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TANEY COUNTY EMERGENCY TREATMENT PROTOCOLS
Effective: November 8, 2019 Version 2019.5
Abbreviated Table of Contents
Introduction 13
Scope of Practice 14
Clinical Operating Guidelines 17
General Orders 36
General Considerations 38
Cardiac Protocols 46
Medical Protocols 62
Trauma Protocols 77
Special Needs Patients 87
Community Paramedic Protocols 96
Procedures 102
Medications 148
Appendix 165
Bibliography 186
Index 188
Expanded Table of Contents Introduction .................................................................................................................................................................................. 7 Scope of Practice .......................................................................................................................................................................... 8
Emergency Medical Responder .............................................................................................................................................. 8 EMT-Basic ................................................................................................................................................................................ 8 EMT-Paramedic ...................................................................................................................................................................... 9 Community Paramedic .......................................................................................................................................................... 10
Clinical Operating Guidelines ................................................................................................................................................... 11 Protocol Review ..................................................................................................................................................................... 11 Staffing Level ......................................................................................................................................................................... 11 Transport Decisions ............................................................................................................................................................... 12 Helicopter Transport ............................................................................................................................................................. 13 Psychiatric Patients................................................................................................................................................................ 15 Patients in Police Custody ..................................................................................................................................................... 16 Organ Donor Patients ............................................................................................................................................................ 16 Deceased Patients ................................................................................................................................................................... 17 Non-Transport ....................................................................................................................................................................... 18 Safe Transport of Patient, Crew, and Passengers ............................................................................................................... 23 Transferring Patient Care ..................................................................................................................................................... 25 Patient Care Report ............................................................................................................................................................... 25 Medical Control Plan ............................................................................................................................................................. 26 Pre-Hospital Radio Report.................................................................................................................................................... 26 Equipment Brought To Patient ............................................................................................................................................ 27 Provider In Charge of Patient Care ..................................................................................................................................... 27 Blood Draws for Law Enforcement ...................................................................................................................................... 29
General Orders ........................................................................................................................................................................... 30 Activation................................................................................................................................................................................ 30 Types of Orders ...................................................................................................................................................................... 31
General Considerations ............................................................................................................................................................. 32 Medical Values ....................................................................................................................................................................... 32 Scene Size-up .......................................................................................................................................................................... 33 Patient Triaging ..................................................................................................................................................................... 33 Primary Survey ...................................................................................................................................................................... 34
Adult Primary Survey ...................................................................................................................................................... 34 Pediatric Primary Survey ................................................................................................................................................ 35
Secondary Survey .................................................................................................................................................................. 36 Treatment Considerations..................................................................................................................................................... 36 Standing Orders ..................................................................................................................................................................... 37
Pain management ............................................................................................................................................................ 37 Sedation ............................................................................................................................................................................. 37 Nausea/Vomiting ............................................................................................................................................................. 38 Pediatric Pain Management / Sedation / Nausea ....................................................................................................... 38
Cardiac Protocols ....................................................................................................................................................................... 39 Chest Pain Pit Crew Model ............................................................................................................................................... 40 General Considerations ....................................................................................................................................................... 41
Cardiac Arrest ....................................................................................................................................................................... 43 Pit Crew Model .................................................................................................................................................................. 46
Adult Post-Resuscitative Care .............................................................................................................................................. 47 Pediatric Dysrhythmias ......................................................................................................................................................... 48
Tachycardia ...................................................................................................................................................................... 48 Pediatric Post-Resuscitation Care ........................................................................................................................................ 50
AHA CPR Pediatric Cardiac Arrest ................................................................................................................................. 51 Newborn Resuscitation .................................................................................................................................................... 52 Death of a Child (SIDS) ..................................................................................................................................................... 52
Field Resuscitation Termination .......................................................................................................................................... 54 Medical Protocols ....................................................................................................................................................................... 55
Abdominal Pain ..................................................................................................................................................................... 55 Allergic Reactions & Anaphylaxis ........................................................................................................................................ 55 Behavioral/Psychiatric Disorders ......................................................................................................................................... 56 Dehydration ............................................................................................................................................................................ 57 Diabetic Emergencies ............................................................................................................................................................ 58 Epistaxis .................................................................................................................................................................................. 59 Exertional Heat Illness .......................................................................................................................................................... 59 Gastrointestinal Bleeding ...................................................................................................................................................... 61 Hypertensive Crisis ................................................................................................................................................................ 61 Obstetrics ................................................................................................................................................................................ 62
Nuchal Cord ....................................................................................................................................................................... 63 Prolapsed Cord.................................................................................................................................................................. 63 Shoulders Stuck................................................................................................................................................................. 63
Overdose/Poisoning ............................................................................................................................................................... 63 Respiratory Emergencies ...................................................................................................................................................... 65
Asthma ............................................................................................................................................................................... 65 Chronic Obstructive Pulmonary Disease (COPD) ........................................................................................................ 65 Croup/Stridor.................................................................................................................................................................... 66 Spontaneous Tension Pneumothorax............................................................................................................................ 66
Seizures ................................................................................................................................................................................... 66 Sepsis ....................................................................................................................................................................................... 67
Identification of Sepsis..................................................................................................................................................... 67 Treatment .......................................................................................................................................................................... 68
Stroke / Cerebrovascular Accident (CVA) .......................................................................................................................... 68 Post-tPA Interfacility Transfers ..................................................................................................................................... 68
Syncope ................................................................................................................................................................................... 69 Sexual Assault ........................................................................................................................................................................ 69
Trauma Protocols ....................................................................................................................................................................... 70 Trauma Classification ........................................................................................................................................................... 70
Guidelines for field triage of injured patients (9) ........................................................................................................ 71 Abdominal Trauma ............................................................................................................................................................... 72 Burns ....................................................................................................................................................................................... 72
General Considerations ................................................................................................................................................... 72 Chemical Burns ................................................................................................................................................................. 72 Electrical Burns ................................................................................................................................................................ 73 Thermal Burns .................................................................................................................................................................. 73
Smoke and Carbon Monoxide Exposure ............................................................................................................................. 74 Chest Trauma ......................................................................................................................................................................... 75 Extremity Trauma ................................................................................................................................................................. 75 Head Trauma ......................................................................................................................................................................... 76 Multiple Systems Trauma ..................................................................................................................................................... 76 Snake Bite ............................................................................................................................................................................... 77 Spinal Motion Restriction ..................................................................................................................................................... 77 Spinal Trauma / Neurogenic Shock ...................................................................................................................................... 78 Traumatic Cardiac Arrest .................................................................................................................................................... 79
Special Needs Patients ................................................................................................................................................................ 81 General ................................................................................................................................................................................... 81
Apnea Monitors ..................................................................................................................................................................... 81 Central Lines .......................................................................................................................................................................... 82
Central Venous Catheter .................................................................................................................................................. 83 Peripherally Inserted Central Venous Catheter (PICC) .............................................................................................. 83
Colostomy ............................................................................................................................................................................... 84 CSF Shunts ............................................................................................................................................................................. 84 Feeding Tubes ........................................................................................................................................................................ 85 Tracheostomy Emergencies .................................................................................................................................................. 86 Ventilator Emergencies ......................................................................................................................................................... 88
Community Paramedic Protocols ............................................................................................................................................. 90 MIHCP Participant with Congestive Heart Failure /Pulmonary Edema ......................................................................... 90 MIHCP Participant with Diabetes ....................................................................................................................................... 90 MIHCP Participant with Diabetes Cont. ............................................................................................................................. 91 MIHCP Participant with Hypertension ............................................................................................................................... 92 MIHCP Participant with Nausea and Vomiting ................................................................................................................. 93 MIHCP Participant with Obstructive Airway Disease ....................................................................................................... 94
Procedures .................................................................................................................................................................................. 96 General Considerations ......................................................................................................................................................... 96 Airway Management ............................................................................................................................................................. 96
Oropharyngeal Airway .................................................................................................................................................... 96 Nasopharyngeal Airway .................................................................................................................................................. 97 Endotracheal Intubation ................................................................................................................................................. 97 Bougie ................................................................................................................................................................................ 98 Nasotracheal Intubation ................................................................................................................................................. 99 Esophageal Tracheal Combitube ................................................................................................................................... 99 Pediatric Quicktrach ...................................................................................................................................................... 101 Suctioning Upper Airway .............................................................................................................................................. 102 Surgical Cricothyrotomy ............................................................................................................................................... 103 King LTS-D Laryngeal Tube with Gastric Access ....................................................................................................... 104 Positive End Expiratory Pressure (PEEP) Valve ......................................................................................................... 105 Impedance Threshold Device (ITD) ............................................................................................................................. 105 Rapid Sequence Intubation (RSI) ................................................................................................................................. 106
Blood or Blood Product Administration/Monitoring ....................................................................................................... 108 Blood Glucose Test............................................................................................................................................................... 109 Chest Compressions ............................................................................................................................................................. 110
Manual Chest Compressions ......................................................................................................................................... 110 Automated Chest Compressions (Lucas 2 Compression System) ............................................................................ 111
Chest Seal ............................................................................................................................................................................. 112 12 Lead Electrocardiogram ................................................................................................................................................ 112 15 Lead Electrocardiogram ................................................................................................................................................ 113 ............................................................................................................................................................................................... 113 Electrical Therapies ............................................................................................................................................................. 114
General Considerations ................................................................................................................................................. 114 Synchronized Cardioversion ......................................................................................................................................... 114 Standard Manual Defibrillation ................................................................................................................................... 114 Automatic External Defibrillation (AED) .................................................................................................................... 115 Transcutaneous Pacing (TCP) ...................................................................................................................................... 115
Gastric Tube Insertion ........................................................................................................................................................ 115 Nasogastric Tube ............................................................................................................................................................ 115 Orogastric Tube .............................................................................................................................................................. 116
Intraosseous (IO) Access ..................................................................................................................................................... 117 EZ-IO General Considerations ....................................................................................................................................... 117
EZ-IO Insertion - Proximal Tibia .................................................................................................................................. 117 EZ-IO Insertion - Humerus ............................................................................................................................................ 118 Intravenous (IV) Blood Draw for Law Enforcement .................................................................................................. 119
Intravenous (IV) Blood Draw ............................................................................................................................................. 120 Intravenous (IV) Catheter Insertion .................................................................................................................................. 120 Medication Administration ................................................................................................................................................. 122
General Considerations ................................................................................................................................................. 122 Intramuscular (IM) Injection ....................................................................................................................................... 122 Intravenous (IV) Drip..................................................................................................................................................... 122 Intravenous (IV) Push .................................................................................................................................................... 123 Inhalation (Small Volume Nebulizer) .......................................................................................................................... 123 Inhalation (Nebulizer via BVM) ................................................................................................................................... 123 Inhalation (Nebulizer via Pulmodyne CPAP) ............................................................................................................. 124 Mucosal Atomization Device (MAD) ............................................................................................................................ 124 Endotracheal Tube (ETT) Push .................................................................................................................................... 125
Needle Thoracostomy .......................................................................................................................................................... 126 Oxygen Administration, Devices, and Perfusion Monitoring .......................................................................................... 127
Oxygen Administration & Devices ................................................................................................................................ 127 Continuous Positive Airway Pressure (CPAP) with Pulmodyne O2 Max ................................................................ 127 Non-Invasive Positive Pressure Ventilation via Ventilator (CPAP/BPAP) ............................................................. 128 Ventilator ......................................................................................................................................................................... 129 Pulse Oximetry (SpO2) Monitoring .............................................................................................................................. 130 Capnography (ETCO2) Monitoring ............................................................................................................................... 130
Patient Lifting and Moving Procedures ............................................................................................................................. 132 Bariatric Transfer Sheet................................................................................................................................................ 132 Binder Lift ........................................................................................................................................................................ 132 ErgoSlide .......................................................................................................................................................................... 133 Slideboard ....................................................................................................................................................................... 133
Spinal Motion Restriction Procedures ............................................................................................................................... 133 Cervical Collar ................................................................................................................................................................. 134 Scoop Stretcher ............................................................................................................................................................... 134 Rapid Extrication Technique ........................................................................................................................................ 135 Evac-U-Splint ................................................................................................................................................................... 135
Restraint Use ........................................................................................................................................................................ 136 Pedi-Pac ........................................................................................................................................................................... 136
Splinting ................................................................................................................................................................................ 137 Pediatric Hare Traction Splint ..................................................................................................................................... 137 Pelvic Sling....................................................................................................................................................................... 138 Sager Splint ..................................................................................................................................................................... 138
Temperature Acquisition .................................................................................................................................................... 139 Tourniquet ............................................................................................................................................................................ 140 Wound Packing (hemostatic gauze) ................................................................................................................................... 141
Medications ............................................................................................................................................................................... 142 Adenosine (Adenocard®) .................................................................................................................................................... 142 Albuterol ............................................................................................................................................................................... 142 Amiodarone (Cordarone®) ................................................................................................................................................. 142 Aspirin .................................................................................................................................................................................. 143 Atropine Sulfate ................................................................................................................................................................... 143 Calcium Chloride ................................................................................................................................................................. 143 Dextrose ................................................................................................................................................................................ 144 Diltiazem (Cardizem®) ....................................................................................................................................................... 145
Diphenhydramine (Benadryl®) .......................................................................................................................................... 145 Dopamine (Intropin®) ......................................................................................................................................................... 146 Epinephrine 1:1,000 ............................................................................................................................................................. 146 Epinephrine 1:10,000 ........................................................................................................................................................... 147 Epinephrine (Racemic) ........................................................................................................................................................ 147 Esmolol (Brevibloc® ............................................................................................................................................................ 147 Etomidate (Amidate®) ........................................................................................................................................................ 147 Fentanyl Citrate ................................................................................................................................................................... 149 Glucagon ............................................................................................................................................................................... 149 Hydromorphone (Dilaudid®) ............................................................................................................................................. 150 Ipratropium Bromide/Alubuterol (DuoNeb®) .................................................................................................................. 150 Ketamine (Ketelar®) ........................................................................................................................................................... 151 Ketorolac (Toradol®) .......................................................................................................................................................... 151 Lidocaine 2% (Xylocaine®) ................................................................................................................................................ 152 Magnesium Sulfate .............................................................................................................................................................. 152 Methylprednisolone (Solu-Medrol®) ................................................................................................................................. 152 Metoclopramide (Reglan®) ................................................................................................................................................. 153 Midazolam (Versed®) ......................................................................................................................................................... 153 Morphine Sulfate ................................................................................................................................................................. 154 Naloxone (Narcan®) ............................................................................................................................................................ 154 Nitroglycerin (Nitrostat®) (Nitrolingual®) ....................................................................................................................... 155 Ondansetron (Zofran®) ...................................................................................................................................................... 155 Oral Glucose ......................................................................................................................................................................... 155 Oxygen .................................................................................................................................................................................. 156 Sodium Bicarbonate ............................................................................................................................................................ 156 Succinylcholine ..................................................................................................................................................................... 157 Thiamine (Vitamin B1) ........................................................................................................................................................ 157 Tranexemic Acid (TXA) ...................................................................................................................................................... 157 Vecuronium (Norcuron®) ................................................................................................................................................... 159 Xylocaine Gel ....................................................................................................................................................................... 159
Appendix ................................................................................................................................................................................... 160 Jump START Pediatric Triage ........................................................................................................................................... 160 Simple Triage and Rapid Treatment (START) Flowchart .............................................................................................. 161 Modified ESI Triage Algorithm ......................................................................................................................................... 162 Glasgow Coma Score/ Revised Trauma Score .................................................................................................................. 163 APGAR Score ....................................................................................................................................................................... 163 Cincinnati Prehospital Stroke Scale (6) ............................................................................................................................. 164 AVPU Scale .......................................................................................................................................................................... 165 Blood Draw Consent Form .................................................................................................................................................... 166 MHT Flowchart ..................................................................................................................................................................... 167 Medical Abbreviations ........................................................................................................................................................ 168 Taney County Homicide and Questionable Death Protocol ............................................................................................. 176
Bibliography ............................................................................................................................................................................. 181 Index .......................................................................................................................................................................................... 183
Introduction
Emergency Medical Services is a critically important safeguard for
the well-being of all community members, regardless of their social
and financial status, in today’s society. Every one of us, yourself
included, has our fingers (quite literally) on the pulse of our ever-
growing and expanding local community. I am honored to be a
partner with you in our journey together towards the betterment of
medical care for all of those in need.
As the Taney County emergency medical system continues to
grow, all of us are going to be faced with exciting opportunities and
difficult challenges. I hope that you will work to the best of your
ability to meet the challenges head-on, asking questions and
looking for answers where solutions are needed – knowing that
your input is both valued and vital to our improved functionality as a team. In addition, don’t hesitate to
seize opportunities to improve your knowledge base and advance your career. I ask that you spend some
time reviewing these protocols and familiarizing yourself with all of the updates and changes, so that you
are prepared to provide optimal care for our patients.
These protocols are designed to be fluid guidelines, intended to help us all navigate the ever-shifting
landscape of Emergency Medicine. I welcome everyone’s input, questions, and constructive criticisms
moving forward. Please feel free to contact me directly with questions and comments.
Timothy Costello, MD
Medical Director
Scope of Practice
Emergency Medical Responder The Office of the Medical Director defines a First Responder/EMR as any individual possessing said title
within a Taney County Fire Department or Law Enforcement Agency as of February 2013. After that
date, new EMR providers must have completed an EMR course, provided by a training entity licensed by
the Missouri Bureau of EMS that meets or exceeds the minimum standards set forth by the First
Responder National Standard Curriculum and the National Scope of Practice for First Responders. An
EMR working within the Taney County EMS System may perform the following emergency care
procedures:
1. Conduct primary and secondary patient examinations
2. Take and record vital signs
3. Administer oxygen
4. Open and maintain an airway by positioning the patient’s head and utilize the following airway
adjuncts:
a. Nasopharyngeal airway device
b. Oropharyngeal airway device
c. Pharyngeal suctioning device
5. Ventilate with a non-invasive positive pressure delivery device such as a bag valve mask with
reservoir
6. Provide external cardiac resuscitation and obstructed airway care for infants, children, and adults
7. Perform cardiac defibrillation with an automatic or semi-automatic defibrillator
8. Assist patient with the self-administration of aspirin for suspected myocardial infarction
9. Soft tissue care
10. Spinal motion restriction
11. Fracture care and splinting
12. Assist with childbirth
13. Communicate a clear and accurate prehospital emergency care report to the paramedic with the
transporting ambulance and when available provide a written copy of that report
EMT-Basic A Missouri-licensed EMT-Basic working within the Taney County EMS System may perform the
following emergency care procedures:
1. Perform all procedures that a EMR can perform; plus,
2. Insert a cuffed pharyngeal airway device in the practice of airway maintenance including:
a. A single-lumen airway device designed for blind insertion into the esophagus providing
airway protection where the cuffed tube prevents gastric contents from entering the pharyngeal
space
b. A multi-lumen airway device designed to function either as the single-lumen device when
placed in the esophagus, or by insertion into the trachea where the distal cuff creates an
endotracheal seal around the ventilator tube, preventing aspiration of gastric contents
c. Insertion of a supraglottic airway device
3. Transport stable patients with saline locks, heparin locks, Foley catheters, or in-dwelling vascular
devices while representing a licensed ambulance service in the Taney County EMS System.
4. Operate electronic monitoring equipment for the purpose of measuring blood pressure, pulse rates,
respiratory rate, pulse-oximetry, exhaled carbon dioxide, carbon monoxide, and in order to acquire
and transmit 12 lead electrocardiograms.
EMT-Paramedic A Missouri-licensed EMT-Paramedic working for a licensed Emergency Medical Response Agency or
licensed ambulance service within the Taney County EMS System, may perform the following emergency
procedures. Licensed Paramedics not associated with either type of agency may only operate as an ALS
Provider in the authorized presence of a TCAD Paramedic. Rights and authority for patient care lie with
the TCAD Paramedic who may at any time revoke or suspend a non-affiliated Paramedic’s right to
provide care.
1. Perform all procedures that a Missouri-certified EMT-Basic can perform; plus,
2. Initiate the following airway management techniques:
a. Endotracheal or nasotracheal intubation
b. Emergency cricothyrotomy
c. Tracheobronchial suctioning via endotracheal tube
d. Clear airway obstruction via direct laryngoscopy
e. Rapid sequence intubation
3. Initiate and maintain peripheral intravenous (IV), intraosseous (IO) line access
4. Initiate and maintain gastric tubes
5. Provide advanced life support in the resuscitation of patients in cardiac arrest
6. Attempt external transcutaneous pacing of bradycardia that is causing hemodynamic compromise
7. Initiate needle thoracostomy for tension pneumothorax
8. Access indwelling catheters and implanted central IV ports for fluid and medication administration
9. Administer the medications listed in this protocol document as directed under standing orders,
specific written protocols, or direct orders from a licensed physician
10. Maintain intravenous medication infusions, blood transfusions or other procedures which were
initiated in a medical facility, when clear and understandable written and verbal instructions for
such maintenance have been provided by the physician at the transferring medical facility
11. If the EMT-Paramedic provider is uncertain about the maintenance of any products or device,
he/she should consult with Medical Control prior to loading the patient
12. Operate a cardiac monitor for the purpose of acquiring and interpreting electrocardiograms and to
provide manual cardioversion and /or defibrillation
13. Any other procedure as designated by the Medical Director, through verbal or written protocol in
order to provide necessary comfort measure or lifesaving skills
Community Paramedic
A Community Paramedic (MIH/CP) is licensed by the Missouri Bureau of EMS as a Community
Paramedic as per 19 CSR 30-40.800. The Community Paramedic scope of practice only applies to
providers assigned to the MIH/CP program, treating patients that are enrolled in the CP program. If a
licensed CP is treating any patient not enrolled in the program, they will fall into the scope of practice of
the EMT-Paramedic, as described above.
1. As per Section 190.142.4, RSMo, and 19 CSR 30-40.342(3), the MIH/CP may perform only that
patient care which is:
a. Consistent with the training, education and experience of the particular emergency medical
technician; and
b. Ordered by a physician or set forth in protocols approved by the medical director.
2. The MIH/CP may perform all procedures that a EMT-Paramedic may perform, as listed in the
Taney County EMS System Protocols, as well as;
a. Enacting patient-specific care plans approved by the patient’s PCP
b. Detailed evaluation and assessments
c. Health and social assessment
i. Home safety assessment
ii. Fall risk assessment
iii. Nutritional screening
d. Point of care testing
e. Telemedicine; and
f. Any other treatment/procedure listed in the MIH/CP protocols.
3. Providers will focus on the primary care of the participant in lieu of the traditional episodic
approach
4. Providers will identify and educate participants in developing relationships with community
partners and resources to ensure and encourage participant utilization
5. It will be the responsibility of the MIH/CP provider to interact, and coordinate with the patients
Primary Care Provider (PCP) or another medical specialist
Clinical Operating Guidelines
Protocol Review
Purpose
To establish guidelines regarding the review and approval of the Taney County Emergency Treatment
Protocols.
Guideline
1. The Medical Director will review the treatment protocols for clinical appropriateness, relevance
and ensure that they are supported by current evidence-based medical research and practice no less
than once every three years.
2. The Medical Director will also review the treatment protocols for compliance with federal, state,
and local requirements.
Staffing Level
Purpose
To establish guidelines regarding the staffing of ambulances.
Guideline
All transporting ambulances will be staffed with a minimum of one licensed EMT-Basic and one licensed
Paramedic as per 19 CSR 30-40.309 (4) “Each vehicle operated as an ambulance shall meet the following
staffing requirements: (A) When transporting a patient, at least one (1) licensed EMT, registered nurse, or
physician shall be in attendance with the patient in the patient compartment at all times; and (B) When an
ambulance service provides advanced life support care under its protocols, the patient shall be attended by
an EMT-Paramedic, registered nurse or physician.”
Transport Decisions
Purpose
To establish guidelines regarding transport decisions.
Definitions
1. Life Threatening Transport – The patient suffered a significant or potentially significant
compromise of the cardiovascular and/or respiratory system, thus presumably endangering the
patient’s life if the condition is not reversed in a timely fashion. The patient’s condition
necessitates the use of lights & siren during transport.
2. Urgent Transport – The patient’s life is not in immediate danger but needs to be transported to an
acute care hospital to prevent further suffering and/or disability. The patient’s condition does not
necessitate the use of lights & siren during transport.
3. Routine Transport – The patient’s condition is such that it is unlikely to deteriorate or cause
further disability. The patient is in need of transport by ambulance from one facility to another.
The patient’s condition does not necessitate the use of lights & siren during transport.
Guideline
1. The District will offer to provide transport service to any patient, which a District ambulance
responds to, without bias or discrimination. The District will transport the patient to definitive
medical care facility of choice or necessity, 24 hours a day, providing resources and patient
condition allow.
2. Transport decisions may be dictated by medical protocols or patient choice.
3. It is desired that initiation of patient transport not take longer than absolutely necessary. In most
cases patient condition will determine scene times.
a. Trauma patients – 10 minutes.
b. Medical patients – 15 minutes.
c. Cardiac Arrest patients – treatment will continue on scene until return of spontaneous
circulation is achieved or until a Medical Control physician advises a crew to initiate transport
or cease resuscitation efforts.
4. In the event that the attending paramedic identifies a life-threatening condition, the patient will be
transported to the closest appropriate hospital.
5. If two or more patients require transport, and have different hospital preferences, all patients will
be transported to the hospital deemed appropriate for the most seriously ill or injured patient. Said
transport decision will be made at the discretion of the attending paramedic or Shift Captain.
6. Crews will make every effort to comply with hospital diversion statuses or Medical Control
diversion orders. If patient condition or patient request create a conflict with a diversion
status/order, crews will defer to the patient and transport to the hospital of choice. The attending
crew member will inform the patient of potential issues that could arise from overriding the
diversion request. Such issues could include: delays in receiving treatment that could lead to loss
of life or limb, and interfacility transfer if admission is needed. The patient will then sign an
“Acknoledgement of Diversion Status”, thus acknowledging that they understand the risks and
still request to go the diverting facility.
7. By utilizing the Center for Disease Control (CDC) recommended “Field Triage Decision Scheme:
The National Trauma Triage Protocol,” providers should be able to determine the appropriate
destination of any trauma patient. Exceptions to patient destination can be dictated by the inability
to adequately maintain a patent airway, ventilate the patient, or control active bleeding. Other
factors that could alter patient destination may include but are not limited to: inability to transport
via helicopter, vehicle problems, severe weather conditions, or mass casualty incidents.
Helicopter Transport
Purpose
To outline helicopter response criteria and crew responsibilities when requesting the response of an air
ambulance helicopter for transport.
Guideline
Utilization of air medical services must be carefully weighed. Extenuating circumstances including
ground transport, severely ill patients in remote areas, or multiple patients may indicate the use of air
transport. The following general guidelines should be considered: (5)
1. Patients requiring critical interventions should be provided those interventions in the most
expeditious manner possible.
2. Patients who are non-critical and unlikely to deteriorate should be transported in a manner that
best addresses the needs of the patient and the system.
3. Patients with critical injuries or illnesses resulting in unstable vital signs require transport by the
fastest available modality, and with a transport team that has the appropriate level of care
capabilities, to a center capable of providing definitive care.
4. Patients with critical injuries or illnesses should be transported by a team that can provide intra-
transport critical care services.
5. Patients who require high-level care during transport, but do not have time-critical illness or
injury, may be candidates for ground critical care transport (i.e., by a specialized ground critical
care transport vehicle with level of care exceeding that of local EMS) if such service is available
and logistically feasible.
6. Any time ground transport to the nearest hospital would be less than the time of transport by air,
that patient should be transported by ground immediately. Do not delay transport by waiting for
the arrival of an air ambulance service.
7. Always begin transport and rendezvous with an air ambulance if applicable. When unsure about
the necessity of air transport, contact Medical Control for a consult.
8. District crews may request an air ambulance helicopter if the patient meets any of the helicopter
response criteria, or ground transport time to the closest appropriate hospital would exceed the
amount of time it would take for air transport. Taking into consideration the amount of time
needed to transfer care at the landing zone.
9. Once an air ambulance helicopter is enroute to the scene, only District EMS personnel attending
the patient or a Shift Captain or Chief Officer may cancel the air ambulance response.
10. District personnel will work with the air ambulance crew and remain in control of patient care,
following these approved protocols, until the patient is safely loaded into the aircraft and the
control of patient care has been turned over to the flight crew.
11. All calls involving air ambulance transport will be reviewed by the Continuous Quality
Improvement committee.
12. Landing zones may not be established in the geographic “Red Zone” without Shift Captain
approval (see map). Flights from these landing zones to Springfield trauma centers are not a time-
saving intervention when compared to emergency ground transport.
13. Whenever possible, utilization of predesignated landing zones is preferred over scene flights.
Landing Zone Restriction Map
Helicopter Response Criteria
1. Patient meets the Class 1 Trauma classification. Special consideration for the extremely old and
young patients.
a. Class 1 Trauma – Life threatening injury or medical condition that requires immediate
emergency medical intervention. Patient is unstable and any delay may be harmful or lethal
to patient. This classification includes, but is not limited to, any of the following: i. Obvious signs of shock: poor capillary refill, cyanosis, and cardiorespiratory
collapse.
ii. Respiratory distress from airway obstruction and/or chest injuries.
iii. Penetrating or blunt head injury associated with coma, altered LOC and/or
lateralizing signs.
iv. Paralysis
v. Penetrating injury to neck, abdomen, or thorax.
vi. Severe burn (greater than 15% BSA). Burns involving the airway, face, hands or
genitalia
vii. Hemodynamically unstable vital signs: BP less than 100 systolic; heart rate greater
than 100,
viii. Respiratory rate less than 10 or greater than 30, altered LOC, pale-cool-skin.
ix. Two or more system injuries and hemodynamic instability.
2. Severely injured or ill patients located in any remote area where ground ambulance transport could
be delayed or extended, and it is believed that the delay will have a negative impact on the
patient’s outcome
3. Prolonged vehicle extrication time (greater than 20 minutes) with injuries that warrant treatment at
a trauma center and scene flight is possible.
4. Mass Casualty Incidents and/or whenever ground resources are exhausted or exceeded.
5. Any other time a crew feels that the patient’s illness or injury warrants air ambulance transport,
and there is a clear time advantage to air transport, the Paramedic is responsible for evaluating the
patient and contacting Medical Control for consult prior to requesting a helicopter response.
Psychiatric Patients
Purpose
To establish guidelines regarding the routine and emergent transport of psychiatric patients.
Guideline
1. It is the policy of Taney County Ambulance District to provide the same level of care for the
emotionally disturbed patient as it is for all others while maintaining the safety of the crew
members involved with their treatment and transport.
2. The appropriate police agency will be notified and requested to respond to any scene involving a
possible emotionally disturbed patient or any patient who may have the potential to cause harm to
themselves or others.
3. Crews will not enter any suspicious dwelling or scene of a call until police ensure that the scene is
safe.
4. Any patient who possesses the characteristics of an emotionally disturbed patient and who is
attempting to do harm to themselves or others, will be transported to the closest appropriate
facility or where otherwise directed by Medical Control. When necessary, a law enforcement
officer may be requested to accompany the patient in order to control violent behavior.
5. An emotionally disturbed patient may only be transported if one of the following conditions exist:
a. The patient wishes to be transported; or
b. The patient is in police custody; or
c. A court order exists that allows the transfer; or
d. The EMS provider determines the patient to be incompetent to refuse medical care or
transport; or
e. Medical Control authorizes the transport of such patient based on their medical
presentation.
f. A State recognized Mental Health Coordinator orders the transport and all appropriate
paperwork has been prepared to accompany the patient.
6. Before transporting any psychiatric patient, either from the scene or the Emergency Department,
the crew will ensure that the patient has been searched and is not carrying any concealed weapons.
7. If the patient is being transported from one hospital to another:
a. The patient and/or guardian must agree to the transport;
b. The patient must not pose a danger to the transferring crew;
c. The receiving facility must be aware of the transfer and agree to accept the patient;
d. The hospital must assist with the movement of the restrained patient.
e. If the patient does not consent to transport, and/or poses a threat to self or others:
i. Must have court-ordered 96 hour hold, or physician-signed affidavit warranting
necessity for treatment.
ii. Must have orders from the attending physician to chemically and/or physically
restrain the patient during transport.
iii. The receiving facility must be contacted prior to transport to confirm acceptance of
the patient being transported against their will.
8. If while transporting a patient who initially consented to transport, he/she decides to refuse further
treatment or transport, the crew should:
a. Attempt to council the patient and convince them to continue transport and receive
treatment
b. Contact Medical Control and request orders for chemical and/or physical restraints
c. If the safety of the crew or patient is at risk, the crew should pull over at a safe location.
d. Do not leave patient alone; if they become violent, refuse to stay in vehicle, or escape,
contact law enforcement immediately. Keep the patient in sight and only attempt to restrain
them when enough help is present.
e. Notify the receiving facility of the change in patient status and transport to the most
appropriate destination. Some facilities will accept restrained patients and others may
request a diversion to the nearest emergency department.
Patients in Police Custody
Purpose
To outline District guideline regarding the transportation of patients that are incarcerated or in police
custody and patients that have been taken into protective custody.
Guideline
1. Patient must have injury or illness that necessitates treatment in an emergency department or be in
danger of causing harm to themselves or others due to a mental impairment.
2. If a patient who is placed in custody at the scene, a law enforcement officer should accompany the
patient in the ambulance for transport, or follow behind the ambulance, depending on the situation.
3. Patients that are picked up from jails or other institutions must be properly restrained and
accompanied by a law enforcement officer for transport.
4. Patients in police custody may be transported to any hospital that the Police Department requests,
so long as the transport does not violate the District transport policies.
Organ Donor Patients
Purpose
To establish guidelines regarding organ donor patients.
Guideline
1. Crews should be aware of the possibility of patients being organ donors. If you are told a patient is
an organ donor and the patient is critical, the ER should be told upon arrival.
2. If resuscitation efforts are to be terminated, and the patient is found to be an organ donor, the ER
should be consulted.
Deceased Patients
Purpose
To establish guidelines concerning the transportation of deceased patients.
Guideline
1. District employees will deal with the deceased patient in a respectful, professional manner at all
times, and assist law enforcement agencies in proper notification and transportation of these
patients when necessary.
2. It is the policy of the District not to transport deceased patients unless otherwise directed by a
Shift Captain.
3. Determination of death will be made on the scene by the attending paramedics, using care to
protect possible crime scenes.
4. Crews will remain with the body until the arrival of the deputy coroner or local law enforcement
officer.
5. Custody of deceased individuals will be transferred to the law enforcement agency having primary
jurisdiction, upon their arrival. Crews should be prepared to give a brief statement to the deputy
coroner about their findings.
6. Should a body be in public view (or other unusual circumstance) and primary transport service is
unavailable or will be delayed, the Shift Captain may authorize transport to the morgue, as
directed by law enforcement.
7. If a crew responds to a traffic way fatality, even if the body is not transported, they should
complete a Traffic way Fatality Report and submit with the ambulance reporting form.
8. Crews should act as on-scene family advocates, by helping families accept non-transport of the
deceased individual. Crews may assist families in calling a funeral home, Chaplin, or family
minister; and by providing support or answering questions of concern. Crews should not make
medical diagnosis or judgments concerning the cause of arrest. If special concerns arise, crews
should contact a supervisor or medical control for consult or assistance.
Non-Transport
Purpose
To establish guidelines for managing incidents in which the patient, or the patient’s representative refuse
treatment and/or transport by EMS.
Guideline
1. An adult patient, who has passed all three capacity assessments (as described below) and has a
clear understanding of the consequences of his or her decisions, has the right to refuse treatment or
transport by EMS. All patients must be offered treatment and/or transport and advised of the
benefits of receiving treatment and transport. A patient that refuses treatment and/or transport will
be advised of the specific risks of refusing. The offer of treatment and transport and the
description of the risks of refusal will be documented in the PCR.
2. Conversely, a patient who is a minor, or has failed any capacity assessment, or incapacitated (as
defined below) does not have the right to refuse treatment and/or transport for themselves; and
EMS may have implied consent to treat or transport. If there is any question regarding this,
contact Medical Control for direction.
Definitions
1. Patient: Any person who is ill or injured or in need of treatment by medical personnel. This
includes any person that has activated the EMS system or for whom the EMS system has been
activated, including emergency and non-emergency calls for service, or any person that presents
himself to EMS personnel with a medically related complaint such that it could be reasonably
inferred that the person is seeking or in need of medical attention.
2. Not a Patient: A person who is not ill or injured or in need of treatment by medical personnel.
This includes individuals who may have been involved in a situation that either did result in, or
could have resulted in the creation of a patient requiring medical treatment as defined above.
3. Minor: A person who is less than 18 years of age.
4. Emancipated Minor: A minor who is:
a. Married;
b. A parent or legal custodian of a child;
c. Enlisted or commissioned in the U.S. Armed Forces;
d. Self-supporting and the custodial parent has relinquished the child from parental control by
expressed or implied consent; or
e. Declared an adult by a court of competent jurisdiction
5. Capacity Assessments: When a patient wishes to refuse treatment and/or transport, it is the
responsibility of the provider to assess the legal, medical, and decision-making capacity of the
patient before allowing them to refuse.
a. Legal capacity: Assess if the patient has legal authority to make medical decisions
i. 18 years of age or older
ii. Emancipated Minor
iii. Or, Parent/Guardian/Adult (in loco parentis) is present
b. Medical capacity: Assess that the patient does not have a medical condition that would
impair his/her ability to receive and process information, such as;
i. Acute head trauma
ii. New onset altered mental status
c. Decision-making capacity: Assess the patient’s ability to receive, process, and return
information. This is in an effort to ensure that when the risks of refusal are explained to
the patient, you may reasonably infer that the patient is able to understand those risks and
make an informed decision based on those risks.
i. Patient does not have any communication barriers
ii. Patient does not present a significant threat to themselves or others
iii. Patient is oriented to person, place, time and event
iv. Patient is able to meet basic requirements for food, shelter, clothing, and safety
v. Have the patient answer the following questions:
1. Recite three objects to the patient (apple, table, and penny). Ask the patient
to wait until you say all three words then have them repeat the three words
back to you. Tell the patient you will ask them to repeat the words again
later.
2. What year is this?
3. What month is this?
4. What is the day of the week?
5. What were the three objects I asked you to remember?
a. Apple
b. Table
c. Penny
6. Competent Person: For the purpose of this protocol, a competent person is one that has passed
all three capacity assessments.
7. Incapacitated Person: A person who is unable by reason of any physical or mental condition to
receive and evaluate information or to communicate decisions to such an extent that he or she
lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such
that serious physical injury, illness, or disease is likely to occur.
8. Suicidal Patient: There is reason to believe that the patient is at risk of self-inflicted physical
harm as evidenced by, but not limited to, threats or attempts to commit suicide or to inflict
physical harm on himself or herself.
9. Implied Consent: Consent to medical treatment and or transport is implied where an emergency
exists, if there has been no protest or refusal of consent by a person authorized and empowered to
consent or, if so, there has been a substantial change in the condition of the person affected that is
material and morbid and there is no one immediately available who is authorized, empowered,
willing, and capacitated to consent.
10. Emergency: a. For purposes of implied consent, “emergency” is defined as a situation where, in
competent medical judgment, the proposed medical treatment is immediately or
imminently necessary and any delay occasioned by an attempt to obtain consent would
reasonably jeopardize the life, health, or limb of the person affected, or would reasonably
result in disfigurement or impairment of faculties.
b. For purpose of the emergency services statues (RS MO 190.100 (10)) “emergency” is the
sudden and, at the time, unexpected onset of a health condition that manifests itself by
symptoms of sufficient severity that would lead a prudent layperson, possessing an average
knowledge of health and medicine, to believe the absence of immediate medical care could
result in:
i. Placing a person’s health, or with respect to a pregnant woman, the health of the
woman or her unborn child, in significant jeopardy;
ii. Serious impairment to bodily function;
iii. Serious dysfunction of any bodily organ or part; or
iv. Inadequately controlled pain
11. Cancelled Reasons:
a. No Treatment, No Transport (Patient Refused Care): A patient, as defined above,
refused treatment and transport to the hospital. In this incident, a full assessment and vital
signs should be documented and refusal form completed and signed.
b. No Patients Found: A call for service was made by a third party and upon arrival at the
incident scene there are no identifiable patients. Should not be used in cases of 1st or 2nd
party callers.
c. Treatment, No Transport: A patient, as defined above, has consented to receive
treatment but is refusing to be transported by ambulance to the hospital. Treatment, in this
situation, is defined as administering medications to the patient. In this type of incident, a
full assessment, vital signs, and treatments rendered should be documented with a
completed and signed refusal form.
d. Transfer Patient Care: A patient, as defined above, has consented to treatment and
transport to the hospital, but your unit is unable to transport that patient and a second unit
is required. Treatment for this patient is initiated, and then turned over to a second provider
of equal or higher level of training to continue treatment and provide transport of the
patient. A full assessment, vital signs and treatments rendered should be documented, as
well as whom care was transferred to. If possible, obtain signature of the provider
receiving the patient.
e. Assist:
i. Your unit is not the first ALS provider on scene, and you arrive to provide
assistance for that incident. This is most often used by Fly Car responders, but may
also be used in multiple unit responses such as Cardiac Arrests. Document the
assistance provided in the narrative of the PCR.
ii. A request for service is made that is not related to a medical or trauma situation.
The requestor does not meet the definition of a patient, but does require assistance.
Document the assistance provided in the narrative of the PCR.
f. Dead on Scene: This cancellation reason should be utilized by all transport units and
initial patient contact providers on all cardiac arrest responses that are not transported to a
receiving facility.
g. Standby: A unit is dedicated to an event, such as sporting events, special events, and
structure fires; and provides medical coverage. This disposition is not to be used in
conjunction with a patient, only the event itself.
Procedure
1. Competent Adult:
a. The adult patient, determined to have the capacity to make medical decisions , may refuse
treatment and/or transport.
b. The patient should be encouraged to consent to treatment and transport by making them
aware of their condition, and the possible risks of refusal.
c. If the patient, after being made aware of the risks of refusal and their understanding of
those risks, still wishes to refuse treatment and transport, then the patient should sign the
Refusal form.
2. Incompetent/Incapacitated Adult:
a. The adult patient that has been determined to be incompetent, or is incapacitated, may not
refuse treatment or transport.
b. If the patient is refusing treatment and transport, contact Medical Control for assistance.
3. Non-Emancipated Minor:
a. A non-emancipated minor (as defined above) must be treated and transported to the most
appropriate facility.
b. If a competent parent, guardian, or adult (in loco parentis) is on scene and is able and
willing to take responsibility for the patient, they may sign a Refusal form.
c. Law enforcement may take the minor patients into protective custody pending parental
notification and response to the scene. In these instances, the law enforcement officer
should sign the refusal.
4. Suicidal Patient:
a. If the patient meets the definition for “suicidal patient,” then the patient cannot refuse
medical treatment and transport.
b. Patients do not have to verbalize suicidal intent to be a risk of harm to themselves. If a
patient’s actions, behavior, or verbal comments are consistent with and could reasonably
be construed to be an act of suicidal intention, or risk of self-harm, the patient cannot
refuse medical treatment or transport.
c. If the patient attempts to refuse medical treatment and transport:
d. The law enforcement agency having jurisdiction should be contacted for assistance
(protective custody).
e. If the patient is not placed in protective custody, Medical Control should be contacted to
determine the patient’s disposition.
f. When Medical Control is contacted, the physician will be apprised of the patient’s
condition, mental status, and all reasons that the patient is determined to be at risk of
physical harm to themselves. From this information, the Medical Control physician will
determine if treatment and transport will be initiated.
g. If Medical Control determines that the patient is at risk of physical harm and should be
transported, but the patient continues to refuse, reasonable restraint (to assure patient and
healthcare personnel safety) may be utilized to transport the patient to the hospital.
h. The law enforcement agency having jurisdiction should be advised that a Medical Control
physician has determined that the patient is at risk of physical harm to themselves and has
ordered the patient to be transported for evaluation.
i. All actions taken to restrain the patient as well as the Medical Control physician’s orders to
restrain the patient must be documented in the PCR.
