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BLS Protocols Content Page

Updated: 4/11/16

Abdominal Pain

Abuse/Neglect

Airway Management

Airway Management King Airway

Altered Mental Status/Coma

Amputation

Anaphylaxis/Allergic Reaction

Asthma

Burns

Chest Pain

Childbirth

Childbirth Complications

CPAP

CPR Adult/Child

CPR Child

CPR Infant

Croup/Epiglotitis

CVA/Stroke

Death In The Field/Withholding Life Support

Drowning/Near Drowning

Ebola Virus (suspected)

Epistaxis

External Bleeding Control

Foreign Body Obstruction Adult/Child

Foreign Body Obstruction Infant

Glasgow Coma Scale

Hazardous Materials

Hyperthermia

Hypoglycemia

Hypothermia

Neonatal Resuscitation

Physicians at the Scene

Poisoning and/or Overdose

Psychiatric/Behavioral Disorders

Refusing Care

Respiratory Distress

Restraint Protocol

Seizure

Sexual Assault

Shock/Hypotension (Non-traumatic)

Shock/Hypotension (Traumatic)

Snakebites

START Triage

Syncope

Taser Dart Removal

Tourniquet Application

Trauma General Management

Vaginal Bleeding

Porter's EMS Protocols© Copyright 2000 William Porter

Allow patient to assumeposition of comfort

NPONothing by Mouth

BP ?

≥ 90mmHG

< 90mmHG

See SHOCK protocol

Rapid Transport

1. Abdominal Exam: Note pain (nature, duration, intensity on 1-10 scale, radiation). Observe for palpable mass, always palpate with care. Note associated signs & symptoms; (nausea, vomiting, guarding, rebound tenderness, distention). History: previous episodes, last meal, current medications, last menstrual period, possibility of pregnancy. Be aware that ischemic cardiac pain can present as abdominal pain especially in females & older patients.

Abdominal Pain:Not related to pregnancy or trauma

Detailed Assessment:· Abdominal Exam

Document:· Abdominal Signs/Symptoms· Absence or presence of Chest Pain· Nature of Pain· Vital Signs· SpO2· Treatment· Response to Treatment

ABDOMINAL PAIN

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, Respiratory Status

Reviewed: 05/12/14Revised: 05/16/14

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· ABCs · Oxygen, as needed· Vital Signs · History· Exam· Consider cardiac monitor· Consider calling ALS or ILS backup

· ABCs · Oxygen· Vital Signs · History· Exam

Abuse/Neglect

DO NOT CONFRONT OR BECOME HOSTILE TO THE PARENT OR CAREGIVER

© Copyright 2000 William PorterPorter's EMS Protocols

Abuse/Neglect

1. Okanogan County Sheriff’s Dispatch: 1-800-572-6604 Social & Health Services, Dept. of Abuse/Neglect Reporting: 1-800-562-6078

Presentation:The patient may present with patterned burns or injuries suggesting intentional infliction, such as: injuries in varying stages of healing , injuries scattered over multiple areas of the body, fractures or injuries inconsistent with stated cause of injury. The patient, parent, or caregiver may respond inappropriately to the situation. Malnutrition or extreme lack of cleanliness of the patient or environment may indicate neglect. Signs of increased intracraneal pressure (bulging fontanels and altered mental status in an infant) may also be seen.

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All health care providers are obligated by law to report cases of suspected child or vulnerable adult abuse or neglect to either the local police or social service agencies. Do not initiate report in front of the patient, parent, or caregiver.


Treatment and Transport:- Stabilize and treat injuries according to protocol.- Discourage patient from washing if sexual abuse is suspected. Place patient’s extra clothing in a paper bag, not a plastic bag.* Document the following information on the PCR:1. All verbatim statements made by the patient, parent, or caregiver shall be placed in quotation marks, including statements made about the manner of the injuries.2. Any abnormal behavior of either the patient, parent, or caregiver must be documented.3. Document the condition of the environment and other residents present.4. Document the time the police/welfare agency was notified and the name of the person notified.5. Document the name of the receiving health care provider (RN, PA, MD) and any statement made.

1

Consider requesting law enforcement to the scene, but do not delay transport waiting for arrival.

· Open Airway· Consider C-Spine protection. Asses for FBAO· Asses rate, depth and quality of breathing. Monitor SpO2· Consider ALS or ILS backup

Airway Management

- If no gag reflex, insert Oropharyngeal Airway (OPA)- Assist ventilations with 100% O2 via BVM- Consider Alternative Airway

· Transport· Keep patient warm· Monitor LOC, Vital Signs, Respiratory Status, & SpO2

1. See King Protocol. For airway management on pediatric patients with an OPA in place, often adequate BVM ventilations are sufficient.2. Maximize the “3 P’s” (position, percentage, pressure). Consider CPAP.

© Copyright 1996, 1998 William PorterPorter's EMS Protocols

Document:· Respiratory Effort· Lung Sounds· SpO2· Response to Treatment· Skin Color· LOC Glasgow Coma Scale

See RespiratoryDistress Protocol

Mild to ModerateRespiratory

Distress

Administer 100% O2

Patientimproves

?

Patient maintains

airway?

Yes

No

No

Yes

AIRWAY MANAGEMENT

1

Signs & Symptoms of Respiratory Distress· Anxious/restless· Shortness of breath: (air hunger, increased, decreased or absent respirations)· Skin color changes: (cyanotic, pale/clammy, redness/flushing)· Mechanics of respiration: (fatigue due to breathing effort, diaphragmatic breathing, retractions, irregular breathing pattern)· Drooling, difficulty swallowing, seal bark cough

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· ABCs · Oxygen 100%· Assist Ventilations· Consider ALS or ILS backup

Airway Management - King LTD or LTSD Airway

Document:· Tube Markings at Teeth· SpO2· Respiratory Status Before and After Treatment· Lung & Gastric Sounds· Skin Color· Indications for Use· Absence of Gag Reflex· Patient's Age, Height


1. KLTD: Size 2 for pts 35-45 inches, Size 2.5 for pts 41-51 inches, Size 3 for pts 4-5 feet, Size 4 for pts 5-6 feet, Size 5 for pts > 6 feet. KLTSD: Size 3 for pts 4-5 feet, Size 4 for pts 5-6 feet, Size 5 for pts > 6 feet. (See sizing chart above)2. At NO time should the patient's airway or ventilatory status be compromised. If placement is unsuccessful, remove the device and return to oropharyngeal airway and assist via bag-valve-mask.3. If spontaneous respirations begin and removal of KING airway is needed, deflate cuff completely and be prepared to suction.

Place the patient's head in a sniffing or neutral position

Choose appropriate sized KING LTD or LTSDAssemble & check equipment

Insert the King airway till the base of the connector aligns with teeth or gums.

Inflate cuff:

KLTD Size 3 (yellow) 45-60 ml KLTD Size 4 (red) 60-80 mlKLTD Size 5 (purple) 70-90 ml

Confirm placement with lung sounds, chest movement And/or color metric CO2 device.

Begin ventilation while simultaneously withdrawing the airway until ventilation is easy and free flowing. Note depth mark on tube.

Secure KING LT(S)-D using tape or other accepted means

Ventilate with 100% O2Reassess Airway FrequentlyTransport

Indications:· Endotracheal intubation

cannot be performed· Attempts at endotracheal

intubation have been unsuccessful

Contraindications:· Patients with a gag reflex· Patients with known

esophageal disease or alcoholism (possibility of esophageal varices exists)

· Patients who have ingested a caustic substance

AIRWAY MANAGEMENTKING LTD or LTSD Airway

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Inflate cuff:

KLTSD Size 3 (yellow) 40-55 mlKLTSD Size 4 (red) 50-70 mlKLTSD Size 5 (purple) 60-80 ml

1. Detailed Assessment: Document Glasgow Coma Scale. Check odor on breath. Look for Medical Alert tags, needle tracks, and evidence of trauma. If trauma noted consider C-spine precautions.2. Observe environment closely for signs of potential overdose.3. If glucometer not available and the patient is a known diabetic with altered mental status and has the ability to swallow administering oral glucose.4. THE PATIENT MUST BE ABLE TO FOLLOW THE COMMAND TO SWALLOW WITHOUT DIFFICULTY and have an intact gag reflex before oral Glucose can be administered. Glucose may be given as a glass of sweetened juice with 2-3 tsp of sugar added or 1 tube of Glucose Oral Paste PO. If condition does not improve or if a second finger stick blood glucose reading remains below 80 mg/dL. May repeat dose x 2 for a total of 3 doses.5. Narcan via intranasal (IN) 2 mg (1 mg in each nostril). If no response may repeat IN dose x 1. Pediatric dose: 1-5 years of age 1 mg IN ( 0.5 mg in each nostril). If no response may repeat IN dose x 1. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient.

BP ?

See SHOCK protocol

AdministerOral Glucose

> 90mmHG

< 90mmHG

< 80mg/dl

> 80mg/dl

Yes

No

Document:· Glasgow Coma Scale· Clinical Response to oral glucose· Blood Sugar· SpO2· Medical History· Exam· Vital Signs

.

Altered Mental Status/Coma

Glasgow Coma ScaleEye Spontaneous 4 Opening To Voice 3

To Pain 2 None 1

Best Oriented 5Verbal Confused 4Response Inappropriate words 3

Incomprehensible words 2None 1

Best Obeys Commands 6Motor Localizes Pain 5Response Withdraws (Pain) 4

Flexion 3Extension 2None 1

Ability to swallow

?

