update to protocols

Standing Orders

Emergency Medical Protocols

Critical Care Ground and Air Medical Division

Dr. Ronald Charles M.D.

Board Certified Emergency Physician

Chief Medical Director of EMS

Dr. Joseph Varon M.D.

Certified Critical and Intensive Care Physician

Clinical Professor of Medicine, UTHSC-Houston Clinical Professor of Medicine-UTMB

Medical Director of Critical Care and Flight Services

Signature Signature

Protocols Valid from October 01, 2011 through October 31, 2015

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Table of Content

Page

General Protocols GP01 Standard of Care 7

GP02 Standing Orders 8

GP03 General Therapies 9-12

GP04 Patient Assessment Primary Survey 13-14

GP05 Destination Determination 15

GP06 Diagnostics/Procedures 16-18

GP07 Rapid Transport 19

GP08 Air Ambulance Use 20

GP09 Consent for Treatment 21

GP10 Authorization Levels 22

GP11 Pain Management 23

GP12 IV Fluid Selection 24

GP13 Medical Scene Control and Responsibility 25

GP14 Minimum Supply/Equipment List 26

GP15 Minimum Drug Formulary 27

GP16 Storage of Medications and Medical Devices 28

GP17 Pharmacological Assisted Intubation 29

GP18 Non Resuscitation Order 30

GP18a TDSHS STOP Form/DNR Form 31

GP19 Tissue Referral 32

GP20 InService Dispositions 33

GP21 HIPAA Compliancy and Standards 34-37

GP22 Geographical Area and Personnel Status 38

GP23 Disaster Plan 39-40

GP23a Disaster Plan Flow Sheet 41

GP24 Sedation of Confirmed Intubated Patient 42

GP25 Facility Physician Orders 43

GP26 Treating and Release of Patients 44

GP27 Medical Control Consults 45

GP28 Oxygen Calculation Worksheet 46

Adult Medical Protocols AM01 Asystole 48

AM02 Pulseless Electrical Activity 49

AM03 Pulseless Ventricular Fibrillation 50

AM04 Hypothermic Induces Cardiac Arrest 51

AM05 Post Resuscitation Management 52

AM06 Undifferentiated Tachycardia 53

AM07 Unstable Ventricular Tachycardia 54

AM08 Stable Ventricular Tachycardia 55

AM09 Unstable Supraventricular Tachycardia 56

AM10 Stable Supraventricular Tachycardia 57

AM11 Bradycardia 58

AM12 Ventricular Ectopy 59

AM13 Acute Coronary Syndrome 60

AM14 Cardiogenic Shock 61

AM15 Hypertensive Crisis-Unstable 62

AM16 Hypertensive Crisis-Stable 63

AM17 Respiratory Distress-General 64

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Table of Content Continued

Adult Medical Protocols AM18 Pulmonary Edema 65

AM19 Asthma 66

AM20 Chronic Obstructive Pulmonary Disease 67

AM21 Pneumonia 68

AM22 Hyperventilation Syndrome 69

AM23 Pneumonia 70

AM24 Allergic Reactions Mild to Anaphylaxis 71

AM25 Altered Mental Status-Unknown Etiology 72

AM26 Seizures 73

AM27 Cerebral Vascular Accident 74

AM28 Overdose 75

AM29 Poisoning 76

AM30 Neurogenic Shock 77

AM31 Hypoglycemia 78

AM32 Hyperglycemia 79

AM33 Dehydration 80

AM34 Hypothermia 81

AM35 Heat Related Emergencies 82

AM36 Near Drowning 83

AM37 Septic Shock 84

AM38 Nausea/Vomiting 85

AM39 Acute Appendicitis-Diagnosed 86

AM40 Renal Calculi 87

AM41 Acute Abdomen Etiology Unclear 88

AM42 Gastrointestinal Hemorrhage 89

AM43 Sedation / Chemical Restraint 91

AM44 Excited Delirium 92

Adult Trauma Protocols AT01 Traumatic Cardiopulmonary Arrest 94

AT02 Multi-System Trauma 95

AT03 Head Injury 96

AT04 Burns 97

AT05 Muscle-Skeletal and Soft Tissue Injury 98

AT06 Amputations 99

AT07 Eye Injury 100

AT08 Insect/Spider Bites 101

AT09 Snake Bites 102

AT10 Pulmonary Embolism 103

Obstetrics/Gynecology OB01 Abdominal Pain Female 105

OB02 Labor 106

OB03 Childbirth and Delivery 107

OB04 Vaginal Bleeding 108

OB05 Spontaneous Abortion 109

Pediatric Medical Protocols PM01 Asystole 111

PM02 Pulseless Electrical Activity 112

PM03 Pulseless Ventricular Fibrillation 113

PM04 Hypothermic Induced Cardiac Arrest 114

PM05 Post Resuscitation Management 115

PM06 Undifferentiated Tachycardia 116

PM07 Unstable Ventricular Tachycardia 117

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Pediatric Medical Protocols PM08 Stable Ventricular Tachycardia 118


PM10 Stable Ventricular Tachycardia 120

PM11 Bradycardia 121

PM12 Ventricular Ectopy 122

PM13 Hypoperfusion 123

PM14 Cardiac Ischemia 124

PM15 Cardiogenic Shock 125

PM16 Respiratory Failure 126

PM17 Respiratory Distress 127

PM18 Pulmonary Edema 128

PM19 Asthma 129

PM20 Epiglottitis 130

PM21 Croup 131

PM22 Bronchiolitis/Pneumonia 132

PM23 Airway Obstruction by Foreign Body 133

PM24 Allergic Reactions 134

PM25 Altered Mental Status 135

PM26 Seizures/Status Epilepticus 136

PM27 Seizures/Postictal State 137

PM28 Overdose 138

PM29 Poisoning 139

PM30 Hypoglycemia 140

PM31 Hyperglycemia/Diabetic Ketoacidosis 141

PM32 Dehydration 142

PM33 Hypothermia 143

PM34 Heat Related Emergencies 144

PM35 Heat Stroke 145

PM36 Near Drowning 146

PM37 Post Delivery Care 147

PM38 Sepsis 148

PM39 Acute Abdomen-Unknown Etiology 149

Pediatric Trauma Protocols PT01 Traumatic Cardiopulmonary Arrest 151

PT02 Multi-System Trauma 152

PT03 Head Injury 153

PT04 Burns 154

PT05 Muscular-Skeletal and Soft Tissue Injury 155

PT06 Amputations 156

PT07 Eye Injuries 157

PT08 Insect/Spider Bites 158

PT09 Snake Bites 159

Procedures PR01 Electrocardiogram 161

PR02 Esophageal Obturation Airways 162

PR03 External Cardiac Pacing 163

PR04 Defibrillation Zoll Cardiac Monitors 164

PR05 Defibrillation Welsh Allen Monitors 165

PR06 External/Internal Jugular Cannulation 166

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Procedures PR07 Injection Locks 167

PR08 Intraosseous Cannulation EZ/IO Bone Drill and B.I.G. 168

PR09 Intravenous Cannulation 169

PR10 Nasogastric Tube Insertion 170

PR11 Nasotracheal Intubation 171

PR12 Nebulized Brochodilation 172

PR13 Needle Chest Decompression 173

PR14 Oral Tracheal Intubation 174

PR15 Positive End Expiratory Pressure 175

PR16 Surgical Airway 176

PR17 Vagal Stimulation 177

References RF01 Burn Reference 179

RF02 Trauma and Glascow Scoring 180

RF03 Multi Lead ECG 181

RF04 Guide to Drips 182

RF05 Anatomical Positions 184

RF06 Anatomical Reference to Movement 185

RF07 Cardiac Muscle Reference 186

RF08 Skull Bone Reference 187

RF09 Eye Anatomy Reference 188

RF10 Renal and Hepatic Reference 189

RF11 Head and Neck Anatomy Reference 190

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Protocol Preface

These Protocols are to be utilized when the indicated conditions arise. They are not to be deviated from or changed in any way unless specified herein. The use and administration of oxygen in these protocols are not intended to be exact but to be a guideline. The adult protocols refer to patients over the age of 12. The pediatric protocols refer to patients 12 years of age and younger.

It is the requirement of all ACUTE MEDICAL SERVICES, LLC employees and volunteers to be familiar with these protocols and all skills associated with these protocols.

All Medics are to be knowledgeable with all drugs specified herein or used by ACUTE MEDICAL SERVICES, LLC, including but not limited to: indication, contraindication, anticipated effect, possible side effects and dosage. References for medications and drugs utilized can be confirmed by the use of ‘Mosby’s Critical Care Drug Reference’ as this is the reference of choice when cross references medications and administration of medications. Acute Medical Service’s medical director allows all medical certified staff to perform therapies under these protocols and may limit any certified personnel no matter what certification level the employee may hold to perform any therapies herein. If there is any doubt whether you may perform any therapy within these protocols the medical director should be notified for clarification.

Emergency Medical Technician may apply the cardiac monitor but may not interpret any rhythm or treat patients based on any rhythm displayed on the cardiac monitor. EMT Basic technicians can perform ECG and 12 Lead for the receiving facilities. EMT Basic may draw blood and in some instance perform IV cannulations only to the upper extremities under direct supervision of an EMT Intermediate or Paramedic at the discretion of the Medical Director. EMT’s may not administer any IV fluids and may only use Saline Locks. EMT must have the written approval from the medical director before performing such skills and the approval must be placed in the employees file for reference.

Emergency Medical Technician-Intermediate may initiate intravenous access under these protocols and are limited to the use of Normal Saline or Lactated Ringer Solutions. The EMT-Intermediate can initiate airway control on any patient that so requires through the use of all airway adjuncts excluding surgical airways. EMT Intermediates may use the mechanical ventilator for ventilation support and may use the IV pumps for administration of normal saline and LRS.

Emergency Medical Technician Paramedics may practice to their level under the direction of ACUTE MEDICAL SERVICES, LLC Paramedic Incharge.

While performing patient care all ACUTE MEDICAL SERVICES, LLC employees, Fire Services, and First Responders personnel shall comply with current Infection Control Policies and Procedures. This includes utilization of personal protective equipment for every patient in your care while employed with Acute Medical Services, LLC. Personal Protective Equipment shall include:

Gloves

Protective Eyewear

Face shield (if indicated)

Gown (if indicated)

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Standard of Care General Protocol

GP 01

Clinical competence and high standards are vital functions in providing quality prehospital emergency medical care to the customers who rely on our services. The following treatment protocols represent a guideline for the minimum level of patient care that is to be provided. The Standard of Care Statement and the aforementioned treatment protocols represent only the minimal standards of care to be provided to patients in your care.

Acute Medical Services, LLC and the Medical Director embrace as fundamental components of its standard of care and the following concepts:

The emergent patient benefits from early medical interventions, especially the early and aggressive application of airway establishment and maintenance, early administration of oxygen, early protection of the cervical spine, early initiation of definitive therapies and rapid transfer to an institution of higher levels of care. Remember that oxygen therapy should never be withheld while initial patient evaluation takes place.

The patient determines the emergency. As Paramedics and Nurses you are often called upon to assist with social or psychological problems and we must respond as professionally and thoroughly to these as we do for medical or surgical problems.

The Facility providing patient care determines the emergency. As Paramedics and Nurses providing interfacility transfers and emergency inceptions to deliver patients to a higher level of care you may be requested to respond as rapidly as you would by a private caller. The customer determines the emergency. The customer may be a private physician’s office or an emergency department at a local or rural hospital. We will treat these responses as any other emergency response when requested to do so.

The Paramedic’s and Nurse’s role is to act as the eyes, ears, and hands of the physician in the remote and prehospital setting. To successfully do so requires that you educate yourself beyond first aid procedures and dedicate yourself to becoming an integral part of the total health care team. Paramedics, nurses, and healthcare providers acting under Acute Medical Services, LLC will maintain current continuing education as outlined throughout the course of the year. C.E. is mandated and participation is required. It is expected that you maintain and stay on the leading edge of healthcare to be the best practitioners possible. These protocols are intended to be used as guidelines to the paramedic’s and nurse’s treatment regimen. It is impossible to create protocols for every situation and every patient that may arise. The Paramedic and nurse must use his best judgment, along with his knowledge, clinical manuals, references, and the use of the medical director to ensure the best medical care be provided without further complicating the injury or illness. As stated as the basis of medical care, “Do no harm”. Any deviation from these protocols should be well documented and the medical director must be informed prior to such deviations. The Paramedic or nurse has no permission to perform any treatments or intervention in which he has not been trained to perform or therapies that would be considered outside the scope of the protocols and/or the standard of care in Emergency Medical Care.

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Standing Orders General Protocol

GP 02

Standing Orders:

Standing orders are defined as those therapies, interventions, and procedures, which may be performed without or prior to a direct physician's order.

Standing orders represent off-line medical control. They are superseded by any orders received by on-line Medical Control. The only physicians to dictate orders are ACUTE MEDICAL SERVICES, LLC Medical Director or his designee.

At times when the Medical Director is unavailable it will be known which designee will be controlling medical issues in his absence. Paramedics and nurses will receive notice prior to medical direction being designated.

Standing orders are allotted to perform all therapies, interventions, and procedures noted in these Protocols under "Treatment".

In the event of communications failure, treatment is authorized on standing order to include those therapies, interventions, and procedures only under the “Treatment " designation. The use of medical control consultation is to be undertaken prior to the event or during the situation in question. Informing Medical Control “after the fact” though interesting, is not acceptable as “notification”.

Written Physician Orders:

Interfacility transfer orders that are clear and precise and patient’s physician’s orders can be carried out so there is no interruption of the continuity of care. Insure that you have a complete understanding of the orders that should be followed before departing the facility. If the patient’s condition worsens then you will revert back to Acute Medical Services protocols until the patient’s condition stabilizes. A copy of the written order should be photocopied and attached with the patient care report.

It is imperative to cross reference treatment modalities with the references available to you.

Phone Orders by treating Physician:

You may find from time to time that it may be beneficial to contact the physician who initiated treatment on the patient you are transporting. These orders are considered on-line medical control and the orders should be followed if the patient’s condition warrants. The phone orders should be documented on the patient care report to include the date, time, and physician’s name and license number dictating the order. No orders can be taken by third party communication.

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General Therapies General Protocol

GP 03

The following procedures, therapies, and medications are authorized above and beyond those noted in the specific protocols for use at the Paramedic’s and Nurse’s discretion.

1. Oxygen Oxygen may be administered to any patient with demonstrated hypoxemia by pulse oximetry or with any clinical suspicion of hypoxia, chest pain, hemorrhage, or SOB. 2. IV Starts

Unless specifically limited or prohibited by the particular protocol, advanced EMS personnel may initiate an IV on any patient at their discretion. EMT-I and/or EMT-P and/or RN personnel grouping may elevate care as per advanced protocol or direction. The attending Paramedic has discretion to determine whether IV therapy should be administered to patients in the field. EMT-Basics may initiate an IV if approved by the medical director and only with the direct supervision of the Paramedic or Registered Nurse.

3. Endotracheal Intubation/Esophageal Obturation/LMACombitube

Advanced EMS personnel may secure the airway of any patient whom they believe is experiencing airway compromise, respiratory failure, or who requires positive pressure ventilation. The airway may be secured with endotracheal intubation (the preferred method) or an acceptable adjunct, so long as the patient does not have any contraindications to these procedures. In the event that RSI, Rapid Sequence Intubation is anticipated, pretreatment with a benzodiazepine may be administered. The attendant Paramedic has discretion regarding intubation administration to patients in the field. Specific indications for RSI are given in the RSI directive.

4. ET Medication Administration

Medications may be given via the endotracheal tube IF:

1. IV access is delayed and intubation is accomplished AND 2. Auscultation reveals clear lung fields

*Medications given via the ET tube are not picked up as well as IV meds, require higher doses and dilution, and are very susceptible to bronchial/alveolar infiltrates and alveolar wall disturbances. Medications that may be given via ET are:

Naloxone, atropine, epinephrine, lidocaine

The unit or “bolus” dose of any adult medication given via ETT is to be doubled from the standard IV dose

5. Dextrose

Dextrose may be administered to any patient if the EMS personnel suspect hypoglycemia. In the hypoglycemic (or suspected hypoglycemic) patient with an intact gag reflex in whom an IV cannot be established, dextrose may be given orally. Oral dextrose may be administered as PO D50% or glucose paste. IV Dextrose may be given in a “half-amp”, “ampule” or greater than one ampule dosage depending on the patient’s response. For alterations of the dosing schedule MC should be consulted.

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6. Promethazine

Promethazine may be given to a patient complaining of nausea and/or vomiting who has a stable BP and does not have any contraindications to the medication. A BP must be checked and documented immediately before Promethazine may be given either IM or IV. Dosage is 12.5 mg – 25 mg for adults and 0.5 mg/kg up to 12.5 mg for pediatric patients.

7. Thiamine

Thiamine may be administered to any adult patient in whom the paramedic has any reason to suspect malnutrition or alcohol abuse. Thiamine should be given as 50 mg IM and 50 mg IV. However, in the patient with inadequate muscle mass to receive IM injections, the entire 100-mg may be given IV. Conversely, if an IV cannot be established, the provider may administer the entire 100-mg IM. If no muscle mass and no IV, then thiamine should be withheld. 8. Nitroglycerin (Spray, Tablets, Paste, or Gel)

Nitroglycerin may be administered to any patient with an elevated Blood pressure (Systolic at least 90 mmHg), Non Traumatic Chest Pain, and Shortness of Breath and at the discretion of the Paramedic or Nurse. 9. Cardiac Arrest Medications

In addition to those therapies expressly listed in the protocol as standing orders, the following medications are available for use on standing order in any cardiac arrest situation where there is evidence that they are indicated:

D50% 25-50 G

Naloxone 2-8 mg, with decreased respiratory rate or respiratory depression *Refer to the dosage scale for age groups

10. Acetaminophen

Acetaminophen may be administered to any febrile patient (without contraindications to the medication) as 15 mg/kg either PO or PR. EMT-Basic or Intermediate can give this medication at the discretion of the attending Paramedic or Nurse.

11. Sodium Bicarbonate

Sodium Bicarbonate can be administered to any renal failure patient that is found to have any cardiac event leading to cardiac arrest.

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12. Ibuprophen

Ibuprophen may be administered to any febrile patient (without contraindications to the medication) as 200mg- 1000mg for the adult patient. Use the table below to determine pediatric dosing. EMT-Basic or Intermediate can give this medication at the discretion of the attending Paramedic or Nurse.

Weight Dose Oral Drops

(50 mg/1.25 ml)

Suspension

(100 mg/5 ml)

Chewable

50 mg

Chewable

100 mg

Caplets

100 mg

12 - 17 lbs 50 mg 1.25 ml 1/2 tsp

18 - 21 lbs 75 mg 1.875 ml 3/4 tsp

22 - 32 lbs 100 mg 2.5 ml 1 tsp 2 1

33 - 43 lbs 150 mg 3.75 ml 1 1/2 tsp 3 1 1/2

44 - 54 lbs 200 mg 5 ml 2 tsp 4 2 2

55 - 65 lbs 250 mg

2 1/2 tsp 5 2 1/2 2 1/2

66 - 76 lbs 300 mg

3 tsp 6 3 3

77 - 87 lbs 350 mg

3 1/2 tsp 7 3 1/2 3 1/2

88 - 98 lbs 400 mg

4 tsp 8 4 4

13. Zofran

Zofran (ONDANSETRON) may be given to a patient complaining of nausea and/or vomiting who has stable vital signs and does not have any contraindications to the medication. Vital signs must be checked and documented immediately before Zofran administration. Zofran is best used by administering IV as the results are much more rapid than other routes though can be administered IM. Dosage is 2 mg – 8 mg for adults and 1mg to 4mg pediatric patients or 0.1-mg/kg dose for pediatric patients weighing 40 kg or less.

14. Foley Catherization

Advanced providers may place a Foley catheter in any patient older than 12 years old who is incontinent and unable to use the toilet without assistance. This procedure should only be used in patients who are unable or unwilling to use other means of toiletry. This procedure may be useful in long distance transfers where the ability to use a toilet/urinal or the use of such would cause harm to a specific injury like unstable pelvis fracture.

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15. Sedation of the confirmed intubated patient

From time to time the Paramedic or RN may come across a patient that has been intubated in a hospital setting that needs transport to definitive care. Some instances may be found where the patient that is intubated may be lightly sedated enough to achieve a calm state in a controlled environment like an ICU or Emergency Department. If the paramedic or RN attempts to move the patient to achieve patient transport and the patient sedation is such that is poses a risk of dislodging the ET tube or the patient appears to be conscious enough to have an understanding of the surrounding then the Paramedic or RN may administer additional sedatives to achieve a sedation that is appropriate to transport the patient without the patient being coherent enough to have a mental state that would generate fear or pain for the patient. Remember there is a fine line when it relates to humane and ethics. The paramedic or RN at their discretion may use additional sedatives to achieve a humane and ethical transport. If the patient is on a specific sedative you may attempt to increase the sedative being used. The following may be used to achieve sedation for a patient with a confirmed ET placement as long as there are no contraindications of the sedative:

Valium 5-10 mg IV q 15-30 mins

Versed 2-10 mg IV q 15-30 mins

Consider Infusion (see Infusion Chart)

Amidate Above the age of ten (10) years will vary between 0.2 and 0.6 mg/kg of body weight, and it must be individualized in each case. The usual dose for induction in these patients is 0.3 mg/kg, injected over a period of 30 to 60 seconds.

Ativan 2mg IV q 30 mins

Consider Infusion (see Infusion Chart)

Propofol A slow rate of approximately 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg) should be used then a Maintenance Infusion 50 to 200 mcg/kg/min.

Use with caution as Propofol may create Severe Hypotension

If patient SBP falls below 100mmHg stop the infusion until such time the BP is above 100mmHg. Titration of this drug can be challenging. Start at the lowest dose and monitor how the patient reacts with the sedation and blood pressure responses. Increase slowly till you achieve the desired effect. The attempt is to achieve enough sedation to make the patient comfortable without a drastic change in patient blood pressure.

Patients that are intubated must have pulse oximetry measurements, cardiac monitoring, and wave form CO2 capnography along with Vital Signs q 3-5 mins. ET Tubes should be secured with a Thomas ET Tube Tamer if possible. Patient may also need a cervical collar placed to insure and prevent tube displacement. The benefit from the use of wrist restraints may be indicated. Remember to insure the tube placement with auscultation of bilateral breath sounds, pulse oximetry, and end tidal CO2 capnography every 2-3 minutes to insure the tube has not been dislodged.

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Patient Assessment Primary Survey

General Protocol

GP 04

Throughout these protocols, the acronym “CABC’s” is used to indicate the primary survey of the emergent patient. Our primary survey consists of the evaluation and, if needed, management of the following components: • Cervical spine • Level of consciousness • Airway • Breathing • Circulation The following is an outline for the assessment and management of these components. Cervical Spine If there is any possibility of a spinal injury, the provider must assume that one exists and approach the patient accordingly. Once permission to assess the patient is obtained, by actual or implied consent, the provider’s next step on any patient with the possibility of spinal injury is to manually obtain control of the c-spine. This manual c-spine stabilization must be maintained until: Further assessment indicates an absence of spinal injury. Only a physician with radiological support may “rule out”.