5. Intoxicated Patient:
a. Intoxicated patients may have serious underlying medical conditions. These patients
should be properly assessed. This assessment shall include a blood glucose reading.
b. If the patient is competent (as defined above) and is turned over to law enforcement, the
patient must sign a Refusal form along with the highest ranking law enforcement officer as
a witness.
c. If the patient is competent but is in such a condition that a reasonable person would
consider them not capable of being able to adequately care for themselves, the patient
should be transported to the closest appropriate facility. If the patient refuses to be
transported, then contact Medical Control for guidance on medical treatment and transport.
Documentation Requirements
It is important to be thorough in documenting any non-transport of a patient. The patient care report
should include appropriate signature type with patient and witness signatures, notation of any patient
complaints, complete assessment and vital signs, explanation of the associated risks that the crew
explained to the patient and Medical Control consults.
1. If any person at an incident is determined to be a “Patient”, as defined above and is not transported
to the hospital, a full assessment of that patient will be completed and documented in a PCR with a
the appropriate signature fields completed.
2. Patients who refuse medical care and transport despite the risk of illness or injury shall sign the
Refusal” signature form in the ePCR.
a. If the patient refuses to sign, have a witness (preferably someone related to the patient)
sign the PRC.
b. The crew will advise Dispatch to cancel the call as “Patient Refused Care”.
3. Patients consenting to treatment and refusing transport shall be treated according to Taney County
Medical Protocols with Medical Control consult as indicated. Patients must sign the “Accept
Treatment, Refuse Transport” signature statement indicating they understand the risk of not being
transported to a hospital and have consented to the treatment provided. The crew will advise
Dispatch to cancel the call as “Treat and Release”.
4. If all persons involved in an incident are determined to be “Not a Patient”, as defined above, then
Dispatch should be notified to cancel the trip as “No Patients”.
5. In incidents where a unit is the second arriving unit, and only provide assistance to the first
arriving unit, the unit should advise Dispatch to cancel the call as “Assist”.
Safe Transport of Patient, Crew, and Passengers
Purpose
TCAD is committed to ensure the safe transportation of all occupants of our vehicles, so providers should
rely on their knowledge, training, and this guideline when employing safety practices.
Guideline
1. When a family member requests to accompany a patient, the crew will courteously inform the
individual to be seated in the passenger seat of the cab of the ambulance. The crew may make the
decision to deny a family members request to accompany the patient if:
a. The patient’s family cannot be controlled by talking to them.
b. The patient’s family is believed to be under the influence of a controlled substance.
c. The patient’s family is mentally incapable of handling riding in the ambulance.
d. For any other reason the crew believes it would hamper their care of or the safe
transportation of the patient.
2. The family member may request to ride in back with the patient. It is the sole decision of the
attendant as to whether this would be beneficial to patient care and to grant the request.
3. All individuals riding in TCAD vehicles, either as a patient, passenger, or crew member shall wear
properly applied seatbelt restraints.
4. Seats facing an airbag deployment system are reserved for individuals over 12 years of age.
5. Children 12 and under should be appropriately restrained with seatbelts in a patient compartment
seat.
6. Children up to 99 lbs. should be restrained in a child safety seat or secured to the cot with ACR4
according to manufacture recommendations or instructions. Never put a rear-facing child safety
seat in the front passenger seat of a vehicle.
7. All pieces of equipment used in the delivery of patient care should be secured to prevent injury in
case of a vehicle collision.
8. TCAD shall provide crews with adequate securing devices to maintain compliance with this
guideline
Procedure
1. Seatbelts shall be worn anytime the vehicle is in motion; district personnel are responsible for
ensuring all passengers are securely fastened with a seatbelt before transport.
2. Ambulance Cot
a. The ambulance cot is used as the primary securing platform for patients.
b. When securing a patient to the cot, all seat-belts must be applied before movement. This
includes utilizing the shoulder straps 4-point harness.
c. In the event a patient is secured to a long spine board, the seatbelt should be threaded
through one end of the board and tightened down to prevent the patient from being ejected
forward off the cot in a frontal crash.
d. When properly secured in the mounting system, the ambulance cot should not move freely
in any direction. Providers suspecting a malfunctioning cot mounting system shall notify a
Shift Captain immediately and have it inspected/repaired.
3. Child Safety Seat
a. The child safety seat can be secured to the ambulance cot or a forward/rearward facing
chair.
b. If a vehicle has airbags, the airbag may deploy into the path of a child safety seat and cause
serious harm or death to the child. Therefore, the child safety seat is not to be used in the
front seat of an ambulance.
c. When securing the child safety seat to a vehicle seat, follow the printed manufacture
recommendations for installation.
d. Securing to the ambulance cot:
e. The top of the cot should be placed in an upright position to properly secure child safety
seat.
f. The child safety seat should be secured with the shoulder/chest cot straps tightly threaded
through the seat-back.
g. The cot waist straps should go through the bottom slots of the child safety seat and secured
down tightly.
h. When the straps are secured properly, there should be no independent movement of the
child safety seat.
i. Place the child in the seat and snap in both harness locks. Secure the chest harness clip at
the level of the child’s armpit and tighten the straps until only one finger can be slid under
the chest strap.
j. Child safety seats involved in a vehicle crash should not be used to safely restrain a child
unless it is absolutely necessary in emergency situations. In the event another seat is not
available, ensure the seat integrity has not been compromised and replace it as soon as
possible.
4. Ambulance Child Restraint (ACR4)
a. For use in patients from 4 to 99 pounds who need to be secured to the ambulance cot in a
supine or semi-fowlers position for medical treatment.
b. Secure the four blue straps to the cot. Pass the buckle through the loop to secure to the
frame of the cot.
c. To attach the ACR harness, lay ACR on cot and secure using the four buckles, ensuring
straps are not taut and harness is not twisted.
d. Place patient on top of flat, open harness.
e. Fit shoulder straps and connect chest strap.
f. Feed straps through ‘D’ rings. The white marker on the strap has to pass through the ‘D’
ring and be visible. After straps are fed through ‘D’ rings, press hook and loop firmly
together, ensuring correct position of the white marker indicating minimum hook and loop
contact area.
g. Fit and engage waist straps. Press firmly together. Pull waistband over and close hook and
loop. Make sure hook and loop are correctly aligned and slide three fingers under harness
to ensure it is not attached too tightly.
h. Peel back outer waistband leaving inner still attached.
i. Position crotch pad centrally, close and engage upper strap, pressing firmly together.
j. Now tighten the four harness straps ensuring patient remains central on the cot.
k. If needed, secure the patient’s legs with cot straps.
5. Medical Equipment
a. All equipment should be stowed away in its respective compartment when not in use.
b. Providers are responsible for securely fastening all medical equipment with straps or
designed holders during transport to ensure it does not become a projectile during a
collision.
c. Any equipment stowed on an ambulance cot, in anticipation of patient care, shall be
securely fastened to the cot with belts or designed holders. The goal is to prevent any
equipment from falling off the cot while in transit.
6. Other Devices – please remember that any device or object that is not secured in the moving
vehicle may become a deadly projectile if not adequately secured.
Transferring Patient Care
Purpose
To establish guidelines regarding the transfer of patient care to another provider or agency.
Guideline
1. When transferring care of a patient to another agency, providers will continue to provide and
direct patient care until the patient has been placed in the transporting agency’s vehicle or aircraft.
2. Taney County Emergency Treatment Protocols will be utilized until the transfer of care to another
service or agency is complete. If another agency’s staff (i.e. flight crew, transport crew) wishes to
perform a procedure, which is not covered by Taney County Emergency Treatment Protocols, they
must have the approval of the attending paramedic.
3. Providers will only transfer care to someone with an equal or higher level of licensure (i.e. EMT-P
to EMT-P, EMT-P to RN, etc.). If the transporting agency cannot provide someone of equal or
higher level of licensure then the attending provider shall accompany the patient.
4. This protocol shall not apply in cases of a mass casualty incident or when mutual aid responses
results in the initiation of patient care.
Patient Care Report
Purpose
To establish guidelines regarding patient care reporting.
Guideline
1. A patient care report will be completed for every patient.
2. The provider documenting patient care will utilize the forms or reporting tool provided to them by
their respective department or service.
3. A copy of the patient care report will be made available to anyone with need of the report for the
purpose of patient care. This could include a report from a first responder to an EMT or
Paramedic, or may be from a transporting unit to the receiving facility.
4. If the provider is unable to provide a copy of the patient care report at the time of transfer of care,
the provider will provide at a minimum a verbal report or a short written report.
a. When delivering patient to the hospital, the provider will complete and sign an Ambulance
Communication Record.
b. This record will include at a minimum:
i. Patient name
ii. Gender
iii. Age (Date of Birth)
iv. Chief Complaint
v. Assessment findings
vi. Vital Signs
vii. Treatments provided
viii. Crew identification
Medical Control Plan
Purpose
To establish guidelines regarding a Medical Control contact.
Guideline
1. A “call for Medical Control” is defined as direct conversation via phone or radio between an
Emergency Department Physician and the field provider responsible for patient care.
2. Communication between the field provider and the Medical Control physician must be clear,
concise and direct. Contact should include, at a minimum:
a. Name of the provider
b. Patient age
c. Patient sex
d. Chief Complaint
e. Brief HPI
f. Vital signs
g. Exam findings
h. Differential diagnosis
i. Treatments already provided
j. Any changes
k. Requested treatment(s)
3. Upon receiving orders for treatment(s), the field provider will confirm the orders given by
repeating them back to the physician.
4. Orders requested, given and/or refused should be documented in the ePCR.
Pre-Hospital Radio Report
Purpose
To establish guidelines regarding the Pre-Hospital radio report.
Guideline
1. The pre-hospital radio report is meant to be a triage type report. Hospital personnel need to know a
chief complaint and present status in order to put the patient in the right room and have the correct
personnel available.
2. To make sure your initial report is received by the right person, use one of the following prior to
giving your report:
a. “Report only” – for when no orders are needed. An E.R. tech. may take this report with an
R.N. listening.
b. “Medical Control” –when you need to consult with the physician to obtain orders for
medication and/or treatment. When asking for Medical Control, be prepared to give
necessary information, i.e., allergies, vital signs, patient medications, and a brief report.
(See Medical Control Plan)
3. The basic information in this 30-second radio report should include:
a. Age and sex of patient.
b. Chief complaint and mechanism of injury if applicable.
c. Vital signs.
d. Brief statement regarding your intervention, e.g., I.V., NG, ET, O2, etc.
4. A further detailed report will be given to the receiving person at the hospital.
Equipment Brought To Patient
Purpose
The purpose is to guide EMS personnel at the scene for what equipment needs to be brought to the
patient’s side.
Guideline
1. Any call of an emergency nature should be considered to have potential for serious medical
conditions until proven otherwise.
2. The optimal amount and type of equipment brought into the scene is dependent on multiple
factors, including but not limited to, the type of call, the location of the call, ingress and egress
capabilities, and the operating environment.
3. It is incumbent upon the EMS crew to be aware of all problems that could reasonably be foreseen
at the scene.
4. Ultimately the EMS crew must decide which equipment to take to the patient on each call and
must take responsibility for the consequences if the crew fails to recognize problems that could
have reasonably been foreseen.
5. EMS crews should not be complacent with bringing in less equipment on lower priority calls; even
the lowest priority call can have the potential need for emergency medical attention.
6. At a minimum, an EMS crew should bring in the appropriate amount of equipment to provide
medical treatment for any condition which could reasonably be foreseen.
Provider In Charge of Patient Care
Purpose
To define the medical provider in charge of patient care when multiple agencies respond to the scene. All
providers are expected to provide medical care consistent with the Taney County EMS System Protocols
and coordinate efforts to ensure the care provided consistently meets the needs of the patient.
Procedure
Patient Care Response Initiated
Is this a Single or Multiple Patient
Incident?
First Arriving Medical Unit on Scene:· Highest level trained provider
assumes patient care.· They are in charge of patient care
until relieved by a higher trained provider or ambulance/EMS fly car personnel.
First Arriving Medical Unit on Scene:· Initiates/contacts Incident
Command· Begins triaging process using
START Triage Method· Establishes and communicates
EMS staging and resource needs
Ambulance/EMS Fly Car Personnel:· Assume patient care on arrival and
are responsible for patient management at scene.
· Transport EMT-P in charge of pt. care unless replaced by higher ranking TCAD EMT-P.
Ambulance/EMS Fly Car Personnel:· Contact IC and assume Medical
Branch.· Receive pass off from medical
units on scene· Manage incident according to MCI
Plan.
Extrication/Technical Rescue Required?
Ambulance/EMS Fly Car Personnel remain in charge of patient, care provided, and coordinate with First Responders to mitigate scene.
Providers should coordinate efforts to provide the safest and most effective extrication/rescue. All providers shall wear appropriate PPE based on type of rescue:· Fire Rescue Teams direct extrication/rescue
process.· Ambulance/EMS Fly Car Personnel remain in
charge of patient care.· Care should be taken to protect the patient
at all times.
Patient Transported/Scene Mitigated
Single Multiple
YesNo
Blood Draws for Law Enforcement
Purpose
Law Enforcement may request TCAD Paramedics to obtain blood samples from patients involved in a
motor vehicle collision or while incarcerated within law enforcement facility for the purpose of
determining if the person is under the influence of drugs and/or alcohol. On occasion, requests for blood
draws may be made outside of an emergency medical situation to assist law enforcement in obtaining
blood samples from a person who is under arrest. It is the intent of TCAD to assist law enforcement
agencies in obtaining blood samples only when a patient’s life is determined not to be in jeopardy of
immediate harm or death.
Guideline
TCAD Paramedics are permitted under medical direction to complete the request for blood draws
provided all of the following conditions are met. At no time shall a blood sample be forced upon a non-
consenting patient or person for the purposes of determining drug and/or alcohol levels for use by law
enforcement personnel.
1. TCAD is able to accommodate the request for blood draw without jeopardizing our response
system.
2. Law Enforcement is present and has made an official verbal or written request for a blood draw.
3. The person whom a blood sample will be taken is currently in stable condition and not at risk for
major medical problem and/or traumatic injury.
4. The person whom the blood sample will be taken is cooperative, non-combative, and is not being
forcefully restrained to prevent injury to self or others.
5. The person whom the blood sample will be taken is capable of making an informed decision and
has given verbal consent for the blood draw.
6. The person whom the blood sample will be taken has signed TCAD’s official Blood Draw Consent
Form.
Procedure
TCAD Paramedics shall follow the appropriate Medical Procedure listed in the Taney County Medical
Protocols for drawing blood samples with the following procedural considerations.
1. TCAD Paramedics will inform the person, whom the blood sample will be taken, of the procedure
and obtain informed verbal consent to draw blood.
2. TCAD Paramedics will obtain a signature on TCAD’s official Blood Draw Consent Form, from
the person whom the blood sample will be taken, before proceeding with the procedure.
3. Law Enforcement personnel will provide TCAD Paramedics with the vacutainer to be used during
the blood sample collection process.
4. TCAD Paramedics shall not prep the blood draw site with an alcohol swab when performing blood
draws for Law Enforcement.
5. Once obtained, the blood sample shall become the property of the Law Enforcement personnel
who requested the blood draw.
6. TCAD Paramedics shall document the blood draw on the Patient Care Report Form and shall be
detailed enough to recall the procedure should they be asked to testify at a deposition or court
proceeding.
General Orders The Office of the Medical Director and TCAD Administration has created temporary alterations to
clinical standards in the form of General Orders. The purpose is to promote the delivery of optimal
clinical performance in times of severe weather or operational hazards that may interfere with normal day
to day delivery of ambulance services.
General Orders are temporary directives meant to guide ambulance operations in an effort to do the most
good for the most people. The decision to activate a General Order shall be drafted through a
collaborative agreement between TCAD Administration and the EMS System Medical Director. This
document shall serve as the guideline for determination and activation of General Orders.
Activation The following list of rules for activation shall be used to determine when it is acceptable to initiate a
General Order.
1. Occurrence of a severe weather event
2. A “severe weather event” may be declared when conditions and/or meteorological predictions
determine severe weather is occurring or imminent.
3. A “severe weather event” would include:
a. Severe thunderstorms where the risk of tornados, hail, high winds, lightening, and flooding
rains are occurring or expected.
b. Winter precipitation that is expected to hamper normal travel conditions or severely impact
how TCAD normally operates (for example: snow, ice, sleet, freezing rain, etc.)General
Orders Authorization
4. Collaborative agreement between TCAD Administration and the Medical Director.
5. The Duty Chief shall follow the activation rules as listed and notify the Medical Director when
implemented.
6. General Orders are considered “standing orders” pre-authorized by the Medical Director and may
be revoked, updated, or altered with his approval only.
7. Activation/Termination of General Orders
a. The Duty Chief, or those designated through the chain of command have authority to
activate or terminate general orders.
b. Upon determination, the Duty Chief will notify the Communications Center of General
Order activation and which orders are authorized.
c. The Communications Center will notify all on duty personnel of an activation including
new crews at shift change.
d. Notification process shall be in the following manor:
i. Alert message over the radio; sound alert tone and announce, “All personnel,
General Order [#] has been activated.”
ii. Send alert text message to all management and supervisory personnel stating,
“General Order [#] has been activated.”
iii. Send alert message via Navigator to all trucks, “General Order [#] has been
activated.”
e. Once it is determined prudent to return to normal operations, the Duty Chief will authorize
the Communications Center to terminate the General Order.
f. Deactivation of a General Order shall follow the same notification process listed above and
stated, “General Order [#] has been terminated.”
Types of Orders General Order 1 – Responses to scenes where patient transportation does not occur or the act of
obtaining patient refusals would delay EMS availability, TCAD will not need to document a
detailed patient care report. EMS system personnel are allowed to return to service and only
document a response was made. Emergency Medical Responders may cancel TCAD response to
minor motor vehicle collisions when the patient refuses transportation and any injuries are deemed
minor.
General Order 2 – When roadways are covered with wintery precipitation or there is an
imminent threat of a severe weather event, TCAD may elect to go on emergency transfer status.
Managers will stay in contact with hospital personnel, monitor road conditions, and determine
when it is safe to take a transfer.
General Order 3 – TCAD resources are overwhelmed by calls for service or transport to a distant
hospital is determined too dangerous. TCAD Paramedics have the authority to transport the patient
to the closest hospital only and ambulances are expected to have short turnaround times and rapid
availability.
General Order 4 – If in the Paramedic’s clinical judgment, the patient’s condition has been
definitively addressed on scene (e.g. asthmatic with resolution of symptoms after nebulizer
treatment) or does not warrant transport to an emergency department (e.g. chronic pain without
acute change), the Paramedic will contact the on duty shift Captain for consultation to not
transport the patient. If the Shift Captain has concerns regarding non-transport, secondary
consultation will be made with Medical Control.
General Order 5 – EMS system responses may be limited to Medical Priority Dispatch System
identifiable ‘Charlie’, ‘Delta’, and ‘Echo’ level calls only. Requests for service that are triaged for
no response will be listed and a follow up phone call will be made within two (2) hours for a
patient welfare check. Subsequent phone calls for a patient welfare check will continue in intervals
of at least every two (2) hours until EMS response can be made or the patient releases the EMS
system from a response requirement. Requests for service that are triaged for no response will be
advised to immediately redial 911 should clinical symptoms worsen.
General Considerations
The treatment protocols are designed to identify causes, initiate definitive treatment, notify the receiving
facility and provide appropriate transport. Contact Medical Control as early as possible and inform the
receiving hospital about the patient’s status and condition. For any patient presentation not specifically
covered by protocol, providers should consult with Medical Control for treatment. If for any reason
certain modalities of patient care are not proceeding as they should, crews are expected to continue basic
life support and proceed to the nearest hospital. Providers are expected to thoroughly document all care
provided in a designated patient care report form.
Medical Values The following is a list of the recognized values for use in meeting the customer’s medical needs within the
Taney County EMS System. This list of values will be used to evaluate clinical care that falls outside of
the established protocols.
1. Safety: In order to protect the crew, the patient, or the public from a danger on the scene,
established treatment modalities may need to be modified.
2. Follow the ABC’s: Generally, the care of the patient should be in accordance with the following
priorities:
a. Airway maintenance: Beginning with the simple, non-invasive techniques, and working to
the more invasive.
b. Assurance of adequate ventilation and oxygenation: Any patient in significant distress
should receive as high a concentration of Oxygen as is practical to deliver. If any doubt
exists as to the adequacy of ventilation, then the patient should receive positive pressure
ventilation with the maximum available concentration of Oxygen.
c. Assurance of adequate circulation: Through continuous chest compressions
(CCC)/Cardiocerebral resuscitation (CCR) and/or the appropriate treatment of bleeding
and shock.
3. Use Medical Control: When in doubt, call Medical Control.
4. Primum Non Nocere (First Do No Harm):
a. A medication or invasive treatment should only be used if both the treatment is indicated,
and there exists no contraindication to that treatment. On-line medical control should be
used prior to any invasive treatment unless that treatment is authorized as a standing order.
b. Potentially unstable patients may be stressed by exertion, as a general rule, exertion should
be minimized. (Potentially unstable included, but is not limited to, patients with chest pain,
dyspnea, or altered mental status.)
5. Default to Transport: The preference is to transport the patient to an emergency department or a
hospital with inpatient capabilities. If any doubt exists as to the legal or medical competence of the
patient to refuse care, online medical control should be contacted.
6. Customer/Patient Service: The human needs of the patient must be met including physical
(medical and non-medical), and psychological (including the needs of reassurance and comfort).
In all cases, be PROFESSIONAL, POLITE, and ATTENTIVE to those needs.
7. Clear Documentation: All patient encounters must be documented clearly and accurately.
8. Render Timely Care: The clinical needs of the patient must be met in a timely fashion. This
generally includes initiating treatment prior to moving the patient to the ambulance. Exceptions
include major trauma, crew/patient safety, and other circumstances as determined by the senior
paramedic.
Scene Size-up 1. On the appropriate radio frequency, give an initial “windshield” size-up of the scene and establish
or contact Incident Command when indicated.
2. Apply universal precautions/body substance isolation as appropriate.
3. Assure that the scene is safe for all responders and the patient. It may be appropriate to withdraw
and “stage in the area” or rapidly extricate the patient from a dangerous situation.
4. Identify the number of patients.
5. If needed, call for additional resources including: Law Enforcement, Fire/Rescue, additional EMS
units and/or EMS management.
6. Begin triage if appropriate.
7. Identify yourself as an EMS provider and obtain patient consent for treatment.
Patient Triaging It is important to frequently practice triage skills. This assists the EMS provider in learning and
maintaining knowledge of the triage system, so that these skills are second nature when required. EMS
providers are expected to effectively triage and assign a color coded classification to each patient on a
daily basis. Providers should communicate this color code during their radio reports on every transport.
By communicating these color classifications to receiving hospitals; emergency department teams can
prepare for the arrival of patients and deploy resources based on acuity levels.
1. Providers will assign and communicate a color code classification on all patients transported.
2. When triaging at a mass casualty incident (MCI), follow the Taney County Mass Casualty Plan.
3. See Appendix for Triaging Algorithms
a. Medical Patients – Modified ESI Triage Algorithm
b. Trauma Patients – START Method
c. Pediatric Trauma Patients – Jump START
Primary Survey
Adult Primary Survey The primary survey is the initial overview of the patient, their condition, and chief complaint. The
primary survey looks to identify immediate life-threats and the patient’s overall stability. Abnormalities
generally found in the primary survey are often addressed with the appropriate intervention at the time of
discovery. It is often appropriate to move directly from the primary survey to the indicated protocol.
1. Airway - Assess the patient’s airway for patency, protective reflexes and possible need for
intervention.
a. If the airway is obstructed, open airway by performing a head tilt-chin lift maneuver or
modified jaw thrust for suspected trauma.
b. If patient is unable to maintain an open airway, consider placement of an appropriate airway
adjunct.
c. If foreign body airway obstruction is suspected;
i. Perform obstructed airway maneuvers as directed by current American Heart Association
standards.
ii. If the airway obstruction is not relieved, perform direct laryngoscopy to visualize
obstruction and remove obstruction if visible.
iii. If all other attempts to clear the airway fail, and the airway remains completely
obstructed, perform an emergency cricothyrotomy.
iv. Once airway has been opened, protect the airway by placement of an appropriate airway
adjunct and administer oxygen.
2. Breathing - Note the patient’s ability to speak, rate and quality of respirations; note abnormal
noises/stridor, retractions, accessory muscle use, nasal flaring, or cyanosis. If signs of inadequate
ventilations are noted, proceed with the following interventions.
a. Assure airway is patent
b. Apply Oxygen
i. 100% high-flow oxygen for patients with suspected decreased carrying capacity such as
trauma, GI bleed, anemia, or presence of CO or Cyanide.
ii. No supplemental Oxygen is recommended for cardiac and CVA patients with SpO2
>94%. If Oxygen is required to achieve SpO2 of >94%, titrate to <99%.
iii. Titrate Oxygen to a SpO2 target range of 88-92% in patients with exacerbation of COPD,
and chronic neuromuscular disease with difficulty breathing. (1)
iv. Titrate Oxygen to a SpO2 target range of 92-96% in patients with ROSC, post cardiac
arrest. (2) (3) (4)
c. Consider CPAP or BPAP
d. If respiratory failure or arrest is present, ventilate via bag valve mask device with high flow
oxygen. Deliver one breath every 5-6 seconds.
e. Consider placement of an appropriate airway and RSI if indicated.
f. Assess lung sounds and consider needle thoracostomy for suspected tension pneumothorax.
3. Circulation - Note pulses, level of consciousness, skin color/temperature, capillary refill, and
moisture. Control any life-threatening or serious bleeding.
4. Disability - Note level of consciousness, GCS, or AVPU scale and movement of each extremity.
5. Exposure/environmental - Undress patient as needed to expose affected areas, monitor for
hypo/hyperthermia and treat appropriately.
Pediatric Primary Survey 1. Airway - Assess the patient’s airway for patency, protective reflexes and possible need for
intervention.
a. If the airway is obstructed, open airway by performing a head tilt-chin lift maneuver or
modified jaw thrust for suspected trauma.
b. If patient is unable to maintain an open airway, consider placement of an appropriate
airway adjunct by following the medical procedures for insertion.
c. Foreign body airway obstruction;
i. Use age-appropriate techniques to dislodge the obstruction (for infants younger than
one year, apply back blows with chest thrusts; for children one year and older, use
abdominal thrusts).
ii. If the airway obstruction is not relieved, perform direct laryngoscopy to visualize any
foreign body. If visualized, remove with Magill forceps.
iii. If unsuccessful, attempt endotracheal intubation and ventilate the patient. Maintain
spinal immobilization if trauma is suspected.
iv. If all other attempts to clear the airway fail, and the airway remains completely
obstructed, perform an emergency Quicktrach.
v. Once the airway has been opened, protect by placement of an appropriate airway
adjunct and administer oxygen.
2. Breathing - Assess the patient’s breathing including rate, auscultation, inspection, effort and
adequacy of ventilation as indicated by chest rise. Assess for signs of respiratory distress. Obtain
pulse oximetry reading.
a. If chest rise indicates inadequate ventilation, reposition airway and reassess.
b. If signs of respiratory failure or arrest are present, assist ventilations using a bag valve
mask device with high flow oxygen. Deliver one breath every 3 seconds.
c. If abdominal distention arises, consider placing a nasogastric tube to decompress the
stomach. If facial trauma is present or a basilar skull fracture is suspected, use an
orogastric tube instead.
d. If the airway cannot be maintained by other means, including attempts at assisted
ventilation, or if prolonged assisted ventilation is anticipated, place the most appropriate
airway device. Consider RSI if indicated. Confirm placement of endotracheal tube using
clinical assessment and ETCO2 monitoring.
e. Assess lung sounds and consider needle thoracostomy for suspected tension pneumothorax.
f. If breathing is adequate and patient exhibits signs of respiratory distress, administer high-
flow oxygen as necessary. Use a non-rebreather mask or blow-by as tolerated.
3. Circulation - Note pulses, level of consciousness, skin color, temperature, capillary refill and
moisture. Control any life threatening or serious bleeding.
4. Disability - Note level of consciousness, GCS, or AVPU scale and movement of each extremity.
5. Exposure/environmental - Undress patient as needed to expose affected areas, monitor for
hypo/hyperthermia and treat appropriately.
Secondary Survey The secondary survey is a more thorough and systematic exam of the patient’s physical condition and
medical history. It is usually focused on the patient’s chief complaints. The secondary survey seeks to
find problems not caught during the primary survey. Those secondary concerns, although not necessarily
an immediate threat to life and limb, can become so if not addressed appropriately.
1. Obtain chief complaint
2. Obtain “OPQRST” information regarding chief complaint
a. Onset
b. Provocation
c. Quality
d. Radiation
e. Severity
f. Time of onset
3. Obtain “SAMPLER” history
a. Symptoms
b. Allergies
c. Medications
d. Past medical history
e. Last oral intake
f. Events/environment
g. Risk factors
4. Obtain vital signs
a. Pulse (rate and quality)
b. Respirations (rate and quality)
c. Lung Sounds
d. Blood pressure (initial BP should be obtained manually)
e. Pulse oximetry
5. Perform a focused head to toe physical examination
6. Look for Medic-Alert necklace or bracelet
7. Obtain blood glucose level for any patient presenting with an altered LOC
8. Obtain patient temperature (prevent hypo/hyperthermia)
9. Consider information gathered in the survey, determine an impression of the patient’s primary
problem, and proceed to the appropriate treatment protocol
Treatment Considerations 1. Secure the airway using the most appropriate method
2. Oxygen administration
3. IV therapy to maintain a mean arterial pressure (MAP) of 65 or greater
4. Cardiac monitor/12 lead electrocardiogram with transmission, repeat as indicated by patient
condition
5. Follow standing orders for pain management, sedation, and antiemetic for nausea and/or vomiting
6. Spinal motion restriction decision algorithm should be consulted for trauma patients
Standing Orders Every effort should be made to control the patient’s pain regardless of the source. Medical Control should
be contacted for orders in the event the provider feels there is sufficient reason to withhold pain
medications that are not otherwise contraindicated by the patient’s condition or by allergy to the
medication.
Pain management 1. Consider Fentanyl, 1 mcg/kg IV/IO/IM, or 1.5 mcg/kg IN (Max single dose of 100 mcg), q 5 – 20
min. titrated to pain tolerance; maintain SBP > 100 mmHg and may repeat to a maximum total
dose of 200 mcg.
2. If Fentanyl is unavailable, consider Hydromorphone, 0.015 mg/kg IV/IO/ IM slowly titrated to
pain tolerance; maintain SBP > 100 mmHg and may repeat q 15-20 min. up to maximum. total
dose of 2 mg. Administration of Hydromorphone to patients over 65 years of age, with liver
failure, renal failure, or who are debilitated, should receive lower initial dosing; no more than 0.5
mg IV, IM, IO, titrated to pain tolerance.
3. If Fentanyl and Hydromorphone are unavailable, consider Morphine Sulfate, 0.1 mg/kg slow
IV/IO/IM slowly titrated to pain tolerance; maintain SBP > 100 mmHg and may repeat to a
maximum total dose of 10 mg prior to Medical Control contact.
4. Consider Ketorolac (Toradol) 15 mg IV or IM. Use caution in patients with suspected renal
failure or renal insufficiency.
5. Consider administration of benzodiazepines such as Versed 0.1 mg/kg slow IV or 0.2 mg/kg
IN/IM to a max of 2.5 mg if unable to manage pain levels with narcotic analgesics. The use of
benzodiazepines may potentiate already administered narcotics.
6. Or, Ketamine 0.1 mg/kg, up to 30 mg.
7. For severe trauma, burns, and severe pain refractory to narcotics; Ketamine 1-2 mg/kg IV/IO
minimum dose of 100 mg, may repeat once.
Sedation To assist in the management of the difficult airway, the altered mental status patient who is a threat to
themselves or others (remember that no medication will replace good scene safety practices), any patient
who is experiencing uncontrolled acute anxiety, or to facilitate cardioversion or transcutaneous pacing
when patient condition allow.
1. Medical (airway management, cardioversion or transcutaneous pacing)
a. Consider Versed, 0.1 mg/kg slow IV (may repeat once after 3 minutes) or 0.2 mg/kg IN/IM.
i. Never give Versed as a rapid bolus, administer over 2 minutes and allow an additional 2
minutes to fully evaluate sedative effect.
ii. Lower doses are necessary for patients over 60 years of age and in patients receiving
narcotics or other central nervous system depressants.
iii. Versed should not be mixed directly with any other medication in the prehospital
setting.
b. Consider Etomidate 0.3 mg/kg IV/IO slow over 30-60 seconds to induce sedation for
AIRWAY MANAGEMENT ONLY.
c. Do not administer these medications if SBP is < 100 mmHg without prior Medical Control
contact.
2. Behavioral a. Consider Versed, 0.1 mg/kg slow IV (may repeat once after 3 minutes) or 0.2 mg/kg IN/IM.
i. Never give Versed as a rapid bolus, administer over 2 minutes and allow an additional 2
minutes to fully evaluate sedative effect.
ii. Lower doses are necessary for patients over 60 years of age and in patients receiving
narcotics or other central nervous system depressants.
iii. Versed should not be mixed directly with any other medication in the prehospital
setting.
b. If Versed does not produce the desired effect, contact Medical Control to consider Ketamine.
c. Consider Ketamine 2 mg/kg IV or 4 mg/kg IM for excited delirium, half dose if >65 year
old.
i. Ketamine is Contraindicated in patients with schizophrenia as it could worsen the
symptoms.
ii. Ketamine is Contraindicated in patients that have recently used methamphetamines.
iii. Ketamine can cause significant increase in blood pressure. Do not use if an increase in
blood pressure might prove harmful, such as patients with possible intracranial
hemorrhage, AMI, chest pain, hypertensive emergency, or in the older patients.
d. Do not administer these medications if SBP is < 100 mmHg without prior Medical Control
contact.
Nausea/Vomiting Consider Zofran 0.15 mg/kg (max of 4 mg per dose) slow IV or Reglan 10 mg slow IV over 1-2 minutes
or IM.
If possible, perform a 12-lead ECG prior to administration of Zofran and evaluate for prolonged QT
interval, especially before giving multiple administrations.
Pediatric Pain Management / Sedation / Nausea 1. Consult pediatric reference guide to maintain age-appropriate systolic blood pressures or contact
Medical Control for orders or consult if unable to adequately manage patient’s pain.
a. Consider Fentanyl 0.5 mcg/kg IV/ IO/IM, or 1.5 mcg/kg IN, titrated to pain tolerance
(max100 mcg).
b. Consider Hydromorphone, (if Fentanyl is not available) 0.015 mg/kg/dose IV/IM/IO
titrated to pain tolerance (max. single dose 1 mg) or;
c. Morphine Sulfate 0.05 mg/kg titrate to effect.
d. Consider Ketorolac (Toradol) for patients weighing <50kg and over the age of 2 years, 0.5
mg/kg IV, or 1.0 mg/kg IM
e. For severe pain refractory to narcotics, severe burns or other severe trauma; Ketamine 1
mg/kg IV/IO, may repeat once at 0.5 mg/kg.
2. In the event that undue respiratory depression and/or hypotension develop, narcotic analgesics
can be counteracted by administration of Naloxone, 0.1 mg/kg IV/IN. Repeat as needed to improve
patient’s respiratory status.
3. Nausea/vomiting - Consider Zofran, 0.15 mg/kg (max 4mg) or Reglan (if pt is ≥ 8 y/o) 5 mg slow
IV over 1-2 minutes or IM.
4. Sedation: To assist in the management of the difficult airway, the combative patient who is a
threat to themselves or others, or any patient who is experiencing uncontrolled acute anxiety. To
facilitate cardioversion or transcutaneous pacing when patient condition allows.
a. Consider Versed, 0.1 mg/kg IV, 0.2 mg/kg IN/IM. Never give Versed as a rapid bolus,
administer over 2 minutes and allow an additional 2 minutes to fully evaluate sedative
effect. Lower doses are necessary for patients receiving narcotics or other CNS
depressants. Versed should not be mixed directly with any other medication in the
prehospital setting.
5. Do not administer these medications without prior Medical Control contact if patient is
hypotensive (refer to published charts for age-based vital signs).
Cardiac Protocols
Symptomatic Bradycardia
Heart rate <60 (pulse confirmed) with signs and symptoms of hypoperfusion.
1. Consider Atropine Sulfate, 0.5 mg IV repeat 0.5 mg every 3 – 5 minutes up to a total of 3 mg.
Atropine should be used with caution in 2nd degree type II block and new 3rd degree blocks with
wide QRS complexes. Denervated transplanted hearts will not respond to Atropine; go at once to
pacing.
2. Initiate transcutaneous pacing. Do not delay for IV attempts. Severe hypothermia is a relative
contraindication to cardiac pacing in the patient with bradycardia.
3. Consider Versed for sedation.
4. Consider Dopamine 5 – 20 mcg/kg/min IV if signs of hypoperfusion persist. Titrate to systolic
blood pressure of >100 mmHg.
Cardiogenic Shock
Cardiogenic shock results from a volume, pump, or rate problem. Patients may present with
hypotension, distended neck veins, delayed capillary refill, tachycardia, or cyanosis.
1. If systolic blood pressure is <90 mmHg and patient is not in acute pulmonary edema infuse a 250
ml bolus, may repeat if needed and then maintain at 125 ml/hr. Patients in cardiogenic shock are
susceptible to pulmonary edema. Caution should be used in IV fluid administration. Always
reassess lung sounds between boluses.
2. Consider Dopamine 5 mcg/kg/min IV, may increase up to 20 mcg/kg/min titrate to blood pressure.
Chest Discomfort The overall goals of chest pain management are achieved by following the “5-5-10 Rule.”
1. Aspirin within 5 minutes, 324 mg PO (4 Chewable Aspirin 81 mg each), if patient has not taken
ASA 324 mg within the last hour.
a. ASA is also contraindicated if the patient has vomited blood or coffee ground material in
the last 24 hours, passed black or bloody stools in the last 24 hours, or has a known allergy
to ASA.
2. 12-Lead within 5 minutes and transmit all 12-Leads to Medical Control for review.
3. If 12-lead indicates ST-segment elevation in leads 2, 3, and aVf, isolated ST-segment depression
in V1, or no ST-segment changes in the presence of chest pain, Obtain a 15-lead ECG.
4. Nitroglycerin within 10 minutes, 0.4 mg SL, repeat every 3 - 5 minutes until pain relieved
(maintain systolic BP >100 mmHg). Obtain a 12-Lead and consider establishing an IV prior to
NTG administration if there are sufficient ALS personnel on scene. If there is suspicion of an
inferior, posterior, or right-sided MI, withhold Nitroglycerin unless Medical Control is contacted
first.
5. Treat cardiac dysrhythmias according to appropriate protocols.
6. Complete a thrombolytic therapy inclusion/exclusion criteria checklist for STEMI patients.
Chest Pain Pit Crew Model
P2 – EMT· Assist with vitals· Places 12-lead ECG· Prepares Pt for transport
P1 – 1st Responder · Provides O2· Initial assessment & vitals· Provides hand-down report
to paramedic· Places limb lead ECG on
EMS arrival· Gathers Pt medications and
prepares Pt for transport
TIME MANAGEMENT GOALS
Pt contact to ASA – 5 minutesPt contact to 12-Lead trans – 5 minutesPt contact to Nitro – 10 minutesPt contact to transport – 15 minutes
P3 – PARAMEDIC· Obtains hand-down report from 1st resp.· Obtains SAMPLE hx· Ask if ASA has been taken: YES – Go to next step NO – Administer ASA if no evidence of
active bleeding· Administers 0.4mg Nitro SL· Analyze and transmit 12-lead ECG· Establishes IV access & draws blood
sample without delaying prompt transport.
P4 – SCENE SUPPORT· Assists interventions
without interrupting P1,P2,P3
· Assists P1 & P2 in prepping Pt and equipment for transport.
P1
P2 P3
P4
Congestive Heart Failure & Pulmonary Edema
Common symptoms are a history of CHF and hypertension with the presence of cool & clammy skin,
tachycardia, peripheral edema, jugular vein distension, tachypnea, and rales/rhonchi.
1. Consider immediate use of CPAP:
a. If improvement is not seen, consider increasing the level of expiratory pressure. It is
recommended to increase in increments of 2 cmH2O.
b. If the patient has ventilatory compromise, consider BPAP to assist with increasing tidal
volume and inspiratory pressure.
c. If patient will not tolerate, Administer high flow oxygen or assist ventilations with BVM.
2. Administer Nitroglycerin, 0.4 mg SL every 3-5 minutes (maintain systolic BP >100 mmHg) for
continuous symptoms until relieved.
3. Consider Versed for anxiety that exacerbates dyspnea. Maintain BP >100 mmHg.
4. If SBP < 90 mmHg consider administering Dopamine, 5 - 20 mcg/kg/min (Start with a low dose).
Adult Dysrhythmias
General Considerations After rhythm interpretation, the patient should be assessed for signs and symptoms of hypoperfusion or
cardiac instability. Unstable patients with dysrhythmias should be treated for volume, pump, or rate
cardiovascular problems. If patient is hemodynamically stable and does not meet any of the above criteria,
observe and transport. Patients presenting with a symptomatic 2nd degree type II heart block or a 3rd
degree complete heart block should have combo patches applied for pacing.
Wide-complex tachycardia
1. Stable - heart rate >150 (confirmed by pulse count), QRS complex ≥0.12 seconds, and patient is
hemodynamically stable (no signs or symptoms of hypoperfusion).
a. Obtain and transmit a 12 lead electrocardiogram. Consult with Medical Control as
indicated.
b. With Medical Control approval, give Amiodarone 150 mg IV over 10 minutes. (6) Dilute
150 mg of Amiodarone in 100 ml bag of Normal Saline and infuse at 150 gtts/minute. This
equals approximately 2.5 gtts/second using 15gtts IV tubing.
c. Determine QRS axis and morphology treat chest discomfort according to chest discomfort
protocol, and determine the specific tachydysrhythmia and treat according.
2. Unstable - heart rate >150 (confirmed by pulse count), QRS complex ≥0.12 seconds, with signs
and symptoms of hypoperfusion.
a. Perform immediate synchronized cardioversion of 100 J progressing to 200, 300, 360 J as
necessary. (6)
b. If patient is conscious and condition permits, consider sedation with Versed.
c. Be prepared to ventilate and/or suction the patient.
Atrial fibrillation/atrial flutter with rapid ventricular response 1. Stable - heart rate >150 (confirmed by pulse count), QRS complex ≤ 0.11 seconds, and patient is
hemodynamically stable (no signs or symptoms of hypoperfusion).
a. Obtain and transmit a 12 lead electrocardiogram, and transport patient.
b. Consult with Medical Control as necessary.
2. Unstable - heart rate >150 (confirmed by pulse count), QRS complex ≤ 0.11 seconds, with signs
and symptoms of hypoperfusion.
a. Contact Medical Control for Diltiazem 10 mg slow IV over 2 minutes.
b. If Wolf Parkinson White (WPW) syndrome is suspected with atrial fibrillation, contact
Medical Control for consult. Administration of atrioventricular (AV) node blocking agents
such as Adenosine or Diltiazem is not recommended in WPW cases.
c. Atrial fibrillation lasting longer than 48 hours has an increased risk of cardioembolic
events. Consult with Medical Control prior to any electrical or pharmacologic
cardioversion.
Symptomatic Supraventricular Tachycardia (SVT) – regular heart rate >150 (confirmed by pulse
count), QRS complex ≤0.11 seconds, with signs and symptoms of hypoperfusion.
1. Attempt vagal maneuvers (valsalva, cough).
2. If unsuccessful, prepare large-bore proximal IV access and saline flushes.
3. Consider applying Combo pads to the patient prior to administration of Adenosine.
4. Elevate extremity and administer Adenosine, 6 mg rapid IV.
5. May repeat at 12 mg rapid IV after 2 minutes, may repeat again at 12 mg rapid IV after another 2
minutes. Each dose must be followed by a rapid normal saline flush.