ALTERED MENTAL STATUS/COMA

4

Bloodsugar

?

3


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· ABC’s· Oxygen Assist Ventilations, as needed. Detailed Assessment. Check blood sugar. Consider cardiac monitor· Consider IV/IO (if certified)· Consider ALS or ILS backup

Possible causes:· Head Injury · CVA· Diabetes · Seizure· Overdose · Hypotension. Hypertension . Poisonings. Metabolic . Psychiatric. Sepsis

1 2

Improvement?

No

If available, rendezvous with ALS or ILS back up


Consider Narcan intranasal (IN) 5


Amputation

· ABC's· Oxygen · Transport (consider air transport)· Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup

ActiveBleeding

? Yes

No

Control bleeding with direct pressure

Shock present

?

See Shock protocol

Stump: cover with a moist sterile dressing, covered by a dry dressing.

Severed portion: wrap in moist, sterile dressing and place in plastic bag with a cold pack.

Detailed Assessment

1. Keep severed part moist with normal saline. Do not allow to soak in a solution.2. If transport delayed or otherwise extensive (entrapped patient, etc.), consider air

transport and/or transporting severed part before patient, to allow early examination and surgical preparation for reimplantation.

3. History: note time of amputation, mechanism involved, current medications. Exam: note anatomical location of amputation. Estimate total blood loss.

4. Notify hospital for Trauma Team activation if patient meets WA State Trauma Triage Criteria.

Bleedingcontrolled

?

Tourniquet

Yes

Yes

No

AMPUTATION

Document:· GCS· Mechanism of Injury· Time of Injury· Current Medications· Last Meal· Vital Signs, SpO2· Treatment

1

2

3

No

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status· Notify receiving hospital 4

BLSProtocol

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1. Bee sting: gently remove stinger if still present.2. May assist the patient with their own prescription Epinephrine auto-injector or use an Epi Pen off the ambulance or administer the Epinephrine 1:1,000 IM via syringe drawn from ampule. See page 2 for IM injection technique. If administering via Epinephrine auto-injector or Epi Pen preferred route is IM mid- lateral thigh.3. Can administer one more dose of Epinephrine 1:1,000 IM.

Epinephrine 1:1,000- Adult Dose: 0.3 mg IM (deltoid)- Pediatric Dose (<70 lbs): 0.15 mg IM (deltoid)

Signs & Symptoms :S.O.B., wheezing, hoarseness, chest tightness, hypotension, nausea, abdominal cramps, vomiting, hives, itching, generalized or local edema (especially common within oropharynx, lips, tongue, face).

ANAPHYLAXIS/ALLERGIC REACTION

Document:· ABCs· Detailed Assessment· SpO2, Vital Signs· Glasgow Coma Scale· Skin Color· Lung Sounds· Respiratory Effort· Treatment· Response to Treatment· Amount of medication given

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status

· ABC’s· Oxygen· Assist Ventilations, as needed. Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup

1

No improvement

BLSProtocol

Reviewed: 02/03/16Revised:

Signs & Symptoms :hives, itching, flush, mild local edema.

Mild Severe

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Epinephrine 1:1,000- Adult Dose: 0.3 mg IM (deltoid)- Pediatric Dose (<70 lbs): 0.15 mg IM (deltoid)

2

Page 1 of 2

No improvement


BLS

Protocol

Technique

Scrub the skin vigorously with an alcohol wipe

Dosage

Adults and children over 70 lbs (30 kg): 0.3 mg of 1:1,000 IM

Children under 70 lbs (30 kg): 0.15 mg of 1:1,000 IM

Break open ampule, or if using a vial cleanse vial top with an alcohol wipe

Ampule:Remove needle from syringe and place a filter needle on syringe. Insert the needle into the ampule and withdraw the appropriate amount of medication. Remove the filter needle, discard needle safely and place the original needle back on the syringe.

Vial:Insert the needle into the vial and withdraw the appropriate amount of medicaiton.

Hold the syringe upright and push any air bubbles or extra medication out of syringe

The deltoid muscle is the preferred injection site. Injection site is 2-3 fingers below the point of the shoulder midline. Broadly hold the muscle, do not pinch the skin.

Hold the syringe like a dart. Insert the needle with a quick stab at a 90 degree angle to the skin surface. Gently hold the syringe and pull back on the plunger to verify no blood enters the syringe. If no blood enters the syringe depress the plunger with a slow, steady motion until the syringe is empty.If blood did enter the syringe when pulling back on the plunger withdraw needle and reinsert approximately 1 inch to the left or right from original injection site. It’s ok to use the medication in the syringe.

Discard the syringe in an appropriate sharps container. Cover the puncture site with an adhesive bandage. Document the time, dosage, and injection site.

Reassess your patient and take vital every 5 minutes. If patient’s vitals and signs/symptoms have not improved within 10 minutes call medical control or incoming paramedic unit for permission to give a second equivalent dose.


Page 2 of 2



Asthma

Respdistress

?

No

Yes

Assist Pt. with their Rx MDI- Up to 3 doses of patient’s Rx. MDI instructions


1. If COPD co-exists titrate Oxygen to maintain SpO2 > 90%.

Document:· Airway· Breath Sounds· Skin Color· Vital Signs, SpO2· Glasgow Coma Scale· Treatment · Response to treatment

ASTHMA

· ABC’s· Oxygen 100%· Assist Ventilations, as needed· Consider cardiac monitor· Consider IV/IO (if certified)· Consider ALS or ILS backup

1

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status

BLSProtocol


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No Improvement

Burns

Secure the scene

Stop the burn process

ABCs· Airway · Breathing· Circulation Transport (consider air transport)- Detailed Assessment· Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup

Evaluate degree of burnand % body surface area involved

Criticalburn

?

Dress burns with appropriate dressings

Treat other injuries

· Notify receiving facility · Prevent unnecessary cooling· Monitor: LOC, Vital Signs, SpO2, & Respiratory Status

Types of Burns· Thermal Stop the burning process· Chemical Brush off and/or dilute chemical without exposing rescuer. Consider need for HAZMAT team.· Electrical Make sure victim is de-energized and suspect internal injuries

1. Make sure rescuers can safely help the victim.2. Remove clothes & jewelry. Flood with water ONLY if flames or smoldering is present.3. If shock is present consider underlying causes.4. Use the Rule of Nine to calculate the percentage of burned suface area. Note: the patient's palm represents 1% of their BSA.5. Consider the burn critical if > 25% BSA, 3rd degree > 10%, respiratory injury, involvement of face, hands, feet, or genitalia, circumferential burns, electrical or deep chemical burns. Consider air transport.6. For Superficial Thickness (1st degree) or Partial Thickness (2nd degree) burns of <10% consider using a water gel burn dressing. For Full Thickness (3rd degree) burns cover with a dry sterile burn sheet.7. Notify hospital for Trauma Team activation if patient meets WA State Trauma Triage Criteria.


Transport to the most appropriate facility

Yes

No

Document:· Degree of Burn· Percent of Body Burned· Respiratory Status· Singed Nares?· SpO2· Type of Burn· Medical History· Confined Space?

BURNS

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Consider the following treatment options:· Patient’s prescription Nitroglycerin SL 0.4 mg· Aspirin PO 324 mg

Chest PainSuspected Ischemic Chest Pain

1. If the patient becomes unresponsive, check pulse & respirations. If no pulse begin CPR (follow current AHA standards). Attach AED (Automatic External Defibrillator).2. Nitroglycerin must be the patient’s prescription Nitro and within the expiration date. Do not administer if patient’s BP is < 100 mmHg or if the patient has taken Viagra or Levitra within 24 hours, or Cialis within 48 hours. If the patient meets criteria administer 1 dose sublingual (under the tongue). Max of 3 doses total given at one dose at a time of 0.4 mg per dose every 3-5 minutes for chest pressure/pain. Recheck BP prior to each dose.3. Aspirin is contraindicated in cases of known hypersensitivity and may be withheld if the patient has definitely taken 324 mg of Aspirin within the last 24 hours.

· ABCs. Vital Signs. Sp02 @ room air · Oxygen, as needed · Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup


CHEST PAIN

3

2

1

Document:· ABCs· Medical History· Signs & Symptoms· Quality of Pulses· SpO2, VS· Glasgow Coma Scale· Color, Diaphoresis· Lung Sounds· Response to Treatment

SAMPLE Questions

Signs/SymptomsAllergiesMedicationsPast Medical HistoryLast Oral IntakeEvents Prior

· Transport per County “Emergency Cardiac” operating procedure· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status

BLSProtocol


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OPQRST Questions

OnsetProvokesQuality (describe pressure/pain)RadiationSeverity (1-10 scale)Time (signs/symptoms started)

Childbirth

· ABCs· Oxygen, as needed · Prepare for immediate transport· Consider ALS or ILS backup

3rdtrimester

bleeding orpain

?

Contact Medical Controland see Childbirth Complications protocol

Position left lateral recumbentand see SHOCK protocol

Slip cord over head & shoulderOR place clamps 2" apart & cut cord.

See page 2 of 2

History & Exam:previous births, prenatal care, edema, multiple births, previous c-section, medical history, vital signs, frequency of contractions, fetal heart rate.

Activelabor

?

Crowning?

Prepare OB kit and for delivery

Abnormalpresentation

?

