adult als protocol
TRANSCRIPT
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Advanced Life SupportTreatment Protocol
St. Mary Medical Center
EMS Program_________________________________________________________ _________________________________________________________John P. Mulligan, M.D. Robert Boby, R.N.
EMS Medical Director EMS Coordinator
Revision #12 (02/21/13)
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St. Mary Medical Center ALS Protocol
Table of Contents
Medical
Code Description
1 Routine Patient Care
2 Radio Report
3 Accelerated Transport
4 Refusal of Services
5 DNR Orders, Out of Hospital
6 Hazmat Response
7 Mass Casualty Response
8 Abdominal Emergencies
9 Pain Management10 Suspected Cardiac Patient
11 Pulmonary Edema
12 Cardiogenic Shock
13 PVCs
14 Asystole
15 VF/Pulseless VT
16 Bradycardia
17 Tachycardia
18 PEA
19 Airway Obstruction20 Asthma/COPD
21 Allergic Reaction/Anaphylaxis
22 Diabetic Emergencies
23 Drug Overdose
24 Coma
25 Seizures
26 Stroke Brain Attack
27 Near Drowning
28 Cold Emergencies
29 Heat Emergencies
Code Description
30 Psychological Emergencies
31 Implanted defibrillator
32 Medication Assisted Intubation
33 Hypertensive Crisis
39 Poison/Toxin Emergencies
Trauma
Code Description
40 Routine Trauma Care
41 Suspected SCI
42 Hemorrhagic Shock
43 Head Trauma
44 Amputated parts
45 Burns
46 Chest Trauma
47 Trauma in Pregnancy
48 Trauma Arrest
49 Ophthalmic Emergencies
OB
Code Description
50 Emergency Childbirth
51 Maternal Care
52 Newborn Care
53 Prolapsed Cord
54 Breech Birth
55 Pre-Eclampsia
56 Third Trimester Bleeding
57
58
59
Pediatric
Code Description
60 Pediatric Bradycardia
61 Pediatric VF/Pulseless VT
62 Pediatric PEA
63 Pediatric Asystole
64 Pediatric Diabetic Emergencies65 Pediatric Seizures
66 Pediatric Respiratory Distress
67 Pediatric Allergic Anaphylactic
Reaction
68 Pediatric Narrow Tachycardia
69 Pediatric Wide Tachycardia
70 Pediatric Altered Level of
Consciousness71 Pediatric Airway Obstruction
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St. Mary Medical Center ALS Protocol
Revision Sheet
Revision Date Codes Amended System Approval Medical Director Approval Comments
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Code 1
Routine Medical Care
1. Perform Scene Survey and ensure the safety of all personnel.2. Reassure patient, provide comfort, and loosen tight clothing.3. Place patient in position of comfort.4. Assess and maintain ABCs.5. Supplemental oxygen at 2-6 L/min nasal cannula
10-15 L/min mask
6. Perform EKG And perform 12-lead if indicated7. Obtain IV access if appropriate, Attempt x 2-3. See IV Access Appendix.8. Contact receiving hospital as soon as patients condition permits.
Transmit assessment information. Contact supervising hospital as needed.
9. Recheck vitals every 15 minutes for stable patients and every 5 minutes for unstablepatients and record on the run form with proper times noted.
10. Transport to the closest most appropriate hospital.11. If medical direction is ever needed you may speak to a St. Mary Medical Center ER
Physician at (219) 947-6232.
Note: In a combative or uncooperative patient, the requirement to initiate routine patient care,
as written, may be altered or waived in favor of rapidly transporting the patient for definitive
care. Document the patients actions or behaviors which interfered with the performance ofany assessments and/or interventions.
SAMPLE HISTORYS= Signs & SymptomA= Allergies
M= Medications
P = Past History
L= Last Oral Intake
E= Events Leading To
Incident or Illness
Trauma AssessmentD= Deformity
C= Contusions
A= Abrasions
P= Puncture
B= Burns
T= Tenderness
L= Lacerations
S= Swelling
Medical AssessmentO= Onset
P= Precipitating
Q= Quality
R= Radiating
S= Severity
T= Time
Level of Consciousness
A= ALERT
V= VERBAL STIMULI
P= PAINFUL STIMULI
U= UNRESPONSIVE
* Nausea/Vomiting
If no contraindications
are present, may
administer a one time
dose of zofran 4mg IV
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Code 2
Radio Re ort
Outline for Radio Report(Transmitting as few words as possible)
1. Name and unit number of provider.2. ALS or BLS designation3. Age, Sex, and approximate weight of patient.4. Chief complaint, to include symptoms and degree of distress.5. Level of consciousness, orientation.6. Vital signs (include pain scale)7. Clinical condition: Focused and detailed patient assessment findings (only pertinent +/- findings)8. History of present illness/injury.9. History: allergies, medications, past history, last oral intake, events surrounding incident.10. Treatment rendered and response.11. Destination and ETA
Trauma
1. Name and unit number of provider.2. Age, Sex, and mechanism of injury.3. Chief complaint, to include symptoms and degree of distress.4. Level of consciousness, orientation.5. Vital signs (include pain scale)6. Focused and detailed patient assessment findings (only pertinent +/- findings)7. Medical history: allergies, medications, past history, last oral intake, events surrounding incident.8. Treatment rendered and response.9. Destination and ETA.
Mass Casualty Incident
1. Name and unit number of provider.2. Approximate number of victims and approximate triage levels: green, yellow, red, black.3. Mechanism of injury.4. Report any scene hazards.5. Medical communication should utilize the IHERN radio frequency unless otherwise specified by
local plans.
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Code 3
Accelerated Trans ort
Certain situations require treatment within minutes. These situations occur when a problem is discovered in the primary
survey that cannot be rapidly resolved by field intervention. Only airway and spinal immobilization should be managed prior totransport. Further efforts at stabilization should be performed en route and should not delay transport.
If circumstances demand hospital care for patient stability, rapid transport is indicated. Each case will be unique and
compelling reasons must be documented. Notify receiving hospital of the situation so that preparations can be made. Primary
resuscitative measures must be initiated. Contact receiving hospital/medical control ASAP.
Examples include, but are not limited to:
Inability to secure airway Severe head trauma Profound shock Respiratory failure Penetrating wounds to chest, neck, abdomen Trauma arrest Pediatric arrest
Trauma Transports
Consider transporting to the nearest appropriate Trauma Center (Within a 45 minute transport time) whenyour patient meets these criteria:
They fall under Level I or II under the CDC 2011 Field Triage Guidelines. (See ALS Appendicies)
A thorough assessment determines that your patient is stable enough to endure a 45 minute transport time.