Torsades de Pointes with pulse - Administer Magnesium Sulfate, 50 mg/kg (max dose of 2000 mg)
diluted in 100 ml of NS over 5-60 minutes. Use slower rate of infusion for stable patients and faster rates
for unstable patients.
Ventricular Ectopy - Symptomatic patients presenting with premature ventricular contractions (PVC)
greater than 6 per minute which may be multifocal, couplets, bigeminy, trigeminy, or R on T phenomena.
Rule out patients who are at high risk for complete heart block. Ensure patient is receiving high flow
oxygen. Treat causes of PVC’s such as ischemia or infarction. If unresolved and patient is unstable due to
PVC’s, contact Medical Control for Amiodarone 150 mg IV over 10 minutes; may repeat if needed.
(dilute 150 mg of Amiodarone in 100 ml bag of Normal Saline and infuse at 150gtts/minute. This equals
approximately 2.5 gtts/second using 15 gtts IV tubing.
Cardiac Arrest A patient is deemed to be in cardiac arrest if they are found to be pulseless and apneic. Resuscitation
efforts should be initiated unless the patient meets the following guideline.
Presumption of Death in the Field 1. Presumption of death in the field, without initiation of resuscitation, should be considered only in
the following instances:
a. Decomposition
b. Rigor mortis
c. Dependent lividity
d. Pulseless, apneic patients with injuries not compatible with life, with the exception of
pregnant patients.
i. Decapitation
ii. Hemisection of torso
iii. Catastrophic brain trauma
iv. Injuries that would prevent effective chest compressions.
v. Pulseless, apneic patient in a MCI where system resources are required for
stabilization of living patients.
2. Other obviously lethal injuries. Do not guess future outcomes based on the appearance of the
patient.
3. Do not allow attempted suicide to prejudice the decision to resuscitate. It is inappropriate to agree
with the patient that death would be preferable, and therefore fail to act.
4. When employing presumption of death in the field, certain extenuating circumstances, particularly
hypothermia and submersion, the potential for salvage should be taken into account.
5. When in doubt, full resuscitative efforts should be initiated without delay.
6. After presumption of death in the field has been employed, the paramedic or dispatch shall inform
the law enforcement agency that has jurisdiction that a death has occurred. The crew will remain
on the scene until relieved by a law enforcement officer and may be requested to remain on the
scene until a deputy coroner arrives for investigation.
7. Every effort should be made to cooperate with law enforcement agencies and the coroner’s office
regarding disturbing crime scenes.
Cardiac Arrest Resuscitation w/Pit Crew Model
1. Begin continuous chest compressions (CCC) with Lucas2 mechanical CPR device.
a. If patient is too small, or too large for use of the Lucas2, begin manual chest compressions
i. Push hard (at least 2 inches) and fast (100 bpm)
ii. Allow for full chest recoil
b. Minimize interruptions in chest compressions to no more than 10 secs.
c. Cycles of chest compressions should be 2 minutes, or 200 chest compressions
2. Insert a pharyngeal airway device (OPA, or NPA)
3. Administer Oxygen by NC at 10 lpm
4. Attach cardiac monitor or automated external defibrillator (AED)
5. If there is clear evidence that the arrest is of a respiratory etiology (i.e. drowning, hanging,
FBAO), advanced airway placement should be performed as soon as possible.
6. At the end of a chest compression cycle, analyze the cardiac rhythm
a. Go to identified rhythm protocol below.
Asystole– also called cardiac standstill, refers to the absence of all ventricular activity.
1. Continue chest compressions in 2 minute cycles
2. Initiate IV/IO vascular access
3. Administer Epinephrine 1:10,000 1 mg IV/IO, repeat every 4 minutes
4. Secure airway with an advanced airway device
5. Begin BVM ventilations w/Oxygen and waveform capnography, 1 breath every 6-8 seconds.
a. If Lucas device is used, add Impedance Threshold Device (ITD) (6) (7) (8)
b. If ROSC occurs, remove ITD and continue ventilatory support as needed
6. If rhythm change is identified, go to corresponding rhythm protocol
7. If no change, consider termination of efforts
a. Unwitnessed = 15 minutes (9)
b. Witnessed = 30 minutes
Pulseless Electrical Activity (PEA) – The absence of a detectable pulse and the presence of some type
of electrical activity other than ventricular tachycardia or ventricular fibrillation.
1. Continue chest compressions in 2 minute cycles
2. Secure airway with an advanced airway device
3. Begin BVM ventilations w/Oxygen and waveform capnography, 1 breath every 6-8 seconds.
a. If Lucas device is used, add Impedance Threshold Device (ITD) (6) (7) (8)
b. If ROSC occurs, remove ITD and continue ventilatory support as needed
4. Initiate IV/IO vascular access
5. Administer Epinephrine 1:10,000 1 mg IV/IO, repeat every 4 minutes (9) (10) (11)
6. Initiate Dopamine infusion, 10 mcg/kg/min and continue as long as PEA persists. (12) (13)
a. If ROSC occurs, titrate Dopamine to MAP of at least 65. (see Post-resuscitative Care)
7. If rhythm change is identified, go to corresponding rhythm protocol
8. If no change after 30 minutes of resuscitation has been completed, contact medical control to
terminate efforts.
Ventricular Fibrillation/Tachycardia 1. Defibrillate
2. Continue chest compressions in 2 minute cycles
3. Initiate IV/IO access
4. Administer Epinephrine 1:10,000 1 mg IV/IO, repeat every 4 minutes
5. Secure airway with an advanced airway device
6. Begin BVM ventilations w/Oxygen and waveform capnography, 1 breath every 6-8 seconds.
a. If Lucas device is used, add Impedance Threshold Device (ITD) (6) (7) (8)
b. If ROSC occurs, remove ITD and continue ventilatory support as needed
7. Administer Amiodorone 300 mg, repeat once at 150 mg
8. At each rhythm check, if VF/VT is present, Defibrillate and quickly return to CCC
9. If VF/VT persists after 3 consecutive defibrillations and the administration of Amiodorone, Go to
Refractory Ventricular Fibrillation protocol
10. Prepare patient for transport
Refractory Ventricular Fibrillation – Persistent VF/VT, without even transient interruption of
fibrillation following a minimum of 3 consecutive standard external defibrillations.
1. At each rhythm check, if VF/VT is present, Defibrillate and quickly return to CCC
2. Administer Esmolol 500 mcg/kg IV/IO bolus
3. Initiate Esmolol infusion at 50 mcg/kg/min. (14) (15)
4. Stop administration of Epinephrine
5. If second dose of Amiodorone has not been administered yet, administer 150 mg Amiodorone
IV/IO.
6. Begin transport to the closest appropriate facility
7. If rhythm change is identified, go to corresponding rhythm protocol
Pit Crew Model
#1 – Compressor
· Performs 200 CCC
· Announces
compression #170
“170 Charge”
· Continues to count
compressions when the
Lucas device is utilized
#3 – Airway
· Places OPA/NPA & NC @ 10 lpm
· Suction as necessary
· Rotates with Compressor if necessary
· ETT or King LTS-D as directed
#2 – Monitor
Team Leader &
Transport Medic
· Activates metronome
and places pads without
stopping chest
compressions
· At compression #170,
charges for defibrillation
· Assesses ECG rhythm
only during compressor
rotations
#4 – IV/IO & Meds
· Obtains IV/IO access
· Administers meds and
records time
Optional
Compressor On Deck
Optional
#5 – Team Leader
· Assumed by Transport Medic after Monitor is
delegated to another ALS provider
· Directs team efforts and records interventions
Optional
#6 – Staging
· Ensures that only #1 - #5
members are in the Pit Crew area
· Assembles additional equipment
in the staging area
Adult Post-Resuscitative Care 1. Treat the rate problems according to appropriate protocol.
2. Treat the rhythm problems according to appropriate protocol.
3. Treat the pressure problems as follows.
a. If patient remains hypotensive, assess lung sounds for pulmonary edema. If clear,
administer fluid challenge of Normal Saline 100 – 200 ml at a time until desired effect or
500 ml infused.
b. Consider Dopamine, 5 – 20 mcg/kg/min, starting with a low dose and titrating to effect.
4. Titrate Oxygen to a SpO2 target range of 92-96%
5. Immediately transport patient to nearest facility with frequent reassessment of vital signs.
6. Consider Versed for sedation if patient is fighting endotracheal tube.
Figure 1 - Adult Post-Resuscitation Care (7)
Pediatric Dysrhythmias
Bradycardia
1. Initiate cardiac monitoring and determine rhythm.
2. Signs of severe cardiorespiratory compromise is indicated by:
a. Inadequate perfusion (delayed capillary refill, weak or absent peripheral pulses)
b. Altered mental status
c. Hypotension
d. Respiratory difficulty
3. If signs of severe cardiopulmonary compromise are present in an infant or neonate, or the heart
rate remains slower than 60 bpm despite oxygenation and ventilation, initiate chest compressions.
4. If signs of severe cardiopulmonary compromise persist despite oxygenation and ventilation:
a. Epi 1:10,000, 0.01 mg/kg IV/IO (max dose 1 mg). Repeat every 3-5 minutes until
bradycardia or cardiopulmonary compromise resolves.
b. Administer Atropine 0.02mg/kg up to max 0.5mg.
c. Consider transcutaneous pacing.
5. Perform a glucose test and treat if < 60 mg/dl (<45 mg/dl for neonates).
6. Reassess patient frequently.
7. Transport the patient in recovery position if unresponsive, or position of comfort if alert.
Tachycardia 1. Initiate cardiac monitoring and determine rhythm. Obtain and transmit 12-Lead
electrocardiogram.
2. After rhythm interpretation, the patient should be assessed for signs and symptoms of
hypoperfusion or cardiac instability.
3. Patients meeting any of the following criteria are to be considered unstable and should be treated
immediately, according to the appropriate protocol:
a. Chest discomfort
b. Altered mental status
c. Respiratory distress
d. Hypotension
e. Pulmonary edema
4. Determine the specific type of dysrhythmia and treat accordingly.
5. Transport the patient in position of comfort.
Cardiogenic Shock - Results from a volume, pump, or rate problem. Patients may present with
hypotension, distended neck veins, delayed capillary refill, tachycardia, or cyanosis.
1. If patient is hypotensive, and patient is not in acute pulmonary edema, infuse a 20 ml/kg bolus. A
second bolus of 20 ml/kg may be administered after 20 minutes if needed. If further fluid
replacement is needed, contact Medial Control. Patients in cardiogenic shock are susceptible to
pulmonary edema. Caution should be used in IV fluid administration. Always reassess lung sounds
between boluses.
2. Consider Dopamine, 5 – 20 mcg/kg/min IV/IO, titrated to effect.
Supraventricular Tachycardia (SVT) - Heart rate >180 (child) or >220 (infant), QRS less than or
equal to 0.12 seconds.
1. With pulses and adequate perfusion:
a. Consider vagal maneuvers.
b. Consider Adenosine, 0.1 mg/kg rapid IV. May repeat with 0.2 mg/kg once if patient fails
to convert after first dose. Maximum single dose is 12mg.
2. With pulses and poor perfusion:
a. Consider vagal maneuvers (no delays).
b. If IV access is readily available, administer Adenosine, 0.1 mg/kg rapid IV. May repeat
with 0.2 mg/kg once if patient fails to convert after first dose. Maximum first dose is 6mg.
Maximum sequential dosages is 12mg.
c. Perform immediate synchronized cardioversion at 1.0 J/kg. If not effective, increase to 2
J/kg. If patient is conscious and condition permits, consider sedation with Versed, 0.1
mg/kg IV/IN (max 2 mg)
d. Contact Medical Control to consider Amiodarone, 5mg/kg over 20 to 60 min. Max
15mg/kg.
3. Be prepared to suction or intubate the patient.
Ventricular Tachycardia
Heart rate at least 120/min and regular, and QRS greater than 0.12seconds.
1. With pulses and adequate perfusion:
a. Consider Amiodarone, 5 mg/kg IV over 20 – 60 minutes.
b. May attempt Adenosine, 0.1 mg/kg Rapid IV (max dose 6 mg) if not already administered.
c. Attempt synchronized cardioversion at 1.0 J/kg. If not effective, increase to 2 J/kg. Sedate
with Versed, 0.1 mg/kg IV/IN (max 2 mg) prior to cardioversion.
2. With pulses and poor perfusion:
a. Perform immediate synchronized cardioversion at 1.0 J/kg. If not effective, increase to 2
J/kg. If patient is conscious and condition permits consider sedation with Versed, 0.1mg/kg
IV/IN (max 2 mg).
3. May attempt Adenosine, 0.1 mg/kg Rapid IV (max dose 6 mg) if not already administered.
4. Consider Amiodarone, 5 mg/kg IV over 30 – 60 minutes.
5. Be prepared to suction or intubate the patient.
Refractory Ventricular Fibrillation – Persistent VF/VT, without even transient interruption of
fibrillation following a minimum of 5 standard external defibrillations.
1. Consider Double Sequential External Defibrillation (DSED).
a. Ensure that at least 5 standard external defibrillations have been delivered.
b. Ensure that 2 doses of 5 mg/kg of Amiodarone has been administered.
c. Administer up to 3 DSED attempts at 4 J/kg.
i. If V-fib is converted to any rhythm other than V-fib, discontinue any further DSED
attempts.
2. If V-fib is still refractory following 3 DSED attempts, transport to the closest appropriate facility.
3. All further defibrillations are standard (single monitor) external defibrillations.
Pediatric Post-Resuscitation Care 1. Treat the rate problems according to appropriate protocol.
2. Treat the rhythm problems according to appropriate protocol.
3. Treat the pressure problems as follows.
a. If patient remains hypotensive, assess lung sounds for pulmonary edema. If clear,
administer fluid bolus of Normal Saline 20 ml/kg. Contact Medical Control for further
fluid administration.
b. Consider Dopamine 5 – 20 mcg/kg/min. Method is to mix 6 mg/kg with enough NS to
make 100 ml. Contact Medical Control prior to administration.
4. Immediately transport patient to nearest facility with frequent reassessment of vital signs.
5. Consider Versed, 0.1 mg/kg IV/IO for sedation, if patient is fighting endotracheal tube.
AHA CPR Pediatric Cardiac Arrest
Doses/Details
CPR Quality· Push hard (>1/3 of the anterior-
posterior diameter of chest) and fast (at least 100/min) and allow the chest to completely recoil.
· Minimize Interruptions in compressions
· Avoid excessive ventilation· Rotate compressor every 2 minutes· Compression-ventilation ratio:
One rescuer - 30:2Two rescuer - 15:2
· If advanced airway, 8-10 breaths per minute with CCC
Drug & Defibrillation· Defibrillation – Subsequent shocks
after 2nd should be > 4 j/kg. Max 10 j/kg or adult dose
· Epinephrine IO/IV Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000) Repeat every 3-5 minutes. If no IV access, may give ET tube dose: 0.1 mL/kg of 1:1000 · Amiodarone IO/IV Dose: 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/VT.· Sodium Bicarbinate IV/IO Dose:
1mEq/Kg( dilute by ½ with Normal Saline if <1y/o).
Advanced Airway· Superglottic airway or Endotracheal
intubation· Waveform capnography to confirm
and monitor ET tube placement· Once airway is in place, give 1 breath
every 6-8 seconds (8-10 breaths per minute )
Reversible Causes
· Hypovolemia· Hypoxia· Hydrogen ion (acidosis)· Hypo-/hyperkalemia· Hypothermia· Tension pneumothorax· Tamponade, cardiac· Toxins· Thrombosis, pulmonary· Thrombosis
Assess rhythm
SHOCKABLE
DEFIB 2j/kg
· CPR 2 Minutes· IV/IO access· Epinephrine every
3-5 minutes
Assess rhythm
· CPR 2 Minutes· Consider Advanced Airway
Capnography· Consider Amiodarone · Treat reversible causes (H&Ts)
NON-SHOCKABLE· CPR 2 Minutes· IV/IO access· Epinephrine every 3-5 minutes· Consider Advanced Airway· Consider Capnography
After 30 minutes of therapy, does patient meet criteria to terminate efforts?
Contact Medical Control for termination of efforts
Initiate transport as indicated & contact Medical Control for
consult
YesNo
NON-SHOCKABLE· CPR 2 Minutes· Advanced Airway · Capnography· Treat reversible causes (H&Ts)
SHOCKABLE
DEFIB 4j/kg
Start CPRPlace airway adjunct
Begin BVM ventilationAttach monitor/defibrillator
Continue resuscitation efforts Re-analyze ECG in-between CPR sets (2 min)
Newborn Resuscitation 1. Suction the infant’s airway using a bulb syringe as soon as the infant’s head is delivered and
before delivery of the body. Suction the mouth first, then the nasopharynx.
2. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the
baby in a thermal blanket or dry towel. Cover the infant’s scalp to preserve warmth.
3. Open and position the airway. Suction the infant’s airway again using a bulb syringe. Suction the
mouth first, then the nasopharynx.
4. If thick meconium is present, initiate endotracheal intubation before the infant takes a first breath.
Suction the airway using a meconium aspirator while withdrawing the endotracheal tube. Repeat
this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows,
discontinue suctioning immediately and provide ventilation until the infant recovers. Note: If the
infant is already breathing or crying, this step may be omitted.
Death of a Child (SIDS) There is no normal parental reaction to the death of a child or a SIDS event. Individual responses may
range from emotional outbursts to apparent withdrawal. Rescuers should not make any assumptions or
judgments. Maintain a professional demeanor at all times. Perform the initial assessment, environmental
assessment, and focused history as part of the clinical process. Observe, assess, and document accurately
and objectively.
1. Perform a scene survey to assess environmental conditions and mechanism of illness or injury.
2. Establish patient responsiveness.
3. Assess airway and breathing. Confirm apnea.
4. Assess circulation and perfusion.
5. Initiate cardiac monitoring. Confirm absent pulse.
6. Determine whether to perform further resuscitation measures:
a. If patient does not exhibit lividity or rigor, initiate CPR. Initiate transport.
b. If patient exhibits lividity and rigor, do not resuscitate as permitted by medical direction.
Note: Lividity can be mistaken for bruising and evidence of abuse. Do not make any
assumptions or judgments.
7. Provide supportive measures for parents and siblings:
a. Explain the resuscitation process, transport decision, and further actions to be taken by
hospital personnel or the medical examiner.
b. Reassure parents that there was nothing they could have done to prevent death. Allow the
parents to see the child and say goodbye.
c. Maintain a supportive, professional attitude no matter how the parents react.
d. Whenever possible, be responsive to parental requests. Be sensitive to ethnic and religious
needs or responses and make allowances for them.
8. Obtain patient history using a nonjudgmental approach. Ask open-ended questions as follows:
a. Has the child been sick?
b. Can you describe what happened?
c. Who found the child? Where?
d. What actions were taken after the child was discovered?
e. Has the child been moved?
f. When was the child last seen before this occurred, and by whom?
g. How did the child seem when last seen?
h. When was the last feeding provided?
9. Reassess the environment. Document findings, noting the following:
a. Where the child was located upon arrival
b. Description of objects located near the child upon arrival
c. Unusual environmental conditions, such as a high temperature in the room, abnormal
odors, or other significant findings
10. If the parents interfere with treatment or attempt to alter the scene, initiate the following actions:
a. Remain supportive, sympathetic, and professional
b. Avoid arguing with the parents or exhibiting anger
c. Do not restrain the parents or request that they be restrained unless scene safety is clearly
threatened
11. Document the emergency call, including the following information:
a. Time of arrival
b. Initial assessment findings and basis for resuscitation decision
c. Time of resuscitation decision
d. Time of arrival at hospital if resuscitation and transport were initiated
e. Parental support measures provided if resuscitation was not initiated
f. History obtained (note who provided the information)
g. Environmental conditions
h. Time law enforcement personnel arrived on scene
i. Time that scene responsibility was turned over to law enforcement personnel
Field Resuscitation Termination 1. The resuscitation team will provide conscientious and competent care, provided the patient has not
expressed a decision to forgo resuscitative efforts. The final decision to stop efforts can never be
as simple as an isolated time interval. Clinical judgment and respect for human dignity must enter
into the decision making process. Transportation with continuous resuscitation is justified if
interventions are available in the ED that cannot be performed in the field, such as
cardiopulmonary bypass or extracorporeal circulation for victims of severe hypothermia.
2. If the patient is found to be pulseless and apneic with other obvious signs of advanced death, or
the patient's family or medical staff produce Do Not Resuscitate (DNR) orders in writing such as
the Out-of-Hospital Do Not Resuscitate (OHDNR) order, or OHDNR identification following the
State regulations no resuscitations efforts need be initiated. Copies of DNR orders will be accepted
as long as there are no signs of tampering to such document.
3. A properly executed OHDNR order authorizes emergency medical services personnel to withhold
or withdraw BLS and ALS cardiopulmonary resuscitation from the patient in the event of cardiac
or respiratory arrest. Emergency medical services personnel shall not withhold or withdraw other
medical interventions, such as intravenous fluids, oxygen, or therapies other than cardiopulmonary
resuscitation such as those to provide comfort care or alleviate pain. Nothing in this regulation
shall prejudice any other lawful directives concerning such medical interventions and therapies.
4. After noting the properly executed OHDNR order or OHDNR identification, cardiac monitoring
should be performed to obtain an ECG tracing and attach it to the PCR. For any ECG rhythm other
than asystole, contact Medical Control for consult.
5. Emergency medical services personnel shall document review of the OHDNR order and/or
OHDNR identification in the patient care record.
6. If any doubt exists about the validity of OHDNR order/identification or any other DNR order,
resuscitation shall be initiated and Medical Control shall be contacted.
7. Emergency medical services personnel shall not comply with an OHDNR order or the OHDNR
protocol when the patient or patient’s legal representative (one who can legally and explicitly
make health care decisions for the patient) expresses to such personnel in any manner, before or
after the onset of a cardiac or respiratory arrest, the desire to be resuscitated. And an OHDNR
order shall not be effective during such time as the patient is pregnant.
8. If the patient is found to be pulseless and apneic without signs of advanced death and without
written DNR orders, full resuscitation efforts should be initiated.
9. After all appropriate interventions have been accomplished (including good CCR, adequate airway
with good ventilation, IV/IO, appropriate medications) and there is no return of Spontaneous
Circulation, contact Medical Control for consult. At this time the resuscitation team, including the
Doctor, should make the decision to continue or terminate resuscitation efforts.
10. If the resuscitation has been terminated, the paramedic will have the responsibility of informing
the family that the patient has been declared dead. If the family has questions about the decision,
they will be referred to Medical Control for counseling.
11. After the resuscitation has been terminated and the family informed, the paramedic or dispatch
shall inform the law enforcement agency that has jurisdiction that a death has occurred. The
paramedic may be requested to remain on the scene until a deputy or the coroner arrives for
investigation. The paramedic will determine the appropriateness of leaving the scene, considering
the family’s needs.
12. If at any time the paramedic does not feel comfortable with following the field resuscitation
termination protocol they may continue full resuscitative efforts and transport the patient.
13. There may be times when termination in the field may cause conflict with the public or patient’s
family, in these cases, transport of the patient may be more appropriate.
Medical Protocols
Abdominal Pain 1. Secure the patient in position of comfort for transport.
2. Note last bowel movement, possible pregnancy, and be alert for patients with abdominal aortic
aneurysm (i.e. pulsatile abdominal mass or elderly patient with abdominal/back/flank pain and low
blood pressure).
3. If patient has a suspected abdominal aortic aneurysm, titrate IV to maintain systolic blood pressure
of 90 mmHg.
Pediatric
1. Consider non-accidental trauma.
2. Closely monitor vital signs; blood pressure may drop quickly.
Allergic Reactions & Anaphylaxis 1. Assess symptom severity:
a. Mild symptoms
i. Skin symptoms (Flushing, Hives, Itching)
ii. Erythema
iii. Normal Blood Pressure and perfusion
b. Moderate symptoms
i. Skin symptoms (Flushing, Hives, Itching)
ii. Erythema
iii. Respiratory symptoms (wheezing, dyspnea, hypoxia)
iv. Gastrointestinal symptoms (nausea, vomiting, abd pain)
v. Normal Blood Pressure and perfusion
c. Severe Symptoms
i. Skin symptoms may or may not be present (depending on perfusion)
ii. Respiratory symptoms (wheezing, dyspnea, hypoxia)
iii. Gastrointestinal symptoms (nausea, vomiting, abd pain)
iv. Hypotension (SBP <90 mmHg) and poor perfusion
2. If Mild Symptoms are present
a. Diphenhydramine 1 mg/kg to a maximum of 50 mg IV/IM
3. If Moderate Symptoms are present
a. Diphenhydramine 1 mg/kg to a maximum of 50 mg IV/IM
b. Methylprednisone (Solu-medrol) 2 mg/kg IV (max dose of 125 mg)
c. Albuterol 2.5 mg via nebulizer for wheezing; repeat as needed
d. Consider Epinephrine 1:1,000 0.01 mg/kg IM (max dose 0.5 mg); may repeat q 15 minutes
as needed
4. If Severe Symptoms are present:
a. 1:1,000 Epinephrine 0.01 mg/kg IM (max dose 0.5 mg); or if altered mental
status/cardiovascular collapse is present, Epinephrine 1:10,000 0.1 mg IV/IO; if no
improvement repeat q 5 minutes;
b. Diphenhydramine 1 mg/kg to a maximum of 50 mg IV/IM
c. Albuterol 2.5 mg via nebulizer for wheezing
d. Methylprednisone (Solu-medrol) 2 mg/kg IV (max dose of 125 mg)
5. If unable to secure a protected airway or unable to ventilate with BVM after Epinephrine has been
administered, cricothyrotomy may be required.
Pediatric
1. If Mild symptoms are present:
a. Consider Diphenhydramine 1 mg/kg IV/IM to a maximum of 50 mg
2. If Moderate symptoms are present:
a. Consider Epinephrine 1:1,000 0.01 mg/kg IM to a maximum of 0.3 mg
b. Diphenhydramine 1 mg/kg IV/IM to a maximum of 50 mg
c. Consider Albuterol 0.15mg/kg up to 5 mg in 3ml of NS via nebulizer for wheezing; repeat
as needed
d. Consider Methylprednisone (Solu-Medrol) 1-2 mg/kg IV to a maximum of 125 mg
3. If Severe symptoms are present:
a. 1:1,000 Epinephrine, 0.01 mg/kg IM to a maximum of 0.3 mg, or
1:10,000 Epinephrine, 0.01mg/kg IV to a maximum of 0.1 mg; may repeat every 5 minutes
if no improvement is noted. (May consider contacting Medical Control prior to use of IV
Epinephrine due to potential complications. IM administration is preferred.)
b. Diphenhydramine 1 mg/kg IV/IM to a maximum of 50 mg
c. Consider Albuterol 0.15 mg/kg up to 5 mg in 3 ml of NS, for wheezing; may repeat as
needed
d. Treat with fluid challenge if still hypotensive
e. Consider Methylprednisone (Solu-Medrol) 1-2 mg/kg IV to a maximum of 125 mg
If unable to secure patients airway or unable to ventilate with BVM after Epinephrine has been
administered, Quicktrach may be required
Behavioral/Psychiatric Disorders 1. Assure personnel safety. Attempt to establish rapport with the patient. If patient appears to be
dangerous, do not approach until law enforcement is on scene and able to restrain him/her. If
patient is suicidal, do not leave the patient alone.
2. If the patient has to be restrained (refer to Restraint Use in Procedures section), do not remove
restraints during transport.
3. Consider Versed 0.1 mg/kg slow IV (may repeat once after 3 minutes) or 0.2 mg/kg IM for
sedation.
4. Consider Ketamine 2 mg/kg IV or 4 mg/kg IM for excited delirium requiring immediate
behavioral control. For patients 65 years or greater, administer 1 mg/kg IV or 2 mg/kg IM.
5. Remember that no medication will replace good scene safety practices.
Pediatric - same as adult, but Versed is 0.1 mg/kg.
Dehydration For patients who have a history of heat exposure and/or inadequate fluid intake, personnel are authorized
to administer oral fluids (EMT or EMT-P) or intravenous fluids (EMT-P) for rehydration. This medical
directive does not preclude providing bottled oral replacement fluid to “walk-up” patients who simply
request oral fluids.
1. Obtain a patient temperature, vital signs and a brief history, noting the duration of exposure to heat
and/or inadequate fluid intake.
2. If patient presents with hyperthermia consider transport.
3. Determine the level of dehydration (symptoms may appear alone or in combination).
a. Mild dehydration: thirst, pale/clammy skin, cramping pains in limbs or abdomen, pre-
syncope, nausea, one or less vomiting episodes, mild headache, heart rate < 120, systolic
blood pressure > 90 mmHg, and glasgow coma score (GCS) of < 15.
b. Moderate/ severe dehydration: severe thirst, dry/hot/flushed skin, feeling exhausted,
continuous cramping pains in limbs or abdomen after oral hydration, postural syncope,
vomiting more than once, no urge to void within the last 4-6 hours, heart rate >120,
systolic blood pressure < 90 mmHg, or GCS <15.
4. If patient exhibits signs and symptoms of mild dehydration, offer oral fluid replacement as
tolerated up to a maximum volume of 1.5 L/hr and monitor patient for improvement. If patient
does not improve, continue with ALS treatment and/or contact Medical Control for consult.
5. If patient exhibits signs and symptoms of moderate/severe dehydration, initiate IV of Normal
Saline and administer up to 1,000 ml.
6. Reassess patient’s vital signs, lung sounds and temperature.
7. If patient’s condition has not improved and lung sounds are clear, repeat Normal Saline up to max
of 1,500 ml.
8. Reassess patient for improvement after 30 – 60 minutes. If patient’s condition has not improved,
contact Medical Control. Maximum duration of treatment allowed is two hours.
9. If no improvement or condition worsens, contact Medical Control for consult and/or transport to
the hospital.
10. When patient’s condition improves, they can be released provided the following criteria are met:
a. Skin no longer feels dry and hot.
b. Patient feels subjectively improved with resolution of heat cramps.
c. No postural presyncope.
d. Able to tolerate oral intake.
e. Heart rate is < 100, systolic blood pressure is >100 mmHg, and GCS is 15.
11. All patients admitted to the treatment area must have complete documentation showing physical
exam, vital signs, treatment provided, and changes in condition. If patient is transported to the
hospital, document transport assignment. If patient is released, document refusal of further
medical care and transport to the hospital. All released patients should be counseled on proper
fluid intake and follow-up care by a physician.
Diabetic Emergencies Hypoglycemia is defined as blood glucose level < 70 mg/dl.
1. Perform a glucose test. If glucose level is <70 mg/dl, proceed with following treatment until
glucose is >70 mg/dl:
2. If patient is able to swallow and is alert enough to follow commands, give oral glucose (1 tube) or
other form of sugar orally. Repeat if necessary.
3. If frequent/chronic alcohol use is suspected, give Thiamine 100 mg IV.
4. Give D10W, 25 g IV drip (if unable to initiate IV give Glucagon, 1 mg IM).
5. Repeat glucose test in 5-10 minutes after D10W or instant glucose administration.
6. Repeat D10W, 25 g IV as needed.
Pediatric
1. Perform a glucose test. If glucose level is < 60 mg/dl (< 45 mg/dl for neonates) or patient shows
signs/symptoms of hypoglycemia:
2. If patient is ≥3 years of age, able to swallow and is alert enough to follow commands, give Oral
Glucose PO (1 tube) or other form of sugar orally.
3. If patient is unable to follow commands or protect their airway:
a. Older than 13 years: D10W, 25 g
b. Younger than 13 years: D10W, 0.5g/kg (5 ml/kg) max dose of 25 g.
c. Consider Glucagon, 1 mg IM (< 20 kg: 0.5 mg IM) if unable to initiate IV/IO.
d. Repeat glucose test 1 – 2 minutes after Dextrose 10% is administered. Dextrose 10% may
be repeated once at the same dosage if blood glucose remains < 60 mg/dl (< 45 mg/dl for
neonates).
4. If patient presents with symptomatic hyperglycemia, begin infusing Normal Saline 20 ml/kg/hr.
5. Transport the patient in recovery position if unresponsive, or position of comfort if alert. If
trauma is suspected follow appropriate traumatic emergencies protocol
Symptomatic Hypoglycemia Treat and Release Criteria - If the patient recovers from hypoglycemia and there was a reasonable
explanation for the hypoglycemia without other underlying medical causes (document thoroughly), the
patient may elect to refuse transport without consulting Medical Control. Utilize criteria below:
1. The patient must be completely alert and oriented.
2. The patient's glucose level must be within or slightly above normal range.
3. The patient demonstrates ability to monitor their glucose levels.
4. The crew should counsel the patient on the importance of maintaining their blood sugar, follow up
treatment with a meal, and contact their personal physician.
5. It is preferred the patient be left with someone else who is competent and understands the potential
for further problems, can assist the patient, and (if needed) call EMS.
6. The patient should never be left in a situation that requires them to place themselves or others at
risk by driving or operating any type of equipment after a hypoglycemic episode.
7. Through ALS assessment, the paramedic must verify patient is competent to refuse further care
and transport. The patient must present as conscious, alert, oriented and able to make their own
decision. All patients refusing further medical care should sign a patient refusal of care document.
Symptomatic Hyperglycemia Hyperglycemic patients (> 200 mg/dl) with symptoms require large quantities of fluid replacement.
Begin infusing IV Normal Saline and initiate transport.
1. ETCO2 ≥ with glucometry reading of “HIGH” ≠ DKA
2. ETCO2 ≤ 21 with glucometry reading of “HIGH” = DKA
Epistaxis 1. Attempt to control bleeding by pinching the nostrils.
2. Keep the patient in a sitting position, leaning forward.
3. Encourage the patient not to swallow blood or blood clots, as this tends to lead to vomiting
Exertional Heat Illness Heat illness is a broad term, which encompasses some specific conditions. These include:
1. Guideline
a. Heat Cramps (Exercise Associated Muscle Cramps) and Dehydration
i. The first sign of heat illness
ii. Dark urine color
iii. Greater than 1.5% of body weight lost due to sweat during activity.
iv. Painful spasms/contractions of large muscle groups (quadriceps, hamstrings, calf,
etc.).
b. Heat Syncope
i. Can occur at any time during the heat illness cycle.
ii. Signs and Symptoms include:
1. Feeling faint, or actually fainting as a result of getting overheated during
physical activity.
2. Dizziness/Light-headedness
3. Weakness
4. Tunnel Vision
5. Pale or sweaty skin
6. Loss of consciousness
7. Decreased or weakened pulse
c. Heat Exhaustion
i. Can be potentially life threatening.
ii. Inability to sustain adequate cardiac output.
iii. Signs and Symptoms include:
1. Fatigue
2. Nausea/vomiting
3. Weakness
4. Fainting, Dizziness/Light-headedness
5. Diarrhea
6. Chills
7. Heavy sweating
8. Headache
9. Decreased Blood Pressure
10. Hyperventilation
11. Decreased muscle coordination.
d. Exertional Heat Stroke
i. LIFE THREATENING MEDICAL EMERGENCY
ii. Signs and Symptoms include:
1. Altered mental status
2. Hot and red skin, flushed skin
3. Rapid heart rate,
4. Nausea/vomiting
5. Headache
6. Rectal body temperature ≥ 104 degrees Fahrenheit.
2. Protocol
a. Heat Cramps
i. Remove the patient from any activity
ii. Rehydration with cool water (sipped slowly to avoid GI irritation)
1. Small amounts of commercial sports drink may be beneficial. 3:1 ratio of
water to commercial sports drink
2. IV fluids may be necessary in extreme cases. See Dehydration protocol
iii. Encourage movement of cramping extremity
iv. Monitor patient vital signs
b. Heat Syncope
i. Remove the patient from any activity
ii. Move to shaded or cooled area
iii. Remove all excess/unneeded clothing and protective equipment
iv. Elevate legs
v. Rehydration with cool water (sipped slowly to avoid GI irritation)
1. Small amounts of commercial sports drink may be beneficial. 3:1 ratio of
water to commercial sports drink
2. IV fluids may be necessary in extreme cases. See Dehydration protocol
vi. Monitor vital signs. Include orthostatic blood pressures
c. Heat Exhaustion
i. Remove the patient from any activity
ii. Move to shaded or cooled area
iii. Remove all excess/unneeded clothing and protective equipment
iv. Elevate legs
v. Rehydration with cool water (sipped slowly to avoid GI irritation)
1. Small amounts of commercial sports drink may be beneficial. 3:1 ratio of
water to commercial sports drink
2. IV fluids may be necessary in extreme cases. See Dehydration protocol
vi. Cool the patient with fans, ice towels or ice bags (arm pits, groin area, neck and
behind knees).
vii. Monitor vital signs and watch for progression to Heat Stroke
d. Heat Stroke
i. Check ABC’s and perform life-saving techniques as needed
ii. Remove all excess/unneeded clothing and protective equipment
iii. Before cooling, obtain baseline vital signs
1. Obtain rectal temperature if available
2. Blood pressure, heart rate, respiratory rate and CNS status should be
continuously monitored
iv. If rectal temperature cannot be measured, cool patient for approximately 10-15
minutes prior to transport
1. An approximate estimate of cooling, via cold water immersion is 1°C for
every 5 minutes, or 1°F for every 3 minutes of cooling (if water is
aggressively stirred).
v. Begin rapid cooling measures (ice water immersion or “Taco Method”)
1. Patient should be submerged up to their neck
2. Water should be kept between 35○F and 59○F.
a. Water should be continuously stirred to maximize cooling effect
b. Ice should cover the surface of the water at all times
3. Patient should be removed when core temperature (per rectal thermometer)
reaches 102○F (39○C)
vi. Initiate IV access Normal Saline.
vii. Transport to advanced care AFTER core temperature cooling has occurred.
Gastrointestinal Bleeding 1. Load the patient into the ambulance and begin transport as soon as possible.
2. Monitor the patient for hypotension and treat accordingly with IV Normal Saline bolus.
Hypertensive Crisis Hypertensive Crisis can present as hypertensive urgency or as hypertensive emergency.
Hypertensive urgency is a situation where the blood pressure is severely elevated (systolic ≥180
mmHG or diastolic ≥110 mmHG), but there is no associated organ damage. Symptoms of hypertensive
urgency may include:
· Severe headache
· Dizziness
· Shortness of breath
· Nosebleeds
· Severe anxiety
Treatment of hypertensive urgency generally requires readjustment and/or additional dosing of oral
medications, but most often does not necessitate rapid blood pressure reduction.
1. Record time of onset and current mean arterial pressure (MAP).
2. Provide comforting measures.
a. Turn the lights down or off
b. Place in a position of comfort
3. Administer Oxygen, maintain SpO2 above 94%.
4. Perform 12-lead ECG. If signs of AMI are present, follow the chest discomfort protocol.
5. Transport.
Hypertensive emergency exists when blood pressure reaches levels that are damaging organs. Signs
and symptoms of organ damage from uncontrolled hypertension include:
· Numbness/weakness
· Loss/change in vision
· Difficulty speaking
· Seizures
· Paralysis
· Altered LOC
1. Record time of onset and current mean arterial pressure (MAP).
2. Elevate the head 30○ in an effort to reduce cerebral hypertension.
3. Administer Oxygen, maintain SpO2 above 94%.
4. Perform 12-lead ECG. If signs of AMI are present, follow the chest discomfort protocol.
5. Contact Medical Control to consider Nitroglycerin, 0.4 mg SL q 3–5 min (maintain systolic BP
>100 mmHg) for continued symptoms until MAP is decreased by 20% of original.
6. Transport.
Obstetrics Antepartum Emergencies
1. Obtain a complete history, noting gestation, previous C-sections, gravida, para, and other pertinent
information.
2. Assess fetal movement if possible.
3. Transport patient in position of comfort. If patient is to be transported supine and she is past the
first trimester, place patient on her left side or tilt at an angle >10 to 15 degrees.
Eclampsia / Hypertension 1. Patients presenting with hypertension generally have a blood pressure >140/90mmHg, abnormal
weight gain, headache, edema in the face, hands, and ankles.
2. Calm and reassure the patient.
3. Dim the lights in the ambulance and quietly transport patient avoiding loud noises.
4. Observe for and be prepared to treat seizure activity with Magnesium Sulfate 4 grams slow IV
push over 5 minutes.
5. Magnesium Sulfate administration can cause respiratory depression or arrest. . Have Calcium
Chloride ready as antidote. Dose is 1 gram of 10% solution given IV over 3 – 5 minutes. When
treating hypertension, assess deep tendon reflexes for depression. May need to reduce or
discontinue infusion. Contact Medical Control for guidance regarding use of Calcium Chloride to
treat Magnesium Sulfate overdose.
Emergency Childbirth
1. Obtain a complete history, noting gestation, gravida, para, frequency of contractions, ruptured
membranes, and if the mother feels the need to move her bowels.
2. Examine the mother to determine if she is crowning or has an abnormal presentation. If so,
delivery is imminent and you must deliver the baby in the field.
3. If there is a breech presentation or if the umbilical cord is prolapsed, begin transport to the closest
hospital immediately.
4. If delivery is not imminent:
a. Begin transport of the patient in a position of comfort as soon as possible.
b. Monitor the patient’s vital signs and frequency of contractions.
c. Be prepared to stop the ambulance if delivery becomes imminent.
d. Notify the receiving facility as soon as possible.
5. If delivery is imminent and there is not enough time to transport the patient to the hospital, prepare
for delivery in the field. Never attempt to restrain or delay deliver in any fashion.
6. Request a second ambulance or paramedic.
7. Ensure the patient’s privacy and use sterile technique if possible. Encourage the mother to relax
and take slow, deep breaths through her mouth. Reassure her, and explain what you are doing as
you go along.
a. When the baby’s head begins to emerge from the vagina, support it gently to prevent
explosive delivery. Be sure the umbilical cord is not wrapped around the baby’s neck. If
the amniotic sac is still intact, rupture it with your fingers.
b. Suction the mouth then the nose of the infant after the head is delivered.
c. Deliver the shoulders and body, supporting the head at all times. Record the time of
delivery.
d. Tie or clamp the umbilical cord about 10 inches from the infant’s naval, with two clamps
placed 3 inches apart. Cut the cord between the two clamps, handling the cord very gently.
e. Keep the infant level with the perineum, dry with a towel and wrap in a thermal layer of
blankets to keep them warm.
f. Evaluate the infant using the APGAR scoring system (see Appendix) one minute after
birth and at five minutes after birth. Resuscitate as needed prior to each assessment.
g. Gently massage the abdomen above the uterus to control bleeding and aid in contraction.
h. Do not wait for the placenta to deliver. Load the mother and baby and begin transport to
the hospital. If the placenta delivers spontaneously, place it in a basin or plastic bag and
bring it to the hospital.
i. Continue to monitor both the mother and baby during transport.
Breech Presentation Follow guidelines for emergency childbirth, but try to elevate the baby anteriorly while delivering so as to
maintain a head flexed position rather than an extended head position. Gentle pressure applied to the fetal
head through maternal abdomen will also assist in maintaining flexion.
Meconium Presentation Suction oropharynx then nose after the head and anterior shoulder has delivered, but before complete
delivery of the infant. Refer to Neonatal Resuscitation for care of the infant.
Nuchal Cord 1. Attempt to gently slip cord around the baby’s head and continue with delivery.
2. If the cord is tight around the neck and cannot be removed, then clamp the cord in two places and
carefully cut it using a sterile scalpel or scissors.
Prolapsed Cord 1. Place patient on side in left trendelenburg position, or preferably in the knee to chest position.
2. Place gloved index finger-middle fingers into vagina, pushing infants presenting part upward to
relieve cord compression until arrival in hospital. Check frequently for loss of cord pulsation.
Shoulders Stuck 1. Take maternal legs and flex at the hip joint as if you were going to touch her toes to her ears. The
knees are generally flexed. Apply suprapubic pressure to assist delivery.
2. If the above procedure is not effective, cut a generous episiotomy, including into the rectum if
necessary, while another person applies suprapubic pressure. If this fails, then attempt to deliver
either arm by gently bringing the arm across the fetal chest and out of the vagina.
