Santa Fe County Fire Department

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					Santa Fe County
Fire Department
   EMS Protocols




    September 2008
Santa Fe County Fire Department EMS Protocols
                 January 2009
                Page 2 of 179
                                      Table of Contents


I.        INTRODUCTION………………………………………………………………….. 7
     Preface………………………………………………………...............................................7
     Guidelines and Protocols………………………………………………………………….. 7
     Santa Fe County Fire Department………………………………………………………….7
II.     GENERAL OPERATING GUIDELINES………………………………………... 8
   Professional Conduct……………………………………..……………………………….. 8
   Patient Care Responsibility……………………………………………………………....... 8
   Patient Status and Transport Decisions…………………………...………………………..9
   Transfer of Care Responsibility and Delegation…………………….…………………...... 10
   Medical Control Physician Consult………………………………………………….......... 11
   Continuous Quality Improvement………………………………………………………….11
   Protocol Review and Revisions…………………………………………………………… 11
III.    EMS PROTOCOLS - STANDING ORDERS…………………………………......12
   Protocol Format…………………………………………………………………………… 12
   Standing Orders…………………………………………………………………………….12
   Intraosseous Access……………………………………………………………………….. 17
   Central Venous Catheter Access………………………………………………………….. 19
   Medical Control for Controlled Substances………………………………………………. 20
IV.    AIRWAY MANAGEMENT………………………………………………………. 21
  Airway Management - Trauma……………………………………………………………. 21
  RSI and Endotracheal Intubation - ALS Provider Guidelines…………………………….. 22
  Tube Confirmation………………………………………………………………………… 27
  RSI and Endotracheal Intubation Pathway……………………………………………….. 28
  Emergency Airway Algorithm - Adult……………………………………………………. 30
  Crash Airway Algorithm - Adult………………………………………………………….. 31
  Difficult Airway Algorithm - Adult…………………………………………………….…. 32
  Failed Airway Algorithm - Adult…………………………………………………………. 33
  CPAP - BLS and Above Provider Guidelines…………………………………………….. 34
  CPAP Pathway - BLS and Above Provider Guidelines……………………………………36
  Combitube Insertion - BLS and Above Provider Guidelines …………………………….. 37
  Cricothyrotomy - ALS Provider Guidelines ……………………………………………… 40
  Post-Intubation Sedation / Analgesia During Patient Transport…………………………... 42
  Transfer of Care Responsibility - Intubated Patient………………………………………. 42
V.        CARDIOVASCULAR EMERGENCIES - ADULT………………………………43
     Acute Coronary Syndrome / Cardiac Chest Pain………………………………………….. 43
     AMI STAT Activation - St. Vincent Hospital, Santa Fe………………………………….. 44
     AMI Activation - Presbyterian Hospital, Albuquerque…………………………………… 45
     Asystole…………………………………………………………………………………… 46
     Atrial Fibrillation / Flutter - Unstable …………………………………………………….. 48
     Bradycardia - Poor Perfusion……………………………………………………………… 49
     Sedation / Analgesia for Transcutaneous Pacing………………………………………….. 50
                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
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  Cardiogenic Shock ……………………………………………………………………….. 51
  Cardiopulmonary Arrest - Hypothermia ………………………………………………….. 52
  Cardiopulmonary Arrest - Non-traumatic…………………………………………………. 54
  Congestive Heart Failure / Pulmonary Edema……………………………………………..56
  Pulseless Electrical Activity ……………………………………………………………… 57
  Supraventricular Tachycardia……………………………………………………………... 59
  Ventricular Fibrillation / Pulseless Ventricular Tachycardia………………………………60
  Ventricular Tachycardia / Wide-QRS Tachycardia……………………………………….. 62
VI.   CARDIOVASCULAR EMERGENCIES - PEDIATRIC…………………………64
  General - Pediatric Resuscitation………………………………………………………….. 64
  Pediatric Asystole / PEA…………………………………………………………………... 65
  Pediatric Bradycardia / Poor Perfusion……………………………………………………. 66
  Pediatric Supraventricular Tachycardia …………………………………………………... 67
  Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia …………………... 68
  Pediatric Ventricular Tachycardia / Wide-QRS Tachycardia……………………………... 69
VII. MEDICAL EMERGENCIES…………………………………………………….... 70
  Allergic Reaction / Anaphylaxis ………………………………………………………….. 70
  Asthma…………………………………………………………………………………….. 72
  Carbon Monoxide Poisoning……………………………………………………………….74
  Cerebrovascular Accident (CVA)…………………………………………………………. 75
  Coma………………………………………………………………………………………. 77
  Croup / Epiglottitis ………………………………………………………………………... 79
  Diabetic Emergencies …………………………………………………………………….. 80
  Drug Intoxication / Substance Abuse……………………………………………………... 82
  Dystonic Reaction…………………………………………………………………………. 82
  Fever………………………………………………………………………………………. 83
  Hazardous Materials Response (HAZMAT) / Toxic Substance Exposure……………….. 84
  Heat Illness……………………………………………………………................................86
  High Altitude Illness………………………………………………………………………. 87
  Hypothermia ……………………………………………………………………………… 88
  Narcotic Poisoning………………………………………………………………………… 89
  Organophosphate Poisoning ……………………………………………………………… 90
  Poisoning / Overdose……………………………………………………………………… 91
  Seizure…………………………………………………………………………………….. 94
  Syncope……………………………………………………………………………………. 95
  Tricyclic Antidepressant (TCA) Poisoning ………………………………………………. 96
  Vomiting…………………………………………………………………………………... 97
VIII. OBSTETRIC AND GYNECOLOGIC EMERGENCIES……………………….. 98
  Delivery - Breech………………………………………………………………………….. 98
  Delivery - Uncomplicated ………………………………………………………………… 100
  High Risk Pregnancy…………………………………………………………………….... 102
  Neonatal Resuscitation …………………………………………………………………….103
  Obstetric Transport / Trauma / Interfacility Transfer……………………………………... 106
  Placenta Previa / Abruptio Placentae……………………………………………………… 108
  Postpartum Hemorrhage ………………………………………………………………….. 109
                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
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     Pre-Eclampsia / Eclampsia (Toxemia)……………………………………………..............110
     Prolapsed Cord ……………………………………………………………………………. 111
IX.    PSYCHIATRIC / BEHAVIORAL EMERGENCIES……………………………. 112
  Involuntary Restraint / Transport………………………………………………………….. 112
  Psychiatric Facility Transport……………………………………………………………... 115
X.        TRAUMA…………………………………………………………………………….116
     Bite Injury / Snake Envenomation………………………………………………………… 116
     Burns………………………………………………………………………………………. 117
     Burns - Delayed Transport / Interfacility Transfer ……………………………………….. 120
     Extremity Trauma - Amputation…………………………………………………………... 121
     Extremity Trauma - Fractures……………………………………………………………... 122
     Eye Injury…………………………………………………………………………………..123
     Head Injury - Increased ICP………………………………………………………………. 124
     Sexual Assault……………………………………………………………………………... 125
     Spinal Injury Assessment / Immobilization ………………………………………………. 126
     TASER Projectile Removal……………………………………………………………….. 128
     Trauma - Blunt ……………………………………………………………………………. 129
     Trauma - Penetrating……………………………………………………………………….130
     Trauma STAT Activation - St. Vincent Hospital, Santa Fe………………………………. 131
XI.    COMMUNICATIONS……………………………………………………………....132
  ALS Dispatch Activation …………………………………………………………………. 132
  EMS Medical Director Notification ……………………………………………………….133
  Helicopter Transport………………………………………………………………………. 134
  Medical Control - On-Line………………………………………………………………... 138
  Multi-Casualty Incident (MCI)……………………………………………………………. 139
  Radio Reports ……………………………………………………………………………...143
XII. PROCEDURES AND EQUIPMENT……………………………………………… 144
  Assisting with Medications ……………………………………………………………….. 144
  Automatic External Defibrillator (AED) - Transition to ALS…………………………….. 145
  12-lead ECG ……………………………………………………………………………….146
  External Jugular Vein (EJ) IV Access…………………………………………………….. 147
  Jump Kits …………………………………………………………………………………. 148
  Needle Thoracostomy……………………………………………………………………... 150
  Skills Approval Process…………………………………………………………………… 151
XIII. SPECIAL SITUATIONS……………………………………………………………152
  Cancellation By Non-medical Provider…………………………………………………… 152
  Dead At Scene………………………………………….…………………………………. 153
  Do Not Resuscitate (DNR) Order…………………………………………………………. 154
  Emergency Incident Rehabilitation ………………………………………………………..156
  Emergency Transport by Medical Rescue Vehicle………………………………………... 159
  Minors……………………………………………………………………………………... 160
  OMI Investigation…………………………………………………………………………. 160
  Physician Assistance On Scene …………………………………………………………... 161

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                                            January 2009
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 Refusal of Treatment and/or Transport …………………………………………………… 162
 Termination of Resuscitation……………………………………........................................ 165
XIV. APPENDICES………………………………………………………………………. 167
  Emergency Airway Pathway - General Adult…………………………………………….. 168
  EMS Liability Release …………………………….……………………………………… 171
  Descargo De Obligación ………………………………………………………………….. 173
  Protocol Improvement Form……………………………………………………………….. 175

     INDEX……………………………………………………………………………….. 177




                            Santa Fe County Fire Department EMS Protocols
                                             January 2009
                                            Page 6 of 179
                                        I. Introduction

                                               Preface
These protocols were designed and reviewed under direction of the Medical Director and the
Protocol Review Committee. Personnel may only function as EMS providers under the authority
of the Medical Director. Errors in prehospital care are generally errors of omission. EMS
providers will be proactive in the implementation of these protocols, and should not withhold or
delay any indicated intervention. Providers should remember to “FIRST DO NO HARM”.

                               Guidelines and Protocols
Every attempt has been made to reflect sound medical guidelines and protocols based on
currently accepted standards of care for out-of-hospital emergency medicine. The working group
urges the readers to speak to their respective service point of contact for any specific questions
that may arise. The working group assumes no responsibility directly or indirectly for this
document. It is the reader’s responsibility to stay informed of any new changes or
recommendations made at the state or service level. Despite our best efforts, these guidelines
may contain typographical errors or omissions.

Activities of EMS personnel must be in compliance with all applicable federal, state, county and
local laws and regulations including: PRC Regulation 18 NMAC 4.2 “Ambulance Medical
Rescue Services”, DOH Regulation 7 NMAC 27.3 “Medical Direction for Emergency Medical
Services”, and the Federal Controlled Substances Act.

This document was developed specifically for Santa Fe County Fire Department and its Districts.
As such, these protocols may need to be modified for use in other EMS systems and require a
comprehensive education and CQI program. A disk copy of this protocol may be obtained by
written request from an EMS Medical Director. For further information contact Assistant Chief
Kimmet Holland, NREMT-P, at Santa Fe County Fire Department (505) 992-3079.

                        Santa Fe County Fire Department
Santa Fe County Fire Department is comprised of fifteen (15) Fire Districts throughout Santa Fe
County, NM. All fire districts are trained as a minimum to the EMS First Responder level and in
most cases include EMT-Basic/Intermediate level care. Five Districts - Edgewood, El Dorado,
Hondo, Pojoaque, Turquoise Trail - are certificated ambulance service carriers as recognized by
the Public Regulatory Commission. Currently, volunteer ALS providers are located in the El
Dorado and Hondo Districts. The Department has 24/7 ALS teams located in the northern,
southern, western and eastern regions of the county. The Chief of Santa Fe County Fire
Department is Stan Holden. The Assistant Chief of Operations is Kimmet Holland, NREMT-P.
The EMS Medical Director is Kendall Lee, MD.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
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                          II. General Operating Guidelines
The following are guidelines to be used by Santa Fe County Fire Department (SFCFD) - First
Responders, EMT-Basics, EMT-Intermediates and EMT-Paramedics - to ensure quality and
standardized medical care, and to establish standards by which prehospital care may be audited
for continuous quality improvement (CQI).

Professional Conduct
Our patients are our primary focus. Their requests must be heard and honored. Patients deserve
to be fully informed of all decisions affecting their care and medical outcome, including any
potential complications. Competent and informed adults have a right to accept or refuse
treatment recommendations. Whenever possible, family members should be included and
informed of events, encouraged to remain present during transport and supported in their role as
patient advocates.

It is expected that EMS personnel will perform in a professional manner at all times. Interactions
with patients, family members, bystanders, emergency responders, and other medical
professionals are expected to be courteous and appropriate. Any disagreements involving direct
patient care should be resolved immediately by consulting a medical oversight physician. Other
potential conflicts at a scene should be discussed after the call in a private setting. Efforts should
be made to resolve the conflict at the lowest possible level. In the event the conflict cannot be
resolved, the appropriate department chain of command shall be utilized.

Critiques and debriefings play a valuable role in solving system issues following certain calls.
Informal meetings are encouraged for educational purposes. Substantive issues should be
addressed through formal meetings set up by chain of command, preferably within 72 hours after
a call.

It is recognized there are circumstances, particularly involving traumatic mechanisms of injury,
when it is helpful for Emergency Department physicians to see photographs of a scene.
Photographs can become part of a hospital medical record. Whenever possible, no people or
other identifying information, such as license plates, should be included in the photograph.
Discretion must be used in the storage and distribution of scene photographs to protect patient
confidentiality.

All personnel will adhere to the SFCFD HIPPA policy, and HIPPA as mandated.

Patient Care Responsibility
The authorized individual with the highest level of licensure as recognized by the New Mexico
EMS Act is in charge of patient care. These protocols shall take effect with the on-scene arrival
of a certified/licensed EMS provider who is duly dispatched or requested through the EMS
system standard operating procedures, and who is affiliated with an EMS department/service
participating in these protocols.

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                                                  January 2009
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In no case should a higher licensed EMS provider who is dispatched or requested within the
EMS system be prevented from making patient contact, regardless of patient condition. In the
event that more than one person represents the highest licensed EMS provider on scene, a
ranking officer shall be in charge, followed by the person with the highest training who makes
initial patient contact. If a provider is off duty or out-of-district, he/she may be relieved with the
arrival of personnel of equal or higher training. Once the patient is in the patient compartment
area of an ambulance, the highest trained provider assigned to that unit will assume control of
patient care while en route to the hospital.
A person who is a recognized active medical service member (e.g. PA, RN, NP) may assist in
patient care within their scope of practice, but only to the level of the highest licensed EMS
provider on-scene. Assistance will be subject to the approval, direction and control of the on-
scene EMS provider. The presence of other health care providers does not release an EMS
service from the staffing requirements as outlined by the Public Regulatory Commission.
On-scene medical oversight may be provided by the SFCFD EMS Medical Director.

Patient Status and Transport Decisions
Based on information obtained by history, mechanism of injury and physical examination,
patient stability is classified as follows:

                              Medical and Trauma Triage Criteria
STABLE - Patient is stable, with no apparent risk of developing a life-threatening or disabling
condition. Non-emergent transport is appropriate.
SERIOUS - Patient is at moderate risk of developing a life-threatening or disabling condition.
Most circumstances merit non-emergent transport.
CRITICAL - Patient has a severe and acute life-threatening or disabling condition. Immediate
intervention is required. Emergency transport at the EMS provider’s discretion. Establish
communication with receiving ED as early as possible. For transport to St. Vincent
Hospital/Santa Fe Regional Medical Center consider Trauma-STAT activation.
                                 Transport Destination Decisions
STABLE - Patients will be transported to the closest appropriate facility. Patient preference may
be considered only when the destination does not compromise care, and does not result in the
transport vehicle leaving the established EMS response area. In select cases (e.g. patient is a
minor, subject to the guardianship of another, incapable of making an informed decision, or
incarcerated) a responsible party, or Medical Control if the responsible party is unavailable, will
select a facility of choice. Medical Control shall be contacted when the decision of the
responsible party conflicts with the best interest of the patient.
SERIOUS - Patients will be transported to the closest appropriate facility within the transporting
vehicle’s service area.
CRITICAL - Patients will be transported to the closest appropriate facility that is staffed and
equipped to provide immediate and definitive care.




                                  Santa Fe County Fire Department EMS Protocols
                                                   January 2009
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Transfer of Care Responsibility and Delegation

Transfer to hospital - EMS personnel will maintain charge and control of the patient until:
♦ Proper unloading has occurred. EMS personnel are solely responsible for unloading. Hospital
   personnel should stay outside the ambulance unless assistance is requested.
♦ A full patient report is provided to the appropriate receiving personnel.
♦ Treatment provided during transport (e.g. oxygen, cardiac monitoring) must be continued
   during transfer from the ambulance into the Emergency Department (ED).
♦ A copy of the EMS report should be left with the receiving hospital on delivery of the patient
   whenever possible, and in all cases within 24 hours.

Transfer to residence - EMS personnel will remain with the patient and remain responsible for
patient care until:
♦ Another licensed EMS provider of equal or higher training and capability receives an oral
    report and assumes responsibility for patient care; or,
♦ The patient is returned to the originating facility following a diagnostic/therapeutic outpatient
    procedure; or,
♦ The patient is transported to his/her place of residence by physician order.

Transfer to lower level of care:
♦ Following a full patient assessment and examination, an EMT-Paramedic or EMT-
   Intermediate may transfer patient care to an EMT-Basic, if there is no reasonable expectation
   that the patient will require a higher level of care. The assessment and decision for transfer of
   care shall be documented.
♦ In the event of a transfer from ALS/ILS to a lower level of care, the EMT-
   Paramedic/Intermediate will be held responsible for the appropriateness of care provided.
♦ Transfer to a lower level of care is acceptable in a MCI to ensure the greatest benefit for the
   greatest number of patients.

Transfer to law enforcement:
♦ Law enforcement has NO AUTHORITY in transport decisions unless a law enforcement
   officer elects to take a patient into custody. The law enforcement officer is then responsible
   for ALL actions and decisions occurring as a result of his/her direct orders. Liability and
   system consequences should be clearly relayed to law enforcement officers. Whenever a
   conflict exists, CONTACT MEDICAL CONTROL.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 10 of 179
Medical Control Physician Consult
EMS providers are encouraged to request a physician consult for patients who might merit the
immediate attention of the receiving ED physician. However, medical oversight may be used as a
resource at any time. On-line Medical Control should be viewed as a valuable asset for personnel
and their patients. When requested, a direct report from the EMS provider to a physician should
be accomplished soon after arrival in the ED.

Continuous Quality Improvement
To maximize the quality of prehospital patient care, it is necessary to continually review EMS
activity in order to identify areas of excellence and potential sources of error. CQI provides a
framework for actively assessing the performance and direction of the EMS system. Components
of CQI include: active communication; documentation; case presentations; protocol review and
refinement; medical direction involvement; medical community involvement; continuing
medical education; reassessment of expected goals and outcomes.

Participation in the CQI process is mandatory to function within the system. The primary focus
of CQI is improving system performance, with an emphasis on education. A CQI form has been
created to provide feedback and follow-up for specific cases. The EMS Medical Director may
request additional documentation for the purpose of gathering information about a particular call,
event, treatment or procedure. Failure to cooperate with the CQI process may result in
withdrawal of Medical Direction, and may lead to formal action up to and including termination.

Protocol Review and Revisions
Protocols will be reviewed at least annually to keep current with changing medical practices,
treatment modalities, and patient demographics based on data obtained from CQI activities. Any
recommendations for revision of protocols should be made in writing to the EMS Medical
Director. Change to any protocol will require the notification of all personnel, and completion of
any applicable training.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
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                     III. EMS Protocols – Standing Orders


Protocol Format

Definitions
ALL EMS PROVIDERS: Includes certified EMS First Responders (unless specified otherwise), EMT-
Basics, EMT-Intermediates and EMT-Paramedics.
BLS AND ABOVE PROVIDERS: Basic Life Support (BLS) care provided by licensed EMT-Basics and
above.
ILS AND ABOVE PROVIDERS: Intermediate Life Support (ILS) care provided by licensed EMT-
Intermediates and above.
ALS PROVIDERS: Advanced Life Support (ALS) care provided by licensed EMT-Paramedics who
have at their disposal a monitor/defibrillator/pacer, ACLS medications, controlled substances and
advanced airway equipment.



Standing Orders

Establish Primary Management - Patient assessment and basic life support procedures are to
be initiated appropriate to the patient’s condition, and in accordance with state guidelines. EMS
personnel at all levels should provide care in accordance with their most current training. A
complete primary and secondary survey should be performed, and all necessary and appropriate
skills, treatments and procedures should be immediately used to maintain airway, breathing and
circulatory function.

Specific protocols address the treatment and disposition of each condition. Interventions are
listed in recommended sequential order. It is recognized that circumstances may require
flexibility. Interventions are grouped according to the state EMS Scope of Practice.

Interventions preceding the words “CONTACT MEDICAL CONTROL” may be considered
standing orders for the specific condition addressed by each protocol.

Interventions following the words “CONTACT MEDICAL CONTROL” may be considered
standing orders only in rare circumstances when: location or circumstances prohibit
communication, OR Medical Control communication cannot readily be established. The
barrier(s) to contacting Medical Control should be clearly documented and submitted to
the Medical Director within 24 hours.




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                                                 January 2009
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Standing Orders (contd)

Authorization of treatment requiring Medical Control is at the discretion of the physician at the
receiving facility. Once contacted, the receiving facility will routinely remain the source of
Medical Control for the duration of the call. If requested orders are not authorized by Medical
Control, concerns may be referred through chain of command to the Medical Director. Medical
Control orders for interventions not specifically listed in the protocols may be performed if:

♦ The order is within an EMS provider’s scope of practice, and the intervention is indicated for
  the condition; and,
♦ The order is within the specifications of the approved skill list.

EMS providers have the right to refuse orders or procedures that are outside SFCFD Protocols,
outside an EMS provider’s scope of practice, or that are considered inappropriate for a patient’s
condition.

There may be situations where more than one clinical impression exists. After initiating routine
emergency care, EMS providers should contact Medical Control in order to differentiate the most
emergent clinical problem and define the most suitable intervention. In general, two sets of
standing orders should not be implemented simultaneously.




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                                                 January 2009
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Standing Orders (contd)

Primary Management
Routine emergency care should be instituted as appropriate for all patients.

AIRWAY - Ensure or establish AIRWAY PATENCY

All EMS PROVIDERS
♦   Positioning maneuvers
♦   Suction (nasopharyngeal, oropharyngeal, stomal)
♦   Nasopharyngeal airways (NPA)
♦   Oropharyngeal airway (OPA)
♦   Pulse Oximetry

BLS AND ABOVE PROVIDERS
♦ Rescue Airway Device/Combitube
♦ Capnography

ALS PROVIDERS
♦   Direct laryngoscopy
♦   Magill forceps manipulation
♦   Nasotracheal intubation
♦   Endotracheal intubation
♦   Stomal intubation
♦   Suction (endotracheal)
♦   Cricothyrotomy

BREATHING - Ensure/establish ADEQUATE VENTILATION and OXYGENATION

All EMS PROVIDERS
♦ Administer OXYGEN commensurate with level of respiratory distress
♦ BVM

BLS AND ABOVE PROVIDERS
♦ CPAP
♦ Ventilator



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                                                 January 2009
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Standing Orders (contd)

ALS PROVIDERS
♦ Needle Thoracostomy

CIRCULATION - Ensure/establish ADEQUATE CIRCULATION

All EMS PROVIDERS
♦   Glucometry
♦   Wound management
♦   Positioning (supine, Trendelenburg)
♦   CPR
♦   Initiate cardiac monitoring
♦   Semi-automatic defibrillation

ILS AND ABOVE PROVIDERS
♦ Peripheral venous access (includes external jugular for patients > 12 yo) and IVF
♦ Intraosseous access

ALS PROVIDERS
♦   Utilize pre-existing vascular access as necessary (PICC, external dialysis catheter)
♦   Access of central venous catheters
♦   ACLS
♦   Cardioversion and defibrillation
♦   External cardiac pacing




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
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Standing Orders (contd)

Assessment Guidelines
Perform complete assessment to level of training.

♦   Determine scene safety/Triage
♦   Use appropriate personal protective medical equipment/universal precautions
♦   Vital signs and pulse oximetry
♦   Level of consciousness
♦   History of chief complaint
♦   Pertinent past medical history, medications and allergies
♦   Physical exam (primary and secondary survey)
♦   Cardiac monitor (12 lead ECG, rhythm strip)
♦   Mental status exam
♦   Request ILS/ALS assistance as required
♦   Establish communication with receiving ED as early as possible
♦   Ongoing patient assessment
♦   Full documentation on appropriate EMS form




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                                                January 2009
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Intraosseous Access

Designation of Condition: Critically ill or injured patient requiring immediate vascular access
for IVF/medication for resuscitation, when peripheral access cannot be secured.

ILS AND ABOVE PROVIDERS

Adult IO (Sternal access): ‘F.A.S.T 1 - First Access for Shock and Trauma’
♦ Intended for adult patients
♦ IO device using depth-controlled “position and press” mechanism to penetrate into the
  manubrium.
♦ Contraindications: severe skin compromise over the infusion site (e.g. trauma, infection,
  burns), or previous midline sternotomy may interfere with device placement or function.
  Sternal fracture may compromise the vascular integrity of the manubrium.

♦ Position: expose sternum. Use aseptic technique. Locate patient’s sternal notch with fingertip
  held perpendicular to manubrium, and align notch of the adhesive target patch with the
  sternal notch.
♦ Verify Target Zone (circular hole in patch) is over patient’s midline
♦ Twist and remove sharps cap from introducer. Place bone probe cluster in Target Zone.
  Ensure that the introducer is 90° to the skin at the insertion site.
♦ Pressing straight along the introducer axis, with hand and elbow in line, push with firm and
  increasing force until a distinct release is heard and felt. The introducer must remain
  perpendicular to the skin during insertion. After release, pull straight back to remove
  introducer, exposing the infusion tube.
♦ Attach right angle female connector on patch to infusion tube. Confirm IO placement by
  aspirating marrow and/or by easy flushing of 5-10 cc NS.
♦ Connect to standard IV tubing
♦ Place protective dome over patch. Ensure delivery of attached remover package to receiving
  hospital.

♦ The F.A.S.T. 1 is compatible with CPR
♦ A new F.A.S.T. 1 device may be placed immediately after the original device has been
  removed. A small amount of leakage may occur through the first access hole.




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                                                 January 2009
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Intraosseous Access (contd)

Pediatric IO (Tibial access): ‘B.I.G. - Bone Injection Gun’
♦ Intended for children 0-12 yr
♦ Automatic IO device with spring loaded 18G needle using “position and press” mechanism.
   Depth adjusted for age.
♦ Contraindications: skin infection, fracture at insertion site, compromised extremity or burns.

♦ Position: towel roll under knee and foot facing outward. Use aseptic technique.
♦ Identify injection site: from tibial tuberosity (A) go 1-2 cm toward inner leg (B) and 1-2 cm
  down toward foot (C).
     · Infants 0-6 yo - 1 cm medial and 1 cm distal to the tibial tuberosity.
     · Children 6-12 yo - 1-2 cm medial and 1-2 cm distal to the tibial tuberosity.




♦ Adjust needle penetration depth according to patient age (marked on device):
      · Infants 0-3 yo - 0.5-0.7 cm
      · Children 3-6 yo - 1-1.5 cm
      · Children 6-12 yo - 1.5 cm
♦ Position the BIG firmly with one hand 90° to the skin at the site. Do not direct towards joint
  space. Pull out safety latch with the other hand by squeezing ends together, DO NOT
  DISCARD.
♦ Trigger the BIG gently by pushing down. Remove BIG slowly, pull out the stylet trochar
  leaving the cannula in the bone.
♦ Fix the safety latch around the base of the cannula and secure with tape
♦ Confirm IO placement by aspirating marrow and/or by easy flushing of 5-10 cc NS
♦ Connect to standard IV tubing




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
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Central Venous Catheter Access

Designation of Condition: Critically ill or injured patient with pre-existing central line requiring
immediate vascular access for IVF/medication for resuscitation, when peripheral IV/IO access
cannot be secured.

ALS PROVIDERS

♦ Use meticulous aseptic technique due to concern for infection and line sepsis leading to loss
  of central line.
♦ Unclamp line as needed
♦ Aspirate and discard 10 cc of blood. Sample may be used for BGL if no DEXTROSE-
  containing solutions or TPN infusing prior to access.
♦ Flush catheter with 10 cc NS, and connect to standard IV tubing
♦ If aspiration or flushing is met with resistance DO NOT USE LINE (it may be clotted or
  dislodged from vein). Attempting to flush with pressure may damage catheter and cause
  injury.
♦ Maintain baseline TKO rate of 50 cc/hr NS
♦ Notify receiving hospital RN of line access upon arrival so the line can be secured with
  heparin flush.
♦ Dialysis AV fistulas or subcutaneous ports may not be accessed




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 19 of 179
Medical Control for Controlled Substances

The following is a framework of standing orders for the administration of controlled substances
by EMT-Paramedics.
Use of controlled substances:
♦ In general, NARCOTICS or BENZODIAZEPINES are not appropriate for patients with
   multi-system trauma prior to physician approval.
♦ NARCOTICS or BENZODIAZEPINES are generally only given to patients with isolated
   injuries and stable/normal vital signs, or an assessment consistent with severe pain (e.g.
   kidney stones) or an isolated musculoskeletal injury (e.g. fracture, severe sprain).
♦ No NARCOTICS or BENZODIAZEPINES shall be given to a pregnant patient without on-
   line Medical Control (except for acute airway management).
♦ Administration of medications beyond standing orders shall be done with on-line Medical
   Control.

Standing Orders for Adults

                                                                                               Post-
         Drug              Analgesia            Anticonvulsant                  Sedation    Intubation
                                                                                             Sedation
 Fentanyl - ALS           1 -2 mcg/kg                                           1 mcg/kg    1 -2 mcg/kg
 Fentanyl - ILS           1 -2 mcg/kg
 Morphine - ALS            2 - 20 mg                                                         2 - 10 mg
 Morphine - ILS            2 - 20 mg
 Valium - ALS                                        2 - 20 mg
 Versed - ALS                                        1 - 10 mg                  1 - 10 mg    2 - 20 mg

♦ Pediatric doses and limits are referenced in individual protocols
♦ When administering NARCOTICS or BENZODIAZEPINES it is desirable to start with
  a low dose and titrate for effect.
♦ Use extreme caution when administering NARCOTICS and BENZODIAZEPINES
  together.

Note: See Post-Intubation Sedation/Analgesia During Patient Transport




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 20 of 179
                              IV. Airway Management



Airway Management - Trauma

Designation of Condition: Patient unable to adequately maintain an airway in the setting of
trauma.

All EMS PROVIDERS
♦ In-line spine immobilization, as appropriate

BLS AND ABOVE PROVIDERS
♦ Rescue airway device

ALS PROVIDERS
♦ For the patient not maintaining an airway or in respiratory arrest, manual in-line spine
  immobilization and endotracheal intubation (avoid cervical extension or flexion).
♦ One provider shall be dedicated to in-line spine immobilization
♦ Endotracheal intubation is preferred for airway management in the setting of head/face/neck
  trauma.
♦ For the unresponsive breathing patient, consider nasotracheal intubation
♦ If attempt at endotracheal intubation unsuccessful, consider:
       · Airway support, BVM/NPA/OPA and transport
       · Nasotracheal Intubation
       · Rescue Airway Device/Combitube
       · Cricothyrotomy




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 21 of 179
RSI and Endotracheal Intubation – ALS Provider Guidelines

Designation of Condition: Patient in need of emergent airway control and ventilation.

RSI refers to a specific method of inducing general anesthesia while securing active airway control. This procedure
using sedatives and paralytics to facilitate advanced airway management before and during transport helps to
prevent complications such as aspiration, airway trauma and failed intubations. The key agent is succinylcholine,
because of its short half-life allowing return to spontaneous ventilation if the effort is unsuccessful. A decision to use
this agent is made after considering the known side effects of increased intraocular pressure, transient hyperkalemia,
and total paralysis mandating ventilation during the 5-10 minute period of active drug effect.