Control deliverySupport head with rotation

Cordaround neck

?

Guide head upward to deliver lower shoulder, then downward to deliver upper shoulder.

Control deliveryTrunk and legs

- Assure patent airway, stimulate cry by tapping soles of feet. If necessary, wipe blood and mucus from mouth and nose.- Do APGAR assessment on infant one minute after delivery.

No

Yes

Yes

Yes

No

No

Yes

Page 1 of 2

CHILDBIRTH

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Protocol

- Keep infant level with vagina. - Clamp cord 8" from navel with 2 clamps approx. 2 " apart.- Cut the cord between the clamps

Prepare for placental deliveryMonitor Vital Signs for baby and momKeep baby and mom warmNotify hospital of delivery

Bleeding> 250cc

?

Massage fundus and place baby to breast to promote placental delivery

Transport

continued from page one

See SHOCK protocol

Continue fundus massage

1. Normal fetal heart rate = 120-150.2. Do NOT preform a digital exam. Possible placental previa or abruptio placenta.3. Crowning may first appear during a contraction. Look for crowning between and during contractions. NO digital exams. Do NOT allow anyone to perform a digital exam.4. Deliver baby on the scene ONLY if delivery is eminent.5. Note exact time of birth. 6. Keep baby warm. Dry infant and wrap in a blanket. Protect from falls.7. Massage fundus: gentle but firm, intermittent massage.8. Do NOT pull on cord. Once placenta is delivered place in a red bio bag to give to hospital staff. Place sterile pad over vaginal opening.

Document:· Time of Birth· APGAR at 1 minute and 5 minutes· Time of Placental Delivery· Estimated Fluid and Blood Loss· Complications if any· Care and Supportive Measures· Oxygen administered. Amount of IV fluid administered· Communication with Medical Control· Clinical Assessment and Vital Signs


Page 2 of 2

No

Yes

References: Bledsoe, Bryan: Paramedic Emergency Care. 32:965. 1994Caroline, Nancy: Emergency Care in the Streets. 35:775. 1991

CHILDBIRTH

8

6 7

5

APGAR Scoring System(taken at 1 minute and 5 minutes after delivery)

Sign 0 1 2Appearance (skin color): Blue, pale Body pink, blue extremities Completely pinkPulse rate (heart rate): Absent <100/minute >100/minuteGrimace (irritability): No response Grimace Cough, sneeze, cryActivity (muscle tone): Limp Some flexion Active motionRespirations (resp. effort): Absent Slow, irregular Good, crying


If infant complications, see Neonatal Resuscitation protocol

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Protocol

Childbirth Complications

· ABCs· Oxygen, as needed · Prepare for immediate transport. Consider contacting Medical Control· Consider IV/IO (if certified)· Consider ALS or ILS backup

Spontaneousabortion

?

Elevate hips of mom. Prevent cord compression with gloved hand in vaginal opening. Saline to cord.

Slip cord over head & shoulderOR place clamps 2" apart & cut cord.

Armsbeforehead

?

Do not stimulate infant to breath prior to suctioning. Thoroughly suction mouth then nose.

See page 2 of 2

MeconiumStain

?

Yes

Yes

No

Yes

No

No

Yes

Yes

No

Page 1 of 2

Place mom in semi-fowlers position.As hairline appears, raise body by ankles upward. The head should deliver. If head does not deliver within 4-6 minutes insert gloved hand into vagina, create an airway for the baby

Support legs & trunk

CHILDBIRTHCOMPLICATIONS

2

Foothand,cord

face?

Buttocksbreech

?

Cordaround neck

?

Treat for shock, as neededPlace sterile pad over vaginal openingBring fetal tissues to the hospital 1

No

Yes

Infantdelivered

? Yes

No

- Assure patent airway, stimulate cry by tapping soles of feet. If necessary, wipe blood and mucus from mouth and nose.- Do APGAR assessment on infant one minute after delivery.

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Protocol

Bleeding> 250cc

?

Massage fundus and place baby to breast to promote placental delivery

Transport

continued from page two

See SHOCK protocol

Continue fundus massage

1. Patient may c/o cramp-like lower abdominal pain similar to labor.2. Do NOT pull on baby. If the babies head does not deliver and the baby begins to breath with its face pressed against the vaginal wall, place a gloved hand in the vagina with the palm toward the babies face. Form a "V" with the index and middle finger on either side of the infant's nose and push the vaginal wall away from the infant's face to allow unrestricted respiration.3. Note exact time of birth. 4. Keep baby warm. Dry infant and wrap in a blanket. Protect from falls.5. Massage fundus: gentle but firm, intermittent massage.6. Do NOT pull on cord. Once placenta is delivered place in a red bio bag to give to hospital staff. Place sterile pad over vaginal opening.

Document:· Time of Birth· APGAR at 1 minute and 5 minutes· Time of Placental Delivery· Estimated Fluid and Blood Loss· Complications if any· Care and Supportive Measures· Oxygen administered. Amount of IV fluid administered· Communication with Medical Control· Clinical Assessment and VS


Page 2 of 2

No

Yes

References: Bledsoe, Bryan: Paramedic Emergency Care. 32:965. 1994Caroline, Nancy: Emergency Care in the Streets. 35:775. 1991

CHILDBIRTHCOMPLICATIONS

5

4

Prepare for placental deliveryMonitor Vital Signs for baby and momKeep baby and mom warmNotify hospital of delivery

6


Sign 0 1 2Appearance (skin color): Blue, pale Body pink, blue extremities Completely pinkPulse rate (heart rate): Absent <100/minute >100/minuteGrimace (irritability): No response Grimace Cough, sneeze, cryActivity (muscle tone): Limp Some flexion Active motionRespirations (resp. effort): Absent Slow, irregular Good, crying


- Keep infant level with vagina. - Clamp cord 8" from navel with 2 clamps approx. 2 " apart.- Cut the cord between the clamps

If infant complications, see Neonatal Resuscitation protocol

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Protocol

CPAP

- If giving oral/sublingual medications, try to administer prior to CPAP placement to prevent aspiration. Otherwise, remove mask to give needed medications (i.e. NTG, ASA). Allow them to be completely swallowed or dissolved.

Assess lung sounds and vitals after placement

If adjustable PEEP, start setting at 5 cm H2O. Increase in 2.5 cm H2O increments as needed for oxygenation

Monitor for side effects of positive pressure ventilation

Notify receiving facility that the patient is arriving on CPAP

1. Use CPAP early or if initial round of therapy is ineffective. For example, if arriving to a COPD call and the patient looks poor at the initial evaluation (i.e. hypoxia, increased work of breathing) move quickly to CPAP. Consider assisting the patient with their Rx. MDI prior to CPAP application.2. Do not increase PEEP if systolic BP is < 90 mmHg.3. For patients with severe asthma prioritize assisting the patient with their Rx MDI before CPAP.4. Positive pressure ventilation can cause hypotension by decreasing venous return. If patient’s systolic BP remains < 90 mmHg remove CPAP and continue with supplemental oxygen as needed. Watch for gastric distension and vomiting. Remove mask if vomiting occurs. 5. If patient continues to deteriorate despite CPAP, remove CPAP and assist ventilations with 100% O2 via BVM as needed. Prepare for advance airway placement.

Porter's EMS Protocols© Copyright 1997-2002 William Porter

Apply oxygen as indicated

CPAP

Prepare patient for CPAP- inform them of procedure and sensation of CPAP

Place CPAP mask and seucre to patient

Reassess breath sounds/vital signs frequently (slowing of heart rate is a typical sign of improvement)

For progressive respiratory failure, consider calling ALS

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Possible Causes:· COPD· CHF· Pneumonia· Aspiration· Asthma

For patients with moderate to severe respiratory distress or progressive symptoms 1

Administer BLS medications as indicated

3

Contraindications:· Unconscious· Vomiting· Hypotension (SBP<90 mmHg)· Trauma· Suspected Pneumothorax· Inability to seal mask· Patient unable to cooperate (this can often be mitigated with effective coaching)

2

BLSProtocol

5

CPR (high performance)Adult/Child (> 8 yrs old)

HPCPR- Compression rate 100-120/min- Compression depth at least

2-2.4 inches (5cm)- Allow complete chest recoil

after each compression- Minimize interruptions in

chest compression- Ratio: 10 compressions to 1 ventilation simultaneously- Avoid excessive ventilations

No Pulse

1. See Withholding Life Support Protocol.2. While checking carotid pulse, may open pt’s airway. Do not take the time to listen or feel for breathing.3. High performance CPR should be performed for 2 minutes prior to delivery of the first shock. Rescuers should change compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions given.4. While AED or monitor/defibrillator is charging deliver 30 pre-shock compressions, if equipment allows.5. Consider placement of a supraglottic airway. Do not interrupt chest compressions during placement. Follow current HPCPR guidelines for compression/ventilation ratio.6. If circumstances allow and high performance CPR is able to be continued, consider transporting to the nearest most appropriate facility.

Document:· Detailed Assessment· Chief Complaint· SpO2, Cardiac Rhythm, Vital Signs· LOC· Lung Sounds· Treatment· Medications Given· Response to Treatment

CPR (high performance)Adult/Child (> 8 yrs old)

- Unresponsive- No breathing or normal breathing (ie, only gasping)

- Verify the patient does not meet “Compelling Reasons” to withhold CPR

Reviewed: 2/3/16Revised: 2/25/16A

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Check pulse (10 seconds) - Give 1 breath every 5-6 seconds- Recheck pulse every 2 minutes

Definite Pulse

Begin HPCPR- Immediately begin with chest compressions

- Attach AED or monitor/defibrillator pads- Ratio: 10 compressions to 1 ventilation simultaneously

After 2 minutes of HPCPR turn on AED or monitor/defibrillator

Analyze rhythmShockable rhythm ?