Preterm Labor True labor with gestation less than 36 weeks is preterm labor.
1. Inspect for crowning/imminent delivery.
2. If crowning is not apparent, administer a 500 – 1,000 ml fluid bolus.
Postpartum Hemorrhage Defined as blood loss greater than 500 ml.
1. Massage patient’s fundus and put the baby to nurse. Do not pack the vagina with dressings.
2. Load the mother and baby and begin transport to the hospital.
3. Do not wait for the placenta to deliver. If the placenta delivers spontaneously, place it in a basin or
plastic bag and bring it to the hospital.
4. Continue to monitor both the mother and baby during transport.
Overdose/Poisoning 1. Assure personnel safety. Attempt to establish rapport with the patient. If patient appears to be
dangerous, do not approach until law enforcement is on scene and able to provide restraint. If
patient is suicidal, do not leave the patient alone.
2. If a patient who appears to be a threat to self or others refuses evaluation, transport, or medical
care, and law enforcement refuses to put them in custody for necessary medical care; an affidavit
should be completed.
3. Obtain vital signs and a brief history, noting the substance involved, time since exposure or
overdose, route, and amount involved.
4. Specific overdose or poison management depends upon the substance involved. Contact Poison
Control or Medical Control for consult.
5. If tricyclic antidepressant overdose is suspected or confirmed, administer Sodium Bicarbonate
1mEq/Kg IV/IO.
6. If an Opioids overdose is suspected, paramedics may administer Naloxone (Narcan) 0.4mg IV/IO,
or 2 mg IN/IM. If desired degree of counteraction and improvement in respiratory function is not
achieved, may repeat every 2-3 minutes.
a. Naloxone (Narcan) may be administered by a qualified first responder per Revised
Missouri Statute Section A, Chapter 190.255
i. If using an auto-injectable naloxone (EVZIO®), follow the printed and verbal
instructions provided by the manufacturer. *intramuscular injections may only be
made with an auto-injector.
ii. If using prepackaged nasal spray (NARCAN®), administer a single spray in one
nostril. Repeat every three minutes as needed if no or minimal response.
iii. If using a pre-filled leur-lock syringe of injectable solution with an intranasal
mucosal atomizing device (MAD), spray 1 ml (1 mg) in each nostril. Repeat every
three minutes as needed if no or minimal response.
b. If administered prior to EMS arrival, the authorized first responder must provide, at a
minimum, a verbal report describing the patient’s presentation, the noted indications for
administration, the dose and route administered, and any changes in the patient’s condition.
7. Transport the patient in recovery position if unresponsive or position of comfort if alert.
Pediatric
1. Assure personnel safety. Attempt to establish rapport with the patient. If patient is combative or
dangerous, allow law enforcement to restrain them. If patient is suicidal, do not leave the patient
alone.
2. Note the substance involved, time since exposure or overdose, route, and amount involved.
3. Specific overdose or poison management depends upon the substance involved. Contact Poison
Control or Medical Control for consult.
4. Transport the patient in recovery position if unresponsive, or position of comfort if alert.
Respiratory Emergencies
Asthma History of asthma, audible wheezes, warm & dry
1. Administer High-flow Oxygen
2. Assess ETCO2 waveform
3. Administer Albuterol, 2.5 mg via nebulizer; repeat continuously as needed.
4. Consider Ipratropium Bromide/Albuterol (Duoneb) 3ml via nebulizer; may repeat 3 times. (8)
a. If patient presents with severe exacerbation of Asthma symptoms, administer Ipratropium
Bromide/Albuterol (Duoneb) first, or;
b. If Albuterol has already been administered prior to EMS without improvement, Administer
Ipratropium Bromide/Albuterol (Duoneb) first.
c. If further treatments are needed, follow with Albuterol, 2.5mg via nebulizer
5. Administer Solu-Medrol, 2 mg/kg to a max of 125 mg IV.
6. Consider Epinephrine, 1:1000, 0.5 mg IM injection.
7. Consider Magnesium Sulfate, 50 mg/kg IV (max dose 2000 mg).
Pediatric Asthma
1. Assess ETCO2 waveform
2. Administer Albuterol:
a. If ≥2 y/o 2.5 mg/3ml; repeat continuously as needed.
b. If <2 y/o 1.25mg/ 3ml of NS; (1.5 ml of albuterol solution + 1.5 ml of NS) repeat
continuously as needed.
3. Consider Ipratropium Bromide/Albuterol (Duoneb)-half dose 1.5 ml (add 1.5 ml of NS) via
nebulizer; may repeat 3 times. (8)
a. If patient presents with severe exacerbation of Asthma symptoms, administer Ipratropium
Bromide/Albuterol (Duoneb) first, or;
b. If Albuterol has already been administered prior to EMS without improvement, Administer
Ipratropium Bromide/Albuterol (Duoneb) first.
4. If further treatments are needed, follow with Albuterol
5. After initiation of IV, begin Infusion of Normal Saline 20 ml/kg bolus.
6. Consider Epinephrine 1:1000 IM, 0.01 ml/kg to 0.5 mg max: 3 doses 15min apart, if patient shows
signs of respiratory failure with inadequate ventilation or respiratory arrest.
7. Consider Solu-Medrol, 1- 2 mg/kg to a max 125mg IV/IM for long transport times. Contact
Medical Control prior to administration.
8. Consider Magnesium Sulfate, 50 mg/kg IV (max dose 2000 mg).
Chronic Obstructive Pulmonary Disease (COPD) Emphysema & Chronic Bronchitis with history of COPD, audible wheezing, warm & dry
1. Assess ETCO2 waveform
2. Oxygen therapy is based on patient’s clinical picture
a. Severe distress – poor perfusion
i. Oxygen titrated to a SpO2 of 88-92%
ii. Administer CPAP or BPAP
b. Minor distress – good perfusion
i. Oxygen titrated to a SpO2 of 88-92%
3. Administer Albuterol, 2.5 mg via nebulizer; repeat continuously as needed.
4. Administer Solu-Medrol, 2 mg/kg to a max of 125 mg IV
5. Consider Ipratropium Bromide/Albuterol (Duoneb) 3ml via nebulizer; may repeat 3 times.
Croup/Stridor Patients between 6 months and 6 years that present with sudden onset of barky cough, inspiratory stridor
at rest, respiratory distress.
1. Administer Racemic Epinephrine 2.25% solution; 3 ml via nebulizer. Do not repeat.
Spontaneous Tension Pneumothorax 1. Carefully assess for symptoms of a tension pneumothorax (absent lung sounds on affected side,
jugular vein distension, increasing respiratory distress, hypotension) in order to differentiate the
patient’s condition from a simple/asymptomatic pneumothorax.
2. If immediately life threatening, perform needle thoracostomy on the affected side (follow Needle
Thoracostomy Procedure).
3. If not immediately life threatening, contact Medical Control for orders or consult prior to
decompressing the chest.
Pediatric
1. If immediately life threatening, perform thoracic needle decompression on the affected side with
an 18 gauge catheter for children or 20 gauge catheter for infants (follow Needle Thoracostomy
Procedure).
2. If not immediately life threatening, contact Medical Control for orders or consult prior to
decompressing the chest.
Seizures 1. Protect patient from injury and aspiration. Suction airway as needed.
2. Note time of onset, type of seizure, and duration of each episode.
3. Perform a glucose test and treat if blood glucose level is < 70 mg/dl.
4. If patient is actively seizing, administer medication as follows.
a. Versed 0.1 mg/kg slow IV, max dose of 5 mg (may repeat once after 3 minutes); or
b. Versed 0.2 mg/kg IM, max dose of 5 mg
c. Providers may administer up to a total of 10 mg Versed for status epilepticus (continuous
seizure for ≥ 30 or ≥ 2 seizures during the same period of time without full recovery of
consciousness between seizures).
5. Transport patient in recovery position if unresponsive, or position of comfort if alert.
Pediatric
1. Protect patient from injury and aspiration. Suction airway as needed.
2. Note time of onset, type of seizure, and duration of each episode.
3. Perform a glucose test and treat if blood glucose level is < 60 mg/dl (< 45 mg/dl for neonates).
4. If patient is actively seizing, administer Versed 0.1 mg/kg IV/IO
5. If IV access cannot be obtained and seizure last > 5 minutes, administer Versed 021mg/kg IM/IN.
6. Transport patient in recovery position if unresponsive, or position of comfort if alert.
Sepsis Patients that present with the signs and symptoms of systemic inflammatory response syndrome (SIRS)
and have a documented or identifiable infection.
Identification of Sepsis 1. Patient presents with 2 or more of the following criteria and has a documented or identifiable
infection:
a. Temperature <96.8 or >101.0
b. Heart rate >90
c. Respiratory Rate >20
d. Serum Glucose >119 mg/dl in the non-diabetic patient
e. Altered LOC
f. End-Tidal CO2 reading of <25
2. OR, the patient scores “3” or greater on the “Sepsis Ticket”
Treatment 1. Identify the possible causes
2. Titrate Oxygen administration to an SpO2 >94%
3. Monitor ETCO2
4. Attach the Cardiac Monitor with pulse oximetry
5. Obtain vital signs and note the Mean Arterial Pressure
6. Obtain a Blood Glucose reading
7. Initiate 2 large bore IVs or humoral IO
8. Initiate Normal Saline wide open. 20mg/kg in the first hour
9. Rapid transport to the ED
10. Advise the receiving facility of “Possible Sepsis” via radio report
Stroke / Cerebrovascular Accident (CVA) 1. Assess patient for stroke symptoms utilizing the RACE Stroke Scale. (8), or the Cincinnati Stroke
Scale.
2. Rapid identification of the acute stroke patient is imperative and indicates immediate notification
of the receiving facility, advising Medical Control of a “Stroke Alert.” Report should include time
of onset, time last seen normal, time of discovery, neurological deficits, vital signs and
treatment provided.
3. Obtain blood glucose reading.
4. Obtain an emergency contact name and phone number of someone knowledgeable of the patient’s
past and present medical condition. This information should be provided to the receiving facility
and documented in the PCR.
5. Load the patient into the ambulance and begin transport immediately to the closest designated
stroke facility.
6. Observe and treat for seizures.
Post-tPA Interfacility Transfers PRIOR TO DEPARTURE FROM TRANSFER FACILITY:
1. 1. Verify that SBP < 180 and DBP < 105.
a. If BP is above limits, sending hospital should stabilize prior to transport or document prior
to discharge the reason for deviation.
b. Transferring physician should be consulted for hyptertension treatment orders during
transport.
2. Obtain contact method for family or caregiver (preferably cell phone) to allow contact during
transport or upon patient arrival at receiving facility.
3. Verify total dose and time of IV tPA bolus
4. If IV tPA dose administration will continue during transport, verify estimated time of completion.
a. Verify with the sending hospital that the excess tPA has been withdrawn from the tPA
bottle and wasted, so that the tPA bottle will be empty when the full dose is finished
infusing.
b. The sending hospital should apply a label to the bottle with the number of cc's of fluid that
should be in the bottle (So if there is a problem with the pump during transport, the correct
dosage is noted).
DURING TRANSFER:
1. Keep strict NPO including medications
2. Document stroke scale q15 min (RACE and/or Cincinnati Stroke Scale)
3. If swelling of the lips and/or tongue, and/or the voice is muffled, or the patient experiences
increased work of breathing, TURN OFF tPA drip and call medical control for further
instructions. Maintain O2 sat > 94%, treat allergic reaction per protocol.
4. Monitor and document vital signs q15 minutes.
5. If SBP>180 or DBP>105: TURN OFF tPA drip, then;
a. If no continuous infusion was intiated prior to transport, begin an Esmolol drip, starting at
50 mcg/kg/min. Titrate to desired blood pressure. Hold if SBP <140, or DBP <80, or HR
<60.
b. If a continuous infusion was initiated prior to transport, contact medical control for further
orders.
6. If patient becomes hemodynamically unstable (SBP <140, DBP< 80, and/or HR <60, TURN OFF
tPA drip and contact medical control.
7. Monitor tPA (Alteplase) infusion
a. When the pump alarms to signify the bottle is empty, there is still t-PA in the tubing which
must be infused.
b. When the tPa infusion is complete, remove the IV tubing connector from the tPA
(Alteplase) bottle and attach it to a newly spiked bag of 0.9% NS and re-start the infusion.
c. Continue the NS infusion at the SAME RATE AS TPA to flush the line (add 25 mL to
VTBI if necessary).
8. If patient develops severe headache, acute hypertension, nausea, or vomiting (suggestive of
intracerebral hemorrhage):
a. TURN OFF tPA infusion (if still being administered)
b. Call medical control for further instructions including decision to adjust blood pressure
medications.
c. Continue to monitor vital signs and neurological exam q15 minutes
d. Contact the receiving hospital ED with an update and ETA
9. For all Stroke patients, alert receiving facility at least 10 minutes prior to arrival
Syncope 10. Keep alert for underlying problems (hypotension, hypoglycemia, etc.) or associated injuries and
treat according to appropriate protocol. It is important to consider all possible causes.
11. Perform a 12 lead electrocardiogram.
12. Assess Blood Glucose level
13. Any time a patient refuses care after an abnormal 12 lead electrocardiogram has been obtained,
contact Medical Control for consult.
Sexual Assault 1. Do not disturb the crime scene. Preserve evidence by limiting access of non-essential personnel.
2. Protect the patient’s privacy and respect the patient’s right to confidentiality.
3. Limit physical exam to a search for injuries requiring immediate attention.
4. Discourage the patient from changing clothes, bathing, etc. until evaluated at the hospital. Place
any blood-stained clothing in a separate paper bag then place paper bag in a protective plastic bag.
5. Treat any injuries or medical conditions the patient may have according to appropriate protocols.
Trauma Protocols
Trauma Classification 1. RED - Class 1 Trauma – Life threatening injury or medical condition that requires immediate
emergency medical intervention. Patient is unstable and any delay may be harmful or lethal to
patient. This classification includes, but is not limited to, any of the following:
a. Obvious signs of shock: poor capillary refill, cyanosis, and cardiorespiratory collapse.
i. ETCO2 of 20 is generally accepted as the threshold in the transition between
compensated and decompensated shock.
b. Respiratory distress from airway obstruction and/or chest injuries.
c. Penetrating or blunt head injury associated with coma, altered LOC and/or lateralizing
signs.
d. Paralysis
e. Penetrating injury to neck, abdomen, or thorax.
f. Severe burn (greater than 15% BSA). Burns involving the airway, face, hands or genitalia
g. Hemodynamically unstable vital signs: BP less than 100 systolic; heart rate greater than
100,
h. Respiratory rate less than 10 or greater than 30, altered LOC, pale-cool-skin.
i. Two or more system injuries and hemodynamic instability.
2. YELLOW - Class 2 Trauma – Potentially life threatening injury or medical condition that requires
immediate emergency medical intervention. Patient is currently hemodynamically stable and may
or may not necessitate emergency transportation. This classification includes, but is not limited to,
any of the following:
a. Chest or abdominal injuries in the uncompromised patient.
b. Multiple or single long bone fractures in the uncompromised patient.
c. Two or more systems injuries with stable vital signs.
d. Isolated skeletal trauma to upper or lower extremities.
e. Mechanism of injury with high probability of serious injury.
f. Surviving victim of vehicular accident in which fatalities occurred.
g. Surviving victim of fall greater than twenty feet.
h. Patients below the age of 5 or above the age of 55 or those with previous medical histories,
which would place them in a high-risk category.
i. Automobile versus pedestrian collision.
j. Ejection from any motorized vehicle.
k. Extrication from entanglement greater than 20 minutes.
l. Rearward displacement of front axle.
m. Vehicle rollover.
3. GREEN - Class 3 Trauma – Currently stable with potentially serious injury or medical condition,
and does not require immediate emergency medical intervention. Vital signs are stable and patient
does not necessitate emergency transportation. This classification includes, but is not limited to,
any of the following:
a. Uncomplicated fracture.
b. No hypovolemia or hypotension.
c. No neurological injuries.
d. No abdominal injuries.
e. Soft tissue injuries are of moderate degree.
Guidelines for field triage of injured patients (9)
Abdominal Trauma 1. Blunt Injury – Assess the chest, abdomen, and pelvis checking for major associated injuries. If an
associated pelvic fracture is suspected, consider the use of the pelvic sling to stabilize the fracture.
Remember that a long backboard with full SMR is a universal splint for all fractures.
2. Evisceration – Do not attempt to replace the protruding organs into the abdomen. Leave the
viscera on the surface of the abdomen, and cover gently with dressings soaked in sterile saline.
These should be covered with bulky dressings and taped gently in place.
3. Impaled Objects – Do not remove objects impaled in the abdomen. Stabilize the object with
bulky dressings and tape in place.
4. Penetrating Injury – Control any external bleeding with sterile dressings and direct pressure.
Look for any exit wounds.
a. Wound packing is not indicated for abdominal injuries.
5. If severe bleeding cannot be controlled, or the mechanism suggests potential for major hemorrhage
(i.e. multiple long bone fractures, flail chest, abdominal injuries, etc) and there is evidence of
hypovolemia (BP <90 or HR >115).
a. Administer Tranexemic Acid (TXA) 1 gram in 100 ml NS over 10 minutes (2.5 drops/sec),
followed by 1 gram in 250 ml NS over 8 hours (31ml/hr).
Burns
General Considerations 1. During primary survey, assess closely for respiratory involvement and intubate the patient if signs
of laryngeal edema develop. Remember to take spinal trauma precautions as indicated.
2. Assess and treat the burn according to the appropriate protocol, noting the depth and area
involved. Determine the percent of body surface area (BSA). Any patient that has one or more of
the following is considered to be a critical burn and should be taken to a Burn Center.
a. Burns with respiratory tract involvement.
b. Burns to the face, hands, feet or genitalia.
c. Burns involving 30% or more BSA regardless of degree
d. Serious caustic substance burns.
e. All electrical burns.
f. Burns associated with other injuries.
g. Burns to the very young, very old, or a patient with serious disease.
3. Be alert for any associated injuries or aggravated medical conditions. Start IV’s in an unburned
area if possible and initiate flow rate as follows in critical burns:
a. If >15% BSA and age is <16 years, administer 250 ml/hr of Normal Saline
b. If >15% BSA and age is ≥16 years, administer 650 ml/hr of Normal Saline
c. Consult Medical Control at the Burn Unit for small children.
4. Cover burns with clean, dry, lint-free dressings or saran wrap.
5. Oral Intubation is the preferred intervention for airway management. If a Nasal-gastric tube is
placed, do not tape it to the ETT.
Chemical Burns 1. Maintain scene safety and use the appropriate personal protective equipment.
2. Try to determine the type of chemical involved. Take pictures of the container for reference at the
hospital. If safety of container is questionable then leave it alone!
3. Remove all clothing and thoroughly irrigate the contaminated area with large amounts of water. If
chemical is a dry powder, brush off as much of the chemical as possible before irrigating.
4. After flushing is complete, the burn area should be covered with sterile dressings or sheets. Protect
patient from hypothermia by covering with warm blankets.
5. If the eyes are involved, flush with copious amount of water for at least 20 minutes. Remove
contact lenses as soon as possible. After irrigation is complete, do not patch the eyes; apply moist
compresses with gauze soaked in normal saline.
Electrical Burns 1. Be sure the patient is not energized and the scene is safe before you approach. Downed power
lines frequently remain charged on the ground, and may attempt re-charging even if initially
“tripped” by being grounded. Never approach downed power lines until they are secured by
the local utility company.
2. Put out the fire! Remove smoldering clothing and any articles that may retain heat, such as rings,
bracelets, watches, etc.
a. Cool the burn area with clean water/saline then cover with sterile dressings or sheets.
b. Protect patient from hypothermia by covering with warm blankets.
3. Get an accurate history of injury including: AC/DC source, voltage.
4. Consider SMR or splinting based upon the mechanism of injury.
5. Treat cardiac dysrhythmias.
6. Assess peripheral pulses in all affected extremities.
Thermal Burns 1. Put out the fire! Remove smoldering clothing and any articles that may retain heat, such as rings,
bracelets, watches, etc.
2. Obtain an accurate history of injury, noting whether the burns occurred in a confined space with
steam, smoke or toxic fumes.
3. Gently wrap burned areas in dry sterile dressings or sheets, leaving unbroken blisters intact. If the
burn area is isolated and less than 10% BSA, you may cool the area by moistening the dressings
with saline. At no time should more than 10% BSA be covered with wet dressings, patients may
become hypothermic quickly if large burned areas
are cooled for a prolonged period of time.
Body Surface Area (BSA) Estimation BSA is an assessment measure of burns of the skin. In
adults, the "Rule of Nines" is used to determine the total
percentage of area burned for each major section of the
body. In some cases, the burns may cover more than one
body part, or may not fully cover such a part; in these
cases, burns are measured by using the patient's palm as a
reference point for 1% of the body.
Pediatric - For children and infants, the Lund-
Browder chart is used to assess the burned body
surface area. Different percentages are used because
the ratio of the combined surface area of the head
and neck to the surface area of the limbs is typically
larger in children than that of an adult.
Figure 3 - Lund-Browder chart
Figure 2 - Chart for the "Rule of Nines"
Smoke and Carbon Monoxide Exposure 1. All personnel should be aware that materials and new manufacturing processes used in industry
and in residential areas have created new and potentially lethal hazards. Any person suffering
smoke inhalation or carbon monoxide poisoning or suspected of suffering the same should be
evaluated at a trauma center, even if the individual is asymptomatic.
2. SpCO monitoring is an essential tool in the diagnoses of carbon monoxide poisoning and (when
available) should be used on all patients with suspected carbon monoxide exposure.
3. Any person with signs or symptoms as indicated below should be treated with high flow oxygen
and transported to the hospital.
a. Respiratory burns
b. Dyspnea or tachypnea
c. Hoarseness, cough or sore throat
d. Burns of face, lips, pharynx or singed nasal hair
e. Wheezing, rales or rhonchi
f. Carbonaceous or bloody sputum
g. Carbon particles in the nose or throat
h. Chest or neck pain
i. Cardiac arrhythmia
j. Central nervous system disruption
k. Dizziness
l. Headache
m. Mental confusion
n. Hallucinations
o. Seizures
p. Syncope
q. Conjunctivitis
r. Gastrointestinal
s. Epigastric pain
t. Nausea and vomiting
4. Any person who has had any of these above signs or symptoms, but becomes asymptomatic,
following on scene treatment should still be transported for evaluation and observation.
5. Certain types and intensities of smoke and/or fire exposure that are associated with high
probability of injury include the following:
a. Exposure in an enclosed space.
b. Unconsciousness or inebriation associated with smoke exposure.
c. Fire involving plastics (polymers) such as polyvinyl chloride (PVC).
d. Hot air or steam explosions.
6. Treat with high flow oxygen and do not rely on pulse oximetry for an accurate oxygen saturation
reading.
7. If available obtain SpCO and SpMet reading and treat according to patient presentation. If SpCO
level is >10 or SpMet level is >3, initiate oxygen therapy and transport.
Chest Trauma 1. Perform a detailed chest assessment, specifically noting flail segments, open wounds, tracheal
deviation, unequal chest movements, absent or diminished breath sounds, or subcutaneous
emphysema.
2. Flail Chest – Management should include ventilatory support, pain management and monitoring
for deterioration. Do not attempt to stabilize flail section.
3. Open Chest Wounds – Cover with an occlusive dressing and tape on three sides to allow for air to
escape. Be alert for a developing tension pneumothorax.
4. Penetrating Wounds – Control any external bleeding with sterile dressings and direct pressure.
Look for any exit wounds. Do not remove objects impaled in the chest. Stabilize the object with
bulky dressings and tape in place. Be alert for a developing tension pneumothorax.
a. Wound packing is not indicated in chest trauma.
b. Apply chest seal(s)
5. Tension Pneumothorax – Perform a needle decompression on affected side. (Refer to Needle
Thoracostomy in procedures section)
6. If severe bleeding cannot be controlled, or the mechanism suggests potential for major hemorrhage
(i.e. multiple long bone fractures, flail chest, abdominal injuries, etc) and there is evidence of
hypovolemia (BP <90 or HR >115).
a. Administer Tranexemic Acid (TXA) 1 gram in 100 ml NS over 10 minutes (2.5 drops/sec),
followed by 1 gram in 250 ml NS over 8 hours (31ml/hr).
Extremity Trauma 1. Amputations – Apply pressure with bulky dressings to control external bleeding.
a. Tourniquets should be applied if direct pressure and dressings fail to control bleeding
b. The tourniquet should be applied just proximal to the bleeding wound. Tighten until
bleeding ceases and secure in place; add additional tourniquets as required. Record the
time the tourniquet was applied on a piece of tape and attach to the tourniquet. Leave the
tourniquet uncovered so it can be monitored for further bleeding.
c. Cover proximal stub with sterile moistened dressings. Apply direct pressure to control
bleeding. Wrap the amputated part in a dressing moistened with sterile saline and place in
a watertight container with ice or cold packs. Keep amputated part away from direct
contact with ice or cold packs in order to prevent frostbite.
d. Partial amputations should be dressed and splinted in alignment with the extremity,
avoiding torsion.
e. Transport immediately, time is of the greatest importance to assure viability of amputated
part.
2. Dislocations, Fractures and Sprains – In most cases, splint the injured extremities in the position
found and apply sterile dressings to all open wounds. Commercial splinting products (such as the
SAM Splint) are preferred over improvised devices.
a. Splints should immobilize the joint above and below the site of injury.
b. Assess circulation and sensation before and after applying splints.
c. If circulation is absent or diminished, gentle traction and straightening should be attempted
as long as no resistance is met.
d. If at all possible, do not reduce exposed bone ends into the wound.
e. Consider application of cold packs to closed injuries.
f. Apply pressure with bulky dressings and elevate to control external bleeding. If bleeding
cannot be controlled with direct pressure, consider applying hemostatic gauze.
3. Severe Bleeding – a tourniquet should be applied if direct pressure and dressings fail to control
bleeding.
a. The tourniquet should be applied just proximal to the bleeding wound.
b. Tighten until bleeding ceases and secure in place; properly applied tourniquets will be
painful for a conscious patient.
c. Record the time the tourniquet was applied on a piece of tape and attach to the tourniquet.
d. If the wound is such that the use of a tourniquet is not possible, or impractical, consider
packing the wound with hemostatic gauze or Kerlix.
i. Hemostatic gauze may also be used in conjunction with a tourniquet to assist in
clotting.
ii. Hemostatic gauze is not indicated for minor bleeding.
e. If severe bleeding cannot be controlled, or the mechanism suggests potential for major
hemorrhage (i.e. multiple long bone fractures, flail chest, abdominal injuries, etc) and there
is evidence of hypovolemia (BP <90 or HR >115).
i. Administer Tranexemic Acid (TXA) 1 gram in 100 ml NS over 10 minutes (2.5
drops/sec), followed by 1 gram in 250 ml NS over 8 hours (31ml/hr).
Head Trauma 1. All head injured patients have a cervical spine injury until proven otherwise.
2. Any patient with a suspected head injury and a GCS of 8 or less, insufficient respiratory effort or
inability to maintain their own airway should be considered a candidate for tracheal intubation.
3. Provide a BLS airway and ventilate the patient at 12 bpm while preparations for intubation are
made.
4. Consider Rapid Sequence Intubation (RSI) if available.
5. In-line spinal immobilization must be maintained during intubation of any head trauma patient.
6. After tube placement is confirmed, ventilations should be provided at 10bpm.
7. End tidal CO2 levels of 35-40 mmHg are desirable. However, if signs of herniation are noted
controlled hyperventilation to maintain CO2 levels of 30-35 mm Hg is indicated. (10)
Pediatric
1. Provide a BLS airway and ventilate the patient at 20-24 bpm while preparations for intubation are
made.
2. Consider Rapid Sequence Intubation (RSI) if available.
3. Consider Atropine, 0.02 mg/kg prior to or simultaneously with Succinylcholine.
4. Consider Versed, 0.1 mg/kg IV or 0.2 mg/kg IN (max 4 mg dose) for sedation prior to intubation if
RSI is unavailable.
5. Intubate orally while maintaining in-line spinal immobilization.
6. After tube placement is confirmed, ventilations should be provided at 20-24 bpm.
7. Maintain ETCO2 30-35 mmHg.
Multiple Systems Trauma 1. Rapidly assess and extricate the patient utilizing industry standard trauma life support techniques.
2. Begin transport of the patient as soon as possible to the closest trauma center.
3. Consider the use of air medical services if transport time to the nearest trauma center will be
delayed by extrication or transporting from a rural area.
4. Exceptions to patient destination can be dictated by the inability to adequately maintain a patent
airway, ventilate the patient, or control active bleeding. Other factors that could alter patient
destination may include but are not limited to, inability to transport via helicopter, vehicle
problems, severe weather conditions, or mass casualty incidents.
Snake Bite 1. Transport patient immediately; do not delay transport for treatment or wait for signs of
envenomation.
2. Remove all jewelry; wash infected area with copious amounts of water.
3. If bite is located on an extremity, immobilize extremity in full extension and maintain below the
level of the heart. Immobilizing in full extension is preferred to prevent the pooling of venom in
the antecubital or popliteal fossae.
4. Mark the proximal edges of the infected area with an ink pen being sure to note the time, repeat
every 15 minutes.
5. Treat for allergic reaction or anaphylaxis if signs/symptoms are present.
6. Do not apply a tourniquet, restricting band or cold compress to the infected area. If a tourniquet is
in place prior to EMS arrival, contact Medical Control.
7. All venomous snakes common to Missouri use the same antivenom. If possible and only if it is
safe to do so, identify the snake or take a picture of it to show the physician. Do not attempt to
capture or transport a live snake to the hospital.
Spinal Motion Restriction EMS providers routinely respond to patients with the potential for spinal trauma and the necessity of
treating with spinal motion restriction (SMR).
Indications: (11)
1. Focal neurologic deficit on motor or sensory exam
2. High risk patients:
a. Ejection from vehicle
b. Motorcycle crash >20 mph
c. Auto vs. pedestrian or cycle at >20 mph
d. Axial load to head (i.e. diving)
e. Fall from 3 times patient’s height
3. Low risk patients are patients who have at least one of the following:
a. Point tenderness on palpation of spinous process
b. Are not reliable due to:
i. Altered LOC
ii. Evidence of chemical impairment
iii. Distracting injury. Examples:
1. Long bone fractures
2. Large burns
3. Large laceration, degloving, or crush injury
4. Any other injury producing acute functional impairment
iv. Unable to communicate adequately
Contraindications:
1. Patients with penetrating traumatic injuries should NOT be immobilized unless a focal neurologic
deficit is noted. (12) (13) (14) (15) (16)
Techniques:
1. See Spinal Motion Restriction in the Procedures section for step-by-step process.
2. If the patient is ambulatory, place an appropriate sized cervical collar and position the patient
directly on the ambulance cot.
3. Stable patients without neurological deficits may be allowed to self-extricate or move to the
ambulance cot after placement of an appropriately sized cervical collar.
4. Patients that do NOT have any of the findings identified in subsections 1, 2, or 3 of this protocol
may be transported without a cervical collar.
5. In the event a long spine board or scoop stretcher is utilized for patient extrication or movement, at
the paramedic’s discretion, the patient should be removed from the device and placed directly on
the ambulance cot for transport.
Spinal Trauma / Neurogenic Shock Neurogenic shock is a distributive type of shock resulting in hypotension, occasionally with bradycardia,
that is attributed to the disruption of the autonomic pathways within the spinal cord.
1. Package patient in SMR and begin rapid transport.
2. Monitor cardiac rhythm and vitals closely.
3. Initiate two large-bore IV lines.
4. Titrate IV therapy to a mean arterial pressure (MAP) of 85 - 90mmHg and contact Medical
Control.
Traumatic Cardiac Arrest 1. A traumatic arrest is defined as a patient that has blunt or penetrating trauma that is found
pulseless and apneic upon EMS arrival to the patient.
a. It is recommended by The National Association of EMS Physicians and the American
College of Surgeons Committee on Trauma to withhold resuscitation for patients with: (17)
i. Injuries that are obviously incompatible with life, such as;
1. Hemisection of torso
2. Decapitation
3. Catastrophic brain trauma
4. Pulseless and apneic in a MCI
5. Injuries that would prevent effective CPR
ii. Patients with evidence of a prolonged arrest, such as;
1. Rigor mortis
2. Dependent lividity
3. Known downtime of greater than 15 minutes
iii. On arrival of EMS, patient is pulseless, apneic and has no organized electrical
activity.
1. Asystole
2. PEA less than 40 bpm.
2. If the above conditions are not met, begin resuscitation efforts.
3. If the incident is within 10 minutes of a trauma center, load and go rapid transport and resuscitate
during transport. If not, remain on scene and resuscitate until ROSC is obtained or efforts
terminated.
4. Resuscitation of the traumatic arrest patient is not the same as a cardiac arrest patient. Do not
follow CCR protocols. Instead;
a. Begin CPR with 30:2 compressions to ventilations ratio with rhythm checks every 2
minutes. Defibrillate as needed.
b. Secure the airway with an advanced airway adjunct as soon as possible
c. Initiate large-bore IV/IO access and begin fluid resuscitation.
d. Consider Dopamine if the patient presents with a PEA rhythm. 10 mcg/kg/min IV drip.
e. If any injuries to the chest are noted, perform bilateral chest needle decompression
f. Continue resuscitation efforts until ROSC is obtained, or 15 minutes has passed.
i. If no ROSC after 15 minutes, contact medical control and terminate efforts. (18)
ii. If ROSC is obtained, begin rapid transport to a trauma center. Consider HEMS
transport if it is available and would not delay further care.
iii. Prior to transport, ensure that the Lucas device is in place if needed.
iv. If patient rearrests during transport, continue resuscitation and transport to the
nearest hospital.
Pulseless and Apneic upon EMS arrival
Any Injuries Incompatable
With Life?1
WithholdResuscitation
ProlongedArrest?2
ECG Rhythm?
Start Chest Compressions
Secure Advanced Airway
Initiate IV/IO,Fluid Bolus
Perform Bilateral Needle
Decompression
After 15 minutes of efforts, ROSC?
Terminate Efforts
Transport to Trauma Center
1. Injuries that are obviously incompatible with life: a. Hemisection of torso b. Decapitation c. Catastrophic Brain Trauma d. Pulseless, apneic in a MCI e. Injuries that would prevent effective chest compressions.
2. Prolonged Arrest: a. Rigor Mortis b. Dependent lividity c. Known downtime > 15 minutes
Asystole or PEA <40bpm
V-Fib or PEA >40bpm
Yes
No
No
Yes
No
Yes
RESUSCITATION INSTRUCTIONS: 1. Do not follow CCR protocol: a. 30:2 Compression to Ventilation Ratio, 2 minute cycles b. Defibrillate at rhythm checks if needed c. No Epinephrine is indicated d. If ECG rhythm is PEA, administer Dopamine 10 mcg/kg /min e. Do not delay securing advanced airway. Perform as soon as possible. 2. Load and Go rapid transport if incident is within 10 minutes of a Trauma Center. 3. Consider HEMS transport if available 4. If in doubt, Resuscitate!
Defibrillate V-fib
Special Needs Patients General
1. Assess and treat a patient with special health care needs as you would any other patients—treat the
ABC’s first.
2. The best source of information about a patient is the person who cares for the patient on a daily
basis. Listen to this caregiver and follow their guidance regarding the patient’s treatment. Patients
with chronic illnesses often have different physical development from well patients. Therefore,
their baseline vital signs may differ from normal standards. Also, the size and developmental level
may be different from age-based norms and length based tapes to calculate drug dosages may not
be accurate. Ask the caregivers if the patient normally has abnormal vital signs (i.e. a fast heart
rate or a low pulse ox).
3. Treat the patient, not the equipment. For technology assisted patients, determine if the emergency
may be related to an equipment malfunction and manage the patient appropriately using your own
equipment. Some patients may have sensory deficits (i.e. they may be hearing impaired or blind)
but may have age appropriate cognitive abilities. Follow the caregiver’s lead in talking to and
comforting a patient during treatment and transport. Do not assume that a patient is
developmentally delayed.
4. When moving a special needs patient, a slow careful transfer with two or more people is
preferable. Do not try to straighten or unnecessarily manipulate contracted extremities as it may
cause injury or pain to the patient.
5. Caregivers of patients often carry “Go Bags” or diaper bags that contains supplies to use with the
patient’s medical technologies and additional equipment such as extra tracheostomy tubes,
adapters for feeding tubes, suction catheters etc. Before leaving the scene, ask the caregivers if
they have a “go bag” and carry it with you.
6. Caregivers may also carry a brief medical information form or card, or the patient may be enrolled
in a medical alert program whereby emergency personnel can get quick access to the patient’s
medical history. Ask the caregivers of they have an emergency information form or some other
form of medical information for their patient.
7. Caregivers of patients often prefer that their patient be transported to the hospital where the patient
is regularly followed or the “home” hospital. When making the decision as to where to transport a
patient, take into account; the patient’s condition, capabilities of the local hospital, caregiver
request, ability to transport to certain locations and the ability to request helicopter transport for
distant “home” hospitals.
Apnea Monitors 1. Look at the apnea monitor and determine the alarm code (i.e. heart rate, apnea, etc.).
2. Check the electrodes or monitor chest belt and ensure proper placement.
3. Make sure that the monitor is powered and is not low on batteries.
4. Bring the apnea monitor to the hospital. Disconnect and power off the apnea monitor to prevent
interference with ALS cardiac monitor.
5. If breathing is adequate, place the patient in a position of comfort and administer 100% oxygen.
6. Bring any of the patient's medical charts or medical forms that the caregiver may have, as well as
any supplies for other adjuncts the patient may have.
7. Perform focused history and detailed physical exam enroute to the hospital.
8. Reassess at least every 3-5 minutes or more frequently as necessary and possible.
Central Lines 1. Determine if the cause of the emergency is related to the central line by examining the central line
and its site of placement. Determine whether it is an implanted catheter, peripherally inserted
central venous catheter (PICC) or tunneled central venous catheter.
2. If the central venous line is partially or completely dislodged, or damaged, or if there is bleeding
from the site, apply direct pressure to the skin site, stop any infusions, and clamp the catheter.
3. Estimate blood loss and assess for signs and symptoms of an air embolism (tachypnea, chest pain,
shortness of breath, or loss of consciousness) or blood clots. If an air embolism is suspected,
clamp the central line with the clamp on the tube itself, place the patient on the left side in a head
down position, and administer high flow oxygen.
4. If there are fluids infusing through the central line, determine the nature of the fluids and the time
that the fluids were started.
5. Obtain a complete medical history for the patient, including a history of the present illness and the
past medical history.
6. If there are fluids infusing through the central line, stop the infusion, and clamp the central line
before transport. Note: There are some infusions that may be detrimental to stop. Ask the
caregiver if it is all right to stop or change the infusion first. Contact Medical Control for
additional instructions
7. Initiate cardiac monitoring and treat dysrhythmias.
8. If the patient has a fever or if the central line is damaged, stop fluid infusion immediately. If the
patient does not have a fever, contact Medical Control to determine whether fluid infusion should
be stopped or changed to normal saline.
9. If the patient is in cardiac arrest, the central line is not damaged, and the catheter is not an
implanted catheter, utilize the central line to infuse fluids and medications. Note: An implanted
central venous line cannot be used unless it has been accessed prior to EMS arrival or the care
givers have additional equipment to access the line.
10. If the patient is not in cardiac arrest, or the central venous line is damaged, obtain IV access.
Note: If the central line is damaged, or it is an implanted catheter that has not been previously
accessed, it cannot be used. If you do not have the equipment to access the central line, ask the
caregivers for supplies. Do Not Use The Catheter If It Is Damaged.
Central Venous Catheter 1. Wash hands and wear sterile gloves
2. Scrub the injection cap with alcohol. Do not use
Providine-iodine.
3. Clamp the catheter 3 inches from the cap prior to
removing the injection cap.
4. Remove the cap and secure a 10 ml or 12 ml syringe filled
with 5 ml of normal saline onto the injection port site of
the central line. Note: Always hold the connecting syringe
with the plunger straight up to avoid an accidental
injection of air.
5. Unclamp the catheter and attempt to slowly aspirate 5 ml
of blood
6. If blood clots are aspirated, immediately clamp the catheter, contact Medical Control and do not
proceed further.
7. Clamp the catheter and discard aspirate.
8. Secure a new syringe filled with 10 ml of normal saline, unclamp and slowly infuse 5 to 7 ml into
the catheter to ensure patency.
9. If resistance is met, immediately stop procedure and clamp catheter.
10. Clamp the catheter and remove the syringe.
11. Place a well-primed IV line onto the injection port and secure with tape.
12. Unclamp the line and catheter.
13. Administer fluids and medications as necessary.
Peripherally Inserted Central Venous Catheter (PICC) 1. Access using the same procedure as that of a central venous line (see
A above). Observe the following precautions:
2. Do not place a tourniquet on the same arm as the PICC.
3. Do not clamp the PICC tubing. Instead, clamp the extension tubing.
4. Do not flush or aspirate from a PICC with less than a 10 cc syringe
(smaller size syringes generate too much pressure and can damage the
catheter.)
5. The maximum flow rates for a PICC line is 125 ml/hour for less than
2.0 sized Fr. Catheters and 250 ml/hour for catheters over 2.0 sized
Fr. Catheters.
6. If signs and symptoms of shock exist, infuse a fluid bolus of 20 ml/kg
of normal saline. This bolus may be repeated up to two times. If signs
and symptoms of shock do not exist, infuse normal saline at a KVO rate. Note: Do not take blood
pressure in the same arm as PICC line.
Figure 5 - PICC line
Figure 4 - Central Venous Catheter
Colostomy 1. Assess the patient’s colostomy container and note any damage to the container or irritation around
the site of the colostomy.
2. If the colostomy site appears irritated or infected (signs of infection include red, warm, tender skin
spreading away from the stoma site), empty the colostomy container (or ask the caregivers to
empty the container) and transport immediately.
3. If the collection container breaks or is torn off, ask the caregivers for a replacement container and
ensure that it fits and seals over the stoma. If a replacement container is not available, place moist
gauze over the stoma opening and place a plastic bag over the gauze to collect any contents.
Alternatively, several layers of dressing may be applied over the stoma to collect any contents.
4. Assess the abdomen and note any significant findings.
5. Obtain a complete medical history including history of the present illness. Also, ask the time and
amount of the last feeding. Obtain any medical information forms that the caregivers may have for
emergency medical providers. Note: Do not delay emergent treatment or transport to obtain a
history.
6. Assess for signs and symptoms of dehydration.
7. Bring any of the patient's medical charts or medical forms that the caregiver may have, as well as
any supplies for other adjuncts the patient may have. Perform focused history and detailed
physical exam enroute to the hospital. Reassess at least every 3-5 minutes or more frequently as
necessary and possible.
CSF Shunts 1. Assess for signs and symptoms of shunt obstruction or shunt infection. (Signs and symptoms of
shunt obstruction or infection include headache, nausea, vomiting, increased sleep, blurred vision,
irritability, loss of coordination, altered mental status, bradycardia or other dysrhythmias, redness
along the shunt track, apnea, seizures, high pitched cry, fever, or full or bulging fontanel, unequal
pupils and irregular respiratory pattern).
2. Treat seizure activity.
Feeding Tubes 1. Assess the abdomen for signs of distention. If distention is present, follow step 8.
2. Obtain a complete medical history for the patient, including a history of the present illness and the
past medical history.
3. Determine if the cause of the emergency is related to the feeding tube by examining the feeding
tube and its site of placement. Determine the type of feeding tube that is in place.
4. Treat problems associated with the tube as per the following table:
Nasal or Oral Feeding Tube Treatment
Complete catheter
dislodgement
Assess respiratory status. Assess for dehydration. Ask if the patient
has missed any feedings.
Partially dislodged catheter Ask the caregiver to check the tube position. If the tube’s position
cannot be confirmed, remove the tube by gently pulling the tube out of
the nose or mouth.