Indications
♦ Acute respiratory failure despite basic airway support and OXYGEN (RR <10 or >30, O2 Sat
   < 90%, Altered mental status).
♦ GCS ≤ 9 and inability to protect airway
♦ Respiratory failure with trismus, biting or agitation
♦ Impending respiratory failure (Face/Airway burns, status asthmaticus, status epilepticus).
♦ Application of ACLS

Contraindications
♦ Maxofacial/Neck trauma
♦ Anatomic abnormalities
♦ Angioedema
♦ Anticipated difficulty securing Rescue Airway Device
♦ SUCCINYLCHOLINE: history of penetrating eye injury, malignant hyperthermia, open-
   angle glaucoma, burn/crush/denervating injury > 24 hours old.
♦ Allergic reaction to any RSI medication
♦ Patient unconscious and flaccid
♦ EMS Provider not RSI-certified by Medical Director

General sequence
♦ Pre-oxygenate
♦ Preparation
♦ Pre-medication
♦ Paralysis
♦ Passage of ETT
♦ Post-intubation care



                                        Santa Fe County Fire Department EMS Protocols
                                                         January 2009
                                                        Page 22 of 179
RSI and Endotracheal Intubation – ALS Provider Guidelines (contd)

ALS PROVIDERS
♦ Assess for difficult airway, consider alternative airway management.
     “DO NOT TAKE AWAY WHAT YOU CANNOT REPLACE”
♦ Pre-oxygenate with 100% O2 by NRB (BVM if respiratory effort ineffective). Consider
  nasopharyngeal airways, team ventilation.
♦ Assemble and test function of equipment:
     · BVM with O2 source
     · Yankauer with suction
     · Laryngoscope with functioning light (alternative blade availability)
     · ETT with functioning balloon, stylet and 10 cc syringe (alternate ETT size
       availability)
♦ Have backup plans in mind and in place (locate Rescue Airway Device)

♦ Pre-medication:
     · ATROPINE: 0.02 mg/kg IV/IO (min dose = 0.1 mg, max dose = 0.5 mg)
       Administer to pediatric patients < 12 yo.
     · FENTANYL: 1 mcg/kg IV/IO
       Administer to all patients with CHI, suspected increased intracranial pressure (CVA),
       ischemic CAD; OR,
     · LIDOCAINE:1.5 mg/kg IV/IO (pediatric dose: 1 mg/kg)
       Alternative if FENTANYL unavailable, for patients with CHI, or suspected increased
       ICP.

♦ Induction/Sedation:
     · ETOMIDATE: 0.3 mg/kg IV/IO (max dose = 20 mg); OR,
     · VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg (pediatric dose: 0.05-0.1
       mg/kg/dose, max 0.2 mg/kg). Alternative for RSI if ETOMIDATE is
       unavailable. Administer as sedative prior to Awake Intubation.
♦ Apply Cricoid pressure/Sellick maneuver until airway secured (release in the event of
  vomiting).

♦ Paralysis:
      · SUCCINYLCHOLINE: 1.5 mg/kg IV/IO (contraindications above); OR,
      · ROCURONIUM: 0.6-1.2 mg/kg IV/IO (pediatric dose: 1 mg/kg)
        Alternative only when SUCCINYLCHOLINE is contraindicated (EXTREME
        CAUTION due to total paralysis > 30 minutes).
♦ Ventilate with BVM until fasciculations stop (30-60 sec). Assess loss of corneal reflex and
  flaccidity.

                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 23 of 179
RSI and Endotracheal Intubation – ALS Provider Guidelines (contd)

♦ Intubate visualizing passage of ETT through the vocal cords. Advance gently until the
  proximal end of the balloon (or indicator line on uncuffed pediatric ETT) lies just beyond
  cords. Inflate balloon with minimum pressure needed to assure no air leak. Attempt at
  intubation should last < 30-40 sec, and stop for significant decrease in O2 Sat.
♦ Verify ETT placement: chest movement, tube fogging, auscultation of chest and
  epigastrum, O2 Sat, ETCO2.
♦ Ventilate gently with Ambu-Bag
♦ Maintain primary control of ETT until secured with tape or commercial device
♦ Place bite-block
♦ Continue cardiac, O2 Sat and ETCO2 monitoring

♦ Maintain sedation/analgesia:
     · Sedation - VERSED: 5 mg IV/IO Q 30 min (pediatric dose:
                     0.05-0.1 mg/kg/dose Q 30 min, max 0.2 mg/kg).
     · Analgesia - FENTANYL: 1 mcg/kg IV/IO Q 30 min; OR,
                   - MORPHINE: 5 mg IV/IO Q 30 min (pediatric dose:
                     0.1-0.2 mg/kg/dose Q 30 min).
♦ Place nasogastric tube to suction, especially after prolonged BVM ventilation

♦ In case of unsuccessful intubation attempt:
      · Ventilate with BVM/NPA’s
      · Reposition airway (maintain in-line spine immobilization, as appropriate),
        and suction.
      · Consider alternative laryngoscope blade and/or size
      · Consider effectiveness of sedation/paralysis
      · Consider change of operator
      · RE-ATTEMPT INTUBATION ONE TIME ONLY. IF UNABLE TO
        INTUBATE, IMMEDIATELY PLACE RESCUE AIRWAY DEVICE
        AND TRANSPORT.
      · Cricothyrotomy

♦ ETCO2 confirmation and continuous monitoring is required for all intubations
  and Rescue Airway Device placements. Colorimetric CO2 detectors may be used as an
  adjunct in confirming initial ETT placement. Ventilation rate and depth should be
  adjusted to optimize ETCO2 values.
♦ Maintain primary control of ETT during all patient transfers to avoid dislodgement.
  Verify tube placement immediately after every transfer.

                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 24 of 179
RSI and Endotracheal Intubation – ALS Provider Guidelines (contd)

Assessment for Difficult Intubation
Multiple methods exist to identify patients at risk for difficult intubations in the OR;
unfortunately, no studies have assessed their utility in predicting failed intubations in the field. A
quick examination for functional and anatomic factors can assist airway management and
planning.

♦ Mallampati classification - Predicts anticipated difficulty with laryngoscopy on the basis of
  the ability to visualize posterior pharyngeal structures. Mallampati class I or II predicts a
  relatively easy laryngoscopy. Mallampati class > II indicates a difficult intubation and the
  need for specialized techniques.




                         A. Cormack-Lehane laryngeal view grade.
                         B. Mallampati classification for grading airways from the least difficult airway (I)
                         to the most difficult airway (IV). Class I = visualization of the soft palate, uvula,
                         and anterior and posterior pillars; Class II = visualization of the soft palate, and
                         uvula; Class III = visualization of the soft palate and the base of the uvula;
                         Class IV = soft palate not visible at all.



♦   Mouth opening < 3 cm (2 fingertips)
♦   Thyromental distance < 7 cm (3 finger widths)
♦   Long incisors
♦   Short thick neck
♦   Poor mandibular translation/overbite
♦   Narrow palate < 7 cm (3 finger widths)




                                     Santa Fe County Fire Department EMS Protocols
                                                      January 2009
                                                     Page 25 of 179
RSI and Endotracheal Intubation – ALS Provider Guidelines (contd)

♦ Cervical range of motion < 35° of atlantooccipital extension: C-Spine injury/collar,
  rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, Down’s syndrome.
♦ Oropharyngeal obstruction: stridor, edema/angioedema, hematoma, abscess, trismus.

Pediatric parameters

        AGE            Wt (kg)             RR                   HR               ETT Size   Laryngoscope
                                                                                             Blade Size
       Prematr          2 kg              30-60               100-145             2.5-3.0        0
      Newborn           3 kg              30-60               100-145             3.0-3.5       0-1
        Infant          5 kg              30-50               110-180             3.5-4.0        1
         1 yo           10 kg             20-45               100-160             4.0-4.5       1.5
         3 yo           15 kg             20-25               90-150              4.5-5.0      1.5-2
         6 yo           20 kg             20-25               60-130              5.0-5.5        2
        10 yo           30 kg             12-20               60-100              6.0-6.5        2
                                                                                  cuffed
        Adol            50 kg             10-14                60-80              7.0-7.5       2-3
                                                                                  cuffed
        Adult           70 kg             10-14                60-80              7.5-8.0       3-4
                                                                                  cuffed




♦ ETT size for children > 1yo: [ETT size = (16+Age in yr)/4]; or, size to child’s small finger.
♦ Intubation is not recommended for the neonate, infant or small child as an initial airway
  management intervention. Appropriate and aggressive basic airway support should be
  initiated as early as possible.
♦ Ventilate gently with Newborn or Pediatric Ambu-Bag

♦ Use extreme caution during pediatric transfers: maintain primary control of ETT to
  avoid dislodgement. Verify tube placement immediately after every transfer.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 26 of 179
Tube Confirmation

Indicators
♦ Visualizing passage of ETT through the vocal cords
♦ ETCO2 confirmation and continuous monitoring. ETCO2 values and waveforms shall be
   documented as an additional vital sign.
♦ Clinical signs, which may be false indicators include: chest movement, tube fogging,
   bilateral equal breath sounds, absence of breath sounds over the epigastrum, O2 Sat,
   improving/stabilizing vital signs, normal skin color.
♦ A Toomey/suction tip syringe may be used to confirm ETT or Combitube placement. Free air
   easily drawn into the syringe almost certainly confirms placement in the trachea.




                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
                                             Page 27 of 179
RSI and Endotracheal Intubation Pathway
                   Preparation                                                  Setup
         · ABC’s                                              · BVM / Ventilator
         · Basic Airway Management                            · Yankauer suction
           Position & Suction                                 · Laryngoscope w/ light
           Nasopharyngeal Airways
           Team Ventilation
                                                              · ETT w/ Stylet & Syringe
         · Pre-Oxygenate 100% O2                              · ID Rescue Airway Device
         · Secure IV/IO
         · Monitor: O2 Sat, Cardiac




                           REASSESS FOR DIFFICULT AIRWAY
                             CONSIDER ALTERNATIVE AIRWAY MGT




                                            Pre-Medication
                                      Atropine1: 0.02 mg/kg IV/IO
                                      Fentanyl2: 1 mcg/kg IV/IO; or,

                                      Lidocaine3: 1.5 mg/kg IV/IO
                                                     (Peds: 1 mg/kg)




                                         Induction / Sedation
                         Etomidate: 0.3 mg/kg IV/IO; or,
                         Versed4:   2 mg/dose IV/IO, titrate to 0.1 mg/kg
                                           (Peds: 0.05-0.1 mg/kg/dose, max 0.2 mg/kg)




                                             Cricoid Pressure




                                                 Paralysis
                                Succinylcholine5: 1.5 mg/kg IV/IO; or,

                                Rocuronium6 :             0.6-1.2 mg/kg IV/IO
                                                          (Peds: 1 mg/kg)




                                      Ventilate & Assess Loss of
                                      Corneal Reflex / Flaccidity

                                    Santa Fe County Fire Department EMS Protocols
                                                     January 2009
                                                    Page 28 of 179
RSI and Endotracheal Intubation Pathway (contd)




                                                           Intubate




                      Successful                                                   Unsuccessful



          · Verify ETT Placement                                      · BVM
          · ETCO2 Confirmation                                        · Basic Airway Management
          · Maintain Primary Control of ETT                           · Consider Alternative Laryngoscope Blade
          · Monitor: ETCO2, O2 Sat, Cardiac                           · Consider Effectiveness of Sedation /
          · Re-verify ETT Placement after                               Paralysis
            every patient transfer                                    · Consider Change of Operator
                                                                      · Re-attempt ONE TIME ONLY




                 Sedation / Analgesia                                     Difficult / Failed Airway Mgt
       Versed:      5 mg IV/IO Q 30 min                               Place Rescue Airway Device & Transport
                    (Peds: 0.05-0.1 mg/kg/dose Q 30 min,
                    max 0.2 mg/kg)
       Fentanyl:    1 mcg/kg IV/IO Q 30 min; or,
       Morphine:    5 mg IV/IO Q 30 min
                    (Peds: 0.1-0.2 mg/kg/dose Q 30 min)



1.   ATROPINE is indicated for all pediatric patients < 12 yo.
2.   FENTANYL is indicated for all cases of CHI, suspected increased ICP (CVA), ischemic CAD.
3.   LIDOCAINE may be used for pre-medication if FENTANYL unavailable, for cases of CHI or suspected
     increased ICP (CVA).
4.   VERSED may be used for RSI sedation if ETOMIDATE unavailable. Administer as sedative prior to Awake
     Intubation.
5.   SUCCINYLCHOLINE contraindicated in setting of penetrating eye injury, malignant hyperthermia, open-angle
     glaucoma, burn/crush/denervating injury > 24 hours old. Drug Onset 30-60 sec; Total Paralysis 5-10 min.
6.   ROCURONIUM may be used for paralysis if SUCCINYLCHOLINE contraindicated. Use EXTREME
     CAUTION due to Total Paralysis > 30 min.

                                         Santa Fe County Fire Department EMS Protocols
                                                          January 2009
                                                         Page 29 of 179
Emergency Airway Algorithm - Adult


           NEEDS
        INTUBATION



               Y


       Unresponsive and             Y                                                               CRASH
          Hypoxic?
                                                                                                   AIRWAY

               N


    Predict difficult airway?       Y                                                            DIFFICULT
                                                                                                  AIRWAY

               N                    N


    Good candidate for OTI?                      Consider BNTI with
                                                     anesthesia

                                                                                        Post-Intubation
               Y                                     Successful?        Y
                                                                                         Management


          RSI                                             N
       PROTOCOL

                                                Repeat OTI (or BNTI)
          Successful?           N                      attempt


               Y


        Post-Intubation
                                          Y          Successful?
         Management

                                                          N


                                                 BVM ventilation with         Y                    FAILED
                                                   NPA/OPA fails?
                                                                                                   AIRWAY

                                                          N


                                               Consider Rescue Airway
                                                 Device/Combitube




                                        Santa Fe County Fire Department EMS Protocols
                                                         January 2009
                                                        Page 30 of 179
Crash Airway Algorithm – Adult



          CRASH
         AIRWAY




    Predict difficult airway?       Y                                                   DIFFICULT
                                                                                         AIRWAY
               N


       Unconscious and              N               RSI
          flaccid?
                                                 PROTOCOL

               Y



         Attempt OTI



          Successful?           N                 Repeat OTI attempt


               Y


        Post-Intubation
                                          Y          Successful?
         Management

                                                          N


                                                 BVM ventilation with         Y          FAILED
                                                   NPA/OPA fails?
                                                                                         AIRWAY

                                                          N


                                               Consider Rescue Airway
                                                 Device/Combitube




                                        Santa Fe County Fire Department EMS Protocols
                                                         January 2009
                                                        Page 31 of 179
Difficult Airway Algorithm – Adult


         DIFFICULT
          AIRWAY




      Oxygenation/Ventilation         Y           Able to maintain airway    Y              Rapid transport with
            adequate?                                during transport?                     NRB/BVM/NPA/OPA


                 N


       BVM ventilation with           Y            Place Rescue Airway                    Combitube ventilation
         NPA/OPA fails?                             Device/Combitube                             fails


                 Y                    Y


        Consider BNTI with                          Consider OTI with
            anesthesia                               sedation/Awake
                                                        Intubation




             Y                   Successful?


                                      N


                          Place Rescue Airway
                           Device/Combitube

                                                                                                   FAILED
                                 Successful?           N
                                                                                                   AIRWAY

                                      Y


                                Post-Intubation
                                 Management




                                          Santa Fe County Fire Department EMS Protocols
                                                           January 2009
                                                          Page 32 of 179
Failed Airway Algorithm – Adult


         FAILED
         AIRWAY




     BVM ventilation with       Y          Rapid transport with                     Consider Rescue Airway
     NPA/OPA adequate?                            BVM                                 Device/Combitube


              N


     Place Rescue Airway
      Device/Combitube

                                              Post-Intubation
          Successful?       Y
                                               Management

              N


      Place QuickTrach or
        perform surgical
         cricothyrotomy




                                    Santa Fe County Fire Department EMS Protocols
                                                     January 2009
                                                    Page 33 of 179
CPAP - BLS and Above Provider Guidelines

Designation of Condition: Patient with respiratory distress exhibiting signs/symptoms
consistent with asthma, COPD, pulmonary edema/CHF, or pneumonia.

Continuous Positive Airway Pressure (CPAP) refers to a system that provides noninvasive ventilatory support for
patients with respiratory distress refractory to basic airway management. CPAP has been shown to rapidly improve
vital signs, improve gas exchange, reduce the work of breathing, decrease the sense of dyspnea, and, most
importantly, decrease the need for intubation. In patients with CHF, CPAP improves hemodynamics by reducing
preload and afterload. Use of a CPAP mask requires patient cooperation, and is not for use in cases where the airway
may be compromised or consciousness impaired.


Indications
♦ Patient with respiratory distress secondary to asthma, COPD, pulmonary edema/CHF, or
   pneumonia who meets the following criteria:
       · Awake and able to follow commands
       · Age > 12 yo, and able to fit the CPAP mask
       · Ability to maintain a patent airway
       · Exhibits two or more of the following:
           - Respiratory rate > 25 breaths/min
           - Retractions or accessory muscle use
           - O2 Sat < 92% at any time

Contraindications
♦ Decreased LOC or inability to cooperate
♦ Inadequate respiratory effort or apnea
♦ Respiratory arrest
♦ Patient with major trauma, chest trauma or suspicion of pneumothorax
♦ Nausea/Vomiting or upper GI bleeding
♦ Tracheostomy
♦ Facial or orotracheal trauma
♦ Recent gastric surgery (< 2 weeks)

Procedure
♦ Request ALS intercept
♦ Explain procedure to patient
♦ Ensure adequate O2 supply to ventilation device
♦ Monitor: O2 sat, cardiac
♦ Secure mask with provided straps

                                      Santa Fe County Fire Department EMS Protocols
                                                       January 2009
                                                      Page 34 of 179
CPAP - BLS and Above Provider Guidelines (contd)

♦ Insert 5 cmH20 PEEP valve for asthma, COPD or pneumonia
  Insert 10 cmH20 PEEP valve for pulmonary edema/CHF
♦ Check for air leaks
♦ Monitor and document respiratory response to treatment
♦ Document complete set of vital signs every 5 minutes
♦ ALBUTEROL: 5 mg/3 cc NS NEB, repeat as needed
  Administer through CPAP mask for SOB, wheezing or hypoxia.
♦ Continue to coach patient to keep the mask in place, readjust as needed
♦ Notify receiving hospital of CPAP initiation for timely equipment setup. Do not remove
  CPAP until hospital equipment is ready to be placed on patient.
♦ CPAP may be performed on patient with DNR/DNI order
♦ CPAP needs to be continuous and should not be removed unless patient is unable to tolerate
  mask (e.g. claustrophobia, anxiety), experiences vomiting, or becomes unresponsive.
♦ Higher CPAP pressures may result in decreased patient cooperation, decrease in blood
  pressure, or gastric distention and vomiting. Consider change to 7.5 cmH20 PEEP valve if
  patient is unable to tolerate higher PEEP.
♦ If respiratory status worsens and patient deteriorates, discontinue CPAP and initiate
  BVM ventilation, securing airway as required.
♦ Consider BVM ventilation if patient condition does not improve in 10 minutes
♦ Patient with severe COPD may not respond predictably to CPAP. Be conservative and
  monitor closely.

Pediatric Considerations
♦ CPAP should not be used in children < 12 yo
♦ Insert 5 cmH20 PEEP valve for children < 15 yo

ILS AND ABOVE PROVIDERS
♦ Administer appropriate medication for treatment of asthma, COPD, pulmonary edema/CHF,
  or pneumonia per protocols.

ALS PROVIDERS
♦ IPRATROPIUM: 0.5 mg/3 cc NS NEB, single dose combined with ALBUTEROL
  Administer through CPAP mask for SOB, wheezing or hypoxia.
♦ VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg (pediatric dose: 0.05-0.1 mg/kg/dose, max
  0.2 mg/kg).
  Administer for anxiety. Start with a low dose and titrate for effect.


                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                              Page 35 of 179
CPAP Pathway - BLS and Above Provider Guidelines

                       START
                                                                        Indicated Conditions for CPAP:
            Patient with indicated condition                               · Asthma/COPD
                 in respiratory distress?                                  · Pulmonary Edema/CHF
                                                                           · Pneumonia

                           Y                                            CPAP Inclusion Criteria (exhibits 2 or more):
                                                                          · RR > 25 breaths/min
                                                                          · Retractions/Accessory muscle use
                                                                          · O2 Sat < 92% at any time

                                                                        CPAP Exclusion Criteria:
              Does patient meet 2 or more                                 · Unable to follow commands
                  inclusion criteria?                                     · Apnea
                                                                          · Vomiting or UGIB
                                                                          · Major trauma or pneumothorax
                           Y                                              · Tracheostomy
                                                                          · Children < 12 yo




            Does patient meet any exclusion          Y                  Provide 100% O2 by NRB/BVM/NPA/OPA and
                       criteria?                                                   secure airway as required


                           N


   Initiate CPAP:
       · 5 cmH20 PEEP for asthma/COPD/pneumonia
       · 10 cmH20 PEEP for pulmonary edema/CHF
       · 5 cmH20 PEEP for children < 15 yo




            Reassess condition and document
          complete Vital Signs every 5 minutes



               Request ALS intercept and
                notify Medical Control



                                                                        Discontinue CPAP, initiate BVM/NPA/OPA and
              Patient condition improving?           N                             secure airway as required


                           Y


          Continue CPAP and reassess patient                                        Notify Medical Control
                   every 5 minutes




                                            Santa Fe County Fire Department EMS Protocols
                                                             January 2009
                                                            Page 36 of 179
Combitube Insertion - BLS and Above Provider Guidelines

Indications
♦ Definitive airway required in unresponsive patient with no gag reflex
♦ Need for blind insertion/limited access to patient’s head
♦ Inability to visualize vocal cords (e.g. C-Spine injury, edema, fluid)
♦ Alternative airway management in setting of difficult airway
♦ Rescue Airway Device after two (2) unsuccessful attempts at endotracheal intubation.

Contraindications
♦ Intact gag reflex
♦ Known esophageal disease (e.g. cancer, varices, stricture)
♦ Caustic oral ingestion
♦ Patent tracheotomy
♦ Patient height < 4 feet
♦ Patient age < 15 yo (unless height > 4 feet)

Height parameters
♦ Regular-Adult Combitube - Five feet to six feet seven inches (5’ - 6’7”)
♦ Small-Adult Combitube - Four feet to five feet six inches (4’ – 5’6”)

Preparation
♦ Pre-oxygenate patient
♦ Assess gag reflex
♦ Check both balloons and lubricate tube
♦ Remove dentures/dental plates

Insertion
♦ Head in neutral position, use gloved hand to move tongue forward
♦ Insert the Combitube following the natural curvature of the airway
♦ If resistance is encountered, remove the tube, oxygenate, reposition the head and re-attempt.
♦ Advance tube until the upper teeth are positioned just above the highest black ring of the
   main tube (tube will slide up when inflated, aligning teeth between rings).
♦ Inflate BLUE #1 CUFF with 100 cc air. This will inflate the proximal/ pharyngeal balloon
   and advance the tube a small distance out of the mouth.
♦ Inflate WHITE #2 CUFF with 15 cc air. This will inflate the distal balloon.
♦ Attach BVM to the BLUE TUBE and ventilate patient



                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 37 of 179
Combitube Insertion - BLS and Above Provider Guidelines (contd)

Assess Placement
♦ Observe chest rise and fall
♦ Listen for bilateral lung sounds
♦ Listen over epigastrum for air gurgling in stomach
♦ ETCO2 confirmation
♦ Identifying placement of the tube is the most critical step:
       · The most common and expected tube placement is in the esophagus
       · With esophageal placement, ventilation through the BLUE TUBE will produce
       chest rise, bilateral lung sounds and no epigastric sounds.
       · With tracheal placement, ventilation through the BLUE TUBE will produce
       epigastric sounds only, and no chest rise or lung sounds.
       · If tracheal placement identified, remove BVM from the BLUE TUBE and
       attach to the WHITE TUBE. Ventilation through the WHITE TUBE will
       produce chest rise, bilateral lung sounds and no epigastric sounds.
♦ Secure tube to patient with tape or commercial device
♦ Place piece of tape over tube lumen not in use
♦ Monitor inflation of both cuffs. If pilot balloon is empty and does not reinflate, a cuff has
   been damaged and is leaking air. Remove and replace with new tube.
♦ Maintain primary control of tube during all patient transfers to avoid dislodgement. Verify
   tube placement immediately after every transfer.
♦ ETCO2 continuous monitoring
♦ With esophageal placement (85% of the time), medications cannot be administered through
   the tube.

Stomach Decompression
♦ With confirmation of esophageal placement, temporary use of a suction catheter through the
   WHITE TUBE can relieve gastric distention.
♦ Decompression should always be performed after prolonged BVM ventilation, when there is
   emesis, or prior to removal of the Combitube.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 38 of 179
Combitube Insertion - BLS and Above Provider Guidelines (contd)

Combitube Removal in the Field
♦ Patient regains consciousness and no longer tolerates tube/return of gag reflex
♦ Ventilation is inadequate
♦ Tube placement cannot be determined
♦ Procedure:
      · Prepare suction
      · Deflate BLUE #1 CUFF/proximal balloon, withdrawing 100 cc air
      · Log roll patient
      · Deflate WHITE #2 CUFF/distal balloon, withdrawing 15 cc air
      · Remove tube and suction as necessary

Transfer of Care Responsibility
♦ Ensure all EMS providers and ED personnel are aware of tube location (esophagus vs.
   trachea), and which tube lumen is in use.
♦ Please assist ED personnel unfamiliar with the Combitube in its use
♦ A Paramedic or ED physician may choose to remove a Combitube for ETT placement.
   Please ensure medical personnel understand the specifics of the device, enabling them to
   make an informed decision about airway management, and assist in its removal.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 39 of 179
Cricothyrotomy – ALS Provider Guidelines

Designation of Condition: Patient who is unconscious with immediate life-threatening airway
compromise, when other modalities of airway management are ineffective, not feasible, or
contraindicated.

Indications
♦ Supra-glottic airway obstruction (e.g. foreign body, laryngeal trauma, edema)
♦ Inability to intubate and ventilate after use of paralytic agent and Rescue Airway Devices are
   ineffective.
♦ All other methods of establishing a patent airway have failed

Contraindications
♦ Children < 12 yo, due to difficulty in identifying and isolating landmarks




ALS PROVIDERS
♦ Hyperextend patient’s neck (unless C-Spine immobilized), bringing larynx/cricothyroid
  membrane to extreme anterior position.
♦ Prepare area with betadine solution
♦ Identify the cricothyroid membrane between the cricoid and thyroid cartilage by palpating
  the depression in the middle. Immobilize it between thumb and index finger. Throughout
  procedure never move this hand.
♦ Make a vertical midline skin incision (1-2 cm in length), down to the cricothyroid
  membrane. Lateral traction of tissues will provide exposure.
♦ Make a horizontal puncture of the cricothyroid membrane with the scalpel to access the
  trachea. Use the blunt handle of the scalpel, or hemostat, to open the cricothyroid space and
  confirm location. Maintain traction to maintain the opening.



                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 40 of 179
Cricothyrotomy – ALS Provider Guidelines (contd)

♦ Gently pass appropriately sized ETT (5.0-6.0 for adult), advance cuff 2 cm past opening. If
  resistance is felt, withdraw tube and reassess incision and/or ETT size.
♦ Follow standard tube placement confirmation procedures
♦ Secure ETT (Place C-Collar to minimize ETT dislodgement), and apply dressing to
  control bleeding.
♦ CONTACT MEDICAL CONTROL, emergency transport to closest hospital for definitive
  airway management.
♦ Notify SFCFD Medical Director

Adult Airway: ‘QuickTrach’
♦ Preassembled one-step cricothyrotomy device
♦ Position and preparation as with surgical cricothyrotomy
♦ Identify the cricothyroid membrane between the cricoid and thyroid cartilage by palpating
  the depression in the middle. Immobilize it between thumb and index finger. Throughout
  procedure never move this hand.
♦ Firmly hold the syringe and puncture the skin at a 90°
♦ Change angle of insertion to 60° and advance forward into the trachea up to the stopper. Free
  aspiration of air identifies correct placement.
♦ Remove stopper. Caution - do not advance device further with the needle still in place.
♦ Hold the syringe firmly and slide the plastic cannula along the needle into the trachea until
  flange rests on the neck.
♦ Remove needle and syringe
♦ Follow standard tube placement confirmation procedures
♦ Secure with tracheostomy neckband (Place C-Collar)

Pediatric Airway: Needle Cricothyrotomy
♦ May be only ventilation option for children < 12 yo
♦ Position and preparation as with surgical cricothyrotomy
♦ Identify the cricothyroid membrane between the cricoid and thyroid cartilage by palpating
   the depression in the middle. Immobilize it between thumb and index finger. Throughout
   procedure never move this hand.
♦ Using a 14g needle with syringe attached, advance needle through the cricothyroid
   membrane until free aspiration of air identifies correct placement. Direct needle caudally
   with bevel-side down and advance cannula.
♦ Attach BVM to the cannula hub using the 15 mm adapter from a 3.0-3.5 ETT




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 41 of 179
♦ Consider jet ventilation (hypercarbia limits this technique to 30 min). May be performed
  manually by direct connection to O2 source at 15 L/min. Ventilate by providing insufflation
  for 1 sec, disconnecting/allowing exhalation for 4 sec.
♦ Follow standard airway confirmation procedures


Post-Intubation Sedation / Analgesia During Patient Transport

Designation of Condition: Patient intubated by EMS provider being transported to hospital, or
interfacility transport of previously intubated patient.

ILS AND ABOVE PROVIDERS
♦ Ensure adequate sedation/analgesia is provided for patient comfort
♦ Clinical signs of distress or pain include agitation, “bucking” against the ventilator,
  tachycardia, hypertension, and tearing.
♦ Chemically paralyzed patients are unable to demonstrate usual signs of distress, and may
  only exhibit tachycardia, hypertension or tearing.
♦ Analgesia - FENTANYL OR MORPHINE may be considered for distress believed to be
  secondary to pain. Start with a low dose and titrate for effect.
♦ Continue ongoing ETCO2, O2 Sat and cardiac monitoring, with special attention to blood
  pressure.

ALS PROVIDERS
♦ When administering NARCOTICS or BENZODIAZEPINES it is desirable to start with
  a low dose and titrate for effect.
♦ Use extreme caution when administering NARCOTICS and BENZODIAZEPINES
  together.
♦ Pediatric doses and limits are referenced in individual protocols
♦ Sedation/Analgesia- VERSED along with FENTANYL OR MORPHINE may be considered
  for ongoing management.
♦ For medication dosing beyond the standing orders CONTACT MEDICAL CONTROL.


Transfer Of Care Responsibility - Intubated Patient

Maintain primary control of ETT to avoid dislodgement. Verify tube placement immediately
after every transfer. Use extreme caution during all pediatric transfers.

Before releasing charge and control of an intubated patient to a receiving hospital physician, the
EMS provider must confirm and document tube placement and patency. The receiving physician
should be asked to verify tube placement and patency prior to patient transfer and the transfer of
care. Document ETCO2 and waveform readings.


                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 42 of 179
                    V. Cardiovascular Emergencies - Adult



Acute Coronary Syndrome / Cardiac Chest Pain

Designation of Condition: Patient with substernal chest pain described as dull, pressure-like,
tightness, or indigestion. Often with associated discomfort of the neck, jaw, shoulder, arm, or
back; and with associated symptoms, such as dyspnea, diaphoresis, dizziness, or nausea. Women
and patients with diabetes may present with atypical symptoms. When unsure, treat as an
AMI. Consider other life-threatening causes of chest pain, including aortic dissection, pulmonary
embolism, tension pneumothorax, and pericardial effusion/tamponade.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Provide supplemental O2
♦ Monitor: O2 Sat, cardiac. Consider early placement of AED/defibrillator pads.
♦ ASPIRIN: 162 mg PO (2 chewable baby ASPIRIN)
♦ Request ALS intercept with concern for acute ischemia/AMI based on history and symptoms.
  ALS assessment required for any patient with active symptoms who refuses care.
♦ 12-lead ECG, if available. Serial ECG’s recommended, especially following administration
  of medication or change in symptoms. Include V4R in the setting of inferoposterior MI, JVD,
  or hypotension/cardiogenic shock.
♦ Establish communication with receiving ED as early as possible. Early notification
  required for STEMI (ST-segment elevation > 1 mm in two or more contiguous leads), or
  ECG with “AMI Suspected”.
♦ For transport to St. Vincent Hospital/Santa Fe Regional Medical Center consider AMI-STAT
  activation. For transport to Presbyterian Hospital, Albuquerque, consider AMI Activation.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ The goal of treatment is relief of ischemic chest pain, while preserving hemodynamic
  stability. Use caution administering NTG and NARCOTICS in the setting of
  inferoposterior MI or ST-segment changes in V4R, due to profound hypotension that may
  result from RV infarct (volume expansion may be critical in improving cardiac output).




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 43 of 179
Acute Coronary Syndrome / Cardiac Chest Pain (contd)

♦ NTG: 0.4 mg SL, repeat Q 3-5 min
  Hold for SBP < 100 mmHg. Do not use for patients with recent ingestion (< 24 hours)
  of erectile dysfunction medication (e.g. VIAGRA, CIALIS, LEVITRA).
♦ FENTANYL OR MORPHINE may be considered for chest pain. Start with a low dose and
  titrate for effect. Hold for SBP < 100 mmHg.


AMI STAT Activation - St. Vincent Hospital, Santa Fe

Designation of Condition: Patient with signs/symptoms suggestive of an AMI being transported
to St. Vincent Hospital/Santa Fe Regional Medical Center. AMI STAT is the terminology used
to request the highest state of readiness and preparation prior to arrival at SVH, as well as
activation of the Cardiac Cath Lab.