The EMS personnel can be reasonably certain that the transport time will take no longer than 45 minutes
taking into account weather conditions, traffic problems, construction, etc.
If any of the above conditions are not met, then transport to the closest appropriate Emergency Department.
If any questions arise, contact Medical Control.
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Code 4
Refusal of Services
Begin evaluation and care
The patient refuses care
Altered Mental Status
(i.e., alcohol, drugs, head trauma,
mental retardation, etc.)
If No, Age >18 years, (unless
emancipated or parent or guardian
present)
Altered medical decision capacity?
If yes, Deny refusal and refer to
appropriate SOP
1. Document situation in all cases of refusal and contact medical control as needed.2. List the presence or absence of factors that enable refusal.3. For refusals, initiate a refusal form. Obtain a full set of vital signs, if patient refuses, document the refusal.4. List the consequences of refusal and have each refusing patient or guardian sign.5. Each refusing patient should be evaluated and each should sign a refusal form.6. If a patient wishes to refuse, and yet will not sign the refusal form, document the situation on the EMS report
form.
7. All personnel who witness the event should sign the EMS report form.8. Patients signature should be witnessed by family, friends, police,(EMS personnel when no one else is available).9. For minors, attempt to contact parents or adult caregiver to inform them of situation. Obtain phone consent of
refusal and document who you spoke with.
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General Guidelines:
-Provide comfort care and compassion for the patient.
- Treat acute airway obstruction, even if intubation is required.
- Treat problems not specifically listed (i.e., atropine for symptomatic
Bradycardia with
Code 5
DNR, Out of Hospital
DNR
Identify Patient
Identify Valid DNR
Orders
Revocation of a Valid
DNR Order
Care Instructions
Cause of action prescribed by a physician to withhold resuscitation measures on a
victim of cardiac arrest.
- Pre-hospital personnel must make a reasonable attempt to verify the
identification
of the patient named in a valid DNR Order.
- Patient should be a resident of a long-term care facility; hospice patient;
home
care patient; or inter-hospital transfer.
- Must contain the following information:
1) State form #49559 (Indiana State Form)2) Patients name and signature (or legal representative)3) Name and signature of attending physician4) Effective Date5) Signature of witnesses- The patient, physician who signed the DNR Order, or the consenting party to
the DNR
Transport
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Code 6
Hazardous Materials
Scene survey: Ensure scene safety
Request additional resources
Isolate scene, Notify Medical Control and receiving hospital ASAP
Identify hazard (DOT Emergency Response Guide)
Product Name, U.N. number, STML number, MSDS, Container Type
Maintain Airway, Administer 100%
oxygen
IV Normal Saline TKO
Cardiac Monitoring
Treat per SOP:
Shock, Arrhythmias, PulmonaryEdema, Seizures, Burns, Hypothermia
Unconsciousness, Wheezing
If indicated, flush skin with copious amounts of water
Other Treatment: per Medical Control
Transport
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Code 7
Mass Casualt Incident Res onse
Basic IMS Structure
Incident Command
Safety Officer
Medical Command
Treatment StagingTriage Supply Transport
With this format, resources can be managed for any size incident, large or small. Medical communication should
utilize the IHERN Radio frequency, unless otherwise specified by local plans.
The use of the S.T.A.R.T. triage system wi ll help maintain the continuity of care and control of every victim,injured or uninjured. Every victim will be placed into one of the four Triage categories listed below with
necessary information completed on the corresponding Triage tags.
Green Yellow Red Black
Minor Injuries
Uninjured
BurnsFractures
Non-life Threats
Multi-SystemTrauma
Head Injuries
Chest TraumaLife-Threats
Dead PatientsNon-salvageable
Patients
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Code 8
Abdominal
Routine Patient Care
Position Patient for Comfort
Assess Pain Level
Administer 0.9% Normal Saline Bolus
250-500cc
I f nausea and vomiting occur and no
contraindications are present, may
administer 4mg Zofran IV
Monitor patient conditionIf continued pain and SBP greater than 100mmHg,
may administer morphine 2-4 mg IV
Transport
* Analgesic AlternativePatients with right flank pain and
history of kidney stones with nocontraindications mayreceive
Toradol 30mg IV.
If unsure, contact medical control
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Code 9
Pain Management
Routine Patient Care
Position Patient for Comfort
Assess Pain Level (0-10)Appropriate splinting, ice, positioning
Indications
1. Extremity injury (including hip and shoulder injury)2. Back or flank pain3. Burns4. Chest Pain5. Crush Injuries6. Minor Traumatic Injuries
CONTACT MEDICAL CONTROL FOR OTHER
INDICATIONS OR UNSURE OF DOSAGE
Contraindications
Contact Medical Control prior to administration of pain medication if any of the
following are observed:1. Altered level of consciousness, any etiology
2. Hypotension, auscultated BP less than 90 mmHG
3. Respiratory compromise, hypoxemia4. Mechanism of injury meeting multi-system trauma criteria
5. Pregnancy
6. Known allergy or hypersensitivity to pain medication
7. Toradol may only be given to patients 15-70 years old, no renal/dialysis patients,
no diabetics, no NSAID/ASA allergies.
May administer:
1. Toradol 30 mg IV2. Morphine Sulfate 2-4 mg slow IV / IO every five (5) minutes until pain
resolved, or to a total of 10mg in adults. Burn patients up to a maximum of
20 mg.
OR
Fentanyl 25-50 mcg slow IV / IO with 1 repeat dosage
3. May administer MORPHINE SULFATE 5 10 mg IM or FENTANYL 50-100mcg IM if unable to establish IV.
4. Weight based dosing of morphine is 0.1 mg/kg IV for patients
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Consider medical controlcontact (for Nitro order
and/or MS orders)
Code 10
Suspected Cardiac Patient(Based on chest pain or equivalent)
Routine Medical Care
SBP < 90 mmHg SBP > 90mm Hg
Nitroglycerine 0.4mg SL or spray
May repeat X2. (if no IV, considerhospital contact prior to
administration).
Transport
Repeat Vital Signs
Note:
Contraindications to ASA would include ASA allergy,
Asthma, active bleeding or inability to swallow.
