DENVER METROPOLITAN by mikeholy

VIEWS: 32 PAGES: 213

									D ENVER M ETROPOLITAN

P ARAMEDIC P ROTOCOLS




   These protocols are effective January 1, 2002.
             (Revised October 2003)
Denver Metro Paramedic Protocols




             DENVER METROPOLITAN PARAMEDIC PROTOCOL MANUAL -
      ACKNOWLEDGEMENT OF RECEIPT AND PARAMEDIC PRACTICE EXPECTATIONS


The completed information below verifies that the Denver Metropolitan Paramedic Protocol Manual has been
received and that the recipient accepts the responsibility for knowing and practicing as a paramedic in accordance with
these protocols.




Name of Recipient (please print)


Signature of Recipient


Agency                                                                      Date received




For office and administrative use only:


Protocol Examination Results
Denver Metro Paramedic Protocols

                                                ACKNOWLEDGEMENTS

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

The process that has been initiated in the construction of this revised set of metro-wide protocols will remain in place. The
authors will continue to edit and revise the protocols to reflect the dynamic role of emergency medical services within the
medical care community.

We wish to acknowledge the contributions, talent, and cooperation of all members of the EMS community who bring
purpose to the protocols and humanity to their patients.

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

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


                 Dedicated to Carol J. Shanaberger, Esq., EMT-P. May her memory be eternal.

The protocols have been adapted from Protocols for Prehospital Care, 2nd ed., 1989, Williams & Wilkins by:
                                          Jean Abbott, M.D., F.A.C.E.P.
                                        Marilyn Gifford, M.D., F.A.C.E.P.
                                                 Peter Rosen, M.D.

                                                             i
Denver Metro Paramedic Protocols

                                                   INTRODUCTION


The paramedic prehospital protocols are listed in alphabetical order within each section.

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

The following protocols were written with innate flexibility. The desire is not to dictate or confine medical practice,
but rather to provide an example of what is to be expected of prehospital performance.




PLEASE REMEMBER THAT PROTOCOLS DEFINE PROCESS; PEOPLE
PROVIDE CARE.




                                                          IX-2
Denver Metro Paramedic Protocols

                                   TABLE OF CONTENTS

I      Prehospital Patient Assessment                                      Section/Page Number
              Patient Assessment Algorithm                                                   I-2
              Scene Size-Up                                                                  I-3
              Initial Assessment                                                          I-3, 4
              Focused Assessment
                       Medical                                                                 I-5
                       Trauma                                                                  I-6
              Rapid Assessment
                       Medical                                                                 I-7
                       Trauma                                                               I-7, 8
              Special Assessment Notes                                                         I-9
              Detailed Assessment                                                        I-10, 11
              Ongoing Assessment                                                             I-12
              Neurologic Assessment                                                      I-13, 14

II     Treatment Protocols: Medical Treatment
             Abdominal Pain                                                                   II-2
             Allergy/Anaphylaxis                                                           II-3, 4
             Arrhythmias: General                                                             II-5
             Algorithms:
                      Premature Ventricular Contractions (PVCs)                                II-6
                      Ventricular Fibrillation/Pulseless Ventricular Tachycardia           II-7, 8
                      Asystole                                                                 II-9
                      Pulseless Electrical Activity (PEA)                                    II-10
                      Bradycardia with Pulse                                                 II-11
                      Wide Complex Tachycardia with Pulse                                    II-12
                      Narrow Complex Tachycardia with Pulse                                  II-13
             Cardiac Arrest                                                                  II-14
             Chest Pain                                                                      II-15
             Coma/Altered Mental Status/Neurologic Deficit                                   II-16
             Hypertension                                                                    II-17
             OB/GYN                                                                     II-18, 19
             Poisons and Overdoses                                                           II-20
             Psychiatric/Behavioral                                                         II-21
             Respiratory Distress                                                       II-22, 23
             Seizures                                                                        II-24
             Shock: Medical                                                             II-25, 26
             Syncope                                                                        II-27
             Vomiting                                                                        II-28
III    Treatment Protocols: Trauma Treatment
             Multiple Trauma Overview                                                     III-2, 3
             ATAC Adult Prehospital Trauma Triage Algorithm                                   III-4
             Algorithm: Trauma                                                                III-5
             Abdominal Trauma                                                                III-6
             Amputations                                                                     III-7
             Burns                                                                        III-8, 9
             Chest Injury                                                              III-10, 11
             Extremity Injuries                                                             III-12
             Face and Neck Trauma                                                      III-13, 14
             Head Trauma                                                               III-15, 16
             Spinal Trauma                                                                  III-17
             Trauma Arrest                                                                  III-18


                                                     IX-3
Denver Metro Paramedic Protocols

                                                                                 Section/Page Number
IV     Treatment Protocols: Environmental Injuries Treatment
             Bites and Stings                                                                   IV-2
             Drowning/Near-Drowning                                                             IV-3
             High Altitude Illness                                                              IV-4
             Hyperthermia                                                                       IV-5
             Hypothermia and Frostbite                                                        IV-6, 7
             Snake Bites                                                                        IV-8

V      Treatment Protocols: Pediatric Treatment
             General Guidelines for Pediatrics                                                  V-2
             Pediatric Patient Assessment                                                       V-3
             ATAC Pediatric Prehospital Trauma Triage Algorithm                                 V-4
             Infant and Child Resuscitation                                                   V-5, 6
             Infant Found Down/ Possible Sudden Infant Death Syndrome (SIDS)                    V-7
             Pediatric Dehydration                                                              V-8
             Pediatric Respiratory Distress                                                  V-9, 10
             Pediatric Seizures                                                                V-11

VI     Drug Protocols
              Adenosine (Adenocard)                                                            VI-2
              Albuterol Sulfate (for Amiodarone, see below after IV solutions)                 VI-3
              Aspirin (ASA)                                                                    VI-4
              Atropine Sulfate                                                                 VI-5
              Dextrose 50%                                                                     VI-6
              Diazepam (Valium)                                                                VI-7
              Diphenhydramine (Benadryl)                                                       VI-8
              Dopamine (Intropin)                                                           VI-9, 10
              Epinephrine                                                                  VI-11, 12
              Fentanyl Citrate                                                                VI-13
              Furosemide (Lasix)                                                              VI-14
              Glucagon                                                                        VI-15
              Haloperidol (Haldol)                                                         VI-16, 17
              Ipratropium Bromide (Atrovent)                                                  VI-18
              IV Solutions                                                                 VI-19, 20
              Amiodarone (replaced lidocaine HCl/Xylocaine)                                VI-21, 22
              Magnesium Sulfate                                                               VI-23
              Mark I Nerve Agent Antidote Kit                                              VI-24, 25
              Methylprednisolone (Solu-Medrol)                                                VI-26
              Metoclopramide (Reglan)                                                         VI-27
              Midazolam (Versed)                                                              VI-28
              Morphine Sulfate                                                                VI-29
              Naloxone Hydrochloride (Narcan)                                                 VI-30
              Nitroglycerin                                                                   VI-31
              Oral Glucose                                                                    VI-32
              Oxygen                                                                       VI-33, 34
              Phenylephrine (Intranasal)                                                      VI-35
              Racemic Epinephrine (Vaponephrine)                                              VI-36
              Sodium Bicarbonate                                                              VI-37
              Topical Ophthalmic Anesthetics                                                  VI-38

VII    Procedure Protocols
              Airway Management: General Principles                                            VII-2
              Airway Management: Opening the Airway                                          VII-3, 4
              Airway Management: Obstructed Airway                                             VII-5

                                                         IX-4
Denver Metro Paramedic Protocols

Procedure Protocols (continued)                                         Section/Page Number

               Airway Management: Clearing and Suctioning the Airway                 VII-6, 7
               Airway Management: Assisting Ventilation                                 VII-8
               Airway Management: Capnography                                           VII-9
               Advanced Airway Management: Orotracheal Intubation                 VII-10, 11
               Advanced Airway Management: Nasotracheal Intubation                    VII-12
               Advanced Airway Management: Percutaneous Cricothyrotomy                VII-13
               Bandaging                                                              VII-14
               Cardioversion Algorithm                                                VII-15
               Defibrillation                                                     VII-16, 17
               Field Drawn Blood Samples                                              VII-18
               Medication Administration (Parenteral)                             VII-19, 20
               PASG (Formerly MAST)                                                   VII-21
               Restraints                                                         VII-22, 23
               Splinting: Axial                                                   VII-24, 25
               Splinting: Extremity                                               VII-26, 27
               Tension Pneumothorax Decompression                                 VII-28, 29
               Transcutaneous Cardiac Pacing                                          VII-30
               Transport of the Handcuffed Patient                                    VII-31
               Vascular Access Devices                                            VII-32, 33
               Venous Access Technique                                         VII-34, 35, 36


VIII   Operational Guidelines
              Automated External Defibrillator (AED): Coordination of
              ALS-Trained Provider With Personnel Using AEDs                           VIII-2
              AED/Cardiac Arrest Algorithm                                             VIII-3
              Blood Draw for Alcohol Determination                                     VIII-4
              Combined Advance Directives and CPR Directive                      VIII-5, 6, 7
              Communication                                                            VIII-8
              Confidentiality                                                          VIII-9
              Consent                                                            VIII-10, 11
              Destination Policy                                                 VIII-12, 13
              Divert Policy                                                      VIII-14, 15
              Hazardous Materials (HAZMAT)                                           VIII-16
              Infectious and Communicable Diseases                                   VIII-17
              Mental Health Holds (MHH)                                              VIII-18
              Non-Transport of Patients                                          VIII-19, 20
              Non-Transport of Patients Algorithm                                    VIII-21
              Patient Care Report Requirements                                       VIII-22
              Physician at the Scene/Medical Direction                               VIII-23
              Physician at the Scene/Medical Direction Algorithm                     VIII-24
              Resuscitation and Field Pronouncement Guidelines                VIII-25, 26, 27
              Triage: Multiple Patient Assessment                             VIII-28, 29, 30

IX     Appendix
             A.        Commonly Accepted Abbreviations for Field Use        IX-2, 3, 4, 5, 6, 7
             B.        Critical Care Transport Utilization Guidelines             IX-8, 9, 10
             C.        Protocols Requiring Base Contact – TABLES                   IX-11, 12
             D.        Refusal of Transport and Treatment Sample Document               IX-13
             E.        Required Records on Treatment and Transportation                 IX-14
             F.        Triage/MCI Templates IX-15, 16, 17



                                                   IX-5
Denver Metro Paramedic Protocols




                                              SECTION I

                                   PREHOSPITAL PATIENT ASSESSMENT

       CONTENTS
                                                                    Page Number
I      Prehospital Patient Assessment

               Patient Assessment Algorithm                                   I-2
               Scene Size-Up                                                  I-3
               Initial Assessment                                          I-3, 4
               Focused Assessment
                        Medical                                               I-5
                        Trauma                                                I-6
               Rapid Assessment
                        Medical                                                I-7
                        Trauma                                              I-7, 8
               Special Assessment Notes                                        I-9
               Detailed Assessment                                       I-10, 11
               Ongoing Assessment                                            I-12
               Neurologic Assessment                                     I-13, 14




                                               IX-6
Denver Metro Paramedic Protocols

Prehospital Patient Assessment

                                   PATIENT ASSESSMENT ALGORITHM




                                              IX-7
Denver Metro Paramedic Protocols

                                            Prehospital Patient Assessment

                                                   SCENE SIZE UP

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



                                              INITIAL ASSESSMENT


Initial Assessment

A.     Form a general impression of the patient (sick/not sick; hurt/not hurt)
B.     Determine the chief complaint/apparent life threats
C.     Assess mental status (AVPU)
                A----Alert
                V----Responsive to verbal stimulus
                P----Responsive to painful stimulus
                U----Unresponsive
D.     Briefly note body position and extremity movement.
E.     Airway:
       1.       Observe the mouth and upper airway for air movement.
       2.       Open airway if needed: use head tilt-chin lift in medical patients; chin lift (without head tilt) or jaw
                thrust in trauma victims.
       3.       Protect cervical spine from movement in appropriate trauma victims. Use assistant to provide
                continuous manual stabilization.
       4.       Look for evidence of upper airway problems, such as vomitus, bleeding, facial trauma.
       5.       Clear upper airway of mechanical obstruction with finger sweep or suction, as needed.
F.     Breathing:
       1.       Expose chest and observe chest wall movement.
       2.       Note respiratory rate (qualitative), noise, and effort.
       3.       Auscultate for breath sounds.
       4.       Treat respiratory arrest with:
                a.        Pocket mask or bag-valve-mask for initial ventilatory control.
                b.       Check pulse and begin CPR if no pulse.
                c.        Intubate after initial ventilation if necessary.
       5.       Assess for partial or complete obstruction. (Treat according to Section VII: Airway Management:
                Obstructed Airway)
       6.       If respiratory rate < 12/min or breathing appears inadequate:
                a.       Assist respirations with pocket mask or BVM; administer supplemental O2.
                b.        Consider tracheal intubation to secure airway if necessary.
                c.        Transport rapidly
       7.       Observe skin color, mentation for signs of hypoxia.
       8.      Administer O2 if signs of hypoxia
       9.       Look for life-threatening respiratory problems and briefly stabilize (See Section III: Treatment

                                                         IX-8
Denver Metro Paramedic Protocols

                 Protocols: Trauma Treatment, Chest Injury protocol):
                 a.       Open or sucking chest wound: seal.
                 b.       Large flail segment: stabilize.
                 c.       Tension pneumothorax: transport rapidly and decompress chest. (See Section III: Treatment
                          Protocols: Trauma Treatment, Tension Pneumothorax Decompression)
G.      Circulation:
        1.       Pulse
                 a.       Palpate for pulse: radial pulse presence implies BP>80 systolic; carotid or femoral pulse pre-
                          sence implies BP>60-70. If the patient is pulseless and apneic, begin CPR
                 b.       Note pulse quality (strong, weak) and general rate (slow, fast, moderate).
                 c.       Check capillary refill time in fingertips: 2 sec. is normal. Pediatric patients only.
        2.       Major Bleeding
                 a.        Control hemorrhage by direct pressure with clean dressing to wound. (If needed, use
                           elevation, pressure points; tourniquet ONLY in extreme situation)
H.      Identify priority of patients
        1.       If evidence of medical shock or severe hypovolemia, obtain baseline vital signs immediately and
                 begin treatment according to protocols: medical and trauma.

Special notes
A.      Initial assessment may take 30 seconds or less in a medical patient or victim of minor trauma. In the severely
        traumatized patient, however, assessment and treatment of life-threatening injuries evaluated in the initial
        assessment may require rapid intervention, with treatment and further assessment en route to the hospital.
B.      In the awake patient, the initial assessment may be completed by your initial greeting to the patient. This may
        make it clear that the ABCs are stable and emergency intervention is not required before completing
        assessment.
C.      Neck should be immobilized and secured during airway assessment or immediately following initial
        assessment if indicated.
D.      Vital signs should be obtained during the focused and detailed assessment. If immediate intervention for
        profound shock or hypoventilation is required, this may need to be initiated before numerical vital signs are
        taken.
E.      Pediatric assessment (See Section V - Treatment Protocols: Pediatric Treatment - Infant and Child
        Resuscitation)




                                                        IX-9
Denver Metro Paramedic Protocols

                                              FOCUSED ASSESSMENT

MEDICAL

A focused medical assessment is done on all conscious medical patients. In awake patients, this may consist only of
identifying yourself and noting the patient’s responsiveness and general appearance. The formal detailed assessment
may not need to be done on patients with a specific complaint, such as “chest pain”. Assessment must be no less
thorough, but it may be limited to the body systems that are pertinent to the presenting problem.

A. Based on the information obtained from the initial assessment, perform either a rapid or focused medical
   assessment, and a detailed exam.

Focused-Responsive

A.      Assess history of present illness

                O---Onset                   (When it first began?)
                P---Provocation             (What brings it on or makes it better or worse?)
                Q---Quality                 (On scale of 1-10 rate the pain?)
                R---Radiation               (Does pain go anywhere & where is the pain?)
                S---Severity                (Compare the pain to before, is it worse or the same?)
                T---Time                    (How long does the pain last, how long did it last before, what helped
                                             before for relief?)

B.     Obtain SAMPLE Information:
           S---Signs and Symptoms, chief complaint
           A--- Allergies
           M---Medications
           P--- Pertinent Medical History
           L--- Last oral intake, Last menstrual period
           E--- Events leading to illness

C.    Perform a focused Medical Assessment
            1. Chief Compliant
            2. Signs
            3. Symptoms

D.     Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature and color.

E.     Based on the exam findings, initiate proper interventions.

F.     Make transport decision.

G.     Perform detailed physical exam: see Detailed Assessment (Section I)

H.     Transport as soon as possible.

I.      Perform Ongoing Assessment




                                                         IX-10
Denver Metro Paramedic Protocols

TRAUMA

Focused-No Significant
The Focused Assessment is performed on the Specific Injury Site.

A. As you inspect and palpate specific injury, look and feel for the following examples of injuries or signs of injury:
               D---Deformity
               C---Contusions/Crepitation
               A---Abrasions
               P---Punctures/Penetrations/Paradoxical Movement
               B---Burns
               T---Tenderness
               L---Lacerations
               S---Swelling
B. Assess baseline vital signs: blood pressure, pulse, respirations, skin temperature, and color
C. Assess SAMPLE history:
               S--- Signs and Symptoms, chief complaint
               A--- Allergies.
               M--- Medications
               P--- Pertinent past medical history
               L--- Last oral intake, last menstrual period
               E--- Events leading to injury, illness

D     Based on the exam findings, initiate proper intervention
E.   Transport as soon as possible.
F.   Perform Detailed Assessment: see Detailed Assessment (Section I)
F.    Perform Ongoing Assessment




                                                        IX-11
Denver Metro Paramedic Protocols

                                               RAPID ASSESSMENT

MEDICAL-Unresponsive

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

TRAUMA

A. Perform a rapid trauma assessment on patients with significant mechanism of injury (MOI) to determine life-
   threatening injuries. The rapid trauma assessment should be performed on responsive and unresponsive patients
   alike. An integral part of this assessment is evaluation using the simple mnemonic "DCAP-BTLS". For each area
   of the body, you should quickly look for Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns,
   Tenderness, Lacerations, and Swelling. In the responsive patient, symptoms should be sought before and during
   the trauma assessment.
                1.       Continue spinal immobilization.
                2.       Reconsider transport decision.
                3.       Assess mental status:
                         A----Alert
                         V----Verbal
                         P----Painful
                         U----Unresponsive
A. As you inspect and palpate, look and feel for the following examples of injuries or signs of injury:
                D----Deformity
                C----Contusions/Crepitation
                A----Abrasions
                P----Punctures/Penetrations/Paradoxical Movement
                B----Burns
                T----Tenderness
                L----Lacerations
                S----Swelling
B. Assess the Head; inspect and palpate for injuries of signs of injury (DCAP BTLS)
C. Assess the Neck; inspect and palpate for injuries of signs of injury (DCAP BTLS)
D. Assess the Chest; inspect and palpate for inures of signs of injury (DCAP BTLS)



                                                        IX-12
Denver Metro Paramedic Protocols

E. Assess the Abdomen; inspect and palpate for injuries of signs of injury (DCAP BTLS)
F. Assess the Pelvis; inspect and palpate for injuries of signs of injury (DCAP BTLS)
G. Assess the Extremities; inspect and palpate for injuries of signs of injury (DCAP BTLS)
H. Roll patient with spinal precautions and assess posterior body; inspect and palpate for injuries or signs of injury
   (DCAP BTLS)
J. Assess baseline vital signs: Blood pressure, Pulse, Respirations, Skin Temperature, and Color
K. Assess SAMPLE history:
            S---Signs and Symptoms, chief complaint
            A--- Allergies
            M---Medications
            P--- Pertinent Medical History
            L--- Last oral intake, LMP
            E--- Events leading to illness
L. Based on the exam findings, initiate proper intervention
M. Transport as soon as possible
N. Perform ongoing assessment




                                                        IX-13
Denver Metro Paramedic Protocols

                                         SPECIAL ASSESSMENT NOTES

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




                                                        IX-14
Denver Metro Paramedic Protocols

Prehospital Patient Assessment
                                              DETAILED ASSESSMENT

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

1.      Initial assessment
2.      Stabilization and initial treatment of life-threatening airway, breathing, or circulatory difficulties
3.      Cervical immobilization as needed

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

A.      Initial vital signs

B.      Head and Face:
        1.     Observe for deformities, asymmetry, bleeding.
        2.     Palpate for deformities, tenderness, crepitation.
        3.     Recheck airway for potential obstruction: dentures, bleeding, loose or avulsed teeth, vomitus,
               abnormal tooth position from mandible fracture, absent gag reflex.
        4.     Eyes: pupils (equal or unequal, responsiveness to light), foreign bodies, contact lenses
        5.     Nose: deformity, bleeding, discharge
        6.     Ears: bleeding, discharge, bruising behind ears

C.      Neck:
        1.       Recheck for deformity or tenderness if not already immobilized.
        2.       Observe for wounds, neck vein distention, use of neck muscles for respiration, altered voice, and
                 medical alert tags.
        3.       Palpate for crepitation, tracheal shift.

D.      Chest:
        1.       Observe for wounds, chest wall movement, and accessory muscle use.
        2.       Palpate for tenderness, wounds, fractures, crepitation, unequal rise of chest.
        3.       Have patient take deep breath: observe for pain, symmetry, air leak from wounds.
        4.       Auscultate chest for rales, wheezes, rhonchi, or decreased breath sounds.

E.      Abdomen:
        1.    Observe for wounds, bruising, distention.
        2.    Palpate all 4 quadrants for tenderness, rigidity.
        3.    Consider orthostatic vital signs for volume status.

F.      Pelvis:
        1.      Palpate and compress lateral pelvic rims, symphysis pubis, for tenderness or instability.

G.      Shoulders/Upper Extremities:
        1.     Observe for angulation, protruding bone ends, symmetry.
        2.     Palpate for tenderness, crepitation.
        3.     Note distal pulses, color, medical alert tags.
        4.     Check sensation.
        5.     Test for weakness if no obvious fracture present (have patient squeeze your hands).
        6.     If no obvious fracture, gently move arms to check overall function.




                                                         IX-15
Denver Metro Paramedic Protocols

H.     Lower Extremities:
       1.     Observe for angulation, protruding bone ends, symmetry.
       2.     Palpate for tenderness, crepitation.
       3.     Note distal pulses, color.
       4.     Check sensation.
       5.     Test for weakness if no obvious fracture present (have patient push feet against your hands and pull
              back against your hands).
       6.     If no obvious fracture, gently move legs to check overall function.

I.     Back:
       1. Immobilize if any suspicion of back injury. To the extent immobilization allows, palpate for wounds,
          fractures, tenderness.
       2. Recheck motor and sensory function as appropriate.




                                                     IX-16
Denver Metro Paramedic Protocols

                                           ONGOING ASSESSMENT

       A.      Repeat initial assessment for a stable patient, repeat and record every 15 minutes. For an unstable
               patient, repeat and record at a minimum every 5 minutes.

               1.      Reassess mental status.
               2.      Maintain an open airway.
               3.      Monitor breathing for rate and quality.
               4.      Reassess pulse for rate and quality.
               5.      Monitor skin color and temperature.
               6.      Reassess and record vital signs.

       B.      Repeat focused assessment regarding patient complaint or injuries.

       C.      Check interventions:
               1.      Assure adequacy of oxygen delivery/artificial ventilation.
               2.      Assure management of bleeding.
               3.      Assure adequacy of other interventions.




                                                      IX-17
Denver Metro Paramedic Protocols

                                           NEUROLOGIC ASSESSMENT

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

A.      Vital Signs: observe particularly for adequacy of ventilations; depth, frequency, and regularity of respirations.
B.      Level of consciousness:
                                                                          Glasgow Coma Score
                          Eye opening:     None                                       1
                                           To pain                                    2
                                           To speech                                  3
                                           Spontaneously                              4
                  Best verbal response:    None                                       1
                                           Garbled sounds                             2
                                           Inappropriate words                        3
                                           Disoriented sentences                      4
                                           Oriented                                   5
                  Best motor response:     None                                       1
                                           Abnormal extension                         2
                                           Abnormal flexion                           3
                                           Withdrawal to pain                         4
                                           Localizes pain                             5
                                           Obeys commands                             6
                           Score = Sum of scores in 3 categories: (15 points possible)

C.      Eyes:
        1.       Direction of gaze, extraocular movement.
        2.       Size and reactivity of pupils.
D.      Movement: observe whether all four extremities move equally well.
E.      Sensation (if patient awake): observe for absent, abnormal, or normal sensation at different levels if cord
        injury is suspected.

Special Notes
A.      The Glasgow Coma Scale (GCS) used above has gained acceptance as one method of scoring and monitoring
        patients with head injury. It is readily learned, has little observer-to-observer variability, and accurately re-
        flects cerebral function. Always record specific responses rather than just the score (sum of observations). In
        areas where numerical assignment of scores is not a formal procedure, the observations of the GCS still
        provide an excellent basis for field neurologic assessment. Note also that the other parameters listed must be
        observed to assess fully the neurologically impaired patient.




                                                        IX-18
Denver Metro Paramedic Protocols

B.     Use your written report to follow and document changes in neurologic findings.
C.     At a minimum, gross motor function must be documented before and after moving a patient with suspected
       spinal injury.
D.     Sensory deficit levels should be marked gently on the patient's skin with a pen to help identify any changes.
E.     Note what stimulus is being used when recording responses. Applied noxious stimuli must be adequate to the
       task but not excessive. Initial mild stimuli can include light pinch, dull pinprick, or light sternal rub. If these
       are unsuccessful at eliciting a pain response, pressure with a dull object to base of nailbed, stronger pinch
       (particularly in axilla), or sternal rub will be necessary to demonstrate the patient's best motor response.
F.     When responses are not symmetrical, use motor response of the best side for scoring GCS and note asymmetry
       as part of neurologic evaluation.
G.     Use of restraints or intubation of patient will make some observations less accurate. Be sure to note on chart if
       circumstances do not permit full verbal or motor evaluation.
H.     Remember that a patient who is totally without response will have a score of 3, not 0.
I.     In small children, the GCS may be difficult or impossible to evaluate. Use an age-appropriate neurological
       assessment for small children. Children who are alert and appropriate should focus their eyes and follow your
       actions, respond to parents or caregivers, and use language and behavior appropriate to their age level. In
       addition, they should have normal muscle tone and a normal cry. Several observers should attempt to elicit a
       "best verbal response," to avoid over or underestimation of level of consciousness.




                                                       IX-19
Denver Metro Paramedic Protocols

                                                 SECTION II

                        TREATMENT PROTOCOLS: MEDICAL TREATMENT

TABLE OF CONTENTS

II     Treatment Protocols: Medical Treatment                                    Page Number
             Abdominal Pain                                                                    II-2
             Allergy/Anaphylaxis                                                           II-3, 4
             Arrhythmias: General                                                              II-5
             Algorithms:
                      Premature Ventricular Contractions (PVCs)                                II-6
                      Ventricular Fibrillation/Pulseless Ventricular Tachycardia           II-7, 8
                      Asystole                                                                 II-9
                      Pulseless Electrical Activity (PEA)                                    II-10
                      Bradycardia with Pulse                                                 II-11
                      Wide Complex Tachycardia with Pulse                                    II-12
                      Narrow Complex Tachycardia with Pulse                                  II-13
             Cardiac Arrest                                                                  II-14
             Chest Pain                                                                      II-15
             Coma/Altered Mental Status/Neurologic Deficit                                   II-16
             Hypertension                                                                    II-17
             OB/GYN                                                                     II-18, 19
             Poisons and Overdoses                                                           II-20
             Psychiatric/Behavioral                                                         II-21
             Respiratory Distress                                                       II-22, 23
             Seizures                                                                        II-24
             Shock: Medical                                                             II-25, 26
             Syncope                                                                        II-27
             Vomiting                                                                       II-28




                                                     IX-20
Denver Metro Paramedic Protocols

Medical Treatment
                                                ABDOMINAL PAIN

Specific information needed

A.      Pain: nature (crampy or constant), duration, location; radiation to back, groin, chest, shoulder
B.      Associated symptoms: nausea, vomiting (bloody or coffee-ground), diarrhea, constipation, black or tarry
        stools, urinary difficulties, menstrual history, fever
C.      Past history: previous trauma, abnormal ingestions, medications, known diseases, surgery


Specific objective findings

A.      Vital signs
B.      General appearance: restless, quiet, sweaty, pale
C.      Abdomen: tenderness, guarding, distention, rigidity, pulsatile mass
D.      Emesis, stool, or urine, describe, amount
E.      Check for equality of pulses.

Treatment

A.      Position of comfort
B.      NPO
C.      If BP <90 systolic and signs of hypovolemic shock:
        1.       Administer O2.
        2.       Establish venous access with 2 large bore lines; NS fluid bolus
        3.       Cardiac monitor
        4.       Consider transport to a trauma center based upon destination protocol.
D.      Establish venous access even if vital signs normal.
E.      Monitor vitals during transport.
F.      Cardiac monitor and 12 lead EKG (if available) for upper abdomen pain.
G.      Consider pain medication for hemodynamically stable patients with transport times >10 minutes
        1.       Fentanyl per protocol

Specific precautions

A.      The most important diagnoses to consider are those associated with catastrophic internal bleeding: ruptured
        aneurysm, liver, spleen, ectopic pregnancy, etc. Since the bleeding is not apparent, you must think of the
        volume depletion and monitor patient closely to recognize shock. If a patient presents in shock (See Section II
        –Medical Treatment, Shock), consider transport to a trauma center where appropriate surgical consultation is
        readily available.
B.      Elderly patients may have significant hypovolemic shock with systolic blood pressures above 90 mm Hg.
        With signs of hypovolemia (See Section II –Medical Treatment, Shock), treat with fluids.
C.      Upper abdomen and lower chest pain may reflect thoracic pathology such as myocardial infarction, etc.
        Massive fluid resuscitation may be contraindicated.




                                                       IX-21
Denver Metro Paramedic Protocols

Medical Treatment
                                             ALLERGY/ANAPHYLAXIS

Specific information needed

A.      History: current sequence of events, exposure to allergens (bee stings, drugs, nuts, seafood most common),
        prior allergic reactions
B.      Current symptoms: itching, wheezing, respiratory distress, nausea, weakness, rash, anxiety, swelling
C.      Medications, past medical history

Specific objective findings

A.      Vital signs, level of consciousness
B.      Respirations: wheezing, upper airway noise, effort
C.      Mouth: tongue and airway swelling

Treatment

A.      Ensure airway. Early endotracheal intubation may be advisable before swelling becomes severe. Suction as
        needed. Prepare to assist ventilations.

B.      Position of comfort (upright if respiratory distress predominates; supine if shock prominent)

C.      Administer O2 as indicated.

D.      Remove injection mechanism if still present (stinger, needle, etc). Do not squeeze venom sac; rather, scrape
        with straight edge.

E.      If signs of severe generalized reaction present, establish venous access.

F.      Monitor cardiac rhythm.

G.      Administer diphenhydramine as indicated. (See Section VI – diphenhydramine)

H.      For objective findings of respiratory distress such as stridor, wheezing, hypoxia, tachypnea or angioedema, SQ
        Epinephrine is indicated.

        1.      Epinephrine 1:1000 SQ
        2.      Contact base for additional epinephrine orders.

I.      For signs of shock (BP < 90) or altered mental status:
        1.      Fluid bolus 20cc/kg
        2.      Contact base for IV epinephrine.

J.      Transport rapidly if patient is unstable.

Specific precautions

A.      Allergic reactions can take multiple forms. Early consult with base physician is encouraged.
B.      Anxiety, tremor, palpitations, tachycardia, and headache are not uncommon with administration of
        epinephrine. These may be particularly severe with IV administration. In children, epinephrine may induce
        vomiting. (continued on next page)
C.      Angina, MI, or dysrhythmias may be precipitated.
D.      Use caution in the administration of epinephrine in cardiac patients or the elderly.


                                                        IX-22
Denver Metro Paramedic Protocols

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




                                                     IX-23
Denver Metro Paramedic Protocols

Medical Treatment
                                           ARRHYTHMIAS: GENERAL

Specific information needed

A.      Present symptoms: sudden or gradual onset, palpitations
B.      Associated symptoms: chest pain, dizziness or fainting, trouble breathing, abdominal pain, fever
C.      Prior history: arrhythmias, cardiac disease, exercise level, pacemaker
D.      Current medications, particularly cardiac

Specific objective findings

A.      Vital signs
B.      Signs of poor cardiac output:
        1.       Altered level of consciousness
        2.       "Shocky" appearance: cool/clammy skin, pallor
        3.       Blood pressure < 90 systolic
C.      Signs of cardiac failure (increased back-up pressure):
        1.       Neck vein distention
        2.       Lung congestion, rales
        3.       Peripheral edema: sign of chronic failure, not acute
D.      Signs of hypoxia: marked respiratory distress, cyanosis, tachycardia

Advanced treatment, general

A.      Administer O2, position of comfort.
B.      Establish venous access.
C.      Evaluate the patient. Is the patient perfusing adequately or are there signs of inadequate perfusion?
D.      Apply cardiac monitor and evaluate arrhythmia.
        1.      Is there a pulse corresponding to monitor rhythm?
        2.      Rate: tachycardia, bradycardia, normal?
        3.      Are the ventricular complexes wide or narrow?
        4.      What is the relation between atrial activity (P waves) and ventricular activity?
        5.      Is the arrhythmia potentially dangerous to the patient? (See Specific Precautions D)

E.      Document the arrhythmia by rhythm strip and 12 lead EKG if available.
F.      Treat if needed according to pulse rate (see algorithms) or as directed by base physician.
G.      Document results of treatment (or lack thereof) by checking pulse and recording change on paper tape.
H.      Transport nonemergent if patient has stabilized. Monitor condition enroute.

Specific precautions

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

                                                         IX-24
Denver Metro Paramedic Protocols

F.     Drug dosages vary in the pediatric and elderly populations. See drug protocols for details, Section VI.




                                                      IX-25
Denver Metro Paramedic Protocols

Medical Treatment
                                           ARRHYTHMIA ALGORITHMS

                          PREMATURE VENTRICULAR CONTRACTIONS (PVCs)

1.     The treatment of PVCs is rarely, if ever, indicated in the prehospital setting.

2.     Patients with PVCs and active chest pain should have their pain treated aggressively with oxygen, aspirin,
       nitrates, and pain medications.

3.     Prophylactic use of amiodarone is contraindicated.




                                                        IX-26
Denver Metro Paramedic Protocols

Medical Treatment
             VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA

                                   INITIATE SUPPORTIVE MEASURES:
                                            - ABCs
                                            - CPR until cardiac monitor attached

                                      VF/VT PRESENT
                                             -Defibrillate up to 3 times if needed


                              RHYTHM AFTER FIRST 3 COUNTERSHOCKS?



 Pulseless VT/VF                                         NSR                              Other
                                                                                       Dysrhythmias


                                                      Reassess                        Support ABCs
 CPR
                                                    Support ABCs                     Treat per protocol
 Endotracheal intubation
 Hyperventilate 100% O2
 Establish venous access


 EPINEPHRINE (1:10,000)                            AMIODARONE                 INITIATE TRANSPORT
 1 mg IV push                                  150 mg over 3 –5 minutes
 repeat every 3-5 min


 DEFIBRILLATE
                                             INITIATE TRANSPORT


 AMIODARONE
 300 mg IV push

 DEFIBRILLATE


 CONSIDER MAGNESIUM SULFATE
 2 g IV push (See Note A)

 DEFIBRILLATE


 INITIATE TRANSPORT
 (continued on next page)




                                                  IX-27
Denver Metro Paramedic Protocols


 Special notes
 A.      Torsade de pointes is a rare and
         special form of V-tach. See
         magnesium sulfate protocol. (Section
         VI-Drug Protocol)

 B.      Shocks must not be delayed until an
         IV or airway is established.




                                                IX-28
Denver Metro Paramedic Protocols

Medical Treatment
                                                 ASYSTOLE


                                       INITIATE SUPPORTIVE MEASURES:
                                       -     ABCs
                                       -     CPR
                                       -     Endotracheal intubation
                                       -     Establish venous access
                                       -     Confirm asystole in at least two leads
                                       -     Consider pacing (see special Note A below)


                                       EPINEPHRINE (1:10,000)
                                       1.0 mg IV push, repeat every 3 – 5 minutes



                                       ATROPINE
                                       1.0 mg IV push repeat every 3 – 5 minutes, not to exceed 0.04 mg/kg


                                       SODIUM BICARBONATE
                                       Consider in patients with prolonged cardiac arrest, 1.0 mEq/kg IV push


                                       CONTACT BASE:
                                       Consult for possible termination of efforts



Special notes

A.     Patients who convert from a viable rhythm into asystole should have transcutaneous pacing
       instituted immediately. However, pacing should be withheld from those patients who present in
       asystole.
B.     The effectiveness of transcutaneous pacing is directly related to the speed with which this therapy is
       initiated.
C.     When asystole is diagnosed, check the integrity of the leads and electrode patches and confirm this
       interpretation in at least two leads.
D.     In pediatric patients, after ABCs have been initiated, hyperventilate, give an IV fluid bolus, reassess,
       consider epinephrine.




                                                   IX-29
Denver Metro Paramedic Protocols

Medical Treatment
                              PULSELESS ELECTRICAL ACTIVITY (PEA)


                       INITIATE SUPPORTIVE MEASURES:
                       -     ABCs
                       -     CPR
                       -     Endotracheal intubation
                       -     Establish venous access



                       CONSIDER POSSIBLE CAUSES:            TREATMENT:
                       -    Hypovolemia -                   -IV fluid bolus (20 ml/kg NS)
                       -    Tension pneumothorax -          -Chest decompression (per protocol)
                       -    Hypoxia -                       -Check tube placement
                       -    Acidosis -                      -Ventilation
                       -    Cardiac tamponade               -IV fluid bolus (20 ml/kg NS)
                       -    Hypothermia                     -see Hypothermia protocol
                       -    Pulmonary embolism
                       -    Myocardial infarction
                       -    Drug overdose
                       -    Hyperkalemia                    -Sodium bicarbonate



                       EPINEPHRINE (1:10,000)
                       1.0 mg, repeat every 3 – 5 minutes



                       ATROPINE for BRADYCARDIA
                       1.0 mg IV push repeat every 3 – 5 minutes, not to exceed 0.04 mg/kg



                       INITIATE TRANSPORT


Special notes

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




                                                  IX-30
Denver Metro Paramedic Protocols

Medical Treatment
                                       BRADYCARDIA WITH PULSE

Patients who are asymptomatic with normal blood pressure do not need treatment of bradycardia in the field.

       INITIATE SUPPORTIVE MEASURES:
       -     Airway management as indicated
       -     Initiate oxygen therapy
       -     Establish venous access

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

_


YES                                               NO


INITIATE TRANSPORT                                ATROPINE
                                                  0.5 – 1.0 mg IV push

                                                  EVALUATE RESPONSE

_

       BP > 90 mm Hg                              Heart rate normal           Persistent hemodynamically
                                                                              unstable bradycardia
                                                  BP < 90 mm Hg

       INITIATE TRANSPORT                         Fluid bolus to              REPEAT ATROPINE
                                                  250cc maximum               0.5 – 1 mg IV push

                                                  INITIATE TRANSPORT
                                                  and CONTACT BASE            TRANSCUTAN-
                                                  For possible                EOUS PACING (if
                                                                              available)
                                                  approval to
                                                  administer                  INITIATE
                                                  dopamine                    TRANSPORT AND
                                                  or epinephrine drip         CONTACT BASE for
                                                                              dopamine or epinephrine
Special notes
A.     Do not delay TCP while awaiting IV access or for atropine to take effect if the patient is showing
       signs of poor perfusion.
B.     When pacing, verify mechanical capture and patient tolerance. Administer midazolam for sedation
       per protocol, if conscious, after initial pacing.
C.     Differentiate premature ventricular beats from escape beats, which are wide complexes occurring late
       after preceding beat as a lower pacemaker cell takes over. Escape beats are beneficial to the patient
       and should be treated by increasing the underlying rate and conduction; not by suppressing the escape
       beats.
D.     In pediatric patients, bradycardia is most often a sign of hypoxia. After therapy for the ABCs has
       been initiated, hyperventilate, give fluid bolus, reassess, and consider epinephrine. Epinephrine
       should be the first medication utilized (see protocol for dosage, section VI).

                                                    IX-31
Denver Metro Paramedic Protocols

Medical Treatment
                             WIDE COMPLEX TACHYCARDIA WITH PULSE

                                INITIATE SUPPORTIVE MEASURES:
                            - ABCs
                            - Airway management as indicated

                            - Initiate oxygen therapy

                            - Establish venous access

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


                                                              NO
                YES
                                                              REFER TO
                                                              SYNCHRONIZED
                                                              CARDIOVERSION
                INITIATE TRANSPORT                            PROTOCOL

                                                              INITIATE TRANSPORT


                CONTACT BASE
                to consult for possible approval to
                administer one of these medications:
                       -Amiodarone
                       -Magnesium
                       -Adenosine

Special notes

A.              A wide QRS complex is defined as a complex with a width greater than 0.12 sec.
B.              A wide complex tachycardia is usually ventricular in origin, but may, on occasion, be a
                supraventricular rhythm with aberrant conduction.
C.              Consider sedation with midazolam for cardioversion in conscious patients.
D.              Immediate cardioversion is rarely needed for heart rates < 150.