AMI STAT Criteria:
♦ Persistent chest pain (> 20 minutes), unrelieved by NTG
♦ Time of onset < 12 hours
♦ STEMI (ST-segment elevation > 1 mm in two or more contiguous leads), or ECG with “AMI
  Suspected”.
♦ Left Bundle Branch Block
♦ Internally paced rhythm with signs/symptoms of Acute Coronary Syndrome
♦ ST-segment depression > 2 mm in V1-4, suggestive of posterior AMI

Establish communication with the ED as early as possible.




                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                              Page 44 of 179
AMI Activation - Presbyterian Hospital, Albuquerque

Designation of Condition: Patient with signs/symptoms suggestive of an AMI being transported
to Presbyterian Hospital, Albuquerque. As part of a national initiative, this new hospital-wide
protocol will attempt to improve door-to-balloon times through early activation of the Cath Lab,
with potential bypass of the ED by EMS Providers.

Abnormal ECG: STEMI/ “AMI Suspected”
♦ Identify STEMI (ST-segment elevation > 1 mm in two or more contiguous leads, or
  new/presumed new LBBB), or ECG with “AMI Suspected”.
♦ Establish communication with the ED (“ED Dispatcher”) as early as possible for
  activation of the Cath Lab.
♦ Upon arrival at hospital:
      · Cath Lab Available - Unit will be directed to bypass the ED and transport
        directly to the Cath Lab/Interventional Cardiology.
      · Cath Lab Unavailable/Unstable Patient - Unit will be directed to the ED.
        Unstable patient defined as O2 Sat < 85% (on O2), SBP < 80,
        rales > 50% lung fields, CPAP, advanced airway management (ETT,
        Combitube), Ventricular Tachycardia, symptomatic high-degree AV block
        without pacemaker capture, cardiac arrest.

Normal ECG
♦ Provide direct report to the ED Physician for review of ECG and transfer of care




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 45 of 179
Asystole

Designation of Condition: Patient who is unconscious, apneic, with no pulse and no discernable
electrical activity on the cardiac monitor. Asystole may be the first rhythm identified in a patient
with unwitnessed or prolonged arrest, or represent a terminal rhythm confirming patient
deterioration and prolonged myocardial ischemia.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current ACLS Pulseless Arrest Algorithm as it applies to Asystole
♦   Ongoing high-quality CPR
♦   Confirm Asystole in at least 2 leads with 10 sec rhythm strips during pulse checks (rule out
    lead disconnection and low signal gain).
♦   Consider reversible causes of Asystole/PEA: Hypovolemia, Hypoxia, Hydrogen ion
    (acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia, Toxins, Tamponade
    (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma.
♦   There is no evidence supporting routine defibrillation or TCP for Asystole. If unclear
    whether a rhythm is fine VF or Asystole, an initial attempt at defibrillation may be
    warranted. Before shock administration, consider a period of CPR.
♦   Ongoing concern for oxygenation/ventilation
♦   To consider terminating resuscitation of a patient who remains pulseless despite CPR if
    ACLS delayed (> 20 minutes), or who presents and remains in Asytole, CONTACT
    MEDICAL CONTROL.

BLS AND ABOVE PROVIDERS
♦ Place and confirm Rescue Airway Device/Combitube as required

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF. Do not routinely insert an
  advanced airway unless BVM ventilation is ineffective. Do not interrupt CPR for IV/IO
  insertion if possible.
♦ EPINEPHRINE (1:10,000): 1 mg IV/IO, repeat Q 3-5 min during CPR; OR
♦ EPINEPHRINE (1:1000): 2.5 mg in 5-10 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 46 of 179
Asystole (contd)

ALS PROVIDERS
♦ Intubate as required
♦ VASOPRESSIN: 40 units IV/IO/ETT, single dose to replace first or second dose of
  EPINEPHRINE.
♦ ATROPINE: 1 mg IV/IO/ETT, repeat Q 3-5 min (max dose = 3 mg)
♦ For patient with suspected Hyperkalemia (e.g. renal failure, hemodialysis/AV fistula,
  diabetes/DKA), Acidosis (e.g. renal failure, diabetes/DKA, severe gastrointestinal
  hemorrhage, prolonged resuscitation), or Hypocalcemia (e.g. multi-unit blood transfusion),
  administer early in resuscitation:
      · CALCIUM CHLORIDE (10%): 10 cc IV/IO, may repeat for recurrent rhythm
        deterioration.
      · SODIUM BICARBONATE: 2 amps (100 cc) IV/IO
♦ Termination of unsuccessful resuscitation under standing orders may be decided by
  ALS Providers only. Continued efforts may not be appropriate for adult cardiac arrest
  patients who do not respond to ACLS (including airway management, defibrillation and
  medications); when there are reliable criteria indicating irreversible death; or when there is a
  threat to the safety of EMS Providers. Special resuscitation interventions and prolonged
  resuscitation efforts may be indicated for patients with potentially reversible causes of arrest.
  ALS Providers are strongly encouraged to CONTACT MEDICAL CONTROL.
♦ In cases involving drowning, electrocution, hypothermia or overdose, continue
  CPR/ACLS and CONTACT MEDICAL CONTROL.

Note: See Termination of Resuscitation and Do Not Resuscitate (DNR) Order




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 47 of 179
Atrial Fibrillation / Flutter - Unstable

Designation of Condition: Patient with Atrial Fibrillation/Flutter and a heart rate > 150 bpm,
exhibiting severe signs/symptoms: SOB, CP, hypotension, pulmonary edema/CHF, poor
peripheral perfusion, decreased LOC, syncope, ischemic ECG changes.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current ACLS Tachycardia (With Pulses) Algorithm as it applies to the Unstable
  Patient.
♦ Rapid transport

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ Attach electrode pads to dry skin
♦ Synchronized Cardioversion for critically unstable patients with new-onset Atrial
  Fibrillation/Flutter known to be < 48 hours duration. If the duration of onset is unknown or
  suspected to be > 48 hours (high risk of embolic complications), prior to cardioversion,
  CONTACT MEDICAL CONTROL.
♦ Ensure adequate sedation/analgesia is provided for patient comfort, but do not delay
  cardioversion.
      · Sedation - VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg.
♦ Synchronized Cardioversion in the following sequence:
      · Atrial Fibrillation - (Biphasic) 75 J, 120 J, 150 J, 200 J
                               (Monophasic) 100 J, 200 J, 300 J, 360 J
      · Atrial Flutter -       (Biphasic) 75 J, 120 J, 150 J, 200 J
                               (Monophasic) 50 J, 100 J, 200 J, 300 J, 360 J
♦ If pulseless arrest develops, follow ACLS Pulseless Arrest Algorithm
♦ If cardioversion is needed and it is not possible to synchronize a shock (rhythm very fast and
  irregular), defibrillate patient with unsynchronized shock (360 J).
♦ For unstable patient with Atrial Fibrillation/Flutter refractory to synchronized cardioversion,
  CONTACT MEDICAL CONTROL.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 48 of 179
Bradycardia - Poor Perfusion

Designation of Condition: Patient with Bradycardia and a heart rate < 60 bpm, exhibiting
severe signs/symptoms: SOB, CP, hypotension, pulmonary edema/CHF, decreased LOC,
syncope, ventricular arrhythmias related to Bradycardia.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current ACLS Bradycardia Algorithm

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ Initiate transcutaneous pacing (TCP) for critically unstable patients, particularly those with a
  high-degree block (Mobitz type II second-degree block, third-degree AV block).
      · Attach pacer pads and cardiac monitor leads. Set the demand rate at 70 bpm.
      · Increase current in 20 milliampere (mA) increments until consistent electrical capture is
         observed. Electrical capture is verified by noting a QRS complex following every
         pacemaker spike. Next, increase current in 5 mA increments until mechanical capture
         achieved. Check for mechanical capture by palpating for a pulse that corresponds with
         the cardiac monitor. Pace at lowest current that provides mechanical capture.
      · Re-verify electrical and mechanical capture after any patient movement/transfer
♦ Ensure adequate sedation/analgesia is provided for patient comfort. For hemodynamic
  instability or rapid deterioration, it may be necessary to start TCP without prior sedation.
♦ ATROPINE: 0.5 mg IV/IO/ETT, repeat Q 3-5 min (max dose = 3 mg)
  Administer as first-line drug prior to TCP in absence of immediately reversible causes,
  in mildly symptomatic patient, or for vagal-induced Bradycardia. Use with caution in setting
  of cardiac ischemia/AMI. If ATROPINE ineffective, begin TCP.
♦ DOPAMINE: 5-20 mcg/kg/min IV/IO drip
  Administer if ATROPINE ineffective, or if TCP is delayed or ineffective.
♦ The goal of therapy is improvement in clinical status (target heart rate > 60 bpm/SBP > 90
  mmHg). Once TCP is initiated, adjust demand rate based on the patient’s clinical response.
  In the setting of cardiac ischemia, pace at the lowest rate that allows clinical stability.

Note: See Sedation/Analgesia for Transcutaneous Pacing




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                                                 January 2009
                                                Page 49 of 179
Sedation / Analgesia for Transcutaneous Pacing

Designation of Condition: Conscious patient requiring noninvasive transcutaneous pacing
(TCP), or patient with an active implanted defibrillator/pacemaker needing sedation/analgesia.

ILS AND ABOVE PROVIDERS
♦ To facilitate TCP for a conscious patient, ensure adequate sedation/analgesia is provided for
  patient comfort. For cardiovascular collapse or rapid deterioration, it may be necessary to
  start pacing without prior sedation.
♦ Analgesia - FENTANYL OR MORPHINE may be considered. Start with a low dose and
  titrate for effect.
♦ Continue ongoing O2 Sat and cardiac monitoring, with special attention to respiratory
  status.
ALS PROVIDERS
♦ When administering NARCOTICS or BENZODIAZEPINES it is desirable to start with
  a low dose and titrate for effect.
♦ Sedation/Analgesia- VERSED along with FENTANYL OR MORPHINE may be considered
  for ongoing management.
      · Sedation - VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg.
♦ For medication dosing beyond the standing orders CONTACT MEDICAL CONTROL.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 50 of 179
Cardiogenic Shock

Designation of Condition: Patient with typical historical features of an MI, exhibiting anxiety,
SOB (rales, wheezing), pulmonary edema, hypoxia, tachycardia, hypotension, poor peripheral
perfusion, decreased LOC, JVD, and ischemic ECG changes. Multiple non-ischemic causes, but
most often secondary to AMI.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Provide supplemental O2
♦ Position of comfort
♦ ALBUTEROL: 5 mg/3 cc NS NEB, repeat as needed
  Administer for SOB, wheezing or hypoxia.
♦ ASPIRIN: 162 mg PO (2 chewable baby ASPIRIN)
♦ Rapid transport

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ For SBP < 90 mmHg, bolus 250 cc NS then reassess
♦ NTG: 0.4 mg SL, repeat Q 3-5 min
  Hold for SBP < 100 mmHg.
♦ FENTANYL OR MORPHINE may be considered for chest pain. Start with a low dose and
  titrate for effect. Hold for SBP < 100 mmHg.

ALS PROVIDERS
♦ DOPAMINE: 5-20 mcg/kg/min IV/IO drip
  Administer for ongoing SBP < 90 mmHg.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 51 of 179
Cardiopulmonary Arrest - Hypothermia

Designation of Condition: Patient in cardiac arrest with hypothermia and a core body
temperature < 95° F/35° C.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Provide supplemental O2
♦ Monitor: O2 Sat, cardiac
♦ If ANY pulse is detected, DO NOT perform CPR; otherwise,
♦ Follow current ACLS Pulseless Arrest Algorithm
♦ Treatment of VF/Pulseless VT:
      · Severe Hypothermia (< 86° F/30° C) - One attempt at Unsynchronized
        Defibrillation (Biphasic: 200 J, Monophasic: 360 J). If no response, defer subsequent
        shocks until core temperature > 86° F/30° C.
      · Moderate Hypothermia (86°-93° F/30°-34° C) - Attempt defibrillation as
        required.
♦ Treatment of Asystole/PEA: Ongoing high-quality CPR until patient rewarmed
♦ Ventilate with warm humidified O2
♦ Remove all wet clothing/begin external warming

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate warm IVF
♦ Treatment of VF/Pulseless VT/Asystole/PEA:
      · Severe Hypothermia (< 86° F/30° C) - Defer drug therapy until core
        temperature > 86° F/30° C.
      · Moderate Hypothermia (86°-93° F/30°-34° C) - Administer medications
        spaced at twice the normal time intervals.

ALS PROVIDERS
♦ Treatment of Bradycardia/Atrial Fibrillation/Atrial Flutter with Pulse:
      · Assuming severe hypothermia, DO NOT treat
      · TCP contraindicated in severe hypothermia
♦ Treatment of VT/Uncertain Wide-QRS Tachycardia with Pulse:
      · AMIODARONE: 150 mg IV/IO over 10 min, may repeat x 2 doses
♦ Treatment of Torsades de Pointes/Polymorphic VT with Pulse, or potential hypomagnesemic
  states (e.g malnutrition, ETOH abuse):
      · MAGNESIUM: 2 g IV/IO over 5 min


                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 52 of 179
Cardiopulmonary Arrest - Hypothermia (contd)

♦ For patient with suspected Hyperkalemia (e.g. renal failure, hemodialysis/AV fistula,
  diabetes/DKA), Acidosis (e.g. renal failure, diabetes/DKA, severe gastrointestinal
  hemorrhage, prolonged resuscitation), or Hypocalcemia (e.g. multi-unit blood transfusion),
  administer early in resuscitation:
      · CALCIUM CHLORIDE (10%): 10 cc IV/IO
      · SODIUM BICARBONATE: 2 amps (100 cc) IV/IO
♦ Continue CPR/ACLS and CONTACT MEDICAL CONTROL




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 53 of 179
Cardiopulmonary Arrest - Non-traumatic

Designation of Condition: Patient with non-traumatic cardiopulmonary arrest.

ALL EMS PROVIDERS
♦ ALS Providers should be dispatched simultaneously for all cardiopulmonary arrest
  responses. Ensure that an ALS unit is en route at the first opportunity.
♦ Establish Primary Management
♦ Determine scene safety, and consider moving patient for safe and effective resuscitation.
♦ Determine timeline of events
♦ Determine if patient meets Dead at Scene criteria
♦ Confirm underlying rhythm
♦ Follow current ACLS Pulseless Arrest Algorithm
♦ Ongoing high-quality CPR
♦ Early defibrillation critical for VF/Pulseless VT
      · Power on the AED/Manual Defibrillator
      · Attach electrode pads to dry skin
      · Analyze the rhythm (confirm VF/Pulseless VT on screen)
      · Clear patient and defibrillate (Biphasic: 200 J, Monophasic: 360 J)
      · Resume CPR immediately
♦ For refractory VF/Pulseless VT, repeat cycles of defibrillation (360 J) and immediate
  CPR.
♦ Minimize interruptions in chest compressions
♦ Ongoing concern for oxygenation/ventilation
♦ For Asystole/PEA consider reversible causes
♦ Transport on backboard at earliest opportunity
♦ To consider terminating resuscitation of a patient who remains pulseless despite
  CPR/defibrillation if ACLS delayed (> 20 minutes), or who presents and remains in Asytole,
  CONTACT MEDICAL CONTROL.
♦ Continue resuscitation and transport patient when in doubt about timeline or rhythm, or for
  unique situations (e.g. hypothermia, overdose, emotional bystanders, hostile scene,
  pediatric cardiac arrest).

BLS AND ABOVE PROVIDERS
♦ Place and confirm Rescue Airway Device/Combitube as required




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 54 of 179
Cardiopulmonary Arrest - Non-traumatic (contd)

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF
♦ EPINEPHRINE (1:10,000): 1 mg IV/IO, repeat Q 3-5 min during CPR; OR
♦ EPINEPHRINE (1:1000): 2.5 mg in 5-10 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.

ALS PROVIDERS
♦ Intubate as required
♦ VASOPRESSIN: 40 units IV/IO/ETT, single dose to replace first or second dose of
  EPINEPHRINE.
♦ Administer appropriate ACLS medications for persistent VF/Pulseless VT, or Asystole/PEA.
♦ Patient may be managed in the field as appropriate. ALS Providers are strongly encouraged
  to transport at the earliest opportunity.
♦ Termination of unsuccessful resuscitation under standing orders may be decided by
  ALS Providers only. Continued efforts may not be appropriate for adult cardiac arrest
  patients who do not respond to ACLS (including airway management, defibrillation and
  medications); when there are reliable criteria indicating irreversible death; or when there is a
  threat to the safety of EMS Providers. Special resuscitation interventions and prolonged
  resuscitation efforts may be indicated for patients with potentially reversible causes of arrest.
  ALS Providers are strongly encouraged to CONTACT MEDICAL CONTROL.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 55 of 179
Congestive Heart Failure / Pulmonary Edema

Designation of Condition: Patient with moderate to severe dyspnea, characterized by rales,
rhonchi, or wheezing (“cardiac asthma”). Often with associated fatigue, weakness or anxiety;
and underlying dependent edema, ascites or JVD. May present in the setting of hypertensive
emergencies. Severe dyspnea may progress to cough productive of frothy pink sputum, hypoxia,
tachycardia, hypotension, cyanosis, and decreased LOC. Consider other life-threatening causes
of dyspnea, including pneumonia, asthma/COPD, AMI, pulmonary embolism, tension
pneumothorax, and pericardial effusion/tamponade.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Provide supplemental O2
♦ Elevate head of bed
♦ Monitor: O2 Sat, cardiac
♦ ASPIRIN: 162 mg PO (2 chewable baby ASPIRIN)
  Administer if AMI suspected.
♦ ALBUTEROL: 5 mg/3 cc NS NEB
  Administer for SOB, wheezing or hypoxia.
♦ Request ALS intercept with concern for patient deterioration, or need for CPAP/advanced
  airway management.
♦ For hemodialysis patients, emergent dialysis is the definitive treatment

BLS AND ABOVE PROVIDERS
♦ CPAP

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF. Set TKO if patient normotensive.
♦ NTG: 0.4 mg SL, repeat Q 3-5 min
  Hold for SBP < 100 mmHg. Do not use for patients with recent ingestion (< 24 hours)
  of erectile dysfunction medication (e.g. VIAGRA, CIALIS, LEVITRA).
♦ FENTANYL OR MORPHINE may be considered for additional symptom relief. Start with a
  low dose and titrate for effect. Hold for SBP < 100 mmHg.

ALS PROVIDERS
♦ Intubate as required
♦ FUROSEMIDE: 20-80 mg IV/IO
  Hold for SBP < 100 mmHg. Administer twice the oral dose (40-160 mg IV/IO) for
  patients taking FUROSEMIDE at home.
♦ DOPAMINE: 5-20 mcg/kg/min IV/IO drip
  Administer for SBP < 90 mmHg.
                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 56 of 179
Pulseless Electrical Activity

Designation of Condition: Patient who is unconscious, apneic, and pulseless, with organized or
semi-organized electrical activity on the cardiac monitor. PEA is defined as any rhythm without
a pulse, and is the most common rhythm present following defibrillation.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current ACLS Pulseless Arrest Algorithm as it applies to PEA
♦ Ongoing high-quality CPR
♦ Identify and correct any reversible cause of PEA: Hypovolemia, Hypoxia, Hydrogen ion
  (acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia, Toxins, Tamponade
  (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma.
♦ 12-lead ECG, if available
♦ Ongoing concern for oxygenation/ventilation
♦ To consider terminating resuscitation of a patient who remains pulseless despite CPR if
  ACLS delayed (> 20 minutes), or who remains in Asystole, CONTACT MEDICAL
  CONTROL.

BLS AND ABOVE PROVIDERS
♦ Place and confirm Rescue Airway Device/Combitube as required

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF. Do not routinely insert an
  advanced airway unless BVM ventilation is ineffective. Do not interrupt CPR for IV/IO
  insertion if possible.
♦ EPINEPHRINE (1:10,000): 1 mg IV/IO, repeat Q 3-5 min during CPR; OR
♦ EPINEPHRINE (1:1000): 2.5 mg in 5-10 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.
♦ Consider volume infusion for PEA associated with a narrow-complex tachycardia consistent
  with hypovolemia.
♦ NARCAN: 2 mg IV/IO, may repeat Q 2-3 min (max dose = 10 mg)
  Administer for PEA in the setting of drug overdose; OR
♦ NARCAN: 4 mg in 5-10 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 57 of 179
Pulseless Electrical Activity (contd)

ALS PROVIDERS
♦ Intubate as required
♦ VASOPRESSIN: 40 units IV/IO/ETT, single dose to replace first or second dose of
  EPINEPHRINE.
♦ ATROPINE: 1 mg IV/IO/ETT, repeat Q 3-5 min (max dose = 3 mg)
  Administer for slow PEA rate.
♦ For patient with suspected Hyperkalemia (e.g. renal failure, hemodialysis/AV fistula,
  diabetes/DKA), Acidosis (e.g. renal failure, diabetes/DKA, severe gastrointestinal
  hemorrhage, prolonged resuscitation), or Hypocalcemia (e.g. multi-unit blood transfusion),
  administer early in resuscitation:
      · CALCIUM CHLORIDE (10%): 10 cc IV/IO, may repeat for recurrent rhythm
        deterioration.
      · SODIUM BICARBONATE: 2 amps (100 cc) IV/IO
♦ Consider SODIUM BICARBONATE administration for PEA associated with a wide-
  complex rhythm, particularly in the setting of drug overdose (e.g. tricyclic antidepressants,
  cocaine, amphetamines).
♦ CALCIUM CHLORIDE (10%): 10 cc IV/IO, may repeat for recurrent rhythm deterioration.
  Administer for calcium channel blocker overdose/toxicity. Do not use for patients receiving
  DIGOXIN.
♦ GLUCAGON: 1-3 mg IV/IO (or 0.05 mg/kg), may repeat in 10 min
  Administer for calcium channel blocker or beta blocker overdose/toxicity.
♦ Termination of unsuccessful resuscitation under standing orders may be decided by
  ALS Providers only. Continued efforts may not be appropriate for adult cardiac arrest
  patients who do not respond to ACLS (including airway management, defibrillation and
  medications); when there are reliable criteria indicating irreversible death; or when there is a
  threat to the safety of EMS Providers. Special resuscitation interventions and prolonged
  resuscitation efforts may be indicated for patients with potentially reversible causes of arrest.
  ALS Providers are strongly encouraged to CONTACT MEDICAL CONTROL.
♦ In cases involving drowning, electrocution, hypothermia or overdose, continue
  CPR/ACLS and CONTACT MEDICAL CONTROL.

Note: See Termination of Resuscitation and Do Not Resuscitate (DNR) Order




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 58 of 179
Supraventricular Tachycardia

Designation of Condition: Patient with a Narrow-QRS Tachycardia and a heart rate
> 150 bpm (QRS < 0.12 sec). For the unstable patient, exhibiting decreased LOC, ongoing
SOB/CP, hypotension, or other signs of shock, immediate cardioversion is required.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current ACLS Tachycardia (With Pulses) Algorithm as it applies to the Stable
  Patient with Narrow-QRS Tachycardia, or the Unstable Patient.
♦ Monitor: O2 Sat, cardiac
♦ ALS intercept required

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
Stable Patient:
♦ Initiate continuous recording on cardiac monitor prior to conversion efforts
♦ Vagal maneuvers (valsalva, carotid sinus massage) may terminate 20% of SVT
♦ ADENOSINE: 6 mg RAPID PUSH IV/IO with 20 cc NS flush
   Administer via AC vein, or other large peripheral vein followed by elevation of the
   extremity. If SVT does not convert within 1-2 minutes, repeat:
♦ ADENOSINE: 12 mg RAPID PUSH IV/IO with 20 cc NS flush
   If SVT does not convert within 1-2 minutes, repeat:
♦ ADENOSINE: 12 mg RAPID PUSH IV/IO with 20 cc NS flush

Unstable patient:
♦ Ensure adequate sedation/analgesia is provided for patient comfort, but do not delay
   cardioversion.
       · Sedation - VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg.
♦ Synchronized Cardioversion (Biphasic: 75 J, 120 J, 150 J, 200 J/ Monophasic: 100 J, 200 J,
   300 J, 360 J).
♦ If pulseless arrest develops, follow ACLS Pulseless Arrest Algorithm




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 59 of 179
Ventricular Fibrillation / Pulseless Ventricular Tachycardia

Designation of Condition: Patient who is unconscious, apneic, and pulseless, with Ventricular
Fibrillation or Ventricular Tachycardia on the cardiac monitor.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current ACLS Pulseless Arrest Algorithm as it applies to VF/Pulseless VT
♦   Ongoing high-quality CPR
♦   Early defibrillation critical for VF/Pulseless VT
        · Power on the AED/Manual Defibrillator
        · Attach electrode pads to dry skin
        · Analyze the rhythm (confirm VF/Pulseless VT on screen)
        · Clear patient and defibrillate (Biphasic: 200 J, Monophasic: 360 J)
        · Resume CPR immediately
♦ For refractory VF/Pulseless VT, repeat cycles of defibrillation (360 J) and immediate
  CPR.
♦ Minimize interruptions in chest compressions
♦ Ongoing concern for oxygenation/ventilation
♦ To consider terminating resuscitation of a patient who remains pulseless despite
  CPR/defibrillation if ACLS delayed (> 20 minutes), or who presents and remains in
  Asystole, CONTACT MEDICAL CONTROL.

BLS AND ABOVE PROVIDERS
♦ Place and confirm Rescue Airway Device/Combitube as required

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF
♦ EPINEPHRINE (1:10,000): 1 mg IV/IO, repeat Q 3-5 min during CPR; OR
♦ EPINEPHRINE (1:1000): 2.5 mg in 5-10 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.

ALS PROVIDERS
♦ Intubate as required
♦ VASOPRESSIN: 40 units IV/IO/ETT, single dose to replace first or second dose of
  EPINEPHRINE.
♦ AMIODARONE: 300 mg IV/IO, repeat additional 150 mg IV/IO
  Administer For refractory VF/Pulseless VT; OR,
                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 60 of 179
Ventricular Fibrillation / Pulseless Ventricular Tachycardia (contd)

♦ LIDOCAINE: 1.5 mg/kg IV/IO, repeat 1.5 mg/kg IV/IO (max = 3 mg/kg)
  Alternative if AMIODARONE unavailable. If no IV/IO access available, may give
  2-4 mg/kg via ETT.
♦ MAGNESIUM: 2 g IV/IO
  Administer for Torsades de Pointes, Polymorphic VT, potential hypomagnesemic states (e.g.
  malnutrition, ETOH abuse), and refractory VF/Pulseless VT.
♦ For patient with suspected Hyperkalemia (e.g. renal failure, hemodialysis/AV fistula,
  diabetes/DKA), Acidosis (e.g. renal failure, diabetes/DKA, severe gastrointestinal
  hemorrhage, prolonged resuscitation), or Hypocalcemia (e.g. multi-unit blood transfusion),
  administer early in resuscitation:
      · CALCIUM CHLORIDE (10%): 10 cc IV/IO, may repeat for recurrent rhythm
        deterioration.
      · SODIUM BICARBONATE: 2 amps (100 cc) IV/IO
♦ Termination of unsuccessful resuscitation under standing orders may be decided by
  ALS Providers only. Continued efforts may not be appropriate for adult cardiac arrest
  patients who do not respond to ACLS (including airway management, defibrillation and
  medications); when there are reliable criteria indicating irreversible death; or when there is a
  threat to the safety of EMS Providers. Special resuscitation interventions and prolonged
  resuscitation efforts may be indicated for patients with potentially reversible causes of arrest.
  ALS Providers are strongly encouraged to CONTACT MEDICAL CONTROL.
♦ In cases involving drowning, electrocution, hypothermia or overdose, continue
  CPR/ACLS and CONTACT MEDICAL CONTROL.

Note: See Termination of Resuscitation and Do Not Resuscitate (DNR) Order




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 61 of 179
Ventricular Tachycardia / Wide-QRS Tachycardia

Designation of Condition: Patient with a Wide-QRS Tachycardia with pulses, and a heart rate
generally > 150 bpm (QRS ≥ 0.12 sec). For the unstable patient, exhibiting decreased LOC,
ongoing SOB/CP, hypotension, or other signs of shock, immediate cardioversion is required.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current ACLS Tachycardia (With Pulses) Algorithm as it applies to the Stable
  Patient with Wide-QRS Tachycardia, or the Unstable Patient.
♦ Monitor: O2 Sat, cardiac
♦ 12-lead ECG, if available
♦ ALS intercept required
♦ Rapid transport

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
Stable Patient:
♦ Consider consultation, CONTACT MEDICAL CONTROL.
♦ AMIODARONE: 150 mg IV/IO over 10 min, may repeat x 2 doses
   Administer for sustained VT, or Wide-QRS Tachycardia with concern for patient
   deterioration.
♦ LIDOCAINE: 1 mg/kg IV/IO, repeat 0.5-0.75 mg IV/IO (max = 3 mg/kg)
   Alternative if AMIODARONE unavailable. Initiate LIDOCAINE drip at 2-4 mg/min
   (reduce drip rate by half for patient age > 70 yo, ESLD, or CHF).
♦ MAGNESIUM: 2 g IV/IO
   Administer for Torsades de Pointes, Polymorphic VT, or potential hypomagnesemic states
   (e.g.malnutrition, ETOH abuse).

Unstable patient:
♦ For Wide-QRS Tachycardia in an Unstable Patient, assume VT until proven otherwise.
♦ Ensure adequate sedation/analgesia is provided for patient comfort, but do not delay
   cardioversion.
       · Sedation - VERSED: 2 mg/dose IV/IO, titrate to 0.1 mg/kg.



                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                              Page 62 of 179
Ventricular Tachycardia / Wide-QRS Tachycardia (contd)

♦ Monomorphic VT - Synchronized Cardioversion (Biphasic: 75 J, 120 J, 150 J, 200 J/
  Monophasic: 100 J, 200 J, 300 J, 360 J).
♦ Polymorphic VT - Unsynchronized Defibrillation, treat as VF (Biphasic: 200 J,
  Monophasic: 360 J).
♦ If uncertain whether an Unstable Patient has Monomorphic or Polymorphic VT, do not delay
  treatment for rhythm analysis. Provide Unsynchronized Defibrillation.
♦ If pulseless arrest develops, follow ACLS Pulseless Arrest Algorithm
♦ AMIODARONE: 150 mg IV/IO over 10 min, may repeat x 2 doses
  Administer following cardioversion, and for recurrent or refractory Wide-QRS
  Tachycardia.
♦ LIDOCAINE: 1 mg/kg IV/IO, repeat 0.5-0.75 mg IV/IO (max = 3 mg/kg)
  Alternative if AMIODARONE unavailable. Initiate LIDOCAINE drip at 2-4 mg/min
  (reduce drip rate by half for patient age > 70 yo, ESLD, or CHF).
♦ MAGNESIUM: 2 g IV/IO
  Administer for Torsades de Pointes, Polymorphic VT, or potential hypomagnesemic states
  (e.g.malnutrition, ETOH abuse).




                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
                                             Page 63 of 179
                  VI. Cardiovascular Emergencies - Pediatric



General - Pediatric Resuscitation

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current PALS guidelines
♦   Rapid transport of critically ill children is crucial, avoid prolonged scene time
♦   Cardiopulmonary failure in children is usually the result of primary respiratory failure, but is
    the potential end point of all untreated or unresponsive critical illness.
♦ Emphasis is on early recognition and stabilization of respiratory failure and shock
♦ All pediatric patients with underlying cardiopulmonary disorders require ALS assessment
  and intervention regardless of presentation.
♦ Ongoing resuscitation and transport should be performed for all pediatric
  cardiopulmonary arrest patients except when there are reliable criteria indicating
  irreversible death.
♦ Establish communication with receiving ED as early as possible
♦ In cases involving drowning, electrocution, hypothermia or overdose, continue
  CPR/PALS and CONTACT MEDICAL CONTROL.

♦ Termination of unsuccessful pediatric resuscitation shall be decided by the receiving
  ED physician.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 64 of 179
Pediatric Asystole / PEA

Designation of Condition: Patient who is unconscious, apneic, with no pulse and no discernable
electrical activity on the cardiac monitor.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current PALS guidelines
♦ Ongoing high-quality CPR
♦ Confirm Asystole in at least 2 leads with 10 sec rhythm strips during pulse checks (rule out
  lead disconnection and low signal gain).
♦ Consider reversible causes of Asystole/PEA: Hypovolemia, Hypoxia, Hydrogen ion
  (acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia, Toxins, Tamponade
  (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma.
♦ Ongoing concern for oxygenation/ventilation

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF. Do not routinely insert an
  advanced airway unless BVM ventilation is ineffective. Do not interrupt CPR for IV/IO
  insertion if possible.
♦ EPINEPHRINE (1:10,000): 0.01 mg/kg (0.1 cc/kg) IV/IO, repeat Q 3-5 min during CPR;
  OR
♦ EPINEPHRINE (1:1000): 0.1 mg/kg (0.1 cc/kg) in 2.5-5 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.