The spine is adequately immobilized when adjuncts are applied which relieve the need for manual stabilization, or the patient refuses further treatment. In this case, the pt must sign an “Against Medical Advice” form.

Level of Consciousness The level of consciousness should be briefly assessed next, to determine only the patient’s rating on the “AVPU” scale (alert, responsive to pain, responsive to voice, unresponsive). Further assessment of the level of consciousness is to be deferred until the secondary survey. This will also include judgment (“a good place for a baby to play is: a highway, a playpen, a battlefield), memory (three numbers recalled after one minute). Airway The patient’s airway must next be evaluated for patency. If there is any indication of a compromise in the patient’s airway or threat that the patient is in impending failure, the provider should intervene to secure the airway. Indications of compromise may be as overt as apnea or a visible obstruction, or may be indicated by a less obvious sign such as airway noises (stridor, snoring, gurgling, etc.). The airway should be secured first with positioning, using a jaw-thrust if spinal injury cannot be ruled out or a head-tilt/chin-lift if spinal injury is not a concern. If material must be physically removed from the airway, this should be done next using abdominal or chest thrusts, possibly a finger sweep, and/or oral suctioning, or direct laryngoscopy and Magill forceps, as appropriate. If the patient’s level of consciousness is diminished (GLS<8), an airway adjunct should be placed next. Use an oral airway if the patient will tolerate it; otherwise use a nasal trumpet unless basal skull fracture is suspected. Manual positioning must be maintained concurrently with the use of such an adjunct. If possible, the airway should next be definitively secured with ET intubation (or esophageal obturation, CombiTube, KingTube or LMA). Even in the patient whose airway is initially patent, the provider must continuously re-assess and be prepared to intervene against any airway compromise.

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Breathing The next component to be assessed is the patient’s respiratory status. If the patient is not breathing spontaneously, ventilation with supplemental oxygen must be initiated immediately. If the patient is breathing spontaneously, the adequacy of the patient’s respiratory effort must be evaluated. One useful but not conclusive method is evaluation with pulse oximetry. If saturation is consistently below 86% then intubation must be considered. If the patient’s rate or tidal volume is inadequate, assisted ventilation with supplemental oxygen is to be provided immediately. The patient’s chest should also be rapidly assessed for open wounds, which would compromise respiration. If any open chest wound is found, it must be immediately occluded, initially with the provider’s gloved hand and then with an occlusive dressing. The bag-valve-mask device with oxygen at 10-15 1/min and a reservoir bag is the preferred method of providing ventilation. The demand-valve (oxygen-driven, manually triggered device) should not be used unless a properly functioning BVM is not available as the demand-valve offers, no sense of compliance or resistance to the operator and often results in excessive gastric distention. If possible, the airway should always be secured with ET intubation if positive pressure ventilation is to be instituted. As with the airway, the provider must continuously reassess the ventilatory status of even the most stable patient and be prepared to rapidly intervene if respiratory compromise develops. Circulation The patient shall next be assessed for adequate circulation and presence of major external hemorrhage. If the patient is awake or at least responsive to verbal or physical stimulus, the provider shall assume that circulation is adequate for the moment and move on. If the patient is unresponsive, the provider will assess for the presence and adequacy of a palpable carotid pulse. If the patient does not have a palpable carotid pulse, or has a pulse of less than 40/min in the adult (less than 50/Min in a child or less than 70/min in an infant), the provider must initiate CPR. A more accurate evaluation of the patient’s perfusion status will be done during the secondary survey. Next, the patient should be assessed for external bleeding. If major bleeding is found, it should be immediately controlled with direct pressure. In summary, the primary survey includes (in order): 1. Obtain manual control of cervical spine. 2. Quickly establish level of consciousness (AVPU). 3. Evaluate airway. Establish patent airway if needed. 4. Evaluate breathing. Initiate ventilation or ventilatory assistance if needed. Assess for open

chest wounds. Occlude any found. 5. Check for presence and adequacy of circulation. Initiate chest compressions if needed. 6. Check for external bleeding. Control any significant bleeding found.

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Destination Determination

General Protocol

GP 05 This protocol shall serve as the basis for the decision by both Paramedic or RN and Medical Director as to the transport destinations of patients. This protocol is a standing order. The patient shall always be transported to a facility in which appropriate definitive therapy can be administered; we should avoid facilities which are medically inappropriate We should try and limit transport to the closest appropriate facility unless the paramedic or nurse deems it necessary for the patient's well-being to be transported to a facility outside our service area. In some instances the family or patient may desire transport to a facility outside our distance boundary or one of their choice when the patient can receive the same or better level of care at a hospital in our general service area. In these instances the EMS Director must be notified for approval for transport to other hospitals outside the normal hospitals we generally deliver to. ACUTE MEDICAL SERVICES, LLC must transport any unstable patient that meets the Application listed below and may not transfer care to any other service unless the service is responding as mutual aid. 1. Systolic BP of less than 90mm/Hg 2. Respiratory compromise or difficulty breathing including Hyperpnea or Bradypnea 3. Chest Pain of any etiology including trauma 4. Altered Mental Status of unknown etiology 5. Any Trauma related emergencies If the patient is deemed to be medically unstable, that patient must be transported to the closest appropriate hospital emergency department. If that facility is on divert and cannot accept the patient, the Paramedic will make arrangements to have the patient diverted to the next closest hospital emergency department. If the patient or patient representative does not specify a facility, the patient shall be transported to a facility within the operational boundaries of the transporting service, if appropriate. Should the patient or the patient's representative request a facility which is in conflict with this protocol or which the attending Paramedic or Nurse feels is inappropriate for the patient's medical problem, The Paramedic or Nurse should decide conservatively based on the patient’s status. A separate incident report should be filed with the patient chart. The following represent patient types for which a specific facility or set of facilities is designated as the appropriate transport destination. Paramedics and Nurses MUST transport patients meeting these type definitions to the nearest facility, unless ordered otherwise by on-line Medical Control. CPR’s: All CPR patients (from any etiology) will go to the closest appropriate Emergency Department. NO EXCEPTIONS [unless pronounced deceased with agreement of Medical Control.] Amputations: All amputation patients will go to the closest appropriate facility. Hospital Utilization: All Patients needing advanced trauma care or immediate surgical intervention will be transported to either hospital below: Ben Taub General Hermann Hospital

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Diagnostics/Procedures General Protocol

GP 06 Diagnostic tools and procedures are defined as vital signs, blood glucose determination, temperature, ECG evaluation, pulse oximetry, urinalysis, blood chemistry, complete blood count, strep screens, doppler, snelling eye chart, any other component not mentioned here that will help differentiate a diagnosis in patient’s illness/injury. Vital Signs Complete vital signs are defined as respiratory rate, pulse or heart rate (indicate which), capillary refill, temperature, and blood pressure (auscultated if possible with both systolic and diastolic). Capillary refill (CR) may be used as an adjunct to blood pressure in assessing/describing the perfusion status of any patient. A systolic BP alone (palpated BP) is acceptable ONLY:

As an additional vital sign in the non-urgent patient in whom an auscultated BP has already been obtained and was within normal limits.

In the critical trauma patient in who serial palpated BP's are being obtained.

In the patient in whom an auscultated BP ABSOLUTELY cannot be obtained. An initial complete set of vital signs is to be obtained within 5 mins. of patient contact. Patients refusing treatment/transport must have one complete set of v/s taken and charted, if the patient allows. If the vitals are out of normal limits, at least a second set should be obtained a minimum of 5 minutes after the first. All subsequent repeat v/s should be at least 5 mins. apart. "Stable" patients with non-life or limb-threatening problems should have vitals repeated every 15 mins. Urgent or critical patients must have vitals taken every 5 to 10 mins. Respiratory rate, blood pressure, and pulse rate are to be obtained on all patients assessed The accuracy of an obtained blood pressure is influenced by many factors, one of, which is the size of the cuff used. It is important that the size of the cuff be correct for the patient. A cuff too small for the arm will yield a falsely elevated blood pressure while one too large will result in a falsely low reading in patients’ blood pressure. The cuff should easily go around the patient's upper arm, but the air bladder should not overlap itself. The cuff itself should be 2/3 the length of the patient's upper arm. It is imperative to note the difference between a heart rate and a pulse rate. The term "heart rate" refers most correctly to the rate of electrical depolarization (usually ventricular) noted on the ECG monitor. "Pulse rate" refers to the palpable rate of perfusion noted at a pulse point. While in most patients these are identical values, this is not always the case. When reporting the rate on the ECG monitor, use the term "heart rate". When reporting the rate derived by feeling the radial, brachial, or carotid pulse, use the term "pulse rate". When using the ECG monitor or an apical pulse to observe the patient's heart rate, one must be absolutely certain that this rate correlates with the palpable pulse rate. For a critical patient, for whom time is a factor, the Paramedic may use palpable pulses to estimate and document blood pressure. The acceptable values are as follows:

Palpable radial pulse: systolic pressure of at least 80 mm Hg

Palpable axillary or brachial pulse: systolic pressure of at least 70 mm Hg

Palpable femoral pulse: systolic pressure of at least 60 mm Hg

Palpable carotid pulse: systolic pressure of at least 50 mm Hg

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Remember that the pulse, not the BP, is the most sensitive and earliest indicator of volume and metabolic status. In all patients suspected of hypovolemia then orthostatic blood pressure monitoring must be performed. Remember that a positive change in pulse, even without BP change, is still positive. Blood Glucose Blood Glucose may be performed on any patient. Blood glucose must be assessed on all patients with altered mental status. Those patients with altered mental status which appears to be secondary to trauma should also have their blood glucose assessed IF such assessment will not delay definitive interventions, such as airway management, cervical spine immobilization, bleeding control, transport, or IV access. Blood glucose must be assessed on all patients with a history of Diabetes Mellitus or glucose problems, or altered mental status, regardless of complaints or findings or any other patient at the discretion of the Paramedic. Blood glucose must be assessed on all patients who experience a seizure prior to Paramedic care or while in the care of the Paramedic. Blood glucose values are reported or documented in terms of milligrams per deciliter (mg/dl). After administering D25 % or D50 %, the blood glucose value will remain falsely elevated for quite some time as the cells attempt to uptake the glucose. Therefore, repeat D-sticks may not be useful in determining accurate BG levels. The patient's clinical status should be used to determine whether or not to administer additional dextrose. If a repeat Blood Glucose Analysis is used, wait at least 10 minutes after dextrose administration before obtaining one. Temperature Temperature must be assessed on all seizure patients, all patients suspected of being septic, and all patients whose complaints or findings indicate possible fever. Temperature also must be obtained on all patients suspected of either hypothermia or heat stroke, and all near drowning patients who present in cardiopulmonary arrest. Temperature will be taken orally in patients who are capable of holding the thermometer correctly. Temperature will be taken rectally in all other patients. Neither rectal nor oral temperature represents true "core" temperature. Therefore, neither of these may be used to truly determine hypothermia. For our purposes, a rectal temperature may be used to determine temperature in hyperthermic states (heat stroke, febrile seizures, or sepsis), and should be used to guide cooling along with the patient's clinical response. A rectal temperature is to be used in Hypothermic patients. Axillary temperatures are absolutely not acceptable. When reporting or documenting a temperature value, indicate the source (oral, rectal). ECG Monitoring ECG should be assessed and monitored on ALL patients on whom ALS intervention involving medication administration is given intravenously. ECG may be assessed on any patient. ECG must be assessed on ALL patients complaining of chest pain (or other possible myocardial ischemia pain), shortness of breath, syncope or dizziness, or nausea/vomiting, or who display tachycardia, hypotension, or altered mental status. ECG must also be assessed on all patients who have suffered a convulsion or syncopal episode. ECG must be assessed within 5 mins of patient contact. Stable patients presenting in rhythms thought to be either SVT or VT MUST have a multi-lead (12 Lead) ECG obtained and recorded. See the "ECG" procedure and the "Multi-Lead ECG Interpretation" reference.

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Pulse Oximetry Pulse oximetry, if available, should be used in part to evaluate the oxygen saturation status of all patients in whom hypoxia or ischemia is suspected. Remember, 02 therapy must not be withheld to establish baseline saturation in cases of suspected chest pain, N/V or other possible “cardiac” presentations. Pulse oximetry may be used to titrate oxygen delivery, and will permit the Paramedic to utilize delivery devices or flow rates other than those dictated in the protocols. Pulse oximetry readings are accurate only if: The probe is able to "see" the arterial blood flow, The patient is reasonably well perfused peripherally. This means that the probe must be firmly attached to a clean finger or toe. Nail polish may occlude the probe's light beam, so unpolished nails are preferred. Additionally, hypotensive, CO Poisonings, hypo-perfused, or peripherally vasoconstricted patients are generally not good candidates for pulse oximetry. Be sure the pulse oximeter's heart rate matches the patient's palpable pulse rate, that the waveform is peaked sharply or the light is green, and that the light is flashing in concert with the patient's pulse before accepting the SaO2 value. Pulse oximeter values are reported as % SaO2 (saturation of oxygen). Pulse oximetry readings below normal may indicate either a problem with oxygenation or perfusion. Doppler Doppler, if available, should be used to evaluate the fetal heart rate of all pregnant patients. It may also be used to determine the presence of a peripheral pulse or to obtain a systolic BP in patients when such cannot be heard or felt otherwise. CO2 Monitoring/Capnography CO2 Monitoring/Capnography should be used to evaluate the CO2/Oxygen exchange in all patients that are intubated. Disposable End-Tidal CO2 detection devises are also useful diagnostic tool, but not a substitute for continuing capnography, that will be used on any patient that ACUTE MEDICAL SERVICES, LLC intubates and results will be clearly documented on patient care report. In cases where capnography is available, continuous ETCO2 must be monitored on intubated patients and the results must be recorded.

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Rapid Transport General Protocol

GP 07 Occasionally, The Paramedic or Nurse will encounter a patient whose injury can only be treated definitively with surgery. When confronted with such a patient, the attending Paramedic or Nurse shall institute the basic interventions noted here and begin the process of transport to an appropriate facility following ACUTE MEDICAL SERVICES, LLC ‘Emergency Evacuation Procedures’. Remember: If there is a chance that this is the case with the patient, err on the side of conservative management while loading and perform all advanced interventions while enroute to definitive care. Always transport as rapidly as possible. ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INTIATING EMERGENCY EVACUATION PROCEDURE.

Spinal immobilization

BLS airway and ventilation procedures

Intubation IF it can be accomplished rapidly

Surgical airway if necessary

Occlusion of open chest wounds

Vital signs (may use peripheral pulses to estimate--see "Diagnostic Tools and Procedures" reference)

Freeing patient from entrapment. All other interventions are to be done once RAPID TRANSPORT is initiated. The following represent patients for whom rapid transport is required:

Adult Trauma as described by BTLS/ATLS Guidelines

Head Injury or CVA with evidence of increasing ICP

Suspected aortic aneurysm

Suspected ectopic pregnancy, abruptio placenta, or uterine rupture (vaginal bleeding in pregnant patients greater than or equal to 20 weeks gestation)

All abdominal pain patients with unstable vital signs (Tachycardia with normotension, hypotension)

Obstetrical emergencies resulting in possible fetal distress, such as limb presentation, breech delivery, or prolapsed cord

GI bleeding with unstable vital signs (Tachycardia with normotension or hypotension)

Any other patient requiring urgent surgical intervention

GCS/Revised Trauma Score These scores will be reported with the appropriate letter in front of the score: GSC Example: ATS Example: E-2 (Eye Opening) R-3 (Respiratory) M-5 (Motor) S-3 (Systolic BP) V-3 (Verbal) G-3 (Glasgow Score) ---------------------------- ------------------------------ Total GCS=10 Total ATS=9 *Note* Transport requires the incharge paramedic or nurse to be in the patient care compartment (if possible) overseeing or administering patient care.

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Air Ambulance Use General Protocol

GP 08 This protocol provides guidelines and authorization for the use of helicopter ambulance to transport a patient directly from a scene. By standing order, The Paramedic or Nurse is authorized to utilize helicopter ambulances to evacuate patients at his/her discretion. The following are guidelines for their use; however, these do not represent absolute rules. The Incharge Paramedic or Nurse is personally responsible for selecting the mode of transport most beneficial for the patient. All helicopter utilizations will be reviewed by the Medical Director. Things to consider when utilizing an air-ambulance:

Time of Day, Location from Major Street/Highway, Weather Conditions, Flight ETA

Remember to consider flight team loading, takeoff, landing, passing off patient and care report, reloading patient, helicopter restarting, flight time to hospital, landing, etc.

The primary indication for the use of a helicopter ambulance is when the helicopter can deliver the patient to definitive care (i.e., surgery) faster than any other transportation available. This usually means:

A critically ill or injured patient requiring care not available from local facilities in which extrication, basic procedures, and transport time will exceed the total call-received to arrival at the hospital time for the helicopter.

A multi-patient scene including urgent or critical patients where the time for other transportation to arrive and provide transport would exceed the total time for the helicopter.

Many trauma victims would be better served by transporting them directly to a Level 1 or Level 2 Trauma Center. Situations like:

Trauma victims with no spontaneous eye openings

Penetrating cranial injuries

Penetrating thoracic injury between the mid-clavicular lines

Gunshot wounds to the abdomen or thorax.

Blunt trauma to the chest with an unstable chest wall

Penetrating wounds to the neck

All patients that have suffered burns of second degree or better that are greater than 15% of BSA over face, hands and genitalia.

Other patients may need to be transported to the trauma center. Field personnel may use helicopter evacuation on the following trauma victims:

Surviving victims of vehicular accidents in which fatalities occurred.

Pedestrians struck by fast-moving vehicles.

Patients requiring extrication which takes longer than 30 minutes.

Patients who were ejected from the vehicle. If a helicopter evacuation is required, the incharge paramedic or nurse will contact Harris County EMS Dispatch Center and give location or GPS Coordinates of where the air ambulance is being requested Any patient transported by helicopter will receive, if time allows on scene, complete documentation by the crew. Any patient that the in-charge medic feels should be flown, but does not meet the above requirements, can utilize the air ambulance. However, the in-charge medic or nurse should file an incident report with the EMS Director and Medical Director for review.

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Consent for Treatment General Protocol

GP 09 Following are guidelines to be utilized in the decision process to determine whether to transport or allow the patient to refuse treatment. Definitions:

Informed Consent-when a patient has been told (in a way that the patient will understand) by the attending medical team of their suspected medical condition, the type of treatment that will be rendered and the consequences and possible risk of that treatment or the refusal thereof and the patient agrees to the treatment or refusal.

Implied Consent-when the treatment is performed on a patient who is unable to give consent due to the inability to comprehend or hear the informed consent requirements or on a minor when a guardian cannot be contacted, but for whom implied consent is held reasonable, i.e. matters of life and death.

Refusal-when a patient refuses either transport or treatment after being informed of their suspected medical condition, the type of treatment that will be rendered and the consequences and possible risk of that treatment.

Mental Competence-a patient who is oriented of person, place and time, exhibits sound judgment and memory, and who understands their medical condition and can comprehend the treatment description and the consequences of the treatment or refusal thereof. Policy: Treatment / Transport

All paramedics and nurses must have consent before treating / transporting a patient.

Consent may be either implied or informed.

Any mentally competent adult may refuse treatment / transport.

Any mentally competent guardian may either give consent for, or refuse treatment / transport for a patient they are responsible for.

A police officer may order treatment or transportation of any prisoner in their custody.

A patient may be transported against their will if the medic has a court order for the patient to receive treatment or the patient is in custody of a law enforcement officer.

Mentally Incompetent Patients Patients who are considered mentally incompetent by either the courts or by the definition of this policy may be treated with implied consent. If the patient still refused to be treated / transported, Law Enforcement should be notified to help safely restrain the patient. If law enforcement refuses to restrain patient for transport the Operations Manager and Medical Director should be notified. Refusals Any competent adult has the right to refuse treatment, even if that lack of treatment may result in his or her death. Any patient refusing treatment / transport shall be informed of the possible consequences of that refusal and shall sign a refusal form. Individuals other than employees should witness this form if possible. Any medic who does not feel comfortable with a patient refusing treatment / transport because the medic feels that the refusal may result in death, should contact the Medical Director and Operations Manager. Special Situations The Paramedic may be faced with several “special situations” in which the patient does not fit any of the above policies. While it is impossible to discuss every situation, in most cases the paramedic or nurse will have to rely on their training, experience and judgment to determine if the patient meets Application for refusal. If at any time the medic or nurse is in doubt as to either treating or transporting a patient, a supervisor must be consulted. If the supervisor has reasonable doubt, Medical Control must be consulted. If at all possible always elect to treat/transport rather than leave the patient.

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Authorization Level General Protocol

GP 10 The following represents those patient care activities, which are authorized to be performed by personnel as stated in the "Protocols" protocol. All BLS activities are authorized on standing order, to be used as needed. Authorization for ALS activities is indicated in the protocol or procedure document for each intervention. The incharge paramedic or registered nurse determines who practices using these guidelines and has the authority to delegate beyond the guidelines if needed.

Emergency Medical Technician EMT Intermediate Paramedic/Registered Nurse

Oxygen administration All EMT Skills All EMT-I Skills

Oral Airways IV Accesses Nebulized bronchodilators

Nasal Airways IV Fluid Administration Obtaining ECGs

Bag Valve Mask Administration of NS Interpretation of ECGs

Oral Suctioning Administration of LRS Defibrillation

AHA approved CPR Administration of D50 Cardioversion

Vital Signs Administration of D25 External Cardiac Pacing

Bandaging Administration of Thiamin Vagal Maneuvers

Splinting Administration of Naloxone Administration of IV Medications

Traction Splinting Oral tracheal Intubation Administration of IM Medications

Cervical Spinal Restriction Nasal tracheal intubation Administration of SQ Medications

Patient Assessment Intraosseous Cannulation Administration of PO Medications

Manual Airway Maintenance Combi Tube Insertion Administration of PR Medications

Manual Ventilatory Support Operation of Mechanical Vent Administration of SL Medications

Airway Obstruction Relief CPAP/BiPAP Operation Chest Decompression

Control External Hemorrhage External Jugular Cannulation

Automated External Defibrillator Nasogastric Tube Insertion

Automatic CPR Devices Nasogastric Lavage

Blood Glucose Reagents Oralgastric Tube Insertion

Esophageal Obturation Oralgastric Lavage

King Tube Surgical Airway

ASA administration Pharmacological Assisted Intubation

*NTG Spray/Tablets Administration of Rx Medications

Nebulization of Albuterol Foley Catheter Insertion

*Nebulization of Atrovent

*Blood Draw

*IV Catheter Insertion for SL

Restraint Devices

Kendrick Extrication Device

Items indicated by an astrics * should have the approval of the Medical Director or under direct supervision of the incharge paramedic or nurse NOTE: The In-Charge or Attending Paramedic or Nurse is responsible for the care, selection of treatment, and selecting the mode of transportation that is most beneficial for the patient. Thus, the final determination is that of the attending Paramedic unless superseded by the Medical Director of Acute Medical Services, LLC.