Gastric distention Connect an appropriately sized syringe to the external opening of the
feeding tube. Aspirate until resistance is met (see Step F). If blood is
seen in the aspirated contents, contact Medical Control and report
findings.
Button or Gastrostomy
Tube
Treatment
Complete catheter
dislodgement
Assess for dehydration. Ask if the patient has missed any feeding.
Place some gauze over the site with direct pressure to site. Rapidly
transport to an appropriate facility. Reinsertion of the tube is
immediately needed.
Insertion site is irritated or
bleeding
Cover the site with a sterile dressing and control any bleeding with
direct pressure.
Gastric contents are leaking
around catheter
Cover the site with sterile gauze and assess the abdomen. Causes for
leakage may include balloon deflation, coughing, constipation, bowel
obstruction and seizure. Treat any medical problem according to the
appropriate protocol.
Gastric distention Connect the appropriate tubing and syringe to the external opening of
the feeding tube (if the equipment is not available on the ambulance,
ask the caregivers for supplies). Slowly aspirate until resistance is met.
Distention may be a cause of bowel obstruction or air in the stomach.
Obstructed tube Transport immediately to an appropriate facility. The tube needs to be
cleared or replaced immediately. Do not force fluids through the tube.
Clamp the tube.
Feeding tube adaptor breaks Clamp the tube and transport immediately to an appropriate facility.
The tube needs to be replaced.
5. If there are fluids infusing through the feeding tube, determine the nature of the fluids and the time
that the fluids were started. If the feeding tube appears damaged, or the site is irritated, stop all
infusing fluids, flush the tube with enough water to clear the tube (in the same port that was being
used for infusion), then clamp the tube.
6. If abdominal distention is noted, decompress the stomach as follows:
7. Ask the caregivers for an appropriate size syringe (or tubing adaptor if the patient has an anti-
reflux valve).
8. Unclamp the distal end of the tube.
9. Connect the syringe and tubing adaptor (if indicated), to the external opening of the tube.
10. Gently and slowly aspirate air and gastric contents until resistance is met.
11. The tube can either then be re-clamped or left open. If left open, place the distal end of the tube in
a cup below the level of the stomach so the contents can drain.
12. Bring any of the patient's medical charts or medical forms that the caregiver may have, as well as
any supplies for other adjuncts the patient may have. Perform focused history and detailed
physical exam enroute to the hospital. Reassess at least every 3-5 minutes or more frequently as
necessary and possible.
Tracheostomy Emergencies 1. Assess the tracheostomy tube. If the obturator has been left in place, remove it to open the
tracheostomy tube. If the patient has a fenestrated tube, make sure the decannulation plug is
removed. If suctioning is needed, follow step 8.
2. Position the patient in a neutral position with a towel roll underneath the shoulders as needed.
3. Assess the patient's breathing including rate, auscultation, inspection, effort and adequacy of
ventilation as indicated by chest rise. Obtain a pulse oximeter reading.
4. If the patient is in respiratory distress, attempt assisted ventilation through the tracheostomy tube.
For ventilator dependent patients, follow the “Special Needs Patients - Ventilator Emergencies”
protocol in addition to the following steps. Note: If the tracheostomy is a double lumen tube, the
inner cannula must be in place for the bag-valve mask to connect.
5. Ask the caregivers for the patient's baseline vital signs, if they are on home oxygen, and the
amount and method by which they receive the oxygen.
6. Obtain a complete history including a history of the present illness, past medical history and
interventions taken to correct the emergency before EMS arrival.
7. Deliver high flow oxygen by placing an oxygen mask directly over the tracheostomy opening or
with manual ventilations. Insert 1 ml of normal saline into the tracheostomy tube every 15 minutes
if humidified oxygen is not available.
8. Check breath sounds while ventilating. If breath sounds are not clear (or gurgling sounds are
heard), suction the tracheostomy tube as follows.
9. If thick secretions are noted, inject 1 to 2 ml of sterile normal saline into the tracheostomy tube.
10. Use a suction catheter from the patient's supplies, if available. If unavailable select a suction
catheter small enough to pass easily through the patient's tracheostomy tube.
11. If using a portable suction machine, set it to 100 mmHg or less. Note: To estimate the size of the
suction catheter, double the inner diameter of the tracheostomy size. For example, a neonatal or
pediatric inner diameter 3.5 tracheostomy tube (3.5 x 2 = 7) would take a size 6 suction catheter.
12. Determine proper suction catheter length by measuring the obturator. If the obturator is
unavailable, insert the suction catheter approximately 2 to 3 inches into the tracheostomy tube.
13. Apply suction for no more than 10 seconds while slowly withdrawing the catheter, rolling the
catheter between the fingers.
14. If unable to pass a suction catheter, proceed directly to the next step.
15. If ventilation continues to be difficult, change the tracheostomy tube as follows.
16. Ask the caregivers for a replacement tracheostomy tube. If the caregivers do not have a
replacement tube, follow steps to remove the tracheostomy tube. Ventilate by placing the bag-
mask device with an infant mask attached, directly over the stoma. Cover the patient's mouth and
nose. Note: Do not use force! This procedure requires the presence of two people. Initiate the help
of a knowledgeable caregiver when available.
17. Alternatively, the patient can be ventilated by placing a mask over the nose and mouth and
covering the stoma.
18. If the patient has a cuffed tracheostomy tube, deflate the balloon by connecting a syringe to the
valve on the pilot balloon. Draw air out until the pilot balloon collapses. Note: Do not cut the pilot
balloon, as this will not deflate the cuff. If the pilot balloon was cut, do not remove the
tracheostomy tube. Contact Medical Control.
19. If the patient has a double cannula tracheostomy tube, remove the inner cannula. If removal of the
inner cannula fails to clear the airway, the outer cannula should then be removed.
20. Cut the cloth or Velcro ties that hold the tracheostomy tube in place.
21. Remove the tracheostomy tube using a slow, outward and downward motion.
22. Gently insert the same-size tracheostomy tube, with the obturator in place. Point the curve of the
tube downward. The tracheostomy tube may be lubricated with a water-soluble gel or normal
saline. Do not force the tube.
23. If the tracheostomy tube cannot be inserted easily, withdraw the tube and attempt to pass a smaller
size tracheostomy tube.
24. If a replacement tube cannot be inserted, ventilate by placing the bag mask device with an infant
mask attached, directly over the stoma. Cover the patient's mouth and nose. Alternatively, the
patient can be ventilated by placing a mask over the nose and mouth and covering the stoma.
25. Attempt to insert an endotracheal tube (ETT) if a smaller tracheostomy tube is not available or
cannot be inserted. Select an endotracheal tube with an inner diameter equal to or smaller than the
inner diameter of the last tracheostomy tube attempted. Make sure the outer diameter of the
endotracheal tube is smaller than the outer diameter of the tracheostomy tube most recently
attempted. Attempt to insert an endotracheal tube no more than two inches into the opening. Aim
the tip of the endotracheal tube downward to prevent tissue damage after passing it through the
stoma. If the endotracheal tube has a cuff, inflate the cuff after checking proper placement. Note:
Do not cut the endotracheal tube to make it shorter.
26. If ventilations fail through the mouth and nose, or stoma, insert a suction catheter approximately
two inches into the stoma. Connect to oxygen at rate prescribed by Medical Control. Transport
immediately.
27. If the tracheostomy tube is successfully placed, assess breath sounds, then secure the tube with the
tracheostomy ties.
28. If an ET tube was placed and there is chest rise and equal breath sounds with manual ventilation,
secure the tube with tape.
29. Reassess breath sounds every 3-5 minutes.
30. If ventilation is successful through the nose and mouth, and a replacement tracheostomy or ET
tube is unable to be passed through the stoma, orally intubate with an appropriately sized
endotracheal tube.
31. If breathing is adequate, place the patient in a position of comfort and administer 100% oxygen by
placing an infant mask directly over the stoma (or as tolerated by the patient). If patient is
ventilator-dependent, manually ventilate patient by placing an infant face mask directly over the
stoma.
32. Obtain the patient's medical history from the caregiver, including a history of the present illness
and past medical history.
33. Assess circulation and perfusion.
34. If bronchospasm is present in a patient with adequate ventilation, administer Albuterol 2.5 mg by
placing the aerosol mask directly over the tracheostomy tube. If the patient is being assisted with
ventilations, set up an inline albuterol nebulizer treatment and administer directly through the
tracheostomy tube. Repeat as needed.
35. Initiate transport to the nearest appropriate facility as soon as possible.
36. Bring any of the patient's medical charts or medical forms that the caregiver may have, as well as
any supplies that the caregiver may have for the tracheostomy tube.
37. If the patient has a ventilator or apnea monitor, bring it to the hospital.
38. Perform focused history and detailed physical exam enroute to the hospital.
39. Reassess at least every 3-5 minutes, more frequently as necessary and possible.
Ventilator Emergencies 1. Establish patient responsiveness. If cervical spine trauma is suspected, manually stabilize the
spine.
2. Assess the patient's airway and breathing including rate, auscultation, inspection, effort and
adequacy of ventilation as indicated by chest rise.
3. Look at the ventilator and determine the alarm code (i.e. heart rate, respiratory rate, apnea etc.).
4. If no breathing is present, follow the steps below:
5. Disconnect the ventilator tubing from the tracheostomy tube.
6. Ask the caregivers to turn the ventilator off to prevent the alarm from sounding.
7. Attach the bag-valve device to the opening of the tracheostomy tube and begin manual ventilation.
If the tracheostomy has an inner cannula, it must be present in order to attach the bag-valve
device.
8. Assess for equal chest rise and breathe sounds on both sides.
9. If chest rise is shallow, adjust the patient's airway position and check to see that the bag-valve
device is securely connected to the tracheostomy tube. If chest rise does not improve, assess the
tracheostomy tube for obstructions by following the tracheostomy protocols.
10. Obtain a pulse oximeter reading.
11. Assess circulation and perfusion.
12. Ask the caregivers for the patient's baseline vital signs, ventilator settings, and if they are on home
oxygen, the amount and method by which they receive the oxygen.
13. Obtain a complete history including a history of the present illness, past medical history and
interventions taken to correct the emergency before EMS arrival.
14. Ask the caregivers or assess the ventilator to determine if the machine is a ventilator, a BiPAP or
CPAP machine. A patient can be transported on CPAP and BiPAP providing his or her respiratory
drive is not compromised. If the patient has a poor or non-existent respiratory drive, manual
ventilations must be initiated immediately. Note: BiPAP and CPAP machines do not have internal
batteries and only function if they are powered by a source of electricity.
15. If bronchospasm is present in a patient with adequate ventilation, administer Albuterol 2.5mg by
placing the aerosol mask directly over the tracheostomy tube.
16. If the patient is being assisted with ventilations, set up an inline albuterol nebulizer treatment and
administer directly through the tracheostomy tube.
17. Repeat Albuterol once if necessary at the same dose (for a total of 2 doses).
18. If breathing is adequate, place the patient in a position of comfort and administer 100% oxygen.
19. Check the ventilator and correct any ventilator problems per the following table:
Alarm Possible Causes Interventions
Low Pressure/Apnea
(results in inadequate
ventilations or chest rise)
· Loose or disconnected circuit
· Leak in the circuit
· Leak around the tracheostomy
site
· Ensure that all circuits are
connected
· Check the tracheostomy balloon
· Ensure that the tracheostomy is
well seated
Low Power Internal battery is nearly depleted Plug the ventilator into a power
outlet
High Pressure · Plugged or obstructed airway
or circuit (secretions, water)
· Patient coughing or
bronchospasm
· Clear obstruction
· Suction tracheostomy
· Administer bronchodilator
Setting Error Ventilator settings are not within
equipment capacity (settings have
been incorrectly adjusted)
· Manually ventilate the patient
· Transport the patient and
ventilator
Power Switchover The unit has switched from AC
power to internal battery
Press the “Alarm silent” button after
ensuring that the battery is powering
the ventilator
20. If the patient has excessive secretions, or receives humidified oxygen at home, insert 1 ml of
normal saline into the tracheostomy tube every 15 minutes.
21. Contact Medical Control for additional instructions.
22. Bring any of the patient's medical charts or medical forms that the caregiver may have, as well as
any supplies that the parent may have for the tracheostomy tube.
23. Bring the ventilator, BiPAP or CPAP machine to the hospital. If the patient is not experiencing
respiratory distress, ensure that the ambulance can power the ventilator, or that the ventilator has
adequate battery power. If power is not available, disconnect the patient from the ventilator and
manually ventilate the patient.
24. Initiate transport to the nearest appropriate facility as soon as possible.
25. Perform focused history and detailed physical exam enroute to the hospital.
26. Reassess at least every 3-5 minutes, more frequently as necessary and possible.
Community Paramedic Protocols
The following treatment protocols are only for use by TCAD Community Paramedics, licensed by the
Missouri Bureau of EMS as a Community Paramedic on patients that are actively enrolled in the Mobile
Integrated Community Access Program, while conducting home visits. If the Community Paramedic
encounters a medical/trauma situation that is not addressed in these protocols, they are to follow the
standard Taney County EMS System protocols and consult with the patient’s PCP for further direction.
MIHCP Participant with Congestive Heart Failure /Pulmonary Edema 1. Measure weight of patient & compare to their ideal body weight
2. Assess and document more controlled cardiac and lung exam with focus on subtle rales, wheezes,
dullness or murmurs such as gallop or S3
3. If iStat is available:
a. Obtain Potassium Level, taking care to prevent hemolysis
i. May repeat test x 1 if suspicion of error or hemolysis
ii. If Potassium < 2.5mEq/L transport to ED
iii. If Potassium > 5.5mEq/l transport to ED
iv. If clinical judgment indicates concerning patient presentation, transport to ED
b. Obtain Creatinine level. If it is > 3mg/Dl;
i. Consult with PMD for follow-up appointment in 24 – 48 hours and any medication
alterations (if unable to schedule appointment in 24 – 48 hours, transport to ED)
ii. Avoid administering additional furosemide
iii. Avoid administering additional potassium
iv. Discontinue prescribed potassium supplement until PCP follow up
4. Provide education regarding appropriate diet and medication compliance as indicated from
focused history
a. Recommend ingestion of food to reduce indigestion if potassium is increased
5. Instruct patient to obtain and record daily weight
6. Measure current patient weight and compare to established baseline weight
7. Caution to only use and compare weights on calibrated scales to prevent error in measurements
8. If patient is 2 – 3 pounds over established baseline weight
a. Increase PO furosemide dose 50% for 48 hours
b. Notify PMD of the medication dose change and consider permanent dose change
c. Schedule a return visit for evaluation in 48 hours
9. If patient is 3 – 5 pounds over established baseline weight
a. Double PO furosemide for 48 hours
b. Increase PO potassium supplement by 25% for 48 hours
c. Discuss plan with PMD and establish a PMD evaluation in 48 hours
d. Schedule a return visit for evaluation in 24 hours
10. If patient is 5 pounds over established baseline weight
a. Administer PO dose of furosemide once
b. Double PO furosemide dose for 48 hours starting with next scheduled dose
c. Increase potassium by 25% for 48 hours
d. Discuss plan with PMD and establish a PMD evaluation in 24 hours
e. Reevaluate patient in 2 hours MIHCP Participant with Diabetes
1. Perform finger stick glucose.
a. Glucose between 70-299 mg/dl
i. Continue with home visit
b. If the blood glucose is less than 70 mg/dl or symptomatic of hypoglycemia
i. Altered mental status or unable to complete swallow assessment
1. Administer 250 ml 10% dextrose IV
a. Improved glucose (>100)
i. Unclear cause for hypoglycemia
1. Assist patient in calling PCP for further instruction
2. Continue home visit
ii. Clear cause for hypoglycemia- Example missed meal
1. Continue home visit
b. Unimproved glucose
i. Consider EMS transport
ii. Normal mental status able to complete a swallow assessment
1. Provide meal with a simple and complex sugar- continue with home visit,
Reassess glucose in 30 minutes
a. Improved glucose (>100)
i. Unclear cause for hypoglycemia
1. Assist patient in calling PCP for further instruction
2. Continue home visit
ii. Clear cause for hypoglycemia- Example missed meal
1. Continue home visit
b. Unimproved glucose
i. Administer 250 ml 10% dextrose IV
ii. Consider EMS transport
iii. If patient is hypoglycemic and taking oral sulfonylureas such as glyburide, ED
evaluation and possible admission are recommended.
c. If the blood glucose is greater than 300 mg/dl.
i. Altered mental status or symptomatic of hyperglycemia
1. Administer 10 ml/kg NS (max 1000 ml) and reassess
ii. Normal mental status without signs of hyperglycemia
1. Continue with home visit
2. Set up a call to follow up with patient in 24 hours MIHCP Participant with Diabetes Cont.
1. Consider discharge from the program if select patients resolve issues with their hypoglycemia, or
improving hyperglycemia
a. Patient must be baseline mental status
b. Simple identified cause for episode such as:
i. Diet noncompliance (Missing meals, eating sugary foods)
ii. Inadvertent excessive dosage of insulin with clear understand of the error and
importance of future medication compliance
iii. Recent steroid burst dose for acute limited medical condition (asthma, allergic
reaction)
c. Tolerating PO
d. Have adequate food and medication to support appropriate glucose management
e. Provide education regarding appropriate diet and medication compliance as indicated from
focused history.
f. No untreated or dangerous source for glucose abnormalities
i. Example- dangerous source: Sulfonylureas such as glyburide can cause prolonged
hypoglycemia and may need admission
ii. May require simple POC labs as Urine Dip, Urine HCG, or in some patient’s
additional blood testing such as CBC or BMP
g. Resolution of acute visual changes
h. Patient should check blood sugars each hour for 3 hours to ensure they remain in a safe
range.
2. Patient should be instructed on maintaining a clear log of blood sugars and notations made of any
recent changes in diabetic medications should be noted.
3. Effort should be made to reduce insulin dose with PMD if recent increase in dosage associated
with a hypoglycemia event.
4. Consider additional fluids to help reduce free-water deficit in hyperglycemic patients
MIHCP Participant with Hypertension
Note
· Hypertensive emergencies are characterized by severe elevations in BP (>180/120 mmHg)
associated with acute end – organ damage
o Examples include hypertensive encephalopathy, intracerebral hemorrhage, acute
myocardial infarction, acute left ventricular failure with pulmonary edema, aortic
dissection, unstable angina pectoris, eclampsia, or posterior reversible encephalopathy
syndrome “PRES” (a condition characterized by headache, alter mental status, visual
disturbances, and seizures)
o Patients with hypertensive emergencies should be transported to the emergency department
and monitored in ICU setting
1. History
a. Be sure inquire and document any environmental factor or any hypertensive diet
noncompliance and educate as required
2. Assessment should focus on signs and symptoms of end organ damage such as:
a. Pulmonary edema, renal insufficiency or failure, myocardial symptoms such as chest
pressure, headache for cerebrovascular abnormalities
b. If history or physical suggestive of organ damage, transport to a facility capable of
checking associated screening labs and providing intravenous parenteral antihypertensive
therapy
3. Initial treatment goals are to reduce the mean arterial BP by no more than 25% within minutes to 1
hour
a. If the patient is stable, reduce the BP to 160/100 – 110 mmHg within the next 2 - 6 hours
i. Asymptomatic hypertension may not need to be altered acutely and may cause
more harm than good
ii. Work within the MIH/CP Care Plan to determine any alterations in blood pressure
regiment or patient specific medication instructions
iii. Consider referral to outpatient resource in asymptomatic patients with elevated
blood pressure (<180/110 mmHg)
4. Medical therapy and close follow – up are necessary in patients who present with acutely elevated
BPs (systolic BP > 200 mmHg or diastolic > 120 mmHg) that remain significantly elevated
5. Contact PCP for alterations in medication dosing and follow – up recommendations prior to
disposition
MIHCP Participant with Nausea and Vomiting 1. History
a. Brief past medical history including dry mucous membranes, >2 sec capillary refill,
tachycardia, skin tenting, orthostatic BP, lethargy, restlessness, sunken fontanels
2. Assessment
a. If risk for radiation exposure, ensure adequate decontamination
b. Query about water/food contamination; symptom onset and duration, quantity of vomiting
or diarrhea, frequency, PO intake (is patient able to keep down liquids) alcohol abuse, and
urine output including when patient last urinated
c. For patients with suspected carbon monoxide exposure (i.e. emergency generator use, fires,
excavation crawl spaces), obtain oximetry, place patient on oxygen by NRB at 100%, to
maintain O2 sat above 95% and notify EMS for transport to ED.
3. Abdominal exam
4. Neurological exam-neck supple, mental status changes, focal neurological signs
5. Females of childbearing age-consider pregnancy and urine pregnancy test
a. Special Considerations
i. Elderly-Intravenous fluid rates need to be adjusted if underlying cardiac problems,
particularly history of congestive heart failure
ii. Pregnant Women-Pregnant women with uncontrolled vomiting must be referred to
definitive care or consult with OB for fluid management
Dehydration
1. If signs of dehydration, obtain Intravenous access and give 1 Liter (20ml/kg) Normal Saline over
10-20 minutes
a. Estimate urine output. Reassess patient after 1 Liter
b. If no improvement, start second liter (20ml/kg) of Normal Saline over 30 minutes
c. Give antiemetic one dose if continued nausea and vomiting
i. Zofran (Ondansetron) 4mg Intravenous
d. Reassess after 2nd liter of fluid
e. Estimate urine output. If no improvement, start second Intravenous line access
f. Consider electrolyte replacement with any additional fluids
g. If improved, start PO challenge and discharge if tolerating fluids, baseline mental status
and no dangerous symptoms
h. If signs of dehydration include evidence of circulatory collapse at any time (decreased
blood pressure, mottle skin, mental status changes, absent peripheral pulses)
i. Establish 2 large bore Intravenous access, start Intravenous NS fluid bolus
(20ml/kg children and 2 Liters in adults) wide open
ii. Start supplemental oxygen (maintain O2 saturations >92%) and place on monitor
(consider ECG) labs-Consider Hematocrit for hemoconcentration electrolytes, UA
MIHCP Participant with Obstructive Airway Disease
Asthma Exacerbation
1. Transport to ED near fatal, life threatening and acute severe asthma patients
2. If any concerns exist regarding the clinical stability or suitability of the
patient for treatment at home, transport to ED
3. Educate patient on PEF and instruct on its use and daily PEF log
4. Focus on patient specific areas such as environmental or weather-related
exposure, smoking dangers and cessations options, allergic exposures,
compliance with medications and routine as indicated
5. If mild symptoms completely resolve after a single nebulized treatment, and
PEF is in Green Zone and source of exacerbation identified as simple
missed medication, and patient has access to rescue inhaler, then consider
discharge patient with instructions for Q4 hour treatments scheduled for 3
days
6. If moderate asthma exacerbation and symptoms resolve after up to
maximum of 2 nebulizer treatments, and patient is afebrile and HR<110 and
BP normotensive, and PEF>75% of best or predicted
7. Call PCP for follow up scheduling
COPD Exacerbation
Document “GOLD” Severity if available from History
Gold 1 Mild—FEV1 ≥80% predicted
Gold 2 Moderate—FEV1≥50% - <80% predicted
Gold 3 Severe— FEV1≥30% - <50% predicted
Gold 4 Very Severe—FEV1<50%
MMRC Dyspnea Scale
Grade 0 I only get breathless with strenuous exercise
Grade 1 I get short of breath when hurrying on level ground or walking up a slight hill.
Grade 2 On level ground, I walk slower than people of the same age because of breathlessness or
must stop for breath when walking at my own pace.
Grade 3 I stop for breath after walking about 100 yards or after a few minutes on level ground.
Grade 4 I am too breathless to leave the house, or I am breathless when dressing.
Document Historic Best or Calculate Predicted Peak Flow
Assess and Record Current Peak Flow (best of 3 times)
1. Transport all patients to the emergency department that are
a. Gold 3 (severe) and Gold 4 (very severe) patients with persistent symptoms or peak flows
below baseline
b. Unable to cope at home
c. Grade level above baseline on MMRC Dyspnea Scale after initial treatment and all Grade
4 with persistent symptoms
d. Use of accessory muscles or increased work of breathing or Peak flows outside of baseline
Gold level percentage range
e. Altered LOC or altered mental status
f. New oxygen requirement of Oxygen<92% or persistent below baseline despite treatment
g. Unstable vital signs
h. Indications of cardiac source including but not limited to (ECG changes, chest pain, CHF,
worsening peripheral edema or weight gain)
i. Arrange immediate transport of patient to appropriate accepting location with Chest X-ray
availability and Antibiotic Prescribing capability for patients with signs of infection such
as fever or increased sputum production or pulmonary rales
i. 80% COPD exacerbation are infectious sources with half of those bacterial
2. Consider option of non-transport for patients with NONE of the above contraindications AND are
not experiencing exacerbation of another comorbid condition
a. Cardiovascular diseases, osteoporosis, depression and anxiety, skeletal muscle
dysfunction, metabolic syndrome, and lung cancer occur frequently in COPD patients
b. Remain asymptomatic without new oxygen requirement
c. Infrequent exacerbations (first exacerbation within 30days of hospitalization)
3. Non-transport patients
a. Ensure steroid dose (if not already established)
b. Schedule a prednisone burst 40 mg PO x 5 days (increase on home dosing or through PMD
Rx)
c. Schedule a PMD visit OR return APP follow up reassessment within 24hrs.
d. Discuss possible antibiotic with PMD such as Azithromycin (Z-pack)
Procedures General Considerations
1. The medical procedures are designed to give general instructions to the provider.
2. All personnel should be well versed in the utilization of all medical procedures contained here
within based on the providers level of training and authorization to perform each procedure.
3. The following medical procedures are approved local guidelines only and are not meant to replace
current manufacturer recommendations for use.
4. All medical procedures listed should be initiated based on instruction of the appropriate protocol
in preceding sections.
5. Any time the provider encounters the need for a medical procedure that is not specifically outlined
in this section, they should rely on their professional training and/or contact Medical Control for a
consult.
6. At no time should a provider initiate a critically invasive procedure that is not contained in the
medical procedure section without contacting Medical Control first.
7. If for any reason certain modalities of patient care are not proceeding as they should, crews are
expected to continue good, effective basic life support and proceed to the nearest hospital.
8. The importance of thorough documentation cannot be over-emphasized both when providers are
acting “under protocol,” and when acting directly from on-line Medical Control.
Airway Management Airway maneuvers may be performed without on-line Medical Control where the patient does not have a
patent airway or is not breathing. The simplest method that will maintain the patient’s airway without
compromising care should be utilized. Manual airway maneuvers (i.e. head tilt-chin lift, jaw thrust, or
modified jaw thrust) should be utilized before invasive airway maneuvers are attempted. Monitor the
airway continuously to be sure your treatment remains effective.
Oropharyngeal Airway Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Unconscious, unresponsive patients.
Contraindications: Gag reflex present.
Procedure:
1. Pre-oxygenate patient if possible.
2. Measure airway from corner of mouth to earlobe.
3. Grasp the tongue and jaw, lifting anteriorly.
4. Insert airway inverted and rotate 180º into place.
5. A tongue depressor may also be used.
6. Ventilate patient and listen for lung sounds.
Nasopharyngeal Airway Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responders
Indications: Conscious or semiconscious patients unable to control their airway. Clenched jaws, altered
LOC, with a gag reflex.
Contraindications: Fluid or blood from ears or nose. Signs of a basilar skull fracture.
Procedure:
1. Pre-oxygenate patient if possible.
2. Measure the tube from the tip of the nose to the earlobe.
3. Lubricate the airway with water-soluble jelly (KY, surgilube, or Xylocaine jelly).
4. Insert tube (attempt right nare first) with bevel of tube toward the septum, angling toward the base
of the floor of the nasopharynx, re-assess the airway. If resistance is met in right nare, attempt
insertion in left nare.
5. Ventilate patient as needed and listen for lung sounds.
Endotracheal Intubation Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Cardiopulmonary arrest, need for definitive airway, positive pressure ventilation, risk of
aspiration, aid for assisting ventilation.
Precautions: Can induce hypertension and increased intracranial pressure (ICP) in head injured patients.
Can induce vagal response and bradycardia. Can also induce hypoxia related dysrhythmias.
Procedure:
1. Preoxygenate the patient with BVM and basic adjunct or non-rebreather and OPA during CCR.
2. Assemble, check, and prepare all equipment. Have rescue airway and suction equipment ready.
3. Place patient’s head in sniffing position or hyperextend the neck slightly. If patient has a possible
spinal injury, the provider must maintain in-line immobilization and have second provider assist
with c-spine control during intubation.
4. If utilizing direct laryngoscopy:
a. Insert laryngoscope blade, avoid pinching the bottom lip or resting blade on upper teeth,
and sweep tongue to the left.
b. Lift the laryngoscope forward to displace the jaw.
c. Advance the endotracheal tube past the vocal cords until cuff disappears.
d. Inflate the cuff with 7 – 10 ml of air.
5. If utilizing video laryngoscopy:
a. Open the mouth
b. Carefully insert the laryngoscope blade into the mouth, advancing to the vallecula, or just
over the epiglottis.
c. Advance the endotracheal tube either through the channel of the blade, or using a stylet
with the standard blade until the cuff passes the vocal cords.
d. Remove stylet if utilized.
e. Inflate the cuff with 7-10 ml of air.
6. Ventilate patient while observing for chest rise.
7. Auscultate lung sounds and over the epigastrium.
8. Secure the tube, noting the tube depth at the patient’s teeth.
9. Apply capnography and monitor ETCO2 and waveform constantly.
10. Apply a commercial tube holder and bite block. Also place a cervical collar on patient (regardless
of medical or trauma etiology), and reassess tube placement often.
Bougie The Bougie is a one-time use, disposable flexible
stylet that is designed to aid in the intubation of
patients where visualization of the glottic opening is
not readily and easily obtained.
Authorization: TCAD Paramedics, and EMRA
Paramedics (optional)
Indications:
1. Unable to intubate the patient after your
initial optimized attempt.
2. Any patient with a visualized Grade III or IV
Cormack/Lehane view of glottic opening.
3. May be used for Grade II if unsure as well.
4. Patients with very anterior anatomy.
5. Patients that are spinally immobilized, and therefore cannot have any extension of neck.
6. Patients with airway edema/narrowing which limits ability to visualize glottic opening (using a
smaller ETT than you would normally use for your patient’s size).
7. Patients with inability to fully open mouth.
8. Airway full of emesis/blood which makes it not possible to visualize glottic opening.
Precaution: You must use a 6.0 (or greater) sized ETT for the stylet to fit.
Procedure:
1. Hold stylet like a pencil to help ‘tweak’ it into correct position.
2. Perform laryngoscopy using all aids to obtain your best possible view.
3. Place the tip of stylet underneath the epiglottis (and above arytenoids if at all visible) and direct or
‘tweak’ it anteriorly.
4. Gently advance stylet forward maintaining upward pressure and feel for:
a. ‘Ratcheting’ of the stylet tip against the tracheal rings
b. Mild resistance indicating it is at the carina or smaller airways (no eventual resistance
indicates a probable esophageal placement)
5. Once ‘ratcheting’ or resistance is felt, then the stylet should be withdrawn until the 25cm line is at
lips/incisors, and the stylet should then be held firmly in place.
6. Optimally, you should hold the stylet and keep the laryngoscope in place to hold tongue and tissue
out of way for your tube to advance.
7. If possible, have an assistant slide a tube down the stylet. Be sure the stylet remains still, and is not
inadvertently being withdrawn as the tube is advanced.
8. If advancement meets resistance, the ETT is probably hanging up on the right side of the glottic
opening; withdraw slightly and rotate the tube 90 degrees counter-clockwise and advance again.
9. Once tube is placed, hold the tube securely and withdraw the stylet.
10. Perform all endotracheal tube placement confirmation steps thoroughly, as there is not true visual
placement past cords.
Figure 6 - Cormack-Lehane grading system. (19)
Nasotracheal Intubation Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Need for definitive airway, conscious patients or those not tolerating endotracheal
intubation. Need to assist ventilation. Nasotracheal intubation is performed on breathing patients.
Contraindications: Signs of a basilar skull fracture, bleeding from the nose or ears.
Precautions: High risk of nosebleeds could cause aspiration. Risk of sinus infection with diabetic
patients.
Procedure:
1. Preoxygenate patient with BVM and NPA.
2. Assemble, check, and prepare all equipment. This includes (but is not limited to) a Beck Airflow
Airway Monitor (BAAM) whistle, a lubricated Endotrol tube, capnography, and suction
equipment.
3. Place patient’s head in midline, neutral position. If patient has a possible spinal injury, maintain
in-line immobilization and have second provider assist with c-spine control during intubation.
4. Remove nasopharyngeal airway and insert lubed Endotrol with the bevel towards the nasal
septum.
5. Advance tube aiming the tip down along the nasal floor. Use one hand to advance tube and the
other hand to palpate the larynx.
6. Gently advance the tube along the airway while rotating it medially until the best airflow is heard
through the tube. Use the BAAM whistle to aid in hearing airflow.
7. Gently and swiftly advance the tube during early inspiration. Patient may cough as the tube passes
through the vocal cords. Be sure to advance the tube all the way to the nare.
8. Inflate the cuff with 7 – 10 ml of air.
9. Ventilate patient while observing for chest rise.
10. Auscultate lung sounds and over the epigastrium.
11. Secure the tube, noting the tube’s depth at the nose mark.
12. Perform all endotracheal tube placement confirmation steps thoroughly, as there is not true visual
placement past cords.
13. Apply capnography and monitor ETCO2 and waveform constantly.
14. Continue ventilation with 100% oxygen and reassess tube placement often.
Esophageal Tracheal Combitube Authorization: All Paramedics and EMT-Basics
Indications: Emergency backup device for difficult intubations in the unconscious or cardiac arrest
patient. To provide sufficient ventilation for patients at risk of aspiration and those patients requiring
positive pressure ventilation.
Contraindications: Responsive patients with active gag reflex, known esophageal disease or who have
ingested caustic substances, and any patient under 5 feet tall.
Precautions: The Combitube contains natural rubber latex, which may cause allergic reactions.
Procedure: 1. Preoxygenate the patient with BVM and basic adjunct.
2. Assemble, check, and prepare all equipment. Have suction equipment ready.
3. If patient has a possible spinal injury, maintain in-line immobilization and have second provider
assist with cervical spine control during insertion.
4. In the supine patient, lift the tongue and jaw with one hand. Caution: When facial trauma has
resulted in sharp, broken teeth or dentures, remove dentures and exercise extreme caution when
passing the Combitube into the mouth to prevent the cuffs from tearing.
5. With the other hand, hold the Combitube so that it curves in the same direction as the natural
curvature of the pharynx. Insert the tip into the mouth, advance in a downward curved movement
until the teeth or alveolar ridges lie between the two printed bands. Caution: Do not force the
Combitube. If the tube does not advance easily, redirect it or withdraw and reinsert.
6. Inflate #1 blue pilot balloon with 100 ml of air using the 140 ml syringe. Inflate #2 white pilot
balloon with 15 ml of air using the 20 ml syringe.
7. Begin ventilation through tube #1. If auscultation of breath sounds are positive and epigastric
sounds are absent, continue ventilating through this tube. The tube has been directed into the
esophagus and in this circumstance tube #2 may be used for removal of gastric contents with a
suction tube.
8. If auscultation of breath sounds are absent and gastric insufflation is positive when ventilating
through tube #1, immediately begin ventilating through tube #2. Confirm positive breath sounds
on auscultation and absence of gastric sounds. In this case the tube has been directed into the
trachea and cannot be used for evacuation of gastric contents.
9. If both auscultation of breath sounds and gastric insufflation are negative, the Combitube may
have been advanced too far into the pharynx. Reposition the tube and reassess the patient until
positioned correctly.
10. Secure the tube and continue ventilation with 100% oxygen.
11. Reassess tube placement often by auscultation and watching for chest rise.
Pediatric Quicktrach Authorization: TCAD Paramedics only
Age of patient?
Use 2.0 mm QuicktrachUse Surgical
Cricothyrotomy procedure
Greater than 5 years of age1 – 5 years of age
Hyperextend the patient’s neck (if there are no C-spine concerns). Locate the cricothyroid ligament and clean with aseptic technique.
Firmly hold the Quicktrach and puncture the site at a 90° angle.
Change angle of insertion to 60° and advance the device further into the trachea to the level of the red
stopper.
Remove the red stopper and carefully advance the device until air can be aspirated.
Remove the red stopper while holding the device firmly.
Slide ONLY the PLASTIC CANNULA along the needle into the trachea until the flange rests on the
neck.
Remove the needle and syringe. Secure the cannula with neck tape provided.
Apply the connecting tube to cannula and attach to BVM or ventilation circuit.
Change angle of insertion to 60° and advance the device further into the trachea, taking care to avoid
puncturing the posterior tracheal wall.
Attempt to aspirate air into syringe.
NO (Air Return)YES (Air Return)
START
Ventilate patient.
Suctioning Upper Airway Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Trauma to the upper airway with blood, teeth, or other material causing partial obstruction.
Presence of excess fluid, secretions, vomitus, food, or other foreign material in the airway.
Precautions: Can cause hypoxia, coughing, increased intracranial pressure, and soft tissue damage to
respiratory tract. Can also induce hypoxia related dysrhythmias. If fluid, vomitus, or other material
continues to well up and completely obstruct airway, suctioning must continue until airway is
reestablished. Patients with pulmonary edema may have endless frothy secretions, be sure to oxygenate
and assist ventilations even though you might be tempted to suction continuously.
Procedure:
1. Open the airway and inspect for visible foreign material.
2. If possible, turn patient on side to facilitate clearance of airway.
3. Remove large or obvious foreign matter with gloved hands. Sweep finger across posterior
pharynx and clear material out of mouth.
4. Prepare suction equipment with appropriate size and style of suction tip or catheter.
5. Ventilate patient with 100% oxygen as needed.
6. Suctioning oropharynx:
a. Using tonsil tip or open end of tube for large debris, insert tip into oropharynx under direct
visualization.
b. Using a sweeping motion, suction oropharynx for no more than 10 seconds (unless there
are copious amounts of fluid or debris obstructing airway).
c. Use positive pressure ventilation or active oxygenation with a mask between each attempt.
d. If suction becomes clogged, dilute by suctioning water from a container to clean tubing.
7. Suctioning nasopharynx:
a. Using catheter, insert tip into nasopharynx without applying suction.
b. Advance tip gently until resistance is felt. It may be necessary to lubricate catheter prior to
attempt.
c. Apply suction and gently twist while withdrawing catheter, this should take no longer than
10 seconds.
8. Use positive pressure ventilation or active oxygenation with a mask between each attempt.
9. If suction becomes clogged, dilute by suctioning water from a container to clean tubing.
10. If suctioning patient continually, monitor pulse oximetry and assess patient for hypoxia.
11. Suctioning attempts should continue until patient’s airway is clear.
12. Continually reassess patient for the necessity to repeat suctioning procedure.
Surgical Cricothyrotomy Authorization: TCAD Paramedics only
Indications: Patients needing emergency airway access and control when they are unable to be
adequately ventilated or intubated due to trauma or other causes. This procedure is a last resort airway
technique when attempts at ventilation and intubation or other airway devices have failed.
Precautions: Complications include hemorrhage from great vessel or thyroid gland lacerations, damage
to surrounding structures, false passage, perforation of the esophagus, subcutaneous or mediastinal
emphysema, and/or aspiration.
Procedure:
1. Quickly assemble, check, and prepare all equipment. Have suction equipment ready.
2. Place patient supine. If patient has a possible spinal injury, maintain in-line immobilization and
have second provider assist with c-spine control during surgical cricothyrotomy.
3. Cleanse the neck with Betadine swabs.
4. Stabilize the larynx using the thumb and middle finger of one hand. Palpate the cricothyroid
membrane and pull the skin taut.
5. Make a 1 cm horizontal incision at the cricothyroid membrane. A small amount of bleeding is to
be expected and you can use sterile 4 4’s to control bleeding. If severe hemorrhaging ensues
apply direct pressure to site.
6. Insert nasal speculum and spread open incision site just wide enough to safely pass endotracheal
tube. This procedure should allow direct visualization into the trachea.
7. Place endotracheal tube through the opening of the nasal speculum. The endotracheal tube cuff
should be just inside the trachea and then remove speculum. Inflate the cuff using 10 ml syringe
with 7 – 10 ml of air.
8. If it is difficult to pass the endotracheal tube through the opening of the speculum, consider the use
of a bougie. The Bougie device can be inserted into the opening to keep the hole open, then
carefully expand the size of the opening with the scalpel. Then insert the ETT over the Bougie.
9. Ventilate the patient with a BVM and 100% Oxygen. Auscultate for the presence of lung sounds
and absence of epigastric sounds. Watch for chest rise and fall, moisture in endotracheal tube and
apply capnometer as soon as possible to monitor CO2 level.
10. Dress the incision site with drain sponges and secure the tube in place with a tube tie. Note: never
let go of the endotracheal tube before it is properly secured in place.
11. Continue ventilation with 100% Oxygen and reassess for placement and effectiveness often.
12. For a complicated procedure the provider may utilize all tools provided in Cricothyrotomy Kit to
successfully place the endotracheal tube. This may include the use of a curved Kelly, a trach
hook, or a skin retractor.
King LTS-D Laryngeal Tube with Gastric Access Authorization: All Paramedics and EMT-Basics
Indications: Failed intubation or anticipated difficult intubation in patient without a gag reflex.
Precautions: Patients that have ingested caustic substances.
Procedure:
1. Select the most appropriate size tube (measured by patient height):
a. Size 3: 4-5 feet (122-155 cm) in height
b. Size 4: 5-6 feet (155-180 cm) in height
c. Size 5: >6 feet (>180 cm) in height
2. Apply chin lift and introduce King LTS-D into corner of mouth
3. Advance tip under base of tongue, while rotating tube back to midline.
4. Without exerting excessive force, advance tube until base of connector is aligned with teeth or
gums.
5. Inflate cuffs to 60 cmH20. Typical inflation volumes:
a. Size 3: 40-55 ml
b. Size 4: 50-70 ml
c. Size 5: 60-80 ml
6. Attach bag-valve device. While gently bagging the patient to assess ventilation, simultaneously
withdraw the airway until ventilation is easy and free flowing.
7. Check cuff volume. If air is leaking around the cuff, add a small amount of additional air to the
cuff.
8. When using the gastric access lumen: Lubricate gastric tube (up to an 18Fr) prior to inserting into
the King LTS-D.
Positive End Expiratory Pressure (PEEP) Valve Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Patients receiving positive pressure ventilations with a bag valve
mask.
Procedure:
1. After patient is intubated adjust PEEP valve to desired setting:
a. Pediatric patient – set at 5.
b. Adult patient – set at 8 – 10.
2. Attach PEEP to bag-valve device.
3. Ventilate patient allowing each exhalation phase to complete prior to
the next positive pressure ventilation.
4. To adjust the desired PEEP flow from above procedure, contact
Medical Control for orders.
5. Document the PEEP setting used on the patient’s report form.
Impedance Threshold Device (ITD) Authorization: All Paramedics, EMT-Basics, and Emergency Medical
Responder
Indications: Any pulseless patient with an advanced airway and mechanical
CPR.
Procedure:
1. After patient’s airway is secured with either an ETT or SGA, attach
the ITD directly on top of the airway device.
2. Attach a CO2 detection device on top of the ITD.
3. Attach a BVM to the CO2 detection device.
4. Ventilate patient allowing each exhalation phase to complete prior to
the next positive pressure ventilation.
5. Slide the blue switch to the side to active a visual indicator for
respiratory rate if desired.
Figure 7 - PEEP valve
attached to a BVM
Zoll ResQPod ITD 10
Rapid Sequence Intubation (RSI) Authorization: TCAD Paramedics only
Indications: A critical need for airway control exist, such as: Patients with impending respiratory failure,
decreased LOC or combative patients with compromised airway, patients with hypoxia refractory to
oxygen administration, multi-systems trauma patients who require airway control, anytime the risk of
potential or actual airway compromise is suspected.
Precautions: Benefits of airway control must be weighed against risk. When utilizing RSI, even with
adequate sedation, the patient may still be aware of the situation. Please inform the patient of any
procedures you will be performing, just as you would with a conscious and alert patient.
