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					Texoma EMS
 Patient Treatment Protocols




            Fifth Edition
          Revised May 2001
                                                       Table of Contents


Trauma Protocols:
     Introduction..........................................................................................................................1
     Initial Scene Survey .............................................................................................................2
     Decision to Attempt Resuscitation ......................................................................................3
     Initial Trauma Assessment and Treatment ..........................................................................4
     Traumatic Arrest ................................................................................................................10
     Traumatic Shock ................................................................................................................11

          Penetrating Injuries
                 Truncal Wounds.....................................................................................................12
                 Neck Wounds.........................................................................................................13
                 Head/Face Wounds ................................................................................................14
                 Isolated Extremity Wounds....................................................................................15

          Impaled Objects .................................................................................................................16
          Sucking Chest Wound........................................................................................................17
          Traumatic Brain Injury ......................................................................................................18

          Eye Injuries
                 Corneal Burns and Abrasions ................................................................................19
                 Blunt or Penetrating Eye Injuries...........................................................................20
                 Chemical Injuries to Eye........................................................................................21

          Burn
                     Thermal Burns .......................................................................................................22
                     Chemical Burns......................................................................................................24
                     Electrical Burns / Electrocutions ...........................................................................25

          Amputation ........................................................................................................................26
          Isolated Musculoskeletal and Soft Tissue Injuries ............................................................28
          Pain Control .......................................................................................................................29
          Geriatric Trauma................................................................................................................31
          Domestic Violence Document ...........................................................................................33
          Pregnant Trauma Patient....................................................................................................35
          Pediatric Trauma................................................................................................................37




                                                                                                                                             ii
                                               Table of Contents - continued


Medical Protocols:
      Abdominal Pain .................................................................................................................44
      Allergic Reaction
             Allergic Reaction - Mild ........................................................................................45
             Allergic Reaction - Moderate ................................................................................46
             Anaphylaxis ...........................................................................................................47
      Altered Mental Status ........................................................................................................48
      Behavioral/ Emotionally Disturbed ...................................................................................49
      Cardiovascular Emergencies
             Cardiac Arrest
                         Cardiac Arrest ............................................................................................50
                         Asystole .....................................................................................................51
                         Pulseless Electrical Activity ......................................................................52
                         VF / Pulseless VT ......................................................................................53
                         Post Resuscitation ......................................................................................54
             Cardiac Arrhythmias
                         Bradycardia ................................................................................................55
                         Narrow Complex Tachycardia: Stable.......................................................56
                         Wide Complex Tachycardia (VT): Stable .................................................57
                         Unstable Tachycardia ................................................................................58
             Chest Pain - Suspect MI.........................................................................................59
             CHF and Pulmonary Edema ..................................................................................60
             Cardiogenic Shock .................................................................................................61
             Hypotension / Shock - unexplained .......................................................................62
             Hypertensive Crisis................................................................................................63
             Stroke .....................................................................................................................64
      Diabetic Emergencies ........................................................................................................65
      Environmental Emergencies
             Carbon Monoxide Poisoning .................................................................................66
             Heat Cramps / Exhaustion .....................................................................................67
             Heat Stroke ............................................................................................................68
             Hypothermia ..........................................................................................................69
             Near Drowning.......................................................................................................70
             Radiation Exposure................................................................................................71
             Snakebite................................................................................................................72
      Overdose / Poisoning .........................................................................................................73
      Respiratory Emergencies
             Asthma ...................................................................................................................74
             COPD.....................................................................................................................75
             Pneumonia / Bronchitis..........................................................................................76
      Seizures ..............................................................................................................................77
      Sexual Assault....................................................................................................................78




                                                                                                                                           iii
                                               Table of Contents - continued

OB/GYN Protocols:
     Vaginal Bleeding ...............................................................................................................79
     Pre-eclampsia / Eclampsia .................................................................................................80
     Labor ..................................................................................................................................81
     Delivery .............................................................................................................................82
             Complications of Delivery
                         Breech Presentation ...................................................................................84
                         Cord Presentation.......................................................................................85
                         Limb Presentation ......................................................................................86


Pediatric Protocols:
       Post Delivery......................................................................................................................87
       Neonatal Resuscitation ......................................................................................................88
       Meconium Staining............................................................................................................89
       Cardiac Arrest
              Cardiac Arrest ........................................................................................................90
              Asystole .................................................................................................................91
              PEA ........................................................................................................................92
              VF / Pulseless VT ..................................................................................................93
              Post Resuscitation ..................................................................................................94
       Cardiac Arrhythmias
              Bradycardia ............................................................................................................95
              Narrow Complex Tachycardia: Stable...................................................................96
              Wide Complex Tachycardia: Stable ......................................................................97
              Unstable Tachycardia ............................................................................................98
       Allergic Reaction
              Allergic Reaction - Mild ........................................................................................99
              Allergic Reaction - Moderate ..............................................................................100
              Anaphylaxis .........................................................................................................101
       Altered Mental Status ......................................................................................................102
       Hypoglycemia ..................................................................................................................103
       Environmental Emergencies
              Hyperthermia .......................................................................................................104
              Hypothermia ........................................................................................................105
              Near Drowning.....................................................................................................106
       Overdose Poisoning .........................................................................................................107
       Respiratory Emergencies
              Asthma .................................................................................................................108
              Bronchiolitis.........................................................................................................109
              Croup....................................................................................................................110
              Epiglottitis............................................................................................................111
              Obstructed Airway - Foreign Body .....................................................................112
       Seizures ............................................................................................................................113




                                                                                                                                            iv
                                            Table of Contents - continued

Appendix:
     Air Evacuation Protocol....................................................................................................... I
     Automated External Defibrillation .....................................................................................II
     Dopamine Dosage Chart ................................................................................................... III
     Glasgow Coma Score........................................................................................................ IV
     Intraosseous Needle Insertion.............................................................................................V
     On-Board Drugs................................................................................................................ VI
     Pediatric Drug Chart ........................................................................................................ VII
     Pediatric General Guidelines ........................................................................................... VII
     Rectal Administration Protocol ......................................................................................VIII
     Revised Trauma Score ...................................................................................................... IX
     Rule of Nines - Adult..........................................................................................................X
     Rule of Nines - Child ........................................................................................................ XI
     Transcutaneous Pacing .................................................................................................... XII




                                                                                                                                    v
Trauma Protocols
                                                                                          Trauma


                                       Trauma Protocols

                                            Introduction

The initial assessment and treatment of a trauma patient must be performed in a rapid, systematic,
and thorough fashion. Evaluation of the patient according to established priorities will help one to
identify serious life-threatening situations quickly, so that intervention can take place, possibly
preventing further deterioration in the patient’s status. The systematic evaluation of the trauma
patient should be performed on all injured patients, even those with minor trauma.

The most important priorities in the evaluation and treatment of the trauma patient are found in the
primary survey of the patient. Frequently, patient assessment must occur simultaneously with
patient treatment during this phase of the patient’s evaluation. At times, invasive procedures (e.g.,
intubation with in-line cervical stabilization) or initiation of rapid transport may be required before
the complete, overall patient assessment is achieved.

The primary survey in a trauma patient includes assessment and treatment of the following:

1.     Airway          Evaluation, establishment, and maintenance of an airway using C-spine
                       precautions; determination of the patient’s level of consciousness in order
                       to provide additional information concerning the patient’s airway status.

2.     Breathing       Determination of whether or not a trauma patient is adequately breathing
                       and oxygenating. Serious chest injuries may rapidly progress to cardio-
                       respiratory arrest, and certain chest injuries may require immediate
                               intervention (sucking chest wounds, tension pneumothorax, etc.).

3.     Circulation     Determination if a pulse is present, controlling external bleeding, and
                       identification of injuries that may cause significant blood loss. Initiation of
                       rapid transport and intravenous fluids play a role in the treatment of the
                       patient at this stage.

4.     Disability      Performance of a rapid neurological evaluation to establish a patient’s level
                       of consciousness, and pupillary size and reaction.

5.     Exposure        The clothing is removed to identify all injured areas with special care to
                       avoid hypothermia.




                                 MINIMIZE ON-SCENE TIME




                                                                                                     1
                                                                                          Trauma

                                      Initial Scene Survey

Definition: This protocol should be used in the initial assessment of the scene where a trauma
patient is located.

1.     Survey the scene for possible hazards and resurvey periodically.

2.     Protect yourself first, then victims from hazards (do not become a victim).

3.     Identify mechanism of injury.

4.     Identify all potential patients.

5.     Prioritize patients, if more than one, using the same ABC system. If multiple severely
       injured patients are present with inadequate resources, leave cardiac arrest victims until last.

6.     Secure the scene.




                                                                                                     2
                                                                                           Trauma

                             Decision To Attempt Resuscitation

The following are guidelines regarding the decision to attempt resuscitation in the field. Good
judgment and common sense shall be used in the application of these guidelines.

1.     In all situations where there is any possibility that life exists, every effort should be made to
       resuscitate the patient and transport to the hospital.

2.     The paramedic should be aware of the following facts:

       a.      That persons in VF, PEA, and asystole can potentially be resuscitated. These
               rhythms are however associated with a uniformally bad outcome especially in the
               face of blunt trauma. If there are multiple victims, and some do not manifest these
               specific rhythms, efforts are best spent on these victims if manpower issues exist.
       b.      That “time down” is an inaccurate parameter of resuscitation, as the patient could
               have been in bradycardia or simply unconscious for all of that time, yet still
               perfusing blood to the brain. Additionally, information received from bystanders in
               regard to time is often inaccurate.
       c.      That pupil size and response to light can be inaccurate as medications taken orally
               or intraocularly can affect them. Additionally, children and hypothermic patients
               may have fixed and dilated pupils from anoxia and yet be resuscitated without
               neurological deficit.

3.     Resuscitation need not be attempted in the field in cases of:

       a.      Decapitation.
       b.      Decomposition.
       c.      Rigor mortis.
       d.      Dependent lividity.
       e.      Visual massive trauma to the brain or heart conclusively incompatible with life.
       f.      Patients with a blunt mechanism of injury who have a cardiac arrest have minimal, if
               any, chance of survival and many pre-hospital providers do not attempt resuscitation.

4.     Mass Casualty Incidents - In these situations, the acceptable triage protocol will apply.

5.     Living Wills - The paramedic’s actions should not be changed by a Living Will described or
       produced by the family or bystanders.

6.     Decisions to not transport must be approved through MEDICAL CONTROL.




                                                                                                      3
                                                                                          Trauma

                        Initial Trauma Assessment and Treatment

Definition: This protocol is to be used for establishing priorities in the initial assessment and
treatment of trauma patients. The trauma patient must be evaluated and treated in a rapid and
orderly fashion in order to achieve the best patient outcome. When a treatable problem is identified,
treatment is initiated for that problem before proceeding with the next step in the protocol. Using
this approach, life-threatening injuries are identified and treated in a stepwise manner.

                                              NOTE

1.     Assume the following in ALL severely injured patients.

       a.      The patient has a spinal injury until proven otherwise.
       b.      The patient has an immediate threat to life that has not yet been found.
       c.      The patient is going to decompensate at any moment.

2.     The only aspects of patient care that, in most cases, would be performed prior to the
       initiation of patient transport include:

       a.      Establishing/ maintaining an adequate and appropriate airway with oxygenation and
               ventilation as required.
       b.      Immobilize and protect the spine as indicated and required.
       c.      Initial attempts to control significant external hemorrhage.

I.     AIRWAY:

Basic and First Responders:
1.     Assess level of consciousness. Remember there may exist medical reasons for an altered
       mental status such as hypoglycemia, narcosis and treat per local protocols.

2.     Assess, establish, and/or maintain an adequate airway, while also observing C-spine
       precautions. Apply cervical collar if indicated (all serious trauma) and while doing so, note:

       a.      Is trachea midline?
       b.      Any bruising, swelling, or crepitus in the neck?
       c.      Is carotid pulse present? If no pulse present, begin CPR and immediately refer to
               Traumatic Arrest Protocol.

3.     Insert oral or nasopharyngeal airway as indicated. Remember facial trauma may be a
       contraindication for placement of nasopharyngeal devices such as a nasal trumpet.

4.     Administer high flow oxygen (100% by face mask or BVM) and assist patient’s ventilation
       as needed. If the patient has a decreased level of consciousness, ventilate at 20 breaths/min
       for adults and larger children and at 30 breaths/min for children less than 4 years of age. If
       the patient has a decreased level of consciousness or other signs of a traumatic brain injury,
       see Traumatic Brain Injury Protocol after completing the Initial Trauma Assessment and
       Treatment Protocol.

                                                                                                   4
                                                                                         Trauma

                Initial Trauma Assessment and Treatment - continued

5.     Reassess patient frequently including adequacy of ventilations.

Intermediate and Paramedic:
6.    Establish need for in-line endotracheal intubation. Remember prior to intubation, to be
      sure medical reasons for altered mental status have been addressed such as
      hypoglycemia, narcosis and treat with D50 and/or narcan when indicated as this may
      sometimes obviate the need for intubation itself. Observe C-spine precautions.

7.     If intubation is necessary, it should be performed using the two-man technique with one
       person stabilizing the cervical spine while the other person performs the intubation.
       Extreme care must be taken to avoid flexion or extension of the neck.

8.     If intubation is performed, endotracheal tube placement should be assessed and documented
       using the following techniques:

       a.     Visualization of endotracheal tube passing through vocal cords.
       b.     Equal breath sounds.
       c.     Rise and fall of chest wall.
       d.     CO2 in exhalation gas by end-tidal CO2 monitor (if available but strongly encouraged
              to be part of intubation equipment whether colorimetric or electronic).

       If the tube cannot be confirmed in the proper position, it should be removed and the patient
       reintubated. When proper placement is confirmed, the tube should be properly secured to
       minimize the chances of dislodgment.

9.     Reassess patient’s airway/ventilation status frequently.

10.    If intubation cannot be performed and the patient needs his airway managed, refer to section
       on Cricothyrotomy. Contact MEDICAL CONTROL.

11.    NOTE: Failure to provide and maintain an adequate airway is the most common cause of
       preventable pre-hospital morbidity and mortality. The airway should be carefully assessed
       initially and frequently reassessed to assure a competent airway is maintained during the pre-
       hospital phase of treatment. If there is any doubt about the adequacy of the airway (either
       the patient’s natural airway or a previously placed artificial airway), endotracheal intubation
       should be performed or repeated.




                                                                                                    5
                                                                                     Trauma

               Initial Trauma Assessment and Treatment - continued

II.   BREATHING:

Basic and First Responders:

1.    Observe chest wall movement for symmetry and auscultate breath sounds on both sides of
      the chest. Rate, depth, and pattern of breathing as well as the integrity of the chest wall
      should be assessed.

2.    Assist or deliver ventilations as required. All patients with a decreased level of
      consciousness should be ventilated at a rate of about 20 per minute for adults and larger
      children and at 30 breaths/min for children less than 4 years of age.

3.    All patients with more than minor injuries (e.g., isolated extremity fractures, minor
      lacerations, etc.) Should receive supplemental 100% oxygen by face mask or BVM.

4.    If sucking chest wound has been identified, apply dressing as described in Open Chest
      Wound Protocol.

Intermediate and Paramedic:

5.    If patient is breathing inadequately, assist ventilations with 100% oxygen through bag-valve
      mask or endotracheal tube.

6.    If signs of tension pneumothorax are present, contact MEDICAL CONTROL.




                                                                                                6
                                                                                         Trauma

                Initial Trauma Assessment and Treatment - continued

III.   CIRCULATION/ BLEEDING:

Basic and First Responders:

1.     Control serious external bleeding by direct pressure or pressure dressings.

2.     If not already done, palpate for a pulse. If not present, initiate CPR and proceed to
       Traumatic Arrest Protocol.

3.     If pulse is present, then obtain pulse rate and BP. If systolic BP < 90, heart rate > 120 bpm,
       and/or clinical evidence of shock is present, proceed to Traumatic Shock Protocol.

4.     Palpate abdomen for rigidity or tenderness and pelvis for pain or crepitus (identifying
       potential sources for significant blood loss).

5.     Examine the patient’s back, if possible, for gross deformities or penetrating injuries prior to
       placing the patient on the backboard. Maintain C-spine precautions prior to this maneuver.

6.     For penetrating injuries, also see Penetrating Injuries Protocol.

Intermediate and Paramedic:

7.     If there is evidence of a significant mechanism of injury, external blood loss, or evidence of
       possible pelvic or femur fracture or other significant injuries, attempt to establish 2 large
       bore IVs with NS/ LR and run wide open if patient’s blood pressure is less than 90 mmHg
       systolic. When your fluid resuscitation approaches 20 cc/kg, reassess vital signs and contact
       MEDICAL CONTROL. Otherwise, run IV at TKO rates or at the direction of MEDICAL
       CONTROL. Attempts to establish intravenous access are usually made en route but may be
       made at the scene if long transports are anticipated after consulting MEDICAL CONTROL.
       Transport should not be delayed for multiple attempts at initiation of an IV. If long
       transports are necessary, maximum volumes and flow rates should be determined by
       MEDICAL CONTROL. Pressurized infusion devices may be used. If the patient has a
       systolic BP < 90, or heart rate > 120 bpm, see Traumatic Shock Protocol.