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Pain Management General Protocol

GP 11 With today’s technology, advanced medical care, and improved medications there is no reason any patient meeting this application should be withheld from receiving pain management in the field. Application:

Patient must have no neurological deficits from the injury.

Patient must have vital signs within normal limits.

Systolic BP must be Minimum of 100 mm/Hg

Patient cannot have multi system trauma.

Patient must have +Pulse Motor Sensory + Range Of Motion in extremities

Patient not Allergic to Pain Medications

Patient must weigh minimal of 35kg. A Complete Neurological Exam must be completed prior to administering any Pain Medications and results of the exam fully documented on the patient report. Pain:

Any fracture of a long bone that meets the above Application

Pain associated from End Stage Cancer of known Etiology

Amputations/Crushing Injuries of the extremities

Stabbing/GSW/Penetration injuries to the extremities (Excluding Torso)

Pelvic Fractures meeting the above Application

Renal Calculi

Burns that are greater than 20% BSA of the First or Second Degree

Chronic Back Pain

Acute Back Pain

Acute Appendicitis

Known History of Cholecystitis

Known History of Diverticulitis If BP is > 90 systolic, then consider: Treatment: 12.5 - 25 mg Phenergan IVP or 4 - 8mg Zofran and any one of the following if not contraindicated or allergic

Analgesic Adult Dosage Child Dosage

Morphine 2-10mg IVP with a max dose of 12mg.

.05 - .25 mg/kg IVP q 30 min

Hydromorphone 0.25 to 2 mg IVP may repeat q 30 to a max of 4mg

Fentanyl 25-100 mcg IVP, with a max of 200 mcg

2-3 mcg/kg IVP

Demoral 0.5 to 1.0 mg/kg IVP q 4-6 hrs 0.5 -1.0 mg/kg IVP q 4-6 hrs

Toradol 15-30 mg IV q 4-6 hrs

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IV Fluid Selection General Protocol

GP 12 Purpose: This protocol shall guide Paramedics and Nurse in making the most appropriate choice in IV Fluid therapy. Some flexibility is permitted specifically pertaining to Lactated Ringers and Normal Saline. These fluids are considered interchangeable throughout these protocols, except where explicit protocols prohibit such changes. If the Paramedic or Nurse has any doubt which fluid is appropriate Normal Saline should be used at the appropriate rate for the patient’s condition.

D5W 0.9% Normal Saline Lactated Ringers Hespan/Dextran

Cardiac Ischemia All CPR’s Renal Failure Hypovolemia

Cardiac Dysrhythmias V-Tach and SVT Acidosis

Hypoglycemia Cardiogenic Shock Burns

Allergic Reactions Hypovolemia

Altered Mental Status Hyperthermia

Hypothermia Heat Exhaustion

Heat Related Emergency Heat Cramps

Overdoses

Poisoning

Airway Obstructions

Sepsis

Surgical

OB/GYN emergencies

Asthma

COPD

Seizures

Hyperglycemia

Near Drowning

CVA

Hypertensive Crisis

Head Injuries

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Medical Scene Control Responsibility

General Protocol

GP 13 Occasionally, the Paramedic will encounter a scene in which other medical personnel may be present. Whether it be co-workers, medical care providers from other services and or facilities; the Incharge Medic or Nurse initiated to a scene by Harris County EMS Dispatch is responsible for their patients’ care, mode of transport, and medical scene control that is most beneficial for the patient. If the scene or call is a multi-unit response, the Incharge Medics or Nurse responsible is those who are assigned to a Texas Department of Health Licensed MICU Unit (Ambulance). The only persons who may dictate or give orders for a patient’s care counteracting the Incharge Medic’s or Nurse’s judgment/decision are: 1. Harris County EMS Medical Director 2. Medical Directors Designees (Listed Below) 3. Quality Assurance Officer/Medical Control Officer 4. EMS Director 5. Clinical Director/Manager 6. Supervisors 7. Field Training Officers Note: This protocol only pertains to patient care issues and mode of transport and in no way carries over to operational issues.

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Minimum Supply/Equipment List for Ambulances

General Protocol

GP 14

4X4 Non sterile Loaf 2 ECG Batteries 2 Trauma Shears 2

4X4 Sterile Package 40 ECG Electrodes Adult/pedi 5pk/3pk Miller-0 1 Triage Tags 10

AA Batteries 2 ECG Paper 2 Miller-1 1 Triangular Bandages 6

Alcohol Preps 10 Emergency Rain Blanket 2 Miller-2 1 Tube Securing Device Pedi 2

BAAM Whistle 1 Emesis Bags 5 Miller-3 1 Tube Securing Device Adult 2

Bacteriostatic NaCl Flush 10 Endotrol Tube 6.0 2 Miller-4 1 Urinal/Bedpan 1/1

Band Aids Large/Small Box 10 Endotrol Tube 7.0 2 Multi Trauma Dressings 2 Vacutainer Barrels 4

Blood Tubes Blue 5 Endotrol Tube 8.0 2 NG Tube 8 French 2 Vacutainer Leur Adaptors 6

Blood Tubes Purple 5 Face Shields 4 NG Tube 14 French 2 Vacutainer Needles 6

Blood Tubes Red 5 NG Tube 18 French 2 V-Vac portable suction 1

BP Cuff Adult child infant 1/1/1 Gloves Small 2 NaCl Infusion 100 cc 2 V-Vac replacement cartridge 1

BP Cuff Adult large/thigh 1/1 Gloves Medium 2 NaCl/LRS Infusion 250 cc 4 Webbing 4

Pedi Wheel/Broslow Tape 1 Gloves Large 2 NaCl/LRS Infusion 1000 cc 4 ECG Monitor 1

Bulbs large/small 1/1 Gloves X-Large 2 NaCl/LRS Irrigation 500 cc 2 Pulse ox sensor adult 2

Burn Sheets 2 Glucometer 1 Nail Polish Removal Pads 10 Pulse ox sensor pedi 2

Butterflies 19g/21g 5/5 Glucometer Lancets 10 Nasal Cannula Pedi/Adult 3 Bags-Garbage 5

BVM Adult 2 Glucometer Test Strips 10 Nebulizers Pedi/Adult 3 Bags-Red Biohazard 5

BVM Child 1 Headbeds 4 Needles 18g/25g 10/10 Cleaner-Tubercularcidal 1

BVM Infant 1 Hot Packs 2 Nasopharyngeal Airways 2 sets Emergency Response Guide 1

C Batteries 2 Humidifier 1 O2 Wrench L/S 1/1 Emergency Triangles 3

Capnography Adaptor 2 Hydrogen Peroxide 1 OB Kit 2 Fire Extingushers 1

C-Collar Infant 4 Intraosseous Needle 2 Occlusive Dressing 5 Flashlight 1

C-Collar Pedi 4 Isolation Kit 2 Oropharyngeal Airways 2 sets Keymap 1

C-Collar Neckless 4 Isolation Mask X-Small 2 Padded Arm Splints 2 No Smoking Signs 2

C-Collar Short 4 Isolation Mask Small 2 Pedi Restraint System 1 Protocol Book 1

C-Collar Regular 4 Isolation Mask Medium 2 Pen Light 1 Provider License 1

C-Collar Tall 4 Isolation Mask Large 2 Pillow 1 TDH Designation 1

Chest Decompression Kit 1 IV Cath 14g L/S 6 Portable O2 tanks/regulator 4/2

CO2 Detector Adult/Pedi 2/2 IV Cath 16g L/S 6 Portable Suction 1

Cold Packs 4 IV Cath 18g 6 Pulse Oximeter w/sensor S/L 1/1/1

Combi-Dressing 6 IV Cath 20g 6 Razors (disposable) 2

Combi-Tube Large/Small 1/1 IV Cath 22g 6 Ring Cutter w/extra blade 1/1

Combo Pads Adult/Pedi 2/2 IV Cath 24g 6 Sharps Container S/L 1/1

Cricothyrotomy Kit 1 IV Tubing Blood-Y 2 Sheets 5

Fire Extinguisher 1 IV Tubing Buretrol 2 Silver Rescue Blanket 2

D5W 250 ml 4 IV Tubing Dial-A-Flow 2 Soft Restraints 2pr

Disposable Pulse Ox Sensor Adult/Pedi 2/2 IV Tubing Extension Sets 6 Splints, Cardboard S/L 2/2

Duct Tape 1 IV Tubing Maxi Drip 6 Sterile H2O 4

ET Tube 2.0 2 IV Tubing Mini Drip 6 Stethoscope 2

ET Tube 2.5 2 KED 1 Stretcher fixed/portable 1/1

ET Tube 3.0 2 Kerlex/Rolled Gauze 6 Suction, Main/Canisters(Disp) 1/2

ET Tube 3.5 2 Laryngoscope Handle L/S 1/1 Suction Caths-Yankauer 4

ET Tube 4.0 2 Long Spine Board 2 Suction Caths 6f/10f/14f/18f 2/2/2/2

ET Tube 4.5 2 MacIntosh-1 1 Suction Tubing 4

ET Tube 5.0 2 MacIntosh -2 1 Supply Tubing (oxygen) 2

ET Tube 5.5 2 MacIntosh-3 1 Surgilube 6

ET Tube 6.0 2 MacIntosh-4 1 Syringe 1cc/3cc./10cc 8/8/6

ET Tube 6.5 2 Magill Forceps Adult/Pedi 1/1 Syringe 20cc/60cc 2/2

ET Tube 7.0 3 Main O2 /Regulator 1/1 Tape, Cloth 1”/2” 2/2

ET Tube 7.5 3 Mask-Adult NRB 6 Tape, Transpore 2

ET Tube 8.0 2 Mask-Infant 4 Thermometer w/probe covers 1/20

ET Tube 8.5 2 Mask-Pedi NRB 4 Tourniquets/Veniguards 6/6

ET Tube 9.0 2 MAST Trousers 1 Traction Splint adult/pedi 1/1

10/1/2011 10/31/2015 Dr. Ronald Charles, M.D. Board Certified Emergency Physician Effective Date Expiration Date

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Drug Formulary Minimal Inventory

General Protocol

GP 15 Medication Generic Trade Name Preferred Supplied/Packaged Min.Total Mg

Acetaminophen Tylenol 325 mg Capsules/500 mg Tablets and Elixir 3000mg

Acetylsalicylic Acid Aspirin 81mg chewable Tab 810 mg

Activated Charcoal Activated Charcoal 30ml or 60ml 30ml

Adenosine Adenocard 6mg/2ml pre-filled syringes or 6mg vial or 12mg vial 30mg

Adrenaline Chloride Epinephrine 1:1000 1 ml ampule /1:10000 10ml Prefilled & MDV 30mg

Amiodarone Amiodarone 50mg/ml 300mg

Atropine Sulfate Atropine 0.1mg/ml @ 1 mg/10ml prefilled syringe 8mg

Ketamine Ketamine 500mg/10ml 500mg

Calcium Chloride Calcium Chloride 100mg/ml 1000mg

D25 Dextrose 15 gr /5ml 30 gr

D50 Dextrose 25 Grams/50ml 25gr

D5W D5W 250ml and 500 ml bags 500ml

Diazepam Valium 5 mg inj. 15mg

Diphenhydramine Benadryl 25mg/ml injectable 100mg

Dopamine Hydrochloride Intropin 40mg/ml –Must be Diluted 400mg

Esomeprazole Nexium IV 40mg Vial 80mg

Etomidate Amidate 20 mg ampules 30mg

Furosemide Lasix 40mg/5ml injectable 120mg

Glucagon Glucagon 1mg powdered injectable 1mg

Hydralazine Apresoline 20mg/ml 40mg

Hydromorphone Dilautid 2mg/ml 4mg

Ibuprophen Motrin 200mg/capsule or tablet and Elixir/Solution/Liquid 2000mg

Ipratropium Bromide Atrovent 0.5mg/2.5ml 1.5mg

Labetalol HCL Trandate 5mg/ml injectable 100mg

Lidocaine HCL Lidocaine 100mg/5ml 2% inj & 2%Viscous 300mg

Maalox Maaolox Suspension 30 ml Unit Dose 60ml

Magnesium Sulfate Mag sulfate 500mg/ml prefilled injectable or 1gr/2ml 2gr

Methyleprednisolone Solu-Medrol 125mg/ml 1 gram powered injectable 2gr

Metoprolol Tartrate Lopressor or Toprol 1mg/ml injectable (5mg and 10mg vials) 10mg

Morphine HCL Morphine 1mg/ml prefilled jets or 10mg/ml ampules 30mg

Naloxone HCL Narcan 0.4mg/ml & 1mg/ml 4mg

Nitroglycerin Nitroglycerin 0.4mg/metered spray or 0.4mg/tablets or Paste 8mg

Norpinephrine Levophed 1mg/ml 4mg

Oral Glucose Oral Glucose 15 Gr 30gr

Oxytocin Pitocin 10 units/ml 10 units

Procainamide HCL Pronestyl 100mg/ml 1000mg

Promethazine HCL Phenergan 25mg/ml ampules 75mg

Propofol Diprivan 10mg/ml 100mg

Salbutamol Sulfate Albuterol 2.5 mg premix bullets/0.5% Solution 15mg

Sodium Bicarbonate Sodium Bicarbonate 4.2% and 8.4% prefilled injectable 200 Meq

Succinylcholine HCL Anectine 20mg/ml 10ml Vials 200mg

Terbutaline Sulfate Brethine 1mg/ml ampules 2mg

Thiamine Vitamin B1 100mg/ml vial 200mg

Vecuronium Norcuron 10mg ampules 1mg/ml 10mg

Versed

Midazolam 5mg/2ml 15mg

Haldol

Haloperidol 5mg/ml 10mg

Effective Date: 10/1/2011

Dr. Ronald Charles, M.D. Board Certified Emergency Physician

Expiration Date: 10/31/2015

From time to time the drugs on the above list may be supplied in concentrations or amounts other than those indicated. Regardless of the particular manner in which drugs are supplied, equivalent total amounts must be present, and it is the paramedics’ and nurses responsibility to be certain that correct dosages are administered to patients. Unless specified otherwise, generics and brand name products are considered interchangeable. Some instances there may be a national shortage or back log of some medications as we have seen in the past. For reasons beyond the control of Acute Medical Services to fulfill the required medications because of the unavailability inform the medical director of such shortages so temporary adjustment may be made to these Protocols.

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Storage of Medications and Medical Devices

General Protocol

GP 16

Acute Medical Services, LLC maintains compliancy with the strict FDA and United States

Pharmacopia recommended storage of Drugs and Medical Devices by:

Overstock of medication and medical devices are maintained at the administrative offices at Acute Medical Services, LLC. Such facility is climate controlled and secured by a locking device. Controlled substances are secured by at least two locking devices.

Medical devices such as (but not limited to): 1. ECG Machines 2. Pulse Oximeters 3. Blood Glucometers 4. Stretchers

Are maintained according to manufactures specifications with such records kept on file.

All Mobile Intensive Care Units are climate controlled through shore lines, even when not in use.

Reserve units have no drugs or medical devices stored on them when not in service.

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Pharmacological Assisted Intubation

General Protocol

GP 17 The utilization of PAI should never be attempted in any patient that cannot be intubated. Anatomical abnormalities including traumatized airway, the absence of materials necessary, a lack of adequate experience, and patients with intact breathing mechanisms are just a few of the definite contraindications to PAI. Simply put, if there is a question that the airway can be obtained and protected, do not perform PAI. Supervising paramedics that have a proven capability in airway management may only perform PAI. Indications for PAI include:

Glasgow Coma Score <8

Burn patients with evidence of respiratory injury or compromise

Masseter spasm with deoxygenation

Chest trauma with compromise

Risk of massive aspiration

Severe head trauma Equipment Checklist:

BMV

Oxygen source

Laryngoscope blade of appropriate size including backup

Suction with Yankauer handle

Appropriately sized endotracheal tube, with the next size above and below available

Ten cc syringe

Lubricated Stylet

Airway Adjunct for failed intubation (Combitube, LMA, COPA, King LT)

Cricothyrotomy kit

Medications should be drawn and labeled in syringes before utilization. Equipment MUST be in place, tested and prepared for use before PAI is initiated. Procedure:

CABC

Pre-oxygenation – 100% oxygen ventilation with a sealed system ( minimum of 60 seconds or 20 ventilations)

Pulse Oximetry Monitoring

Cricoid pressure must be applied

Lidocaine 1-1.5 mg/kg IVP (half the dose for patients >70 years of age)

Pretreatment with 5 mg IV Diazepam or 5-10 mg Versed may be administered prior to initiation of sequence

Administration of induction agents (etomidate, and succinylcholine if needed)

Etomidate 0.3mg/kg IVP (if SBP <100mmHg, then Etomidate 0.2mg/kg IVP)

Succinylcholine 1-1.5mg/kg IVP

Direct laryngoscopy and endotracheal intubation Maintenance of patient comfort and paralysis may be achieved by the following once a definitive airway is established and secured: Rocuronium 0.6-1.2mg/kg IV or Vecuronium 0.1mg/kg IV Remember to keep patient oxygenated even with multiple attempts of laryngoscopy and endotracheal intubation. Secondary adjuncts may be used for failed endotracheal intubation: LMA, KingTube, CombiTubes, and BVMs, Cricothrothmy for failed airway.

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Non Resuscitation Order

General Protocol

GP 18 It is the policy of Acute Medical Services, LLC to follow Do Not Resuscitate guidelines in accordance to the guidelines set forth by the Texas Department of Health. A valid Do Not Resuscitate directive must be executed by one of the following mechanisms:

Current (within one month) written, original (not a photocopy) DNR order signed by the patient’s physician.

A valid State of Texas Out Of Hospital DNR order. (Please see following page). These patients might be identified by other means as well such as a bracelet or necklace containing the DNR logo. This device is a reminder to ask for the original form.

The Texas Department of Health standardized DNR form specifically lists designated treatments that shall be withheld. Those treatments include:

Cardiopulmonary Resuscitation

Advanced Airway Management

Artificial Ventilation

Defibrillation

Transcutaneous Cardiac pacing Should a dispute arise regarding an OOH-DNR, the Medical Control Officer must be notified immediately. It is the duty of the Medical Control Officer to notify the Director of EMS Services, and the Medical Director to resolve any conflicts regarding DNR patients. It is acceptable under certain circumstances for Acute Medical Services, LLC EMS personnel to elect to withhold resuscitative measures from an apneic/pulseless patient or discontinue resuscitative attempts initiated by non-medical personnel. These circumstances include:

Decapitation

Rigor Mortis

Decomposition

Dependent Lividity

Visible trauma to the head or trunk with injuries clearly incompatible with life.

Instances which mass casualties START Triage are initiated.

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TDSHS STOP Form DNR Form

General Protocol

GP 18a

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Tissue Referral General Protocol

GP 19 Purpose: To have a phone referral system between LifeGift™ (or other regional tissue donation center) and Acute Medical Services, LLC for potential tissue donors. Statistics show that the earlier a referral is made, the higher the recovery rate. When deaths occur in the field, EMS agencies have proven to be one of the most reliable referral sources and actually facilitate the process by providing valuable clinical information about the decedent. Disqualification for donation will be determined by the LifeGift™ coordinator, and not the EMS crew on scene. Indications:

Obvious trauma with injuries incompatible with life

Extended down time with evidence of rigor mortis or dependent lividity.

Any death not transported regardless of down time, age or disease. Procedure: LifeGift will determine suitability of the donor and will approach the family for donor consent.

Contact LifeGift™ (from scene if at all possible) @ 800-633-6562.

Inform call taker that you would like to report a death. Be prepared to provide vital patient information including:

1. Location of deceased 2. Next of Kin or contact person with phone number (when possible) 3. Name, age, sex, and race of deceased. 4. Cause of death (mechanism of injury) 5. Brief medical history if available

The following information must be provided for follow up on referral

1. EMS Agency and Unit number 2. Name of referring medic 3. Agency telephone number (281-448-0200)

LifeGift™ will provide follow-up information directly to the crew regardless of outcome. This will be done either by phone or letter within thirty business days.

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Inservice Dispositions General Protocol

GP 20 In order to accurately calculate transport statistics on a monthly basis, only the following dispositions should be utilized before returning to service following a no transport: Disregard- This should be used when you never reach the scene and have been disregarded by another unit, law enforcement, or dispatch. Refusal AMA- This should be used when you have a patient that refuses to go to the hospital. Parental Refusal AMA- This should be used when the parent or guardian refuses transport to the hospital of a minor. Referral-This should be used when you release the patient to another service or entity. If you release the patient to law enforcement with injuries, a patient refusal must be obtained. Gone on Arrival- This should be used when you reach the scene and no patient is found or the patient has left the scene. False Alarm- This can only be used when an alarm company has been notified and the alarm company disregards EMS. No other reason is this disposition to be used. Mutual Aid Handled- In most instances dispatch will utilize this disposition. This will be used if you pass the patient off to another EMS agency. DOS- Dead on scene. Cancelled Incident- This will only be used by Acute Medical Services Communications personnel. Pt by Air Ambulance- This will be used when you have a patient transported by an air ambulance. Remember that there are three services providing air ambulance transportation, so it is important to use generic terminology as not to discriminate. In the event that a patient or family member decides to seek medical treatment on their own or “POV”, a patient refusal must be obtained. This will reduce any liability on the part of the individual crew and Acute Medical Services, LLC. Acute Medical Services, LLC does not recognize any type of “public service” disposition. If a caller requests an ambulance and does not request transportation to a healthcare facility, then a patient refusal must be obtained.

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HIPAA Compliancy General Protocol

GP 21 Acute Medical Services, LLC and its employees must make every attempt to conform to all policies and regulations mandated by Federal and State governments regarding patient confidentiality issues. The following policies must be adhered to: Privacy Officer

Acute Medical Services, LLC will maintain a designated Privacy Officer to oversee all confidentiality issues and to serve as a contact point for patients and their families to voice concerns, complaints, to access records, or to request amendments to be made to their patient records. This individual will have authority to gain ready access to all patient records. All requests for patient information/records should be referred to the Privacy Officer.

The Privacy Officer will be responsible for monitoring employee and company compliance with all State and Federal Privacy Standards. Should a complaint or accusation arise against an employee or the company regarding privacy issues, the Privacy Officer will investigate the situation and follow company procedures regarding appropriate disciplinary action if the investigation supports the complaint.

The Privacy Officer will provide initial and ongoing training regarding privacy issues to all personnel who have direct or indirect access to PHI. The Privacy Officer will also be responsible for ensuring that all personnel have signed a Confidentiality Statement and have attended appropriate training sessions.