ALS PROVIDERS
♦ Intubate as required




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 65 of 179
Pediatric Bradycardia - Poor Perfusion

Designation of Condition: Patient with Bradycardia causing severe cardiopulmonary
compromise: poor perfusion, hypotension, respiratory difficulty, decreased LOC.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current PALS guidelines
♦ Ongoing concern for oxygenation/ventilation. Pediatric Bradycardia is usually the result of
  hypoxia.
♦ Perform chest compressions if, despite adequate oxygenation/ventilation for 30-60 sec, the
  HR < 60 bpm in a neonate (age 0-1 mon), or the HR < 60 bpm with poor systemic perfusion
  in an infant/child (age 1 mon-8 yo).

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ EPINEPHRINE (1:10,000): 0.01 mg/kg (0.1 cc/kg) IV/IO, repeat Q 3-5 min during CPR;
  OR
♦ EPINEPHRINE (1:1000): 0.1 mg/kg (0.1 cc/kg) in 2.5-5 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.

ALS PROVIDERS
♦ Intubate as required
♦ ATROPINE: 0.02 mg/kg IV/IO/ETT (min dose = 0.1 mg, max dose child = 0.5 mg, max
  dose adol = 1 mg), may repeat once.
♦ Consider TCP
♦ If ATROPINE ineffective, or if TCP is delayed or ineffective, CONTACT MEDICAL
  CONTROL.




                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                              Page 66 of 179
Pediatric Supraventricular Tachycardia

Designation of Condition: Patient with a Narrow-QRS Tachycardia (QRS ≤ 0.08 sec) and a
heart rate > 220 bpm (infants), > 180 bpm (children). History incompatible with Sinus
Tachycardia, and P waves absent or abnormal.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current PALS guidelines
♦   Ongoing concern for oxygenation/ventilation
♦   ALS intercept required

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
Stable Patient:
♦ Initiate continuous recording on cardiac monitor prior to conversion efforts
♦ Vagal maneuvers (valsalva, carotid sinus massage)
♦ Rapid transport

Unstable patient:
♦ CONTACT MEDICAL CONTROL for immediate conversion if the patient exhibits
   cardiopulmonary compromise: poor perfusion, hypotension, respiratory difficulty, decreased
   LOC.
♦ ADENOSINE: 0.1 mg/kg (max dose = 6mg) RAPID PUSH IV/IO with 2-10 cc NS flush.
   Administer via AC vein, or other large peripheral vein followed by elevation of the
   extremity. If SVT does not convert within 1-2 minutes, repeat:
♦ ADENOSINE: 0.2 mg/kg (max dose = 12mg) RAPID PUSH IV/IO with 2-10 cc NS flush.
♦ Ensure adequate sedation/analgesia is provided for patient comfort, but do not delay
   cardioversion.
       · Sedation - VERSED: 0.05-0.1 mg/kg/dose IV/IO, max 0.2 mg/kg
♦ Synchronized Cardioversion in the following sequence: 0.5 J/kg, 1 J/kg, 2 J/kg




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 67 of 179
Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia

Designation of Condition: Patient who is unconscious, apneic, and pulseless, with Ventricular
Fibrillation or Ventricular Tachycardia on the cardiac monitor.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Follow current PALS guidelines
♦ Ongoing high-quality CPR
♦ Early defibrillation critical for VF/Pulseless VT
      · Power on the AED/Manual Defibrillator
      · Attach electrode pads to dry skin
      · Analyze the rhythm (confirm VF/Pulseless VT on screen)
      · Clear patient and defibrillate in the following sequence: 2 J/kg, 4 J/kg, 4 J/kg
      · Resume CPR immediately
♦ For refractory VF/Pulseless VT, repeat cycles of defibrillation (4 J/kg) and immediate
  CPR.
♦ Minimize interruptions in chest compressions
♦ Ongoing concern for oxygenation/ventilation

ILS AND ABOVE PROVIDERS
♦ Give priority to establishing IV/IO access, and bolus IVF
♦ EPINEPHRINE (1:10,000): 0.01 mg/kg (0.1 cc/kg) IV/IO, repeat Q 3-5 min during CPR;
  OR
♦ EPINEPHRINE (1:1000): 0.1 mg/kg (0.1 cc/kg) in 2.5-5 cc NS via ETT
  Alternative route if IV/IO access cannot be established or is delayed.

ALS PROVIDERS
♦ Intubate as required
♦ AMIODARONE: 5 mg/kg IV/IO, repeat additional 5 mg/kg
  Administer For refractory VF/Pulseless VT; OR,
♦ LIDOCAINE: 1 mg/kg IV/IO/ETT
  Alternative if AMIODARONE unavailable.
♦ MAGNESIUM: 25-50 mg/kg IV/IO (max dose = 2 g)
  Administer for Torsades de Pointes and refractory VF/Pulseless VT.
♦ In cases involving drowning, electrocution, hypothermia or overdose, continue
  CPR/PALS and CONTACT MEDICAL CONTROL.


                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 68 of 179
Pediatric Ventricular Tachycardia / Wide-QRS Tachycardia

Designation of Condition: Patient with a Wide-QRS Tachycardia with pulses (QRS > 0.08 sec).
For the unstable patient, exhibiting poor perfusion, hypotension, respiratory difficulty, or
decreased LOC, immediate cardioversion is required.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current PALS guidelines
♦   Monitor: O2 Sat, cardiac
♦   12-lead ECG, if available
♦   ALS intercept required
♦   Rapid transport

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
Stable Patient:
♦ Consider consultation, CONTACT MEDICAL CONTROL.
♦ AMIODARONE: 5 mg/kg IV/IO, infuse over 20-60 min
   Administer for sustained VT, or Wide-QRS Tachycardia with concern for patient
   deterioration.
♦ LIDOCAINE: 1 mg/kg IV/IO/ETT
   Alternative if AMIODARONE unavailable. Initiate LIDOCAINE drip at 20-50
   mcg/kg/min.

Unstable patient:
♦ Ensure adequate sedation/analgesia is provided for patient comfort, but do not delay
   cardioversion.
       · Sedation - VERSED: 0.05-0.1 mg/kg/dose IV/IO, max 0.2 mg/kg
♦ Synchronized Cardioversion in the following sequence: 0.5 J/kg, 1 J/kg, 2 J/kg




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 69 of 179
                              VII. Medical Emergencies



Allergic Reaction / Anaphylaxis

Designation of Condition: Localized allergic reactions may be characterized by
hives/urticaria/erythema, pruritis, angioedema, throat tightness, dyspnea, or wheezing, and differ
from anaphylaxis in that they do not manifest multi-system involvement. However, any symptom
that potentially represents a systemic reaction must by taken seriously. Anaphylaxis,
characterized by the acute reaction of multiple organ systems, may progress rapidly, leading to
laryngeal edema/stridor/spasm, bronchospasm with respiratory failure, and shock.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Symptoms present > 1 hr with no increasing severity are unlikely to worsen suddenly.
  Isolated rash, not associated with respiratory symptoms, swallowing difficulty, or altered
  vital signs, is unlikely to progress to anaphylaxis in a delayed fashion.
♦ Consider EPINEPHRINE (EpiPen) via auto-injection device for severe symptoms
♦ ALBUTEROL: 5 mg/3 cc NS Neb (pediatric dose < 30 kg: 2.5 mg/3 cc NS)
  Administer for symptoms of bronchospasm (e.g. cough, dyspnea, wheezing, decreased
  breath sounds, hypoxia).

BLS AND ABOVE PROVIDERS
♦ EPINEPHRINE (1:1000): 0.3 cc SC/IM [pediatric dose < 30 kg: 0.01 mg/kg (0.01cc/kg),
  max dose = 0.3 cc].
  Administer for anaphylaxis using premeasured or fixed-dose syringe.

ILS AND ABOVE PROVIDERS
Stable Patient:
♦ Establish IV/IO access and titrate IVF
♦ DIPHENHYDRAMINE: 25-50 mg IV/IM (pediatric dose: 1 mg/kg)
   Administer for hives/urticaria/erythema, pruritis, bronchospasm, or anaphylaxis.
Unstable Patient:
♦ Aggressive IVF therapy (1-2 L) via multiple large-bore IVs for refractory hypotension.
♦ Consider repeat dose of EPINEPHRINE IM once in 10 min for refractory bronchospasm,
   stridor or hypotension.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 70 of 179
Allergic Reaction / Anaphylaxis (contd)

♦ Consider repeat/continuous ALBUTEROL Neb for refractory bronchospasm
♦ Cardiac monitor required for all patients receiving repeat doses of EPINEPHRINE and/or
  ALBUTEROL.

ALS PROVIDERS
Stable Patient:
♦ SOLUMEDROL: 125 mg IV/IM (pediatric dose: 1 mg/kg)
   Administer for severe hives/urticaria/erythema, pruritis, bronchospasm, or anaphylaxis.

Unstable Patient:
♦ Consider repeat doses of EPINEPHRINE IM Q 5-10 min (max = 3 doses) for refractory
   bronchospasm, stridor or hypotension.
♦ NEBULIZED EPINEPHRINE (1:1000): 1 mg (1 cc)/3 cc NS via Neb
   Consider administration for refractory stridor.
♦ For severe anaphylaxis (e.g. upper airway obstruction, acute respiratory failure, SBP < 80
   mmHg, not in association with ventricular tachyarrhythmia):
      · EPINEPHRINE (1:10,000): 0.1 mg (1 cc) slow IV push (over 3-5 min), may
        repeat x 2 doses [pediatric dose: 0.01 mg/kg (0.1 cc/kg)].
      · EPINEPHRINE drip: 2-10 mcg/min IV (pediatric dose: 0.1-1 mcg/kg/min)
        To prepare drip: EPINEPHRINE (1:1000) 1 mg (1cc)/250 cc NS, initiate at
        2 mcg/min (30 microdrops/min) [pediatric dose: initiate at 0.1 mcg/kg/min
        (1 microdrop/kg/min)].
      · Consider administration of EPINEPHRINE IO or via ETT as required
      · Consider DOPAMINE for refractory hypotension




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 71 of 179
Asthma

Designation of Condition: Patient with bronchial hyperreactivity producing bronchospasm,
airway inflammation, mucosal edema, and mucous plugging. Symptoms include cough, dyspnea,
or wheezing, and vary from mild to severe/unremitting (status asthmaticus). Wheezing in itself
does not designate the presence, severity or duration of asthma. Severe airway
obstruction/impending respiratory arrest may be indicated by tripod position, accessory muscle
use, decreased breath sounds/quiet chest, tachycardia, agitation, or decreased LOC.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Ongoing concern for oxygenation/ventilation
♦ Rapid transport during treatment
♦ ALBUTEROL: 5 mg/3 cc NS Neb (pediatric dose < 30 kg: 2.5 mg/3 cc NS)
♦ For patients with poor respiratory effort, deliver ALBUTEROL Neb via assisted
  ventilation/BVM.
♦ May administer patient-own bronchodilator by metered dose inhaler

BLS AND ABOVE PROVIDERS
♦ EPINEPHRINE (1:1000): 0.3 cc SC [pediatric dose < 30 kg: 0.01 mg/kg (0.01cc/kg), max
  dose = 0.3 cc].
  Administer for severe refractory status asthmaticus using premeasured or fixed-dose syringe.
  Contraindications: age > 50, known coronary artery disease, HTN, ventricular
  tachyarrhythmia.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Consider repeat/continuous ALBUTEROL Neb for refractory bronchospasm
♦ Consider repeat dose of EPINEPHRINE SC once in 10 min for severe refractory status
  asthmaticus.
♦ Cardiac monitor required for all patients receiving repeat doses of ALBUTEROL and
  EPINEPHRINE.




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                                                January 2009
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Asthma (contd)

ALS PROVIDERS
♦ IPRATROPIUM: 0.5 mg/3 cc NS Neb, single dose combined with ALBUTEROL
♦ SOLUMEDROL: 125 mg IV/IM (pediatric dose: 1 mg/kg)
  Administer for severe bronchospasm or status asthmaticus.
♦ Consider repeat doses of EPINEPHRINE SC Q 5-10 min (max = 3 doses) for severe
  refractory status asthmaticus.
♦ If intubation required, maintain O2 Sat > 90% with gentle and controlled ventilation. Allow
  for prolonged expiratory phase. Do not hyperventilate due to risk of breath
  stacking/increased peak airway pressures. Consider mechanical exhalation for the patient.




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Carbon Monoxide Poisoning

Designation of Condition: Colorless, odorless, nonirritating gas produced by incomplete
fuel combustion in engines, heaters/ovens/furnaces, and closed-space fires. CO binds
hemoglobin, decreasing blood O2-carrying capacity and O2 release to tissues, and acts as a direct
cellular toxin. Patients with CO poisoning may present with headache, vomiting, dizziness,
dyspnea, chest pain, ataxia, altered LOC, syncope, and seizure.

ALL EMS PROVIDERS
♦ Remember your own safety first. When appropriate, wear a SCBA into closed-spaces.
  Always relocate patient to safe environment before beginning resuscitation efforts.
♦ Establish Primary Management
♦ O2 Sat and cardiac monitor
♦ O2 Sat reading may be falsely elevated (device cannot distinguish carboxyhemoglobin)
♦ Provide 100% O2 via NRB, or assist ventilation with 100% O2 via BVM
♦ ALBUTEROL: 5 mg/3 cc NS Neb (pediatric dose < 30 kg: 2.5 mg/3 cc NS)
  Administer for cough, dyspnea, wheezing, decreased breath sounds, or hypoxia.
♦ Ongoing concern for oxygenation/ventilation
♦ Ensure safety of individuals at the scene prior to patient transport




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
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Cerebrovascular Accident (CVA)

Designation of Condition: Patient with rapidly developing neurologic deficits resulting from
interruption of regional cerebral blood flow. Onset may be sudden or stuttering, and caused
either by occlusion of cerebral vasculature or hemorrhage into the brain or subarachnoid space.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Monitor: O2 Sat, cardiac
♦   Glucometry
♦   Obtain accurate Time of Onset (last time seen normal)
♦   Emergent transport if Time of Onset < 3 hrs
♦   Establish communication with the ED as early as possible
♦   Ensure adequate oxygenation/ventilation (O2 Sat > 90%)
♦   Elevate head of bed 30º
♦   Monitor VS Q 5 min with ongoing patient assessment/GCS score
♦   Potential CVA patients should be transported to the closest appropriate facility with a CT
    scanner.
♦ Potential CVA patients should not receive ASPIRIN by EMS providers
♦ Potential CVA patients should not receive medication (e.g. NTG) in an attempt to lower
  blood pressure.
♦ Obtain detailed medical history with attention to possible Exclusion Criteria for ED
  Thrombolytic therapy:
       ·   Onset > 3 hrs
       ·   Rapidly improving symptoms
       ·   Uncontrolled severe HTN (> 180/110)
       ·   Glucose > 400
       ·   Seizure at onset
       ·   History of CVA/serious head trauma within 3 mo
       ·   Prior intracranial hemorrhage
       ·   Coumadin therapy
       ·   Known bleeding disorder/intracranial cancer/AV malformation
       ·   Major surgery within 14 days
       ·   GI/GU hemorrhage within 21 days
       ·   Liver disease
       ·   Pregnancy
       ·   Suspected aortic dissection




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                                                     January 2009
                                                    Page 75 of 179
Cerebrovascular Accident (CVA) (contd)

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Ensure adequate perfusion (SBP > 90 mmHg)
♦ DEXTROSE (D50): ½-1 amp IV/IO
  Administer for BGL < 60 mg/dl.

ALS PROVIDERS
♦ If intubation required, premedicate with FENTANYL (or LIDOCAINE)
♦ Provide controlled ventilation with target ETCO2 35-40 mmHg (16-20 breaths/min)
♦ Hyperventilation is not indicated for increased ICP unless patient presents with severe
  signs/symptoms suggesting herniation (e.g. decreasing LOC, bradycardia, hypertension,
  diminished/irregular respiratory rate, blown pupil with decorticate/decerebrate posture,
  seizure). Attempt hyperventilation with target ETCO2 30-35 mmHg.




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                                                January 2009
                                               Page 76 of 179
Coma (Unconscious/Unresponsive)

Designation of Condition: Unconscious or unresponsive patient with regular cardiorespiratory
function.


                                              Glasgow Coma Score (GCS)
                   Age 4 – Adult                       Child 1 – 5 yrs                     Infant < 1 yr
                                                              EYES
                      Open                                 Open                               Open                 4
                    To Voice                             To Voice                           To Voice               3
                     To Pain                              To Pain                            To Pain               2
                   No Response                          No Response                        No Response             1
                                                           VERBAL
                      Oriented                   Oriented/Interacts/Social                Coos/Babbles             5
                      Confused                     Confused/Consolable              Irritable Cry/ Consolable      4
                Nonsensical Speech            Nonsensical Speech/Inconsolable    Cries Persistently/Inconsolable   3
            Unintelligible/Moans to Pain           Unintelligible/Moans                   Moans/Grunts             2
                    No Response                        No Response                         No Response             1
                                                            MOTOR
                   To Command                       Normal/Spontaneous                Normal/Spontaneous           6
                  Localizes Pain                      Localizes Pain                  Withdraws to Touch           5
                Withdraws to Pain                    Withdraws to Pain                 Withdraws to Pain           4
            Flexion to Pain/Decorticate               Flexion to Pain                   Flexion to Pain            3
           Extension to Pain/Decerebrate             Extension to Pain                 Extension to Pain           2
                   No Response                         No Response                       No Response               1


ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Detect and treat reversible causes
♦   Monitor: O2 Sat, cardiac
♦   Glucometry
♦   Ongoing concern for oxygenation/ventilation
♦   C-spine immobilization in setting of trauma
♦   Consider ALS intercept
♦   Exclude coma-like states (note resistance to passive opening of eyelids, fluttering of eyelids
    when stroked, ability to blink on command).

BLS AND ABOVE PROVIDERS
♦ Administer NALOXONE for suspected narcotic overdose

Note: See Narcotic Poisoning




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                                                            January 2009
                                                           Page 77 of 179
Coma (Unconscious/Unresponsive) (contd)

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Administer DEXTROSE for hypoglycemia

Note: See Diabetic Emergencies

ALS PROVIDERS
♦ Intubate as required for airway protection or GCS ≤ 8 (assess loss of gag reflex)




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 78 of 179
Croup / Epiglottitis

Designation of Condition: Croup is characterized by viral infection of the respiratory tract
presenting with barking cough and/or inspiratory stridor due to inflammatory edema of the
subglottic region/narrowest part of the pediatric airway. Severe airway obstruction/ impending
respiratory arrest may be indicated by audible stridor at rest, retractions, decreased breath
sounds, cyanosis, or decreased LOC. Differential diagnosis includes airway or esophageal
foreign body. Epiglottis presents more commonly in slightly older to adult patients, with rapid
onset, high fever, drooling/dysphagia/subjective sense of obstruction, voice change, stridor, and
toxic appearance. Patients with respiratory distress are at high risk for complete airway
obstruction. Presentation in adults may be more indolent; immune compromised patients may be
particularly fulminant.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Allow patient to maintain position of comfort
♦   Keep patient comfortable and quiet, with parent
♦   Defer invasive procedures unless lifesaving intervention required
♦   Ongoing concern for oxygenation/ventilation
♦   Consider O2 via blowby for children

ALS PROVIDERS
♦ NEBULIZED EPINEPHRINE (1:1000): 1 mg (1 cc)/3 cc NS via Neb
  Consider administration for severe stridor.
♦ For impending or existing respiratory failure:
     · Intubation by most experienced person available
     · Prepare for definitive airway management, including surgical airway, with all
       equipment on hand.
     · Use ETT 0.5-1 mm smaller than usual size
     · BVM ventilation may be successful in children with sudden airway obstruction
       due to epiglottitis.

For suspected epiglottitis:
♦ Rapid transport of patient in position of comfort for definitive airway management in
   surgical setting.
♦ Defer invasive procedures unless lifesaving intervention required
♦ Establish communication with the ED as early as possible
♦ Intubation indicated only for severe distress. Consider likely difficult airway with significant
   chance of exacerbating compromise with laryngoscopy attempts.


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                                                 January 2009
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Diabetic Emergencies

Designation of Condition: Disorders in glucose metabolism and homeostasis characterized by
hypoglycemia and hyperglycemia.

Hypoglycemia: caused by increased insulin levels (e.g. overdose of oral hypoglycemic agent or
insulin, sepsis, renal failure, liver disease), and/or decreased glucose production (e.g. ETOH
abuse, drugs, beta blockers, liver disease, malnutrition, dehydration, third-trimester pregnancy).
Signs/symptoms include diaphoresis, anxiety, tachycardia, dizziness, altered LOC, focal
neurologic deficit, and seizure.

Hyperglycemia: caused by inadequate management of DM, increased dietary intake, decreased
insulin production (e.g. pancreatic disease, electrolyte disorders), and/or insulin resistance (e.g.
infection, AMI, trauma, surgery, stress, pregnancy).

Diabetic Ketoacidosis/DKA: syndrome of insulin deficiency/stress hormone excess producing
hyperglycemia, dehydration, acidosis, and electrolyte disturbances. Most often occurs with
medication noncompliance, new-onset DM, infection, AMI, GI hemorrhage, CVA, ETOH abuse,
and pregnancy. Signs/symptoms include weakness, abdominal pain, vomiting, tachycardia,
hypotension, altered LOC, Kussmaul respirations, odor of ketones.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Glucometry
♦ For BGL < 60 mg/dl, consider Oral Glucose administration if patient is awake and alert with
  intact swallow reflex.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

Hypoglycemia:
♦ DEXTROSE (D50): ½-1 amp IV/IO, may repeat dose in 10 min
  Administer for BGL < 60 mg/dl with symptoms of hypoglycemia.
  Pediatric dose:
      · Child > 30 kg (D50): 0.5-1 g/kg (1-2 cc/kg)
      · Child < 30 kg (D25): 0.5-1 g/kg (2-4 cc/kg)
        D25 = D50 diluted 1:1 with NS
      · Neonate (D10 or D12.5): 0.5-1 g/kg (4-8 cc/kg)
        D12.5 = D25 diluted 1:1 with NS (or D50 diluted 1:4 with NS)
♦ Repeat BGL should be performed following all DEXTROSE administrations
♦ Perform repeat BGL checks at site away from IV

                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 80 of 179
Diabetic Emergencies (contd)

♦ GLUCAGON: 1 mg IM, may repeat dose in 15 min x 2
  Administer for hypoglycemia when IV/IO access not obtainable. Follow with administration
  of Oral Glucose as soon as the patient is awake and alert with intact swallow reflex.
  Pediatric dose:
      · Child > 30 kg: 0.5 mg
      · Child < 30 kg: 0.02 mg/kg
♦ For clearance of patient who declines transport following glucose administration and
  stabilization, CONTACT MEDICAL CONTROL.
♦ Hypoglycemia from sulfonylureas (e.g. DIABINESE, AMARYL, GLIPIZIDE,
  GLYBURIDE) may be severe and prolonged, warranting ED observation and therapy.
♦ When used alone METFORMIN therapy does not produce hypoglycemia

Note: See Refusal of Transport

Hyperglycemia:
♦ For BGL > 300 mg/dl, bolus IVF 500 cc (pediatric dose: 20 cc/kg), and repeat following
  assessment of pulmonary function. Contraindications: pulmonary edema/
  CHF.




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                                               January 2009
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Drug Intoxication / Substance Abuse

Designation of Condition: Patient with acute intoxication from ingestion, injection, or
inhalation of recreational drugs. EMS providers should be aware of the signs/symptoms
associated with the abuse of ETOH, cocaine, heroin, amphetamines, hallucinogens, and
depressants, as well as the effects of polysubstance abuse.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Monitor: O2 Sat, cardiac
♦   Glucometry
♦   Ongoing concern for oxygenation/ventilation
♦   Transport all pills/pill bottles for ED identification

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Consider DEXTROSE and NALOXONE administration, as required.

Note: See Coma


Dystonic Reaction

Designation of Condition: Adverse reaction to antipsychotic, antiemetic or antidepressant
drugs, characterized by involuntary motor spasms of the periorbital muscles/eye (ocular
deviation), facial muscles/tongue (e.g. grimacing, trismus, tongue protrusion, dysphagia,
dysarthria), neck (torticollis), or trunk (twisting, arching). Common drugs include THORAZINE,
COMPAZINE, PHENERGAN, HALDOL, DROPERIDOL, and REGLAN.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Stabilize airway to prevent larynx or tongue spasm from causing respiratory compromise.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ DIPHENHYDRAMINE: 25-50 mg IV/IM (pediatric dose: 0.5 mg/kg)




                                  Santa Fe County Fire Department EMS Protocols
                                                   January 2009
                                                  Page 82 of 179
Fever

Designation of Condition: Elevation in the body’s set thermoregulatory point, influenced by
hormonal and autonomic control from the hypothalamus. Causes may include any infectious
process, drugs, systemic inflammatory disease, cancer, hyperthyroidism, PE, environmental
hyperthermia, overbundling (children), and malignant hyperthermia.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Patient may drink fluids if awake and alert with intact swallow reflex
♦ For temperature > 102º F (39º C), consider cooling with tepid sponge bath
♦ For temperature > 104º F (40º C) or seizure, proceed with more aggressive cooling measures
♦ Core temperature is most accurately measured rectally
♦ Febrile Seizure: may occur in otherwise healthy children 6 mo-5 yo with spiking fever.
  Typically generalized/tonic-clonic and brief/self-limited. May occur concurrent with
  recognition of febrile illness.
♦ ALS intercept for prolonged seizure (> 5 min), recurrent seizure, or status epilepticus

Note: See Seizure

BLS AND ABOVE PROVIDERS
♦ ACETAMINOPHEN: 650 mg PO/PR (pediatric dose: 10 mg/kg)
  Consider administration for febrile children (> 102º F/39º C), pregnant women,
  patients with seizure disorder or severe cardiac disease, hemodynamically unstable
  patients, or patients with altered mentation.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF for unstable patients or patients with altered LOC.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 83 of 179
Hazardous Materials Response (HAZMAT) / Toxic Substance Exposure

Designation of Condition: Patient with signs/symptoms or history suggesting overdose or
exposure to poisons, toxins, or hazardous materials (e.g. household, industry, agriculture,
transportation accidents).

ALL EMS PROVIDERS
♦   Recognize HAZMAT situation
♦   Establish Incident Command and scene security, as appropriate
♦   Do not attempt to retrieve or decontaminate patients until specifically equipped
♦   Remember your own safety first. Do not enter scene until safety of material is established.
    Wear appropriate-level chemical protective gear/SCBA, especially in closed-spaces, or if
    material safety remains in question. Approach from upwind/uphill.
♦   Attempt to identify substance, determine toxicity and precautions, and need for
    decontamination using:
        · Material Safety Data Sheet (MSDS)
        · Department of Transportation (DOT) placard
        · Shipping papers, hazard label
        · Department of Transportation Emergency Response Guide
        · New Mexico Poison Control (800-222-1222)
        · CHEMTREC (Chemical Transportation Emergency Center, 24 hr Emergency Response
          hotline, 800-424-9300).
        · Agency for Toxic Substances and Disease Registry (ATSDR, 24 hr Emergency
          Response hotline, 770-488-7100).
♦   New Mexico Poison Control is not recognized as Medical Control. Poison Control can aid in
    identification of unknown pills, identification of commercial toxins, and assist receiving
    hospitals with treatment guidelines.
♦   Notify regional New Mexico State Police Emergency Response Officer (NMSP ERO)
        · NM State Police Headquarters (24 hr Emergency Response, 505-827-9300)
♦   Always relocate patient to safe environment before beginning resuscitation efforts
♦   Establish Primary Management
♦   Use appropriate personal protective medical equipment
♦   Decontamination of patient and protection of providers are priorities
♦   Determine route and duration of exposure
♦   When in doubt, decontaminate. Copious irrigation with water/soap, with attention to
    contaminated areas, wounds, and exposed eyes. Irrigation contraindicated for elemental
    metals (e.g. sodium, potassium, magnesium).
♦   Secondary triage after decontamination
♦   Monitor: O2 Sat, cardiac

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                                                 January 2009
                                                Page 84 of 179
Hazardous Materials Response (HAZMAT) (contd)

♦ Ongoing concern for oxygenation/ventilation
♦ Establish communication with receiving ED as early as possible. Alert ED to HAZMAT
  response, determine number of patients and need for further decontamination.
♦ Transport only after adequate decontamination
♦ Ensure safety of individuals at the scene prior to patient transport
♦ Keep patient outside ED until plan for decontamination established

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Aggressive fluid resuscitation
♦ Provide adequate analgesia, as required

ALS PROVIDERS
♦ Aggressive airway management




                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                              Page 85 of 179
Heat Illness

Designation of Condition: Continuum of illness secondary to overwhelming environmental heat
stress, beginning with dehydration and electrolyte disturbances and progressing to
thermoregulatory dysfunction and multi-system organ injury.

Heat Cramps: severe muscle fatigue/spasms due to excessive sweating/sodium loss

Heat Exhaustion (core temp < 104º F/40º C): fluid and electrolyte depletion characterized by
headache, vomiting, dizziness, weakness, or diaphoresis.

Heat Stroke (core temp > 104º F/40º C): loss of thermoregulatory function characterized by
decreased LOC (e.g. confusion, delirium, coma, seizure), progression to hot/dry skin, and multi-
system organ injury. May be Nonexertional (Classic), developing over several days in patients
at risk due to old age, impaired mobility, chronic illness, obesity, enclosed residence,
dehydration, ETOH abuse, or use of sedatives/ anticholinergics/ antipsychotics. May be
Exertional, developing rapidly in younger athletic individuals due to combined environmental
and exertional heat stress overwhelming heat dissipating mechanisms.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Relocate patient to cool environment
♦ Patient may drink fluids if awake and alert with intact swallow reflex, consider commercial
  electrolyte solution.
♦ Accelerated cooling with fan evaporation, maximum body surface area exposure,
  misting/cool wet sheets, ice packs at neck/chest/axilla/groin. Avoid causing severe shivering.
♦ Glucometry
♦ Monitor core temp

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 86 of 179
High Altitude Illness


Designation of Condition: Complex of symptoms brought on by hypoxic conditions associated
with travel to high elevations (typically > 8000 ft). Incidence dependent on rate of ascent, final
altitude, sleeping altitude, duration at altitude, individual susceptibility, age < 55.

Acute Mountain Sickness (AMS): manifested by headache, fatigue, dizziness, nausea/vomiting,
and insomnia. Onset typically 4-12 hrs after ascent. Highest incidence, usually benign and self-
limited.

High Altitude Pulmonary Edema (HAPE): characterized by cough, dyspnea at rest, cyanosis,
rales, hypoxia. Onset typically 2-4 days after ascent. Caused by uneven pulmonary
vasoconstriction and capillary leak resulting in pulmonary edema. More common in younger
individuals.

High Altitude Cerebral Edema (HACE): characterized by severe headache, nausea/vomiting,
altered mental status, ataxia. Onset typically 2-4 days after ascent. Caused by cerebral
vasodilation and capillary leak resulting in cerebral edema. Occurs rarely, and in the presence of
HAPE and/or AMS.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Oxygenation/Ventilation
♦ Descend patient to lower altitude

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ FUROSEMIDE: 20-40 mg IV/IO




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 87 of 179
Hypothermia

Designation of Condition: Patient with a core body temperature < 95° F/35° C. Most common
presentation is cold exposure due to ETOH abuse, but also commonly seen with extremes of age,
sepsis, CVA, subdural hematoma, drugs, DKA, and cold-water immersion. Signs/symptoms vary
with temperature at presentation:

            Stage      Tempº <                               Characteristics
            Mild      95 F / 35 C    Shivering, slow mentation/flat affect, dysarthria
           Moderate   90 F / 32 C    Extinction of shivering, stupor, bradycardia, AFib, hypotension
                                     J-wave/Osborn
            Severe    82 F / 28 C    Coma, apnea, bradycardia, ↑susceptibility to VF
                      64 F / 18 C    Asystole
                      60 F / 16 C    Lowest accidental hypothermia survival


ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Relocate patient to warm environment
♦   Provide supplemental warm humidified O2
♦   Monitor: O2 Sat, cardiac
♦   For Moderate-Severe Hypothermia, the susceptibility to VF is significantly increased, and
    unnecessary manipulation, jostling, and esophageal/tracheal manipulation should be avoided.
♦   Prolonged palpation/auscultation for cardiac activity (> 30-45 sec at carotid)
♦   If ANY pulse is detected, DO NOT perform CPR. Apparent arrest may be depressed
    cardiac output, often sufficient to meet decreased metabolic demand.
♦   Remove all wet clothing/begin external warming (e.g. blankets, heat packs at
    neck/chest/axilla/groin).
♦   Glucometry
♦   Ongoing concern for oxygenation/ventilation
♦   Monitor core temp

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate warm IVF

ALS PROVIDERS
♦ When indicated, gentle intubation by most experienced person available

Note: See Cardiopulmonary Arrest – Hypothermia




                                    Santa Fe County Fire Department EMS Protocols
                                                     January 2009
                                                    Page 88 of 179
Narcotic Poisoning

Designation of Condition: Patient with overuse or abuse of oral prescription opioid analgesics,
or acute intoxication from the ingestion, injection, or inhalation of street narcotics. Patient may
present with miosis, vomiting, altered LOC, respiratory depression, bradycardia, hypotension,
and coma.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Monitor: O2 Sat, cardiac
♦   Glucometry
♦   Remove transdermal patches (wearing gloves)
♦   Ongoing concern for oxygenation/ventilation

BLS AND ABOVE PROVIDERS
♦ NALOXONE: 0.4-2 mg IM (pediatric dose: 0.01 mg/kg, repeat dose 0.1 mg/kg). Adult route
  option: 2 mg (1 mg/naris) via MAD (Mucosal Atomization Device). MAD contraindications:
  apnea, facial trauma, excessive secretions.
      · Administer at low dose and titrate for narcotic-habituated patients
      · Treatment goal is providing adequate oxygenation/ventilation
      · Abrupt reversal of narcotic depression possible
      · Monitor for recurrent respiratory depression, consider repeat of lowest effective
        dose that reversed symptoms Q 10-20 min.
      · High doses may be required to reverse effects of PROPOXYPHENE,
        METHADONE, and FENTANYL.
      · If a Rescue Airway device is required, once the airway is controlled and the
        patient stabilized, avoid further administration of NALOXONE.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Consider administration of NALOXONE IV/IO, may repeat dose Q 2-3 min up to 10 mg for
  severe refractory respiratory depression.