                                                                                                    7
                                                                                            Trauma

                Initial Trauma Assessment and Treatment - continued

IV.   DISABILITY (Neurological Exam):

Basic and First Responders:

1.    Evaluate neurological status by noting the following:

      a.      Mental status/level of consciousness.
      b.      Presence/absence of movement in extremities, either spontaneously or in response to
              pain.
      c.      Pupillary size and reactivity.
      d.      Evidence of trauma to the head or neck.

2.    If evidence of head trauma, have suction ready and observe for any seizure activity.

3.    If altered level of consciousness, assist or ventilate patient at rate of 20, if patient will allow.

4.    If evidence of closed head injury, see Traumatic Brain Injury Protocol.




                                                                                                        8
                                                                                         Trauma

                 Initial Trauma Assessment and Treatment - continued

V.     EXPOSE AND EXAMINE:

Basic and First Responders:

1.     Examine for specific injuries - burns, chemicals, drowning, eye, etc. If present, see specific
       protocol.

2.     Assess extremities by inspection and palpation for present of tenderness, gross deformity,
       soft tissue swelling, lacerations, or abrasions. Also, note motor, sensory, and vascular
       integrity in each extremity. Appropriately dress and splint extremity injuries as required and
       as time will allow. Elevate injured extremities when possible.

3.     If possible, when patient is log rolled onto backboard, palpate and inspect back for evidence
       of trauma.

4.     Calculate Revised Trauma Score and Glasgow Coma Score.


                                               NOTE

The patient’s status must be reassessed at frequent intervals to detect any changes, and these changes
should be immediately reported to MEDICAL CONTROL. The ABC’s including vital signs should
be repeated every 5 minutes in potentially unstable patients and more frequently, if possible, in
unstable patients.




                                                                                                    9
                                                                                        Trauma

                                       Traumatic Arrest

Definition: This protocol should be used for the treatment of a patient who has suffered a traumatic
cardiac arrest. Patients with a blunt mechanism of injury and who have a cardiac arrest have
minimal, if any, chance of survival, and many prehospital providers do not attempt resuscitation. For
those providers who attempt resuscitation, the following protocol should be used. Resuscitation
should be attempted in all patients with a penetrating injury.

Basic and First Responders:

1.     If not already done, evaluate/treat ABC’s according to Initial Trauma Assessment and
       Treatment Protocol.

2.     Initiate CPR and prepare for rapid transport. Immobilize spine, if appropriate.

Intermediate and Paramedic:

3.     Intubate using in-line cervical spine stabilization, if appropriate. If applicable, in your
       specific EMS System, alternative airway modalities can be used if traditional Intubation
       itself is unsuccessful.

4.     Identify correctable causes of hypoxia and initiate treatment:

       a.      Administer 100% oxygen.
       b.      For sucking chest wounds, treat according to Sucking Chest Wound Protocol.
       c.      For tension pneumothorax, consider decompression if local protocols permit.

5.     Attempt to establish 2 large bore IVs with NS/ LR and run wide open. Attempts at IV access
       should be made en route but can be attempted at the scene. Transport should not be delayed
       for multiple attempts at initiation of an IV. If long transports are necessary, maximum
       volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized
       infusion devices may be used.

6.     Apply ECG electrodes and determine cardiac rhythm.

7.     If rhythm other than PEA, treat cardiac arrhythmia per protocol during transport.

8.     Continue evaluation as per Initial Trauma Assessment and Treatment Protocol.

       Note: PEA in a trauma patient is most likely due to hypovolemia from blood loss.
       Definitive therapy is usually required to stop the source of hemorrhage and blood
       transfusions are needed usually ASAP. Hence rapid extrication and transport is essential.
       Remember that NS/ LR helps expand the circulating blood volume BUT DOES NOT
       CARRY OXYGEN.

                                 MINIMIZE ON-SCENE TIME



                                                                                                  10
                                                                                        Trauma

                                       Traumatic Shock

Definition: This protocol should be used for the treatment of patients with traumatic shock (systolic
BP < 90 or heart rate > 120 bpm) but with a palpable pulse. If no pulse is palpable, proceed to
Traumatic Arrest Protocol. Frequently, shock in a trauma patient is due to internal or external
bleeding (i.e., hemorrhagic shock). Hemorrhagic shock can be recognized by hypotension,
tachycardia, diaphoresis, pallor, cyanosis, tachypnea, and other clinical signs of shock.

Basic and First Responders:

1.     If not already done, evaluate/treat ABC’s according to Initial Trauma Assessment and
       Treatment Protocol.

2.     Prepare for rapid transport.

Intermediate and Paramedic:

3.     If indicated, intubate the patient using C-spine precautions.

4.     Attempt to establish 2 large bore IVs with NS/ LR and run wide open. Attempts at IV access
       should be made en route but may be attempted at the scene. Transport should not be delayed
       for multiple attempts at initiation of an IV. If long transports are necessary, maximum
       volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized
       infusion devices may be used.

5.     Apply ECG electrodes and determine cardiac rhythm.

6.     Continue evaluation as per Initial Trauma Assessment and Treatment Protocol.

       Note: -Fluid resuscitation in children is performed according to weight. See special
             considerations in pediatric protocols.
             -Definitive therapy is usually required to stop the source of hemorrhage and blood
             transfusions are needed usually ASAP. Hence rapid extrication and transport is
             essential. Remember that NS/ LR helps to expand the circulating blood volume BUT
             DOES NOT CARRY OXYGEN.

                                 MINIMIZE ON-SCENE TIME




                                                                                                  11
                                                                                        Trauma

                                     Penetrating Injuries

Definition: Any injury in which there is evidence for penetration of the skin by an object that could
result in injury to underlying structures. Examples include gunshot wounds, stab wounds, ice pick
wounds, impaled objects, sucking chest wounds, etc. Other protocols may apply in cases of
penetrating injuries, such as traumatic shock, traumatic arrest, etc. Refer to all of the appropriate
protocols that apply.


                            General Guidelines: Truncal Wounds
                        (Chest, Abdomen, Back, Proximal Extremities):

Basic and First Responders:

1.     Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.     Prepare for rapid transport, even if vital signs are stable.

3.     If impaled object - do not remove (see Impaled Object Protocol).

4.     Treat open chest wounds according to guidelines for sucking chest wounds (see Sucking
       Chest Wounds Protocol).

5.     Treat evisceration of abdominal contents by covering the tissue with saline-moistened gauze
       sponges or sterile towels. DO NOT try to replace abdominal contents through the wound.

Intermediate and Paramedic:

6.     Attempt to establish 2 large bore IVS with NS/ LR and run at appropriate rate per local
       protocol or contact MEDICAL CONTROL. Attempts at IV access should be made en route
       but may be attempted at the scene. Transport should not be delayed for multiple attempts at
       initiation of an IV.

                                 MINIMIZE ON-SCENE TIME




                                                                                                  12
                                                                                    Trauma

                                    Penetrating Injuries

                              General Guidelines: Neck Wounds

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. Maintain
      high index of suspicion for C-spine injury, tracheal injury, blood vessel injury, and lung
      injury.

2.    Prepare for rapid transport, even if vital signs are stable.

3.    If impaled object - do not remove (see Impaled Object Protocol).

4.    Monitor closely for signs of soft tissue swelling in the neck that could lead to airway
      obstruction.

5.    Have suction set up and ready to clear airway of blood or secretions.

6.    Observe closely for signs of a tension pneumothorax.

Intermediate and Paramedic:

7.    Attempt to establish 2 large bore IVs and NS/ LR and run at appropriate rate per local
      protocol or contact MEDICAL CONTROL. Attempts at IV access should be made en route
      but may be attempted at the scene. Transport should not be delayed for multiple attempts at
      initiation of an IV.

8.    Prophylactic intubation may be required if airway compromise from neck swelling is
      suspected or occurs. Consult MEDICAL CONTROL if necessary. For this particular trauma
      scenario, contact MEDICAL CONTROL prior to initiation of either RSI or cricothyrotomy
      protocols.

                                MINIMIZE ON-SCENE TIME




                                                                                              13
                                                                                    Trauma

                                    Penetrating Injuries

                           General Guidelines: Head/Face Wounds

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. Maintain
      high index of suspicion for C-spine injury, tracheal injury, and/or blood vessel injury.

2.    Prepare for rapid transport, even if vital signs are stable.

3.    If impaled object - do not remove (see Impaled Object Protocol).

4.    Have suction set up and ready to clear airway of blood or secretions.

5.    Elevate head of backboard 15 to 30 degrees - DO NOT elevate head by flexing neck!

Intermediate and Paramedic:

6.    Attempt to establish 2 large bore IVs with NS/ LR and run at appropriate rate per local
      protocol or contact MEDICAL CONTROL. Attempts at IV access should be made en route
      but may be attempted at the scene. Transport should not be delayed for multiple attempts at
      initiation of an IV.

7.    Prophylactic intubation may be required if airway compromise from neck swelling is
      suspected or occurs. Consult MEDICAL CONTROL if necessary. For this particular trauma
      scenario, contact MEDICAL CONTROL prior to initiation of either RSI or cricothyrotomy
      protocols.


                                MINIMIZE ON-SCENE TIME




                                                                                              14
                                                                                       Trauma

                                    Penetrating Injuries

                       General Guidelines: Isolated Extremity Wounds


Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. Check
      neurovascular status distal to wound (presence of pulse, feeling, movement).

2.    If impaled object - do not remove (see Impaled Object Protocol).

3.    Control external bleeding with direct pressure first, then pressure dressings.

4.    Splint affected extremity in position found without “straightening” body part involved.

5.    Prepare for rapid transport, even if vital signs are stable.

Intermediate and Paramedic:

6.    If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or
      wound close to trunk or thigh area, attempt to establish 2 large bore IVs with NS/ LR and run
      at appropriate rate per local protocol or contact MEDICAL CONTROL. Attempts at IV
      access should be made en route but may be attempted at the scene. Transport should not be
      delayed for multiple attempts at initiation of an IV.




                                                                                                 15
                                                                                        Trauma

                                       Impaled Objects

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.    In general, do not remove impaled object. If impaled object is causing airway compromise
      resulting in respiratory distress, and this distress cannot be corrected without removal of the
      foreign body, remove the foreign body immediately and contact MEDICAL CONTROL
      immediately for further orders.

3.    When possible, stabilize the impaled object on the body so that it does not move around and
      cause more internal injury.

4.    Any impaled object to the torso (chest, abdomen, back, lower neck, or proximal extremities)
      should be considered a potentially life-threatening injury and treated as such. Transportation
      should be initiated as soon as possible, even if the patient appears stable.

5.    If manpower is available and time exists during transport, continue further evaluation and
      treatment of patient according to Initial Trauma Assessment and Treatment Protocol.

Intermediate and Paramedic:

6.    If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or
      wound close to trunk or thigh area, attempt to establish 2 large bore IVs and NS/ LR and run
      at appropriate rate per local protocol or contact MEDICAL CONTROL. Attempts at IV
      access should be made en route but may be attempted at the scene. Transport should not be
      delayed for multiple attempts at initiation of an IV.

                               MINIMIZE ON-SCENE TIME




                                                                                                  16
                                                                                    Trauma

                                     Sucking Chest Wound

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.    Seal the wounds as rapidly as possible, preferably with an occlusive dressing such as
      Vaseline-coated gauze, to prevent further collapse of the lung.* In general, the dressing
      should be sealed on two or three sides only. This allows it to act as a one-way valve
      allowing air in the pleural space (chest cavity) to get out when the lung expands, but
      preventing air on the outside from entering the chest cavity through the wound.

3.    Watch closely for signs and symptoms of a tension pneumothorax. If these signs develop,
      usually lifting one corner of the occlusive dressing will relieve the tension pneumothorax.

4.    Prepare for rapid transport.

5.    As time allows and manpower permits, continue evaluation and treatment of the patient
      according to Initial Trauma Assessment and Treatment Protocol.

Intermediate and Paramedic:

6.    Attempt to establish 2 large bore IVs and NS/ LR and run at appropriate rate per local
      protocol or contact MEDICAL CONTROL. Attempts at IV access should be made en route
      but may be attempted at the scene if approved by MEDICAL CONTROL. Transport may
      not be delayed for multiple attempts at initiation of an IV.

      *Note: If patient is awake and cooperative, have him/her cough (this removes as much of the
      air as possible from the chest cavity), and then apply the Vaseline gauze immediately
      afterwards.




                                                                                              17
                                                                                       Trauma

                                   Traumatic Brain Injury

Definition: Any traumatic injury to the face or head which results in an injury to the brain, as
manifested by some degree of impairment in mental function. Typically, these patients range from
being comatose to wild and combative.

Basic and First Responders:

1.     Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. Maintain
       high index of suspicion for C-spine injury. Provide supplemental oxygen.

2.     If patient is hypoventilating, assist or provide ventilations (with supplemental oxygen) at a
       rate of 20 per minute.

3.     Have suction hooked up and readily available. Be prepared to roll patient, if necessary,
       should vomiting occur.

4.     Take seizure precautions.

5.     Prepare for rapid transport.

6.     Elevate head of backboard 15 to 30 degrees. DO NOT try to elevate head by flexing neck!

7.     Consider other causes of decreased mental status, such as hypoglycemia, narcosis and
       prepare to treat per local protocols.

Intermediate and Paramedic:

8.     Appropriate airway management may require endotracheal intubation while observing C-
       spine precautions. If patient is unconscious or has decreased LOC without a gag reflex,
       endotracheal intubation with in-line cervical spine stabilization and ventilation should be
       performed to control the airway. Remember to check for medical reasons for altered mental
       status (hypoglycemia, narcosis). Consider Lidocaine at 1 mg/ kg IVP which can be
       administered 30 seconds to one minute prior to intubation to help decrease the increase in
       intracranial pressure associated with intubation.

9.     Start IV with NS/ LR at TKO rate, unless hypotension, evidence of significant volume loss,
       or traumatic arrest exists - then run at appropriate rate for condition.

10.    Apply cardiac monitor (if available, monitor oxygen saturation).

11.    If seizures occur and are prolonged (greater than 15-30 seconds), administer diazepam
       (Valium) slow IV push in 2-5 mg increments (10 mg maximum for adult) until seizure stops.
       If intubation not performed prior to seizure, it should be performed after diazepam has been
       administered so that ventilation may be more effectively performed and the airway is better
       protected.



                                                                                                 18
                                                                                           Trauma

                                           Eye Injuries

                                  Corneal Burns and Abrasions

Definition: These injuries usually occur when the eye is exposed to sources of high intensity light or
ultraviolet radiation such as associated with tanning booths, or sun lamps. Also corneal injuries may
be produced by prolonged wearing of contact lenses.

Basic and First Responders:

1.     Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.     Lie patient down and have them close both eyes.

Intermediate and Paramedic:

3.     If available, and no contraindication exists (especially an allergy to topical anesthetics), have
       patient open eyes and instill two drops of a topical anesthetic for eyes (such as Alcaine) to
       the affected eye(s). Instruct patient not to rub their eyes once medication has been
       administered.

4.     Transport patient.




                                                                                                     19
                                                                                   Trauma

                                         Eye Injuries

                               Blunt or Penetrating Eye Injuries


Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.    DO NOT attempt to open the injured eye(s).

3.    Have the patient lie flat or with the head slightly elevated.

4.    Instruct the patient to close both eyes.

5.    DO NOT place any type of compressive dressing over the injured eye(s), and be careful not
      to apply any pressure to the eye.

6.    In general, DO NOT remove any penetrating object from the eye.

7.    Transport the patient.




                                                                                            20
                                                                                          Trauma

                                          Eye Injuries

                           Chemical Substances Injuries to the Eye


Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.    Flush the affected eye(s) with copious amounts of water, RL, or NS, using a minimum of 2
      liters for each eye. If the substance is alkaline in nature, perform continuous irrigation
      during transport. Contact lenses should be removed if present.

Intermediate and Paramedic:

3.    If available, and no contraindication exists, have patient open eyes and instill two drops of a
      topical anesthetic for eyes (such as Alcaine) to the affected eye(s). Instruct patient not to rub
      their eyes once medication has been administered.

4.    Transport patient.




                                                                                                    21
                                                                                        Trauma

                                              Burn

                                         Thermal Burns

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. Look
      closely for any evidence of inhalation injury (hoarseness, stridor, sooty sputum, facial burns,
      and singed facial hair). If present, provide supplemental oxygen, preferably humidified.

2.    Prepare for rapid transport, if significant burn or inhalation injury.

3.    Remove any jewelry, belts, shoes, etc. from areas of burns as these objects may retain heat
      and increase the burn; also swelling of burned areas may make subsequent removal difficult.
       In addition, remove any burned or singed clothing that is not stuck to the underlying skin of
      the patient.

4.    Assess depth of burn (first, second, third) as well as the total area of the burn (use “rule of
      nines”) or fact that palmar surface of the patient’s hand usually represents 1% of body
      surface area.

5.    Perform local burn care as follows:

      a.     Do not apply ice to burned area.
      b.     Do not apply ointments or solutions to burns.
      c.     Do not attempt to open blisters.
      d.     Small burns (<10% of BSA):

             (1)     If burn occurred less than 15 minutes prior to your arrival, cover burn with
                     sterile towels or gauze sponges soaked with cool saline, water or non-
                     menthol shaving cream - otherwise apply dry dressing.

      e.     Larger burns:

             (1)     Wear sterile gloves and mask until large burns are covered.
             (2)     Cover large burns with dry, sterile or clean sheets. Do not use wet dressings
                     since they may cause hypothermia on large burns.
             (3)     Cover patients who have large burns with additional sterile or clean sheets or
                     blankets to prevent loss of body heat.

