPTIONS TO EMS FIELD TRIAGE TO A TRAUMA CENTER
1. It is medically necessary to transport to another hospital for stabilization.
2. It is unsafe or inappropriate due to excessive ground transport time or adverse weather.
3. Would cause a shortage of local EMS resources.
4. No trauma center is able to accept the patient.
5. Patient or guardian request transport to a specific hospital.
                     AEROMEDICAL UTILIZATION CONSIDERATIONS
1. An unstable patient who requires stabilization of ABC’s and time to aeromedical team is
   shorter than ground time to closest hospital.
2. It is necessary to maximize available resources.
3. Other Considerations should include time to definitive care, capabilities of receiving
   hospital, patient wishes and family continuity.
   REGION V EMS TRIAGE PROTOCOLS: APPROVED BY THE STATE EMS BOARD –
                                        JUNE 16, 2004
     THESE PROTOCOLS SUPERCEDE OAC 4765-14-01, 4765-14-02, 4765-14-05
EMS Providers should refer to the Ohio Revised Code, §4765.40 and to the Ohio Administrative
          Code 4765-14 for the full text of the laws and rules regarding trauma triage.

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Special Situations
NON-TRANSPORTS
A number of EMS calls result in non-transport of the patient or victim. EMT's dispatched for ill,
and/or injured person(s) in public buildings or locations, and on the street, shall offer to
transport the patient to the closest, most appropriate Emergency Department. The decision to
not transport a patient to the closest, most appropriate Emergency Department will be made
by the patient, based on information provided by the EMT's on the scene. The patient should
understand that transport may not be warranted in many cases. However, if the patient still
chooses to be transported, EMS will transport the patient to the closest, most appropriate
Emergency Department. If an individual is not transported by the squad, the following
guidelines will apply:
1. In the event of a patient assist call and no Emergency Medical Services are rendered, a
    Patient Care Report will be made, but Medical Control need not be contacted.
2. If the patient refuses treatment or transport, the patient refusal procedures should be
    followed. See Protocol for Patient Refusals.
3. Non – Transports for minors: If after evaluation of the minor, the EMT and medical control
    agree the patient has a slight illness or injury, that minor can be left in the care of a
    responsible adult that is not the parent or legal guardian. The responsible adult may be a
    family friend, neighbor, school bus driver, teacher, school official, police officer, social
    worker, or other person at the discretion of Medical Control and the EMT.
EMERGENCY CARE OF MINOR PATIENTS
 When minors are injured and require treatment, the parents should be contacted from the
    scene if possible. If the situation requires immediate transport, transport to the most
    appropriate medical facility. Parental consent will be obtained by the hospital.
 INJURED minors cannot refuse treatment or transport, telephone contact with a parent or
    guardian is only necessary for a refusal, NOT FOR TREATMENT.
 If a parent or guardian consents to refusal via telephone, exact instructions must be given
    to the minor, the mental status of the patient must not be impaired, and all instructions
    must be clearly understood. This must be painstakingly documented on the patient care
    report. Only minors between the ages of 16 to 18 y/o can be released to his/her own care.
    All others must be released to another adult of the parent’s approval.
 The only minors who are capable of refusing for them are those who are married
    (evidenced ONLY by a valid marriage certificate in hand) or who are in ACTIVE military
    Status (evidenced by a valid military ID in hand). In all cases, documentation must be
    produced ON SCENE for them to be excluded.
DANGEROUS PERSONS
 When faced with a patient that poses potential violence to the EMS crew, the first duty of
    the crew is to protect themselves and bystanders. The crew has the right to refuse placing
    themselves in jeopardy of physical harm from violent patients.
 At no time will any EMS system member place themselves in a situation that they cannot
    control without the presence of law enforcement.
 The EMT In-charge shall ascertain from law enforcement officials whether the patient is
    under arrest and a ward of the State.
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  If the patient is under arrest at time of transport, the law enforcement agency will be
   asked to escort the patient aboard the ambulance.
 If law enforcement personnel do not escort the patient, EMS personnel are under no
   obligation to maintain custody outside medical guidelines (i.e., if the patient is coherent, he
   or she has the right to refuse treatment and leave).
 If physical restraint of the patient is warranted for safety of the EMS crew, law
   enforcement personnel should be asked to assist in restraining the patient before
   departure.
 EMS personnel have the right to restrain a patient for the safety of the EMS crew when
   violent personalities are suspected. Such suspicion can be warranted for reasons including,
   but not limited to:
   o Currently under arrest for a violent crime.
   o Past history of violence.
   o Displayed behavior symptomatic of intoxication.
   o Displayed behavior symptomatic of drug abuse.
 Transportation and/or treatment can be denied by EMS for any violent or suspected violent
   patient for the following reasons:
   o The patient is mentally alert, capable of making decisions about his/her care, and
       refuses restraint.
   o The patient cannot be adequately restrained by the EMS crew.
   o The patient is deemed unsafe to transport while restrained without law enforcement
       presence, and law enforcement declines to escort aboard vehicle.
   o The patient has not been properly searched for weapons.
 If acceptable to the EMT In-Charge, law enforcement escort by following in a separate
   vehicle may be allowed for maintaining custody. Such decision should be based on the
   perceived threat of violence to the EMS crew:
   o The patient shall be transported to the most appropriate medical facility according to
       normal transportation guidelines.
   o EMS crews shall transport prisoners for medical reasons ONLY.
USE OF RESTRAINTS
1. Soft restraints are to be used only when necessary in situations where the patient is
   potentially violent and may be of danger to themselves or others. EMS providers must
   remember that aggressive violent behavior may be a symptom of medical conditions such
   as but not limited to:
   a. Head trauma.
   b. Alcohol/drug related problems.
   c. Metabolic disorders (i.e., hypoglycemia, hypoxia, etc).
   d. Psychiatric/stress related disorders.
2. Patient health care management remains the responsibility of the EMS provider. The
   method of restraint shall not restrict the adequate monitoring of vital signs, ability to
   protect the patient’s airway, compromise peripheral neurovascular status or otherwise
   prevent appropriate and necessary therapeutic measures. It is recognized that evaluation

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   of many patient parameters requires patient cooperation and thus may be difficult or
   impossible.
3. All restraints should have the ability to be quickly released, if necessary.
4. Restraints applied by law enforcement (i.e., handcuffs) require a law enforcement officer to
   remain available to adjust restraints as necessary for the patient’s safety. This policy is not
   intended to negate the need for law enforcement personnel to use appropriate restraint
   equipment to establish scene control.
5. Patients shall not be transported in a face down prone position to ensure adequate
   respiratory and circulatory monitoring and management.
6. Restrained extremities should be monitored for color, nerve and motor function, pulse
   quality and capillary refill at the time of application and every 15 minutes thereafter.
7. After addressing and/or treating metabolic causes of aggressive or violent behavior,
   administration of Midazolam as a chemical restraint should be considered, if available.
8. Restraint documentation on the EMS report shall include:
   a. Reason for restraint.
   b. Agency responsible for restraint application (i.e., EMS, Police).
   c. Documentation of cardio-respiratory status and peripheral neurovascular status.
INTERVENING PHYSICIAN – ON EMERGENCY SCENE
1. This is a physician with no previous relationship to the patient, who is not the patient’s
   private physician, but is offering assistance in caring for the patient. The following criteria
   must be met for this physician to assume any responsibility for the care of the patent:
   a. Medical Control must be informed and give approval.
   b. The physician must have proof they are a physician. They should be able to show you
        their medical license. Notation of physician name, address, and certification numbers
        must be documented on the run report.
   c. The physician must be willing to assume responsibility for the patient until relieved by
        another physician, usually at the emergency department.
   d. The physician must not require the EMT to perform any procedures or institute any
        treatment that would vary from protocol and/or procedure.
   e. Any procedures performed by the physician beyond the training and/or authority of the
        EMT, the physician will accompany the patient to the hospital:
        i) Exception – Mass casualty incident or disaster situation were the physician must
            remain on scene.
        ii) If the physician is not willing or able to comply with all the above requirements, his
            assistance must be courteously declined.
INTERVENING PHYSICIAN – IN THEIR OFFICE
1. EMS should perform its duties as usual under the supervision of Medical Control or by
   protocol.
2. The physician may elect to treat the patient in his/her office.
3. The EMT should not provide any treatment under the physician’s direction that varies from
   protocol. If asked, the EMT should decline until contact is made with Medical Control.


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4. Once the patient has been transferred into the squad, the patient’s care comes under
   Medical Control.
5. Direct Admissions are not appropriate for an EMS unit responding to an emergency 911
   call. Direct Admissions assume the patient is stable and non-emergent. A non-emergent
   BLS/ALS unit should be dispatched in this situation. Emergency Units shall transport to the
   most appropriate Emergency Department:
   a. If an Emergency Unit is asked to transport a direct admission (physician’s office to ICU)
       the lead EMT shall courteously decline stating this is outside their protocol and
       recommend calling a private service if the patient is stable. If it becomes necessary, to
       avoid confrontation with the physician, perform the transport to the most appropriate
       Emergency Department.
6. EMS shall perform its duties according to these PCGs.
7. The physician may elect to supervise care provided by EMS.
8. If the physician directs the EMS providers to perform a procedure or administer a
   medication which is not covered by these PCGs, the crew should advise him/her of such,
   and will NOT perform the procedure. However, the EMS provider may assist the physician
   in performing the procedure. If the physician initiates a medication which is to be
   continued during patient transportation which is not covered by this protocol, the physician
   MUST accompany the patient to the hospital.
INTERVENING EMT – ON THE SCENE
1. On an EMS run where an unknown EMT from outside the responding EMS agency wishes
   to intervene in the care of patients, the following steps should be initiated:
   a. Ideally, if no further assistance is needed, the offer should be declined.
   b. If the intervener’s assistance is needed or may contribute to the care of the patient:
       i) An attempt should be made to obtain proper identification of a valid Ohio EMT card.
           Acceptance of borderline states’ EMT cards are at the discretion of individual EMS
           services. Notation of intervener name, address, and certification numbers must be
           documented on the run report.
   c. The EMT in charge is responsible to ensure the intervener’s actions are in compliance
       with this protocol.
   d. Significant involvement with patient care or variance from protocol will require the
       intervener to accompany the patient to the hospital.




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Patient Refusal
GENERAL STATEMENT
Competent adult patients have the right to give consent for, or refuse, any and/or all
treatments. EMS should attempt to obtain vital signs on all patients. Competent adult
patients also have the right to give consent for, or refuse ambulance transport. EMS
dispatched for ill, and/or injured person(s) in public buildings or locations, and on the street,
shall offer to transport the patient to the closest, most appropriate Emergency Department.
The decision to not transport a patient to the closest, most appropriate Emergency
Department will be made by the patient, based on information provided by the EMT’s on the
scene. The patient should understand that transport may not be warranted in many cases.
However, if the patient still chooses to be transported, EMS will transport the patient to the
closest, most appropriate Emergency Department.
CONSENT
When waiting to obtain lawful consent from the person authorized to make such consent
would present a serious risk of death, serious impairment of health, or would prolong severe
pain or suffering of the patient, treatment may be undertaken to avoid those risks without
consent. In no event should legal consent procedures be allowed to delay immediate required
treatment.
ADULTS – CONSENT
A competent patient may withdraw consent for treatment at any time.
1. Prior to discontinuing or withdrawing treatment, the EMT shall determine if the patient is
    competent.
2. Mental Competence – Decision Making Capability:
       a. A person is mentally competent if he/she:
                i. Is capable of understanding the nature and consequences of the proposed
                   treatment.
               ii. Has sufficient emotional control, judgment, and discretion to manage his/her
                   own affairs.
       b. Ascertaining that the patient is oriented, has an understanding of what happened
           and what may possibly happen if treated or not treated, and a plan of action – such
           as whom he/she will call for transportation home – should be adequate for these
           determinations.
3. Impairment
       a. Patients may be considered incompetent to refuse care and/or transportation when
           they appear impaired. Patients who appear impaired include:
                i. Suicidal patients.
               ii. Patients impaired by alcohol.
              iii. Patients impaired by illicit drugs.
              iv. Patients impaired by prescription or nonprescription drugs.
               v. Patients impaired by medical conditions such as:
                       1. Hypoglycemia
                       2. Hypoxia
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                         3. Hypoperfusion
                         4. Head Trauma.
                         5. Psychiatric conditions.
PEDIATRIC – CONSENT
1. A critically ill or injured child should be treated and transported immediately.
2. In non-emergency cases involving minors, consent should be obtained from the parent or
    legal guardian prior to undertaking any treatment. All children must be evaluated for
    acuity of illness, regardless of obtaining parental consent.
PROCEDURE FOR REFUSAL
All patients who are unconscious or who appear impaired shall be treated and transported per
protocol to the closest appropriate Emergency Department.
REFUSAL PROCEDURE – ADULTS
If a competent patient or responsible person for the patient, refuses to consent or withdraws
consent for treatment, EMS shall document all care provided, including: patients competency
to refuse consent and the counseling given to the patient or responsible person regarding
possible consequences of not receiving care. The patient or responsible person should sign
the refusal form. If the patient or responsible person refuses to sign the refusal form, then
their refusal should be witnessed by at least two people and the reason for refusing to sign.
1. Patients should be advised by the EMT in charge of his/her impression and the course of
    treatment prescribed by this protocol. Explain indications for transport and explain possible
    complications that could arise without proper treatment and transport. This should be
    explained in terminology understood by the patient.
2. A competent patient or responsible person for that patient may withdraw consent for
    treatment at any time. Should a patient withdraw their consent for treatment, their wishes
    shall be followed.
3. Prior to discontinuing or withdrawing treatment, the EMT shall determine if the patient or
    responsible person for that patient remains competent to withdraw consent.
PROCEDURE FOR REFUSAL - MINORS
EMS personnel called to evaluate minors must consider the status of the child, the availability
of a parent, guardian, or custodian and the possible presence of an emergency. As always,
careful and meticulous documentation of these calls is essential.
1. A critically ill or injured child should be treated and transported immediately:
        a. Call law enforcement personnel if a parent or other person refuses treatment or
           interferes with emergency care.
        b. Contact Medical Control for advice and direction.
        c. Document interactions with all involved parties in addition to the nature of the
           critical illness or injury.
2. A child that has a serious or potentially serious illness or injury and the child attempts to
    refuse care when a parent or guardian are unavailable should:
        a. Minors cannot refuse treatment or transport, if less than 16 years of age. Contact
           with a parent, relative, or guardian may be necessary.
        b. The EMT should contact Medical Control and Law Enforcement personnel.

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       c. If the child is an emancipated minor, the child may refuse care if competent; if not
           competent the child should be treated, transported, and interactions documented.
3. Parents of ill or injured minors that require treatment should be contacted, if possible:
       a. If the situation requires immediate transport, transport to the most appropriate
           medical facility. Parental consent will be obtained by the hospital.
       b. If the minor is in a remote location, they may be transported to their home, if
           nearby and will not compromise the patients’ condition, for parental consent or
           release to the parent if there is no need for transport.
4. If a minor is released to his/her own care (16 – 18 years of age,) the mental status of the
   patient must not be impaired, exact instructions must be given to the patient, and all
   instructions must be understood. This must also be documented on the Patient Care
   Report.
5. Guidelines for several situations that can occur:
       a. Child wants care – Parent does not: If no abuse or neglect is suspected, the parents
           should be informed of the potential problems and advised to call EMS if further
           problems occur, and then have the parent sign the refusal form. Refer to Protocol
           for Patient Refusal.
       b. Child wants care – Parents unavailable: The most prudent decision would be to
           transport the child. If after evaluation of the minor, the EMT and medical control
           agree the patient has a slight illness or injury, that minor can be left in the care of a
           responsible adult that is not the parent or legal guardian. The responsible adult
           may be a family friend, neighbor, school bus driver, teacher, school official, police
           officer, social worker, or other person at the discretion of Medical Control and the
           EMT.
       c. Child refuses care – Parents want care: Treat and transport to the hospital,
           attempting reasonable persuasion. If force becomes necessary to treat or transport,
           contact Medical Control and Law Enforcement personnel first. Refer to Restraint
           Policy.
       d. Child refuses care – Parents refuse care: Advise child and parents of possible
           problems and advise them to call EMS if needed. Have parents sign refusal form.
           Refer to Protocol for Patient Refusal. Document all instructions given. If parent or
           responsible person for that patient refuses to sign refusal form, document all
           interactions and witnesses to them.
       e. Child refuses care – Parent unavailable: If the EMT and Medical Control feel that
           care is necessary, attempt to persuade child. No force should be exercised unless
           Law Enforcement personnel are in attendance, and then only necessary force to
           protect patient. Refer to Restraint Policy. Carefully document the need for
           transport, the method of restraint, and witnesses to the interaction.
PATIENT REFUSAL QUALITY ASSURANCE CHECKLIST AND REFUSAL INFORMATION
SHEET
The EMT will complete a Patient Refusal Checklist and a Refusal Information Sheet:
1. The patient must be advised of the benefits of treatment and transport as well as the
   specific risks of refusing treatment and transport.