ALS PROVIDERS
♦ Intubate as required. Once the airway is controlled and the patient stabilized, avoid further
  administration of NALOXONE. May consider repeat doses for severe refractory bradycardia
  or hypotension.
♦ Consider DOPAMINE for refractory hypotension




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 89 of 179
Organophosphate Poisoning

Designation of Condition: Patient with exposure to insecticides (organophosphorus
compounds), or chemical nerve agents with signs/symptoms characteristic of cholinergic
toxidrome: (DUMBELS) Diarrhea/diaphoresis, Urination, Miosis/muscle fasciculations,
Bradycardia/bronchorrhea/bronchospasm, Emesis, Lacrimation, Salivation. Death is usually
secondary to respiratory failure resulting from bronchorrhea, bronchospasm, pulmonary edema,
weakness of respiratory muscles, and central depression of respiratory drive.

ALL EMS PROVIDERS
♦ Remember your own safety first. Do not enter scene until safety of material is established.
  Wear appropriate-level chemical protective gear/SCBA, especially in closed-spaces, or if
  material safety remains in question. Always relocate patient to safe environment before
  beginning resuscitation efforts.
♦ Establish Primary Management
♦ Use appropriate personal protective medical equipment (e.g. nitrile gloves, gown, eye
  protection).
♦ Decontamination of patient and protection of providers are priorities
♦ Remove all clothes and store as toxic waste
♦ Decontaminate skin with soap and water
♦ Ongoing concern for oxygenation/ventilation
♦ Monitor: O2 Sat, cardiac
♦ Frequent suctioning of respiratory secretions required
♦ Ensure safety of individuals at the scene prior to patient transport

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ ATROPINE: 1-4 mg IV/IO Q 5 min (pediatric dose: 0.05-0.2 mg/kg)
  Administer with goal of treatment being relief of bronchospasm and drying of airway
  secretions.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
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Poisoning / Overdose

Designation of Condition: Patient with signs/symptoms or history suggesting overdose or
exposure to poisons, toxins, or hazardous materials. Poisoning may be intentional, or accidental
(e.g. pediatric ingestion, therapeutic error). Any patient presenting with altered LOC without
definitive cause should have poisoning/overdose considered as a diagnosis.

Selected Toxidromes
♦ Anticholinergic (e.g. antihistamines, antipsychotics, antispasmodics, tricyclic
   antidepressants, jimson weed, poisonous mushrooms, nightshade).
       · Altered LOC/delirium (“mad as a hatter”)
       · Dry skin/mucous membranes (“dry as a bone”)
       · Mydriasis (“blind as a bat”)
       · Hyperthermia (“hot as a hare”)
       · Flushing (“red as a beet”)
       · Tachycardia
       · Hypertension
       · Urinary retention
♦ Cholinergic (e.g. insecticides, chemical nerve agents, poisonous mushrooms) - (DUMBELS)
       · Diarrhea/diaphoresis
       · Urination
       · Miosis/muscle fasciculations
       · Bradycardia/bronchorrhea/bronchospasm
       · Emesis
       · Lacrimation
       · Salivation
♦ Narcotic (e.g. prescription opioid analgesics, street narcotics)
       · Depressed LOC/coma
       · Respiratory depression/apnea
       · Miosis
       · Bradycardia
       · Hypotension




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                                                 January 2009
                                                Page 91 of 179
Poisoning / Overdose (contd)

♦ Sympathomimetic (e.g. cocaine, methamphetamines, ecstasy, amphetamines, ephedrine)
     · CNS excitation/agitation
     · Tachycardia
     · Hypertension
     · Diaphoresis
     · Mydriasis
     · Hyperthermia
     · Seizure
♦ Withdrawal Syndrome: ETOH, benzodiazepines, barbiturates
     · Tremor/agitation
     · Hallucinations
     · Tachycardia
     · Hypertension
     · Mydriasis
     · Seizure
     · Hyperthermia
♦ Withdrawal Syndrome: narcotics
     · Nausea/vomiting
     · Diarrhea
     · Cramps
     · Tachycardia
     · Hypertension
     · Mydriasis
     · Lacrimation
     · Salivation

ALL EMS PROVIDERS
♦ Remember your own safety first. Always relocate patient to safe environment before
  beginning resuscitation efforts.
♦ Establish Primary Management
♦ Use appropriate personal protective medical equipment
♦ Decontamination of patient and protection of providers are priorities
♦ Attempt to identify substance, determine toxicity and precautions, and need for
  decontamination using:
      · New Mexico Poison Control (800-222-1222)
      · Material Safety Data Sheet (MSDS)
                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
                                             Page 92 of 179
Poisoning / Overdose (contd)

♦ New Mexico Poison Control is not recognized as Medical Control. Poison Control can aid
  in identification of unknown pills, identification of commercial toxins, and assist receiving
  hospitals with treatment guidelines.
♦ When in doubt, decontaminate. Copious irrigation with water/soap, with attention to
  contaminated areas, wounds, and exposed eyes.
♦ Monitor: O2 Sat, cardiac
♦ Ongoing concern for oxygenation/ventilation
♦ Transport all pills/pill bottles, or household material containers for ED identification
♦ Ensure safety of individuals at the scene prior to patient transport
♦ Establish communication with receiving ED as early as possible
♦ Keep patient outside ED until plan for decontamination established

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ For any drug overdose (e.g. tricyclic antidepressants, cocaine, amphetamines) causing
  QRS widening > 0.12 sec, or ventricular arrhythmias, administer SODIUM
  BICARBONATE.

Note: See Tricyclic Antidepressant (TCA) Poisoning

♦ CALCIUM CHLORIDE (10%): 10 cc IV/IO [pediatric dose: 20 mg/kg (0.2 cc/kg)], may
  repeat for recurrent rhythm deterioration.
  Administer for calcium channel blocker overdose/toxicity presenting with hypotension
  refractory to IVF bolus, and/or arrhythmias. Do not use for patients receiving DIGOXIN.
♦ GLUCAGON: 1-3 mg IV/IO, or 0.05 mg/kg (pediatric dose: 0.05-0.1 mg/kg), may repeat in
  10 min.
  Administer for calcium channel blocker or beta blocker overdose/toxicity presenting with
  hypotension refractory to IVF bolus, and/or arrhythmias.




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                                                January 2009
                                               Page 93 of 179
Seizure

Designation of Condition: Patient typically presents with a generalized seizure, characterized
by altered LOC, involuntary, repetitive, and sustained muscle movements lasting 90-120
seconds, followed by a brief postictal state of confusion and somnolence. Patient may also
present with a partial seizure, involving motor symptoms without altered LOC, or a
nonconvulsive generalized seizure or partial seizure, characterized by altered LOC without motor
symptoms. Status epilepticus, generally defined as a prolonged seizure, or recurrent seizures
without a lucid interval, is a life-threatening emergency with a high mortality rate.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Glucometry
♦   Ongoing concern for oxygenation/ventilation
♦   C-spine immobilization in setting of head trauma
♦   ALS intercept for prolonged seizure (> 5 min), recurrent seizure, or status epilepticus

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ DIAZEPAM: 2-10 mg IV/IO, max dose = 20 mg (pediatric dose: 0.1-0.2 mg/kg,
  max dose ≤ 5 yo = 5 mg, max dose > 5 yo = 10 mg). Adult/pediatric route option: 0.2-0.5
  mg/kg PR (rectal gel).
  Administer for active seizures, titrate for effect. Decrease dose in elderly.
♦ VERSED: 1-5 mg IM/IV/IO, max dose = 10 mg (pediatric dose: 0.05-0.1 mg/kg,
  max 0.2 mg/kg).
  Administer if IV access unavailable, or if DIAZEPAM ineffective.
♦ Intubate as required for status epilepticus, or in the setting of high-dose BENZODIAZEPINE
  administration.
♦ Administer MAGNESIUM for seizure during pregnancy

Note: See Pre-Eclampsia / Eclampsia




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                 Page 94 of 179
Syncope

Designation of Condition: Transient loss of consciousness associated with loss of postural tone,
most commonly due a drop in cardiac output and decreased cerebral perfusion. Detailed medical
history is often the key to diagnosis, including pre-prodrome activities, prodrome symptoms (e.g.
lightheadedness, diaphoresis, visual disturbance, nausea, weakness), predisposing factors (e.g.
age, chronic disease, family history of sudden death), precipitating factors (e.g. stress, postural
symptoms), passerby/witness history, postictal phase (suggests seizure). Syncope that is
sudden/without prodrome symptoms, or associated with chest pain/palpitations suggests severe
cardiopulmonary disease. Pediatric syncope that occurs during exertion, secondary to stress,
while supine, or with family history of sudden death suggests severe underlying disease.

Neural Mediated: reflex vasodilation/bradycardia
    · Vasovagal Syncope (common faint): typical prodrome symptoms, stress induced
    · Carotid Sinus Syncope: triggered by cough/sneeze, GI stimulation, micturition
Orthostatic: positional change causing decreased venous return to heart
    · Volume Depletion: dehydration, hemorrhage
    · Autonomic Disease: diabetic neuropathy, Parkinson’s disease, drugs (e.g. beta
      blockers, ETOH).
Cardiopulmonary:
    · Arrhythmias: sudden and without prodrome symptoms (e.g. tachyarrhythmia,
      bradyarrhythmia, long QT syndrome, pacemaker/AICD malfunction).
    · Structural Disease: AMI, PE, aortic dissection, cardiomyopathy, valve disease,
      pericardial tamponade.
Neurologic: spike in intracranial pressure, postsyncope headache common
    · CVA, subarachnoid hemorrhage

ALL EMS PROVIDERS
♦ Establish Primary Management

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Cardiac monitor (12 lead ECG, rhythm strip)




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                                Page 95 of 179
Tricyclic Antidepressant (TCA) Poisoning

Designation of Condition: Patient with overuse or overdose of oral prescription tricyclic
antidepressant (e.g. AMITRIPTYLINE, NORTRIPTYLINE, IMIPRAMINE, DOXEPIN).
Overdose may be characterized by tremor/agitation or sedation, hypotension, tachycardia or
bradycardia, and ECG changes. Rapid deterioration may occur, including altered LOC,
arrhythmias, seizures, and coma.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Continuous cardiac monitor, 12 lead ECG
♦   Glucometry
♦   Transport all pills/pill bottles for ED identification
♦   Newer antidepressants, including atypical antidepressants (e.g. EFFEXOR, WELLBUTRIN,
    TRAZODONE, REMERON), selective serotonin reuptake inhibitors/SSRIs (e.g. PROZAC,
    PAXIL, CELEXA, LEXAPRO), and atypical antipsychotics (e.g. CLOZARIL, ZYPREXA,
    SEROQUEL, RISPERDAL, GEODON) have different toxicity profiles (including sedation,
    QTc prolongation, and seizure), less cardiovascular toxicity, and wider margins of safety
    than TCAs.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ SODIUM BICARBONATE: 1 amp IV/IO (pediatric dose: 1-2 mEq/kg), repeat for recurrent
  symptoms.
  Administer for any of the following signs/symptoms of cardiac toxicity:
      · ST > 130 (ST almost always present at some time after overdose)
      · QRS widening > 0.12 sec
      · Ventricular arrhythmias
      · Any arrhythmia/sudden change in rhythm
      · Hypotension
      · Seizures
♦ Terminal R-wave in lead aVR > 3 mm, and QTc prolongation also suggest TCA toxicity
♦ Intubate as required
♦ Administer DIAZEPAM for seizures
♦ Administer DOPAMINE for hypotension refractory to IVF bolus, may require high dose.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 96 of 179
Vomiting

Designation of Condition: Patient with severe or intractable nausea/vomiting.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Glucometry

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ PHENERGAN: 12.5-25 mg IM/slow IV (pediatric dose > 2 yo: 6.25-12.5 mg)
  Administer using lowest effective dose. Dilute with NS to minimum volume of 10 ml, and
  inject over 10 min through running IV line at port farthest from patient vein. For patient
  complaint of local pain, stop injection immediately. Contraindications: children < 2 yo,
  altered LOC, multi-system trauma (CONTACT MEDICAL CONTROL for physician
  approval). Precautions: children < 10 yo, trauma, severe cardiovascular disease, elderly.
♦ Provide adequate analgesia, as required

Note: See Dystonic Reaction




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 97 of 179
                VIII. Obstetric and Gynecologic Emergencies



Delivery - Breech

Designation of Condition: Abnormal delivery in which the buttocks or a foot is the presenting
part.

ALL EMS PROVIDERS
♦ Establish maternal Primary Management
♦ Provide O2 via NRB
♦ Place patient in left lateral recumbent position
♦ ALS intercept required
♦ Rapid transport
♦ Establish communication with receiving ED as early as possible
♦ Single limb presentation (e.g. footling breech, arm) or other abnormal presentations may
  require emergency C-section. Do not attempt manual reduction of limb. Do not attempt
  field delivery. Place patient prone in knee-chest position and transport.
♦ Prepare for neonatal resuscitation
♦ Assist breech delivery (buttocks presenting part) if needed:
      · Delivery in 3 stages: legs/abdomen, abdomen/shoulders, head
      · 2 critical moments with risk of fetal hypoxia: cord compression after delivery to the
        abdomen, head entrapment
      · Never attempt to pull infant by the legs or trunk from the vagina
      · Delivery of legs usually spontaneous, support infant’s body wrapped in towel
      · Once umbilicus is delivered, cord should be gently pulled down from vagina
      · Anterior arm/shoulder is delivered by extraction with a gloved finger, while gently
        angling infant’s body down.
      · Posterior arm/shoulder is delivered while gently elevating infant’s body
      · Infant will usually rotate until back faces anteriorly
      · Head should deliver within 30 seconds. For delay, place index/middle fingers of
        gloved hand into vagina, locate infant’s nose/mouth, push vaginal wall away from
        infant’s face to create air space.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 98 of 179
Delivery – Breech (contd)

       · If head does not deliver within 3 min, attempt Mauriceau Maneuver to tuck/flex head:
               - If needed, gently rotate infant until back faces anteriorly
               - With infant’s body in neutral position resting on forearm, place index/middle
                 fingers of gloved hand over fetal maxillary prominence on either side of the
                 nose. Apply gentle pressure to tuck/flex head for delivery.
               - Place other hand over fetal occiput to assist flexion

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                               Page 99 of 179
Delivery - Uncomplicated

Designation of Condition: Spontaneous delivery in which no complications are anticipated,
usually occurring in multiparous patient with history of prior rapid labor, nulliparous patient not
recognizing symptoms of labor, or patient with no prenatal care, lack of transportation, or
premature labor. Signs/symptoms of imminent delivery include history of ruptured membranes,
uterine contractions occurring at least Q 5 min and lasting 30-60 sec, desire to push, palpable
fetal parts, bulging of perineum, and widening of vulvovaginal area. Vaginal hemorrhage during
labor requires emergent transport/assessment for placenta previa or abruption.

ALL EMS PROVIDERS
♦   Establish maternal Primary Management
♦   Provide O2 via NRB
♦   Place patient in left lateral recumbent position
♦   ALS intercept required
♦   Rapid transport
♦   Establish communication with receiving ED as early as possible
♦   Patients in active labor should be transferred to Labor & Delivery immediately, unless
    delivery is imminent.
♦   Do not attempt to restrain or delay delivery
♦   Create clean field for delivery
♦   Use appropriate personal protective medical equipment/universal precautions
♦   Prepare for neonatal resuscitation
♦   If time permits, sterilize vaginal area with Betadine
♦   As crowning occurs, deliver head in controlled fashion, protect perineum with gentle direct
    pressure.
♦   Puncture amniotic membrane with gentle finger pressure if it remains intact/visible outside
    vagina.
♦   Quickly suction nose/mouth, then feel around neck for wrapped umbilical cord
♦   Presence of Nuchal Cord:
    · Attempt immediate gentle loosening of cord with fingers, manually reduce over head
    · If cord too tight, double clamp, cut cord, and deliver infant immediately
♦   Apply gentle downward pressure on fetal head with uterine contractions
♦   After delivering the anterior shoulder, the posterior shoulder and rest of infant will deliver
    rapidly
♦   Hold infant at level of uterus and suction nose/mouth
♦   Once cord pulse undetectable, double clamp middle of cord with sterile clamps and cut
    between


                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 100 of 179
Delivery – Uncomplicated (contd)

♦ Initial neonatal resuscitation steps: dry, warm, position, suction, stimulate
♦ Provide blowby O2 for central cyanosis
♦ Periodic evaluation at 30 sec intervals: respirations, HR, color

Note: See Neonatal Resuscitation

♦ Clean, dry and wrap newborn, cover head
♦ Placenta will spontaneously deliver in 5-30 min, do not pull on cord
♦ Observe for postpartum hemorrhage, gently massage fundus

Note: See Postpartum Hemorrhage

ILS AND ABOVE PROVIDERS
♦ Establish maternal IV/IO access and titrate IVF



                                   APGAR Score (1 & 5 minutes)
                  Element                   0                       1                    2
                 Appearance       Body & Extremities         Body Pink,            Completely Pink
                  (Color)            Blue or Pale          Extremities Blue
                 Pulse Rate              Absent                < 100 bpm             > 100 bpm
                   Grimace                None                  Grimace            Cough, Sneeze,
                 (Irritability)                                                        Cry
                  Activity                Limp               Some Flexion           Active Motion
                (Muscle Tone)                                of Extremities
                 Respirations            Absent            Slow & Irregular          Strong Cry




                                   Santa Fe County Fire Department EMS Protocols
                                                    January 2009
                                                  Page 101 of 179
High Risk Pregnancy

Designation of Condition: Any high risk obstetric condition, abnormal childbirth situation,
vaginal hemorrhage during labor, or anticipation of newborn complications. A high risk
pregnancy is indicated by any condition that may affect maternal or fetal health:

       · Maternal Disease: Autoimmune disease (e.g. lupus, thyroid disease), blood disorder
         (e.g. sickle cell anemia, thalassemia, thrombocytopenia), cardiopulmonary disease,
         diabetes, DVT/anticoagulant therapy, HIV/infectious disease, HTN, kidney
         disease/dialysis, organ transplant, physical disability, psychiatric disorder, seizure
         disorder, substance abuse.

       · Obstetric Conditions: Fetus with known birth defect, gestational age < 36 wks, history
         of preterm labor, lack of prenatal care, multiple gestation/IVF, pre-eclampsia/
         eclampsia, previous breech/C-section delivery, previous high risk pregnancy, previous
         poor pregnancy outcome, teenage pregnancy.

ALL EMS PROVIDERS
♦   Establish maternal Primary Management
♦   Provide O2 via NRB
♦   Place patient in left lateral recumbent position
♦   ALS intercept required
♦   Rapid transport
♦   Establish communication with receiving ED as early as possible

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 102 of 179
Neonatal Resuscitation

Designation of Condition: Delivery of newborn in the presence of meconium (green/brown
amniotic fluid), and/or newborn who presents with poor respiratory effort, poor muscle tone,
cyanosis, or prematurity. Approximately 10 % of newborns require some assistance at birth, with
only 1 % requiring extensive resuscitation. High risk pregnancies predict the need for
resuscitation.

                         Inverted Pyramid of Newborn Resuscitation

                                       Temperature (dry & warm)
            Assess &                   Airway (position & suction)
            Support                    Breathing (stimulate to cry)
                                       Circulation (heart rate & color)


             Always
             Needed                 Dry, Warm, Position, Suction, Stimulate


                                                   Oxygen


                                        Establish effective ventilation
                                                   · BVM
                                                   · ETT

             Rarely                          Chest Compressions
             Needed

                                                     ALS




ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Follow current NALS guidelines
♦   ALS intercept required
♦   Rapid transport
♦   Establish communication with receiving ED as early as possible
♦   Presence of meconium:
        · Suction nose/mouth/hypopharynx with bulb syringe upon delivery of head to the
          perineum.
        · If newborn is vigorous on delivery (e.g. good respiratory effort, crying, good muscle
          tone, good color), suction nose/mouth/hypopharynx with bulb syringe.
♦ Initial resuscitation steps: dry, warm, position, suction, stimulate
♦ Periodic evaluation at 30 sec intervals: respirations, HR, color
                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 103 of 179
Neonatal Resuscitation (contd)

♦ Assess HR by auscultation, or palpation of cord
♦ Provide blowby O2 for central cyanosis
♦ If reevaluation within 30 sec reveals gasping/apnea, central cyanosis despite blowby O2,
  and/or HR < 100 bpm, provide gentle ventilation with 100% O2 via BVM (rate of 40-60
  breaths/min).
♦ Newborn bradycardia is usually the result of hypoxia
♦ If reevaluation after 30 sec of BVM ventilation reveals HR < 60 bpm, begin chest
  compressions:
       · 2 thumb/encircling-hands technique
       · 3 compressions : 1 ventilation
       · 120 events/min (90 compressions : 30 ventilations)
♦ Continue chest compressions until HR ≥ 60 bpm
♦ Continue BVM ventilation until HR ≥ 100 bpm
♦ Glucometry

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access
♦ EPINEPHRINE (1:10,000): 0.01-0.03 mg/kg (0.1-0.3 cc/kg) IV/IO; OR 0.1 mg/kg (1 cc/kg)
  via ETT if IV/IO access cannot be established or is delayed.
  Administer for refractory bradycardia (HR < 60) despite adequate BVM ventilation/chest
  compressions for 30 sec. Repeat Q 3-5 min during CPR.
♦ Consider bolus IVF (10 cc/kg, may repeat once) for suspected blood loss, or refractory
  bradycardia (HR < 60) despite adequate BVM ventilation/chest compressions for 1 min.
♦ DEXTROSE (D10 or D12.5): 0.5-1 g/kg (4-8 cc/kg). D12.5 = D25 diluted 1:1 with NS (or
  D50 diluted 1:4 with NS).
  Administer for BGL < 60 mg/dl or prolonged resuscitation.
♦ NALOXONE: 0.1 mg/kg IM/IV/IO
  Consider administration in setting of isolated maternal narcotic treatment within 4 hrs of
  delivery, or for prolonged refractory central cyanosis/bradycardia (HR < 60) despite adequate
  BVM ventilation/chest compressions. Contraindication: maternal substance
  abuse/methadone therapy. Not recommended as part of initial resuscitative efforts.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 104 of 179
Neonatal Resuscitation (contd)

ALS PROVIDERS
♦ Presence of meconium:
      · If newborn is vigorous on delivery (e.g. good respiratory effort, crying, good muscle
        tone, good color), suction nose/mouth/hypopharynx with bulb syringe.
      · If newborn is not vigorous on delivery (e.g. poor/absent respiratory effort, poor muscle
        tone, central cyanosis), suction trachea immediately:
              - Insert ETT
              - Suction with ETT/meconium aspirator while slowly withdrawing (< 5 sec)
              - If no meconium retrieved, do not repeat intubation
              - If meconium retrieved and no bradycardia present, reintubate and suction.
                Repeat as necessary until little meconium recovered. If bradycardia present,
                provide BVM ventilation and consider suctioning again later.
♦ Intubate as required (e.g. BVM ventilation is ineffective or prolonged, chest compressions
  are performed, ETT administration of medication needed, prematurity).




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 105 of 179
Obstetric Transport / Trauma / Interfacility Transfer

Designation of Condition: Transport or interfacility transfer of the pregnant patient.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Provide supplemental O2
♦   Place patient in left lateral recumbent position
♦   Place safety belts over chest (below breasts and above gravid uterus), and over the thighs
♦   Monitor: O2 Sat, cardiac
♦   Monitor frequency and duration of contractions by palpation
♦   Establish communication with receiving ED as early as possible

Trauma in Pregnancy
♦ Fetal/uterine trauma includes placental abruption, fetal maternal hemorrhage, premature
   labor, uterine contusion or rupture (prior C-section), fetal demise, premature rupture of
   membranes, and hypoxemic or anatomic fetal injury.
♦ Signs/symptoms include abdominal pain, contractions, vaginal bleeding or leakage of fluid,
   and abdominal wall contusion/seatbelt injury.
♦ Identify maternal condition first
♦ Direct therapy at mother with no delays due to pregnancy
♦ Manage airway and resuscitate as required
♦ Ongoing concern for oxygenation/ventilation due to earlier risk of hypoxemia from
   diminished maternal oxygen reserve and buffering capacity.
♦ Physiologic hypervolemia during pregnancy may lead to underestimation of blood loss.
   Maternal tachycardia and hypotension may not occur until blood loss > 1500 cc.
♦ For full-spine immobilization after 24 wks gestational age, tilt patient on backboard 15/30° to
   left (or manually displace uterus to left).
♦ Determine gestational age to assess viability. Fetus generally considered viable at 24 wks,
   approximated by uterine fundus 3-4 cm above umbilicus.

ILS AND ABOVE PROVIDERS
Establish IV/IO access and titrate IVF




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 106 of 179
Obstetric Transport / Trauma / Interfacility Transfer (contd)

ALS PROVIDERS
♦ No NARCOTICS or BENZODIAZEPINES shall be given to a pregnant patient without on-
  line Medical Control (except for acute airway management).
♦ Monitor Fetal Heart Tones (FHTs) by Doppler (if available) before transport, en route, and
  upon arrival at the receiving hospital. If tocolytics are administered during transport and/or
  there is reported/suspected fetal distress, monitor FHTs Q 15 minutes.
♦ For interfacility transfer, consult receiving hospital physician or Labor and Delivery charge
  nurse for:
      · Temperature > 100.5° F/38° C
      · Maternal HR > 100 bpm
      · Maternal BP > 160/110 mmHG
      · FHTs > 160 or < 120
      · Active/worsening vaginal hemorrhage
      · Reported cervix dilation > 3 cm (EMS providers shall not perform exam)
      · Spontaneous rupture of membranes
      · Strong contractions occurring < Q 10 min, lasting > 30 sec
♦ If MAGNESIUM is administered during transport for preterm labor or pre-eclampsia/
  eclampsia, monitor for signs/symptoms of toxicity and decrease or discontinue drip as
  required. Maintain urine output > 0.5 cc/kg/hr.
♦ If blood/blood products are administered during transport, monitor for signs/symptoms of
  transfusion reaction (e.g. fever, pain at infusion site, urticaria/erythema/pruritis, dyspnea,
  tachycardia, hypotension, chest pain, nausea/vomiting, low back pain) and stop infusion as
  required, CONTACT MEDICAL CONTROL.

Note: See Allergic Reaction/Anaphylaxis




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 107 of 179
Placenta Previa / Abruptio Placentae

Designation of Condition: Placenta Previa involves the implantation of the placenta over the
internal cervical os, causing rupture of placental blood vessels from uterine enlargement and
cervical dilation. Painless vaginal bleeding in the second half of pregnancy is placenta previa
until proven otherwise. Abruptio Placentae involves the premature separation of the normally
implanted placenta, occurring in the second half of pregnancy prior to delivery. Painful vaginal
bleeding, contractions, and abdominal pain/tenderness are common, but may occur with no
external bleeding. Multiple risk factors include maternal HTN, blunt abdominal trauma, and use
of cocaine/ sympathomimetic drugs.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Provide O2 via NRB
♦   Place patient in left lateral recumbent position
♦   Monitor: O2 Sat, cardiac
♦   ALS intercept required
♦   Rapid transport
♦   Establish communication with receiving ED as early as possible
♦   Vaginal hemorrhage during labor requires emergent transport/assessment
♦   Physiologic hypervolemia during pregnancy may lead to underestimation of blood loss.
    Maternal tachycardia and hypotension may not occur until blood loss > 1500 cc.

ILS AND ABOVE PROVIDERS
Establish IV/IO access and bolus IVF




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 108 of 179
Postpartum Hemorrhage

Designation of Condition: Patient with ongoing blood loss, usually painless, that may result in
significant hypovolemia/shock. May occur immediately postpartum (e.g. uterine atony, genital
laceration, retained placental tissue, placenta accreta, uterine rupture, uterine inversion, puerperal
hematoma, coagulopathy), or delayed > 24 hrs (e.g. retained products of conception, edometritis,
withdrawal of exogenous estrogen, puerperal hematoma).

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Provide O2 via NRB
♦   Place patient in Trendelenburg position
♦   If perineum is torn/bleeding, apply direct pressure with dressing and have patient bring her
    legs together.
♦   If no laceration found, assume uterine atony and, after delivery of placenta, begin gentle
    uterine massage until firm.
♦   Encourage newborn breastfeeding to stimulate endogenous oxytocin
♦   Keep mother NPO (nothing by mouth)
♦   Physiologic hypervolemia during pregnancy may lead to underestimation of blood loss.
    Maternal tachycardia and hypotension may not occur until blood loss > 1500 cc.

ILS AND ABOVE PROVIDERS
Establish IV/IO access and bolus IVF

ALS PROVIDERS
♦ OXYTOCIN: 20 IU/1 L NS drip at 10 cc/min (or 20 IU IM)
  Administer for atony/hemorrhage after delivery of placenta, until bleeding controlled. Do not
  use as bolus for resuscitation.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 109 of 179
Pre-Eclampsia / Eclampsia (Toxemia)

Designation of Condition: Spectrum of disease ranging from pregnancy-induced hypertension
(PIH) with BP > 140/90 mmHg, to hypertension with proteinuria/peripheral edema (Pre-
Eclampsia), to Pre-Eclampsia with seizure (Eclampsia). Usually occurs from the third trimester
to 30 days postpartum. Pre-Eclampsia occurs in 6-8% of all pregnancies, and is the second
leading cause of maternal mortality. Etiology is unknown, but likely involves placental-mediated
diffuse arteriolar vasospasm and increased vascular permeability. Severe Pre-Eclampsia (BP >
160/110 mmHg) may be characterized by abdominal pain, nausea/vomiting, hyperreflexia,
severe headache, visual changes, and pulmonary edema.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Provide O2 via NRB
♦   Place patient in left lateral recumbent position
♦   Monitor: O2 Sat, cardiac
♦   Establish communication with receiving ED as early as possible

ILS AND ABOVE PROVIDERS
Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ MAGNESIUM: 4 g IV/IO over 10 min (dilute in 250 cc NS), followed by drip at 1-2 g/hr
  (5 g/250 cc NS = 20 mg/cc, 2 g/hr = 100 cc/hr).
  Administer for severe pre-eclampsia/eclampsia. Monitor for signs/symptoms of
  MAGNESIUM toxicity: hypotension, loss of patellar reflex, respiratory depression;
  decrease/discontinue drip if present.
♦ CALCIUM CHLORIDE (10%): 10 cc IV/IO over 10 min, may repeat
  Administer for MAGNESIUM toxicity.
♦ For seizure unresponsive to MAGNESIUM, administer DIAZEPAM

Note: See Seizure

♦ For interfacility transfer, consult receiving hospital physician for BP > 160/110, reported
  urine output < 0.5 cc/kg/hr, or signs/symptoms of MAGNESIUM toxicity. Ensure placement
  of Foley catheter for ongoing assessment of urine output.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 110 of 179
Prolapsed Cord

Designation of Condition: Abnormal delivery in which the umbilical cord precedes the fetal
presenting part, leading to cord compression, loss of placental circulation, and fetal hypoxia.

ALL EMS PROVIDERS
♦ Establish maternal Primary Management
♦ Provide O2 via NRB
♦ ALS intercept required
♦ Rapid transport
♦ Establish communication with receiving ED as early as possible
♦ Counsel patient to not push
♦ Do not attempt manual reduction of cord. Do not attempt field delivery. Place patient
  prone in knee-chest position and transport.
♦ Place gloved fingers/hand in the vagina to exert counter pressure against the presenting part,
  relieving pressure on cord.
♦ Keep exposed cord covered with gauze soaked in warm saline, do not manipulate




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 111 of 179
                     IX. Psychiatric / Behavioral Emergencies



Involuntary Restraint / Transport

Designation of Condition: Patient in need of medical and/or psychiatric evaluation and
treatment who is deemed by an EMS provider at risk of physical harm to self (e.g. threats/
attempts at suicide, mixed/labile mood or psychosis, unsafe behaviors due to impaired judgment,
unstable medical/psychiatric conditions, intoxication, inadequate diagnostic evaluation), physical
harm to other persons (e.g. homicidal or violent behaviors, persons in reasonable fear of violent
behavior), or physical impairment due to inability to care for self (e.g. unstable medical/
psychiatric conditions, impaired or extremely poor judgment, reasonable protection not available
in community).