6.    Treat any associated injuries (bandage and splint).

7.    If eyes are affected, go to Eye Injury Protocol.




                                                                                                  22
                                                                                        Trauma

                                  Thermal Burns - continued

Intermediate and Paramedic:

8.    If evidence of inhalation injury present with progressive airway compromise, prophylactic
      intubation may be required. Consult MEDICAL CONTROL.

9.    IV therapy with LR should be initiated in patients with the following:

      a.     Evidence of inhalation injury.
      b.     Elderly or underlying chronic illnesses or other associated injuries that require an IV.
      c.     Burn exceeds 10% BSA.
      d.     Electrical burns.

10.   Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA).

11.   Pain control is an adjunct to all of the above if approved by local protocols.

12.   For patients with less than 10% BSA burn and no evidence of inhalation injury, nitrous oxide
      may be used if available. Follow local protocol regarding administration. Other agents such
      as Morphine, Demerol or other narcotics can be used but their effects on hemodynamic
      parameters must be understood (see Pain Control Protocol).




                                                                                                  23
                                                                                     Trauma

                                            Burn

                                       Chemical Burns

Basic and First Responders:

1.    Refer to Initial Scene Survey Protocol for establishment of scene safety.

2.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

3.    Remove any and all clothing that has been saturated or contaminated with the chemical.

4.    If dry chemicals are present on the skin, brush them off prior to irrigation. (Contact
      MEDICAL CONTROL with name and amount of chemical as special considerations are
      needed for certain chemicals).

5.    Flush the chemical off of the body with large volumes of water or saline unless a
      contraindication to irrigation with water exists. (e.g., sodium metal generates tremendous
      heat when exposed to water.) Contact MEDICAL CONTROL if unsure of chemical.

6.    If chemical burns involve the eyes, flush with copious amounts of water, RL, or NS using a
      minimum of 2 liters for each eye. If the substance is alkaline in nature, perform continuous
      irrigation during transport. Contact lenses should be removed, if present.

7.    If thermal burn is present, follow thermal burn protocols also.

Intermediate and Paramedic:

8.    For chemical burns to the eyes, apply two drops of a topical anesthetic to eyes (such as
      Alcaine), if available, and irrigate profusely, unless a contraindication exists.




                                                                                               24
                                                                                     Trauma

                                             Burn

                              Electrical Burns and Electrocutions

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.    Cover entrance and/or exit wounds with dry sterile dressings.

3.    Splint any fractures or deformities as required.

Intermediate and Paramedic:

4.    Apply cardiac monitor and determine rhythm. Refer to appropriate arrhythmia protocol as
      required.

5.    Start IV with NS/ LR and run TKO unless hypotension or clinical evidence of shock exists -
      then run WO for first liter.

6.    For moderate to severe pain, allow self administration of nitrous oxide, if available and no
      contraindications.




                                                                                               25
                                                                                       Trauma

                                          Amputation

Definition: This protocol applies to patients who have any isolated extremity amputation.

Basic and First Responders:

1.     Evaluate patient according to Initial Trauma Assessment and Treatment Protocol.

2.     Control bleeding with direct pressure or pressure points. Tourniquet is used only as a last
       resort.

3.     Remove gross contaminants on part by rinsing with saline solution. No other attempt should
       be made to debride the part.

4.     Wrap amputated part in moistened saline gauze and place in plastic bag or container (sterile,
       if available). Seal the plastic tightly, so fluid cannot come in contact with the amputated
       part. Place sealed container in iced solution of water or saline.

Intermediate and Paramedic:

5.     Initiate IV NS/ LR if indicated.

6.     Contact MEDICAL CONTROL.

7.     Administer nitrous oxide, if available. Follow local protocol regarding administration.
       Refer to Pain Control Protocol.


Field Amputation Considerations

If the patient cannot be extricated or moved and this is due to extremity entrapment, then consider:

1.     Refer to local protocols and if none exists then consider early activation of an amputation
       team. This team will usually consist of a trauma surgeon and one assistant. This specialized
       team can be activated in a number of ways.

       a.      Existing agreement with local hospital entity.

       b.      If no such agreement exists, then contact the NCTTRAC Communications Center for
               assistance.

Contraindications for field amputation activation:

       Patient is undergoing CPR at scene.




                                                                                                 26
                                                                                        Trauma

                                    Amputation - continued

Considerations for Re-Implantation of amputated body parts:

Certain Hospitals hold themselves out to be available and possessing the expertise for re-
implantation of amputated extremities. Initial Trauma Assessment and Treatment Protocols must be
adhered to primarily. An amputated body part should not distract our attention away from basic
protocols. Remember, if bleeding is controlled at the amputation site, then re-implantation can occur
some hours later. After routine protocols have been followed for care of the injured patient, and
there does exist evidence of an amputated extremity:

1.     Contact the NCTTRAC Communication Center for assistance.

2.     Diversion of a patient to such a center should not take precedent over basic field
       resuscitation protocols. If necessary the patient should be taken to the closest appropriate
       facility first and transfer can be arranged later.




                                                                                                  27
                                                                                       Trauma

                   Isolated Musculoskeletal and Soft Tissue Injuries

Definition: Isolated musculo-skeletal/ soft tissue injury, such as unstable fracture or severe crush
injury, with no potential head, abdominal, chest, or multi-system injuries. Mechanism of injury
consistent with an isolated musculoskeletal injury; deformity, swelling, or ecchymosis to the injury
site; pain present on movement or palpation of injury site.

Basic and First Responders:

1.     ABC's with C-spine control.

2.     Control external bleeding.

3.     Oxygen per patient.

4.     Vital signs, including SpO2.

5.     Appropriately splint/ immobilize.

Intermediate:

6.     IV NR/ LR if:

       a.       Open fracture.
       b.       Closed femur fracture.
       c.       Hypotensive or other signs of hypo-perfusion.

Paramedic:

7.     ECG if IV initiated.

8.     Administer pain medications (see Pain Control Protocol) for severe distress or if patient
       continues to have severe distress after immobilization.

9.     Promethazine:                                         12.5 mg IVP, repeat once as needed
                                                             for severe nausea/ vomiting

10.    Contact MEDICAL CONTROL.




                                                                                                 28
                                                                                         Trauma

                                          Pain Control

Definition: This is probably a unique topic in pre-hospital discussions, but with the fact that many
of our patients for various reasons may have prolonged transport times, it should be discussed. This
section involves more of an understanding of the various agents available and less procedure driven
protocols. This section also requires intimate oversight by the Medical Director as well as ongoing
monitoring of its use.

Basic and First Responders:

1.     Assess ABC’s and level of consciousness.

Intermediate and Paramedic:

1.     Continue ABC’s.

2.     Ensure that the patient is conscious and can validate drug allergies or reactions.

3.     If it appears that the patient is experiencing pain compatible with his injury pattern contact
       MEDICAL CONTROL prior to administering any analgesics.

Contraindications:

1.     Any evidence of the shock state being present (hypotension, poor tissue perfusion, etc.)
2.     Known allergies to the agent to be used for analgesia.
3.     Altered level of consciousness not previously addressed (hypoglycemia, etc.)

Choice of agents:

There are multiple agents, which can be used, as well as multiple agents which must be avoided.
Narcotics in the trauma patient should be avoided as these agents can cause hypotension,
tachycardia, apnea, and confusion. Another class of drugs that have some application are the
benzodiazepines. Though classically not included as analgesics, they are amnestic agents and
sedatives. These might include Valium, Ativan, and Versed. This class of drug can cause
hypotension and respiratory depression. They can to a certain extent be reversed with Romazicon.
The other available agents include Nitrous Oxide, an inhaled agent with analgesic qualities. This
drug can cause myocardial depression and must be self administered by the patient himself.
Contraindications include barotrauma (pneumothorax, penetrating or blunt abdominal trauma).
Despite the above discussion, there may exist some situations where medical control may want to
utilize one or more of these agents (transfer of stabilized patient from one facility to another). The
choice and dose of these agents must be made in concert with an online Medical Control Physician.




                                                                                                   29
                                                                                      Trauma

                                 Pain Control - continued

Drug Dosing Guidelines:

a.      Morphine Sulfate:                                   2 mg IVP increments

b.      Valium:                                             2 mg IVP increments

c.      Ativan:                                             1 mg IVP increments

d.      Promethazine:                                       12.5 mg IVP increments

e.      Toradol:                                            30 mg IVP

f.      Nubain:                                             5 mg IVP increments

NOTE:         repeat vital signs every 5 minutes prior to further administration of any
              medication.




                                                                                               30
                                                                                         Trauma

                                       Geriatric Trauma

With the ever-increasing percentage of the adult population in this country entering their 6th and 7th
decade of life, we will see a disproportionate amount of trauma in these age groups. It is obvious
that we must look at this unique population with certain caveats related to the pre-hospital
management of the traumatized older patient. These patients should be given the same
considerations afforded any victim of trauma, age not considered. This should include appropriate
triage and hospital destination (i.e. appropriate trauma center utilization).

In order to accomplish this in an orderly fashion, we will identify certain pathophysiologic facts
unique to this age group. This adult population is living longer and remaining more active in many
activities to include driving motor vehicles, swimming, etc. This group of patients are not just
“grayer” adults.

1.     The geriatric trauma victim will average three chronic medical problems.

2.     The average number of medications taken on a continual basis in this age group is four.

3.     Any one or combination of these above facts can dramatically alter these patient’s
       response(s) to a traumatic event. Some of the important points to consider:

       A.      The usual hemodynamic parameters used to monitor volume status are altered. Pulse
               and blood pressure measurements may be misleading as they may be taking
               medications, which change their responses. Beta blockers and Calcium channel
               blockers will decrease both pulse and blood pressure and hence when volume
               depleted, as in hemorrhage, these parameters may not respond in the usual way
               (increase in pulse and decrease in blood pressure). Even drugs used for glaucoma
               can have a similar effect.
       B.      Many of these patients are on “blood thinners” such as coumadin, Lovenox, aspirin,
               Plavix, Ticlid, and others. These agents and their desired effects may have a
               deleterious effect if blood loss is suspected.
       C.      This group of patients have a high incidence of endocrine disorders. This might
               include diabetes and thyroid disorders. These disease states may alter their ability to
               conserve heat and hence pre-dispose them to hypothermia in the face of trauma. This
               effect can be very deleterious. Hypoglycemia is not uncommon and its presentation
               may mimic those of the head-injured individual.
       D.      This population may also remain active even in the presence of “neuropsychiatric”
               disorders such as dementia, diabetes, which may mimic the presentation of that of a
               head injured patient when they may indeed be hypoglycemic or demented.
       E.      This population might include those with cardiovascular disease. They might have
               marginal cardiovascular reserves and hence any deviation from this (blood loss)
               might result in worsening cardiovascular instability. Fluid resuscitation may, even in
               “normal” dosing, push the geriatric victim into volume overload. It is far better to be
               aggressive with fluid resuscitation to correct fluid loss than to withhold fluids and
               compromise their hemodynamic stability. Hypotension, whether from volume loss
               or sudden heart failure, may promote further pump failure and myocardial ischemia.



                                                                                                   31
                                                                                         Trauma

                                Geriatric Trauma - continued

       F.      Anatomical changes of importance include cervical spine arthritis, osteoporosis, and
               thinning skin (epidermis). These entities may have a dramatic impact on how issues
               such as the airway might be managed (cervical spine immobility); effect of CPR with
               respect to iatrogenic thoracic fractures (rib fractures) and predisposition to
               hypothermia. Falls, so common in this age group, even trivial, may have significant
               morbidity. Hip fractures, spinal column fractures, and skull fractures occur with a
               higher incidence than that seen in the younger age group victims.
       G.      Spinal immobilization techniques may need to be altered. Some of these individuals
               cannot tolerate being totally supine so tilting of the backboard in a “head up”
               position might be necessary.
       H.      There exist some issues we should be aware of at all times in the geriatric trauma
               victim. They frequently have certain disabilities we must respect such as hard of
               hearing, visual impairment, and others. Knowledge of these facts may assist one in
               their assessment of issues which might otherwise make us think the patient is
               “altered” as a result of his trauma.
       I.      Remember this category of patient has requirements for pain management just like
               the non-geriatric patient. The requirements for analgesic agents may need to be
               altered to lower doses however.
       J.      Remember with the ever-increasing percentage of the total population being
               classified as geriatrics, there is known to be a disproportionate number of these to be
               victims of abuse as the cause of their trauma. Appropriate action (reporting) should
               be undertaken.

With these considerations in mind, certain recommendations are warranted in the geriatric trauma
victim. After review of these recommendations, the usual pre-hospital protocols should be utilized.

1.     Short field times are essential.
2.     Liberal use of oxygen.
3.     Clear the airway to include removal of dentures.
4.     Keep patient warm, even if warm ambient temperature.
5.     Maintain a low threshold for transportation to a trauma center.
6.     Maintain index of suspicion for elder abuse.
7.     With no delay in transport times, attempt to get a medication list from family as these
       medications may alter the victim’s response to trauma itself.




                                                                                                   32
                                                                                          Trauma

                                Domestic Violence Document

The document below should be used as a tool for EMS Medical Directors to build a policy regarding
domestic violence reporting and procedural issues.

In accordance with “Sec. 91.003 Information Provided by Medical Professions” of the Family Code
of the Texas Criminal and Traffic Law

A medical professional who treats a person for injuries that the medical professional has reason to
believe were caused by family violence shall:

1.     Immediately provide the person with information regarding the nearest family violence
       shelter center:

2.     Document in the person’s medical file:

       A.      the fact the person received the information provided under subdivision (1); and the
               reasons for the medical professional’s belief that the person’s injuries were caused by
               family violence; and

3.     Give the person a written notice in substance the following form, completed with the
       required information, in both English and Spanish:

NOTICE TO ADULT VICTIMS OF FAMILY VIOLENCE

It is a crime for any person to cause you any physical injury or harm even if that person is a member
or former member of your family or household. You may report family violence to a law
enforcement officer by calling the following telephone numbers: ____________________. If you,
your child, or any other household resident has been injured or if you feel you are going to be in
danger after a law enforcement officer investigating family violence leaves your residence or at a
later time, you have the right to ask the local prosecutor to file a criminal complaint against the
person committing family violence; and to apply to a court for an order to protect you. You may
want to consult with a legal aid office, a prosecuting attorney, or private attorney. A court can enter
an order that: (1) prohibits the abuser from committing further acts of violence; (2) prohibits the
abuser from threatening, harassing, or contacting you at home; (3) directs the abuser to leave your
household; and (4) establishes temporary custody of the children or any property.

A VIOLATION OF CERTAIN PROVISIONS OF COURT-ORDERED PROTECTION MAY BE A
FELONY. CALL THE FOLLOWING VIOLENCE SHELTERS OR SOCIAL ORGANIZATIONS
IF YOU NEED PROTECTION: ________________________________

Leg.h. Stats. 1997 75th Leg. Sess, Ch. 34, effective May 5, 1997.

Sec. 91.004. Application of Subtitle.
This subtitle does not affect a duty to report child abuse under Chapter 261. Leg. H. Stats. 1997 75th
Leg. Sess., Ch. 34, effective May 5, 1997.
                          Domestic Violence Document - continued

                                                                                                    33
                                                                                            Trauma


Sec. 92.001. Immunity.

(a) Except as provided by Subsection (b), a person who reports family violence under Section
    91.002 or provides information under Section 91.003 is immune from civil liability that might
    otherwise be incurred or imposed.
(b) A person who reports the person’s own conduct or who otherwise reports family violence in bad
    faith is not protected from liability under this section. Leg. H. Stats. 1997 75th Leg. Sess. Ch. 34,
    effective May 5, 1997.

The NCTTRAC encourages each pre-hospital entity to direct the appropriate persons to assistance
groups within the area. The EMT or Paramedic will make use of this information when the need
arises. The EMT or Paramedic will promptly notify law enforcement officials when a family
violence, domestic assault, or child abuse case is suspected. The EMT or Paramedic is responsible
for directly reporting this information to law enforcement officials at the time of call.




                                                                                                      34
                                                                                          Trauma

                               The Pregnant Trauma Patient

It is felt that this represents such a unique patient population in which there are many unusual
nuances and hence some physiologic facts should be understood. The following protocol
recommendations are primarily for the blunt trauma gravid as all the other protocols contained in
this document would apply to her as they are written. Fetal viability should not be assessed in the
field.

In order to adequately care for the mother and unborn child that have been traumatized, one MUST
be aware of the following facts:

1.     The average maternal heartbeat will increase by 10 to 15 beats per minute when compared
       to the nonpregnant patient.

2.     The systolic and diastolic blood pressure of the pregnant patient will often decrease by 10 to
       15 mmHg in the second trimester of pregnancy and then return to normal by term.

3.     The pregnant patient undergoes a significant increase in circulating blood volume - about 40
       to 50%. This represents an increase in both plasma and red blood cells. However, there is
       usually a greater increase in plasma compared to the increase in red blood cells, thereby
       resulting in a relative anemia for many pregnant patients.

4.     The pregnant patient may lose 30 to 45% of her circulating blood volume before hypotension
       develops hence signs of the shock state occur later in the process than in the non gravid state.

