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					                D ENVER M ETROPOLITAN

          EMT-I NTERMEDIATE P ROTOCOLS




                       These protocols are effective_____________.



Revision Date   Protocol Page Changes                                Complete
Denver Metro EMT-Intermediate Protocols




       DENVER METROPOLITAN EMT-INTERMEDIATE PROTOCOL MANUAL -
ACKNOWLEDGEMENT OF RECEIPT AND EMT-INTERMEDIATE PRACTICE EXPECTATIONS


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




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Agency                                                                      Date received




For office and administrative use only:
Denver Metro EMT-Intermediate Protocols

                                                ACKNOWLEDGEMENTS

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

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

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

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

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


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

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

                                                             i
Denver Metro EMT-Intermediate Protocols

                                                   INTRODUCTION


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

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

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




Please remember that protocols define process; people provide care.




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Denver Metro EMT-Intermediate Protocols

                                   TABLE OF CONTENTS

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

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




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Denver Metro EMT-Intermediate Protocols

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

V      Treatment Protocols: Pediatric Treatment
             General Guidelines for Pediatrics                                         V-2
             Pediatric Patient Assessment                                               V-3




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


VI     Drug Protocols
              Adenosine (Adenocard)                                                  VI-2
              Albuterol Sulfate                                                      VI-3
              Amiodarone                                                             VI-4
              Aspirin (ASA)                                                          VI-5
              Atropine Sulfate                                                       VI-6
              Dextrose 50%                                                           VI-7
              Diazepam (Valium)                                                      VI-8
              Epinephrine                                                         VI-9, 10
              Ipratropium Bromide (Atrovent)                                        VI-11
              IV Solutions                                                       VI-12, 13
              Morphine Sulfate                                                      VI-14
              Naloxone Hydrochloride (Narcan)                                       VI-15
              Nitroglycerin                                                         VI-16
              Oral Glucose                                                          VI-17
              Oxygen                                                             VI-18, 19
              Sodium Bicarbonate                                                    VI-20

VII    Procedure Protocols
              Airway Management: General Principles                                   VII-2
              Airway Management: Opening the Airway                                VII-3, 4
              Airway Management: Obstructed Airway                                    VII-5
              Airway Management: Clearing and Suctioning the Airway                VII-6, 7
              Airway Management: Assisting Ventilation                                VII-8
              Airway Management: Capnography                                           VII-9
              Advanced Airway Management: Orotracheal Intubation                 VII-10, 11
              Bandaging                                                             VII-12
              Defibrillation                                                     VII-13, 14
              Field Drawn Blood Samples                                             VII-15
              Medication Administration (Parenteral)                             VII-16, 17
              PASG (Formerly MAST)                                                  VII-18
                                                      iv
Denver Metro EMT-Intermediate Protocols

               Restraints                                                           VII-19, 20
               Splinting: Axial                                                     VII-21, 22
               Splinting: Extremity                                                 VII-23, 24
               Transport of the Handcuffed Patient                                      VII-25
               Venous Access Technique                                           VII-26, 27, 28


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

IX     Appendix
             A.        Commonly Accepted Abbreviations for Field Use          IX-2, 3, 4, 5, 6, 7
             B.        Critical Care Transport Utilization Guidelines                        IX-8




               C.      Protocols Requiring Base Contact – TABLES                      IX-9, 10
               D.      Refusal of Transport and Treatment Sample Document                IX-11
               E.      Required Records on Treatment and Transportation                 IX-12
               F.      Triage/MCI Templates                                        IX-13, 14, 15


                                                                                 IX-15, 16, 17F.
                                                           Utilization of Critical Care Transport




                                                       v
Denver Metro EMT-Intermediate Protocols




                                             SECTION I

                               PREHOSPITAL PATIENT ASSESSMENT

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




                                               I-1
Denver Metro EMT-Intermediate Protocols

Prehospital Patient Assessment

                                   PATIENT ASSESSMENT ALGORITHM




                                               I-2
Denver Metro EMT-Intermediate Protocols

                                              Prehospital Patient Assessment

                                                     SCENE SIZE UP

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



                                                INITIAL ASSESSMENT


Initial Assessment

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

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

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




                                                           I-4
Denver Metro EMT-Intermediate Protocols

                                                FOCUSED ASSESSMENT

MEDICAL

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

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

Focused-Responsive

A.      Assess history of present illness

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

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

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

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

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

F.     Make transport decision.

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

H.     Transport as soon as possible.

I.      Perform Ongoing Assessment




                                                            I-5
Denver Metro EMT-Intermediate Protocols

TRAUMA

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

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

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




                                                           I-6
Denver Metro EMT-Intermediate Protocols

                                                 RAPID ASSESSMENT

MEDICAL-Unresponsive

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

TRAUMA

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




                                                           I-7
Denver Metro EMT-Intermediate Protocols

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




                                                            I-8
Denver Metro EMT-Intermediate Protocols

                                           SPECIAL ASSESSMENT NOTES

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




                                                           I-9
Denver Metro EMT-Intermediate Protocols


Prehospital Patient Assessment                  DETAILED ASSESSMENT

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

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

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

A.      Initial vital signs

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

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

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

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

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

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




                                                            I-10
Denver Metro EMT-Intermediate Protocols

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

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




                                                        I-11
Denver Metro EMT-Intermediate Protocols


                                                 ONGOING ASSESSMENT

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

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

       B.      Repeat focused assessment regarding patient complaint or injuries.

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




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Denver Metro EMT-Intermediate Protocols


                                              NEUROLOGIC ASSESSMENT

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

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

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

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




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Denver Metro EMT-Intermediate Protocols

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




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Denver Metro EMT-Intermediate Protocols

TREATMENT PROTOCOLS: MEDICAL TREATMENT


II      Treatment Protocols: Medical Treatment              Page Number

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




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Denver Metro EMT-Intermediate Protocols


Medical Treatment                                ABDOMINAL PAIN

Specific information needed

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


Specific objective findings

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

Treatment

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

Specific precautions

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




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Denver Metro EMT-Intermediate Protocols



Medical Treatment                              ALLERGY/ANAPHYLAXIS

Specific information needed

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

Specific objective findings

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

Treatment

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

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

C.      Administer O2 as indicated.

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

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

F.      Monitor cardiac rhythm.

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

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

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

I.      Transport rapidly if patient is unstable.


Specific precautions

A.      Allergic reactions can take multiple forms. Early consult with base physician is encouraged.
B.      Anxiety, tremor, palpitations, tachycardia, and headache are not uncommon with administration of epinephrine.
        These may be particularly severe with IV administration. In children, epinephrine may induce vomiting.
C.      Angina, MI, or dysrhythmias may be precipitated.
D.      Use caution in the administration of epinephrine in cardiac patients or the elderly.
E.      Two forms of epinephrine are carried as part of paramedic equipment. The standard ampules of aqueous epine-
        phrine contain a 1:1000 dilution appropriate for SQ or IM injection. IV epinephrine should be given in a 1:10,000

                                                           II-3
Denver Metro EMT-Intermediate Protocols

       dilution. Use the 1:10,000 premix for IV dosing to avoid mistakes. Be sure you are giving the proper dilution
       to your patient, and give slowly.
F.     Before treating anaphylaxis, be sure your patient has objective signs as well as subjective symptoms and history.
       Hyperventilators will occasionally think they are having an allergic reaction. Epinephrine will just aggravate their
       anxiety.
G.     Lethal edema may be localized to the tongue, uvula, or other parts of the upper airway. Examine closely, and be
       prepared for early intubation before swelling precludes this intervention.




                                                         II-4
Denver Metro EMT-Intermediate Protocols

Medical Treatment                           ARRHYTHMIAS: GENERAL

Specific information needed

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

Specific objective findings

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

Advanced treatment, general

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

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

Specific precautions

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

                                                          II-5
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                                           ARRHYTHMIA ALGORITHMS

                            PREMATURE VENTRICULAR CONTRACTIONS (PVCs)

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

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

3.     Prophylactic use of lidocaine is contraindicated.




                                                           II-6
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                                    VENTRICULAR FIBRILLATION/
                               PULSELESS VENTRICULAR TACHYCARDIA

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

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


                               RHYTHM AFTER FIRST 3 COUNTERSHOCKS?



 Pulseless VT/VF                                         NSR                              Other
                                                                                       Dysrhythmias


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




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




 DEFIBRILLATE
                                             INITIATE TRANSPORT


 AMIODARONE
 300 mg IV push

 DEFIBRILLATE




 DEFIBRILLATE


 INITIATE TRANSPORT



                                                     II-7
Denver Metro EMT-Intermediate Protocols




 Special notes
 A.      Torsade de pointes is a rare and
         special form of V-tach.
 B.      Shocks must not be delayed until an
         IV or airway is established.