                                                  IX-32
Denver Metro Paramedic Protocols

Medical Treatment
                            NARROW COMPLEX TACHYCARDIA WITH PULSE

                INITIATE SUPPORTIVE MEASURES:
                  - ABCs
                  - Airway management as indicated
                  - Initiate oxygen therapy
                  - Establish venous access


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



                YES                                                         NO

                Transport                                  Administer midazolam if awake

                Adenosine 6mg                              Synchronized Cardioversion

                Adenosine 12mg                             Transport and contact base

                Contact base


Special notes

A.     A narrow, QRS complex is less than 0.12 seconds in duration.
B.     Tachycardia is most likely a secondary problem when the pulse is less than 150 in an adult. Treat
       hypoxia, hypovolemia, pain, and other problems first.
C.     Adenosine is not effective in treating atrial fibrillation, which is an irregular rhythm.
D.     Adenosine must be administered over 1-3 seconds and followed by a rapid 20ml saline flush. A
       proximal vein and port are preferred.
E.     If patient takes theophylline or xanthine derivatives, higher doses of adenosine may be needed.




                                                   IX-33
Denver Metro Paramedic Protocols

Medical Treatment
                                           CARDIAC ARREST

Specific information needed

A.     History of arrest: onset, preceding symptoms, bystander CPR, other treatment, duration of arrest
B.     Past history: diseases, medications
C.     Surroundings: evidence of drug ingestion, trauma, other unusual presentations

Specific objective findings

A.     Absence of consciousness
B.     Terminal or no respirations
C.     Absence of pulse
D.     Signs of trauma, blood loss
E.     Air temperature; skin temperature

Treatment

A.     Check surroundings for safety to rescuers.
B.     Initiate CPR.
C.     Call for back-up if needed.
D.     Check rhythm with monitor or quick look paddles; treat rhythm by protocol.

Specific precautions

A.     Cardiac arrest in a trauma situation is not treated according to this protocol (Section III: Trauma
       Treatment, Trauma Arrest protocol). In a trauma situation, transport should be rapid, with IV, CPR
       en route (See Section III - Multiple Trauma Overview protocol).
B.     Survival from cardiac arrest is related to the time to BOTH BLS and ALS treatment. Don't forget
       CPR in the rush for advanced equipment. A call for back-up should be initiated promptly by any
       BLS unit. Likewise, standing order administration of the first steps in treatment is recommended to
       minimize time delays to ALS.
C.     See Infant and Child Resuscitation protocol (Section V) for special pediatric details.
D.     Large peripheral veins (antecubital or external jugular) are preferred IV sites in an arrest.
E.     Quick-look paddles preferred for initial rhythm check. Change to patches for more secure reading.
       Be sure machine is set to record from whichever mode is in use.
F.     Be sure to recheck for pulselessness and unresponsiveness upon arrival, even if CPR is in progress.
       This will avoid needless and dangerous treatment of "collapsed" patients who are inaccurately
       diagnosed initially, or who have spontaneous return of cardiac function after an arrhythmia or
       vasovagal episode.




                                                 IX-34
Denver Metro Paramedic Protocols

Medical Treatment
                                                     CHEST PAIN

Specific information needed

Symptoms:       Patient of either gender, more than 20 years old, with any of the following chief complaints:

A.     Suspected Acute Coronary Syndrome
       1.      Pressure, tightness, heaviness
       2.      Radiating in neck, jaw, shoulders, back, one or both arms, left-sided, or both
       3.      Indigestion or heartburn/nausea and/or vomiting, unexplained indigestion/belching
       4.      Persistent shortness of breath
       5.      Weakness/dizziness/lightheadedness/loss of consciousness
       6.      No pain or discomfort; however, patient may experience painless syncope, change in mental status, or
               dyspnea.
       7.      Cocaine use

B.     Respiratory
       1.       Acute onset of shortness of breath
       2.       Wheezing

Specific objective findings

A.     Vital signs
B.     General appearance: color, apprehension, sweating
C.     Signs of heart failure: neck vein distention, peripheral edema, respiratory distress
D.     Lung exam by auscultation: rales, wheezes or decreased sounds
E.     Chest wall tenderness, abdominal tenderness

Treatment

A.     Reassure and place patient at rest, position of comfort.
B.     Administer O2.
C.     If patient’s history suggests a potential cardiac origin to the chest pain:
       1.Monitor cardiac rhythm and obtain 12 lead EKG if available. If patient has 1mm ST elevation in two or
          more continuous leads, contact base for CARDIAC ALERT.
       2.Administer aspirin chewable tables if patient is able to swallow.
       3.Establish venous access.
       4.Administer nitroglycerin SL if BP > 100 systolic. Repeat until pain relieved: every 5 min up to 3 doses, or
       systolic BP < 100.
       5.If pain persists after third nitroglycerin, administer morphine sulfate for patients with no alteration of mental
       status and systolic BP > 100.
       6.Consider base contact for additional nitroglycerin and or morphine sulfate if pain persists.
       7.Consider NS fluid challenge or vasopressor if hypotensive.

Specific precautions
A.     Remember that there are many causes for chest pain and consider pulmonary embolus, pneumonia, aneurysm,
       pneumothorax.
B.     Beware of IV fluid overload in the potential cardiac patient.
C.     Patients taking Viagra should not be given nitroglycerin.




                                                        IX-35
Denver Metro Paramedic Protocols

Medical Treatment
                       COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT

Specific information needed

A.      Present history: duration of illness, onset and progression of present state illness; preceding symptoms such as
        headaches, seizures, confusion, trauma, etc.
B.      Past history: previous medical or psychiatric problems
C.      Medications: use, misuse, or abuse
D.      Surroundings: check for pill bottles, syringes, etc., and bring with patient. Note odor in house.

Specific objective findings

A.      Safety to rescuer: check for gases or other toxins.
B.      Vital signs
C.      Level of consciousness and neurological status
D.      Signs of trauma: head, body
E.      Breath odor
F.      Needle tracks
G.      Medical alert tag

Treatment

A.      Airway: protect as needed (positioning, nasopharyngeal or oropharyngeal airway, suctioning, endotracheal
        intubation)
B.      Administer O2.
C.      Establish venous access and fluid bolus as indicated.
D.      Draw appropriate blood tubes; test for blood glucose level
E.      Administer dextrose 50% if blood glucose reading <60, and if clinically indicated.
F.      Administer naloxone, if clinically indicated.
G.      Monitor cardiac rhythm.
H.      Transport in lateral recumbent position. (If trauma suspected, transport supine with cervical collar and back-
        board; logroll as necessary.)
I.      Monitor vitals during transport.

Specific precautions

A.      Be particularly attentive to airway. Difficulty with secretions, vomiting, and inadequate tidal volume are
        common.
B.      Hypoglycemia may present as focal neurologic deficit or coma (stroke-like picture).
C.      Coma in the diabetic may be due to hypoglycemia or to hyperglycemia (diabetic ketoacidosis). IV dextrose
        should be given to all unconscious diabetics, as well as patients with coma of unknown origin unless a blood
        glucose reading in the high range is obtained. The treatment may be life-saving in hypoglycemic patient, and
        will do no harm in the normal or hyperglycemic patient. Do not give oral sugar to an unconscious patient (see
        Dextrose).
D.      Stroke patients may be alert but unable to respond (aphasic); therefore, communicate with the patient and
        explain what you are doing. Avoid inappropriate comments.
E.      Naloxone is useful in any potential narcotic overdose, but be sure the airway and the patient are controlled
        before giving naloxone to a known drug addict. The acute withdrawal precipitated in an addict may result in
        violent combativeness.




                                                        IX-36
Denver Metro Paramedic Protocols

Medical Treatment
                                                  HYPERTENSION

Specific information needed

A.      History of hypertension and current medications
B.      New symptoms: dizziness, nausea, confusion, visual impairment, paresthesia, weakness
C.      Drug use: phenylpropanolamine (found in a wide variety of over-the-counter weight-loss products),
        amphetamines, cocaine
D.      Other symptoms: chest pain, breathing difficulty, abdominal/back pain, severe headache

Specific objective findings

A.      Evidence of encephalopathy: confusion, seizures, coma, vomiting
B.      Presence of associated findings: pulmonary edema, neurologic signs, neck stiffness, unequal peripheral pulses

Treatment

A.      Administer O2.
B.      Place patient at rest in position of comfort.
C.      Recheck BP, with special attention to diastolic pressure, correct cuff size and placement.
D.      Treat chest pain, pulmonary edema, seizure activity as per usual protocols.
E.      Establish venous access.
F.      If diastolic remains above 130 on repeated readings and patient has symptoms of encephalopathy, chest pain,
        or pulmonary edema, contact base to consider:
        1.        Nitroglycerin
        2.        Morphine sulfate

G.      Monitor cardiac rhythm.
H.      Monitor vital signs and mental status during transport.

Specific precautions

A.      Secondary hypertension (high BP in response to stress or pain) is commonly seen in the field. It does not
        require field treatment, and may not even mean the patient has chronic hypertension requiring ongoing
        treatment.
B.      Hypertensive encephalopathy is rare, but can be treated with nitroglycerin or morphine. Hypertension is more
        common in association with other problems (pulmonary edema, seizures, chest pain, coma, or altered mental
        states). It should be managed by treating the primary problem.
C.      Diastolic pressures and mean arterial pressures are much more important in determining danger of severe
        hypertension than is systolic pressure. These are poorly measured in the field. The diagnosis of "malignant"
        hypertension is not based on numerical levels, but rather on microscopic changes in blood vessels and damage
        to organs, which place this disease beyond the scope of prehospital care.
D.      Don't forget that false elevation of BP can result from a cuff that is too small for the patient. The cuff should
        cover 1/3 to 1/2 of the upper arm, and the bladder should completely encircle the arm.
E.      Hypertension is seen in severe head injury and intracranial bleeding, and is thought to be a protective response
        that increases perfusion to the brain. Treatment should be directed at the intracranial process, not the blood
        pressure.




                                                        IX-37
Denver Metro Paramedic Protocols

Medical Treatment
                                                        OB/GYN

Specific information needed

A.      Symptoms: pain, cramping, passage of clots or tissue, dizziness, weakness; if pregnant, inquire about swelling
        of face and extremities, urge to push, contractions (regularity and timing), ruptured membranes, fever
B.      Obtain menstrual history: last normal menstrual period, duration of period, amount of flow, birth control
        method
C.      If pregnant, inquire about due date, prior problems with pregnancy.
D.      Past and present history of hypertension (preeclampsia/eclampsia)
E.      Past history: bleeding problems, pregnancies, medications, allergies

Specific objective findings

A.      Vital signs and orthostatic changes
B.      Evidence of blood loss, clots or tissue fragments; bring tissue to the ED
C.      Signs of hypovolemic shock, altered mental status, hypotension, tachycardia, sweating, pallor
D.      Fever
E.      If pregnant, observe for contractions and relaxation of uterus. Where privacy is possible, examine perineum
        by observation only for:
        1.       Vaginal bleeding or fluid (note color)
        2.       Crowning (check during contraction)
        3.       Abnormal presentation (i.e. foot, arm, face, or cord)

Treatment

A.      If patient is bleeding vaginally (moderate to heavy):
        1.        Administer 02.
        2.        Establish venous access.
        3.        If hypotensive, give NS fluid bolus, further fluids as directed and consider a second line.
        4.        If hypotensive and pregnant, position onto left side.

B.      If patient is in late pregnancy and there is crowning or other indication of imminent delivery, deliver or
        transport. Be prepared to stop ambulance if delivery occurs enroute.
C.      Transport immediately any pregnant patient with an abnormal presenting part or vaginal bleeding.
D.      If patient is delivering:
        1.        Use clean or sterile technique.
        2.        Guide and control, but do not retard or hurry the delivery.
        3.        Suction the mouth (not throat), then nose with a bulb syringe.
        4.        Protect the infant from fall and temperature loss; wipe off amniotic fluid and wrap in a clean or sterile
                  blanket, check vital signs, provide CPR as indicated.
        5.        Clamp the umbilical cord in two places approximately 8-10" from the infant.
        6.        Cut the cord between the clamps.
        7.        Establish venous access in mother and monitor vital signs.
        8.        Transport. Do not wait for or attempt delivery of placenta. If placenta delivers spontaneously, bring
                  to the hospital.

E.      If patient is bleeding in the postpartum period (within 24 hours of delivery):
        1.        Massage uterus and have mother nurse infant to aid in uterine contractions.
        2.        Establish venous access.

F.      Refer to destination policy (Section VIII) as needed.




                                                         IX-38
Denver Metro Paramedic Protocols

Specific precautions

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


APGAR Score


            Sign                        0                        1                               2

Muscle tone (Activity)         Limp               Some flexion                    Active, good flexion
Pulse                          Absent             <100/min                        =100/min

Reflex irritability*           No response        Some grimace or avoidance       Cough, cry or sneeze
(Grimace)
Color (Appearance)             Blue, pale         Pink body, blue hands/feet      Pink
Respirations                   Absent             Slow, irregular, ineffective    Crying, rhythmic, effective

*Nasal or oral suction catheter stimulus




                                                        IX-39
Denver Metro Paramedic Protocols

        Medical Treatment
                                          POISONS AND OVERDOSES

Specific information needed

A.      Type of ingestion. What, when, and how much was ingested? Bring the poison, the container, description of
        emesis, all medications and everything questionable in the area with the patient to the Emergency Department.
B.      Reason for exposure: think of child neglect, depression, etc.
C.      Symptoms: respiratory distress, sleepiness, nausea, agitation or decreased level of consciousness
D.      Past history: medications, diseases, psychiatric
E.      Action taken by bystanders: induced emesis? "antidote" given?

Specific objective findings

A.      Vital signs
B.      Airway: patency and adequacy of ventilation
C.      Level of consciousness and neurologic status: check frequently.
D.      Breath odor, increased salivation, oral burns
E.      Skin: sweating, cyanosis
F.      Systemic signs: vomitus, arrhythmias, lung sounds

Treatment

A.      Assess and support ABCs.
B.      Administer O2.
C.      Support patient on side and protect airway.
D.      Establish venous access.
E.      Test for blood glucose, if available. Administer dextrose 50%, if blood <60 and if clinically indicated.
F.      Administer naloxone in patients with decreased respiratory effort and observe patient for improved
        ventilations.
G.      Monitor cardiac rhythm.
H.      May need to administer sodium bicarbonate if widened QRS or ventricular arrhythmias on monitor after
        excessive tricyclic antidepressant(s) ingested. May need to administer diazepam in suspected stimulant
        use/abuse (cocaine, Ecstasy, etc.) Contact base in these circumstances.
I.      Frequent monitoring of vital signs during transport

Specific precautions

A.      There are few specific "antidotes." Product labels and home kits can be misleading and dangerous. Watch the
        ABCs: these are important.
B.      Do not neutralize acids with alkalis. Do not neutralize alkalis with acids. These "treatments" cause
        heat-releasing chemical reactions that can further injure the GI tract.
C.      Inhalation poisoning is particularly dangerous to rescuers. Recognize an environment with ongoing
        contamination and extricate rapidly.
D.      Organophosphate exposure may require massive doses of atropine. Contact base for direction.
E.      For personal exposure to nerve agents refer to Mark I auto-injector protocol. (See section VI – Mark I Nerve
        Agent Antidote Kit)



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




                                                       IX-40
Denver Metro Paramedic Protocols

Medical Treatment
                                           PSYCHIATRIC/BEHAVIORAL

Specific information needed

A.      Obtain history of current event, inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma,
        suicidal or homicidal ideation
B.      Obtain past history; inquire about previous psychiatric and medical problems, medications.

Specific objective findings

A.      Evaluate vital signs.
B.      Note medic alert tags, odor to breath.
C.      Determine ability to relate to reality.
D.      Note hallucinations and behavior.

Treatment

A.      Attempt to establish rapport.
B.      Assure airway.
C.      Restrain if necessary (See Section VII - Restraints protocol).
D.      Monitor vital signs.
E.      If altered mental status or unstable vital signs:
        1.        Administer O2.
        2.        Establish venous access.
        3.        Draw appropriate blood tubes.
        4.        Consider dextrose 50% and naloxone.
        5.        Consider diazepam for agitation or stimulant use/abuse. Contact base for repeat dosing.
F.      Refer to destination policy (Section VIII).

Specific precautions

A.      Psychiatric patients often have an organic basis for mental disturbances. Beware of hypoglycemia, hypoxia,
        head injury, intoxication, or toxic ingestion.
B.      If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to
        violate the patient's personal space.
C.      If the situation appears threatening, consider a show of force involving police before attempting to restrain.
D.      Beware of weapons. These patients can become very violent.
E.      The paramedic may initiate a MHH only with the permission and online contact with the base physician (See
        Section VIII - Mental Health Hold)




                                                        IX-41
Denver Metro Paramedic Protocols

Medical Treatment
                                            RESPIRATORY DISTRESS

Specific information needed
A.      History: acute change or injury, slow deterioration
B.      Past history: chronic lung or heart problems or known diagnosis, medications, home O2, past allergic
        reactions, recent surgery, tobacco abuse
C.      Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia

Specific objective findings
A.      Vital signs
B.      Oxygenation: level of consciousness, cyanosis
C.      Respiratory effort: accessory muscle use, forward position, pursed lips
D.      Neurologic signs: slurred speech, impaired consciousness, evidence of drug/alcohol ingestion
E.      Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest wall movements, inspiratory
        stridor
F.      Signs of congestive failure: neck vein distention in upright position, rales, peripheral edema
G.      Breath sounds: clear, decreased, rales, wheezing, or rhonchi
H.      Hives, upper airway edema
I.      Evidence of trauma: crepitation of neck or chest, bruising, steering wheel damage, penetrating wounds

Treatment
A.    Put patient in position of comfort, usually upright.
B.    Identify and treat upper airway obstruction if present (suctioning, nasopharyngeal airway, endotracheal
      intubation, etc.).
C.    Administer O2, high flow.
D.    Assist ventilation with pocket mask or bag valve mask if necessary.
E.    Assess and consider treatment for the following problems if respiratory distress is severe and patient does not
      respond to proper positioning and administration of O2.
      1.       Asthma:
               a.        Establish venous access.
               b.        Monitor cardiac rhythm
               c.        Administer albuterol. Consider adding ipratropium.
               d.        Use continuous nebulization of albuterol for respiratory distress.
               e.        Consider epinephrine 1:1000.
               f.        Consider methylprednisolone.
               g.        Contact base for magnesium sulfate administration.
      2.       Pulmonary edema (except in patients with evidence of COPD):
               a.        Sit patient up, legs dangling if possible.
               b.        Establish venous access.
               c.        Monitor cardiac rhythm.
               d.        Consider:
                         1)       Nitroglycerin
                         2)       Lasix
                         3)       Morphine sulfate
               e.        Assist ventilations and consider intubation if patient has altered mentation or signs of
                         respiratory failure.
      3.       Chronic lung disease with deterioration:
               a.        Administer O2.
               b.        Monitor cardiac rhythm.
               c.        Establish venous access.
               d.        Administer albuterol. Consider adding ipratropium.
               e.        Use continuous nebulization of albuterol for respiratory distress.
               b.        Consider methylprednisolone.
               c.        Contact base for possible magnesium sulfate administration.
      4.       Pneumothorax: watch for signs of tension. If patient deteriorating rapidly, consider chest
               decompression.
F.    If diagnosis unclear, place patient in position of comfort, and administer oxygen, transport.
                                                       IX-42
Denver Metro Paramedic Protocols

G.      Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs.
(continued on next page)




                                                          IX-43
Denver Metro Paramedic Protocols

Specific precautions

A.     Don't overdiagnose "psychogenic" in the field. Your patient could have a pulmonary embolus or other serious
       problem; give him or her the benefit of the doubt. Treatment with oxygen will not harm the “hyperventilator”,
       and it will keep you from underestimating the problem.
B.     Wheezing in older persons may be due to pulmonary edema ("cardiac asthma"). Pulmonary embolus is an un-
       common cause of wheezing.




                                                     IX-44
Denver Metro Paramedic Protocols

Medical Treatment
                                                      SEIZURES

Specific information needed
A.      Seizure history: onset, time interval, previous seizures, type of seizure
B.      Medical history: especially head trauma, diabetes, headaches, drugs, alcohol, medications, compliance with
        anticonvulsants, pregnancy

Specific objective findings
A.      Vital signs
B.      Description of seizure activity
C.      Level of consciousness
D.      Head and mouth trauma
E.      Incontinence
F.      Air temperature; patient temperature
G.      Skin color and moisture

Treatment
A.    Airway: ensure patency-nasopharyngeal airways are useful. NOTE: Don’t force anything between the teeth.
B.    Administer O2.
C.    Suction as needed.
D.    Protect patient from injury.
E.    Check pulse immediately after seizure stops.
F.    Keep patient on side.
G.    Establish venous access.
H.    Administer diazepam for status seizures.
I.    If venous access unsuccessful after two attempts, administer midazolam IM.
J.    Draw appropriate blood tube; test for blood glucose if available.
K.    Administer dextrose 50%, if blood glucose <60 and if clinically indicated.
L.    Administer naloxone, if clinically indicated.
M.    Monitor cardiac rhythm.
N.    Keep in lateral recumbent position for transport.
O.    Monitor vitals.

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




                                                        IX-45
Denver Metro Paramedic Protocols

Medical Treatment
                                                SHOCK: MEDICAL

Specific information needed

A.      Onset: gradual or sudden; precipitating cause or event
B.      Associated symptoms: itching, peripheral or facial edema, thirst, weakness, respiratory distress, abdominal or
        chest pain, dizziness on standing
C.      History: allergies, medications, bloody vomitus or stools, significant medical diseases, history of recent
        trauma, last menstrual period, vaginal bleeding, fever

Specific objective findings

A.      Vital signs: pulse > 120 (occasionally < 50); BP < 90 systolic
C.      Mental status: apathy, confusion, restlessness, combativeness
D.      Skin: flushed, pale, sweaty, cool or warm, hives, or other rash
E.      Signs of trauma
F.      Signs of cardiogenic shock: jugular venous distention in upright position, rales, peripheral edema
G.      In children <8 y/o, 2 or more of the following signs: tachycardic for age, diminished
        capillary refill, thready pulses, cool extremities, poor color, altered mental status,
        diminished respiratory effort

Treatment

A.      Administer O2.
B.      Cover patient to avoid excess heat loss. Do not over bundle.
C.      Assess for cardiogenic cause:
        1.       If P > 150, treat tachyarrhythmia according to protocol.
        2.       If P < 60, treat bradyarrhythmia according to protocol.
        3.       If distended neck veins, chest pain, or other evidence of cardiac cause:
                a.       Position of comfort
                b.       Be prepared to assist ventilations or initiate CPR.
                c.       Establish venous access.
                d.       Monitor cardiac rhythm.
                e.       Evaluate for possible tension pneumothorax. (See Section VII – Procedures)

D.       Consider dopamine.
E.       Transport rapidly for definitive diagnosis and treatment.
F.       If no evidence of cardiogenic cause, institute general treatment measures:
         1. Place patient supine, elevate legs 10-12 inches. (If respiratory distress results, leave patient in position
              of comfort.)
         2. Establish venous access.
         3. Fluid bolus NS.
G.       Assess and treat for specific cause, such as anaphylaxis, if this can be determined.
H.       Monitor VS, cardiac rhythm, and level of consciousness during transport.

Specific precautions

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

                                                        IX-46
Denver Metro Paramedic Protocols




                                   SHOCK: MEDICAL
            Mechanism/Causes                              Differential/Symptoms

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




                                                IX-47
Denver Metro Paramedic Protocols

Medical Treatment
                                                      SYNCOPE

Specific information needed

A.       History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing,
         or lying? Pregnant?
B.       Past history: medications, diseases, prior syncope
C.       Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache, palpitations

Specific objective findings

A.       Vital signs
B.       Neurological status: level of consciousness, residual neurological deficit
C.       Signs of head trauma, mouth trauma, incontinence
D.       Neck stiffness

Treatment

A.       Position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert
B.       Monitor vital signs and level of consciousness closely for changes or recurrence.
C.       Establish venous access and administer NS, if indicated.
D.       Consider hypoglycemia. If signs of hypoglycemia are present (clinical indications and blood glucose<60):
         1.     Establish venous access.
         2.     Draw appropriate blood tubes.
         3.     Administer oral dextrose or IV bolus of dextrose 50% in secure vein.

E.       If vital signs unstable or age > 40 years:
         1.      Administer O2.
         2.      Keep patient supine, elevate legs 10-12 inches.
         3.      Establish venous access.
         4.      Monitor cardiac rhythm.

Specific precautions

A.       Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the
         patient is still unconscious, treat as coma. If the patient is confused, treat according to Coma/Altered Mental
         Status/Neurologic Deficit protocol. (See Section II – Treatment Protocols: Medical Treatment)
B.       Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position
         should be sufficient to restore vital signs and level of consciousness to normal.
C.       Syncope which occurs without warning or while in a recumbent position is potentially serious, and often
         caused by arrhythmia.
D.       Patients with syncope, even though apparently normal, should be transported. In middle-aged or elderly
         patients, syncope can be due to a number of potentially serious problems. The most important of these to
         monitor and recognize are: arrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm.
E.       Any elderly patient with syncope and back pain should be considered to have a ruptured abdominal
         aortic aneurysm until proven otherwise.
F.       In children 1-4 years of age, breath-holding spells, associated with heightened emotional states, can cause
         syncopal-like events. Children may be pallid or cyanotic, and seizures can occur. No specific treatment is
         indicated for these events. Consult base station if questions.




                                                        IX-48
Denver Metro Paramedic Protocols

Medical Treatment
                                                    VOMITING

Specific information needed

A.       Frequency, duration of vomiting
B.       Presence of blood or bile in vomitus
C.       Associated symptoms: abdominal pain, weakness, confusion
D.       Medication ingestion
E.       Past medical history: diabetes, cardiac disease, abdominal problems, alcoholism

Specific objective findings

A.       Vital signs
B.       Color of vomitus: presence of blood
C.       Abdomen: tenderness, guarding, rigidity, distention
D.       Signs of dehydration: poor skin turgor, dry mucous membranes, confusion

Treatment

A.       Position patient: left lateral recumbent if vomiting; otherwise, supine.
B.       Administer O2.
C.       Nothing by mouth
D.       If BP < 90 systolic and signs of hypovolemic shock or for signs of poor perfusion in pediatric patients:
         1.     Elevate legs 10-12 inches.
         2.     Establish venous access.
         3.     Fluid bolus: IV, NS
E.       Monitor vital signs during transport.
F.       For patients with vomiting and transport time >10 minutes, consider IV metoclopramide (Reglan)
         administration. (Section VI)

Specific precautions

A.       Vomiting may be a symptom of a more serious problem. The most serious causes are GI bleed or other
         intra-abdominal catastrophe. A rare cardiac patient may also present with vomiting as the predominant
         symptom.
B.       Consider drug overdose; a patient who does not call the ambulance for medication ingestion may call later
         when GI symptoms become severe.
C.       The vast majority of persons with vomiting have become sick over days, not minutes. Treat appropriately.
D.       Dehydration may be particularly severe in children with simple vomiting. IVs may be very difficult to start,
         particularly with infants.




                                                       IX-49
Denver Metro Paramedic Protocols



                                               SECTION III

                        TREATMENT PROTOCOLS: TRAUMA TREATMENT


TABLE OF CONTENTS
                                                                Page Number
III    Treatment Protocols: Trauma Treatment

               Multiple Trauma Overview                              III-
       2, 3
               ATAC Adult Prehospital Trauma Triage Algorithm             III-4
               Algorithm: Trauma                                          III-5
               Abdominal Trauma                                          III-6
               Amputations                                               III-7
               Burns                                                  III-8, 9
               Chest Injury                                        III-10, 11
               Extremity Injuries                                       III-12
               Face and Neck Trauma                                III-13, 14
               Head Trauma                                         III-15, 16
               Spinal Trauma                                            III-17
               Trauma Arrest                                            III-18




                                                 IX-50
Denver Metro Paramedic Protocols

Trauma Treatment
                                         MULTIPLE TRAUMA OVERVIEW

Specific information needed

A.      Mechanism of injury:
        1.        Cause, precipitating factors, weapons used
        2.        Trajectories and forces involved
        3.        For vehicular trauma:
                           a. Specific description of mechanism such as auto vs. pole, rollover, broadside, high speed
                           b. Condition of vehicle including windshield, steering wheel, compartment intrusion,
                               condition of dashboard/firewall/pedals, type and use of seatbelts, supplemental restraint
                               system (e.g. airbag) deployment
        4.        Helmet use; motorcycle, bicycle, skiing, snowboarding, skateboarding, rollerblading
B.      Patient complaints.
C.      Initial position and level of consciousness of patient.
D.      Patient movement, treatment since injury
E.      Other factors such as drugs, alcohol, medications, diseases, pregnancy

Specific objective findings

A.      Scene evaluation:
        1.       Note potential hazard to rescuers and patient.
        2.       Identify number of patients; organize triage operations if appropriate
        3.       Observe position of patient, surroundings, probable mechanism, and vehicle condition
B.      Patient evaluation: see treatment below

Treatment

Initial assessment in multiple trauma is performed at the same time as treatment.

A.      Airway with C-spine immobilization
B.      Breathing
C.      Circulation, with control of major bleeding
D.      Transport decision (See Section VIII - Destination Policy)
        1.       If patient unstable, transport immediately. Treat enroute.
        2.       If patient stable, assess for potentially life-threatening injuries and treat accordingly.
E.      Monitor vital signs, neurologic status and cardiac rhythm enroute.
F.      Contact base.

Specific precautions

A.      Assessment and management of trauma in the field has changed considerably in the past 5 years. There are
        patients who cannot tolerate a full assessment before life-saving intervention is needed. Likewise, splinting,
        bandaging, and, often, the focused history and physical examination are procedures that may need to be
        bypassed in the critical patient. Time and the treatment available in a trauma center are critical elements in
        resuscitation. Therefore, with severely injured patients, it is most appropriate to rapidly transport (“load and
        go”) the patient rather than using extended stabilization or the old "grab and run," with no trauma stabilization
        or care rendered.

B.      Critical injuries involve:

                 1.       Difficulty with respiration
                 2.       Difficulty with circulation (hypoperfusion a.k.a. shock)
                 3.       Decreased level of consciousness

                                                          IX-51
Denver Metro Paramedic Protocols

(continued on next page)

        Any trauma patient with one or more of these above conditions is a "load and go," with treatment occurring
        enroute.

C.      Even in the noncritical patient with significant injury, "stabilization in the field" does not occur. With major
        injuries, the very most you can do is to buy time. If the initial bolus of fluids results in improved vitals, do not
        become complacent. This patient frequently needs blood and an operating room to truly "stabilize" the
        traumatic process. Rapid transport is still the highest priority.
D.      Serial vital signs and observations of respiratory, circulatory and neurologic status prior to arrival are critical.
E.      The trauma patient is the greatest risk to the rescuer for exposure to "bodily fluids." Use BSI.




                                                         IX-52
Denver Metro Paramedic Protocols

                                                  COLORADO STATEWIDE TRAUMA SYSTEM
                                                      AREA TRAUMA ADVISORY COUNCILS
                                             ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM
                               (NOTE: chart below is currently under revision by state and will be replaced when completed)

Triage and transport requirements for adult trauma patients

                                                         HIGH RISK ADULT TRAUMA PATIENT

                                  FIELD CRITERIA                                                            TRANSPORT DESTINATION

 Significant Blunt Trauma with Physiologic Compromise as Evidenced By:                  1.      Transport to Level I trauma center if available < 15 minutes
 *       Systolic BP < 90 or                                                                    additional prehospital time.
 *       Pulse > 120
 *       Respiratory rate < 10 or > 29 or required endotracheal intubation              2.      If Level I trauma center is not available, transport to the
 *       Altered mental status (GCS < 10) with focal neurologic deficit                         nearest trauma center unless a higher level trauma center is
                                                                                                available within < 15 minutes additional prehospital time.
 Penetrating Trauma To:
 *      Thorax                                                                          3.      If a trauma center is not available within 60 minutes additional
 *      Abdomen                                                                                 prehospital time, refer to medical control for appropriate
 *      Neck                                                                                    destination.

 High Risk Criteria (without Physiologic Compromise):                                   1.      Triage to an upper level trauma center when available.
 *      Death of same car occupant                                                              Consult with medical control for appropriate destination as
 *      Extrication time > 20 minutes                                                           needed.

                                                      MODERATE RISK ADULT TRAUMA PATIENT

                                  FIELD CRITERIA                                                            TRANSPORT DESTINATION

 *       Flail Chest                                                                    1.      Transport to Level I or Level II trauma center if available
 *       Spinal Cord injury w/neurologic deficit                                                within < 15 minutes additional prehospital time.
 *       Multi-system blunt injuries (> 2 systems injured)
 *       Long Bone Fractures/In conjunction with multi-system injuries                  2.      If Level I or Level II trauma center is not available transport to
 *       Pelvis Fractures/In conjunction with multi-system injuries                             nearest trauma center unless a higher level trauma center is
 *       Altered mental status (GCS < 10) with significant trauma                               available in < 15 minutes additional prehospital time.
 *       Burn > 15% or involving face, airway
 *       Amputation above wrist or ankle                                                3.      If a trauma center is not available within 60 minutes of
 *       Pedestrian hit @ > 20 MPH or thrown > 15 feet                                          transport, contact medical control for appropriate destination.

                                                              OTHER RISK FACTORS FOR INJURY

                                   RISK FACTORS                                                             TRANSPORT DESTINATION

 *       Fall > 20 feet                                                                 1.      Transport to nearest trauma center if available or other facility
 *       High energy transfer situations such as                                                as determined by medical control.
         *       Auto crash w/significant vehicle body damage, motorcycle, ATV,
                 bicycle accident

                COMORBID FACTORS-MODERATE TRAUMA OR                                                         TRANSPORT DESTINATION
                      OTHER RISK FACTORS PLUS:

 *       extremes of age (>60)                                                          1.      Transport to nearest trauma center if available or other facility
 *       Medical illness (COPD, CHF, renal failure, anticoagulant therapy, etc.)                as determined by medical control.
 *       2nd/3rd trimester pregnancy

                      If there are equivalent trauma centers in an area destination will be made in accordance with the regional ATAC plan.

 PATIENTS WITH UNCOMPLICATED SINGLE SYSTEM EXTREMITY INJURIES MAY BE TRANSPORTED TO THE NEAREST FACILITY OR IN
 ACCORDANCE WITH ATAC PROTOCOLS.




                                                                         IX-53
Denver Metro Paramedic Protocols

Trauma Treatment
                                           ALGORITHM TRAUMA

                                        Scene Size-up and Initial Assessment

                                                       ↓
                                              Immediate intervention for
                      airway management, control of bleeding, and c-spine immobilization



                                               "LOAD & GO" CRITERIA

                                        Airway compromise/Respiratory difficulty
                                                 Clinical signs of shock
                                                 Altered mental status


                                                      ↓
                              ______________________________________________
                          ↓                                                             ↓

                         YES                                                          NO

                          ↓                                                             ↓

               Rapid extrication                                 Detailed and Focused Assessment
                      for access                                                 on scene

                          ↓                                                             ↓

                   "Load & Go"                                                 Splint all fractures


                          ↓                                                             ↓

               INITIATE TRANSPORT AND TREATMENT                                     Routine transport
                  CONTACT RECEIVING FACILITY

                          ↓                                                             ↓

                   Detailed and Focused
                Assessment enroute to trauma center

                          ↓                                                           ↓
                           ________________________________________________
                                                       ↓
                          Repeat exam if any change in condition or after any interventions.




                                                      IX-54
Denver Metro Paramedic Protocols

Trauma Treatment
                                             ABDOMINAL TRAUMA

Specific information needed

A.   Patient complaints
B.   For penetrating trauma: weapon, trajectory
C.   For auto: condition of steering wheel, dash, vehicle; speed, patient trajectory; seatbelts in use, airbag deployment
D.   Past history: medical problems, medications, pregnancy, drugs, alcohol

Specific objective findings

A.   Observe: distention, bruising, entrance/exit wounds
B.   Palpate: areas of tenderness, guarding; pelvis stability to lateral and suprapubic compression

Treatment

A.   Stabilize life-threatening airway and circulatory problems first.
B.   Administer 02.
C.   Establish venous access.
D.   Observe carefully for signs of blood loss. If signs of shock:
     1.     Rapid transport
     2.     Second IV, large bore
     3.     Administer fluid bolus, NS; further fluids as directed.
     4.     Contact base.
E.   For penetrating injuries: cover wounds and eviscerations with moist saline gauze to prevent further
     contamination and drying. Do not attempt to replace.
F.   Monitor vital signs during transport.

Special precautions

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




                                                       IX-55
Denver Metro Paramedic Protocols

         Trauma Treatment
                                                   AMPUTATIONS

Specific information needed
A. History: time and mechanism of amputation; care for severed part prior to rescuer arrival
B. Past history: medications, bleeding disorders, medical problems

Specific objective findings

A.   Vital signs
B.   Other injuries
C.   Blood loss at scene
D.   Structural attachments in partial amputations if identifiable

Treatment

A.   Resuscitate and treat other more urgent injuries.
B.   Control hemorrhage with direct pressure, elevation.
C.   If hypotension or signs of shock:
     1.    Establish venous access.
     2.    Fluid bolus: NS
     3.    Contact base.

D.   Patient: gently cover stump with sterile dressing. Saturate with sterile saline. Cover with dry dressing. Elevate.
E.   Severed part: wrap in sterile gauze, preserving all amputated material. Moisten with sterile saline. Place in
     watertight container (specimen cup, plastic bag, etc). Place container in cooler with ice (do not freeze).
F.   Contact base for optimal transport destination.

Specific precautions

A.   Partial amputations should be dressed and splinted in alignment with extremity to ensure optimum blood flow.
     Avoid torsion in handling and splinting.
B.   Do not use dry ice to preserve severed part.
C.   Control all bleeding by direct pressure only to preserve tissues. The most profuse bleeding may occur in partial
     amputations, where cut vessel ends cannot retract to stop bleeding. Avoid tourniquet if at all possible. Never
     clamp bleeding vessels.
D.   Many factors enter into the decision to attempt reimplantation (age, location, condition of tissues, other options).
     A decision regarding treatment cannot be made until the patient and part have been examined by a physician and
     may not be made at the primary care hospital. Try to help the family and patient understand this, and don't
     falsely elevate hopes.




                                                        IX-56
Denver Metro Paramedic Protocols

Trauma Treatment
                                                        BURNS

Specific information needed
A. History of injury: time elapsed since burn. Was patient in a closed space with steam or smoke? Electrical
     contact? Loss of consciousness? Accompanying explosion, toxic fumes, other possible trauma?
B. Past history: prior cardiac or pulmonary disease, medications?

Specific objective findings
A. Vital signs
B.   Extent of burns: description or diagram of areas involved
C.  Depth of burns: superficial - erythema only; partial or full thickness - blistered or charred areas. D.
    Estimate size of burn. Use Rule of Nines or area of one patient palm = 1% burn.
E   Evidence of CO poisoning or other toxic inhalation: altered mental state, headache, vomiting, seizure, coma
F. Evidence of inhalation burns: respiratory distress, cough, hoarseness, singed nasal or facial hair, soot erythema of
    mouth, carbonaceous sputum
G. Entrance and exit wounds for electrical burns
H. Associated trauma

Treatment
THERMAL BURNS:

A.   Remove clothing which is smoldering or which is non-adherent to the patient.
B.   Administer O2 if indications from history or physical of respiratory burns, toxic inhalation, or significant flame or
     smoke exposure.
C.   Assess and treat for associated trauma (blast or fall). Consider cervical spine injury.
D.   Remove rings, bracelets, and other constricting items.
E.   If burn is moderate-to-severe (over 15% of body surface area), cover wounds with dry clean dressings to avoid
     hypothermia. Preheat ambulance to maximum temperature to prevent hypothermia during transport.
F.   Use cool, wet dressings in smaller burns (less than 15%) for patient comfort.
G.   Establish venous access in non-burned extremity when possible.
H.   Consider morphine sulfate for pain relief.
I.   Transport, monitoring vital signs (Section VIII - Destination Policy).
J.   Observe for airway distress and be prepared to intubate.

NOTE:      Patients older than 12 years of age, with isolated second degree or third degree burns greater than 20%
           body surface area, should be transported directly to the University Hospital Emergency Department.
           Patients 12 years of age and younger, with isolated second degree or third degree burns greater than 20%
           body surface area, should be transported directly to the Children's Hospital Emergency Department.
           Patients in immediate need of airway management should be transported to the nearest Emergency
           Department.