5.     When the pregnant patient is lying flat on her back, the enlarged uterus can cause significant
       compression of the inferior vena cava, thereby reducing venous return to the heart by up to
       25 or 30%. This can then result in hypotension. Therefore, when possible, pregnant patients
       should be transported in the left lateral decubitus position. If it is necessary to immobilize
       the patient supine, then the backboard should be tilted upward 20 to 30 degrees towards the
       patient’s left. This will help to roll the pregnant uterus away from the inferior vena cava.

6.     Gastric emptying and motility are decreased during pregnancy. This, combined with the
       compressive effects of the enlarging uterus on the stomach, increases the risk of aspiration in
       patients with a decreased level of consciousness.

7.     Trauma to the pregnant patient can result in very significant amounts of OCCULT bleeding
       - either intrauterine or retroperitoneal.

8.     Abruptio placenta is the leading cause of traumatic fetal death. Vaginal bleeding is seen in
       about 75% of cases.

9.     Maternal hemorrhage that does not result in decreased blood pressure can still reduce fetal
       blood flow by 90 to 95%. Trauma significant enough to cause shock in the mother is
       associated with a fetal mortality of about 75%.




                                                                                                    35
                                                                                     Trauma

                       The Pregnant Trauma Patient - continued

Basic and First Responders:

1.    Evaluate patient according to Initial Trauma Assessment and Treatment Protocols. These
      protocols should recognize this unique patient population and reference some
      pathophysiologic variations.

2.    If patient is hypoventilating, assist or provide ventilations (such as with supplemental
      oxygen).

3.    If signs or shock are present (remember the changes noted in the pregnant state with regards
      to blood pressure and pulse), place patient in the left lateral decubitus position with
      appropriate cervical spine precautions and roll the back board to 20-30% of tilt.


Intermediate and Paramedic:

4.    If indicated, intubate the patient using c-spine precautions.

5.    Attempt to establish 2 large bore IV’s of LR/ NS and run at rate decided by local protocol.
      The end point of this fluid resuscitation is changed, as the vital signs in the gravid are
      different. Her resting pulse is 10-15 higher than in the non-gravid and her blood pressure
      will be 10-15 mmHg less than in the non-gravid state.

6.    There should be no internal vaginal exams performed in the field.

7.    Transport as quickly as possible.




                                                                                               36
                                                                                          Trauma

                                       Pediatric Trauma

Definition:

1.     Intended for the use in pediatric trauma patients who are less than 13 years of age or 45 kg.
2.     Consider activation of air transport as soon as possible if in a rural or suburban areas for
       transport to a Pediatric Trauma Facility. This should not delay the transport of the injured
       pediatric patient.
3.     PRIMARY SURVEY – PAT – Pediatric Assessment Triangle can be completed in 30 seconds
       and identify critical patients by assessing appearance, work of breathing and circulation to
       the skin.

A.     Airway Assessment for stridor, debris, obstruction by tongue and C-spine alignment.

Basic and First Responders:

1.     Open airway using the jaw thrust while maintaining C-spine stabilization.

2.     Assess airway patency and suction as needed.

3.     Consider insertion of OPA in an unconscious patient or NPA in a semiconscious patient with
       no signs of head trauma. Remember, insertion of an oral pharyngeal airway in pediatrics is
       different from adults as it is introduced into the mouth in its final position and not “rotated”
       as done in adults.

Intermediate and Paramedic:

4.     None.

PEARLS:

1.     Smaller upper and lower airways. Infant’s tracheal diameter is approximately the diameter
       of the little finger of the pediatric patient.
2.     Infants are obligate nose breathers for the first several months of life and any obstruction of
       the nose could impair respirations.
3.     Tongue is larger in proportion to the mouth and could possibly obstruct the airway.
4.     Cartilage of the larynx is softer and can be compressed with hyperextension or hyperflexion
       and lead to airway obstruction.
5.     The cricoid cartilage is the narrowest part of the larynx and provides a natural seal for un-
       cuffed ETT in children less than 8 years of age. (5.0 ETT size or less)
6.     Provide shoulder support in infants to help maintain airway and cervical immobilization.




                                                                                                    37
                                                                                          Trauma

                                Pediatric Trauma - continued

B.     Breathing assessment for retractions, nasal flaring, or grunting.

Basic and First Responders:

1.     Apply oxygen at 10-15 lpm via non-rebreather facemask.

2.     Assist breathing with BVM, adequate ventilations indicated by chest rise.

Intermediate and Paramedic:

3.     Intubation if indicated with in-line cervical stabilization.

4.     Note ETT tube depth and immediately secure tube.

5.     If unable to intubate after three attempts and able to bag effectively, transport with BVM
       support.

PEARLS:

1.     By 8 years of age, the child respiratory anatomy is comparable to that of an adult.
2.     Do not attempt blind nasotracheal intubation in pediatric patients that are less than 8 years of
       age or with a suspected basilar skull fracture.




                                                                                                    38
                                                                                         Trauma

                                Pediatric Trauma - continued

C.     Circulation assessment of pulse quality and rate, capillary refill time, skin color, and
       temperature.

Basic and First Responders:

1.     If pulse is absent and child appears to show no signs of perfusion, start CPR.

Intermediate and Paramedic:

2.     Establish 2 large bore intravenous lines. IV attempts should not delay the transport of the
       patient to a Trauma Facility. Administer a 20 cc/kg bolus of LR/ NS and then run line to
       keep open.

3.     If the patient remains tachycardic (refer to chart of heart rates) or exhibits signs of poor
       perfusion (delayed cap refill, cool-mottled extremities) administer 20 cc/kg of LR/ NS.

4.     Reassess after bolus. If patient remains symptomatic, contact MEDICAL CONTROL for
       orders to administer another 20 cc/kg bolus of LR/ NS.

NOTE: If after 90 seconds or 3 attempts at gaining intravenous accesses without success, consider
intraosseous placement if the patient displays signs of hemodynamic compromise!!

PEARLS:

1.     Circulating blood volume is 80 – 85 cc/kg.
2.     A small blood loss can cause circulatory compromise.
3.     Capillary refill is a key assessment as to the adequacy of circulation. This value should be
       three seconds or less.
4.     Administer fluid bolus according to weight.
5.     Heart rate, cap refill, central/ peripheral pulses best indicator of child’s cardiac status.

D.     Disability assessment for level of consciousness, neurological status, pupil size and reaction.

Basic and First Responders:

1.     AVPU.

Intermediate and Paramedic:

2.     Consider medical causes for decreased level of consciousness (i.e., hypoglycemia, drug
       effects (narcotics).

PEARLS:
1.   If calculating GCS, use pediatric Glasgow Scale.



                                                                                                   39
                                                                                       Trauma

                                 Pediatric Trauma - continued

4.     SECONDARY SURVEY – should be conducted to identify other injuries but should not delay
       the transport of the patient to a Trauma Facility. The secondary survey should include serial
       assessment of the primary survey and treatment modified as indicated.


E.     Expose the patient so that a thorough head-to-toe assessment can be performed.

PEARLS:

1.     Infants and young children have an increased body surface ratio and therefore a larger area
       for heat loss.
2.     Hypothermia in the pediatric trauma patient can lead to CNS depression, respiratory
       depression, metabolic acidosis and hypoglycemia. This is why it is imperative to protect the
       pediatric patient from hypothermia.

F.     Fahrenheit.

Basic and First Responders:

1.     Cover the patient, keep them warm.

2.     Keep head covered/ warmed in infants at all times.

3.     Remove wet/ bloody clothing if possible.

Intermediate and Paramedic:

4.     Warmed IV fluids (if available).

G.     Get a full set of vital signs.

Basic and First Responders:

1.     Obtain apical heart rate for initial pulse.

2.     Obtain blood pressure with appropriate sized cuff.

3.     Respirations to include rate and quality.

PEARLS:

1.     Full set of serial vital signs is important to reassessment.
2.     Hypotension is a late sign of shock.
3.     Consider oximetry as the 5th vital sign.



                                                                                                 40
                                                                                         Trauma

                                Pediatric Trauma - continued

H.     Head-to-toe assessment.

1.     General appearance assessment.

       a.      Reaction to caregiver or family members.
       b.      Presence of unusual odors.
       c.      Position and alignment of head, trunk and extremities.
       d.      Stiffness, rigidity, posturing or flaccidity.

2.     Head/ Face/ Neck assessment (limit exam to 30-60 seconds).

       a.      Anterior and posterior fontanels in infants to assess for bulging.
       b.      Pupillary reaction to light and symmetry.
       c.      Raccoon’s eyes (may indicate basilar skull fracture that is greater than 12 hours old).
       d.      CSF drainage from the ears or nose (does indicate a basilar skull fracture).
       e.      Battle’s sign.
       f.      Bony deformities and facial symmetry.
       g.      Tracheal deviation.
       h.      Petechia to neck or face.
       i.      Subcutaneous emphysema.
       j.      Open or closed soft tissue swelling.

PEARLS:

Increased amount of soft tissue in the neck area, which if edematous can lead to airway compromise.

3.     Chest assessment.

       a.      Rate and depth of respirations.
       b.      Use of accessory muscles and abdominal muscles.
       c.      Paradoxical chest wall movement.
       d.      Breath sounds equal with symmetrical chest wall excursion.
       e.      Heart sounds.
       f.      Rib cage integrity.
       g.      Subcutaneous emphysema.
       h.      Open or closed soft tissue swelling.

PEARLS:

Children’s ribs are pliable; therefore, pulmonary or cardiac injuries may be present without chest
wall deformity.




                                                                                                   41
                                                                                         Trauma

                                 Pediatric Trauma - continued

4.     Abdominal assessment.

       a.      Rigidity, tenderness, guarding or distension.

PEARLS:

1.     The liver and spleen are disproportionately larger than in adults and more exposed leading to
       increased proneness for injury.
2.     The abdomen is the most frequent site of injury causing shock.
3.     Many pediatric patients with abdominal injuries have no immediate signs or complaints.


5.     Pelvis and Genitalia assessment.

PEARLS:

Pelvic fractures in pediatrics can cause massive blood loss.


6.     Extremities assessment.

       a.      Angulation or deformity. Splint in position found if pulses adequate.

PEARLS:

1.     Bones are more flexible in the pediatric patient. Suspect a fracture in patients with decreased
       range of motion and point tenderness, even if there is no swelling or deformity.
2.     Long bone fractures may result in large blood loss relative to the pediatric patients blood
       volume.


7.     Posterior Assessment.

       a.      Should be accomplished when the patient is logrolled, while maintaining C-spinal
               stabilization.
       b.      Inspect and palpate the posterior for any evidence of trauma.


8.     The primary survey should be repeated as part of the secondary survey and modified as
       needed.




                                                                                                   42
                                                                                         Trauma

                                  Pediatric Trauma - continued

Normal Pediatric Vital Signs:

1.     Systolic blood pressure:              80 + two times age in years

2.     Heart rate taken while child calm (crying child will have elevated pulse rate):

              Newborns (< 6 weeks)                  120 – 160
              Infants (7 weeks – 1 year)            80 – 140
              Toddler (1 – 2 years)                 80 – 130
              Preschool (2 – 6 years)               80 – 120
              School age (6 – 13 years)             60 – 100

3.     Respirations:

              Newborns                              30 – 50
              Infants                               20 – 30
              Toddler                               20 – 30
              Preschooler                           20 – 30
              School age                            20 – 30

4.     Estimated Pediatric Endotracheal Tube Sizes:

              Newborn                               2.5 - 3.0*
              6 months                              3.5*
              1 year                                4.0*
              2-3 years                             4.0 - 4.5*
              4-5 years                             5.0 - 6.0*
              6-8 years                             6.0 - 6.5*
              10-12 years                           6.5 - 7.0
              > 14 years                            7.5 - 8.5

              * un-cuffed ETT should be used on pediatric patients that are 8 years and younger.




                                                                                                  43
Medical Protocols
                                                                              Medical

                                    Abdominal Pain

Definition:   Non-traumatic abdominal pain.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Oxygen per patient.

3.     VS, including SpO2.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG, 12 lead if available.

6.     For severe nausea and vomiting:

       a.     Promethazine:                          12.5 IVP or 25 mg IM
                                                     repeat once as needed
                                                     start with lowest dose

7.     Contact MEDICAL CONTROL.




                                                                                        44
                                                                          Medical

                                  Allergic Reaction - Mild

Definition:   urticaria, itching, without dyspnea or hypotension.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV, Saline lock.

Paramedic:
5.   ECG, 12 lead if available.

6.     Benadryl:                                           25 mg IVP or
                                                           50 mg IM

7.     Contact MEDICAL CONTROL.




                                                                                    45
                                                                                   Medical

                               Allergic Reaction - Moderate

Definition: urticaria, itching, dyspnea without hypotension.
Note: if significant wheezes, see Asthma Protocol.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     EPIPEN, if available.                              0.3 mg IM

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, 12 lead if available.

7.     Epinephrine (1:1,000):                             0.5 mg SQ

8.     Benadryl:                                          25 mg IVP or
                                                          50 mg IM

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Repeat Epinephrine (1:1,000):               0.3 mg SQ

       b.     If patient has moderate to severe dyspnea, meds may be given prior to IV access.

       c.     Dexamethasone:                              8 mg IVP

              OR

              Methylprednisolone:                         125 mg IVP




                                                                                             46
                                                                                      Medical

                                        Anaphylaxis

Severe reaction:      urticaria, edema, dyspnea and hypotension (BP < 90 systolic).
Note: if significant wheezes, see Asthma Protocol.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     EPIPEN, if available.                              0.3 IM

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, 12 lead if available.

7.     Epinephrine (1:10,000):                            0.5 mg slow IVP

8.     Benadryl:                                          25 mg IVP or
                                                          50 mg IM

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Repeat Epinephrine (1:10,000):              0.5 mg slow IVP

       b.     Dexamethasone:                              8 mg IVP

              OR

              Methylprednisolone:                         125 mg IVP




                                                                                                47
                                                                                     Medical

                        Altered Mental Status: Unknown Etiology

Definition: Unresponsive or disoriented patient without a clear mechanism for altered mentation.
Refer to appropriate protocols as needed (ie., diabetes, head injury, etc.)

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

5.     Glucose testing, if < 60:

       a.     D50:                                          25 g IVP

Paramedic:
6.   ECG, 12 lead if available.

7.     Contact MEDICAL CONTROL.

       If unable to secure airway and pupils pinpoint or respiratory depression:

       a.     Narcan:                                       2 mg IVP
                                                            to improve respiratory rate only
                                                            may repeat




                                                                                               48
                                                                                    Medical

                          Behavioral/ Emotionally Disturbed


1.   Assess patient, scene, and contact control hospital.

2.   Treat life-threatening injuries.

3.   Assess the situation and call for law enforcement support. If the patient appears dangerous,
     has lethal weapons, or seems in danger of losing control, or has violent disruptive or self-
     destructive impulses, the law enforcement personnel may aid in providing the necessary
     physical restraints.

4.   Approach the patient in a direct, honest manner:

     a.     Maintain continuous contact with the patient.

     b.     Encourage the patient to discuss situational stresses.

     c.     Check for emotional instability (mood swings), paranoid delusions, and depression.

5.   Avoid restraining the patient, if possible, but once restraints are applied, DO NOT remove
     until accepted by receiving facility.

6.   Treat non-life-threatening injuries as the patient allows.




                                                                                              49
                                                                                 Medical

                                      Cardiac Arrest

Definition:   Unresponsive, no respirations, no pulse.

Basic and First Responders:
1.     Assess ABC's.

2.     AED, as soon as available.

3.     CPR.

4.     Maintain airway with best available adjunct and ventilate with 100% O2.

Intermediate:
5.    IV NS/ LR.

6.     Endotracheal Intubation.

Paramedic:
7.   Refer to appropriate protocol:
            Asystole
            PEA
            VF and Pulseless VT

8.     Contact MEDICAL CONTROL.




                                                                                           50
                                                                                       Medical

                                             Asystole

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   CPR.

2.     Confirm asystole in two leads.

3.     Measure SpO2.

4.     Intubate and ventilate with 100% O2.

5.     IV NS/ LR.

6.     Consider and treat possible causes:

              Hypoxia
              Acidosis
              Overdose
              Diabetic reaction
              Hyperkalemia
              Hypokalemia
              Hypothermia

7.     TCP (external pacing), highly recommended if available.

8.     Epinephrine (1:10,000):                                1 mg IVP or 2 mg ET
                                                              Repeat every 3 - 5 min

9.     Atropine:                                              1 mg IVP or 2 mg ET
                                                              Repeat every 3 - 5 min
                                                              MAX 0.04 mg/kg

10.    Contact MEDICAL CONTROL.

       Consider:

       a.     SpO2 may help confirm tube placement and adequate ventilations.

       b.     Withholding or ceasing resuscitative efforts.




                                                                                                 51
                                                                                       Medical

                                 Pulseless Electrical Activity
                                            (PEA)

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   CPR.