                                               II-8
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                 ASYSTOLE


                                       INITIATE SUPPORTIVE MEASURES:
                                       -     ABCs
                                       -     CPR
                                       -     Endotracheal intubation
                                       -     Establish venous access
                                       -     Confirm asystole in at least two leads

                                       CONTACT BASE STATION PHYSICIAN FOR THE
                                           FOLLOWING



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



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


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


                                       CONTACT BASE:
                                       Consult for possible termination of efforts



Special notes

A.     When asystole is diagnosed, check the integrity of the leads and electrode patches and confirm this
       interpretation in at least two leads.
B.     In pediatric patients, after ABCs have been initiated, hyperventilate, give an IV fluid bolus, reassess,
       consider epinephrine.




                                                      II-9
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                              PULSELESS ELECTRICAL ACTIVITY (PEA)


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

                       CONTACT BASE STATION PHYSICIAN PRIOR TO ANY MEDICATION
                       THERAPY FOR PEA



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



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



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



                       INITIATE TRANSPORT


Special notes

A.     Rapid transport is the goal.
B.     In pediatric patients, hyperventilate, give fluid bolus, reassess, consider epinephrine.




                                                     II-10
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                                       BRADYCARDIA WITH PULSE

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

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

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

_


YES                                               NO

                                                  CONTACT BASE STATION PHYSICIAN FOR
                                                  FOLLOWING

INITIATE TRANSPORT                                ATROPINE
                                                  0.5 – 1.0 mg IV push

                                                  EVALUATE RESPONSE

_

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

       INITIATE TRANSPORT                         Fluid bolus to                REPEAT ATROPINE
                                                  250cc maximum                 0.5 – 1.0 mg IV push

                                                  INITIATE TRANSPORT            INITIATE
                                                  and CONTACT BASE              TRANSPORT AND
                                                  For possible approval to      CONTACT BASE for
                                                  administer                    epinephrine
                                                  epinephrine drip

Special notes
A.     Differentiate premature ventricular beats from escape beats, which are wide complexes occurring late
       after preceding beat as a lower pacemaker cell takes over. Escape beats are beneficial to the patient and
       should be treated by increasing the underlying rate and conduction; not by suppressing the escape beats.
B.     In pediatric patients, bradycardia is most often a sign of hypoxia. After therapy for the ABCs has been
       initiated, hyperventilate, give fluid bolus, reassess, and consider epinephrine. Epinephrine should be the
       first medication utilized (see protocol for dosage, section VI).




                                                       II-11
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                                    WIDE COMPLEX TACHYCARDIA
                                           WITH PULSE

                                  INITIATE SUPPORTIVE MEASURES:
                            - ABCs
                            - Airway management as indicated

                            - Initiate oxygen therapy

                            - Establish venous access

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


                                                               NO
                YES


                INITIATE TRANSPORT                             INITIATE TRANSPORT



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

Special notes

A.              A wide QRS complex is defined as a complex with a width greater than 0.12 sec.
B.              A wide complex tachycardia is usually ventricular in origin, but may, on occasion, be a
                supraventricular rhythm with aberrant conduction.
C.




                                                       II-12
Denver Metro EMT-Intermediate Protocols

Medical Treatment
                                  NARROW COMPLEX TACHYCARDIA
                                          WITH PULSE

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


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



                YES                                        NO

                Contact base

                Transport

                Adenosine 6mg

                Adenosine 12mg                             Transport and contact base




Special notes

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




                                                     II-13
Denver Metro EMT-Intermediate Protocols

Medical Treatment                           CARDIAC ARREST

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                   II-14
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                     CHEST PAIN

Specific information needed

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

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

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

Specific objective findings

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

Treatment

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

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




                                                          II-15
Denver Metro EMT-Intermediate Protocols



Medical Treatment        COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                          II-16
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                  HYPERTENSION

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                         II-17
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                        OB/GYN

Specific information needed

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

Specific objective findings

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

Treatment

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

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

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

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




                                                          II-18
Denver Metro EMT-Intermediate Protocols

Specific precautions

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


APGAR Score


            Sign                        0                       1                             2

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

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

*Nasal or oral suction catheter stimulus




                                                         II-19
Denver Metro EMT-Intermediate Protocols

        Medical Treatment        POISONS AND OVERDOSES

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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



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




                                                         II-20
Denver Metro EMT-Intermediate Protocols

Medical Treatment                            PSYCHIATRIC/BEHAVIORAL

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                          II-21
Denver Metro EMT-Intermediate Protocols

Medical Treatment                              RESPIRATORY DISTRESS

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

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

Treatment
A.    Put patient in position of comfort, usually upright.
B.    Identify and treat upper airway obstruction if present (suctioning, nasopharyngeal airway, endotracheal intubation,
      etc.).
C.    Administer O2, high flow.
D.    Assist ventilation with pocket mask or bag valve mask if necessary.
E.    Assess and consider treatment for the following problems if respiratory distress is severe and patient does not
      respond to proper positioning and administration of O2.
      1.       Asthma:
               a.       Establish venous access.
               b.       Monitor cardiac rhythm
               c.       Contact Base to administer albuterol and /or albuterol and ipratropium.
               d.       Contact Base to discuss the use continuous nebulization of albuterol for respiratory distress.
               e.       Contact Base to Consider epinephrine 1:1000.

        2.       Pulmonary edema (except in patients with evidence of COPD):
                 a.     Sit patient up, legs dangling if possible.
                 b.     Establish venous access.
                 c.     Monitor cardiac rhythm.
                 d.     Contact Base to Consider:
                        1)       Nitroglycerin
                        2)       Morphine sulfate
                 e.     Assist ventilations and consider intubation if patient has altered mentation or signs of respiratory
                        failure.
        3.       Chronic lung disease with deterioration:
                 a.     Administer O2.
                 b.     Monitor cardiac rhythm.
                 c.     Establish venous access.
                 d.     Contact base to administer albuterol and /or albuterol and ipratropium.
                 e.     Contact Base to discuss the use continuous nebulization of albuterol for respiratory distress.

        1. Pneumothorax: watch for signs of tension

F.      If diagnosis unclear, place patient in position of comfort, and administer oxygen, transport.
G.      Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs.




                                                           II-22
Denver Metro EMT-Intermediate Protocols

Specific precautions

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




                                                       II-23
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                       SEIZURES

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

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

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

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




                                                          II-24
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                 SHOCK: MEDICAL

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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



                                                          II-25
Denver Metro EMT-Intermediate Protocols




                                   SHOCK: MEDICAL
            Mechanism/Causes                                   Differential/Symptoms

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




                                                         II-26
Denver Metro EMT-Intermediate Protocols

Medical Treatment                                       SYNCOPE

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                          II-27
Denver Metro EMT-Intermediate Protocols


Medical Treatment                                     VOMITING

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                        II-28
Denver Metro EMT-Intermediate Protocols




                                             SECTION III

                       TREATMENT PROTOCOLS: TRAUMA TREATMENT


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




                                                 III-1
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                           MULTIPLE TRAUMA OVERVIEW

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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

B.      Critical injuries involve:
                  1.       Difficulty with respiration
                  2.       Difficulty with circulation (hypoperfusion a.k.a. shock)
                  3.       Decreased level of consciousness

        Any trauma patient with one or more of these conditions is a "load and go," with treatment occurring enroute.
C.      Even in the noncritical patient with significant injury, "stabilization in the field" does not occur. With major

                                                            III-2
Denver Metro EMT-Intermediate Protocols

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




                                                         III-3
Denver Metro EMT-Intermediate Protocols

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

Triage and transport requirements for adult trauma patients

                                                         HIGH RISK ADULT TRAUMA PATIENT

                                  FIELD CRITERIA                                                            TRANSPORT DESTINATION

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

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

                                                      MODERATE RISK ADULT TRAUMA PATIENT

                                  FIELD CRITERIA                                                            TRANSPORT DESTINATION

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

                                                              OTHER RISK FACTORS FOR INJURY

                                   RISK FACTORS                                                             TRANSPORT DESTINATION

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

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

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

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

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




                                                                           III-4
Denver Metro EMT-Intermediate Protocols

Trauma Treatment
                                                    ALGORITHM

                                                      TRAUMA

                                          Scene Size-up and Initial Assessment

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



                                                 "LOAD & GO" CRITERIA

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


                                                        ↓
                                  ______________________________________________
                              ↓                                                           ↓

                            YES                                                         NO

                              ↓                                                           ↓

                   Rapid extrication                                Detailed and Focused Assessment
                          for access                                                on scene

                              ↓                                                           ↓

                      "Load & Go"                                                Splint all fractures


                              ↓                                                           ↓

               INITIATE TRANSPORT AND TREATMENT                                      Routine transport
                  CONTACT RECEIVING FACILITY

                              ↓                                                           ↓

                   Detailed and Focused
                Assessment enroute to trauma center

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




                                                        III-5
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                ABDOMINAL TRAUMA

Specific information needed

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

Specific objective findings

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

Treatment

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

Special precautions

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




                                                          III-6
Denver Metro EMT-Intermediate Protocols

         Trauma Treatment                           AMPUTATIONS

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                           III-7
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                          BURNS

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

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

Treatment
THERMAL BURNS:

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

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

INHALATION INJURY:

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




                                                          III-8
Denver Metro EMT-Intermediate Protocols

CHEMICAL BURNS:

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

ELECTRICAL INJURY:

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

Specific precautions

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




                                                        III-9
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                      CHEST INJURY

Specific information needed

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

Specific objective findings

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

Treatment

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

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

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




                                                          III-10
Denver Metro EMT-Intermediate Protocols

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

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

Specific precautions

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




                                                         III-11
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                EXTREMITY INJURIES

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

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

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

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




                                                         III-12
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                            FACE AND NECK TRAUMA

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

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

Treatment
A. Control airway with C-spine immobilization if indicated:
     1.   Open airway using jaw thrust, keeping neck in alignment with in-line cervical immobilization.
     2.   Use finger sweep to remove oral foreign bodies.
     3.   Suction blood and other debris.
     4.   Stabilize tongue and mandible with chin lift. Manual traction of the tongue may be necessary to keep posterior
          pharynx open as needed.
     5.   Note evidence of laryngeal injury and transport immediately if signs present.
     6.   Orally Intubate if bleeding severe or airway cannot be maintained.
     7.   If intubation cannot be performed due to severe facial injury, attempt to manage with suctioning and bag-
          valve-mask.