Thrombolytic Checklist
Clinical Presentation
Y N Chest Pain
Y N Unrelieved with Ntg x3
Y N Last > 30 Minutes
Contraindications to Thrombolytics
Y N History of CVA or TIA (6mo)
Y N Active Internal Bleeding
Y N Hx of Bleeding Disorders
Y N Uncontrolled HypertensionY N Intracranial or Intraspinal surgery past 2 months
Y N Intracranial or Intraspinal neoplasm, AVM or aneurysm
Y N Hx Trauma or Surgery Within 2 weeks
Y N PregnancyY N Previous Thrombolytic Use
Y N Recent (1 month) Head Trauma
Y N Suspected aortic dissectionY N Suspected Pericarditis
4 baby ASA (324MG) chew
and swallow
Transport
MS 2mg slow IV to a maximum of 10
mg for chest pain as needed. UseNarcan 2 mg IV to reverse effect if
necessary. Repeat vitals after q 2 mg
4 baby ASA (324MG) chew and
swallow unless contraindicated
12-lead
12-lead
If 12 lead EKG is positive for
STEMI, notify receiving hospital ofa Cardiac Alert
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Code 11
Pulmonary Edema
Routine Medical Care
SBP100mm Hg
Lasix40mg IV push
(may double home dose up to 80mg)
Refer to Cardiogenic Shock Code 12with limited fluid bolus of 200ml NS
TransportNitroglycerine 1.2mg SL
or spray.
May repeat every 5
minutes X2. If no IV,
consider hospital contact
Administer Morphine
2-4mg increments to a maximum
of 10 mg IV Push
Contact Medical Control for
additional medication
Transport
* Consider initiating the use of
CPAP with patients in respiratory
distress associated with pulmonary
edema. If CPAP does not improve
patient condition consider
intubation as per protocol.
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Code 12
Cardio enic Shock
Routine Medical Care
SBP < 100mm Hgwithout Dysrhythmias
SBP > 100mm Hgwith Dysrhythmias
Transport ASAP Treat underlying dysrhythmia and
transport ASAP
IV NS fluid challenge in200ml increments up to
1000ml (if lungs are
clear)
SBP > 100mm Hg
YES NO
Continue Routine
Medical Care and Rapid
Transport
Dopamine drip at5-20mcg/kg/min titrate
to maintain SBP >
100mm Hg
Continue Routine MedicalCare and Rapid Transport
Dopamine Drip Chart
400mg/250ml D5W
Starting Drip Rate (5mcg/kg/min)
WeightLb Kg Hypotension
88 40 8gtts/min
99 45 8 gtts/min
110 50 9gtts/min
154 70 13gtts/min
176 80 15gtts/min
198 90 17gtts/min
209 95 18gtts/min220 100 19gtts/min
253 115 22gtts/min
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Code 13
Premature Ventricular Contractions
Do not treat PVCs unless directed by medical control.
See VT protocol if necessary
Routine Medical Care
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Code 14
*may give double the dose via ETT
As stole
Assess and Maintain CABs
Begin CPR within 10 seconds of finding pulses absent
EKG Monitor(Confirm asystole in 2 leads)
Intubate & ventilate with 100%
Oxygen
Establish IV/IO access
Consider possible
causes and treatments:
**Administer Epinephrine 1:10,000*1mg IVP/IO
May repeat every 3-5 minutes
Consider Sodium Bicarb Administration0.5-1.0mEq/kg IVP/IO for extended down
time
Transport
Possible Causes & Management:
Hypoxia:
Confirm ET tube placement
Pre-oxygenate with 100% Oxygen
Hypovolemia:Administer IV/IO bolus 20ml/kg
Tension Pneumothorax:
Perform needle decompression
Overdose:
Administer Naloxone 2mg IV/IO push
Consider D50if hypoglycemic
Electrolyte imbalance (Dialysis Patient):
Consider CaCl 10ml IV/IO push
Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO
Consider D50 if hypoglycemic
Consider Magnesium Sulfate 12 gm IVP/IO
Acidosis:
Confirm adequate airway tube placementPre-oxygenate with 100% Oxygen
Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO
Hypothermia:
Passive rewarming
Active rewarming
*IO insertion may be consideredif no other IV access is available
*May give 1 dose of vasopressin 40 UIV/IO to replace first or second dose of
epinephrine.
ROSC? Induce Hypothermia
(See Appendices)
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Consider Magnesium Sulfate (see insert)
Code 15
Ventricular Fibrillation / Pulseless V-Tach
Assess and maintain CABs
Begin CPR within 10 seconds of finding pulses absentdefibrillate at maximum joules
(360j monophasic) or biphasic (200j)
resume CPR immediately
Rh thm after first 5 c cles of CPR?
Persistent VF/VT Return of Spontaneous
Circulation
PEA
Refer to Code 18
Asystole
Refer to Code 14
CPR, Intubate, IV
Defibrillate at maximum joules
Epinephrine(1:10,000) 1mg IVP/IO
or 2mg ETT *(see insert)
Repeat every 3-5 minutes
Consider an Anti-arrhythmic:
Consider Amiodarone bolus: 300mg IV/IO
Repeat Amiodarone @ 150mg IV/IO
OR
Lidocaine 1-1.5mg/kg IVP/IO
Repeat Lidocaine @ .5 1.5mg/kg
Continue drug-shock-drug-shock sequence
Routine Medical
Care
Lidocaine 1-1.5mg/kg IVP/IO
Begin Lidocaine drip at
2mg/min
Transport
Lidocaine Drip: (premixed) (2 gm/500ml)
60 gtt tubing =
Drops/min = 15 30 45 60
mg/min = 1 2 3 4
Titrate to effect
Magnesium Sulfate: dilute 1gm in 10ml NS. Give
slow IVP/IO or dilute 1gm in 100ml NS and give
rapid IV drip.
*May give 1 dose of vasopressin 40 U IV/IO to
replace first or second dose of epinephrine.
*IO insertion may be considered
if no other IV access is available
Consider Calcium Chloride if dialysis patient.
Consider Sodium Bicarb Administration0.5-1.0mEq/kg IVP/IO
Induce Hypothermia
(See Appendices)
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Code 16
Bradycardias
Routine Medical Care
Protocol
Hemodynamically Unstable Patient
(Signs of hypoperfusion or altered
mental status)
Administer Atropine 0.5-1.0mgIV/IO*
May repeat every 3-5 min
(max dose 0.04mg/kg or 3.0 mg total)
Consider External Pacing at rate
of 70, increase mA until capture.