2.     Intubate and ventilate with 100% O2.

3.     IV NS/ LR, WO to 500 cc.

4.     Consider and treat cause:

              Hypovolemia                     “Tablets” (OD)
              Hypoxia                         Tamponade, cardiac
              Hydrogen ion – acidosis         Tension pneumothorax
              Hyper- / Hypokalemia            Thrombosis, coronary/ pulmonary
              Hypothermia

5.     Epinephrine (1:10,000):                                1 mg IVP or 2 mg ET
                                                              Repeat every 3 - 5 min

6.     If bradycardic (HR < 60):

              Atropine:                                       1 mg IVP
                                                              Repeat every 3 - 5 min
                                                              MAX 0.04 mg/kg

7.     Contact MEDICAL CONTROL:




                                                                                                 52
                                                                                   Medical

                                    VF or Pulseless VT

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   CPR with 100% O2.

2.     ECG, quick look with paddles.

3.     Defib: 200j, 300j, 360j.

4.     Intubate and ventilate with 100% O2.

5.     IV NS/ LR.

6.     Epinephrine (1:10,000):                            1 mg IVP or 2 mg ET
                                                          repeat every 3 - 5 min
       OR

       Vasopressin                                        40 units IVP
                                                          Single dose only

7.     Defib: 360j within 30 - 60 seconds of each administration.

8.     Consider antiarrhythmics:

       Amiodarone:                                        300 mg IVP
                                                          Consider repeat 150 mg IVP

       Magnesium Sulfate: (for Torsade de Pointes)        1 - 2 g IVP.

9.     Defib: 360j within 30 - 60 seconds of each administration.

10.    Contact MEDICAL CONTROL.

       Consider antiarrhythmics:

       a.     Lidocaine:                                  1.5 mg/kg IVP, repeat in 5 min, or
                                                          3.0 mg/kg ET
                                                          MAX 3 mg/kg IVP or ET

       b.     Procainamide:                               20 mg/min IVPB
                                                          MAX of 17 mg/kg.




                                                                                               53
                                                                                     Medical

                                     Post Resuscitation

NOTE:           If patient in bradycardia, refer to bradycardia protocol. DO NOT treat post-
resuscitation tachycardia, which can be caused by medications given during resuscitation.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG, 12 lead if available.

6.     If patient hypotensive (BP < 90 systolic) after 5 min:

       a.     Fluid challenge:                              250 cc IV NS/ LR

7.     Contact MEDICAL CONTROL.

       Consider:

       a.     Dopamine:                                     5 - 20 mcg/kg min IVPB
                                                            to raise BP > 100 systolic




                                                                                               54
                                                                                                   Medical

                                              Bradycardia

Definition: HR < 60 with one or more of the following: BP < 90 systolic, PVC’s, altered LOC,
chest pain, dyspnea.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG, 12-lead if available.

6.     Atropine:                                                    0.5 mg IVP
                                                                    Repeat every 3 - 5 min to
                                                                    MAX 0.04 mg/kg
              Use Atropine with caution in
              2nd Type II and 3rd AV blocks.

7.     TCP (external pacing) highly recommended if available.

              If 2nd   Type II or 3rd   AV block and S/S are not serious, consult physician prior to pacing.

8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Dopamine, if BP < 60 systolic:                        5 - 20 mcg/kg/min IVPB

       b.     Epinephrine, if dopamine ineffective:                 2 – 10 mcg/kg/min IVPB

       c.     Valium for pacing:                                    5 mg IVP, repeat as needed
                                                                    MAX 10 mg IVP




                                                                                                               55
                                                                                 Medical

                            Narrow complex tachycardia: stable

Definition:    BP > 90 without serious signs and symptoms.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ RL, antecubital vein.

Paramedic:
5.   ECG, 12-lead if available.

6.     Vagal maneuvers (valsalva).

7.     Adenosine:                                        6 mg rapid IVP
             *Adenosine is contraindicated in patients   Repeat at 12 mg every 1 - 2 min
               taking TEGRITOL (carbamazepine) and       MAX 30 mg
               PERSANTINE (dipyridamole).

8.     Contact MEDICAL CONTROL.




                                                                                           56
                                                               Medical

                       Wide Complex Tachycardia (VT): Stable

Definition:   BP > 90 without serious S/S.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Oxygen per patient.

3.     VS, including SpO2.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG, 12-lead if available.

6.     Vagal maneuvers (valsalva).

7.     Contact MEDICAL CONTROL.

       Consider antiarrhythmic:

       a.     Amiodarone:                         150 mg IVP




                                                                         57
                                                                                          Medical

                                      Unstable Tachycardia

Definition:   BP < 90 systolic, altered LOC, dyspnea, diaphoresis or chest pain.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG, 12-lead if available.

6.     Synchronized cardioversion:                               100j, 200j, 300j, 360j
              consider premedication with Valium, if indicated

7.     Consider antiarrhythmics.

8.     Contact MEDICAL CONTROL.




                                                                                                    58
                                                                                     Medical

                                 Chest Pain - Suspect MI

Definition:   Chest, back, neck, jaw pain indicative of myocardial ischemia, dyspnea, diaphoresis

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Complete survey of exclusion criteria for thrombolysis.

5.     Aspirin:                                            160 mg PO or 325 mg PO

6.     Nitroglycerin, if pt prescribed and HR > 60:        0.4 mg SL
                                                           Repeat every 5 min to 3 doses
Intermediate:
7.    IV, Saline Lock.

Paramedic:
8.   ECG, 12 lead recommended; early notification if infarct.

9.     Nitroglycerin:                                      0.4 mg SL
                                                           Repeat every 5 min to 3 doses

10.    Nubain:                                             5 mg IVP
                                                           Repeat every 5 min to MAX of 20 mg
       OR

       Morphine:                                           2 mg IVP
                                                           Repeat every 5 min to MAX 10 mg
11.    Contact MEDICAL CONTROL.

       Consider:

       a.     Fluid challenge with BP < 90 systolic:       250 cc Normal Saline

       b.     Promethazine (for nausea/ vomiting):         12.5 IVP or 25 mg IM
                                                           Repeat once as needed

       c.     Dopamine (symptomatic hypotension):          2 - 10 mcg/kg/min IVPB
                          < 90 systolic                    Titrate to raise BP > 100 systolic




                                                                                                59
                                                                                  Medical

                              CHF and Pulmonary Edema

Definition: Severe respiratory distress, cyanosis, diaphoresis, adventitious lung sounds, JVD,
altered LOC, chest pain.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen via BVM.

Intermediate:
4.    IV, Saline Lock.

Paramedic:
5.   ECG, 12 lead if available.

6.     Nitroglycerin:                                    0.4 mg SL
                                                         Repeat every 5 min to 3 doses

7.     Lasix:                                            0.5 mg/kg IVP
                                                         Repeat once as needed

8.     Contact MEDICAL CONTROL.

       Consider, with severe dyspnea and pulmonary edema:

       a.       Nubain:                                  5 mg slow IVP
                                                         Repeat every 5 min to MAX 20 mg
                OR

                Morphine:                                2 mg IVP
                                                         repeat every 5 min to MAX 10 mg

       Consider, with hypotension (BP < 100 systolic):

       a.       Dopamine:                                5 - 20 mcg/kg/min IVPB




                                                                                            60
                                                                             Medical

                                  Cardiogenic Shock

Definition: BP < 90 systolic in the absence of trauma, altered LOC, tachycardia or other
arrhythmias, diaphoresis, pulmonary congestion, tachypnea.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR:

Paramedic:
5.   ECG, 12 lead if available.

6.     Dopamine:                                      5-20 mcg/kg/min IVPB

7.     Contact MEDICAL CONTROL.




                                                                                       61
                                                                                      Medical

                             Hypotension / Shock - unexplained

Definition: BP < 90 systolic, with S/S: pale, cold, clammy skin, syncope, vomiting and/or diarrhea,
decreased intake and output.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

5.     Fluid challenge:                                     250 - 500 cc Normal Saline

6.     Glucose testing, if < 60:

       a.      D50:                                         25 g IVP

Paramedic:
7.   ECG, 12 lead if available.

8.     Contact MEDICAL CONTROL.

       a.      If hypotensive after 10 minutes, repeat fluid challenge.

       b.      Discontinue fluid challenge if S/S of Pulmonary Edema arise.

       c.      Second IV optional.




                                                                                                62
                                                                                      Medical

                                     Hypertensive Crisis

Definition: Systolic BP > 200 and Diastolic > 120, headache, blurred vision, numbness, chest pain.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Evaluate arm drift, facial droop, and speech impairment for stroke. If present, go to Stroke
       Protocol.

Intermediate:
5.    IV, Saline Lock.

Paramedic:
6.   ECG, 12 lead if available.

7.     Nitroglycerine:                                      0.4 mg SL

8.     Contact MEDICAL CONTROL.

       Consider:

       a.      Labetalol:                                   20 mg IVP




                                                                                                63
                                                                                     Medical

                                             Stroke

Definition:   Unilateral weakness, paralysis, facial droop, speech impairment, dizziness, syncope,
              nausea/ vomiting, seizures, apnea, blindness.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Evaluate arm drift, facial droop, and speech impairment.

5.     Determine time of onset; early notification if less than 3 hours.

6.     Complete exclusion criteria survey for fibrinolysis.

Intermediate:
7.    IV NS/ LR.

8.     Glucose testing, if < 60:

       a.     D50:                                            25 g IVP

Paramedic:
9.   ECG, 12 lead if available.

10.    Contact MEDICAL CONTROL as soon as possible.

       Consider:

       a.     Labetalol:                                      20 mg IVP




                                                                                               64
                                                                                                    Medical

                                        Diabetic Emergencies

Definition:    Symptoms related to altered blood glucose levels

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     If alert, and suspected hypoglycemia, administer Oral Glucose.

Intermediate:
5.    IV, Normal Saline.

6.     Glucose testing

       a.      if < 60 and symptomatic:

               1.        If alert, administer Oral Glucose.

               2.        If altered LOC:

                                 a.       D50:                                25 g IVP

       *advanced only*   If IV unobtainable:

                                 a.       Glucagon:                           1 mg IM

               3.        Repeat glucose testing in 3 - 5 minutes.

       b.      if > 250 and S/S of DKA:

               1.        Infuse IV NS/ LR 250 cc/hr.

Paramedic:
7.   ECG, 12 lead if available.

8.     Contact MEDICAL CONTROL.

       NOTE: Diabetic emergencies are sometimes mistaken for other illnesses (CVA, substance abuse, ETOH abuse
       or withdrawal), and vice versa. Be sure to thoroughly assess patient and treat all symptoms. If there is any
       doubt, consult medical control.




                                                                                                               65
                                                                                    Medical

                             Carbon Monoxide Poisoning

Basic and First Responders:
1.     Remove victim from source.

2.    Assess and treat ABC’s.

3.    VS, including SpO2.

4.    High flow oxygen.

Intermediate:
5.    Draw a green top tube of blood.

6.    IV NS/ LR.

Paramedic:
7.   ECG, 12 lead if available.

8.    Transport to appropriate facility. If history of loss of consciousness or pregnancy, go to
      nearest HBO facility.

9.    Contact MEDICAL CONTROL.




                                                                                              66
                                                                                                    Medical

                                   Heat Cramps - Exhaustion

Definition: Hot, humid weather and cramping in the extremities, nausea, syncope, profuse
sweating, tachycardia.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     External cooling:

       a.     Remove to cool environment.
       b.     Remove excessive clothing.
       c.     Cover with wet sheet.
       d.     Fan patient.
       e.     Ice packs around IV tubing.

              Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient.

5.     If patient is not nauseated, give fluids PO (balanced electrolyte solution).

Intermediate:
6.    IV NS/ LR.

Paramedic:
7.   ECG, 12 lead if available.

8.     Contact MEDICAL CONTROL.




                                                                                                              67
                                                                                                    Medical

                                              Heat Stroke

Definition:   absence of sweating, red skin, altered LOC, seizures, core temp > 105.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Aggressive external cooling:

       a.     Remove to cool environment.
       b.     Remove excessive clothing.
       c.     Cover with wet sheet.
       d.     Fan patient.
       e.     Ice packs to groin, axilla, and neck.
       f.     Ice packs around IV tubing.

              Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient.

Intermediate:
5.    IV NS/ LR.

6.     Glucose testing, if < 60:

       a.     D50:                                                   25 g IVP

Paramedic:
7.   If seizures:

       a.     Valium:                                                5 mg IVP, repeat as needed to
                                                                     MAX 10 mg

8.     ECG, 12 lead if available.

9.     Contact MEDICAL CONTROL.




                                                                                                              68
                                                                                      Medical

                                         Hypothermia

Mild to Moderate:     core temp of 90    - 95 , shivering, possible altered LOC.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Begin external warming:

       a.     Remove wet clothing.
       b.     Wrap in blanket.
       c.     Heat packs to groin, axilla, neck, lateral chest.
       d.     Heat packs around IV tubing.

Intermediate:
5.    IV NS/ LR.

6.     Glucose testing, if < 60:

       a.     D50:                                           25 g IVP

Paramedic:
7.   ECG, 12 lead if available.

8.     Contact MEDICAL CONTROL.

       Consider:

       b.     Nubain (pain from frostbite):                  5 mg IVP, repeat as needed
                                                             MAX 10 mg

Severe: core temp < 90 , no shivering, cyanosis, altered LOC, apnea.

       Treat as mild or moderate except, if pulseless, begin CPR. Maintain good basic life support.
       Contact MEDICAL CONTROL as to whether to begin advanced life support.




                                                                                                69
                                                                                         Medical

                                         Near Drowning

Definition: This protocol should be used for the treatment of patients who have survived, at least
temporarily, from a submersion incident. Neurologically intact survivors have been reported from
prolonged submersion in cold water. Field attempts at resuscitation should be made in these patients
in spite of initial presentation, unless submersion time can be reliably documented to be greater than
one hour and the patient has been known to have been asystolic for at least 10 minutes.

Basic and First Responders:

1.     Confirm near drowning and submersion time. If submersion is greater than one hour and the
       patient is pulseless and with no respirations, do not attempt resuscitation.

2.     Assess ABC’s and level of consciousness. If patient is pulseless and without breathing,
       proceed to Traumatic Arrest Protocol.

3.     Immobilize the cervical spine. Many near drownings involve diving injuries to the cervical
       spine.

4.     If patient is conscious with spontaneous respirations, administer high flow oxygen via non-
       rebreathing mask. Continue to monitor respirations since near drownings are associated with
       the rapid development of pulmonary edema.

5.     If patient is unconscious, assist ventilation with 100% oxygen via bag-valve-mask.

6.     Keep the patient dry and covered. Hypothermia is common with near drownings.

Intermediate and Paramedic:

7.     If the patient is unconscious, intubate the patient and support respirations with 100% oxygen.

8.     Attempt to establish 1 large bore IV with LR/ NS and run at TKO rate unless hypotension is
       present. If hypotension occurs, attempt to start another large bore IV and run both IV’s wide
       open. Transport should not be delayed for multiple attempts at initiation of an IV. If long
       transports are necessary, maximum volumes and flow rates should be determined by
       MEDICAL CONTROL.




                                                                                                   70
                                                                                        Medical

                                     Radiation Exposure

                                 Notify nearest HAZMAT team


The vast majority of accidents involving radioactive materials occur in facilities in which these
materials are used daily. In these circumstances, rescue squads should seek and follow the
professional advice that is readily available to them in these centers. For accidents involving
radioactive materials where professional guidance is unavailable, the following guidelines should be
followed:


1.     Assess scene, patient, and contact controlling hospital, who is expected to coordinate this
       care and control with law enforcement, fire control, and state agencies.

2.     If victims without serious injury are involved in the accident:

       a.      Do not enter the area suspected of having radioactive material present.
       b.      Do not permit spectators to enter the area.
       c.      Do not allow the victim(s) to leave the area.
       d.      After conferring with the emergency physician, treat the victim’s other injuries.
       e.      Notify the hospital that a patient exposed to radiation is being transported.

3.     If victims with serious injury are involved in the accident:

       a.      Treat life-threatening injuries.
       b.      Remove the patient from the hazard area as soon as possible.
       c.      Remove contaminated outer clothing and wash all exposed skin.
       d.      Obtain vital signs every 10 minutes.
       e.      Search for and treat other injuries.
       f.      Wrap the patient in a blanket.
       g.      Notify the hospital that a patient exposed to radiation is being transported.




                                                                                                   71
                                                                                       Medical

                                           Snakebite

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Keep victim quiet.

5.    Remove all jewelry and tight clothing from the affected limb which is maintained below
heart level.

6.     Treat for shock.

7.     Immobilize the affected part below heart level.

8.     If available, the dead snake should be transported to the hospital for proper identification.

Intermediate:
9.    IV NS/ LR.

Paramedic:
10.  ECG, 12 lead if available.

11.    Contact MEDICAL CONTROL.

       Consider:

       a.     Nubain:                                        5 mg IVP




                                                                                                 72
                                                                                    Medical

                                      Overdose/ Poisoning

Definition:   known/ suspected ingestion/injection/inhalation/absorption of harmful substance

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Oxygen per patient.

3.     If contact poisoning, brush off or flush with H2O NOW.

4.     VS, including SpO2.

Intermediate:
5.    IV NS/ LR:

Paramedic:
6.   ECG, 12 lead if available.

7.     If altered mentation, see Altered Mental Status Protocol.

8.     If known organophosphate poisoning:

       a.     Atropine:                                     2 mg IVP
                                                            Repeat every 5 min as needed
                                                            High dose may be required

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Charcoal:                                     50 g PO, repeat to MAX 100 g

       b.     Benadryl: (dystonic reaction)                 25 mg IVP or 50 mg IM

       c.     Sodium Bicarbonate:                           50 mEq/L IVPB, 125 cc/hr

                      tricyclic antidepressant      anti-freeze
                      lithium                       hydrofluoric acid
                      beta-blocker                  quinine
                      calcium channel blocker

       e.     If patient refuses transport and/or is in potential danger, contact MEDICAL
              CONTROL and law enforcement.