B.   Administer O2 .
C.   Control hemorrhage, check pulse and circulation.
D.   Establish venous access:
         1.     TKO if stable
         2.     With signs of hypovolemia:
                a.        Fluid bolus, NS; contact base.
E.   Obtain vital signs, assess neurologic status.
F.   Complete detailed assessment/focused assessment if no life-threatening injuries present.
G.   Cover injured eyes with protective shield or cup - avoid pressure or direct contact to eye.
H.   Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing to avoid contamination.
I.   Bring avulsed teeth with you. Keep moist in saline-soaked gauze.
J.   Monitor airway closely during transport for development of obstruction or respiratory distress. Suction and treat as
     needed.




                                                        III-13
Denver Metro EMT-Intermediate Protocols

Specific precautions

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




                                                         III-14
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                   HEAD TRAUMA

Specific information needed

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

Specific objective findings

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

Treatment

A.   Assess airway and breathing; treat life-threatening conditions: (See Section III - Multiple Trauma Overview). Use
     assistant to provide in-line cervical immobilization when indicated, while managing respiratory difficulty.
B.   Administer O2.
C.   Control hemorrhage. Stop scalp bleeding with direct pressure. Continued pressure may be needed.
D.   TRANSPORT RAPIDLY if patient has multiple injuries, or unstable neurologic, respiratory or circulatory status.
E.   Obtain initial vital signs, neurologic assessment.
F.   If unconscious:
     1. Assist ventilations.
     1. Consider ORAL intubation
     3. Ventilate at 10 breaths per minute for adults (15 breaths for children, 20 breaths for infants).
     4. If signs of cerebral herniation are present, hyperventilate at 20 bpm for adults (30 bpm for children, 35 bpm for
          infants).
     5. If patient is combative, Contact base to consider sedation (See Section VI - Drug Treatment Protocols).

G.   Immobilize cervical, thoracic and lumbosacral spine when indicated.
H.   If signs of hypovolemic shock are present, initiate treatment en route:
     1.     Establish venous access.
     2.     Fluid bolus: NS.
     3.     Look carefully for possible sources of bleeding (abdomen, pelvis, chest).
     4.     Contact base.
I.   If patient stable:
     1.     Establish venous access.
     2.     Complete detailed assessment.
     3.     Splint fractures and dress wounds if time permits.
J.   Monitor and record airway, vital signs, and level of consciousness repeatedly at scene and during transport. Status
     changes are important.




                                                        III-15
Denver Metro EMT-Intermediate Protocols

Specific precautions

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




                                                       III-16
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                   SPINAL TRAUMA

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions


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




                                                         III-17
Denver Metro EMT-Intermediate Protocols

Trauma Treatment                                   TRAUMA ARREST

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                          III-18
Denver Metro EMT Intermediate Protocols



                                              SECTION IV

            TREATMENT PROTOCOLS: ENVIRONMENTAL INJURIES TREATMENT


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




                                                     IV- 1
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment                   BITES AND STINGS

Specific information needed

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

C.      History of previous exposures, allergic reactions

Specific objective findings

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

Treatment

SNAKES: See Snake Bites.

SPIDERS:

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

BEES AND WASPS:

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

Specific precautions

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




                                                               IV- 2
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment          DROWNING/NEAR-DROWNING

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                              IV- 3
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment              HIGH ALTITUDE ILLNESS

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                              IV- 4
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment                  HYPERTHERMIA

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific precautions

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




                                                             IV- 5
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment         HYPOTHERMIA AND FROSTBITE

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

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

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

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

Specific precautions

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




                                                              IV- 6
Denver Metro EMT Intermediate Protocols

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

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




                                                             IV- 7
Denver Metro EMT Intermediate Protocols

Environmental Injuries Treatment                     SNAKE BITES

Specific information needed

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

Specific objective findings

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

Treatment

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

Specific precautions

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




                                                             IV- 8
Denver Metro EMT-Intermeidate Protocols

SECTION V

                      TREATMENT PROTOCOLS: PEDIATRIC TREATMENT


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




                                                   V-1
Denver Metro EMT-Intermeidate Protocols

Pediatric Treatment                   GENERAL GUIDELINES FOR PEDIATRICS

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

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

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

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


                      NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP


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

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




Prehospital Patient Assessment
                                                              V-2
Denver Metro EMT-Intermeidate Protocols

                                        PEDIATRIC PATIENT ASSESSMENT

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

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


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




                                                           V-3
Denver Metro EMT-Intermeidate Protocols

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

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

                                                      HIGH RISK PEDIATRIC TRAUMA PATIENT

                                  FIELD CRITERIA                                                             TRANSPORT DESTINATION

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

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

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

                                                      MODERATE RISK PEDIATRIC TRAUMA PATIENT

                                  FIELD CRITERIA                                                                 TRANSPORT DESTINATION

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

                                                              OTHER RISK FACTORS FOR INJURY

                                  FIELD CRITERIA                                                                 TRANSPORT DESTINATION

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

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

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




                                                                               V-4
Denver Metro EMT-Intermeidate Protocols

Pediatric Treatment       INFANT AND CHILD RESUSCITATION


Specific information needed

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

Specific physical findings

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

Treatment

A.   Airway/Breathing:

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

B.   Circulation:

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

C.   Medications:

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




                                                            V-5
Denver Metro EMT-Intermeidate Protocols

Specific precautions

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




                                                           V-6
Denver Metro EMT-Intermeidate Protocols

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

Specific information needed

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

Specific physical findings

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

Treatment

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

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

Special considerations


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

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




Pediatric Treatment

                                                          V-7
Denver Metro EMT-Intermeidate Protocols

                         PEDIATRIC DEHYDRATION

Specific information needed

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

Specific physical findings

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

Treatment

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

Specific precautions

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




                                                           V-8
Denver Metro EMT-Intermeidate Protocols

Pediatric Treatment                   PEDIATRIC RESPIRATORY DISTRESS

Specific information needed

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

Specific objective findings

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

Treatment

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




                                                           V-9
Denver Metro EMT-Intermeidate Protocols

Specific precautions

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

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

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

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

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

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

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

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




                                                          V-10
Denver Metro EMT-Intermeidate Protocols

E.   Pediatric Treatment                        PEDIATRIC SEIZURES

Specific information needed

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

Specific objective findings

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

Treatment

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

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

Specific Precautions

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




                                                           V-11
Denver Metro EMT-Intermeidate Protocols



                                                SECTION VI

                                          DRUG PROTOCOLS


TABLE OF CONTENTS


VI     Drug Protocols                                        Page Number
              Adenosine (Adenocard)                                    VI-2
              Albuterol Sulfate                                        VI-3
              Amiodarone                                               VI-4
              Aspirin (ASA)                                            VI-5
              Atropine Sulfate                                         VI-6
              Dextrose 50%                                             VI-7
              Diazepam (Valium)                                        VI-8
              Epinephrine                                           VI-9, 10
              Ipratropium Bromide (Atrovent)                          VI-11
              IV Solutions                                         VI-12, 13
              Morphine Sulfate                                        VI-14
              Naloxone Hydrochloride (Narcan)                         VI-15
              Nitroglycerin                                           VI-16
              Oral Glucose                                            VI-17
              Oxygen                                               VI-18, 19
              Sodium Bicarbonate                                      VI-20




                                                  VI-1
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                ADENOSINE (ADENOCARD)

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                          VI-2
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                  ALBUTEROL SULFATE

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                          VI-3
Denver Metro EMT-Intermeidate Protocols



Drug Protocol                                  AMIODARONE (Cordarone)
Pharmacology and actions

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

Indications Base Station Contact Required

     A.        Cardiac arrest from VT/VF –
     B.        Following successful defibrillation –
     C.        Pediatric pulseless VT/VF –

Precautions

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

Administration Base Station Contact Required for all administrations

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

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

C.        Pediatric pulseless VT or VF after unsuccessful defibrillation: 5mg/kg IV over 3-5 minutes.

D.        May be given IV only.

Side effects and special notes

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

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




                                                            VI-4
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                      ASPIRIN (ASA)

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

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

C.     Patients taking Coumadin may receive aspirin.




                                                        VI-5
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                     ATROPINE SULFATE

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

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

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

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

Administration

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

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




                                                           VI-6
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                      DEXTROSE 50%

Pharmacology and action

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                          VI-7
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                   DIAZEPAM (VALIUM)

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                          VI-8
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                         EPINEPHRINE

Pharmacology and actions

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

C.      Pulmonary:
        1.     Potent bronchodilator

Indications

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

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

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

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


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

                                                         VI-9
Denver Metro EMT-Intermeidate Protocols

            Reassure parents.