INHALATION INJURY:

A. Administer 100% O2 during transport.
B. Be prepared to intubate or assist if respirations inadequate.
A. Monitor cardiac rhythm.

(continued on next page)




                                                        IX-57
Denver Metro Paramedic Protocols

CHEMICAL BURNS:

A.   Protect rescuer from contamination. Wear appropriate gloves and clothing.
B.   Remove all clothing and any solid chemical that might provide continuing contamination.
C.   Assess and treat for associated injuries.
D.   Decontaminate patient using running water for 15 min. prior to transport if patient stable.
E.   Check eyes for exposure and rinse with free-flowing water for 15 min. (See Section VI - Drug Protocol Topical
     Ophthalmic Anesthetics)
F.   Evaluate for systemic symptoms that might be caused by chemical contamination. Contact base for possible
     treatment.
G.   Remove rings, bracelets, constricting bands.
H.   Wrap burned area in clean, dry cloths for transport. Keep patient as warm as possible after decontamination.

ELECTRICAL INJURY:

A.   Protect rescuers from continued live electric wires.
B.   Separate victim from electrical source when area safe for rescuers.
C.   Initiate CPR as needed, monitor cardiac rhythm and treat arrhythmias per protocols.
D.   Prolonged respiratory support may be needed.
E.   Immobilize cervical spine when appropriate, assess for other injuries.
F.   Establish venous access.

Specific precautions

A.  Leave blisters intact when possible.
B.  Suspect airway burns in any facial burns or burns received in closed places. Edema may become severe, but not
    be immediately apparent. Avoid unnecessary trauma to the airway. Humidified O2 is useful if available.
B.  Assume carbon monoxide poisoning in all closed space burns. Treatment is 100% O2 continued for several
    hours. In addition, other toxic products of combustion are more commonly encountered than realized.
C. Contact base for special instructions if other toxic inhalations are suspected. Consider suicide attempt as cause of
    burn, and child abuse in pediatric burns.
D.  Lightning injuries can cause ventricular asystole and prolonged respiratory arrest. Prompt, continuous
    respiratory assistance (sometimes for hours to days) can result in full recovery.
E.  Field decontamination of chemical exposures has been shown to significantly reduce extent of burn. Gross
    decontamination should occur prior to transport. Notify hospital immediately to mobilize internal resources.
F.  EMS personnel should not participate in decontamination unless trained and equipped to do so.
G. In patients with severe burns, their ability to prevent heat loss is significantly compromised. The time of
   transport may be enough to cause hypothermia. Keep the ambulance as warm as possible during transport
   despite discomfort to EMS personnel.
H. Isolated CO poisoning should be taken to a hyperbaric oxygen chamber. Multiple trauma patients with suspected
   CO poisoning should be taken to the appropriate trauma center. (See Section III State Trauma Triage Algorithm.)




                                                       IX-58
Denver Metro Paramedic Protocols

Trauma Treatment
                                                    CHEST INJURY

Specific information needed

A.   Patient complaints: chest pain type (pleuritic, positional, location sharp, dull, etc.) respiratory distress, neck pain,
     other areas of injury
B.   Mechanism: amount of force involved (particularly deceleration), speed of impact, seatbelt use/type, airbag.
C.   Penetrating trauma: size of object, caliber of bullet, trajectory, distance from patient.
D.   Past medical history: medications, prior medical problems

Specific objective findings

A.   Observe: wounds, air leaks, chest wall movement, neck veins
B.   Palpate: tenderness, crepitation, tracheal position, tenderness on sternal compression, pulse pressure
C.   Auscultate: breath sounds, heart sounds (quality)
D.   Surroundings: vehicle, steering wheel condition, dashboard.

Treatment

A.    Clear and open airway. Immobilize cervical spine, if indicated.
B.    Manage airway/ventilations as indicated.
C.    Administer O2.
D.    If penetrating injury present, transport rapidly with further stabilization en route.
E.    For open chest wound with air leak, use Vaseline-type gauze or occlusive dressing taped on three sides only, to
      allow air to escape but not enter the chest.
F.    Observe chest for paradoxical movements.
G.   Control exsanguinating hemorrhage with direct pressure.
H.   Obtain baseline vital signs, neurologic assessment.

     1.     If neck veins flat and patient in shock, transport rapidly and treat hypovolemia en route:
            a.    Establish venous access.
            b. Fluid bolus: NS
            c.    Monitor cardiac rhythm.
            d. Contact base.

     2.     If patient in shock with neck veins distended, also transport rapidly, and consider:
            a.    Tension pneumothorax if respiratory status markedly deteriorating with clinical findings of
                  pneumothorax:
            1) Release occlusive dressings on open chest wounds.
                  2)       Needle decompression; contact base for orders
            b. Pericardial tamponade, if suggested by clinical findings (distant heart sounds, narrow pulse pressure):
                  1)       Establish venous access.
                  2)       Fluid bolus: NS
            c.    Cardiac contusion with typical ischemic chest pain or severe chest wall contusion:
                  1)       Monitor cardiac rhythm.

(continued on next page)




                                                         IX-59
Denver Metro Paramedic Protocols

     3.    If patient stable without signs or symptoms of shock:
          a.     Complete focused assessment.
           b. If significant injury suspected:
                 1)       Establish venous access.
                 2)       Monitor cardiac rhythm en route.

I.   Immobilize impaled objects in place with dressings to prevent movement. Large objects may require manual
     stabilization during transport.
J.   Monitor and record vital signs, and level of consciousness every five minutes with significant injury.

Specific precautions

A.   Chest trauma is treated with difficulty in the field and prolonged treatment before transport is not indicated if
     significant injury is suspected. If patient is critical, transport rapidly and avoid treatment of nonemergent
     problems at the scene. Penetrating injury particularly should receive immediate transport with minimal
     intervention in the field.
B.   Consider medical causes of respiratory distress such as asthma, pulmonary edema or COPD that have either
     caused trauma or been aggravated by it.
C.   Chest injuries sufficient to cause respiratory distress are commonly associated with significant blood loss.
     Consider hypovolemia.
D.   Myocardial contusion can occur, particularly with sudden deceleration injury, as from a steering wheel. Pain is
     similar to myocardial infarct pain. Monitor the patient and treat arrhythmias as in a medical patient, but think
     first of hypoxia and hypovolemia as potential causes of arrhythmias.
E.   Check the back for injuries, especially the patient in shock, where a cause is not evident (check the back, axillary
     region and base of neck).
F.   Significant intrathoracic injuries can exist without external signs of injury.




                                                        IX-60
Denver Metro Paramedic Protocols

Trauma Treatment
                                              EXTREMITY INJURIES

Specific information needed
A. Mechanism of injury: direction of forces, if known
B. Areas of pain, swelling or limited movement
C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations, movement of patient
D. Past medical history: medications, medical illnesses

Specific objective findings
A. Vital signs
B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone fragments, loss of function,
     guarding
C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation
D. Note estimated blood loss at scene.

Treatment
A. Treat airway, breathing, and circulation as first priorities (See Section III - Multiple Trauma Overview).
B. Immobilize cervical spine when appropriate.
C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with higher priority first.
D. If patient unstable, transport rapidly, treating life-threatening problems en route. Splint patient to minimize
     fracture movement by securing to long board.
E. If patient stable, or isolated extremity injury exists:
     1.    Check and record distal pulses and sensation prior to immobilization of injured extremity.
     2.    Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone.
     3.    Splint areas of tenderness or deformity: apply gentle traction throughout treatment and try to immobilize
           the joint above and below the injury in the splint (See Section VII - Splinting: Extremity).
     4.    Realign angulated fractures by applying gentle axial traction if indicated:
           a.    To restore circulation distally
           b. To immobilize adequately, i.e., realign femur fracture
     5.    Check and record distal pulses and sensation after reduction and splinting.
     6. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries allow.
     7.    Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of injury
           during transport.
     8.    Establish venous access.
     9.    Consider fentanyl for pain control.

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




                                                        IX-61
Denver Metro Paramedic Protocols

Trauma Treatment
                                           FACE AND NECK TRAUMA

Specific information needed
A. Mechanism of injury: impact to steering wheel, windshield, or other objects; clothesline-type injury to face or
     neck; blunt object to head, face, or neck
B. Management before arrival by bystanders, first responders
C. Patient complaints: areas of pain; trouble with vision, hearing; neck pain; dental occlusion, tooth loss; short of
     breath
D. Past medical history: medications, medical illnesses

Specific objective findings
A. Vital signs
B. Airway: jaw or tongue instability, loose teeth, vomitus or blood in airway, other evidence of impairment or
     obstruction
C. Neck: tenderness, crepitation, hoarseness, bruising, swelling, stridor
D. Blood or drainage from ears, nose
E. Level of consciousness, evidence of head trauma
F.   Injury to eye: lid laceration, blood anterior to pupil, abnormal pupil, abnormal globe position

Treatment
A. Control airway with C-spine immobilization if indicated:
     1.    Open airway using jaw thrust, keeping neck in alignment with in-line cervical immobilization.
     2.    Use finger sweep to remove oral foreign bodies.
     3.    Suction blood and other debris.
     4.    Stabilize tongue and mandible with chin lift. Manual traction of the tongue may be necessary to keep
           posterior pharynx open as needed.
     5.    Note evidence of laryngeal injury and transport immediately if signs present.
     6.    Intubate if bleeding severe or airway cannot be maintained. When midface fractures are suspected,
           nasotracheal intubation is contraindicated. No nasotracheal intubation under age 12.
     7.    If intubation cannot be performed due to severe facial injury, attempt to manage with suctioning and bag-
           valve-mask.
     8.    If necessary, consider percutaneous cricothyrotomy (See Section VII - Advanced Airway Management:
           Percutaneous Cricothyrotomy protocol)
B. Administer O2 .
C. Control hemorrhage, check pulse and circulation.
D. Establish venous access:
         1.       TKO if stable
         2.       With signs of hypovolemia:
                  a.      Fluid bolus, NS; contact base.
E. Obtain vital signs, assess neurologic status.
F.   Complete detailed assessment/focused assessment if no life-threatening injuries present.
G. Cover injured eyes with protective shield or cup - avoid pressure or direct contact to eye.
H. Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing to avoid contamination.
I.   Bring avulsed teeth with you. Keep moist in saline-soaked gauze.
J.   Monitor airway closely during transport for development of obstruction or respiratory distress. Suction and treat
     as needed.

(continued on next page)




                                                       IX-62
Denver Metro Paramedic Protocols

Specific precautions

   A. Fracture of the larynx should be suspected in patients with respiratory distress, abnormal voice, and history of
      direct blow to neck from steering wheel, rope, fence wire, etc. Both intubation and percutaneous cricothyro-
      tomy may be unsuccessful in the patient with a fractured larynx, and attempts may result in increased injury.
      Transport rapidly for definitive treatment if you suspect this potentially lethal injury. Do not attempt intuba-
      tion or percutaneous cricothyrotomy unless the patient is in severe respiratory distress. Bag-valve-mask
      ventilation is preferred.
   B. Airway obstruction is the primary cause of death in persons sustaining head and face trauma. Meticulous
      attention to suctioning and basic airway maneuvers may be the most important treatment rendered.
   C. Remember that the apex of the lung extends into the lower neck and may be injured in penetrating injuries of
      the lower neck, resulting in pneumothorax or hemothorax.
   D. Do not be concerned with contact lens removal in the field.




                                                      IX-63
Denver Metro Paramedic Protocols

Trauma Treatment
                                                 HEAD TRAUMA

Specific information needed

A. History: mechanism of injury, estimate of force involved; helmet use.
B. History since injury: loss of consciousness (duration), change in level of consciousness, memory loss for
   events before and after trauma, movement (spontaneous or moved by bystanders), seizure activity
C. Past history: medications (esp. insulin), medical problems, seizure history, alcohol or drug use

Specific objective findings

A.   Vital signs (note respiratory pattern and rate)
B.   Neurologic assessment: Glasgow Coma Score
C.   External evidence of trauma: contusions, abrasions, lacerations, drainage from nose, ears

Treatment

A.   Assess airway and breathing; treat life-threatening conditions: (See Section III - Multiple Trauma Overview).
     Use assistant to provide in-line cervical immobilization when indicated, while managing respiratory difficulty.
B.   Administer O2.
C.   Control hemorrhage. Stop scalp bleeding with direct pressure. Continued pressure may be needed.
D.   TRANSPORT RAPIDLY if patient has multiple injuries, or unstable neurologic, respiratory or circulatory status.
E.   Obtain initial vital signs, neurologic assessment.
F.   If unconscious:
     1.     Assist ventilations.
     2. Consider intubation.
     3. Ventilate at 10 breaths per minute for adults (15 breaths for children, 20 breaths for infants).
     4. If signs of cerebral herniation are present, hyperventilate at 20 bpm for adults (30 bpm for children, 35 bpm
          for infants).
     5. If patient is combative, consider sedation (See Section VI - Drug Treatment Protocols).
     6. Contact base.
G.   Immobilize cervical, thoracic and lumbosacral spine when indicated.
H.   If signs of hypovolemic shock are present, initiate treatment en route:
     1.     Establish venous access.
     2.     Fluid bolus: NS.
     3.     Look carefully for possible sources of bleeding (abdomen, pelvis, chest).
     4.     Contact base.
I.   If patient stable:
     1.     Establish venous access.
     2.     Complete detailed assessment.
     3.     Splint fractures and dress wounds if time permits.
J.   Monitor and record airway, vital signs, and level of consciousness repeatedly at scene and during transport.
     Status changes are important.

(continued on next page)




                                                      IX-64
Denver Metro Paramedic Protocols

Specific precautions

   A. When head injury patients deteriorate, check first for airway, oxygenation and blood pressure. These are the
      most common causes of "neurologic" deterioration. If the patient has tachycardia or hypotension, evaluate for
      hypovolemia from associated injuries.
   B. Secondary brain injury and adverse outcomes can occur in brain-injured patients who exhibit hypotension
      and/or hypoxia. Early aggressive treatment of hypotension and administration of high flow oxygen may
      prevent further injury.
   C. The most important information you provide for the base physician is level of consciousness and its changes.
      Is the patient stable, deteriorating or improving?
   D. Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent cause of death in head injury.
   E. If active airway ventilation is needed, intubate and ventilate at rates listed above section F, #3 and #4.
      Hypoventilation aggravates cerebral edema.
   F. If patient is combative from head injury, consider sedation. (See section VI - Drug Treatment). Contact base
      for orders if indicated. The airway and C-spine can be more appropriately managed with a relaxed patient.
   G. Scalp lacerations can cause profuse bleeding, and are difficult to define and control in the field. If direct local
      pressure is insufficient to control the bleeding, evacuate any large clots from flaps and large lacerations with
      sterile gauze, and use direct hand pressure to provide hemostasis. If the underlying skull is unstable, pressure
      should be applied to the periphery of the laceration over intact bone.
   H. Routine prophylactic hyperventilation should be avoided. It has been shown to be detrimental to cerebral
      blood flow and patient outcome. Hyperventilation in the field for head trauma is indicated only when signs of
      cerebral herniation such as extensor posturing or pupillary abnormalities (asymmetric or bilaterally fixed and
      dilated pupils) are present after correcting hypotension and/or hypoxemia.




                                                        IX-65
Denver Metro Paramedic Protocols

Trauma Treatment
                                                 SPINAL TRAUMA

Specific information needed

A.   Mechanism of injury and forces involved: be suspicious with falls, decelerations, diving accidents and motor
     vehicle accidents.
B.   Past medical problems and medications

Specific objective findings

A.   Vital signs, including neurologic assessment
B.   Level of sensory and motor deficit; presence of any evidence of neurologic function below level of injury
C.   Physical exam, with careful attention to organs or limbs which may not have sensation

Treatment

A.   Assess airway and breathing; treat life-threatening difficulties. Use controlled ventilation for high cervical cord
     injury associated with abdominal breathing. Use assistant to provide in-line cervical immobilization while
     managing ABCs.
B.   Administer O2.
C.   Control hemorrhage.
D.   Immobilize cervical, thoracic and lumbosacral spine as indicated. (See Section VII - Axial Splinting)
E.   Obtain and record vital signs and neurologic assessment before and after immobilization.
F.   Establish venous access. If signs of hypovolemia: fluid bolus, NS, contact base
G.   Monitor airway, vitals, and neurologic status frequently at scene and during transport.

Specific precautions


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




                                                        IX-66
Denver Metro Paramedic Protocols

Trauma Treatment
                                                 TRAUMA ARREST

Specific information needed

A.   Time of arrest
B.   Mechanism: blunt vs. penetrating
C.   Signs of irreversible death (decapitation, dependent lividity, etc.)

Specific objective findings

A.   Vital signs
B.   Evidence of massive external blood loss
C.   Evidence of massive blunt head, thorax or abdominal trauma

Treatment

A.   Blunt trauma arrest:
     1.    Initiate basic life support, administer O2
     2.    Manage airway and breathing.
     3.    If no vital signs or other signs of life present after above treatments, consider field pronouncement.
     4.    If pulse returns with above treatment, treat per protocol and transport rapidly.
     5.    Contact base.

B.   Penetrating trauma arrest:
     1.   Initiate basic life support, administer O2
     2.   Manage airway and respirations
     3.   Rapid transport
     4.   Establish venous access, fluid bolus NS.
     5.   Contact base to report patient status.
     6.   If cardiac activity returns with above treatment, treat arrhythmias per protocols. (See Section II)
     7.   Consider field pronouncement (See Section VIII - Resuscitation and Field Pronouncement Guidelines for
          the following:
          a.    Signs of irreversible death
          b. ALS has been unavailable for at least 20 minutes from the time EMS personnel initiate on-scene
                assessment and there is no return of vital signs or signs of life

Specific precautions

A.   Victims of blunt trauma arrest without vital signs at the scene after initiation of ALS have a mortality rate of
     100%.
B.   Trauma arrests secondary to penetrating truncal injuries can be resuscitated and saved. There is a higher rate of
     survival in victims of low velocity penetrating injuries versus victims of high velocity injuries.




                                                         IX-67
Denver Metro Paramedic Protocols



                                              SECTION IV

            TREATMENT PROTOCOLS: ENVIRONMENTAL INJURIES TREATMENT


TABLE OF CONTENTS
                                                               Page Number
IV     Treatment Protocols: Environmental Injuries Treatment

               Bites and Stings                                       IV-2
               Drowning/Near-Drowning                                 IV-3
               High Altitude Illness                                  IV-4
               Hyperthermia                                           IV-5
               Hypothermia and Frostbite                            IV-6, 7
               Snake Bites                                            IV-8




                                                IX-68
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                                 BITES AND STINGS

Specific information needed

A.      Type of animal or insect; time of exposure.
B.      Symptoms:
        1.      Local: pain, stinging
        2.      Generalized: dizziness, weakness, itching, trouble breathing, muscle cramps

C.      History of previous exposures, allergic reactions

Specific objective findings

A.      Identification of spider, bee, marine animal if possible
B.      Local signs: erythema, swelling, heat in area of bite
C.      Systemic signs: hives, wheezing, respiratory distress, abnormal vital signs

Treatment

SNAKES: See Snake Bites.

SPIDERS:

A.      Ice for comfort
B.      Bring in spider, if captured and contained or if dead, for accurate identification, if possible.
C.      Transport for observation if systemic signs and symptoms present.

BEES AND WASPS:

A.      Remove sting mechanism. Do not squeeze venom sac if this remains on stinger, rather, scrape with straight
        edge.
B.      Observe patient for signs of systemic allergic reaction. Transport rapidly if needed. Treat anaphylaxis per
        protocol.
C.      Transport all patients with systemic symptoms or history of systemic symptoms from prior bites.

Specific precautions

A.      For all types of bites and stings, the goal of prehospital care is to prevent further inoculation and to treat
        allergic reactions.
B.      Allergy kits consist of injectable epinephrine and oral antihistamine, and are prescribed for persons with
        known systemic allergic reactions. Prehospital care personnel need not contact the resource hospital before
        assisting the patient with their own medication.
C.      About 60% of patients who have experienced a generalized reaction to a bite or sting in the past will have a
        similar or more severe reaction upon reinoculation. Thus, although it is not inevitable, this group of patients
        must be considered at high risk for anaphylaxis. In addition, a small group of patients will have anaphylaxis
        as a "first" reaction.
D.      Time since envenomation is important. Anaphylaxis rarely develops more than 60 minutes after inoculation.




                                                         IX-69
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                         DROWNING/NEAR-DROWNING

Specific information needed

A.      How long patient was submerged?
B.      Degree of contamination, water temperature?
C.      Diving accident? Water depth?

Specific objective findings

A.      Vital signs
B.      Neurologic status: monitor on a continuing basis.
C.      Lung exam: rales or signs of pulmonary edema, respiratory distress

Treatment

A.      Clear upper airway of vomitus or large debris.
B.      Start CPR if needed.
C.      Stabilize neck prior to removing patient from water if any suggestion of neck injury.
D.      Suction as needed.
E.      Administer O2.
F.      If patient not awake and alert:
        1.       Assist ventilation using pocket mask or BVM.
        2.       Intubate when indicated and apply positive pressure ventilation.
        3.       Establish venous access.
        4.       Monitor cardiac rhythm during transport; treat arrhythmias per protocol.

G.      Transport patient, even if normal by initial assessment.

Specific precautions

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




                                                        IX-70
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                            HIGH ALTITUDE ILLNESS

Specific information needed

A.     Presenting symptoms generally fall into two categories:
       1. Acute mountain sickness (AMS) - headache, sleeplessness, anorexia, nausea, fatigue.
       2. High-altitude pulmonary edema (HAPE) - breathlessness, cough, headache, trouble breathing, confusion,
           fatigue, nausea
       3. High-altitude Cerebral Edema (HACE) – ataxia, headache, confusion, stroke like picture with focal
           deficits, seizure and coma
B.     Current and highest altitude, time at this altitude, duration of ascent
C.     Medical problems, medications, previous experience at altitude

Specific objective findings

A.      Vital signs
B.      Mental status: confusion, lack of coordination, coma
C.      Lungs: respiratory rate, distress, rales, sputum (bloody or frothy)

Treatment

A.      Put patient at rest, position of comfort.
B.      Administer O2.
C.      Suction as needed. Assist ventilation if patient has cyanosis, confusion, and poor respiratory effort.
D.      Establish venous access, if conditions permit
E.      Monitor vitals during transport.

Specific precautions

A.      Recognition of the problem is the most critical part of treating high altitude illness. While in the mountains,
        recognize symptoms which are out of proportion to those being experienced by the rest of the party: fatigue,
        or trouble breathing (particularly at rest).
B.      The mainstay of treatment is descent from altitude. Even a loss of 1,000 - 1,500 feet makes enough
        difference in the O2 content of air that symptoms may be relieved or stop progressing. O2 administration can
        also relieve symptoms and may allow more time for orderly evacuation.
C.      In addition to the more common pulmonary edema, cerebral edema may occur, with confusion and a stroke-
        like picture with focal deficits. Treatment is the same.
D.      Acute mountain sickness, the mild form of illness during altitude adaptation, consists of fatigue, headache, and
        poor sleeping, without severe CNS or respiratory symptoms. Treatment is rest. This increases the body's time
        to acclimatize. Descend if symptoms progress, or ataxia present.
E.      Commercial airlines pressurize cabins to a level equivalent to about 5,000 - 8,000 feet.
F.      Patients at risk for high altitude illness for whatever reason may be taking Diamox (acetazolamide). Diamox
        may be useful in preventing some altitude illness because of direct effects on acid-base balance. Diuretics are
        not useful, however, in treating high altitude pulmonary edema, because the cause is excess capillary leakage
        of fluid, rather than increased venous pressure.




                                                        IX-71
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                                  HYPERTHERMIA

Specific information needed

A.      Patient age, activity level
B.      Medications: depressants, tranquilizers, alcohol, etc.
C.      Associated symptoms: cramps, headache, orthostatic symptoms, nausea, weakness

Specific objective findings

A.      Vital signs: temperature; usually 104 degrees Fahrenheit or greater (if thermometer available)
B.      Mental status: confusion, coma, seizures, psychosis
C.      Skin flushed and warm to hot: with or without sweating
D.      Air temperature and humidity; patient dress

Treatment

A.      Ensure airway.
B.      Remove clothing.
C.      Administer O2.
D.      Cool with water-soaked sheets.
E.      Establish venous access:
        1.      TKO if vital signs stable
        2.      Fluid bolus if signs of hypovolemia.

F.      Treat seizures per protocol.
G.      Monitor cardiac rhythm.
H.      Monitor vitals during transport.

Specific precautions

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




                                                        IX-72
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                       HYPOTHERMIA AND FROSTBITE

Specific information needed
A.      Length of exposure
B.      Air temperature, water temperature, winds, patient wet?
C.      History and timing of changes in mental status
D.      Drugs: alcohol, tranquilizers, anticonvulsants, others
E.      Medical problems: diabetes, epilepsy, alcoholism, etc.
F.      With local injury: history of thawing/refreezing?

Specific objective findings
A.      Vital signs, mental status, shivering. (Prolonged observation for 1-2 min. may be necessary to detect pulse,
        respirations.)
B.      Skin temperature (estimated); also note current temperature of environment
C.      Evidence of local injury: blanching, blistering, erythema of extremities, ears, nose
D.      Cardiac rhythm

Treatment
A.    Generalized:
      1.      CPR with intubation only if no organized electrical activity on cardiac monitor.
      2.      Administer O2. Assist with bag-valve-mask as needed. Intubate only to protect airway or in absence
              of organized cardiac electrical activity.
      3.      Avoid unnecessary suctioning or airway manipulation.
      4.      Remove wet or constrictive clothes from patient. Wrap in blankets and protect from wind exposure.
              Increase ambient temperature in ambulance.
      5.      Establish venous access. Solution should be warmed if possible. Do not start IV until patient is
              moved to transport vehicle.
      6.      Monitor cardiac rhythm. Attempt defibrillation, if appropriate, up to 3 shocks.
      7.      No more than one round of ACLS drugs should be administered to a hypothermic patient in the
              prehospital setting.
      8.      Monitor vitals during transport.

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

Specific precautions

HYPOTHERMIA:
A.   Shivering does not occur below 90 degrees F. Below this the patient may not even feel cold, and occasionally
     will even undress and appear vasodilated.
B.   The heart is most likely to fibrillate below 85-88 degrees Fahrenheit. Defibrillation should be attempted
     with no more than 3 shocks. Prolonged CPR may be necessary until the temperature is above this level.

(continued on next page)




                                                        IX-73
Denver Metro Paramedic Protocols

        C.       ALS drugs should be used sparingly, since peripheral vasoconstriction may prevent entry into central
        circulation until temperature is restored. At that time, a large bolus of unwanted drugs may be infused into the
        heart.
D.      Bradycardias are normal and should not be treated.
E.      If patient has organized monitor rhythm, CPR is currently felt to be unnecessary. In general, even very slow
        rates are probably sufficient for metabolic demands. CPR is indicated for asystole and ventricular fibrillation.
F.      Patients who appear dead after prolonged exposure to cold air or water should not be pronounced "dead" until
        they have been rewarmed. Full recovery from hypothermia with undetectable vital signs, severe bradycardia,
        and even periods of cardiac arrest has been reported.
G.      Rewarming should be accomplished with careful monitoring in a hospital setting, whenever possible.
H.      Consider other reasons for altered mental status.

FROSTBITE:
A.   Thawing is extremely painful and should be done under controlled conditions, preferably in the hospital.
     Careful monitoring, pain medication, prolonged rewarming, and sterile handling are required.
B.   It is clear that partial rewarming, or rewarming followed by refreezing, is far more injurious to tissues than
     delay in rewarming or walking on a frozen extremity to reach help. Do not rewarm prematurely. Indications
     for field rewarming are almost nonexistent.
C.   Warming with heaters or stoves, rubbing with snow, drinking alcohol and other methods of stimulating the
     circulation are dangerous and should not be used.




                                                       IX-74
Denver Metro Paramedic Protocols

Environmental Injuries Treatment
                                                    SNAKE BITES

Specific information needed

A.      Appearance of snake (e.g. rattle, color, banding)
B.      Time of bite
C.      Prior first-aid by patient or friends
D.      Symptoms: local pain and swelling, peculiar or metallic taste sensations. Severe envenomations may result in
        hypotension, coma, and bleeding.

Specific objective findings

A.     Bite wound: location, configuration (1, 2, or 3 fang marks; entire jaw imprint, none)
B.     Snake identification: look for elliptical pupils, thermal pit and rattle
C.     Signs of envenomation: spreading numbness and tingling from the site, local edema and pain,
       ecchymosis, bleeding, hypotension. Mark time and extent of erythema and edema with pen.

Treatment

A.      Remove patient and rescuers from area of snake, to avoid further injury.
B.      Remove rings or other bands which may become tight with local swelling.
C.      Immobilize bitten part at heart level.
D.      Minimize venom absorption by keeping bite area still and patient quiet.
E.      Transport promptly for definitive observation and treatment.
F.      Do not use ice or refrigerants.
G.      For all suspected envenomations, establish venous access and administer O2.
H.      Monitor vital signs, cardiac rhythm, and swelling.

Specific precautions

A.      The prairie rattlesnake is native to the Denver metro region. If the snake is dead, bring it in for examination.
        Do not jeopardize fellow rescuers by attempting to "round it up." Be careful: a dead snake may still
        reflexively bite and envenomate. Do not pick up with hands, even if dead. Use a shovel or stick.
B.      At least 25% of poisonous snake strikes do not result in envenomation. Conversely, the initial appearance of
        the bite may not reflect the severity of envenomation.
C.      Fang marks are characteristic of pit viper bites, such as from the rattlesnake, water moccasin, or copperhead,
        which are native to North America. Jaw prints (without fangs) are more characteristic of nonvenomous
        species.
D.      Ice can cause serious tissue damage. Never use!
E.      Exotic poisonous snakes, such as those found in zoos, have different signs and symptoms than those of pit
        vipers.




                                                        IX-75
Denver Metro Paramedic Protocols


SECTION V

                       TREATMENT PROTOCOLS: PEDIATRIC TREATMENT


TABLE OF CONTENTS
                                                                                 Page Number
V      Treatment Protocols: Pediatric Treatment

               General Guidelines for Pediatrics                                         V-2
               Pediatric Patient Assessment                                              V-3
               ATAC Pediatric Prehospital Trauma Triage Algorithm                        V-4
               Infant and Child Resuscitation                                          V-5, 6
               Infant Found Down/ Possible Sudden Infant Death Syndrome (SIDS)           V-7
               Pediatric Dehydration                                                     V-8
               Pediatric Respiratory Distress                                         V-9, 10
               Pediatric Seizures                                                       V-11




                                                  IX-76
Denver Metro Paramedic Protocols

Pediatric Treatment
                                    GENERAL GUIDELINES FOR PEDIATRICS

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

The following should be kept in mind during the care of children in the prehospital setting:

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

         INFANTS:                  birth to one year
         TODDLERS:                 one through five years
         SCHOOL AGE:               six through fourteen years


                      NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP


 AGE                        PULSE                       RESPIRATIONS               BLOOD PRESSURE
                            average/minute              breaths/minute             systolic in mm Hg

 Newborn                    150                         40-60                      60-80
 6 mo                       140                         25-40                      65-105
 1 yr                       135                         20-30                      70-110
 3 yr                       110                         20-30                      76-116
 5 yr                       100                         20-30                      80-120
 8 yr                        90                         12-25                      86-126
 12 yr                       80                         12-25                      95-120




                                                          IX-77
Denver Metro Paramedic Protocols

Prehospital Patient Assessment
                                       PEDIATRIC PATIENT ASSESSMENT

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

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


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




                                                         IX-78
Denver Metro Paramedic Protocols

                                                  COLORADO STATEWIDE TRAUMA SYSTEM
                                          PEDIATRIC PREHOSPITAL TRAUMA TRIAGE ALGORITHM
                               (NOTE: chart below is currently under revision by state and will be replaced when completed)

Triage and transport requirements for pediatric (< 12 years old*) trauma patients.

                                                      HIGH RISK PEDIATRIC TRAUMA PATIENT

                                  FIELD CRITERIA                                                             TRANSPORT DESTINATION

 Significant Blunt Trauma with Physiologic Compromise as Evidenced By:                    Blunt & Penetrating Trauma
 *       Tachycardia for age plus at least 2 signs of poor perfusion:                     1.     For children < 5 years of age: transport shall be to a
         *       Capillary refill > 2 seconds                                                    regional pediatric trauma center if available within < 15
         *       Cool extremities                                                                minutes additional prehospital time. If a regional pediatric
         *       Decreased pulses                                                                trauma center is not available, transport to a Level I trauma
         *       Altered mental status                                                           center with pediatric commitment. If a Level I trauma
         *       Respiratory distress                                                            center with pediatric commitment is not available, transport
                                     OR                                                          to a Level II trauma center with pediatric commitment.
 *       BP < lower limits for age
 *       Altered mental status (GCS < 10) with significant head trauma or focal           2.      For children 6-12 years of age: transport shall be to a
         neurologic deficit                                                                       regional pediatric trauma center or a Level I trauma center
 *       Spinal cord injury with neurologic deficit                                               with pediatric commitment if available within < 15 minutes
                                                                                                  additional prehospital time. If neither of those is available,
 Penetrating Trauma To:                                                                           transport to a Level II trauma center with pediatric
 *      Thorax                                                                                    commitment.
 *      Abdomen
 *      Neck                                                                              3.      If none of the above centers is available, transport to the
 *      Head                                                                                      nearest trauma center unless a higher level trauma center is
                                                                                                  available within < 15 minutes additional prehospital time.

                                                                                          4.      If a trauma center is not available within 60 minutes
                                                                                                  additional prehospital time, refer to medical control for
                                                                                                  appropriate destination.

 Burns                                                                                    Burns
 *     Second degree burns > 10% body surface area (TBSA)                                 1.    Transfer to a specialized pediatric burn facility after initial
 *     Third degree burns > 5% (TBSA)                                                           assessment and stabilization at an emergency department.

                                                      MODERATE RISK PEDIATRIC TRAUMA PATIENT

                                  FIELD CRITERIA                                                                 TRANSPORT DESTINATION

 *       Flail Chest                                                                      1.      Transport to a regional pediatric trauma center or a Level I
 *       Multi-system blunt injuries (> 2 systems injured)                                        or Level II trauma center with pediatric commitment if
 *       Long Bone Fractures/In conjunction with multi-system injuries                            available within < 15 minutes additional prehospital time.
 *       Pelvis Fractures/In conjunction with multi-system injuries
 *       Altered mental status (GCS < 10) with significant trauma                         2.      If a regional pediatric trauma center or a Level I or Level II
 *       Amputation above wrist or ankle                                                          trauma center with pediatric commitment is not available
 *       Pedestrian hit @ > 20 MPH or thrown > 15 feet                                            within < 15 minutes additional prehospital time, transport
                                                                                                  to the highest level trauma center available; if none,
                                                                                                  transport to nearest facility.

                                                              OTHER RISK FACTORS FOR INJURY

                                  FIELD CRITERIA                                                                 TRANSPORT DESTINATION

 *       Fall > 20 feet                                                                   1.      Transport to a regional pediatric trauma center or a Level I
 *       High energy transfer situations                                                          or Level II trauma center with pediatric commitment if
         *       Auto crash w/significant vehicle body damage                                     available within < 15 minutes additional prehospital time.
         *       Motorcycle, ATV
                                                                                          2.      If a regional pediatric trauma center or a Level I or Level II
                                                                                                  trauma center with pediatric commitment is not available
                                                                                                  within < 15 minutes additional prehospital time, transport
                                                                                                  to the highest level trauma center available; if none,
                                                                                                  transport to the nearest facility.

                         If there are equivalent trauma centers in an area destination will be made in accordance with the regional ATAC plan.

 * Individuals 13 to 18 years of age, transport can follow adult or pediatric prehospital destination algorithms based on severity of illness.




                                                                          IX-79
Denver Metro Paramedic Protocols

Pediatric Treatment
                                      INFANT AND CHILD RESUSCITATION


Specific information needed

A.   Time since the child was last in good health
B.   History of any recent illness or injury
C.   Past medical history

Specific physical findings

A.   General appearance: LOC, muscle tone, color
B.   Airway: obstruction, stridor, inspiratory phase work, drooling, cough
C.   Breathing: respiratory rate, skin color (cyanosis late sign), chest wall symmetry and depth of movement, work of
     breathing (grunting, nasal flaring, retractions), wheezing
D.   Circulation: heart rate, peripheral pulses, capillary filling time, skin color, extremity skin temperature
E.   Level of consciousness, pupil size and reaction to light
F.   Physical assessment

Treatment

A.   Airway/Breathing:

     1.     Manage airway. Effective airway management is by far the most critical aspect of treatment. Bag-mask
            ventilation may be as good as and in some cases superior to endotracheal intubation for EMS treatment.
     2.     Administer oxygen via blow-by, non-rebreather mask, or bag-mask ventilation.
     3.     If apneic, ventilate with a BVM, intubate as indicated, ventilation rate per AHA BLS protocols. Ensure
            adequate chest rise and fall (tidal volumes), and air entry.
     4.     Note the drugs that are appropriate for endotracheal administration (naloxone, epinephrine, atropine).
            (mnemonic: N.E.A.)

B.   Circulation:

     1.     Initiate CPR if indicated.
     2.     Monitor cardiac rhythm.
     3.     Establish peripheral venous access.
     4.     If unable to establish a peripheral IV after 1 attempt, establish an intraosseous infusion. If unable to see
            good peripheral vein, go straight to IO infusion.
     5.     If any signs of poor perfusion, infuse a 20 cc/kg NS fluid bolus. Contact base if you feel perfusion is
            compromised on reassessment.

C.   Medications:

     1.     Stabilizing the airway and supporting respiration are the mainstays of treatment. Specific treatment should
            be focused on the etiology of the arrest.
     2.     Arrhythmias are treated as noted in Arrhythmia Algorithms. See drug protocols for pediatric doses.
     3.     Hypoglycemia is common in younger children. If the child has altered mental status, either administer
            dextrose IV or rule out hypoglycemia with a bedside blood sugar check.


(continued on next page)




                                                         IX-80
Denver Metro Paramedic Protocols

Specific precautions

A.   The most successful pediatric resuscitations occur before a full cardiopulmonary arrest. Assess pediatric patients
     carefully and assist with airway, breathing, and circulatory problems before the arrest occurs, to improve the
     outcome in pediatric patients.
B.   Pediatric arrests are most likely to be primary respiratory events. The rescuer's primary attention must be
     directed to securing the airway and providing good ventilation before specific treatment of cardiac rhythm. Any
     cardiac rhythm can spontaneously convert to sinus rhythm in a well-ventilated child.
C.   Oxygen and epinephrine are the mainstays of pediatric resuscitations. Atropine and sodium bicarbonate are not
     first line drugs in pediatrics.
D.   Cardiopulmonary arrest from trauma is treated with airway management, rapid transport, CPR and fluid
     administration en route.
E.   Recommendations for obstructed airway are abdominal thrusts over the age of one year. Infants less than one
     year old should be treated with back blows and chest thrusts. Early laryngoscopy should be used in an attempt to
     visualize and remove upper airway obstructions.
F.   If a child 8 years or older is in arrest, AEDs can be used.
G.   Use of a length-based emergency tape (LBET) such as the Broselow™ tape is highly accurate and allows for
     rapid drug and fluid doses and correct equipment size and use. LBET use should be routine for any pediatric
     emergency.




                                                       IX-81
Denver Metro Paramedic Protocols

Pediatric Treatment
            INFANT FOUND DOWN (POSSIBLE SUDDEN INFANT DEATH SYNDROME (SIDS))

Specific information needed

A.   History: position in which the child was found, condition of the bed, last time the child was seen well, seizure
     activity, trauma, possibility of ingestion
B.   Associated symptoms: history of fever, respiratory symptoms, infection, vomiting, diarrhea, other signs of
     infections
C.   Past medical history: prematurity, chronic illness

Specific physical findings

A.   ABCs (See Section V - Infant and Child Resuscitation protocol)
B.   Neurologic: level of consciousness, responsiveness, muscle activity and tone
C.   Skin: signs of trauma
D.   Check for presence of froth or blood-tinged sputum at mouth or nose. (consistent with SIDS)
E.   Dependent lividity or early rigor mortis. Body temperature.