                                                                                              73
                                                                                      Medical

                                            Asthma

Definition:   Respiratory distress, wheezing on expiration, coughing, tripod positioning, accessory
muscle use.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Albuterol:                                           2.5 mg nebulized updraft
                                                            Consider continuous updraft
Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, 12 lead if available.

7.     Contact MEDICAL CONTROL.

       Consider:

       a.     Terbutaline:                                  0.25 mg SQ

       b.     Epinephrine (1:1,000):                        0.3 mg SQ

       c.     Methylprednisolone:                           125 mg IVP




                                                                                                74
                                                                                   Medical

                                          COPD

Definition:   Dyspnea with history of chronic bronchitis or emphysema.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Albuterol:                                          2.5 mg nebulized updraft
                                                           Consider continuous updraft

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, 12 lead if available.

7.     Contact MEDICAL CONTROL.

       Consider:

       a.     Terbutaline:                                 0.25 mg SQ

       b.     Methylprednisolone:                          125 mg IVP

              NOTE:          Epinephrine is not an alternate drug!




                                                                                             75
                                                                                     Medical

                                  Pneumonia / Bronchitis

Definition: Dyspnea with adventitious breath sounds and history of respiratory infection,
productive purulent cough, fever, chest wall pain, and no evidence of CHF (ie., pedal edema, JVD,
pertinent cardiac history).

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Encourage productive coughing. Suction as needed.

5.     Albuterol:                                          2.5 mg nebulized updraft
                                                           Consider continuous updraft

Intermediate:
6.    IV NS/ LR.                                           250 cc/hr

Paramedic:
7.   ECG, 12 lead if available.

8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Terbutaline:                                 0.25 mg SQ




                                                                                               76
                                                                                        Medical

                                            Seizures

Definition:   Active seizures (tonic/ clonic) or post-ictal.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV, Saline Lock.

5.     Glucose testing, if < 60:

       a.     D50:                                             25 g IVP

Paramedic:
6.   ECG, 12 lead if available.

7.     If seizures are prolonged or recurrent:

       a.     Valium:                                          5 mg IVP or rectal
                                                               Repeat, as needed, every 5 min to
                                                               MAX 20 mg

8.     Contact MEDICAL CONTROL.

       NOTE: If Valium is given to patients suspected of using alcohol, ensure and monitor
       airway.




                                                                                                   77
                                                                                        Medical

                                        Sexual Assault


1.   Assess scene, patient, contact control hospital, and contact law enforcement with patient
     permission or to protect crew safety.

2.   Treat life-threatening injuries.

3.   Offer emotional support. Concentrate history on medical aspects of the case.

4.   Search for and treat other injuries. (If possible, do not disturb the scene of assault or remove
     any clothing.)

5.   When contacting law enforcement and the control hospital, do not identify the victim by
     name. Do your utmost to protect the patient’s privacy.

6.   Before transporting the patient to the appropriate hospital, discourage them from taking a
     shower, bath or douche, brushing teeth or changing their clothing.




                                                                                                  78
OB/GYN Protocols
                                                                                   OB/GYN

                                     Vaginal Bleeding

Definition:   Non-traumatic vaginal bleeding in the absence of labor.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Oxygen per patient.

3.     VS, including SpO2.

4.     If severe bleeding, examine vaginal area and retain any tissue or clots. Place a sterile
       dressing over vaginal opening and leave loose.

Intermediate:
5.    IV NS/ LR. Increase IV rate or multiple IV’s should be established if shock is present.

Paramedic:
6.   ECG, optional.

7.     Monitor fetal heart tones > 20 weeks.

8.     For severe nausea and vomiting:

       Promethazine:                                       12.5 IVP or 25 mg IM
                                                           Repeat once as needed

9.     Contact MEDICAL CONTROL.

       a.     Consider possible causes:

              Abruptio placenta:    pain, uterine contractions, may appear to be normal labor.

              Placenta previa:      painless, bright red hemorrhaging, usually at end of second
                                    trimester.

              Spontaneous           abdominal cramps, vaginal hemorrhage, back pain, presence
              abortion:             of tissue of fetus. Do not attempt placental delivery.




                                                                                                79
                                                                                     OB/GYN

                                 Pre-eclampsia/ Eclampsia

Definition: Gestation > 20 weeks and hypertension (BP > 140 systolic, > 90 diastolic) with
peripheral edema, moderate to severe nausea/vomiting, severe headache, hyperreflexia, proteinuria.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Oxygen per patient.

3.     Assess VS, including SpO2, with patient on left side, every 5 minutes.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG.

6.     Magnesium sulfate:                                   4 g/ 50 cc over 20 min IVPB
                                                            OR 2 g IM, if unable to obtain IV

7.     Consider if seizures refractory to Mag Sulfate:

       Valium:                                              2 mg IVP, repeat to MAX 10 mg

       OR

       Ativan:                                              1 mg IVP, repeat every 5 min to
                                                            MAX 4 mg

8.     Contact MEDICAL CONTROL.

       a.      Repeat Magnesium sulfate:                    2 g IM

       b.      Labetalol:                                   10 mg IVP




                                                                                                80
                                                                                     OB/GYN

                                               Labor

Definition:   Back and/or abdominal cramping or pain with gestation > 20 weeks.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     Perform visual exam; check for crowning (if present, prepare for delivery).

3.     Oxygen per patient.

4.     VS, including SpO2.

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, optional.

7.     Monitor fetal heart tones > 20 weeks.

8.     For severe nausea and vomiting:

       Promethazine:                                       12.5 IVP or 25 mg IM
                                                           Repeat once as needed

9.     Contact MEDICAL CONTROL

       a.     Transport as soon as possible, if delivery not imminent.




                                                                                              81
                                                                                       OB/GYN

                                             Delivery

Definition:     Active labor with presentation of fetus, delivery of infant and placenta.

NOTE:           Refer to Labor Protocol to prepare patient for delivery.

All Levels:
Preparations:

1.     Open OB kit.
2.     Place mom supine with knees bent.
3.     Place clean sheet under buttocks.
4.     Put on sterile gloves, if possible.
5.     Have mom pant between contractions.
6.     Inspect for crowning.
7.     Provide supplemental Oxygen to all delivery patients.

Procedure:

1.     Monitor fetal heart tones until delivery.

2.     As crowning begins, apply gentle pressure to infant’s head (take caution of fontanelle).

3.     Continue gentle pressure as head delivers.

4.     With bulb syringe, suction infant’s mouth then nose.

5.     Check for umbilical cord around neck. If present, gently slip cord from around neck. If
       unable to slip around head, apply clamps 2" apart and cut in between, then unwrap cord from
       around neck.

6.     The infant will naturally rotate 45   for shoulder delivery.

7.     Gently guide head downward to assist shoulder delivery. Be prepared to support infant,
       delivery is quicker at this point.

8.     Suction again, mouth then nose.

9.     Note time of delivery.

10.    Dry infant and wrap infant in insulating blanket to keep warm.

11.    Clamp cord at 6" from infant and another at 2" distal from the first clamp. Cut cord.

12.    Perform APGAR scoring at 1 and 5 minutes (treat infant per score). See Pediatric Post
       Delivery Protocol.
                                 Delivery - continued

                                                                                                  82
                                                                             OB/GYN


Placenta:

1.    Placenta will deliver approximately 20 minutes after birth.

2.    If severe bleeding persists:

      a.     Treat for shock to level of training.

      b.     Gently massage abdominal area over uterus to cause contractions and placenta
             delivery.

      c.     Transport.

3.    Retain placenta and transport to hospital.




                                                                                      83
                                                                                        OB/GYN

                                    Breech Presentation

Definition:   Presentation of buttocks or feet first.

NOTE:         Best delivered in hospital, however if delivery is imminent assist as follows:

Basic and First Responders:
1.     Assess and treat ABC's.

2.     Oxygen per patient.

3.     VS, including SpO2.

5.     Procedure:
       a.    Monitor fetal heart tones until delivery.

       b.     Prepare mother for delivery as described in Delivery Protocol.

       c.     Allow fetus to deliver spontaneously up to the level of the umbilicus. If the fetus is
              in a front presentation, gently extract the legs downward after the buttocks are
              delivered.

       d.     After the legs are clear, support the baby’s body with the palm of the hand and volar
              surface of the arm.

       e.     After the umbilicus is visualized, gently extract a 4 to 6 inch loop of cord to allow
              delivery without traction on the cord. Gently rotate the fetus to align the shoulders in
              an anterior-posterior position. Continue with gentle traction until the axilla is
              visible.

       f.     Gently guide the infant upward to allow delivery of the posterior shoulder then
              gently guide the infant downward to deliver the anterior shoulder.

       g.     Be aware that the head often is delivered without difficulty. If the head is not
              delivered in 2 - 3 minutes, use two fingers in a “V” on either side of the nose to
              provide an airway and transport immediately.

       h.     Complete delivery procedure as described in Delivery Protocol.

Intermediate and Paramedic:
5.    IV NS/ LR.

6.     Contact MEDICAL CONTROL.




                                                                                                   84
                                                                                     OB/GYN

                                     Cord Presentation

Definition:   Umbilical cord presents with or before presenting part of fetus.

NOTE:         Transport Immediately.

Basic and First Responders:
1.     Assess and treat ABC's.

2.     Oxygen via non-rebreather.

3.     VS, including SpO2.

4.     Procedure:

       a.     Place mother in knee-chest or Trendelenburg position on left side.

       b.     TRANSPORT IMMEDIATELY.

       c.     Instruct mother to “pant” with each contraction to prevent bearing down.

       d.     Apply moist sterile dressing to the exposed cord to minimize temperature changes
              that may cause umbilical artery spasm.

       e.     With a gloved hand, gently push the fetus back into the vagina and elevate the
              presenting part to relieve pressure on the cord. The cord may spontaneously retract,
              but NO ATTEMPT SHOULD BE MADE TO REPOSITION THE CORD.

       f.     Monitor fetal heart tones.

Intermediate and Paramedic:
5.    IV NS/ LR.

6.     Contact MEDICAL CONTROL.




                                                                                               85
                                                                                      OB/GYN

                                     Limb Presentation

Definition:   Presentation of extremity.

NOTE:         Transport Immediately.

Basic and First Responders:
1.     Assess and treat ABC's.

2.     Oxygen via non-rebreather.

3.     VS, including SpO2.

4.     Procedure:

       a.     Place mother in knee-chest or Trendelenburg position on left side.

       b.     TRANSPORT IMMEDIATELY.

       c.     If the fetus’s head is presenting with extremity use 2 fingers in a “V” to provide an
              airway.

       d.     Monitor fetal heart tones.

Intermediate and Paramedic:
5.    IV NS/ LR.

6.     Contact MEDICAL CONTROL.




                                                                                                86
Pediatric Protocols
                                                                                                    Pediatrics

                                                   Post Delivery

Definition:         Care and evaluation of the newborn infant.

All Levels :
1.     Dry, warm, position, suction, stimulate.

        a.          Prevent heat loss. Dry neonate and keep warm. Cover with dry wrappings. Be sure
                    to cover the head.

        b.          Place infant on the back or side with the neck slightly extended in the sniffing
                    position.

        c.          Ensure patent airway, suctioning mouth and nose.

        d.          Provide tactile stimulation to induce respirations if necessary. Appropriate methods
                    are slapping or flicking the soles of the feet and rubbing the infant’s back.

2.      Perform APGAR scoring at 1 and 5 minutes.

        a.          If Respiratory Distress:

                    1. Rate > 80 consistantly, nasal flaring, grunting or
                       retractions, and Sat < 96%, consistantly:                  Blow-by O2 at 10 lpm.

                    2. Sat < 90, apnea:                                           O2 via BVM at 30-40/min

        b.          If Bradycardia:

                    1. Rate 80 - 100:                                       Blow-by O2 at 10 lpm.

                    2. Rate < 80:                                                 CPR, O2 via BVM at 30-40/min

3.      Contact MEDICAL CONTROL:

                                                The APGAR Score
             Sign                       0                     1                         2         1 min   5 min
 Appearance (skin color)        Blue, pale      Body pink, extremities blue     Completely pink
 Pulse rate (heart rate)        Absent          Below 100                       Above 100
 Grimace (irritability)         No response      Grimaces                       Cries
 Activity (muscle tone)         Limp             Some flexion of extremities    Active motion
 Respiratory (effort)           Absent          Slow and irregular              Strong cry

                                                                                Total Score:



                                                                                                                 87
                                                                                       Pediatrics

                                    Neonatal Resuscitation

Definition: Resuscitation of the depressed neonate (infant born at >38 weeks gestation, less than
30 days old).

NOTE:         Dry, warm, position, suction, stimulate. Transport immediately.

Basic and First Responders:
1.     Assess and treat ABC's.

2.     Dry and keep infant warm.

3.     Place infant on back with neck in sniffing position.

4.     If meconium is present refer to Meconium Staining Protocol.

5.     Assess respiratory effort.    Mildly stimulate (drying, warming, suctioning) to induce
       respirations.

       a.     If respiratory response is slow, shallow, or absent, begin positive-pressure ventilation
              (40-60 bpm) with pediatric bag-valve-mask and supplemental oxygen.

6.     Assess heart rate:

       a.     If heart rate <100, initiate positive-pressure ventilation with supplemental oxygen if
              not already done.

       b.     If heart rate < 80, begin chest compressions.

7.     If central cyanosis is present in an infant with spontaneous respirations and an adequate heart
       rate, administer blow-by oxygen at 5 L/min.

Intermediate:
10.   Endotracheal intubation is indicated if BVM ventilation is ineffective.

11.    IV/IO NS/ LR.

Paramedic:
12.  ECG.

13.    Refer to appropriate protocol.

14.    Contact MEDICAL CONTROL.

       a.     If shock present:                               20 cc/kg fluid bolus
                                                              repeat at 10 cc/kg



                                                                                                    88
                                                                                     Pediatrics

                                     Meconium Staining

Definition:   Presence of fetal stool in amniotic fluid.

Basic and First Responders:
1.     Suction mouth, pharynx, and nose in that order.

2.     Provide blow-by oxygen.

Intermediate and Paramedic:
3.    Suction hypopharynx under direct visualization.

4.     If the neonate is depressed or the meconium is thick or particulate, perform direct
       endotracheal suctioning using the ET tube as a suction catheter. Quickly intubate the trachea
       and apply suction to the proximal end of the endotracheal tube while withdrawing the tube.

5.     Repeat the intubation-suction-extubation cycle until no further meconium is obtained. Do
       not ventilate between intubations.

6.     Continue resuscitative measures as needed.

7.     Contact MEDICAL CONTROL.




                                                                                                  89
                                                                                   Pediatrics

                                       Cardiac Arrest

Definition:   Unresponsive, no respirations, no pulse.

Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest. ENSURE
PROPER VENTILATIONS.

Basic and First Responders:
1.     Assess ABC's.

2.     AED, as soon as possible, if > 9 years old.

3.     CPR.

4.     Maintain airway with best available adjunct and ventilate with 100% O2.

Intermediate:
5.    IV NS/ LR.

6.     Endotracheal Intubation.

Paramedic:
7.   Refer to appropriate protocol:
            Asystole
            PEA
            VF and Pulseless VT

                            8.     Contact MEDICAL CONTROL.




                                                                                                90
                                                                                    Pediatrics

                                           Asystole

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest. ENSURE
PROPER VENTILATIONS.

1.     Determine pulselessness.

2.     Begin CPR with good ventilations and supplemental O2.

3.     Determine cardiac rhythm (confirm asystole in 2 leads).

4.     Intubate.

5.     IV or IO NS/ LR.

6.     Epinephrine:                                           (1:10,000) 0.01 mg/kg IV/IO or
                                                              (1:1,000) 0.1 mg/kg ET
                                                              Repeat every 3 - 5 min

7.     Identify and treat causes:

              Hypoxemia                      Tamponade
              Hypovolemia                    Tension pneumothorax
              Hypothermia                    Toxins/ poisons/ drugs
              Hyper- / hypokalemia           Thromboembolism

8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Dopamine:                                       2 – 20 mcg/kg/min IVPB

       b.     Epinephrine:                                    0.1 – 1.0 mcg/kg/min IVPB




                                                                                                 91
                                                                                    Pediatrics

                                Pulseless Electrical Activity

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   Determine pulselessness.

2.     Begin CPR with good ventilations and supplemental O2.

3.     Determine cardiac rhythm.

4.     Determine possible causes:    if TRAUMA, transport NOW.

5.     Intubate.

6.     IV or IO NS/ LR.

7.     Epinephrine:                                           (1:10,000) 0.01 mg/kg IV/IO or
                                                              (1:1,000) 0.1 mg/kg ET
                                                              Repeat every 3 - 5 min

8.     Identify and treat causes:

              Hypoxemia                      Tamponade
              Hypovolemia                    Tension pneumothorax
              Hypothermia                    Toxins/ poisons/ drugs
              Hyper- / hypokalemia           Thromboembolism

8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Dopamine:                                       2 – 20 mcg/kg/min IVPB

       b.     Epinephrine:                                    0.1 – 1.0 mcg/kg/min IVPB




                                                                                                 92
                                                                                   Pediatrics

                                      VF and Pulseless VT

Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest. ENSURE
PROPER VENTILATIONS.