Resume HPCPR immediately beginning with chest compressions for 2 minutes

Analyze rhythm every 2 minutes; continue until ALS providers take over

or victim starts to move

2

3

Deliver 30 pre-shock compressionsDeliver shock

Immediately begin HPCPR starting with chest compressions for 2 minutes

Shockable Not Shockable

5 5

1

66

- Continue HPCPR- If appropriate, consider transporting to the nearest most appropriate medical facility- Consider ALS rendezvous- Consider contacting Medical Control

4

High-Quality CPR- Rate at least 100-120/min- Compression depth at least

1/3 anterior-posterior diameter of chest, about2 inches (5 cm)

- Allow complete chest recoil after each compression

- Minimize interruptions in chest compression

- Avoid excessive ventilations

No Pulse

1. While checking carotid pulse, may open pt’s airway. Do not take the time to listen or feel for breathing.2. High quality CPR should be performed for 2 minutes prior to delivery of the first shock. Rescuers should change compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions given.3. If circumstances allow and high performance CPR is able to be continued, consider transporting to the nearest, most appropriate medical facility.


CPRChild (1-8 yrs old)

UnresponsiveNo breathing or normal breathing (ie, only gasping)


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Check pulse (10 seconds)

- Give 1 breath every 3-5 seconds- Add compressions if pulse remains <60 bpm

with poor perfusion despite adequate oxygenation and ventilation

- Recheck pulse every 2 minutes

Definite Pulse

Begin CAB- Immediately begin with chest compressions

- One Rescuer: 30:2 ratio- Two Rescuers: 15:2 ratio

AED/defibrillator arrives

Check rhythmShockable rhythm ?

Resume CPR immediately beginning with chest compressions for 2 minutes

Check rhythm every 2 minutes; continue until ALS providers take over


1

2

Deliver shockImmediately begin CPR starting with

chest compressions for 2 minutes


3

3

- Continue CPR- If appropriate, consider transporting to the nearest most appropriate medical facility- Consider ALS rendezvous- Consider contacting Medical Control

CPRChild (1-8 yrs old)

High-Quality CPR- Rate at least 100-120/min- Compression depth at least

1/3 anterior-posterior diameter of chest, about1 ½ inches (4 cm)

- Allow complete chest recoil after each compression

- Minimize interruptions in chest compression

- Avoid excessive ventilations

No Pulse

1. While checking brachial pulse, may open pt’s airway. Do not take the time to listen or feel for breathing.2. High quality CPR should be performed for 2 minutes prior to delivery of the first shock. Rescuers should change compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions given.3. If circumstances allow and high performance CPR is able to be continued, consider transporting to the nearest, most appropriate medical facility.


CPRInfant (< 1 yr old)

UnresponsiveNo breathing or normal breathing (ie, only gasping)


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Check pulse (10 seconds)

- Give 1 breath every 3-5 seconds- Add compressions if pulse remains <60 bpm

with poor perfusion despite adequate oxygenation and ventilation

- Recheck pulse every 2 minutes

Definite Pulse

Begin CAB- Immediately begin with chest compressions

- One Rescuer: 30:2 ratio- Two Rescuers: 15:2 ratio

AED/defibrillator arrives

Check rhythmShockable rhythm ?

Resume CPR immediately beginning with chest compressions for 2 minutes

Check rhythm every 2 minutes; continue until ALS providers take over


1

2

Deliver shockImmediately begin CPR starting with

chest compressions for 2 minutes


3

3

- Continue CPR- If appropriate, consider transporting to the nearest most appropriate medical facility- Consider ALS rendezvous- Consider contacting Medical Control

CPRInfant (< 1 yr old)

Croup/Epiglotitis

Approach the patient in a calm, reassuring fashion. Allow the child to adopt position of comfort.


Document:· ABCs· Detailed Assessment· Vital Signs· SpO2· Glasgow Coma Scale· Lung Sounds· Color· Treatment· Response to Treatment· Communication with Medical Control

- Open & maintain airway- Positive pressure ventilations with 100% O2 via BVM- If available, rendezvous with ALS or ILS back up

RespArrest

?

No

Yes Croup:· Age 6 months - 3 years· Onset gradual· Signs & SymptomsOften preceded by an upper respiratory infection. Worse at night. May or may not have a fever. Condition varies from mild to severe.

1. Consider blow-by Oxygen. Pediatric patients rarely tolerate a mask.2. Avoid startling the patient. Anxiety is likely to exacerbate the child's condition.

CROUP/EPIGLOTITIS

Common Characteristics

2

· ABC’s· Oxygen· Maintain airway· Consider ALS or ILS backup

· Transport pt. in appropriate pediatric restraint system· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status. Contact Medical Control if any questions or complications arise.


1

Epiglottitis:· Age usually > 2 years· Onset rapid· Signs & SymptomsFever, often look sick. Air hunger, nasal flaring, restlessness, drooling, retractions. Wants to sit upright.

Common Characteristics

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CVA StrokeCerebral Vascular Accident

Document:· ABCs· Detailed Assessment· Vital Signs· SpO2· Glasgow Coma Scale· Neurologic Deficits· Lung Sounds· Color· Treatment· Response to Treatment

© Copyright 1996, 1997 William PorterPorter's EMS ProtocolsAdapted from American Heart Association 1997

See Hypoglycemia protocol

≤ 80 mg/dl

≥ 80 mg/dl

CVA STROKE

1. Do Not delay transport waiting for ALS, consider rendezvous. 2. Glucose-containing solutions should be avoided unless hypoglycemia is documented by glucose test.3. Time in the field must be minimized.

F.A.S.T.Facial Droop (have patient show teeth or smile): · Normal--both sides of face move equally · Abnormal--one side does not move as well as the otherArm Drift (patient closes eyes and holds arms out): · Normal--both arms move the same OR both arms do not move at all · Abnormal--one arm does not move OR one arm drifts down compared with the otherSpeech (have the patient say "You can't teach old dogs new tricks"): · Normal--patient uses correct words with no slurring · Abnormal--patient slurs words, uses inappropriate words, or is unable to speakTime:- The time patient was last seen without symptoms

Advise receiving facility of ‘Stroke Alert’


To Pain 2 None 1





· ABC’s· Oxygen. Protect airway. Detailed Assessment/F.A.S.T.· Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup

2

· Transport per county ‘Emergency Stroke’ operating procedures to the appropriate facility· Transport in position of comfort· Protect airway· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status

3

BLSProtocol


Bloodsugar

?

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1


Death in the Field and/or Withholding Life Support Measures

Life support shall be withheld if any of the following exists: · Patient has confirmed DNR/POLST status in place · Decapitation or rigormortis in a warm environment · Dependent lividity: venous pooling in dependent body parts

Life support may be withheld if any of the following exists: · Unsafe scene, prolonged extrication and/or MCI The following compelling reasons are both present:

~ verbal indication from family members or caretakers of patient’s desire to not be resuscitated~ A terminal condition is present

1. If the patient is a pulseless, apneic victim of a multiple casualty incident and resources from the EMS system are required for stabilization of other patients.

2. Consider contacting Medical Control for confirmation.3. Consider cold water submersion.

All hypothermic patients, victims of electrocution, lightning strike, drowning and/or submersion times of < 25 minutes should receive resuscitation measures and be transported.

DEATH IN THE FIELD AND/OR WITHHOLDING LIFE SUPPORT MEASURES

Document:· All Patient Care & Assessment· Record EKG Strip· Time Law Enforcement was notified· DNR Status, if applicable

Consider covering the body with a sheet.Contact Law Enforcement.

Secure the scene:Do not remove personal property from the body. Do not disturb the scene or move the body.

Complete your scene report and relinquish scene control to Law Enforcement.

Assess need for pastoral services for family/friends if present.

1

2

3


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Protocol

Fall or diving accident

?

No

Full-SpineImmobilization

See Hypothermia protocol

1. If victim is in the water insure the safety of emergency personnel prior to rescuing the victim.2. Ventilation should be initiated while the patient is being rescued.3. Consider Alternative Airway if patient meets criteria.4. All near drowning victims should be examined by a physician5. Observe for Pulmonary Edema.


TEMP?

Yes

Document:· Onset & Duration of LOC· Recent or Chronic Illness· Trauma· Seizure Activity· Activity Prior to LOC· Pregnancy· Glasgow Coma Scale· SpO2· Capillary Refill· Vital Signs

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Drowning/Near Drowning

Remove victim from water ABC’s

OxygenAssist ventilations, as neededConsider Alternative AirwayConsider IV/IO (if certified)Consider Cardiac MonitorConsider ALS or ILS backup

< 96º F

> 96º F

· Transport· Keep patient warm, remove wet clothing prevent further heat loss. Monitor LOC, Vital Signs, SpO2, Respiratory Status· Support respiratory effort with 100% oxygen

1

2

3

4

5


DROWNING/NEAR DROWNING

Ebola Virus Disease (Suspected)

Does the patient have a history of traveling to an affected country in West Africa or has had contact with a known or high-risk Ebola patient within the past 21 days (?)