Treatment

A.   Initiate or continue resuscitation based on field pronouncement protocol.
B.   Airway: manage as indicated.
C.   Breathing: ventilate with 100% oxygen; suction as needed.
D.   Circulatory: support cardiac output as indicated by:
     1.     External chest compressions
     2.     Establish venous access.
     3.     Pediatric ALS as indicated
     4.     Monitor cardiac rhythm

E.   Contact base for field pronouncement if appropriate.
F.   Support the parents and siblings.

Special considerations


A.   Activate appropriate support for the family if the patient is pronounced dead in the field. Police, County Social
     Services, and the SIDS support line should be contacted.
B.   Avoid premature assessments. Rarely are "SIDS" cases homicides.
C.   SIDS cause is unknown. Cases occur between one month and one year of age. All cases are mandatory coroner
     cases.
D.   Consider possible NAT (non-accidental trauma, child abuse) and pass on any concerns to receiving facility
     personnel.
E.   For family support and community education, family members may welcome the following contact information:
     The Colorado SIDS Program, Inc., 6825 East Tennessee Avenue, Suite 300, Denver, Colorado 80224

     Local#: 303-320-7771 or toll-free# at 1-888-285-7437
     Website access is http://www.coloradosids.org




                                                       IX-82
Denver Metro Paramedic Protocols

Pediatric Treatment
                                            PEDIATRIC DEHYDRATION

Specific information needed

A.    History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine output, oral intake,
      recent trauma, possible drug ingestion
B.    Past medical history

Specific physical findings

A.    General appearance: LOC, muscle tone, color
B.    ABCs and vital signs
C.    Skin: warmth of distal extremities, color, skin turgor, capillary fill time (should be less than 2 seconds), pulses
D.    Mucous membranes: wetness of mouth, presence of tears
E..   Musculoskeletal: evaluate for trauma
F.    The signs of dehydration are:
            EARLY - tachycardia and tachypnea for age, decreased LOC, capillary filling time longer than two
            seconds, cool skin, mucous membranes dry, sunken eyes and fontanelle;
            LATE - loss of skin turgor, diminished pulses, and shock

Treatment

A.    Airway: manage as indicated, administer O2
B.    Breathing: ventilation as indicated
C.    Circulation:
      1.   Establish peripheral venous access.
      2.   Consider fluid bolus of NS 20cc/kg.
      3.   Do not delay transport for IV attempts.
      4.   The patient with simple dehydration is not a candidate for intraosseous infusion, contact base for approval
           of IO if shock is present.
D.    Determination of tachycardia or hypotension is based on age. (See Section V - table in General Guidelines)

Specific precautions

A.    Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but they are nonspecific.
B.    Monitor carefully for signs of decreased tissue perfusion (shock). Early shock is present if capillary fill time is
      greater than 2 seconds, and there are poor pulses, muscle tone and color, or decreased mental status.
      Decompensated shock is present if systolic BP is <normal for age.




                                                         IX-83
Denver Metro Paramedic Protocols

Pediatric Treatment
                                    PEDIATRIC RESPIRATORY DISTRESS

Specific information needed

A.   History: sudden or gradual onset of symptoms, cough, fever, sore throat, hoarseness
B.   History of potential foreign body aspiration or trauma
C.   Past medical history
E.   Current medication use

Specific objective findings

A.   Airway: look for respiratory distress during inspiration, listen for abnormal breathing sounds such as stridor,
     cough (croupy?), and wheezing, feel for air movement, crepitation, and tracheal deviation
B.   Breathing: respiratory rate and effort, chest wall movement/adequacy of tidal volume, color, use of accessory
     muscles, retractions, nasal flaring, head bobbing, or grunting
C.   Respiratory sounds by auscultation of chest: wheezing, rales, decreased (unilateral?), prolonged inspiratory
     (croup) or expiratory (wheezing) phases.
E.   Mental status: AVPU
F.   General appearance: leaning forward or drooling (suggests upper airway obstruction), skin color and
     temperature, muscle tone.

Treatment

A.   Administer high-flow oxygen by blow-by or non-rebreather mask.
B.   As long as the child is adequately ventilating and has adequate mentation, avoid agitating the patient. Keep the
     patient in his position of comfort.
C.   If the child is not ventilating adequately, assist with a BVM.
D.   In the rare case that the child cannot be ventilated with a BVM device:
     1.     Reposition airway. Consider oral airway if patient unconscious.
     2.     If still unable to ventilate, visualize the airway with a laryngoscope. Remove any foreign object with
            Magill forceps.
     3.     If nothing is seen, orally intubate the patient.
E.   Consider intubation only if unable to provide ventilatory support with a BVM and oral airway.
F.   Assess and consider treatment for the following problems if respiratory distress is severe and the patient does not
     respond to proper positioning and administration of high flow O2.
     1.     Croup or epiglottitis:
            a.              Allow patient to remain in position of comfort if alert.
            b.              Consider administering nebulized racemic epinephrine or L-epinephrine via nebulizer if
                            croup is likely and there is respiratory distress.
     2.     Asthma:
                   a.      Administer albuterol. Consider adding ipratropium for age >2y/o
                   b.       Use continuous nebulization of albuterol sulfate for respiratory distress.
                   c.       Consider epinephrine, SQ.
G.   If diagnosis is unclear, transport patient with 100% O2, reassess frequently and be prepared to manage the
     patient's airway.

(continued on next page)




                                                       IX-84
Denver Metro Paramedic Protocols

Specific precautions

A.   Children with croup, epiglottitis, or laryngeal edema usually have respiratory arrest due to exhaustion. Most
     children can still be ventilated with a BVM.

B.   Children with severe asthma may not exhibit wheezing. The patients will have prolonged expiratory phases and
     may appear listless, agitated, or unresponsive.

C.   Respiratory distress is a critical situation that can be made worse with prolonged scene times.

D.   Intubation of the infant is most easily accomplished with an infant-sized straight laryngoscope blade.

E.   Do not intubate unless you can visualize the ETT going through the cords. If you are unable to intubate the
     trachea quickly, withdraw, re-oxygenate with BVM, and try again. No harm will result to the child if you keep
     the patient well oxygenated and don't traumatize the airway with intubation attempts. Transporting while using
     BVM only is acceptable and may be preferable in many circumstances.

F.   Any child with a witnessed or suspected apnea episode should be transported.

G.   Cyanosis is a late sign in pediatric hypoxia. Provide 100% oxygen for any child in distress.

H.   Consider the differential assessment for each finding:
          Stridor: foreign body, croup, epiglottitis or other bacterial upper airway infection, larynx trauma, etc
          Wheezing: foreign body, asthma, bronchiolitis, hydrocarbon exposure, etc
          Respiratory distress: pneumothorax, foreign body, pneumonia, shock, CHF, etc




                                                       IX-85
Denver Metro Paramedic Protocols

Pediatric Treatment
                                               PEDIATRIC SEIZURES

Specific information needed

A.   History: preceding activity level, onset and duration of seizure, description of seizure activity, fever, color
     change, recent illness, head trauma, possibility of ingestion, cardiac symptoms.
B.   Past history: previous seizures, current medications, chronic illness

Specific objective findings

A.   Airway: look for respiratory distress, listen for abnormal breathing sounds, feel for air movement, crepitation,
     tracheal deviation.
B.   Breathing: respiratory rate and effort, chest wall movement (adequacy of tidal volume), use of accessory
     muscles, retractions
C.   Circulation: heart rate, pulse, capillary filling time, skin color, blood pressure
D.   Neurologic: mental status, muscle tone, focal findings, post-ictal period, incontinence. Note improvement or
     deterioration in mental status with time.
E.   Musculoskeletal: note any associated injuries.

Treatment

A.   Airway: Maintain patent airway by BLS maneuvers. Suction as needed. Administer 100% O2.
B.   Breathing: Assist ventilation as needed. (rarely necessary)
C.   If child is in status seizure:
     1.     Attempt peripheral venous access x1. If successful, administer IV diazepam.
     2.     If unable to start peripheral IV:
            a. for ages 8 and under, administer diazepam rectally
            b. for ages 9 and above, administer midazolam IM
     3.     Determine blood glucose level and draw appropriate blood tubes if possible.
     4.     If hypoglycemic, give IV dextrose.
     5.     If seizures continue, contact base.

D.   If the child has stopped seizing and is post-ictal, transport while continuing to monitor vital signs and neurologic
     condition.
E.   If child is febrile initiate cooling measurers.

Specific Precautions

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




                                                        IX-86
Denver Metro Paramedic Protocols



                                                      SECTION VI

                                                 DRUG PROTOCOLS


TABLE OF CONTENTS

                                                                                  Page Number
VI     Drug Protocols

               Adenosine (Adenocard)                                                     VI-2
               Albuterol Sulfate (for Amiodarone, see below after IV solutions)          VI-3
               Aspirin (ASA)                                                             VI-4
               Atropine Sulfate                                                          VI-5
               Dextrose 50%                                                              VI-6
               Diazepam (Valium)                                                         VI-7
               Diphenhydramine (Benadryl)                                                VI-8
               Dopamine (Intropin)                                                    VI-9, 10
               Epinephrine                                                           VI-11, 12
               Fentanyl Citrate                                                         VI-13
               Furosemide (Lasix)                                                       VI-14
               Glucagon                                                                 VI-15
               Haloperidol (Haldol)                                                  VI-16, 17
               Ipratropium Bromide (Atrovent)                                           VI-18
               IV Solutions                                                          VI-19, 20
               Amiodarone (replaced lidocaine HCl/Xylocaine)                         VI-21, 22
               Magnesium Sulfate                                                        VI-23
               Mark I Nerve Agent Antidote Kit                                       VI-24, 25
               Methylprednisolone (Solu-Medrol)                                         VI-26
               Metoclopramide (Reglan)                                                  VI-27
               Midazolam (Versed)                                                       VI-28
               Morphine Sulfate                                                         VI-29
               Naloxone Hydrochloride (Narcan)                                          VI-30
               Nitroglycerin                                                            VI-31
               Oral Glucose                                                             VI-32
               Oxygen                                                                VI-33, 34
               Phenylephrine (Intranasal)                                               VI-35
               Racemic Epinephrine (Vaponephrine)                                       VI-36
               Sodium Bicarbonate                                                       VI-37
               Topical Ophthalmic Anesthetics                                           VI-38




                                                         IX-87
Denver Metro Paramedic Protocols

Drug Protocol
                                           ADENOSINE(ADENOCARD)

Pharmacology and actions

A.      Adenosine is an endogenous nucleoside with antiarrhythmic activity.
B.      Because of its short plasma half-life (less than 10 seconds with IV doses), the clinical effects of adenosine
        occur rapidly and are very brief.
C.      Produces a transient slowing of the sinus rate.
D.      Has a depressant effect on the AV node.

Indications

A.      For termination of episodes of acute supraventricular tachycardia involving the AV-node
B.      Wide complex tachycardia with pulse, refractory to amiodarone and magnesium sulfate

Precautions

A.      Adverse effects include hypotension, flushing, dyspnea, chest pain, anxiety, and occasionally, hemodynamic
        disturbances - all of which are of short duration.
B.      Transient arrhythmias including asystole and blocks are common at the time of chemical cardioversion.

Administration


A.      Direct rapid intravenous bolus over 1-2 seconds of 6 mg initially, followed immediately by 20 ml saline flush.
         A second dose of 12 mg may be given after an interval of 1-2 minutes if the tachycardia persists. Total dose
        should not exceed 18 mg.
B.      Contact the base physician after the second dose for any additional orders.
C.      Pediatric dose: rapid IV 0.1 mg/kg initial dose. Second dose 0.2 mg/kg rapid IV, if SVT persists.

Side effects and special notes

A.      Whenever possible establish the IV at the antecubital.
B.      Adenosine is safe in patients with Wolff-Parkinson-White Syndrome.
C.      Concomitant use of dipyridamole (Persantine) enhances the effects of adenosine. Smaller doses may be
        required.
D.      Caffeine and theophylline antagonize adenosine's effects. Larger doses may be required.
E.      Warn patients to expect a brief sensation of chest discomfort.
F.      If patient becomes hemodynamically unstable, see appropriate tachycardia algorithm.
G.      Stable, asymptomatic patients, without a history of PSVT, may not need to be treated.
H.      Any patient receiving adenosine must be on a monitor and a 12-lead EKG should be performed and
        documented, if available.




                                                        IX-88
Denver Metro Paramedic Protocols

Drug Protocol
                                             ALBUTEROL SULFATE

Pharmacology and actions

A.      Has selective beta-adrenergic stimulating properties resulting in potent bronchodilation
B.      Rapid onset of action (under 5 minutes), and duration of action between 2-6 hours

Indications

A.      For relief of bronchospasm in patients with obstructive airway disease (asthma, emphysema, COPD) or
        allergic reactions.

Precautions

A.      Albuterol sulfate has sympathomimetic effects. Use with caution in patients with known coronary disease.
        Monitor pulse, blood pressure, cardiac monitor and 12-lead EKG (if available) in CAD patients.
B.      When inhaled, albuterol sulfate can result in paradoxical bronchospasm, which can be life threatening. If this
        occurs, the preparation should be discontinued immediately.

Administration

A.      For nebulizer use only

        1. For adults and children: place 2.5 mg/3 ml albuterol into an oxygen-powered nebulizer and run at 6-8
           lpm. Deliver as much of the mist as possible by nebulizer over 5-15 minutes.
        2. In more severe cases place 3 premixed containers of albuterol (2.5 mg/3ml) for a total dose of 7.5 mg in 9
           ml, into an oxygen-powered nebulizer and run a continuous neb at 6-8 lpm.
        3. Endotracheally intubated patients may be given albuterol sulfate by attaching the nebulizer in-line.

Side effects and special notes

A.      Monitor blood pressure and heart rate closely and contact base physician if any concerns arise.
B.      Medications such as MAO inhibitors and tricyclics may potentiate tachycardia and hypertension.




                                                       IX-89
Denver Metro Paramedic Protocols

Drug Protocol
                                                 ASPIRIN (ASA)

Pharmacology and actions

A.     ASA inhibits blood clotting. It inhibits the formation of thromboxane A2, a platelet aggregating,
       vasoconstricting prostaglandin. ASA in low doses, however, inhibits the production of thromboxane A2 in the
       platelet more than it does the production of prostacyclin in the endothelial cells.
B.     Platelet aggregation has been implicated in the pathogenesis of atherosclerosis contributing to the acute
       episodes of TIAs, unstable angina, and acute myocardial infarction.
C.     Unstable angina is precipitated by a sudden fall in coronary blood flow. One possible mechanism is platelet
       aggregation.
D.     ASA has been shown to be beneficial in decreasing sudden cardiac death and myocardial infarction in patients
       with unstable angina.
E.     ASA has been shown to be of added benefit in maintaining vessel patency after thrombolytic therapy.

Indications

A.     Patients with chest pain or other symptoms, which may be of cardiac origin
B.     ASA is not to be used for analgesia (i.e. headache)

Precautions

A.     Contraindicated in patients
       1.      allergic to ASA
       2.      evidence of active GI bleeding

Administration

A.     Chew four 81 mg ASA chewable tablets (324 milligrams total) if the patient is able to swallow voluntarily.

B.     Aspirin is one of the few interventions that has been shown to decrease mortality and therefore should be
       considered early in the care of the patient.

C.     Patients taking Coumadin may receive aspirin.




                                                       IX-90
Denver Metro Paramedic Protocols

Drug Protocol
                                                ATROPINE SULFATE

Pharmacology and actions
Atropine is a parasympathetic or cholinergic blocking agent. As such, it has the following effects:
A.      Increases heart rate (by blocking vagal influences)
B.      Increases conduction through A-V node
C.      Reduces motility and tone of GI tract
D.      Reduces action and tone of urinary bladder (may cause urinary retention)
E.      Dilates pupils

Note:   This drug blocks cholinergic (vagal) influences already present. If there is little cholinergic stimulation
        present, effects will be minimal.

Indications
A.      To counteract excessive vagal influences responsible for some bradyasystolic and asystolic arrests
B.      To increase heart rate in hemodynamically significant bradycardia
C.      To improve conduction in 2nd and 3rd degree heart block or in pacemaker failure
D.      As an antidote for some insecticide exposures (organophosphate poisoning - OPP) and nerve gases with
        symptoms of excess cholinergic stimulation: salivation, constricted pupils, bradycardia, tearing, diaphoresis,
        vomiting, and diarrhea

Precautions
A.     Bradycardias in the setting of an acute MI are common and may be beneficial. Do not treat them unless there
       are signs of poor perfusion (low blood pressure, mental confusion). If in doubt, consult the base physician.
B.     People do well with chronic 2nd and 3rd degree block. Symptoms occur mainly with acute change. Treat the
       patient, not the arrhythmia.
C.     Pediatric bradycardias are most commonly secondary to hypoxia. Correct the ventilation first, and only treat
       the rate directly if that fails. Epinephrine is almost always the first-line drug for bradycardia in pediatric
       patients.

Administration
A.     Asystole and PEA:
       1.      Adult: 1.0 mg IV rapidly. Repeat every 3-5 min., not to exceed 0.04 mg/kg.
B.     Hemodynamically unstable bradycardia:
       1.      Adult: 0.5-1.0 mg IV, repeated if needed at 3-5 minute intervals to a dose of 3 mg, or 0.04 mg/kg
               whichever is greater. (Stop at ventricular rate which provides adequate mentation and B/P. Aim for
               HR = 60/minute)
       2.      Pediatric: 0.02 mg/kg IV, minimum 0.1 mg
       3.      Contact base if bradycardia persists after 2 doses.
       C.         May be given through ET tube at 2 times the IV dose. Maximum ET dose is 6 mg.
D.     For symptomatic insecticide/organophosphate poisoning (OPP) exposures: contact base for dosage (usually
       begin with 2 mg IV and titrate (2 mg IV q 5 min) until secretions are dried. Total required dose may be
       massive).

Side effects and special notes
A.       Remember in cardiac arrest situations that atropine dilates pupils.




                                                         IX-91
Denver Metro Paramedic Protocols

Drug Protocol
                                                   DEXTROSE 50

Pharmacology and action

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

Indications

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

Precautions

A.      In patients with clinical findings suggestive of a CVA, caution should be used when considering dextrose
        unless the patient has a measurable hypoglycemia (when measurement is available).
B.      Draw appropriate blood tubes for blood sugar determination prior to administering dextrose.C.
                 Extravasation of glucose can cause tissue necrosis. Ensure IV patency before and during dextrose
        infusion.

Administration

A.      Adult dose: 1 (one) 50 ml amp of D50, IV into a secure vein (D50 is 25 gm of dextrose per 50 ml)
B.      In patients ages 1 - 8: 2-4 ml/kg of D25
C.      In patients less than 1 year: 2-4 ml/kg of D10
D.      May give oral glucose preparations if the patient is awake.
E.      Contact base if second dose is required.

Side effects and special notes

A.      One bolus should raise the blood sugar 50-100 mg/ml and, therefore, will be adequate for most patients.
B.      Effect may be delayed in the elderly patients with poor circulation.
C.      Do not administer dextrose to a patient who is seizing due to trauma.
D.      Dextrose should be diluted 1:1 with normal saline (to create D25W) for patient 8 years and younger.
E.      Do not withhold dextrose in a patient suspected of being hypoglycemic.




                                                        IX-92
Denver Metro Paramedic Protocols

Drug Protocol
                                               DIAZEPAM (VALIUM)

Pharmacology and actions

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

Indications

A.      Status seizures: in the field this will be any seizure which has lasted longer than 5 minutes, or two consecutive
        seizures without regaining consciousness.
B.      For the treatment of drug-induced hyperadrenergic states manifested by tachycardia and hypertension (i.e.,
        cocaine, amphetamine overdose)
C.      For patients who are combative from head injury
D.      Combative (out-of-control) patients from suspected stimulant abuse (i.e.: cocaine, PCP, ecstasy,
        amphetamines)
E.      Severe musculoskeletal back spasms

Precautions

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

Administration

A.      Contact base for direct physician order for use other than status seizures.
B.      Adult dose: 1-10 mg slow IV push
C.      Pediatric dose: 0.3 mg/kg slow IV or 0.5 mg/kg rectally, up to a maximum of 10 mg

Side effects and special notes

A.      Common side effects include drowsiness, dizziness, fatigue, and ataxia. Paradoxical excitement or stimulation
        can occur.
B.      Should not be mixed with other agents or diluted with intravenous solutions
C.      If the patient is seizing on your arrival, status seizure can be assumed.
D.      When used to treat drug-induced hyperadrenergic states, larger doses of diazepam may be required. Base
        contact is required.
E.      Rectal administration in children should be through a TB/1 cc syringe with the needle removed. Lubrication
        may be required before insertion of the syringe. The syringe barrel should be completely inserted prior to
        administration.




                                                        IX-93
Denver Metro Paramedic Protocols

Drug Protocol
                                      DIPHENHYDRAMINE (BENADRYL)

Pharmacology and actions

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

Indications

A.      Moderate allergic reaction
B.      The second-line drug in anaphylaxis and severe allergic reactions (after epinephrine)
C.      To prevent or counteract extrapyramidal reactions from antipsychotic medications

Precautions

May have additive effect with alcohol or depressants

Administration

A.      Adult: 50 mg slow IV push or IM
B.      Children 8 years and younger: 1-2 mg/kg slow IV (not to exceed 50 mg total)


Side effects and special notes

A.      May cause CNS stimulation in children
B.      Side effects include dry mouth, dilated pupils, flushing, and drowsiness.
C.      Diphenhydramine should be used with caution in patients with asthma/COPD, glaucoma, and bladder
        obstruction, as all of these conditions can be exacerbated by its administration.
D.      If an IV has been or will be established for other reasons, the IV route is preferred over the IM route.
E.      Extrapyramidal reactions may be noted with the administration of haloperidol (Haldol). Be prepared to
        administer diphenhydramine to help counteract these side effects. An IM dose of haloperidol may be followed
        by diphenhydramine via either slow IV or IM administration.




                                                        IX-94
Denver Metro Paramedic Protocols

Drug Protocol
                                             DOPAMINE (INTROPIN)

Pharmacology and actions

A.      Dopamine is a chemical precursor of epinephrine. It occurs naturally in humans.
B.      Dopamine has the following dose-related effects:

        1.       1-2 mcg/kg/min: dilates renal and mesenteric blood vessels (no effect on heart rate or blood
                 pressure).
        2.       2-10 mcg/kg/min: beta effects on heart, usually increases cardiac output without increasing heart rate
                 or blood pressure.
        3.       10-20 mcg/kg/min: alpha peripheral effects cause peripheral vasoconstriction and increased blood
                 pressure.
        4.       20-40 mcg/kg/min: alpha effects reverse dilatation of renal and mesenteric vessels with resultant
                 decreased flow.

Indications

A.      Symptomatic hypotension from causes other than hypovolemia such as cardiogenic shock, neurogenic shock,
        septic shock and anaphylactic shock

Precautions

A.      Dopamine is contraindicated in hypovolemic shock. Pressor agents worsen tissue hypoxia in the presence
        of hypovolemia from diuretics and poor intake; careful differentiation is necessary. Invasive monitoring is
        often the only way to differentiate forms of shock in the elderly, and treatment with dopamine is therefore
        indicated in the field only in severely unstable patients with evidence of increased venous pressure.
B.      Dopamine is best administered by an infusion pump to accurately regulate rate. This is another reason it is
        hazardous for field use. Monitor closely.
C.      Dopamine may induce tachydysrhythmias. If the heart rate exceeds 140, the infusion should be stopped.
D.      At low doses, decreased blood pressure may occur due to peripheral vasodilatation. Increasing infusion rate
        will correct this.
E.      Should not be added to sodium bicarbonate or other alkaline solutions, since dopamine will be inactivated at
        higher pH
F.      Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure to make
        Emergency Department personnel aware if there has been any extravasation of dopamine-containing solutions,
        so that proper treatment can be instituted.
G.      Can cause hypertensive crisis in susceptible individuals
H.      Certain antidepressants potentiate the effects of this drug. Check for medications and contact base if other
        medications are being used.

Administration

A.      Contact base for direct physician order.
B.      Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/ml.

(continued on next page)




                                                       IX-95
Denver Metro Paramedic Protocols

                                INTRAVENOUS DRIP RATES FOR DOPAMINE

                                          Concentration: 1600 mcg/ml
                         Dose

              Weight        5        10         15        20           (mcg/kg/min)
                 50        10        20         30        40       microdrips/min
                 60        10        25         35        45
                 70        15        25         40        50
                 80        15        30         45        60
                 90        15        35         50        70
                100        20        35         55        75
                110        20        40         60        85




                                                 IX-96
Denver Metro Paramedic Protocols

Drug Protocol
                                                      EPINEPHRINE

Pharmacology and actions

A.      Catecholamine with alpha and beta effects
B.      Cardiovascular:
        1.     Increased heart rate
        2.     Increased blood pressure
        3.     Arterial vasoconstriction
        4.     Increased myocardial contractile force
        5.     Increased myocardial oxygen consumption
        6.     Increased myocardial automaticity and irritability

C.      Pulmonary:
        1.     Potent bronchodilator

Indications

A.      Medical cardiac arrest, including:
        1.      Ventricular fibrillation
        2.      Asystole
        3.      Pulseless electrical activity (PEA)

B.      Bradycardia:
        1.     If refractory to atropine, adults with BP < 90 with signs of poor perfusion
        2.     Pediatric patients with signs of poor perfusion

C.     Asthma
D.     Mild to moderate allergic reactions
E.     Anaphylaxis or severe angioedema
F.     Life-threatening airway obstruction suspected secondary to croup or epiglottitis
Precautions

A.      The beating heart is extremely sensitive to epinephrine. For bradycardia indication, if pulses are present,
        titrate epinephrine to desired effect using 1 mg in 250 cc as an infusion to avoid untoward side effects. Begin
        infusion at 2 mcg/min.
B.      Do not add to solutions containing bicarbonate.
C.      Increase in myocardial oxygen consumption can precipitate angina or MI in patients with coronary artery
        disease.
D.      Use with caution in patients with hypertension, hyperthyroidism, peripheral vascular disease, or
        cerebrovascular disease or any patient over the age of 50.
E.      Asthma is not the only cause of wheezing. Epinephrine is contraindicated in pulmonary edema.
F.      Anaphylaxis is a systemic allergic reaction with cardiovascular collapse. Angioedema involves swelling of
        mucous membranes; potential exists for airway compromise. Mild or moderate allergic reactions with
        urticaria or wheezing may progress to anaphylaxis or severe angioedema. Monitor patient carefully and treat
        according to patient status.
G.      Epinephrine comes in two strengths. Use of the wrong formulation will result in a ten-fold difference in
        dosage. Be sure you use the right one.
H.      Anxiety, tremor, palpitations, vomiting, and headache are common side effects.
I.      For nebulized administration:
        B. In the less-than-critical patient, saline alone via nebulizer may bring symptomatic relief from croup.


(continued on next page)

                                                        IX-97
Denver Metro Paramedic Protocols


       C. Tachycardia and agitation are the most common side effects. Since these are also the hallmarks of
          hypoxia, watch the patient very closely! Other side effects of parenteral epinephrine may also be seen.


       D. Nebulizer treatment may cause blanching of the skin in the mask area due to local epinephrine absorption.
          Reassure parents.

Administration

A.     Adult
       1.        Cardiac arrest
                 a.      1.0 mg (10 ml of 1:10,000 solution) IV every 3-5 minutes

       2.        Bradycardia (contact base for direct physician order)
                 a.     1.0 mg in 250 ml NS. Begin at 2 mcg/min. Titrate to blood pressure of 90 systolic

       3.        Moderate or severe allergic reactions
                 a.     0.3 mg (0.3 ml of 1:1,000 solution) SQ

       4.        Anaphylaxis (contact base for direct physician order)
                 a.     0.1 mg IV 1:10,000 followed by 1.0 mg in 250 cc NS titrate infusion to desired effect (signs
                        of improved perfusion, systolic BP > 90). Begin at 2 mcg/minute

       5.        Asthma
                 a.     0.3 mg (0.3 ml of 1:1,000 solution) SQ

B.     Pediatric
       1.       Cardiac arrest
                a.      First dose: 0.1 mg/kg IV/IO/ET (0.1 ml/kg of 1:1,000 solution)
                b.      Subsequent doses: 0.2 mg/kg, IV/IO/ET (0.2 ml/kg of 1:1,000 solution)

       2.        Bradycardia (contact base for direct physician order)
                 a.     0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV

       3.        Mild or Moderate allergic reactions
                 a.      0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) SQ

       E.        Anaphylaxis (contact base for direct physician order)
                 a.     0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV

       5.        Asthma
                 a.     0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) SQ

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

C.     IV doses may be given through ET tube at 2 times the IV dose.




                                                       IX-98
Denver Metro Paramedic Protocols

Drug Protocol
                                                       FENTANYL

Pharmacology and actions:

A.             Analgesia and Sedation
B.             Rapid onset (5 minutes), peak 30 minutes, short half-life (90 minutes)
C.             Does NOT cause histamine release

Indications:

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

Contraindications:

A.      Hypersensitivity to opiates
B.      Hypotension
C.      Myasthenia Gravis

Precautions:

A.      Can cause significant respiratory depression and hypotension especially when used in combination with other
        sedatives such as alcohol or benzodiazepines. Continuous pulse oximetry and cardiac monitoring are
        necessary. Frequent evaluation of the patient’s vital signs is also necessary. Emergency resuscitative
        equipment must be immediately available.
B.      Can increase intracranial pressure
C.      Chest wall rigidity has been reported with rapid administration.

Administration

A.      SLOW IV only
B.      Adult dose: 1-2 mcg / kg, slow IV
                 Contact base for any single dose or cumulative doses > 100 mcg
C.      Pediatric dose: 1-2 mcg / kg

Side effects and special notes:

A.      Sedation, bradycardia, hypotension, respiratory depression, respiratory arrest, laryngospasm
B.      Effects increased by other CNS depressants (alcohol, benzodiazepines, muscle relaxants, opiates)
C.      Naloxone reverses the effects of narcotics, particularly respiratory depression, due to narcotic drugs ingested,
        injected or administered in the course of treatment. (See Section VI – Drug Protocols, Naloxone)
D.      Pediatric patients may develop apnea without manifesting significant mental status changes.




                                                          IX-99
Denver Metro Paramedic Protocols

Drug Protocol
                                              FUROSEMIDE (LASIX)

Pharmacology and actions:

A.      Rapid acting, potent diuretic; inhibits reabsorption of NaCl.
B.      Venous dilator that decreases preload.

Indications:

A.      Cardiogenic Pulmonary Edema (CHF)

Contraindications:

A.      Known hypersensitivity to this drug
B.      Pregnancy
C.      Dehydration or Shock

Precautions:

A.      Drug may be deactivated by exposure to light
B.      Rapid administration can cause auditory changes including tinnitus and hearing loss.
C.      Patients with allergies to sulfonamides may be sensitive to furosemide.
D.      Use caution if patient blood pressure less than 100 systolic

Administration:

A.      Adult Dosage: 20 – 80 mg slow IV push
B.      Patients who are not currently taking Lasix should be started at 20 mg.
C.      Patients who are already on Lasix may require higher doses; 40-80 mg

Side effects and special notes:

A.      Headache, dizziness, hypotension, hypovolemia, potassium depletion, nausea and vomiting, diarrhea.
B.      Furosemide (Lasix) is not considered a first line drug. Be sure to attend to the patient’s primary treatment
        priorities (i.e. airway, ventilation, arrhythmia treatment) first. If primary treatment priorities have been
        completed and there is time while in route to the hospital, then furosemide can be administered. Do not delay
        transport to administer furosemide.




                                                       IX-100
Denver Metro Paramedic Protocols

Drug Protocol
                                                   GLUCAGON




Pharmacology and actions:

A.      Increases blood sugar concentration by converting liver glycogen to glucose.
B.      Relaxes smooth muscle of the GI tract
C.      Increases heart rate and cardiac contractility

Indications:

A.      Symptomatic hypoglycemia when IV access is unsuccessful (after 2 unsuccessful attempts).
B.      Hypotension from beta-blocker or calcium channel blocker overdose unresponsive to normal saline bolus

Contraindications:

A.      Known hypersensitivity to this drug

Precautions:

A.      Use with caution in patients with a history of cardiovascular disease, renal disease, pheochromocytoma or
        insulinoma.

Administration:

A.      Hypoglycemia                                      Adult dose: 1 mg IM



B.      Beta-blocker / Ca++ Channel Blocker OD Contact Base
                                                       Adult dose: 2 mg IV                           Pediatric dose:
                                               0.1 mg/kg IV
                                                       (maximum peds. dose: 1 mg)

Side effects and special notes:

A.      Nausea, vomiting, and headache
B.      When glucagon is given for hypoglycemia the patient should receive glucose as soon
        as possible after the administration of glucagon.




                                                     IX-101
Denver Metro Paramedic Protocols

Drug Protocol
                                            HALOPERIDOL (HALDOL)
Pharmacology and actions:

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

B.      Onset of action is 10 minutes after IM administration with peak effect in 30 minutes. Duration of the sedative
        effect is 2 - 4 hours but may be prolonged in certain individuals.

Indications:

A.      Primary indication: to act as a chemical restraint in patients that require transport and are behaving in a
        manner that poses a threat to their own well-being or others.


Contraindications:

A.      Do not administer to any patient:
        1.      with a suspected acute myocardial infarction
        2.      with a systolic blood pressure under 100 mm Hg, or the absence of a radial pulse
        3.      exhibiting signs of sedation, respiratory depression, or CNS depression
        4.      with known Parkinson's Disease
        5.      with a known pregnancy
        6.      with severe liver or cardiac disease
        7.      under the age of 8

Precautions:

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

(continued on next page)




                                                       IX-102
Denver Metro Paramedic Protocols

Administration:

A.     Chemical restraint
       1.     Standing orders
       1.     Adult dose: 5 mg – 10 mg IM administration
       3.     May be followed with 25 – 50 mg diphenhydramine, IV or IM.

B.     After 10 minutes, if desired effect has not been achieved, contact base to consider a second dose.

Special Considerations:

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




                                                     IX-103
Denver Metro Paramedic Protocols

Drug Protocol
                                     IPRATROPIUM BROMIDE (ATROVENT)


Pharmacology and actions:

A.      Bronchodilation
B.      Dries respiratory tract secretions

Indications:

A.      Bronchospasm related to asthma, chronic bronchitis, or emphysema

Contraindications:

A.      Hypersensitivity to this drug, atropine, soy, or peanuts

Precautions:

A. Should not be used as the primary agent for treatment of bronchospasm.
B. Use with caution in patients with coronary artery disease.
C. Pulse, blood pressure, and EKG must be monitored.

Administration:

A.      Adult and Pediatrics (> 2 years) dosage:
                Premixed Container:       0.5 mg in 2.5ml NS

        1.        Mild / Moderate Bronchospasm:
                          Ipratropium may be used in combination with albuterol as described below if patient is
                          unresponsive to initial albuterol nebulization treatment.

        2.        Severe Bronchospasm:
                          Place one premixed vial of ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer
                          and administer via oxygen-powered nebulizer to create a fine mist. If patient requires further
                          treatment, continuous nebulization of plain albuterol should be utilized (See Section VI –
                          Drug Protocols – Albuterol protocol).


Side effects and special notes:

A.      Palpitations, dizziness, anxiety, tremors, headache, nervousness, and dry mouth.
B.      Can cause paradoxical bronchospasm. If this occurs discontinue treatment.




                                                        IX-104
Denver Metro Paramedic Protocols

Drug Protocol
                                                    IV SOLUTIONS

Pharmacology and actions

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


TKO FLUID RATE

Indications
A.      Prophylactic IV
B.      Drug administration

Administration
A.     TKO = 5-10 drops/min. or buffalo cap.


FLUID REPLACEMENT/BOLUS

Indications
A.      Hemorrhagic shock, volume depletion (dehydration, burns, severe vomiting)
B.      Shock caused by increased vascular space (neurogenic shock)

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

Administration
A.     20 ml/kg NS through large bore cannula, as rapidly as possible. Contact base if more than one fluid bolus is
       indicated.



FLUID CHALLENGE

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

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

(continued on next page)




                                                        IX-105
Denver Metro Paramedic Protocols

Side effects and special notes

A.      Flow rate through a 14g cannula is twice the rate through an 18g cannula, and volume administration in
        trauma patients can be accomplished more rapidly. If the patient has poor veins, a smaller bore is better than
        no IV at all, in some instances.

B.      IVs in an unstable trauma patient should be placed enroute, and may be left to the hospital setting for short
        transports. Do not delay transport in critical patients for IV attempts.

C.      If you are unable to start in two attempts, another qualified attendant may try, or you may leave the IVs for the
        hospital.

D.      If IV access is required but volume expansion is not, consider starting a buff cap.

E.      1 ml/min = 60 microdrops/min = 15 regular drops/min.




                                                       IX-106
Denver Metro Paramedic Protocols

Drug Protocol
                                                AMIODARONE

Pharmacology and actions

A.     Cardiovascular
       1. Amiodarone has multiple effects showing Class I, II, III and IV actions.
       2. The dominant effect is prolongation of the action potential duration and the refractory period.
       3. Onset is within minutes.

Indications

A.     Cardiac arrest from VT/VF – standing order
B.     Following successful defibrillation – standing order
C.     Sustained wide complex tachycardia with a pulse (except wide complex irregular rhythms)
D.     Unstable wide complex tachycardia following unsuccessful cardioversion
E.     Pediatric pulseless VT/VF – standing order

Precautions

A.     WPW is a relative contraindication.
B.     Use caution in wide complex irregular tachycardia
C.     Do not treat ventricular escape beats or accelerated idioventricular rhythm with amiodarone.
D.     Pulmonary congestion and cardiogenic shock are contraindications.
E.     May cause severe hypotension and profound bradycardia.
F.     Use with caution in sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose.

Administration

A.     Cardiac Arrest - adult
       1.      300 mg IV bolus
       2.      May repeat 150mg IV bolus (x1) in 3 - 5 minutes. Contact base for further doses. (Maximum
               cumulative dose is 2 G IV / 24 hrs)

B.     Successfully defibrillated cardiac arrest from VF/VT - adult
       1.     150mg IV over 10 minutes

C.     Wide complex tachycardia (Stable) - Adult
       1.     Contact base for all indications with a pulse except for post-arrest dosing.
       2.     Dose is 150mg IV over 10 minutes. Contact base for additional doses.

D.     Unstable wide complex tachycardia after unsuccessful cardioversion
       1.     Contact base.
       2.     Dose is 150mg IV over 10 minutes

E.     Pediatric pulseless VT or VF after unsuccessful defibrillation: 5mg/kg IV over 3-5 minutes. Contact
       base for additional doses.

F.     May be given IV only.




                                                   IX-107
Denver Metro Paramedic Protocols

Side effects and special notes
A.      Amiodarone is a toxic drug. PVCs should not be treated with amiodarone. Hypoxia can generate PVCs
        and amiodarone will not help; treat the cause.

B.   Patients with PVCs and active chest pain should have their pain treated aggressively with oxygen, aspirin,
       nitrates, and pain medications.




                                                   IX-108
Denver Metro Paramedic Protocols

        Drug Protocol
                                              MAGNESIUM SULFATE

Pharmacology and actions

A.      Cardiac: stabilizes potassium pump, correcting repolarization. Shortens the Q-T interval in the presence of
        ventricular arrhythmias due to drug toxicity or electrolyte imbalance.
B.      Respiratory: may act as a bronchodilator in acute bronchospasm due to asthma or other bronchospastic
        diseases. For best results, it should be used after normal field inhalation therapy has been attempted.
C.      Obstetrics: controls seizures by blocking neuromuscular transmission. Also lowers blood pressure and
        decreases cerebral vasospasm.

Indications

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

Precautions

A.      AV block
B.      Decrease in respiratory or cardiac function
C.      Use with caution in patients taking digitalis

Administration

A.      Cardiac Arrest - Refractory VF and pulseless VT or torsade de pointes: 2 g IV push
B.      Wide complex tachycardia with pulse and without poor perfusion:
        2 g IV over 2 minutes, contact base for order.
C.      Acute bronchospasm:
        2 g IV over 2 minutes, contact base for order.
D.      In pre-eclampsia/eclampsia patients, mix 6 g in 50 ml of NS and run over 15-30 minutes: contact base for
        order.

Side effects and special notes

A.      Principle side effect is respiratory depression. Ventilatory assistance may be needed.
B.      Not for pediatric use




                                                        IX-109
Denver Metro Paramedic Protocols

Drug Protocol
                                     MARK I NERVE AGENT ANTIDOTE KIT

Background:

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




                                  Mark I Nerve Agent Antidote Kit

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

Injection Sites:
Outer thigh - mid lateral thigh (preferred site)
Buttocks -       upper lateral quadrant of buttock (gluteal) in thin individual.

Procedure (general):
   1. Immediately place protective mask (if available) after identifying nerve agent exposure.
   2. Grasp and remove the smaller, green-tipped (atropine) auto-injector with the thumb and first
       two fingers and pull the injector from the clip. It is now activated. Use caution not to
       unintentionally inject self.
   3. Form a fist around the injector and position needle against the injection site.
   4. Apply firm even pressure (not a jabbing motion) to the injector until it pushes the needle
       through the skin and into the muscle.
   5. Hold the injector firmly in place for at least 10 seconds.
   6. Repeat process with the larger, black-tipped (2-PAM) auto-injector.

Comments:
   1. Within 5-10 minutes after administration, tachycardia and dry mouth may occur. This
      indicates the antidote is working and that you should not need another injection.
   2. No more that 3 sets of antidote (total of 6 injections) should be used.
   3. Attempt to decontaminate skin and clothing between injections.