Contraindications: Patients in whom Quicktrach insertion, or surgical cricothyrotomy would be difficult
or impossible. Massive neck trauma and/or swelling. Patients who would be impossible to intubate or
ventilate after paralysis. Acute epiglottitis episode. Upper airway obstruction preventing ventilation.
Procedure:
1. Preparations: Thorough preparation is essential for successful RSI, and its importance cannot be
overstated. Assure patient is being adequately oxygenated. Place patient on high flow oxygen for
4-5 minutes if possible, or ventilate with BVM & high flow oxygen for 1-2 minutes (or 3 vital
capacity breaths if no time).
a. Draw up and label all needed medications into separate syringes.
b. Prepare a backup airway (i.e. King Airway, Combitube, etc.).
c. Assign specific duties to team members (BVM, cricoid pressure, medication
administration, etc.).
d. If not already done, place patient on cardiac monitor and pulse oximeter.
e. Make sure one free flowing IV is in place.
2. Premedication:
a. Fentanyl 1 mcg/kg for pain relief
b. If patient presents with or develops bradycardia, give Atropine 0.5 mg.
c. If patient presents with or develops bradycardia, give Atropine 0.02 mg/kg (min. dose 0.1
mg)
3. Sedation: a. Etomidate 0.3 mg/kg for adults (average adult dose is 20 mg) and 0.2 to 0.6mg/kg in
pediatrics single, or;
b. Ketamine 2 mg/kg IV/IO or 4 mg.kg IM for ages 4 months to 65 years. >65 years of age,
half dose.
4. Paralysis:
a. Succinylcholine 1.0 mg/kg for adults and 2.0 mg/kg for pediatrics
b. Vecuronium 0.1 mg/kg (usual adult dose 10 mg) or Rocuronium 1 mg/kg for adults and
pediatrics (if Succinylcholine is contraindicated or unavailable)
5. Cricoid pressure must be maintained from time of sedation until intubation is completed.
6. Perform intubation and confirm tube placement.
7. Maintenance: Continue sedation with Versed 0.1 mg/kg IV/IO (max single dose of 5 mg) for
adults and 0.1 mg/kg for pediatrics every 10-15 min.
8. Continue paralysis with Vecuronium 0.1 mg/kg (usual adult dose 10 mg) every 25-40 minutes; or
Rocuronium 0.1-0.3 mg/kg (usual adult dose 10-30 mg) every 15-25 minutes.
9. Continue pain relief with Fentanyl 1 mcg/kg for every 5-20 minutes. If patient is hypotensive,
consider Ketamine for pain and/or sedation 1-2 mg/kg minimum dose of 100 mg.
10. Remember the duration of Etomidate and Succinylcholine is only 5-10 minutes, so maintain
sedation and paralysis as indicated for post intubation care. Monitor heart rate and other signs of
agitation for additional sedation/paralysis requirements. Watch for any development of
hypotension, especially when administering Versed, and contact Medical Control as needed for
consult or orders.
Rapid Sequence Intubation (RSI)In
du
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rep
rato
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Benefits of Airway Control Must be Weighed Against Risk
RSI Indicated &Contraindications Reviewed
1. Oxygenate Patient (BLS Airways, BVM, O2)2. Attach Cardiac Monitor & SpO23. Initiate free flowing IV
1. Assemble and Check Equipment2. Draw up medications3. Prepare backup airway devices (Bougie, King Airway, Combitube, Quictrach, Surgical Cricothyrotomy)
Indications:Immediate Need for Airway Control
Impending Resp. FailureCombative Patient w/Compromised Airway
Depressed LOC (GCS<8)Hypoxia Refractory to Oxygen
Multi-System TraumaPotential/Actual Airway Compromise
Assign Duties:Ventilation & Cricoid Pressure
Medication Administration
Contraindications:Difficult Cricothyrotomy
Massive Neck Trauma/SwellingImpossible to Ventilate after Paralysis
Acute EpiglottitisUpper Airway Obstruction Preventing Ventilation
In Arkansas, Patients Under 8 yr. of Age
Premedicate:1. Fentanyl 1 mcg/kg for pain2. If bradycardia is present, give Atropine 0.5 mg
Sedation:Etomidate 0.3 mg/kg, or Ketamine 2 mg/kg IV/IO
Paralysis:· Succinylcholine 1.0 mg/kg· If Sux is contraindicated, then use
Vecuronium 0.1 mg/kg; or Rocuronium 1 mg/kg
Intubate and confirm placement
Adult orPediatric <10 yr.
Premedicate:1. Fentanyl 1 mcg/kg for pain2. If bradycardia is present, give Atropine 0.02 mg/kg (min. dose 0.1 mg)
Post Intubation Care:· Sedation – Versed 0.1 mg/kg q 10-15 min.· Paralysis – Vecuronium 0.1 mg/kg; or
Rocuronium 0.1-0.3 mg/kg q 25-40 min.· Pain Relief – Fentanyl 1 mcg/kg q 5-20 min.
AdultPediatric
Blood or Blood Product Administration/Monitoring Ambulances do not routinely carry blood or blood products for administration in the prehospital setting. It
may become necessary to administer or monitor blood or blood products during interfacility transfers or
in the mass casualty incident setting. Special attention should be given any time a provider is
administering blood or blood products to a patient. It is the responsibility of the provider to cross check
the blood type being administered. When in doubt about a specific blood type or possible complication,
the administration should be stopped until the safety of that administration can be verified.
Authorization: TCAD Paramedics only
Indications: Patients with hemorrhagic shock or other conditions as directed by a physician.
Contraindications:
1. Un-typed blood recipient, except those receiving “O” negative blood.
2. Medication administration through the same IV line.
3. Use of blood product exposed to room temperature for more than 4 hours.
Procedure:
1. Obtain baseline set of vital signs and monitor patient’s temperature.
2. Must have a physician’s order for administration.
3. IV established with 18-gauge catheter or larger.
4. Blood administration setup:
a. Hang Normal Saline on one of the “Y” adapters.
b. Flush the tubing with the Normal Saline, being sure to fill the filter chamber.
c. Recheck contraindications and blood type.
d. Spike the blood or blood product on the other part of the “Y” adapter.
e. Close the clamp to the Normal Saline side.
f. Open the clamp to the blood/blood product side and start infusion.
g. Set flow rate as prescribed by physician.
i. Blood tubing is rated at 10 gtts/ml.
ii. Whole blood is run at least 50 gtts/min.
iii. Packed cells are administered at least 30 gtts/min.
5. Reassess vital signs 10 minutes after infusion has started and repeatedly thereafter in accordance
with the patient’s condition (not to exceed 30 min. intervals).
6. Stay with the patient and observe for signs or symptoms of transfusion reaction.
a. Hypotension, tachycardia, or loss of consciousness.
b. Fever, chills, hives, skin flushing, headaches, backaches, or nausea.
c. Increased dyspnea, pulmonary congestion, edema, or altered mental status.
7. If signs or symptoms occur:
a. Stop the infusion immediately.
b. Replace the blood/blood product with Normal Saline.
c. Conduct a rapid primary survey.
d. Administer high flow oxygen.
e. Contact Medical Control for consult or orders.
f. Consider use of diuretics or Benadryl with Medical Control approval to maintain renal
function.
g. If monitoring blood/blood products on a transport, watch for additional signs or symptoms
of fluid overload.
8. Document all vital signs, any reactions, or complications and notify the receiving facility of your
findings.
9. Document the specific unit of blood/blood products, using labels on the IV bag, on the patient’s
run report form. Careful documentation as to what type of blood or blood product, the rate of
administration, and the total amount given cannot be over-emphasized.
Blood Glucose Test Authorization: TCAD Paramedics and EMT-Basics, EMRA Paramedics and EMT-Basics (must have
CLIA Certificate)
Indications: Suspected hypo- or hyperglycemia
Procedure:
1. Determine the appropriate site for obtaining a blood sample.
2. Prepare blood glucose monitor and necessary equipment.
3. Prepare the site of puncture by cleaning with an alcohol swab.
4. Puncture site with approved instrument and obtain blood sample.
5. Clean site of puncture and control any excess bleeding as necessary.
6. Allow glucose monitor to process blood sample and document the numerical reading.
7. Repeat this process as needed to obtain an accurate reading or after medical treatment produces a
change in patient’s condition.
Chest Compressions
Manual Chest Compressions Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Unresponsive patients without a definite pulse or normal breathing
Contraindications: Do Not Resuscitate (DNR) orders, patients with LVAD device
Procedure:
1. Adult/teen:
a. Place the patient in the supine position on the floor or a rigid surface
b. Place the heel of one hand in the center of the chest
c. Place the other hand on top of the first hand
d. Position your shoulders directly above your hands, lock your elbows and use your upper
body weight to push.
e. Push hard at least 2 inches deep
f. Lift hands, allowing the chest to return to a normal position, but not off of the chest
g. Continue at a rate of 100 compressions per minute
h. Minimize interruptions in compressions and attempt to keep interruptions to less than 10
seconds each.
i. Rotate compressors every two minutes
2. Child:
a. Place the patient in the supine position on the floor or a rigid surface
b. Place the heel of one hand on the lower half of the chest
c. Push down 1½ -2 inches or 1/3 the depth of the chest
d. Release without removing the hand from the chest, allowing the chest to return to a normal
position.
e. Continue at a rate of 100 compressions per minute
f. Minimize interruptions in compressions and attempt to keep interruptions to less than 10
seconds each.
g. Rotate compressors every two minutes
3. Infant:
a. Place the patient in the supine position on the floor or a rigid surface
b. Place the tips of two fingers on the breastbone just below the nipple line
c. Push down 1½ inches or 1/3 the depth of the chest
d. Release without removing the hand from the chest, allowing the chest to return to a normal
position.
e. Continue at a rate of 100 compressions per minute.
f. If two providers are available, compress the breastbone using two thumbs, with your
fingers encircling the chest.
g. Minimize interruptions in compressions and attempt to keep interruptions to less than 10
seconds each
h. Rotate compressors every two minutes
Automated Chest Compressions (Lucas 2 Compression System) Authorization: TCAD Paramedics and EMT-Basics only
Indications: Unresponsive patients without a definite pulse or normal breathing
Contraindications: Do Not Resuscitate (DNR) orders, patients with LVAD device
Procedure:
1. Apply the Lucas device immediately without waiting for
rhythm checks
2. Activate the Lucas by pushing the ON/OFF for
1 second to start the self-test and power up.
3. Lift or roll the patient and carefully put the Back Plate
under the patient, below the armpits
4. On the compression device, pull the release rings to open
the claw locks, then let go of the release rings.
5. Quickly attach the compressor to the Back Plate; listen
for a “click”. Pull up once to ensure attachment.
6. Center the Suction Cup over the chest. The lower edge
of the suction cup should be immediately above the end
of the sternum.
7. Push the Suction Cup down with two
fingers (make sure it is in Adjust mode)
8. Pressure pad inside Suction Cup should touch patient’s
chest. If the pad does not touch, or fit properly, continue
manual chest compressions.
9. Adjust position if necessary
10. Press the Pause button to set the compression position
11. Start compressions by pushing Active (play). Continuous or 30:2
12. Attach the stabilization strap
13. Pause compressions every two minutes for pulse and rhythm analysis, then continue
compressions. See Cardiac Arrest protocol.
Chest Seal Authorization: All Paramedics and EMT-Basics
Indications: Penetrating chest trauma
Procedure:
1. Wipe dirt and fluid from skin with towel or gauze
2. Grip red tab to peel the clear liner from the dressing
3. Place the dressing on the patient, adhesive side down, centered over the wound
4. Firmly press dressing to the skin for a good seal. Make sure to smooth out all edges flat against the
skin.
5. Evaluate the patient for exit wound. Check the back, side and armpit areas. If exit wound is found,
apply a second seal to the wound.
12 Lead Electrocardiogram Authorization: TCAD Paramedics, and EMRA Paramedics
Indications:
1. All patients being treated for chest pain, syncope, or a suspected cardiac event.
2. Any patient with return of spontaneous circulation following cardiac arrest.
3. Suspected drug/medication/poly-pharmacological overdose.
4. Electrical injuries, including application of taser by law enforcement.
Procedure:
1. Assess patient and monitor cardiac status with limb leads.
2. Administer oxygen as patient condition warrants.
3. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after
treatment, perform a 12 lead ECG.
4. Prepare ECG monitor and connect patient cable with electrodes.
5. Enter the required patient information into the monitor.
6. Expose and prep chest. Modesty of the patient should be respected.
7. Apply chest leads and extremity leads using the following landmarks:
a. RA -Right arm
b. LA -Left arm
c. RL -Right leg
d. LL -Left leg
e. V1 -4th intercostal space at right sternal border
f. V2 -4th intercostal space at left sternal border
g. V3 -Directly between V2 and V4
h. V4 -5th intercostal space at midclavicular line
i. V5 -Level with V4 at left anterior axillary line
j. V6 -Level with V5 at left midaxillary line
8. Instruct patient to remain still.
9. Press the appropriate button to acquire the 12 lead ECG and
transmit to the receiving hospital (regardless of findings).
Figure 8 - Placement of V1 - V6.
15 Lead Electrocardiogram Authorization: TCAD Paramedics, and EMRA Paramedics
Indications:
1. Should be done on all Inferior MIs (ST-elevation in leads II, III, aVf)
2. Used to locate isolated Posterior MI (ST-depression in lead V1 is good indicator)
3. No ST-segment changes in presence of chest discomfort
Procedure:
1. Obtain 12-lead ECG
2. Move lead V4 or V4R (5th intercostal space midclavicular line
on right side of patient)
3. Move lead V5 to V8 (On the back, 5th intercostal space,
midscapular line)
4. Move lead V6 to V9 (On the back, 5th intercostal space,
between V8 and the spine)
5. Run second 12-lead
6. Label the different leads
Placement of V8-V9
Electrical Therapies
General Considerations 1. Exercise extreme caution when cardioverting or defibrillating patients. The safety of all providers
is the number one priority. Take appropriate steps to ensure all providers are clear of the patient
prior to shocking.
2. Be alert for patients who may have Nitroglycerin patches on the chest or torso. Remove any
patches and thoroughly clean off any residual medication left on the patient’s body.
3. Be alert for patients who have internal pacemakers or defibrillators. When shocking a patient with
one of these devices, apply patches as far away from them as possible.
4. It may be necessary to shave excess body hair prior to applying combo patches.
Synchronized Cardioversion Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Patients experiencing unstable tachydysrhythmias such as SVT, and VT with a pulse.
Precautions: Cardiovert with extreme caution in patients on digitalis preparations.
1. Verify ECG rhythm and make decision to cardiovert.
2. If appropriate, consider use of antiarrhythmic medications as an alternative to electrical
cardioversion.
3. If patient is conscious, explain procedure to the patient.
4. If time and patient condition permits, sedate patient with Versed.
5. Attach combo patches to patient’s torso, and limb leads on extremities.
6. Select ECG lead that displays the tallest “R” wave and activate synchronized mode.
7. Select appropriate joule setting for adult (6) or pediatric (17) patient.
a. Adult atrial flutter and SVT: 50 J. Increase in 50 J increments for subsequent attempts.
b. Adult pulsatile monomorphic VT: 100 J. Increase in 50 J increments for subsequent
attempts.
c. Pediatric unstable tachycardia, both narrow and wide complex: 0.5 - 1.0 J/kg. Increase to
2 J/kg for subsequent attempts.
8. Depress the charge button and clear the patient.
9. Call “CLEAR” and look up and down the patient to ensure patient is clear.
10. Press discharge button and hold until discharge is observed.
11. Reassess the patient and rhythm. Repeat the procedure if indicated.
Standard Manual Defibrillation Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Ventricular fibrillation and pulseless ventricular tachycardia.
Procedure:
1. Verify patient is in cardiac arrest.
2. Apply appropriate adult or pediatric combo pads. Pads should be placed in the Anterior/Posterior
positions.
3. Identify and record pre-shock rhythm by monitor leads or combo patches.
4. Place combo patches in the sternum/apex position or posterior/anterior position.
5. Select appropriate joule setting for adult (360 J) or pediatric patient (2 J/kg, then 4 J/kg for
subsequent shocks).
6. Depress the charge button and clear the patient.
7. Call “Clear,” and look up and down the patient to assure patient is clear.
8. Press discharge button and hold until discharge is observed.
9. Continue with adult CCR or pediatric CPR as necessary.
Automatic External Defibrillation (AED) Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Ventricular fibrillation and pulseless ventricular tachycardia.
Procedure:
1. Verify patient is in cardiac arrest.
2. Apply appropriate adult or pediatric combo pads.
3. Perform resuscitation until AED patches are attached in the sternum/apex position.
4. Stop resuscitation, clear the patient and press analysis button.
5. If shock is indicated, call “Clear” and ensure that no one is touching the patient.
6. Deliver the defibrillation by pushing the “Shock” button.
7. Continue resuscitation for 2 minutes or until instructed further by AED.
8. Continue to repeat this process until the arrival of an ALS unit or begin transport immediately if
available.
Transcutaneous Pacing (TCP) Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Symptomatic bradydysrhythmias, symptomatic heart blocks
Precautions: Do not place the pacer electrodes directly over an AICD device.
Procedure:
1. Consider Atropine Sulfate instead of TCP if indicated.
2. Explain procedure to the patient and evaluate the potential need for sedation.
3. Connect limb leads in proper position and record a baseline rhythm strip prior to pacing.
4. Adjust ECG size if necessary or select the lead with the tallest “R” wave.
5. Attach combo patches to patient’s torso.
6. Turn pacer unit on and set rate at 70 bpm.
7. Gradually increase energy (milliamps) until electrical capture is observed (generally a wide bizarre
QRS complex).
8. Check the pulse for mechanical capture. If pulse is present, assess blood pressure and record a
rhythm strip.
9. If mechanical capture is not achieved, continue to increase energy (milliamps) to maximum in an
effort to achieve capture.
10. Follow standing orders for sedation if discomfort to the patient is intolerable.
Gastric Tube Insertion
Nasogastric Tube Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Evacuation of air or fluids in the stomach or dilution of ingested poisons.
Contraindications: Facial trauma, basilar skull fracture, epiglottitis or croup.
Procedure:
1. If possible, have the patient sitting up. Use a pad or towel to protect the patient’s clothing.
2. Measure the tube from the nose, around the ear, and down to the xiphoid process. Mark the point
at the xiphoid process with a piece of adhesive tape or with your fingers.
3. Lubricate the distal end of the tube 6 to 8 inches with water-soluble lubricant.
4. Gently bend the tip of the tube in a downwards fashion prior to insertion to ease passage.
5. Insert the tube in the nostril and gently advance it towards the posterior nasopharynx along the
nasal floor.
6. When you feel the tube at the nasopharyngeal junction, rotate it inward towards the other nostril.
7. As the tube enters the oropharynx, instruct the patient to swallow.
8. Pass the tube to the pre-measured point. If resistance is met, back the tube up and try again. Do not
force it.
9. Check placement of the tube by aspirating gastric contents, or by auscultating air over the
epigastric region while injecting 20 – 30 ml of air.
10. Tape the tube in place and connect to low suction.
11. Document procedure including the time placed, size of tube used, and contents, if any, aspirated.
Orogastric Tube Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Unconscious patients or those with absent gag reflex. Need to evacuate air or fluids in the
stomach or dilution of ingested poisons.
Contraindications: Facial trauma, basilar skull fracture, epiglottitis, or croup.
Procedure:
1. Have suction available and be prepared to protect patient’s airway.
2. Measure the tube from the lips, around posterior angle of the jaw, and down to the xiphoid
process. Mark the point at the xiphoid process with a piece of adhesive tape or with your fingers.
3. Lubricate the distal end of the tube 6 - 8 inches with water-soluble lubricant.
4. Insert the tube in the mouth and gently advance it towards the posterior oropharynx.
5. When you feel the tube at the posterior oropharynx, rotate the tube and advance it into the
esophagus.
6. Pass the tube to the pre-measured point. If resistance is met, back the tube up and try again. Do not
force it.
7. Check placement of the tube by aspirating gastric contents, or by auscultating air over the
epigastric region while injecting 20 – 30 ml of air.
8. Tape the tube in place and connect to low suction.
9. Document procedure including the time placed, size of tube used, and contents, if any, aspirated.
Intraosseous (IO) Access
EZ-IO General Considerations Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Alternative to intravenous access to facilitate emergency resuscitation through the use of
drugs and fluids.
1. Cardiac Arrest
2. Multi-system trauma with associated shock or hypovolemia
3. Severe dehydration with vascular collapse
4. Any unresponsive patient in need of immediate drug or fluid therapy
Contraindications:
1. Fracture above the IO site
2. Prior infection at the site
3. Large scar over the top of the knee or confirmation
of knee replacement
4. Site has been used for previous attempt
Sizing:
1. EZ-IO AD (BLUE NEEDLE) – Any patient
weighing greater than 3 kg.
2. EZ-IO LD (Yellow-Needle) - Any patient with
excessive soft tissue, muscle tissue or edema at the
insertion site, or if blue needle is too short.
EZ-IO Insertion - Proximal Tibia 1. Identify landmark (antero-medial aspect of the proximal
tibia) about 1 - 2 fingerbreadths below the tibial
tuberosity.
2. Cleanse the puncture site.
3. Insert needle through the tissue at a 90 degree angle to
the flat plane of the tibia. As long as you can see the
dark line on the needle shaft, closest to the hub (5 mm
mark), the needle can be placed correctly into the
medullary space. Apply very little pressure after
powering up the driver on pediatric patients. Adult
patients may need more pressure added to facilitate
insertion. Feel for the “give” or “pop” indicating
penetration into the medullary space and stop. Be careful
not to draw back so as to dislodge needle placement.
4. Stabilize the needle and remove the driver by pulling directly back and off needle hub. Do not
twist, turn, or rock the driver.
5. Stabilize hub while turning stylet counterclockwise to remove.
6. Prime the “EZ connect” extension tubing with Lidocaine if the patient has a GCS of 8 or higher.
7. If patient is alert enough to respond, they may have pain with infusion of fluids. Administer:
a. Pediatrics – 2% Lidocaine, 0.2 mg/kg IO and flush with fluid.
b. Adults – 2% Lidocaine, 20 – 40 mg IO and flush with fluid.
8. Attach the “EZ connect” extension tubing that has been charged with fluid. If catheter will not
flush, it will not flow. “No flush = No flow”
9. If catheter will not flush, remove by taking 5 ml syringe attached to the hub and twist clockwise
while pulling needle straight out. A bandaid or small pressure bandage should control any
bleeding from the site.
Figure 9 - EZ-IO needle sizing
Figure 10 - Proximal tibia insertion
10. If catheter will flush, secure the needle hub to patient’s leg with an EZ-IO stabilizer or tape.
11. Administer medications and/or fluids as required for patient condition. The use of a pressure bag
on the IV fluids may be needed to adjust the desired flow rate. Monitor site around hub of needle
and leg for signs of infiltration. Discontinue use if signs are apparent.
12. Apply the wristband to patient and inform receiving staff of insertion site.
EZ-IO Insertion - Humerus 1. Position patients arm in proper position for insertion: hand resting over belly button and elbow
resting on cot or ground with arm in the abducted position.
2. With arm in abducted position, palpate humerus shaft up to greater tubercle. Insertion site will be
1 - 2 fingerbreadths below the clavicle bone and humerus bone space and approximately 1
fingerbreadth anterior to the mid axillary line.
3. Cleanse the puncture site.
4. Insert the needle, at a 90 degree angle to the insertion site, through
the flesh to the bone. Ensure the mark closest to the hub can be
seen (15 mm mark).
5. Power up the driver and apply pressure to insert the needle into the
bone. Feel for the “give” or “pop” indicating penetration into the
medullary space and stop. Be careful not to draw back so as to
dislodge needle placement.
6. Stabilize the needle and remove the driver by pulling directly back
and off needle hub. Do not twist, turn, or rock the driver.
7. Stabilize hub while turning stylet counterclockwise to remove.
Caution: monitor hub closely throughout usage, humerus bones are
not as dense and could possibly dislodge easier than the tibial site.
8. Prime the “EZ connect” extension tubing with Lidocaine if the
patient has a GCS of 8 or higher.
9. If patient is alert enough to respond, they may have pain with
infusion of fluids and/or drugs. If this is apparent or becomes
apparent, administer the following:
a. Pediatrics – 2% Lidocaine, 0.2 mg/kg IO and flush with fluid.
b. Adults – 2% Lidocaine, 20 – 40 mg IO and flush with fluid.
10. Attach the “EZ connect” extension tubing that has been charged with fluid. If catheter will not
flush, it will not flow. “No flush = No flow”
11. If catheter will not flush, remove by taking 5 ml syringe attached to the hub and twist clockwise
while pulling needle straight out. A bandaid or small pressure bandage should control any
bleeding from the site.
12. If catheter will flush, secure the needle hub to patient’s arm with an EZ-IO stabilizer or tape.
13. Administer medications and/or fluids as required for patient condition. The use of a pressure bag
on the IV fluids may be needed to adjust the desired flow rate. Monitor site around hub of needle
and arm for signs of infiltration. Discontinue use if signs are apparent.
14. Apply the wristband to patient and inform receiving staff of insertion site.
Figure 11 - Proximal humerus
insertion
Intravenous (IV) Blood Draw for Law Enforcement Law Enforcement may request paramedics to obtain blood samples from patients involved in a motor
vehicle collision or while incarcerated within law enforcement facilities for the purpose of determining
if the person is under the influence of drugs and/or alcohol. On occasion, requests for blood draws may
be made outside of an emergency medical situation to assist law enforcement in obtaining blood
samples from a person who is under arrest. It is the intent of these protocols to assist law enforcement
agencies in obtaining blood samples only when a patient’s life is determined not to be in jeopardy of
immediate harm or death.
Authorization: TCAD Paramedics only
Indications: Paramedics are permitted under medical direction to complete the request for blood draws
provided all of the following conditions are met. At no time shall a blood sample be forced upon a legally
non-consenting patient or person for the purposes of determining drug and/or alcohol levels for use by law
enforcement personnel.
1. TCAD is able to accommodate the request for blood draw without jeopardizing our
response system.
2. Law Enforcement is present and has made an official verbal or written request for a
blood draw.
3. The person whom a blood sample will be taken is currently in stable condition and not at risk for
major medical problem and/or traumatic injury.
4. In the opinion of the attending Paramedic, the blood sample can safely be obtained without
significant physical risk to the patient and/or provider.
5. The person whom the blood sample will be taken is capable of making an informed decision and
has given verbal consent for the blood draw or there is a valid warrant for the blood draw provided
by the requesting agency.
6. For all cases of informed consent, the person whom the blood sample will be taken has signed the
official Blood Draw Consent Form (see Appendix).
Procedure: Paramedics shall follow the appropriate procedure listed previously in the protocols for
drawing blood samples with the following procedural considerations.
1. For blood draws under the informed consent conditions, TCAD paramedics will inform the
person, whom the blood sample will be taken, of the procedure and obtain informed verbal
consent to draw blood. The paramedic will also obtain a signature on the official Blood Draw
Consent Form (see Appendix), from the person whom the blood sample will be taken, before
proceeding with the procedure.
2. For blood draws under the authority of a court ordered warrant, TCAD paramedics will inform the
person, whom the blood sample will be taken, of the procedure and draw their blood in a safe
manor.
3. TCAD ambulances shall be stocked with a Law Enforcement Blood Draw Kit used for these
procedures and Law Enforcement personnel shall provide the paramedic with the vacutainer to be
used during the blood sample collection process.
4. The paramedic shall not prep the blood draw site with an alcohol swab when performing blood
draws for Law Enforcement.
5. Once obtained, the blood sample shall become the property of the Law Enforcement personnel
who requested the blood draw.
6. The paramedic shall document the blood draw on the Patient Care Report Form and shall be
detailed enough to recall the procedure should they be asked to testify at a deposition or court
proceeding.
Intravenous (IV) Blood Draw Authorization: TCAD Paramedics only
Indications: Patients with suspected STROKE, STEMI, or probable SEPSIS
Precaution: Condition of patient should be taken into account through the provider’s impression.
Drawing blood in the field is not required but will enable receiving facilities to complete diagnostic tests
more rapidly and could mean faster definitive diagnosis and treatment for the patient.
Contraindication: None when performed properly and coinciding with needed IV establishment.
Procedure:
1. Select a site that is appropriate for IV cannulation, as well as phlebotomy. Prepare all necessary
equipment.
2. Cannulate the vein, as described in the Intravenous (IV) Catheter Insertion procedure.
3. Attach the vacutainer hub
4. Press blood tubes into the vacutainer needle to fill them. After filling the tube with blood, remove
it from the vacutainer and gently invert it several times before moving to the next tube.
5. Tubes should be filled in the following order:
a. Blue
b. Gold (yellow)
c. Green x 2
d. Purple x 2
6. After filling all tubes, remove the tourniquet and replace the vacutainer hub with a clave
connector.
7. Secure the catheter and clave connector with a veniguard or tape.
8. Attach IV tubing to clave connector and flush with Normal Saline.
9. Note time of blood draw on blood tubes. Label one tube with patient’s last name, date of birth, and
provider initials. Secure all of the tubes together. Tape tubes directly to IV bag, or place in zip
lock style bag and keep with patient.
10. Upon arrival at hospital, transfer blood to staff with appropriate patient identifying information
and time of blood draw.
Intravenous (IV) Catheter Insertion Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Patient requiring medication or fluid therapy.
Precaution: Avoid catheter shear. A severed catheter piece can flow through the systemic circulation
and cause problems. To minimize the possibility of a severed catheter, do not reinsert the needle into the
catheter tip has been pushed past the needle tip.
Procedure:
1. Apply a tourniquet. Remember to use caution with certain patients. Many elderly patients and
patients on prednisone have very delicate skin.
2. Select a suitable vein by palpation and sight. Avoid areas of the veins where a valve is situated.
Avoid using fistulas, shunts or graphs.
3. Cleanse the site using aseptic technique.
4. Stabilize the vein by anchoring it with the thumb and stretching the skin downward.
5. Perform the venipuncture without contaminating the equipment or site. Depending on the type of
venipuncture device and manufacturer recommendations, hold the needle at a 15, 30, or 45 degree
angle to the skin.
6. Penetrate the skin with the bevel of the needle pointed up. If significant resistance is felt, do not
force the catheter.
7. Enter the vein with the needle from either the top or side. Normally, a slight “pop” or “give” is
felt as the needle passes through the wall of the vein. Be careful not to enter too fast or too deeply,
because the needle can go through the back wall of the vein.
8. Note when blood fills the flashback chamber.
9. Lower the venipuncture device and advance it another 1 cm until the tip of the catheter is well
within the vein.
10. Once the catheter is within the vein, apply pressure to the vein beyond the catheter tip to prevent
blood from leaking out of the catheter hub once the needle is completely withdrawn.
Medication Administration
General Considerations 1. All medication administrations must be carefully documented including times, route, dosage, site
and effects.
2. Medication administration should strictly follow protocol. Any deviation from protocol requires
direct Medical Control and should be documented according to policy.
3. Any medication administration requires accurate and complete assessment of patient’s known
drug allergies.
4. Select the correct medication. Confirm orders, dosage, expiration date, and check drug for
cloudiness or particulates.
Intramuscular (IM) Injection Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Patient requiring medication when IV access is hindered.
Contraindications: Shock or cases of decreased perfusion, severe burns, patients with cardiac
complaints.
Procedure:
1. Assemble appropriate sized equipment:
a. Syringe of sufficient size to hold medication.
b. Needle: 21 – 25 gauge, 1” to 1½” in length.
2. Select appropriate site
a. Maximum 1 ml (at one site) into deltoid.
b. Maximum 3 ml (at one site) into gluteus.
3. Cleanse site with aseptic technique.
4. Stretch skin taut and press down to facilitate entry into muscle.
5. Enter skin at a 90 degree angle.
6. Aspirate the syringe to assure you are not in a vein. If blood return is seen, withdraw and try at
another site.
7. Inject medication slowly. Remove syringe and dispose in sharps container.
8. Cover injection site with an adhesive strip.
9. Observe patient for effects and document them on patient’s report form.
Intravenous (IV) Drip Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: To facilitate administration of a mixed medication drip or to administer IV fluids through a
saline lock.
Procedure:
1. Calculate appropriate dosage and flow rate.
2. Select appropriate tubing for administration of medication. Spike the bag with the tubing; flush
tubing with the drug solution.
3. Secure and label the medication drip bag.
4. Lower the primary infusion bag below the secondary line of the medication being infused.
5. Open piggyback line and set rate. Stop flow from primary line.
6. Observe patient for effects and document them on the patient’s report form.
Intravenous (IV) Push Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: For rapid IV bolus or slow IV push as indicated by the specific drug.
Procedure:
1. Cleanse the injection port closest to the injection site.
2. Puncture the injection port with needle.
3. Pinch off tubing above injection port.
4. Inject drug at appropriate rate.
5. Flush medication with IV fluid and resume IV flow rate.
6. Evaluate patient’s response to the medication.
7. Document the time, dose, route, site, and patient’s response to therapy.
Inhalation (Small Volume Nebulizer) Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Bronchodilator therapy as indicated by protocol.
Procedure:
1. Add medication to reservoir of nebulizer. Add saline solution if necessary to equal 3 ml total
volume. Albuterol medication vials do not need saline added.
2. Connect oxygen tubing to nebulizer and set flow rate at 6 – 8 lpm.
3. Have patient take deep breaths, holding for a second, and then exhaling through the tube.
4. If patient is unable to hold nebulizer, use the nebulizer mask.
5. Medication is delivered in 5 - 10 minutes.
6. Assess and record lung sounds before and after treatments.
Inhalation (Nebulizer via BVM) Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Bronchodilator therapy as indicated by protocol, in the intubated (or other advanced airway)
patient, or in the respiratory compromised patient needing ventilatory support.
Procedure: 1. Add medication to reservoir of nebulizer. Add saline solution if necessary to equal 3 ml total
volume. Albuterol medication vials do not need saline added
2. Connect oxygen tubing to nebulizer and set flow rate at 6 – 8 lpm
3. Connect medication reservoir to the T-connector.
4. Connect the reservoir tube (blue tube) to the T-connector.
5. Connect the other end of the reservoir tube to the BVM
6. Connect a Multi Adaptor to the other end of the T-Connector
7. Connect the other end of the Multi
Adaptor to the ETT, or BVM mask
8. Ventilate at appropriate rate and volume
9. Medication is delivered in 5-10 minutes.
10. Assess and record lung sounds before
and after treatments
Inhalation (Nebulizer via Pulmodyne CPAP) Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Bronchodilator therapy as indicated by protocol, in
conjunction with Continuous Positive Airway Pressure (CPAP).
Procedure: 1. Add medication to reservoir of nebulizer. Add saline solution
if necessary to equal 3 ml total volume. Albuterol medication
vials do not need saline added.
2. Connect oxygen tubing to nebulizer and set flow rate at 6 – 8
lpm
3. Connect the medication reservoir to the medication port on the
patient end of the circuit.
4. Medication is delivered in 5-10 minutes.
5. Assess and record lung sounds before and after treatments
Mucosal Atomization Device (MAD) Authorization: All Paramedics and EMTs
Indications: To facilitate administration of a specific medications in a quick manner when IV/IO
administration is delayed.
Procedure:
1. Draw up desired dose of medication to be administered in a syringe.
2. Attach MAD atomizer to syringe and expel any air in syringe.
3. Insert atomizer into nostril 1.5 cm and briskly compress syringe plunger to properly atomize half
of the dose into the nostril.
4. Apply atomizer to remaining nostril and repeat step 3.
5. Have working suction available for possible run-off and to protect the airway.
6. If no improvement after 3 minutes, establish an IV if not already done and administer medication
IV.
7. Observe patient for effects and document them on patient’s report form.
8. Administration of the medication may be inhibited due to trauma and/or bleeding from the nose,
previous surgery to the nasal cavity, or excessive mucous build up in the nasal passages.
9. Inhalation of narcotics that may constrict blood flow in the mucous membranes, and patients with
perfusion compromise such as severe hypotension and severe vasoconstriction.
Endotracheal Tube (ETT) Push Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Intubated patients who require Epinephine, Atropine, or Naloxone and provider has
attempted but failed to gain IV/IO access.
Precaution: ETT medication delivery has shown varied degrees of effectiveness, and should be
considered a last resort route. The medication in the tube may also interfere with capnography device
readings by partially or completely clogging the device’s gas intake port.
Procedure:
1. Prepare desired medication (Epinephrine, Atropine, or Naloxone) at twice the dosage indicated for
IV/IO route.
2. Hyperventilate the patient with several consecutive ventilations and 100% oxygen.
3. Disconnect the bag-valve mask from the endotracheal tube connector and instill no more than 5 ml
(adults) or 2 ml (pediatrics) of medication at any one time into tube.
4. Reconnect the BVM and rapidly hyperventilate the patient with several full breaths before
administering any remaining amount of medication.
5. After administering the required amount of medication, ventilate the patient for a minimum of one
minute before repeating any medication to allow complete dispersal of remaining medications in
the lungs.
Needle Thoracostomy Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: Increased ventilatory pressure resulting in difficulty ventilating the patient (with an open
airway). Signs of a tension pneumothorax, including:
1. Absent lung sounds on affected side.
2. JVD (may not be present with massive blood loss).
3. Hypotension (no radial pulses).
4. Increasing respiratory distress.
5. Decreased pulse oximetry.
6. Traumatic cardiac arrest with chest pathology.
Contraindications: None in the presence of a tension pneumothorax.
Procedure:
1. Eliminate ½ the volume from a 10ml pre-filled
saline syringe and attach to hub of ARS.
2. Identify the 2nd or 3rd intercostal space along
the mid-clavicular line of the affected side.
3. Quickly prep the area with an aseptic technique.
4. Insert ARS in a 900 angle to the chest wall just
over the top of the 3rd rib. If that anatomical
location is not available, place the ARS in the
same manner in the 5th intercostal space along
the mid-axillary line.
5. Insert the needle into the parietal pleura until air
escapes. (Note: If a steady flow of blood
escapes, withdraw ARS.) As the trapped air is
expelled you will see air bubbles in the syringe
and the plunger will be forced outward. Do not
advance the needle any further than the point at
which you achieved air release. The catheter
alone should be advanced at this point until the hub is seated against the chest wall.
6. Remove the needle completely from the catheter and dispose of properly.
7. Assess patient. Relief from a tension pneumothorax should be almost immediately evident by the
patient’s clinical presentation as well as improved vital signs.
8. Re-assess frequently for re-development of this condition.
9. In the event the tension pneumothorax returns, the procedure may be repeated.
Figure 12 - Bubbles visible in a saline-filled
syringe during a needle thoracostomy are
evidence of proper placement
Oxygen Administration, Devices, and Perfusion Monitoring
Oxygen Administration & Devices Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Any patient standing to benefit from higher levels of tissue oxygenation. Patients presenting
with or at risk for ventilatory compromise.
Procedure:
1. Explain the procedure to the patient.
2. Select appropriate adjunct and connect to oxygen port.
3. Flush the device with oxygen before application.
4. Apply the device to the patient and set the appropriate flow rate:
a. 2 – 6 lpm for nasal cannula (24 – 44% Fi O2).
b. 10 – 15 lpm for nonrebreather mask (80 – 100% Fi O2).
c. 15 lpm flush for bag-valve mask device (100% Fi O2).
5. Monitor patient for effects.
Continuous Positive Airway Pressure (CPAP) with Pulmodyne O2 Max Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Indications: Acute respiratory distress caused by pulmonary edema ,
COPD or Asthma, in the spontaneously breathing adult (>30 kg)
patient.
Contraindications:
1. Respiratory or cardiac arrest
2. Systolic blood pressure < 90 mmHg
3. Altered level of consciousness
4. Inability to maintain airway patency
5. Major trauma, especially head injury with increased ICP or
significant chest trauma
6. Vomiting (or high risk of vomiting), or upper GI bleeding
7. Signs and symptoms of pneumothorax
8. Gastric distention
Procedure:
1. Remove contents from the packaging.
2. Attach appropriately sized face mask.
3. If supplemental Oxygen is needed, replace the fixed-oxygen
supply hose with the O2-Max trio control unit.
4. Connect the generator to a 50 psi oxygen source. This may be
the power take-off of an oxygen regulator on a cylinder or a
quick connect to a wall outlet. (use the quick connect adaptor)
5. Ensure the device is free of obstructions and verify proper
valve function.
6. Explain the procedure to the patient and apply the mask to the
patient’s face. Tell them it is high flow oxygen with some
pressure and the mask needs to fit snugly on their face. They
may be more comfortable holding the mask in place if they are
fearful. If possible, slip the head strap over the head and attach
the fourth point to hold it in place.
7. Adjust PEEP and FiO2 titrated to patient condition.
Non-Invasive Positive Pressure Ventilation via Ventilator (CPAP/BPAP) Authorization: TCAD Paramedics Only
Indications: 1. Acute respiratory distress caused by pulmonary edema in the spontaneously breathing adult (>30
kg) patient.
2. Acute COPD exacerbation.
Contraindications:
1. Respiratory or cardiac arrest
2. Systolic blood pressure < 90 mmHg
3. Altered level of consciousness
4. Inability to maintain airway patency
5. Major trauma, especially head injury with
increased ICP or significant chest trauma
6. Vomiting (or high risk of vomiting), or upper
GI bleeding
7. Signs and symptoms of pneumothorax
8. Gastric distention
Procedure:
1. Connect the gas supply hose to the gas supply input.
2. Connect the other end of the hose to the pressure outlet of the pressure regulator or wall outlet of
the oxygen system or tank. Do not attach the ventilator to a flow control valve.
3. Attach the O-Two patient circuit to the 22mm gas output connector.
4. Connect the 2 sensor hoses of the patient circuit to their corresponding connectors.
5. CAUTION! Do not connect patient valve to the patient before turning on the ventilator!
6. Attach appropriately sized face mask. (small, medium, or large)
7. Press the On/Off button for one second to turn on the ventilator.
8. Start default ventilation:
a. Select the appropriate age group figure for your patient. (Infant, Child, Adult)
b. Ventilation will begin.
c. Note: A/CV with volume control is the default start-up mode.
9. Change the ventilation mode from A/CV to CPAP.
a. CPAP mode is used for both CPAP and BPAP.
b. It is recommended to start with CPAP and if needed switch to BPAP.
10. Set the CPAP setting to 5 cmH2O.
11. Change the FiO2 setting to 60%.
12. Have the patient hold the mask tightly to their face in a position that is comfortable for them.
13. Secure the mask in place with the head strap.
14. If the patient’s condition is not improving, Consider:
a. Increase the CPAP level in increments of 2 cmH2O at a time. (Maximum of 15 cmH2O)
b. If needed to maintain the desired SpO2 level, increase the FiO2 to 100%
15. If the patient needs tidal volume support, switch to BPAP
a. Set the PSV setting to 10 cmH2O (should always be set 5 cmH2O above the CPAP level,
maximum of 20 cmH2O).
Ventilator Authorization: TCAD Paramedics only
Indications: Adult, child, and infant patients who are in respiratory and/or cardiac arrest, or respiratory
distress and who require ventilatory support.
Contraindications:
1. Noninvasive ventilation is indicated in preference to invasive mechanical ventilation
2. Intubation and mechanical ventilation are contrary to the patient’s expressed wishes.
3. Patients under 10 kgs.
Procedure:
1. Connect the gas supply hose to the gas supply input.
2. Connect the other end of the hose to the pressure outlet of the pressure regulator or wall outlet of
the oxygen system or tank. Do not attach the ventilator to a flow control valve.
3. Attach the O-Two patient circuit to the 22mm gas output connector.
4. Connect the 2 sensor hoses of the patient circuit to their corresponding connectors.
5. CAUTION! Do not connect patient valve to the patient before turning on the ventilator!
6. Press the On/Off button for one second to turn on the ventilator.
7. Start default ventilation:
a. Select the appropriate age group figure for your patient. (Infant, Child, Adult)
b. Ventilation will begin.
c. Note: A/CV with volume control is the default start-up mode.