Administration

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

       2.        Bradycardia
                 a.     1.0 mg in 250 ml NS. Begin at 2 mcg/min. Titrate to blood pressure of 90 systolic

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

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

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

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

       2.        Bradycardia
                 a.     0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV

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

       4.        Anaphylaxis
                 a.     0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV

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



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




                                                        VI-10
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                IPRATROPIUM BROMIDE (ATROVENT)


Pharmacology and actions:

A.      Bronchodilation
B.      Dries respiratory tract secretions

Indications:

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

Contraindications:

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

Precautions:

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

Administration:

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

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

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


Side effects and special notes:

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




                                                          VI-11
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                         IV SOLUTIONS

Pharmacology and actions

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


TKO FLUID RATE

Indications
A.      Prophylactic IV
B.      Drug administration

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


FLUID REPLACEMENT/BOLUS

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

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

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



FLUID CHALLENGE

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

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




                                                           VI-12
Denver Metro EMT-Intermeidate Protocols

Side effects and special notes

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

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

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

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

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




                                                          VI-13
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                              MORPHINE SULFATE

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

Indications

A.      Presumed cardiac chest pain
A.      Severe burns
B.      Cardiogenic pulmonary edema
C.      General Pain Control

Precautions

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

Administration
A.     Contact Base prior to administration
D.     Adult dose: 2 - 10 mg IV. The goal is decreased anxiety and patient comfort; patient need not be completely
       pain-free.
C.     Pediatric dose: 0.1 mg - 0.2 mg/kg IV slowly.

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




                                                         VI-14
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                    NALOXONE (NARCAN)

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                           VI-15
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                     NITROGLYCERIN

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                         VI-16
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                   ORAL GLUCOSE (GLUTOSE and INSTA-GLUCOSE)

Pharmacology and Actions

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

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


Precautions

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

Administration

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

Side Effects and Special Notes

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




                                                           VI-17
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                          OXYGEN

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                         VI-18
Denver Metro EMT-Intermeidate Protocols



                                                 OXYGEN FLOW RATE

             METHOD                           FLOW RATE                     OXYGEN INSPIRED AIR
                                                                                (approximate)

 Room Air                                                             21%


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




                                                         VI-19
Denver Metro EMT-Intermeidate Protocols

Drug Protocol                                  SODIUM BICARBONATE

Pharmacology and actions

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

Indications

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

Precautions

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

Administration

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

Side effects and special notes

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




                                                          VI-20
Denver Metro EMT-Intermediate Protocols


                                              SECTION VII

                                          PROCEDURE PROTOCOLS


TABLE OF CONTENTS
                                                                      Page Number
VII    Procedure Protocols
              Airway Management: General Principles                            VII-2
              Airway Management: Opening the Airway                         VII-3, 4
              Airway Management: Obstructed Airway                             VII-5
              Airway Management: Clearing and Suctioning the Airway         VII-6, 7
              Airway Management: Assisting Ventilation                         VII-8
              Airway Management: Capnography                                   VII-9
              Advanced Airway Management: Orotracheal Intubation         VII-10, 11
              Bandaging                                                      VII-12
              Defibrillation                                             VII-13, 14
              Field Drawn Blood Samples                                      VII-15
              Medication Administration (Parenteral)                     VII-16, 17
              PASG (Formerly MAST)                                           VII-18
              Restraints                                                 VII-19, 20
              Splinting: Axial                                           VII-21, 22
              Splinting: Extremity                                       VII-23, 24
              Transport of the Handcuffed Patient                            VII-25
              Venous Access Technique                                 VII-26, 27, 28




                                                  VII-1
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                            AIRWAY MANAGEMENT
                                               GENERAL PRINCIPLES

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

Medical Respiratory Arrest

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

Medical Respiratory Insufficiency

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

Traumatic Respiratory Arrest

1.      Open airway using jaw thrust maneuver, protecting neck.
2.      Clear the airway using finger sweep; suction as needed.
3.      Have assistant stabilize head and neck.
4.      Draw tongue and mandible forward if needed in patients with facial injuries.
5.      Use pocket mask (or BVM) for initial control of ventilation.
6.      Perform orotracheal intubation with in-line immobilization of neck. Pressure over larynx may make intubation
        easier.

Traumatic Respiratory Insufficiency

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

        a.       Attempt orotracheal intubation with neck stabilized.




                                                         VII-2
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                             AIRWAY MANAGEMENT

                                                OPENING THE AIRWAY

Indications

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

Precautions

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

Technique

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

       3.       Nasopharyngeal airway:
                a.       Lubricate tube (viscous lidocaine or K-Y Jelly).
                b.       Insert in right or largest nostril, along floor of nose until flange is seated at nostril. Keep curve in
                         line with normal airway curve. If you meet resistance, try the left side.
G.     Listen to breathing to be sure maneuver has resolved problem.
H.     Consider intubation to provide adequate airway.
I.     Resume ventilatory assistance and oxygenation as appropriate.




                                                           VII-3
Denver Metro EMT-Intermediate Protocols

Complications

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

Side effects and special notes

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


                              METHODS OF OPENING THE AIRWAY


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


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




                                                            VII-4
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                             AIRWAY MANAGEMENT

                                                OBSTRUCTED AIRWAY

Indications

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

Precautions

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

Technique

COMPLETE AIRWAY OBSTRUCTION:
A.   Open airway using head tilt-chin lift or jaw thrust.
B.   Attempt to ventilate using mouth-to-mask or BVM ventilations.
C.   If unable to ventilate, reposition airway and reattempt ventilations.
D.   If airway remains obstructed, visualize with laryngoscope and remove any obvious foreign body.
E.   Reposition the airway and attempt to ventilate.
F.   If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts.
G.   Reposition the airway and reattempt to ventilate.
H.   When obstruction relieved:
     1.       Keep patient on side, sweeping airway to remove debris.
     2.       Apply O2, high flow; reservoir mask.
     3.       Assess adequacy of ventilation, and support as needed.
     4.       Suction aggressively.
     5.       Restrain if combative.

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

Complications

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




                                                          VII-5
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                          AIRWAY MANAGEMENT

                                 CLEARING AND SUCTIONING THE AIRWAY

Indications

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

Technique

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

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

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




                                                       VII-6
Denver Metro EMT-Intermediate Protocols

Complications

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

Side effects and special notes

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




                                                         VII-7
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                           AIRWAY MANAGEMENT

                                            ASSISTING VENTILATION

Indications

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

Precautions

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

Technique

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

Complications

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




                                                        VII-8
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                           AIRWAY MANAGEMENT

                                                   CAPNOGRAPHY

Indications

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

Precautions

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

Technique – Colorimetric End-tidal CO2 Detectors

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

Complications

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

Note

A.     Adhere to the expiration dates on these devices.




                                                          VII-9
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                         ADVANCED AIRWAY MANAGEMENT

                                           OROTRACHEAL INTUBATION

Indications

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

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

Precautions

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

Technique

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

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




                                                         VII-10
Denver Metro EMT-Intermediate Protocols

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

Complications

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



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


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




                                                        VII-11
Denver Metro EMT-Intermediate Protocols

                                                     BANDAGING

Indications

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

Precautions

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

Technique

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

Complications

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




                                                        VII-12
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                                  DEFIBRILLATION


Indications

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

Precautions

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

Technique

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




                                                          VII-13
Denver Metro EMT-Intermediate Protocols

Complications

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

B.      Skin burns from inadequate contact between paddles and skin

Side effects and special notes

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

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

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

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




                                                         VII-14
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                        FIELD DRAWN BLOOD SAMPLES

Indications

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


Precautions

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

Technique

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

Side effects and special notes

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

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

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




                                                         VII-15
Denver Metro EMT-Intermediate Protocols

Procedure Protocol              MEDICATION ADMINISTRATION (PARENTERAL)

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

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

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

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

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

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




                                                         VII-16
Denver Metro EMT-Intermediate Protocols

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




                                                          VII-17
Denver Metro EMT-Intermediate Protocols

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

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




                                                      VII-18
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                                     RESTRAINTS

Indications

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

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

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

Precautions

A.      Restraints shall be used only when necessary to prevent a patient from seriously injuring themselves or others
        (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done
        without restraints. They may not be used as punishment, or for the convenience of the crew.
B.      Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts to restrain a
        patient should only be done with adequate assistance present.
C.      Be sure to evaluate the patient adequately to determine the medical condition, mental status and decisional
        capacity of the patient. The hostile, angry, unwilling patient with decision-making capacity may refuse treatment.