May sedate if conscious,
Administer Versed 2.5 5 mg IV or
Diazepam 2-10mg slow IV
(Contact medical control foradditional sedation
Consider Dopamine 5mcg/kg/min
IV/IO Drip
(See chart)
to maintain SPB > 100mm Hg
Transport
Hemodynamically Stable Patient
Continue monitoring
Transport
Note:
1. Signs of hypoperfusion include: severe chest pain, severe SOB, SBP < 100mm Hg,diaphoresis, altered mental status.
2. Do Not delay transcutaneous pacer while awaiting IV/IO access or for Atropine to takeeffect if patient is symptomatic.
3. Do not give Lidocaine to patients with AV blocks, idoventricular rhythm, or severehypoperfusion.
Dopamine Drip Chart400mg/250ml D5W
Starting Drip Rate (5mcg/kg/min)
Weight
Lb Kg Hypotension
88 40 8gtts/min
99 45 8 gtts/min
110 50 9gtts/min
154 70 13gtts/min176 80 15gtts/min
198 90 17gtts/min
209 95 18gtts/min220 100 19gtts/min
253 115 22gtts/min
*May double-dose via ETT
*IO insertion may be considered
if no other IV access is available
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Code 17
Tachycardias (with pulse)
(of Cardiac Origin)
Routine Medical Care Protocol
Consider non-cardiac causes and treatment
Stable
Patient is alert, without any signs of
hypoperfusion
Unstable
(signs of hypoperfusion)
Narrow Complex*
( RS 0.12 sec)
Vagal Maneuvers x 2Lidocaine 1.5mg/kg
Lidocaine 0.75mg/kg
Supraventicular tachycardiaAdenosine (Adenocard) 6mg Rapid IVP
Followed by 12mg Rapid IVP
May Repeat x1.
If no result, consider cardizem.
Continue Routine Medical Care and Transport
Consider sedation with Versed
2.5 5 mg slow IV or
Diazepam (Valium) 2-10 mg slow IV
(if conscious)
Synchronized Cardioversion @ 100J
(no response-200J)
(no reponse-360J)(or bi hasic e uivalent
Wide Complex
Lidocaine 1.5mg/kg
SynchronizedCardioversion @ 360J
Or biphasic equivalent
Narrow Complex
Contact MedicalControl
Accelerated
Transport
Note:
1. Signs of hypoperfusion: severe chestpain, severe SOB, SBP.12sec.
At Discretion of Physician or Radio Nurse:Adenosine (Adenocard) for children < 15 yrs. 0.05mg/kg may be increased to 0.1mg and
0.15mg/kg maximum 12mg/dose. Bolus 5-20ml saline.
Cardioversion for children < 15 yrs., 0.5J/kg up to 1.0J/kg
Fluid Bolus for Hypotension.
For uncontrolled SVT, atrial fibrillation or atrial flutter
administer Cardizem (diltiazem)
0.25mg/kg initial and 0.35 mg/kg for the repeat, with a max
dose of 20mg and 25mg respectively
*0.12 seconds = 3 small boxes
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Code 18
Pulseless Electrical Activity (PEA)
Assess and maintain CABs
Begin CPR within 10 seconds of finding pulses absent
Intubate and Ventilate with 100% Oxygen
Apply and interpret EKG
Establish IV Access
Apply Pulse Oximetry (if available)
Consider Causes and Treatment
Administer **
Epinephrine 1:10,000
1mg IV/IO Push or 2 mgETT
May repeat every 3-5 min
Monitor Patient Condition Initiate
Transport
Contact Medical Control
Causes and Management:
Hypoxia:
Confirm ET tube placement
Hyperventilate with 100% Oxygen
Hypovolemia:
Administer IV/IO Bolus 20ml/kg
Repeat as needed
Tension Pneumothorax:
Perform Needle Decompression
Overdose:Refer to Code 23
Electrolyte imbalance (Dialysis Patient):Consider Calcium Chloride 10ml IV/IO Push
slowly
Consider Sodium Bicarb 1-2mEq/kg IV/IOConsider D50if hypoglycemic
Consider Magnesium Sulfate 1 gm IVP/IO
Acidosis:
Hyperventilate with 100% oxygen
Consider Sodium Bicarb 1-2mEq/kg IV/IO
Hypothermia:
Passively rewarm
Actively rewarm
*IO insertion may be considered
if no other IV access is available
***May give 1 dose of vasopressin
40 U IV/IO to replace first or
second dose of epinephrine.
ROSC? Induce Hypothermia
(See Appendices)
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Code 19
Airwa
Assess and Maintain ABCs
Conscious Patient
(Unable to Speak)
Unconscious Patient
Position Patient Supine
Perform 5 Chest Thrusts
Clear Airway &Ventilate
Repeat if NecessaryPerform Heimlich Maneuver
Provide support for patient
Cleared Obstructed
Administer
supplemental
oxygenRe-assess
Patient Condition
Repeat Heimlich or
Abdominal Thrusts
Clear Airway & Attempt
Ventilation
Initiate Transport
Contact Medical Control
Monitor Patient Condition
If still obstructed refer to
unconscious patient
Remains Obstructed
Attempt to visualize obstruction &
remove with Magill forceps
Ventilate with 100% Oxygen
Remains Obstructed
Consider appropriate
Cricothyroidotomy procedure
Assess & Maintain Airway
If still unable to ventilate, intubate
and pass tube pushing foreign body
into right mainstem bronchus, then
pull back tube and ventilate left lung
Transport STAT
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Code 20
Asthma/COPD with Wheezing
Routine Medical Care *Prepare and initiate Transport
Begin Albuterol (2.5mg) Nebulizer Treatment(May repeat times 3)
For severe cases consider adding a one time
dose of 0.5 mg Atrovent to the albuterol
nebulizer treatment.
Patient Improving?
Yes No
Monitor Patient Continue
Transport
Transport
Consider administration of 125mg
Solumedrol IV Push for continued
dyspnea, if taking Prednisone p.o. or
Cortisone Inhalers
*Do not withhold oxygen to COPD patients in acute, severe distress. Be prepared to
support patients respirations or intubate, if necessary.
If patient < 50 years old
and Pulse < 150
and no history of heart diseaseand patient not having chest pain
Administer Epinephrine 1:1,000
0.1mg - 0.3mg SQ or IM
* Consider initiating the use of
CPAP with conscious patients inrespiratory distress. If CPAP
does not improve patient
condition consider intubation as
per protocol.