Every patient encounter involves a balance of patient rights with the need for EMS to accomplish
its legal duty once summoned. Patients who present as a danger to themselves or others are
considered by law to be without decision-making capacity (e.g. ability to understand their
condition, ability to understand what medical/psychiatric treatment options exist, ability to make
appropriate decisions based on individual beliefs), and are the responsibility of the EMS system.
State mental health codes define the legal parameters for involuntary restraint/transport:

       Any person may be transported to an appropriate health care facility by an emergency
       medical technician, under medical direction, when the emergency medical technician
       makes a good faith judgment that the person is incapable of making an informed decision
       about his own safety or need for medical attention and is reasonably likely to suffer
       disability or death without the medical intervention available at such a facility.

               New Mexico Statutes Annotated Section 24-10B-9.1, Emergency Transportation

Licensed EMTs are strongly encouraged to CONTACT MEDICAL CONTROL for patient
encounters requiring involuntary restraint/transport. Providers shall document all factors leading
to judgment of patient decision-making capacity, including medical, psychiatric, and
environmental conditions. Competent and informed adults have a right to accept or refuse
treatment recommendations.

Behavioral emergencies caused by unstable medical/psychiatric conditions or substance abuse,
involving agitated, aggressive, violent, or dangerous patients at immediate risk for harm to self
or others may require the use of physical restraints and/or sedation for appropriate management,
permitting safe evaluation and treatment.




                                   Santa Fe County Fire Department EMS Protocols
                                                    January 2009
                                                  Page 112 of 179
Involuntary Restraint / Transport (contd)

Summon law enforcement at the first indication of danger.

Ensuring the safety of EMS providers is first priority. Providers shall not enter into or remain
in any situation that poses a threat to individual safety or the safety of the EMS team. Team
members should enter a scene together, and, commonly, depart together. The assessment of
scene safety is shared, but each provider has the authority to decline to enter or elect to leave any
potentially hazardous scene. If any team member elects to leave a scene, indicating a threat to
safety, all team members should leave immediately.

Patients in hazardous or threatening environments should be protected and relocated to safety
before providing definitive care.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Ensure the safety of EMS providers and the safety of the patient
♦ Perform risk assessment and attempt verbal de-escalation of situation before considering
  restraint and/or sedation. Attempt prompt evaluation in a quiet environment in a
  nonconfrontational manner. Develop therapeutic alliance.
♦ Consider all possible causes of agitation/violent behavior including hypoxia, hypoglycemia,
  seizure, pain, fear, confusion/claustrophobia, and brain injury.
♦ Whenever possible, law enforcement should be on scene and involved. For high violence
  potential, consider initial containment by police.
♦ Communicate to patient/family need for restraint to protect patient from self-harm, and
  protect providers.
♦ Restrain in a humane and professional manner using least restrictive method that protects
  patient.
♦ Restraint should be individualized, affording patient as much dignity as possible
♦ Restrain one or more extremities, progressing to four-point restraint as necessary. Restrain
  only the extremities necessary to ensure control, unless, in judgment of the provider, initial
  full-restraint is appropriate. Consider use of roll gauze, leather wrist/ankle restraints, or
  handcuffs/leg shackles. Secure each extremity to the stretcher, cot straps must be in place.
  Providers should be trained in use of handcuffs/shackles. Handcuff/shackle key must
  remain in presence of EMS provider, and be immediately available at all times.
♦ Continually monitor patient airway, breathing, circulation, and neurovascular status of
  restrained extremity.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 113 of 179
Involuntary Restraint / Transport (contd)

♦ Do not restrain patient in prone position. Prone/hobble restraints are inappropriate for EMS
  medical care due to lack of access for medical assessment and procedures, and risk of
  asphyxia. Patients found in prone/hobble restraints should be immediately rolled to side
  position. Assist in conversion to appropriate EMS restraint.
♦ Place intoxicated and/or sedated patient in left lateral recumbent or side position
♦ Documentation shall include the reasons for and means of restraint and/or sedation,
  ongoing patient assessment, and need for continued restraint. Document injuries to
  patient or providers resulting from restraint efforts.

ALS PROVIDERS
♦ The use of sedation to manage behavioral emergencies offers the least restrictive form
  of restraint, and is potentially therapeutic. Consider voluntary sedation as an alternative to
  physical restraint.
♦ For high violence potential, a combination of physical restraint and sedation offers safest
  management.
♦ Agitated delirium, associated with amphetamine overdose (e.g. cocaine, methamphetamine,
  PCP), can cause tachycardia, hypertension, hyperthermia, and sudden death. Combine
  physical restraint with sedation, and provide necessary cooling for the patient.
♦ Sedation contraindicated in multi-system trauma (CONTACT MEDICAL CONTROL for
  physician approval).
♦ HALOPERIDOL: 5 mg IM/IV, may repeat in 10 min
  Administer for unmanageable agitation, mania, agitated delirium, or psychosis. Reduce dose
  for mild agitation, elderly or debilitated patients, or in setting of hepatic/renal disease.
  Monitor for dystonic reaction, hypotension, seizure, QTc prolongation, and hyperthermia.
  Contraindications: depressed LOC (e.g. ETOH, narcotics), Parkinson’s disease, hypotension,
  seizure disorder, severe cardiovascular disease, anticholinergic overdose (e.g. antihistamine,
  antipsychotic, antispasmodic, tricyclic antidepressant), pregnancy, children < 12 yo.

Note: See Dystonic Reaction

♦ VERSED: 2-5 mg IM/IV, titrate to 0.1 mg/kg
  Alternative when HALOPERIDOL contraindicated. CONTACT MEDICAL CONTROL
  for approval of administration in combination with HALOPERIDOL for severe agitation,
  mania, agitated delirium, or psychosis (administer both medications at low dose and titrate
  for effect).




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 114 of 179
Psychiatric Facility Transport

EMS providers shall transport all psychiatric patients directly to an Emergency Department for
evaluation unless, after examination and in consultation with Medical Control and a receiving
hospital, there is confirmation that direct admission has been arranged to a separate mental health
facility, and the patient has no other complicating acute or chronic medical illness or injury.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 115 of 179
                                           X. Trauma



Bite Injury / Snake Envenomation

Designation of Condition: Patient with bite injury from animal, human, or reptile.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Remove constrictive clothing, jewelry
♦   Gently irrigate with NS and dress wound
♦   Achieve hemostasis on any bleeding wound
♦   Notify Animal Control, as appropriate

Snake Envenomation
♦ Establish Primary Management
♦ Remove constrictive clothing, jewelry
♦ Mark boundary of erythema/swelling
♦ Immobilize extremity in functional position
♦ Keep physical activity minimal
♦ Monitor: O2 Sat, cardiac
♦ Establish communication with receiving ED as early as possible to assure CroFab/Antivenin
   availability.
♦ Increased urgency in transport of children since envenomation more likely to be severe
♦ Transport snake, if available (severed head can still envenomate)
♦ For exotic/non-indigenous snake envenomation (e.g. pet, zoo or research specimen) notify
   New Mexico Poison Control (800-222-1222).

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and bolus IVF
♦ Provide adequate analgesia, as required

ALS PROVIDERS
♦ Consider DOPAMINE for refractory hypotension




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 116 of 179
Burns

Designation of Condition: Burns should be classified by source (e.g. scald, contact, thermal,
radiation, chemical, electrical), and severity, estimating depth and size. Particular attention
should be paid to risk of inhalation injury, characterized by facial burns, singed nasal hair,
carbonaceous sputum, oropharyngeal injection, voice change, or wheezing. Carbon monoxide
and/or cyanide poisoning may result from exposure to combustion. Electrical burns may have
minimal external findings.

Classification:
     · Superficial (first-degree): local erythema and pain (epidermis only)
     · Partial-Thickness (second degree): divided by depth (epidermis and dermis)
     · Superficial Partial-Thickness – erythema, pain, blisters/wet, good capillary
       refill.
     · Deep Partial-Thickness – dermis white to yellow, no pain, blisters/wet, absent
       capillary refill.
     · Full-Thickness (third-degree): leathery, pale or charred skin, no pain, no blisters/dry
       (epidermis, dermis and subcutaneous tissue).

Body Surface Area:
♦ Report burn as percent involvement of BSA

                                             Rule of Nines




♦ Palm Surface Area of patient approximates 1% BSA, helpful in estimating size of
  small/scattered burns.


                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 117 of 179
Burns (contd)

Moderate Burns:
♦ Partial-Thickness burns < 20% BSA for adults, < 10% BSA for children
♦ Full-Thickness burns < 10% BSA

Major Burns:
♦ Partial-Thickness burns > 20% BSA for adults, > 10% BSA for children
♦ Full-Thickness burns > 10% BSA
♦ Burns involving hands, face, eyes, ears, feet, or perineum
♦ Inhalation injury, high-voltage electrical injury, multi-system trauma, preexisting disease.
♦ Circumferential burns
♦ Patients with respiratory symptoms from smoke or chemical inhalation, respiratory tract
  burns, and/or burns involving the face, head, or chest are at increased risk for respiratory
  failure, hypothermia, and later for shock and infection. Transport to closest appropriate
  facility for initial stabilization, and subsequent transfer to Regional Burn Center (UNM
  Hospital).

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Stop the burning process, remove smoldering clothes/jewelry
♦ Chemical burns:
      · Identify contaminant
      · Brush off dry contaminant prior to irrigation
      · Unless contraindicated, flush gently with water for 10 min
♦ Estimate depth and size of injury
♦ Partial thickness burns < 10% BSA for adults, < 5% BSA for children may be cooled with
  water for 10-15 min.
♦ Cover wounds with clean dry sheets and keep patient warm
♦ Ongoing concern for oxygenation/ventilation
♦ For suspected carbon monoxide poisoning, 100% O2 via NRB
♦ Burns with suspected airway involvement, and major burns > 20% BSA require ALS
  intercept.
♦ Multi-system trauma protocols supersede burn protocols
♦ Spine immobilization in setting of trauma or decreased LOC
♦ Initial stabilization at closest appropriate facility



                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 118 of 179
Burns (contd)

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Avoid IV placement in region of injury unless required
♦ For major Partial-Thickness and Full-Thickness burns, bolus IVF 500 cc (pediatric dose: 20
  cc/kg). May repeat following assessment of pulmonary function.
♦ Provide adequate analgesia, as required

Cyanide Poisoning:

♦ CYANOKIT (HYDROXOCOBALAMIN): 5 g (two 2.5 g vials) IV over 15 min, may repeat
  once (infused over 15 min-2 hrs) depending on severity of poisoning/clinical response
  (suggested pediatric dose: 70 mg/kg, though safety and effectiveness not established). May
  produce substantial increase in BP.
  Administer for known or suspected cyanide poisoning.
♦ Patients with cyanide poisoning may present with mydriasis, headache, nausea/vomiting,
  dyspnea, chest tightness, hypertension, altered LOC, shock, seizure, or cardiorespiratory
  arrest.
♦ Cyanide poisoning may result from inhalation, ingestion, or dermal exposure to cyanide-
  containing compounds including smoke from closed-space fires. The presence and extent of
  poisoning are often initially unknown. Decision to treat must be made on the basis of clinical
  history and signs/symptoms of cyanide intoxication. If clinical suspicion of cyanide
  poisoning is high, CYANOKIT should be administered without delay.
♦ Not all smoke inhalation victims will have cyanide poisoning and may present with similar
  symptoms (e.g. headache, dyspnea, vomiting), as well as exposure to other toxic substances
  making diagnosis difficult. Exposure to closed-space fire/smoke, and the presence of
  altered LOC (e.g. confusion, disorientation) and/or mydriasis is suggestive of true
  cyanide poisoning.

ALS PROVIDERS
♦ Airway control paramount. Consider early intubation for severe nasolabial burns, inhalation
  injury or circumferential neck burns.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 119 of 179
Burns – Delayed Transport / Interfacility Transfer

Designation of Condition: Patients with burns sustained > 1 hr prior to EMS contact due to
delayed system activation, and/or interfacility transfer.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Ensure the patient is dry and warm
♦ Ongoing concern for oxygenation/ventilation

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Fluid resuscitation for major Partial-Thickness and Full-Thickness burns using Parkland
  Formula: 4 cc NS/kg/% BSA IV/IO over 24 hours, give one half of the total over the first 8
  hrs post burn, give the remaining half over the next 16 hrs.
      · Example for delayed transport: 4 cc x 70 kg x 30% BSA = 8400 cc/24 hrs, give
        one half (4200 cc) over the first 8 hrs, give the remaining half (4200 cc) over the
        next 16 hrs. For this patient presenting 3 hrs post burn, give the first 4200 cc
        over 5hrs.
      · Goal of resuscitation is a patient with stable VS, good mentation, and adequate
        urine output.
♦ For interfacility transfer of major Partial-Thickness and Full-Thickness burns, ensure that a
  foley catheter is placed for adequate monitoring of resuscitation efforts. Maintain urine
  output of 0.5-1 cc/kg/hr for adults (1-1.5 cc/kg/hr for children).
♦ Provide adequate analgesia, as required
♦ Monitor VS Q 15 min with ongoing patient assessment

ALS PROVIDERS
♦ Ensure appropriate airway control prior to transport. For interfacility transfer, if a question
  exists regarding adequacy of airway management, encourage the sending physician to contact
  the receiving physician. Contact the EMS Medical Director for assistance if an issue remains
  unresolved after a physician-to-physician consult.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 120 of 179
Extremity Trauma - Amputation

Designation of Condition: Patient with partial or complete amputation who may be a candidate
for revascularization or replantation surgery.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Prognosis for surgery dependent on location of injury, ischemia time, mechanism of injury,
  and co-morbid disease.
      · Warm ischemia time (elapsed time since injury without cooling): 4-6 hrs for major
        amputations, 8 hrs for digits.
      · Cold ischemia time (elapsed time since injury with cooling of amputated part):
        10-12 hrs for major amputations, 24 hrs for digits
♦ Collect amputated part, including all pieces of bone, tissue, or skin
♦ Care of amputated part:
      · Remove gross contamination/foreign material with gentle NS irrigation
      · Wrap in NS moistened gauze
      · Place in clean dry plastic bag or cup
      · Place sealed bag/cup in ice water (half water/half ice)
      · Do not place part directly onto ice or in ice water
♦ Care of stump:
      · Remove gross contamination/foreign material with gentle NS irrigation
      · Cover with NS moistened gauze
      · Elevate injured limb
      · For hemorrhage, direct pressure using bulky dressing or pressure points if ineffective
      · For uncontrolled hemorrhage, tourniquet with BP cuff (inflate to 30 mmHg above SBP)
      · Partial amputations bleed more due to lack of retraction/spasm of vessels
      · Splint partial amputations in anatomic position
      · Avoid clamps or debridement
♦ Avoid repeated examinations of stump or amputated part
♦ Rapid transport to nearest hospital with surgery/trauma service
♦ Helicopter transport from remote locations should be considered for major amputations if
  ischemia time of concern.
♦ Establish communication with the ED as early as possible
♦ All pediatric amputations considered for replantation

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Provide adequate analgesia, as required
                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 121 of 179
Extremity Trauma - Fractures

Designation of Condition: Patient with extremity pain, swelling, and decreased ROM, and
mechanism suggesting bone injury. Complications include neurovascular injury, open fracture
(deformity with obvious or subtle nearby violation in skin integrity), and compartment syndrome
(characterized by severe pain, especially in forearm/calf/foot, severe pain with passive stretching
of fingers/toes, or sensory deficit in distal extremity). Significant strains, sprains, and
dislocations should be treated as fractures until proven otherwise.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Spine immobilization in setting of head injury, major trauma, or decreased LOC
♦ Minimal splinting of extremities in critical trauma patients is acceptable
♦ Sterile dressings over open wounds
♦ Perform neurovascular exam before and after splinting, reassess frequently
♦ Splint extremity in position found. Immobilize joints above and below fracture (splint limb).
  If extremity movement required for extrication, gently straighten and splint.
♦ Provide gentle longitudinal traction to correct deformity of angulated extremity if distal
  pulses or sensation absent. Reassess neurovascular exam.
♦ For femur fractures, traction splint for pain control if transport time prolonged
♦ For isolated hip fractures, transport without use of a backboard/vacuum splint will increase
  comfort and minimize pain.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Provide adequate analgesia, as required:
      · FENTANYL: 1-2 mcg/kg IV/IO Q 30 min; OR,
     · MORPHINE: 2-20 mg IV/IO (pediatric dose: 0.1-0.2 mg/kg/dose Q 30 min)
        Administer at low dose and titrate for effect.
♦ Narcotics contraindicated in multi-system trauma (CONTACT MEDICAL CONTROL for
  physician approval).




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 122 of 179
Eye Injury

Designation of Condition: Patient with exposure to foreign objects, chemicals, heat, or radiant
energy causing damage to the cornea and often extending to adjacent structures.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ For obvious penetrating trauma, do not irrigate. Cover both eyes with loose dry dressing and
  transport patient sitting upright.
♦ Suspect penetrating foreign body with high-speed mechanism (e.g. machine operation,
  hammering metal), or teardrop-shaped pupil. May cover with eye shield.
♦ Remove contact lens if possible
♦ For chemical or foreign body exposure, irrigate with NS ≥ 15 min or until 1 L used
♦ For Alkali exposure (e.g. ammonia, cleaning agents, soaps, chemical fertilizer, refrigerant,
  fireworks, lime, plaster, mortar, cement, whitewash, automobile airbag powder), continuous
  irrigation en route to hospital indicated.
♦ For exposure to chemical irritants used by law enforcement (e.g. mace, pepper spray/foam),
  irrigate at scene for 15-30 min unless coexisting conditions require transport. If
  signs/symptoms of irritation resolve, transport may not be required.
♦ For thermal injury (e.g. flash burn, flame, steam, smoke/hot gas, hot liquid), or ultraviolet
  keratitis (e.g. welder’s burns, snow blindness), apply cool moist dressing with overlying ice
  packs.
♦ Automobile airbag deployment may cause direct contact injury and/or alkali exposure
♦ Consider covering both eyes to decrease eye movement and control pain.

ALS PROVIDERS
♦ PROPARACAINE: 2 drops to affected eye Q 15 min, as needed for comfort
  Administer for ocular pain, foreign body sensation, photophobia, or prior to irrigation.
  Contraindication: penetrating trauma.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 123 of 179
Head Injury – Increased ICP

Designation of Condition: Patient with closed head injury or penetrating head trauma with
suspected increased ICP or herniation, characterized by decreasing LOC, bradycardia,
hypertension (Cushing response), diminished/irregular respiratory rate, blown pupil with
decorticate/decerebrate posture, and seizure.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Spine immobilization
♦   Monitor VS Q 5 min with ongoing patient assessment/GCS score
♦   Monitor: O2 Sat, cardiac
♦   Glucometry
♦   Ensure adequate oxygenation/ventilation (O2 Sat > 90%)
♦   Elevate head of bed 30º
♦   ALS intercept required
♦   Rapid transport to nearest hospital with neurosurgery/trauma service
♦   Establish communication with the ED as early as possible
♦   Patients should not receive medication (e.g. NTG) in an attempt to lower blood
    pressure.

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF
♦ Ensure adequate perfusion (SBP > 90 mmHg)
♦ DEXTROSE (D50): ½-1 amp IV/IO
  Administer for BGL < 60 mg/dl.

ALS PROVIDERS
♦ If intubation required, premedicate with FENTANYL (or LIDOCAINE)
♦ Provide controlled ventilation with target ETCO2 35-40 mmHg (16-20 breaths/min for
  adults, 20-24 breaths/min for children, 24-26 breaths/min for infants).
♦ Hyperventilation is not indicated for increased ICP unless patient presents with severe
  signs/symptoms suggesting herniation. Attempt hyperventilation with target ETCO2 30-35
  mmHg.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 124 of 179
Sexual Assault

Designation of Condition: Patient subjected to forced sexual contact without consent, often
with associated external and internal injuries.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Request law enforcement
♦ Provide comfort and reassurance
♦ Treat injuries, as appropriate
♦ Do not examine genital area unless serious injuries suspected
♦ Survey scene and preserve articles of evidence on or around patient in collaboration with law
  enforcement.
♦ Discourage patient from changing clothes, washing/showering, douching, or eating/drinking
♦ Carefully and objectively document all findings including patient history, location of assault,
  description of assailants, how/where patient was found, and all physical complaints/injuries.
♦ Patient referrals:
      · Santa Fe Rape Crisis and Trauma Treatment Center / Rape Crisis Hotline
        (800-721-7273)
      · SANE (Sexual Assault Nurse Examiner) Program / Family Advocacy Center
        (505-995-4999, 505-989-5952 ans. serv.)
      · Hospital Emergency Department
      · Any law enforcement agency (City of Santa Fe, Santa Fe County Sheriff, NM State
        Police, Tribal Police)
      · For suspected child sexual assault contact SANE, CYFD, or any law enforcement
        agency.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 125 of 179
Spinal Injury Assessment / Immobilization

Designation of Condition: Patient with suspected direct or associated spinal injury based on
significant mechanism of blunt or penetrating trauma, or with subjective or objective spinal pain
or neurologic deficit. All multi-system or critical trauma patients should be managed and
transported with full spine immobilization.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Limit movement and provide in-line stabilization until arrival of trained providers and
  equipment.
♦ Use clinical judgment. If in doubt, immobilize.
♦ Ongoing concern for oxygenation/ventilation

BLS AND ABOVE PROVIDERS
♦ Patients shall be managed/transported with spine immobilization if any criteria are met:
      · Significant or unknown mechanism of injury*
             - Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in
                structural collapse).
             - Sudden acceleration/deceleration, or lateral bending forces to neck or torso
                (e.g. MVA, pedestrian vs. auto, explosion injury).
             - Fall > 3 ft. For age > 65 yo, includes fall from bed or standing position.
             - Ejection or fall from transportation (e.g. automobile, motorcycle, ATV,
                bicycle, skateboard, scooter).
             - Axial load (e.g. diving, football)
             - Unwitnessed LOC

               * Mechanism alone may not necessitate immobilization but should alert providers
                 to the need for spinal injury assessment.

       · Altered LOC, altered mentation, or intoxication
              - CHI
              - Substance abuse or medication
              - Medical/psychiatric conditions affecting mentation
              - Difficult historian (e.g. children, elderly with cognitive disorders)
              - Inability to communicate (e.g. developmental delay, language barrier)




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 126 of 179
Spinal Injury Assessment / Immobilization (contd)

      · Painful or distracting injury
             - CHI
             - Fractures, lacerations, crush injuries
             - Abdominal or pelvic pain
             - Burns
             - Acute medical conditions (e.g. cardiac chest pain, dyspnea)
      · Subjective/Objective spinal pain
             - Complaint of pain
             - Examination reveals tenderness, swelling, bruising, abrasion, or deformity
      · Subjective/Objective neurologic deficit
             - Complaint of transient or ongoing altered sensation, tingling, or weakness
             - Examination reveals altered sensation, weakness, or paralysis
      · Neck pain with unassisted motion
             - Complaint of pain
             - Complaint of altered sensation, tingling, or weakness
♦ Patients with penetrating trauma shall be managed/transported with spine immobilization for
  subjective/objective spinal pain or neurologic deficit, or suspected spinal injury based on
  wound location.

Management of Positive Spinal Injury Assessment
♦ In-line stabilization
♦ Bring head to eyes-forward position if no pain or resistance met
♦ Apply properly-sized rigid cervical collar
♦ Follow current Department of Transportation (DOT) extrication guidelines
♦ With cervical collar, immobilization, and physical support, extricate patient to long back
  board. Maintain infants in car seat.
♦ Secure with head immobilizer or blanket rolls/tape

Management of Negative Spinal Injury Assessment
♦ Spine clearance requires an alert, sober, and cooperative patient
♦ Immobilization not indicated, transport for hospital evaluation
♦ For patients > 65 yo with significant or unknown mechanism of injury, apply cervical collar
♦ For unclear, vague, or uncertain cases, apply cervical collar




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 127 of 179
Spinal Injury Assessment / Immobilization (contd)

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ Intubate as required using manual in-line spine immobilization

Note: See Airway Management – Trauma


TASER Projectile Removal

Designation of Condition: EMS providers may be requested to remove TASER projectiles
imbedded in a patient’s skin following law enforcement deployment.

ALL EMS PROVIDERS
♦   Confirm TASER has been disconnected
♦   Establish Primary Management
♦   Monitor: O2 Sat, cardiac/rhythm strip
♦   Glucometry
♦   Evaluate and treat secondary injuries
♦   Transport for hospital evaluation for abnormal vital signs, abnormal ECG/rhythm strip, or
    altered LOC.
♦   Transport for hospital evaluation/projectile removal as required due to pain
♦   During projectile removal, avoid self-injury with barbed tip. Inspect projectile to confirm its
    removal intact. Transport to hospital for possible retained foreign body.
♦   Basic wound care
♦   Document per protocol




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 128 of 179
Trauma - Blunt

Designation of Condition: Patient with trauma from direct blunt force to the head, neck, chest,
abdomen, or back, or from forces related to rapid deceleration. Blunt chest trauma typically
occurs in combination with other injuries, though some severe intrathoracic injuries, such as
traumatic aortic disruption, may occur with no external signs. Abdominal solid organs are
injured more frequently than hollow viscous organs, with injury usually manifesting as
hemorrhage. Normal vital signs do not preclude significant intra-abdominal injury.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Primary concerns are spine immobilization, airway management, and fluid resuscitation
♦   Initiate transport AS SOON AS POSSIBLE
♦   Avoid long scene times. Delays may occur due to prolonged extrication, emergent airway
    management, MCI, or a dangerous patient.
♦   Provide O2 via NRB
♦   Monitor: O2 Sat, cardiac
♦   Rapid transport to nearest hospital with surgery/trauma service
♦   Call for ALS intercept
♦   For helicopter transport, call for rendezvous en route when necessary
♦   Pediatric considerations:
        · Children tend to tolerate trauma better
        · Rib cage is elastic and can withstand significant forces without signs of external
          trauma, though major internal injuries may exist.
        · Small intrathoracic abdomen exposes spleen and liver to more injury because they lie
          outside the ribcage.

ILS AND ABOVE PROVIDERS
♦ Establish multiple IV/IO access and titrate IVF en route
♦ Aggressive fluid resuscitation, as appropriate

ALS PROVIDERS
♦ Aggressive airway management, intubate as required using manual in-line spine
  immobilization.
♦ Needle thoracostomy for tension pneumothorax
♦ Apply occlusive dressing taped on 3 sides for open pneumothorax

Note: See Trauma STAT Activation


                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 129 of 179
Trauma - Penetrating

Designation of Condition: Patient with penetrating trauma to the head, neck, chest, abdomen,
back, or proximal extremities.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Primary concerns are spine immobilization, airway management, and fluid resuscitation
♦ Initiate transport AS SOON AS POSSIBLE
♦ Avoid long scene times. Delays may occur due to prolonged extrication, emergent airway
  management, MCI, or a dangerous patient.
♦ Provide O2 via NRB
♦ Monitor: O2 Sat, cardiac
♦ Sterile dressings over open wounds or exposed bowel
♦   Secure impaled foreign objects in place – Do not remove
♦   Control hemorrhage with direct pressure using bulky dressing or pressure points if ineffective
♦   Rapid transport to nearest hospital with surgery/trauma service
♦   Call for ALS intercept
♦   For helicopter transport, call for rendezvous en route when necessary

ILS AND ABOVE PROVIDERS
♦ Establish multiple IV/IO access and titrate IVF en route
♦ Aggressive fluid resuscitation, as appropriate

ALS PROVIDERS
♦ Aggressive airway management, intubate as required using manual in-line spine
  immobilization.
♦ Needle thoracostomy for tension pneumothorax
♦ Apply occlusive dressing taped on 3 sides for open pneumothorax

Note: See Trauma STAT Activation




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 130 of 179
Trauma STAT Activation - St. Vincent Hospital, Santa Fe

Designation of Condition: Patient with multi-system or critical trauma being transported to
St. Vincent Hospital/Santa Fe Regional Medical Center. Trauma STAT is the terminology used
to request the highest state of readiness and preparation prior to arrival at SVH, as well as
activation of the Trauma Service.

Trauma STAT Criteria:
♦ Confirmed SBP < 90 mmHg at any time in adults
♦ Hypotension (age-specific) at any time in children

                               Pediatric (Age-Specific) Hypotension
                               Any Age        Loss of Peripheral Pulses
                                 0-2 yo           SBP < 65 mmHg
                                 2-5 yo           SBP < 75 mmHg
                                6-12 yo           SBP < 80 mmHg


♦ RR > 30, or airway obstruction, or intubation
♦ GCS ≤ 8 secondary to trauma
♦ GSW to head, neck, chest, abdomen, groin, back, or proximal extremity with absent distal
  pulse.
♦ SW to neck, chest, abdomen, groin, back, or proximal extremity with absent distal pulse.
♦ Penetrating injury with major external arterial hemorrhage
♦ Obvious pelvic fracture with significant mechanism
♦ Obvious flail chest
♦ Interfacility transfer receiving blood transfusion to maintain stable vital signs
♦ Consider Trauma STAT Activation for significant injury mechanism in patient < 5 yo,
  > 55 yo, pregnant, or with serious co-morbid disease.
♦ Use clinical judgment. If in doubt, call Trauma STAT.

Establish communication with the ED as early as possible.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 131 of 179
                                  XI. Communications



ALS Dispatch Activation

EMS providers should request dispatch of an ALS unit for complex patients, patients with
worsening symptoms, or patients needing a higher level of care. Request for ALS dispatch may
be encouraged or required in individual protocols. Never exceed your ability, experience, or
scope of practice. Use clinical judgment. If in doubt, request ALS dispatch.

EMS Dispatch should simultaneously dispatch a BLS unit and the nearest ALS unit for the
following calls (not limited to):
♦ Cardiac Arrest
♦ Respiratory Arrest
♦ Airway emergencies
♦ Active chest pain consistent with acute coronary syndrome/AMI
♦ Major trauma
♦ CVA
♦ Altered LOC
♦ Allergic reactions
♦ Abdominal pain
♦ Critical pediatrics
♦ Active labor
♦ Major burns
♦ Overdose
♦ Emergency Medical Dispatch priority

Providers should confirm that the nearest ALS unit is en route. However, transport of critical
patients to an appropriate receiving hospital should not be delayed.

Providers may cancel ALS dispatch after arriving on scene and gaining additional patient
information. Responding ALS providers may cancel previously activated ALS dispatch as
appropriate. Following a full patient assessment and examination, an ALS unit my transfer to a
lower level of care if there is no reasonable expectation that the patient will require more
advanced intervention or treatment. The assessment and decision for transfer of care shall be
documented.

Note: See Transfer of Care Responsibility and Delegation
                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 132 of 179
EMS Medical Director Notification

The EMS Medical Director shall be notified by the appropriate chain of command of the
following events and issues:
♦ RSI
♦ Critical Airway Events/Failed Airways (unsuccessful placement of ETT or rescue airway
    device).
♦ Cricothyrotomy
♦ IO placement
♦ HALOPERIDOL administration
♦ Medication errors or omissions
♦ Procedure errors or omissions
♦ Failure to contact Medical Control for medication administration or intervention when
    required.
♦ Protocol deviation
♦ Poor patient outcome considered secondary to EMS care or transport
♦ Unresolved disputes with physicians




                              Santa Fe County Fire Department EMS Protocols
                                               January 2009
                                             Page 133 of 179
Helicopter Transport

Time is a crucial factor in the treatment of critically ill and injured patients. The mortality rate
for untreated trauma is approximately 50 % during the “Golden Hour” following injury, time that
is easily used up with patient extrication, stabilization, and ground transport to the nearest
facility. To preserve this critical period, and ensure timely delivery of patients to definitive
treatment, emergency helicopter transport may be required.

Helicopter transport complements the basic and advanced life support available in the regional
EMS system. Activation of the service dispatches a Critical Care Team (flight nurse and
paramedic) directly to a scene for emergency care and stabilization, and rapid transport with
advance life support during flight. Flight crews can also be called upon to supplement EMS
providers in assisting with the care of critical, complex, or unusual patients or injuries, and can
provide consultation and assistance with ground transport issues affecting patient care.


                             Air Ambulance Companies                             Dispatch



                      CAREFLIGHT (TriState CareFlight) 800-800-0900


                      PHI (Petroleum Helicopters Intl)                    800-633-5438



Aircraft radio equipment permits air-to-ground communications with all area hospitals, EMS
providers, fire departments, state and local law enforcement agencies. Flight crews maintain
awareness of currently available specialty services at regional hospitals and are able to select
among resource facilities to provide direct transport for definitive care.