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2. The patient must be able to relate to the EMT in his/her own words what these risks and
   benefits are.
3. The patient will be provided with a copy of the Refusal Information Sheet. The Refusal
   Information Sheet will be signed and dated by both the patient and the EMS crew.
4. The Refusal Information Sheet and the Patient Refusal Checklist will be attached to patient
   care report.




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Terminating and/or Withholding Resuscitation Efforts
INTENT
The intent of this section is to avoid the risks of emergency transport of patients who are
almost certainly non-viable.
TERMINATING RESUSCITATION
“Resuscitation may be discontinued in the prehospital setting when the patient is non-
resuscitable after an adequate trial of ACLS.”
In accordance with the Journal of the American Medical Association’s guidelines for
cardiopulmonary resuscitation and emergency cardiac care, the above statement encourages
prehospital systems to develop guidelines for the ability to terminate resuscitation efforts when
the patient’s survivability is unlikely.
An adequate trial of ACLS, according to the guidelines, occurs when:
     Adequate BLS has been provided for a reasonable length of time, and;
     An advanced airway (ETT, Combitube, LMA) is placed successfully, confirmed, and
        secured, and;
     IV/IO access has been achieved, rhythm-appropriate medications and counter shocks
        for ventricular fibrillation have been administered, and;
     Persistent asystole present and no reversible causes are identified.
If a patient is found to be in an asystolic rhythm without one of the above collaborating
guidelines, full ACLS measures should be initiated and continued for a minimum of 20 minutes
or until two full courses of ACLS medications have been administered IV, IO, or via the ET
along with CPR, advanced airway, and defibrillation.             If during the course of ACLS
interventions the patient develops a rhythm other than asystole, then treatment should be
continued as per protocol and transport initiated. If the patient remains in asystole, confirmed
in at least two (2) leads after above ACLS interventions, then the patient may be pronounced
DOA. After the pronouncement of death, be sure to record the time (“Time of Death”). If
resuscitative efforts are ceased, all IV lines, endotracheal tubes, and/or other interventions
must be left in place.
WITHHOLDING RESUSCITATION
With the above understanding, there are times when withholding resuscitation is deemed
appropriate. Patients exhibiting the following signs and symptoms will be deemed
“inappropriate for resuscitative efforts”. Resuscitation will not be initiated if any of the
following are present:
1. There is an injury which is incompatible with life (i.e., decapitated, or burned beyond
    recognition, brain matter exposed, etc).
2. The victim shows signs of decomposition, rigor mortis, or extremely dependent lividity.
3. If the patient is an adult with an unwitnessed cardiac arrest, has a history of an absence of
    vital signs for greater than 20 minutes, and is found in asystole (confirmed in two or more
    leads), not secondary to hypothermia, cold water drowning, or drug overdose:
        a. Patients thought to be hypothermic and asystolic should be transported to the
            nearest appropriate facility and treated as per appropriate protocol.


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       b. An ECG rhythm of asystole without any of the above findings is not enough to
           declare a DOA patient. Asystole in two (2) or more leads is a helpful corroborative
           finding along with no spontaneous respirations and fixed, dilated pupils. However, it
           must be associated with at least one of the above findings.
4. If there are valid DNR (Do Not Resuscitate) orders, see DNR Guidelines.
5. If the patient has a history of terminal disease, the family refuses resuscitation and
    permission to pronounce the patient dead is given by Medical Control.
WITHHOLDING RESUSCITATION WHEN ALS IS NOT AVAILABLE
When no ALS equipment is available – (Paramedics are unavailable, or when Paramedics are
present, but ALS equipment is not available):
1. When EMS providers (excluding EMT - Basics) are faced with a PNB patient and no ALS
    equipment is available at the scene, and transport time to a medical facility will exceed 30
    minutes, they may consider contacting a Medical Control Physician for orders to terminate
    the resuscitation.
2. Medical control must be contacted and the physician must speak directly with the EMS
    provider, and must give consent for the resuscitation effort to cease:
       a. Give verbal report of negative vital signs and document.
       b. If applicable, present additional medical history such as cancer, heart disease,
           diabetes, COPD, epilepsy, etc.
If the above does not apply, resuscitative measures should be initiated. If resuscitative efforts
are later ceased, all IV lines, endotracheal tubes and other interventions must be left in place.
PHYSICIAN PRESENT
If a physician is present and has pronounced the patient dead, the physicians name and time
of death should be documented on the PCR. Documentation of identification of the physician
is recommended by the crew.
ON SCENE OF DOA
When a DOA is encountered, the squad members should avoid disturbing the scene or the
body as much as possible, unless it is necessary to do so in order to care for and assist other
victims. Once it is determined that the victim is in fact deceased, the squad members should
move as rapidly as possible to transfer responsibility for management of the scene to law
enforcement and/or the Coroner’s Office. It is the squad member’s responsibility to notify the
Coroner’s Office directly or to ensure that the Coroner’s Office has been notified by law
enforcement on the scene. The crew should not leave until the responsibility for management
of the scene has been transferred to law enforcement and/or the Coroner’s Office arriving on
scene, or if released by the Coroner, to the appropriate funeral home.
DOCUMENTATION
Concise, and complete, documentation, in all cases, is ABSOLUTELY ESSENTIAL. Record time
of the pronouncement of death.
Patient Care Report:
1. Retain one copy for the EMS agency records (White Copy).
2. One copy to the Coroner’s Officer (Yellow Copy).
3. One copy to Medical Control for QA (Pink Copy).


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DNR – Do-Not-Resuscitate




DEFINITION & IDENTIFICATION
Resuscitation is a medical procedure which seeks to restore cardiac and/or respiratory function
to individuals who have sustained a cardiac and/or respiratory arrest. "Do Not Resuscitate"
("DNR") is a medical order to provide no resuscitation to individuals for whom resuscitation is
not warranted.
Cardiopulmonary resuscitation ("CPR") is the common term used to refer to resuscitation.
However, the options available to treat very sick patients are broader than CPR as literally
defined. Appropriate comfort care measures should be employed for all patients, especially
terminally ill patients.
In the State of Ohio, a DNR Comfort Care patient’s status is confirmed when the patient has
one of the following: A DNR Comfort Care card or form completed for the patient, or a DNR
Comfort Care necklace or bracelet bearing the DNR Comfort Care official logo. Copies of these
items are sufficient for EMS workers. EMS is not required to search a person to see if they
have a DNR order. If EMS discovers one of these items in the possession of a patient, EMS
must make a reasonable effort to identify the DNR patient in appropriate circumstances (i.e.,
the patient or family member, caregiver or friend gives the patient’s name, driver’s license). If
you cannot ID the patient, you should still follow the DNR protocol. Verification is not required
for patients or residents of extended care facilities when a current DNR order is present on the
person’s chart. A DNR Comfort Care order for a patient of a health care facility shall be
considered current in accordance with the facility’s policy.
TYPES OF DNR ORDERS
DNR Comfort Care - "DNR Comfort Care" orders permit comfort care only both before and
during a cardiac or respiratory arrest. Resuscitative therapies will not be administered prior to
an arrest. This order is generally regarded as appropriate for patients who have a terminal
illness, short life expectancy, little chance of surviving CPR, and a desire to let nature take its
course in the face of an impending arrest.
DNR Comfort Care-Arrest - "DNR Comfort Care-Arrest" orders permit the use of all
resuscitative therapies before an arrest, but not during or after an arrest. A cardiac arrest is
defined as an absence of a palpable pulse. A respiratory arrest is defined as no spontaneous
respirations or there is agonal breathing. Once an arrest is confirmed, all resuscitative efforts
should be stopped and comfort care alone initiated.




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DNR COMFORT CARE PROTOCOL
After the State of Ohio DNR Protocol has been activated for a specific DNR Comfort Care
patient, the Protocol specifies that EMS and other health care providers are to do the
following:
  WILL (Comfort Care):                                                    WILL NOT:
      Suction the airway                                                     Administer chest compressions
      Administer oxygen                                                      Insert artificial airway
      Position for comfort                                                   Administer resuscitative drugs
      Splint or immobilize                                                   Defibrillate or cardiovert
      Contact other appropriate health care                                  Provide respiratory assistance (other
       providers such as hospice, home health,                                 than suctioning the airway and
       attending physician/CNS/CNP                                             administering oxygen)
      Provide pain medication                                                Initiate resuscitative IV
      Provide emotional support                                              Initiate cardiac monitoring
      Control bleeding
INITIAL STATUS UNKNOWN
If you have responded to an emergency situation and initiated any of the “WILL NOT” actions
prior to confirming a DNR Comfort Care Protocol, discontinue them. You may continue
respiratory assistance, IV medications, etc., that have been part of the patient’s ongoing
course of treatment for an underlying disease.
INTERACTION WITH THE PATIENT, FAMILY, AND BYSTANDERS
The patient always may request resuscitation even if he or she is a DNR Comfort Care patient
and this protocol has been activated. The request for resuscitation amounts to a revocation of
DNR Comfort Care status.
If family or bystanders request or demand resuscitation for a person for whom the DNR
Comfort Care Protocol has been activated, do not proceed with resuscitation. Provide comfort
measures as outlined above and try to help the family understand the dying process and the
patient’s choice not to be resuscitated.
DOCUMENTATION
When EMS implements the DNR Protocol for a DNR Comfort Care patient, they should
document in their records:
     The item that identified the person as DNR Comfort Care.
     The method of verifying the person’s identify, if any was found through reasonable
       efforts.
     Whether the person was a DNR Comfort Care or DNR Comfort Care – Arrest patient.
     The actions taken to implement the DNR Protocol.




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Safe Harbor


                                CENTRAL OHIO TRAUMA SYSTEM
1. The intent of these regional guidelines is to:
    a. Promote consistency in the central Ohio region when an infant less than 72 hours old
         with no indication of abuse or neglect is relinquished to a medical service worker, peace
         officer, or hospital employee.
    b. Provide guidance on the care of such newborns until transfer to a children’s agency.
    c. Present options for support services to the parent(s) presenting such newborns.
SUPPORTING LEGISLATION
The Ohio Revised Code Sections 2151.3515 through 2151.3517 supports the actions in these
guidelines. This law is the result of Amended House Bill 660 of the 123rd General Assembly,
which took effect on April 9, 2001. This legislation provides immunity from criminal
prosecution for a parent who voluntarily gives up a newborn less than 72 hours old to a
medical service worker, peace officer, or hospital employee. The legislation does not specify
that a medical service worker, peace officer, or hospital employee must be on-duty for the law
to apply.
AGE VERIFICATION
1. Determining a neonate’s age as less than 72 hours may be difficult. Clues that would
    typically indicate that a neonate is less than 72 hours old include:
    a. Vernix caseosa, meconium, or other fluids associated with a recent birth evident on the
         infant’s body.
    b. The accompaniment of a fresh placenta. It is possible for the newborn to still be
         attached.
    c. An umbilical stump at early to moderate stages of drying. The umbilical stump typically
         has some type of clamp or tie in place. If there is no ligature on the cord, there may
         still be some oozing.
2. A verbal question may be asked regarding the child’s age. If in doubt about the neonate’s
    age but reasonable appearances indicate that the baby may be less than 72 hours old,
    accept the infant and proceed with Interventions. A medical service worker, peace officer,
    or hospital employee who accepts the neonate in good faith is immune from civil liability
    (ORC Sec 2151.3523[C]).
INTERVENTIONS
1. Once a child has been received, the medical service worker, peace officer, or hospital
    employee shall initiate interventions necessary to protect the neonate’s health and safety.
    It is paramount that the infant be kept warm.
2. Notification shall occur as soon as possible to the following agencies:
    a. Local Dispatch Center for EMS/Law enforcement personnel to notify them of the
         incident.

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   b. Nearest most appropriate hospital to notify them that a relinquished neonate is being
        brought in for medical evaluation.
   c. Local public Children’s Services Agency: ORC Sec 2151.3517 mandates that the local
        public children’s services agency be notified by the recipient (medical service worker,
        peace officer, or hospital employee) or recipient agency of the neonate.
   d. Local law enforcement in order to provide community notification in the event that this
        is not a parental relinquishment situation but rather a disposal after abduction.
The accepting medical service worker, peace officer, or hospital employee may contact these
agencies directly, or in the case of EMS and law enforcement, notification may occur through
their local dispatch center. Notification of these agencies should not delay initial interventions
and transport of the neonate.
Once the parent relinquishes the child to a medical service worker, peace officer, or hospital
employee, custody may not be regained by that parent at that episode. Protect the neonate as
necessary and proceed to the nearest most appropriate emergency department. Remain
nonjudgmental of the parent.
PROHIBITIONS
1. During relinquishment of a child, the recipient emergency medical services worker, peace
   officer, or hospital employee may not:
   a. Coerce or otherwise try to force the relinquishing parent to reveal their identity or the
         identity of the other parent. The parent has the legal right to remain anonymous.
   b. Pursue or follow the parent after the parent leaves the place at which the child was
         delivered.
   c. Coerce or otherwise try to force the parent not to desert the infant.
   d. Coerce or otherwise try to force the parent to leave medical or demographic
         information.
   e. Coerce or otherwise try to force the parent to accept any materials made available
         concerning services available to assist parents and newborns.
EXCLUSIONS
1. This law is null and void in instances where the infant suffers abuse or neglect at the hands
   of the relinquishing parent. This includes:
     a. Infants with a physical or mental wound, injury, disability, or condition of a nature that
         reasonably indicates abuse or neglect of the child (ORC Sec 2151.3517 [A][3]).
     b. If the parent is attempting to deliver an infant obviously greater than 72 hours of age.
     c. A neonate delivered with obvious birth trauma or disability for which the parent is not
         seeking medical treatment may constitute a case of abuse or neglect (ORC Sec
         2151.3527[B]).
     d. If signs of abuse or neglect are evident or reasonably suspected based on actions of
         the care provider or symptoms of the infant:
            a. Provide immediate care and protect the child as necessary. Keep the infant
                warm.
            b. Proceed immediately to nearest most appropriate hospital for a medical
                evaluation and stabilization as needed.


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    e. The ORC allows that “If the child has suffered a physical or mental wound, injury,
        disability, or condition of a nature that reasonably indicates abuse or neglect of the
        child, attempt to identify and pursue the person who delivered the child (Sec
        2151.3517[A][5]).”
    f. Call for immediate law enforcement assistance, detaining the caregiver if feasible.
        Gather as much information as possible, including a license plate number, to relay in
        the event that the possible perpetrator leaves the area.
2. Do Not Delay Care of a neonate who is symptomatic for abuse while attempting to
   detain and elicit information from the parent. Obtain assistance from team members to
   intervene with the parent. Proceed with the infant to the nearest most appropriate hospital
   immediately.
REQUEST FOR NEWBORN INFORMATION
1. If possible, offer the parent the opportunity to complete the Ohio Department of Job and
   Family Services Medical Information Form (ORC Sec 2151.3525 & 2151.3529). The parent
   shall be told that:
    a. Completion of the form is voluntary. The parent is not required to complete all or any
        part of the form.
    b. The information will be used only to facilitate medical care for the child.
    c. If the parent wishes to give some but not all information, any parts of the form may be
        left blank.
    d. The person completing the form may remain anonymous.
    e. No adverse legal consequence will result from failure to complete any part of the form.
    f. The form may be completed at the time that the child is relinquished, or may be
        completed at another time.
    g. If the parent chooses to not complete the form at the time that the child is
        relinquished, they shall be given the option of taking the form with them as they leave
        and returning it at a later time to a local public children’s services agency or the
        agency (EMS, law enforcement, or hospital) where the infant was relinquished.
    h. If the parent refuses the form altogether, they shall be given the option of contacting
        their local public children’s services agency or the agency where the infant was
        relinquished to obtain or complete a form at a future time.
    i. The parent will not be pursued, followed, or contacted to complete the form.
PARENTAL SOCIAL SUPPORT
1. If possible, offer to the parent the Ohio Department of Job and Family Services information.
   The parent has the right to refuse the information. If the parent verbalizes a desire for the
   information but acknowledges a state of illiteracy or is unable to read the material, the
   information shall be read to the parent by a team member as available. This information
   includes:
    a. Community social services available to assist parents and newborns.
    b. Information relevant to situations that might lead parents to relinquish a neonate.
    c. Procedures for the parent to follow in the event that they would seek to reunite with
        the relinquished infant at a future time, including notice that the parent will need to
        submit to a DNA test.