D.      Be sure that restraints are in good condition (will not break and will not injure the patient).
E.      Do not use "hobble" restraints and do not restrain patient in the prone position.
F.      Ensure that patient has been searched for weapons.

Technique

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




                                                          VII-19
Denver Metro EMT-Intermediate Protocols

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

Complications

A.     Aspiration can occur, particularly if the patient is supine. It is the responsibility of the attendant to continually
       monitor the patient's airway.
B.     Nerve injury can result from hard restraints.
C.     Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia, stroke, hyperthermia,
       hypothermia, or drug ingestion.




                                                         VII-20
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                                 SPLINTING: AXIAL

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

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

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

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




                                                           VII-21
Denver Metro EMT-Intermediate Protocols

Complications

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

Side effects and special notes

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




                                                        VII-22
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                             SPLINTING: EXTREMITY

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

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

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

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




                                                          VII-23
Denver Metro EMT-Intermediate Protocols

Complications

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

Side effects and special notes

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




                                                        VII-24
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                TRANSPORT OF THE HANDCUFFED PATIENT

Indications

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

Precautions

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

Technique

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

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

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

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




                                                          VII-25
Denver Metro EMT-Intermediate Protocols

Procedure Protocol                          VENOUS ACCESS TECHNIQUE

GENERAL PRINCIPLES

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

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

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

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




                                                         VII-26
Denver Metro EMT-Intermediate Protocols

BUFF CAP (SALINE LOCK)

Indications
A.      Prophylactic IV access
B.      Drug administration

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

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

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

EXTREMITY

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

INTRAOSSEOUS INFUSION

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

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

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



                                                          VII-27
Denver Metro EMT-Intermediate Protocols

Contraindications
A.     Fractures
B.     Cellulitis
C.     Osteogenesis imperfecta

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




                                                         VII-28
Denver Metro EMT-Intermediate Protocols



                                      SECTION VIII

                            OPERATIONAL GUIDELINES


TABLE OF CONTENTS

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




                                                   VIII-1
Denver Metro EMT-Intermediate Protocols

Operational Guidelines

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

General Principles

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

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

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

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

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




                                                        VIII-2
Denver Metro EMT-Intermediate Protocols

Procedure

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

                                                  ALGORITHM
                                              AED/CARDIAC ARREST

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

Precautions

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




                                                        VIII-3
Denver Metro EMT-Intermediate Protocols

Operational Guidelines          BLOOD DRAW FOR ALCOHOL DETERMINATION

Purpose

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

Indications

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

Precautions

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

Technique

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




                                                         VIII-4
Denver Metro EMT-Intermediate Protocols

Operational Guidelines
                          COMBINED ADVANCE DIRECTIVES AND CPR DIRECTIVE

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

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

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

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




                                                        VIII-5
Denver Metro EMT-Intermediate Protocols

CPR DIRECTIVE PROTOCOL


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

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

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

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

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

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

A.      Perform initial patient assessment.

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

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

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

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

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

G.      Provide appropriate emotional support to family if possible.

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




                                                           VIII-6
Denver Metro EMT-Intermediate Protocols

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

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

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

Additional considerations

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

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

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

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




                                                        VIII-7
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                            COMMUNICATION

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

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

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

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

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

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

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




                                                         VIII-8
Denver Metro EMT-Intermediate Protocols


Operational Guidelines                            CONFIDENTIALITY


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

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

Exceptions

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

Additional Considerations

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




                                                         VIII-9
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                                  CONSENT

General Principles: Adults

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

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

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

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

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

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

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

Procedure: Adults

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

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

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

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

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

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




                                                         VIII-10
Denver Metro EMT-Intermediate Protocols

General Principles: Minors

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

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


Procedure: Minors

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

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




                                                       VIII-11
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                           DESTINATION POLICY

Purpose:

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

Philosophy:

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

Special Needs:

A.      Carbon Monoxide Poisoning

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

B.      Burns

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

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

C.      Trauma

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

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

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



E.      Obstetric/Gynecologic

                                                         VIII-12
Denver Metro EMT-Intermediate Protocols


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

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




                                                       VIII-13
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                                                  DIVERT POLICY

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


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

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




                                                                              VIII-14
Denver Metro EMT-Intermediate Protocols




    ZONE             HOSPITALS                ZONE MASTER                ZONE MASTER PHONE NUMBER


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


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


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

                                          2nd and 4th quarter -
                                          University

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


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




                                                       VIII-15
Denver Metro EMT-Intermediate Protocols


Operational Guidelines                 HAZARDOUS MATERIALS (HAZMAT)

Indications

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

Precautions

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

Procedure

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

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

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




                                                        VIII-16
Denver Metro EMT-Intermediate Protocols

Operational Guidelines
                                 INFECTIOUS and COMMUNICABLE DISEASES

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

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

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

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

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

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

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

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




                                                       VIII-17
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                  MENTAL HEALTH HOLDS (MHH)

Indications

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

Procedure

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

General Principles

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




Operational Guidelines                  NON-TRANSPORT OF PATIENTS
                                                      VIII-18
Denver Metro EMT-Intermediate Protocols


General Principles

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

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

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

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


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

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

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

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

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

     If the patient still refuses transport, contact base.




                                                             VIII-19
Denver Metro EMT-Intermediate Protocols

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

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

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

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

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

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

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




                                                         VIII-20
Denver Metro EMT-Intermediate Protocols

Operational Guidelines
                                                           ALGORITHM
                                                  NON-TRANSPORT/REFUSAL OF CARE

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

                                                     ↓
         ____________________________________________________________
           ↓                                                                                                 ↓

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

           ↓                                                                                                 ↓

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

 1
    Alcohol Treatment Hold




                                                                         VIII-21
Denver Metro EMT-Intermediate Protocols

Operational Guidelines              PATIENT CARE REPORT REQUIREMENTS

General Principles

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

Procedure

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

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

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

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

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

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




Operational Guidelines         PHYSICIAN AT THE SCENE/MEDICAL DIRECTION


                                                         VIII-22
Denver Metro EMT-Intermediate Protocols

Purpose

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

General Principles

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

Procedure

See algorithm.

Special notes

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




                            NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMTs

THANK YOU FOR OFFERING YOUR ASSISTANCE.

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

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

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

THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.




Physician Advisor                                                              Agency




                                                         VIII-23
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                       ALGORITHM for
                               PHYSICIAN AT THE SCENE/MEDICAL DIRECTION

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

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


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




                                                        VIII-24
Denver Metro EMT-Intermediate Protocols

Operational Guidelines                        RESUSCITATION AND
                                      FIELD PRONOUNCEMENT GUIDELINES

Purpose

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

General Principles

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

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

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


Special Considerations in Resuscitation Decisions:

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

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

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

B.      Penetrating Trauma:

        1.       Research data shows that a significant number of victims of penetrating trauma to the neck or torso, who
                 are found without signs of life, may be successfully resuscitated. Therefore, resuscitation and rapid
                 transport to a trauma facility should be initiated on all patients found in full arrest secondary to
                 penetrating trauma. Exceptions may exist in the following circumstance:

                 a.       Patients found pulseless and apneic with penetrating trauma if the provision of ALS (EMT-
                          Intermediate or EMT-Paramedic or emergency department) has been unavailable for at least 10
                          minutes from the time EMS personnel initiate on-scene assessment. (Some of the injuries
                          sustained by these patients may be compatible with life. "Appropriate" interventions will vary
                          and should be dictated by guidance from the base physician.)
                 b.       However, if there is any doubt about duration of the arrest, then resuscitation and rapid
                          transport should be initiated.




                                                         VIII-25
Denver Metro EMT-Intermediate Protocols


C.     Medical Patients (i.e., no evidence of trauma and presumed medical arrest) should receive resuscitative treatment
       until there is:

       1.      No return of spontaneous pulse or respirations during 15 minutes of CPR (after successful intubation and
               medications) and no reversible causes have been identified; or
       2.      Continuous asystole for at least 10 minutes in the adult patient, and 30 minutes in a pediatric patient
               (after successful intubation and medications), and no reversible causes have been identified
       3.      The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes and
               should be transported:
               a.       Hypothermic; or
               b.       Drowning with submersion less than 60 minutes (with hypothermia); or
               c.       Pregnant and estimated to be 20 weeks or later in gestation
D.     After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.) as the patient is
       now a potential coroner’s case.