1. See PPE Donning Checklist under ‘Infectious Disease’ tab in the appendix of protocol book.2. Lauri Jones 509-422-7158 or 509-429-7989. Brian Piper 509-422-7159 or 509-429-19163. Cathy St Amand: AMR – 509-323-8829 or 509-268-0101. www.amr.net/ebola

Ebola Virus Disease (Suspected)

Document:· PPE procedures· Vital Signs, SpO2· Glasgow Coma Scale· Treatment· Communication with Medical Control

Don appropriate PPE

· Transport· Keep patient warm· Monitor Vital Signs, SpO2, Cardiac Rhythm & Respiratory Status


No

Presence or history of fever (subjective or > 100.4) and any of the following symptoms: - Headache- Nausea/Vomiting/Diarrhea- Abdominal pain- Muscle cramps/pain- Unexplained bleeding

NoYes

- Do not make unnecessary physical contact with patient (“door triage”)- Have the patient don a simple facemask- Encourage transport by POV if appropriate and patient is stable- Minimize number of personnel that may come into contact with patient and maintain as much distance as you can (6 feet distance)

* Avoid CPAP, intubation, nebulizers, suction, IV, ect.* Do not resuscitate patients who have arrested* Consider two providers to transport using the buddy system* One person provides care

- Notify receiving facility- Notify Medical Control- Notify Okanogan County Public Health Nurse- If applicable, Notify AMR (American Medical Response) for non-emergent, inter- facility, prolonged or out of the area transport. 3

- Use standard precautions and protocols- If in doubt regarding symptoms or exposure potential use full EVD precautions- Contact Medical Control for questions

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1

Yes

2

· ABCs· Oxygen, as needed· Detailed Assessment· Consider IV/IO (if certified)

Epistaxis

Have the patient sit up straight and lean their head forward.

If the patient has blood in their mouth have them spit it out and not swallow it.

Have the patient pinch the nostrils together with their thumb and index finger.

EPISTAXIS

2

1

1. DO NOT have the patient tilt their head back. This will only cause the patient to swallow the blood. 2. If the patient is unable to pinch nostrils together for a full 10 minutes have an EMS personnel pinch the nostril together.

Document:· ABCs· Detailed Assessment· Vital Signs· SpO2· Glasgow Coma Scale· Lung Sounds· Treatment· Response to Treatment



BLSProtocol

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External Bleeding Control

Bleeding controlled (?)

1. See Tourniquet Protocol.2. See Trauma General Management Protocol.

EXTERNAL BLEEDING CONTROL

Document:· Airway· Cardiac Rhythm· Type of injury· Vital Signs, SpO2· Glasgow Coma Scale· Treatment· Communication with Medical Control

Apply direct pressure to site while maintaining ABC’s

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, Cardiac Rhythm, Respiratory Status, Bleeding Control


Yes

No

Extremity (?)

Apply commercial tourniquet at least 4 inches proximal to bleeding site and tighten until bleeding stops

- Apply appropriate pressure dressing- Monitor for continued bleeding control

No

No

Yes

1

Bleeding controlled (?)

- Consider second tourniquet- Consider a Hemostasis Agent

Open Chest or Abdominal Wound (?) 2

- Continue direct pressure- Consider a Hemostasis Agent

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Protocol

Complete Airway Obstruction Present

Conscious?

Foreign Body Obstruction: Adult/Child

· Lay supine· Open Airway

Series of Abdominal Thrusts

· Support respiratory status· Oxygen, as needed

Transport

Attempt to ventilate

Able to ventilate

?

1. This protocols assumes the patient has a pulse. Assessment: ask the patient "Can you speak?"2. Assist ventilations until consciousness returns. Consider Alternative Airway.3. Anyone that received abdominal thrust to remove a foreign body object should be further evaluated at the hospital

© Copyright 2000-2002 William PorterPorter's EMS Protocols

Yes

No

Yes

No

FOREIGN BODY OBSTRUCTION: ADULT/CHILD

1

Repeat Abdominal Thrusts until unconscious or object expelled

Foreign body seen

? Yes

No

Able to ventilate

? No

Yes

Reposition airwayattempt to ventilate

2

Open Airway


Foreign body seen

?

Yes

No

Remove digitally or with forceps


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Begin 30 chest compressions

Complete Airway Obstruction Present

Conscious?

Foreign Body Obstruction: Infant

Less than 1 year of age

· Lay supine· Open Airway

5 Back Blows

· Support respiratory status· Oxygen, as needed

Transport


Able to ventilate

?

1. This protocols assumes the patient has a pulse.2. Chest Thrusts are slower the chest compressions, place head lower than trunk.3. Transport any patient that received back blows and/or chest thrust.


Yes

No

Yes

No

FOREIGN BODY OBSTRUCTION: INFANT

1

5 Chest Thrusts 2

Foreign body seen

? Yes

No

Able to ventilate

? No

Yes

Reposition airwayattempt to ventilate

Begin 30 chest compresiions

Remove digitally or with forceps

Reviewed: 6/2/14Revised: 6/4//14

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3


To Pain 2 None 1






Glasgow Coma Scale


To Pain 2 None 1

Best Smiles, Interacts 5Verbal Consolable 4Response Cries to Pain 3

Moans to Pain 2None 1

Best Normal Movement 6Motor Localizes Pain 5Response Withdraws (Pain) 4


Adult & Children

Infant & Toddler

Glasgow Coma Scale

Assess the patient in each catagory (eye opening, best verbal response, best motor response) and add the scores from each catagory. Example: if the patient's BEST verbal response is a string of muffled, incomprehensible words give them a 2 for that catagory. The patient's Glasgow Coma Scale will be the total of all three catagories. A Glasgow Coma Scale of 7 indicates coma.

Reassess the patient's score frequently, record each observation and the time it was made.

GLASGOW COMA SCALE

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Suspect hazardous materials@ scene

?

IncidentCommandestablished

?

Hazardous MaterialsFor Non-HAZMAT personnel

Report to Incident Commanderor Staging Area

Assume all scenes have a potential for hazardous materials

- Notify Okanogan County Sheriff’s dispatcher of situation and verify Washington State Patrol has been notified and is in route to the scene. - Assume Incident Command- Identify Hazardous Material(s) per ‘Emergency Response Guidebook’ (ERG) and follow guidelines.

Isolate scene. Keep others away!

Patient Care

See page 1 of 2

Approach cautiously from upwind and uphill

Position vehicle well away from incident and headed away from the scene

You are first onscene

?

- Verify material(s) have been identified per the ‘Emergency Response Guidebook’- Report to Incident Command or Staging Area

If not already done, identify material(s) involved from ‘ERG’

Don appropriate personal protective equipment, ie: body suit, eye protection, mask, & gloves.

Decontaminate patient

© Copyright 1996 William Porter

No

No

No

Yes Yes

Yes

HAZMAT

1


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Transport

EMS Personnel Exposure

- Notify ER staff regarding decontamination for the EMS crew- Decontaminate ASAP- Notify your supervisor of possible exposure


Document:· Patient care· Response to treatment· Hazardous Material· Communication with ER staff & HAZMAT trained personnel· Measures taken to limit exposure· Decontamination

Notify receiving facility of Hazardous Material(s) and the possibility of a second decontamination of the patient

Do NOT enter the ER without specific direction from the ER staff

Page 2 of 2

HAZMAT

1. Emergency Management Specialist, with Okanogan County Sheriff’s Office should be notified through dispatch. Washington State Patrol is the agency in charge for Hazardous Materials and typically the agency that notifies Chemtrec. Chemtrec phone number 800-851-8061

Reviewed:6/2/14Revised: 12/17/13

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Hyperthermia


1. Fan patient, apply moist dressings. Guard against shivering. If shivering occurs, stop cooling measures and monitor patient.

TEMP?

Rapid cooling measures

Shockpresent

? Yes

No

Document:· Neurological Status· Glasgow Coma Scale· Temperature· Clinical response to treatment· Signs & Symptoms· SpO2, Vital Signs

See Shock Protocol

HYPERTHERMIA

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· ABC’s. Move patient to a cool environment· Oxygen, as needed Assist Ventilations, as needed. Detailed Assessment· Consider IV/IO (if certified)· Consider Cardiac Monitor· Check blood sugar· Consider Hyperthermia due to environmental exposure· Consider ALS or ILS backup

Check blood sugar

See Hypoglycemia protocol< 80 mg/dl

> 80 mg/dl

> 101º F

· Transport· Monitor LOC, Vital Signs, SpO2, Respiratory Status. Anticipate seizure activity


< 101º F


Hypoglycemia

Bloodsugar

?

> 80 mg/dl

< 80 mg/dl

Yes

No

· Maintain Airway· Rendezvous with ALS or ILS backup


1. 1 tube of Glucose Oral Paste PO. If condition does not improve or if a second finger stick blood glucose reading remains below 80 mg/dL. May repeat dose x 2 for a total of 3 doses. Must have the ability to swallow.

Glucose may be given as a glass of sweetened juice with 2-3 tsp of sugar added.2. Observe for decreased LOC, focal neurological findings, and hypothermia.

HYPOGLYCEMIA

Document:· Airway· Airway Management· Respiratory Effort· Vital Signs, SpO2· Treatment· Signs & Symptoms· LOC· Blood Sugar· Glasgow Coma Scale

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· ABC’s· Oxygen· Assist ventilations, as needed· Check blood glucose level· Consider IV/IO (if certified)· Consider cardiac monitor· Consider ALS or ILS backup

Able to swallow (?)