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    d. That the parent may need to assume financial expenses related to proving that they
        are the infant’s parent.
    e. If the parent refuses the Ohio Department of Job and Family social services
        information at this time, they shall be told that they may obtain a copy of the
        information in the future by contacting their local public children’s services agency.
Offer medical evaluation services to the mother if possible. The infant may be the
result of a home birth and the mother may need treatment for a complication. Some
complications may be evident upon physical examination such as a perineal tear, but others
such as retained placenta, will require evaluation at a hospital with obstetric capabilities.




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CCW – Patients with Concealed Carry Weapons



                                         CENTRAL OHIO TRAUMA SYSTEM
PURPOSE
The purpose of these guidelines is to outline common expected procedures for intervening
with patients and/or their families who under the law may be carrying a concealed deadly
weapon. The intent is to reduce the potential risk of injury to emergency responders,
healthcare personnel and the public. These guidelines aim to mutually respect the rights of
citizens who lawfully carry a concealed weapon as well as to provide safety for emergency
responders and healthcare providers.
SCOPE
These guidelines are for voluntary use by central Ohio law enforcement, fire departments,
emergency medical services, and healthcare facilities when caring for individuals who require
medical intervention. These guidelines describe mutually agreed-upon best practices for
promoting the safety of the public and those caring for ill or injured patients. Commissioned
law enforcement officers who are responding to a prehospital scene or medical facility in the
line of duty are exempt from these guidelines.
BACKGROUND
Effective April 8, 2004, Ohio citizens can obtain a permit to legally carry a concealed weapon.
Ohio emergency responders and healthcare personnel are likely to encounter an increasing
number of patients with such weapons. Of concern is the potential for inadvertent harm to
emergency responders and healthcare personnel as they care for these patients, most
significantly the unintentional discharge of a firearm.
The Central Ohio Trauma System (COTS) is a regional consortium of emergency medical
technicians, paramedics, physicians, nurses, data specialists, trauma researchers, acute care
hospitals and trauma centers, and others working together to resolve issues related to trauma
and emergency care in the central Ohio region. COTS maintains an Internal Revenue status of
501[c][3] and operates with charitable, educational, and scientific intent. COTS provided the
forum for these guidelines to be written; the expertise contained herein comes from the
dedicated emergency and healthcare responders who seek to provide the best care possible to
the citizens of central Ohio.
DEADLY WEAPONS DEFINED
Deadly Weapon means any instrument, device, or thing capable of inflicting death, and
designed or specially adapted for use as a weapon, or possessed, carried or used as a weapon
(O.R.C. § 2923.11[A]). Handgun means any firearm that has a short stock and designed to be
held and fired by the use of a single hand (O.R.C. § 2923.11 [C] [1]). Firearm means any
deadly weapon capable of expelling or propelling one or more projectiles by the action of an
explosive or combustible propellant. Firearms includes an unloaded firearm, and any firearm
that is inoperable but can readily be rendered operable (O.R.C. § 2923.11 [B] [1]). In the

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case of explosives or a hazardous substance, the fire department/bomb squad/hazmat team
may be called.
PATIENT SCENARIOS
These guidelines will address the following scenarios in the prehospital and hospital setting:
    a. Conscious patients willing to relinquish a weapon.
    b. Conscious patients unwilling to relinquish a weapon.
    c. Patients with altered levels of consciousness.
    d. Family members and friends who have weapons and want to be with patients in
        emergency response vehicles.
    e. Chain of custody transfer between emergency responders and medical facilities.
GENERAL GUIDELINES FOR ALL EMERGENCY RESPONDERS AND HEALTHCARE
WORKERS
1. Emergency responders and healthcare workers should anticipate that any patient may have a
   concealed weapon. The safety of emergency responders and healthcare personnel is
   paramount. Emergency responders and healthcare personnel should never approach a patient
   who appears threatening with a weapon, no matter how ill the person seems. Law
   enforcement shall be called to secure the scene to disarm threatening individuals.
2. Ideally patients will self-disclose that they have a weapon. However it is likely that at times
   patients may choose not to declare or may not be able to indicate that they have a weapon.
   The following concepts pertain to the discovery of a weapon on a patient, and are to be
   considered throughout this document:
   a. Emergency responders and healthcare personnel should always assume that all firearms
       are loaded.
   b. Optimally weapons should be safely secured by the patient at their residence and not
       be transported with the patient or family/friend in an emergency response vehicle or to
       a healthcare facility.
   c. Patients with an altered level of consciousness, severe pain, or with difficulties in motor
       control should not be encouraged to disarm themselves. An emergency response or
       healthcare worker may need to obtain control of the weapon for the safety of
       responding personnel, the public and the patient. Caution should be used at all times
       when handling a weapon. Emergency response and healthcare workers should not
       attempt to unload a firearm. Regardless of a person’s familiarity with firearms, there is
       no way to know if the gun is in proper working order.
   d. Patients carrying a firearm while under the influence of alcohol or drugs are committing
       a criminal offense. Law enforcement should be notified of such instances (O.R.C. §
       2923.15 [A] [B]; (O.R.C. § 2923.13 [A] [4]).
   e. Private EMS agencies and healthcare facilities have the option and are encouraged to
       designate themselves as a weapons-free facility or a “forbidden-carry zone.” No-carry
       signage should be clearly posted in emergency squads and medical facilities.            Law
       enforcement shall be called if patients insist on carrying weapons in emergency vehicles
       or in hospitals that have declared themselves as no-carry zones.
   f. Under no circumstances should an emergency responder or healthcare worker
       compromise his/her safety in regards to these guidelines. When in doubt about a
       patient with a weapon or the weapon itself, emergency responders and healthcare
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      personnel should contact local law enforcement. Law enforcement officers will make
      the decisions regarding disarming the patient and the weapon.
   g. It is recommended that emergency healthcare workers and facility safety/security
      personnel partner with their local law enforcement agencies in obtaining education
      regarding basic firearm safety.
PREHOSPITAL ACTIONS OF EMERGENCY MEDICAL SERVICES
1. Prehospital emergency responders may discover a weapon on a patient at the scene, or in
   some instances during a secondary survey while en route to a hospital. Based on the possible
   scenarios previously listed, an emergency responder shall adhere to the following steps when a
   weapon is discovered.
2. Conscious Patient Willing to Relinquish a Weapon:
   a. Patients who are alert and oriented and for whom the emergency response is occurring
      at their place of residence should be asked to leave their weapons in a secure location
      at home prior to transport. Patients can be told that EMS vehicles and central Ohio
      hospitals are no-carry zones.
   b. Patients for whom the emergency response is occurring away from their residence may
      relinquish their weapon to a law enforcement officer on scene if one is available.
   c. If a patient is not at their residence or if a law enforcement officer is not available,
      emergency response personnel should do the following:
      (1) Place or have the patient place the deadly weapon into the “Lock Box.” The barrel
          of a firearm should be pointing in the direction that is indicated on the outside of the
          Lock Box.
      (2) Secure the Lock Box with Security Seals® (Health Care Logistics Corporation) or
          similar numbered security seal and place the Box in the locked drug cabinet or
          locked exterior vehicle compartment for transport.
      (3) Complete and have the patient sign the Chain of Custody Form.
      (4) Conduct a thorough secondary survey.
      (5) If additional weapons are found, begin again at step (1). If no additional weapons
            are found, load the patient into the vehicle and transport to an appropriate
            medical facility.
      (6) While en route, emergency response personnel shall notify the receiving facility that
            a Lock Box weapon is being transported with the patient.
      (7) Facility security personnel shall meet the transport vehicle at the doors to take
            control of the weapon. Emergency response personnel shall hand over the Lock
            Box with coded snap locks in place.
      (8) Medical facility and emergency response personnel shall document the transaction
            on the Chain of Custody Form.
      (9) Facility security personnel shall give an empty replacement box to the emergency
            responders.
      (10) Facility security may in conjunction with a law enforcement officer validate and
            unload a weapon in the Lock Box. Coded snap locks should be replaced and
            documented on the Chain of Custody Form if the Lock Box is opened.
3. Conscious Patient Unwilling to Relinquish a Weapon:

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   a. Emergency responders should engage alert and oriented patients in calm discussion
       about the rationale to secure the weapon prior to transport. Simple explanations can
       be given including that these regional guidelines are in place.
   b. If the patient continues to refuse to relinquish the weapon, emergency responders
       should refrain from continuing the assessment and from transporting to a medical
       facility.
   c. EMS Providers should be suspicious of ill or injured patients unwilling to relinquish
       weapons. Law enforcement may be called to intervene in the situation.
   d. If the situation becomes threatening, emergency responders should evacuate the scene
       to a secure rendezvous point a safe distance away and notify law enforcement.
4. Patients with Altered Levels of Consciousness:
   a. Emergency responders must use extreme caution when approaching patients with
       altered levels of consciousness.
   b. If a weapon is found on an awake patient with an altered level of consciousness,
       emergency responders should not attempt to have the patient hand over the weapon.
       EMS personnel should not attempt to remove a weapon from a patient whose level of
       consciousness could precipitate use of that weapon against them. Law enforcement
       should be called to assist in disarming these patients. If a weapon is removed by a law
       enforcement officer, the officer will maintain possession of the weapon.
   c. If the patient is unconscious and requires emergent care but law enforcement is not on
       the scene, emergency medical services (EMS) personnel will need to carefully separate
       the weapon from the patient prior to transport. Optimally a firearm should be removed
       from the patient while still in the holster. If removing the holster and weapon together
       jeopardizes the safety of the patient or emergency response personnel, or it is
       physically impossible to remove the holster and firearm together, the weapon may be
       removed without the holster. Once removed, emergency response personnel shall:
       (1) Handle all weapons carefully.
       (2) Place the weapon or weapon-in-the-holster into the Lock Box.
       (3) Secure the Lock Box with Security Seals® (Health Care Logistics Corporation) or
              similar numbered security seal and place the Box in the locked drug cabinet or
              locked exterior vehicle compartment for transport.
       (4) Complete the Chain of Custody Form.
       (5) Conduct a thorough secondary survey.
       (6) If additional weapons are found and removed, begin again at step (1). If no
              additional weapons are found, load the patient into the vehicle and transport to an
              appropriate medical facility.
       (7) While en route, emergency response personnel shall notify the receiving facility
              that a Lock Box weapon is being transported with the patient.
       (8) Facility security personnel shall meet the transport vehicle at the doors to take
              control of the weapon. Emergency response personnel shall hand over the Lock
              Box with coded snap locks in place.
       (9) Medical facility and emergency response personnel shall document the transaction
              on the Chain of Custody Form.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 154
Dr. Mark Seher DO, Medical Director.
      (10) Facility security personnel shall give an empty replacement box to the emergency
            responders.
5. Family members and friends who have weapons and want to be with patients in emergency
   response vehicles:
   a. The decision to transport family members and/or friends with the patient solely rests
      with existing policies of individual emergency response agencies.
   b. Agencies that permit transport of family/friends with the patient shall:
      (1) Ask the family member/friend to declare if they have a concealed weapon.
      (2) Explain that no unsecured weapons may be transported in the emergency vehicle.
   c. If a family member/friend discloses a concealed weapon AND the patient’s condition is
      such that the emergency medical personnel deem it in the best interest of the patient to
      transport the family member/friend with them.
   d. The family member/friend should be instructed to leave the weapon in a secure place at
      the home. If the family member/friend refuses, emergency response personnel have
      the prerogative to decline transport of the family member/friend with the patient. No
      family member/friend should be transported with an unsecured weapon.
   e. If the scene is not at the family member’s/friend’s residence, or circumstances prevent
      the weapon from being secured in the home:
      (1) Have the family member/friend place the weapon into the “Lock Box.” The barrel
            of a firearm should be pointing in the direction that is indicated on the outside of
            the Lock Box.
      (2) Secure the Lock Box with Security Seals® (Health Care Logistics Corporation) or
            similar numbered security seal and place the Box in the locked drug cabinet or
            locked exterior vehicle compartment for transport.
      (3) Complete and have the family member/friend sign the Chain of Custody Form.
      (4) While en route, emergency response personnel shall notify the receiving facility that a
            weapon is being transported in a Lock Box with the patient.
      (5) Facility security personnel shall meet the transport vehicle at the doors to take control
            of the weapon. Emergency response personnel shall hand over the Lock Box with
            coded snap locks in place.
      (6) Medical facility and emergency response personnel shall document the transaction on
            the Chain of Custody Form.
      (7) Facility security personnel shall give an empty replacement box to the emergency
            responders.

PATIENTS TRANSPORTED VIA EMERGENCY RESPONDERS TO A MEDICAL FACILITY
1. EMS should make every attempt to screen all patients for concealed weapons prior to transport
   to a medical facility.
2. Patients with concealed weapons that could not be secured at their residence may have had
   them placed in a Lock Box by emergency personnel. In the absence of an established
   community protocol whereby the local law enforcement agency of the emergency responders
   meets the transport vehicle at the medical facility to assume control of the weapon, medical
   facilities may need to assume control when the patient is delivered.

EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.          Page 155
Dr. Mark Seher DO, Medical Director.
    a. While en route, emergency response personnel shall notify the receiving facility that a
        weapon is being transported in a Lock Box with the patient.
    b. Facility security personnel shall meet the transport vehicle at the doors to take control
        of the weapon. Emergency response personnel shall hand over the Lock Box with
        coded snap locks in place.
    c. Medical facility and emergency response personnel shall document the transaction on
        the Chain of Custody Form.
    d. Facility security personnel shall give an empty replacement box to the emergency
        responders.
LOCK BOX
A regional exchange program is established under these guidelines such that all emergency
response agencies and healthcare facilities participating shall purchase similar safety boxes to
secure deadly weapons. The box chosen for the prototype is an “SE single-scoped
pistol/accessory case” by Doskosport, model # 10137, dimensions 13x9.5x2.5 inches
(Attachment B). The cost of these boxes ranges from approximately $6-12 depending on the
retailer. Each agency shall procure their own boxes. Each agency shall draw/paint a gun
template on the outside of the boxes to indicate the direction of the barrel of a stored firearm.
A gun template is attached with these guidelines (Attachment C).
These Lock Boxes shall be secured with Security Seals® locks (Health Care Logistics
Corporation) or similar numbered security seal to document a chain of evidence. Emergency
response agencies and healthcare facilities shall procure their own locks. Each Lock Box shall
have an outside label indicating “CAUTION: DEADLY WEAPON (Attachment D).” Such labels
are available through COTS.
Lock Boxes containing weapons must be stored in a secure, locked storage compartment or
cabinet by emergency response agencies and healthcare facilities. The Lock Boxes will be
exchanged at the interface of emergency responders and healthcare facilities when patients
are delivered who had a weapon that could not be left at their residence. Emergency
response personnel shall hand-over a Lock Box secured with coded snap locks to a healthcare
facility security officer. In exchange the healthcare security officer will provide an empty box
back to the emergency responder. The intent is to minimize the handling of potentially
dangerous weapons by emergency response and healthcare facility staff. Additionally, at the
discretion of the emergency response agency, a family member/friend may be transported
with the patient. If the family member/friend has a weapon and is transferred, the family
member’s/friend’s weapon must also be secured and given to a healthcare facility’s security
staff by emergency response personnel. As above, the healthcare facility security officer and
emergency responder shall exchange the Lock Box with the weapon for an empty Lock Box.




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.         Page 156
Dr. Mark Seher DO, Medical Director.
CCW – Patient With Altered Level Of Consciousness
Central Ohio Trauma System
                                                      EMS to Patient



                                                 Awake but decreased LOC?



                                       YES                                           NO, UNCONSCIOUS



 Do not attempt to have a semi-conscious patient disarm
                                                                       Call law enforcement to disarm patient. If the patient is
 himself. Call law enforcement to disarm patient. If the
                                                                       unstable or potentially unstable and law enforcement is
    patient is unstable or potentially unstable and law
                                                                          not yet on the scene, carefully remove the weapon
enforcement is not yet on the scene, carefully remove the
                                                                        from patient. Consider evidentiary aspect of removed
weapon from patient: USE EXTREME CAUTION. Consider
                                                                                               weapon.
         evidentiary aspect of removed weapon.



     Transport per agency SOPs after                                         Can patient remain on scene until law
   weapon secured by Law Enforcement                                            enforcement secures weapon?