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   Determine pulselessness.

2.     Begin CPR with good ventilations and supplemental O2.

3.     Determine cardiac rhythm (quick look).

4.     Defibrillate:   2 j/kg, 4 j/kg, 4 j/kg.

5.     Intubate.

6.     IV or IO NS/ LR.

7.     Epinephrine:                                        (1:10,000) 0.01 mg/kg IV/IO or
                                                           (1:1,000) 0.1 mg/kg ET
                                                           Repeat every 3 - 5 min

8.     Defibrillate:   4 j/kg after each dose.

9.     Contact MEDICAL CONTROL.

10.    Consider Antiarrhythmics:

       a.     Amiodarone:                                  5 mg/kg IV/IO, MAX 15 mg/kg/24 hrs

       b.     Magnesium sulfate:                           25 mg/kg IV/IO, MAX 2 g

11.    Defibrillate:   4 j/kg after each dose.




                                                                                                93
                                                                       Pediatrics

                                    Post Resuscitation

Basic, First Responders, and Intermediate:

       Refer to Cardiac Arrest Protocol.

Paramedic:
1.   Continue 100% O2 via NRB or BVM.

2.     VS, including SpO2.

3.     IV NS/ LR.

4.     If bradycardic, see Bradycardia Protocol.

              Up to one year        rate < 80.
              One to eight years    rate < 60.



6.     Contact MEDICAL CONTROL.

       Consider:

       a.     Dopamine:                                  2.0 - 20.0 mcg/kg/min IVPB




                                                                                    94
                                                                                    Pediatrics

                                         Bradycardia

Definition:   Ventricular rate < 80.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV or IO NS/ LR.

Paramedic:
5.   Epinephrine:                                             (1:10,000) 0.01 mg/kg IV/IO or
                                                              (1:1,000) 0.1 mg/kg ET
                                                              Repeat every 3 - 5 min

6.     Atropine:                                              0.02 mg/kg IV/IO/ET
                                                              Repeat in 3 - 5 min to
                                                              MAX of 0.04 mg/kg
                                                              Minimum single dose: 0.1 mg
                                                              Maximum single dose: 0.5 mg

7.     Transcutaneous Pacing, if available.

8.     Identify and treat possible causes:

              Hypoxemia                      Heart block
              Hypothermia                    Heart transplant
              Head injury                    Toxins/ poisons/ drugs

6.     Contact MEDICAL CONTROL.




                                                                                                 95
                                                                                  Pediatrics

                         Narrow Complex Tachycardia: stable

Definition:   Infants: rate usually < 220; children: rate usually < 180.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   Vagal maneuvers.

6.     ECG monitoring.

7.     Adenosine:                                           0.1 mg/kg IVP, repeat 1 – 2 min
                                                            0.2 mg/kg IVP

8.     Contact MEDICAL CONTROL.




                                                                                               96
                                                                                Pediatrics

                       Wide Complex Tachycardia (VT): stable

Definition:   Infants: rate usually < 220; children: rate usually < 180.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG monitoring.

6.     Contact MEDICAL CONTROL.

7.     Consider antiarrhythmics:

       Amiodarone:                                          5 mg/kg IV, MAX 15 mg/kg/24 hrs

       Procainamide:                                        15 mg/kg IV




                                                                                             97
                                                                                   Pediatrics

                                   Unstable Tachycardia

Definition: Infants: rate usually < 220; children: rate usually < 180 with signs and symptoms of
poor perfusion.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

Intermediate:
4.    IV NS/ LR.

Paramedic:
5.   ECG monitoring.

6.     Synchronized cardioversion:                                0.5 – 1.0 j/kg

7.     Contact MEDICAL CONTROL.

8.     Consider antiarrhythmics.




                                                                                                98
                                                                          Pediatrics

                                 Allergic Reaction - Mild

Definition:   urticaria, itching, without dyspnea or hypotension.

Basic, First Responders and Intermediate:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen per patient.

Paramedic:
4.   Benadryl:                                             1.0 mg/kg IM
                                                           MAX 25 mg

5.     Contact MEDICAL CONTROL.




                                                                                       99
                                                                                 Pediatrics

                               Allergic Reaction - Moderate

Definition:   urticaria, itching, dyspnea without hypotension.

NOTE: If significant wheezes, see Pediatric Asthma Protocol.

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Pediatric EPIPEN, if patient prescribed.                  0.15 mg IM

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   Benadryl:                                             1.0 mg/kg IV/IM
                                                           MAX 25 mg

7.     Epinephrine (1:1,000):                              0.01 mg/kg SQ
                                                           MAX 0.3 mg

8.     ECG.

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Epinephrine:                                 2 – 10 mcg/kg/min IVPB

       b.     If patient has moderate to severe dyspnea, meds may be given prior to IV access.

       c.     Dexamethasone:                               0.1 mg/kg IVP

              OR

              Methylprednisolone:                          1 mg/kg IVP




                                                                                           100
                                                                                   Pediatrics

                                       Anaphylaxis

Definition:   Urticaria, edema, dyspnea and hypotension.

NOTE: If significant wheezes, see Pediatric Asthma Protocol.

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Pediatric EPIPEN, if patient prescribed.                  0.15 mg IM

Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   Benadryl:                                             1.0 mg/kg IV/IM
                                                           MAX 25 mg

7.     Epinephrine (1:10,000):                             0.01 mg/kg slow IV/IO
                                                           MAX 0.3 mg

8.     ECG.

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Epinephrine:                                 2 – 10 mcg/kg/min IVPB

       b.     If patient has moderate to severe dyspnea, meds may be given prior to IV access.

       c.     Dexamethasone:                               0.1 mg/kg IVP

              OR

              Methylprednisolone:                          1 mg/kg IVP




                                                                                            101
                                                                                  Pediatrics

                                   Altered Mental Status

Definition: Unresponsive or disoriented patient without a clear mechanism for altered mentation.
Refer to appropriate protocols as needed (ie., diabetes, head injury, etc.)

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     High flow oxygen, assist respirations via BVM, if needed.

Intermediate:
4.    IV NS/ LR.

5.     Glucose testing, if < 60:

       a.     Preterm infants:                             D10 5 - 10 cc/kg IV

       b.     Children under 3 years:                      D25 2 - 4 cc/kg IV, slowly

       c.     Children 3 years or older:                   D50 1 cc/kg IV

Paramedic:
6.   Narcan:                                               0.1 mg/kg IV/IO
                                                           MAX SINGLE DOSE 2.0 mg

7.     Contact MEDICAL CONTROL.

       a.     Glucagon:                                    1 mg IM, if IV not available.


* D10 may be prepared with D50 diluted 1:4 with sterile H20.
* D25 may be prepared with D50 diluted 1:1 with sterile H20.




                                                                                            102
                                                                                  Pediatrics

                                        Hypoglycemia

Definition:   Symptoms related to altered blood glucose levels.

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen as tolerated.

4.     If alert, and suspected hypoglycemia, administer Oral Glucose.

Intermediate:
5.    IV NS/ LR.

6.     Glucose testing, if < 60:

       a.     Preterm infants:                             D10 5 - 10 cc/kg IV

       b.     Children under 3 years:                      D25 2 - 4 cc/kg IV, slowly

       c.     Children 3 years or older:                   D50 1 cc/kg IV

Paramedic:
7.   ECG.

8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Glucagon:                                    1 mg IM, if IV not available

* D10 may be prepared with D50 diluted 1:4 with sterile H20.
* D25 may be prepared with D50 diluted 1:1 with sterile H20.




                                                                                           103
                                                                              Pediatrics

                                         Hyperthermia

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     High flow oxygen.

4.     Rapid external cooling:

       a.     Remove to cool environment.
       b.     Remove all clothing.
       c.     Sponge with cool water.
       d.     If shivering occurs, stop cooling.
       e.     Avoid large amounts of fluid PO.
       f.     Fan patient.

5.     Contact MEDICAL CONTROL:

       Consider:

Intermediate:
      a.      IV NS/ LR at 15-20 cc/kg/hr, wrap ice packs around IV tubing.

Paramedic:
     b.       Valium:          seizure activity          0.2 mg/kg slow IVP
                                                         May repeat once




                                                                                       104
                                                                                    Pediatrics

                                            Hypothermia

Definition: Core temperature < 90 degrees, cessation of shivering activity, altered mental status.

Basic and First Responders:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen at highest concentration, assist with BVM if necessary. Warm oxygen by wrapping
       heat packs around tubing.

4.     Cardiac arrest should be treated with CPR only.

5.     External warming:

       a.      Move to warm environment.
       b.      Remove wet clothing.
       c.      Wrap in blankets.
       d.      Heat packs to neck, groin, and axilla.

Intermediate:
6.    IV NS/ LR. Warm fluids by wrapping tubing with heat packs or prewarmed fluids.

7.     Glucose testing.

Paramedic:
8.   ECG.

9.     Glucose testing, if < 60:

               Preterm infants:                             D10 5 - 10 cc/kg IV

               Children under 3 years:                      D25 2 - 4 cc/kg IV, slowly

               Children 3 years or older:                   D50 1 cc/kg IV

10.    Contact MEDICAL CONTROL.

       a.      Use cardiac drugs only on medical control order.

       b.      Minimize rough handling or agitation of patient.




                                                                                              105
                                                                                  Pediatrics

                                     Near Drowning

Basic and First Responders:
1.     C-spine precautions.

2.    Ensure patent airway.

3.    Suction as needed.

4.    VS, including SpO2.

5.    High flow oxygen.

Intermediate:
6.    IV NS/ LR.

Paramedic:
7.   ECG (see appropriate protocol).

8.    Contact MEDICAL CONTROL.

      Consider:

      a.     Water temperature and possible hypothermia.

      b.     Transportation is necessary due to complications that may arise later.




                                                                                           106
                                                                                 Pediatrics

                                   Overdose/ Poisoning

Definition:   Known/ suspected ingestion/injection/inhalation/absorption of harmful substance.

Basic and First Responders:
1.     Ensure patent airway.

2.     Determine overdose substance.

3.     VS, including SpO2.

4.     If contact poisoning, brush off or flush with H2O NOW.

5.     High flow oxygen, assist respirations via BVM, if needed.

Intermediate:
6.    IV NS/ LR.

Paramedic:
7.   ECG.

8.     If altered mentation, see Pediatric Altered Mental Status Protocol.

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Activated Charcoal:                          < 1 yr 1 g/kg
                                                           > 1 yr 25 g




                                                                                          107
                                                                                      Pediatrics

                                                 Asthma

Definition:   Respiratory distress, wheezing on expiration, coughing, tripod positioning, accessory
muscle use.

Basic and First Responders:
1.     Assess and treat ABC’s.

2.     VS, including SpO2.

3.     Oxygen per patient.

4.     Albuterol:                                           2.5 mg nebulized updraft
              if under 2 years, half dose, and repeat       Consider continuous updraft
              only with Medical Control permission.         if no improvement in 15 min
Intermediate:
5.    IV NS/ LR.

Paramedic:
6.   ECG, 12 lead if available.



8.     Contact MEDICAL CONTROL.

       Consider:

       a.     Identify all drugs taken prior to arrival before administration of any drugs.

       b.     Epinephrine (1:1,000)                         0.01 mg/kg SQ
                                                            MAX single dose 0.3 mg

       d.     Terbutaline:                                  0.25 mg SQ or
                                                            Nebulized in 2cc saline




                                                                                               108
                                                                                     Pediatrics

                                              Bronchiolitis

Definition: History of upper respiratory infection, rapid onset, hacking cough and audible wheezing,
lethargy, may or may not be febrile. Under 2 years of age.

Basic, First Responders and Intermediate:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen, humidified (blow-by if delivery device not tolerated).

4.     Position of comfort.

5.     Albuterol:                                             2.5 mg nebulized updraft
               if under 2 years, half dose, and repeat        may repeat once in 10 min
               only with Medical Control permission.

Paramedic:
6.   ECG.

7.     If febrile:

               Tylenol Suspension:                            15 mg/kg PO or RECTAL

8.     Contact MEDICAL CONTROL.

       Consider:

       a.      Epinephrine (1:1,000):                         0.01 mg/kg SQ

       b.      IV NS/ LR.




                                                                                                109
                                                                                    Pediatrics

                                             Croup

Definition:    History of upper respiratory infection, “barking” cough, most common at night, ages
6 months to 4 years. Do not examine throat.

Basic, First Responders and Intermediate:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen, humidified (blow-by if delivery device not tolerated).

4.     Position of comfort.


Paramedic:
5.   ECG.

6.     If febrile:

       a.      Tylenol Suspension:                          15 mg/kg PO or RECTAL

7.     Contact MEDICAL CONTROL.




                                                                                              110
                                                                                      Pediatrics

                                           Epiglottitis

Definition: Rapid onset, high fever, sore throat, drooling, inspiratory stridor, tri-pod positioning.
Under 5 years. Do not examine throat or place anything in mouth.

Basic, First Responders and Intermediate:
1.     Ensure patent airway.

2.     VS, including SpO2.

3.     Oxygen, humidified (blow-by if delivery device not tolerated).

4.     Position of comfort.

Paramedic:
5.   ECG.

6.     Contact MEDICAL CONTROL.

       Consider:

       a.      If complete airway obstruction:                Attempt intubation
                                                              Cricothyrotomy

       b.      Agitation can increase edema or swelling.

       c.      IV NS/ LR.




                                                                                                 111
                                                                                        Pediatrics

                              Obstructed Airway - Foreign Body

Basic and First Responders:
1.     If patient able to cough, allow patient to relieve obstruction on his/her own.

2.     If patient unable to relieve obstruction, perform Heimlich Maneuver appropriate to age.

Intermediate and Paramedic:
3.    Attempt to visualize obstruction and remove with Magill Forceps.

4.     Oxygen and intubation, as needed.

5.     Transport immediately.

6.     Contact MEDICAL CONTROL.

       Consider:

       a.      Cricothyrotomy, if all other efforts fail.

       b.      IV NS/ LR only in deteriorating patients.




                                                                                                 112
                                                                                        Pediatrics

                                            Seizures

Definition:   Active seizures (tonic/ clonic) or post-ictal.

Basic and First Responders:
1.     Aggressively ensure patent airway.

2.     Determine possible cause:      Elevated Temperature
                                      Head Injury
                                      Medical History

3.     Protect patient from injury.

4.     VS, including SpO2.

5.     Oxygen as tolerated.

Intermediate:
6.    IV, Normal Saline.

7.     Glucose testing, if < 60:

       a.     Preterm infants:               D10               5 - 10 cc/kg IV

       b.     Children under 3 years:        D25               2 - 4 cc/kg IV, slowly

       c.     Children 3 years or older:     D50               1 cc/kg IV

Paramedic:
8.   ECG.

9.     Contact MEDICAL CONTROL.

       Consider:

       a.     Valium:                                          0.1 mg/kg IV/IO, or
                                                               0.5 mg/kg RECTAL
                                                               May be repeated in 5 min

       b.     Glucagon:                                        1 mg IM, if IV not available.

* D10 may be prepared with D50 diluted 1:4 with sterile H20.
* D25 may be prepared with D50 diluted 1:1 with sterile H20.




                                                                                                 113
Appendix
                                                                                        Appendix

                                   Air Evacuation Protocol

The following criteria justify but do not require air evacuation for adult trauma patients:

1.     Estimated ground transport to the nearest Level I/II Trauma Center is greater than the
       response and transport time for the helicopter and the patient has one of the following
       injuries or conditions (The helicopter may carry blood, if requested. If so, only the response
       time should be considered.):

       a.      Multisystem blunt or penetrating trauma with unstable vital signs (BP < 90 mmHg,
               HR > 120, RTS < 11, or GCS < 14).
       b.      Penetrating injury to head, neck, chest, abdomen, or groin.
       c.      Burns > 20% TBSA (2nd or 3rd degree) or involving face, airway, hands, feet or
               genitalia.
       d.      Amputations with the potential for reimplantation.
       e.      Paralysis or other signs of spinal cord injury.
       f.      Flail chest.
       g.      Open or suspected depressed skull fracture.
       h.      Open or unstable pelvis fracture.
       I.      Two or more proximal bone fractures.

2.     Patient extrication time greater than 20 minutes.

3.     Number of critically injured patients exceeds capabilities of local EMS agencies.

4.     Closest hospital is on diversion for trauma patients.

5.     Ambulance access to the scene, or away from the scene, is impeded by road conditions,
       weather conditions, or traffic.

The following criteria justify air evacuation for pediatric trauma patients:

1.     Experienced or at risk for developing acute respiratory failure or respiratory arrest and is not
       responsive to initial therapy.

2.     Invasive airway procedure with assisted ventilation.

3.     Respiratory rate less than 10 or greater than 60 breaths per minute.

4.     Systolic blood pressure:
              Neonate:                less than 60 mmHg
              Infant (< 2 yr):        less than 65 mmHg
              Child (2 - 5 yr):       less than 70 mmHg
              Child (6 - 12 yr):      less than 80 mmHg

5.     Near drowning with signs of hypoxia or altered mental status.
                            Automated External Defibrillation

                                                                                                      I
                                                                                      Appendix


1.   Assess and treat ABC’s.

2.   CPR until defibrillator attached.

3.   Press “analyze”.

4.   Defib:                                                        200j, 300j, 360j

5.   Check pulse, if present:

     a.       VS, including SpO2.
     b.       Support airway and breathing.
     c.       Provide appropriate medications for blood pressure, heart rate, and rhythm.