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, and Respiratory Status. Observe for decreased LOC 2


Adapted from American Heart Association, 2000Porter's EMS Protocols

Hypothermia

· Remove wet clothing· Prevent heat loss/wind chill · Maintain horizontal position· Avoid rough movement· Determine baseline core temperature with rectal thermometer, ASAP· Consider cardiac monitor. Consider warmed IV/IO (if certified)

1. Methods include: electrical or charcoal warming devices, or radiant heat sources.2. Consider air transport.

Pulse & breathing present

?

Yes

No

· Start CPR· Follow current AHA Cardiac Arrest guidelines· Consider Alternative Airway· Ventilate with 100% Oxygen· Establish IV/IO (if certified)· Infuse warm NS

Core Temp

?

93-96ºF Mild Hypothermia· Passive rewarming· Active external rewarming

86-93ºF Moderate Hypothermia· Passive rewarming· Active external rewarming of truncal & groin areas only

< 86ºF Severe Hypothermia· Transport to CWH for active internal warming

Core Temp

?

> 86º F< 86º F

· Continue CPR· Limit defibrillation for VF/VT to 3 attempts· Transport to CWH for active internal warming

· Continue CPR· See cardiac arrest protocol · Transport

HYPOTHERMIA

Document:· Signs & Symptoms· Vital Signs, SpO2· Core Temp· Mechanism of Injury· Treatment· Response to Treatment

1

· ABC’s· Oxygen Assist Ventilations, as needed· Consider ALS or ILS backup

1

· Transport· Prevent further heat loss· Monitor LOC, Vital Signs, SpO2, Respiratory Status, & Core Temperature

2

BLSProtocol


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2

Neonatal ResuscitationNRP

Birth

Routine care· Provide warmth· Clear airway· Dry

© Copyright 2000 American Heart AssociationPorter's EMS Protocols

NEONATAL RESUSCITATION

Assess· Clear of meconium?· Breathing or crying?· Good muscle tone?· Term gestation? APGAR Score

Assist ventilations via BVM with room air

Yes

HR, breathing,

color?

pink, HR >100, breathing

HR<60

Ongoing care

· Assist ventilations via BVM with 100% 02· Begin CPR for 2 minutes

1. Only suction for occluded airway.2. Discontinue O2 is SpO2 is > 90%

30 sec

30 sec

Approximate time

HR, breathing,

color?

pink, HR >100, breathingApnea or

HR<100

Supportive care

No

· Provide warmth· Position, clear airway· Dry, stimulate, reposition· Oxygen, if needed

1

Consider IV/IO(if certified)


Sign 0 1 2Appearance (skin color) Blue, pale Body pink, blue extremities Completely pinkPulse rate (heart rate) Absent <100/minute >100/minuteGrimace (irritability) No response Grimace Cough, sneeze, cryActivity (muscle tone) Limp Some flexion Active motionRespirations (resp. effort) Absent Slow, irregular Good, crying


· Transport pt. in appropriate pediatric restraint system· Keep patient warm· Monitor LOC, Vital Signs, SpO2, & Respiratory Status. Contact Medical Control if any questions or complications arise.

2

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Physicians (Medical Professionals) at the Scene



Medical professionals at the scene of an emergency call may provide assistance to the EMS team and should be treated with professional courtesy. Medical professionals who offer assistance should identify themselves. If on scene physicians wish to assume or retain responsibility for direction of patient care, they should provide proof of identification, follow the guidelines below, and accompany the patient to the receiving hospital.

When the patient’s private physician is in attendance and has identified him/herself, the EMS team will comply with the private physician’s instructions for the patient. Medical Control will be contacted for reporting. If orders are given by the private physician which are in conflict with Okanogan County’s EMS Patient Care Protocols, clearance must be obtained through Medical Control.

In such cases, the physician at the scene may:Request to talk directly to the Medical Control physician to offer advice and assistance. Offer assistance to the EMS team with another pair of eyes, hands and/or suggestions, yet leave the EMS team under Medical Control and established patient care protocols. Take total responsibility for the patient with the concurrence of the Medical Control Physician. Remember: if the on scene/private physician wishes to take total responsibility for patient care they will accompany the patient to the receiving hospital.

If during transport the patient’s condition should warrant treatment other than that requested by the private physician, then Medical Control will be contacted for information and for concurrence with the requested treatment.

These guidelines will also apply to cases where a physician may happen upon the scene of ongoing EMS care and chooses to interact/assist the EMS team.Medical professional, other that physicians, may offer assistance to the EMS providers but are not authorized to give orders to the EMS team except in pre-approved circumstances (e.g. a critical care RN accompanying the patient and EMS crew on an inter-facility transport).

For Medical Professionals at the scene who offer assistance, please provide them with the “Physicians On Scene” card.


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Physicians (Medical Professionals) at the Scene



(Front of Card)

Physicians On Scene Card

The EMS team is operating under Washington State Law and EMS policy approved by the Okanogan County Emergency Medical Services Council. The EMS team is functioning under standing orders from the Medical Program Director of Okanogan County and is in direct radio contact with an authorized Medical Control Physician at Mid Valley Hospital. If you wish to assist, please see the back side of this card for options.

Larry O Smith, MDMedical Program DirectorOkanogan County EMS

(Back of Card)

In general, the physician who has the most expertise in management of the emergency should take control. This is usually the base hospital physician (on-line Medical Control).

You may:1. Request to talk directly to the base hospital physician to offer your advice and assistance.2. Offer your assistance to the EMS team with another pair of eyes, hands, or suggestion, but allow the EMS team to remain under the medical control of the base hospital physician.3. If you have an area of special expertise for the patient’s problem, you may take total responsibility, if delegated by the base hospital physician, and you accompany the patient to the hospital.

Page 2 of 2

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Poisoning and/or Overdose

1. Poison Control EMS #: 800-709-09112. Narcan via intranasal (IN) 2 mg (1 mg in each nostril). If no response may repeat IN dose x 1. Pediatric dose: 1-5 years of age 1 mg IN ( 0.5 mg in each nostril). If no response may repeat IN dose x 1. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient.3. CO levels > 10 is consider serious.

Document:· Signs & Symptoms· Treatment· Clinical Response to treatment· Vital Signs, SpO2· Airway Management

POISONING AND/OR OVERDOSE

· ABC’s· Oxygen, Assist Ventilations, as needed· Alternative Airway, as needed· Consider cardiac monitor· Check Blood Sugar & Temperature· Detailed Assessment· Consider IV/IO (if certified)· Consider calling Poison Control· Consider ALS or ILS backup

· Transport· Keep patient warm· Monitor LOC, Vital Signs, SpO2, Respiratory Status, CO levels

Yes

No


1

Organophosphate Exposure (?)(Parathion, Malathion, Pesticides & Herbicides)

Carbon Monoxide Poisoning (?)

- S/S: Salivation, Lacrimation, Urination, Defecation, Gastric emptying, Emesis

- S/S: mild HA, dyspnea on mild exertion, irritability, fatigue, N/V, confusion, ataxia, syncope, seizures, incontinence, respiratory arrest, skin may be bright red in some cases- Provide 100% Oxygen with a tight fitting NRB at 12-15 LPM

3

Narcotics (?)- S/S: CNS and/or respiratory depression, drowsiness, N/V, pinpoint pupils, coma, cyanosis, bradycardia- Consider Narcan via intranasal (IN)

Internal Contamination:· What was ingested ?· Time of consumption ?· Amount consumed ?· Past medical history ?

External Contamination:· Protect self and crew· Remove contaminated clothing· Flush contaminated skin and eyes with copious amount of water

Yes

Yes

No

No

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2


No

Yes

Danger to others

?

Psychiatric & Behavioral Disorders

ABCsVital SignsObtain History Assess Neurologic StatusPossible head injury (?)Consider blood sugar checkConsider ALS or ILS backup

Suicidal?

Do not leave patient alone

Have police search patient and remove any dangerous objects

Agitated?

Consider your own safety and limitations.Request Police assistance as needed.

Refer to Physical Restraint Protocol

- Transport to the most appropriate facility- Monitor LOC, Vital Signs, SpO2 & Respiratory Status

No

Yes

No

Yes

Yes

No

1. Note: Bizarre behavior, abrupt change in behavior, suicidal ideation, possible drug or alcohol ingestion, history of diabetes, etc. Look for Medic Alert tag.2. Consider possibility of hypoglycemia. A low blood sugar can cause agitation, confusion, irritability. Consider head injury.

Document:· Behavior· Speech Patterns· Suicidal Ideation· Glasgow Coma Scale· Level of Cooperation· Medical History· SpO2· Current Medications· Communication with Police

and/or Medical Control

PSYCHIATRIC BEHAVIORAL DISORDERS

1

2

Consider causes for behavior

Consider your own safety and limitations.Request Police assistance and to search patient as needed.


Violent or not cooperating with needed medical interventions (?)

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Refusal of Care/Treatment

Document:- Any statements made by the patient

or responsible party indicating they understand your instructions and the potential consequences of refusing care.

- LOC, awareness of self, others, time & place.

- Complete prehospital chart.

Determine: · Mental Status · History of Illness · Mechanism of Injury

Coherent?