Any EMS provider may request helicopter transport based on patient condition, mechanism of
traumatic injury, or scene assessment (see Helicopter Transport Guidelines). Activate Dispatch
as early as possible, even if patient ground transport has been initiated to the nearest facility, for
rendezvous with helicopter en route. Providers are encouraged to alert helicopter Dispatch for
any potential patient transport call, putting the helicopter on stand-by and allowing the flight
crew to by fully prepared and ready upon notice. Cancellation of helicopter activation should be
by the requesting EMS provider, or a responding ALS provider following full patient assessment
and examination. The assessment and decision for cancellation shall be documented.

Hot Loading is the process of placing a critical patient in the helicopter with rotor blades turning
for expedited transport. Never approach helicopter until authorized to do so by direct
contact from a member of the flight crew. The medical crew will identify individuals to assist
with patient loading.
                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 134 of 179
Helicopter Transport (contd)

Helicopter Transport Guidelines
Criteria which suggest the need for air transport include, but are not limited to:
♦ Need for ALS services (e.g. multi-system trauma, critical trauma, critical medical, serious
    pediatric, major burns).
♦ When time is crucial
♦ Ground transport time > 15 min to Trauma Center or nearest appropriate hospital
♦ Patient inaccessible to ground unit (e.g. traffic conditions, geographic terrain)
♦ Anticipated prolonged extrication time or scene time
♦ Abnormal Vital Signs:
        · RR < 10 or > 30 breaths/min, or
        · SBP < 90 mmHg, or
        · HR < 60 or > 120 bpm
♦ GCS ≤ 12
♦ Intubated patients
♦ Injury mechanism:
        · MVA/MCA (high speed, intrusion, rollover, ejection, associated fatality, pedestrian vs.
          auto).
        · GSW or SW
        · Blunt trauma/traumatic injury to head, neck, chest, abdomen, or groin
        · Fall > 15 ft
        · Major burns
        · Traumatic paralysis
        · Significant amputation
♦ Medical Patients:
        · Airway emergencies/respiratory failure
        · Acute cardiac patients, transcutaneous pacing
        · Suspected acute aortic dissection/aneurysm
        · Acute hemorrhage/GIB
        · Serious pediatrics
        · Complicated obstetrics
        · Complicated overdose/poisoning
        · Hypothermia/near-drowning
        · Status epilepticus
♦ Insufficient EMS personnel, equipment, supplies, or transport to provide optimal care
♦ MCI

                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 135 of 179
Helicopter Transport (contd)

Contraindications to Helicopter Transport
♦ Terminal patient with no acute correctable medical problems
♦ Patient DNR order
♦ Cardiopulmonary arrest with asystole/PEA
♦ Active labor with cervical dilation
♦ Psychotic/violent behavior (without restraint and/or sedation)
♦ Prisoners of law enforcement agencies (without specific safeguards)

Flight Request
♦ Contact Dispatch
♦ Provide Agency name, scene contact unit, and call back number/radio frequency
♦ Location and directions/GPS coordinates (e.g. highway numbers, milepost markers, cross
    streets, nearby landmarks, RR tracks, water towers, construction sites)
♦ Patient information: age, weight, nature and extent of injuries/illness
♦ Landing Zone area hazards and conditions

Landing Zone (LZ) Preparation and Communications
♦ LZ size should be ≥ 100 ft x 100 ft day or night (larger the better), mark and secure corners
♦ LZ should be clear of all vertical hazards (e.g. poles, wires, signs, trees, towers)
♦ Mark obstructions by parking vehicles next to or under them (parking/flashing lights on at
   night).
♦ Surface should be level (< 10° slope), compacted, and clear of ground hazards (e.g. loose
   debris, sticks, stumps, small trees). A trim surface is preferred. Advise pilot of conditions
   (e.g. dust, sand, gravel, cut grass, mud).
♦ LZ should be upwind of HAZMAT incidents
♦ Establish radio communication with incoming helicopter
♦ Expect pilot to circle the LZ before landing
♦ Expect pilot to land into the wind, if possible
♦ LZ Commander is responsible for assigning one person to stand in the center of the LZ with
   arms raised until the helicopter is ready to land. The person should exit the LZ when the
   helicopter turns onto final approach.
♦ Cockpit silence is always observed during takeoff and landing. Do not attempt contact unless
   for hazard warning.
♦ Avoid 10-codes when talking to pilots and crew (not used in aviation industry)



                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 136 of 179
Helicopter Transport (contd)

♦ LZ Commander is responsible for advising pilot of wind direction, LZ hazards, or conditions.
  LZ Commander is responsible for security, with the assistance of law enforcement, directing
  those authorized to be in the area, and keeping bystanders > 200 ft away. Post one person on
  each corner of the LZ while the aircraft is on the ground.
♦ For night operations, mark the LZ with flashing lights. Keep all vehicle lights on dim. It is
  ideal to have 4 vehicles, each placed at one corner of the LZ with headlights pointed inward
  to form an X. Switch to parking lights just prior to helicopter landing.
♦ Do not shine any lights toward the pilot at night

Landing Zone (LZ) Safety
♦ NEVER APPROACH THE REAR OF THE AIRCRAFT. KEEP CLEAR OF TAIL
   ROTOR AT ALL TIMES.
♦ Never approach the aircraft while rotor blades are turning unless instructed to do so by
   direct contact from the flight crew.
♦ Never approach the aircraft from the front or rear, always approach from the side (3 or 9
   o’clock position), and only after you are acknowledged by the flight crew.
♦ Never approach the aircraft from the uphill side of an LZ. Approach and exit from the
   downhill side within pilot view.
♦ Always wear hearing and eye protection
♦ Do not allow loose items (e.g. hats, sheets, debris) around the aircraft. Remove hats
   before approach.
♦ Do not allow loose sheets or blankets on the stretcher brought to the aircraft
♦ Never retrieve items that have fallen near turning rotors. Alert flight crew.
♦ Do not use IV poles or hold IV bags overhead near the aircraft
♦ Never jump on the stretcher to perform CPR
♦ Do not assist with equipment or aircraft doors
♦ Always leave in the same direction as approach
♦ Secure LZ for takeoff and landing by storing all ground equipment and closing ambulance
   doors.
♦ Do not shine headlights, spotlights, or flashlights toward the front of the aircraft during
   takeoff and landing.
♦ Do not drive vehicles into the LZ
♦ No smoking near LZ




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 137 of 179
Medical Control – On-Line

EMS providers in Santa Fe County provide medical care under the supervision of the EMS
Medical Director. Receiving hospital Emergency Department physicians are available 24 hr/day,
and may provide on-line Medical Control by radio or phone. On-line Medical Control should be
viewed as a valuable asset for personnel and their patients, and providers are encouraged to
contact Medical Control for resource assistance or information at any time.


                                      AREA HOSPITALS
                              Facility ED                Med Control           Med Com
                                                          Phone #               UHF
                      Santa Fe Region
                      St. Vincent Hosp                      995-3934            Med 5
                      Española Hosp                         753-1565            Med 5
                      Los Alamos Med Ctr                    662-2455            Med 5
                      Albuquerque Region
                      UNM Hosp                              272-2411            Med 1
                      Heart Hosp of NM                      724-2375            Med 6
                      Lovelace Med Ctr – Downtown           727-1010            Med 6
                      Lovelace Women’s Hosp                 727-7703            Med 6
                      Lovelace Westside Hosp                727-2050            Med 6
                      Presbyterian Hosp                     841-1111            Med 7
                      Kaseman Presbyterian Hosp             291-2122            Med 7
                      VA Hosp                               256-2793            Med 3



Santa Fe Region
Patients may not be transported to PHS Hospital (Indian Health Service) in Santa Fe without
on-line clearance by PHS Medical Control. All serious medical or trauma patients shall be
transported to St. Vincent Hospital.

Albuquerque Region
For updated or changed contact information for area hospitals in the Albuquerque Region,
contact Albuquerque Base (761-8200, Med 2).




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 138 of 179
Multi-Casualty Incident (MCI)

The Multi-Casualty Incident (MCI) Plan establishes a common organizational management
structure for the coordination of multi-jurisdictional emergency response, supports a dynamic
emergency response capability, and directs triage, care and transport methods to ensure the
survivability of the greatest number of patients. The plan incorporates the NIIMS Incident
Command System (ICS), and the Simple Triage and Rapid Treatment (START) triage system.

The MCI Plan assumes that the incident is limited in scope of area, number of casualties, and
time required for control, that EMS resources have not been decommissioned by the incident,
and that direction, control, and coordination are maintained at the scene of the incident and at
affected hospitals.


                                                        MCI
                            Designation                            Number of Patients   Red Tag (Critical)
       System Level MCI – (Any incident that fully engages                   >7                ≥3
       the medical capabilities of the immediate jurisdiction)
       Low Level MCI                                                        ≤ 12               ≤5
       High Level MCI                                                       > 12               >5


Agency Responsibilities
♦ SFCFD EMS
      · Incident coordination/command
      · Triage (START)
      · Emergency medical care
      · Organization/coordination of rescue efforts
      · Hazard control/safety
      · Extrication
      · Fire suppression
      · Landing zone coordination (helicopter)
♦ Receiving Hospitals
      · Advise Incident Command of resources/capabilities
      · Provide definitive medical care
      · Resource for additional medical supplies at scene
♦ EMS Dispatch
      · Initial dispatch of medical resources/personnel
      · Maintenance of normal operational EMS response
      · EMS/Fire response to incident and zone coverage
      · EMS/Fire mutual aid
                                     Santa Fe County Fire Department EMS Protocols
                                                      January 2009
                                                    Page 139 of 179
Multi-Casualty Incident (contd)

♦ Law Enforcement
     · Scene protection/security
     · Investigation
     · Traffic control

On-Scene Priorities
♦ First arriving unit must give an accurate report of conditions (do not commit to treatment):
      · Confirm location of incident
      · Assess nature of incident
      · Estimate the number of patients/Level of MCI
      · Request activation of MCI Plan
      · Determine the need for additional EMS resources
      · Identify hazardous conditions/unusual circumstances
      · Determine the need for additional outside-agency resources (e.g. law enforcement,
         HAZMAT, specialized heavy equipment).
      · Identify best access route
♦ Initial action priorities:
      · Identify hazards, determine needs to control or eliminate them
      · Perform START Triage on all victims (utilize BLS providers)
      · Establish Command
               - Command Post
               - Treatment Area (utilize ALS providers)
               - Staging Area
♦ EMS provider priorities:
      · Report to Staging Area or IC on arrival
      · Staff the treatment area
               - Establish entrance/exit corridors
               - Establish ambulance loading area
               - Perform secondary triage on all patients
               - Provide stabilizing medical care
      · Establish medical communications




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 140 of 179
Multi-Casualty Incident (contd)

Hospital Notification
Appropriate notification to area hospitals concerning the existence of a MCI should be given as
early as possible by the Incident Commander or designated officer. Periodic updates with
specific information (e.g. incident overview, Level of MCI, estimated patients/triage categories,
unusual circumstances/pediatrics/burns) should be conveyed directly to hospitals as the MCI
progresses.
♦ Notify closest Trauma Center (St. Vincent Hospital or UNM Hospital)
♦ Notify closest receiving hospitals, as appropriate
♦ Receiving hospital radio reports should be abbreviated (e.g. approximate age, chief complaint
    and/or injury mechanism, critical deficiencies, ETA). During a High Level MCI, transport
    units should refrain from making individual radio reports unless transporting critical patients
    or reporting significant change in patient condition.

Standing Orders
During a High Level MCI, providers may administer medication or perform life-saving
procedures following standing orders as deemed appropriate without being required to contact
medical control. Report of interventions shall be made to the EMS Medical Director for review.

Assignment of Officers
The IC may assign the following positions (not limited to):
♦ Triage Officer
♦ Staging Officer
♦ Treatment Officer
♦ Communications Officer
♦ Transportation Officer
♦ Landing Zone Officer
♦ Rehabilitation Officer
♦ Public Information Officer

On-Scene Physician Assistance
Physicians known in the community, or able to produce valid ID, shall be directed to the IC for
assignment.

Role of EMS Medical Director
The EMS Medical Director shall be notified of all MCIs at the earliest opportunity. If on-scene,
the Medical Director shall report to the IC for briefing and assignment.



                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 141 of 179
Multi-Casualty Incident (contd)

START Triage System (Simple Triage and Rapid Treatment)
During a MCI, injured will outnumber rescuers and emergency medical treatment must by
prioritized.
♦ Primary triage performed by first-in providers functioning individually
♦ Primary triage takes priority over emergency treatment
♦ Separate ambulatory patients by stating “anyone who can walk…” followed by an area
    assignment.
♦ Casualties are sorted according to seriousness of injuries and identified with tags/colors
    establishing priority of treatment and transport.
♦ Triage casualties where they lie, unless in unsafe area requiring relocation
♦ Perform triage, categorize, and attach tag near the head in < 60 sec
♦ All victims must be tagged whether injured or not
♦ Emergency care administered by Triage Team is restricted to opening airway, controlling
    severe hemorrhage, and elevating patient’s feet.
♦ Following triage of all patients, report for reassignment
♦ Providers assigned to treatment areas will perform secondary exam/secondary triage and
    complete tag.

START Categories
♦ BLACK – Dead or non-salvageable
    · No ventilation present after airway opened
    · Fatal injury with imminent death
♦ RED – Immediate/Critical
    · Ventilation present after positioning airway, or RR > 30 breaths/min, or capillary refill
      > 2 sec, or unable to follow simple commands.
♦ YELLOW – Delayed/Serious
    · Any patient not in Immediate or Stable categories
    · Generally non-ambulatory
♦ GREEN – Stable/Minor
    · Walking wounded
    · Passes triage screening
♦ CONTAMINATED
    · Require gross decontamination prior to transport
    · May belong to any triage category



                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 142 of 179
Radio Reports

The state of New Mexico does not require licensure or training for auxiliary hospital personnel
receiving base station radio or phone reports from EMS providers. In general, the following
communication guidelines should be used:

♦ Advisory Communication: Involves brief notification of patient presentation, vital signs
  and status, care provided, and ETA.

♦ Medical Control Communication: Involves a request for physician consult regarding pre-
  hospital medical care. On-line Medical Control may be established with an RN as
  intermediary, but a physician must be identified by name. EMS providers have the right to
  refuse orders or procedures that are outside SFCFD Protocols, outside an EMS provider’s
  scope of practice, or that are considered inappropriate for a patient’s condition.

The importance of the radio report is to provide an opportunity for the receiving hospital to
activate appropriate resources and prepare necessary services given the patient presentation.
Radio reports should be concise, followed by a more detailed report on arrival. For serious
medical or trauma patients it is important to convey a clear impression of the patient’s condition.
Include details of the past medical history if important to the immediate presentation. Providing
patient identifying information is discouraged.

EMS providers are encouraged to request a physician consult for patients who might merit the
immediate attention of the receiving ED physician. For critical trauma or medical cases establish
communication with the ED as early as possible.

Radio Report Structure
♦ Service and Unit ID
♦ Designate emergency or non-emergency traffic
♦ Consider Trauma STAT, AMI STAT, AMI Activation as appropriate
♦ Patient information: gender, age, weight (kg)
♦ Mechanism of traumatic injury
♦ Chief complaint/critical deficiencies
♦ Significant co-morbid disease
♦ Vital signs (“within normal limits” acceptable for stable patients)
♦ Care provided
♦ ETA




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 143 of 179
                          XII. Procedures and Equipment



Assisting With Medication

Designation of Condition: Patient request to take own medication for acute or chronic medical
condition while under the care of an EMS provider.

ALL EMS PROVIDERS
♦   Establish Primary Management
♦   Document vital signs
♦   Obtain a complete list of patient medications and drug allergies
♦   Establish medication belongs to patient and is used to treat the specific condition
♦   Determine previous dosing of medication

BLS AND ABOVE PROVIDERS
♦ For approval, CONTACT MEDICAL CONTROL
♦ Patient must self-administer medication

Providers may administer the following patient-own medications, per protocol:
♦ Bronchodilator using metered dose inhaler - ALL EMS PROVIDERS
♦ EPINEPHRINE using auto-injection device (EpiPen) - ALL EMS PROVIDERS
♦ NTG SL - For EMSFR and BLS approval, CONTACT MEDICAL CONTROL




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 144 of 179
Automatic External Defibrillator (AED) – Transition to ALS

Designation of Condition: Patient in cardiopulmonary arrest with an applied AED by first
responder (e.g. bystander, law enforcement, EMS provider, health care worker), upon arrival of
ALS provider.

ALS PROVIDERS
♦ Post-resuscitation, if the patient is breathing, leave AED attached to allow for acquisition and
  detection of rhythm.
♦ Obtain report from first responder including number of shocks (joule setting, if known) and
  rounds of CPR delivered.
♦ If a shockable rhythm recurs, follow AED prompts after automatic charging
♦ Convert to cardiac monitor/manual defibrillator when appropriate
♦ Follow current ACLS guidelines




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 145 of 179
12-lead ECG

The 12-lead ECG is an important diagnostic tool, aiding in the detection of acute coronary
syndromes, AMI, and arrhythmias, as well as the diagnosis and treatment of a variety of acute
and chronic medical problems (e.g. metabolic disorders, cardiopulmonary disease, pulmonary
embolism, assessment of overdose). The most important factors affecting the diagnostic value of
the ECG are the quality of the tracing and the qualifications of the interpreter.


Procedure
♦ Skin should be clean and dry
♦ Avoid excess tension on lead cables
♦ Reduce patient movement and talking, and avoid movement of lead cables to eliminate
   artifact.
♦ For female patients, minimize bystanders, but maintain a chaperone. Allow patient to hold
   breast away from lead placement area, or use back of a hand to move breast. Cover patient
   chest.
♦ 4-Lead Placement [“white over right, and smoke (black) over fire (red)”]
        · White (right arm, upper outermost location)
        · Black (left arm, upper outermost location)
        · Red (left side, just above pelvis, outside nipple line)
        · Green (right side, just above pelvis, outside nipple line)
♦ Chest Lead Placement (easiest placement order)
        · V1 (4th intercostal space, right sternal border)
        · V2 (4th intercostal space, left sternal border)
        · V4 (5th intercostal space, midclavicular line)
        · V6 (horizontal with V4, midaxillary line)
        · V5 (between V6 and V4)
        · V3 (between V4 and V2)
♦ Enter age, instruct patient to lie still, and acquire ECG (20 sec)




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 146 of 179
External Jugular Vein (EJ) IV Access

Designation of Condition: External jugular vein cannulation provides a rapid route for IV fluid
therapy and/or drug administration when other peripheral veins are inaccessible. EJ placement is
indicated in patients ≥ 8 yo, and can be attempted initially for emergent treatment when no
obvious peripheral site is noted or obtainable.

Contraindications
♦ Lack of anatomic landmarks
♦ Suspected C-spine injury
♦ With coagulopathies, consider other more easily compressible sites
♦ Unsuccessful attempt at insertion with significant hematoma
♦ Infection at insertion site

ILS AND ABOVE PROVIDERS
♦ Select appropriate catheter (18 gauge or larger preferred), and prepare equipment
♦ Place patient in supine or Trendelenburg position to distend external jugular vein
♦ Turn patient’s head to opposite side and locate insertion site
♦ To increase vein distention, ask patient to briefly hold breath or perform Valsalva maneuver
♦ Skin prep with betadine solution
♦ Align catheter with vein and direct insertion caudally (toward clavicle)
♦ Place fingertip just above clavicle to further distend vein. Insert IV midway between angle of
  the mandible and the clavicle.
♦ Secure catheter and line. Do not use circumferential dressing or tape.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 147 of 179
Jump Kits

The use of medical jump kits in private vehicles is encouraged for active SFCFD volunteers and
staff. Departments or service areas with the potential for significant delay in on-scene arrival of
EMS equipment, and with the high probability of individual first-responder medical care may
choose to standardize jump kit contents, as appropriate.

The EMS Medical Director or his stated designees must provide final authorization for jump kit
contents and medications. A quality control plan must be in place for assigned medications,
including signed pharmacy logs, and regularly scheduled inventory and inspection by appointed
department personnel, the SFCFD Consulting Pharmacist, and the New Mexico Board of
Pharmacy. Providers shall store jump kits containing medications in such a manner as to avoid
temperature extremes.

Suggested Jump Kit Contents
ALL EMS PROVIDERS
♦   Gloves
♦   Eye protection
♦   Two-way radio
♦   Pocket mask
♦   BVM
♦   Oral and nasal airway
♦   Manual suction
♦   Stethoscope
♦   BP cuff
♦   Miscellaneous first aid/bandaging supplies
♦   C-collar

BLS AND ABOVE PROVIDERS
♦ Combitube
♦ MAD
♦ NALOXONE

ILS AND ABOVE PROVIDERS
♦   2 L NS
♦   IV equipment and tubing
♦   Syringes and needles
♦   D50
♦   EPINEPHRINE
                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 148 of 179
Jump Kits (contd)

ALS PROVIDERS
♦   Intubation equipment
♦   Additional IVF
♦   ACLS medications, as approved
♦   Cardiac monitor/manual defibrillator

Optional Equipment for All Providers
♦ Glucometer
♦ O2 Sat monitor
♦ Portable O2, tubing and mask supplies
♦ Cardiac monitor/manual defibrillator




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 149 of 179
Needle Thoracostomy

Designation of Condition: Emergency procedure for adult or pediatric patient with spontaneous
or traumatic tension pneumothorax, characterized by chest pain, worsening dyspnea, tachycardia,
decreased/absent breath sounds, unilateral enlargement of chest, Hamman’s sign (crunching
heart sound on auscultation), agitation, JVD, and hypotension. Typically occurs with obvious
blunt or penetrating chest trauma, in the setting of subcutaneous crepitus.

ALL EMS PROVIDERS
♦ Establish Primary Management
♦ Provide O2 via NRB
♦ Monitor: O2 Sat, cardiac

ILS AND ABOVE PROVIDERS
♦ Establish IV/IO access and titrate IVF

ALS PROVIDERS
♦ Immediate pleural decompression indicated for suspected tension pneumothorax or
  unstable patients.
♦ Identify placement area:
      · 2nd or 3rd intercostal space, midclavicular line
      · 4th or 5th intercostal space, anterior axillary line
♦ Skin prep with betadine solution
♦ Insert 14 gauge angiocath perpendicular to chest wall over superior border of rib until rush of
  air evident.
♦ Remove needle, tape and secure catheter
♦ For worsening symptoms, consider repeat thoracostomy, or bilateral thoracostomy




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 150 of 179
Skills Approval Process

Prior to authorization to perform any new procedure, skill, or technique, to employ any new
medical devices or equipment, or to administer any new medication or therapeutic intervention,
it shall be documented per SFCFD policies and procedures that an individual EMS provider has
been appropriately and satisfactorily trained.

Never exceed your ability, experience, or scope of practice.

Use of department protocols assumes an agreement by EMS providers to participate in any CQI
process.




                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 151 of 179
                                XIII. Special Situations



Cancellation by Non-medical Provider

EMS providers responding to any request for medical evaluation or assistance should continue to
the scene as planned despite attempt at cancellation of the request by a non-medical provider.
Medical personnel should coordinate appropriate dispatch and response to a scene to ensure that
no patient care issues exist.

EMS first responders may cancel additional resources as appropriate, following full patient
assessment and examination.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 152 of 179
Dead at Scene

On arrival at a scene where death is obvious, resuscitation efforts should be withheld. If an EMS
unit is the first agency on scene it should immediately notify the appropriate law enforcement
agency and OMI, and preserve the integrity of the scene until their arrival. Only those EMS units
necessary to preserve the lives of victims should enter the scene. Law enforcement personnel
will take custody of the scene immediately upon arrival, and should be provided with
district/service information and the name of the EMS Medial Director.

To withhold resuscitation, the patient must be not-breathing, pulseless, and asystolic, and have
one of the following injuries and/or long term indications of death:
♦ Decapitation or extruded brain matter
♦ Thoracic/abdominal transection
♦ Obvious exsanguination
♦ Severe blunt trauma with no reversible cause of cardiopulmonary arrest
♦ Severe penetrating trauma with cardiopulmonary arrest prior to EMS arrival
♦ Rigor mortis without hypothermia
♦ Profound dependent lividity
♦ Decomposition
♦ Mummification/putrification
♦ Incineration
♦ Frozen state
♦ Trauma where CPR is impossible

EMS providers should document in their report absence of a carotid pulse and absence of heart
sounds on auscultation, and record the name and badge number of officer on scene.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 153 of 179
Do Not Resuscitate (DNR) Order

EMS personnel are required to provide emergency care to the fullest extent possible, including
resuscitative measures, and to transport patients to an appropriate health care facility. However,
providers will frequently encounter patient Do Not Resuscitate (DNR) orders, a legally
recognized advanced directive that, when medically appropriate, directs that an individual not be
resuscitated in the event of respiratory or cardiac arrest. For a patient unable to competently
convey directions regarding medical treatment, and due to the difficulty of ascertaining the
validity of wishes asserted by family members or other witnesses on scene, a recognized and
verified DNR order allows EMS providers to honor a patient request for no resuscitation, as
documented, and to provide appropriate palliative or comfort care.

Content of the DNR Order
♦ Patient name and signature
♦ Legal guardian or health care proxy name and signature (if any)
♦ Attending physician name and signature, or authorized PA or NP signature with name of
   supervising physician.
♦ Date of issuance, and expiration (if any)
♦ Authorization for health care providers to withhold specific care (e.g. DNI, DNR)

EMS Provider Requirements
♦ Confirm patient identity
♦ Confirm DNR order is current and valid
♦ Document DNR order and any palliative care provided
♦ EMS providers must continue emergency care until DNR order is located, or unless a patient
  is wearing a DNR bracelet/medallion.
♦ In the event a patient revokes a DNR order, verbally, in writing, or by defacing the order, at
  any time and regardless of mental or physical condition, full emergency care shall be
  provided. Document oral or written revocation.
♦ In the event a DNR order expires, full emergency care shall be provided
♦ In any situation where EMS providers have a good faith basis to doubt the validity or
  applicability of a DNR order, including revocation by a legal guardian or health care proxy,
  full emergency care shall be provided.
♦ For suspected suicide or homicide, a DNR order is not valid
♦ For other advanced directives or living wills, providers are encouraged to contact Medical
  Control for consultation and orders.
♦ If faced with an unclear or uncertain situation, CONTACT MEDICAL CONTROL.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 154 of 179
Do Not Resuscitate (DNR) Order (contd)

Patient Care
♦ If the patient is in full respiratory or cardiac arrest, EMS providers shall not
   resuscitate:
       · Do not initiate CPR
       · Do not insert airway devices or provide ventilation assistance
       · Do not administer chest compressions
       · Do not defibrillate or apply TCP
       · Do not administer ACLS medications
♦ If the patient is not in full respiratory or cardiac arrest, but breathing and heart beat are
   inadequate, EMS providers shall not resuscitate but shall provide, within their scope of
   practice and training, full palliative or comfort care, and transport as appropriate:
       · Supplemental oxygen
       · Airway suctioning
       · Control of bleeding
       · Position for comfort
       · Initiate IV line (as appropriate, and accepted)
       · Provide adequate analgesia, as required
       · Emotional support
       · Splinting
       · Cardiac monitor
       · For additional orders, CONTACT MEDICAL CONTROL.
♦ If the patient is not in full respiratory or cardiac arrest, and breathing and heart beat are
   adequate, but there is some other acute illness or injury, EMS providers shall provide full
   treatment, and transport as appropriate.
♦ If resuscitation efforts are initiated prior to confirmation of the DNR order, discontinue
   efforts upon verification:
       · Discontinue CPR
       · Discontinue airway management
       · Discontinue chest compressions or TCP
       · Discontinue ACLS medications
       · Established airway devices and IVs should remain in place




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 155 of 179
Emergency Incident Rehabilitation

The physical and mental demands associated with firefighting and emergency services
operations, coupled with the environmental dangers of extreme heat and humidity, or extreme
cold, create conditions that have an adverse impact on the health and safety of individual
emergency responders. Department members not provided adequate rest and rehydration during
emergency operations are at increased risk for illness and injury, and jeopardize the safety of
others on scene. Rehabilitation is an essential and established element of operations that can
prevent serious medical problems, reduce accidents and injuries, and allow safe reentry of
responders to the incident scene reducing the requirement for additional resources.

Responsibilities
♦ Incident Commander
      · Consider circumstances of each incident, and make early and adequate provisions for
        rest/rehabilitation of all responders operating on scene.
              - Medical evaluation, monitoring, treatment, and transport
              - Fluid replenishment/food
              - Mental rest
              - Relief from extreme climatic conditions
♦ Officers
      · Maintain awareness of each responder and provide for health and safety
      · Utilize command structure to request relief and reassignment
♦ Responders
      · Maintain adequate rest and hydration at all times
      · Notify supervisor if fatigue or exposure to conditions could affect themselves, their
        crew, or scene operations.
      · Maintain awareness of health and safety of crewmembers

Medical Evaluation
♦ EMS shall be provided and sufficiently staffed by the most highly trained/qualified personnel
  on scene.
♦ All responders involved in operations should be routinely evaluated, as appropriate
♦ Monitor vital signs, examine/treat responders, and provide disposition (e.g. return to duty,
  continued rehabilitation, medical treatment/transport).
♦ Special attention should be paid to responders with cardiopulmonary disease, or taking beta
  blockers, calcium channel blockers, or diuretics.
♦ Any responder with abnormal vital signs, a chief complaint suggesting need for emergency
  care, or signs/symptoms of exhaustion shall be removed from duty for thorough evaluation.


                               Santa Fe County Fire Department EMS Protocols
                                                January 2009
                                              Page 156 of 179
Emergency Incident Rehabilitation (contd)

Rehabilitation Operations
♦ Gear should be removed, as appropriate
♦ Check/document vital signs, repeat at least Q 20 min. Record at least 2 sets of vital signs on
   all responders.
♦ Rehydrate with at least 1 L of water and/or electrolyte solution
♦ Re-nourish
♦ Minimum of 20 min in Rehab
♦ Recovery guidelines for return to duty:
     · HR < 110 bpm
     · Oral temperature < 100.6° F
     · BP < 160/100 mmHg
     · No orthostatic changes
     · No severe symptoms (e.g. dizziness, chest pain, dyspnea, altered LOC, vomiting,
       headache).
     · Responders who exceed limits shall be assigned additional 20 min in Rehab
     · If abnormal vital signs persist, remove from duty and transport to hospital

Hydration
♦ Critical factor in preventing heat illness/injury is maintenance of water and electrolytes
♦ During high heat index days, responders should consume at least 1 L of water/hr (avoid
  caffeine and carbonation). Hydration also important during cold weather operations.
♦ For persistent or severe tachycardia and/or hyperthermia after initial 20 min in Rehab, or for
  inability to rehydrate orally, consider IV hydration.

ILS AND ABOVE PROVIDERS
♦ Establish IV access and bolus IVF
♦ For persistent or severe tachycardia and/or hyperthermia after 3 L of IVF, remove from duty
  and transport to hospital.

♦ Medical treatment and transport to hospital:
  Any emergent condition/injury shall be treated/transported as soon as possible. Transport
  shall also be initiated for the following guidelines, after ≥ 40 min in rehabilitation:
      · HR > 110 bpm, or < 60 bpm with hypotension
      · Oral temperature > 100.6° F
      · BP > 160/100 mmHg
      · Chest Pain
                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 157 of 179
Emergency Incident Rehabilitation (contd)

♦ Medical treatment and transport to hospital (contd):
    · Dyspnea
    · Vomiting
    · Headache
    · Arrhythmia
    · Altered LOC
    · Symptoms of CO poisoning




                             Santa Fe County Fire Department EMS Protocols
                                              January 2009
                                            Page 158 of 179
Emergency Transport by Medical Rescue Vehicle

Emergency transport of critically ill or injured patients may be provided by a Medical Rescue
Vehicle associated with SFCFD for rendezvous with certified ambulance or helicopter transport.
In general, transport may be required if the closest appropriate certified ambulance is ≥ 15 min
from patient contact. Patient assessment and appropriate resuscitation shall be initiated prior to
and during transport.

Transport Requirements
♦ The Medical Rescue Vehicle must comply with the intent of PRC Regulation 18 NMAC 4.2
   “Ambulance Medical Rescue Services”, regarding minimum equipment requirements.
♦ EMS providers involved in transport must have EVOC training, bloodborn pathogens
   exposure training, and Hepatitis B vaccination (or clearance on file).
♦ For transport, a minimum of two licensed EMS providers shall accompany the patient in the
   vehicle patient compartment.

Transport Guidelines
Criteria which suggest the need for Medical Rescue Vehicle transport include, but are not limited
to:
♦ Need for ALS services (e.g. multi-system trauma, critical trauma, critical medical, serious
    pediatric, major burns).
♦ Cardiopulmonary arrest
♦ Airway emergencies
♦ GCS ≤ 8
♦ Complicated obstetrics
♦ Complicated overdose/poisoning
♦ Hypothermia/near-drowning
♦ MCI

During a High Level MCI, if certified ambulance transport unavailable, Medical Rescue
Vehicles may be required for direct transport of appropriate patients to receiving hospitals.