(continued on next page)




                                                        IX-110
Denver Metro Paramedic Protocols




                        1. Hold the set of auto-injectors with the non-dominant hand
                                            and by the plastic clip.




       2. Grasp the atropine injector with                3. Remove the atropine injector.
       the thumb and first two fingers.




                                                     IX-111
Denver Metro Paramedic Protocols




4. Removal of the 2-PAM auto-injector.




                                         IX-112
Denver Metro Paramedic Protocols

Drug Protocol
                                   METHYLPREDNISOLONE (SOLU-MEDROL)

Pharmacology and actions:

A.       Anti-inflammatory
B.       Suppresses immune / allergic responses

Indications:

A.       Anaphylaxis
B.       Severe asthma / COPD

Contraindications:

A.       Hypersensitivity to this drug

Precautions:

A.       Must be reconstituted and used promptly

Administration:

A.       Adult dosage: 125 mg IV
B.       Pediatric dosage: 2 mg / kg IV

Side effects:

A.       GI Bleeding


Special Notes:

     A. Be aware that the effect of methylprednisolone is generally delayed for several hours. Although it is
        worthwhile to administer methylprednisolone early in the treatment of a patient with severe respiratory distress
        or anaphylaxis you may not see any effect from the drug for several hours. Do not expect to see any immediate
        response.

B.       Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s primary treatment
         priorities (i.e. airway, ventilation, beta-agonist neublization) first. If primary treatment priorities have been
         completed and there is time while in route to the hospital, then methylprednisolone can be administered. Do
         not delay transport to administer this drug.




                                                         IX-113
Denver Metro Paramedic Protocols

Drug Protocol
                                        METOCLOPRAMIDE (REGLAN)


Pharmacology and actions:

    A. Metoclopramide is a dopamine antagonist that has two main effects:
          1. Blockade of the CNS vomiting chemoreceptor trigger zone (CRT) to inhibit vomiting.
          2. Stimulation of upper GI motility by contracting the lower esophageal sphincter and speeding up
              gastric emptying time.

    B. Onset of action is 1-3 minutes for IV and 10 to 15 minutes for IM administration. The effects persist 1-2 hours
       following single dose administration.


Indications:

    A. Treatment of severe intractable vomiting.


Contraindications:

    A.   Known pheochromocytoma
    B.   Known Parkinson’s disease
    C.   Hypertensive crisis
    D.   Under age 8
    E.   Known allergy to metoclopramide
    F.   Known bowel obstruction


Precautions:

    A. Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity, or anxiety
       following metoclopramide administration.
    B. Extra-pyramidal reactions have been noted hours to days after treatment, usually presenting as spasm of the
       muscles of the tongue, face, neck and back.
    C. Side effects may be increased by rapid administration.


Administration:

    A. Adult dose 10 mg slow IV push over 1-2 minutes or IM
    B. Children 8-12 years 5mg slow IV push or IM. Do not give in children under 8.

Special Considerations

    A. Although extra-pyramidal reactions have an incidence of less than 1%, be prepared to administer 50 mg
       diphenhydramine IVP/IM (adult dose). (See Section VI – Drug Treatment – Diphenhydramine (Benadryl))
    B. Metoclopramide may cause sedation.
    C. Metoclopramide is photosensitive and should be protected from light during storage




                                                      IX-114
Denver Metro Paramedic Protocols

Drug Protocol
                                             MIDAZOLAM (VERSED)


Pharmacology and actions:

A.      CNS depressant leading to sedation and amnesia
B.      Anticonvulsant

Indications:

A.      Airway management in combative patients – requires base contact.
B.      Sedation for cardioversion or transcutaneous pacing (TCP)
C.      Status epilepticus in adults; as an IM benzodiazepine when two IV attempts have been unsuccessful. If an IV
        is obtained, then diazepam should be used.

Contraindications:

A.      Patients with a history of hypersensitivity to benzodiazepines
B.      Narrow angle glaucoma

Precautions:

A.      Can cause significant respiratory depression, apnea, and hypotension especially when used in
        combination with other sedatives such as alcohol or narcotics. Continuous pulse oximetry and cardiac
        monitoring are mandatory. Emergency resuscitative equipment must be immediately available.
B.      Consider lower doses for elderly patients; significant respiratory depression, apnea, and hypotension are
        more frequently encountered.

Administration:

A.      Adults:          1 - 5 mg IV/IM, titrate to effect
B.      Pediatrics:      0.1 mg/kg IV/IM (maximum dose 10 mg)


Side effects:

A.      Hypotension, respiratory depression, amnesia




                                                       IX-115
Denver Metro Paramedic Protocols

Drug Protocol
                                               MORPHINE SULFATE

Pharmacology and actions
A.    Analgesia
B.    Pupil constriction
C.    Respiration: decreased rate and tidal volume
D.    Peripheral vasodilatation
E.    Reflex cardiac effect (from vasodilatation):
      1.      Decreased myocardial oxygen consumption
      2.      Decreased left ventricular end-diastolic pressure
      3.      Decreased cardiac work
F.    Effect: maximum within 7 minutes IV

Indications

A.      Presumed cardiac chest pain
B.      Severe burns
C.      Cardiogenic pulmonary edema
D.      Isolated extremity injuries
E.      Pain management

Precautions

A.      Hypotension is a relative contraindication to use. Smaller doses are less likely to cause or aggravate
        hypotension.
B.      Do not use in persons with respiratory difficulties (except pulmonary edema), because their respiratory drive
        may become depressed.
C.      Do not use in the presence of major blood loss. The body's compensatory mechanisms will be suppressed by
        the use of morphine and the hypotensive effect will become very prominent.
D.      May cause vomiting; administer slowly.

Administration
A.     IV only
B.     Adult dose: 2 - 10 mg IV. Initial dose up to 4 mg, then 2 mg increments up to a total of 10 mg, then contact
       base. The goal is decreased anxiety and patient comfort; patient need not be completely pain-free.
C.     Pediatric dose: 0.1 mg - 0.2 mg/kg IV slowly.

Side effects and special notes
A.       Patients receiving morphine should have vital signs and oxygen saturation monitored.
B.       The major side effects and complications from morphine result from vasodilatation. This causes no problems
         if the patient is supine and not volume depleted. It may cause problems if the patient is upright, hypovolemic,
         or has decreased cardiac output (after MI).
C.       Morphine can cause respiratory depression. Be prepared to assist ventilation if the patient stops breathing.
D.       Naloxone reverses the effects of narcotics, particularly respiratory depression, due to narcotic drugs either
         ingested, injected, or administered in the course of treatment. (See Section VI – Drug Treatment - Naloxone)




                                                       IX-116
Denver Metro Paramedic Protocols

Drug Protocol
                                               NALOXONE (NARCAN)

Pharmacology and actions

Naloxone is a narcotic antagonist which completely binds to narcotic sites, but which exhibits almost no
pharmacological activity of its own. Duration of action: 1-4 hours.

Indications

A.      Reversal of narcotic effects, particularly respiratory depression, due to narcotic drugs either ingested, injected,
        or administered in the course of treatment. Narcotic drugs include morphine sulfate, Fentanyl, meperidine
        (Demerol), heroin, hydromorphone (Dilaudid), oxycodone (Percodan, Percocet), codeine, propoxyphene
        (Darvon), pentazocine (Talwin).
B.      Diagnostically in coma or altered mental status of unknown etiology, to rule out (or reverse) narcotic
        cardiorespiratory depression
C.      Seizure of unknown etiology, to rule out narcotic overdose (particularly propoxyphene)

Precautions

A.      In patients physically dependent on narcotics, frank and occasionally violent withdrawal symptoms may be
        precipitated. Be prepared to restrain the patient. Titrate the dose (1-2 ml at a time) to reverse cardiac and
        respiratory depression, but to keep the patient groggy.
B.      May need large doses (8-12 mg) to reverse propoxyphene (Darvon) overdose.

Administration

A.      Age 8 - Adult: 2 mg (2 ml) IV, or IM if IV not available
B.      Pediatric: less than 8 years of age: 1 mg IV
C.      If no response is observed, this dose may be repeated after 5 min., if narcotic overdose strongly suspected.
D.      May be given through ET tube at 2 times the IV dose.

Side effects and special notes

A.      This drug is remarkably safe and free from side effects. Do not hesitate to use it if indicated.
B.      The duration of some narcotics is longer than naloxone and the patient must be monitored closely. Repeated
        doses of naloxone may be required. Patients who have received this drug must be transported to the hospital
        because coma may reoccur when naloxone wears off.
C.      With an endotracheal tube in place and assisted ventilation, narcotic overdose patients may be safely managed
        without naloxone. Think twice before totally reversing coma; airway may be lost, or (worse) the patient may
        become violent and may refuse transport.




                                                        IX-117
Denver Metro Paramedic Protocols

Drug Protocol
                                                NITROGLYCERIN

Pharmacology and actions

A.      Cardiovascular effects include:
        1.      Reduced venous tone; causes blood-pooling in peripheral veins, decreasing venous return to the heart
        2.      Decreased peripheral resistance
        3.      Dilatation of coronary arteries (if not already at maximum) and relief of coronary artery spasm
B.      Generalized smooth muscle relaxation

Indications

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

Precautions

A.      Generalized vasodilatation may cause profound hypotension and reflex tachycardia.
B.      NTG tablets lose potency easily; should be stored in dark glass container with tight lid and not exposed to
        heat.
C.      Use with caution in hypotensive patients.
D.      Use with caution in patients with EKG evidence of RV infarct

Administration

A.      0.4 mg (1/150) tablet sublingually, or one metered spray; may repeat every 5 minutes as needed for effect.
        Contact base for direct physician order for administration beyond 3 paramedic administered doses.
B.      Blood pressure to be checked prior to each dose.
C.      Contact base for direct physician order for patients with BP less than 100 mm Hg or with signs of poor
        peripheral perfusion or with hypertension.

Side effects and special notes

A.      Common side effects include throbbing headache, flushing, dizziness, and burning under the tongue. These
        side effects may be used to check potency.
B.      Less common: orthostatic hypotension, sometimes marked
C.      NOTE: Therapeutic effect is enhanced, but adverse effects are increased when patient is upright.
D.      Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in relieving chest pain
        caused by esophageal spasm.
E.      May be effective even in patients using paste, discs, or oral long-acting nitrate preparations.
F.      Patients taking Viagra should not be given nitroglycerin.




                                                      IX-118
Denver Metro Paramedic Protocols

Drug Protocol
                              ORAL GLUCOSE (GLUTOSE and INSTA-GLUCOSE)

Pharmacology and Actions

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

Indications
A.      Hypoglycemia
B.      Altered mental status and history of (hypoglycemia) diabetes


Precautions

A.       Any patient who is unable to swallow may experience an airway obstruction or aspiration due to the gel.

Administration

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

Side Effects and Special Notes

A.      There are no side effects if administered properly.
B.      Due to the gel thickness, there is a potential for airway obstruction or aspiration if the patient has no gag
        reflex.
C.      It is best to have the suction available when administering this.




                                                        IX-119
Denver Metro Paramedic Protocols

Drug Protocol
                                                       OXYGEN

Pharmacology and actions

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

Indications

A.      Suspected hypoxemia or respiratory distress from any cause
B.      Acute chest or abdominal pain
C.      Hypotensive states from any cause
D.      Trauma
E.      All acutely ill patients
F.      Any suspected carbon monoxide poisoning
G.      Pregnant females

Precautions

A.      If the patient is not breathing adequately, the treatment of choice is ventilation not just oxygen.
B.      A small percentage of patients with chronic lung disease breathe because they are hypoxic. Administration of
        oxygen will inhibit their respiratory drive. Do not withhold oxygen because of this possibility. Be prepared
        to assist ventilations if needed.
C.      When pulse oximeter is available, titrate SaO2 to 90% or greater.
D.      In the COPD patient: increase oxygen in increments of 2 liters/minute every 2-3 minutes until improvement is
        noted (color improvement or increase in mental status).

Administration

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

Side effects and special notes

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

(continued on next page)




                                                       IX-120
Denver Metro Paramedic Protocols



                                                 OXYGEN FLOW RATE

             METHOD                           FLOW RATE                     OXYGEN INSPIRED AIR
                                                                                (approximate)

 Room Air                                                             21%


 Nasal Cannula                         1 L/min                        24%
                                       2 L/min                        28%
                                       6 L/min                        44%
 Simple Face Mask                      8 - 10 L/min                   40-60%
 Non-rebreather Mask                   10 L/min                       90%
 Mouth to Mask                         10 L/min                       80%
                                       15 L/min                       50%
 Bag/Valve/Mask (BVM)                  Room Air                       21%
                                       12 L/min                       40%
 Bag/Valve/Mask with Reservoir         10-15 L/min                    90-100%
 O2 -powered breathing device          hand-regulated                 100%
 NOTE:
 Most hypoxic patients will feel more comfortable with an increase of inspired oxygen from 21% to 24%.




                                                       IX-121
Denver Metro Paramedic Protocols

Drug Protocol
                                         PHENYLEPHRINE (INTRANASAL)

Pharmacology and actions

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

Indications

Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa.

Precautions

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

Administration

Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation.




                                                         IX-122
Denver Metro Paramedic Protocols

Drug Protocol
                                 RACEMIC EPINEPHRINE (VAPONEPHRINE)

Pharmacology and actions

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

Indications

A.      Life-threatening airway obstruction suspected secondary to croup or epiglottitis

Precautions

A.      Mask and noise may be frightening to small children. Agitation will aggravate symptoms of respiratory ob-
        struction. Try to enlist the support of parents for administration.
B.      Try to differentiate croup from epiglottitis by history. Cough is usually present in croup. Do not use a tongue
        blade to examine the back of the throat. The diagnosis is frequently difficult in the field, but a critical patient
        deserves a trial of racemic epinephrine during transport. Although used as specific therapy for croup, it may
        also buy some time in patients with epiglottitis.
C.      In the less-than-critical patient, saline alone via nebulizer may bring symptomatic relief from croup.
D.      Racemic epinephrine is heat and light sensitive. It should be stored in a dark, cool place. Discoloration is an
        indication for discarding it.
E.      Tachycardia and agitation are the most common side effects. Since these are also the hallmarks of hypoxia,
        watch the patient very closely! Other side effects of parenteral epinephrine may also be seen.
F.      Nebulizer treatment may cause blanching of the skin in the mask area due to local epinephrine absorption.
        Reassure parents.
G.      Clinical improvement in croup can be dramatic after administration of racemic epinephrine, and presentation
        in the ED may be markedly altered. Rebound worsening of airway obstruction can occur in 1-4 hours. For
        this reason some physicians may admit patients who have been given racemic epinephrine.
H.      If respiratory arrest occurs, it is usually due to patient fatigue or laryngeal spasm. Complete obstruction is not
        usually present. Ventilate the patient, administer O2, and transport rapidly. If you can ventilate and oxygenate
        the patient adequately with mouth-to-mask, pocket mask, or BVM, intubation is best left to a specialist in a
        controlled setting.

Administration

A.      0.5 ml racemic epinephrine (acceptable dose for all ages) + 2 ml saline, via nebulizer driven by O2 (6-8 lpm) to
        create fine mist
B.      In the absence of racemic epinephrine, plain L-epinephrine can be used:
        Place 5 mg (5.0 ml of 1:1000 solution) of L-epinephrine, undiluted into the nebulizer, driven by O2 (6-8 lpm)
        to create a fine mist. In small infants (< 10 kg) the recommended dose is 0.5 ml/kg of 1:1000 L-epinephrine.
C.      When possible, administer enroute to hospital.




                                                        IX-123
Denver Metro Paramedic Protocols

Drug Protocol
                                             SODIUM BICARBONATE

Pharmacology and actions

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

Indications

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

Precautions

A.      Addition of too much sodium bicarbonate may result in alkalosis. Alkalosis is very difficult to reverse and can
        cause as many problems in resuscitation as acidosis.
B.      Should not be given with catecholamines or calcium
C.      May increase cerebral acidosis

Administration

A.      Contact base for direct physician order for tricyclic overdose.
B.      Solutions:
        1.      Adult / Pediatric: 8.4% = 1.0 mEq/ml
        2.      Neonatal: 4.2% = 0.5 mEq/ml
                (Either prepackaged or adult solution diluted 1:1 with sterile NS or water)
C.      For cardiac arrest / Tricyclic Overdose:
        1.      Adult: 1 mEq/kg (1 ml/kg)
        2.      Pediatric: 1 mEq/kg (1 ml/kg)
        3.      Neonatal: 1 mEq/kg (2 ml/kg)

Side effects and special notes

A.      Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a paradoxical
        intracellular acidosis.
B.      Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This increases intravascular volume,
        which increases the workload of the heart.
C.      Hyperosmolality of the blood can occur, resulting in cerebral impairment.
D.      Sodium bicarbonate's lack of proven efficacy and its numerous adverse effects have lead to the reconsideration
        of its role in cardiac resuscitation. Effective ventilation and circulation of blood during CPR are the most
        effective treatments for acidemia associated with cardiac arrest.
E.      Administration of sodium bicarbonate has not been proven to facilitate ventricular defibrillation or to increase
        survival in cardiac arrest. Metabolic acidosis lowers the threshold for the induction of ventricular fibrillation,
        but has no effect on defibrillation threshold.
F.      The inhibition effect of metabolic acidosis on the actions of catecholamines has not been demonstrated at the
        pH levels encountered during cardiac arrest.
G.      Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field treatment is rarely indicated.
H.      Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest due to suspected hyperkalemia.




                                                       IX-124
Denver Metro Paramedic Protocols

Drug Protocol
                                    TOPICAL OPHTHALMIC ANESTHETICS

Pharmacology and actions

A.      Topical, local ophthalmic anesthetics have a rapid (20-30 seconds) onset of action and a 15-30 minute
        duration.

Indications

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

Precautions

A.      Use of topical ophthalmic anesthetics is contraindicated in patients with global laceration/rupture injuries.
B.      Do not apply until patient consents to transport to an emergency department for definitive therapy since
        application may totally relieve pain and, therefore, instigate an inappropriate refusal.
C.      Contraindicated in patients with any known allergy to local anesthetics.
D.      Topical ophthalmic anesthetics should never be given to a patient for self-administration.
E.      The patient may further damage the eye secondary to anesthesia of the cornea.
F.      Occasional burning/stinging can occur when initially applied, although this is usually transient.
G.      Only use a fresh, unopened bottle for each patient. If discolored, do not use (discard immediately as this
        implies contamination).
H.      Do not touch the tip of the bottle on anything as this will contaminate the medication.

Administration

A.      Only the following agents are approved: proparacaine or tetracaine.
B.      Place 2 drops in the affected eye(s).
C.      Indications for repeat administration (such as delayed transport, loss of therapeutic effect, etc.) shall be
        determined via consultation with base physician. Any repeat application requires base physician
        approval.

Side effects and special notes

A.      Do not administer until patient consents to transport to an emergency department for definitive therapy.
B.      Each bottle is for single patient use only.




                                                        IX-125
Denver Metro Paramedic Protocols


                                             SECTION VII

                                      PROCEDURE PROTOCOLS


TABLE OF CONTENTS
                                                                         Page Number
VII    Procedure Protocols

               Airway Management: General Principles                              VII-2
               Airway Management: Opening the Airway                           VII-3, 4
               Airway Management: Obstructed Airway                               VII-5
               Airway Management: Clearing and Suctioning the Airway           VII-6, 7
               Airway Management: Assisting Ventilation                           VII-8
               Airway Management: Capnography                                     VII-9
               Advanced Airway Management: Orotracheal Intubation           VII-10, 11
               Advanced Airway Management: Nasotracheal Intubation              VII-12
               Advanced Airway Management: Percutaneous Cricothyrotomy          VII-13
               Bandaging                                                        VII-14
               Cardioversion Algorithm                                          VII-15
               Defibrillation                                               VII-16, 17
               Field Drawn Blood Samples                                        VII-18
               Medication Administration (Parenteral)                       VII-19, 20
               PASG (Formerly MAST)                                             VII-21
               Restraints                                                   VII-22, 23
               Splinting: Axial                                             VII-24, 25
               Splinting: Extremity                                         VII-26, 27
               Tension Pneumothorax Decompression                           VII-28, 29
               Transcutaneous Cardiac Pacing                                    VII-30
               Transport of the Handcuffed Patient                              VII-31
               Vascular Access Devices                                      VII-32, 33
               Venous Access Technique                                   VII-34, 35, 36




                                               IX-126
Denver Metro Paramedic Protocols

Procedure Protocol
                              AIRWAY MANAGEMENT GENERAL PRINCIPLES

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

Medical Respiratory Arrest

1.      Open airway using head tilt-chin lift or head tilt-neck lift.
2.      Apply pocket mask (or BVM) with supplemental oxygen to ventilate.
3.      Insert nasopharyngeal airway or oropharyngeal airway if patency is difficult to maintain.
4.      Suction as needed.
5.      Perform orotracheal intubation prior to transport if arrest continues.
6.      Conduct appropriate tube position verification.

Medical Respiratory Insufficiency

1.      Open the airway using most efficient method.
2.      Insert nasopharyngeal airway.
3.      Suction as needed.
4.      Apply supplemental O2 by nasal cannula or mask as needed.
5.      Assist respirations by pocket mask (or BVM) as needed.
6.      Perform nasotracheal or orotracheal intubation if prolonged support is needed, or if airway requires continued
        protection from aspiration.
7.      Conduct appropriate tube position verification.

Traumatic Respiratory Arrest

1.      Open airway using jaw thrust maneuver, protecting neck.
2.      Clear the airway using finger sweep; suction as needed.
3.      Have assistant stabilize head and neck.
4.      Draw tongue and mandible forward if needed in patients with facial injuries.
5.      Use pocket mask (or BVM) for initial control of ventilation.
6.      Perform orotracheal intubation with in-line immobilization of neck. Pressure over larynx may make intubation
        easier.
7.      If intubation cannot be performed due to severe facial injury, and patient cannot be ventilated with mask,
        perform percutaneous cricothyrotomy. Percutaneous cricothyrotomy is a difficult and hazardous technique
        that is to be used only in extraordinary circumstances.

Traumatic Respiratory Insufficiency

1.      Open airway using jaw thrust maneuver, protecting neck.
2.      Clear the airway using finger sweep; suction as needed.
3.      Have assistant provide continuous stabilization to head and neck.
4.      Use hand to draw tongue and mandible forward if needed with facial injuries.
5.      Administer high flow O2; support with mask ventilations.
6.      Attempt nasotracheal intubation to secure airway, if needed, and if no significant midface trauma.
7.      If patient deteriorates, and cannot be supported by less invasive means:

        a.      Attempt orotracheal intubation with neck stabilized.
        b.      If intubation cannot be performed due to severe facial injury, and patient cannot be ventilated with
                mask, perform cricothyrotomy. Cricothyrotomy is a difficult and hazardous technique that is to be
                used only in extraordinary circumstances.

                                                      IX-127
Denver Metro Paramedic Protocols

Procedure Protocol                             AIRWAY MANAGEMENT

                                             OPENING THE AIRWAY

Indications

A.      Inadequate air exchange in the lungs due to jaw or facial fracture, causing narrowing of air passage
B.      Lax jaw or tongue muscles causing airway narrowing in the unconscious patient
C.      Noisy breathing or excessive respiratory effort that could be due to partial obstruction
D.      In preparation for suctioning, assisted ventilation or other airway management maneuvers

Precautions

A.      For trauma victims, keep neck in midline and avoid flexion, extension, traction or rotation.
B.      For medical patients, neck extension may be difficult in elderly persons with extensive arthritis and little neck
        motion. Do not use force; jaw thrust or chin-lift without head tilt will be more successful.
C.      All airway maneuvers should be followed by an evaluation of their success; if breathing is still labored, a
        different method or more time for recovery may be needed.
D.      Children's airways have less supporting cartilage; overextension can kink the airway and increase the
        obstruction. Watch chest movement to determine the best head angle.
E.      Dentures should usually be left in place since, they provide a framework for the lips and cheeks and allow
        more effective mouth-to-mask or bag-valve-mask ventilation.

Technique

A.      Use BSI. To open the airway initially, choose method most suitable for patient.
B.      Assess ventilations.
C.      Begin BVM ventilation if patient is not breathing.
D.      Relieve partial or complete obstruction, if present.
E.      Assess oxygenation; use supplemental O2 as needed.
F.      Choose method to maintain airway patency during transport:
        1.      Consider positioning the patient on side (if medical problem).
        2.      Oropharyngeal airway:
                a.        Choose size by measuring from mouth to ear margin.
                b.        Depress tongue with tongue blade, or insert gently with curve pointing UPWARD. Avoid
                          snagging posterior tongue or palate.
                c.        Insert to back of tongue, then turn to follow curve of airway. Move gently to be sure the tip
                          is free in back of pharynx.
                d.        In pediatric patients, depress tongue and insert airway with curve down to avoid injury to
                          palate and pushing tongue posterior.

        3.       Nasopharyngeal airway:
                 a.       Lubricate tube (viscous lidocaine or K-Y Jelly).
                 b.       Insert in right or largest nostril, along floor of nose until flange is seated at nostril. Keep
                          curve in line with normal airway curve. If you meet resistance, try the left side.
G.      Listen to breathing to be sure maneuver has resolved problem.
H.      Consider intubation to provide adequate airway.
I.      Resume ventilatory assistance and oxygenation as appropriate.
J.      Consider cricothyrotomy only after conservative measures have failed to intubate or ventilate adequately with
        bag-valve mask. Cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary
        circumstances.

(continued on next page)



                                                       IX-128
Denver Metro Paramedic Protocols

Complications

A.      Cervical spinal cord injury from neck hyperextension in trauma victim with cervical fracture
B.      Death due to inadequate ventilation or hypoxia
C.      Nasal or posterior pharyngeal bleeding due to trauma from tubes
D.      Increased airway obstruction from tongue following improper oropharyngeal airway placement
E.      Aspiration of blood or vomitus from inadequate suctioning and continued contamination of lungs from upper
        airway

Side effects and special notes

A.      Researchers have found that the head tilt-chin lift is successful at least as often as the head tilt-neck lift, and
        that it may even be more reliable and less fatiguing. Unfortunately, it cannot be simulated on manikins, but
        with use it is easy to get comfortable with this excellent technique.
B.      During transport, medical patients can be placed in a stable position on their sides for effective airway
        control. Use a flexed leg, arms, or pillows for support.
C.      Nasopharyngeal airways are very useful for airway maintenance, and are underused in most regions. The
        nasal insertion provides more stability, the airway is better tolerated in partially awake patients, and it does not
        carry the risk of blocking the airway further like the stiff oropharyngeal airway.


                              METHODS OF OPENING THE AIRWAY


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


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




                                                        IX-129
Denver Metro Paramedic Protocols

Procedure Protocol                            AIRWAY MANAGEMENT

                                             OBSTRUCTED AIRWAY

Indications

A.      Complete or partial obstruction of the airway due to a foreign body
B.      Complete or partial obstruction due to airway swelling from anaphylaxis, croup, or epiglottitis
C.      Patient with unknown illness or injury who cannot be ventilated after procedures of previous protocol:
        Opening the Airway.

Precautions

A.      Perform chest thrusts only in visibly pregnant patients, obese patients, and in infants.
B.      Patients with partial airway obstruction can be very uncomfortable and vociferous. Abdominal or chest thrusts
        will not be effective and may be injurious to the patient who is still ventilating. Resist the temptation to
        attempt relief of obstruction if it is not complete, but be ready to intervene promptly if arrest occurs.
C.      Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts may not be effective until the
        patient becomes relaxed after the seizure is over.

Technique

COMPLETE AIRWAY OBSTRUCTION:
A.   Open airway using head tilt-chin lift or jaw thrust.
B.   Attempt to ventilate using mouth-to-mask or BVM ventilations.
C.   If unable to ventilate, reposition airway and reattempt ventilations.
D.   If airway remains obstructed, visualize with laryngoscope and remove any obvious foreign body.
E.   Reposition the airway and attempt to ventilate.
F.   If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts.
G.   Reposition the airway and reattempt to ventilate.
H.   Consider percutaneous cricothyrotomy if obstruction above the cords unrelieved or unusable to ventilate
     adequately with bag-valve. Percutaneous cricothyrotomy is a difficult and hazardous technique that is to be
     used only in extraordinary circumstances.
I.   When obstruction relieved:
     1.       Keep patient on side, sweeping airway to remove debris.
     2.       Apply O2, high flow; reservoir mask.
     3.       Assess adequacy of ventilation, and support as needed.
     4.       Suction aggressively.
     5.       Restrain if combative.

PARTIAL AIRWAY OBSTRUCTION:
A.    Have patient assume most comfortable position.
B.    Apply O2, high flow by non-rebreather mask.
C.    Attempt suctioning of upper airway.
D.    If patient unable to move air, confused, or otherwise deteriorating, visualize airway, remove foreign body or
      perform abdominal thrusts as noted above.

Complications

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




                                                      IX-130
Denver Metro Paramedic Protocols

Procedure Protocol                           AIRWAY MANAGEMENT

                                CLEARING AND SUCTIONING THE AIRWAY

Indications

A.      To remove foreign material that can be removed by a suction device
B.      To remove excess secretions or pulmonary edema fluid in upper airway or lungs (with endotracheal tube in
        place)
C.      To remove meconium or amniotic fluid in mouth, nose and oropharynx of newborn

Technique

A.      Use BSI.
B.      Turn patient on side if possible, to facilitate clearance.
C.      Open airway and inspect for visible foreign material.
D.      Remove large or obvious foreign matter with gloved hands. Use padded tongue blade or oropharyngeal
        airway (do not pry) to keep airway open. Sweep finger across posterior pharynx and clear material out of
        mouth.
E.      Attach suction machine and test motor.
F.      Suction of oropharynx:
        1.      Attach tonsil tip (or use open end for large amounts of debris).
        2.      Ventilate and oxygenate the patient as needed prior to the procedure.
        3.      Insert tip into oropharynx under direct vision, with sweeping motion.
        4.      Continue intermittent suction interspersed with active oxygenation by mask or cannula. Use positive
                pressure ventilation if needed.
        5.      If suction becomes clogged, dilute by suctioning water from a glass to clean tubing. If suction clogs
                repeatedly, use connecting tubing alone, or manually remove large debris.

G.      Catheter suction of endotracheal tube:
        1.     Attach suction catheter to tubing of suction device (leaving suction end in sterile container).
        2.     Hyperventilate patient 4-5 times rapidly.
        3.     Put on sterile gloves.
        4.     Detach bag from endotracheal tube and insert sterile tip of suction catheter without suction.
        5.     When catheter tip has been gently advanced as far as possible, apply suction and withdraw catheter
               slowly.
        6.     Rinse catheter tip in sterile water or saline.
        7.     Hyperventilate patient before each suction attempt.

H.      Suction of the newborn:
        1.      Use neonatal suctioning device.
        2.      As soon as infant's head has delivered, insert suction tip into the mouth and back to oropharynx.
        3.      Apply suction while slowly withdrawing catheter from the mouth.
        4.      Insert catheter tip into each nostril and back to posterior pharynx.
        5.      Apply suction while slowly withdrawing catheter from each nostril.
        6.      As soon as infant has delivered, repeat process. Suction trachea under direct vision with laryngoscope
                if there is evidence of meconium aspiration.

(continued on next page)




                                                      IX-131
Denver Metro Paramedic Protocols

Complications

A.      Hypoxia due to excessive suctioning time without adequate ventilation between attempts
B.      Persistent obstruction due to inadequate tubing size for removal of debris
C.      Lung injury from aspiration of stomach contents due to inadequate suctioning
D.      Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning
E.      Conversion of partial to complete obstruction by attempts at airway clearance
F.      Trauma to the posterior pharynx from forced use of equipment
G.      Vomiting and aspiration from stimulation of gag reflex
H.      Induction of cardiorespiratory arrest from vagal stimulation

Side effects and special notes

A.      Complications may be caused both by inadequate and overly vigorous suctioning. Technique and choice of
        equipment are very important. Choose equipment with enough power to suction large amounts rapidly to
        allow time for ventilation.
B.      Proper airway clearance can make the difference between a patient who survives and one who dies.
        Airway obstruction is one of the most common treatable causes of prehospital death.




                                                      IX-132
Denver Metro Paramedic Protocols

Procedure Protocol                           AIRWAY MANAGEMENT

                                           ASSISTING VENTILATION

Indications

A.     Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory depression
B.     To apply positive pressure breathing in patients with pulmonary edema and severe fatigue
C.     To ventilate patients in respiratory arrest
D.     For use in conjunction with ET tube or BVM to ventilate

Precautions

A.     Two people are often required to obtain an adequate mask fit and also ventilate.
B.     Assisted ventilation will not hurt a patient, and should be used whenever the breathing pattern seems shallow,
       slow, or otherwise abnormal. Do not be afraid to be aggressive about assisting ventilation, even in patients
       who do not require or will not tolerate intubation.
C.     Early intubation may be of benefit for patients who continue to bleed or vomit.

Technique

A.     Use BSI.
B.     Open the airway. Check for ventilation.
C.     If patient is not breathing, perform 2 full breaths using BVM and check pulse. Begin CPR as needed.
D.     If pulse is present, but patient is not breathing, continue assisted ventilation until adjuncts are available.
E.     Attach O2 to BVM.
F.     Position yourself above patient's head, continue to hold airway position, seat mask firmly on face, and begin
       assisted ventilation.
G.     Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as needed.
H.     If patient resumes spontaneous respirations, continue to administer supplemental oxygen. Intermittent
       assistance with ventilation may still be needed.
I.     Continuous SaO2 monitoring is required.

Complications

A.     Continued aspiration of blood, vomitus, and other upper airway debris
B.     Inadequate ventilations due to poor seal between patient's mouth and ventilatory device
C.     Gastric distention, possibly causing vomiting
D.     Trauma to the upper airway from forcible use of airways
E.     Pneumothorax




                                                      IX-133
Denver Metro Paramedic Protocols

Procedure Protocol                           AIRWAY MANAGEMENT

                                                CAPNOGRAPHY

Indications

A.     All intubated patients require either a colorimetric end-tidal CO2 detector or a continuous end-tidal CO2
       monitoring device.
B.     Colorimetric end-tidal CO2 detectors are to be used to assess proper placement of an endotracheal tube.
C.     Continuous end-tidal CO2 monitors if available, are to be used to monitor patients requiring a mechanical
       ventilator during transportation. The monitor is used to determine if an endotracheal tube has become
       displaced or to detect the disruption of the ventilator circuit.

Precautions

A.     Caution should be exercised to ensure that the clinical picture matches the colorimetric end-tidal CO2 detector
       reading.

Technique – Colorimetric End-tidal CO2 Detectors

A.     The colorimetric end-tidal CO2 detector should be placed in-line between the endotracheal tube and the BVM
       immediately after the endotracheal tube is passed.
B.     Proper tube placement is confirmed by a color change in the colorimetric device, indicating the elevated
       concentrations of CO2 expected in the trachea. Elevated concentrations of CO2 are not expected in the
       esophagus.

Complications

A.     Contamination with blood and secretions may render colorimetric end-tidal CO2 detectors ineffective.
B.     Device may be ineffective or inaccurate in patients without spontaneous circulation.

Note

A.     Adhere to the expiration dates on these devices.




                                                     IX-134
Denver Metro Paramedic Protocols

Procedure Protocol                         ADVANCED AIRWAY MANAGEMENT

                                          OROTRACHEAL INTUBATION

Indications

In most cases orotracheal intubation provides definitive control of the airway. Its purposes include:

A.      Actively ventilating the patient
B.      Delivering high concentrations of oxygen
C.      Suctioning secretions and maintaining airway patency
D.      Preventing aspiration of gastric contents, upper airway secretions, or bleeding
E.      Preventing gastric distention due to assisted ventilation
F.      Administering positive pressure when extra fluid is present in alveoli
G.      Administering drugs during resuscitation for absorption through the lungs
H.      Allowing more effective CPR

Precautions

A.      Do not use intubation as the initial method of managing the airway in an arrest. Oxygenation prior to
        intubation should be accomplished with pocket mask or BVM as needed.
B.      Appropriate intubation precautions should be taken in the trauma patient. Nasotracheal intubation is preferred
        in the breathing patient. Oral intubation with in-line cervical immobilization is the best alternative for a
        trauma patient requiring definitive airway control.
C.      Never lever the laryngoscope against the teeth. The jaw should be lifted with direct upward traction by the
        laryngoscope.
D.      Prepare suction beforehand. Vomiting is particularly common when the esophagus is intubated.
E.      Intubation should take no more than 15-20 sec to complete: do not lose track of time. If visualization is
        difficult, stop and re-ventilate before trying again.
F.      Orotracheal intubation can be accomplished in trauma victims if an assistant maintains stabilization and keeps
        the neck in neutral position. Careful visualization with the laryngoscope is needed, and McGill forceps may
        be helpful in guiding the ET tube.


Technique

A.      Use BSI including gloves, mask, eye protection. Assemble the equipment while continuing ventilation:
        1.     Choose tube size (see table on next page). Use as large a tube as possible.
        2.     Introduce the stylette and be sure it stops ½ ” short of the tube’s end
        3.     Assemble laryngoscope and check light.
        4.     Connect and check suction.

B.      Position patient: neck flexed forward, head extended back. Back of head should be level with or higher than
        back of shoulders.
C.      Give a minimum of 4 good ventilations before starting procedure.
D.      Have an assistant apply gentle cricothyroid pressure to prevent aspiration and to assist in visualization of vocal
        cords.

(continued on next page)




                                                       IX-135
Denver Metro Paramedic Protocols

E.     Gently insert laryngoscope to right of midline. Move it to midline, pushing tongue to left and out of view.
F.     Lift straight up on blade (no levering) to expose posterior pharynx.
G.     Identify epiglottis: tip of curved blade should sit in vallecula (in front of epiglottis); straight blade should slip
       over epiglottis.
H.     With gentle further traction to straighten the airway, identify trachea from arytenoid cartilages and vocal
       cords.
I.     Insert tube from right side of mouth, along blade into trachea under direct vision.
J.     Advance tube so cuff is 1-1.5" beyond cords. Inflate cuff with 5-10 ml of air, clamp if necessary to secure
       against leaks. Positioning the ET tube so that the 19 cm mark (females) or 21 cm mark (males) is at the teeth
       will help to avoid endobronchial intubation.
K.     Ventilate and watch for chest rise. Listen for breath sounds over stomach (should not be heard) and lungs and
       axillae.
L.     Note proper tube position and secure tube with tape or ties.
M.     Re-auscultate over stomach and both sides of chest whenever patient is moved.
N.     Tube placement should also be evaluated by other devices such as an end-tidal CO2 detector.
O.     Accurate documentation includes indications for intubation as well as measures taken for tube verification.

Complications

A.     Esophageal intubation: particularly common when tube not visualized as it passes through cords. The greatest
       danger is in not recognizing the error. Auscultation over stomach during trial ventilations should reveal air
       gurgling through gastric contents with esophageal placement. Also make sure patient's color improves as it
       should when ventilating.
B.     Intubation of right mainstem bronchus: be sure to listen to chest bilaterally.
C.     Upper airway trauma due to excess force with laryngoscope or to traumatic tube placement
D.     Vomiting and aspiration during traumatic intubation or intubation of patient with intact gag reflex
E.     Hypoxia due to prolonged intubation attempt
F.     Cervical spine fracture in patients with arthritis and poor cervical mobility
G.     Cervical cord damage in trauma victims with unrecognized spine injury
H.     Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of airway
I.     Induction of pneumothorax, either from traumatic insertion, forceful bagging, or aggravation of underlying
       pneumothorax



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


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




                                                        IX-136
Denver Metro Paramedic Protocols

Procedure Protocol                     ADVANCED AIRWAY MANAGEMENT

                                         NASOTRACHEAL INTUBATION

Indications

A.      Same function as orotracheal intubation in patients greater than 12 years of age
B.      Used in the breathing patient requiring intubation
C.      Asthma or pulmonary edema with respiratory failure, where intubation may need to be achieved in a sitting
        position

Precautions

A.      Head must be exactly in midline for successful intubation.
B.      Have suction ready. Vomiting can occur, as with any stimulation of the airway.
C.      Often nares are asymmetrical and one side is much easier to intubate. Avoid inducing bilateral nasal
        hemorrhage by forcing a nasotracheal tube on multiple attempts.
D.      The use of nasotracheal intubation should be discouraged in patients with significant nasal or craniofacial
        trauma.
E.      Blind nasotracheal intubation is a very gentle technique. In the field, the secret of blind intubation is perfect
        positioning and patience.
F.      Only absolute contraindication is apnea
G.      Should not be attempted in children under 12 years of age

Technique

A.      Choose correct ET tube size (usually 7 mm tube in adult). Limitation is nasal canal diameter.
B.      Position patient with head in midline, neutral position (cervical collar may be in place, or assistant may
        provide cervical stabilization in trauma patients).
C.      Administer phenylephrine nasal drops in both nostrils.
D.      Assist ventilations prior to procedure if spontaneous respirations are inadequate.
E.      Lubricate ET tube with Xylocaine jelly or other water-soluble lubricant.
F.      With gentle steady pressure, advance the tube through the nose to the posterior pharynx. Use right or largest
        nostril. Abandon procedure if significant resistance is encountered.
G.      Keeping the curve of the tube exactly in midline, continue advancing slowly.
H.      There will be a slight resistance just before entering trachea. Wait for an inspiratory effort before final
        advance into trachea. Patient may also cough or buck just before breath.
I.      Continue advancing until air is exchanging through the tube.
J.      Advance about 1 inch further, then inflate cuff.
K.      Ventilate and auscultate chest and abdomen for proper tube placement.
L.      Note proper tube position and tape securely.