Complete Patient Assessment

Contact Police as needed

Treat & Transport

Refusescare

?

- Inform patient and/or responsible party of potential consequences of their decision to refuse treatment and/or transport.- Consider contacting Medical Control.

Continuesto refuse

?

Ensure the following information is provided:· The release is against medical advise· The release applies to this incident only· EMS should be requested again if necessary or desired

Have patient sign release formin the presence of a witness

Refusesto sign

?

Document refusal to sign.Obtain 2 witnesses if possible.

Obtain signature

When possible, leavethe patient in the care of family, friend, or legal guardian

Treat & Transport

NOTE: This protocol assumes it is medically indicated to treat or transport this patient.

1. "Coherent" implies the patient is conscious, oriented to person, place, and time. Glasgow Coma Scale = 15.2. Ensure patient understands these consequences. With patient’s consent, consider contacting a 3rd party for the patient. If patient refuses a specific treatment, document specific treatment refusal.3. Witness should be someone other than EMS personnel, if possible, and must sign the release.

No

Yes

No

Yes

Yes

No

Yes

No

REFUSAL OF CARE/TREATMENT

2

1

3


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Respiratory Distress

· ABC’S. Oxygen, admin. 100% · Assist ventilations, as needed· Consider ALS or ILS backup· Consider cardiac monitor· Consider IV/IO (if certified)

1. Maximize the “3 P’s” (position, percentage, pressure).2. Consider Alternative Airway. See King Protocal.3. Consider ALS or ILS backup &/or contact medical control if: ventilations need to be assisted, decreased LOC, SpO2 < 90% despite therapy, respiratory rate < 10 > 29, patient responds with single word phrases, obvious signs of fatigue, use of accessory muscles, unilateral lung sounds, or on your discretion.4. < 8 breaths per minute should be assisted with 100% O2 via BVM.5. Assist patient with self administration prescribed metered dose inhaler (MDI).6. See CPAP protocol.7. Do not delay transport at any time in this protocol.

See SHOCK protocol.


BP ?

Possible causes of Respiratory Distress: · PE · Pneumonia · COPD · Cardiac Failure · Asthma · Anxiety · Bronchitis · FBO - AMI

> 90mmHG

< 90mmHG

RESPIRATORY DISTRESS

Asses rate, depth, & quality of breathing

4


Consider MDI 5

Signs & Symptoms of Respiratory Distress:· Anxious/restless· Shortness of breath: (air hunger, increased/decreased/absent respirations)· Skin color changes: (cyanotic, pale/clammy, redness/flushing)· Mechanics of respiration: (fatigue due to breathing effort, diaphragmatic breathing,

retractions, irregular breathing pattern)· Drooling, difficulty swallowing, seal bark cough

Document:· Respiratory Effort· Lung Sounds· SpO2· Response to Treatment· Skin Color· LOC- Glasgow Coma Scale

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3

Consider CPAP 6


Restraint Protocol (Physical)

- Determine the need for restraint- Consider potential medical or traumatic causes for patient’s behavior, provide treatment as needed- Attempt de-escalation tactics prior to any use of restraint- Insure the patient does not have the legal right to refuse the proposed treatments and/or transport for which the restraints are required

- Transport to the most appropriate facility- Monitor: Vital Signs, SpO2, and Respiratory Status

Document:· Behavior· Reason for Restraint· Suicidal Ideation· Glasgow Coma Scale· Level of Cooperation· Medical History· Restraint Process· Current Medications· Communication with Police

and/or Medical Control

RESTRAINT PROTOCOL(PHYSICAL)

If physical restraint is deemed necessary, consider requesting law enforcement for assistance.

Indications:- Reduce potential self inflicted harm- Reduce potential harm to others- Reduce potential delay in needed medical interventions


Contraindications:- Patients without altered mentation and refusing treatments and/or transport- Patients compliant with medically necessary interventions

Restraint Procedure:- Assign 1 person to each limb and head (total 5)- Once the decision has been made, act quickly- Place the patient face up on the stretcher (NEVER face down)- Secure limbs with commercially made padded restraints- If patient is spitting, cover the patient’s face with a loosely fitting mask or commercially made spit hood- Re-asses circulation and vital signs frequently

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If physical restraint is unsuccessful consider ALS back up for chemical restraint.

Seizure

Protect patient from injury during and after seizure. Place in lateral recumbent position if no trauma noted.

Document:· ABCs· Activity during seizure· Duration of seizure· Postictal Phase· Vital Signs· SpO2· Glasgow Coma Scale· Lung Sounds· Color· Treatment· Response to treatment· Communication with

Medical Control


BloodSugar

?

Ability to swallow

?

Rendezvous with ALS or ILS backup


ElevatedTemp

?

Dress loosely

· Transport · Anticipate additional seizures· Monitor: LOC, Vital Signs, SpO2, Respiratory Status

1. Consider Alternative Airway. See King Protocol. Ventilatory assistance may be required yet most postictal patients do Not need assistance. Do NOT attempt to insert an OPA (oralpharyngeal airway) during a seizure. NOTE: most postictal patients do not need an OPA. If an OPA is used, be prepared to remove OPA as consciousness returns. Consider an (NPA) nasopharyngeal airway.2. THE PATIENT MUST BE ALERT and have the ability to swallow before oral Glucose can be administered. Glucose Oral Paste PO. Glucose may be given as a glass of sweetened juice with 2-3 tsp of sugar added 3. Provide a quiet, calm environment.

Yes

No

No

Yes

> 80mg/dl

< 80mg/dl

SEIZURE

2

· ABC’s. Consider C-spine precautions· Oxygen, admin. 100% · Assist Ventilations, as needed· Consider ALS or ILS backup· Consider cardiac moniotr· Consider IV/IO (if certified)

1

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Reviewed: 6/2/14 Revised: 6/9/14

Document:· ABCs· Vital Signs · Direct Quotes · Chain of Evidence· Communication with Police


Protect the scene and evidence

ABCsVital Signs

Sexual Assault

Offer reassurance and emotional support

- Do not allow the patient to bathe, change clothes, or use the restroom.- Do not cut clothes.- If the patient must urinate, collect the specimen and do not allow patient to wipe.- If possible, place all clothing in a paper bag, not plastic.

- Notify Police if they are not already present. Final jurisdiction will rest on law enforcement where the assault took place.- If victim is a minor consider contacting CPS.

Transport to nearest appropriate facility

Follow appropriate treatment protocols

SEXUAL ASSAULT

Chart direct quotes

1

1. If possible have the patient attended by the same sex care provider.2. Do Not delay transport if critical patient.3. Limit physical exam to significant injuries needing treatment.

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· Transport (consider air transport)· Keep Patient Warm· Notify Receiving Hospital· Monitor LOC, Vital Signs, SpO2, Cardiac Rhythm, Respiratory Status


Shock/Hypotension (Nontraumatic)

· ABCs· Oxygen· Assist ventilations, as needed- IV/IO (if certified)- Consider ALS or ILS backup- Consider cardiac monitor- Detailed Assessment

1. Control external bleeding, see protocol.2. Assess for fluid overload. Do Not fluid overload the patient. If BP < 90 mmHg may repeat fluid bolus at 250-500 ml IV/IO.3. Notify Hospital for Trauma Team activation if patient meets WA State Trauma Triage Criteria.

Shockpresent

?

Fluid ChallengeAdult: 500ml IV/IOPeds: 20 cc/kg NS, repeat as needed

Reassess ABCsSupport respiratory effort

Signs & Symptoms of Shock:· Pulse > 120· BP < 90 systolic· Delayed capillary refill · Confusion, restlessness, apathy· Thirst, postural syncope· Skin moist/cool

SHOCK/HYPOTENSION (NONTRAUMATIC)

Document:· Airway· Respiratory Effort· Lung Sounds· Quality of Pulses· Signs & Symptoms of Shock· Vital Signs, SpO2, Glucose· Glasgow Coma Scale· Skin Color, Temperature· Response to Fluid

> 90 mmHG

3

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< 90 mmHG

> 90 mmHG

· Transport· Keep Patient Warm· Notify Receiving Hospital· Monitor LOC, Vital Signs, SpO2, Respiratory Status


Shock/Hypotension (Traumatic)

· ABCs· Oxygen· Assist Ventilations, as needed· Consider ALS or ILS backup· Consider cardiac monitor· IV/IO (if certified)· Detailed assessment

1. Consider alternative causes of hypotension.2. See External Bleeding Control protocol.3. If tension pneumothorax is suspected, call and/or advise ALS backup.4. Assess for fluid overload. Do Not fluid overload the patient. If BP < 90 mmHg may repeat fluid bolus at 250-500 ml IV/IO.5. Notify Hospital for Trauma Team activation if patient meets WA State Trauma Triage Criteria.

Fluid ChallengeAdult: 500 ml IV/IOPeds: 20 cc/kg NS, repeat as needed

Signs & Symptoms of Shock:· Pulse > 120· BP < 90 systolic· Delayed capillary refill · Confusion, restlessness, apathy· Thirst, postural syncope· Skin moist/cool

SHOCK/HYPOTENSION (TRAUMATIC)

Document:· Airway· Respiratory Effort· Lung Sounds· Quality of Pulses· Signs & Symptoms of Shock· Vital Signs, SpO2, Glucose· Glasgow Coma Scale· Skin Color, Temperature· Response to Fluid

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BLSProtocol


1

Internal Bleeding:- Stabilize/Splint fractures- Possible Pelvis fracture: consider Pelvis Binder Splint

Stop External Bleeding 2

4

Evaluate for Tension Pneumothorax 3

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Notify receiving facility of possible envenomation and verify anti-venom availability.