Confidentiality Statement

All personnel, riders, students, first responders, office managers, billing personnel or agency, administrators, board members, or any other individual who may have direct or inadvertent access to patient records will be required to sign a Confidentiality Statement that will remain in effect permanently. Should the person no longer be employed by Acute Medical Services, LLC or have no further access to patient records in the future, they must still maintain the necessary confidentiality of any PHI with which they may have had contact or knowledge during their employment, rotations, contact period, etc.

Patient Consent Form Signatures All adult mentally competent patients must sign consent to use or disclose PHI on all patient contacts – transports and no transports. All transported patients must sign a billing authorization/financial responsibility form. The patient’s legal guardian or adult parent (if a minor) should sign for the patient. Other next of kin may be able to sign if the patient can reasonably be expected not to be able to sign the form at a later date, if mailed to the patient. If there is just cause why the patient or other authorized person cannot sign the form at the time of service, the reason must be documented on the consent form including a notation of when the follow-up consent letter was mailed and the crew member’s signature. The follow-up letter should be mailed and the activity documented in the Follow-Up Consent Log. Reasonable efforts must be documented showing that attempts to gain the patient’s signature were made. It is the crew’s responsibility to ensure that proper consents are obtained from every patient at the time of service or appropriate follow-up is completed. Patient Care Record Security All patient charts and associated paperwork are to be treated as highly confidential and security must be maintained at all times to ensure that PHI is not inadvertently shared with those who do NOT have the right to know. Verbal and written information being received from or given to other healthcare providers that is necessary to maintain the continuity of care if NOT to be withheld. While this information remains confidential, it must be shared under patient care circumstances to provide adequate assessment and treatment.

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Acute Medical Services, LLC personnel should make every effort to minimize information that can be heard or read by those who do NOT have a “right to know”. This includes bystanders, law enforcement officers, and even some family members. Because the decision on who has the right to know is so difficult to prove, Acute Medical Services, LLC personnel should not share information with anyone unless it is necessary to continue care for the patient. If in doubt, tactfully decline the information until proper lines of authority have been established. Without exception, any information classified as PHI will not be shared in verbal, written, electronic or any other format unless it is required by the following criteria:

As necessary for continuity of patient care, and treatment

As necessary for payment or collection services

Case reviews

Education

Obtaining legal and accounting services

Business planning

Resolving complaints

Employee discipline

Fundraising and marketing activities, including contacting the patients to tell them about services we can offer to them

Medical research

Databases which involve PHI, but do not identify individual information

Reminders of patient appointments for scheduled transports or care

As indicated and mandated by state and federal requirements

As legally required by law, either local, state or federal such as:

To law enforcement officials when necessary to identify someone who has committed a crime

To law enforcement officials when there is an immediate need for the information to prevent or solve a crime

To public health authorities to report births, deaths, or a disease that we are required to report

To people why may have been exposed to a communicable disease by the patient

To report child abuse, elder abuse, or domestic violence as required by law

To the FDA and other agencies to report an adverse event from the use of a drug or medical device

To government agencies who have a right to the information for conducting investigations, audits, inspections, disciplinary proceedings or other administrative or judicial actions in order to determine our compliance with the law

In response to subpoenas, search warrants, and other legal requests or directives which require us to produce and disclose your PHI

To government military, defense, investigative, security and other agencies who have a right to your PHI or order to protect citizens, officials of the United States or a foreign country and to investigate or prevent terrorist activities

To public health officials of the US or foreign countries to avert a serious threat to the safety and health of the people

As required by worker’s compensation laws. When working on PCR’s/Medical Charts prior to submitting them for Quality Improvement and billing, the employee must take extra care to ensure that no patient information or records are left out in the open where they can inadvertently be seen by those who have no “right to know”. Once the PCR/Medical Chart is complete, it should be placed in the locked container/area provided. Appropriate personnel responsible for handling the PCR/Medical Chart for billing, Quality Improvement, or record keeping purposes will continue to ensure the security of these records by keeping them in locked rooms/locked cabinets or drawers when not physically in use.

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Release of Records/Amendments/Restrictions The patient or the patient’s legal representative has the right to require us to restrict our use and disclosure of PHI with certain exceptions, but we don’t have to agree if any of the following exceptions apply: Exceptions We are not required to agree with the request for restriction if:

The information requested might be used in a civil or criminal suite, proceeding, or other administrative action

The information requested would reveal the source of confidential information provided by others

The information requested could cause or produce a threat to any person’s physical safety or life. If we DO agree to the request for restrictions, we must honor them and must tell all others to whom we would normally disclose the patient’s PHI about the restrictions and require them to honor them when we are required by law to disclose your information or when the PHI is needed for the patient’s treatment in an emergency. A patient or his/her legal guardian may also request a restriction for release of certain PHI by using the proper form supplied by the Privacy Officer. Such requests will also be evaluated and approval or denial will be postmarked within 60 days of the original request. If a patient or patient’s legal representative believes the PHI is not correct, he/she can ask us to amend it using the appropriate form. If we agree, we must do so within 60 days from the date of the original request. However, we can refuse the request if:

The records were not created by us

We don’t have access to the records or we can’t get access to them

We believe our records are correct

Amendment would result in our being unable to obtain payment for services rendered to the patient The patient or patient’s legal representative may request an accounting for our use and disclosures of the patient’s PHI for a 6 year period prior to the request unless that time period involves records before April 14, 2003. We are not legally required to account for use and disclosures prior to April 14, 2002. We also do not have to account to the patient for disclosures made in connection with treatment, for payment, health care operations or disclosures that we were required by law to make. A patient has the right to one free accounting in any 12 month period; for additional accountings we may charge a reasonable fee. All requests for PHI or any PCR/Medical Chart information will be made through the Privacy Officer. All requests will be carefully reviewed prior to the approval or denial of such requests. Requests other than routine disclosures, state or federally mandated information releases, or other releases mandated by law will not require any other type of consent by the patient or the patient’s legal guardian. Any other record release or request for amendments to PHI shall be utilizing the proper forms as provided by the Privacy Officer. Approvals or denials for release of records or amendments to records will be post-marked within 30 business days if held by us or 60 business days if held by another agency of the original written request. An approvals or denials for release of information, amendments to patient care records, or restrictions on PCR’s/Medical Charts will be based on accepted interpretation of the HIPAA rule. Training All Acute Medical Services, LLC personnel will be provided with initial training and updates on HIPAA rules and policies. Such training is considered to be mandatory. This training may be live or through other media presentations as indicated. Personnel must ensure that they have completed and signed the roster for each training session provided.

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Complaint Procedure All complaints or potential violations of these policies should be forwarded to the Privacy Officer. If the complaint or suspected violation is found to be valid and justified, following a thorough investigation by the Privacy Officer, then the following actions will be taken:

The Privacy Officer will follow the company-designated chain of command for notification of the violation, including the names of specific employees and circumstances surrounding the event

Company disciplinary policies and procedures will be followed with the nature and severity of the infraction considered to determine appropriate action

The Privacy Officer will review the event to determine need for individual or company training or policy revisions as indicated.

If the incident involves a filed complaint with the Secretary of the Department of Health and Human Services, all requested documentation, policies and information regarding the related incident or any other requested HIPAA related documentation or information will be provided by the Privacy Officer to the investigating agency. All employees will make every attempt to comply with the investigating agency’s requests, and any questions or concerns should be directed to the Privacy Officer.

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Geographical Area Personnel Status

General Protocol

GP 22 Geographical Area These Protocols are in effect within the service area covered by ACUTE MEDICAL SERVICES, LLC, any area covered by mutual-aid agreements or understandings and when on transfers. Personnel operating within ACUTE MEDICAL SERVICES, LLC or on ACUTE MEDICAL SERVICES, LLC units will utilize these protocols anytime contact is made with a patient or injured person. Medics and nurses may practice under these protocols while on duty with ACUTE MEDICAL SERVICES, LLC in any geographical area within the State of Texas and may continue practicing if the patient’s destination leads you to another state or country. Medics and nurses may practice under these protocols for air ambulance operations if the medic or nurse departs from Texas or the final destination for the patient is Texas. Medics and nurses will as well be covered under these protocols if an emergency arises and the intended destination is bypassed in order to seek immediate definitive medical care in another state or country. Medics and nurses may practice under these protocols while on duty with ACUTE MEDICAL SERVICES, LLC on other services unit or ambulance. Duty Status ACUTE MEDICAL SERVICES, LLC employees, Fire Services, and First Responders personnel shall utilize these protocols under my medical direction only when acting in their official capacity when representing ACUTE MEDICAL SERVICES, LLC. Non-EMS certified or licensed medical personnel not associated with ACUTE MEDICAL SERVICES, LLC Non-EMS certified or licensed medical personnel may not operate under these protocols without the written authorization of the medical director or an ACUTE MEDICAL SERVICES, LLC Incharge on scene.

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Disaster Plan General Protocol

GP 23

A Disaster or Mass Casualty Incident is defined as any accident or emergency situation that overwhelms local response capabilities. The determining factor is not the magnitude of the incident per say, but the number of casualties versus the amount of available resources on hand. It is the responsibility of Acute Medical Services, LLC personnel to set up an organized Incident Command System in order to do the greatest good for the greatest number of victims. An Incident Command System is an organized management program designed to quickly and effectively integrate and manage all emergency response resources when faced with a Mass casualty incident.

INCIDENT COMMAND / MEDICAL COMMAND

Incident Command- Individual responsible for the management of all incident operations at the incident site.

Medical Command- This is typically the role of the first arriving In-Charge Paramedic until relinquished to the higher ranking EMS Supervisor. The focus of Medical Command shall include (but not limited to):

Rapid Scene Size Up

Request necessary Resources

Create strategy plan

Delegate Duties to various staff, and organizations

Set up various Sectors and Sector Officers for direct communications. Medical Command shall retain his role until:

The incident is complete

He is relieved by a higher ranking or more appropriate person

Physically cannot complete the incident

Medical Command will be in constant communications following:

Incident Command

Triage Officer

Extrication Officer

Treatment Officer

Transportation Officer

Communication Officer

TRIAGE Triage- The theory behind the triage system is to recognize the most critically ill or injured for prompt treatment. Acute Medical Services, LLC utilizes the START Triage System. START is an acronym for Simple Triage and Rapid Treatment. (Please refer to flow chart on the following page)

The Triage Officer is directly responsible for categorizing the severity of injuries. He shall report directly to Incident Command. The focus of the Triage Officer shall include (but not be limited to):

Estimate number of victims and inform Medical Command.

Inform the Extrication Officer to determine resources needed.

In a systematic formation, account for all victims and categorize accordingly. Triage tags are provided for this purpose. Patients shall be identified as Immediate, Delayed, Minor, or Dead.

Maintain accurate count of patients with their initial status to cross check upon conclusion of incident. Patients shall immediately be extricated to the treatment sector following triage.

Report all progress and complications to Medical Command.

After ensuring that all victims are triaged and extricated, the Triage Officer shall report to the treatment sector.

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Disaster Plan General Protocol

GP 23 EXTRICATION

It is the duty of the Extrication Officer to ensure that all victims are removed from the mass casualty site and extricated to the treatment sector. The Extrication Officer shall report to Medical Command. The focus of the Extrication Officer shall include (but not limited to):

Communication with Triage Officer and Medical Command to determine resources needed to extricate patients and get them delivered to the Treatment Sector.

Provide site safety for personnel and patients.

Supervise all Extrication Sector activities.

Delegate duties to arriving personnel and allocate equipment.

Remove patients from incident site safely and in an acceptable order. Patients shall be moved directly to treatment sector unless there is a contamination issue.

Report progress and complications to Incident Command.

Decides suitable location for temporary Morgue.

When all patients have been extricated, report to Incident Command for reassignment. TREATMENT The treatment sector is where the treatment phase begins for the patient. Patients will be treated according to severity of illness or injury. It is the duty of the Treatment Officer to ensure that all patients are being treated appropriately to all treatment guidelines. The Treatment Officer shall report to Medical Command. The focus of the Treatment Officer shall include (but not limited to):

Communication with Medical Command for additional resources (medical personnel and medical supplies).


Locates suitable location and reports location to Medical Command.

Decides need for additional Treatment Sectors (Immediate, Delayed).

Supervise all Treatment Sector activities.

Provide continuous triage of all patients even after arrival.

Report progress and complications to Medical Command.

Reports to Medical Command when all patients have been delivered to Transportation Sector for reassignment.

TRANSPORTATION / COMMUNICATION The transportation sector is where actual transportation of patients begins. Patients will be transported according to severity of illness or injury. It is the duty of the Transportation Officer to ensure that all patients are being transported appropriate to guidelines. The Transportation Officer shall report to Medical Command. The focus of the Transportation shall include (but not limited to):

Communication with Medical Command to determine resources to provide transportation of all patients to an appropriate facility. (Air ambulances, buses, etc.)

Supervise all Transportation Sector Activities.


Locates suitable site for Transportation Sector, and reports location to Medical Command.

Delegate organization and operation of helicopter landing zone to Fire Department Personnel.

Determine capabilities of regional hospitals.

Assign a Communication Officer to handle transportation information to Harris County Emergency Communications.

Coordinate patient allocation and safe departure.

Maintain an accurate MCI log of all patients with destinations, units, major injuries to be cross checked with initial triage information.

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Disaster Plan Flow Sheet

General Protocol

GP 23a

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Sedation of Confirmed Intubated Patient

General Protocol

GP 24 From time to time the Paramedic or RN may come across a patient that has been intubated in a hospital setting that needs transport to definitive care. Some instances may be found where the patient that is intubated may be lightly sedated enough to achieve a calm state in a controlled environment like an ICU or Emergency Department. If the paramedic or RN attempts to move the patient to achieve patient transport and the patient sedation is such that is poses a risk of dislodging the ET tube or the patient appears to be conscious enough to have an understanding of the surrounding then the Paramedic or RN may administer additional sedatives to achieve a sedation that is appropriate to transport the patient without the patient being coherent enough to have a mental state that would generate fear or pain for the patient. Remember there is a fine line when it relates to humane and ethics. The paramedic or RN at their discretion may use additional sedatives to achieve a humane and ethical transport. If the patient is on a specific sedative you may attempt to increase the sedative being used. The following may be used to achieve sedation for a patient with a confirmed ET placement as long as there are no contraindications of the sedative:

Valium 5-10 mg IV q 15-30 mins Versed 2-2.5 mg IV q 15-30 mins Consider Infusion (see Infusion Chart) Etomidate Above the age of ten (10) years will vary between 0.2 and 0.6 mg/kg of body weight, and it must

be individualized in each case. The usual dose for induction in these patients is 0.3 mg/kg, injected over a period of 30 to 60 seconds.

Ativan 2mg IV q 30 mins Consider Infusion (see Infusion Chart) Propofol A slow rate of approximately 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg)

should be used then a Maintenance Infusion 50 to 200 mcg/kg/min. Use with caution as Propofol may create Severe Hypotension If patient SBP falls below 100mmHg stop the infusion until such time the BP is above

100mmHg. Titration of this drug can be challenging. Start at the lowest dose and monitor how the patient reacts with the sedation and blood pressure responses. Increase slowly till you achieve the desired effect. The attempt is to achieve enough sedation to make the patient comfortable without a drastic change in patient blood pressure.

Rocuronium 0.6-1.2 mg/kg IV Vecuronium 0.1 mg/kg IV Patients that are intubated must have pulse oximetry measurements, cardiac monitoring, and wave form CO2 capnography along with Vital Signs q 3-5 mins. ET Tubes should be secured with a Thomas ET Tube Tamer if possible. Patient may also need a cervical collar placed to insure and prevent tube displacement. The benefit from the use of wrist restraints may be indicated. Remember to insure the tube placement with auscultation of bilateral breath sounds, pulse oximetry, and end tidal CO2 capnography every 2-3 minutes to insure the tube has not been dislodged.

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Facility Physician Orders

General Protocol

GP 25 This protocol is designed to preserve the treatment regimen that is currently in place for patients we are called to transport to definitive care. We should always follow the orders of the attending physician who has knowledge or who has been caring for the patient. We will only go outside the orders if the patient’s condition worsens or the patient’s condition changes while in our care. Though the patient may require treatment beyond the orders of the physician like emetics or pain control the paramedic or nurse will find the protocol that most closely matches the diagnosis of the patient at time of patient transfer. For physician orders that are outside the scope of these protocols, the paramedic or nurse should obtain a photocopy of the orders if possible and attach the physician orders to the patient care chart. If a photocopy of the orders is not obtainable, document the ordering physicians name and patient medical chart number in your patient care report. Remember you may only carry out orders that you are trained to perform and or comfortable with. In any instance where the paramedic or nurse feels uncomfortable with the orders of a physician then the paramedic or nurse should revert back to the standing orders/protocols and contact medical control immediately. The paramedic or nurse may only carry out orders of a medical doctor or doctor of osteopathy. Orders cannot be carried out from Physicians Assistance, Nurse Practitioners, Registered Nurses not affiliated with Acute Medical Services LLC. In some rare instances you may have a patient that requires transport without physician’s orders; you are then to revert to the protocol most appropriate for the patient’s condition.

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Treating and Release of Patients

General Protocol

GP 26 Some instances you may find that the paramedic or nurse has begun to treat a patient and the patient then wants to refuse transport. In these instances the paramedic or nurse should attempt to talk the patient into being transported to seek medical treatment from a licensed physician. In the event that the patient in persistent in not being transported to definitive care medical control must be notified before departing the patients care. For those patients that are being discharged to a lower level of care that may need some treatment that is scheduled and the transport is being performed during the scheduled treatment then the paramedic or nurse may deem in necessary to continue the treatment on the normal and routing schedule so the patient does not miss a scheduled treatment or therapy. Examples of this would be for patients that require breathing treatment ever 4-6 hours. For patient that are being returned back to a nursing care home or residence that treatment may need to be rendered, medical control should be consulted prior to the initiation of treatment.

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Medical Control Consultations

General Protocol

GP 27 Medical Control consultations should be made any time there is a question about the treatment modality of a patient. Because the majority of the patients we transport are patients that are critically ill, and some instances where the standing protocol or standing orders do not fit the patient’s condition medical control is available for consult 24/7. I have in place a medical control system and a group of physicians that are ready to assist you in the event that assistance is needed. The medical control physicians may change from time to time and the most current schedule will be located in these protocols after the table of content and labeled ‘Medical Control Schedule’. When calling on medical control the patient report to the physician should be clear and precise. The outline below will assist you in insuring medical control has a clear understanding of the patients history, medical condition, treatment being rendered, and possible diagnosis of the patient. We should follow this format anytime we are relaying patient information to medical control or a receiving facility.

Outline of Patient Care Consultation

Give your name and unit number

Inform Medical Control you have a patient consult

Give the following information in this order: o Patient being transferred from where and what department o Patient being transferred to where and what department o Patient age, race, sex o Patient being transferred for o Patient’s vital signs, GCS, ATS o Patient’s complaint o Patients past medical history o Patient’s current prescribed medications o Patients Allergies o Patients Diagnosis from receiving facility o Treatment that receiving facility has performed and or initiated o Patient’s general appearance o Treatment that you are continuing or have initiated

Advise medical control of your needs and or problem o Let medical control know the treatment you want to perform or initiate

Document your medical control consultation on the patient care report and include the physician name and time consulted and the treatment ordered. Document the outcome of the treatment ordered.

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Oxygen Calculation General Protocol

GP 28

OXYGEN CYLINDER ENDURANCE CALCULATION FORMULA duration of flow in minutes = (gauge pressure - safe residual pressure) x constant flow rate in liters per minute safe residual pressure: 200 Constants: D cylinder 0.16 E cylinder 0.28 M cylinder 1.56 H cylinder 3.14 Example: To calculate the duration flow in minutes for a full M cylinder being used at 15 LPM: duration of flow in minutes = (3000 - 200) x 1.56 = 291.2 minutes = 4 hours 50 minutes 15LPM Example: In order to figure out whether an ambulance's oxygen cylinder has the minimum O2 required for a trip, use the formula above. Minimum required gauge pressure = duration of trip in minutes x LPM + 200 constant for the size of cylinder · Minnedosa to Winnipeg = 2.5 hours = 150 minutes · cylinder in use: M cylinder constant is 1.56 · oxygen flow rate for the patient = 15 LPM · minimum required gauge pressure = 150 min x 15 LPM + 200 = 1642 PSI 1.56

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Protocol Description Page AM01 Asystole 48

AM02 Pulseless Electrical Activity 49

AM03 Pulseless Ventricular Fibrillation 50

AM04 Hypothermic Induces Cardiac Arrest 51

AM05 Post Resuscitation Management 52

AM06 Undifferentiated Tachycardia 53

AM07 Unstable Ventricular Tachycardia 54

AM08 Stable Ventricular Tachycardia 55

AM09 Unstable Supraventricular Tachycardia 56

AM10 Stable Supraventricular Tachycardia 57

AM11 Bradycardia 58

AM12 Ventricular Ectopy 59

AM13 Acute Coronary Syndrome 60

AM14 Cardiogenic Shock 61

AM15 Hypertensive Crisis-Unstable 62

AM16 Hypertensive Crisis-Stable 63

AM17 Respiratory Distress-General 64

AM18 Pulmonary Edema 65

AM19 Asthma 66

AM20 Chronic Obstructive Pulmonary Disease 67

AM21 Pneumonia 68

AM22 Hyperventilation Syndrome 69

AM23 Pneumonia 70

AM24 Allergic Reactions Mild to Anaphylaxis 71

AM25 Altered Mental Status-Unknown Etiology 72

AM26 Seizures 73

AM27 Cerebral Vascular Accident 74

AM28 Overdose 75

AM29 Poisoning 76

AM30 Neurogenic Shock 77

AM31 Hypoglycemia 78

AM32 Hyperglycemia 79

AM33 Dehydration 80

AM34 Hypothermia 81

AM35 Heat Related Emergencies 82

AM36 Near Drowning 83

AM37 Septic Shock 84

AM38 Nausea/Vomiting 85

AM39 Acute Appendicitis-Diagnosed 86

AM40 Renal Calculi 87

AM41 Acute Abdomen Etiology Unclear 88

AM42 Gastrointestinal Hemorrhage 89

Adult Medical Protocols

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Asystole-Adult Adult Medical Protocol

AM01 Application: Pulseless/apneic in two or more leads

Ba

sic

EM

T CABC's

CPR American Heart Association Guidelines

O2 by Bag Valve Mask or King Tube

Automated External Defibrillator

Blood Glucose Check

EM

T In

term

ed

iate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Conscider cervical collar for stabilization of the head and to prevent dislodging of the ET tube

IV access

If BG < 80mg/dL administer D50% 25-50 gm IVP

Consider Naloxone if question of opiate overdose

Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose administration

Pa

ram

ed

ic o

r R

N

ECG (consider Transcutaneous Pacing)

Epinephrine 1:10,000 – 1mg IVP or 1:1000 – 2 mg ET Repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET

ACLS Guidelines

External Cardiac Pacing

Atropine 1.0mg IVP or 2.0mg ET Repeat every 3-5 minutes up to 0.04mg/kg Additional Atropine at 1.0mg IVP or 2.0mg ET may be administered if a clinically beneficial response is obtained even is maximum recommended dosage is exceeded.