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Code 21
Allergic Reaction/Anaphylactic Shock
ABCs
Routine Medical Care
Remove insult
Cryotherapy to bite, sting
Mild
Local reaction onlyLocal redness, itching etc.
Alert, oriented, normo-tensive
SevereAny respiratory distress, severe allergic symptoms, altered
level of consciousness, hypotensive
Transport
Cool packs to site
(if not contraindicated)
Moderate
Generalized itching, hives etc.
Mild respiratory signs/symptoms
normotensive
Benadryl
25-50 mg slow IVP
Epinephrine (1:1,000)
0.3-0.5 ml subQ or IMor
Epi-pen
If wheezing or respiratory
symptoms, Albuterol Nebulizer
May add .5mg atrovent x1
Transport ASAP
If severely compromised, attempt intubation. Ifunsuccessful: appropriate cricothyroidotomy procedure
IV wide open
If IV present:
Epi (1:10,000): 0.5mg slow IVP. May repeat in 3-5min.If no IV present:
Epi pen or Epi 1:1000 subQ (0.5ml) or IM or
Benadryl 25-50 mg IVP (may give IM if no IV)
Albuterol/Atrovent
Nebulizer
(if able)
Dopamine drip
Transport STAT
Dopamine Drip Chart
400mg/250ml D5WStarting Drip Rate (5mcg/kg/min)
Weight
Lb Kg Hypotension88 40 8gtts/min
99 45 8 gtts/min
110 50 9gtts/min
154 70 13gtts/min
176 80 15gtts/min
198 90 17gtts/min
209 95 18gtts/min
220 100 19gtts/min
253 115 22gtts/min
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Code 22
Diabetic Emer encies
Routine Medical Care
Obtain Random Blood Sugar*
Blood Sugar 180mg/dl
Signs & Symptoms of ketoacidosis
Administer 50% Dextrose 50ml IVP (slow)
or
Administer Glucagon 1mg IM
(if unable to establish IV access)
If no response, may repeat
50% Dextrose 50ml IVP
Monitor Patient Condition
Recheck blood sugar
Transport
Administer 250ml IV Bolus
of NS
If lungs remain clear, repeat 250ml bolus
Monitor Patient Condition
Transport
Note to Pre-hospital Personnel:
If after treatment, patient is awake, alert, and
competent, and refuses transport, contact medical
control for assistance*If unable to obtain blood sugar in an unconscious,
known diabetic, administer 50% dextrose IV or
GlucagonIM.
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Code 23
Dru Overdose
Routine Medical Care
Obtain Random Blood Sugar
Treat per suspected overdose:
Narcotic: (Respiratory depression, pinpoint pupils)Narcan (Naloxone): 2mg IVP to a maximum of 6mg
Cyclic: (wide QRS, hypoperfusion)
IV wide open
Sodium Bicarbonate: 1mEq/kg IVP
Beta/Calcium Channel Blockers (Bradycardia, hypoperfusion): Glucagon 1mg slow IVP. May repeat X 1
For known meth-amphetamine type overdose, i.e. Bath Salts,: Consider ativan 1-2 mg IV/IM for extreme agitation.
Call medical control for any additional orders.
Narcotic or Synthetic Narcotic: Morphine, Demerol, Heroin, Methadone, Codeine, Fentanyl, Vicodin,Hydrocodone, Dilaudid, Darvon.
Tricyclic antidepressants include: Elavil, Amtiriptyline, Triavil, Norpramine, Tofranil, Pamelor, Sinequan,
Ludiomil, Desyrel, Clomipramine (Anafranil), Endep, Doxepine (Sinequan),
Imipramine, Trimipramine (Surmontil), Amoxapine (Ascendin), Despramine
(Norpramin), Nortriptyline, Aventyl, Protriptyline (Vivactil).
Benzodiazepines: Halcion, Ativan, Centrax, Doral, Restoril, Versed, Valium, Xanax, Librium,
Klonopin, Dalmane, Rophynol.
Beta-Blocker: Enderal, Corgard, Lopressor, Atenolol, Labetalol, Propanolol,
Calcium Channel Blocker: Cardizem, Procardia, Calan/Verapamil/Isoptin/Adalat, Diltiazem
Code 22 for diabetic
emergencies
Manage ABCs
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Code 24
Coma (No History of Trauma)
Routine Medical Care
Assess Level of Consciousness
Glasgow Coma Scale
AVPU Scale
Wave ONE broken Ammonia
Capsule under patients nose
Note Response
Obtain Random Blood Sugar
Consider Naloxone (Narcan) 2mg IVP Slowly
Monitor Patient Condition
Secure Patient Using Spinal Precautions(if indicated)
Protect airway.
Transport
If Diabetic Emergency
Refer to Code 22
Identify Possible
Causes:
A = Alcohol
E = Endocrine
I = InsulinO = Oxygen/Opiates
U = Uremia, Renal
T = Trauma
I = Infection
P = Psychiatric
S = Space occupying
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Code 25
Seizures
Routine Medical Care
Protect patient from injury
Protect Airway
Obtain Random Blood Sugar
If seizure activity last > 2-3 minutesAtivan 1-2mg IVP Slowly
May give Ativan 2 mg IM if unable to obtain IV
Monitor respiratory status closely and be
prepared to support patient
Observe patients sensorium during
postictal period. Note any injuries
incurred and/or incontinence
Transport
Treat as per Code 22 if
Hypoglycemic
If allergic to ativan may administervalium 2-10mg IV
(titrate to end seizure activity)
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Code 26
Stroke/ Brain Attack
Routine Medical Care
100% Oxygen
Limit scene time
Obtain stroke time of onset
Random blood glucose
treat per protocol
Monitor respiratory status closely
and be prepared to support patient
Perform Pre-hospital Stroke Scale
Transport Family member with
patient to hospital if possible
Notify Receiving Hospital of Stroke Alert i f Pre-
hospital stroke scale is positive
Pre-hospital Stroke Screen
1. Facial Droop (ask patient to show teeth or smile).Normal-(Both sides of face move equally well).
Abnormal-(one side doesnt move as well as other).
2. Arm driftNormal-Both arms remain steady
Abnormal-(one arm doesnt move at all or drifts
down as compared to other arm).
3. Speech (Have the patient say, Its a sunny day atSuperior).
Normal-Clear speech
Abnormal-(patient slurs words, says wrong words,unable to speak).