                                                                               YES                             NO




                                                                                    Secure weapon in Lock Box; tab lock;
                            Transport per agency SOPs after
                                                                                       store in vehicle compartment;
                          weapon secured by Law Enforcement
                                                                                      complete Chain of Evidence form



                                                                                      Transport to hospital; notify
                                                                                       hospital of weapon being
                                                                                          brought in Lock Box



                                                                               Can law enforcement secure weapon
                                                                                  upon EMS arrival to hospital?




                                                               YES                                            NO



                           Remit weapon to Law Enforcement;                     Exchange Lock Box with hospital Security
                            complete Chain of Evidence form                    Personnel; complete Chain of Evidence form




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                           Page 157
Dr. Mark Seher DO, Medical Director.
 CCW – Conscious, Alert, and Oriented Patient
 Central Ohio Trauma System
                                                               EMS to Patient




                                Patient declares a weapon or weapon found on secondary survey?


                                             YES                                           NO




                     Willing to relinquish weapon?                                    Assess & transport per agency SOPs


                    YES                         NO


 Can Patient safely secure weapon at
                                                        Discuss with patient that no patient can be transported with unsecured weapon & that
 patient’s residence prior to transport?
                                                        hospitals are “no-carry” zones. Simple explanations can be given including that these
                                                     regional guidelines are in place. EMS Providers should be suspicious of ill or injured
                                                                           patients unwilling to relinquish weapons.



        YES                        NO                                                                          Willing to relinquish weapon?




     Have patient secure weapon            Can law enforcement secure                           YES                                            NO
             at residence                        weapon at scene?



Assess & transport               YES                    NO                           Refrain from care; leave scene. Law enforcement should
 per agency SOPs                                                                       be called to ascertain situation. If situation becomes
                                                                                     threatening, evacuate scene to safe distance and call law
                                                                                                     enforcement immediately.


                                                    Secure weapon in Lock Box; tab lock;
  Have law enforcement secure
                                                   store in vehicle compartment; complete
            weapon
                                                            Chain of Evidence form



                                       Transport to hospital; notify
Assess & transport                                                                                    Once scene secured, begin again at
                                        hospital of weapon being
 per agency SOPs                                                                                            top (“EMS to scene.”)
                                           brought in Lock Box




                                           Can law enforcement secure weapon upon
                                                   EMS arrival to hospital?



                                             YES                                NO




                  Remit weapon to Law Enforcement;                      Exchange Lock Box with hospital Security Personnel;
                   complete Chain of Evidence form                              complete Chain of Evidence form


 EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                                                         Page 158
 Dr. Mark Seher DO, Medical Director.
     SECTION XII – Medical Abbreviations
     To ensure consistency in patient care reporting, the Medical Director approved the following list of
     abbreviations:

               -A-                              APGAR - Appearance,                      Oriented to Person, Place,
A&Ox3 - Alert & oriented to                     Pulse, Grimace, Activity,                Time & Events
(PPT)                                           Respiratory effort                       Cc - Cubic centimeter
AAA - Abdominal aortic                          AS - Left ear (auris sinistra)           Cm - Centimeter
aneurysm                                        ASA - Acetyl salicylic acid              CCB - Calcium channel
Abd - Abdomen                                   (aspirin)                                blocker
ABC - Airway, breathing,                        ATF - Arrived to find                    CHF - Congestive heart
circulation                                     AV - Atrioventricular                    failure
a.c. - Before meals                             AVA - Alternate vascular                 CHI - Closed head injury
A/C Aircraft                                    access                                   CID - Cervical
ACE - Angiotensin                               AVM - Arteriovenous                      Immobilization Device
converting enzyme                               malformation                             Cl - Chlorine
ACLS - Advanced                                              -B-                         CNS - Central nervous
Cardiovascular Life Support                     BBB - Bundle branch block                system
ACS - Acute Coronary                            BBS - Bilateral breath                   COPD - Chronic obstructive
Syndrome                                        sounds                                   pulmonary disease
a.d. - Right ear (auris                         B.E. - Below elbow                       CO - Cardiac output / carbon
dexter)                                         (amputation)                             monoxide
ADD - Attention deficit                         BGL - Blood glucose level                C02 - Carbon dioxide
disorder                                        b.i.d. - Twice a day                     +CMS - Positive circulatory,
A.E. - Above elbow                              B.K. - Below knee                        motor & sensory function
(amputation)                                    (amputation)                             CNS - Central nervous
AED - Automated external                        BLS - Basic life support                 system
defibrillator                                   BM - Bowel movement                      CP - Chest pain
A Fib - Atrial fibrillation                     BP - Blood Pressure                      CPAP - Continuous positive
AF - Atrial flutter                             BS - Breath, bowel sounds                airway pressure
AIDS - Acquired                                 BSA - Body surface area                  CPR - Cardiopulmonary
immunodeficiency syndrome                       BVM Bag valve mask                       resuscitation
AIVR - Accelerated                                           -C-                         CPS - Child Protective
Idioventricular rhythm                          Cº - Centigrade                          Services
A.K. - Above knee                               C/C - Chief complaint                    CRT - Capillary refill time
(amputation)                                    c/o - Complains /                        C-spine - Cervical spine
AMI - Acute myocardial                          complaining of                           CSF - Cerebrospinal fluid
infarction                                      CA - Carcinoma, cancer                   CSM - Carotid sinus massage
Ant - Anterior                                  Ca+ - Calcium                            CTA - Clear to auscultation
AOS TF - Arrived On Scene                       CABG - Coronary artery                   CVA - Cerebrovascular
to Find                                         bypass graft                             accident
APAP - Acetaminophen                            CAD - Coronary artery                    CVP - Central venous
APS - Adult Protective                          disease                                  pressure
Services                                        CAO x 3 or 4 or PPT -                    Cx - Chest
                                                Conscious, Alert, &                      CXR - Chest x-ray

     EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                         Page 159
     Dr. Mark Seher DO, Medical Director.
               -D-                                 ET - Endotracheal                hs - At bedtime
DCAPS BLS TIC -                                    ETCO2 - End-tidal carbon         HTN - Hypertension
Deformities, Contusions,                           dioxide                          Hx - History
Abrasions, Penetrations,                           ETOH - Ethyl alcohol,                           -I-
Paradoxical movements,                             alcoholic beverage               ICD - Implanted cardioverter
Burns, Lacerations, Swelling,                      ETT - Endotracheal tube          defibrillator
Tenderness, Instability,                           EXP - Expansion                  ICP - Intracranial pressure
Crepitis                                           EXT - Extremity(s)               IDDM/DM I - Insulin
Diff - Difficulty                                               -F-                 dependent diabetes mellitus
Disch - Discharge                                  F - Female                       (Type I)
D&C - Dilatation & curettage                       Fº - Fahrenheit                  IM - Intramuscular
dL - Deciliter (1/10 liter: 100                    FBAO - Foreign body              IMV - Intermittent
ml)                                                airway obstruction               mechanical ventilation
DKA - Diabetic ketoacidosis                        FHx - Family history             Inf - Inferior
DM - Diabetes mellitus                             FHR - Fetal heart rate           IO - Intraosseous
DNAR - Did not attempt                             Fr - French                      IPPB - Intermittent positive
resuscitation                                      FSP - Full spinal precaution     pressure breathing
DNR - Do-not-resuscitate                           FUO - Fever of unknown           IU - International units
DOB - Date of birth                                origin                           IV - Intravenous
DOE - Dyspnea on exertion                          Fx - Fracture                    IVP - IV push
DOS - Dead on scene                                             -G-                 IVR - Idioventricular rhythm
DPT - Diphtheria, pertussis,                       G (+ #) - Gravida (G3, G4                       -J-
tetanus                                            etc.)                            J - Joules
DT’s - Delirium tremens                            GCS - Glasgow coma               JVD - Jugular venous
D5W - Dextrose 5% in water                         scale/score                      distention
D50 - Dextrose 50%                                 GERD - Gastroesophageal                         -K-
DVT - Deep vein thrombosis                         reflux disease                   K+ - Potassium
Dx - Diagnosis                                     GI - Gastrointestinal            KED - Kendrick extrication
               -E-                                 Gm, g - Gram                     device
ECG – Electrocardiogram                            Gtts - Drops                     KTD - Kendrick traction
ECF – Extended Care Facility                       GU - Genitourinary               device
(Nursing Home)                                     GYN - Gynecology                 KVO - Keep vein open
EDC - Estimated date of                                         -H-                 Kg - Kilogram
confinement                                        h, hr - Hour                                    -L-
EEG - Electroencephalogram                         H/A - Headache                   L - Liter
EF - Ejection fraction                             HAV - Hepatitis A virus          L spine - Lumbar spine
e.g. - For example                                 HBV - Hepatitis B virus          L&D - Labor and delivery
EPS - Electrophysiological                         HCTZ - Hydrochlorothiazide       L/S - Lung sounds
study                                              HCV - Hepatitis C virus          Lac - Laceration
ER/ED - Emergency                                  HEENT - Head, eyes, ears,        LAD - Left axis deviation /
room/department                                    nose, throat                     left anterior descending
Epi - Epinephrine                                  Hg - Mercury                     Lbs – Pounds
Est. - Estimated                                   HIV± - Human                     LBB – Long backboard
ESRD - End stage renal                             immunodeficiency virus           LBBB - Left bundle branch
disease                                            HR - Heart rate                  block
ETA - Estimated time of                            HRT - Hormone                    Liq - Liquid
arrival                                            replacement therapy              LLQ - Lower left quadrant
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                    Page 160
Dr. Mark Seher DO, Medical Director.
LMA - Laryngeal Mask                               NIDDM/DM II - Non insulin        PAI - Pharmacologically
Airway                                             dependent diabetes               assisted intubation, Pre-
LMP - Last menstrual period                        mellitus (Type II)               Arrival Instructions
LOC - Level/loss of                                NKA - No known allergies         PCI - Percutaneous coronary
consciousness                                      NKDA - No known drug             intervention
Lpm - Liter per minute                             allergies                        pCO2 - Carbon dioxide
LR - Lactated Ringer’s                             NMB - Neuromuscular              pressure
LSD - Lysergic acid                                blockade                         PCP - Phencyclidine, Primary
diethylamide                                       NOI - No obvious injury          Care Physician
LUQ - Left upper quadrant                          NPA - Nasopharyngeal             PCR – Patient Care Report
LVAD - Left Ventricular                            airway                           PCT - Patient care to
Assist Device                                      NPO - Nothing by mouth           PE - Physical exam,
LVH - Left ventricular                             NRB - Non-rebreather             pulmonary emboli,
hypertrophy                                        mask                             pulmonary edema
               -M-                                 NS - Normal saline               PEA - Pulseless electrical
m - Meter                                          NSAID - Non-steroidal anti-      activity
M - Male                                           inflammatory drug                PEEP - Positive end
mA - Milliamperes                                  NT - Nasotracheal                expiratory pressure
mg - Milligram                                     NTG - Nitroglycerin              PERRL - Pupils equal round
MAE - Moves all extremities                        N/V/D - Nausea, vomiting,        reactive to light
MAP - Mean arterial pressure                       diarrhea                         PID - Pelvic inflammatory
[(SBP-DBP)÷3 + DBP                                              -O-                 disease
Mcg - Microgram                                    O2 - Oxygen                      PMD - Primary/Private
MCL - Midclavicular line,                          OB - Obstetrics                  medical doctor
modified chest lead                                OBS - Organic brain              Pn – Pain
MDI - Metered dose inhaler                         syndrome                         PNB – Pulseless Non
mEq - Milliequivalent                              OBV - Obvious                    Breather
mL - Milliliter                                    OD - Overdose, right eye         PND - Paroxysmal nocturnal
mm - Millimeter                                    (oculus dexter)                  dyspnea
MMR - Measles, mumps,                              OOH - Out of hospital            PO2 - Partial pressure of
rubella                                            OPA - Oropharyngeal              oxygen
MOI - Mechanism of injury                          airway                           PO - By mouth
mph - Miles per hour                               OPP - Organophosphate            POC - Position of comfort
MS - Multiple Sclerosis                            poisoning                        post. - Posterior
MVA/MVC - Motor vehicle                            OR - Operating room              POV - Privately
accident/crash                                     OS - Left eye (oculus            operated/owned vehicle
MVP - Mitral valve prolapse                        sinister)                        PPE - Personal Protective
               -N-                                 OSS - Oregon Spine Splint        Equipment
   +
Na - Sodium                                        oz -. Ounce                      PR - Per rectum
NAD - No apparent / acute                          Ø - No or none                   PRBC’s - Packed red blood
distress                                                        -P-                 cells
N/C - Nasal cannula                                p - After                        PRN - As needed
NES - Non-English Speaking                         p.c. - After meals               PSVT - Paroxysmal
NGT - Nasogastric tube                             P (+ #) - Parity (P3, P4         supraventricular tachycardia
NH - Nursing home                                  etc)                             Pt - Patient
                                                   PA - Physician assistant,        PTA/PTOA - Prior to (our)
                                                   pulmonary artery                 arrival
EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                    Page 161
Dr. Mark Seher DO, Medical Director.
PTS - Pediatric trauma score                       SQ - Subcutaneous                UTO - Unable to obtain
PVC - Premature ventricular                        SCI - Spinal cord injury                       -V-
contraction                                        SIDS - Sudden infant death       Vol - Volume
PVT - Polymorphic                                  syndrome                         VO - Verbal order
ventricular tachycardia                            SL - Sublingual, Saline Lock     VF - Ventricular fibrillation
P/W/D - Pink warm and dry                          SOB - Shortness of breath        VS - Vital signs
              -Q-                                  SROM - Spontaneous               Vt - Tidal volume
Q - Every                                          Rupture of Membranes             VT - Ventricular tachycardia
Qh - Every hour                                    St - States                                    -W-
q.i.d. - Four times a day                          STD - Sexually transmitted       w/ - With
              -R-                                  disease                          w/o - Without, wide open
RAD - Right axis deviation,                        SUV - Sport utility vehicle      WDWN - Well developed,
reactive airway disease                            SVT - Supraventricular           well nourished
RBBB - Right bundle branch                         tachycardia                      WNL - Within normal limits
block                                              SX - Symptoms                    WPW - Wolf-Parkinson-
RBC - Red blood cell, red                                        -T-                White
blood (cell) count                                 T spine - Thoracic spine                       -X-
RCA - Right coronary artery                        TBI - Traumatic brain            X-fer - transfer
RHD - Rheumatic heart                              injury                           X-prt - Transport
disease                                            Temp - Temperature                             -Y-
RLQ - Right lower quadrant                         tab - Tablet
ROSC - Return of                                   TB - Tuberculosis                y/o - years old
spontaneous circulation                            Tbsp - Tablespoon                          -Symbols-
+ROM - Positive range of                           TCP - Transcutaneous             α - Alpha
motion                                             pacing                           β - Beta
RN - Registered nurse                              TCA - Tricyclic                  @ - At
RR - Respiratory rate                              antidepressant                   ? - Questionable, possible
RSI – Rapid sequence                               TdP - Torsades de Pointes        1° - First degree
intubation                                         TIA - Transient ischemic         2° - Second degree
RSV - Respiratory syncytial                        attack                           3° - Third degree
virus                                              t.i.d. - Three times a day       x - Times
RTS - Revised trauma score                         TKO - To keep open               + - Positive
RUQ - Right upper quadrant                         TOT - Turned Over To             – - Negative
Rx - Prescription                                  Tsp - Teaspoon                   = - Equal
              -S-                                  TX - Treatment                   ↓ - Decreased / below /
s/s - Signs / symptoms                                          -U-                 lower
SAO2 - Oxygen saturation of                        U/A - Upon arrival, urine        ↑ - Elevated / increased /
arterial oxyhemoglobin                             analysis                         upper
SARS - Severe acute                                URI - Upper respiratory          → - Move/went to
respiratory syndrome                               infection                        # - Number
SBP - Systolic blood                               UTI - Urinary tract infection
pressure                                           UTL - Unable to locate