Advance Medical Directives

A.     There are several types of advance medical directives (documents in which a patient identifies the treatment to be
       withheld in the event the patient is unable to communicate or participate in medical treatment decisions).

       1.      Do not resuscitate (DNR) orders are generally intended to be written by a physician for a patient whose
               medical condition is such that commencement of resuscitation efforts would be futile.
       2.      A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a
               terminal condition, as certified in the patient's hospital chart by two physicians. For the document to
               become operative, the patient must be unresponsive because of a terminal condition for a period of seven
               days.
       3.      Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health Care
               Proxy" (the CPR Directive is covered separately; see Section VIII - CPR Directive protocol). Each of
               these documents can be very complex and require careful review and verification of validity and
               application to the patient's existing circumstances. Therefore, the consensus is that resuscitation should
               be initiated until a physician can review the document or field personnel can discuss the patient’s
               situation with the base physician.

B.     Resuscitation may be withheld from or terminated for a patient who has a valid, written do not resuscitate order or
       other advance medical directive (See Section VIII - CPR Directive protocol) only if:

       1.      The document is clear, unequivocally to the prehospital provider that CPR, intubation and defibrillation
               are refused by the patient or by the patient's attending physician who has signed the document; and
       2.      Base physician has approved of withholding or ceasing resuscitative efforts; and
       3.      There is no apparent indication of suicidal gesture or intent by the patient.
       4.      If there is disagreement at the scene about what should be done, the base should be contacted
               immediately for guidance.
       5.      Prehospital providers presented with equivocal DNR orders or advance medical directives should
               proceed with resuscitation and establish base contact for guidance on treatment and transport.
               a.        If the directive document is long and detailed, then it is probably more reasonable for
                         resuscitation to be initiated and the patient to be transported so that the base physician can
                         review the document and possibly contact the patient's attending physician.
               b.        The duration of the resuscitation should be guided by the same factors of any medical cardiac
                         arrest (see section C above).




                                                      VIII-26
Denver Metro EMT-Intermediate Protocols

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

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

Additional Considerations:

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




                                                       VIII-27
Denver Metro EMT-Intermediate Protocols

Operational Guidelines             TRIAGE: MULTIPLE PATIENT ASSESSMENT

REFER TO:        THE COLORADO STATE UNIFIED DISASTER TAG AND TRIAGE SYSTEM -
                 A GUIDE TO MCI (multiple/mass causality incident)
Definition
MCI:             The combination of numbers and types of injuries that goes beyond the capability of an entity's normal
                 response.
Triage:          From French - means to sort, sift, or pick out; specifically, the sorting of and allocation of treatment to
                 patients.

Indications
Medical emergency involving more than one patient, interaction between different agencies, and the need to make choices
regarding treatment.

Procedure
A.     Park vehicle in safe location.
B.     Contact appropriate command personnel and follow instructions.
C.     If assigned to triage, do initial assessment of scene; proceed only when safe to rescuer.
D.     Rapidly estimate number of victims and severity of injuries. Do not provide extensive treatment.
E.     Establish communications and request necessary assistance as per department or agency procedure; this may
       include contacting the appropriate hospital and providing initial estimate of number and types of injuries.
F.     Designate or ensure designation of:
       1.        The Incident Command System (ICS) depending on the size of the event and the number of agencies
                 involved (see Diagram A - Incident Command System)
       2.        Medical command: follow departmental and jurisdictional procedures.
       3.        Medical Triage Team:
                 a.       Categorize patients after brief assessment using the Simple Triage and Rapid Treatment START)
                          system (see Diagram B - START Algorithm).
                 b.       Update categorizations and provide transport to stabilization area as able.
                 c.       Initiate medical stabilization to patients awaiting transport after triage duties completed.
       3.        Transport Team (if necessary):
                 a.       Transport patients in order of priority from field to stabilization area.
                 b.       Establish venous access or perform other stabilization procedures as needed in support of triage
                          team.
                 c.       If ongoing assessment, categorization, and transport are to be required, organize the area into an
                          appropriate Triage/MCI format (see Appendix Section F, Triage/MCI Templates; diagrams C-1,
                          C-2, and C-3)
Precautions
A.     Identification of medical charge personnel is extremely important and often overlooked. Use vests, hats, or other
       labeled equipment consistent with departmental or agency procedures.
B.     Location of stabilization area is very important. It should fulfill the following criteria as much as possible:
       1.        Away from objective dangers of scene
       2.        Close enough for access from scene for stretchers
       3.        Accessible by multiple rescue vehicles, both in and out
       4.        Near communications and other command personnel for coordination of evacuation
C.     If triage tags are part of departmental or agency procedures, attach triage tags to patient, not clothing.
D.     Triage assessment and management differs from single patient assessment. Certain problems recur in major
       disasters, and should be avoided:
       1.        Do not use up ambulance space initially transporting class III (green) patients before more serious
                 injuries have been transported (red and yellow).
       2.        Do not delay transport to treat patients at the scene.




                                                         VIII-28
Denver Metro EMT-Intermediate Protocols

        3.       Reassess patients when able and communicate any changes to the medical command and transport
                 officers.
        4.       Disaster scenes require discipline within the team. Be sure that the leadership and individual roles are
                 well identified. It is important that individuals fulfill their roles as members of the team and in turn give
                 up those roles appropriately as personnel and officers arrive to the MCI scene.
Special notes
A.      The Incident Command Structure developed and disseminated by the National Interagency Incident Management
        System (NIIMS) and Federal Emergency Management Agency (FEMA) provides an excellent overall approach to
        disaster management. The structure is designed to allow flexibility and local differences, as well as incorporation
        of different training levels (physician, nurse, paramedic, EMT-B) within Medical Control at the scene. It is
        important that individuals are aware of the command structure and follow instructions. (see ICS Flow chart
        below).
B.      Multiple-trauma patients with no vital signs upon arrival of rescue personnel have a very poor chance of survival
        even if they are the only victim. If there are additional victims with any signs of life, attention will be better spent
        with the living.
                                            INCIDENT COMMAND SYSTEM
                          * Command system with group and branch divisions based on functions
                                                       Incident Commander


                                                             Operations




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




     Triage                         Treatment                                      Transport                       Supply
    Supervisor                      Supervisor                                     Supervisor                      Officer


  Triage Group                     Area Leaders                                Deputy Transport
                                                                                 Supervisor


                                                                                     Clerk




                             Leader,              Leader,                     Leader,                Leader,
                             Area 0               Area I (Red)                Area II                Area III
                             (Black)                                          (Yellow)               (Green)


                             Area Staff            Area Staff                  Area Staff                 Area Staff
                                                         (Diagram A)




                                                          VIII-29
Denver Metro EMT-Intermediate Protocols


                                              START ALGORITHM

        Is patient able to walk and follow basic commands? If so, classify as delayed. (“walking wounded”)

                          If patient is non-ambulatory, then respiratory rate is assessed:


                                                     RESPIRATIONS
                               NO                                                            YES



             POSITION AIRWAY                                      >30/MINUTE                  <30/MINUTE




        No                        Yes


 Non-salvageable              Immediate                               Immediate                Assess perfusion




                                                            PERFUSION


                                Cap. refill >2 seconds or              Cap. refill <2 seconds or
                                no palpable radial pulse                palpable radial pulse




                         Control bleeding




                                        Immediate                     Assess mental status




                                                MENTAL STATUS


                                   Fails to follow                     Follows
                                 simple commands                   simple commands


                                    Immediate                          Delayed

                                                      Diagram B



                                                      VIII-30
Denver Metro Paramedic Protocols


                                                SECTION IX

                                                 APPENDIX


TABLE OF CONTENTS

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




                                                    IX-1
Denver Metro Paramedic Protocols

Appendix A              COMMONLY ACCEPTED ABBREVIATIONS FOR FIELD USE

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




                                                         IX-2
Denver Metro Paramedic Protocols

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


1o             first degree/primary




                                                       IX-3
Denver Metro Paramedic Protocols

GB             gallbladder
GC             gonorrhea or gonococcus
GCS            Glasgow coma scale
GI             gastrointestinal
g              gram
GPA            gravida, para, abort
gr             grain
GSW            gunshot wound
gtt(s)         drop(s)
GU             genitourinary
GYN            gynecology
→              going to/leading to
>              greater than
h/hr           hour
HA             headache
HACE           high-altitude cerebral edema
HAPE           high-altitude pulmonary edema
HAZMAT         hazardous materials (incident)
HB             heart block
HBV            hepatitis B virus
Hct            hematocrit
HEENT          head, eyes, ears, nose, throat
Hg             mercury
Hgb            hemoglobin
HIV            human immunodeficiency virus
H&P            history and physical
HR             heart rate
ht             height
Hx             history
hypo-          low
H2O            water
ICS            intercostal space
ICU            intensive care unit
I&D            incision and drainage
IM             intramuscular
inf            inferior
int            internal
IV             intravenous
↑              increase
J              Joule(s)
JVD            jugular venous distention
K+             potassium
KVO/ TKO       keep vein open / to keep open
L/l            liter
L              left
lac            laceration
lat            lateral
LBBB           left bundle branch block
lb             pound
lg             large
LLL            left lower lobe
LLQ            left lower quadrant
LMP            last menstrual period
LOC            loss of consciousness
L-spine        lumbar spine
LUL            left upper lobe
LUQ            left upper quadrant
<              less than
O   /\         lying