4. Glucose level5. Symptom duration6. Hx seizures?7. Anticoagulant therapy? (Coumadin, Ticlid)
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Code 27
Near Drownin
Initial Trauma Care(C-spine precautions as indicated)
100% OxygenEstablish and maintain airway
Intubate if Necessary
Remove wet clothingConsider hypothermia
Awake, alert, or semiconscious withpurposeful response to pain, normal
respirations and pupil response
Comatose, unresponsive to verbalstimuli, abnormal response to pain,
abnormal respirations or pupil
response
TransportBegin CPR if indicated
Hypothermic
See Cold EmergenciesCode 28
Transport
Normothermic
Treat dysrhythmias perappropriate SOP
Transport
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Code 28
Cold Emer encies
Move Patient to a warm environment
as soon as possible
Frostbite Severe HypothermiaSystemic Hypothermia
Mild/Moderate 95-90F (35-32C):
Conscious or altered sensorium
with shivering
Oxygen 10-15L/mask
IV NS TKO
Re-warm patient
Place patient in a warm
environment.
Remove wet clothing.Apply hot packs wrapped in towels
to axilla, groin, neck, thorax.
Wrap patient in blankets.
Transport ASAP
Rapidly warm frozen area with tepid
water (105F)
Hands or hotpacks wrapped intowels may be used. DO NOT RUB.
Do not thaw if there is a chance of
refreezing.
-Handle skin like a burn
-Protect with light sterile dressings.
-Do not let skin rub on skin (between
fingers or toes.
Cover with warm blankets and
prevent re-exposure.
Transport
90F or less (
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Code 29
Heat Emergencies
Move patient to a cool environment
Initial Medical Care
Heat Cramps or Tetany
(IV may not be necessary)
Allow for oral intake of water or electrolyte replacement
fluids
Do not massage cramped muscles
Transport
Heat Stroke
100% 02Manage Airway
IV NS boluses (200ml) up to1000ml -or-
SBP>100
(check lungs after each bolus)
Heat Exhaustion or Syncope
IV NS rapid rate
Place patient in supine position with feet
elevated Trendelenberg
Remove as much clothing as possible to
facilitate cooling
Transport
Seizure precautions(Code 25 if seizures)
Initiate rapid cooling:Remove as much clothing as possible.
Cool packs to lateral chest wall, groin, axilla, carotid arteries, temples, and
behind knees and/or sponge with cool water or cover with wet sheet and
fan body. Wet head if possible, avoid shivering.Transport
Position with head elevatedunless contraindicated
Rapid cooling while preparing IV
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Code 30
Ps cholo ical Emer encies
I. Purpose/DefinitionGiven the magnitude of the problems of abuse and violence in our society, early detection of domestic violence
victims, appropriate legal and social service referrals and the delivery of timely medical care are essential.
Domestic violence is a pattern of coercive behavior engaged in by someone who is or who was in an intimate
relationship with the recipient. These behaviors may include: repeated battering, psychological abuse, sexual assault
or social isolation such as restricted access to money, friends, transportation, healthcare or employment. Typically,
the victims are female but it must be recognized that males can be victims of abuse as well.
II. Domestic Violence IndicatorsWhile sometimes the specific history of abuse is offered, many times the victim of abuse, (either out of fear or
because of the coercive nature of the relationship or out of the desire to protect the abuser) will not volunteer a true
history but instead ascribe injuries to another cause. Therefore, an appropriate review must be undertaken with
respect to patients presenting with injuries:
-That do not seem to correspond with the explanation offered.
-That are of varying ages.-That have the contour of objects commonly used to inflict injury (i.e. hand, belt, rope, chain, teeth, cigarette)
-During pregnancy
Other factors include:
-Partner accompanies patient and answers all questions directed to patient.-Patient reluctant to speak in front of partner.
-Denial or minimalization of injury by partner or patient.
-Intensive, irrational jealously or possessiveness expressed by partner.
Physical injuries commonly associated with domestic violence:
-Central injuries, specifically to the face, head, neck, chest, breasts, abdomen, or genital areas.
-Contusions, lacerations, abrasions, stab wounds, burns human bites, fractures (particularly of nose and orbits), andspiral wrist fractures.
-Complaints of acute or chronic pain without tissue injury
-Signs of sexual assault-Injuries or vaginal bleeding during pregnancy, spontaneous or threatened miscarriage
-Multiple injuries in different stages of healing
Direct impact of domestic violence on pregnancy may include:
-Abdominal trauma leading to abruption, pre-term labor, and delivery-Fetal fracture
-Ruptured maternal liver, spleen, uterus
-Antepartum hemorrhage
-Exacerbation of chronic illness
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Code 30 (Continued)
Code 31
III. Approaches for Interviewing the patientThe goals of the physical examination are to identify injuries requiring further medical intervention and to make
observations and collect evidence that may corroborate the patients report of abuse. A thorough physical examination isessential to uncover hidden injuries or compensated trauma. If the patient reports sexual assault, the sexual assault
protocol should be followed:
-Always interview the patient in a private place, away from anyone accompanying them to the ED. Questioning the patient
in front of the batterer may place the patient and any children in danger.
-You may be the first person or professional to acknowledge the abuse. It is important that you convey your concerns
about what has happened to the patient to the Emergency Physician and Nurse.
-When interviewing, do not ask patients if they were battered or abused (many battered persons do not consider
themselves in this light). Instead, you can ask the patient:
Have you had a fight with someone?
Did anyone hurt you?Many times we have seen these types of injuries in patients who are hurt by someone else, did someone hurt you?
I am concerned that someone may be hurting you or scaring you, can you tell me what has happened?
-Most battered persons feel very shamed and humiliated about what has happened to them.
It is important to acknowledge that you understand how difficult it is to talk about what happened.
-Most battered persons will minimize the abuse or blame themselves for what happened.
It is important that you repeatedly reinforce that no one deserves to be hurt no matter what they may or may not have
done.
-Questions/attitudes Not to ask/Express:
-What keeps you with a person like that?
-Do you get something out of violence?
-What did you do at the moment that caused them to hit you?
-What could you have done to avoid or defuse the situation?
IV. Practice-Treat obvious injuries: transport
-Report your suspicion and supporting findings to the Emergency Department Physician and on the prehospital report form.
-If the patient refuses transport, make appropriate referral and documentation on run sheet.