6.   If no pulse:

     a.       CPR for 1 minute.

     b.       Check pulse, if absent:

              1.     Press “analyze”.
              2.     Defib: 360j.
              3.     Repeat “analyze” and Defib 3 times.

     c.       CPR for 1 minute.

     d.       Check pulse, if absent:

              1.     Press “analyze”.
              2.     Defib: 360j.
              3.     Repeat “analyze” and Defib 3 times.

     e.       If VF persists after 9 shocks, repeat sets of three stacked shocks with 1 min of CPR
              between each set until “no shock advised” message is received. Shock until VF is no
              longer present or the patient converts to a perfusing rhythm.

7.   If no shock advised, check pulse, repeat 1 min of CPR, check pulse again, and then
     reanalyze. After three “no shock advised” messages, repeat “analyze” period every 1 - 2
     min.




                                                                                                 II
                                                                                                   Appendix

                                     Dopamine Dosage Chart

              For a concentration of 1600 mcg Dopamine (800 mg/ 500 cc)

Body       lbs:   77   88   99   110   121   132   143     154      165      176   187   198      209   220   231    242

Weight kgs:       35   40   45    50    55    60   65      70        75       80   85     90       95   100   105    110


mcg/kg/min        D    R    O    P     S           p        e        r             M      I       N     U     T      E

       2           3    3    4     4    4      5       5        5        6    6     6         7    7     8      8      8

    2.5            3    4    4     5    5      6       6        7        7    8     8         8    9     9     10     10

       3           4    5    5     6    6      7       7        8        8    9    10     10       11   11     12     12

    3.5            5    5    6     7    7      8       9        9    10       11   11     12       12   13     14     14

       4           5    6    7     8    8      9   10      11        11       12   13     14       14   15     16     17


    4.5            6    7    8     8    9     10   11      12        13       14   14     15       16   17     18     19

       5           7    8    8     9    10    11   12      13        14       15   16     17       18   19     20     21

    5.5            7    8    9    10    11    12   13      14        15       17   18     19       20   21     22     23

       6           8    9   10    11    12    14   15      16        17       18   19     20       21   23     24     25

    6.5            9   10   11    12    13    15   16      17        18       20   21     22       23   24     26     27

       7           9   11   12    13    14    16   17      18        20       21   22     24       25   26     28     29

    7.5           10   11   13    14    15    17   18      20        21       23   24     25       27   28     30     31

       8          11   12   14    15    17    18   20      21        23       24   26     27       29   30     32     33

    8.5           11   13   14    16    18    19   21      22        24       26   27     29       30   32     33     35

       9          12   14   15    17    19    20   22      24        25       27   29     30       32   34     35     37

    9.5           12   14   16    18    20    21   23      25        27       29   30     32       34   36     37     39

    10            13   15   17    19    21    23   24      26        28       30   32     34       36   38     39     41




                                                                                                               III
                                                                       Appendix

                                      Glasgow Coma Score
Adult
        Eye Opening
              Spontaneously                        4
              To Verbal Command                    3
              To Pain                              2
              No Response                          1
                           Score:                      _____
        Best Verbal Response
              Oriented                             5
              Confused                             4
              Inappropriate words                  3
              Incomprehensible sounds              2
              No Response                          1
                           Score:                      _____
        Best Motor Response
              Obeys                                6
              Localizes Pain                       5
              Withdraws to pain                    4
              Abnormal flexion to pain             3
              Extension to pain                    2
              No Response                          1
                               Score:                  _____

                                                               TOTAL        _____
Pediatric
       Eye Opening
              Spontaneously                        4
              To Verbal Command                    3
              To Pain                              2
              No Response                          1
                           Score:                      _____
        Best Verbal Response
              Appropriate words or social smile,
                       fixes and follows           5
              Cries, but consolable                4
              Persistently irritable               3
              Restless, agitated                   2
              None                                 1
                           Score:                      _____
        Best Motor Response
              Obeys                                6
              Localizes Pain                       5
              Withdraws to pain                    4
              Abnormal flexion to pain             3
              Extension to pain                    2
              No Response                          1
                               Score:                  _____

                                                               TOTAL        _____




                                                                                  IV
                                                                                      Appendix

                              Intraosseous Needle Insertion

1.    Place the patient in the supine position.

2.    Put a small towel roll under the knee.

3.    Prepare the skin over the insertion site.

4.    Use the flat surface of the proximal medial tibia, medial to the tibial tuberosity on the flat
      side of the bone.

5.    Introduce the IO needle in the skin, directed away from the growth plate or pointing
      toward the foot.

6.    Pierce the bony cortex with a firm, twisting motion. Use a back-and-forth twisting
      motion to enter the marrow space. Do not push hard on the needle. A "pop" may be felt
      as the needle passes through the bony cortex and into the marrow cavity.

7.    Remove the stylet and aspirate marrow contents. Keep any bone marrow aspirate for
      glucose check or for other tests in the ED. Sometimes marrow cannot be aspirated.

8.    Confirm correct placement by infusing 10 ml of NS without resistance.

9.    Attach IV line to the hub, or to a stopcock, and infuse fluids or drugs directly into
      intraosseous space.

10.   Secure the needle to the overlying skin with tape.

11.   Monitor the calf to ensure that there is no swelling to indicate leakage of fluid.




                                                                                                  V
                                                                                                  Appendix

                                          On-Board Drugs - Adult

DRUG NAME                 INITIAL DOSE          ADMINISTRATION        CLASSIFICATION/ACTIONS
Adenosine                 6 mg                  IVP - rapid           Antiarrhythmic
Albuterol                 2.5 mg                Nebulized updraft     Bronchodilator
Alcaine                   2 drops               Topical - eye drops   Analgesic
                          300 mg (arrest)
Amiodarone                150 mg (tach)         IVP                   Antiarrhythmic
Aspirin                   160 - 325 mg          PO                    Thrombolytic
Ativan                    1 mg                  IVP                   Analgesic
Atropine                  0.5 - 1.0 mg          IVP - rapid           Anticholinergic
Benadryl                  50 mg                 IVP                   Antihistamine
Charcoal                  1 g/kg                PO                    Absorption
D50                       25 g                  IVP                   Restores blood sugar level
Dexamethasone             8 mg                  IVP                   Steroid anti-inflammatory
Dobutamine                2 - 20 mcg/kg/min     IVPB                  Vasopressor
Dopamine                  2 - 10 mcg/kg/min     IVPB                  Vasopressor
Epinephrine (1:10,000)    1 - 3 - 5 mg          IVP
                          2 mg                  ET

              (1:1,000)   0.5 mg                SQ                    Adrenergic
Glucagon                  1 mg                  IM                    Glycogenolytic
Labetalol                 10 mg                 IVP                   Alpha-/Beta- blocker, antihypertensive
Lasix                     0.5 - 1 mg/kg         IVP                   Diuretic, vasodilator
Lidocaine                 1.0 - 1.5 mg/kg       IVP                   Antiarrhythmic
Magnesium Sulfate         1-2g                  IVP                   Antiarrhythmic, antiseizure
Methylprednisolone        125 mg                IVP                   Steroid anti-inflammatory
Morphine Sulfate          2 - 5 mg              IVP                   Analgesic
Narcan                    2 mg                  IVP                   Narcotic antagonist
                                     1
Nitroglycerine            0.4 mg ( /150 gr)     SL                    Vasodilator
Nubain                    5 mg                  IVP                   Analgesic, vasodilator
Oxygen                    per patient           appropriate device    Reverses hypoxemia
Procainamide              30 mg/min             IVPB                  Antiarrhythmic
Promethazine              12.5 - 25.0 mg        IVP                   Reduces nausea, vomiting
Sodium Bicarbonate        50 mEq @ 125 cc/hr    IVPB                  Buffer
Terbutaline               0.25 mg               SQ                    Bronchodilator
Toradol                   30 mg                 IVP                   Analgesic
Tylenol Suspension        15 mg/kg              PO                    Antipyretic
Valium                    5 mg                  IVP                   Anticonvulsant, antianxiety
Vasopressin               40 units              IVP                   Vasopressor




                                                                                                               VI
                                                                                                                             Appendix

                                                        Pediatric Drug Chart

                                               NEW           6                1        3         6            10             12        14
                               DOSE            BORN        MONTH            YEAR     YEAR      YEAR          YEAR           YEAR      YEAR

WEIGHT                                          3 kg           7 kg         10 kg     15 kg     20 kg        30 kg          40 kg     50 kg
                                                7 lb           15 lb        22 lb     33 lb     44 lb        66 lb          88 lb     110 lb

DEFIB                        1j/lb, 2j/kg        6j              14 j        20 j     30 j      40 j          60 j           80 j     100 j

Adenosine                    0.1 mg/kg         0.3 mg       0.7 mg          1.0 mg   1.5 mg    2.0 mg        3.0 mg         4.0 mg    5.0 mg

Albuterol                      2.5 mg          2.5 mg       2.5 mg          2.5 mg   2.5 mg    2.5 mg        2.5 mg         2.5 mg    2.3 mg

Amiodarome                    5 mg/kg          15 mg           35 mg        50 mg    75 mg     100 mg        150 mg        200 mg    250 mg

Atropine                     0.02 mg/kg        0.1 mg       0.14 mg         0.2 mg   0.3 mg    0.4 mg        0.6 mg         0.8 mg    1.0 mg

Benadryl                     1.0 mg/kg          3 mg           7 mg         10 mg    15 mg     20 mg         25 mg          25 mg     25 mg

                         <1 yr: 1 g/kg
Charcoal                                        3.0 g          7.0 g        10.0 g    25 g      25 g          50 g           50 g      50 g
                         >1 yr: 25-50 g

D25                           0.5 g/kg          1.5 g          3.5 g         5.0 g    7.5 g     10 g          15 g           20 g      25 g

D50                           0.5 g/kg          1.5 g          3.5 g         5.0 g    7.5 g     10 g          15 g           20 g      25 g

Dexamethasone                0.1 mg/kg         0.3 mg       0.7 mg          1.0 mg   1.5 mg    2.0 mg        3.0 mg         4.0 mg    5.0 mg

EPI (1:1,000)                0.1 mg/kg         0.3 mg       0.7 mg          1.0 mg   1.5 mg    2.0 mg        3.0 mg         4.0 mg    5.0 mg

Fluid Challenge               20 cc/kg          30 cc        140 cc         200 cc   300 cc    400 cc        600 cc         800 cc   1000 cc

Glucagon                       1.0 mg          1.0 mg       1.0 mg          1.0 mg   1.0 mg    1.0 mg        1.0 mg         1.0 mg    1.0 mg

Lidocaine                    1.0 mg/kg         3.0 mg       7.0 mg          10 mg    15 mg     20 mg         30 mg          40 mg     50 mg

Mag Sulfate                  25 mg/ kg         75 mg        175 mg          250 mg   375 mg    500 mg        750 mg          2g        2g

Methylpredisolone            1.0 mg/kg         3.0 mg       7.0 mg          10 mg    15 mg     20 mg         30 mg          40 mg     50 mg

Narcan                       0.1 mg/kg         0.3 mg       0.7 mg          1.0 mg   1.5 mg    2.0 mg        3.0 mg         4.0 mg    5.0 mg

Procainamide                 15 mg/kg          45 mg        105 mg          150 mg   225 mg    300 mg        450 mg        600 mg    750 mg

Terbutaline                   0.25 mg          0.25 mg      0.25 mg        0.25 mg   0.25 mg   0.25 mg     0.25 mg        0.25 mg    0.25 mg

Tylenol suspension           15 mg/kg          45 mg        105 mg          150 mg   225 mg    300 mg        450 mg        600 mg    750 mg

Valium                       0.1 mg/kg         0.3 mg       0.7 mg          1.0 mg   1.5 mg    2.0 mg        3.0 mg         4.0 mg    5.0 mg


                                               Pediatric General Guidelines
                                                  VITAL SIGNS                                            EQUIPMENT
AGE               WEIGHT             HEART              RESP            SYSTOLIC       ET          ET            SUCTION              IV
                   kg (lb)            RATE              RATE               BP        BLADES       TUBE            CATH               CATH
NEWBORN              3 (7)         120 - 160           30 - 50           50 - 70      0-1        2.5 - 3.0            5/6             24
6 MONTH             7 (15)          80 - 140           20 - 30          80 - 100       1           3.5                5/6             24
1 YEAR            10 (22)           80 - 140           20 - 30          80 - 100      1-2          4.0                8               22
3 YEARS           15 (33)           80 - 130           20 - 30          80 - 110      1-2        4.0 - 4.5            8               20
6 YEARS           20 (44)           80 - 120           20 - 30          80 - 110       2         5.0 - 6.0            8               20
10 YEARS          30 (66)           60 - 100           20 - 30          90 - 120       2         6.0 - 6.5            8               18
12 YEARS          40 (88)           60 - 100           20 - 30          90 - 120       2         6.5 - 7.0            14              18
14 YEARS          50 (110)          60 - 100           20 - 30          90 - 120       3         7.5 - 8.5            14              18


                                                                                                                                           VII
                                                                                   Appendix

                            Rectal Administration Protocol

1.   Calculate the appropriate dose.

2.   Draw up the calculated dose into a disposable tuberculin syringe or 3- to 5- ml syringe.

3.   Lubricate the syringe or catheter.

     a.     If using the tuberculin syringe, remove needle and apply lubricant to the tip of the
            syringe.

     b.     If using a 3- or 5-ml syringe, remove needle, attach over-the-needle catheter
            (plastic portion only), and lubricate catheter.

4.   Position patient in the decubitus position, knee-chest position, or supine position with a
     second provider or caregiver holding the legs apart.

5.   Carefully introduce the syringe or over-the-needle catheter approximately 5 cm (2
     inches) into the rectum.

6.   Inject the solution into the rectum. Remove the syringe.

7.   Hold buttocks closed for 10 seconds. (Optional: tape buttocks closed.)




                                                                                             VIII
                                                                      Appendix

                                               Revised Trauma Score
Adult
Respiratory Rate
  10 – 29 =                                         4
  > 29 =                                            3
  6–9=                                              2
  1–5=                                              1
  0=                                                0
                                           Score:
Systolic Blood Pressure
   > 89 =                                           4
   76 – 89 =                                        3
   50 – 79 =                                        2
   1 – 49 =                                         1
   0=                                               0
                                           Score:
Glasgow Coma Score
  13 – 15 =                                         4
  9 – 12 =                                          3
  6–8=                                              2
  4–5=                                              1
  3 =0                                              0
                                           Score:
                                                         TOTAL


Pediatric
Size
   Child/ adolescent, < 20 kg                       +2
   Toddler, 11 - 20 kg                              +1
   Infant, < 10 kg                                  -1
                                           Score:
Airway
   Normal                                           +2
   Assisted O2                                      +1
   Intubated, ETT, Cric                             -1
                                           Score:
Consciousness
  Awake                                             +2
  Obtunded, lost consciousness                      +1
  Coma, unresponsive                                -1
                                           Score:
Systolic Blood Pressure
   90 mmHg, good pulses, perfusion                  +2
   51 - 90 mmHg, pulses palpable                    +1
   < 50 mmHg, weak or no pulses                     -1
                                           Score:
Fracture
  None seen or suspected                            +2
  Single closed fracture                            +1
  Open or multiple fracture                         -1
                                           Score:
Cutaneous
  No visible injury                                 +2
  Contusion, abrasion,                              +1
   laceration < 7 cm, not through fascia
  Tissue loss, GSW/ Stab through fascia             -1
                                           Score:
                                                         TOTAL




                                                                                 IX
                Appendix

Rule of Nines




   Adult



                           X
                Appendix

Rule of Nines

   Child




                           XI
                                                                                       Appendix

                                  Transcutaneous Pacing

Indication: For temporary pacing in patients with symptomatic bradycardia, or asystole when
atropine is contraindicated or ineffective.

1.     Attach lead wires to the adhesive electrode pads.

2.    Apply anterior adhesive electrode on left side of sternum over the point of maximum
      intensity; posterior electrode just below the left scapula. If possible, place pads on clean dry
      skin. If necessary, trim hair.

3.     Turn pacer on. DO NOT start current flow.

4.     Set pacer rate to 80.

5.    Increase milliamp setting by 20's until capture is obtained or up to the maximum energy
      available.

      Electrical capture:            wide QRS and tall, broad T-waves.
      Mechanical capture:            palpable pulse, rise in BP, improved LOC, skin color/temp.

6.    Once capture is obtained begin decreasing milliamp setting by 5's until capture is lost. Then
      increase by 5's until capture is regained. (Obtain stimulation threshold.)

7.    Confirm mechanical capture. If there is electrical capture but not mechanical capture,
      increase the rate only, up to a maximum of 120. DO NOT increase the energy.

8.    If no response is obtained from maximum pacing output, interrupt pacing and continue with
      the appropriate cardiac protocol. Intermittently check for possible capture using maximum
      pacer setting.

9.    If mechanical capture is obtained, interrupt pacing every 2 - 3 minutes to check for return of
      spontaneous pulse for 5 - 10 seconds.




                                                                                                  XII

				
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