Nasogastric or Oralgastric Tube Insertion

Sodium bicarbonate 1mEq/kg IVP if metabolic acidosis is likely

Consider Calcium Chloride 0.5 – 1.0 Gram IVP

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Pulseless Electrical Activity Adult

Adult Medical Protocol

AM02 Application:

Pulseless/apneic in conjunction with any ECG rhythm other than Ventricular Fibrillation, Ventricular Tachycardia, or Asystole

Ba

sic

EM

T CABC's




Blood Glucose Check

EM

T In

term

ed

iate


IV access


Consider Naloxone 1-2 mg IVP if question of opiate overdose

Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Pa

ram

ed

ic o

r R

N


If due to a surgical problem or injury initiate Rapid Transport Procedure

If Tension Pneumothorax chest decompression

Epinephrine 1:10,000 – 1mg IVP or 1:1000 – 2 mg ET Repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET

ACLS Guidelines

External Cardiac Pacing

If Bradycardia rhythm Atropine 1.0mg IVP or 2.0mg ET Repeat every 3-5 minutes up to 0.04mg/kg Additional Atropine at 1.0mg IVP or 2.0mg ET may be administered if a clinically beneficial response is obtained even is maximum recommended dosage is exceeded.

If evidence of hypovolemia Bolus Infusion of 500ml NS or 500ml LRS


Sodium bicarbonate 1mEq/kg IVP if metabolic acidosis is likely

If evidence of hemorrhage induced hypovolemia consider Hespan 250ml-750ml IV infusion at no more than 20ml/kg/hr. Use only after a minimum of 1:2 ratio (blood loss) fluid bolus of NS or LRS has been administered. Use caution in Renal Insufficient patients. Do not mix or administer any other medications is same IV administration set.

of 192

Pulseless Ventricular Fibrillation

Adult


AM03 Application:

Pulseless/apneic or pulseless with agonal respirations and Ventricular Fibrillation of Ventricular Tachycardia on the ECG

Ba

sic

EM

T CABC's




Blood Glucose Check

EM

T In

term

ed

iate


IV access




Pa

ram

ed

ic o

r R

N

ECG

Defibrillation at the following until conversion BiPhasic Defibrillation: 120 J then 150 J then 200 J Monophasic Defibrillation: 200 J then 300 J then 360 J

Epinephrine 1:10,000 – 1mg IVP or 1:1000 – 2 mg ET or Vasopressin 40 units in place of 1st and 2nd dose of epinephrine. If using epinephrine, repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET or

ACLS Guidelines

Check rhythm, resume CPR, Shock if indicated

Amiodarone 300mg Bolus IVP or Lidocaine 1.0-1.5 mg/kg IVP


2nd Dose Amiodarone 150mg Bolus IVP or Lidocaine 1.0-1.5 mg/kg IVP



Anti-rhythmic Infusion: If Amiodarone was administered then 1mg/min Amiodarone Infusion If Lidocaine was administered them 2-4 mg/min Lidocaine Infusion

Consider: Sodium bicarbonate 1mEq/kg IVP if Hyperkalemia or tricyclic toxicity

Consider: Magnesium 1-2 grams if hypomagnesemia or Torsades de points

of 192

Hypothermic Induced Cardiac Arrest

Adult


AM04 Application:

Pulseless/apneic or pulseless with environmental evidence of hypothermia

Ba

sic

EM

T CABC's




Blood Glucose Check

EM

T In

term

ed

iate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube

IV access




Pa

ram

ed

ic o

r R

N

ECG

If V-Fib or V-Tach Defibrillation at the following until conversion BiPhasic Defibrillation: 120 J then 150 J then 200 J Monophasic Defibrillation: 200 J then 300 J then 360 J

Epinephrine 1:10,000 – 1mg IVP or 1:1000 – 2 mg ET or Vasopressin 40 units in place of 1st and 2nd dose of epinephrine. If using epinephrine, repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET

ACLS Guidelines

Do Not Attempt defibrillation again if temperature is below 85 degrees F.

Temperature is 85 degrees or greater appropriate Protocol for Dysthythmia


NS 500ml Bolus or LR 500ml Bolus if evidence of hypovolemia



Resuscitation may not be terminated until the patient is normothermic

of 192

Post Resuscitation Management

Adult


AM05 Application:

Patient with spontaneous circulation or respiratory efforts after treatment of a non-perfusing rhythm

Ba

sic

EM

T CABC's


Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate


IV access




Pa

ram

ed

ic o

r R

N

ECG

If V-Fib or V-Tach Defibrillation converted from defibrillation and patient is not bradycardic If Amiodarone was administered prior to then 150mg slow IVP over 8-10 minutes and infusion of 1mg/min If Lidocaine was administered prior to then 0.5-1.0 mg/kg IVP then infusion of 2-4 mg/min

Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg

If Hypotensive 500ml of NS Consider Induced Hypothermia-Use chilled bolus of NS Cooling blanket, Artic Sun, or Ice Pacs to carotid, inguinal, and axilla

If Hypotensive after flood bolus Dopamine Infusion 2-20 mcg/kg/min Start infusion at 2mcg/kg/min and continue to increase until systolic is > 90 mmHg

Norepinephrine Infusion 0.5 – 1.0 mcg/min titrate to a max of 30mcg.min for severe refractory hypotension

Bradycardia after resuscitation: Refer to Bradycardia Protocol


Patients intubated that are attempting to dislodge or fighting the ET tube Consider the following for sedatives:

Versed IVP or Versed Infusion

Benzodiazepine IVP

Etomidate IVP or Infusion

Propofol Infusion

of 192

Undifferentiated Tachycardia

Adult


AM06 Application:

A wide complex Tachycardia with a QRS > 0.12 seconds with a rate heart rate > 150 bpm with uncertain origin with symptoms of impaired perfusion, diaphoresis, chest pain, or shortness of breath without hypotension, altered mental status, or pulmonary edema. Patients with hypotension, hypotension, altered mental status, or pulmonary edema should be managed using either the Unstable SVT or VT Protocol Note: If uncertain, consider the rhythm as undifferentiated. Do not treat specific arrhythmias unless certain

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate

IV access should be large bore and minimal of 2 cannulations



Pa

ram

ed

ic o

r R

N

ECG

Adenosine 6mg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg

If ectopy still not resolved Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min


If patient becomes unstable Prepare for Cardioversion and use Unstable V-Tach or SVT Protocol

of 192

Unstable Ventricular Tachycardia

Adult


AM07 Application:

Ventricular Tachycardia on ECG with Systolic BP < 90mm Hg or Pulmonary Edema or Significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate




Consider Intubation if hypoxemia present

Pa

ram

ed

ic o

r R

N

ECG

Prepare for Synchronized Cardioversion

Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion

Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion

Synchronized Cardioversion in energy sequence below until conversion of rhythm Monophasic Cardioversion use 100j then 200j then 300j then 360j Biphasic Cardioversion use 100j then 120j then 150j then 200j

Anti-arrhythmic Medication: Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min

Alternate with synchronized cardioversion at highest level of energy noted above


of 192

Stable Ventricular Tachycardia

Adult


AM08 Application:

Ventricular Tachycardia on ECG with Systolic BP > 90mm Hg without Pulmonary Edema or Significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate





Pa

ram

ed

ic o

r R

N

ECG



Prepare for Synchronized Cardioversion if patient becomes unstable




of 192

Unstable Supraventricular Tachycardia

Adult


AM09 Application:

SVT on ECG at rates >150 bpm with systolic BP <90 mmHg and one or more of the following: Severe dyspnea or Pulmonary Edema or significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate





Pa

ram

ed

ic o

r R

N

ECG




If known PSVT or Atrial Flutter, may start with synchronized cardioversion at 50 j otherwise:



of 192

Stable Supraventricular Tachycardia

Adult


AM10 Application:

SVT on ECG with a rate >150 bpm with systolic BP of > 90 mmHg without severe dyspnea, pulmonary edema, or significant altered mental status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate




Pa

ram

ed

ic o

r R

N

ECG

Vagal Maneuvers


If ectopy still not resolved Prepare for Synchronized Cardioversion for unstable patient




of 192

Bradycardia Adult


AM11 Application:

Any underlying cardiac rhythm with a ventricular rate of <60 bpm with and one or more of the following: Systolic BP<90 mmHg or PVC’s at >6 complexes per minute or Pulmonary Edema or Dyspnea or Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate




Pa

ram

ed

ic o

r R

N

ECG

Atropine 0.5mg IVP May repeat every 3-5 minutes up to a total dose of 0.04mg/kg

Refractory Bradycardia External Cardiac Pacing Use the following for sedatation and pain management of the paced patient Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion

For Bradycardia or cardiogenic hypotension refractory to atropine and or pacing Dopamine 5-20 mcg/kg/min IV Infusion

Norepinephrine Infusion 0.5 – 1.0 mcg/min IV and titrate to a max of 30 mcg/min

of 192

Ventricular Ectopy Adult


AM12 Application:

Premature ventricular complexes occurring whether unifocal or multifocal in origin with 12 or more complexes occurring per minute for more than 3-5 minutes and in the setting of Acute Coronary Syndrome and in the absence of Bradycardia

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate

IV access should be large bore



Pa

ram

ed

ic o

r R

N

ECG and if time permits diagnostic 12 Ld recording



of 192

Acute Coronary Syndrome Adult


AM13

Application: Non Traumatic pain of visceral quality from the neck to the pelvis inlet in cause for suspicion and chest/back/shoulder/neck/jaw or other discomfort may be indicative of myocardial ischemia and associated symptoms indicating myocardial ischemia or Acute Coronary Syndrome or Angina to include shortness of breath, nausea, vomiting, diaphoresis with a systolic BP of 90 mmHg or greater or 30% of baseline systolic.

Ba

sic

EM

T

CABC's

O2 by NRB preferred if patient will tolerate or Nasal Cannula

Blood Glucose Check If BG <80mg/dL administer Oral Glucose if patient has an intact gag reflex

Vital Signs

Assistance with self-administration of NTG if patient has a script 0.4mg tablet dissolved under tongue if systolic BP is >100 mmHg may repeat another dose after 10 minutes if systolic BP is >90mmHg

ASA 324 mg PO chewable

If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EM

T

Inte

rme

dia

te

IV access Preferred D5W but NS can be used

Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes



Pa

ram

ed

ic o

r R

N

ECG with diagnostic 12 Ld recording and include a Right Sided evaluation

If Positive Right Sided MI Flood Bolus of 250ml may repeat if symptoms improve

NTG spray or tablet 0.4mg SL May repeat every 3-5 minutes with a maximum of 3 doses/30 Minutes or if relief is found after 1-2 doses then NTG Paste 1” applied to chest wall if systolic BP is >90mmHg

Antiemetic Therapy: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.5-25 mg IVP

If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP

Pain Management Therapy: They are listed in preferred order if not contraindicated Morphine Sulfate 2.0 mg every 5 minutes to a maximum of 10mg every hour Hydromorphone 0.5mg to 1mg every 30 minutes to a maximum of 2mg every hour Fentanyle 50 – 100 mcg slow IVP may repeat as 50 mcg every 30 minutes to a maximum of 150 mcg per hour

Consider NTG Infusion 5 mcg/min by infusion pump increasing 5mcg/min every 5 minutes if Systolic BP >90 mmHg to desired effect to a maximum of 20 mcg/min

Consider Metoprolol IVP 5mg every 2 minutes for 3 doses (give each dose over a 2 minutes) Do not use if patient is in cardiogenic shock, Acute Coronary Syndrome with a rate less than 45 beats/minute or systolic BP <100 mmHg, or heart blocks.

of 192

Cardiogenic Shock Adult


AM14

Application: Hypotension with a systolic BP <90mmHg and is symptomatic for MI or Acute Coronary Syndrome which may include myocardial ischemia, ECG changes, or pulmonary edema with an altered mentation or GCS <8 without evidence of hypovolemia, dehydration, sepsis, or other non-cardiogenic source of hypotension without bradycardia

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate



Pa

ram

ed

ic o

r R

N ECG with diagnostic 12 Ld recording and include a Right Sided evaluation

If Positive Right Sided MI Consider fluid bolus of 20ml/kg

Epinephrine 1mg IVP may repeat every 3-5 minutes if systolic BP >70mmHg

Dopamine Infusion 2.0 – 20 mcg/kg/min start at 2.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until systolic BP >90 mmHg

Refractory to above treatment: Norepinephrine Infusion 0.5 – 1.0 mcg/min titrate to a max of 30 mcg/min

of 192

Hypertensive Crisis-Unstable

Adult


AM15

Application: Systolic BP > 200mmHg and or Diastolic BP of >110mmHg and clinical evidence of end-organ dysfuction, including one or more of the following: Altered Mentation, CVA like symptoms, Chest Pain or Acute Coronary Syndrome, Shortness of Breath, Headache, Nausea or Vomiting, and/or Diaphoresis

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


ASA 324 mg PO chewable


EM

T In

term

ed

iate





Pa

ram

ed

ic o

r R

N


If Positive Right Sided MI caution with use of Nitrates



If refractory to Nitrates consider one of the following treatment modalities: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Metoprolol Tartrate 5mg Slow IVP every 5-10 minutes to a total maximum of 15mg Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

of 192

Hypertensive Crisis-Stable

Adult


AM16

Application: Systolic BP > 200mmHg and or Diastolic BP of >110mmHg without clinical evidence of end-organ dysfunction

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access




Pa

ram

ed

ic o

r R

N



Antiemetic Therapy if indicated: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.5-25 mg IVP

Consider one of the following: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Metoprolol Tartrate 5mg Slow IVP every 5-10 minutes to a total maximum of 15mg Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

of 192

Respiratory Distress-General

Adult


AM17

Application: Dyspnea without a clear etiology

Ba

sic

EM

T

CABC's

Pulse Oximetry without Oxygen if possible


Blood Glucose Check

Vital Signs

Albuterol 2.5mg by Nebulization or assistance in self-administration of patient own inhalers


EM

T In

term

ed

iate

IV access

Blood Draw



Albuterol 2.5mg by Nebulization every 10 minutes to a total of 3 doses

Pa

ram

ed

ic o

r R

N ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation

Terbutaline 0.25mg SQ if tidal volume inadequate for inhalation therapy or refractory to Albuterol

Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses

Consider Combi Vent after the initial dose of Atrovent

Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

of 192

Pulmonary Edema

Adult


AM18

Application: Shortness of Breath with evidence of pulmonary edema and cardiac history with systolic BP greater than 100mmHg

Ba

sic

EM

T

CABC's



Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access

Blood Draw


Pa

ram

ed

ic o

r R

N

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation



Consider Morphine Sulfate 2-4mg IVP every 5 minutes to a total dose of 10mg

Consider Furosemide 1.0mg/kg IVP

Consider CPAP


of 192

Asthma Adult


AM19

Application: Dyspnea with evidence of bronchospasm with or without wheezing or silent breath sounds

Ba

sic

EM

T

CABC's



Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access with NS at 250-500 ml per hour

Blood Draw




Pa

ram

ed

ic o

r R

N



Consider Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses

Solu-Medrol or Solu-Cortef 250 mg to 500 mg IVP over 2 minutes

Asthma refractory to above treatment regimens: Consider Mag Sufate 1-2 grams IV Infusion over 15 minutes Consider Atropine by Nebulization 0.5mg in 3ml NS


of 192

COPD Adult


AM20

Application: Exacerbation of chronic bronchitis or emphysema with shortness of breath or dyspnea or a history of COPD

Ba

sic

EM

T

CABC's



Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate


Blood Draw




Pa

ram

ed

ic o

r R



Consider Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses

Solu-Medrol or Solu-Cortef 250 mg to 500 mg IVP over 2 minutes

Consider CPAP with peep


of 192

Pneumonia Adult


AM21

Application: Pneumonia cannot be diagnosed in the field without confirmation of imaging however it may be supported or suggested with the following: a history of mucopurulent sputum production, fever, dyspnea, abnormal CBC findings, and a positive sputum culture. Use this protocol for dyspnea with one or more of the following: Fever, Productive and Purulent Cough, Chest wall or Pleuritic Pain

Ba

sic

EM

T

CABC's



Blood Glucose Check

Vital Signs


If Febrile Acetaminophen 15mg/kg PO or Ibuprophen 200mg – 600mg PO


EM

T In

term

ed

iate


Blood Draw Red or Green Top Lavender Top If available Blood Culture Tubes




Pa

ram

ed

ic o

r R

N



Consider CPAP with peep

Consider Atrovent 500ug/3.0ml Saline, may be beneficial if patient has underlying COPD or emphysema. May repeat dosage if proven to be effective after initial dose up to 3 doses


of 192

Hyperventilation Syndrome Adult


AM22

Application: An increased rate and depth of respirations without evidence of hypoxemia with one or more of the following: Facial and peripheral tingling and/or extremity cramping or carpopedal spasms without adequate oxygenation SaO2 greater than 98%

Ba

sic

EM

T

CABC's


O2 by NRB preferred if patient will tolerate or Nasal Cannula Verbal coaching on breathing

Blood Glucose Check

Vital Signs

Psychological and Emotional Support


EM

T In

term

ed

iate

IV access

Blood Draw



Pa

ram

ed

ic o

r R


Consider sedative or sedative like pharmacology 25mg Diphenhydramine IVP 12.5 mg Promethazine IVP 2mg Diazapam IVP

Continue psychological and emotional support

of 192

Foreign Body Airway Obstruction

Adult


AM23

Application: Partial of complete airway obstruction secondary to a foreign body aspiration with evidence of one or more of the following: asymmetric and paroxysmal chest movement, decreased LOC, cyanosis, obvious inadequate air exchange

Ba

sic

EM

T

CABC's

Abdominal Chest Thrust per AHA guidelines

Reassess the airway and if not clear repeat abdominal thrust per AHA guideline, if clear then


Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate

Direct Laryngoscopy and attempt to visualize the object and remove with Magill forceps If available Video/Camera Laryngoscopy maybe beneficial

Intubate as needed

IV Access

Blood Draw



Pa

ram

ed

ic o

r R

N

If all interventions have failed and the patient airway is a complete obstructions Surgical Airway See Cricothyrotomy Procedure

of 192

Allergic Reaction-Mild to Moderate Anaphylaxis with Hypotension

Adult


AM24

Application: Mild allergic reaction that involves contact dermatitis and or uticaria and dermal itching without evidence of dyspnea, hypotension, wheezing, or complaint of airway fullness or Moderate allergic reaction that also includes localized or generalized peripheral edema, shortness of breath without hypotension

Ba

sic

EM

T

CABC's

O2

Blood Glucose Check

Vital Signs

If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.3ml SQ

EM

T In

term

ed

iate

IV Access

Blood Draw



If severe Anaphylaxis with airway restriction Epi 1:10,000 0.5mg IVP or Epi 1:1,000 0.3ml SQ

Pa

ram

ed

ic o

r R

N

ECG

Diphenhydramine 25mg IVP or Diphenhydramine 25mg IM

Solumedrol 125 – 250mg IVP over 30 seconds

If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization

Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.3ml SQ may repeat one time after 5 minutes Terbutaline 0.25mg SQ if refractory to Epinephrine

Anaphylaxis with Hypotension ECG

Epinephrine 1:10,000 0.5 mg IVP or 0.5mg SL Injection



If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Terbutaline 0.25mg SQ if refractory to Epinephrine

Consider Intubation

Consider Pharmacologically Assisted Intubation

of 192

Altered Mental Status Etiology Unknown

Adult


AM25

Application: Unresponsive or disoriented patient without a clear mechanism for altered mental status

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

AED application


EM

T In

term

ed

iate

IV access with NS or LRS

Blood Draw



Naloxone 1-2mg IVP every 5 minutes to a total dose of 10mg

Consider Intubation if GCS <8 or patient unable to protect their own airway

Pa

ram

ed

ic o

r R

N


Refer to a more specific protocol

of 192

Seizures/Status Epilepticus Adult


AM26

Application: Witnessed, reported, or suspected seizures prior to arrival or active seizure activity with normothermia

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with NS

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG

Consider one of the following: (Airway control measures should be available) Diazepam 2.0-10.0 mg IVP or 4-20 mg per rectum if IV unobtainable Versed 2mg IV may repeat once Ativan 0.05-0.1 mg/kg IVP

For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg IVP (if available) Mag Sulfate 4 Grams IV Infusion over 20 minutes then 1-4 grams per hour IV Infusion

of 192

Cerebral Vascular Accidents Transient Ischemic Attaches

Adult


AM27

Application: Altered mental status or slurred speech without probable etiology or unilateral weakness, paralysis, facial drooping, dysphagia, aphagia, or other neurological deficit. Patient has a history of CVA or TIA.

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with NS

Blood Draw

If BG < 80mg/dL administer half of the usual dose of D50% 12.5-25 gram IVP


Pa

ram

ed

ic o

r R

N

ECG

Consider one of the following for nausea: Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP

If hypertensive:

ECG with diagnostic 12 Lead recording and include a Right Sided evaluation



If refractory to Nitrates consider one of the following treatment modalities: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

of 192

Overdose Adult


AM28

Application: Known or suspected ingestion, injection of pharmacoactive substance, whether intentional or accidental.

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

Poison Control Consultation


EM

T In

term

ed

iate

IV access with NS

Blood Draw

If BG < 80mg/dL administer of D50% 25-50 gram IVP


If respiratory compromised: Intubation

Naloxone 0.4 – 2mg IV may repeat every 2-5 minutes to a maximum dose of 10mg

Pa

ram

ed

ic o

r R

N

ECG

If dystonic reaction: Diphenhydramine 25-50mg IVP or IM

If TCA overdose with significant CNS and Cardiovascular symptoms : Sodium Bicarbonate 1.0 mEq/kg IVP may repeat every 2-5 minutes if patient responds to initial dose

Activated Charcoal 25-50 Grams PO if oral overdose and patient airway reflexes intact Maybe administered through a NG or OG tube if patient has no airway reflex intact after confirmed Oral Tracheal Intubation

of 192

Poisoning Adult


AM29

Application: Known or suspected ingestion, injection of pharmacoactive substance, whether intentional or accidental.