-Document your findings on the prehospital report form:-Presenting condition.
-Any suspicious indicators.
-Physical exam including any evidence of abuse.-Treatment rendered.
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Implanted Cardiac Defibrillation
(ICD, PCD, AICD)
1. Treat Dysrhythmias per appropriate SOP.2. If external defibrillation is required:
Avoid placement of pads or paddles over the ICD unit or path of wires (if possible) Defibrillate at 360 joules or biphasic equivalent; repeat as indicated
3. If ICD is repeatedly firing and patient is stable, may administer sedation order (Versed in 2mg increments)
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Code 32
Medication Assisted Intubation
Indications:1. Patients with actual or potential airway compromise due to
altered mental status, GCS less than 8.
2. Patients whose combativeness and agitation threatens theairway or spinal cord stability.
3. Patients who demonstrate a high probability of airwaycompromise for any reason prior to, or during transport.
4. Patients requiring ventilator assistance or airway protection.5. CONTACT MEDICAL CONTROL PRIOR TO
USE.
Premedicate:1. Lidocaine: 1.5 mg/kg IV, IO (utilize for patients with a
head injury)
2. Atropine : 0.5 mg/IV,IO for adult patients withbradycardia
Induction:1. Versed 2.5 5 mg IV, IO
ORAFTER CONSULTATION WITH MEDICAL CONTROL:
2. Etomidate 0.3mg/kg IV, IO, may repeat one time
Post Intubation Sedation:1. Versed 2mg IV, IO increments unless patient is hemodynamically unstable.2. Ativan 1-2 mg IV, IO may also be used for post intubation sedation unless patient
is hemodynamically unstable.
3. Etomidate 0.3mg/kg IV, IO may be utilized one time for post intubation sedation.4. Consider pain management with patients with high probability of pain and
normal sedation is not working adequately. Follow pain management protocol
where indicated.
Etomidate dosing chart0.3 mg/kg IV
Weight
Lb Kg Dose
88 40 12 mg IVP
99 45 13.5 mg IVP
110 50 15 mg IVP
154 70 21 mg IVP
176 80 24 mg IVP
198 90 27 mg IVP
209 95 28.5 mg IVP
220 100 30 mg IVP
253 115 34.5 mg IVP
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Code 33
Hypertensive Crisis
Aggressive
prehospital
treatment of the
A hypertensive emergency exists when the systolic blood pressure is > 200mmHg or diastolic BP is > 100mmHg
and the patient is symptomatic. Symptomatic examples include but are not limited to headache, diaphoresis,
chest pain. Contact medical control prior to any medication administration if patient has signs and symptoms
of CVA. Pregnant patients with hypertension follow protocol 55.
Establish Code 1
Nitroglycerin 0.4mg SL. May repeat
every five minutes up to three doses, if
no relief and systolic blood pressure
>100 mmHg
If no improvement, administer Lopressor
(metoprolol) 5mg IV over 1-2 minutes. Repeat 5mg
IV every 5 minutes up to three doses.
Code 33
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Code 39
Poisoning Toxic Ingestion or Exposure
Routine Medical Care
Maintain ABCs
1. Exposure protection as indicated2. Contact Poison Control 1-800-222-12223. Be prepared for seizures4. Be prepared for vomiting
Bring all medication, poison bottles to the hospital (unless HAZMAT)
Monitor closely
Do not induce vomiting
Contact medicalcontrol for permission
to Administer activated
Charcoal*
Adult dose: 50gm
Pediatric dose: 1 gm/kg
Transport STAT
Conscious Patient Unconscious Patient
Support ABC's
Recovery position
Be Prepared to SuctionMonitor closely
Treat per appropriate protocol
Transport STAT
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Code 40
Routine Trauma Care
Assess Scene Safety
(Consider Crime Scene)
Body Substance Isolation
Primary Patient
Assessment
Resuscitation:
Secure & maintain airway Perform spinal immobilization Transport as soon as possible
performing treatment enroute
Establish TWO (2) large-bore IVsenroute (if able)
Evaluate ECG See analgesia insert
Analgesia Order
May give Morphine
Sulfate 2-4mg slow
IV repeating in 2mg
increments (max
10mg) or Fentanyl
25-50 mcg slow
IVfor:
severe burns isolated fx isolated crush amputationsCall medical control for
Secondary Patient Assessment: Vital Signs Systematic head-to-toe exam Obtain SAMPLE History Contact hospital as soon as patients
condition permits, transmit
assessment information and await
orders. Refer to appropriate protocolif unable to contact medical control
Re-assess patient
1) Airway:- secure with c-spine precautions- remove foreign bodies- provide 100% oxygen
2) Breathing:- assess rate: depth; and adequacy- note & manage JVD & tracheal deviation- inspect, palpate, auscultate, and percuss
the chest
3) Circulation:- stop life threatening hemorrhage- assess peripheral pulses- check capillary refill
4) Disability:- AVPU Score- motor & sensory exam- pupillary size and reactivity
5) Expose:- fully expose patient- log roll to evaluate back for injuries
Note to Pre-hospital Personnel:
- In a combative or uncooperative patient, the requirement to
initiate initial trauma care, as written, may be altered or waived in
favor of rapidly transporting the patient for definitive care.
Document the patients actions and behaviors which interferedwith the performance of any assessment and/or interventions.
- Initiate Trauma Alert for the following mechanisms of injury:
ejection from motor vehicle death in same passenger compartment falls greater than 20 feet pediatric falls of greater than 3 times the
height of the patient
pregnant patient of greater than 24 weeksgestation
Analgesia Alternative
May give 30mg Toradol IVP
Or 60 mg Toradol IM
Be aware of contraindications
*IO insertion may be
considered if unable to obtain
IV access
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Code 41
Sus ected S inal Cord
Routine Trauma Care
Secure Airway with C-spine precautions
in-line intubation di ital etc.
Immobilize patient using backboard,
c-collar, blanket rolls or other
device, and secure patient to
backboard
Monitor for spinal shock
(low BP, normal HR or relative
bradycardia)
If no motor or sensory deficit, record as
such and transport
Vomiting precautionshave suction
ready, be prepared to log roll patient
if needed
Transport
Note to Prehospital Providers:1. Suspect spinal injuries in all patients
with:
A. Any head or facial trauma (ie.
injuries above the clavicle).B. Decreased or altered level of
consciousness.
C. Suspected deceleration injuries.D. Complaints of neck or back pain.
E. Physical findings suggesting neck
or back in ur .