Snakebites

Consider IV/IO (if certified)

1. Attempt to verify envenomation (ie: bite mark showing two fang marks, pain and/or swelling at site). Any rattlesnake bite, or unknown snakebite that produces fang marks should be observed in a hospital setting for 8 hours.

Note: CroFab, sheep derived (antivenom of choice). Wyeth, eqiune derived. Once a strain of antivenom is given need to stay with that specific strain through out patient care.

* ABC's* Oxygen* Splint extremity, if applicable* Patient exam

- Measure extremity at bite site and mark edges. Continue measurements every 15-20 minutes until swelling subsides.- Keep bitten area just below or at heart level.- No tourniquets or constricted bands.- NO ICE due to increase of tissue necrosis.

SNAKEBITES

Document:AirwayCardiac RhythmVital Signs, SpO2Extremity measurement at bite siteTreatment ~ Antivenom givenCommunication with receiving hospital

1

· Transport· Keep patient warm· Monitor: Respiratory Status, SpO2, Cardiac Rhythm, LOC Vital Signs (watch for hypotension)

Reviewed: 6/2/14Revised 1/18/14

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START Triage

Green (minor)

Position airway

Yes

No

Patient maintains

airway?

No

Yes

Black (deceased)

Red (immediate)

RespRate (?)

> 30/min

≤ 30/min

Red (immediate)

Perfusion

Yes

No

CapillaryRefill (?)

> 2 sec

< 2 sec

ControlBleeding

Red (immediate)

Mental Status

followssimple

commands?

Yes

NoRed (immediate)

Yellow (delayed)

Resp present

?

START TRIAGE

Adapted from START Triage, originally developed by: Hoag Memorial Hospital Presbyterian and Newport Beach Fire Department

Porter's EMS Protocols

Ableto walk

?

No

Yes

Red: Transport immediatelyYellow: Transport can be delayed up to 2 hoursGreen: Transport last, lowest priorityBlack: Leave in place


* For further information refer to Okanogan County’s MCI Plan

Radial pulse present (?)

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Syncope

Consider possible causes and treat appropriately

· ABCs· C-Spine precautions, as needed· SpO2 @ room air· Oxygen, as needed· Consider cardiac monitor· Consider IV/IO (if certified)· Consider ALS or ILS backup· Check blood sugar

· Detailed Assessment· Obtain History

BP ?

> 90mmHG

< 90mmHG

See Shock Protocol

1. Establish spinal immobilization if associated with fall or trauma.2. Monitor SpO2, Pulse rate & quality, Capillary Refill, Glasgow Coma Scale.

Document:· Medications· Onset & Duration of LOC· Activity Prior to LOC· Recent or Chronic Illness· Trauma· Seizure Activity· SpO2, GCS, Vital Signs· Capillary Refill. Incontinence

Possible causes:· Medications· Vasovagal Response· Hypovolemia· Vasodilatation· Arrhythmias· Fatigue· Heart Disease· Heat Stroke. OD. Hypoglycemia. PE. AAA. Seizures· CVA/Stroke

SYNCOPE

1


BLSProtocol


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Blood Sugar?

See Hypoglycemia Protocol

< 80mg/dl

> 80 mg/dl

Porter's EMS Protocols© Copyright 2000 William Porter

· Scene safety· ABCs

Break or cut wires before removing darts

Grasp dart firmly with one hand, pull skin tight and pull to remove, one dart at a time.

Dispose of darts in sharps container or TASER cartridge

1. Police must have custody of patient. DO NOT REMOVE darts if: Patient is not under control, or if the dart(s) are located in the eye, face, neck, groin, or breast. (patient must be transported to hospital for dart removal).2. If not easily removed, leave in place. Patient must be transported to hospital for dart removal.3. BURN HAZARD: When a TASER is used in the presence of pepper spray propellant, there is a burn hazard. Electrical

arcing from imperfect (but effective) dart contact can ignite the propellant. The resulting combustion may not be visible, but can lead to complaints of heat and burning. If a patient complains of heat or burning, evaluate for possible minor burns.

Taser Dart Removal

Patient Assessment:· PPE · Don gloves and eye protection

Document:· Medical or behavioral problems· Situation & patient contact

Taser Dart Removal

1

2

· Bandage wound· Re-assess for secondary injuries· Release to law enforcement, if indicated

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Tourniquet Application

Application

A commercially available tourniquet (CAT, SWAT, TK-4)

Placement

Expose the extremity by removing clothing in proximity to the injury

Place directly on exposed skin at least 4 inches proximal to the injury. DO NOT place over a joint.

Record the date/time of application on the tourniquet

Apply tourniquet and tighten until bleeding stops(May need a second tourniquet for leg injuries or bleeding that is unable to be controlled with just one tourniquet. Apply second tourniquet proximal to the first one.)

Tourniquet application


Indications: (to stop bleeding when)· Life-threatening limb hemorrhage is

not controlled with direct pressure or other simple measures, as may occur with a mangled extremity

· Traumatic amputation has occurred

The tourniquet is effectively applied when there is cessation of bleeding from the injured extremity, indicating total occlusion of arterial blood flow

Evaluation

· Transport· Keep Patient Warm· Notify Receiving Hospital· Monitor LOC, Vital Signs, SpO2, Cardiac Rhythm, Respiratory Status, Bleeding Control

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Trauma: General Management

1. Whenever possible scene time with major trauma patients should be limited to 10-15 minutes. Notify receiving hospital for Trauma Team activation if patient meets WA State Triage Criteria.2. If certified, administer IV/IO fluids to maintain systolic BP > 90-100 mmHg. Do not overload the patient.3. Control major external bleeding. See External Bleeding Control protocol.4. Patch unaffected eye. Offer reassurance and orientation as needed. Encourage patient to limit movement of eyes.5. Remove contact lenses. 6. Immobilize the joint above & below the injured bone, or the bone above & below the injured joint. Check distal CMS before & after splinting. Consider pain management, see Pain Management protocol.7. If unable to splint due to malformation or compromised distal CMS, realign/reduce the fracture/dislocation by applying gentle axial traction. If unable to re-establish distal CMS notify receiving facility.

Document:· MOI, Signs & Symptoms· Treatment(s)· Distal CMS· LOC, Vital Signs, SpO2, GCS· Airway Management· Trauma Band ID number, if applicable

TRAUMA: GENERAL MANAGEMENT

Yes

Yes

- Pelvis Fracture: Consider pelvis binder splint- Open fracture: Control bleeding, splint fracture- Deformity: Based on presence or absence of pulse consider the need to realign/reduce the fracture/dislocation.

· ABC’s· Consider C-spine immobilization· Oxygen, Assist Ventilations, as needed· Consider cardiac monitor· Monitor for S/S of shock· Check Blood Sugar & Temperature· Detailed Assessment & GCS score· Consider IV/IO (if certified)· Consider ALS or ILS backup


Eye Injury (?)- Impaled Object: Do not remove object, stabilize object in place & dress affected eye - Chemical Burn: Flush affected eye for a minimum of 20 minutes or until patient is asymptomatic.

4

Orthopedic Injury (?)

Yes

Head Injury and/or Spinal Injury (?)- Consider C-spine immobilization.- Active scalp bleeding: Apply direct pressure.- Combative (?): Consider ALS back up


6

1

Abdominal Injury (?)

Facial Injury (?)

- Palpate: note guarding, masses, distension. Assess associate injury site with underlying anatomy.- Penetrating Injury: Stabilize object. Note: injury instrument, location & size of wound(s), stated caliber and approx. distance from muzzle.- Blunt Injury: Consider MOI, monitor for shock.- Evisceration Injury: Cover exposed tissue with sterile saline soaked dressing then cover with an occulisive dressing. Do not attempt to re-insert abdominal contents.

- Maintain airway, control external bleeding.- Remove dislodged teeth from mouth. Protect root of tooth, if root present place tooth in NS while enroute to the hospital.- Fracture to mandible/maxilla: If no C-spine precautions are in place, transport patient in position of comfort.

7

Chest Injury (?)- Open Pneumothorax: Apply occlusive dressing, monitor for tension pneumothorax- Tension Pneumothorax: Call for ALS back upYes

Yes

Yes

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Vaginal Bleeding

1. Administer IV fluids to maintain systolic BP @ 80-90 mmHG. Do not overload the patient.2. Determine possibility of pregnancy. If possibility of assault exists maintain chain of evidence and place items in a paper bag, if possible. Preserve tissue fragments and collect products of conception, if present.3. If possible, have a female attendant in the patient care area.

· ABCs· Oxygen

· Consider IV/IO (if certified)

Shock present

?

No

Yes

See Shock protocol

Detailed AssessmentPossible causes:· Miscarriage · Placenta previa· Trauma · Abruptio plencentae· Infection · Ectopic pregnancy

Document:· Hx. of pregnacies & births · Estimated Blood Loss· Color of Blood· Presence of Tissue· Last Menstrual Period· Possibility of Pregnancy· Possibility of Assault· Vital Signs, SpO2· Detailed Assessment

VAGINAL BLEEDING

1

2


· Transport· Keep patient warm & provide supportive care· Monitor LOC, Vital Signs, Respiratory Status, SpO2

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