Complications

Same as orotracheal intubation. In addition:

A.      Further craniofacial injury particularly in patients presenting with facial trauma
B.      Nasal bleeding caused by tube trauma
C.      Vomiting and aspiration in the patient with intact gag reflex




                                                        IX-137
Denver Metro Paramedic Protocols

Procedure Protocol
                                    ADVANCED AIRWAY MANAGEMENT

                                    PERCUTANEOUS CRICOTHYROTOMY

Introduction

Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in extraordinary
circumstances as defined below. The reason for performing this procedure must be documented and submitted for
review to the physician advisor or designee within 24 hours. Percutaneous cricothyrotomy is to be performed only by
paramedics trained in the procedure.

Indications

A.      When a life threatening condition exists and advanced airway management is indicated, and you are unable to
        establish airway by other means.

Precautions

A.      Bleeding is possible, even with correct technique. Straying from the midline is very dangerous and likely to
        cause hemorrhage from the carotid or jugular vessels, or their branches.

Technique

A.      Using aseptic technique (Betadine/alcohol wipes) cleanse the area.
B.      Position the patient in a supine position, with in-line spinal immobilization if indicated.
C.      At this time the scalpel included with the kit may be used to make a ¼ inch vertical incision through the skin,
        over the cricothyroid membrane.
D.      Using the prepackaged set, insert the needle or over-the-needle-catheter through the cricothyroid membrane in
        a caudal direction at a 45-degree angle.
E.      If using an over-the-needle-catheter, remove the syringe and needle. Otherwise remove the syringe.
F.      Insert the guidewire through the catheter or needle.
G.      Remove the catheter or needle over the wire.
H.      Slide the dilator and tracheostomy tube onto the wire into the neck incision.
I.      Push the dilator through the cricothyroid membrane with a twisting motion, and insert the tracheostomy tube
        into the trachea.
J.      Remove the dilator and wire, leaving the tracheostomy tube in place.
K.      Ventilate with BVM and 100% oxygen.
L.      Confirm tube placement is successful. (Chest rise and fall, breath sounds, secondary confirmation device).
        Observe for subcutaneous air, indicating tracheal injury or improper placement.
M.      Secure tube with ties.
N.      Transport to appropriate facility.




                                                      IX-138
Denver Metro Paramedic Protocols

                                                   BANDAGING

Indications

A.     To stop external bleeding by application of direct and continuous pressure to wound site
B.     To protect patient from contamination to lacerations, abrasions, burns

Precautions

A.     Although external skin wounds may be dramatic, they are rarely a high management priority in the trauma
       victim.
B.     Do not use circumferential dressings around neck. Continued swelling may block airway.

Technique

A.     Use BSI.
B.     Control hemorrhage with direct pressure, using sterile dressing.
C.     Assess patient fully and treat all injuries by priority once assessment is complete.
D.     Remove gross dirt and contamination from wound: clothing (if easily removable), dirt, gasoline, acids, or
       alkalis. Use copious irrigating saline or tap water for chemical contamination.
E.     Evaluate wound for depth, presence of fracture in wound, foreign body, or evidence of injury to deep
       structures. Note distal motor, sensory, and circulatory function prior to applying dressings.
F.     Apply sterile dressing to wound surface. Touch outer side of dressing only.
G.     Wrap dressing with clean gauze or cloth bandages applied just tightly enough to hold dressing securely (if no
       splint applied).
H.     Assess wound for evidence of continued bleeding.
I.     Check distal pulses, color, capillary refill, and sensation after bandage applied.
J.     Continue to apply direct hand pressure over dressing, or use air splint if bleeding not controlled with bandage
       alone.
K.     For deep or gaping muscle wounds in which bleeding cannot be controlled with direct pressure, pack the
       wound with sterile gauze than reapply a sterile dressing with pressure.

Complications

A.     Loss of distal circulation from bandage applied too tightly around extremity; for this reason, do not use elastic
       bandages or apply bandages too tightly.
B.     Airway obstruction due to tight neck bandages
C.     Restriction of breathing from circumferential chest wound splinting
D.     Continued bleeding no longer visible under dressings. (This is particularly common with scalp wounds that
       continue to lose large amounts of unnoticed blood.)
E.     Inadequate hemostasis: some wounds require continuous direct manual pressure to stop bleeding.




                                                      IX-139
Denver Metro Paramedic Protocols

Procedure Protocol
                                         CARDIOVERSION ALGORITHM
                                           (Patient is not in cardiac arrest)


       Tachycardia
       With serious signs and symptoms related to the tachycardia
                        ↓

       If ventricular rate is > 150 beats/min., prepare for IMMEDIATE
       CARDIOVERSION. May give brief trial of medications based on
       specific arrhythmia algorithms. Immediate cardioversion is generally
       not needed for rates < 150 beats/min.
                          ↓
       Check
       •        Ensure adequate oxygenation
       •        Suction device
       •        IV line
       •        Intubation equipment
       •        Select a lead in which the amplitude of the R wave is higher than the T wave
                          ↓

       Premedicate with midazolam whenever possible
                      ↓

       Synchronized cardioversion
                 VT                                      Adult dose          Pediatric dose
                 PSVT                                    100j, 200j          0.5 j/kg, 1.0 j/kg
                 Atrial fibrillation                     300j, 360j          1.5 j/kg, 2.0 j/kg
                 Atrial flutter
Precautions

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




                                                        IX-140
Denver Metro Paramedic Protocols

Procedure Protocol
                                                 DEFIBRILLATION


Indications

A.      Ventricular fibrillation by monitor
B.      Wide complex tachycardia in pulseless patient

Precautions

A.      Do not treat the monitor strip alone. Treat the patient! A patient who is talking is not in ventricular
        fibrillation, whatever the monitor shows. Artifact can commonly simulate ventricular fibrillation.
B.      Dry the chest wall if wet. Do not drip saline or electrode jelly across the chest. This results in bridging, which
        conducts the current through the skin rather than through the heart.
C.      Nitroglycerin paste, which is commonly used by cardiac patients, is flammable, and may ignite if not wiped
        from the chest prior to paddle contact. Other transdermal patches should be removed.
D.      Defibrillation should be accompanied by visible muscle contraction by patient. If this does not occur, the
        paddles did not discharge; recheck equipment.
E.      Unsuccessful defibrillation is often due to hypoxia or acidosis. Careful attention to airway management and
        proper CPR is important.
F.      Protect rescuers - "Clear" the area!

Technique

A.      Determine unresponsiveness and pulselessness.
B.      Open airway, check for breathing, and initiate CPR.
C.      Maintain CPR with 1 or 2 rescuers.
D.      Second or third person should get monitor-defibrillator and turn it on.
E.      Use peds paddles if available, or use adapters.
F.      Place "quick look" paddles in appropriate position to determine rhythm. Obtain printout if possible.
G.      Stop CPR and evaluate rhythm (5-10 sec maximum). If ventricular fibrillation is present, continue with
        protocol. (Otherwise, See Section II - Cardiac Arrest Protocol).
H.      Resume CPR.
I.      Check that synchronizer switch is "off."
J.      Charge defibrillator with paddles in hand or patches placed on chest.
K.      Place one paddle or patch just to the right of the upper sternum and below the clavicle, and the other just to the
        left of the apex, or just to the left of the left nipple in the anterior axillary line. Use twist to distribute
        conductive gel evenly on chest wall.
L.      Recheck rhythm. "Clear" the area.
M.      Apply firm pressure (about 25 lb) to paddles; be careful not to lean and let paddles slip off.
N.      Press defibrillator buttons and defibrillate. Watch for muscle contraction. Leave paddles or patches in place to
        check rhythm.
O.      If ventricular fibrillation persists, recharge and reshock immediately at an increased energy level.
P.      If organized rhythm appears, check pulse.
Q.      If no pulse, repeat defibrillation to a maximum of 360 Joules.
R.      If no pulse, resume CPR and continue with Cardiac Arrest Protocol. (See Section II)

(continued on next page)




                                                       IX-141
Denver Metro Paramedic Protocols

Complications

A.      Rescuer defibrillation may occur if you forget to clear the area or lean against metal stretcher or patient during
        the procedure.

B.      Skin burns from inadequate contact between paddles and skin

Side effects and special notes

A.      Defibrillation is not the only step in treating fibrillation due to traumatic hypovolemia. CPR and fluid
        resuscitation should be started first.

B.      Defibrillation may not be successful in ventricular fibrillation due to hypothermia until the core temperature is
        above 88 degrees F. Attempt to defibrillate up to 3 times, but prolonged CPR during rewarming may be
        necessary before conversion is possible.

C.      Knowledge of your defibrillator is important! Delivered energy varies with different machines.

D.      Make sure your machine is maintained regularly. Testing with full discharge is recommended weekly. Low
        energy discharge is recommended daily when operating (a periodic full discharge can also improve battery
        performance). A chart listing actual delivered energy for usual energy levels should be attached to the
        machine.




                                                       IX-142
Denver Metro Paramedic Protocols

Procedure Protocol
                                        FIELD DRAWN BLOOD SAMPLES

Indications

A.      Patients receiving an IV in the field and who, in the judgment of the field providers, will need blood tests in
        the emergency department
B.      Patients receiving IV dextrose in the field
C.      Patients that may have been exposed to carbon monoxide


Precautions

A.      Use BSI.
B.      Proper identification of the patient and the specimen(s) is mandatory.
C.      Improper technique in obtaining the specimen will result in inaccurate or invalid test results. This wastes
        critical time and defeats the purpose of drawing specimens in the field.

Technique

A.      After initiating an IV and removing the needle, attach the Vacutainer holder to the hub of the IV catheter.
        (This is accomplished using the Luer adaptor attached to the Vacutainer holder.)
B.      Fill all the desired blood tubes in appropriate order per system requirements.
C.      Tubes containing anticoagulant should be inverted gently back and forth at least ten times to insure adequate
        mixing of blood with the substance in the tube. Do not shake the tube as this could cause hemolysis, which
        could interfere with test results.
D.      The tubes should be placed in a small biohazard bag. The bag should be labeled with the patient's name and
        time of draw, and taped to the patient's IV bag. The tubes may also be handed directly to the nurse attending
        the patient.

Side effects and special notes

A.      Any discrepancy in identification must be reported immediately to the emergency department charge nurse.

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

D.     Blood samples should be drawn prior to the administration of IV fluid, in order to provide a better and less
       dilute sample for potential “donor” patients.




                                                       IX-143
Denver Metro Paramedic Protocols

Procedure Protocol
                              MEDICATION ADMINISTRATION (PARENTERAL)

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

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

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

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

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

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

(continued on next page)



                                                        IX-144
Denver Metro Paramedic Protocols

Intravenous Injection Technique
A.       Use needle appropriate for viscosity of fluid injected. Glucose requires larger gauge needle; for most other
         medications, smaller is appropriate.
B.       Wipe IV tubing injection site with alcohol.
C.       Check medication in hand. Confirm medication, dose, amount, and expiration date.
D.       Eject air from syringe.
E.       Insert needle into injection site.
F.       Pinch IV tubing closed between bag and needle.
G.       Inject at a rate appropriate for medication.
H.       Withdraw needle and release tubing to restore flow.
I.       Record medication given, dose, amount, and time.
J.       Give 20 cc saline fluid flush after giving any drugs.
Nebulization Technique
A.       Use hand-held nebulizer with mouthpiece (or mask for patient unable to hold mouthpiece).
B.       Check medication in hand. Confirm medication, dose, amount, and expiration date.
C.       Draw up dose of medication in syringe or dropper; inject into nebulizer.
D.       Attach to O2 tubing and set at 6-8 L/min (sufficient to produce good vaporization).
E.       Administer for approximately 5 minutes, until solution is gone from chamber.
F.       Record medication given, dose, amount, and time.
Rectal Technique
A.       Technique One
         1.        Use a tuberculin syringe (without needle) lubricated with a water-soluble, lubricating jelly.
         2.        Check medication in hand. Confirm medication, dose, and expiration date.
         3.        Insert needleless syringe into rectum completely to end of syringe (4-5cm).
         4.        Inject the medication and withdraw the syringe. No flushing is necessary.
B.       Technique Two
         1.        Lubricate with a water-soluble lubricating jelly and insert a feeding tube 4-5 cm into the rectum.
         2.        Attach a syringe containing the appropriate dose of the medication to be given and instill.
         3.        Remove the syringe from the tube, draw up 1 cc of air, reattach the syringe to the tube, and instill the
                   air to clear the tube of medication. Then withdraw the feeding tube from the rectum.
Subcutaneous Injection Technique
A.       Use 25 g needle, 5/8" length for most subcutaneous injections.
B.       Check medication in hand. Confirm medication, dose, amount, and expiration date.
C.       Select injection site (usually just distal and posterior to deltoid).
D.       Cleanse site with alcohol or Betadine wipe.
E.       Eject air from syringe.
F.       Pinch skin. Insert needle at 45o angle.
G.       Aspirate, and if there is no blood return, inject medication.
H.       Remove needle and put pressure over injection site with sterile swab.
I.       Record medication given, dose, amount, and time.
Complications
A.       Local extravasation during IV medication injection, particularly with dopamine or dextrose, may cause tissue
         necrosis. Watch carefully and be ready to stop injection immediately.
B.       Allergic and anaphylactic reactions occur more rapidly with IV injections, but may occur with medication
         administered by any route.
C.       Too rapid IV injection can cause untoward side effects (except for adenosine); for example, diazepam can
         cause apnea, and epinephrine can cause asystole or severe hypertension.
D.       IM or SQ injection causes uncertain medication levels over time. Later treatment may be jeopardized because
         of slow release and late effects of medication given hours before.
Side effects and special notes
A.       Several medications are carried in different concentrations in an emergency medical kit. Be sure you are using
         the correct concentration!
B.       Endotracheal medication administration provides onset of drug effect almost as rapidly as with IV
         administration.




                                                        IX-145
Denver Metro Paramedic Protocols

Procedure Protocol
                      PNEUMATIC ANTI SHOCK GARMENT (PASG-formerly MAST)

Indications
A.      The Denver Metropolitan Physician Advisor Group does not recommend the use of this device in the field.




                                                    IX-146
Denver Metro Paramedic Protocols

Procedure Protocol
                                                     RESTRAINTS

Indications

Use of physical restraint on patients is permissible if the patient poses a danger to himself or to others. Only
reasonable force is allowable, i.e., the minimum amount of force necessary to control the patient and prevent harm to
the patient or others. Contact base for physician direction if there is uncertainty as to whether or not the use of
restraints is warranted to transport the unwilling or uncooperative patient.

Restraints are to be applied to patients only in limited circumstances:

A.      A patient whose medical or mental condition warrants immediate ambulance transport and who is exhibiting
        behavior that the prehospital provider feels may or will endanger the patient or others
B.      The prehospital provider reasonably believes the patient's life or health is in danger and that delay in treatment
        and transport would further endanger the patient's life or health, and there is no reasonable opportunity to
        obtain the necessary consent to provide treatment or obtain informed refusal.
C.      The patient is being transported under the direction of a mental health hold, security hold, or police custody.

Precautions

A.      Restraints shall be used only when necessary to prevent a patient from seriously injuring themselves or others
        (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done
        without restraints. They may not be used as punishment, or for the convenience of the crew.
B.      Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts to restrain a
        patient should only be done with adequate assistance present.
C.      Be sure to evaluate the patient adequately to determine the medical condition, mental status and decisional
        capacity of the patient. The hostile, angry, unwilling patient with decision-making capacity may refuse
        treatment.
D.      Be sure that restraints are in good condition (will not break and will not injure the patient).
E.      Do not use "hobble" restraints and do not restrain patient in the prone position.
F.      Ensure that patient has been searched for weapons.

Technique

A.      Determine that the patient's medical or mental condition warrants ambulance transport to the hospital and that
        the patient lacks decision-making capacity, or there is basis for police custody or a mental health hold to be
        instituted.
B.      Treat the patient with respect. Attempts to verbally calm the patient should be done prior to the use of
        restraints. To the extent possible, explain what is being done and why.
C.      Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints, and
        adequate number of personnel).
D.      Use assistance such that, if possible, one rescuer handles each limb and one manages the head or supervises
        the application of restraints.
E.      Consider the patient's strength and range of motion in the need for and method of applying restraints.
F.      Apply restraints to the extent necessary to subdue the patient. Do not use restraints to punish the patient.
G.      After application of restraints, check all limbs for circulation. During the time that a patient is in restraints, an
        assessment of the patient's condition including assessment of the patients airway, circulation and vital signs
        shall be made at least every fifteen minutes, but more frequently if conditions warrant.

(continued on next page)




                                                         IX-147
Denver Metro Paramedic Protocols

       H.       During transport and pending the arrival at the hospital, the patient shall be kept under constant
       supervision.
I.     The run report shall include: attempts at verbal persuasion to calm patient; description of the facts justifying
       use of restraints; the type of restraints; a description of the steps taken to assure that the patient's needs,
       comfort and safety were properly cared for; the condition of the patient during restraint, including
       reevaluations during transport; and the condition of the patient on arrival at the hospital.
J.     Removal of restraints should be done with sufficient manpower and caution for protection of the patient and
       healthcare providers.
K.     Utilize police assistance if necessary and if possible.
L.     Handcuffs or other "hard restraints" are not to be applied by prehospital providers. If police apply handcuffs,
       the officer should be requested to stay with the patient and ride in the ambulance during transport. (See
       Section VII - Transport of the Handcuffed Patient)
M.     The use of chemical restraints is limited to the use of IM haloperidol (see Section VI - Drug Protocols -
       Haloperidol). If used, cardiac monitoring and intravenous access should be performed as soon as possible.

Complications

A.     Aspiration can occur, particularly if the patient is supine. It is the responsibility of the attendant to continually
       monitor the patient's airway.
B.     Nerve injury can result from hard restraints.
C.     Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia, stroke, hyperthermia,
       hypothermia, or drug ingestion.
D.     Contraindications, precautions, and special considerations regarding the use of chemical restraints are found in
       the haloperidol protocol. (See Section VI – Drug Protocols – Haloperidol)




                                                       IX-148
Denver Metro Paramedic Protocols

Procedure Protocol
                                                 SPLINTING: AXIAL

Indications
A.      Pain, swelling, or deformity of spine which may be due to fracture, dislocation, or ligamentous instability
B.      Neurologic deficit that might be due to spine injury
C.      Prevention of neurologic deficit or further deficit in patients with suspected spine injury or instability
D.      In all trauma victims who are unconscious or with impaired consciousness due to head injury or drug
        ingestion, to protect against damage or further damage in patients where injury to the spine cannot be ruled out
        by accurate exam or history

Precautions
A.     All patients with significant head trauma should be immobilized because of the potential for unrecognized
       coexistent neck trauma.
B.     Perform and document complete neurologic exam prior to moving the patient. Reassess and document finding
       after splinting is completed and after each set of vital signs (i.e. - every 5 minutes for a critical patient and
       every 15 minutes for a non-emergent patient).

Cervical Splinting Technique
A.     Perform cervical splinting immediately following initial assessment (if indicated). If necessary, use assistant
       to maintain cervical stabilization while completing initial assessment.
B.     Use two people to apply splint if at all possible.
C.     Do not use excessive force to straighten. Gently restore normal alignment.
D.     Advise patient of procedure and purpose before and during application.
E.     Immobilize the cervical spine with a semi-rigid collar of appropriate size for age.
F.     Pad behind head in adults to maintain an anatomically neutral position.
G.     Use long/short spine board or orthopedic scoop to support patient as situation dictates.
H.     Use tape, straps, or both to secure patient effectively and allow turning as a unit for airway control.
I.     Continue to monitor airway and effectiveness of immobilization.
J.     Board with an appropriate size collar is preferred to KED in pediatric patients.

Spine Immobilization Technique
A.     Splint cervical spine concurrent with the initial assessment. Document neurologic findings.
B.     Complete detailed assessment and splint fractures prior to movement of patient when possible.
C.     Document neurologic findings.
D.     In a sitting patient, use short board or Kendrick Extrication Device (KED) may be beneficial for extrication:
       1.        Slide short board or KED behind patient.
       2.        Apply thigh straps snugly as close to groin as possible.
       3.        Apply shoulder or chest straps.
       4.        Use padding as needed to keep neck (in cervical collar) in a neutral position. For pediatrics, use
                 padding as needed to prevent misalignment.
       5.        Secure head to board.
E.     1.        Use long backboard or full body vacuum splint for supine patients.
       2.        For sitting patients, after short board or KED is applied:
                 a.        Logroll or lift patient as a unit to board. Apply continuous cervical stabilization during
                           movement. One person should protect neck in collar. Do not use force to straighten spine.
                 b.        Release leg straps if short board or KED was used.
                 c.        Use padding as needed behind knees to support a neutral axis under small of back, neck and
                           knees.
                 d.        Use towel rolls or commercially available cervical immobilization device and tape to secure
                           neck immobilization.
                 e.        Apply straps or tape to secure chest, thighs, and lower legs to allow turning as a unit in case
                           of vomiting or airway difficulty.
F.     Reassess patient status, particularly airway and neurologic findings frequently.

(continued on next page)



                                                        IX-149
Denver Metro Paramedic Protocols

Complications

A.      Vomiting is common in head/spine-injured patients. Your splinting must be good enough to allow turning of
        the patient for airway protection but must not impede breathing efforts.
B.      It is easy to miss injuries below the level of a neurological deficit. Look carefully for abdominal and chest
        injuries, pelvic fractures, and extremity injuries without symptoms. With loss of sensation below T-8, there
        will be no guarding, rebound pain, or tenderness to alert you to internal abdominal injuries.
C.      Pelvis fractures are difficult to diagnose in the field. Suspected pelvis injury can be immobilized by use of the
        long board during spine immobilization or by use of a full body vacuum splint.

Side effects and special notes

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




                                                       IX-150
Denver Metro Paramedic Protocols

Procedure Protocol
                                             SPLINTING: EXTREMITY

Indications
A.      Pain, tenderness, swelling, or deformity in extremity which may be due to fracture or dislocation
B.      In an unstable extremity injury: to reduce pain; limit bleeding at the site of injury; and prevent further injury
        to soft tissues, blood vessels or nerves

Precautions
A.     Critically injured trauma victims should not be delayed in transport by lengthy evaluation of possible
       noncritical extremity injuries. Prevention of further damage may be accomplished by securing the patient to a
       spine board when other injuries demand prompt hospital treatment.
B.     The patient with altered level of consciousness from head injury or drug/alcohol influences should be carefully
       examined and conservatively treated, because his ability to recognize pain and injury is impaired.
C.     Make sure the obvious injury is also the only one. It is particularly easy to miss fractures proximal to the most
       visible one.
D.     In a stable patient where no environmental hazard exists, splinting should be done prior to moving the patient.

Extremity Splinting Technique
A.     Check pulse and sensation distally prior to movement or splinting.
B.     Remove bracelets, watches, or other constricting bands prior to splint application.
C.     Identify and dress open wounds. Note wounds that contain exposed bone or are near fracture sites and may
       communicate with a fracture.
D.     To minimize pain and soft tissue damage, avoid sudden or unnecessary movement of fracture site.
E.     Choose splint to immobilize joint above and below injury. Pad rigid splints to prevent pressure injury to
       extremity.
F.     Apply gentle continuous traction to extremity and support to fracture site during splinting operation.
G.     Reduce angulated fractures (if no pulses), including open fractures, with gentle axial traction as needed to
       immobilize properly.
H.     Check distal pulses and sensation after reduction splinting. Realign gently if adequate circulation and
       sensation is lost.

Traction Splinting Technique (for suspected femur fractures):
A.     Use two persons for splint application procedure.
B.     Remove sock and shoe and check for distal pulse and sensation (unless you cannot protect exposed foot from
       weather; then just ask patient about sensation and observe movement).
C.     Identify and dress open wounds, and note exposed bone or wounds overlying fractures and potential
       communicating wounds.
D.     Measure splint length prior to application.
E.     Apply gentle axial traction with support to calf and fracture site, reducing angulation of open fractures as
       necessary for secure tractioning.
F.     Position ischial pad under buttocks, up against bony prominence (ischial tuberosity). Empty pockets if
       necessary for patient comfort and appropriate splinting.
G.     Secure groin strap carefully.
H.     Maintain continuous traction and support to fracture site throughout procedure.
I.     Adjust support straps to appropriate positions under leg.
J.     Apply ankle hitch and tighten traction until patient experiences improved comfort. (Movement at the fracture
       site will cause some pain, but if traction continues to cause increased pain, do not proceed. Splint and support
       leg in position of most comfort.)
K.     Secure support straps after traction properly adjusted.
L.     Recheck distal pulses and sensation.

(continued on next page)




                                                        IX-151
Denver Metro Paramedic Protocols

Complications

A.      Circulatory compromise from excessive constriction of limb
B.      Continued bleeding not visible under splint
C.      Pressure damage to skin and nerves from inadequate padding
D.      Delayed treatment of life-threatening injuries due to prolonged splinting procedures

Side effects and special notes

A.      Traction splints should only be used if the leg can be straightened easily and patient is comfortable with the
        traction device on. Particularly with injuries about the hip and knee, forced application of traction device can
        cause increased pain and damage. If this occurs, do not use traction device, but support in position of most
        comfort and best neurovascular status.
B.      When in doubt and the patient is stable, splint. Do not be deceived by absence of deformity or disability.
        Fractured limbs often retain some ability to function.
C.      Splinting body parts together can be a very effective way of immobilizing: arm-to-trunk or leg-to-leg.
        Padding will increase comfort. This method can be very useful in children when traction devices and pre-
        made splints do not fit.
D.     Administration of analgesics prior to splinting may be needed.




                                                       IX-152
Denver Metro Paramedic Protocols

Procedure Protocol
                               TENSION PNEUMOTHORAX DECOMPRESSION

Indications

A.      Tension pneumothorax is rare, but when present may rapidly lead to death and must be treated promptly.
B.      Nontension pneumothorax is relatively common, is not immediately life threatening, and should not be treated
        in the field.
C.      Treatment of tension pneumothorax is not difficult, although complications of the procedure can be severe, but
        diagnosis must be accurate and is not always easy.
D.      The following signs are significant. Signs of pneumothorax as well as signs of tension must be present before
        treatment is undertaken:

        1.      Simple Pneumothorax:
                a.      Respiratory distress - mild to severe
                b.      Chest pain
                c.      Decreased or absent breath sounds on affected side to auscultation of chest
                d.      Subcutaneous crepitation, and

        2.      Signs of Tension:
                a.      Progressive respiratory distress (severe)
                b.      Tympanitic percussion note on affected side
                c.      Hyperexpanded chest on affected side
                d.      Tracheal shift away from affected side
                e.      Distended neck veins
                f.      Shock - low BP
                g.      If patient is intubated, increasing difficulty in bagging

Precautions

A.      Accurate diagnosis is paramount. Note that simple pneumothorax has one set of signs and tension
        pneumothorax has an additional set of signs.
B.      Tension pneumothorax is a rare condition, but can occur both with trauma and spontaneously. It can also
        occur as a complication of CPR.

Technique

A.      Contact base.
B.      Decompress using one of the following techniques:

        1.      Needle:
                a.      Expose entire chest. Clean chest vigorously with alcohol, Betadine, or soap.
                b.      Insert an angiocath (14g or larger in adult; 18g in children) with syringe attached, in the 4th
                        or 5th intercostal space, midaxillary line (horizontal "nipple line" in children). Alternatively,
                        the angiocath may be inserted between the 2nd and 3rd intercostal space, midclavicular line.
                c.      Hit the rib, then slide above it.
                d.      If air is under tension, barrel will pull easily and "pop" out the back. Remove syringe,
                        advance catheter and remove needle.
                e.      Only one attempt to be done per side.

(continued on next page)




                                                       IX-153
Denver Metro Paramedic Protocols

Complications

A.      Complications include:
        1.     Creation of pneumothorax if none existed previously
        2.     Laceration of lung
        3.     Laceration of blood vessels: slide above rib (intercostal vessels run in grove under each rib)
        4.     Severe pain: if you're doing this in the field, patient should be sick enough not to require anesthesia,
               but they'll let you know when you go through pleura. Don't let that deter you - move briskly on.
        5.     Infection: clean rapidly but vigorously. Use sterile gloves, if possible.

Side effects and special notes

A.      Sudden onset of chest pain and shortness of breath in a normal individual may also be caused by a
        pneumothorax (particularly in patients with COPD or asthma). These can also progress to a "tension" state.

B.      Tension pneumothorax can be precipitated by occlusion of an open chest wound with a dressing. If, after
        dressing an open chest wound, the patient deteriorates, remove the dressing.




                                                       IX-154
Denver Metro Paramedic Protocols

Procedure Protocol
                                     TRANSCUTANEOUS CARDIAC PACING

Indications

Use cardiac pacing only when there is insufficient cardiac rate to maintain adequate perfusion, and rate is unaffected
by atropine and adequate oxygen and ventilation.

A.      Symptomatic bradyarrhythmias (includes A-V block)
B.      P.E.A. (Pulseless Electrical Activity) with bradycardia
C.      Patients who convert from a viable rhythm into asystole

Precautions

A.      Capture can be difficult in some patients.
B.      Patient may experience discomfort; consider midazolam.
C.      Use the same precautions as with defibrillation.
D.      Patients in atrial fibrillation may require higher energy settings for capture than others.

Technique

A.      Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left posterior.
B.      Turn pacer unit on.
C.      Select pacing rate at 80 beats per minute (BPM)
D.     If the patient is awake, consider the use of sedation (See Section VI – Drugs - Midazolam)
E.      Start pacing unit.
F.      Confirm that pacer senses intrinsic cardiac activity by adjusting ECG size. If not, pacer may discharge on an
        existing complex.
G.      Set initial current to 40 mAmps.
H.      Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually captures around 100
        mAmps).
I.      If there is capture, check for pulses.
J.      If there are no pulses with capture, consider a fluid challenge or dopamine. (See Section VI)
K.      If no capture occurs with maximum output, discontinue pacing and resume ACLS.

Complications

A.      V-fib and V-tach are rare complications, but follow appropriate protocols if either occur.
B.      Pacing is rarely indicated in patients under the age of 12 years.
C.      Muscle tremors may complicate evaluation of pulses.
D.      Pacing may cause diaphragmatic stimulation.
E.      CPR is safe during pacing. A mild shock may be felt if direct active electrode contact is made.




                                                        IX-155
Denver Metro Paramedic Protocols

Procedure Protocol
                                TRANSPORT OF THE HANDCUFFED PATIENT

Indications

The patient is being transported under police custody and has already been placed in handcuffs by a police officer.

Precautions

A.      Any attempt to restrain a patient involves risks to the patient and the prehospital provider. Efforts to restrain a
        patient should only be done with adequate assistance present.
B.      At no time should the patient be placed in a prone position for a prolonged time at the scene or during
        transport to the hospital.
C.      Ensure that patient has been searched for weapons.

Technique

A.      For the patient who does not require spinal immobilization or transport in a supine position:
        1.       Maintain restraint via the handcuffs.
        2.       Escort the patient to the bench seat inside the ambulance.
        3.       Secure the patient in a sitting position with the seat belt.
        4.       Treatment and transport should be done with the patient remaining in the handcuffs.
        5.       Request that the officer stay with the patient and ride in the ambulance during transport. Ultimately,
                 we are not responsible for the hold on this patient.

B.      For the patient who requires transport with spinal immobilization or in a supine position and is found in
        standing or sitting position:
        1.       Ensure that you have adequate assistance available to maintain restraint of the patient.
        2.       Secure the patient's cervical spine with a cervical collar if indicated.
        3.       Assign one individual to support the patient's head.
        4.       Bring the stretcher, with backboard or scoop if indicated, to the patient.
        5.       Have the patient sit down on the stretcher and secure each arm with Kerlix before having the officer
                 remove the handcuffs.
        6.       Lie the patient down on the stretcher in a supine position.
        7.       Secure one arm of the patient to the scoop or backboard with the handcuffs. If further restraint is
                 required, use Kerlix or Velcro cuffs to restrain other extremities.

C.      For the patient who requires transport with spinal immobilization or in a supine position and is found in a
        prone position:
        1.       Ensure that you have adequate assistance available to maintain restraint of the patient.
        2.       Secure the patient's cervical spine with a cervical collar if indicated.
        3.       Assign one individual to support the patient's head.
        4.       Secure each arm and both legs with Kerlix prior to having the officer remove the handcuffs.
        5.       Roll the patient onto a backboard or scoop.
        6.       Place the stretcher next to the patient and lift the patient onto the stretcher.
        7.       Secure one arm of the patient to the scoop or backboard with handcuffs. If further restraint is
                 required, use Kerlix or Velcro cuffs to restrain other extremities.

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




                                                        IX-156
Denver Metro Paramedic Protocols

Procedure Protocol
                                          VASCULAR ACCESS DEVICES

Special Information Needed:

A.      Obtain pertinent medical history if possible.
B.      Obtain any information possible regarding the type of Vascular Access Device (VAD), number of lumens,
        purpose of the VAD, etc.

Indications

A.      To obtain rapid venous access for the critical patient when peripheral access cannot be obtained.


Precautions

A.      Obtain information and assistance from family members or home health professionals who are familiar with
        the device.
B.      Discontinue any intermittent or continuous infusion pumps.
C.      Assure placement and patency of the VAD prior to infusing any fluids or medications.
D.      Flush the catheter completely with sterile normal saline.
E.      Use aseptic technique.

Central Venous Catheters or PICC Lines

A.      Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of
        VAD.
B.      Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted central catheter).
C.      Utilize knowledgeable family members, significant others or home visiting nurse if available.
D.      Discontinue and/or disconnect any pumps or medications.
E.      Clamp the VAD closed to prevent air embolus.
F.      If multiple lumen, identify the lumen to be used.
G.      Utilize aseptic technique.
H.      Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad.
I.      Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive blood return. Obtain blood
        samples if necessary. Then flush the line with solution.
J.      Insert the needle (attached to a medication syringe or IV tubing) and infuse medications or fluids.
K.      Secure the IV tubing.
L.      Reassess the infusion site.
M.      Reassess patient condition.

Implanted Ports

A.      Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of
        the VAD.
B.      Identify the location and type of VAD (e.g. implanted port).
C.      Utilize knowledgeable family members, significant others or home visiting nurse if available.
D.      Discontinue and/or disconnect any pumps or medications.
E.      Carefully palpate the location of the implanted port.
F.      If multiple ports, identify the port to be used.

(continued on next page)




                                                        IX-157
Denver Metro Paramedic Protocols

       G.       Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from the center
       outward three times in a circular motion.
H.     Using a sterile gloved hand, press the skin firmly around the edges of the port.
I.     Using a syringe filled with solution, insert the needle perpendicular to the skin.
J.     Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood from a VAD, use
       a syringe that is 10cc or less to avoid complications.
K.     Secure the IV tubing.
L.     Reassess the infusion site.
M.     Reassess the patient.

Complications:

A.     Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at all times.

B.     Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not utilize the lumen.

C.     Rarely, a catheter will migrate. The symptoms may include the following:
       1.       burning with infusion
       2.       site bleeding
       3.       shortness of breath
       4.       chest pain
       5.       tachycardia and/or
       6.       hypotension

       If a catheter migration is suspected, do not use the VAD and treat the patient according to symptoms.

D.     Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs and may cause
       burning and tissue damage. Clamp the catheter and do not use.

E.     Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by properly clamping
       the catheter and preventing air from entering the system.




                                                      IX-158
Denver Metro Paramedic Protocols

Procedure Protocol
                                           VENOUS ACCESS TECHNIQUE

                                                GENERAL PRINCIPLES

Indications
A.      Administer fluids for volume expansion
B.      Administer drugs

Precautions
A.     Do not start IVs distal to a fracture site or through skin damage with more than erythema or superficial
       abrasion.
B.     Due to the uncontrolled environment in which prehospital IVs are started, take extra care to use sterile
       technique.
C.     Due to the high complication rate associated with prehospital IV therapy, use good judgment when deciding
       which patients should receive an IV.

Technique
A.     Connect tubing to IV solution bag.
B.     Fill drip chamber one-half full by squeezing.
C.     Tear sufficient tape to anchor IV in place.
D.     Use BSI.
E.     For pediatric patients consider applying an arm board or splint prior to venipuncture.
F.     Scrub insertion site with alcohol or iodine pads.
G.     Don't palpate, unless necessary, after prep.
H.     Perform venipuncture or enter bone marrow as described in the specific techniques described in this protocol.
I.     After the catheter is in place, remove the needle or stylette, draw bloods when possible and connect tubing.
J.     Open full to check flow and placement, then slow to TKO rate unless otherwise indicated or ordered.
K.     Secure tubing with tape, making sure of at least one 180-degree turn in the tubing when taping to be sure any
       traction on the tubing is not transmitted to the cannula itself.
L.     Anchor with arm board or splint as needed to minimize chance of losing line with movement.
M.     Recheck to be sure IV rate is as desired.

Complications
A.       Pyrogenic reactions due to contaminated fluids become evident in about 30 min after starting the IV. Patient
         will develop fever, chills, nausea, vomiting, headache, backache, or general malaise. If observed, stop and
         remove IV immediately. Save the solution so it may be cultured.
B.       Local: hematoma formation, infection, thrombosis, phlebitis. Note: the incidence of phlebitis is particularly
         high in the leg. Avoid use of lower extremity if possible.
C.       Systemic: sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from solution in IV
Side effects and special notes
A.       Antecubital veins are useful access sites for patients in shock, but if possible, avoid areas near joints (or splint
         well!).
B.       The point between the junction of two veins is more stable and often easier to use.
C.       Start distally, and if successive attempts are necessary, you will be able to make more proximal attempts on
         the same vein without extravasating IV fluid.
D.       Venipuncture has little morbidity; however, the excess fluids inadvertently run in when nobody is watching
         can be fatal!
E.       The most difficult problem with IV insertion is knowing when to try and when to stop trying. Valuable time is
         often wasted attempting IVs when a critical patient requires blood. IV solutions may "buy time," but they
         frequently lose time instead. In critical patients do not delay transport while attempting IV insertion at the
         scene. IVs may be placed en route.
F.       For the purpose of this protocol, peripheral IV will be defined as extremity or external jugular vein.

(continued on next page)




                                                         IX-159
Denver Metro Paramedic Protocols

BUFF CAP (SALINE LOCK)

Indications
A.      Prophylactic IV access
B.      Drug administration

Precautions
A.     Consider the patient, and whether a running IV or a buff cap is needed.
B.     For any buff cap established in the prehospital setting, the attendant is responsible for showing the buff cap to
       the receiving nurse.

Technique
A.     Assemble the necessary equipment.
B.     Prefill the saline lock with sodium chloride.
C.     Proceed with the technique for extremity IVs.
D.     Remove the needle from the catheter and insert the saline lock.
E.     Flush the saline lock with 2-5 ml of sodium chloride.

Contraindications
A.     Any catheter placed in the external jugular vein
B.     Any patient who is in need of fluid or is hypotensive
C.     The cardiac arrest patient


EXTERNAL JUGULAR VEIN

Indications
A.      Inability to secure extremity IV access

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


EXTREMITY

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

(continued on next page)




                                                       IX-160
Denver Metro Paramedic Protocols

INTRAOSSEOUS INFUSION

Indications (Must meet all criteria)
A.      Children less than 8 years old
B.      Shock, cardiac arrest, status seizure
C.      Unable to start peripheral line after one attempt; peripheral IV is always attempted first, intraosseous second.
        If in visual inspection unable to see good peripheral, go straight to intraosseous infusion.
D.      Paramedics and Intermediates may insert intraosseous catheters.

Technique
A.     Site of choice – tibial plateau - one finger breadth below the tuberosity on the anteromedial surface
B.     Clean skin with povidone-iodine.
C.     Place intraosseous needle perpendicular to the bone.
D.     Apply firm downward pressure on the needle. A "screwing motion" facilitates advancement of the needle.
       Entrance into the bone marrow is indicated by a sudden loss of resistance.
E.     Even if properly placed, the needle will not be secure. The needle must be secured and the IV tubing taped.
       The IO needle should be stabilized at all times. A person should be assigned to monitor the IV at the scene
       and en route to the hospital.
F.     Only one intraosseous attempt is to be done in each tibia.
G.     Puncture site should be covered with a dressing.