In the event of termination of patient resuscitation following intercept by a certified
ambulance/ALS Provider, a Medical Rescue Vehicle may be required to complete transport
services, including interaction with law enforcement agencies and OMI.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 159 of 179
Minors

Any patient who is legally a minor does not have legal standing to refuse medical evaluation,
treatment, and/or transport to a medical facility. EMS providers may render care without the
consent of a parent or legal guardian when a good faith judgment is made that an emergency
exists, that the minor is in need of medical attention, and that an attempt to secure consent would
result in delay of treatment and increase risk to life or health. A parent or legal guardian of a
minor must refuse medical care for that minor.

If faced with an unclear or uncertain situation, CONTACT MEDICAL CONTROL and/or
appropriate law enforcement. If there is suspicion that a parent or legal guardian does not have
decision-making capacity or is incapable of making an informed decision, initiate transport.
When in doubt, transport minors to a medical facility for evaluation.


OMI Investigation

In general, all unattended deaths, those deaths occurring at home without antemortem care by a
licensed medical physician, or occurring outside a licensed nursing home or hospital, fall under
the jurisdiction of OMI and require investigation. If an EMS unit is the first agency on scene it
should immediately notify the appropriate law enforcement agency and OMI, and preserve the
integrity of the scene until their arrival. Law enforcement personnel will take custody of the
scene immediately upon arrival, and should be provided with district/service information and the
name of the EMS Medial Director.

Deaths resulting from violence or trauma should be considered part of an active crime scene,
with special attention paid to preserving undisturbed all elements that may provide information
(e.g. skid marks, debris scattering patterns, clothing location, weapons). Only those EMS units
necessary to preserve the lives of victims should enter the scene.

Scene Guidelines
♦ Established medical equipment, airway devices, and IVs should remain in place
♦ Body of the deceased should not be moved until authorized by law enforcement
♦ Weapons should not be handled or moved, unless an immediate threat to safety exists
♦ An EMS report shall be filled out on scene for OMI, or if arrival of the agency is delayed,
   arrangements shall made for direct delivery of the report.
♦ Avoid parking vehicles within potential boundaries of a crime scene, leaving them subject to
   control by law enforcement.




                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 160 of 179
Physician Assistance On Scene

A physician who is physically present on scene and offering assistance may be allowed to
participate in patient care if all of the following conditions are met:
♦ The physician shows identification as a currently licensed medical physician, or as a
    physician authorized to practice in New Mexico, to the EMS provider in charge of patient
    care.
♦ The physician agrees to function as the attending for the patient in the ambulance en route to
    the hospital, and to provide care until appropriate transfer to the receiving hospital physician.
♦ Approval is obtained from medical control
♦ The physician accepts full responsibility for patient management in accordance with SFCFD
    Protocols. If on scene medical care conflicts with established protocols, the physician shall
    be placed in direct voice contact with the receiving hospital physician. If unable to contact
    medical control, or questions remain unresolved, EMS providers shall follow SFCFD
    Protocols.
♦ Card for presentation to on scene physician:

                                   Santa Fe County Fire Department EMS

       Thank you for your offer of assistance. Please be advised that we are working under medical
       control provided by a physician at a medical control hospital. We are not permitted to relinquish
       medical control to a physician on scene without approval. Should you wish to participate in
       patient care, you may request approval by speaking with the medical control physician. Upon
       showing proof that you are a licensed medical physician, you may take responsibility for patient
       care if you: (1) accept full responsibility for patient management and the issuing of orders in
       accordance with the established protocols of Santa Fe County Fire Department EMS, (2) agree to
       function as the attending for the patient in the ambulance en route to the hospital, (3) document
       your care and sign the EMS patient report. If the EMS providers on scene believe there is an issue
       with patient care they are instructed to CONTACT MEDICAL CONTROL at the appropriate
       receiving hospital. You may be asked to speak to the receiving hospital physician.


♦ Appropriate assistance may be provided from physicians known in the community
♦ A medical office/clinic/urgent care physician may direct patient care prior to transfer of care
  to EMS. Providers shall continue to operate according to their scope of practice, and under
  SFCFD Protocols.
♦ For difficult situations, accept transfer of patient care, relocate patient to ambulance, and
  CONTACT MEDICAL CONTROL.




                                    Santa Fe County Fire Department EMS Protocols
                                                     January 2009
                                                   Page 161 of 179
Refusal of Treatment and/or Transport

A patient or legal guardian who refuses EMS treatment and/or transport in direct conflict with
the advice of providers on scene presents significant challenges and legal risks. Competent and
informed adults have a right to accept or refuse treatment recommendations. Every patient
encounter involves a balance of patient rights with the need for EMS to accomplish its legal duty
once summoned. Always put patient welfare first.

Providers shall attempt to establish primary management and follow general care guidelines for
all patients, including a complete assessment and documentation of medical condition, mental
status, and vital signs. For any refusal of assessment and/or treatment, providers shall obtain and
clearly document informed refusal of care. Licensed EMTs are strongly encouraged to
CONTACT MEDICAL CONTROL for patient encounters involving refusal of treatment
and/or transport. Providers shall document all factors leading to judgment of patient decision-
making capacity, including medical, psychiatric, and environmental conditions.

Note: See EMS Liability Release/Descargo De Obligación

Guidelines
♦ Discuss need for treatment and/or transport. Develop therapeutic alliance.
♦ Include family members, caretakers, private physicians, friends, or others familiar with the
   patient in soliciting consent to treatment.
♦ Consider contacting medical control to encourage consent through direct discussion with a
   physician (by land-line only).
♦ Assess decision-making capacity
     · Assess LOC using AVPU or GCS
     · Identify medical/psychiatric conditions that may limit judgment (not limited to):
             - Altered LOC
             - Abnormal vital signs
             - Intoxication/withdrawal syndrome
             - Psychiatric/behavioral disorders
             - Suicidal/homicidal ideation
             - Unstable medical conditions/trauma (e.g. hypoxia, hypotension, hypoglycemia,
               CHI).
             - Disease affecting mental capacity (e.g. developmental delay, dementia)
             - Physical impairment due to inability to care for self
             - Evidence of abuse
             - Suspicion of physical/emotional coercion
     · Determine if patient is a legal minor



                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 162 of 179
Refusal of Treatment and/or Transport (contd)

♦ A patient or legal guardian DOES NOT have capacity to refuse treatment and/or transport
  when a good faith judgment is made that the individual has limited decision-making capacity,
  is incapable of making an informed decision, or is unable to understand the risks and
  consequences of refusal.

Note: See Involuntary Restraint/Transport

♦ Obtain and clearly document informed refusal
      · A patient or legal guardian capable of making an informed decision shall be fully
        informed/able to verbalize understanding of:
              - EMS recommendations, and need for medical evaluation, treatment, and
                transport.
              - Risks and consequences of refusal of care, which may include worsening illness
                or injury, disability, and death.
      · Encourage patient, legal guardian, caretaker, or family to call EMS for assessment and
        transport at a later time if they so desire, or if the condition worsens by stating “call for
        any of the following signs or symptoms…” followed by a detailed list.
      · Complete EMS Liability Release, including signature of patient and/or witness
      · Providers shall document their medical opinions and recommendations, the reasoning
        of the patient or legal guardian, and steps taken to solicit consent for care.
♦ Offer assistance in arranging alternative transportation
♦ Encourage patient or legal guardian to go directly to an Emergency Department for
  assessment and treatment if they so desire, or if the condition worsens.
♦ Ensure patient is in compliance with established medical treatment plan, and has appropriate
  plan for follow-up.
♦ Ensure necessary social supports are in place for patient safety

Documentation
♦ Patient information, parent or legal guardian
♦ Chief complaint and medical assessment
♦ Medical history
♦ Mental status
♦ Vital signs
♦ Medical treatment/interventions provided and patient response
♦ Refusal of treatment and/or transport
♦ Assessment of decision-making capacity
♦ Medical recommendations
                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 163 of 179
Refusal of Treatment and/or Transport (contd)

♦ Reasoning of the patient or legal guardian
♦ Steps taken to solicit consent for care
♦ Informed refusal of care

Non-Patient Designation
♦ An individual with a minor complaint, illness, or injury may decline assessment and transport
   as a non-patient if the following criteria are met:
       · EMS assessment and all interventions declined
       · No significant medical or psychiatric complaints
       · No signs/symptoms of significant illness or injury
       · No altered LOC
       · No limitation of decision-making capacity
♦ Providers are encouraged to complete appropriate documentation for all encounters involving
   refusal of care.

For any concerns regarding the health, safety, or welfare of a patient or other individual,
CONTACT MEDICAL CONTROL and/or appropriate law enforcement.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 164 of 179
Termination of Resuscitation

In general, full resuscitation efforts, once initiated in the field, should be continued during
transport, and until a receiving hospital physician terminates care. However, for specific adult
patients, suffering non-traumatic cardiac arrest unresponsive to ACLS (including airway
management, defibrillation and medications), continued efforts at resuscitation may not be
appropriate. Termination of unsuccessful resuscitation under standing orders may be
decided by ALS Providers only. Special resuscitation interventions and prolonged resuscitation
efforts may be indicated for patients with potentially reversible causes of arrest (e.g. drowning,
electrocution, hypothermia, overdose). Prior to termination of resuscitation, ALS Providers are
strongly encouraged to CONTACT MEDICAL CONTROL.

Patients with a recognized and verified DNR order in full respiratory or cardiac arrest shall not
be resuscitated, as documented.

Note: See Do Not Resuscitate (DNR) Order

Inclusion Criteria
♦ Adult patient > 18 yo
♦ Non-traumatic cardiac arrest (not associated with acute airway obstruction, drowning,
   electrocution/lightning strike, hypothermia, overdose, poisoning).
♦ Early and appropriate ACLS (e.g. high quality CPR, appropriate/confirmed airway
   management, patent IV access, ACLS medications).
♦ Sustained resuscitation effort > 20 minutes, regardless of previous CPR time or arrest
   interval. Time begins with ALS Provider initiation of ACLS.
♦ For witnessed arrest by EMS providers, sustained resuscitation effort > 30 min
♦ Absence of spontaneous breathing or neurologic activity
♦ Absence of recurring VF/VT
♦ No restoration of spontaneous pulse (asystole, or PEA with no reversible cause)
♦ At least 2 ALS Providers active in the resuscitation and in agreement of termination

Exclusion Criteria
♦ Pediatric patient ≤ 18 yo. For expected death due to chronic terminal disease, CONTACT
   MEDICAL CONTROL for approval.
♦ Visible pregnancy (> 24 weeks)
♦ Cardiac arrest associated with acute airway obstruction, drowning, electrocution/lightning
   strike, hypothermia, overdose, or poisoning.
♦ Patient in custody of law enforcement
♦ Scene environment involves threat to safety of EMS providers
♦ Established organ donor
                                Santa Fe County Fire Department EMS Protocols
                                                 January 2009
                                               Page 165 of 179
Termination of Resuscitation (contd)

Guidelines
♦ EMS providers are encouraged to allow family members to be present during
   resuscitation efforts, as appropriate.
♦ EMS providers shall fully inform and update family members of patient condition during
   resuscitation efforts (including failure to respond), shall advise the family of on-line Medical
   Control, and shall discuss the recommendation to terminate resuscitation if no response to
   treatment.
♦ Conversation between family members on scene and Medical Control physician encouraged
   (by land-line only).
♦ For any family member conflict, disagreement, or objection to termination of resuscitation,
   full resuscitation efforts shall be continued during transport, and until a receiving hospital
   physician assumes care.
♦ For any inability to communicate with family members on scene or by telephone (e.g.
   language barrier, cultural barrier), full resuscitation efforts shall be continued during
   transport, and until a receiving hospital physician assumes care.
♦ Attend to social and psychological support of family members
♦ Established airway devices and IVs should remain in place
♦ Notify appropriate law enforcement agency and OMI
♦ Document clear and detailed history of resuscitation efforts, including response to treatment,
   Medical Control consult, time of death, and individuals present.




                                 Santa Fe County Fire Department EMS Protocols
                                                  January 2009
                                                Page 166 of 179
      XIV. Appendices




Santa Fe County Fire Department EMS Protocols
                 January 2009
               Page 167 of 179
Emergency Airway Pathway - General Adult                                                          (adapt. from SLAM Society algorithm)



          START

  Emergency airway situation
          exists?


              Y




   · Call for help
                                           Unresponsive or responsive only                                   CRASH
   · Provide 100% O2 by
                                           to pain? Hypoxic despite optimal            Y                    AIRWAY
     NRB/BVM/NPA/OPA
   · Monitor O2 Sat                              ventilation attempts?                                      EXISTS!
   · Apply “Emergency
     Airway Maxims”                                        N
     while managing the
     airway




  Emergency Airway Maxims:                          Assess clinical
  · Patients die from failure to                 situation and airway
    oxygenate and ventilate, not                     for difficulty
    failure to intubate.
  · Never exceed your ability,
    experience or scope of practice.
    Do what you do best.
  · Consider NARCAN or
    DEXTROSE to treat coma.
  · If suspicious of trouble, secure                                                                  OXYGENATION/
                                            Does situation favor ventilation                           VENTILATION
    the airway awake.                              over intubation?                    Y
  · Have back up plans in mind and                                                                      PATHWAY
    in place.
  · Intubation attempts should be
    limited to 2 trys and < 5 min.                         N
  · Provide rescue ventilation
    with a Combitube in setting of
    critical airway event.                         Airway difficulty
  · If you encounter trouble, awaken                 anticipated?              Y
    the patient.
  · Always confirm tube
    placement.                                                                     Confident to attempt
  · Avoid blind intubation                                N                            intubation?              N
    techniques in setting of
    orotracheal trauma.

                                                                                             Y

                                                                                                                 Difficult Intubation
          Color Key:                                   RSI                            DIFFICULT                  options may include:
          Decision point - yellow                   PATHWAY                          INTUBATION                  · Awake Intubation
          Action block - blue                                                         PATHWAY                    · Blind Nasotracheal
          Critical block - red                                                                                     Intubation
          Pathway point - gray
          Definitive airway - green
          Explanatory block - white
                                                                                                 Attempt tracheal
                                                                                                  intubation using
                                                                                                  RSI or Difficult
                                                                                                 Intubation option



                                       Santa Fe County Fire Department EMS Protocols
                                                        January 2009
                                                      Page 168 of 179
Emergency Airway Pathway - General Adult (contd)

                                              CRASH                                                               Do you anticipate a
                                             AIRWAY                                                              rapid, uncomplicated
                                             EXISTS!                                                                  intubation?



                                                                                                                           Y             N


                                                                                                                     Attempt direct
                                                                        Provide 100% O2 by                         laryngoscopy and
                            OXYGENATION/                               NRB/BVM/NPA/OPA                                 orotracheal
                             VENTILATION                                or switch to Rescue                          intubation x 2
                              PATHWAY                                   Ventilation Pathway


                                                                                                                 Intubation confirmed?


                                                                                                            Y                  N


                                                                                                       Post-intubation
                              Attempt tracheal                                                          management
                               intubation using
                               RSI or Difficult
                              Intubation option



                                                                                                                         CRITICAL
                            Intubation confirmed?                                 O2 Sat > 90%?             N
                                                                                                                          AIRWAY
                                                                                                                          EVENT!
                                     N                 Y                                    Y
  Assess problem and
  modify technique or
   switch to Rescue                            Post-intubation                                                       RESCUE
  Ventilation Pathway                           management                                                         VENTILATION
                                                                                    Monitor and                     PATHWAY
                                                                                 consider definitive
                                                                                   airway options
                                                                                                                    Attempt rescue
                                                                                                                    ventilation with
                               O2 Sat > 90%?
                                                                                                                      Combitube

                                     Y                 N                                                Y           O2 Sat > 90%?


                                                                     An O2 Sat > 90% cannot
                   N        Intubation attempted                        be attained despite                                 N
                             x 2 or > 5 minutes?                     optimal positive pressure
                                                                         ventilation with
                                                                     NPA/OPA and 100%O2                         CRICOTHYROTOMY
 Intubation-rescue                   Y                                                                              PATHWAY
 options may include:
 · External laryngeal
     manipulation                                                                                                 Place QuickTrach or
 · Backward-upward-                                                                                                 perform surgical
     rightward pressure                                                                                              cricothyrotomy
     on thyroid cartilage
 · Assess paralysis
 · Change blade type            CRITICAL                                                                            Post-intubation
     and/or length               AIRWAY                                                                              management
 · Change operator               EVENT!




                                            Santa Fe County Fire Department EMS Protocols
                                                             January 2009
                                                           Page 169 of 179
Santa Fe County Fire Department EMS Protocols
                 January 2009
               Page 170 of 179
                                                      EMS Liability Release

District(s)/Service(s): _______________________________________                  EMS Report Number: ________________________________

Date: _________________________          Time: __________________                Location: __________________________________________

   Refusal of Care Against Medical Advice
I have been informed that I have a potentially serious medical condition requiring assessment, treatment,and
transportation to a hospital. Of my own free will, without coercion or influence, I hereby refuse the care offered to me by
the attending EMS personnel on scene, and their Medical Control physician. I understand that, by my refusal, I risk
further illness, injury, disability, or death. In the event that I choose to accept treatment or transportation, I will call (911)
for emergency response.
                                                                       Initial Here: ______________________________

   Non-Ambulance Transport
I have been assessed and treated as necessary by the attending EMS personnel on scene. I have been informed and advised
that further assessment and treatment may be necessary and should be performed by a physician. I have declined
ambulance transportation to a medical facility. I will arrange alternative transportation as needed and inform my physician
promptly of my condition. I have been informed of signs and symptoms that could indicate that my condition is
worsening. If I develop any additional signs or symptoms, or have any concern about my health or safety, I will call (911)
for emergency response.
                                                                    Initial Here: ______________________________

   Non-Patient
I have no complaint, illness, or injury, and I do not consider myself to be a patient. If I develop any signs or symptoms, or
have any concern about my health or safety, I will call my physician promptly or I will call (911) for emergency response.

                                                                                 Initial Here: ______________________________

Release of Responsibility
I have read and understood the section initialed above. My condition has been explained to me and I have no questions. I
knowingly and voluntarily release the EMS district(s)/Service(s) and their personnel, the EMS Medical Director, and the
physicians and staff of the hospital having Medical Control from any liability for my decision regarding my medical care.

Patient Name: _________________________________________________________________________________________________________

Patient Address: _______________________________________________________________________________________________________

Patient Date of Birth: _______________________________________________ Patient Telephone: ___________________________________

Patient Signature: _____________________________________________________________________ Date: __________________________

Translator – Guardian – Parent Name: _____________________________________________________________________________________

Translator – Guardian – Parent Signature: __________________________________________________ Date: __________________________

The Patient/Translator/Guardian/Parent has indicated comprehension of the content and meaning of this form and is both alert and oriented.

EMS Provider Name: ___________________________________________________________________________________________________

EMS Provider Signature: _______________________________________________________________ Date: ___________________________

Witness Name: ____________________________________________________________________                       Date: ___________________________

Witness Signature: ____________________________________________________________________ Date: ___________________________

                        This is NOT A BILL. CALL 911 FOR ANY EMERGENCY.
                                               Santa Fe County Fire Department EMS Protocols
                                                                January 2009
                                                              Page 171 of 179
Santa Fe County Fire Department EMS Protocols
                 January 2009
               Page 172 of 179
                                                     Descargo De Obligación

District(s)/Service(s): _______________________________________                  EMS Report Number: ________________________________

Date: _________________________          Time: __________________                Location: __________________________________________

    Negación de Tratamiento Contra Consejo Médico
Me informaron que tengo una condición médica que puede ser seria y es posible que necesite evaluación,
tratamiento, y transportación a un hospital. De voluntad libre, y sin coerción o influencia, por la presente no acepto
la asistencia médica que me ofrecieron los paramédicos y su director de control médico. Comprendo que a causa de
esta decisión, hay un riesgo elevado de enfermedad, herida, incapacidad o muerte. Si cambio de opinión, llamaré
(911) para ayuda médica de emergencia.
                                                                    Póngase iniciales aquí
                                                                                          : _____________________________

    Transporte Aparte de la Ambulancia
Recibí evaluación y tratamiento médico de los paramédicos aquí. Me han informado y avisado que evaluación y
tratamiento adicional pudiera ser necesario y que un médico debe de hacerlo. Rehuso transportación por la
ambulancia a una instalación médica. Arreglaré transportación alternativa si es necesaria y le avisaré a mi médico
personal inmediatamente sobre mi condición. Los paramédicos me informaron de las indicaciones y síntomas que
indicarían que mi salud empeorara. Si cambie la condición, llamaré (911) para ayuda médica de emergencia.
                                                                                 Póngase iniciales aquí
                                                                                                      : ____________________________

   No Paciente
No tengo ningun problema, enfermedad o herida y no me considero un paciente. Si qualquier indicación o síntoma
aparezca, o si tengo preocupaciones sobre mi salud o seguridad, llamaré (911) a mi médico personal o para ayuda
médica de emergencia.
                                                               Póngase iniciales aquí
                                                                                     : ____________________________

Descargo de Responsabilidad
Leí y comprendí lo que firmé arriba. Me explicaron mi condición y no tengo ninguna pregunta. A propósito y de
voluntad libre, descargo de cualquier responsabilidad con respeto a mi tratamiento médico los distritos/servicios de
emergencia y su personal, el director de servicios médicos de emergencia, y los médicos y empleados del hospital
con control médico.
Nombre del Patiente: ___________________________________________________________________________________________________

Dirección del Patiente: __________________________________________________________________________________________________

Fecha de Nacimiento del Patiente: _____________________________________ Teléfono del Patiente: _________________________________

Firma del Paciente: ____________________________________________________________________ Fecha: __________________________

Nombre de Traductor – Guardián – Padre: ___________________________________________________________________________________

Firma de Traductor – Guardián – Padre: ____________________________________________________ Fecha: __________________________

The Patient/Translator/Guardian/Parent has indicated comprehension of the content and meaning of this form and is both alert and oriented.

EMS Provider Name: ___________________________________________________________________________________________________

EMS Provider Signature: _______________________________________________________________ Date: ___________________________

Witness Name: ____________________________________________________________________                        Date: ___________________________

Witness Signature: ____________________________________________________________________ Date: ___________________________
Esta NO ES UNA CUENTA. EN CASO DE CUALQUIER EMERGENCIA MARQUE 911.



                                               Santa Fe County Fire Department EMS Protocols
                                                                January 2009
                                                              Page 173 of 179
Santa Fe County Fire Department EMS Protocols
                 January 2009
               Page 174 of 179
                             Protocol Improvement Form

Name: ______________________________ District/Service: ___________________________

Date: _______________________________

Do you want to be contacted by the Medical Director?            Yes _____         No _____

Contact Phone Number: _________________________________________________________

Please detail your Protocol questions, concerns, ideas, and/or recommendations.
Replacement language is encouraged.

Page: ______ Protocol: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


Page: ______ Protocol: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


Page: ______ Protocol: _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Santa Fe County Fire Department EMS Protocols
                 January 2009
               Page 176 of 179
                                              Index

12-LEAD ECG, 146                                       CEREBROVASCULAR ACCIDENT (CVA), 75
ABRUPTIO PLACENTAE, 108                                CHEMTREC, 84
ACETAMINOPHEN, 83                                      CHEST PAIN, 43, 44
ACUTE CORONARY SYNDROME, 43                            COMA, 77
ADENOSINE, 59, 67                                      COMBITUBE, 27, 37, 38, 39, 148
ADULT IO, 17                                           COMMUNICATION
AGENCY FOR TOXIC SUBSTANCES AND                          Advisory, 143
  DISEASE REGISTRY, 84                                   Medical Control, 143
AIR AMBULANCE COMPANIES, 134                           CONFLICT, 10
AIRWAY ALGORITHM, 30, 31, 32, 33                       CONGESTIVE HEART FAILURE, 56
AIRWAY MANAGEMENT, 21                                  CONTROLLED SUBSTANCES, 20
ALBUTEROL, 35, 51, 56, 70, 72                          CPAP, 34
ALLERGIC REACTION / ANAPHYLAXIS, 70                    CPAP PATHWAY, 36
ALS DISPATCH, 132                                      CQI, 11
AMI, 43, 44, 132                                       CRICOTHYROTOMY, 14, 40, 41, 133
AMI STAT, 44                                           CROUP / EPIGLOTTITIS, 79
AMIODARONE, 48, 52, 60, 62, 63, 68, 69                 CYANIDE POISONING, 119
AMPUTATION, 121                                        CYANOKIT, 119
APGAR SCORE, 101                                       DEAD AT SCENE, 153
AREA HOSPITALS, 138                                    DECISION-MAKING CAPACITY, 162
ASPIRIN, 43, 51, 56                                    DELIVERY, 100
ASSESSMENT GUIDELINES, 16                              DESCARGO DE OBLIGACIÓN, 173
ASSISTING WITH MEDICATION, 144                         DEXTROSE, 80, 104
ASTHMA, 72                                             DIABETIC EMERGENCIES, 80
ASYSTOLE, 46, 47                                       DIAZEPAM, 94
ATRIAL FIBRILLATION, 48                                DIFFICULT INTUBATION, 25
ATROPINE, 23, 47, 49, 58, 66, 90                       DIPHENHYDRAMINE, 70, 82
AUTOMATIC EXTERNAL DEFIBRILLATOR                       DISPATCH, 134
  (AED), 145                                           DO NOT RESUSCITATE (DNR), 154
B.I.G., 18                                             DOPAMINE, 49, 51, 56, 66, 71
BITE INJURY, 116                                       DYSTONIC REACTION, 82
BRADYCARDIA, 49                                        ECLAMPSIA, 106, 107, 110, 111
BREECH, 98                                             EMERGENCY AIRWAY PATHWAY, 168
BURNS, 117                                             EMERGENCY INCIDENT REHABILITATION, 156
CALCIUM CHLORIDE, 47, 49, 93, 110                      EMS LIABILITY RELEASE, 163, 171
CANCELLATION BY NON-MEDICAL                            EPINEPHRINE, 46, 55, 57, 60, 65, 66, 68,
  PROVIDER, 152                                          70, 71, 72, 104
CAPNOGRAPHY, 14                                        ETOMIDATE, 23
CARBON MONOXIDE POISONING, 74                          ETT SIZE FOR CHILDREN, 26
CARDIAC ARREST, 52, 53, 54, 55, 132                    EXTERNAL JUGULAR VEIN (EJ), 147
CARDIOGENIC SHOCK, 51                                  EYE INJURY, 123
CAREFLIGHT, 134                                        F.A.S.T 1, 17
CENTRAL VENOUS CATHETER, 19                            FEBRILE SEIZURE, 83
CEREBRAL EDEMA, 87                                     FENTANYL, 20, 23, 24
                            Santa Fe County Fire Department EMS Protocols
                                             January 2009
                                           Page 177 of 179
FEVER, 83                                             NEEDLE CHEST DECOMPRESSION, 15
FRACTURES, 122                                        NEEDLE CRICOTHYROTOMY, 41
FUROSEMIDE, 56, 87                                    NEEDLE THORACOSTOMY, 150
GLASGOW COMA SCORE (GCS), 77                          NEONATAL RESUSCITATION, 103
GLUCAGON, 49, 71, 81, 93                              NEW MEXICO POISON CONTROL, 84, 116
HALOPERIDOL, 114                                      NM STATE POLICE HEADQUARTERS, 84
HAZMAT, 84                                            NONINVASIVE PACING, 50
HEAD INJURY, 124                                      NON-PATIENT, 164
HEAT ILLNESS, 86                                      NTG, 44, 51, 56
HELICOPTER TRANSPORT, 134                             NUCHAL CORD, 100
HIGH ALTITUDE ILLNESS, 87                             OBSTETRIC TRANSPORT, 106
HIGH RISK PREGNANCY, 102                              OMI, 160
HYPERGLYCEMIA, 81                                     ORGANOPHOSPHATE POISONING, 90
HYPERVENTILATION, 76, 124                             OXYTOCIN, 109
HYPOGLYCEMIA, 80                                      PARKLAND FORMULA, 120
HYPOTHERMIA, 52, 53, 88                               PEDIATRIC (AGE-SPECIFIC) HYPOTENSION,
INCREASED ICP, 124                                      131
INFORMED REFUSAL, 163                                 PEDIATRIC ASYSTOLE, 65
INTRAOSSEOUS ACCESS, 17                               PEDIATRIC BRADYCARDIA, 66
INTUBATION, 14, 20, 21                                PEDIATRIC IO, 18
INTUBATION PATHWAY, 28                                PEDIATRIC PARAMETERS, 26
INVERTED PYRAMID OF NEWBORN                           PEDIATRIC RESUSCITATION, 64
  RESUSCITATION, 103                                  PEDIATRIC SUPRAVENTRICULAR
INVOLUNTARY RESTRAINT / TRANSPORT, 112                  TACHYCARDIA, 67
IPRATROPIUM, 35, 73                                   PEDIATRIC VENTRICULAR FIBRILLATION, 68
JET VENTILATION, 42                                   PEDIATRIC VENTRICULAR TACHYCARDIA, 69
JUMP KITS, 148                                        PHENERGAN, 97
LANDING ZONE (LZ), 136                                PHI, 134
LIABILITY RELEASE, 171, 173, 177                      PHYSICIAN ASSISTANCE ON SCENE, 161
LIDOCAINE, 23, 61, 62, 63, 68, 69                     PLACENTA PREVIA, 108
MAGNESIUM, 52, 61, 62, 63, 68, 110                    PLEURAL DECOMPRESSION, 150
MALLAMPATI CLASSIFICATION, 25                         POSTPARTUM HEMORRHAGE, 109
MAURICEAU MANEUVER, 99                                PRE-ECLAMPSIA, 110
MCI, 10, 141                                          PRIMARY MANAGEMENT, 12, 14
MECONIUM, 105                                         PROLAPSED CORD, 111
MEDICAL CONTROL – ON-LINE, 138                        PROPARACAINE, 123
MEDICAL DIRECTOR NOTIFICATION, 133                    PROTOCOL IMPROVEMENT FORM, 175
MEDICAL RESCUE VEHICLE, 159                           PROTOCOL REVIEW, 11
MINORS, 160                                           PSYCHIATRIC FACILITY TRANSPORT, 115
MORPHINE, 20, 24                                      PULMONARY EDEMA, 56
MULTI-CASUALTY INCIDENT (MCI), 139                    PULSELESS ELECTRICAL ACTIVITY, 57, 58, 67
NALOXONE, 89, 104                                     QRS WIDENING, 93, 96
NARCAN, 57                                            QUICKTRACH, 41
NARCOTIC POISONING, 89                                RADIO REPORTS, 143
NASOTRACHEAL, 14, 21                                  REFUSAL OF TREATMENT AND/OR
NEBULIZED EPINEPHRINE, 71, 79                           TRANSPORT, 162
                           Santa Fe County Fire Department EMS Protocols
                                            January 2009
                                          Page 178 of 179
ROCURONIUM, 23                                        TASER, 128
RSI, 22                                               TENSION PNEUMOTHORAX, 150
RULE OF NINES, 117                                    TERMINATION OF UNSUCCESSFUL
SANE (SEXUAL ASSAULT NURSE                              RESUSCITATION, 47, 165
  EXAMINER), 125                                      TOXIDROMES, 91
SANTA FE RAPE CRISIS, 125                             TRANSCUTANEOUS PACING (TCP), 49
SEIZURE, 94                                           TRAUMA - BLUNT, 129
SEXUAL ASSAULT, 125                                   TRAUMA - PENETRATING, 130
SKILLS APPROVAL, 151                                  TRAUMA IN PREGNANCY, 106
SNAKE ENVENOMATION, 116                               TRAUMA STAT, 131
SODIUM BICARBONATE, 47, 96                            TRIAGE CRITERIA, 9
SOLUMEDROL, 71, 73                                    TRICYCLIC ANTIDEPRESSANT (TCA)
SPINAL INJURY, 126                                      POISONING, 96
SPINE CLEARANCE, 127                                  TUBE CONFIRMATION, 27
START TRIAGE, 142                                     VALIUM, 20
STOMACH DECOMPRESSION, 38                             VASOPRESSIN, 47, 55, 58, 60
SUBSTANCE ABUSE, 82                                   VENTRICULAR FIBRILLATION, 60, 61, 68
SUCCINYLCHOLINE, 23                                   VENTRICULAR TACHYCARDIA, 60, 62, 63, 68,
SUPRAVENTRICULAR TACHYCARDIA, 59                        69
SYNCHRONIZED CARDIOVERSION, 48, 59                    VERSED, 20, 23, 24, 35, 94, 114
SYNCOPE, 95                                           VOMITING, 97
TACHYCARDIA, 60, 61, 68                               WITHDRAWAL SYNDROME, 92




                           Santa Fe County Fire Department EMS Protocols
                                            January 2009
                                          Page 179 of 179

				
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