                                                IX-4
Denver Metro Paramedic Protocols

MAE            moves all extremities
MAST           medical antishock trousers, military antishock trousers
mcg            microgram
MCL            midclavicular line, modified chest lead
med(s)         medication(s)
mEq            milliequivalent
Mg             magnesium
mg/mgm         milligram
MI             myocardial infarction
misc           miscellaneous
ml             milliliter
mm             millimeter
MOE x          movement of extremities times
MS/MSO4        morphine sulfate
MVA            motor vehicle accident
               male

N/A            not applicable
NaCl/NS        normal saline
NaHCO3         sodium bicarbonate
NC             nasal cannula
neg            negative
NKA            no known allergies
noc/noct       night
NPO            nothing by mouth
NSR            normal sinus rhythm
NTG            nitroglycerin
N/V/D          nausea and vomiting and diarrhea
∅              none
O2             oxygen
OB             obstetrics
occ            occasional
O.D.           right eye (oculus dexter)
OD             overdose
OJ             orange juice
ophth          ophthalmology
OPP            organophosphate poisoning
OR             operating room
Ortho          orthopedics
O.S.           left eye (oculus sinister)
O.U.           both eyes (oculus uterque)
oz             ounce
p              after
PAC            premature atrial contraction
PASG           pneumatic antishock garment




                                                        IX-5
Denver Metro Paramedic Protocols

PAT            paroxysmal atrial tachycardia
path           pathology
PD             police department
PE             physical examination/pulmonary edema/pulmonary embolus
peds           pediatrics
per            by or through
PERL           pupils equal and react to light
PERLA          pupils equal and react to light and accommodation
PID            pelvic inflammatory disease
PND            paroxysmal nocturnal dyspnea
po             by mouth
pos/ /+        positive
post           posterior
POV            privately owned vehicle
PSVT           paroxysmal supraventricular tachycardia
psych          psychiatric
pt             patient
PTA            prior to arrival
PVC            premature ventricular contractions
Ψ              psychiatric
q              every
®              right
RBBB           right bundle branch block
RBC            red blood cell
resp           respirations
RHD            rheumatic heart disease/right hand dominant
RLQ            right lower quadrant
R/O            rule out
ROM            range of motion
ROS            review of systems
RUQ            right upper quadrant
Rx             take, treatment
s              without
SAB            spontaneous abortion
SC/sub q       subcutaneous
SL             sublingual
SOB            shortness of breath
sol            solution
sm             small
stat           at once
sup            superior
Sx             sign/symptom
surg           surgery
SVT            supraventricular tachycardia
synch          synchronous
2o             second degree/secondary
               sitting

 ¬_
               standing





                                                      IX-6
Denver Metro Paramedic Protocols

TAB            therapeutic abortion
TB             tuberculosis
tbsp           tablespoon
temp           temperature
TIA            transient ischemic attack
tid            three times a day
TKO            to keep open
TLC            tender loving care, total lung capacity
TM             tympanic membranes
tol            tolerated
tsp            teaspoon
Tx             treatment
∴              therefore
3o             third degree, tertiary
U/A            upon arrival
uncons         unconscious
unk            unknown
URI            upper respiratory infection
uro            urology
UTI            urinary tract infection
≠              not equal/unequal
vag            vaginal
VD             venereal disease
VF             ventricular fibrillation
via            by way of
vol            volume
V/S            vital signs
VT             ventricular tachycardia
WAP            wandering atrial pacemaker
WBC            white blood cell
wc             wheelchair
WNL            within normal limits
WPW            Wolff-Parkinson-White Syndrome
wt             weight
x              times
y/o            year(s) old
yr             year(s)




                                                         IX-7
Denver Metro Paramedic Protocols


                        The following is a complete list of medications that the Denver Metro Protocols authorize
                        Colorado State EMT Intermediates to administer and maintain pursuant to the scope of practice
                        under Acts Allowed for the State of Colorado.

                        Denver Metro Protocol Pharmacy List:

                                   Adenosine (Adenocard)
                                   Albuterol Sulfate
                                   Amiodarone (Cordarone)
                                   Aspirin (ASA)
                                   Atropine
                                   Dextrose 50%
                                   Diazepam (Valium)
                                   Epinephrine
                                   Ipratropium Bromide (Atrovent)
                                   IV Solutions
                                   Morphine Sulfate
                                   Naloxone (Narcan)
                                   Nitroglycerin (Sub Lingual)
                                   Oral Glucose (Glutose, Insta-Glucose)
                                   Oxygen
                                   Sodium Bicarbonate

                Maintenance IV Infusions

                IV Solutions
                               0.9% Normal Saline
                               Lactated Ringers
                               D5W
                               Any combination of the above solutions



Medications or infusions not included in this section will require paramedic or CCT transfer.




                                                          IX-8
Denver Metro Paramedic Protocols

Appendix C - TABLES
                                         REFUSALS, NON-TRANSPORTS and FIELD PRONOUNCEMENTS

 Standing Orders                                           Base Contact

 REFUSAL: Adult, 18 or older, with no                      Adult: All medical complaints and all other trauma, or altered mental status, or impaired
 demonstrable illness or injury, no mechanism              decision making capacity
 of injury, demonstrates competency, and did
                                                           Minor: Uninjured or not ill but unable to contact parent or legal guardian, OR ill or
 not initiate call for help, may refuse treatment
                                                           injured without guardian or parent to support patient refusal of treatment, OR with life-
 and transport.
                                                           threatening illness or injury but parent or legal guardian refusing treatment of minor.
                                                           Dispositions:
 Adult with isolated soft tissue injury and
                                                           * Non-transport - appropriate warnings to pt if Against Medical Advice.
 decision -making capacity may refuse
                                                           * Request Mental Health Hold by police and transport.
 treatment and transport. Base contact dictated
                                                           * Medical emergency exists & lack of decision-making capacity - transport.
 by physician advisor / agency policy.

 PRONOUNCEMENT: Pulseless and apneic                       Any field pronouncement mandated by physician advisor/agency policy.
 and one of the following: decapitated,
                                                           Termination or withholding of resuscitation of patient without criteria for standing order
 decomposed, over 90% burns, lividity, CPR
                                                           for field pronouncement.
 Directive, massive blunt or head trauma, if
 allowed by Physician Advisor/Agency policy.

                                                              ADVANCED PROCEDURES

 Procedure                         Standing Orders                                       Base Contact

 Airway management                 Oral or intubation

 Defibrillation                    All indications

                                         DESTINATION POLICY FOR PATIENTS WITH SPECIAL NEEDS

 Condition              Guideline (Review Protocol)                                             Base Contact

 CO poisoning           If isolated and significant→contact base station for                    All pts with other life-threats; to evaluate for
                        consultation to consider transport to Presbyterian-St. Luke’s           complications, destination

 Burns                  Isolated 2°/3° burns > 20% and >12y/o →University                       Pts with burns AND significant CO exposure in the
                                                                                                absence of multi-system trauma, consider transport
                        Isolated 2°/3° burns > 20% and <12y/o →The Children’s                   to PSL for hyperbaric treatment of CO
                        Hospital

 Multi-system           Per state destination guidelines
 trauma

 Pediatrics             Normal transport destination, except if significant burns or            Early base contact recommended for significant
                        long standing hx treatment @ The Children's Hospital                    complaints.

 Psychiatric            Pt is under Denver MHH → DHMC
                        MHH by other agency → appropriate affiliated hospital
                        Not on MHH → closest appropriate hospital

 OB/GYN                 Delivery not imminent → pt preference                                   If acute or imminent delivery and pt wants
                        Delivery imminent & no more than 5 min transport →pt                    transport to hospital over 5 min away, or if facility
                        preference                                                              w/o 24 hr in-house OB capability




                                                                          IX-9
Denver Metro Paramedic Protocols

                              MEDICATION PROTOCOLS – STANDING ORDERS and BASE CONTACT REQUIREMENTS - Note: Endotracheal dose should be 2x the IV dose.