Ba

sic

EM

T

If Inhalation poisoning, remove from environment and contact local fire department

CABC’s


Decontamination of patient-Contact local fire department

Blood Glucose Check

Vital Signs

Poison Control Consultation


EM

T In

term

ed

iate

IV access with NS

Blood Draw


If respiratory compromised: Supportive Airway Management or Intubation

Naloxone 0.4 – 2mg IV may repeat every 2-5 minutes to a maximum dose of 10mg if suspected opiate related poisoning

Pa

ram

ed

ic o

r R

N

ECG

If organophosphate poisoning and or symptoms parasympathetic response SLUDGE Atropine 2.0mg IVP repeat every 5 minutes as needed

If metabolic acidosis likely Sodium Bicarbonate 1.0 mEq/kg IVP

NG or OG intubation and lavage if indicated

If dystonic reaction: Diphenhydramine 25-50mg IVP or IM

If TCA overdose with significant CNS and Cardiovascular symptoms : Sodium Bicarbonate 1.0 mEq/kg IVP may repeat every 2-5 minutes if patient responds to initial dose

Consider Activated Charcoal 25-50 Grams PO if oral overdose and patient airway reflexes intact Maybe administered through a NG or OG tube if patient has no airway reflex intact after confirmed Oral Tracheal Intubation

of 192

Neurogenic Shock Adult


AM30

Application: Shock that is hemodynamically instable without an etiology, this type of shock is extremely difficult to diagnose in the field. A thorough examination is pertinent in determining and ruling our other sources of instable hemodynamics.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with NS

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG

Treat dysthymias per protocol

SoluMedrol 10-30 mg/kg IV Infusion over 15-30 minutes

Fluid Bolus 20-40 ml/kg IV to a max of 3 L

Consider Vasopressors: Epinephrine Infusion 0.1 – 1.0 mcg/kg/min to maintain systolic BP of 90 mmHg Dopamine Infusion 2.0 – 20.0 mcg/kg/min Levophed Infusion 0.5 mcg -30 mcg per minute Vasopressin Infusion 0.01-0.04 units per minute

Q

uic

k I

nfu

sio

n C

hart

Epinephrine Infusion

Mix 1mg/250ml NS which yields 4mcg per ml

15ml/hr=1mcg/min 30ml/hr=2mcg/min 45ml/hr=3mcg/min 60ml/hr=4mcg/min 75ml/hr=5mcg/min 120ml/hr=8mcg/min 150ml/hr=10mcg/min

Dopamine Infusion DOUBLE STRENGTH

Mix 200 mg/250ml NS which yields 800mcg per ml

See Dopamine Infusion

Chart

Levophed Infusion

Mix 4ml/250ml D5W which yields 16 mcg per ml

3.8ml/hr=1 mcg/min 7.5ml/hr=2 mcg/min 18.8ml/hr=5 mcg/min 37.5ml/hr=10 mcg/min 56.3ml/hr=15 mcg/min 75.0ml/hr=20 mcg/min 112.5ml/hr=30mcg/min

Vasopressin

Mix 20 units/100ml NS which yields 0.2 units per ml

3ml/hr=0.01 units/min 6ml/hr=0.02 units/min 9ml/hr=0.03 units/min 12ml/hr=0.04 units/min

of 192

Hypoglycemia Adult


AM31

Application: Blood Glucose Analysis of less than 80mg/dL with altered mental status or other sign/symptoms of hypoglycemia, including tremors, weakness, nausea, and intense hunger

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs

Blood Glucose <80 mg/dL and airway intact and able to swallow 15g-30g oral glucose


EM

T In

term

ed

iate

IV access with NS or D5W

Blood Draw

If BG < 80mg/dL administer of D50% 25-50 gram IVP may repeat once in 10-15 minutes if symptoms not resolved

Repeat BG analysis every 15 minutes after administration of D50%


Pa

ram

ed

ic o

r R

N

ECG

Consider if available Glucagon 1mg if IV access is unobtainable

of 192

Hyperglycemia Adult


AM32

Application: Blood Glucose Analysis of greater than 180mg/dL with one of the following: Altered mental status, tachypnea, abdominal pain, hypotension, and tachycardia

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with NS

Blood Draw


Pa

ram

ed

ic o

r R

N

ECG

Fluid Bolus of 20-40 ml/kg to a maximum of 3 Liters

If available and Blood Sugar is greater than 300mg/dL Insulin Humulin R 0.1 units/kg IVP then infusion of 0.05 units/kg/hr 100 units/100ml NS yields 1 unit/ml

Fluid Bolus 20-40 ml/kg IV to a max of 3 L

of 192

Dehydration Adult


AM33

Application: Hypovolemia either compensated or uncompensated or other signs and symptoms of dehydration, including any one of the following: Poor skin turgor, decrease in urine output, dry mucous membranes, orthostatic hypotension, dry cracked membranes and with evidence of a dehydration mechanism which may include vomiting, diarrhea, fever, diminished oral intake, and or sweating.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs to include orthostatics


EM

T In

term

ed

iate

IV access with NS or LR 20ml/kg bolus with 10ml/kg every 15 minutes up to a maximum of 3 liters

Blood Draw


Pa

ram

ed

ic o

r R

N

ECG

Fluid Bolus of 20-40 ml/kg to a maximum of 3 Liters

Consider one of the following for nausea: Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP

of 192

Hypothermia Adult


AM34

Application: Temperature of 90 degrees or less and altered mental status or uncoordinated physical activity without shivering

Ba

sic

EM

T

CABC’s

O2 by NRB preferred if patient will tolerate or Nasal Cannula If respiratory compromised BVM for rates less than 12/min or over 30/min

Vital signs and Tympanic or Rectal Temperature

Vital Signs

BG analysis

Remove from environment, remove wet clothing, wrap patient in dry/warm blankets


EM

T In

term

ed

iate

IV access with NS 250-500ml/hour with warm fluid

Blood Draw

If BG <80 mg/dL then D50% 25-50 grams IVP

Consider: Thiamine 50mg IVP if alcohol abuse suspected


Pa

ram

ed

ic o

r R

N

ECG

Consider: Sodium Bicarbonate 1mEq/kg IVP if metabolic acidosis is suspected

Treat cardiac dysrhythmia as per specific protocol

of 192

Heat Related Emergencies Adult


AM35 Application:

Environmental evidence of extreme hot conditions that would have dehydration effects and cramping of the extremities or weakness, vertigo, nausea, profuse sweating, tachycardia, or syncope with an elevated core temperature by 1-2 degrees or patient is dry and core temperature is 105 degrees with altered mental status or seizures present

Ba

sic

EM

T

CABC’s



Vital Signs

BG analysis

Remove from environment, provide external cooling

Commercial electrolyte substitute 250-500ml slow PO


EM

T In

term

ed

iate

IV access with NS or LRS 250-500ml bolus then 125ml/hour infusion

Blood Draw




Pa

ram

ed

ic o

r R

N

ECG

If nauseated consider: Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP

If patient shivering Diazepam 2-10 mg IVP

Supportive Care Continue to cool the patients until the temperature returns to a normal range

of 192

Near Drowning Adult


AM36 Application:

Water submersion without cardiopulmonary arrest and without hypothermia

Ba

sic

EM

T

CABC’s



Vital Signs

BG analysis

Oral/Nasal Airway if patient unconscious

AED


EM

T In

term

ed

iate

IV access with NS or LRS

Blood Draw




Pa

ram

ed

ic o

r R

N

ECG

NG or OG Tube Insertion

Supportive Care Treat dysrhythmias as per specific protocol

of 192

Septic Shock Adult


AM37

Application: Shock that is hemodynamically unstable with evidence of infectious process, one of the following maybe indicative for septicemia: Fever, recent would infection, recent surgery, decubitus ulcerations or dermal breakdown, recent URI or UTI, urinary catheter placement, PEG placement, rash, elevated WBC, and petechial

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs

If febril Tylenol 500-1000 mg PO or 400-800mg Ibuprophen PO


EM

T In

term

ed

iate

IV access with NS or LRS Fluid challenge of 20ml/kg max of 3 L

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Consider Vasopressors: Epinephrine Infusion 0.1 – 1.0 mcg/kg/min to maintain systolic BP of 90 mmHg Dopamine Infusion 2.0 – 20.0 mcg/kg/min Levophed Infusion 0.5 mcg -30 mcg per minute Vasopressin Infusion 0.01-0.04 units per minute

Q

uic

k I

nfu

sio

n C

hart

Epinephrine Infusion

Mix 1mg/250ml NS which yields 4mcg per ml

15ml/hr=1mcg/min 30ml/hr=2mcg/min 45ml/hr=3mcg/min 60ml/hr=4mcg/min 75ml/hr=5mcg/min 120ml/hr=8mcg/min 150ml/hr=10mcg/min

Dopamine Infusion DOUBLE STRENGTH

Mix 200 mg/250ml NS which yields 800mcg per ml

See Dopamine Infusion

Chart

Levophed Infusion

Mix 4ml/250ml D5W which yields 16 mcg per ml

3.8ml/hr=1 mcg/min 7.5ml/hr=2 mcg/min 18.8ml/hr=5 mcg/min 37.5ml/hr=10 mcg/min 56.3ml/hr=15 mcg/min 75.0ml/hr=20 mcg/min 112.5ml/hr=30mcg/min

Vasopressin

Mix 20 units/100ml NS which yields 0.2 units per ml

3ml/hr=0.01 units/min 6ml/hr=0.02 units/min 9ml/hr=0.03 units/min 12ml/hr=0.04 units/min

of 192

Nausea/Vomiting/Gastritis Adult


AM38

Application: Acute Nausea/Vomiting without evidence of internal hemorrhage and physical exam reveals no palpable pulsating masses and no clinical evidence of diaphoresis with normal vital signs and afebrile without guarding on abdominal exam.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with NS or LRS 100-250 ml/hr

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Consider Antiemetics: Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP


of 192

Acute Appendicitis Diagnosed

Adult


AM39

Application: Acute Nausea/Vomiting without evidence of internal hemorrhage and physical exam reveals no palpable pulsating masses and no clinical evidence of diaphoresis with normal vital signs.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs

If febrile and the patient is not nauseated Tylenol 500-1000mg PO or Ibuprophen 400-800mg PO


EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG

Treat any dysthymias per protocol



Consider one of the following for Pain Management: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

Consider in conjunction with pain management anti-inflammatory Ketorolac 15-30mg IVP, or 60mg IM

of 192

Renal Calculi

Adult


AM40

Application: Sudden onset of back or flank pain without association of trauma with excruciating and intermittent pain in the kidney area radiating to flank or groin area with nausea, vomiting, chills, fever, polyuria, or hematuria

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs

If febrile and the patient is not nauseated Tylenol 500-1000mg PO or Ibuprophen 400-800mg PO


EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Consider Antiemetics: *Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP


Consider one of the following for Pain Management: *medication of choice if no contraindications Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg *Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg *Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

Consider in conjunction with pain management anti-inflammatory *Ketorolac 15-30mg IVP, or 60mg IM

of 192

Acute Abdomen Etiology Unclear

Adult


AM41

Application: Non Traumatic abdominal pain without a clear etiology except female patients of childbearing age.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG




of 192

Gastrointestinal Hemmorhage

Adult


AM42

Application: Abdominal pain with guarding, rebound, distention, with or without bowel sounds with evidence of occult blood in stool or vomiting of blood

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access If hypovolemic NS or LR 20-30ml/kg bolus

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Move to a more specific protocol



of 192

Sedation / Chemical Restraint Adult Medical

Protocol

AM43

Application: Sedation or chemical restraint of patients

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG

Mild Sedation (i.e. Anxiety)

Versed 1-2 mg IV/IN, or

Ativan 0.5-2mg IV/IM

Moderate Sedation (Cardioversion, painful procedures, potential harm to self or others)

Versed 2-5 mg IV/IN

Chemical Restraint (Potential harm to self or others)

IV (Must be administered in separate syringes)

Haldol 5mg

Versed 2-5 mg and/or Ativan 2mg IM (Must be administered in separate syringes)

Haldon 5-10 mg

Versed 5mg and/or Ativan 2mg

of 192

Excited Delirium Adult Medical

Protocol

AM44

Application: Sedation of combative or violent patients

Symptoms: Agitation Aggressive, Threatening, or Combative behavior Amazing feats of strength Pressured, loud, incoherent speech Sweating (or loss of sweating late) Dilated pupils/less reactive to light Rapid breathing Stripping of clothes

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs, include temperature


EM

T In

term

ed

iate

IV access

Blood Draw



Pa

ram

ed

ic o

r R

N

ECG, SaO2, ETCO2 Options

Ketamine 1-2 mg/kg IV over 1 minute or 4-5 mg/kg IM

Versed 2-5 mg IV/IN and/or

Ativan 2mg IV/IM

Zofran 4-8 mg IV

Special Considerations

May have clinically significant cardiac effect, Use cautiously in patients with significant cardiac history

Dose section is elderly patients should be cautious, usually starting at the low end of the dosing range

Patient with hepatic or renal insufficiency should receive a half dose

of 192

Protocol Description Page AT01 Traumatic Cardiopulmonary Arrest 91

AT02 Multi-System Trauma 92

AT03 Head Injury 93

AT04 Burns 94

AT05 Muscle-Skeletal and Soft Tissue Injury 95

AT06 Amputations 96

AT07 Eye Injury 97

AT08 Insect/Spider Bites 98

AT09 Snake Bites 99

AT10 Pulmonary Embolism 100

Adult Trauma/Surgical Protocols

of 192

Traumatic Cardiopulmonary Arrest

Adult

Adult Trauma Protocol

AT01

Application: Pulseless/apneic with underlying multi-system trauma or other surgical problem usually caused by hypoxemia secondary to hypovolemia

Ba

sic

EM

T

CABC’s

CPR

AED

Occlude open chest wounds

Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway BVM, KingTube

EM

T In

term

ed

iate

Intubate

IV access x 2 Large Bore Consider: Bone Injection Gun, EZ IO If hypovolemic NS or LR 20-30ml/kg bolus

Blood Draw

Pa

ram

ed

ic o

r R

N

If Incompatible with Life Decision to resuscitate

If Indicated Surgical Airway

ECG



If Tension Pneumothorax Chest Decompression

of 192

Multi-System Trauma

Adult


AT02

Application: Injury to the chest, abdomen, pelvis, or extremities with evidence of significant possible injury or multiple soft tissue or musculoskeletal injuries with evidence of compensated or uncompensated shock

Bas

ic E

MT

CABC’s

Transport Immediately

AED


Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube

EM

T In

term

ed

iate

Intubate if indicated

IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg

Blood Draw

Pa

ram

ed

ic o

r R

N


ECG



Treat pain as per pain management protocol with considerations of hypotension


If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

of 192

Head Injury

Adult


AT03

Application: Injury to the head with altered mental status or loss of consciousness substantial mechanism of injury isolated or in the presence of other injuries with the exception of patients meeting the Multi-System Trauma criteria

Ba

sic

EM

T

CABC’s

Transport as soon as practical

Oxygen of NRB

Vital Signs

AED

Treat underlying injuries

If <10% BSA Cool burns with sterile saline, dress burns, remove loose clothing and jewelry


EM

T In

term

ed

iate

Intubate


Blood Draw

Pa

ram

ed

ic o

r R

N


ECG


If seizures consider one of the following Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available

Solumedrol 30mg/kg IVPB over 10 minutes

Evidence of ICP Consider Intubation using the PAI Protocol





of 192

Burns

Adult


AT04

Application: Tissue injury form direct contact with heat source or chemical reaction, inhalation, or electrical/lightening contact

Ba

sic

EM

T

CABC’s


Oxygen of NRB

Vital Signs

AED




EM

T In

term

ed

iate



Blood Draw

Initiate the Parkland Burn Formula for fluid resuscitation (Burn Area) (Patient Weight in Kg) = ml/hour to administer

4

Pa

ram

ed

ic o

r R

N


ECG



Treat pain as per pain management protocol with considerations of hypotension and inhalation and respiratory burns Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

of 192

Muscle-Skeletal/Soft Tissue Injury

Adult


AT05

Application: Isolated muscular-skeletal/soft tissue injury in the absence of significant head, chest, abdominal, or multi-systems injury with mechanism of injury capable of resulting in a muscular-skeletal injury with pain on palpation or movement and with ecchymosis, swelling, or deformity to the area

Ba

sic

EM

T

CABC’s

Control hemorrhage

Oxygen of NRB

Vital Signs

AED

Treat underlying injuries Splinting/Immobilize/Chemical Cold Packs


EM

T In

term

ed

iate



Blood Draw

Pa

ram

ed

ic o

r R

N

ECG


Move to a more specific protocol If traction, reduction, or realignment of limb pain management must be achieved to be successful

Treat pain as per pain management protocol with one of the following and considerations of potential hypotension Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg


of 192

Amputations

Adult


AT06

Application: Any part of the body, pathologically or surgically separated from the rest of the body

Ba

sic

EM

T

CABC’s

Control hemorrhage

Oxygen of NRB

Vital Signs

AED


Secondary Survey Cervical Spinal Restriction if indicated

Transport amputated part Amputation should be wrapped in a moist dressing of saline and placed in a plastic back and kept cool with a cold pack or ice. Amputation should not be placed directly on ice or cold pack and should not be submersed in water

EM

T In

term

ed

iate



Blood Draw

Pa

ram

ed

ic o

r R

N

ECG





of 192

Eye Injuries

Adult


AT07

Application: Injury to the globe, open or closed, including: Corneal abrasion, foreign body in the eye, chemical burn, lacerated or avulsed globe, “ARC” burn of the globe

Ba

sic

EM

T

CABC’s

Vital Signs

If Chemical Burn: Flush continuously with Normal Saline

If Open Injury to the Globe: Patch both eyes

If Corneal Abrasion, ARC Burn, or Foreign Body: Patch the affected eye

EM

T In

term

ed

iate

IV access

Blood Draw

Pa

ram

ed

ic o

r R

N

ECG




of 192

Insect/Spider Bites

Adult


AT08

Application: Known or suspected envenomation by a hymenoptera, Brown Recluse spider, or Black Widow spider

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Remove jewelry if bite is on the hand

EM

T In

term

ed

iate

IV access

Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Pa

ram

ed

ic o

r R

N

ECG


If allergic reaction: Follow appropriate allergic reaction protocol Benadryl 25mg IM or IV

If Seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available

Solu-Medrol 125mg SIVP

Consider Antiemetic: Promethazine 12.5 – 25mg IVP Zofran 4-8mg IVP

of 192

Snake Bites

Adult


AT09

Application: Known or suspected envenomation by snake with fang marks, swelling, and pain at the site

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs


Wash would with copious amount of soap and water

Keep patient supine and treat symptoms

Immobilize the limb and keep at the level of the heart

EM

T In

term

ed

iate

IV access

Blood Draw

Pa

ram

ed

ic o

r R

N

ECG


If allergic reaction: Follow appropriate allergic reaction protocol Benadryl 25mg IM or IV

If Seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available

Solu-Medrol 125mg SIVP


Consider Pain Management Protocol: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

of 192

Pulmonary Embolism

Adult


AT10

Application: Sudden onset of shortness of breath with mechanism of pulmonary embolism including one of the following: Recent surgery, history of Atrial Fibrillation or CHF, bed confinement, history of thrombophlebitis or DVT, pregnant females, and female patients that are smokers and on oral contraceptive

Ba

sic

EM

T CABC’s

Oxygen by NRB Consider BVM if indicated

Vital Signs

EM

T In

term

ed

iate

IV access

Blood Draw

Pa

ram

ed

ic o

r R

N

ECG




of 192

Protocol Description Page OB01 Abdominal Pain Female 102

OB02 Labor 103

OB03 Childbirth and Delivery 104

OB04 Vaginal Bleeding 105

OB05 Spontaneous Abortion 106

OB/GYN Protocols

of 192

Abdominal Pain-Female

Adult

Adult OB Protocol

OB01

Application: Any female patient of child-bearing potential complaining of abdominal pain without evidence of labor or trauma

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Blood Glucose Check

EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Fetal Heart Tones if suspected pregnancy of > 1st Trimester (Doppler if Available)



Consider the following:

Incomplete Abortion, PID, Ectopic Pregnancy, Abruptio Placenta, Placenta Previa, Uterine Rupture, Non-Obstetric etiologies, Appendicitis, Renal Calculi Consider

Pain Management Protocol: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

of 192

Labor

Adult

Adult OB Protocol

OB02

Application: Patient with intra uterine pregnancy of greater than 20 weeks with back or abdominal cramping or pains, which occur periodically

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Blood Glucose Check

Perineal Exam

EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Fetal Heart Tones if suspected pregnancy of > 1st Trimester (Doppler if Available)



Premature Labor of Gestational Age of 18-37 weeks Consider: Terbutaline 0.25 mg SQ when contractions are less than 10 minutes apart Fentanyl 0.5 to 1 mcg/kg may repeat every 60 mins

of 192

Childbirth/Delivery

Adult

Adult OB Protocol

OB03

Application: Patient with intra uterine pregnancy of greater than 20 weeks with back or abdominal cramping or pains, which occur periodically

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Blood Glucose Check

Perineal Exam

EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Fetal Heart Tones

Deliver Infant Post-Delivery Care

Clamp and cut umbilical cord


Deliver placenta

If continued postpartum bleeding Consider: Uterine Massage Encourage breast feeding Oxytocin Infusion 20 units in 1 liter of Normal Saline-Infuse at 200ml/hour

of 192

Vaginal Bleeding

Adult

Adult OB Protocol

OB04

Application: Vaginal bleeding that is non-menstrual without labor, history of trauma, or evidence of spontaneous or elective abortion (tissue, ect.)