EMS Patient Care Guidelines, Morrow County, Ohio. Effective date January 1, 2011.                     Page 162
Dr. Mark Seher DO, Medical Director.
SECTION XIII – MEDICATIONS
Acetaminophen (Tylenol)
ACTIONS
    Reduces fever by direct action on hypothalamus heat-regulating center with
     consequent peripheral vasodilation, sweating, and dissipation of heat.
INDICATIONS
    Fever > 100.8 F.
CONTRAINDICATIONS
    Hypersensitivity to acetaminophen.
ROUTE
    PO
DOSAGE
    Adults: 325 to 650 mg PO.
    Peds: 15 mg/kg PO.
ADVERSE EFFECTS
    Anorexia, nausea, vomiting, dizziness, lethargy, diaphoreses, chills, abdominal pain,
     diarrhea.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 163
Dr Eric Hansen, Medical Director
Activated Charcoal
ACTIONS
    Binds poisons, toxins, irritants; thereby inhibiting their GI absorption and impact.
INDICATION
    Poisoning or overdose. Administer ONLY at the direction of Poison Control.
CONTRAINDICATIONS
    Hypersensitivity to Activated Charcoal.
    Not effective for poisonings of cyanide, mineral acids, caustic alkalis, organic solvents,
     iron, ethanol, or methanol.
ROUTE
    NG
DOSAGE
   Adults and Peds: 1 gm/kg NG (minimum dose 30 grams).
ADVERSE EFFECTS
    Nausea, vomiting, constipation, diarrhea, black stools.
SPECIAL NOTES
    Drug is most effective when administered as soon as possible after acute poisoning.
    If administered too rapidly, patient may vomit.
    Assure correct placement of NG tube.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 164
Dr Eric Hansen, Medical Director
Adenosine (Adenocard)
ACTIONS
    Slows conduction through the AV and SA nodes, can interrupt reentry pathways
     through the AV node, and can restore normal sinus rhythm in SVT.
INDICATIONS
    Supraventricular tachycardia (SVT), including those associated with accessory bypass
     tracts involving AV node or SA node.
CONTRAINDICATIONS
    Hypersensitivity to Adenosine.
    Second or Third degree AV heart block.
    Wolff-Parkinson-White syndrome.
    Sick sinus syndrome.
    Atrial flutter or atrial fibrillation.
    Ventricular Tachycardia.
ROUTE
    IV/IO
DOSAGE
    Adults: initial dose 6 mg rapid IV/IO. May repeat twice every 2 minutes if no
     response as 12 mg rapid IV/IO. Max cumulative dose 30 mg.
    Reduce initial dose to 3 mg IV/IO in patients receiving dipyridamole (Persantine) or
     carbamazepine (Tegretol), transplanted hearts or central venous administration.
    Peds: 0.1 mg/kg rapid IV/IO (max first dose 6 mg). May repeat twice every
     2 minutes if no response as 0.2 mg/kg IV/IO (max second/third dose of 12
     mg). Max cumulative dose 30 mg.
ADVERSE EFFECTS
    Headache, lightheadedness, dizziness, facial flushing, palpitations, dyspnea, chest pain
     or tightness, brief periods of asystole or bradycardia, ventricular ectopy.
SPECIAL NOTES
    To be certain the medication reaches the systemic circulation quickly, it should be
     injected into an IV line as close to the patient as possible.
    Adenosine should be given as a rapid IV push over 1 to 2 seconds followed by NS
     bolus of 20 ml.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 165
Dr Eric Hansen, Medical Director
Albuterol Sulfate (Proventil)
ACTIONS
    Causes bronchodilation decreasing airway resistance by relaxing smooth muscles of
     bronchial tree. Facilitates mucus drainage.
INDICATIONS
    To relieve bronchospasm associated with acute or chronic asthma, COPD, or wheezing
     not caused by foreign body obstruction.
CONTRAINDICATIONS
    Hypersensitivity to Albuterol Sulfate.
ROUTE
    Inhaled via nebulized aerosol mist.
DOSAGE
    Adults: 2.5 mg (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg of
     Ipratropium (Atrovent).            Albuterol ONLY may be given by continuous
     administration.
    Peds: 2.5 mg (diluted in 3 ml NS) nebulized. May be given by continuous
     administration.
PRECAUTIONS
    Cardiovascular disease, hypertension, seizure disorders, hyperthyroidism, or diabetes
     mellitus.
    Administer with caution if heart rate is greater than 150 bpm (must be on cardiac
     monitor), or in cases of heart block.
    Patients who use bronchodilators excessively.
ADVERSE EFFECTS
    Tachycardia, tremors, anxiety, palpitations, ectopy, hypertension, angina, vomiting,
     and vertigo.
SPECIAL NOTES
    Most patients will have a decrease in heart rate and blood pressure with a relief of
     their bronchospasm. Therefore, do not withhold therapy in patients with hypertension
     and/or tachycardia.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 166
Dr Eric Hansen, Medical Director
Amiodarone (Cordarone)
ACTIONS
    Antiarrhythmic; prolongs duration of action potential and refractory period without
     significantly affecting resting membrane potential. Decreases peripheral vascular
     resistance.
INDICATIONS
    Treatment and prophylaxis of frequently recurring ventricular fibrillation, ventricular
     tachycardia, supraventricular tachycardia, atrial fibrillation.
CONTRAINDICATIONS
    Hypersensitivity to Amiodarone.
    Cardiogenic shock.
    Severe sinus bradycardia.
    2nd or 3rd Degree AV Block unless pacemaker is available.
ROUTE
    IV, IO
DOSAGE
    Adults: Ventricular fibrillation/pulseless VT - 300 mg IV/IO. May repeat 150 mg
     IV/IO once in 3 to 5 minutes.
    If rhythm converts to a perfusing rhythm, hang a maintenance infusion. Infuse 1
     mg/min. Mixing suggestion; inject 100 mg into 100 ml bag of NS. Initiate
     infusion with a 60 gtt set (60 gtt/min).
    Adults: Tachycardia with pulses - 150 mg over 10 minutes IV/IO. Mixing
     suggestion; inject 150 mg into 50 ml bag of NS. Initiate infusion with a 60 gtt
     set. Infuse 50 ml over 10 minutes (15 mg/min).
    Peds: Ventricular fibrillation/pulseless VT - 5 mg/kg IV/IO bolus (max first
     dose 300 mg). May repeat 2.5 mg/kg IV/IO (max second dose 150 mg)
     once in 3 to 5 minutes.
    Peds: Tachycardia with pulses - 5 mg/kg IV/IO over 20 minutes (max
     single dose 150 mg).
ADVERSE EFFECTS
    Hypotension, nausea, bradycardia.
SPECIAL NOTES
    Profound hypotension may occur post resuscitation. Be prepared to treat hypotension
     with vasopressors.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 167
Dr Eric Hansen, Medical Director
Aspirin
ACTIONS
    Inhibits platelet aggregation and thereby reduces risk of thrombus formation.
INDICATIONS
    Acute coronary syndromes (ACS).
CONTRAINDICATIONS
    Hypersensitivity to Aspirin.
    Decreased level of consciousness.
    History of GI ulcers or bleeding.
ROUTE
    PO
DOSAGE
    Adults: 162 mg to 324 mg PO (chewable).
    Not indicated in children.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 168
Dr Eric Hansen, Medical Director
Atropine Sulfate
ACTIONS
    Blocks vagal impulses to heart with resulting decrease in AV conduction time and
      increase in heart rate and cardiac output.
INDICATIONS
    Symptomatic bradycardia and bradyarrhythmias (sinus, junctional or escape rhythms).
    Asystole
    Nerve agent exposure and organophosphate poisonings.
    Blocking vagal reflexes as a pretreatment in pediatric RSI.
ROUTE
    IV, IO, IM, ET
DOSAGE - BRADYARRHYTHMIAS
    Adults: 0.5 mg IV/IO. May repeat every 5 minutes until desired heart rate is
      achieved. Max cumulative dose 3 mg.
    Peds: 0.02 mg/kg IV/IO. May repeat once.
     o Minimum single dose 0.1 mg.
     o Maximum single dose 0.5 mg.
     o Maximum cumulative dose 1 mg.
DOSAGE - ASYSTOLE/PEA
    Adults: 1 mg IV/IO. May repeat every 3 to 5 minutes. Max cumulative dose 3 mg.
    NOT indicated in pediatric Asystole.
DOSAGE - NERVE AGENT EXPOSURE AND ORGANOPHOSPHATE POISONING
    Adults: 2 mg IV/IO. May repeat every 5 minutes until a decrease in secretions is
      observed. No max dose.
    Peds: 0.02 mg/kg IV/IO or 0.05 mg/kg IM. May repeat every 5 minutes
      until a decrease in secretions is observed. No max dose.
DOSAGE - RSI PREMEDICATION FOR CHILDREN < 8 YEARS OLD (IF >8 YEARS OLD
NOT INDICATED)
    Peds: 0.02 mg/kg IV/IO.
     o Minimum single dose 0.1 mg.
     o Maximum cumulative dose 1 mg.
ADVERSE EFFECTS
    Hypertension, tachycardia, palpitations, dizziness, dilated pupils, photophobia, dry
      mouth, paradoxical bradycardia, hypotension.
SPECIAL NOTES
    Inadequate or slowly administered doses may result in a reflex bradycardia.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 169
Dr Eric Hansen, Medical Director
Dextrose 25% / 50% (D25 / D50)
ACTIONS
    Immediate source of glucose for cellular metabolism.
INDICATIONS
    Hypoglycemia established or suspected.
    Unconsciousness caused by unknown etiology.
CONTRAINDICATIONS
    Hyperglycemia
    Intracranial hemorrhage.
    CHF
ROUTE
    IV, IO
DOSAGE
    Adults: 25 grams 50% solution IV/IO. May repeat as necessary.
    Peds: 2 cc/kg of a 25% solution IV/IO (mix D50 with equal parts NS). May
     repeat as necessary.
SPECIAL NOTES
    The infusion site MUST be monitored closely for infiltration. Extravasation requires
     IMMEDIATE discontinuation of the drug! SHUT OFF IV AND LEAVE INFILTRATED IV
     CATHETER IN PLACE. Notify ER staff immediately of infiltrated site prior to or upon
     arrival. Document notification appropriately.
    Obtain blood glucose reading prior to administration if possible.
    Ineffective without thiamine.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 170
Dr Eric Hansen, Medical Director
Diazepam (Valium)
ACTIONS
    Depresses the central nervous system. Relaxes skeletal muscles.
INDICATION
    Seizures
CONTRAINDICATIONS
    Hypersensitivity to benzodiazepines.
    Psychosis
ROUTE
    IV, IM, IO, PR
DOSAGE
    Adults: 5 to 20 mg IV/IO, in 5 mg increments. Push slowly (2 to 5 mg/min).
     Max cumulative dose 20 mg.
    Adults: Rectal dose 0.2 mg/kg, if unable to start IV.
    Peds: 0.2 mg/kg IV push slowly. Max dose 10 mg.
    Peds: Rectal dose 0.5 mg/kg, if unable to start IV.
ADVERSE EFFECTS
    Drowsiness, hypotension, bradycardia, nausea and vomiting, respiratory depression.
SPECIAL NOTES
    Use with caution in shock, alcohol intoxication, impaired respiratory drive.
    Do not mix with other drugs.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 171
Dr Eric Hansen, Medical Director
 Diltiazem (Cardizem)
ACTIONS
    Slows SA and AV node conduction times without affecting normal atrial action potential
     or intraventricular conduction.
INDICATIONS
    SVT refractory to Adenosine with adequate blood pressure.
    Atrial Fibrillation and Atrial Flutter with rapid ventricular response (RVR).
CONTRAINDICATIONS
    Hypersensitivity to Diltiazem.
    Wolff-Parkinson-White syndrome.
    Cardiogenic shock present.
    2nd or 3rd Degree AV Block unless pacemaker is available.
    Sick sinus syndrome.
    CHF or Acute Myocardial Infarction (AMI).
    Hypotension
ROUTE
    IV, IO
DOSAGE
    Adults: 0.25 mg/kg IV/IO (12.5 mg 19 mg 25 mg) over 2 minutes. May
     repeat 0.35 mg/kg IV/IO (18 mg, 25 mg, 35 mg) over 2 minutes in 15 minutes
     if heart rate remains > 110 bpm.
    Following IV dose, response usually occurs within 3 minutes, rarely converting atrial
     fibrillation or atrial flutter to NSR, but decreases heart rate; lasting 1 to 3 hours.
    NOT indicated in children.
ADVERSE EFFECTS
    Headache, dizziness, drowsiness, hypotension, bradycardia, nausea and vomiting.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 172
Dr Eric Hansen, Medical Director
Diphenhydramine (Benadryl)
ACTIONS
    Antihistamine - competes with histamines at receptor sites thus blocking histamine
     release. Reverses dystonic reactions.
INDICATIONS
    Allergic reactions.
    Adjunct to Epinephrine in treating anaphylaxis.
    Dystonic reactions.
CONTRAINDICATIONS
    Hypersensitivity to Diphenhydramine.
    Acute asthma.
    MAO inhibitors.
    Glaucoma
ROUTE
    IV, IO, IM
DOSAGE
    Adults: 25 to 50 mg IV/IO/IM.
    Peds: 1 mg/kg IV/IO/IM (max single dose 50 mg).
ADVERSE EFFECTS
    Drowsiness, headache, fatigue, confusion, palpitation, mild hypotension, blurred vision,
     dry mouth, nausea, vomiting, thickened bronchial secretions, wheezing, chest
     tightness.
SPECIAL NOTES
    May precipitate acute asthma due to drying effect on bronchial mucosa.
    Histamines produce the allergic symptoms of hives, laryngeal edema, bronchospasm
     and vasodilation.
    Dystonic reactions are characterized by distorted, twisting movements of the body,
     face, mouth and tongue.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 173
Dr Eric Hansen, Medical Director
Dopamine (Intropin)
ACTIONS
    Increases blood pressure and cardiac output due to vasoconstriction, increased
     inotropy and chronotropy. Therapeutic action depends on the receptors that are
     stimulated.
INDICATIONS
    Non-traumatic, symptomatic hypotension.
    Bradycardia
CONTRAINDICATIONS
    Hypersensitivity to Dopamine.
    Uncorrected tachyarrhythmias or ventricular fibrillation.
    Hypovolemic shock.
ROUTE
    IV, IO
DOSAGE
    Adults: 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14 gtts/min, 19 gtts/min).
     Titrate to maintain systolic BP > 90 mmHg not to exceed 20 mcg/kg/min. Mix 800
     mg Dopamine in 500 ml NS if premix unavailable (1600 mcg/ml), see chart.
    Peds: 5 to 20 mcg/kg/min IV/IO (same as adults). Titrate to maintain
     systolic BP > 90 mmHg.
ADVERSE EFFECTS
    Headache, palpitations, tachycardia, hypertension, nausea, vomiting.
SPECIAL NOTES
    The infusion site MUST be monitored closely for infiltration. Extravasation requires
     IMMEDIATE discontinuation of the drug! SHUT OFF IV AND LEAVE INFILTRATED IV
     CATHETER IN PLACE. Notify ER staff immediately of infiltrated site prior to or upon
     arrival. Document notification appropriately.
    Do not administer Sodium Bicarbonate in same IV line with Dopamine.
    Any underlying hypovolemia must be corrected, if possible, prior to use.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 174
Dr Eric Hansen, Medical Director
        Reference Charts                                      Dopamine 1600 mcg Concentration
        Dopamine 800mg in 500 ml
              Body Weight            Drip Rate per Minute to Achieve Desired Dose in mcg/kg/min
        kgs     lbs     1 mcg 3mcg 5mcg 6mcg 8 mcg 10mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg
             40      88     1.5    5    8       9      12       15     18      21      24       27  30
             45      99     1.5    5    8      10      14       17     20      24      27       30  34
             50     110       2    6    9      11      15       19     23      27      30       34  38
             55     121       2    6   10      12      17       21     25      29      33       37  41
             60     132       2    7   11      14      18       22     27      32      35       40  45
             65     143     2.5    7   12      15      20       25     30      35      40       45  49
             70     154     2.5    8   13      16      21       26     32      37      42       47  53
             75     165       3    8   14      17      23       28     35      40      45       50  55
             80     176       3    9   15      18      24       30     35      42      48       55  60
             85     187       3   10   16      19      26       32     38      45      50       57  63
             90     198     3.5   10   17      20      27       34     40      47      55       60  68
             95     209     3.5   11   18      21      29       35     43      50      57       65  70
            100     220     3.5   11   19      23      30       38     45      53      60       68  75
            105     231       4   12   20      24      32       40     47      55      63       70  80
            110     242       4   12   21      25      33       41     50      58      66       74  83
            115     253     4.5   13   22      26      34       43     52      60      69       77  86
            120     264     4.5   14   23      27      36       45     54      63      72       81  90
            125     275     4.5   14   23      28      38       47     56      66      75       84  94
            130     286       5   15   25      29      39       49     59      69      78       88  98
            135     297       5   15   26      31      41       51     61      71      82       92 102
            140     308       5   16   26      32      42       53     63      74      84       95 105




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                Page 175
Dr Eric Hansen, Medical Director
Epinephrine
ACTIONS
    Increases cardiac output by increased inotropy, chronotropy and AV conduction.
      Increases systolic BP due to increased cardiac output and vasoconstriction. Alleviates
      wheezing and dyspnea by relaxing smooth muscles of the respiratory tract. Prevents
      hypotension and loss of intravascular fluid in anaphylaxis by counteracting vasodilation
      and decreasing vascular permeability.
INDICATIONS
    Pulseless non-breathing patients (PNB).
    Anaphylaxis
    Status asthmaticus .
    Bradycardia
    Non-traumatic, symptomatic hypotension.
CONTRAINDICATIONS
    Hypersensitivity to Epinephrine.
    Hemorrhagic shock.
    Age > 45 due to possible underlying cardiovascular disease.
ROUTE
    IV, IO, ET, IM, SQ
DOSAGE - PNB
    Adults: 1 mg IV/IO (1:10,000) OR 2 - 2.5 mg ETT (1:1,000) diluted in 10 ml
      NS, if unable to start an IV/IO. May repeat every 3 to 5 minutes. No max dose.
    Peds: 0.01 mg/kg (1:10,000) IV/IO OR 0.1 mg/kg (1:1,000) via ETT if
      unable to start an IV/IO. May repeat every 3 to 5 minutes:
     o Maximum single dose 1 mg.
     o No maximum cumulative dose.
DOSAGE - BRADYCARDIA
    Adults: 2 mcg/min IV/IO (60 gtts/min). Mixing suggestion; inject 1 mg
      (1:1,000) into 500 ml bag NS. Titrate until desired heart rate is achieved.
    Peds: Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5
      minutes as needed until desired heart rate is achieved:
     o Maximum single dose 1 mg.
    Peds: Persistent 0.1 - 1 mcg/kg/min IV/IO. Mixing suggestion; inject 1 mg
      (1:1,000) into 500 ml bag NS. Titrate until desired heart rate is achieved.
DOSAGE - ANAPHYLAXIS
    Adults: 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml). May repeat every 15
      minutes as needed.
    Adults: Severe: 0.5 mg IV/IO of 1:10,000. May repeat every 3 - 5 minutes as
      needed.


EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 176
Dr Eric Hansen, Medical Director
      Peds: 0.01 mg/kg SQ/IM of 1:1,000 (0.01 ml/kg). May repeat every 15
      
      minutes as needed:
     o Maximum single dose 0.5 mg.
    Peds:     Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5
      minutes as needed:
     o Maximum single dose 1 mg.
DOSAGE - STATUS ASTHMATICUS
    Adults: 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml). May repeat every 15
      minutes as needed.
    Peds: 0.01 mg/kg SQ/IM of 1:1,000 (0.01 ml/kg). May repeat every 15
      minutes as needed:
     o Maximum single dose 0.5 mg.
ADVERSE EFFECTS
    Tachycardia, hypertension, nervousness, anxiety, headache, dyspnea, palpitations,
      nausea, vomiting.
SPECIAL NOTES
    Should not be given concurrently with sodium bicarbonate. Positive inotropic and
      chronotropic effects can precipitate or exacerbate cardiac ischemia.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 177
Dr Eric Hansen, Medical Director
Etomidate (Amidate)
ACTIONS
    Primarily a hypnotic. It has minimal respiratory or myocardial depression. It
     attenuates the rise in intracranial pressure that is associated with laryngoscopy and
     intubation by decreasing cerebral blood flow and cerebral metabolic oxygen demand
     without adversely affecting cerebral perfusion pressure.
INDICATIONS
    Rapid Sequence Intubation (RSI).
CONTRAINDICATIONS
    Known hypersensitivity to Etomidate.
ROUTE
    IV, IO
DOSAGE
    Adults: 0.3 mg/kg IV/IO (15 mg, 22.5 mg, 30 mg). One time dose.
    Peds: 0.3 mg/kg IV/IO. One time dose.
ADVERSE EFFECTS
    Myoclonic jerking, nausea, vomiting, coughing, hiccups, pain on injection, may
     exacerbate focal seizure disorders.
SPECIAL NOTES
    Be prepared to manage the airway with multiple techniques.
    Does not provide any pain control.
    Inject with wide open IV/IO.
    Will produce rapid sedation that lasts 10 to 15 minutes.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 178
Dr Eric Hansen, Medical Director
Fentanyl (Sublimaze)
ACTIONS
    Analgesia and Sedation.
INDICATIONS
    For the relief of acute and chronic pain.
CONTRAINDICATIONS
    Known hypersensitivity or intolerance to opiates.
ROUTE
    IV, IO
DOSAGE
    Adults: 25 to 50 mcg slow IV/IO. May repeat every 5 minutes in 25 mcg
     increments. Max cumulative dose 150 mcg.
    Peds: 2 mcg/kg slow IV/IO (max single dose 25 mcg). May repeat once in
     5 minutes.
ADVERSE EFFECTS
    Respiratory depression or arrest, dizziness, diaphoresis, delirium, hypotension,
     bradycardia, nausea, vomiting, rapid administration may cause chest wall rigidity.
SPECIAL NOTES
    Monitor respiratory status carefully.
    Naloxone may be used to reverse Fentanyl.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 179
Dr Eric Hansen, Medical Director
Furosemide (Lasix)
ACTIONS
    A potent diuretic. Inhibits reabsorption of sodium and chloride at proximal and distal
     tubule and in the loop of Henle. This loss of sodium and chloride will cause water to
     follow, hence a loss of water from the circulatory system. A decrease in intravascular
     volume will occur.
INDICATIONS
    Acute Pulmonary Edema with severe respiratory distress and systolic blood pressure >
     90 mmHg.
CONTRAINDICATIONS
    Known hypersensitivity to Furosemide.
    BP < 90 mmHg.
ROUTE
    IV, IO
DOSAGE
    Adults: 40 mg slow IV/IO OR double patient’s oral dose. Max dose 80 mg.
    NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
    Orthostatic hypotension, dizziness, dehydration, hyperglycemia, hypokalemia,
     confusion, headache, syncope, blurred vision, tinnitus, hearing loss.
SPECIAL NOTES
    Closely monitor BP.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 180
Dr Eric Hansen, Medical Director
Glucagon
ACTIONS
    Increases blood glucose levels. Converts liver glycogen to glucose.
INDICATIONS
    Symptomatic blood glucose < 60 mg/dl when unable to establish an IV.
CONTRAINDICATIONS
    Known hypersensitivity to Glucagon.
ROUTE
    IM, SQ
DOSAGE
    Adults: 1 mg IM or SQ.
    Peds: 0.03 mg/kg IM or SQ (max dose 1 mg).
ADVERSE EFFECTS
    Nausea, vomiting.
SPECIAL NOTES
    Use only the diluents supplied by the manufacturer.
    Glucagon is of little help in patients with adrenal insufficiency.
    Administration of Glucagon should be followed by supplemental carbohydrates.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 181
Dr Eric Hansen, Medical Director
Glutose (Oral Glucose)
ACTIONS
    Increases blood glucose levels.
INDICATIONS
    Symptomatic blood glucose < 60 mg/dl.
CONTRAINDICATIONS
    Known hypersensitivity to Glutose.
    Decreased LOC.
    Head injury/CVA.
ROUTE
    PO
DOSAGE
    Adults: 15 g (one tube) PO. May repeat once in 5 - 10 minutes.
    Peds: 7.5 g (1/2 tube) PO. May repeat once in 5 - 10 minutes.
ADVERSE EFFECTS
    Nausea, vomiting.
SPECIAL NOTES
    Must be able to swallow and easily protect own airway.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 182
Dr Eric Hansen, Medical Director
Ipratropium (Atrovent)
ACTIONS
    Produces local site-specific effects on the larger central airways including
     bronchodilation and prevention of bronchospasms.
INDICATIONS
    For relief of acute bronchospasm (reversible airway obstruction).
CONTRAINDICATIONS
    Hypersensitivity to Ipratropium OR Atropine and/or its derivatives.
ROUTE
    Inhaled via nebulized aerosol mist.
DOSAGE
    Adults: 0.5 mg by nebulizer combined with Albuterol (Proventil) in 3 ml of NS. Give
     one dose only.
    NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
    May cause bronchospasm to become worse. Glaucoma patients may experience
     pain/blurred vision if solution comes in contact with the eyes. Palpitations, dizziness,
     anxiety, headache, nervousness, nausea, vomiting, cramps, cough.
SPECIAL NOTES
    Use with caution in patients with a history of hypertension, heart disease, and
     tachydysrhythmias.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 183
Dr Eric Hansen, Medical Director
Lidocaine (Xylocaine)
ACTIONS
    Exerts antiarrhythmic action by suppressing automaticity in HIS-Purkinje system and
     by elevating electrical stimulation threshold of ventricles during diastole. May decrease
     ICP during RSI.
INDICATIONS
    Alternative treatment for wide-complex tachycardia or VF/pulseless VT.
    Ventricular arrhythmias.
    If head injury suspected and time allows prior to intubation.
CONTRAINDICATIONS
    Hypersensitivity to Lidocaine or other amide type anesthetics.
    SVT
    Second or Third degree AV heart block.
    Ventricular ectopy associated with bradycardia.
ROUTE
    IV, IO, IM, ET
DOSAGE - PNB
    Adults: 1 to 1.5 mg/kg IV/IO. May repeat half of original dose every 3 to 5
     minutes PRN. Max cumulative dose 3 mg/kg.
    Adults: If rhythm converts to a perfusing rhythm, hang a maintenance drip.
     Premix of 2 grams in 500 ml infuse at 2 to 4 mg/min IV/IO (30 to 60
           gtts/min).
     Peds: 1 mg/kg IV/IO (max single dose 100 mg). May repeat half of original
      
      dose every 3 to 5 minutes PRN. Max cumulative dose 3 mg/kg.
      
     Peds: If rhythm converts to a perfusing rhythm, hang a Lidocaine
      
     (Xylocaine) drip. Mixing suggestion; inject 100 mg in 500 ml bag of NS (200
     mcg/ml).
    Initiate infusion at 20 to 50 mcg/kg/min IV/IO (see chart).
DOSAGE - RSI
    Adults: 1.5 mg/kg IV/IO (75 mg, 100 mg, 150 mg). If head injury suspected
     and time allows.
    Peds: 1 mg/kg IV/IO (max single dose 100 mg).
DOSAGE - ADULT IO
    Adults: Lidocaine (Xylocaine) - 20 to 50 mg IO for pain control in conscious
     patients.
ADVERSE EFFECTS
    Hypotension, bradycardia, arrhythmias, cardiac arrest, tremors, restlessness,
     convulsions, euphoria, confusion, slurred speech, lightheadedness, tinnitus, blurred, or
     double vision.
SPECIAL NOTES
    Metabolized in the liver and excreted in the kidneys. A reduced dosage should be
     considered for patients with suspected liver or kidney disease, cardiogenic shock,
     congestive heart failure, and in the elderly.

EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 184
Dr Eric Hansen, Medical Director
Lidocaine Jelly 2% (Xylocaine Jelly 2%)
ACTIONS
    Anesthetic and lubrication.
INDICATIONS
    Lubrication to facilitate oral or nasal endotracheal intubation.
    When anesthetic needed.
    To control gagging.
    May be used to relieve Laryngospasms when orally intubating.
    May reduce discomfort associated with nasal intubation.
CONTRAINDICATIONS
    Hypersensitivity to Lidocaine or Novocain.
    Inflamed tissue.
ROUTE
    Topical
DOSAGE
    Apply a liberal amount to device prior to insertion.
    For nasal intubation, apply to nasopharyngeal airway and insert (leave in place for at
     least 1 minute) prior to attempt if possible.
ADVERSE EFFECTS
    Local allergic reaction.
SPECIAL NOTES
    Avoid contact with eyes.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 185
Dr Eric Hansen, Medical Director
Magnesium Sulfate
ACTIONS
    CNS depressant, smooth muscle relaxant and anticonvulsant by decreasing the
     acetylcholine from motor nerve terminals, thus producing peripheral neuromuscular
     blockage.
INDICATIONS
    Seizures due to toxemia of pregnancy.
    Treatment of choice for Torsades de Pointes.
CONTRAINDICATIONS
    Hypersensitivity to Magnesium Sulfate.
    Renal failure.
ROUTE
    IV/IO
DOSAGE - TORSADES DE POINTS
    Adults: 2 grams IV/IO over 5 minutes. Premix available in 50 mL NS.
    Peds: 25 mg/kg IV/IO over 10 minutes (max dose 2 grams).
DOSAGE - PRE-ECLAMPSIA/ECLAMPSIA
    Adults: 2 to 4 grams IV/IO over 5-10 minutes. Premix available of 2 grams
     in 50 mL NS.
ADVERSE EFFECTS
    Toxicity may cause flushing, sweating, mild bradycardia, hypotension.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 186
Dr Eric Hansen, Medical Director
Methylprednisolone (Solu-Medrol)
ACTIONS
    Anti-inflammatory and immunosuppressant.
INDICATIONS
    Acute exacerbation COPD.
    Status asthmaticus.
    Anaphylaxis
CONTRAINDICATIONS
    Hypersensitivity to Methylprednisolone.
    Systemic fungal infections.
ROUTE
    IV, IO
DOSAGE
    Adults: 125 mg slow IV/IO.
    Peds: 2 mg/kg IV/IO (max dose 80 mg).
ADVERSE EFFECTS
    Headache, confusion, psychosis, nausea, vomiting, muscle weakness.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 187
Dr Eric Hansen, Medical Director
Midazolam (Versed)
ACTIONS
    Short acting (15 to 20 minutes) benzodiazepine CNS depressant with muscle relaxant,
      sedative-hypnotic, anticonvulsant and amnestic properties.
INDICATIONS
    Sedation prior to cardioversion or {RSI}.
    Chemical restraint for behavior emergencies in cases of drug/illegal substance
      overdoses for the combative patient who places him/herself or others in danger.
    Seizures
CONTRAINDICATIONS
    Hypersensitivity to Midazolam.
    Pregnancy
    Shock/hypotension.
    Hypoxia
    Acute alcohol intoxication.
    Respiratory distress.
ROUTE
    IV, IO, IN
DOSAGE - SEDATION
    Adults: 2 mg slow IV/IO. May repeat in 5 minutes. Max cumulative dose 10 mg.
    Peds: Sedation - 0.05 mg/kg IV/IO (max single dose 2 mg). May repeat in
      5 minutes. Max cumulative dose 10 mg.
DOSAGE - {RSI}
    Adults and Peds: 0.1 mg/kg IV/IO. May repeat in 5 minutes. Max
      cumulative dose of 10 mg.
DOSAGE: SEIZURES
    Adults and Peds: 0.2 mg/kg atomized IN if unable to start an IV. May repeat
      in 5 minutes. Max cumulative dose 10 mg.
ADVERSE EFFECTS
   Hypotension if pushed too fast, respiratory depression, nausea, vomiting, excessive
     sedation, confusion.
SPECIAL NOTES
    Watch for respiratory depression and be prepared to support ventilations.
    Use only as a last resort for chemical restraint.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 188
Dr Eric Hansen, Medical Director
Morphine Sulfate
ACTIONS
    Analgesia. Manifests hemodynamic effects by increasing venous capacitance and
      decreasing systemic vascular resistance relieving pulmonary congestion.
INDICATIONS
    Severe and chronic pain.
    Chest pain.
    Pulmonary edema.
CONTRAINDICATIONS
    Hypersensitivity to Morphine.
    Severe respiratory depression.
    Shock
    Systolic BP < 90 mmHg.
    Head injury.
    Undiagnosed acute abdominal pain.
    Acute alcohol intoxication.
ROUTE
   IV, IO
DOSAGE
    Adults: 2 to 4 mg IV/IO, slowly titrate to effect. May repeat in 5 minutes. Max
      cumulative dose 10 mg.
    Peds: 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May repeat
      once in 5 minutes.
ADVERSE EFFECTS
    Tachycardia, bradycardia, severe hypotension, cardiac arrest, dizziness, drowsiness,
      confusion, blurred vision, lightheadedness, respiratory depression, apnea, nausea,
      vomiting.
SPECIAL NOTES
   May need to manage hypotension with fluid bolus.
   Watch for respiratory depression and be prepared to support ventilations.
   Naloxone (Narcan) should be readily available when administering Morphine.
   Morphine has been shown in some studies to be harmful in pulmonary edema. Use
     only as a 3rd line treatment.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 189
Dr Eric Hansen, Medical Director
Naloxone (Narcan)
ACTIONS
    Reverses the effects of opiates, including respiratory depression, sedation, and
     hypotension.
INDICATIONS
    High index of suspicion for narcotic overdose.
    To reverse respiratory depression and CNS sedation from narcotics (Fentanyl,
     Morphine, etc.).
CONTRAINDICATIONS
    Hypersensitivity to Naloxone.
ROUTE
    IV, IM, ET, IO, SC, IN
DOSAGE
    Adults: 0.4 to 2 mg IV, IM, SQ, IO, or IN. May repeat in 2 to 3 minutes. Titrate to
     effect.
    Peds: 0.1 mg/kg IV, IM, SQ, IO, or IN. May repeat in 2 to 3 minutes. Max
     single dose 2 mg. Titrate to effect.
ADVERSE EFFECTS
    Withdrawal symptoms in opioid dependent patients, tremors, seizures,
     hyperventilation, tachycardia, hypertension, nausea, vomiting.
SPECIAL NOTES
    Narcotics have a longer duration of action than Naloxone. Continue to monitor
     respirations and level of consciousness. Repeat doses may be necessary.
    Subsequent IM dose will prolong IV effects.
    Naloxone reverses respiratory depression/arrest in narcotic overdose. Administer
     Naloxone prior to considering endotracheal intubation if an opiate overdose is
     suspected.
    Rapid reversal of narcotic overdose may lead to violent or combative behavior or
     precipitate signs of acute narcotic withdrawal. Prepare to appropriately protect the
     patient and EMS personnel.
    Naloxone will not reverse narcotic induced hypotension. Monitor the pulse quality and
     blood pressure. If the patient is hypotensive, place the patient in a shock position and
     consider a fluid challenge.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 190
Dr Eric Hansen, Medical Director
Nitroglycerin (Nitrostat)
ACTIONS
    Potent vasodilator that relaxes vascular smooth muscle resulting in dose-related
     dilation of both venous and arterial blood vessels. Reduces peripheral resistance and
     decreases venous return to the heart. Both left ventricular preload and afterload are
     reduced and myocardial oxygen consumption or demand is decreased.
INDICATIONS
    Chest pain of suspected myocardial origin.
    CHF
CONTRAINDICATIONS
    Hypersensitivity to Nitroglycerin.
    Signs/symptoms of cerebral hemorrhage or increased intracranial pressure.
    BP < 90 mmHg.
    If the patient has taken sildenafil nitrate (Viagra, Revatio) or other phosphodiesterase
     inhibitors for erectile dysfunction in the past 24 hours.
ROUTE
    SL, Topical
DOSAGE
    Adults: 0.4 mg SL (tablet or spray). May repeat in 3-5 minutes x 2.
    Adults: 0.5 - 1 inch (paste) on chest wall.
    NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
    Headache, dizziness, orthostatic hypotension, palpitations, nausea and vomiting.
SPECIAL NOTES
    IV access preferred as soon as possible to treat secondary hypotension quickly with
     fluid boluses.
    Recheck vital signs and reassess pain with 1-10 Pain Scale after each Nitroglycerin
     tablet.
    One spray delivers 0.4 mg of Nitroglycerin. If the container is shaken, it will alter the
     dose delivered. Do Not Shake Container.
    Inhaling the spray affects the absorption rate. Instruct the patient not to inhale spray.
    Be sure to remove any transdermal system before defibrillation.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 191
Dr Eric Hansen, Medical Director
Ondansetron (Zofran)
ACTIONS
    Prevents nausea and vomiting by blocking serotonin peripherally, centrally, and in the
     small intestine.
INDICATIONS
    Prevention of nausea and vomiting.
CONTRAINDICATIONS
    Hypersensitivity to Ondansetron (Zofran).
ROUTE
    IV, IM, IO
DOSAGE
    Adults: 4 mg undiluted, IM or slow IV/IO. May repeat once. Max cumulative
     dose 8 mg.
    Peds: If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single dose 4 mg) OR if
     > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max cumulative dose 8
     mg.
ADVERSE EFFECTS
    Dizziness, drowsiness, fatigue, abdominal pain.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 192
Dr Eric Hansen, Medical Director
Oxymetazoline HCl (Afrin)
ACTIONS
    Constricts smaller arterioles in nasal passages.
INDICATIONS
    Facilitate nasal intubation.
    To lessen the risk of epistaxis.
CONTRAINDICATIONS
    Known hypersensitivity to Oxymetrazoline.
ROUTE
    Intranasal
DOSAGE
    Adults: 2 to 3 sprays in each nostril 1 to 2 minutes prior to intubating.
ADVERSE EFFECTS
    Burning, stinging, sneezing, headache, light-headedness, palpitation.
SPECIAL NOTES
    Single patient use. Dispose of bottle after each patient.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 193
Dr Eric Hansen, Medical Director
Oxygen (O2)
ACTIONS
   Reverses the deleterious effects of hypoxemia on the brain, heart and other vital
     organs. Essential element for normal metabolic function (aerobic metabolism).
INDICATIONS
    Hypoxemia
    Increased oxygen demand.
    Chest pain.
    Respiratory insufficiency.
    Cardiopulmonary arrest.
    Any condition in which global or local hypoxemia may be present.
CONTRAINDICATIONS
    Not significant in above indications.
ROUTE
    Inhalation
DOSAGE
    Percentage may vary slightly depending on technique and equipment: venturi mask,
      nasal cannula, non-rebreather mask, endotracheal tube, bag valve mask, or blow-by.
ADVERSE EFFECTS
    Not significant in above indications.
SPECIAL NOTES
    A patent airway and adequate ventilation must be ensured.
    Never withhold oxygen from a patient in respiratory distress.
    In some COPD (CO2 retaining) patients, oxygen administration may decrease
      respiratory drive. Observe patient closely for changes in respiratory effort and mental
      status. Be prepared to assist ventilations if necessary.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 194
Dr Eric Hansen, Medical Director
Racemic Epinephrine (Vaponephrin)
ACTIONS
    Reduces upper airway swelling and stridor.
INDICATIONS
    Treatment of life-threatening airway obstruction in croup.
CONTRAINDICATIONS
    Known hypersensitivity to Racemic Epinephrine.
ROUTE
    Inhaled via nebulized aerosol mist.
DOSAGE
    Peds: 2.25% (0.5 ml) mixed with 3 ml of NS nebulized. May repeat every
     15 minutes PRN.
ADVERSE EFFECTS
    Tachycardia, nervousness, anxiety, headache, tremors, palpitations, nausea, vomiting.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 195
Dr Eric Hansen, Medical Director
Sodium Bicarbonate (NaHCO3)
ACTIONS
    Neutralizes acid returning the blood towards its normal physiologic composition
     (increases pH). Shifts potassium intracellularly.
INDICATIONS
    Prolonged PNB resuscitation only after other more definitive interventions such as;
     prompt CPR, adequate oxygenation with 100% O2, defibrillation, vasopressors and
     antiarrhythmics have been used.
    Known preexisting hyperkalemia.
    Suspected tricyclic antidepressant overdose.
    Crush injury.
CONTRAINDICATIONS
    Known hypersensitivity to Sodium Bicarbonate.
ROUTE
    IV, IO
DOSAGE - PNB
    Adults: 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100 mEq). May repeat 0.5 mEq/kg
     IV/IO every 10 minutes PRN.
    Peds: 1 mEq/kg IV/IO (same as adults). May repeat 0.5 mEq/kg IV/IO
     every 10 minutes PRN.
DOSAGE - TRICYCLIC ANTIDEPRESSANT OVERDOSE
    Adults: 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100 mEq). If coma, seizures, wide
     QRS, or dysrhythmias develop 2 mEq/kg IV (100 mEq, 150 mEq, 200 mEq). May
     repeat every 3 to 5 minutes PRN.
    Peds: 1 mEq/kg IV/IO. May repeat 0.5 mEq/kg IV/IO every 10 minutes
     PRN.
DOSAGE - CRUSH INJURY
    Adults: Mix Sodium Bicarbonate – 1 amp per liter of NS solution IV/IO. Infuse
     1500ml/hr until extrication, THEN administer 1.0 to 1.5 liter bolus of mixture
     IV/IO right before extrication.
ADVERSE EFFECTS
    Hypernatremia, alkalosis, hypokalemia.
SPECIAL NOTES
    Do not administer Sodium Bicarbonate in same IV line with Dopamine.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 196
Dr Eric Hansen, Medical Director
Sodium Thiosulfate
ACTIONS
    Acts as a donor of sulfur, which is used as substrate by rhodanese and other
     sulfurtransferases for detoxification of cyanide to thiocyanate.
INDICATIONS
    Cyanide poisoning.
    Cyanide poisoning concomitant with carbon monoxide inhalation.
CONTRAINDICATIONS
    Known hypersensitivity to Sodium Thiosulfate.
ROUTE
    IV, IO
DOSAGE
    Adults: 12.5 grams IV/IO over ten minutes. Mixing suggestion; inject 12.5
     grams into a 50 ml bag of NS (gives 100 ml total). Administer 10 ml/minute.
     One time dose.
    Peds: 8 grams IV/IO over ten minutes. Mixing suggestion; inject 8 grams
     (32 ml) into 50 ml bag of NS (gives 82 ml total). Administer 8 ml/minute.
     One time dose.
ADVERSE EFFECTS
    Transient hypotension with rapid IV administration, ECG changes.
SPECIAL NOTES
    If a closed space fire victim, consider cyanide toxicity in anyone who has a decreased
     level of consciousness and is not responding to oxygen.
    Do not delay administration.
    Use with caution in asthma patients.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 197
Dr Eric Hansen, Medical Director
Succinylcholine (Anectine)
ACTIONS
    An ultra-short acting depolarizing muscle paralytic. Inhibits transmission of nerve
     impulses by binding with cholinergic receptor sites, antagonizing action of
     acetylcholine.
INDICATIONS
    Rapid Sequence Intubation (RSI).
CONTRAINDICATIONS
    Known hypersensitivity to Succinylcholine.
    Known anatomical airway anomalies.
ROUTE
    IV administration ONLY!
DOSAGE
    Adults: 1.5 mg/kg IV (75 mg, 112.5 mg, 150 mg).
    Peds > 10 kg: 1.5 mg/kg IV (same as adults).
    Peds < 10 kg: 2 mg/kg IV.
    May be repeated once as necessary if patient begins to resist the endotracheal tube or
     airway becomes difficult to manage.
ADVERSE EFFECTS
    Muscle fasciculations, profound and prolonged muscle relaxation, muscle pain,
     bradycardia, hypotension, arrhythmias, hypoxia.
SPECIAL NOTES
    Onset is within 30 to 60 seconds, duration is 3 to 10 minutes.
    Be prepared to manage the airway with multiple techniques.
    Room temperature shelf life is 30 days. Drug MUST be replaced every 30 days if
     stored at room temperature.

Paramedics must meet required training by the MCEMS Medical director prior to using
paralytics.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 198
Dr Eric Hansen, Medical Director
Tetracaine (Pontocaine)
ACTIONS
    Local anesthetic.
INDICATIONS
    Anesthesia prior to irrigation of the eyes.
CONTRAINDICATIONS
    Known hypersensitivity to Tetracaine.
    Open globe injuries.
ROUTE
    Topical
DOSAGE
    Adults and Peds: 2 drops in the affected eye or eyes prior to irrigation.
ADVERSE EFFECTS
    Stinging, corneal erosion, transient pitting and sloughing of corneal surface, dry
     corneal epithelium.
SPECIAL NOTES
    Onset is within 1 minute, duration is up to 15 minutes.
    Do not allow eye to be rubbed until anesthetic effect dissipated.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 199
Dr Eric Hansen, Medical Director
Vasopressin (Pitressin)
ACTIONS
    Contracts smooth muscle causing vasoconstriction. Increases the reactivity of blood
     vessels to the constrictor actions of catecholamines.
INDICATIONS
    May be used as an alternative vasopressor to Epinephrine in PNB.
CONTRAINDICATIONS
    Known hypersensitivity to Vasopressin.
    Increased peripheral vascular resistance may provoke cardiac ischemia and angina.
ROUTE
    IV, IO
DOSAGE
    Adults: 40 units IV/IO. One time dose to replace 1st or 2nd dose of Epinephrine.
    Not indicated in children.
ADVERSE EFFECTS
    Peripheral constriction, hypertension, chest pain, ventricular fibrillation, ventricular
     tachycardia, reduced cardiac output, tremors, sweating, dizziness, abdominal cramps,
     nausea, vomiting, bronchial constriction.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 200
Dr Eric Hansen, Medical Director
Vecuronium (Norcuron)
ACTIONS
    Paralytic agent that does not alter the level of consciousness
    Blocks cholinergic receptors on motor endplate
    Does not result in muscle depolarization
    Achieves no fasciculations
    Inhibits nerve impulse transmissions
INDICATIONS
    Paralysis in Rapid Sequence Intubation
    The need for long term paralysis
CONTRAINDICATIONS
    Known hypersensitivity
ROUTE
    IV
DOSAGE
    Defasciculating dose
      o 0.01 mg/kg IV
 Paralyzing dose
      o Adult
      o 0.10 mg/kg IV
      o Repeat q 1–2 hours
ADVERSE EFFECTS
    Profound and prolonged muscle relaxation, muscle pain, bradycardia, hypotension,
       arrhythmias, hypoxia.
Special considerations
          – Special considerations
                Consider using sedative or analgesic to decrease cardiovascular side
                   effects
                Be prepared for endotracheal intubation immediately after administering
                   drug
                When intubation is unsuccessful, ventilatory assistance is required
                Eye care to prevent desiccation, abrasions

Paramedics must meet required training by the MCEMS Medical director prior to using
paralytics.