8. Set up the desired ventilation settings:
a. Post-intubated patient in the acute setting:
i. Adjust the PEEP to 0
ii. Adjust the Trigger to 0
iii. Adjust the Pmax to 60
iv. Tidal Volume should be set to 6 ml/kg of ideal body weight
1. TV = ((2.3 x inches above 5’) +50) x 6ml, see Handtevy guide for IBW of
patients under 5’
2. Adjust from there based on CO2, and patient comfort
v. Respiratory Rate should start at 12 bpm, adjust based on patient condition
b. Interfacility transfer settings:
i. Consult with the patient’s respiratory therapist or physician
ii. Adjust the patient specific settings.
9. Attach the patient valve to the patient.
10. Verify adequate ventilation:
a. Listen to lung sounds
b. Monitor Sp02 and end-tidal CO2
Pulse Oximetry (SpO2) Monitoring Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Obtaining a complete set of vital signs.
Precautions: Accuracy is dependent on adequate perfusion at probe site. Can also be affected by bright
lights, carbon monoxide poisoning, cyanide poisoning, nail polish, and cases of polycythemia.
Oxygen administration should not be determined by a pulse oximetry reading. It should be administered
based on clinical presentation.
Procedure:
1. Find a suitable place for probe; such as finger tips, toes, or earlobes.
2. Attach probe and record reading.
3. May also be used to monitor circulation in extremities with traumatic injuries.
4. If readings are erratic, try a different probe site.
Capnography (ETCO2) Monitoring Authorization: TCAD Paramedics, and EMRA Paramedics
Indications: All intubated patients and any patient with significant respiratory distress.
Contraindications: Do not use on patients younger than 3 years of age or less than 22 lbs.
Procedure:
1. Prepare capnography function on cardiac monitor by plugging adaptor into monitor.
2. Place airway adapter between ETT and bag-valve device, or apply nasal cannula device to patients
with their own respiratory drive.
3. ETCO2 level will be measured at each patient expiration.
4. Capnography pearls
a. TUBE PLACEMENT: Confirm via presence of a square waveforms only, not by the
measured ETCO2 value, and document accordingly.
b. APNEA ALARM: Capnography will monitor and alarm you if the patient becomes
apneic for any reason. Common causes that warrant this include narcotic or
benzodiazepine overdose, sedative or anxyolitic administration, and generalized seizures.
c. BRONCHOSPASM: A sloped upstroke into the plateau phase is indicative of
bronchospasm as is most commonly seen in asthma patients. Shark fin morphology
indicates severe bronchospasm.
d. RSI: Capnogram will show a curare cleft (see image) as the paralytic wears off and the
patient begins to breathe. The medic typically has only a few minutes before the return of
muscular function.
5. Capnometry pearls
a. SHOCK : ETCO2 of 20 is generally accepted as the threshold in the transition between
compensated and decompensated shock.
i. Can be helpful with ACS patients when determining stable vs. unstable.
b. DKA:
i. ETCO2 ≥35 with glucometry reading of “High” ≠ DKA.
ii. ETCO2 ≤ 21 with glucometry reading of “High” = DKA
c. SEPSIS:
i. ETCO2 <25 with 2 or more SIRS criteria is highly predictable of sepsis.
ii. SIRS criteria:
1. Temp NOT between 96.8 – 100.4F
2. RR > 20
3. HR > 90
Patient Lifting and Moving Procedures
Bariatric Transfer Sheet Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Large patients needing to be moved to or from the cot.
Procedure:
1. Lay the transfer sheet beside the patient. Webbing straps facing the ground, and smooth vinyl side facing
the patient.
2. Roll the patient to one side. 3. Tuck the transfer sheet under the patient, trying to align the patient in the center of the sheet. 4. Roll the patient to the other side 5. Pull the rest of the sheet out 6. Roll the patient supine
7. With at least four providers, more if needed, lift the patient using the webbing handles. The first four
providers should be placed at the shoulders and hips of the patient. 8. Remove in reverse order.
Binder Lift Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Patients needing to be lifted from a seated position
Procedure:
1. You can attach the Binder Lift to the patient using one of the following methods: a. The Log Roll – Used when patient is in the supine position in an open area
i. Roll the patient onto their side and lay the Binder Lift out with the cushioned edge
in line with patient’s armpits. Bunch up the Lift’s side edge under the patient.
ii. Roll the patient back into the supine position
iii. Pull the Binder Lift underneath the patient until the leg strap receiver buckles are
centered on the patient.
b. The Pull-Down – Used when patient is in the supine position with limited working space
i. Center the Binder Lift just above patients head with the bottom edge of the Lift
touching the patients head.
ii. Ask patient to lift their head and pull the Binder Lift down until the bottom edge is
bunched up just underneath the patient’s shoulders.
iii. Firmly grasping the bunched up section, pull the Binder Lift down until the
cushioned edge is just underneath the patients armpits. (See-saw action may be
necessary).
iv. Ensure leg strap receiver buckles are centered on the patient.
c. The Wrap – Used when patient is already in the sitting position
i. Wrap Binder Lift around patient with the cushioned edge just below patient’s
armpits.
ii. Ensure leg strap receiver buckles are centered on the patient.
2. Starting with the top torso buckle and working down to the bottom, fasten each buckle securely.
Tighten each strap until taut.
3. Rotate the harness left or right as needed so that the front two leg strap buckle receivers are spaced
equally on the patients’ waist. Because of the Binder Lift’s adjustability, this will be slightly
different from patient to patient.
4. Thread the leg straps under the back of the patient’s knee and slide the strap up the inner thigh.
Once all of the excess strap is pulled tight, attach to the front receiver buckles. Be sure the straps
are snug, as any excess slack will result in the harness sliding up the patient’s torso when the lift is
executed. If the patient is in the sitting position, have them shift their body weight to the left while
you snug the right leg strap. Then lean the patient to the right while securing the left leg strap.
Likewise, if the patient is lying in the supine position, simply roll them slightly and thread the leg
strap through the inner thighs and adjust until snug. Use caution to avoid pinching.
5. Leg strap extensions may be needed for individuals with overly large thighs. Simply buckle the
18” extension into existing leg strap and connect to the receiver buckle located on the harness.
6. Re-check tension of each torso strap, ensuring each is taught, but not restricting patients breathing.
7. Once securely attached, grab any of the hand loops to execute the lifting process. Care should be
taken to position your body as close to the patient as possible while keeping your back straight and
arms as close to your body as possible. Utilize the strength in your legs NOT your back to
accomplish the lifting. Partners of differing heights can utilize differing hand loop rows to allow
for the offset of hand/arm elevation in the standing position: taller person utilizes upper row of
hand loops while shorter person utilizes lower row of hand loops.
8. The lifting operation should be accomplished in unison with your partner. Unequal lifting can
result in instability of the patient and could result in injury to the patient and/or caregivers.
ErgoSlide Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Patients requiring movement in bed, or lateral movement from bed to cot
Procedure:
1. Place the ErgoSlide under the patient along the length of the bed by log rolling patient from side to
side. The ErogSlide is tube-shaped and the handles should face the direction you wish to move the
patient.
2. Each provider slides open hands, palms up through the webbing handles along the sides of the
tube, near the patient’s shoulders and hips.
3. Working in unison, slide the patient to the desired position. DO NOT LIFT.
4. If moving patient from one bed to another, a slideboard may be needed to bridge the gap between
beds.
5. Remove the ErgoSlide in reverse order of placement.
6. Do not leave the ErgoSlide under an unattended patient.
Slideboard Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Moving patients from one bed to another or to the cot, to provide a smooth surface to slide
the patient on.
Procedure:
1. Place the second bed or cot beside the bed that the patient is in.
2. Secure any wheel locks if available.
3. Log roll the patient slightly to the opposite side and place the slideboard just under their side.
4. The slideboard should extend over the gap between beds onto the second bed.
5. Using a sheet, or ErgoSlide, slide the patient laterally onto the second bed. The patient should
slide across the board onto the other side.
6. Remove the slideboard after the move is complete.
Spinal Motion Restriction Procedures Spinal motion restriction is achieved by placing an appropriately-sized cervical collar on the patient and
transporting the patient in the position of comfort on the ambulance stretcher (cot), limiting patient
movement whenever possible. Patients should not be transported on a long backboard or scoop stretcher.
If one of these devices is utilized to move an unstable patient to the ambulance stretcher, it should be
removed prior to transport.
Cervical Collar Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Patients requiring spinal motion restriction. All intubated patients.
Procedure:
1. Manually stabilize the head and neck in a neutral inline position unless movement causes pain,
deformity, or resistance. If so, immobilize the head and neck in the position found.
2. Determine the appropriately-sized cervical collar for the patient.
3. Pre-form (roll) the collar prior to application.
4. On a supine patient, slide the loop fastener end under the neck just far enough that it can be
reached. On a seated patient, this step is not necessary.
5. Place both of your hands on the front side of the collar on either side of the collar’s tracheal
opening.
6. Slide the collar up the chest wall and under the chin, making sure the chin is flush with the end of
the chin piece.
7. With the chin piece properly positioned, grasp the collar by the tracheal opening and the loop
fastener to tighten.
8. Tighten by pulling the loop fastener end around to meet the hook fastener on the collar. The hand
at the tracheal opening will prevent any counter-rotational forces and allow proper tightening.
9. Inspect the chin piece to ensure that the chin is properly positioned. Adjust the collar if necessary.
Scoop Stretcher Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Patients requiring assisted movement to the stretcher.
Procedure:
1. Maintain manual in-line c-spine stabilization.
2. After application of appropriate cervical collar, place extra rescuers to control the thorax, pelvis,
and legs.
3. Adjust the length of the scoop stretcher.
4. Separate the two sides of the scoop stretcher.
5. Place one piece of the scoop stretcher on each side of the patient.
6. Leave the patient’s arms at their side.
7. Lift the patient slightly and slide the stretcher into place, one side at a time.
8. Lock the two pieces of the stretcher together starting with the foot end, then the head. Be careful
not to pinch the patient.
9. Move the patient to the ambulance stretcher (cot). Remove the scoop stretcher, in the opposite
manner in which it was applied, while limiting movement of the patient. Secure with cot straps
and transport in position of comfort.
Rapid Extrication Technique Authorization: All Paramedics, EMT-Basics, and Emergency Medical Responder
Indications: Unstable patients with immediate life threats who also have indications for spinal motion
restriction.
Procedure:
1. One rescuer must stabilize the c-spine in neutral position.
2. Do a rapid primary survey and initiate interventions as necessary.
3. Apply the correctly sized c-collar.
4. Slide long backboard under the patient’s buttocks.
5. Rescuer standing outside of the vehicle takes control of c-spine stabilization.
6. A rescuer positions themselves on the opposite side of the vehicle ready to rotate the legs around.
7. Another rescuer, positioned beside the patient. By holding the upper torso, works together with the
rescuer holding the legs to carefully turn the patient as a unit.
8. The patient is turned so that their back is towards the backboard. The legs are lifted and the back is
lowered to the backboard. The neck and back are not allowed to bend during this procedure.
9. Carefully slide the patient to the full length of the backboard and straighten legs.
10. Move the patient to the ambulance stretcher (cot), then remove the long backboard from beneath
the patient while limiting movement of the patient. Transport patient secured to the ambulance
stretcher.
Evac-U-Splint Authorization: TCAD Paramedics and EMT-Basics only
Indications: Patients requiring spinal motion restriction during long inter-facility transports.
Procedure:
1. Maintain manual neutral in-line c-spine stabilization.
2. Assess and record distal pulses, motor function, and sensation prior to any splinting procedure.
3. After application of appropriate cervical collar, place extra rescuers to control the thorax, pelvis,
and legs.
4. Place the Evac-U-Splint mattress beside the patient. The mattress should contain air and be
pliable.
5. Leave the patient’s arms at their side.
6. The person holding the head makes the count, carefully roll the patient as one unit on their side.
7. Perform a quick check of the back for injuries or deformities.
8. Roll the patient onto the Evac-U-Splint mattress.
9. Carefully form the mattress around the patient and attach straps.
10. Using the manual pump, evacuate air out of the mattress until it becomes rigid and patient
movement is restricted.
11. Carefully place the head strap in position forming a snug fit and restricting head movement.
12. Reassess distal pulses, sensation, and motor function.
Restraint Use Authorization: TCAD Paramedics only
Indications: 1. A patient who needs to be transported for medical care and has been determined by law
enforcement or by physician orders to require restraint.
2. To facilitate treatment of a patient who is or may become a threat to themselves.
3. Patient whose actions may interfere or prevent the provider to perform or maintain medically-
necessary interventions for that patient. (18)
Precautions: 1. Any attempt at restraint involves risk to patient and provider. Do not attempt to restrain a patient
without adequate assistance.
2. Physical restraints are a last resort. All possible means of verbal persuasion should be attempted
first.
3. Never restrain a patient in a prone position, but rather in a supine position (or lateral position if
there is risk of aspiration).
Contraindications: 1. A patient who is alert, oriented, aware of their condition, and capable of understanding the
consequences of their refusal is entitled to refuse treatment. They may not be restrained and
treated against their will.
2. Patients may only be restrained by medical providers for medically-necessary care and
interventions. Patients may not be restrained solely for provider safety or preference; that may
only be performed by law enforcement. (18)
Procedure:
1. Obtain adequate manpower for assistance. Organize your help in advance. Assign at least one
person to each limb. A fifth person can coordinate the procedure.
2. Have all equipment ready.
3. Treat the patient with respect. Explain to the patient why they are being restrained.
4. Restrain arms and legs by utilizing only soft restraints manufactured for use in the healthcare
setting. Do not utilize “improvised” restraints.
Pedi-Pac Authorization: TCAD Paramedics and EMT-Basics only
Indications: Uncooperative pediatric patients requiring physical restraint
Procedure:
1. Place extra rescuers to control the thorax, pelvis, and legs.
2. Place the Pedi-Pac beside the patient. Extra padding may be needed based on patient size.
3. Leave the patient’s arms at their side.
4. Carefully roll the patient as one unit on their side.
5. After the person holding the head makes the count, roll the patient onto the Pedi-Pac.
6. Secure the patient utilizing the straps provided. Arm and leg straps may be utilized as necessary.
7. Secure the head last with the provided straps. Carefully place the head strap in position forming a
snug fit and restricting head movement.
8. Assess distal pulses, sensation, and motor function.
Splinting
Pediatric Hare Traction Splint Authorization: TCAD Paramedics and EMT-Basics only
Indications - Suspected closed femur fracture.
Contraindication - Open femur fracture.
Procedure
1. Upon recognizing the injury, Rescuer One should stabilize leg in the position found.
2. Rescuer Two will then expose the injured leg.
a. Assess neurological function distal to injury site.
b. Assess circulatory function distal to injury site.
3. Rescuer Two should prepare traction splint.
a. Position splint against uninjured leg.
b. Place the ischial pad against the iliac crest.
c. Adjust splint to length, extending the splint so that the bend is even with the heel of the
foot.
d. Tighten locking collars.
e. Open and position the Velcro straps along the splint.
f. Release the ratchet, extending the entire length of the traction strap.
g. Place the splint next to the injured leg.
4. Rescuer Two should apply the ankle hitch to the patient and apply gentle but firm traction.
5. Rescuer One will now move the splint into position. The
splint should be firmly seated against the ischial
tuberosity.
6. Rescuer One secures the pubic strap. The strap is
brought over the groin and high over the thigh and
secured.
7. Rescuer One attaches the ankle hitch to the traction
strap.
8. The traction strap is taken in, applying mechanical
traction until the pain and muscle spasms are relieved.
a. Maintain manual traction until the mechanical
traction takes over.
b. Traction can be stopped when the injured leg is approximately the same length as the
uninjured leg.
9. Secure the remaining Velcro straps around the leg.
10. Reevaluate all of the straps. When splint is properly applied, the patient’s foot should be upright.
11. Reassess circulatory and neurological function distal to injury site. Compare to original findings
and note any changes.
12. Transport patient on firm surface, such as a long spine board, so that the splint is supported.
Notes
1. If the patient is determined to be unstable, do not waste time applying the traction splint. Splint the
injured leg against the uninjured leg to expedite transport.
2. Continue to monitor patient’s vital signs during transport.
3. Continue to reassess circulatory and neurological function distal to injury site. Compare to
original findings and note any changes.
4. If the hospital has not removed the splint prior to departing, request the hospital staff to notify an
EMS Officer when it is removed.
Figure 13 – Pediatric Hare Traction splint.
Pelvic Sling Authorization: TCAD Paramedics and EMT-Basics only
Indications: Stabilization of suspected unstable pelvis fractures.
Precaution: Remove patient’s clothes which will be covered by the
pelvic sling. Once applied, the pelvic sling is to be removed only under
the supervision of a physician.
Procedure:
1. After visual examination, the pelvic sling is wrapped around the
patient’s pelvis (hips and buttocks, not abdomen).
2. The pelvic sling is then tightened and securely fastened anteriorly
over the pubic symphysis to reduce motion and internal
hemorrhage of the unstable pelvis fracture during transport to the
hospital.
3. Provide further immobilization by placing the patient on a
backboard and strapping the patient’s knees together and the
ankles together.
Sager Splint Authorization: TCAD Paramedics and EMT-Basics only
Indications: Closed mid-shaft and distal femur fractures
Contraindication: Open femur fracture. Hip, pelvic and/or knee fractures and dislocations
Procedure:
1. Apply manual stabilization to the injured leg and assess motor, sensory, and distal circulation.
2. Properly measure the splint to the unaffected leg, lengthening it approximately to the heel of the
unaffected leg.
3. Place the splint at the inner thigh, apply the ischial strap underneath the patient’s leg, pressing the
half ring pad up firmly against the ischial tuberosity.
4. Secure the ischial strap snugly.
5. Secure the ankle hitch.
6. Apply mechanical traction until pain is relieved or 10% of body weight is achieved. Maximum
traction applied should not exceed 15 pounds. The Sager splint may be used for immobilization of
bilateral fractures. In this situation, both ankle hitches must be utilized and the maximum traction
applied should not exceed 30 pounds. The legs should be secured together using the large Velcro
strap.
7. Apply Velcro support straps.
8. Fold lever down to maintain traction.
9. Velcro straps should not be placed over injury sites or joints.
10. Reassess motor, sensory and distal circulation.
11. Secure the patient to a long board and assess motor, sensory, and distal circulation frequently.
Figure 14 - Pelvic Sling application
Temperature Acquisition Authorization: TCAD Paramedics and EMT-Basics only
Indications: Patients with suspected increased or decreased body temperature.
Contraindications: Blood or body fluids in the ear canal, or trauma to the ear or temporal region of the
head.
Precautions: Temperature may need to be taken 3 times and the highest temperature documented. The
ear must be free from obstructions or excess earwax. Temperature may differ in each ear and should be
taken in the same ear each time. External factors may influence ear temperatures.
Procedure:
1. Attach a new probe cover to the ThermoScan.
2. The LCD will activate and display all segments on the screen.
3. When the ready symbol is displayed the thermometer is ready for use.
4. Perform an ear tug to straighten the ear canal giving the thermometer a clear view of the eardrum.
a. < 1 year old: pull the ear straight back.
b. > 1 year to adult: pull the ear up and back.
5. While tugging the ear, fit the probe snugly into the ear canal as far as possible and press the
activation button.
6. Release the button when you hear a beep, this confirms the end of measurement.
7. Remove the thermometer from the ear canal. The LCD displays the temperature measured and the
probe cover symbol.
8. Replace the probe cover to reset the thermometer and repeat procedure as needed to obtain an
accurate temperature reading.
9. After obtaining patient’s temperature, dispose of the probe cover.
10. The ThermoScan will automatically turn off after 30 seconds.
Tourniquet Authorization: All Paramedics, EMT-Basics, and
Emergency Medical Responder
Indications: Severe bleeding from potentially fatal,
hemorrhagic wounds after all other means of
bleeding control have failed.
Precautions:
1. A tourniquet applied incorrectly can increase
blood loss and lead to patient death.
2. Applying a tourniquet can cause severe nerve
and/or tissue damage, even when applied
correctly; ensure your patient’s injury
warrants the risk.
3. Risk of damage is minimized if the
tourniquet
is removed within one hour. The lower risk
of
tissue damage is preferable to the higher risk
of death secondary to hypovolemic shock.
4. A commercially manufactured tourniquet such
as the Combat Application Tourniquet (CAT),
which is described here, is the only acceptable type of tourniquet. Improvised tourniquets are not
as effective and may cause more harm.
Procedure:
1. Open the CAT and insert the wounded extremity through the opening of the self-adhering band.
2. Unfasten the Velcro portion of the self-adhering band and pull the band tight through the friction
adaptor buckle.
3. Securely fasten the self-adhering band back on itself being careful not to wrap the band past the
windlass clip.
4. Twist the windlass rod until bleeding has stopped. This will be painful for the patient, and
provider will have to coach patient through the procedure.
5. Secure the windlass rod in the windlass clip.
6. For smaller extremities pass the excess self-adhering band over the windlass clip and windlass rod.
7. Using the windlass strap, secure the windlass rod and self-adhering band by attaching the strap to
the clip on the opposite side.
8. Cut away any clothing that may obscure the tourniquet. The tourniquet must be clearly visible.
9. Write the time the tourniquet was applied on the patient’s skin near the tourniquet or on the
patient’s forehead.
Figure 15 - Diagram of the CAT® (Combat Action
Tourniquet)
Wound Packing (hemostatic gauze) Authorization: All Paramedics, EMT-Basics
Indications: External hemorrhage not amendable to tourniquet placement and where direct pressure is
ineffective or impractical. May be used in conjunction with a tourniquet to aid in clotting.
Contraindications: For external hemorrhage only. Not appropriate for minor bleeding. Should not be
used for internal bleeding, chest or abdominal injuries, or vaginal bleeding.
Procedure:
1. Apply direct pressure to the wound with a gloved hand.
2. Tear open pack. Take out the hemostatic gauze and take hold of one end with the other hand
3. Tightly pack the unfolding hemostatic gauze directly to the source of bleeding. Pack remaining
wound cavity with remaining hemostatic gauze or standard gauze. Excess hemostatic gauze can be
torn or cut if necessary
4. Apply FIRM pressure directly to the wound for 3 minutes. If bleeding persists apply direct
pressure for an additional 3 minutes.
5. Wrap and tie with a bandage so as to maintain pressure on the wound.
6. Discard any remaining hemostatic gauze.
7. Immobilize the area if possible.
8. Transport rapidly to a trauma center.
9. Transfer patient to medical facilities as soon as possible.
10. Show empty pack to medical personnel
Medications
Adenosine (Adenocard®) Authorization: TCAD Paramedics only
Class: Antiarrhythmic
Medical Control Required: No
Actions: Slows AV conduction
Indications: Symptomatic SVT
Contraindications: Second-degree or third-degree heart block, sick-sinus syndrome, known
hypersensitivity to the drug.
Precautions: When doses larger than 12 mg are given by injection, there may be a decrease in blood
pressure secondary to a decrease in vascular resistance.
Arrhythmia, including blocks are common at the time of cardioversion
Use with caution in patients with asthma
The effects of Adenosine are antagonized by methylxanthines such as Theophylline and caffeine. Larger
doses of Adenosine may be required.
Adenosine effects are potentiated by dipyridamole (Persantine) resulting in prolonged asystole.
In the presence of carbamazepine (Tegretol), high degree heart block may occur.
Adenosine is not effective in converting atrial fibrillation, atrial flutter or ventricular tachycardia.
All doses of adenosine should be reduced to one-half (50%) in the following clinical settings:
History of cardiac transplantation.
Patients who are on carbamazepine (Tegretol) and Dipyridamole (Persantine).
Administration through any central line.
Side Effects: Facial flushing, headache, shortness of breath, dizziness, and nausea
Routes: Rapid IV push into the medication administration port closest to the patient and followed by
flushing of the line with IV fluid.
Dosage: 6mg rapid IV. May repeat with 12 mg IV x 2 if patient fails to convert after 6 mg dose. Use a
large proximal IV site with fluid bolus flush
Pediatric Dosage: 0.1 mg/kg rapid IV. May repeat with 0.2 mg/kg once if patient fails to convert after
first dose. Maximum single dose is 12mg.
Albuterol Authorization: TCAD Paramedics, EMRA Paramedics, and EMT-Basics
Class: Sympathomimetic (B2 selective)
Medical Control Required: No
Actions: Bronchodilation
Indications: Asthma; Anaphylaxis; Allergic Reaction; Reversible bronchospasm associated with COPD
Contraindication: Known hypersensitivity to the drug
Precautions: Blood pressure, pulse, and ECG should be monitored. Use caution in patients with
hypertension, coronary artery disease, cardiovascular disease, complaining of chest pain or over 55 y/o.
Side Effects: Clinically significant arrhythmias may occur, especially in patients with underlying
cardiovascular disorders such as coronary insufficiency and hypertension. Palpitations, anxiety, headache,
dizziness, and sweating.
Dosage: Nebulizer: 2.5mg via nebulizer. Repeat as needed. Adults and pediatrics ≥2 years of age require
same dosing. Pediatric patients <2 years of age, 1.25mg via nebulizer (add 1.5 ml of albuterol + 1.5 ml of
NS).
Routes: Inhalation
Amiodarone (Cordarone®) Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Antiarrhythmic
Medical Control Required: No for IV push, Yes for IV drip
Actions: Inhibits adrenergic stimulation; Prolongs the action potential and refractory period in
myocardial tissue; Decreases AV conduction and sinus node function
Indications: Sustained or recurring pulseless VF/VT; Stable VT; Ventricular ectopy
Contraindication: Known hypersensitivity to drug, cardiogenic shock, sinus bradycardia, second or
third-degree heart blocks
Precautions: Pregnant or lactating mothers
Side Effects: Hypotension, Bradycardia, Heart block and Q-T prolongation may be seen, Hepatotoxicity
Dosage: Pulseless VF/VT: 300 mg IV/IO, additional 150 mg IV/IO once in 3-5 minutes;
Stable VT/Ventricular Ectopy: 150 mg IV over 10 minutes
Routes: IV/IO
Pediatric Dosage: VT/VF: 5mg/kg. Perfusing tachycardias: 5mg/kg over 20 to 60 min. Max 300 mg.
Aspirin Authorization: TCAD Paramedics, EMRA Paramedics, and EMT-Basics
Class: Platelet inhibitor / anti-inflammatory
Medical Control Required: No
Actions: Blocks platelet aggregation
Indications: New chest pain suggestive of AMI
Contraindication: Patients with hypersensitivity to the drug, active hemorrhage, or have taken full dose
less than 4 hours prior to arrival.
Precautions: GI bleeding and upset stomach
Side Effects: Heartburn, wheezing, nausea and vomiting
Dosage: 324 mg (81mg x 4)
Routes: PO (must be chewed)
Pediatric Dosage: Not indicated
Atropine Sulfate Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Para-sympatholytic (anti-cholinergic)
Medical Control Required: No
Actions: Blocks acetylcholine receptors; Increases heart rate; Decreases gastrointestinal secretions
Indications: Bradycardia; third-degree heart block; organophosphate poisoning; asthma refractory to
bronchodilator therapy
Precautions: Dose of 0.04mg/kg should not be exceeded except in cases of organophosphate poisoning;
Tachycardia; Hypertension
Side Effects: Palpations and tachycardia, headache, dizziness, and anxiety; dry mouth, pupillary dilation,
and blurred vision, urinary retention (especially in older males)
Dosage: Bradycardia: 0.5 mg every 5 minutes to a maximum of 0.04 mg/kg
Organophosphate poisoning: 2–5 mg until symptoms improve. Contact Medical Control for frequency of
dosing
Routes: IV/IO
Pediatric Dosage: Bradycardia: 0.02mg/kg Max 0.5mg. RSI: If patient is between 4 months and 2 years
of age, 0.02 mg/kg prior to or simultaneously with succinylcholine. Not indicated for patients over 2 years
of age.
Calcium Chloride Authorization: TCAD Paramedics only
Class: Electrolyte
Medical Control Required: Yes for pediatric dosage
Actions: Increases cardiac contractility
Indications: Acute hyperkalemia (elevated potassium); acute hypocalcemia (decreased calcium);
calcium channel blocker (Nifedipine, Verapamil) overdose; abdominal muscle spasm associated with
spider bites and Portuguese man-of-war stings; Magnesium Sulfate toxicity
Contraindication: Patients receiving digitalis.
Precautions: IV line should be flushed between Calcium Chloride and Sodium Bicarbonate
administrations; extravasation may cause tissue necrosis
Side Effects: Arrhythmia (bradycardia and asystole); hypotension
Dosage: 1 gram (10% Solution) slow IV over 3-5 minutes.
Routes: IV/IO
Pediatric Dosage: (Contact Medical Control) 20 mg/kg slow administration of a 10% solution
Dextrose Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Carbohydrate
Medical Control Required: No
Actions: Elevates blood glucose level rapidly
Indications: Hypoglycemia as indicated by glucometry; coma of unknown origin
Precautions: A blood sample should be drawn before administering Dextrose. Should be preceded by
100 mg of Thiamine in the patient with alcohol abuse or possible malnutrition.
Side Effects: Local venous irritation
Dosage: Ages 13-Adult; 25 g (250 ml) of D10 solution
Routes: IV/IO
Pediatric Dosage: 0.5 g/kg slow IV of D10 solution, max dose of 25 g.
Diltiazem (Cardizem®) Authorization: TCAD Paramedics only
Class: Calcium channel blocker
Medical Control Required: Yes
Actions: Slows conduction through the AV node
Indications: PSVT; Atrial fibrillation with rapid response; atrial flutter with rapid response
Contraindications: Heart blocks; Conduction disturbances; WPW
Precautions: Hypotension; should not be used in patients receiving IV-B-blockers
Side Effects: Nausea, vomiting, hypotension, dizziness
Dosage: Contact Medical Control to consider 10 mg slow IV over 2 minutes
Routes: IV
Pediatric Dosage: Not indicated
Diphenhydramine (Benadryl®) Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Antihistamine
Medical Control: No
Actions: Block histamine receptors; has some sedative effects
Indications: Anaphylaxis; allergic reactions; dystonic reactions due to phenothiazine
Contraindications: Asthma, nursing mothers
Precautions: Hypotension
Side Effects: Sedation; dries bronchial secretions; headache; palpitations
Dosage: 1 mg/kg (max dose 50 mg)
Routes: Slow IVP/IM/IO
Pediatric Dosage: IM/IV 1 mg/kg slow push over 2-4 min with max 50 mg
Dopamine (Intropin®) Authorization: TCAD Paramedics only
Class: Sympathomimetic
Medical Control Required: Yes
Actions: Increases cardiac contractility; Causes peripheral vasoconstriction
Indications: Cardiogenic shock; Hypovolemic shock (only after complete fluid resuscitation); May be
helpful in other forms of shock
Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred
Precautions: Should not be administered in the presence of severe tachyarrhythmia; should not be
administered in the presence of ventricular fibrillation; Ventricular irritability
Side Effects: Ventricular tachyarrhythmia; Hypertension
Dosage: 5 – 20 mcg/kg/minute, titrate to systolic BP of > 100 mmHg; 5 mcg/kg/min = renal/mesentery
vasodilation; 5 – 10 mcg/kg/min = beta effects (increased rate, contractility); above 10 mcg/kg/min =
alpha effects (vasoconstriction)
Method: 400 mg should be placed in 250 ml of NS giving a concentration of 1600 mcg/ml
Routes: IV drip only
Pediatric Dosage: 5-20 mcg/kg/min. Start at 5 mcg/kg/min and titrate to blood pressure.
Epinephrine 1:1,000 Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Sympathomimetic
Medical Control Required: No
Actions: Bronchodilation
Indications: Bronchial asthma; Anaphylaxis
Contraindications: Patients with underlying cardiovascular disease; Hypertension; Pregnancy; Patients
with tachyarrhythmia
Precautions: Epinephrine increases cardiac work load and can precipitate angina, MI, or major
dysrhythmias in individuals with ischemic heart disease. Should be protected from light; blood pressure,
pulse, and ECG must be constantly monitored
Side Effects: Palpitations and tachycardia; anxiousness; headache; tremor; myocardial ischemia in older
patients
Dosage: 0.5 mg
Routes: IM
Pediatric Dosage: 0.01 mg/kg to 0.5 mg, max of 3 doses 15 minutes apart
Epinephrine 1:10,000 Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Sympathomimetic
Medical Control Required: No
Actions: Increases heart rate; Increases cardiac contractility; causes bronchodilation
Indications: Cardiac arrest; anaphylaxis
Contraindications: None when used in cardiac arrest or anaphylactic shock.
Precautions: Epinephrine increases cardiac work load and can precipitate angina, MI, or major
dysrhythmias in individuals with ischemic heart disease. Should be protected from light; blood pressure,
pulse, and ECG must be constantly monitored
Side Effects: Tachyarrhythmia, PVC’s, angina and hypertension
Dosage: Cardiac arrest: 1 mg IV/IO repeated every 3-5 minutes;
Anaphylaxis: 0.05-0.1 mg/kg slow IV
Routes: IV/IO (ETT as last resort, double dosage)
Pediatric Dosage: 0.01 mg/kg (0.1mL/kg) repeated every 5 minutes
Epinephrine (Racemic) Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Class: Sympathomimetic
Medical Control Required: No
Actions: Causes mucosal vasoconstriction and reduction of subglottic edema
Indications: Croup, stridor in patients ages 6 months to 6 years.
Contraindications: Known larynogomalacia, tracheomalacia, or history of vascular ring or
tracheoesophageal fistula. Drooling or difficulty swallowing. Toxic appearance.
Precautions: Epinephrine increases cardiac work load and can precipitate angina, MI, or major
dysrhythmias in individuals with ischemic heart disease. Should be protected from light; blood pressure,
pulse, and ECG must be constantly monitored
Side Effects: Tachyarrhythmia, PVC’s, angina and hypertension
Pediatric Dosage: 0.5 ml of 2.25% inhalation solution, diluted in 3 ml of NS
Routes: Nebulizer
Esmolol (Brevibloc® Authorization: TCAD Paramedics only
Class: Beta-1 Selective Beta-Blocker, Antidysrhythmic
Medical Control Required: No
Actions: Decreases the force and rate of ventricular contractions by blocking beta-adrenergic receptors of
the sympathetic nervous system.
Indications: Refractory Ventricular Fibrillation
Contraindications: None in this setting
Dosage: 500 mcg/kg loading dose, followed by 50 mcg/kg/min IV infusion
Routes: IV/IO
Etomidate (Amidate®) Authorization: TCAD Paramedics only
Class: Imidazole
Medical Control Required: No
Actions: Etomidate is a non-barbiturate hypnotic that acts at the level of the reticular-activating system to
produce anesthesia
Indications: Sedative for advanced airway management
Contraindications: Hypersensitivity to the drug
Precautions: Patients < 9 y/o; Pregnancy; Immunosuppression; Sepsis; Transplant patients
Side Effects: Apnea; bradycardia; hypotension; arrhythmias; nausea/vomiting
Dosage: 0.3 mg/kg up to a max dose of 40 mg
Routes: IV/IO
Pediatric Dosage: 0.3mg/kg age >4 months of age
Fentanyl Citrate Authorization: TCAD Paramedics only
Class: Narcotic
Medical Control Required: No
Actions: Central Nervous system depressant; Decreased sensitivity to pain
Indications: Severe pain; Adjunct to rapid sequence intubation; Maintenance of analgesia
Contraindications: Shock; Severe hemorrhage; Hypersensitivity to drug
Precautions: Respiratory depression; Hypotension; Nausea
Side Effects: Dizziness; Altered level of consciousness; Bradycardia. With rapid intravenous (IV)
administration, rigidity of the chest muscles (Wooden Chest Syndrome) may be produced, which
interferes with normal breathing. A rise of blood pressure within the brain (intracranial hypertension) and
muscle rigidity and spasms have been reported following fentanyl use. Wooden Chest Syndrome may not
be reversible with Narcan, and will likely require intubation.
Dosage: 1 mcg/kg IV/IO/IM, or 1.5 mcg/kg IN, every 5 – 20 min, max 200 mcg total, then contact
medical control for further.
Routes: IV/IO/IN/IM
Pediatric Dosage: 2 - 12 years of age: 0.5 mcg/kg IV/IO/IM, or 1.5 mcg/kg IN (max dose of 50 mg)
Glucagon Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Class: Glucagon is a protein secreted by the cells of the pancreas
Medical Control Required: Yes for beta blocker overdose
Actions: When released it causes a breakdown of stored glycogen to glucose. It also inhibits the
synthesis of glycogen from glucose. Both actions tend to cause an increase in circulating blood glucose.
Indications: Hypoglycemia; Possible beta blocker overdose per Medical Control
Contraindications: Because glucagon is a protein, hypersensitivity may occur
Precautions: Glucagon is only effective if there are sufficient stores of glycogen within the liver. In an
emergency situation, intravenous glucose is the agent of choice. Glucagon should be administered with
caution to patients with a history of cardiovascular or renal disease.
Dosage: Hypoglycemia - 1 mg IM (must be reconstituted before administration)
Beta blocker overdose - Contact Medical Control for dosing
Routes: IM
Pediatric Dosage: Hypoglycemia - 0.02 mg/kg IM to a max of 1 mg. Contact Medical Control for dosing
in the case of beta blocker overdose.
Hydromorphone (Dilaudid®) Authorization: TCAD Paramedics only
Class: Narcotic analgesic
Medical Control Required: No
Actions: Inhibits pain pathways altering perception and response to pain
Indications: Moderate to severe pain management, Burns, Intractable flank pain, Intractable back pain,
Musculoskeletal and/or fracture pain, Sickle cell pain crisis (use supplemental oxygen), Unremitting
abdominal pain (not of obstetrical origin)
Contraindications: Known hypersensitivity, Head injury or head trauma, Hypotension. Respiratory
depression, Acute or severe asthma or COPD, Obstetrical emergencies (Labor pains), Shock.
Precautions: Liver failure, renal failure, or patients in excess of 65 years should receive
half dose, titrated to their pain tolerance.
If the patient responds with respiratory depression, administer Naloxone (Narcan) to reverse the effects.
Monitor oxygen saturation and administer supplemental oxygen as needed.
Hydromorphone (Dilaudid) will mask pain, so conduct a complete assessment prior to administration.
Use caution if the patient is hypersensitive to sulfites or latex.
May cause CNS depression.
Use caution in patients with hypersensitivity to other narcotics.
Side Effects: Respiratory depression, altered LOC, bradycardia, nausea and vomiting, constricted pupils
Supplied: 1 mg/ml prefilled syringe (Carpuject)
Dosage: 0.015 mg/kg IV, IM, IO (max single dose of 1 mg) slowly titrated to pain relief; maintain SBP >
100 mmHg and may repeat q 15 – 20 min up to a max dose of 2 mg. Over 65 years of age, liver failure,
renal failure, or debilitated patients, administer at low dosage titrated to pain tolerance up to 0.5 mg.
Pediatric Dosage: 0.015 mg/kg/dose IV, IM, IO titrated to pain relief (max. single dose 1 mg); maintain
SBP at appropriate level for patient size and may repeat once.
Ipratropium Bromide/Alubuterol (DuoNeb®) Authorization: TCAD Paramedics, and EMRA Paramedics (optional)
Class: Anticholinergic, Beta2-adrenergic agonist
Medical Control Required: No
Actions: Brochodilation
Indications: Treatment of bronchospasm associated with COPD in patients requiring more than one
bronchodilator
Contraindications: Patients with Congestive Heart Failure (CHF). Pediatric patients. Known
hypersensitivity to any of its components, or to atropine and its derivatives
Precautions: Blood pressure, pulse, and ECG should be monitored. Use caution in patients with
hypertension, coronary artery disease, cardiovascular disease, complaining of chest pain or over 55 y/o.
Should paradoxical bronchospasm occur, discontinue use and contact Medical Control.
Side Effects: Chest pain, pharyngitis, bronchitis, nausea, diarrhea, leg cramps
Supplied: 3 ml vial
Dosage: Ipratropium Bromide 0.5 mg/Albuterol 3.0 mg in 3ml solution
Pediatric Dosage: Administer half dose. 1.5 ml of DuoNeb, then add 1.5 ml of NS.
Ketamine (Ketelar®) Authorization: TCAD Paramedics only
Class: Dissociative anesthetic, NMDA receptor antagonist
Medical Control Required: No
Actions: Acts on cortex and limbic receptors producing dissociative analgesia and sedation
Indications: Delirium requiring immediate behavioral control. RSI/Sedation, Pain Control
Contraindications: Hypertensive crisis, schizophrenia, under the influence of methamphetamine, or
when significant elevations in blood pressure might prove harmful (e.g. intracranial hemorrhage, AMI, or
angina)
Precautions: Can cause an Emergence Reaction (confusion, delirium, excitement, hallucinations,
irrational behavior, pleasant dream-like state, vivid imagery).
Side Effects: Tachycardia, hypertension, arrhythmias, respiratory depression, hallucinations, or delirium
Dosage:
· Delirium or RSI/Sedation: 2 mg/kg IV or 4 mg/kg IM; for patients >65 years of age, 1 mg/kg IV
or 2 mg/kg IM
· Pain Control: 0.1 mg/kg IV/IO (max dose of 30 mg). For severe pain refractory to narcotics, or
severe burns; 1 mg/kg, may repeat once at 0.5 mg/kg
Pediatric Dosage:
· RSI/Sedation: >4 months of age; 2 mg/kg IV/IO or 4 mg/kg IM, Not indicated <4 months of age.
· Pain Control: 1 mg/kg IV/IO for severe pain refractory to narcotics, and severe burns.
Ketorolac (Toradol®) Authorization: TCAD Paramedics only
Class: Non-steroidal Anti-Inflammatory (NSAID)
Medical Control Required: No
Actions: It works by blocking your body's production of certain natural substances that cause
inflammation. This effect helps to decrease swelling, pain, or fever
Indications: Short-term management of moderately severe acute pain.
Contraindications: Following major surgery including CABG, labor and delivery, in conjunction with
other NSAIDs, patients with advanced renal impairment, patients with active or history of peptic ulcer
disease or GI bleed, patients with high bleeding risk, patients with recent head injury, and known
hypersensitivity to the medication.
Precautions: May cause dizziness or drowsiness. May cause gastrointestinal bleeding. Use caution if
patient has known hypersensitivity to Aspirin or other NSAIDs. Patients with renal deficiencies.
Side Effects: Headache, somnolence, dyspepsia, GI pain, nausea, diarrhea, dizziness
Dosage: 15 mg IV/IM
Pediatric Dosage: Patients weighing >50kg same as adult. Not indicated for patients <50 kg.
Lidocaine 2% (Xylocaine®) Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Antiarrhythmic
Medical Control Required: No
Actions: Suppresses ventricular ectopic activity; Increases ventricular fibrillation threshold; reduced
velocity of electrical impulse through conductive system; Local anesthetic which may reduce the pain of
intraosseous infusion
Indications: To be used for pain relief for conscious patients or patients able to perceive pain during
intraosseous infusion of fluid bolus or flush
Contraindications: Hypersensitivity to the drug; Pediatric patients with acute seizure or a history of
non-febrile seizure
Precautions: Monitor for central nervous system toxicity; Dosage should be reduced by 50% in patients
older than 70 years of age or who have liver disease
Side Effects: Anxiety; Drowsiness; Dizziness; Confusion; Nausea, vomiting; Convulsions; Widening of
QRS
Dosage: 0.5 mg/kg, max dose of 40 mg
Routes: IO
Pediatric Dosage: Same as adult
Magnesium Sulfate Authorization: TCAD Paramedics only
Class: Anticonvulsant
Medical Control Required: No
Actions: Central nervous system depressant; Anticonvulsant
Indications: Eclampsia/Pre-Eclampsia (toxemia of pregnancy); Torsades de Pointes, Hypomagnesaemia,
Asthma
Contraindications: Any patient with heart block or recent myocardial infarction
Precautions: Caution should be used in patients receiving digitalis; Hypotension; Calcium chloride
should be readily available as an antidote if respiratory depression ensues
Side Effects: Respiratory depression; Drowsiness
Dosage: Torsades de Pointes: 2 g slow IVP
Eclampsia / HTN: 4 g slow IVP
Severe Asthma/COPD: 50 mg/kg up to 2 g slow IV
Routes: IV/IO
Pediatric Dosage: 50 mg/kg, max dose of 2000 mg.