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Blood Glucose Check

Perineal Exam

EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG



of 192

Spontaneous Abortion

Adult

Adult OB Protocol

OB05

Application: Vaginal bleeding that is non-menstrual

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs

Blood Glucose Check

Perineal Exam

Place pad at vaginal opening

Collect all passed tissue, if possible

EM

T In

term

ed

iate


Blood Draw



Pa

ram

ed

ic o

r R

N

ECG


Fetal Heart Tones

Deliver Infant Post-Delivery Care

Clamp and cut umbilical cord


Deliver placenta

If continued copious vaginal bleeding: Oxytocin Infusion 20 units in 1 liter of Normal Saline-Infuse at 200ml/hour Evacuate visible clots and tissue from vagina (save all)

of 192

Protocol Description Page PM01 Asystole 108

PM02 Pulseless Electrical Activity 109

PM03 Pulseless Ventricular Fibrillation 110

PM04 Hypothermic Induced Cardiac Arrest 111

PM05 Post Resuscitation Management 112

PM06 Undifferentiated Tachycardia 113





PM11 Bradycardia 118

PM12 Ventricular Ectopy 119

PM13 Hypoperfusion 120

PM14 Cardiac Ischemia 121

PM15 Cardiogenic Shock 122

PM16 Respiratory Failure 123

PM17 Respiratory Distress 124

PM18 Pulmonary Edema 125

PM19 Asthma 126

PM20 Epiglottitis 127

PM21 Croup 128

PM22 Bronchiolitis/Pneumonia 129

PM23 Airway Obstruction by Foreign Body 130

PM24 Allergic Reactions 131

PM25 Altered Mental Status 132

PM26 Seizures/Status Epilepticus 133

PM27 Seizures/Postictal State 134

PM28 Overdose 135

PM29 Poisoning 136

PM30 Hypoglycemia 137

PM31 Hyperglycemia/Diabetic Ketoacidosis 138

PM32 Dehydration 139

PM33 Hypothermia 140

PM34 Heat Related Emergencies 141

PM35 Heat Stroke 142

PM36 Near Drowning 143

PM37 Post Delivery Care 144

PM38 Sepsis 145

PM39 Acute Abdomen-Unknown Etiology 146

Pediatrics Medical Protocols

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Asystole Pediatric

Pediatric Medical Protocol

PM01 Application: Pulseless/apneic in two or more leads

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sic

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T CABC's




Blood Glucose Check

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iate


IV access

If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP


Pa

ram

ed

ic o

r R

N


Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET Repeat every 3-5 minutes

ACLS Guidelines

Atropine 0.02 mg/kg IV/IO/ET Minimum single dose of 0.1 mg Maximum single dose of 0.5 mg Maximum total dose of 0.04 mg/kg

Sodium bicarbonate 1mEq/kg IV/IO if metabolic acidosis is likely

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Pulseless Electrical Activity

Pediatric


PM02 Application:

Pulseless/apneic in conjunction with any ECG rhythm other than Ventricular Fibrillation, Ventricular Tachycardia, or Asystole

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sic

EM

T CABC's




Blood Glucose Check

EM

T In

term

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iate


IV access



Pa

ram

ed

ic o

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N


If due to a surgical problem or injury initiate Rapid Transport Procedure

If Tension Pneumothorax chest decompression

Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET Repeat every 3-5 minutes

ACLS Guidelines

If Bradycardia, Atropine 0.02 mg/kg IV/IO/ET Minimum single dose of 0.1 mg Maximum single dose of 0.5 mg Maximum total dose of 0.04 mg/kg

If evidence of hypovolemia Bolus Infusion of NS 20 ml/kg IV


Sodium bicarbonate 1mEq/kg IV/IO if metabolic acidosis is likely

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Pulseless Ventricular Fibrillation

Pediatric


PM03 Application:

Pulseless/apneic or pulseless with agonal respirations and Ventricular Fibrillation of Ventricular Tachycardia on the ECG

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T CABC's




Blood Glucose Check

EM

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IV access



Pa

ram

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ic o

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N

ECG

Defibrillation at the following until conversion Defib 2 j/kg Defib 4 j/kg Defib 4 j/kg

Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET

Defib 4 j/kg

Repeat Epinephrine every 3-5 mins followed by defib 4 j/kg each time

ACLS Guidelines


Lidocaine 1.5 mg/kg IV / 3.0 mg ET, Repeat in 5 min as 1.5 mg/kg IV / 3.0 mg ET, defib 4 j/kg after each administration


Consider: Sodium bicarbonate 1mEq/kg IVP if Hyperkalemia or tricyclic toxicity

of 192

Hypothermic Induced Cardiac Arrest

Pediatric


PM04 Application:

Pulseless/apneic or pulseless with environmental evidence of hypothermia

Ba

sic

EM

T CABC's




Blood Glucose Check

EM

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term

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iate


IV access



Pa

ram

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ic o

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N

ECG ECG

If V-Fib Defib 2 j/kg Defib 4 j/kg Defib 4 j/kg

ACLS Guidelines

Measure Temperature

Do Not Attempt defibrillation again if temperature is below 85 degrees F.

IF Temperature is 85 degrees or greater appropriate Protocol for Dysthythmia


Nasogastric or Oral gastric Tube Insertion

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Post Resuscitation Management

Pediatric


PM05 Application:

Patient with spontaneous circulation or respiratory efforts after treatment of a non-perfusing rhythm

Ba

sic

EM

T CABC's


Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate


IV access



Pa

ram

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ic o

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N

ECG

If V-Fib or V-Tach Defibrillation converted from defibrillation and patient is not bradycardic Lidocaine 1.0 mg/kg IV/IO (if patient did not previously receive Lidocaine) Lidocaine drip 20-50 mcg/kg/min – ACLS Guidelines

Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 25-50 mg/kg IV/IO

Consider Induced Hypothermia-Use chilled bolus of NS Cooling blanket, Artic Sun, or Ice Pacs to carotid, inguinal, and axilla

If Hypotensive after flood bolus Dopamine Infusion 2-20 mcg/kg/min Start infusion at 2mcg/kg/min and continue to increase until systolic is > 90 mmHg

Norepinephrine Infusion 0.5 – 1.0 mcg/min titrate to a max of 30mcg/min for severe refractory hypotension

Bradycardia after resuscitation: Refer to Bradycardia Protocol

Nasogastric or Oral gastric Tube Insertion

Patients intubated that are attempting to dislodge or fighting the ET tube Consider the following for sedatives:

Versed IVP or Versed Infusion

Benzodiazepine IVP

Etomidate IVP or Infusion

of 192

Undifferentiated Tachycardia

Pedi


PM06 Application:

A wide complex Tachycardia with a QRS > 0.12 seconds with a rate heart rate > 190 bpm with uncertain origin with symptoms of impaired perfusion, diaphoresis, chest pain, or shortness of breath without hypotension, altered mental status, or pulmonary edema. Patients with hypotension, hypotension, altered mental status, or pulmonary edema should be managed using either the Unstable SVT or VT Protocol Note: If uncertain, consider the rhythm as undifferentiated. Do not treat specific arrhythmias unless certain

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate


IV access



Pa

ram

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ic o

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N

ECG

Adenosine 0.1 mg/kg IVP followed by a rapid push If ectopy not resolved Adenosine 0.2 mg/kg IVP followed by a rapid push If ectopy still not resolved Adenosine 0.2 mg/kg IVP followed by a rapid push

If ectopy still not resolved Amiodarone 5 mg/kg bolus or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min

Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 25-50 mg/kg IV/IO

If patient becomes unstable Prepare for Cardioversion and use Unstable V-Tach or SVT Protocol Diazepam 0.2-0.3 mg/kg IV for cardioversion if awake, not hypotensive, not respiratory failure

of 192

Unstable Ventricular Tachycardia

Pedi


PM07 Application:

Ventricular Tachycardia on ECG with Hypotension or Pulmonary Edema or Significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

ed

iate


IV access



Pa

ram

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ic o

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N

ECG

Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion (if patient’s mental status requires sedation for cardioversion)

Prepare for Synchronized Cardioversion Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg

Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min

If Lidocaine was chosen and persistent ventricular ectopy consider the following: Do Not Use Amiodarone and Procainamide Together Procainamide 15 mg/kg IVPB over 30-60 minutes

Additional synchronized cardioversion at 2.0 j/kg

Repeat Lidocaine 0.5 mg/kg every 5 mins; alternate with repeat synchronized cardioversion at 2.0 j/kg

of 192

Stable Ventricular Tachycardia

Pediatric


PM08 Application:

Ventricular Tachycardia on ECG with Hypotention without Pulmonary Edema or Significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

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iate




Pa

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N

ECG

Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min


Prepare for Synchronized Cardioversion if patient becomes unstable

Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion

Synchronized Cardioversion in energy sequence below until conversion of rhythm Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg

of 192

Unstable Supraventricular Tachycardia

Pediatric


PM09 Application:

SVT on ECG at rates >190 bpm with profound hypotension and one or more of the following: Severe dyspnea or Pulmonary Edema or significant Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

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iate




Pa

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N

ECG




Adenosine 0.1mg/kg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg

Consider: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min


of 192

Stable Supraventricular Tachycardia

Pediatric


PM10 Application:

SVT on ECG with a rate >190 bpm with evidence of hemodynamic compromise without profound hypotension without severe dyspnea, pulmonary edema, or significant altered mental status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

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Pa

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ECG

Vagal maneuvers


Adenosine 0.1mg/kg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg



If patient becomes unstable move to Protocol PM09

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Bradycardia Pediatric


PM11 Application:

Any underlying cardiac rhythm with a ventricular rate of <60 bpm in a child or <80 bpm in an infant with and one or more of the following: Hypotension or Pulmonary Edema or Dyspnea or Altered Mental Status

Ba

sic

EM

T CABC's

O2

Blood Glucose Check

Vital Signs

EM

T In

term

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iate




Pa

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ic o

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N

ECG

Epinephrine 0.1mg/kg 1:1000 IV/IO/ET (pediatric) Epinephrine 0.1mg/kg 1:10000 IV/IO/ET (neonate) May repeat every 3-5 minutes

Refractor Bradycardia to Epinephrine Atropine 0.02mg/kg IV/IO/ET Minimum single dose 0.1mg Maximum single dose 0.5mg Maximum total dose 0.04mg/kg May repeat every 3-5 minutes

Refractory Bradycardia External Cardiac Pacing

Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to TCP

Epinephrine Infusion 0.1-1.0 mcg/kg/min if refractory to Epinephrine, Atropine, and Pacing

For Bradycardia or cardiogenic hypotension refractory to atropine and or pacing Dopamine 2-20 mcg/kg/min IV Infusion

of 192

Ventricular Ectopy Pediatric


PM12 Application:

Premature ventricular complexes occurring whether unifocal or multifocal in origin with 12 or more complexes occurring per minute for more than 3-5 minutes and in the setting of Acute Coronary Syndrome and in the absence of Bradycardia

Ba

sic

EM

T CABC's

O2-High Flow

Blood Glucose Check

Vital Signs

EM

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Pa

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N

ECG and if time permits diagnostic 12 Ld recording

Oxygenate

Consider one of the following Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min


of 192

Shock Pediatric


PM13

Application: Significant hypoperfusion such as diminished pulses, prolonged capillary refill, cool, pale, mottled skin

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sic

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T

CABC's


Blood Glucose Check

Vital Signs

Maintain normothermia


EM

T In

term

ed

iate

IV access Buretrol


If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP


Consider the use of Mechanical Ventilator if intubated

Naloxone 0.1mg/kg IV for persistent altered mental status or respiratory depression

Pa

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N

ECG

Move to a more specific diagnosis and protocol

of 192

Cardiac Ischemia Pediatric


PM14

Application: Patient with check, back, shoulder, neck, jaw, or other discomfort indicative of myocardial ischemia associated with symptoms indicating myocardial ischemia as in shortness of breath, nausea, or diaphoresis

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access Buretrol



Pa

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ic o

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N ECG

Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg

NTG 0.4mg SL for patients over >40kg

Morphine Sulfate 0.1 -0.2mg/kg IV in increments of 0.05mg/kg every 5 minutes with a maximum single dose of 2.0mg

Move to more specific Protocol

of 192

Cardiogenic Shock Pediatric


PM15

Application: Significant hypoperfusion with evidence of myocardial ischemia without evidence of hypovolemia, dehydration, sepsis, or other non-cardiogenic source of hypotension without bradycardia

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol



Pa

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ic o

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N ECG

Consider fluid bolus of 20ml/kg over 5-10 minutes

Refractory to Fluid Dopamine Infusion 5 – 10 mcg/kg/min start at 5.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until perfusion is present

Consider if refractory to Dopamine

Epinephrine 0.1-1.0 mcg/kg/min IV Infusion

of 192

Respiratory Failure Pediatric


PM16

Application: Dyspnea with tachypnea, bradypnea, or accessory muscle use and cyanosis or agitation or obtundation

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol



Consider CPAP with PEEP




Pa

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N

ECG

Considers if evidence of pneumothorax Chest Decompression


Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator

Consider Nebulization of Epinephine 1:1000 0.5ml + 2.5ml NS

Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg

of 192

Respiratory Distress Pediatric


PM17

Application: Dyspnea with unclear etiology

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sic

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T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol








Pa

ram

ed

ic o

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N

ECG

Considers if evidence of pneumothorax Chest Decompression


May repeat if continued evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator

Atrovent 2.5 mg by nebulization mask or inline by ventilator

If evidence of bronchial constriction consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes

Consider Combi Treatment by mixing the Albuterol and Atrovent in one Nebulization Treatment

Consider Nebulization of Epinephine 1:1000 0.5ml + 2.5ml NS


of 192

Pulmonary Edema Pediatric


PM18

Application: Dyspnea with shortness of breath and auscultated finding of pulmonary edema to include rales, wheezes, or silent breath sounds

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol







Pa

ram

ed

ic o

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N

ECG

NTG 0.4 mg SL for children over 40kg

Furosemide 0.5-1.0 mg/kg IV Maximum single dose of 40mg

Morphine Sulfate 0.1mg/kg every 5 minutes to a maximum dose of 0.2mg/kg IV If respiratory rate not depressed in increments of 0.05mg/kg (Maximum single dose of 2mg)

May repeat if continued evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator

Atrovent 2.5 mg by nebulization mask or inline by ventilator

If evidence of bronchial constriction consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes



of 192

Asthma Pediatric


PM19

Application: Shortness of breath and auscultated finding of bronchospasm, wheezing, and or silence with a history of asthma or reactive airway disease

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol



Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator May repeat every 10 to 15 minutes

Consider Atrovent 2.5 mg by nebulization mask or inline by ventilator

May repeat every 10-15 minutes

Consider Combi Treatment by mixing Albuterol and Atrovent in one nebulization treatment



Pa

ram

ed

ic o

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N

ECG Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes



If refractory to Albuterol and Atrovent consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS

Status Asthmaticus Mag Sulphate 25mg/kg to a maximum of 2 Gram IV Infusion over 30 minutes

of 192

Epiglottitis Pediatric


PM20

Application: Dyspnea with evidence of upper airway obstruction which may include inspiratory stridor, drooling, or hoarseness and any one or more of the following: Fever, recent history of Respiratory infection, dysphagia or severe sore throat

Ba

sic

EM

T

CABC's

O2 by NRB preferred if patient will tolerate or Nasal Cannula preferred to be humidified

Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol



Pa

ram

ed

ic o

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N ECG

Consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes

Consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS

If patient condition deteriorates Prepare for Emergency Airway Procedures

of 192

Croup Pediatric


PM21

Application: Dyspnea with evidence of upper airway obstruction which may include inspiratory stridor, with recent history of Respiratory infection

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


If Febril give anti-pyretic and dose to patient weight Tylenol or Ibuprophen


EM

T In

term

ed

iate

IV access Buretrol



Pa

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N ECG

If doubt as to whether the patient is suffering from Croup or Epiglottitis treat for Epiglottitis Pediatric Medical Protocol 20

If patient condition deteriorates Prepare for Emergency Airway Procedures

of 192

Bronchiolitis/Pneumonia Pediatric


PM22

Application: Dyspnea without evidence of upper airway obstruction with evidence of lower airway involvement such as wheezing crackles, forced inhalation, or abnormal chest imaging with evidence of infiltrates or pulmonary effusion or pneumonia accompanied by mucopurulent sputum, fever, and dyspnea

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs


If Febril give anti-pyretic and dose to patient weight Tylenol or Ibuprophen


EM

T In

term

ed

iate

IV access Buretrol



Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator May repeat every 10 to 15 minutes

Consider Atrovent 2.5 mg by nebulization mask or inline by ventilator

May repeat every 10-15 minutes

Consider Combi Treatment by mixing Albuterol and Atrovent in one nebulization treatment



Pa

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ed

ic o

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N ECG


If refractory to Albuterol and Atrovent consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS

of 192

Airway Obstruction by Foreign Body

Pediatric


PM23

Application: Partial of complete airway obstruction secondary to foreign body aspiration with decreased level of consciousness or cyanosis or obvious inadequate air exchange

Ba

sic

EM

T

CABC's

Abdominal Thrusts

Vital Signs

Reassess Airway

Continue Abdominal Thrusts until ventilations can be obtained

BVM to attempt ventilation

EM

T In

term

ed

iate

Direct Laryngoscopy Attempt to visualize object and remove with Magill forceps

Intubate when able

IV access Buretrol


Pa

ram

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ic o

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N If all attempts have failed prepare

Emergency Airway Procedures

of 192

Allergic Reaction-Mild to Moderate Anaphylaxis with Hypotension

Pediatric


PM24

Application: Mild allergic reaction that involves contact dermatitis and or uticaria and dermal itching without evidence of dyspnea, hypotension, wheezing, or complaint of airway fullness or Moderate allergic reaction that also includes localized or generalized peripheral edema, shortness of breath without hypotension

Ba

sic

EM

T

CABC's

O2

Blood Glucose Check

Vital Signs

If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.1mg/kg SQ

If wheezing/shortness of breath consider

Albuterol 2.5mg via Nebulization

EM

T In

term

ed

iate

IV Access

Blood Draw

If severe Anaphylaxis with airway restriction Epi 1:1,000 0.1mg/kg SQ

Pa

ram

ed

ic o

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N

ECG

Diphenhydramine 1.0mg/kg IVP or Diphenhydramine 1.0mg/kg IM

Solumedrol 2-3mg/kg IVP over 30 seconds

If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization

Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes Terbutaline 0.25mg SQ if refractory to Epinephrine patients over 35kg

Anaphylaxis with Hypotension ECG

Epinephrine 1:10,000 0.5 mg IVP or 0.5mg SL Injection



If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization Terbutaline 0.25mg SQ if refractory to Epinephrine patients over 35kg

Consider Intubation

Consider Pharmacologically Assisted Intubation

of 192

Altered Mental Status Pediatric


PM25

Application: Unresponsive or disoriented without a clear etiology for altered mental status

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol



Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose

Pa

ram

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ic o

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N ECG

Move to a more specific protocol when appropriate

of 192

Seizures/Status Epilepticus Pediatric


PM26

Application: Actively seizing patient

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If febrile administer antipyretic if able to control airway Tylenol or Ibuprophen with dosing for patients weight


EM

T In

term

ed

iate

IV access Buretrol




Pa

ram

ed

ic o

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N ECG

Consider one of the following: (Airway control measures should be available) Diazepam 0.2-0.3 mg/kg IVP or 0.4-0.6 mg/kg per rectum if IV unobtainable Midazolam 0.05-0.2 mg/kg IVP Ativan 0.05-0.1 mg/kg IVP

For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg/kg IVP administer at a rate of 100mg per minute (if available)

of 192

Seizures/Postictal State Pediatric


PM27

Application: Witnessed seizing patient with evidence of altered mental status, confusion, or obtundation

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If febrile administer antipyretic if able to control airway Tylenol or Ibuprophen with dosing for patients weight


EM

T In

term

ed

iate

IV access Buretrol




Pa

ram

ed

ic o

r R

N

ECG

Nasal Gastric or Oral Gastric Tube if prolonged BVM ventilations

If Seizures reappear:



of 192

Overdose Pediatric


PM28

Application: Known or suspected ingestion of a pharmaco-active substance, whether intentional or accidental

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol




Pa

ram

ed

ic o

r R

N ECG

Consult with Poison Control for antidotes, suggested treatments, and possible symptoms

Nasal Gastric or Oral Gastric Tube with lavage of sterile water

Activated Charcoal 1gr/kg PO or through Gastric Tube after confirmation of placement

If TCA overdose with significant CNS or Cardiovascular compromise Sodium Bicarbonate 1.0 mEq/kg IV over 5-10 minutes

Treat symptoms as they arise by changing to corresponding protocol

of 192

Poisoning Pediatric


PM29

Application: Known or suspected ingestion, inhalation, or absorption of a potential harmful non-pharmaceutical substance, whether intentional or accidental

Ba

sic

EM

T

CABC's


Inhalation move from area NOW

Blood Glucose Check

Vital Signs



Consult with Poison Control for antidotes, suggested treatments, and possible symptoms

EM

T In

term

ed

iate

IV access Buretrol




Pa

ram

ed

ic o

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N ECG

Nasal Gastric or Oral Gastric Tube with lavage of sterile water if ingestion

Activated Charcoal 1gr/kg PO or through Gastric Tube after confirmation of placement

If evidence of metabolic acidosis Sodium Bicarbonate 1.0 mEq/kg IV over 5-10 minutes

If evidence of organophosphate poisoning with parasympathetic response Atropine 0.02mg/kg IVP repeat ever 3-5 minutes as needed

Treat symptoms as they arise by changing to corresponding protocol

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Hypoglycemia Pediatric


PM30

Application: Blood Glucose analysis of less than 80mg/dL or less than 40mg/dL in newborn infants with altered mental status or signs and symptoms of hypoglycemia which may include tremors, weakness, nausea, and intense hunger

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If BG <80 mg/dL (40mg/dL in infants < 1 month old) Oral Glucose 5-15 Grams PO if patient can protect their own airway with intact gag reflex


EM

T In

term

ed

iate

IV access Buretrol



Para

me

dic

or

RN

ECG

If no IV access initiated Glucagon 0.5mg IM if less than 20kg or 1.0mg IM if patient is more than 20kg

Initiate D5W IV infusion at a rate of 3-10ml/kg/hr

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Hyperglycemia/DKA Pediatric


PM31

Application: Blood Glucose analysis greater than 180mg/dL and one or more of the following: Altered mental status, abdominal pain, nausea, weakness, tachypnea, hypotension, tachycardia with or without evidence of metabolic acidosis

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If BG >180 mg/dL use this protocol


EM

T In

term

ed

iate

IV access Buretrol 5-10ml/kg/hr of NS


Pa

ram

ed

ic o

r R

N ECG

Sodium Bicarbonate 1.0 mEq/kg IV if profound acidosis present

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Dehydration Pediatric


PM32

Application: Compensated or uncompensated hypovolemia or other signs and symptoms of dehydration including any one of the following: Poor skin turgor, little to no urine output, dry mucous membranes, depressed fontanels, absence of tearing with evidence of the following: vomiting or diarrhea, fever, diminished oral intake

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If febrile administer antipyretic Tylenol or Ibuprophen dosage to patient weight

If BG <80 mg/dL (40mg/dL in infants < 1 month old) Oral Glucose 5-15 Grams PO if patient can protect their own airway with intact gag reflex


EM

T In

term

ed

iate

IV access Buretrol IV fluid challenge of NS or LRS at 20ml/kg may repeat every 10-15 minutes if still symptomatic



Pa

ram

ed

ic o

r R

N ECG

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Hypothermia Pediatric


PM33

Application: Temperature of 90 degrees of less and altered mental status or uncoordinated physical activity

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs IF respiration less than 14/min use BVM to assist at a rate of 20/30 breaths per minute

External Warming


EM

T In

term

ed

iate

IV access Buretrol Warmed IV fluid of NS or LRS at 10ml/kg



Pa

ram

ed

ic o

r R

N ECG

Sodium Biacarbonate 1mEq/kg IV is metabolic acidosis likely

Other medications and treatments based on temperature and cardiac dysthymias

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Heat Cramps/Heat Exhaustion

Pediatric


PM34

Application: Environmental evidence of hyperthermia and cramps in extremities without heat exhaustion signs or symptoms or profuse sweating, tachycardia, and normal temperature or 1-2 degree elevation in normal temperature

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

If BG <80 mg/dL (40mg/dL in infants < 1 month old)

Oral Glucose 5-15gr PO if not nauseated

External cooling

If not nauseated and available Commercial electrolyte solution 250ml to 500ml slow PO


EM

T In

term

ed

iate

IV access Buretrol



Pa

ram

ed

ic o

r R

N

ECG


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Heat Stroke

Pediatric


PM35

Application: Temperature of at least 105 degrees and altered mental status or seizures

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs

External cooling


EM

T In

term

ed

iate

IV access Buretrol IV fluid of NS or LRS at 20ml/kg IV Bolus



Pa

ram

ed

ic o

r R

N ECG


If active seizures or shivering: Diazepam 0.2 -0.3 mg/kg IV may repeat every 5 minutes to 1mg/kg

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Near Drowning

Pediatric


PM36

Application: Water submersion without cardiopulmonary arrest and without evidence of hypothermia

Ba

sic

EM

T

CABC's

Remove from water


Blood Glucose Check

Vital Signs

External warming if required, remove wet clothing

If respiratory compromised BVM


EM

T In

term

ed

iate

IV access Buretrol IV fluid of NS



If respiratory compromised Intubate

Pa

ram

ed

ic o

r R

N ECG

Treat dysrhythmias as per specific protocol

If unconscious NG Tube Insertion

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Post Delivery Care

Pediatric


PM37

Application: Care and resuscitation of the newborn infant

Ba

sic

EM

T

CABC's

Dry, warm, position, suction, stimulate

APGAR assessment and scoring


If respiratory compromised BVM

Vital Signs

If Heart Rate less than 60: Chest compressions


EM

T In

term

ed

iate

If indicated IV access Buretrol IV fluid of NS

If indicated Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes


If respiratory compromised Intubate

Pa

ram

ed

ic o

r R

N

ECG Treat dysrhythmias as per specific protocol

If HR <60, Epinephrine 0.1mg/kg :10000 IV/IO/ET every 3-5 minutes

If persistent obtundation, Naloxone 0.1mg/kg IV/IO/ET repeat every 2-3 minutes if initial dose has a positive response to a maximum of single dose of 2.0mg

For persistent Bradycardia, Atropine 0.02 mg/kg IV with minimum single dose of 0.1mg and maximum single dose of 0.5mg to a total dose of 0.04mg/kg

Repeat Dextrose if continued evidence of hypoglycemia

If evidence of metabolic acidosis Sodium Bicarbonate, 1mEq/kg of 4.2% solution IV

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Sepsis Pediatric


PM38

Application: Significant hypoperfusion with evidence of systemic infection and fever

Ba

sic

EM

T

CABC's


Blood Glucose Check

Vital Signs



EM

T In

term

ed

iate

IV access Buretrol NS at 20ml/kg (10ml/kg in the neonate) may repeat every 5-10 minutes if symtomatic



Pa

ram

ed

ic o

r R

N ECG

Consider fluid bolus of 20ml/kg over 5-10 minutes

Refractory to Fluid Epinephrine 0.1-1.0 mcg/kg/min IV Infusion

Consider if refractory to Epinephrine Infusion Dopamine Infusion 5 – 10 mcg/kg/min start at 5.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until perfusion is present

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Acute Abdomen Etiology Unclear

Pediatric


PM39

Application: Non Traumatic abdominal pain without a clear etiology except female patients of childbearing age.