Guidelines for Field Clearance of Cervical Spine
No reported or suspected loss ofconsciousness
No complaints of head, neck, back pain Must be alert and oriented x 3 No neuro deficits i.e. numbness,
tingling, confusion
Must weigh more than 100 pounds Must be less than 70 years of age and
greater than 18 years of age Must not have any history of
osteoporosis or other skeletal
conditions
No alcohol ingestion No midline cervical tenderness No significant mechanism of injury or
obvious distracting injury (high-speed
collision, open penetrating wounds,
dislocations, electrocution, high-impact
blunt trauma to the head)
* Please Note: These are guidelines, if there is
any question regarding the potential for acervical spine injury, the patient should be
boarded and collared.
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Code 42
Hemorrhagic Shock
Routine Trauma Care
ABCs
Control significant external
hemorrhage
Initiate TWO (2) large-bore IVs
enroute
(Wide Open Rate)
Monitor Patient Condition
Transport
If Patient in Cardiac Arrest:
Treat per appropriate
Treatment Protocol
*IO insertion may be considered if
unable to obtain IV access
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Code 43
Head Trauma Unconscious Patient
Routine Trauma Care
Alert ?Yes No
Transport Record GCS
Record pupil size
100% oxygen
random blood glucose
- Sedation orders
Follow medication assisted intubationprotocol if needed.
- ET intubation with in-line manual
stabilization
Accelerated Transport
C-Spine Precautions
*IO insertion may be considered
if unable to obtain IV access
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Code 44
Am utated and Avulsed Parts
Initial Trauma Care
Control bleeding with direct pressure and elevation
(tourniquet as last resort)
DO NOT use a tourniquet unless allelse fails and the patient is
hemorrhaging:
-Note time of placement-Apply as close to injury as
possible
-DO NOT release once applied
-Wrap part in moist sterile gauze, sheet or towel.-Place part in waterproof bag or container and seal.
-DO NOT immerse part in any solutions.
-Place this container in a second one filled with ice, cold water or cold
pack.
Transport part with patient to hospital
Transport
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Code 45
Burns
Routine Trauma Care
Accelerated transport if airway involvement
Consider Burn Center
Thermal Chemical Electrical
Maintain body temperature
Burn wound care*
Consider analgesic
IV Parkland formula*
Transport STAT
Brush off excess chemical
Flush with copious amount of
water/saline unless
contraindicated.
Protect unaffected eye
Burn wound care*
Attempt to ID chemical
Transport STAT
Do not enter area until scene
is safe.
Assess for entrance and exit
wounds
Immobilize as needed
Treat dysrhythmias
Burn wound care*
Cover with dry, sterile
dressings/sheets
Transport STAT
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Code 45
(continued)
1. Assessment ABCs rapid transport if airway involvement Neurovascular status Depth of burn (partial vs full thickness) Percentage of burn (Rule of 9 vs Palm Rule) Visual acuity if indicated
2. Interventions Stop the burning process
- Cool with tepid saline/water until skin temperature is normal- Remove jewelry and clothing (do not pull away clothing that is stuck to burn)- Do not use ice or ice water
Wound care- Wear gloves/mask if 2nddegree or 3rddegree burns- Do not break blister or use dressings that will stick to burn- Do not apply ointments or creams- Cover cooled skin with appropriate dressing
If 1stdegree burn < 10% BSA, dress with sterile dry dressing If 2ndor 3rddegree burn or > 10% BSA, dress with sterile dry sheets/dressings
Analgesia- Morphine sulfate in 2 mg increments up to 10 mg IVP- Call Medical Control for pediatric dosing and/or for greater than 10mg in adult
Maintain body temperature- Cover patient with dry sheets/blankets over sheets- Prevent hypothermia at all costs
Burns Wound Care
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Code 45
(continued)
Fluid replacement
3. SOP for other problems
Burns Wound Care
Parkland Formula = 4 ml/kg/BSA burned
to be given in the first 8 hours
to be given in the next 8 hours
to be given in the next 8 hours
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Code 46
Chest Trauma
Routine Trauma Care
Chest Assessment
Massive
Hemothorax
Tension
PneumothoraxPericardial
Tamponade
Sucking Chest
Wound
Hemorrhagic Shock
Refer to Code 42
Monitor Condition
Transport
STAT
Hemorrhagic Shock
Refer to Code 42
Needle Decompression
Stabilize with
Partial Occlusive
Dressing*
Monitor Condition
TransportSTAT
Re-assess Patient
Monitor
Condition
Transport
STAT
Re-assess Patient
MonitorCondition
Transport
STAT
*If patient deteriorates, temporarily
remove dressing for air to escape.
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Code 47
Trauma in Pre nanc
Routine Trauma Care
Check EXTERNALLY for uterine contractions
Document Findings
Check EXTERNALLY for vaginal bleeding
Document Findings
Elevate the right side of the backboard 20-30 in order
to minimize uterine compression of the inferior vena
cava while maintaining spinal immobilization.(transport on left side)
Monitor Patient Condition
Transport
IV NS wide open if hypotensive
If CPR indicated, manually displace the
uterus to the left.
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Code 48
Trauma Arrest
Bilateral pleural
Initial Trauma Care
Accelerated transport
Rapid extrication
Spinal immobilization
Refer to appropriate code*
CPR
*
Give EPI via ETT if no IV Do not delay transport to in initiate IV May attempt IVx2 enroute IO insertion may be considered
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Code 49
O hthalmic Emer encies
Initial care:
Assess pain scale Quickly obtain gross visual acuity Elevate head (if not contraindicated) Vomiting precautions Remove contact lenses
Corneal Abrasions
Immediately irrigate eyes if no chance ofpenetrating injury
Contact Medical Controlfor Tetracaine 0.5% 1-2 gtt order
Transport STAT
Chemical Splash
Immediate irrigation withcopious amounts of NS
(at least 1000 per eye)
Contact Medical Control
for Tetracaine 0.5% 1-2 gtt order
Transport STAT
Penetrating injury/ruptured globe
Transport STAT
Do not remove impaled objectDo not irrigate eye
Do not instill any drips
Do not apply any pressure
Cover eye with cup or metal protective
shield. Patch unaffected eye also.
Gross Visual Acuity Test
1. Determine if patient wears glasses/contacts2. Determine distance they can see3. Determine vision by holding up fingers at 1, 2, and 3 foot distance.
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