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.   Page 201
Dr Eric Hansen, Medical Director
SECTION XIV – Index
                                                                              In their Office ............................... 136
                              1                                               On Emergency Scene..................... 136
12-Lead – Monitor Lead Placement ....... 123                                Non-Transport ................................. 134
12-Lead Monitoring .............................. 122                       Restraints ....................................... 135
                                                                          Trauma Triage Protocol ...................... 132
                              A                                          Arrhythmia Guidelines ............................ 39
                                                                         Arrhythmias
Abbreviations ....................................... 158
                                                                          Asystole .............................................. 44
Acetaminophen .................................... 162
                                                                          Atrial Fibrillation - Wide Complex .......... 52
Activated Charcoal ............................... 163
                                                                          Bradycardia ......................................... 46
Adenocard ........................................... 164
                                                                          Pulseless Electrical Activity (PEA) .......... 44
Adenosine ........................................... 164
                                                                          PVCs ................................................... 49
AED .................................................... 120
                                                                          Supraventricular Tachycardia ................ 50
Afrin .................................................... 194
                                                                          Ventricular Fibrillation .......................... 42
Air-Medical Transport ............................. 18
                                                                          Ventricular Tachycardia With Pulse ....... 48
Airway ................................................... 84
                                                                          Ventricular Tachycardia Without Pulse... 42
 Combitube .......................................... 92
                                                                          WPW .................................................. 52
 Cricothyroidotomy.............................. 102
                                                                         Aspirin................................................. 167
 LMA .................................................... 94
                                                                         Assessment
 Nasotracheal Intubation ....................... 90
                                                                          Detailed .............................................. 17
 NPA - Nasopharyngeal Airway .............. 87
                                                                          Focused History ................................... 16
 OPA - Oropharyngeal Airway ................ 86
                                                                          Initial .................................................. 15
 Orotracheal Intubation ......................... 88
                                                                          Ongoing .............................................. 17
 Retrograde Intubation ........................ 100
                                                                          Physical Exam...................................... 16
 RSI - Rapid Sequence Intubation .......... 96
                                                                          Rapid .................................................. 16
 Suctioning ......................................... 104
                                                                         Assessment Guidelines ........................... 14
Albuterol Sulfate .................................. 165
                                                                          AVPU .................................................. 14
Allergic Reaction .................................... 70
                                                                          DCAP-BLS-TIC ..................................... 14
Altered Level of Consciousness ............... 62
                                                                          OPQRST-ASPN ..................................... 14
Amidate .............................................. 178
                                                                          SAMPLE .............................................. 14
Amiodarone ......................................... 166
                                                                         Asthma.................................................. 57
Amputation ............................................ 26
                                                                         Asystole ................................................ 44
Anaphylaxis ........................................... 70
                                                                         Atrial Fibrillation - Wide Complex ............ 52
Anectine .............................................. 199
                                                                         Atropine Sulfate ................................... 168
APGAR .................................................. 81
                                                                         Atrovent .............................................. 184
Appendices .......................................... 126
                                                                         Auto-Injector ....................................... 124
 Differential Causes of Chest Pain and
                                                                         AVPU..................................................... 14
    Dyspnea ......................................... 126
                                                                         Avulsion ................................................ 26
 Glasgow Coma Scale .......................... 125
 Pediatric Vital Signs ........................... 125                                                B
 Special Situations ............................... 134
    Dangerous Persons .......................... 134                     Behavioral Emergency ............................ 74
    Emergency Care of Minors ............... 134                         Benadryl .............................................. 173
    Intervening EMT .............................. 137                   Bites ..................................................... 32
    Intervening Physician                                                Bradycardia ........................................... 46
EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                        Page 202
Dr Eric Hansen, Medical Director
Burns .................................................... 34            CPR Critical Concepts ............................. 38
                                                                         Cricothyroidotomy ................................ 102
                              C                                          Procedures .......................................... 102
C.H.A.R.T. ............................................. 12              Crush Syndrome .................................... 30
Calcium Chloride .................................. 169                  Crushing Injury ...................................... 30
Carbon Monoxide ................................... 76                   CVA....................................................... 63
Cardiac Emergencies .............................. 38
                                                                                                      D
 Arrhythmia Guidelines .......................... 39
 Asystole .............................................. 44              D25 ...................................................... 170
 Atrial Fibrillation – Wide Complex .......... 52                        D50 ...................................................... 170
 Bradycardia ......................................... 46                Dangerous Persons .............................. 134
 Chest Pain ........................................... 54               DCAP-BLS-TIC ....................................... 14
 CHF .................................................... 56             Decreased Level of Consciousness .......... 62
 CPR Critical Concepts ........................... 38                    Detailed Assessment .............................. 17
 PNB .................................................... 40             Dextrose 25%...................................... 170
 Pulmonary Edema ................................ 56                     Dextrose 50%...................................... 170
 Pulseless Electrical Activity ................... 44                    Diazepam ............................................ 171
 Pulseless Non-Breathing ....................... 40                      Differential Causes of Chest Pain and
 PVCs ................................................... 49              Dyspnea ............................................ 126
 Supraventricular Tachycardia ................ 50                        Differential Diagnosis of Airway Distress in
 Ventricular Fibrillation .......................... 42                   Pediatrics ............................................ 59
 Ventricular Tachycardia with Pulse ........ 48                          Diltiazem ............................................. 172
 WPW .................................................. 52               Diphenhydramine ................................. 173
Cardizem ............................................. 172               DNR .................................................... 144
CCW.................................................... 150               DNR Comfort Care ............................. 144
 Concsious, Alert, and Oriented Patient 157                               DNR Comfort Care Arrest ................... 144
 Patient with Altered LOC .................... 156                        Documentation .................................. 145
Central Venous Line Access .................. 112                        DOA .................................................... 143
Charcoal .............................................. 163              Documentation ...................................... 12
Procedures .......................................... 105                 CHART ................................................ 12
Chest Pain ............................................. 54               DNR .................................................. 145
CHF....................................................... 56             Terminating or Withholding Resuscitation
Chronic Obstructive Pulmonary Disease ... 58                                 Efforts ............................................ 143
Cleaning and Disinfection ..................... 130                      Dopamine ............................................ 174
Color Coding ............................................9               Dystonic Reaction .................................. 70
Colorimetric End Tidal CO2 .................... 108
Combitube ............................................. 92                                             E
Concealed Carry Weapons .................... 150                         Elderly Abuse/Neglect ............................ 11
Confidentiality ........................................ 11              Emergency Care Of Minor Patients ........ 134
Congestive Heart Failure ........................ 56                     Emergency Operations Declaration .......... 10
Consent............................................... 138               End Tidal CO2 ...................................... 108
 Adults ............................................... 138              Environmental Emergencies .................... 34
 Pediatric ............................................ 139               Burns .................................................. 34
Continuous Positive Airway Pressure ....... 98                            Heat Related Illness ............................. 37
COPD .................................................... 58              Hyperthermia ...................................... 37
Cordarone ........................................... 166                 Hypothermia ....................................... 36
CPAP ..................................................... 98             Temperature Instability ........................ 37
EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                        Page 203
Dr Eric Hansen, Medical Director
Epinephrine ......................................... 176                  Orotracheal ......................................... 88
Epi-Pen ................................................. 70               Retrograde Intubation ........................ 100
Etomidate ............................................ 178               Ipratropium ......................................... 184
Exposure Follow-up .............................. 130                    IV Access ............................................ 109
Extremity Trauma .................................. 24
Eye Emergencies.................................... 28                                                L
                                                                         Laryngeal Mask Airway ........................... 94
                               F                                         Lasix ................................................... 180
Fentanyl .............................................. 179              Lidocaine ............................................. 185
Focused History ..................................... 16                 Lidocaine Jelly 2% ............................... 186
Furosemide.......................................... 180                 LMA ...................................................... 94
                                                                         Load and Go .......................................... 19
                              G
                                                                                                      M
Glasgow Coma Scoring ......................... 125
Glucagon ............................................. 181               Magnesium Sulfate ............................... 187
Glutose................................................ 182              Mark-1 Kit ............................................. 78
                                                                         MAST .................................................. 115
                              H                                          MDDA ................................................... 10
Haldol ................................................. 183             Medical Abbreviations ........................... 158
Haloperidol .......................................... 183               Medical Director Statement .......................2
Hazardous Materials ............................... 77                   Medical Emergencies .............................. 62
Head Trauma ......................................... 22                  Allergic Reaction .................................. 70
Heat Related Illness ............................... 37                   Altered LOC ......................................... 62
Helmet Removal .................................. 118                     Anaphylaxis ......................................... 70
Hyperglycemia ....................................... 64                  Behavioral ........................................... 74
Hypertension ......................................... 66                 CVA .................................................... 63
 Gestational .......................................... 80                Decreased LOC .................................... 62
Hyperthermia......................................... 37                  Dystonic Reaction ................................ 70
Hypoglycemia ........................................ 64                  Hyperglycemia ..................................... 64
Hypotension .......................................... 66                 Hypertension ....................................... 66
Hypothermia .......................................... 36                 Hypoglycemia ...................................... 64
                                                                          Hypotension, Non-Traumatic ................ 66
                               I                                          Overdose ............................................ 68
                                                                          Pain Management ................................ 72
Immunizations ..................................... 128
                                                                          Seizures .............................................. 67
IN – Intranasal Atomizer ...................... 113
                                                                          Stroke ................................................. 63
Index .................................................. 202
                                                                         Methylprednisolone .............................. 188
Initial Assessment .................................. 15
                                                                         Midazolam ........................................... 189
Intervening EMT .................................. 137
                                                                         Minors
Intervening Physician
                                                                          Consent ............................................ 139
  In their Office .................................... 136
                                                                          Emergency Care of ............................ 134
  On Emergency Scene ......................... 136
                                                                          Refusal, Procedure for........................ 139
Intranasal Atomizer .............................. 113
                                                                         Morphine Sulfate .................................. 190
Intraosseous Access ............................. 110
                                                                         Multi-System Injuries ............................. 20
Intropin ............................................... 174
                                                                         Musculoskeletal Trauma ......................... 24
Intubation
  Nasotracheal ....................................... 90
EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                       Page 204
Dr Eric Hansen, Medical Director
                              N                                          Organophosphates ................................. 78
                                                                         Oropharyngeal Airway ............................ 86
NaHCO3 .............................................. 197
                                                                         Orotracheal Intubation ........................... 88
Naloxone ............................................. 191
                                                                         Overdose ............................................... 68
Narcan ................................................ 191
                                                                          Common Overdose Medications ............ 69
Nasopharyngeal Airway .......................... 87
                                                                         Oxygen ............................................... 195
Nasotracheal Intubation ......................... 90
                                                                         Oxygen Administration ........................... 84
Needle Decompression ......................... 105
                                                                         Oxymetazoline HCl ............................... 194
Nerve Agents ......................................... 78
NG – Nasogastric Tube ......................... 114                                                   P
Nitroglycerin ........................................ 192
Nitrostat .............................................. 192             Pain Management .................................. 72
Non-Priority Patients .............................. 16                  PASG – Pneumatic Anti-Shock Garment . 115
Non-Transports .................................... 134                  Patient Refusal..................................... 138
NPA ...................................................... 87            Patient Restraint .................................... 74
                                                                         Patients with Concealed Carry Weapons 150
                              O                                          Pediatric Vital Signs .............................. 125
                                                                         Personal Protective Equipment .......... 9, 129
O2 ....................................................... 195
                                                                         Physical Exam ........................................ 16
Obstetrical / Gynecological Emergencies .. 80
                                                                         Pitressin .............................................. 201
Obstetrical Emergencies Delivery
                                                                         Pneumatic Anti-Shock Garment ............. 115
 Abortion .............................................. 83
                                                                         Pontocaine .......................................... 200
 Breech Presentation ............................. 82
                                                                         PPE .........................................................9
 Delayed Placenta Delivery .................... 82
                                                                         Preamble .................................................8
 Delivery .............................................. 81
                                                                         Pre-Existing Medical Devices or Drug
 Hemorrhage ........................................ 82
                                                                           Administration ..................................... 10
 Limb Presenatation .............................. 82
                                                                         Priority Patients ..................................... 16
 Meconium Delivery .............................. 82
                                                                         Procedures ............................................ 84
 Nuchal Cord ........................................ 82
                                                                           12-Lead Monitoring ............................ 122
 Prolapsed Cord .................................... 82
                                                                           AED .................................................. 120
 Seizures .............................................. 83
                                                                           Airway ................................................ 84
 Shoulder Dystocia ................................ 82
                                                                           Auto-injector ..................................... 124
 Stillborn .............................................. 83
                                                                           Central Venous Line Access ................ 112
 Uterine Inversion ................................. 83
                                                                           Combitube .......................................... 92
Obstetrical Emergencies During Pregnancy
                                                                           CPAP................................................... 98
 Abruption ............................................ 80
                                                                           End Tidal CO2 .................................... 108
 Eclampsia ............................................ 80
                                                                           Helmet Removal ................................ 118
 Gestational Hypertension ..................... 80
                                                                           Intranasal Atomizer............................ 113
 PlacentaPrevia ..................................... 80
                                                                           Intubation
 Pre-Eclampsia ...................................... 80
                                                                             Nasotracheal ..................................... 90
 Seizure................................................ 80
                                                                             Orotracheal ....................................... 88
 Vaginal Bleeding .................................. 80
                                                                             Retrograde ...................................... 100
Ocular Emergencies ............................... 28
                                                                           IO Access .......................................... 110
Ondansetron ........................................ 193
                                                                           IV Access .......................................... 109
Ongoing Assessment .............................. 17
                                                                           LMA .................................................... 94
OPA ...................................................... 86
                                                                           MAST ................................................ 115
OPQRST-ASPN ....................................... 14
                                                                           Nasopharyngeal Airway ........................ 87
Oral Glucose ........................................ 182
                                                                           Nasotracheal Intubation ....................... 90
EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                        Page 205
Dr Eric Hansen, Medical Director
 Needle Decompression ....................... 105                                                      S
 NG Tube ........................................... 114                 Safe Harbor ......................................... 146
 NPA .................................................... 87             SAMPLE ................................................. 14
 OPA .................................................... 86             Scene Size Up ........................................ 14
 Oropharyngeal Airway .......................... 86                      Seizures ................................................ 67
 Orotracheal Intubation ......................... 88                     Sexual Assault ....................................... 33
 Oxygen Administration ......................... 84                      Sharps Hazards .................................... 130
 PASG ................................................ 115               SLUDGEM .............................................. 78
 Pulse CO-Oximetry ............................. 107                     Sodium Bicarbonate ............................. 197
 Pulse Oximetry .................................. 106                   Sodium Thiosulfate .............................. 198
 Retrograde Intubation ........................ 100                      Solu-Medrol ......................................... 188
 RSI ..................................................... 96            Special Situations ................................. 134
 Spinal Immobilization – Appropriate
                                                                          Dangerous Persons ............................ 134
   Omission ......................................... 117                 Emergency Care of Minor Patients ...... 134
 Suctioning ......................................... 104                 Intervening EMT ................................ 137
 Taser Probe Removal ......................... 116                        Intervening Physician
 Ventilation ........................................... 84                 In their Office .................................. 136
Professionalism ...................................... 12                   On Emergency Scene ....................... 136
Protection Guidelines ............................ 128                    Non-Transports ................................. 134
Proventil .............................................. 165              Use of Restraints ............................... 135
Pulmonary Edema .................................. 56                    Spinal Immobilization - Appropriate
Pulmonary Embolism .............................. 61                      Omission ........................................... 117
Pulse CO-Oximetry ............................... 107                    Splinting Suggestions ............................. 25
Pulse Oximetry .................................... 106
                                                                         Spontaneous Pneumothorax ................... 60
Pulseless Electrical Activity (PEA) ............ 44                      Stings.................................................... 32
Pulseless Non-Breathing (PNB) ............... 40                         Stroke ................................................... 63
                                                                         Sublimaze ............................................ 179
                              R
                                                                         Succinylcholine .................................... 199
Racemic Epinephrine ............................ 196                     Suctioning ........................................... 104
Rapid Assessment .................................. 16                   Supraventricular Tachycardia .................. 50
Rapid Sequence Intubation ..................... 96                       SVT ....................................................... 50
Refusal Information Sheet .................... 140                       Symptomatic PVCs ................................. 49
Refusal QA Checklist ............................ 140
Refusal, Procedure for                                                                                 T
 Adults ............................................... 139              Taser Probe Removal ........................... 116
 Minors............................................... 139               Temperature Instability .......................... 37
Refusal, Procedure for .......................... 139                    Terminating or Withholding Resuscitation
Respiratory Emergencies ........................ 57                       Efforts ............................................... 142
 Asthma ............................................... 57                DOA .................................................. 143
 COPD .................................................. 58               Documentation .................................. 143
 Pneumothorax, Spontaneous ................ 60                            Physician Present ............................... 143
 Pulmonary Embolism............................ 61                        Terminiating Resuscitation With ALS ... 142
 Upper Airway Distress in Pediatrics ....... 59                           Withholding Resuscitation With ALS .... 142
Restraint ............................................... 74              Withholding Resuscitation Without ALS 143
Restraints, Use Of ................................ 135                  Tetracaine ........................................... 200
Retrograde Intubation .......................... 100                     Thoracic Trauma .................................... 21
RSI ....................................................... 96
EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                        Page 206
Dr Eric Hansen, Medical Director
Toxic Exposure ...................................... 77                 Upper Airway Distress in Pediatrics ......... 59
Toxic Exposures / Haz-Mat ..................... 76
 Carbon Monoxide ................................. 76                                                 V
 Hazardous Materials ............................. 77                    Valium................................................. 171
 Nerve Agents....................................... 78                  Vaponephrin ........................................ 196
 Organophosphates ............................... 78                     Vascular Access
 Toxic Exposure .................................... 77                   Intraosseous Access........................... 110
Transfer of Care .......................................9                 IV Access .......................................... 109
Transport Guidelines .............................. 18                   Vasopressin ......................................... 201
 Air-Medical .......................................... 18               Vecuronium……………………………………….
 Load and Go ........................................ 19                 Venous Access
Trauma ................................................. 20               Central Venous Line Access ................ 112
 Amputation ......................................... 26                 Ventilation ............................................. 84
 Avulsion .............................................. 26              Ventricular Fibrillation............................. 42
 Bites ................................................... 32            Ventricular Tachycardia
 Crush Syndrome .................................. 30                     Pulseless ............................................. 42
 Crushing Injury.................................... 30                   With Pulse ........................................... 48
 Extremity ............................................ 24               Versed ................................................ 189
 Eye ..................................................... 28            Vital Signs ............................................. 15
 Head ................................................... 22              Pediatric ............................................ 125
 Musculoskeletal ................................... 24
 Occular ............................................... 28                                          W
 Sexual Assault ..................................... 33
                                                                         Wide Complex Atrial Fibrillation ............... 52
 Stings ................................................. 32
                                                                         Wolff Parkinson White Syndrome ............ 52
 Thoracic .............................................. 21
                                                                         WPW ..................................................... 52
 Traumatic Arrest .................................. 20
Trauma Triage Protocol ........................ 132                                                   X
Traumatic Arrest .................................... 20
Tylenol ................................................ 162             Xylocaine ............................................. 185
                                                                         Xylocaine Jelly 2% ............................... 186
                              U
                                                                                                      Z
Appendices .......................................... 128
Universal Precautions ........................... 128                    Zofran ................................................. 193




EMS Patient Care Guidelines for Morrow County, Ohio. Effective Date: January 1, 2008.                                      Page 207
Dr Eric Hansen, Medical Director

				
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