Complications
A.     Bone fracture (pushing too hard while not twisting the needle enough)
B.     Infection

Contraindications
A.     Fractures
B.     Cellulitis
C.     Osteogenesis imperfecta

Side effects and special notes
A.       Some authorities recommend aspiration of marrow fluid or tissue to confirm needle location. This is not
         recommended for field procedures, as it increases the risk of plugging the needle.
B.       Any drugs or fluids can be infused.
C.       Prior to IO insertion, consider rectal administration of benzodiazepines in patients 8 and under with status
         seizures. Consider IM midazolam for ages 9 and above for patients in status seizures.




                                                        IX-161
Denver Metro Paramedic Protocols



                                      SECTION VIII

                            OPERATIONAL GUIDELINES


TABLE OF CONTENTS

VIII   Operational Guidelines                                            Page Number

               Automated External Defibrillator (AED): Coordination of
               ALS-Trained Provider With Personnel Using AEDs                      VIII-2
               AED/Cardiac Arrest Algorithm                                        VIII-3
               Blood Draw for Alcohol Determination                                VIII-4
               Combined Advance Directives and CPR Directive                 VIII-5, 6, 7
               Communication                                                       VIII-8
               Confidentiality                                                     VIII-9
               Consent                                                       VIII-10, 11
               Destination Policy                                            VIII-12, 13
               Divert Policy                                                 VIII-14, 15
               Hazardous Materials (HAZMAT)                                      VIII-16
               Infectious and Communicable Diseases                              VIII-17
               Mental Heath Holds (MHH)                                          VIII-18
               Non-Transport of Patients                                     VIII-19, 20
               Non-Transport of Patients Algorithm                               VIII-21
               Patient Care Report Requirements                                  VIII-22
               Physician at the Scene/Medical Direction                          VIII-23
               Physician at the Scene/Medical Direction Algorithm                VIII-24
               Resuscitation and Field Pronouncement Guidelines           VIII-25, 26, 27
               Triage: Multiple Patient Assessment                        VIII-28, 29, 30




                                                  IX-162
Denver Metro Paramedic Protocols

Operational Guidelines

                    AUTOMATED EXTERNAL DEFIBRILLATOR (AED):
      COORDINATION OF ALS-TRAINED PROVIDER WITH PERSONNEL USING AEDs

General Principles

With the increasing availability of AEDs ALS-trained emergency personnel will interact frequently with both trained
and untrained AED providers. The following are guidelines for this interface between ALS personnel and personnel
using AEDs:

A.      ALS-trained and authorized providers always have authority over the scene.

B.      On arrival, ALS-trained providers should ask for a quick report from the automated defibrillation providers
        and, if the providers are trained in the use of AEDs; direct them to proceed with their protocols. This is
        particularly applicable when ALS-trained providers are unfamiliar with the operation of the AED. In the event
        that the AED provider is an untrained citizen, attach a conventional defibrillator, as most citizen access AEDs
        will not have a rhythm display monitor.

C.      ALS-trained providers should use the AED for additional shocks and rhythm monitoring. They can direct the
        trained providers to operate the AED. To save time, avoid disorganization, and allow a coordinated transfer
        of care, ALS providers should not remove the AED and attach a separate conventional defibrillator unless the
        AED in use lacks a rhythm display screen. Some AEDs have the capacity for manual override by ALS-trained
        providers, should that be necessary. The method and ease of manual override will vary among models.

D.      ALS-trained providers should consider the shocks delivered by the AED operators as part of their ALS
        protocols. For example, if the patient remains in VF after three shocks by the AED, then ALS personnel
        should enter the ALS VF treatment sequence at the point at which the first three shocks have been delivered.
        Consequently, ALS providers should move immediately to perform endotracheal intubation, establish IV line
        access, and administer epinephrine.


(continued on next page)




                                                      IX-163
Denver Metro Paramedic Protocols

Procedure

The following is an AED/Cardiac Arrest algorithm presented here to familiarize paramedics with the procedure AED-
trained personnel utilize.

                                                   ALGORITHM
                                               AED/CARDIAC ARREST

                                       DETERMINE UNRESPONSIVENESS
                                                       ↓
                                                OPEN AIRWAY
                                                       ↓
                                    BREATHING PRESENT, IF NOT, VENTILATE
                                                       ↓
                                      CHECK PULSE. IF ABSENT, BEGIN CPR
                                                       ↓
                                            ATTACH AED TO PATIENT
                                                       ↓
                                                  STOP CPR
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                        IF NO PULSE, CPR FOR 1 MINUTE
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                  PRESS ANALYZE. IF DIRECTED, DEFIBRILLATE
                                                       ↓
                                        IF NO PULSE, CPR FOR 1 MINUTE
                                                       ↓
                                    REPEAT SET OF THREE STACKED SHOCKS
                                                       ↓
                                        IF NO PULSE, CPR FOR 1 MINUTE

Precautions

A.      After 3 "no shock indicated" messages, repeat analyze set every 1-2 minutes. Continue CPR if patient is
        pulseless.
B.      Check pulse immediately if a "no shock indicated" message appears.
C.      If the patient becomes pulseless after transiently converting, restart the treatment algorithm from the top.
D.      Once the AED is applied to the patient, necessary steps should begin immediately to transport the patient to
        the hospital or rendezvous with an Advanced Life Support Ambulance.
E.      Effort should be made to acquire event data; either in digital or hard copy form, for the patient care record and
        performance improvement purposes.




                                                       IX-164
Denver Metro Paramedic Protocols

Operational Guidelines
                              BLOOD DRAW FOR ALCOHOL DETERMINATION

Purpose

To meet all requirements of the Board of Health rules relating to chemical tests for alcohol determination

Indications

A.      Request of the law enforcement officer, and
B.      Agency authorization

Precautions

A.      Blood samples shall be collected only in an appropriate clinical or public safety facility, in the presence of the
        officer.
B.      In no event shall the collection of blood samples interfere with the provision of essential medical care.
C.      Do not use alcohol or phenolic solutions as a skin antiseptic.

Technique

A.      Utilize blood draw supplies provided by the law enforcement agency.
B.      Use BSI.
C.      Apply tourniquet proximal to the proposed site.
D.      Scrub the insertion site with non-alcohol prep provided in blood draw kit.
E.      Put on disposable medical gloves prior to venipuncture.
F.      Hold vein in place by applying gentle traction on the vein distal to the point of entry.
G.      Puncture the skin and the vein with the bevel of the needle upward.
H.      Once in the vein, collect the sample directly into the sterile blood tubes provided by the officer.
I.      Remove tourniquet.
J.      Remove the needle from the vein and hold pressure to stop any bleeding.
K.      Give the blood sample to the officer.
L.      Sign any paper work the officer needs.
M.      Dispose of contaminated needles appropriately.




                                                        IX-165
Denver Metro Paramedic Protocols

Operational Guidelines
                           COMBINED ADVANCE DIRECTIVES AND CPR DIRECTIVE

ADVANCE MEDICAL DIRECTIVES
A.   There are several types of advance medical directives (documents in which a patient identified the treatment
     to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions).
     1.       Do not resuscitate (DNR) orders are generally intended to be written by a physician for a patient
              whose medical condition is such that commencement of resuscitation efforts would be futile.
     2.       A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires a patient to have
              a terminal condition, as certified in the patient's hospital chart by two physicians. For the document
              to become operative, the patient must be unresponsive because of a terminal condition for a period of
              seven days. In most cases, these do not impact prehospital care, but become effective in the in
              hospital setting.
     3.       "Durable Medical Power of Attorney" or "Health Care Proxy" are documents which can be very
              complex and require careful review and verification of validity, and application to the patient's
              existing circumstances. Therefore, the consensus is that resuscitation should be initiated until a
              physician can review the document or field personnel can discuss the patient’s situation with the base
              physician.
     4.       The Colorado CPR Directive is a specific situation under Colorado law that provides for CPR to be
              withheld or withdrawn. (See section below - CPR Directive protocol).

B.      Resuscitation may be withheld from or terminated for a patient who has a valid, written do not resuscitate
        order or other advanced medical directive only if:
        1.       The documentation is clear, unequivocally to the prehospital provider that CPR, intubation and
                 defibrillation are refused by the patient or by the patient's attending physician who has signed the
                 document, and
        2.       Base physician has approved of withholding or ceasing resuscitative efforts, and
        3.       There is no apparent indication of suicidal gesture or intent by the patient.
        4.       If there is disagreement at the scene about what should be done, the base should be contacted
                 immediately for guidance.
        5.       Prehospital providers presented with equivocal DNR orders or advance medical directives should
                 proceed with resuscitation and establish base contact for guidance on treatment and transport.
                 a.        If the directive document is long and detailed, then it is probably more reasonable for
                           resuscitation to be initiated and the patient to be transported so that the base physician can
                           review the document and possibly contact the patient's attending physician.
                 b.        The duration of the resuscitation should be guided by the same factors of any medical cardiac
                           arrest (See Section II: Medical Treatment - Cardiac Arrest).

C.      Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an attending
        physician directs resuscitation be ceased, the prehospital provider should immediately contact base. The
        prehospital provider should accept verbal orders to cease resuscitation only from the base physician.

                D.       There may be times in which the prehospital provider feels compelled to perform or continue
                resuscitation, such as hostile scene environment, family members adamant that "everything be done",
                or other highly emotional or volatile situations. In such circumstances, the prehospital provider
                should attempt to confer with the base for direction and if this is not possible, the prehospital provider
                must use his or her best judgment in deciding what is reasonable and appropriate, including transport,
                based on the clinical and environmental conditions, and established base contact as soon as possible.
                Documentation of these events must be explicit.

(continued on next page)




                                                       IX-166
Denver Metro Paramedic Protocols

CPR DIRECTIVE PROTOCOL


General Principles
A.     This protocol is for the prehospital management of the statutory "CPR Directive," which refers to a
       specifically identifiable, numbered form that is printed on security paper. The form must be signed by the
       patient or the patient's authorized agent. The form must also be signed by the patient's attending physician.

B.      In addition to the written CPR Directive form, the patient or authorized agent may obtain a CPR Directive
        necklace or bracelet to be worn by the patient. This bracelet or necklace will have imprinted on it the same
        number as the form.

C.      CPR shall be withheld or terminated if the original CPR Directive form is readily accessible with an original
        signature, or if the necklace or bracelet is worn by the patient.

D.      A CPR Directive may be implemented for a minor only after a physician issues a "Do Not Resuscitate" order
        and the parents of the minor (if married and living together), custodial parent, or legal guardian execute(s) a
        CPR Directive for the minor.

E.      A CPR Directive does not only apply to patients in full cardiac arrest, but should also be honored by
        withholding resuscitation in patients who are seriously ill or near arrest.

Procedure
Upon finding a patient with a CPR Directive (form, bracelet, or necklace):

A.      Perform initial patient assessment.

B.      Verify that the CPR Directive form is one of the original copies (it should be light blue color below the title
        portion of document) and is unaltered (not defaced or altered physically in some way).

C.      Verify that the information on the form or, if present, on the back of necklace or bracelet, appears to be
        appropriate for the patient (look at race, sex, date of birth, eye and hair color). If possible, try to verify
        identity of patient by an additional source (e.g., family member, driver's license or other readily available
        sources).

D.      Upon verification of the CPR Directive, withhold CPR. If CPR has been started, it should be stopped.

E.      If there is any question of the validity of the document or the identity of the patient, initiate full resuscitation
        measures and contact the base for guidance. Be sure to inform the base of the CPR Directive form, bracelet,
        or necklace, and the condition and history of the patient.

F.      Complete documentation, including attaching a copy of monitor strips on each copy of the run report (EMT-P
        or EMT-I). Additional required documentation is listed in section K below.

G.      Provide appropriate emotional support to family if possible.

H.      If the death occurs outside of a health care facility or if tissue donation has been declared, then the coroner is
        to be immediately contacted. If the declarant has indicated on the CPR Directives form a desire to donate any
        tissues, appropriate authorities should be notified.

(continued on next page)




                                                         IX-167
Denver Metro Paramedic Protocols

       I.     The following resuscitation measures are to be withdrawn or withheld from a person who has a valid
       CPR Directive:
       1.     CPR and chest compressions
       2.     Endotracheal intubation or other advanced airway management
       3.     Artificial ventilation
       4.     Defibrillation
       5.     Cardiac resuscitation measures and medications.

J.     The following interventions may be administered or provided:
       1.      Assist in maintenance of airway (non-advanced airway management, such as positioning)
       2.      Suctioning
       3.      Oxygen
       4.      Pain medication
       1. Control bleeding

K.     In addition to the standard documentation, the following information should be documented when possible by
       the prehospital provider on the run report:
       1.       Patient's status (e.g. condition found, medical history obtained)
       2.       Type of "CPR Directive" found (document, bracelet or necklace)
       3.       CPR Directive number
       4.       Name of attending physician, if known
       5.       Special circumstances which justify initiating resuscitation if this was done despite the presence of
                the CPR Directive
       6.       Monitor strips in at least two leads (EMT-P and EMT-I)

Additional considerations

A.     The patient may revoke the CPR Directive at any time by oral expression of revocation or by destruction of
       the CPR Directive form, bracelet or necklace. If a guardian, agent or proxy decision-maker executed the CPR
       Directive, then the guardian, agent or proxy decision-maker may revoke the CPR Directive.

B.     CPR is to be initiated if the original CPR Directive form, necklace or bracelet is not readily available, (i.e.,
       being worn by or physically present with the patient). The bracelet or necklace is only available to the patient
       after the form has been properly executed. Removal of the bracelet or necklace may be construed as
       revocation. Therefore, if the bracelet or necklace is readily accessible but not on the patient, any question as
       to whether or not the Directive has been revoked should result in resuscitation until the situation is clarified.
       Consult with base if you have questions about terminating CPR and transport. If not in full arrest, patients
       with CPR Directives may still be transported to provide comfort measures.

C.     In the absence of the existence of a CPR Directive, a person's consent to CPR shall be presumed. The
       statutorily authorized CPR Directive is only one manner for a patient to document resuscitation preferences.
       Other "Do Not Resuscitate" forms and advance directives may be honored but base contact is required (see
       section VIII – Resuscitation and Field Pronouncement Guidelines).

D.     Under Colorado Law, refraining from performing CPR, when there is a CPR Directive, does not constitute
       assisting a suicide, and caregivers who honor a CPR Directive by withholding CPR are protected from legal
       liability.




                                                      IX-168
Denver Metro Paramedic Protocols

Operational Guidelines
                                                COMMUNICATION

The purpose of contacting the receiving hospital is to provide enough data to allow the Emergency Department staff to
decide what preparations they will need to make for the patient. In addition, a base physician may direct appropriate
treatment to be administered en route.

Radio contact should only include essential, relevant information. Remember, the Emergency Department staff may
be busy and radio time is valuable.

First, always identify agency, unit, person, and the reason for contact such as a treatment orders/requests,
notification, and/or consultation

Procedure for Notification to Receiving Facility
A.     Report the following, to the extent pertinent, to the receiving facility:
       1.      Transport status or code
       2.      Chief complaint
       3.      Age and gender of patient
       4.      General status and course of events, stable, improving, deteriorating
       5.      Past medical history, only if pertinent
       6.      State of consciousness
       7.      Vital signs
       8.      Pertinent localized findings
       9.      Treatment in progress
       10.     Estimated time of arrival

Procedure for Requests for Treatment Orders
Only a physician may provide authorization to a paramedic to perform a procedure or administer a medication
pursuant to these protocols. The paramedic should be clear and concise in requesting that a physician be available for
consultation or orders.

A.      Request to talk to a physician to obtain an order.
B.      Identify yourself to the physician and state the order you are requesting.
C.      Provide pertinent information that is the basis of the request, such as:
        1.       Enroute (emergent or non-emergent, estimated time to destination hospital) or on scene
        2.       Chief complaint
        3.       Course of events, stable, improving, deteriorating
        4.       Past medical history, only if pertinent
        5.       General status
        6.       State of consciousness
        7.       Vital signs
        8.       Pertinent localized findings
        9.       Treatment in progress
        10.      Order requested, stating dosage and route to be given
        11.      All allergies the patient has

D.      In the event a request is for a field pronouncement, the report should include information about the responses
        to resuscitation efforts, mechanism, and duration of resuscitation efforts. If the pronouncement is made, state
        the time.
E.      Communication with a physician at the base is appropriate if you are not sure whether or not a treatment,
        procedure or destination is appropriate for a patient. Base contact should be considered as a consultation, not
        just as a source of authorization for medications and procedures.
F.      Requests for orders should be made to a hospital's recorded line whenever possible.



                                                      IX-169
Denver Metro Paramedic Protocols

Operational Guidelines
                                                CONFIDENTIALITY


A.      The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT relationship
        are recognized as privileged. This means that the physician, nurse, or EMT may not testify as to confidential
        communications unless:
        1.      the patient consents or
        2.      the disclosure is allowable by law (such as Medical Board or Nursing Board proceedings, or civil
                litigation in which the patient's medical condition is in issue)

B.      The patient's medical information should be kept confidential by the prehospital provider as private
        information in medical care. The patient likely has an expectation of privacy and trusts that personal, medical
        information will not be disclosed by medical personnel to any person not directly involved in the patient's
        medical treatment.

Exceptions

A.      The patient is not entitled to confidentiality of information that does not pertain to the medical treatment,
        medical condition, or is unnecessary for diagnosis or treatment.
B.      The patient is not entitled to confidentiality for disclosures made publicly.
C.      The patient is not entitled to confidentiality with regard to evidence of a crime.

Additional Considerations

A.      Any disclosure of medical information should not be made or allowed unless necessary for the treatment,
        evaluation or diagnosis of the patient.
B.      Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as
        limited disclosures and not authorizing further disclosures to any other person.
C.      Any discussions of prehospital care by and between the receiving hospital, the crew members in attendance,
        or at in-services or audits are done strictly for educational purposes. Further disclosures are not authorized.
D.      Radio communications should not include disclosure of patient names.




                                                        IX-170
Denver Metro Paramedic Protocols

Operational Guidelines
                                                      CONSENT

General Principles: Adults

A.      An adult in the State of Colorado is 18 years of age or older.

B.      Every adult is presumed capable of making medical treatment decisions. This includes the right to make
        "bad" decisions that the prehospital provider believes are not in the best interests of the patient.

C.      A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent,
        i.e., the patient:
        1.        Understands the nature of the illness/injury or risk of injury/illness;
        2.        Understands the possible consequences of delaying treatment/refusing transport; and
        3.        Given the risks and options, the patient voluntarily refuses or accepts treatment/transport.

D.      A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical
        treatment (IVs, O2, medications), but you should try to inform the patient of the need for therapies, offer
        again, and treat to the extent possible.

E.      The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment. Refer
        to letter C above.

F.      Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening
        injuries/illnesses.

G.      Involuntary Consent: In rare circumstances, consent may be authorized by a person other than the patient
        (such as a court order [guardianship], from a peace officer for prisoners in custody or detention, and persons
        under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled).

Procedure: Adults

A.      Consent may be inferred by the patient's actions or by express statements. If you are not sure that you have
        consent, clarify with the patient or contact base. This may include consent for treatment decisions or
        transport/destination decisions.

B.      Determining whether or not a patient has decision-making capacity to consent or refuse medical treatment in
        the prehospital setting can be very difficult. Every effort should be made to determine if the patient has
        decision-making capacity, as defined above under General Principles: Adults; letter C.

C.      For patients who do not have decision-making capacity, contact base.

D.      If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no
        reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threatening
        injuries/illnesses. If you are not sure how to proceed, contact base.

E.      For patients who refuse medical treatment, see Section VIII - Non-Transport of Patients.

F.      If you are unsure whether or not a situation of involuntary consent applies, contact base.

(continued on next page)




                                                       IX-171
Denver Metro Paramedic Protocols

General Principles: Minors

A.     A parent, including a parent who is a minor, may consent to medical or emergency treatment of his/her child.
       There are exceptions:
       1.      Neither the child nor the parent may refuse medical treatment on religious grounds if the child is in
               imminent danger as a result of not receiving medical treatment, or when the child is in a life-
               threatening situation, or when the condition will result in serious handicap or disability.
       2.      The consent of a parent is not necessary to authorize hospital or emergency health care when an
               EMT-P in good faith relies on a minor's consent, if the minor is at least 15 years of age and
               emancipated or married.
       3.      Minors may seek treatment for abortion, drug addiction, and venereal disease without consent of
               parents. Minors > 15 years may seek treatment for mental health.

B.     When in doubt, your actions should be guided by what is in the minor's best interests and base contact.


Procedure: Minors

A.     A parent or legal guardian may provide consent to or refuse treatment in a non-life-threatening situation.

B.     When the parent is not present to consent or refuse:
       1.     If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt
              to contact the parent(s) or legal guardian. If this cannot be done promptly, transport.
       2.     If the child does not need transport, they can be left at the scene in the custody of a responsible adult
              (e.g., teacher, social worker, grandparent). It should only be in very rare circumstances that a child of
              any age be left at the scene if the parent is not also present.
       3.     If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent
              objects to treatment, contact base immediately and treat to the extent allowable, and notify police to
              respond and assist.




                                                      IX-172
Denver Metro Paramedic Protocols

Operational Guidelines
                                               DESTINATION POLICY

Purpose:

To provide a set of guidelines to help ensure proper disposition of the various patients encountered in the field.

Philosophy:

A.      Critical patients with a special medical need should be taken to the nearest facility that can best provide for
        that need.
B.      Critical patients without a special need (i.e., cardiopulmonary arrest) should be taken to the closest emergency
        department.
C.      All other patients should have their request accommodated, consistent with the ability of that system to meet
        that request.

Special Needs:

A.      Carbon Monoxide Poisoning

        Special Considerations. Complications of airway compromise, cardiovascular instability, or other life threat
        require transport to the nearest appropriate emergency department. For example, carbon monoxide exposure
        associated with burns or trauma should be handled according to burn/trauma protocols. Treat the
        complications above as per protocol. The receiving facility should be notified.

B.      Burns

        Patients older than 12 years of age, with second degree or third degree burns greater than 20% body surface
        area, should be transported directly to the University Hospital emergency department. Patients 12 years of
        age and younger, with second degree or third degree burns greater than 20% body surface area, should be
        transported directly to The Children's Hospital emergency department.

        Special Considerations. Complications of airway compromise or cardiovascular instability, require transport
        to the nearest appropriate emergency department. Burns associated with multi-system trauma should be
        transported according to the State of Colorado Trauma Triage Algorithm, Section III.

C.      Trauma

        1.       The destination of trauma patients should always be in accordance with the Colorado Department of
                 Health approved Rules and Regulations. (See Section III - Trauma Treatment and the State
                 Guidelines).

D.      Psychiatric patients (See also Section VIII – Operational Guidelines, Mental Health Holds)

        1.       Patients placed on a Mental Health Hold (MHH) by the Denver Police Department or Mental Health
                 Corporation of Denver shall be transported to DHMC.
        2.       Patients placed on a MHH by other police departments, private practitioners or other parties shall be
                 taken to their appropriate affiliated institution.
        3.       Patients with psychiatric problems not on an MHH shall be taken to the closest hospital or per patient
                 request.
        4.       Patients with psychiatric problems who have an acute medical or traumatic concern shall be treated
                 according to the appropriate medical or trauma protocol.
        5.       MHH may be placed by a state-certified EMT-P under the auspices of the receiving physician.



                                                        IX-173
Denver Metro Paramedic Protocols

(continued on next page)

E.      Obstetric/Gynecologic

        1.      For patients in uncomplicated labor:
                a.       Delivery not imminent:
                         1)       If the patient has a private obstetrician or gynecologist, then follow the patient's
                                  request for destination, when possible.
                         2)       If the patient has no private physician, then follow the patient's request for
                                  destination (if expressed), or transport to the closest hospital.

                b.         Imminent delivery:
                           1)     If the patient has a private obstetrician/care giver, then follow the patient's request
                                  for destination, provided the requested facility is no greater than five minutes
                                  beyond the closest hospital. If the requested facility does not meet these time
                                  constraints and the patient still requests the facility, consult with the base
                                  physician.
                           2)     If the patient has no private physician, then transport to the closest participating
                                  hospital.




                                                         IX-174
Denver Metro Paramedic Protocols

Operational Guidelines
                                                                     DIVERT POLICY

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


Purpose:
   1. To provide a standard approach to ambulance diversion that is practical for field use.
   2. To facilitate unobstructed access to hospital emergency departments for ambulance patients
   3. To allow for optimal destination policies in keeping with general EMS principles and Colorado State Trauma
       System Rules and Regulations.

General Principles:
  1. EMSystem, an internet-based tracking system, is used to manage diverts in the Denver Metro region
  2. The State Trauma Triage Algorithms should be followed.
  3. The only time an ambulance can be diverted from a hospital is when that hospital is posted on EMSystem as
      being on official divert (RED) status. As of December 15, 2001, Emergency Department divert is the only
      category recognized in the Denver Metro region.
  4. Overriding factors: the following are appropriate reasons for a paramedic to override ED divert and,
      therefore, deliver a patient to an emergency department that is on ED divert:
           a. Cardiopulmonary arrest
           b. Imminent cardiopulmonary arrest
           c. Unmanageable airway emergencies
           d. Unstable “level I” trauma patients for level I and level II trauma centers
  1. Prehospital personnel should honor advisory categories, when possible, considering patient’s condition, travel
      time, and weather. Patients with specific problems that fall under an advisory category should be transported
      to a hospital not on that specific advisory when feasible.
  2. There are several categories that are considered advisory (yellow) alert categories. These categories are
      informational only and should alert field personnel that a hospital listed as being on an advisory alert may not
      be able to optimally care for a patient that falls under that advisory category.
  3. The following are advisory (yellow) categories:
           a. ICU (Intensive Care Unit)
           b. OB (Obstetrics)
           c. Psych (Psychiatric)
           d. Trauma (Trauma Services)
           e. Operating Room (OR)
  1. Zone saturation is when all hospitals in that zone are on ED Divert.
  2. A Zone Master is a hospital contact that is responsible for determining hospital destinations when the zone is
      saturated.
  3. When an ambulance is transporting a patient that the paramedic feels cannot go outside the zone due to patient
      acuity or other concerns, the paramedic should contact the Zone Master and request a destination assignment.
  4. In general, patients contacted within a zone should be transported to an appropriate facility within the zone.
      Patients may be transported out of the primary zone at the paramedic’s discretion, if it is in the patient’s best
      interest or if the transport to an appropriate facility is shorter.
  5. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone numbers are on the next
      page.


(continued on next page)




                                                                            IX-175
Denver Metro Paramedic Protocols



    ZONE            HOSPITALS                ZONE MASTER                ZONE MASTER PHONE NUMBER


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


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


    Zone 3       University              Aurora AND University*
    EAST         Rose                                                   303-695-2946 - Aurora
                 Aurora                  ALTERNATE every
                                         QUARTER:
                                                                        303-372-8901 - University
                                         1st and 3rd quarter – Aurora

                                         2nd and 4th quarter -
                                         University

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


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




                                                     IX-176
Denver Metro Paramedic Protocols


Operational Guidelines
                                     HAZARDOUS MATERIALS (HAZMAT)

Indications

A.      Responding to reported and/or known hazardous materials incident
B.      Vapor clouds, fire, smoke, leaking substances, frost lines on cylinders, sick personnel, dead or distressed
        animals and noxious odors are present on or near scene.

Precautions

A.      Senses are one of the best ways to detect chemicals, particularly the sense of smell. If you smell something
        you are too close.
B.      A safe approach to the scene is the first element of any EMS response. Unless you arrive safely at the site,
        you will not be able to perform your duties.
C.      Observe the site from a distance using binoculars, if possible, before you get too close. Look for danger signs
        such as vapor clouds, fire and smoke, placards, shape of vehicle or container, leaking substances, frost lines
        on cylinders, injured personnel, and dead or distressed animals. These are key clues to warn you not to get
        too close. Remember that you want to be part of the solution, not part of the problem.
B.      If the fire department is already on the scene, report in to the incident commander. If you are first on the
        scene and a hazardous material is suspected, request a hazardous materials team response. Keep yourself
        and your unit at a safe distance. This usually requires your unit to leave the scene, leaving patients and
        bystanders in a hazardous situation. Your safety comes first. Seek a location uphill and upwind from the
        incident.
E.      EMS personnel should not be participating in patient decontamination unless trained and equipped to do so in
        a safe manner.

Procedure

A.      Your safety is the highest priority. EMS operations should be established in the cold zone. You should report
        to the incident commander.
B.      Position your vehicle to make a hasty retreat. This may require you to leave the scene to seek safety.
C.      The hazardous materials team should perform the initial assessment, treatment, and decontamination.
        Decontaminated patients should then be brought to the EMS unit.
D.      Once the situation has been assessed, notify the receiving hospital of the following information:

        1.      Location of the incident
        2.      Name of chemicals/products involved
        3.      Number of injured and contaminated
        4.      Extent of the injuries/contamination
        5.      Extent that the patients will be decontaminated in the field
        6.      Your estimated time of arrival
        7.      Other pertinent information that is available

E.      Patient treatment is usually based on signs and symptoms. Specific patient treatment should be based on
        information obtained from base.




                                                       IX-177
Denver Metro Paramedic Protocols

Operational Guidelines
                                INFECTIOUS and COMMUNICABLE DISEASES

Field personnel occasionally come into contact with infectious and communicable diseases. It is important that a
protocol is followed so that the appropriate persons are notified. Not all diseases require immediate treatment;
however, early awareness will assist those involved to take any necessary precautions and actions.

Contamination by infectious and communicable diseases may be minor or serious. Field personnel should take
precautions to avoid unnecessary exposure. When dealing with a suspected contagious patient, attempt to avoid direct
contact with the patient's blood, sputum, emesis, urine, feces, or respiratory and lesion secretions. The provider
should wear disposable latex or vinyl gloves and any other appropriate BSI. Routine practice of good hand
washing and equipment cleaning may help decrease the incidence of contamination.

The following guidelines have been provided for reference. Follow your individual agency infectious and
communicable disease exposure policy and procedure.

A.      All healthcare personnel should always practice good hygiene before, during and after delivering patient
        care. Each patient contact should be considered to be a potential source of infection.

B.      Persons with significant exposure must report the incident to the designated Infection Control Officer of
        his/her agency. All personnel should be advised to consult with their private physician as well.

C.      Agency policy, developed in conjunction with the Physician Advisor, will dictate procedure with regard to
        screening, follow-up testing, prophylaxis and/or treatment.

D.      Exposed prehospital care personnel may be counseled and treated according to established guidelines.

E.      Refer to the following website resource for information on diseases, means and methods of exposure,
        exposure risks, and recommended precautions, actions, and treatment: www.cdc.gov




                                                      IX-178
Denver Metro Paramedic Protocols

Operational Guidelines
                                       MENTAL HEALTH HOLDS (MHH)

Indications

Any person who appears to be:
A.     mentally ill and
B.     an imminent danger to others or to him/herself or
C.     gravely disabled

Procedure

A.      Restrain if necessary (see Section VIII - Restraint Protocol)
B.      Call receiving facility for the physician to place MHH
C.      Transport to Emergency Department
D.      Provide appropriate documentation of events so 72-hour MHH can be filled out by the physician at the
        receiving facility

General Principles

A.      The paramedic may initiate an MHH only with the permission and online contact with the receiving
        physician.
B.      The law allows only physicians, trained nurses, and peace officers to place MHH.
C.      Paramedics may act as the field representative of the physician when the above protocol is followed.




                                                      IX-179
Denver Metro Paramedic Protocols

Operational Guidelines
                                           NON-TRANSPORT OF PATIENTS

General Principles

A.       A patient who has decision-making capacity may refuse treatment, examination or transport. See Legal Issues
         in Consent protocol.

B.       A person has decision-making capacity sufficient to refuse treatment/transport if he/she:
         1.      Understands the nature of the illness/injury or risk of injury/illness; and
         2.      Understands the possible consequences of refusing treatment/refusing transport; and
         3.      Given the risks and options, the patient voluntarily refuses treatment/transport.

C.       The prehospital provider is responsible for deciding if the patient's refusal is informed and voluntary. The
         prehospital provider should consider the nature of the incident, potential mechanism, obvious actions of the
         patient, as well as the verbal statements of the patient. The prehospital provider is responsible for a
         reasonable assessment of the patient to determine if there is an injury/illness or reason for transport or
         treatment. Only then is a patient's refusal an informed refusal (See Section VIII - Consent). Do not attempt to
         diagnose, do assess carefully.

D.       Remember: it is your assessment and advice to the patient, and proper documentation of it, that are most
         important in the non-transport.


Procedure for Non-Transports (see Non-Transport/Refusal of Care algorithm following)

•    If the patient is 18 years of age or older, has no demonstrable illness or injury, has no mechanism of injury,
     demonstrates competency (as defined in the “Consent” portion of this section), and did not initiate the call for
     help, then base contact is not required.

•    For the patient who has only an isolated soft tissue injury and has decision-making capacity, treatment and
     transport should be offered. If the patient refuses, then warn the patient of the risks of non-transport and delay in
     treatment. Agency policy determines base contact requirement.

•    Patients with medical conditions/injuries that may recur or deteriorate, or may render the patient unable to seek
     medical care, should be carefully evaluated and warned to not delay in obtaining medical treatment. High-risk
     areas in EMS are head injury, chest pain, abdominal pain, "flu" like symptoms, alcohol-related illnesses, or
     injuries.

•    For the patient refusing transport/treatment:
     • Assess patient to the extent possible. Look for objective causes of injuries/illnesses that may impair decision-
         making. Evaluate mechanism/history, scene and potential for unseen injuries/illnesses. Do not diagnose.
     • Inform patient of findings, possible injuries or illnesses that warrant treatment and transport, and of the risks
         of non-transport, delaying treatment, and non-physician examination.
     •   If the patient still refuses treatment/transport, then determine the patient's ability to understand the immediate
         medical situation and need for treatment. Questions asked might include:
              • Why don't you want to go to the hospital?
              • What other means of transport do you have?
              • What will you do if you get sick again?
              • What are the risks I just explained to you about delaying treatment?

     If the patient still refuses transport, contact base.

     (continued on next page)


                                                             IX-180
Denver Metro Paramedic Protocols

    •   The base physician may:
        • Agree or determine that the patient's decision-making capacity is impaired and instruct transport of the
            patient.
            • The patient may be transported under the basis of a medical emergency (i.e., patient is incapacitated
                and unable to consent.)
            • The patient may be transported under the basis of a mental health emergency. Police should be
                requested to place the patient under a Mental Health Hold. Appropriate paperwork, such as the
                Mental Health Hold, must accompany the patient. (See also Section VIII – Operational Guidelines,
                Mental Health Holds)
        • Agree or determine that the patient has decision-making capacity, in which case:
            • The patient may refuse treatment and transport but must be advised of the risks of non-transport
                (informed refusal).
            • The prehospital provider must warn the patient that non-transport is against medical advice (AMA).
            • The patient should be urged to seek medical attention and transport.

    •   For the patient who refuses treatment and transport (against medical advice), providing the patient with clear
        instructions and warnings is imperative. Use of an Information Sheet is recommended. (See sample in
        Appendix D.)

•   Minors: Base is to be contacted any time a minor under the age of 18 is not left in the custody of the parents.

•   The following must be documented for every patient examined, offered and refused treatment/transport (in
    addition to EMS Division guidelines):
        1. All assessment findings
        2. Description of mechanism or scene factors (damage, environment, etc.)
        3. Description of mental status and decision-making capacity
        4. Vital signs, unless the patient refused
        5. Patient's response to warning about risks of non-transport/non-treatment
        6. Base physician's advice
        7. Patient's condition at termination of patient contact, such as “ambulatory”, “with family”

•   The "AMA" (refusal) patient should be provided with an Information Sheet (See sample in Appendix D)
    Obtaining a patient's signature on a run report or release form is encouraged because signing may be evidence of
    the patient's decisional capacity and physical stability. However, do not have a patient sign a release or waiver
    that you do not understand, and do not expect that a signature relieves you of responsibility for a reasonable
    assessment or treatment of the patient.

•   The role of base contact is to assist in determining or verifying the patient's ability or inability to make medical
    treatment decisions and assist when transport should be done. It is imperative that an accurate, concise report be
    given for the physician to give good advice.

•   Have all AMA forms co-signed by a witness. The witness should not be an employee of the responding agency.




                                                        IX-181
Denver Metro Paramedic Protocols

Operational Guidelines
                                                          ALGORITHM
                                                NON-TRANSPORT/REFUSAL OF CARE

                                                     (See Non-Transport of Patients protocol)
                                                           Determine mental status and
                                                           extent and history of injury,
                                                              mechanism, or illness.

                                                   ↓
       ____________________________________________________________
         ↓                                                                                                   ↓

          Pt. alert, oriented and has                                                     Injury or illness or has altered
          decision-making capacity (DMC).                                                          mental status or impaired
                                                                                                   decision-making capacity (DMC).

          ↓                                                                                                  ↓

__________________________________
↓                                             ↓                                                               ↓
No apparent injury/illness,        Limited injury                                                    Pt. refuses consent or offer
No complaints, No                  consistent with                                                   of treatment and transport
significant hx, No MOI, hx and mechanism
18 or older, did not call for
help
↓                                             ↓                                                              ↓
Pt doesn't want tx/transport;     Offer treatment and
Advise Pt. appropriately. transport                                                       Contact base
Document appropriately. ↓
                                   Pt. still refuses.                                                        ↓
                                   Refer to agency policy
                                   regarding base contact.                                            ↓
                                                                              __________________________________
                                                                              ↓                                    ↓
                                                                              Base physician determines   Base physician
                                                                                                          determines
                                                                              pt. does have DMC           pt. does not have DMC.
                                                                                                          (Treatment/transport may
                                                                              ↓                           be authorized under
                                                                              Warn pt. of risks of        MHH1, ATH2, or
                                                                              non-transport/non-treatment implied consent if a
                                                                              against medical advice      medical emergency
                                                                                                          exists.)
                                                                              and document appropriately           ↓
                                                                                                          Transport; request MHH
                                                                                                          or use police if necessary
                                                                                                          for assistance.
1
 Mental Health Hold; see Destination Policy Protocol (Section VIII) if transporting a psychiatric patient.




                                                                        IX-182
Denver Metro Paramedic Protocols
 1
 Alcohol Treatment Hold




                                   IX-183
Denver Metro Paramedic Protocols

Operational Guidelines
                                  PATIENT CARE REPORT REQUIREMENTS

General Principles

A.      The prehospital report is an integral component of patient care, quality improvement and professional
        responsibility.
B.      The prehospital report must be legible.
C.      Vital information should also be immediately communicated to the Emergency Department (ED) staff for
        efficient and safe transfer of care.
D.      A legible copy of the prehospital report should be given to the ED staff at the time of transport to the ED. If
        this is not possible, the report or a facsimile copy must be received in the ED within 24 hours from the time of
        transport.

Procedure

A.      All prehospital run reports must include the information noted in the EMS Division policy statement (refer to
        appendix D).
B.      Additional considerations and information to be included to the extent pertinent.

        1.      The physical examination should include assessment findings:
                a.     Head, Ears, Eyes, Nose and Throat (HEENT), including mentation, skin color and condition,
                       and trauma
                b.     Neck
                c.     Chest
                d.     Abdomen
                e.     Pelvis
                f.     Back
                g.     Extremities
                h.     Neurologic status
                i.     Cardiovascular status
                j.     Respiratory status

        2.      Treatment rendered should be detailed, including:
                a.     The reason or assessment findings that were the basis of the treatment, procedure or
                       medication
                b.     The effects (including lack of effect)
                c.     Treatment rendered prior to your arrival or by others
                d.     Medication administration should include time(s) and dose(s).

        3.      Facility contact information:
                a.       Name of physician and facility
                b.       Orders requested or denied
                c.       Time of contact

        4.      Additional documentation should be included, where pertinent to particular protocols; for example:
                a.      Resuscitations in the field should document time and effects of all procedures and
                        medications, and time of pronouncement or termination of resuscitation.
                b.      Refusals of transport should include documentation of mental status, decision-making
                        capacity, warnings given and condition of patient at termination of contact.
                c.      Copies of EKG tracings should be affixed to copies of run reports left with the hospital.
                d.      The mechanism of injury in trauma should be descriptive, not general.

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




                                                       IX-184
Denver Metro Paramedic Protocols

Operational Guidelines
                             PHYSICIAN AT THE SCENE/MEDICAL DIRECTION

Purpose

To provide guidelines for prehospital personnel who encounter a physician at the scene of an emergency

General Principles

A.      The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct an assessment
        of the patient to the extent possible.
B.      A physician who voluntarily offers or renders medical assistance at an emergency scene is generally
        considered a "Good Samaritan." However, once a physician initiates treatment, he/she may feel a physician-
        patient relationship has been established.
C.      Good patient care should be the focus of any interaction between prehospital care providers and the physician.

Procedure

See algorithm.

Special notes

A.      Every situation may be different, based on the physician, the scene, and the condition of the patient.
B.      Contact base when any question(s) arise.




                            NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMTs

THANK YOU FOR OFFERING YOUR ASSISTANCE.

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

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

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

THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.