                   Drug                    Standing Orders                                                       Base Contact

                   Adenosine                                                                                     Adult: 6mg,; 2nd dose 12mg , * Peds : 0.1mg/kg ; 2nd dose: 0.2mg/kg
                   Albuterol Sulfate                                                                             Mild 2.5mg/3cc NS (adult and ped) via nebulizer, moderate and severe
                                                                                                                 asthma 7.5 mg/9cc NS continuous nebulizer
                   Aspirin (ASA)           Four 81mg chewable tables p.o. (324 mg total)
                   Atropine Sulfate                                                                              Asystole: Adult 1mg q 3-5 min x 2 * Ped 0.02mg/kg
                                                                                                                 Bradycardia w/poor perfusion: 0.5-1.0mg * Ped 0.02mg/kg (min. 0.1mg
                                                                                                                 For bradycardia, after 2 doses, if signs of poor perfusion or pt remains
                                                                                                                 bradycardic. For symptomatic OPP.
                   Dextrose                Adult: 1st dose * 25g (D50) * Peds - 2-4 ml/kg- 1-8yr (D25), 0-1yr    2nd dose
                                           (D10)
                   Diazepam                                                                                      Status seizures: Adult 1-10mg IV *Ped 0.3mg/kg IV or rectal 0.5mg/kg,
                                                                                                                 up to 10mg
                   Epinephrine                                                                                   Cardiac Arrest: Adult—1mg every 3-5min IVP *Pediatric—0.1mg/kg
                                                                                                                 IV/IO/ET (1:1000) then 0.2mg/kg every 3-5 min IV/IO/ET (1:1,000)
                                                                                                                 subsequent doses
                                                                                                                 Allergic reactions: Adult—0.3mg 1:1,000 SQ *Peds 0.01 mg/kg
                                                                                                                 (1:1,000) SQ
                                                                                                                 Asthma: Adult 0.3mg (1:1,000) SQ, *Peds 0.01mg/Kg (1:1,000) SQ
                                                                                                                 Croup/Epiglottitis: Peds: 5mg of 1:1000 (5 cc) neb undiluted; if< 10kg
                                                                                                                 – 0.5mg/kg (1:1000) nebulizedBradycardia: Adult—1mg in 250cc NS
                                                                                                                 infused at 2mcg/min *Pediatric—0.01mg/kg (1:10,000) IVP
                                                                                                                 Anaphylaxis: (refractory to NS Bolus) Adult 0.1mg 1:10,000 IVP
                                                                                                                 followed by 1mg in 250cc NS infused at 2mcg/min.*Peds 0.01mg/kg IV
                                                                                                                 1:10,000



                   Ipratropium                                                                                   Bronchospasm: Adult: 0.5mg in 2.5 cc NS neb. *Peds over 2 y/o: 0.5mg
                   (Atrovent)                                                                                    in 2.5 cc NS neb. ONE TIME DOSE ONLY
                   IV Solutions            Bolus: 1 at 20cc/Kg          Challenge: up to 2 of 250ccs NS          Contact base if additional fluid may be needed.
                   Morphine Sulfate                                                                              Adult: 2 - 10 mg IV. Initial dose up to 4 mg, then 2 mg increments up
                                                                                                                            to a total of 10 mg., all indications; *Peds: 0.1 mg - 0.2
                                                                                                                            mg/kg IV slowly
                   Naloxone                                                                                      Adult 2mg; may repeat x 1 p 5 min * Ped < 8yrs 1mg. Pt must be
                                                                                                                 transported if med is used.
                   Nitroglycerin                                                                                 CP cardiac origin or pulmonary edema: One 0.4mg tab or SL spray q 5
                                                                                                                 min up to 3x
                   Oral Glucose            Hypoglycemia or AMS w/ history of hypoglycemia/diabetes Adult
                                           and peds: one tube
                   Sodium Bicarbonate                                                                            Prolonged cardiac arrest or dialysis patient in cardiac arrest (presumed
                                                                                                                 hyperkalemia) Adult and Peds: 1mEq/kg; Neonate – dilute 1:1 with NS
                                                                                                                 Tricyclic overdose with objective findings- ) Adult and Peds: 1mEq/kg;
                                                                                                                 Neonate – dilute 1:1 with NS
                   Base Station approval is REQUIRED for all medications that EMT-I’s administer: Adenosine, Albuterol, Amiodarone, Atropine, Diazepam, Epi, Ipratropium, Morphine,
                   Narcan, Nitro, Sodium Bicarb,

                                                                                                IX-10
Denver Metro Paramedic Protocols

Appendix D


                                                                                                Trip number #

                          REFUSAL OF AMBULANCE TRANSPORT AND TREATMENT

                                                INFORMATION SHEET

                                         PLEASE READ THIS DOCUMENT!



The Emergency Medical Services personnel of _                                  agency have given this form to you
because you have refused treatment or transportation to the hospital.

Your health and safety are our primary concerns. Even though you have decided not to accept our offer of treatment or
transport to the hospital, please remember the following:

        1.       We recommend that you be evaluated and treated by a physician.

        2.       Your decision to refuse treatment and transport by ambulance may result in delay, which may result in
                 worsening of your condition.

        3.       Medical evaluation or treatment may be obtained by calling your personal physician or by going to
                 any hospital emergency department.

        4.       You may change your mind about using ambulance transport. Please do not hesitate to contact us.
                 We will not hesitate to return to assist you.

        5.       Do not wait! When medical or trauma treatment is needed, it is usually better to get it sooner rather
                 than later.


                                             DIAL 9-1-1 IF YOU NEED
                                         EMERGENCY MEDICAL SERVICES!




_________________________________                                       __________________________________________
Date and Time                                                                                        Patient signature




_________________________________                           Base contact:      _____Yes
EMT / EMT-I / EMT-P                                                            _____No

                                                            Physician contacted and hospital:



                                                            Time of contact:


                                                        IX-11
Denver Metro Paramedic Protocols



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

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

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

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

The Emergency Medical Services Division of the Colorado Department of Health hereby determines that the following
information shall be recorded and preserved by each Prehospital care EMS service in the State on each patient cared
for:
1.               Patient name, if known, as complete as possible and ideally including full first and last name.
2.               Patient residential address, if known, as complete as possible (to allow medical or public health
                 follow up, if needed).
3.               Patient sex (both for purposes of identification and to facilitate diagnosis and treatment).
4.               Patient age, as accurate as possible (both for purposes of identification and to facilitate diagnosis and
                 treatment).
5.               Patient location at time of response and apparent cause of the injury or nature of illness (to assist in
                 subsequent diagnosis and treatment).
6.               Patient condition at time of response, including a preliminary assessment of the patient based on vital
                 signs, apparent symptoms, and known medical history.
7.               Patient vital signs at time emergency medical care is begun, to include respiratory rate, pulse rate,
                 blood pressure, level of consciousness, and pupil size and reaction to light. Subsequent vital signs
                 shall be recorded at least every 15 minutes when either treatment or transport time exceed 15 minutes.
8.               Known patient history related to the apparent illness or injury, including allergies and medications. If
                 it is determined that the patient is on medication of any kind, the prescribing physician should be
                 identified, if possible, so he/she may be contacted for confirmation, consultation, or actual care of the
                 patient.
9.               Treatment rendered to the patient at the scene and during transport, in sufficient detail to permit the
                 receiving facility (i.e., hospital, clinic, etc.), physician advisor, and any other reviewing physician or
                 nurse to determine the nature and extent of treatment rendered.
10.              Patient's apparent condition upon delivery to the receiving facility, and any pertinent comments
                 regarding changes in the patient's condition during transport (to assist the receiving physician in
                 diagnosis and treatment).
11.              Identity and location of the receiving facility and signature or other indication of the physician or
                 nurse receiving the patient and assuming responsibility for the care of the patient.
12.              Full name and level of training and certification or licensure of each member of the EMS crew caring
                 for the patient.
13.              Times of dispatch and departure to the emergency scene, time of arrival at the scene, time of departure
                 from the scene, and time of arrival at the receiving facility.
14.              Indication of whether emergency lights and siren were used enroute to the scene and/or during
                 transport.

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




                                                         IX-12
Denver Metro Paramedic Protocols

Appendix F                                     TRIAGE/MCI TEMPLATES

                                                 Simple Triage Template




                                                                           MCI




                                              Triage Area



       Green                                                                           Black


                           Yellow                                            Red




                                                                                      _
                                                                                      LZ




                                                    Supply
                                   <------------------------------------- < Ingress
                                   >------------------------------------- > Egress


                                                        Diagram C-1




                                                         IX-13
Denver Metro Paramedic Protocols

Appendix E                            TRIAGE/MCI TEMPLATES
                                      Moderate Triage Template




                                                           MCI



                                      Triage Area
  Green                                                                       Black




                           Yellow                            Red




                                                                         _
                                                                        LZ




                                         Supply




                             Egress                       Ingress



                                                                    Staging


                                            Diagram C-2




                                             IX-14
Denver Metro Paramedic Protocols

Appendix E                                   TRIAGE/MCI TEMPLATES
                                             Complex Triage Template




 Bus                                                                                Coroner’s Van

                                                                MCI
       Green                                                                              Black




                                              Triage Area




                           /
                           Yellow
                                                                       \   Red




                                                                                          _
                                                    S                                     LZ
                                                    u
                                                    p
                                                    p
                                                    l
                                                    y




               ∨                                  Ingress                          ∨
         Egress                                                                  Egress

                                              >
                                                            <
                                   Staging                       Staging


                                                   Diagram C-3




                                                   IX-15

				
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