Methylprednisolone (Solu-Medrol®) Authorization: TCAD Paramedics only
Class: Steroid
Medical Control Required: No
Actions: Anti-inflammatory
Indications: Asthma/COPD; Anaphylaxis; Allergic Reactions
Contraindications: None in emergency setting
Precautions: Must be reconstituted and used promptly
Side Effects: GI Bleeding; prolonged wound healing; Suppression of natural steroids
Dosage: 2 mg/kg to a max of 125 mg
Routes: IV
Pediatric Dosage: 2 mg/kg max 125 mg
Metoclopramide (Reglan®) Authorization: TCAD Paramedics only
Class: Dopamine Antagonist
Medical Control Required: No
Actions: Blockade of the CNS vomiting chemoreceptor trigger zone (CRT) to inhibit vomiting.
Stimulation of upper GI motility by contracting the lower esophageal sphincter and speeding up gastric
emptying time.
Indications: Vomiting and nausea with concern for potential vomiting.
Contraindications: Previous allergic reaction
Known pheochromocytoma
Hypertensive crisis
Under the age of 8 years
Known Parkinson’s disease
Known or suspected bowel obstruction
Precautions: Drug is photo-sensitive and needs to be protected from light. If extrapyramidal side effects
occur, give Benadryl 50 mg IV bolus.
Side Effects: Restlessness, hyperactivity, anxiety, or sedation. Extra-pyramidal reactions have been
noted hours to days after treatment, usually presenting as spasm of the muscles of the tongue, face, neck
and back.
Routes: Slow IV/IM
Dosage: 10 mg slow IV over 1-2 minutes or IM
Pediatric Dosage: (8 y/o or older only) 5 mg slow IV over 1-2 minutes or IM
Midazolam (Versed®) Authorization: TCAD Paramedics only
Class: Benzodiazepine
Medical Control Required: No
Actions: Short acting CNS depression; Reduces anxiety; Mild to deep sedation; Hypnotic effects
Indications: Status seizure (any seizure that has lasted longer than 5 minutes or two consecutive seizures
without regaining consciousness); to relieve anxiety, and produce amnesia during cardioversion, pacing or
paralytic intubation.
Contraindications: Hypersensitivity to the drug; Acute angle-closure glaucoma; Shock; Coma;
Respiratory depression; Acute alcohol intoxication with vital sign depression
Precautions: IV use associated with severe respiratory depression, including arrest, especially when used
for conscious sedation; COPD; CHF; Hepatic/renal disease; older adults
Side Effects: Retrograde amnesia; Drowsiness; Slurred speech; Headache; Confusion; Anxiety;
Restlessness; Muscle tremors
Dosage: 0.1 mg/kg slow IV push, or 0.2 mg/kg IM/IN (may repeat once after 3 minutes) for seizures,
behavioral, and post-intubation sedation up to 5 mg; up to 10 mg for status epilepticus
Routes: Slow IV, IN, or IM
Pediatric Dosage: 0.1 mg/kg IV or 0.2 mg/kg IM/IN (max of 5 mg)
Morphine Sulfate Authorization: TCAD Paramedics only
Class: Narcotic analgesic
Medical Control Required: No
Actions: Central nervous system depressant. Causes peripheral vasodilation. Decreases sensitivity to pain
Indications: Pain Management; Pulmonary edema
Contraindications: Head injury; Volume depletion/hypotension; Patients with history of
hypersensitivity to the drug
Precautions: Respiratory depression; undiagnosed abdominal pain; Hypotension
Side Effects: Dizziness; Nausea; Altered level of consciousness
Dosage: 0.1 mg/kg, max single dose of 6 mg. May repeat up to a total max dose of 10 mg, contact
Medical Control for further dosing
Routes: IV, IM
Pediatric Dosage:
· Less than 1 year old; 0.05 mg/kg IV/IM. (max of 5 mg)
· ≥1 year old; 0.1 mg/kg IV/IM (max single dose of 6 mg). Contact medical control for further
orders.
Naloxone (Narcan®) Authorization: All Paramedics, and ***Qualified First Responders (see below)
Class: Narcotic antagonist
Medical Control Required: No
Actions: Reverses the effects of narcotics
Indications: Narcotic overdose including the following: Morphine Sulfate, Methadone, Dilaudid,
Heroin, Fentanyl, Synthetic analgesic overdoses include the following: Nubain, Talwin, Stadol, Darvon;
To rule out narcotics in coma of unknown origin
Contraindications: Patients with a history of sensitivity to the drug
Precautions: Should be administered with caution to patients dependent on narcotics as it may cause
withdrawal effects; Short-acting, should be augmented every 5 minutes
Side Effects: Adverse effects are rare. Patients who have received Naloxone must be transported because
coma may reoccur.
Dosage: 0.4 mg, repeat every 2 minutes (titrate to respirations)
Routes: IV, IO, IM, IN (ETT as last resort, double dosage)
Pediatric Dosage: 0.1 mg/kg up to 2 mg (titrate to respirations)
***Qualified First Responders: may administer 2.0 mg by “unit-dose”, premeasured, intranasal, or
auto-injector if trained.
Nitroglycerin (Nitrostat®) (Nitrolingual®) Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Vasodilator
Medical Control Required: No for chest discomfort, yes for hypertensive crisis
Actions: Smooth muscle relaxant; Reduces cardiac work; Dilates coronary arteries; Dilates systemic
arteries
Indications: Angina pectoris. Chest pain associated with myocardial infarction. Hypertensive crisis.
CHF/Pulmonary edema.
Contraindications: Erectile dysfunction medications (Phsophodiesterase inhibitors) taken in last 24
hours. Patients younger than 12 years of age. Hypotension. Inferior and/or posterior ST-segment
elevation.
Precautions: Constantly monitor blood pressure. Syncope.
Side Effects: Headache, dizziness, hypotension.
Dosage: 0.4 mg every 3-5 minutes until pain is relieved as long as BP >100 mmHg is maintained.
Routes: Sublingual
Pediatric Dosage: Not indicated
Ondansetron (Zofran®) Authorization: TCAD Paramedics only
Class: Serotonin 5-HT3 Receptor Antagonist
Medical Control Required: No
Actions: Anti-Emetic
Indications: Nausea and Vomiting
Contraindications: Hypersensitivity to the drug
Precautions: Not effective for motion sickness
Side Effects: Fever, chills, rash, dry mouth, fainting, lightheadedness, stomach pain, tiredness
Dosage: Age 8 and over, 4 mg slow IVP over 1-2 min (max 8 mg)
Routes: IV/IO
Pediatric Dosage: 0.15 mg/kg slow IVP over 1-2 minutes (max 4 mg)
Oral Glucose Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Carbohydrate
Medical Control Required: No
Actions: Elevates blood sugar levels
Indications: Conscious and alert hypoglycemia as indicated by glucometry
Contraindications: Patients with an altered level of consciousness that cannot protect airway
Precautions: If alcohol abuse is suspected, then glucose should be given after 100mg of Thiamine is
administered.
Side Effects: None
Dosage: One tube or packet; repeat based on blood glucose levels
Routes: PO
Pediatric Dosage: One tube or packet; repeat based on blood glucose levels; minimum age 3
Oxygen Authorization: All Paramedics, EMT-Basics, and EMRs
Class: Gas
Medical Control Required: No
Actions: Necessary for cellular metabolism
Indications: Hypoxia
Contraindications: None
Precautions: Use caution in patients with COPD receiving it during long transports
Side Effects: Drying of mucous membranes
Dosage: 1-4 liters/minute via nasal cannula
10-15 liters/minutes via NRB mask
10-15 liters/minute via BVM (sufficient to allow bag to completely refill between ventilations)
Routes: Inhalation
Pediatric Dosage: 1-4 liters/minute via nasal cannula
10-15 liters/minutes via NRB mask
10-15 liters/minute via BVM (sufficient to allow bag to completely refill between
ventilations)
Sodium Bicarbonate Authorization: TCAD Paramedics only
Class: Alkalinizing agent
Medical Control Required: No
Actions: Combines with excessive acids to form a weak volatile acid; Increases pH in cardiac arrest and
tricyclic overdose
Indications: Acidosis caused by prolonged cardiac arrest; to control arrhythmias or asystole in tricyclic
antidepressant overdose or hyperkalemia
Contraindications: Alkalotic states
Precautions: Correct dosage is essential to avoid overcompensation of pH; Can deactivate
catecholamines; Can precipitate with calcium; Delivers large sodium load; Can worsen acidosis in the
patient who is not intubated and adequately ventilated
Side Effects: Alkalosis
Dosage: Prolonged cardiac arrest: 1 mEq/kg; repeat at 0.5 mEq/kg q 10 minutes as needed
Tricyclic antidepressant overdose: 1 mEq/kg
Routes: IV/IO
Pediatric Dosage:
· <2 years old: 1 mEq/kg (1ml/kg of 8.4% solution), dilute by ½ with Normal Saline
· ≥2 years old: 1 mEq/kg
Succinylcholine Authorization: TCAD Paramedics only
Class: Neuromuscular blocking agent (depolarizing)
Medical Control Required: No
Actions: Skeletal muscle relaxant; Paralyzes skeletal muscles including respiratory muscles
Indications: To achieve paralysis to facilitate endotracheal intubation
Contraindications: Known hypersensitivity to the drug
>10% burns over 48 hours old
Known hyperkalemia (caution should be used with dialysis patients)
Paralysis, abdominal sepsis, or crush injuries over 3 days old
Known denervation syndrome until inactive for 6 months
Known Myasthenia Gravis (autoimmune neuromuscular disorder)
Precautions: Should not be administered unless personnel are skilled in endotracheal intubation.
Endotracheal intubation equipment must be available and prepared before administration. Paralysis occurs
within 1 minute and lasts for approximately 5-10 minutes
Side Effects: Prolonged paralysis; Hypotension; Bradycardia
Dosage: 1.0 mg/kg
Routes: IV/IO
Pediatric Dosage:
<3 years of age: 2 mg/kg
≥3 years of age: 1.0 mg/kg
Thiamine (Vitamin B1) Authorization: TCAD Paramedics, and EMRA Paramedics
Class: Vitamin
Medical Control Required: No
Actions: Allows normal breakdown of glucose
Indications: Coma of unknown origin; Alcoholism; Hypoglycemia; Hypothermia (moderate to severe)
Precautions: Rare anaphylactic reactions have been reported
Side Effects: Adverse effects are rare
Dosage: 100 mg
Routes: IV/IO
Pediatric Dosage: Not indicated
Tranexemic Acid (TXA) Authorization: TCAD Paramedics
Class: Antifibrinolytic
Medical Control Required: No
Actions: Reversibly binds four to five lysine receptor sites on plasminogen. This reduces conversion of
plasminogen to plasmin, preventing fibrin degradation and preserving the framework of fibrin's matrix
structure.
Indications: Mechanism (blunt or penetrating) suggesting potential for major hemorrhage. I.e. multiple
long bone fractures, flail chest, major abdominal injury, etc. and evidence of hypovolemia (BP<90 or HR
>115)
Contraindication: Age less than 16, renal failure, known allergy to TXA, known aneurismal SAH,
injury occurred more than 3 hours prior, history of thromboembolism
Precaution: Should not be given in the same line as blood products
Side effects: Headache, backache, abdominal pain, diarrhea, nasal sinus problems, fatigue, anemia
Dosage: 1 gram in 100 ml of NS infused over 10 minutes, followed by 1 gram in 250 ml of NS infused
over the next 8 hours (31ml/hr).
Routes: IV/IO
Vecuronium (Norcuron®) Authorization: TCAD Paramedics only
Class: Non-depolarizing Neuromuscular Blocker
Medical Control Required: No
Actions: Competes with acetylcholine for cholinergic receptor sites on the post-junctional membrane.
This results in paralysis of muscle fibers served by the occupied neuromuscular junction. The onset of
action is 1 minute with good to excellent intubation conditions within 2-3 minutes. Paralysis will have
duration of 40-60 minutes.
Indications: To achieve temporary paralysis where endotracheal intubation is indicated and where
muscle tone or seizure activity prevents it.
Contraindications: Hypersensitivity to the drug.
Precautions: Should not be administered unless personnel skilled in endotracheal intubation are present
and ready to perform the procedure. Oxygen therapy equipment should be readily available as should all
emergency resuscitative drugs and equipment.
Side Effects: Wheezing; Respiratory depression; Apnea; Aspiration; Arrhythmias; Bradycardia; Sinus
arrest; Hypertension; Hypotension; Increased intraocular pressure; Increased intracranial pressure
Dosage: 0.1 mg/kg
Routes: IV/IO
Pediatric Dosage: 0.1 mg/kg
Xylocaine Gel Authorization: TCAD Paramedics, and EMRA paramedics (if carrying nasal intubation)
Class: Anesthetic
Medical Control: No
Actions: Stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and
conduction of impulses thereby, effecting local anesthetic action.
Indications: Nasal preparation prior to nasotracheal intubation attempt.
Contraindications: Hypersensitivity to the drug and local anesthetics of the amide type
Side Effects: None
Dosage: Lubricate ET tube generously
Pediatric Dosage: Lubricate ET tube generously
Appendix
Jump START Pediatric Triage
Simple Triage and Rapid Treatment (START) Flowchart
Modified ESI Triage Algorithm
Medical Condition Requires Immediate
Life-Saving Intervention?
Including: STEMI, Stroke, Unconscious or
Unstable Vital Signs
Is this a high risk situation?
Pt. is currently stable but at risk for
becoming unstable.
or
Altered LOC?
or
Severe Pain/Distress?
(Currently stable vital signs/may or may
not have elevated temp.)
Are multiple resources needed to
initially manage this patient’s care in
the ED?
· Labs
· ECG
· X-ray
· CT/MRI
· Ultrasound
· Respiratory Therapy
· Specialty Consultation
Patient Has Minor Complaints and/or
manageable with limited resources.
IMMEDIATE
DELAYED
MINOR
NO
NO
YES
YES
YES
NO
YES
Modified ESI Triage Algorithm
Glasgow Coma Score/ Revised Trauma Score
Adult Eye Opening Verbal Response Motor Response
4-Spontaneous 5-Oriented & converses 6-Obeys verbal commands 3-To verbal Commands 4-Disoriented & converses 5-Localizes pain 2-To pain 3-Inappropriate words 4-Withdraws from pain 1-No response 2-Inconprehensible sounds 3-Decorticate to pain 1-No response 2-Decerebate to pain 1-No response
Infant
Eye Opening Verbal Response Motor Response 4-Spontaneous 5-Coos, babbles 6-Spontaneous 3-To speech 4-Irritable cries 5-Localizes pain 2-To pain 3-Cries to pain 4-Withdraws from pain 1-No Response 2-Moans, grunts 3-Flexion 1-No response 2-Extension 1-No response
Values
A Score between 13 and 15 may indicate a mild head injury A score between 9 and 12 may indicate a moderate head injury A score of 8 or less indicate a severe head injury (Endotracheal intubation is usually
required) Revised Trauma Score
Glasgow Coma Score (GCS) Systolic Blood Pressure Respiratory Rate 4=(13-15) 4=(>89) 4=(10-29) 3=(9-12) 3=(76-89) 3=(>29) 2=(6-8) 2=(50-75) 2=(6-9) 1=(4-5) 1=(1-49) 1=(1-5) 0=(3) 0=(0) 0=(0)
APGAR Score
Cincinnati Prehospital Stroke Scale (6)
R.A.C.E Stroke Scale (8)
AVPU Scale
Alert - a fully awake (although not necessarily orientated) patient. This patient will have spontaneously
open eyes, will respond to voice (although may be confused) and will have bodily motor function.
Voice - the patient makes some kind of response when you talk to them, which could be in any of the
three component measures of Eyes, Voice or Motor - e.g. patient's eyes open on being asked "are you
okay?!". The response could be as little as a grunt, moan, or slight move of a limb when prompted by the
voice of the rescuer.
Pain - the patient makes a response on any of the three component measures when pain stimulus is used
on them. Recognized methods for causing the pain stimulus include a sternal rub (although in some areas,
it is no longer deemed acceptable), where the rescuers knuckles are firmly rubbed on the breastbone of the
patient, pinching the patient's ear and pressing a pen (or similar instrument) in to the bed of the patient's
fingernail. A fully conscious patient would normally locate the pain and push it away, however a patient
who is not alert and who has not responded to voice (hence having the test performed on them) is likely to
exhibit only withdrawal from pain, or even involuntary flexion or extension of the limbs from the pain
stimulus. The person assessing should always exercise care when performing pain stimulus as a method
of assessing levels of consciousness, as in some jurisdictions, it can be considered assault. This is a key
reason why voice checks should always be performed first, and the person assessing should be suitably
trained.
Unresponsive - Sometimes seen noted as 'unconscious', this outcome is recorded if the patient does not
give any Eye, Voice or Motor response to voice or pain.
Blood Draw Consent Form
Consent for Drawing Blood Sample for Drug and/or Alcohol Test(s)
I, (print name of individual) , realize that
(print name of emergency response agency)
and its agents, employees, contractors, and
(print name of individual Paramedic drawing blood) _____________________________, have been
directed by (print name of Law Enforcement Agency)___________________________________,
pursuant to 577.020 and 577.029 RSMO to draw my blood for drug and/or alcohol
testing purposes that may relate to possible charges of drunk driving, and/or other
criminal charges, and/or potential loss of driving privileges.
Therefore, I certify that my consent hereby granted to
(print name of emergency response agency) , its agents,
employees and independent contractors to draw my blood for said stated testing purposes
is and has been totally and completely voluntary and the purpose of said drawing of my
blood are and have been completely and knowingly understood by me.
Pursuant to 577.031 RSMO, I further voluntarily agree to hold the
(print name of emergency response agency) ______________________________________, its insurer, its agents,
employees and independent contractors completely and totally harmless and not in any
way liable for any and all conceivable claims or causes of action, whether
administrative, civil, or criminal that might be filed in any forum whatsoever, whether
state or federal, that might arise from the hereby voluntarily consented drawing of my
blood for drug and/or alcohol testing purposes. I further restate that I completely and
knowingly understand that these blood tests could potentially result in possible criminal
charges against me and/or loss of driving privileges. I further voluntarily agree to
indemnify the (print name of emergency response agency) ______________________________________, its
insurer, its agents, its employees and its independent contractors any court costs and
litigation attorney defense costs that might arise from any conceivable claim or cause of
actions relating to this totally voluntary drawing of my blood or subsequent blood
testing.
Date Blood is Drawn Approximate Time Signature of Consenting Individual
Signature of Law Officer Badge Number Signature of Paramedic
MHT Flowchart
Medical Abbreviations
1˚ primary, first degree
2˚ secondary, second degree
3˚ tertiary, third degree
♀ female
♂ male
less than; less than or equal to
greater than; greater than or equal to
≈ approximately
= equals
≠ unequal
increased; upper
moved to
micro (1/1,000,000)
▵ change
∅ no or none
⊕ positive
⊖ negative
# number
× times
ā before
AAA abdominal aortic aneurysm
ABC airway, breathing, circulation
ABD abdomen
ABG arterial blood gas
AC; ac antecubital
ACLS advanced cardiac life support
ADM administered
AED automatic external defibrillator
A-FIB atrial fibrillation
AICD automatic implantable cardioverter defibrillator
AIDS acquired immune deficiency syndrome
ALS advanced life support
a.m. morning
AMA against medical advice
AMB ambulance, ambulatory, ambulated
AMI acute myocardial infarction
AMPLE allergies, medications, past history, last meal, events
ANT anterior
APAP acetaminophen
APGAR appearance, pulse, grimace, activity, respirations
APPROX approximately
ARDS acute respiratory distress syndrome
ASA acetylsalicylic acid (aspirin)
ASAP as soon as possible
Att attendant; attempts
AV atrioventricular
AVPU alert, verbal, painful, unresponsive
AX axillary
BBB bundle branch block
BCA beverage containing alcohol
BIL bilateral
BLS basic life support
BM bowel movement
BP blood pressure
BPM beats per minute
BSA body surface area
BS blood sugar
BVM bag valve mask
c with
Ca calcium
CA cancer
CABG coronary artery bypass graft
CAD coronary artery disease; Computer aided dispatch
CAO conscious, alert, oriented
CAO3 conscious alert and oriented to person, place, time
CAT computed axial tomography
CATH catheter
CBC complete blood count
C/C chief complaint
CCU coronary care unit
CHB complete heart block
CHF congestive heart failure
CID cervical immobilization device
Cl chloride
Cm centimeter
CNS central nervous system
C/O complains of
CO carbon monoxide; cardiac output
CO2 carbon dioxide
Cont. continued
CONX consciousness
COPD chronic obstructive pulmonary disease
CP chest pain
CPR cardiopulmonary resuscitation
C-section cesarean section
CSF cerebrospinal fluid
CTA clear to auscultation
CVA cerebrovascular accident
CX chest
D50 Dextrose 50% in water
D10 Dextrose 10% in water
D/C discontinue
DCAP-BLS deformity, contusions, abrasions, penetrations, burns, lacerations, swelling
DIC disseminated intervascular coaggulation
DKA diabetic ketoacidosis
dl deciliter
DNR do not resusitate
DOA dead on arrival
DOB date of birth
DTP diptheria, tetanus, pertussis vaccine
DT’s delirium tremens
Dx diagnosis
ECG; ECG electrocardiogram
EMS emergency medical service
ER emergency room
et and
ET endotracheal
ETCO2 end tidal carbon dioxide
ETI endotracheal intubation
ETOH ethyl alcohol
ETT endotracheal tube
F female
FA forearm
FB foreign body
F.D. fire department
FiO2 fractional inspired oxygen
Fr french
F.R. first responder
Ft. or ‘ feet
FT feeding tube
Fx fracture
G; g; gm gram
GCS glasgow coma score
GI gastrointestinal
gr grain
GSW gunshot wound
gtt drop
GYN gynecology
H2O water
h, hr hour
HA headache
HAV hepatitis A virus
HBV hepatitis B virus
HCO3 bicarbonate
Hct hematocrit
HCTZ hydrochlorothiazide
HCV hepatitis C virus
HEENT head, eyes, ears, nose, throat
Hg mercury
Hgb hemoglobin
H/H hematocrit and hemoglobin
HIV human immunodeficiency virus
H/L heparin lock
HOB head of bed
HPI history of present illness
HR heart rate
HTN hypertension
Hx history
IC intracranial
ICP intracracial pressure
ICS intercostal space
ICU intensive care unit
IDDM insulin dependent diabetes mellitus
IM intramuscular
in. or " inches
INJ injection
IO intraosseous
IPPB intermittent positive pressure breathing
IUCD intrauterine contraceptive device
IV intravenous
IVP intravenous push
IVPB intravenous line piggyback
J joules
JPTOA just prior to our arrival
JVD jugular vein distention
K+ potassium
KCL potassium chloride
KED Kendrick Extrication Device
kg; kgs kilogram; kilograms
KVO keep vein open
L left, liter
lb pound
LBB long back board
LBBB left bundle branch block
LCA left coronary artery
LCTA lungs clear to auscultation
LLQ left lower quadrant
LLR left lateral recumbent
LMP last menstrual period
LOC level of consciousness
LPM liters per minute
LPN licensed practical nurse
LR lactated ringers
LS lung sounds
LSB long spine board
LUQ left upper quadrant
M male
mA milliamps
MAE moves all extremities
MAO monoamine oxidase
MAP mean arterial pressure
MARF Missouri Ambulance Reporting Form
MAST medical anti-shock trousers
Mcg; µg microgram
MCI mass casualty incident
MCL modified chest lead
Meds medications
mEq milliequivalent
mg milligram
MI myocardial infarction
min minute
ml milliliter
mm millimeter
MOI mechanism of injury
MS multiple sclerosis
MSO4 morphine sulfate
mV millivolt
MVC motor vehicle collision
N/A not applicable
Na sodium
Na Cl sodium chloride
NaHCO3 sodium bicarbonate
NC nasal cannula
NCM no consumed medications
NCN no care needed
Neuro neurological
NG nasogastric
NIDDM non-insulin dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergies
NPA nasopharygeal airway
NPH neutral protamine hagedorn insulin
NPO nothing by mouth
NRB non-rebreather mask
NROM normal range of motion
NS normal saline
NSAID non-steroidal anti-inflammatory drug
NSR normal sinus rhythm
NT nasotracheal
NTG nitroglycerin
N/V nausea and vomiting
O2 oxygen
OB obstetrics
OD overdose
OG orogastric
OOA on our arrival
OR operating room
OPA oropharyngeal airway
OTC over the counter
oz. ounces
P pulse
p after
PAC premature atrial contraction
PASG pneumatic antishock garment
PCA patient control analgesia
PCN penicillin
PCP phencyclidine (angle dust)
PCTA percutaneous transluminal coronary angioplasty
P.D. police department
P.E. physical exam
PE pulmonary embolus
PEA pulseless electrical activity
PED pediatric
PEEP positive end expiratory pressure
PERRL pupils equal, round, react to light
PERRLA pupils equal, round, react to light, accommodate
pH hydrogen ion concentration (acidity)
PID pelvic inflammatory disease
PJC premature junctional contraction
p.m. afternoon
PMH past medical history
PMS pulses, motor function, sensation
p.o. by mouth
POV personally owned vehicle
PRC patient refused care
PRN pro re nata (as needed)
PSVT paroxysmal supraventricular tachycardia
psych psychiatry
PT patient
PTOA prior to our arrival
P.T.S. pediatric trauma score
PVC premature ventricular contraction
PWD pink, warm and dry
q every
® right
R respirations
RBBB right bundle branch block
RCA right coronary artery
reg regular
RLQ right lower quadrant
RLR right lateral recumbent
RM room
RN registered nurse
R/O rule out
ROM range of motion
RPM respirations per minute
RR respiratory rate
R.T.S. revised trauma score
RUQ right upper quadrant
Rx prescription
s without
SAMPLE S/S, allergies, Meds, past Hx, last meal, events leading to emergency
SB sinus bradycardia
SC or SQ subcutaneous
SCBA self contained breathing apparatus
SCUBA self contained underwater breathing apparatus
sec seconds
SIDS sudden infant death syndrome
SIVP slow intravenous push
SL sublingual
SMR spinal motion restriction
SNF skilled nursing facility
SOB shortness of breath
SpO2 oxygen saturation via pulse oximetry
SR sinus rhythm
SS spider straps
S/S signs and symptoms
ST sinus tachycardia
SVT supraventricular tachycardia
Stat immediately
STD sexually transmitted disease
tach tachycardia
TB tuberculosis
tbsp tablespoon
TCA tricyclic antidepressant
TCP transcutanous pacing
temp temperature
TIA transient ischemic attack
TIC tenderness, instability, crepitation
TKO to keep open
TNK Tenecteplase (thrombolytic)
TPN total parenteral nutrition
Torr millimeters of mercury (mm hg)
tsp teaspoon
tPA tissue plasminogen activator (activase)
TX treatment
U units
URI upper respiratory infection
UTI urinary tract infection
VD venereal disease
V-FIB ventricular fibrillation
via by way of
vit vitamin
vol volume
V/S vital signs
VT ventricular tachycardia
W/ with
WBC white blood cells
wk week
WNL within normal limits
W/O with out
WPW wolf-parkinson-white syndrome
wt weight
Y/O year old
yr year
Taney County Homicide and Questionable Death Protocol I. POLICY
All deaths occurring within Taney County will be treated as a homicide unless information to the contrary
becomes available. As such, the following homicide and questionable death protocol will be utilized in all death
investigations.
II. PURPOSE
The purpose of this procedural outline shall be to establish areas of responsibility for various agencies normally
involved in a homicide and questionable death investigations, and to establish procedures for each agency to
follow in pursuing its part in the investigations so that a common procedure will be used throughout Taney
County.
III. PROCEDURE
A. The procedural outline is intended to cover homicide and questionable death investigations
which occur or which are discovered in Taney County.
B. When a person is found deceased and the cause of death is unknown, the person who discovers
the death shall report it immediately to the Coroner and the Coroner shall take legal custody of
the body. The body of any such person shall not be removed from the place of death except
upon the authority of the Coroner and consultation with the local law enforcement agency, or
the County Prosecutor, nor shall any article (i.e. personal property such as a wallet, etc.) on or
immediately surrounding such body be disturbed until authorized by the Coroner and
consultation with the appropriate law enforcement agency.
The ultimate objective of a death investigation is a finding of fact, and if a crime is found to have
been committed, the preservation of evidence necessary for the prosecution of the offender in a
court of law. Because the result of a trial is a reflection on the investigative law enforcement
agency, the Coroner and the Prosecutor’s Office, each has a valid interest in the investigation
and prosecution.
The Taney County Coroner’s Office, the Taney County Law Enforcement Agencies, and the
Taney County Prosecutor mutually agree that in all situations covered with the scope of this
policy where the mortal trauma occurs in Taney County, every reasonable effort will be made to
ensure that a proper post-mortem investigation and/or autopsy, when necessary is provided. This
section shall also apply to child related deaths.
C. Law Enforcement Agencies general areas of responsibility
1. The function of law enforcement agencies is to collect evidence from the death scene and
from other sources, which bears on the issues of a death investigation.
2. If a preliminary death investigation has indicated a probable suicide and there is a note(s)
present, the law enforcement agency will package the note as evidence and process it
accordingly. The law enforcement agency will then provide the Coroner’s Office with a
copy of the note as soon as possible. The note will be released to the Coroner’s Office
when it is no longer deemed as evidence.
D. The Coroner’s function is to make all necessary inquiries to establish a cause and manner of
death of the deceased person. Specific responsibilities include:
1. Taking custody of body.
2. Responsible for the identification of the deceased through various forensic evidentiary
procedures such as medical and dental records, or by other means as the circumstances
warrant.
3. Inventory and seize the personal effects of the deceased.
4. Assure proper notification of the deceased’s next of kin.
E. The fire department and emergency medical service personnel are generally called to the scene
in an effort to preserve the life of the victim. In fire-related deaths, the function of the fire
department is to extinguish the fire and determine the cause and origin of the fire in cooperation
with the law enforcement agency.
1. Any photographs taken of the scene by fire personnel shall be forwarded to the appropriate
investigating law enforcement agency.
F. The Prosecutors function is to act as an advisor on the legal consequences of evidence gathering
and its bearing upon the proof required to gain a conviction and as a monitor to ensure the
consistency of investigations conducted within the jurisdiction.
G. Notification and Custody of the Scene
1. Law Enforcement Agencies
a. The law enforcement agencies have the primary responsibility for conducting
the investigation at a homicide or questionable death scene within their
respective jurisdictions. They must be notified immediately by whatever agency
first arrives on the scene, and a member of the law enforcement agency will go
to the scene upon notification.
b. The law enforcement agency shall have custody of the scene upon its arrival, and
all other agencies shall follow its instructions concerning the processing of the
scene. However, the body shall not be moved or disturbed in any way, except
as is essential for the preservation of life or immediate collection and
preservation of evidence and identification.
H. Coroner
1. When the Coroner arrives at the scene, he should, without disturbance, examine the body,
pronounce death, and immediately notify the appropriate law enforcement agency. He
should then preserve the scene until the arrival of that law enforcement agency. Nothing,
including the body, should be disturbed until the law enforcement agency personnel have
arrived and completed their processing of the scene.
2. The Coroner must be notified by the law enforcement agency when its personnel arrive on
the scene. The Coroner must view the body at the scene prior to its being moved. At the
scene the body will not be disturbed in any manner other than by the Coroner’s personnel.
3. When extraordinary circumstances deem it advisable, it will be to the discretion of the
Coroner if the pathologist is to respond to the scene and consult in the investigation. This
is solely the responsibility of the Coroner.
4. All death notifications to next of kin will be made by the Coroner’s Office. Once
notification has been made, the Coroner shall notify the law enforcement agency in charge
of the investigation that the next of kin have been notified. In some circumstances law
enforcement may want to accompany the Coroner. When the deceased is a police officer,
fire fighter or emergency services worker, the appropriate agency, in conjunction with the
coroner, shall notify the next of kin.
I. Sheriff, Fire, Paramedic, and EMS Units
1. Unless death is obvious, appropriate EMS units shall be notified by the first agency on the
scene.
2. If another police agency, EMS or fire unit is the first agency on the scene where death is
obvious, it shall immediately notify the appropriate law enforcement agency and preserve
the integrity of the scene until the arrival of the agency. Law Enforcement personnel will
take custody of the scene immediately upon their arrival.
3. Immediate notification shall be made to the Coroner by either the fire department personnel,
paramedics, EMS, or law enforcement personnel.
J. County Prosecutor: In all cases of homicide, probable homicide, or questionable death, and in
law enforcement situations that present a substantial risk of homicide, (i.e., barricaded subjects,
hostage situations, riots, etc.), the law enforcement investigator in charge of the incident shall
immediately ensure that the County Prosecutor’s Office is notified. The Prosecutor may respond
with additional personnel as necessary after consultation with the law enforcement officer in
charge of the incident.
K. Uniform, Homicide and Questionable Death Procedures
1. Unless death is obvious at the time the first agency arrives at the scene, all appropriate
aid shall be given. Nothing in this procedure outline shall be interpreted to preclude any
action necessary to save the life of the victim. However, consistent with the foregoing,
all law enforcement agencies, fire, or EMS personnel who render aid to a victim should
observe the following procedure.
a. Only those personnel who are actively aiding the victim should be in the
immediate area. All others will remain away, thus avoiding unnecessary
disturbance of the scene.
b. The victim will not be moved unnecessarily.
c. Nothing in the area shall be touched or disturbed in any way unless required in
giving aid to the victim. If items must be moved, a report of this will be given
to the law enforcement officer in charge of the scene.
d. After death has been established all personnel will withdraw from the scene and
follow the instructions of the law enforcement officer in charge of the crime
scene and the Coroner who is in charge of the body.
e. A list of all persons who enter the area will be compiled by the law enforcement
agency in control of the scene and given to the law enforcement officers in
charge of the scene.
f. Law enforcement agencies and fire departments shall upon arrival at the scene
designate an officer in charge who shall make every effort to enforce these
procedures.
g. All emergency personnel at the scene shall document in writing the identity and
activity of each of his/her personnel on the scene. This report will be turned over
to the law enforcement investigator in charge upon his/her arrival on the scene.
h. Evidence Collection
Investigators collecting evidence at the scene shall follow the standardized
guidelines and principles of evidence collection, keeping the following in mind:
1. Approach the scene with caution.
2. Enter and leave the scene by the same route.
Do not walk through bloodstains or disturb other evidence. Before
leaving the scene check shoes to see if any objects (such as bullets or
debris) have been picked up on the shoe or soles;
3. Allow only one person to initially approach the scene. When possible
wait for law enforcement assistance before approaching the scene;
4. If possible, wear protective gloves to minimize scene contamination;
5. When death is apparent, assess the victim with minimal amount of
physical contact and movement. Check for a carotid pulse and listen for
heart and breath sound. When obvious signs of death are present, such
as lividity, rigor mortis, or putrefaction, do not attach the cardiac monitor
or touch the victim;
6. Notify the Coroner of where the victim was touched;
7. If it is necessary to move the victim, note the exact position and location
of the victim prior to movement;
8. Do not touch or move any items at the scene unless absolutely necessary
to render care to the patient. Document if items were touched or moved;
9. Do not cut through bloodstains or bullet holes in clothing;
10. Document puncture sites that you have made on the victim, if necessary;
11. When leaving the scene, fire and EMS personnel shall not collect
miscellaneous items, which were used during victim treatment (paper,
syringes, etc.), however document what items have been left.
L. The law enforcement agencies, Coroner, and Prosecutor have a continuing responsibility to
coordinate policies and procedures and to provide training to the various fire and rescue services
of their jurisdictions to facilitate compliance with the provision herein.
M. The first law enforcement officer on the scene shall have custody of the scene until relieved by
their supervisor or investigator in charge. This does not preclude the Coroner from the initial
contact of the deceased or the scene.
N. If the victim exhibits obvious signs of death, the officer will secure the scene and allow no
activity, which might disturb the evidence until such time the Coroner has been notified and has
arrived at the scene to pronounce death. Thereafter, no one is allowed access to the death scene
until the law enforcement investigator and Coroner are both present.
O. The removal of the body shall be directed by the Coroner and shall be done in a manner as
prescribed by the Coroner’s Office procedures. This procedure may include, but is not limited
to, the removal of the body placed into a body bag and in some cases the bag may be sealed or
tagged. This does not preclude the law enforcement agency from examining and photographing
all evidence which is disclosed by the movement of the body, however, it will not allow for any
evidence to be removed from the body until approved by the Coroner.
P. Post-Mortem Examination
1. A post-mortem examination will be performed by the coroner, or a forensic pathologist,
in all cases where the suspected manner of death is a homicide or questionable.
Exceptions to this procedure shall be allowed by mutual agreement between the Coroner
and the Prosecutors Office, with input from the law enforcement agency.
2. The Coroner will give the appropriate law enforcement agency sufficient notice of time
and place of autopsy to be performed, so that if warranted they may have representatives
there to collect evidence and observe. Exceptions to the number of representatives may
be made through the Coroner’s Office. The Coroner shall notify the Prosecutors Office
in advance of an autopsy to ensure that a representative of the Prosecutors Office is
available for consultation, whether in person or via telephone.
3. Any opinion given or delivered by the pathologist to the Coroner shall be considered
preliminary in nature. Any other statements made prior to the final autopsy report being
issued shall be considered speculative. The final written autopsy report will not be
available until at such time the inquest date has been established or as such time that the
report is released to the State’s Attorney or the appropriate law enforcement agency by
the Coroner’s Office.
4. The preliminary verbal report of the scene investigation will be made to the Coroner by
the investigator in charge or his designee. A written report of the scene investigation
shall be delivered to the Coroner by the investigator in charge when such report is
requested by the Coroner and prior to the inquest.
5. At the time the autopsy is being performed, the law enforcement agency shall provide
the Coroner and pathologist with all information obtained from the scene investigation
which the Coroner and pathologist deems necessary to the proper performance of
autopsy or the evaluation of autopsy findings.
6. The pathologist and appropriate law enforcement personnel or Coroner’s Office
representative will examine the body. Items on the body and items of physical evidence
or evidentiary nature will also be collected by law enforcement. The release of all
evidentiary items on or in the body will be at the direction of the Coroner. Any body
fluids, tissue, or other samples will be retained and properly examined for evidentiary
value by the Coroner’s Office, unless otherwise so relinquished by the Coroner. Personal
property to be returned to the family will be done by the Coroner with the consensus of
law enforcement.
Q. Organ Transplants: The Coroner, the State Prosecutor, and the law enforcement agencies of
Taney County agree that victims who have died of possible criminal trauma occurring in Taney
County are eligible as prospective donors for organ transplants, unless organ transplant would
impair or impede the criminal investigation.
R. Information Release: The appropriate law enforcement agency shall have the sole responsibility
and authority to regulate release of information, including investigative keys, pertaining to the
case under investigation that are covered by this policy. Any and all inquiries regarding the
victim or the deceased (i.e. injuries, cause of death, manner of death) or any contact regarding
the Coroner’s procedures shall be directed to the Coroner’s Office for release that includes
identification. The press and the media shall be directed to the investigating law enforcement
agency public relations officer unless such questions refer to that of the specific nature of the
body. All information concerning the body involved in the incident shall be released directly
from the Coroner’s Office. The Coroner’s Office shall not give a direct cause of death without
prior consultation with investigating agencies until such time of the inquest, or such time is
necessary for the prosecution of the case.
It is suggested in major cases that the defined responsibility of each agency involved release
only information that concerns that agency’s “definition of office”. Law enforcement agencies
should concern themselves with the release of information concerning the investigation that is
underway. The Coroner should concern himself with the investigation as to the manner and the
cause of death and identity of the individual only. The Prosecutors Office should concern itself
with the investigation and the prosecutorial duties of that particular office. The recommended
way to handle a major case is to have a joint press conference so each of the agencies involved
in the investigation release information in a cooperative spirit and mode where each can address
their own specific requirements or duties in the investigation. This should be done only after
prior conference of all three agencies (Law Enforcement Agencies, Coroner, and Prosecutor).
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Index
abdomen, 33, 37, 41, 43, 54,
55, 116
abdominal, 12, 31, 41, 56, 98,
105, 108, 116
abuse, 27, 98, 106
Adenosine, 20, 25, 96
airway, 8, 9, 10, 11, 12, 13,
15, 27, 29, 31, 32, 34, 40,
41, 47, 57, 58, 59, 106, 116,
120, 121
Albuterol, 31, 39, 58, 96
alcohol, 53
Allergic, 31, 96, 104
allergy, 14
Altered mental status, 24
Amiodarone, 20, 25, 97
anaphylaxis, 48, 100
aneurysm, 31, 116
anxiety, 15, 19, 96, 97, 98,
105
APGAR, 37, 117
aspiration, 8, 40
aspirin, 8, 117
Aspirin, 17, 97
asthma, 39, 96, 97, 100
asystole, 29, 30, 96, 98, 107
atrial fibrillation, 20, 96, 116
Atropine, 17, 24, 47, 97
BiPAP, 11, 19, 58, 59
bradycardia, 9, 17, 24, 54, 97,
98, 100, 122
breech, 36
burn, 41, 43, 44
burns, 43, 44, 108, 118
Calcium Chloride, 36, 98
cardiac arrest, 9, 50, 52, 100,
107
cardioversion, 9, 15, 19, 20,
25, 96, 98, 105
chest pain, 17, 35, 52, 96, 97,
102, 117
childbirth, 8
colostomy, 54
Coroner, 124, 125, 126, 127,
128
CPR, 26, 27, 29, 117
defibrillation, 8, 9
dehydration, 33, 54, 55
Dextrose 50%, 34, 98, 118
Diabetic, 34
Diltiazem, 20, 99
DNR, 29, 118
Dopamine, 17, 19, 23, 24, 25,
99
electrocardiogram, 13, 19, 20,
118
electrocardiograms, 8, 9
Epinephrine, 31, 32, 39, 100
Etomidate, 100
Evisceration, 43
Fentanyl, 14, 15, 101, 105
fracture, 12, 41, 43, 118
Fracture, 8
gastric, 8, 9, 56
GCS, 11, 12, 33, 47, 113, 118
glucose, 13, 24, 34, 40, 98,
101, 106, 108
Hydromorphone, 14, 15
Hypertensive, 35, 106
hypotensive, 15, 23, 24, 25
hypothermia, 17, 29, 30, 43,
44
intubation, 9, 12, 27, 47, 100,
101, 105, 108, 109, 113,
118
Lidocaine, 103
Magnesium Sulfate, 20, 36,
98, 104
Methylprednisolone, 104
Morphine Sulfate, 14, 15, 105
Naloxone, 15, 105
Nasopharyngeal, 8
neonate, 24
Oropharyngeal, 8, 60
oxygen, 8, 11, 12, 19, 20, 29,
45, 51, 52, 56, 57, 58, 59,
118, 121, 122
pelvic, 43, 121
poison, 38
pregnant, 29
pulmonary edema, 17, 23, 24,
25
Rapid sequence intubation, 9
restraint, 38
RSI, 11, 12, 47, 100
seizure, 36, 40, 54, 55, 103,
105, 108
Sepsis, 100
shock, 17, 24, 35, 41, 53, 97,
99, 100, 120
Sodium Bicarbonate, 98, 107
stroke, 40
tachycardia, 17, 19, 20, 24,
96, 97, 100, 121, 122, 123
tachypnea, 19, 45, 52
tension pneumothorax, 9, 11,
46
Tension Pneumothorax, 39,
46
Thiamine, 34, 98, 108
thoracentesis, 9, 11, 12
transcutaneous pacing, 9, 15,
17, 24
triage, 10, 42
Valium, 15, 17, 19, 25, 40, 98
Vecuronium, 108
ventilator, 8, 56, 57, 58, 59
Versed, 15, 23, 25, 32, 40, 47,
105
Zofran, 15, 106