Physician Advisor                                                            Agency

(continued on next page)


                                                       IX-185
Denver Metro Paramedic Protocols

Operational Guidelines                     ALGORITHM for
                            PHYSICIAN AT THE SCENE/MEDICAL DIRECTION

                                       EMT arrives on scene.
                                                 ↓
                                     EMS attempts patient care.
                                                 ↓
                                        Physician on scene.
                                                 ↓
____________________________________________________
↓                                                 ↓
Physician reports on                              Physician wants to help or is
patient. Relinquishes                             involved in patient care and will
patient care.                                     not relinquish patient care.
↓                                                 ↓
Provide care per protocol.               Prehospital provider identifies
                                                  self and level of training.

                                                            ↓
                          _________________________________________
                                  ↓                                                   ↓
                         Physician wishes to                        Physician requests or performs
                         just help out.                             care inappropriate or inconsistent
                                                                    with protocols.
                                  ↓                                                   ↓
                         Provide general instructions               Prehospital care provider shares
                         and utilize physician                      Physician at the Scene/Medical
                         assistance.                                Direction note with physician.
                                                                    Advise physician of your
                                                                    responsibility to patient.
                                                                                      ↓
                                 ________________________________________
                                           ↓                                          ↓
                                  Physician does not relinquish                       Physician complies.
                                  patient and continues care
                                  inconsistent with protocols.                        ↓
                                           ↓                                          Continue patient care
                                  Contact base physician.                             per protocol.
                                        ↓
                                  Follow base physician's directions.


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




                                                      IX-186
Denver Metro Paramedic Protocols

Operational Guidelines
                     RESUSCITATION AND FIELD PRONOUNCEMENT GUIDELINES

Purpose

To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting

General Principles

A.      Agency policy determines base contact requirements for patients for whom resuscitative efforts are being
        withheld.

B.      All patients found pulseless and apneic are to be resuscitated, except patients found in any of the following
        conditions:

        1.       Decapitation or
        2.       Decomposition or
        3.       Third degree burns over more than 90% of the total body surface area or
        4.       Dependent lividity or rigor mortis or
        5.       A valid CPR directive present with the patient (See Section VIII - CPR Directive protocol) or
        6.       Evidence of massive blunt head, chest, or abdominal trauma


Special Considerations in Resuscitation Decisions:

All cases described below require contact with a base physician to approve termination of treatment.

A.      Blunt Trauma: Resuscitative efforts may be withheld or terminated in patients found apneic and pulseless
        with:

        1.       Blunt trauma to the head, neck or torso; and
        2.       No spontaneous pulse or respirations following appropriate medical interventions, which include, for
                 example: ensuring a patent airway or chest decompression. (The majority of injuries sustained by
                 these patients are not compatible with life. "Appropriate" interventions will vary and should be
                 dictated by guidance from the base.)

B.      Penetrating Trauma:

        1.       Research data shows that a significant number of victims of penetrating trauma to the neck or torso,
                 who are found without signs of life, may be successfully resuscitated. Therefore, resuscitation and
                 rapid transport to a trauma facility should be initiated on all patients found in full arrest secondary to
                 penetrating trauma. Exceptions may exist in the following circumstance:

                 a.        Patients found pulseless and apneic with penetrating trauma if the provision of ALS (EMT-
                           Intermediate or EMT-Paramedic or emergency department) has been unavailable for at least
                           10 minutes from the time EMS personnel initiate on-scene assessment. (Some of the injuries
                           sustained by these patients may be compatible with life. "Appropriate" interventions will
                           vary and should be dictated by guidance from the base physician.)
                 b.        However, if there is any doubt about duration of the arrest, then resuscitation and
                           rapid transport should be initiated.

(continued on next page)




                                                        IX-187
Denver Metro Paramedic Protocols


C.      Medical Patients (i.e., no evidence of trauma and presumed medical arrest) should receive resuscitative
        treatment until there is:

        1.      No return of spontaneous pulse or respirations during 15 minutes of CPR (after successful intubation
                and medications) and no reversible causes have been identified; or
        2.      Continuous asystole for at least 10 minutes in the adult patient, and 30 minutes in a pediatric patient
                (after successful intubation and medications), and no reversible causes have been identified
        3.      The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes
                and should be transported:
                a.       Hypothermic; or
                b.       Drowning with submersion less than 60 minutes (with hypothermia); or
                c.       Pregnant and estimated to be 20 weeks or later in gestation
D.      After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.) as the patient
        is now a potential coroner’s case.

Advance Medical Directives

A.      There are several types of advance medical directives (documents in which a patient identifies the treatment to
        be withheld in the event the patient is unable to communicate or participate in medical treatment decisions).

        1.      Do not resuscitate (DNR) orders are generally intended to be written by a physician for a patient
                whose medical condition is such that commencement of resuscitation efforts would be futile.
        2.      A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires a patient to have
                a terminal condition, as certified in the patient's hospital chart by two physicians. For the document
                to become operative, the patient must be unresponsive because of a terminal condition for a period of
                seven days.
        3.      Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health Care
                Proxy" (the CPR Directive is covered separately; see Section VIII - CPR Directive protocol). Each
                of these documents can be very complex and require careful review and verification of validity and
                application to the patient's existing circumstances. Therefore, the consensus is that resuscitation
                should be initiated until a physician can review the document or field personnel can discuss the
                patient’s situation with the base physician.

B.      Resuscitation may be withheld from or terminated for a patient who has a valid, written do not resuscitate
        order or other advance medical directive (See Section VIII - CPR Directive protocol) only if:

        1.      The document is clear, unequivocally to the prehospital provider that CPR, intubation and
                defibrillation are refused by the patient or by the patient's attending physician who has signed the
                document; and
        2.      Base physician has approved of withholding or ceasing resuscitative efforts; and
        3.      There is no apparent indication of suicidal gesture or intent by the patient.
        4.      If there is disagreement at the scene about what should be done, the base should be contacted
                immediately for guidance.
        5.      Prehospital providers presented with equivocal DNR orders or advance medical directives should
                proceed with resuscitation and establish base contact for guidance on treatment and transport.
                a.        If the directive document is long and detailed, then it is probably more reasonable for
                          resuscitation to be initiated and the patient to be transported so that the base physician can
                          review the document and possibly contact the patient's attending physician.
                b.        The duration of the resuscitation should be guided by the same factors of any medical cardiac
                          arrest (see section C above).

(continued on next page)




                                                      IX-188
Denver Metro Paramedic Protocols

       C.      Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an
       attending physician directs resuscitation be ceased, the prehospital provider should immediately contact base.
        The prehospital provider should accept verbal orders to cease resuscitation only from the base physician.

D.     There may be times in which the prehospital provider feels compelled to perform or continue resuscitation,
       such as a hostile scene environment, family members adamant that "everything be done," or other highly
       emotional or volatile situations. In such circumstances, the prehospital provider should attempt to confer with
       the base for direction and if this is not possible, the prehospital provider must use his or her best judgment in
       deciding what is reasonable and appropriate, including transport, based on the clinical and environmental
       conditions, and establish base contact as soon as possible.

Additional Considerations:

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




                                                      IX-189
Denver Metro Paramedic Protocols

Operational Guidelines
                                 TRIAGE: MULTIPLE PATIENT ASSESSMENT

REFER TO:        THE COLORADO STATE UNIFIED DISASTER TAG AND TRIAGE SYSTEM -
                 A GUIDE TO MCI (multiple/mass causality incident)
Definition
MCI:             The combination of numbers and types of injuries that goes beyond the capability of an entity's
                 normal response.
Triage:          From French - means to sort, sift, or pick out; specifically, the sorting of and allocation of treatment
                 to patients.

Indications
Medical emergency involving more than one patient, interaction between different agencies, and the need to make
choices regarding treatment.

Procedure
A.     Park vehicle in safe location.
B.     Contact appropriate command personnel and follow instructions.
C.     If assigned to triage, do initial assessment of scene; proceed only when safe to rescuer.
D.     Rapidly estimate number of victims and severity of injuries. Do not provide extensive treatment.
E.     Establish communications and request necessary assistance as per department or agency procedure; this may
       include contacting the appropriate hospital and providing initial estimate of number and types of injuries.
F.     Designate or ensure designation of:
       1.        The Incident Command System (ICS) depending on the size of the event and the number of agencies
                 involved (see Diagram A - Incident Command System)
       2.        Medical command: follow departmental and jurisdictional procedures.
       3.        Medical Triage Team:
                 a.       Categorize patients after brief assessment using the Simple Triage and Rapid Treatment
                          START) system (see Diagram B - START Algorithm).
                 b.       Update categorizations and provide transport to stabilization area as able.
                 c.       Initiate medical stabilization to patients awaiting transport after triage duties completed.
       3.        Transport Team (if necessary):
                 a.       Transport patients in order of priority from field to stabilization area.
                 b.       Establish venous access or perform other stabilization procedures as needed in support of
                          triage team.
                 c.       If ongoing assessment, categorization, and transport are to be required, organize the area into
                          an appropriate Triage/MCI format (see Appendix Section F, Triage/MCI Templates;
                          diagrams C-1, C-2, and C-3)
Precautions
A.     Identification of medical charge personnel is extremely important and often overlooked. Use vests, hats, or
       other labeled equipment consistent with departmental or agency procedures.
B.     Location of stabilization area is very important. It should fulfill the following criteria as much as possible:
       1.        Away from objective dangers of scene
       2.        Close enough for access from scene for stretchers
       3.        Accessible by multiple rescue vehicles, both in and out
       4.        Near communications and other command personnel for coordination of evacuation
C.     If triage tags are part of departmental or agency procedures, attach triage tags to patient, not clothing.
D.     Triage assessment and management differs from single patient assessment. Certain problems recur in major
       disasters, and should be avoided:
       1.        Do not use up ambulance space initially transporting class III (green) patients before more serious
                 injuries have been transported (red and yellow).
       2.        Do not delay transport to treat patients at the scene.


(continued on next page)




                                                        IX-190
Denver Metro Paramedic Protocols

                          3.       Reassess patients when able and communicate any changes to the medical command
                 and transport officers.
        4.       Disaster scenes require discipline within the team. Be sure that the leadership and individual roles
                 are well identified. It is important that individuals fulfill their roles as members of the team and in
                 turn give up those roles appropriately as personnel and officers arrive to the MCI scene.
Special notes
A.      The Incident Command Structure developed and disseminated by the National Interagency Incident
        Management System (NIIMS) and Federal Emergency Management Agency (FEMA) provides an excellent
        overall approach to disaster management. The structure is designed to allow flexibility and local differences,
        as well as incorporation of different training levels (physician, nurse, paramedic, EMT-B) within Medical
        Control at the scene. It is important that individuals are aware of the command structure and follow
        instructions. (see ICS Flow chart below).
B.      Multiple-trauma patients with no vital signs upon arrival of rescue personnel have a very poor chance of
        survival even if they are the only victim. If there are additional victims with any signs of life, attention will be
        better spent with the living.
                                            INCIDENT COMMAND SYSTEM
                        * Command system with group and branch divisions based on functions
                                                       Incident Commander


                                                             Operations




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




     Triage                         Treatment                                     Transport                        Supply
    Supervisor                      Supervisor                                    Supervisor                       Officer


  Triage Group                     Area Leaders                                Deputy Transport
                                                                                 Supervisor


                                                                                     Clerk




                             Leader,              Leader,                     Leader,                Leader,
                             Area 0               Area I (Red)                Area II                Area III
                             (Black)                                          (Yellow)               (Green)


                             Area Staff            Area Staff                  Area Staff                 Area Staff
                                                         (Diagram A)

(continued on next page)



                                                         IX-191
Denver Metro Paramedic Protocols


                                                START ALGORITHM

      Is patient able to walk and follow basic commands? If so, classify as delayed. (“walking wounded”)

                        If patient is non-ambulatory, then respiratory rate is assessed:


                                                       RESPIRATIONS
                               NO                                                              YES



             POSITION AIRWAY                                        >30/MINUTE                  <30/MINUTE




        No                          Yes


  Non-salvageable             Immediate                                 Immediate                Assess perfusion




                                                             PERFUSION


                                Cap. refill >2 seconds or                Cap. refill <2 seconds or
                                no palpable radial pulse                  palpable radial pulse




                         Control bleeding




                                          Immediate                     Assess mental status




                                                  MENTAL STATUS


                                     Fails to follow                     Follows
                                   simple commands                   simple commands


                                      Immediate                          Delayed

                                                        Diagram B



                                                       IX-192
Denver Metro Paramedic Protocols


                                                SECTION IX

                                                 APPENDIX


TABLE OF CONTENTS

IX    Appendix                                                              Page
Number

               A.      Commonly Accepted Abbreviations for Field Use        IX-2, 3, 4, 5, 6, 7
               B.      Critical Care Transport Utilization Guidelines             IX-8, 9, 10
               C.      Protocols Requiring Base Contact – TABLES                   IX-11, 12
               D.      Refusal of Transport and Treatment Sample Document               IX-13
               E.      Required Records on Treatment and Transportation                 IX-14
               F.      Triage/MCI Templates                                    IX-15, 16, 17




                                                 IX-193
Denver Metro Paramedic Protocols

Appendix A
                       COMMONLY ACCEPTED ABBREVIATIONS FOR FIELD USE

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

(continued on next page)




                                                      IX-194
Denver Metro Paramedic Protocols

CO              carbon monoxide
c/o             complaining of/complaint of
CO2             carbon dioxide
                change
COPD            chronic obstructive pulmonary disease
COR-O           cardiopulmonary arrest
C-spine         cervical spine
C-section       cesarean section
CSF             cerebrospinal fluid
CSM             carotid sinus massage
CVA             cerebral vascular accident
CVP             central venous pressure
CPR             cardiopulmonary resuscitation
d/c             discharge/discontinue
D&C             dilatation and curettage
detox           detoxification
D5W             dextrose 5% in water
D50W            dextrose 50% in water
DOA             dead on arrival
DOB             date of birth
DOE             dyspnea on exertion
DOS             dead on-scene
Dr.             doctor
drsg/dsg        dressing
DT              delirium tremens
Dx              diagnosis
↓               decrease
ea              each
ED              emergency department
ECG/EKG         electrocardiogram
EENT            eye, ear, nose, throat
EMS             emergency medical services
ENT             ear, nose, throat
EOA             esophageal obturator airway
EOM             extraocular movement
et              and
ET              endotracheal
ETT             endotracheal tube
ETA             estimated time of arrival
etc             and so forth
ETOH            alcohol (ethyl)
exam            examination
=               equal
F               Fahrenheit
FB              foreign body
FD              fire department
fl              fluid
Fx              fracture
                female
1o              first degree/primary

(continued on next page)




                                                    IX-195
Denver Metro Paramedic Protocols

GB             gallbladder
GC             gonorrhea or gonococcus
GCS            Glasgow coma scale
GI             gastrointestinal
g              gram
GPA            gravida, para, abort
gr             grain
GSW            gunshot wound
gtt(s)         drop(s)
GU             genitourinary
GYN            gynecology
→              going to/leading to
>              greater than
h/hr           hour
HA             headache
HACE           high-altitude cerebral edema
HAPE           high-altitude pulmonary edema
HAZMAT         hazardous materials (incident)
HB             heart block
HBV            hepatitis B virus
Hct            hematocrit
HEENT          head, eyes, ears, nose, throat
Hg             mercury
Hgb            hemoglobin
HIV            human immunodeficiency virus
H&P            history and physical
HR             heart rate
ht             height
Hx             history
hypo-          low
H2O            water
ICS            intercostal space
ICU            intensive care unit
I&D            incision and drainage
IM             intramuscular
inf            inferior
int            internal
IV             intravenous
↑              increase
J              Joule(s)
JVD            jugular venous distention
K+             potassium
KVO/ TKO       keep vein open / to keep open
L/l            liter
L              left
lac            laceration
lat            lateral
LBBB           left bundle branch block
lb             pound
lg             large
LLL            left lower lobe
LLQ            left lower quadrant
LMP            last menstrual period
LOC            loss of consciousness
L-spine        lumbar spine
LUL            left upper lobe
LUQ            left upper quadrant
<              less than
O   /\         lying

                                                IX-196
Denver Metro Paramedic Protocols


MAE             moves all extremities
MAST            medical antishock trousers, military antishock trousers
mcg             microgram
MCL             midclavicular line, modified chest lead
med(s)          medication(s)
mEq             milliequivalent
Mg              magnesium
mg/mgm          milligram
MI              myocardial infarction
misc            miscellaneous
ml              milliliter
mm              millimeter
MOE x           movement of extremities times
MS/MSO4         morphine sulfate
MVA             motor vehicle accident
                male
N/A             not applicable
NaCl/NS         normal saline
NaHCO3          sodium bicarbonate
NC              nasal cannula
neg             negative
NKA             no known allergies
noc/noct        night
NPO             nothing by mouth
NSR             normal sinus rhythm
NTG             nitroglycerin
N/V/D           nausea and vomiting and diarrhea
∅               none
O2              oxygen
OB              obstetrics
occ             occasional
O.D.            right eye (oculus dexter)
OD              overdose
OJ              orange juice
ophth           ophthalmology
OPP             organophosphate poisoning
OR              operating room
Ortho           orthopedics
O.S.            left eye (oculus sinister)
O.U.            both eyes (oculus uterque)
oz              ounce
p               after
PAC             premature atrial contraction
PASG            pneumatic antishock garment

(continued on next page)




                                                      IX-197
Denver Metro Paramedic Protocols

PAT             paroxysmal atrial tachycardia
path            pathology
PD              police department
PE              physical examination/pulmonary edema/pulmonary embolus
peds            pediatrics
per             by or through
PERL            pupils equal and react to light
PERLA           pupils equal and react to light and accommodation
PID             pelvic inflammatory disease
PND             paroxysmal nocturnal dyspnea
po              by mouth
pos/ /+         positive
post            posterior
POV             privately owned vehicle
PSVT            paroxysmal supraventricular tachycardia
psych           psychiatric
pt              patient
PTA             prior to arrival
PVC             premature ventricular contractions
Ψ               psychiatric
q               every
®               right
RBBB            right bundle branch block
RBC             red blood cell
resp            respirations
RHD             rheumatic heart disease/right hand dominant
RLQ             right lower quadrant
R/O             rule out
ROM             range of motion
ROS             review of systems
RUQ             right upper quadrant
Rx              take, treatment
s               without
SAB             spontaneous abortion
SC/sub q        subcutaneous
SL              sublingual
SOB             shortness of breath
sol             solution
sm              small
stat            at once
sup             superior
Sx              sign/symptom
surg            surgery
SVT             supraventricular tachycardia
synch           synchronous
2o              second degree/secondary
                sitting
⎣
 ¬_
                standing
⎣

(continued on next page)




                                                    IX-198
Denver Metro Paramedic Protocols

TAB            therapeutic abortion
TB             tuberculosis
tbsp           tablespoon
temp           temperature
TIA            transient ischemic attack
tid            three times a day
TKO            to keep open
TLC            tender loving care, total lung capacity
TM             tympanic membranes
tol            tolerated
tsp            teaspoon
Tx             treatment
∴              therefore
3o             third degree, tertiary
U/A            upon arrival
uncons         unconscious
unk            unknown
URI            upper respiratory infection
uro            urology
UTI            urinary tract infection
≠              not equal/unequal
vag            vaginal
VD             venereal disease
VF             ventricular fibrillation
via            by way of
vol            volume
V/S            vital signs
VT             ventricular tachycardia
WAP            wandering atrial pacemaker
WBC            white blood cell
wc             wheelchair
WNL            within normal limits
WPW            Wolff-Parkinson-White Syndrome
wt             weight
x              times
y/o            year(s) old
yr             year(s)




                                                     IX-199
Denver Metro Paramedic Protocols

Appendix B
                       CRITICAL CARE TRANSPORT UTILIZATION GUIDELINES

Revised:       December 4, 2001

Purpose:       To effectively triage and process any request for service in which Critical Care Transport (CCT) may
               be utilized.

Policy:        The Communications Center employees will utilize the standard operating procedures to process CCT
               requests and appropriate utilization of CCTs and ALS resources to manage acute patients. A request
               of services within the scope of an Advanced Life Support paramedic-staffed ambulance will be
               scheduled as a non-CCT transport unless specifically requested by the transferring physician. This
               policy is included as a reference for clarity and support in decision making for Denver Metro
               paramedics and other non-CCT staff.

Definition:    CCT: Transport of a patient whose clinical needs in transport exceed those procedures and
               medications included in the acts allowed for paramedics, and for whom additional care providers are
               required (RN, RT, etc.).

Procedure:     Mandatory Critical Care Utilization

               The following situations will result in utilization of a Critical Care Transport:

               Patient Origin/Destination

                       1.       Intensive care unit (ICU) to ICU or Cardiac Care unit (CCU) unless the following
                                criteria are met:
                                     Patient on a psychiatric hold in an ICU, with medical clearance completed
                                     (versus mental health clearance)
                                     Patients in ICU because of non-ICU overflow or telemetry bed overflow status at
                                     the referring or receiving facility

                       2.       CCU or ICU to Cardiac Cath Lab unless the following criteria are met:
                                   Patients with acute myocardial infarctions 36 hours out or greater from
                                   admission who have no ongoing chest pain, malignant arrhythmias, or
                                   cardiovascular instability (non-emergent cath only).
                                   Patients with Acute Coronary Syndrome who have been ruled out for myocardial
                                   infarction after 12 hours or more. They should have no ongoing chest pain,
                                   malignant arrhythmias, or cardiovascular instability (non-emergent cath only).

                       3.       Cath Lab to CCU or ICU

                       4.       Emergency Department (ED) to ICU, CCU, or Cath Lab unless the following criteria
                                are met:
                                    Patients on psychiatric holds in an ICU with medical clearance completed
                                    (versus mental health clearance)
                                    Patients in ICU because of non-ICU overflow or telemetry bed overflow status at
                                    the referring or receiving facility

               Monitoring/Equipment/Medication Needs

                       5.       Ventilator Dependent < two weeks (not personal ventilators, not wheelchair capable)

                       6.       Transports requiring intra-aortic balloon pump


                                                      IX-200
Denver Metro Paramedic Protocols

(continued on next page)

                           7.      Transports requiring invasive treatment modalities including:
                                          Non-standard airway management, requiring conscious sedation and/or
                                          anesthetic agents
                                          Intensive care monitoring (condition in which clinical presentation in or is at
                                          risk of being unstable, including: intracranial monitoring devices, arterial
                                          lines, Swan-Ganz catheters, etc).

                           8.      Patients requiring medications and infusions not approved by the Denver Metro
                                   Protocols.

                           9.      Patients on vasoactive infusions initiated or adjusted within two hours of transport.
                                   (“2-hour rule”)

                           10.     Patients requiring fetal monitoring/high risk OB patients

                Instability

                           11.     Multi-Systems trauma patient < 24 hours post-injury with a potential for
                                   hemodynamic instability as determined by the transferring physician

                           12.     Patients with known cardio-thoracic compromise (e.g., AAA, dissecting aneurysms)

                           13.     Hemodynamically unstable patient.

                           14.     Any other patient whom the sending facility indicates is clinically unstable (a
                                   physician or registered nurse must authorize the use of the CCT)

                Exceptions

                           Patients may be sent by paramedic ambulance if, in the opinion of the transferring physician,
                           time consideration outweighs the need for RN presence if the following criteria are met:
                                       Critical Care Transport Services are not available in a reasonable response time.
                                       There is no nurse available from the sending facility to accompany the transport.
                                       The transport requirements are not outside of the acts allowed for paramedics, or
                                       the medications specified by the Denver Metro Protocols.
                                       The sending facility will provide additional resources when possible including
                                       other staff, IV pumps, etc.

                Medications

                           The following is a complete list of medications that the Denver Metro Protocols authorize
                           Colorado State Paramedics to administer and maintain pursuant to the scope of practice under
                           Acts Allowed for the State of Colorado.

                           Denver Metro Protocol Pharmacy List:

                                   Adenosine (Adenocard)
                                   Albuterol Sulfate
                                   Amiodarone
                                   Aspirin (ASA)
                                   Atropine
                                   Dextrose 50%
                                   Diazepam (Valium)

                                                        IX-201
Denver Metro Paramedic Protocols

                                   Diphenhydramine (Benadryl)
(continued on next page)
                                   Dopamine (Intropin)
                                   Epinephrine
                                   Fentanyl
                                   Furosemide (Lasix)
                                   Glucagon
                                   Haloperidol (Haldol)
                                   Ipratropium Bromide (Atrovent)
                                   IV Solutions
                                   Amiodarone (replaced lidocaine HCl (Xylocaine))
                                   Magnesium Sulfate
                                   Methylprednisolone (Solu-Medrol)
                                   Metoclopramide (Reglan)
                                   Midazolam (Versed)
                                   Morphine Sulfate
                                   Naloxone (Narcan)
                                   Nitroglycerin
                                   Oral Glucose (Glutose, Insta-Glucose)
                                   Oxygen
                                   Phenylephrine (Intranasal)
                                   Racemic Epinephrine (Vaponephrine)
                                   Sodium Bicarbonate
                                   Topical Ophthalmic Anesthetics

                Maintenance IV Infusions

                IV Solutions
                               0.9% Normal Saline
                               Lactated Ringers
                               D5W
                               Any combination of the above solutions

                Vasoactive Drips
                            Dopamine (2-hour rule)
                            Epinephrine (2-hour rule)
                            Nitroglycerin (2-hour rule)

Medications or infusions not included in this section will most likely require CCT transfer or, at a minimum, an
EMS physician consult and approval.




                                                      IX-202
Denver Metro Paramedic Protocols

Appendix C
                                                                     TABLES
                                        REFUSALS, NON-TRANSPORTS and FIELD PRONOUNCEMENTS

 Standing Orders                                           Base Contact

 REFUSAL: Adult, 18 or older, with no                      Adult: All medical complaints and all other trauma, or altered mental status, or impaired
 demonstrable illness or injury, no mechanism              decision making capacity
 of injury, demonstrates competency, and did
                                                           Minor: Uninjured or not ill but unable to contact parent or legal guardian, OR ill or
 not initiate call for help, may refuse treatment
                                                           injured without guardian or parent to support patient refusal of treatment, OR with life-
 and transport.
                                                           threatening illness or injury but parent or legal guardian refusing treatment of minor.
 Adult with isolated soft tissue injury and
 decision -making capacity may refuse                      Dispositions:
 treatment and transport. Base contact dictated            * Non-transport - appropriate warnings to pt if Against Medical Advice.
 by physician advisor / agency policy.                     * Request Mental Health Hold by police and transport.
                                                           * Medical emergency exists & lack of decision-making capacity - transport.

 PRONOUNCEMENT: Pulseless and apneic                       Any field pronouncement mandated by physician advisor/agency policy.
 and one of the following: decapitated,
                                                           Termination or withholding of resuscitation of patient without criteria for standing order
 decomposed, over 90% burns, lividity, CPR
                                                           for field pronouncement.
 Directive, massive blunt or head trauma, if
 allowed by Physician Advisor/Agency policy.

                                                              ADVANCED PROCEDURES

 Procedure                        Standing Orders                                        Base Contact

 Airway management                Oral or Nasal intubation; Percutaneous
                                  Cricothyrotomy (MUST submit an Incident
                                  Report)

 Cardioversion                    Symptomatic tachycardias, start @100j,
                                  then 200j, 300j, 360j

 Defibrillation                   All indications

 EMT-I Medication                                                                        Base approval is required for all EMT-I med administration:
 Adminstration                                                                           albuterol, aspirin, atropine, epi, lidocaine, nitro, bicarb,
                                                                                         Narcan, and phenylephrine

 Restraint (Chemical)             Haloperidol (Haldol)                                   When uncertain as to whether or not the use of restraints
                                                                                         is warranted to transport the unwilling or uncooperative
                                                                                         patient. For approval of additional doses.
 Tension Pneumothorax                                                                    All indications
 Decompression

 Transcutaneous Pacing            All indications

                                         DESTINATION POLICY FOR PATIENTS WITH SPECIAL NEEDS

 Condition              Guideline (Review Protocol)                                             Base Contact

 CO poisoning           If isolated and significant→contact base station for                    All pts with other life-threats; to evaluate for
                        consultation to consider transport to Presbyterian-St. Luke’s           complications, destination

 Burns                  Isolated 2°/3° burns > 20% and >12y/o →University                       Pts with burns AND significant CO exposure in the
                                                                                                absence of multi-system trauma, consider transport
                        Isolated 2°/3° burns > 20% and <12y/o →Children’s Hospital              to PSL for hyperbaric treatment of CO

 Multi-system           Per state destination guidelines
 trauma

 Pediatrics             Normal transport destination, except if significant burns or            Early base contact recommended for significant
                        long standing hx treatment @ The Children's Hospital                    complaints.

 Psychiatric            Pt is under Denver MHH → DHMC
                        MHH by other agency → appropriate affiliated hospital
                        Not on MHH → closest appropriate hospital

 OB/GYN                 Delivery not imminent → pt preference                                   If acute or imminent delivery and pt wants
                        Delivery imminent & no more than 5 min transport →pt                    transport to hospital over 5 min away, or if facility

                                                                     IX-203
Denver Metro Paramedic Protocols

                 preference                 w/o 24 hr in-house OB capability




                                   IX-204
Denver Metro Paramedic Protocols


  MEDICATION PROTOCOLS – STANDING ORDERS and PARAMEDIC BASE CONTACT REQUIREMENTS - Note: Endotracheal dose should be 2x the IV dos
Drug                 Standing Orders                                                                 Base Contact
                                                                         nd
Adenosine            Adult: 6mg,; 2nd dose 12mg , * Peds : 0.1mg/kg ; 2 dose: 0.2mg/kg               Contact base following second dose.
Albuterol Sulfate    Mild 2.5mg/3cc NS (adult and ped) via nebulizer, moderate and severe            Concern regarding pt, no response or poor response to tx
                     asthma 7.5 mg/9cc NS continuous nebulizer
Amiodarone           Adult: COR – 300 mg IV, May repeat 150 mg IV bolus x1 in 3-5 mins. Max          Adult: All indications with a pulse except for post-arrest.
                     dose in 24 hrs = 2 gm IV                                                        Wide Complex Tach (Stable): 150 mg IV over 10 mins.
                     Post COR VFib/VTach successful conversion– 150 mg IV over 10 mins.              Unstable wide complex tach s/p unsuccessful cardioversion: 1
                     *Pediatric: Pulseless VTach or VFib after unsuccessful defibrillation; 5mg/kg   mg IV over 10 mins.
                     IV over 3-5 mins.                                                               *Pediatric: Additional doses after initial 5 mg/kg IV loading d
Aspirin (ASA)        Four 81mg chewable tables p.o.(324 mg total)
Atropine Sulfate     Asystole: Adult: 1mg q 3-5 min x 2 * Ped: 0.02mg/kg                             For bradycardia, after 2 doses, if signs of poor perfusion or pt
                     Bradycardia w/poor perfusion: 0.5-1.0mg * Ped 0.02mg/kg (min. 0.1mg)            remains bradycardic. For symptomatic OPP.
Dextrose             Adult: 1st dose 25g (D50) * Peds - 2-4 ml/kg- 1-8yr (D25), 0-1yr (D10)          2nd dose
Diazepam             Status seizures: Adult 1-10mg IV *Ped 0.3mg/kg IV or rectal 0.5mg/kg, up to     Use other than status seizures
                     10mg
Diphenhydramine      Adult 50mg slow IV push or IM administration
                     * Ped 1-2mg/kg, up to 50mg slow IV push; Anti-emetic: Adult and Ped (age
                     8 and over): 25 – 50 mg slow IV or IM
Dopamine                                                                                             All indications and doses
Epinephrine          Cardiac Arrest: Adult—1mg every 3-5min IVP *Pediatric—0.1mg/kg                  Bradycardia: Adult—1mg in 250cc NS infused at 2mcg/min
                     IV/IO/ET (1:1000) then 0.2mg/kg every 3-5 min IV/IO/ET (1:1,000)                *Pediatric—0.01mg/kg (1:10,000) IVP
                     subsequent doses
                                                                                                     Anaphylaxis: (refractory to NS Bolus) Adult 0.1mg 1:10,000
                     Allergic reactions: Adult—0.3mg 1:1,000 SQ *Peds 0.01 mg/kg (1:1,000)           followed by 1mg in 250cc NS infused at 2mcg/min.*Peds
                     SQ                                                                              0.01mg/kg IV 1:10,000
                     Asthma: Adult 0.3mg (1:1,000) SQ, *Peds 0.01mg/Kg (1:1,000) SQ
                     Croup/Epiglottitis: Peds: 5mg of 1:1000 (5 cc) neb undiluted; if< 10kg –
                     0.5mg/kg (1:1000) nebulized
Fentanyl             Pain from isolated extremity injury, burns, or appropriate medical problem.     Any single or cumulative dose >100mcg
                     Adult and Peds: 1-2 mcg/kg IV up to 100mcg
Furosemide (Lasix)   Cardiogenic pulmonary edema - Adult: 20-80 mg slow IVP
Glucagon             Hypoglycemia without IV access Adult: 1.0 mg IM, *Peds: .0.1mg/kg IM            Beta blocker/Ca++ Channel blocker OD Adult: 2 mg IV, *Ped
                     (max. dose 1mg)                                                                 0.1mg/kg (max. dose 1mg)
Haloperidol          Chemical restraint: Adult: 5 – 10 mg IM                                         Contact base if desired effect not achieved in 10 minutes
Ipratropium          Bronchospasm: Adult: 0.5mg in 2.5 cc NS neb. *Peds over 2 y/o: 0.5mg in
(Atrovent)           2.5 cc NS neb. ONE TIME DOSE ONLY
IV Solutions         Bolus: 1 at 20cc/Kg         Challenge: up to 2 of 250ccs NS                     Contact base if additional fluid may be needed.
Magnesium Sulfate    Cardiac arrest: Adult only—2gm SIVP                                             Respiratory or Torsades: Adult only—2 grams SIVP
                                                                                                     Pre-eclampsia/eclampsia: 6 g in 50cc NS over 15-30 minutes
Methylprednisolone   Anaphylaxis & severe asthma/COPD Adult: 125mg IV, *Peds: 2mg/kg IV
Metoclopramide       Intractable vomiting: Adult-10 mg slow IV push over 1-2 minutes or IM, ;
(Reglan)             Peds-8-12 years 5mg slow IV push or IM. Do not give in children under 8.
Midazolam (Versed)   Cardioversion: Adults 1-5 mg IV/IM; Status epilepticus: Adults: 1-5 mg IM
                     only; *Peds: 0.1mg/kg IM only, max. dose 10mg
Morphine Sulfate     Adult: 2 - 10 mg IV. Initial dose up to 4 mg, then 2 mg increments up to a      Adults after initial 10 mg, all indications.
                     total of 10 mg., all indications; *Peds: 0.1 mg - 0.2 mg/kg IV slowly

Naloxone             Adult 2mg; may repeat x 1 p 5 min * Ped < 8yrs 1mg. Pt must be transported
                     if med is used.
Nitroglycerin        CP cardiac origin or pulmonary edema: One 0.4mg tab or SL spray q 5 min         More than 3 doses; if BP is <100 systolic prior to administrati
                     up to 3x                                                                        if poor perfusion or hypertension (crisis)
Oral Glucose         Hypoglycemia or AMS w/ history of hypoglycemia/diabetes Adult and peds:
                     one tube
Phenylephrine 1%     2 drops prior to intubation
Racemic Epi          For life-threatening airway obstruction from croup or epiglottitis. Neb only,
                     0.5 ml in 2 ml NS, all ages
Sodium Bicarbonate   Prolonged cardiac arrest or dialysis patient in cardiac arrest (presumed        Tricyclic overdose with objective findings- ) Adult and Peds:
                     hyperkalemia) Adult and Peds: 1mEq/kg; Neonate – dilute 1:1 with NS             1mEq/kg; Neonate – dilute 1:1 with NS
Topical Ophthalmic   2 drops in affected eye once during transport                                   For additional dose

                                                                     IX-205
Denver Metro Paramedic Protocols

Anesthetics




                                   IX-206
Denver Metro Paramedic Protocols

Appendix D


                                                                                                Trip number #

                        REFUSAL OF AMBULANCE TRANSPORT AND TREATMENT

                                                INFORMATION SHEET

                                         PLEASE READ THIS DOCUMENT!



The Emergency Medical Services personnel of _                                  agency have given this form to you
because you have refused treatment or transportation to the hospital.

Your health and safety are our primary concerns. Even though you have decided not to accept our offer of treatment or
transport to the hospital, please remember the following:

        1.       We recommend that you be evaluated and treated by a physician.

        2.       Your decision to refuse treatment and transport by ambulance may result in delay, which may result in
                 worsening of your condition.

        3.       Medical evaluation or treatment may be obtained by calling your personal physician or by going to
                 any hospital emergency department.

        4.       You may change your mind about using ambulance transport. Please do not hesitate to contact us.
                 We will not hesitate to return to assist you.

        5.       Do not wait! When medical or trauma treatment is needed, it is usually better to get it sooner rather
                 than later.


                                             DIAL 9-1-1 IF YOU NEED
                                         EMERGENCY MEDICAL SERVICES!




_________________________________                                       __________________________________________
Date and Time                                                                                        Patient signature




_________________________________                           Base contact:      _____Yes
EMT / EMT-I / EMT-P                                                            _____No

                                                            Physician contacted and hospital:



                                                            Time of contact:


                                                       IX-207
Denver Metro Paramedic Protocols




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

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

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

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

The Emergency Medical Services Division of the Colorado Department of Health hereby determines that the following
information shall be recorded and preserved by each Prehospital care EMS service in the State on each patient cared
for:
1.               Patient name, if known, as complete as possible and ideally including full first and last name.
2.               Patient residential address, if known, as complete as possible (to allow medical or public health
                 follow up, if needed).
3.               Patient sex (both for purposes of identification and to facilitate diagnosis and treatment).
4.               Patient age, as accurate as possible (both for purposes of identification and to facilitate diagnosis and
                 treatment).
5.               Patient location at time of response and apparent cause of the injury or nature of illness (to assist in
                 subsequent diagnosis and treatment).
6.               Patient condition at time of response, including a preliminary assessment of the patient based on vital
                 signs, apparent symptoms, and known medical history.
7.               Patient vital signs at time emergency medical care is begun, to include respiratory rate, pulse rate,
                 blood pressure, level of consciousness, and pupil size and reaction to light. Subsequent vital signs
                 shall be recorded at least every 15 minutes when either treatment or transport time exceed 15 minutes.
8.               Known patient history related to the apparent illness or injury, including allergies and medications. If
                 it is determined that the patient is on medication of any kind, the prescribing physician should be
                 identified, if possible, so he/she may be contacted for confirmation, consultation, or actual care of the
                 patient.
9.               Treatment rendered to the patient at the scene and during transport, in sufficient detail to permit the
                 receiving facility (i.e., hospital, clinic, etc.), physician advisor, and any other reviewing physician or
                 nurse to determine the nature and extent of treatment rendered.
10.              Patient's apparent condition upon delivery to the receiving facility, and any pertinent comments
                 regarding changes in the patient's condition during transport (to assist the receiving physician in
                 diagnosis and treatment).
11.              Identity and location of the receiving facility and signature or other indication of the physician or
                 nurse receiving the patient and assuming responsibility for the care of the patient.
12.              Full name and level of training and certification or licensure of each member of the EMS crew caring
                 for the patient.
13.              Times of dispatch and departure to the emergency scene, time of arrival at the scene, time of departure
                 from the scene, and time of arrival at the receiving facility.
14.              Indication of whether emergency lights and siren were used enroute to the scene and/or during
                 transport.

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




                                                        IX-208
Denver Metro Paramedic Protocols

Appendix F
                                            TRIAGE/MCI TEMPLATES

                                                 Simple Triage Template




                                                                           MCI




                                              Triage Area



       Green                                                                           Black


                           Yellow                                            Red
                                                                                      LZ




                                                    Supply
                                   <------------------------------------- < Ingress
                                                                                      _
                                   >------------------------------------- > Egress


                                                        Diagram C-1
(continued on next page)




                                                        IX-209
Denver Metro Paramedic Protocols

Appendix E                            TRIAGE/MCI TEMPLATES
                                      Moderate Triage Template




                                                           MCI



                                      Triage Area
  Green                                                                       Black




                           Yellow                            Red




                                                                         _
                                                                        LZ




                                         Supply




                             Egress                       Ingress



                                                                    Staging


                                            Diagram C-2
(continued on next page)




                                            IX-210
Denver Metro Paramedic Protocols

Appendix E                                   TRIAGE/MCI TEMPLATES
                                             Complex Triage Template




 Bus                                                                                Coroner’s Van


                                                                 MCI
       Green                                                                              Black




                                              Triage Area




                           /
                           Yellow
                                                                       \   Red
                                                                                          LZ



                                                                                          _
                                                    S
                                                    u
                                                    p
                                                    p
                                                    l
                                                    y




               ∨                                  Ingress                          ∨
         Egress                                                                  Egress

                                              >
                                                            <
                                   Staging                       Staging


                                                   Diagram C-3




                                                  IX-211

								
To top