Ba

sic

EM

T

CABC’s


Blood Glucose Check

Vital Signs


EM

T In

term

ed

iate

IV access with TKO rate unless evidence of Hypovolemia




Pa

ram

ed

ic o

r R

N

ECG



Move to a more specific Protocol

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Protocol Description Page PT01 Traumatic Cardiopulmonary Arrest 148

PT02 Multi-System Trauma 149

PT03 Head Injury 150

PT04 Burns 151

PT05 Muscular-Skeletal and Soft Tissue Injury 152

PT06 Amputations 153

PT07 Eye Injuries 154

PT08 Insect/Spider Bites 155

PT09 Snake Bites 156

Pediatrics Trauma Protocols

of 192

Traumatic Cardiopulmonary Arrest

Pediatric

Pediatric Trauma Protocol

PT01

Application: Pulseless/apneic with underlying multi-system trauma or other surgical problem usually caused by hypoxemia secondary to hypovolemia

Ba

sic

EM

T

CABC’s

CPR

AED


Primary Scene Assessment and Primary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway BVM

EM

T In

term

ed

iate

Intubate

IV access x 2 Large Bore Consider: Bone Injection Gun, EZ IO If hypovolemic NS or LR 20-30ml/kg bolus


Nasogastric or Oral Gastric Tube placement

Pa

ram

ed

ic o

r R

N

If Incompatible with Life Decision to resuscitate


ECG




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Multi-System Trauma

Pediatric


PT02

Application: Injury to the chest, abdomen, pelvis, or extremities with evidence of significant possible injury or multiple soft tissue or musculoskeletal injuries with evidence of compensated or uncompensated shock

Ba

sic

EM

T

CABC’s

Transport Immediately

AED


Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM

EM

T In

term

ed

iate




Pa

ram

ed

ic o

r R

N


ECG






of 192

Head Injury

Pediatric


PT03

Application: Injury to the head with altered mental status or loss of consciousness substantial mechanism of injury isolated or in the presence of other injuries with the exception of patients meeting the Multi-System Trauma criteria

Ba

sic

EM

T

CABC’s


Oxygen of NRB

Vital Signs

AED



EM

T In

term

ed

iate

Intubate



Pa

ram

ed

ic o

r R

N


ECG




Evidence of ICP Consider Intubation using the PAI Protocol





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Burns

Pediatric


PT04

Application: Tissue injury form direct contact with heat source or chemical reaction, inhalation, or electrical/lightening contact

Ba

sic

EM

T

CABC’s


Oxygen of NRB

Vital Signs

AED




EM

T In

term

ed

iate



Blood Draw

Initiate the Parkland Burn Formula for fluid resuscitation (Burn Area) (Patient Weight in Kg) = ml/hour to administer 4

Pa

ram

ed

ic o

r R

N


ECG



Treat pain as per pain management protocol with considerations of hypotension and inhalation and respiratory burns Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours

Rule of Nines for determining BSA

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Muscular-Skeletal and Soft Tissue Injury

Pediatric


PT05

Application: Isolated muscular-skeletal or soft tissue injury in the absence of significant head, chest, abdominal, or multi-systems injury or mechanism of injury capable of resulting in a muscular-skeletal injury and pain on palpation or movement with ecchymosis, swelling, or deformity to area in question

Ba

sic

EM

T

CABC’s

Oxygen delivery

Control hemorrhage

Oxygen delivery

Vital signs

Splint and immobilize


EM

T In

term

ed

iate




Pa

ram

ed

ic o

r R

N

ECG


Treat pain as per pain management protocol with considerations of hypotension Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours


Consider Fracture reduction if distal circulation compromised



of 192

Amputations

Pediatric


PT06

Application: Any part of the body, pathologically or surgically separated from the rest of the body

Ba

sic

EM

T

CABC’s

Control hemorrhage

Oxygen of NRB

Vital Signs

AED


Secondary Survey Cervical Spinal Restriction if indicated

Transport amputated part Amputation should be wrapped in a moist dressing of saline and placed in a plastic back and kept cool with a cold pack or ice. Amputation should not be placed directly on ice or cold pack and should not be submersed in water

EM

T In

term

ed

iate




Pa

ram

ed

ic o

r R

N

ECG




of 192

Eye Injuries

Pediatric


PT07

Application: Injury to the globe, open or closed, including: Corneal abrasion, foreign body in the eye, chemical burn, lacerated or avulsed globe, “ARC” burn of the globe

Ba

sic

EM

T

CABC’s

Vital Signs

If Chemical Burn: Flush continuously with Normal Saline

If Open Injury to the Globe: Patch both eyes

If Corneal Abrasion, ARC Burn, or Foreign Body: Patch the affected eye

EM

T In

term

ed

iate

IV access


Pa

ram

ed

ic o

r R

N

ECG




of 192

Insect/Spider Bites

Pediatric


PT08

Application: Known or suspected envenomation by a hymenoptera, Brown Recluse spider, or Black Widow spider

Ba

sic

EM

T

CABC's

O2

Blood Glucose Check

Vital Signs

Remove jewelry if on the hand or feet

If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.1mg/kg SQ

If wheezing/shortness of breath consider

Albuterol 2.5mg via Nebulization

EM

T In

term

ed

iate

IV access


Pa

ram

ed

ic o

r R

N

ECG


ECG




Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes

If seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available


of 192

Snake Bites

Pediatric


PT09

Application: Known or suspected envenomation by snake with fang marks, swelling, and pain at the site

Ba

sic

EM

T

CABC’s

Oxygen

Vital Signs


Wash would with copious amount of soap and water

Keep patient supine and treat symptoms

Immobilize the limb and keep at the level of the heart

EM

T In

term

ed

iate

IV access


Pa

ram

ed

ic o

r R

N

ECG





Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes

If seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available



Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours

of 192

Protocol Description Page PR01 Electrocardiogram 158

PR02 Esophageal Obturation Airways 159

PR03 External Cardiac Pacing 160

PR04 Defibrillation Zoll Cardiac Monitors 161

PR05 Defibrillation Welsh Allen Monitors 162

PR06 External/Internal Jugular Cannulation 163

PR07 Injection Locks 164

PR08 Intraosseous Cannulation EZ/IO Bone Drill and B.I.G. 165

PR09 Intravenous Cannulation 166

PR10 Nasogastric Tube Insertion 167

PR11 Nasotracheal Intubation 168

PR12 Nebulized Brochodilation 169

PR13 Needle Chest Decompression 170

PR14 Oral Tracheal Intubation 171

PR15 Positive End Expiratory Pressure 172

PR16 Surgical Airway 173

PR17 Vagal Stimulation 174

Procedures

of 192

Electrocardiogram Procedural

Protocol

PR01 Criteria:

Any patient in whom other ALS interventions are perform, Any patient who complains of:

possible myocardial ischemia symptoms (chest pain, etc.) shortness of breath

syncope or dizziness

nausea or vomiting Any patient who displays:

Tachycardia

Hypotension

Altered mental status

Convulsion or syncope, including prior to EMS arrival Multilead ECG MUST be obtained on stable patients (as defined in the VT and SVT protocols) in rhythms thought to be VT or

SVT. It should also be obtained on all patients presenting with signs or symptoms of myocardial ischemia or those with any other cardiac dysrhythmia. 12 lead ECG MUST (if available) be obtained on patients with signs or symptoms suspicious of cardiac ischemia or infarct.

"Stable" cardiac ischemia patients are defined as patients in whom the 12 lead ECG will not result in a delay (that might adversely affect the patient's outcome) in the provision of other urgent or definitive therapies. Any other patient at the paramedic's discretion

Contraindications:

None Treatment:

Obtaining and interpreting ECG include Multilead and 12 lead if available. Equipment:

ECG monitor Patient cables (electrodes) Monitoring electrode patches

Procedure: FOR STANDARD ECG MONITORING

1. Turn on monitor and attach patient cables to monitor as per manufacturer's instructions. 2. Apply electrode patches to patient. If at all possible, apply to clean, dry skin. Electrode patches are to be placed as follows:

a. Right arm in the mid-humerus area, either anteriorly or laterally (or distal right clavicle area).

b. Left arm in the mid-humerus area, either anteriorly or laterally (or distal left clavicle area).

c. Left leg, anywhere between the hip and the lower calf, laterally (or left chest, midaxillary, below the 12th rib). 3. Attach the patient cables to the electrode patches. 4. Select the desired lead (I, II, or III). 5. Record a strip of the ECG of at least 12 seconds duration. Record any changes in rhythm or any significant chances in rate.

Record "pre" and "post" ECG strips before and after any intervention that will affect the cardiac rhythm or rate (meds, electrical therapy, etc.).

6. If using a machine with a memory function, be sure to record or otherwise store the summary or memory of the patient contact prior to disabling the function.

FOR MULTILEAD ECG 1. Prepare the monitor and cables as above. 2. Place 5 electrode patches on patient:

a-c as above

d. on the right sternal border in the 4th intercostal space

e. on the left mid-axillary line on the 6th rib.

1. Attach the patient cables to the right arm (RA), left arm (LA), and left leg (LL) patches as usual.

4. Evaluate and record the ECG in Leads I, II, and III as above. 5. Move the "LL" cable wire to the anterior chest patch. Position the monitor lead selector to "Lead III". 6. This is now modified chest lead 1 (MCL1). Evaluate and record the ECG in MCL1. 7. Move the "LL" cable wire to the mid-axillary patch. Leave the monitor on "Lead III". This is now modified chest lead 6

(MCL6). Evaluate and record the ECG in MCL6.

8. To return to Leads 1, 11, or 111, move the "LL" cable wire back to the LL patch. 9. The ECG may be monitored continuously in any of the 5 leads as the paramedic chooses.

10. If using a machine with a memory function, be sure to record or otherwise store the summary or memory of the patient contact prior to disabling the function.

of 192

Esophageal Obturation Airway

Procedural Protocol

PR02 Criteria: Unconscious, adult in whom endotracheal intubation cannot be immediately obtained. Contraindications:

Age less than 16 years.

Height less than 5' or greater than 6'7".

Esophageal disease or injury

Cirrhosis of the liver or alcoholism

Ingestion of caustic substance Treatment: Intubation and obturation of the esophagus with an EOA or EGTA Equipment:

Esophageal airway (EOA or EGTA).

35 ml syringe.

BVM, complete.

Water soluble lubricant.

Suction equipment.

Stethoscope.

Oxygen. Procedure:

1. Provide or maintain airway and oxygenation with basic methods. 2. Prepare and assemble equipment. 3. Hyperventilate/pre-oxygenate patient for 30 seconds. 4. Remove mask and oral airway. 5. Ensure that patient's head is in a neutral position. 6. Open the patient's mouth by grasping tongue and lower jaw and lifting upward. 7. Insert the tube into the oropharynx and advance the tube gently until the mask seats against the

patient's face. If resistance is encountered, withdraw slightly, emphasize the jaw lift, and advance again.

8. Seal the mask against the patient's face and attach BVM. 9. Auscultate for breath sounds while ventilating patient with the BVM. Listen over the epigastrium

first, then over all four quadrants of the anterior chest. If air is heard in the epigastrium and/or not heard in the lungs, remove the airway and reattempt

intubation after 30 seconds to a minute of pre-oxygenation. 10. Once placement is confirmed, inflate bulb with syringe. 11. Reassess placement after inflating bulb, and frequently thereafter.

of 192

External Cardiac Pacing Procedural

Protocol

PR03 Criteria:

Bradycardic, asystolic and agonal dysrhythmias that do not respond to drug therapy, and that result in insufficient perfusion as evidenced by the symptoms of shock, hypotension or decreased level of consciousness.

Treatment: Initiation of external pacing

Equipment: Cardiac monitor/defibrillator with pacing capability ECG monitoring supplies and equipment Pacing pads, 1 set Pacing lead wires, 1 set Small scissors or razor

Procedure: 1. Apply anterior adhesive electrode on left side of sternum. If possible place pads on clean dry skin. If necessary,

shave or trim hair. 2. Place posterior electrode just below left scapula.

NOTE: Anterior/Anterior placement of electrodes may be used if the anterior/posterior is not feasible. 3. Attach the lead wires to the electrodes as prescribed by the manufacturer. 4. Turn pacer on. DO NOT start current flow yet. 5. Set pacer rate at 80 bpm. 6. Start pacer current. 7. Increase milliamp setting by 20's until a capture is obtained or up to the maximum energy available from the

device. NOTE: Electrical capture is usually evident by a wide QRS and tall, broad T-waves. In some patients it may be less obvious, noted only by a change in QRS morphology. Mechanical capture may be evident by a palpable pulse, rise in blood pressure, improved level of consciousness, and improved skin color/temperature.

8. Once electrical capture is obtained begin decreasing Ma by 5's until capture is lost. 9. Then increase Ma by 5's until electrical capture is regained. This will be the electrical or stimulation threshold (the

minimum level of electrical energy needed to consistently depolarize the heart muscle). 10. Check for a pulse to determine the presence of mechanical capture. 11. If there is electrical capture but not mechanical capture, increase the rate only, up to a maximum of 120. DO NOT

increase the energy (if electrical capture is achieved). 12. If no response is obtained from maximum pacing output at a rate from 80 - 120, interrupt pacing and continue with

the appropriate cardiac protocol. Intermittently check for possible capture using maximum pacer setting.

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

14. Documentation: a) Date and time pacing initiated b) Baseline and pacing rhythm strips c) Current required obtaining capture d) Pacing rate e) Evaluation of patients response to pacing, in terms of electrical and/or mechanical response if applicable f) Date and time pacing terminated.

of 192

Defibrillation Zoll Monitors

Procedural Protocol

PR04 Criteria:

Pulseless/apneic patient V-fib or V-Tach on ECG

Contraindications:

Dysrhythmias other than VF or VT Treatment:

External defibrillation in VF and pulseless VT

Equipment: ECG monitor/defibrillator Defibrillation pads or gel ECG electrodes ECG monitor leads

Procedure: 1. IF patient is unconscious, immediately determine airway, breathing, and circulatory status using

"CABC" procedure. 2. IF patient is pulseless, immediately determine ECG rhythm. Initiate CPR if there is any delay in

determining rhythm. 3. IF ECG reveals VF or VT, ready paddles for use with conductive medium. 4. Charge defibrillator to 120 j. 5. Place paddles against chest in correct positions. Use 20 pounds of pressure. 6. Stop CPR. Clear all other responders from patient contact. 7. Visually re-confirm rhythm as VF or VT 8. IF still VF or VT, defibrillate at 150 j. 9. Leave paddles against chest in correct positions. 10. Charge device to 200 j. 11. Visually reconfirm rhythm as VF or VT. 12. Clear all other responders from patient contact. 13. IF still VF or VT, defibrillate at 200 j. 14. Leave paddles against chest in correct positions. 15. Charge device to 200 j. 16. Clear all other responders from patient contact. 17. Visually re-confirm rhythm as VF or VT. 18. IF still VF or VT, defibrillate at 200 j. 19. Check pulse. 20. IF still pulseless, continue CPR. 21. Continue ALS therapies as directed in "Ventricular Fibrillation" Protocol. 22. If patient's rhythm should change at any point, move to the appropriate ALS protocol. 23. If patient should develop a spontaneous pulse, move to the "Post Resuscitation Management" Protocol.

of 192

Defibrillation Welsh Allen Monitors

Procedural Protocol

PR05 Criteria:

Pulseless/apneic patient V-fib or V-Tach on ECG

Contraindications:

Dysrhythmias other than VF or VT Treatment:

External defibrillation in VF and pulseless VT

Equipment: ECG monitor/defibrillator Defibrillation pads or gel ECG electrodes ECG monitor leads

Procedure: 1. IF patient is unconscious, immediately determine airway, breathing, and circulatory status using

"CABC" procedure. 2. IF patient is pulseless, immediately determine ECG rhythm. Initiate CPR if there is any delay in

determining rhythm. 3. IF ECG reveals VF or VT, ready paddles for use with conductive medium. 4. Charge defibrillator to 120 j. 6. Place paddles against chest in correct positions. Use 20 pounds of pressure. 6. Stop CPR. Clear all other responders from patient contact. 7. Visually re-confirm rhythm as VF or VT 8. IF still VF or VT, defibrillate at 150 j. 10. Leave paddles against chest in correct positions. 11. Charge device to 200 j. 11. Visually reconfirm rhythm as VF or VT. 12. Clear all other responders from patient contact. 13. IF still VF or VT, defibrillate at 200 j. 14. Leave paddles against chest in correct positions. 15. Charge device to 200 j. 16. Clear all other responders from patient contact. 17. Visually re-confirm rhythm as VF or VT. 18. IF still VF or VT, defibrillate at 200 j. 19. Check pulse. 20. IF still pulseless, continue CPR. 21. Continue ALS therapies as directed in "Ventricular Fibrillation" Protocol. 22. If patient's rhythm should change at any point, move to the appropriate ALS protocol. 23. If patient should develop a spontaneous pulse, move to the "Post Resuscitation Management" Protocol.

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External/Internal Jugular Cannulation

Procedural Protocol

PR06 Criteria:

As initial, primary venous access or secondary access in any critical patient unconscious or otherwise at risks for imminent death or in any urgent patient in whom access cannot be obtained in 3 attempts at other peripheral sites. A Paramedic or Intermediate may only do EJ cannulation under the direct supervision and authorization of the Paramedic attendant.

Contraindications: This procedure is contraindicated in anti-coagulated patients or Carotid Atherosclerotic patients. NOTE: DO NOT compromise c-spine while establishing EJ or IJ IV cannulation.

Treatment:

Establishment of external jugular IV Equipment:

IV catheter (over-the-needle type) of appropriate gauge Alcohol /Iodine preps 4x4's Band-Aid and tape or commercial securing device ("Venigaurd", "Opsite", etc.) IV fluid of desired type Volume administration set (60 gtt/ml or 10-12 gtts/ml) as indicated Extension set. 10 cc syringe IF DRAWING BLOOD:

10 cc syringe Blood Collection Tubes Syringe needle, 18 ga.

Procedure: 1. Select and prepare equipment. Attach 10 cc syringe to hub of catheter/needle to assist in identification of

placement in patients with low or no cardiac output. 2. Select IV fluid. Check for expiration date and visually examine for contamination. 3. Connect administration set and extension set. 4. Clear air from IV tubing. Don appropriate personal protective (infection control) items 5. Identify external jugular vein. 6. Prepare site with alcohol or povidone/iodine. 7. Stabilize vein at site with distal (or cephalad) pressure. 8. Direct needlepoint caudally (toward chest). Pierce skin just lateral to vein. 9. Advance needle/catheter until needle enters lumen of vein (recognized by change in resistance and return of

blood into catheter hub). In-patients with low or no cardiac output, it might be necessary to aspirate for blood with the syringe to confirm entry into the lumen.

10. Once the needle has entered the lumen, advance the catheter/needle assembly very slightly farther into the lumen. This ensures that the catheter has entered the vessel.

11. Stop advancing the needle. Advance the catheter off the needle and into the vein. 12. Withdraw needle from catheter. If needed, gentle pressure may be applied proximal to catheter to stop

bleeding from catheter. 13. IF drawing blood, gently draw required volume. Avoid hemolysis. 14. Attach IV tubing, to catheter hub. 15. IF blood drawn, attach needle to syringe and insert into clot tube. Allow tube to draw blood from syringe.

DO NOT push blood into tube. 16. Open IV to wide open briefly, and check for good flow and lack of extravasation. 17. If IV patent, secure catheter/tubing with tape/Band-Aid or commercial device. 18. Set IV flow to desired rate. 19. Properly dispose of contaminated equipment/supplies.

of 192

Injection Locks Procedural

Protocol

PR07 Criteria:

Injection locks may be used to secure venous access in any patient in whom: 1. The EMS personnel do not anticipate the immediate need for administering IV medications

or IV fluid to in the pre-hospital setting. 2. The EMS crew has already secured a patent IV line for medications or fluid and simply

desires a second IV site for "backup". 3. The patient will be receiving, Adenocard. In this situation, the EMS personnel must also

establish a second IV, with large bore catheter, of NS. Contraindications:

None Treatment:

Establishment of IV access with an injection lock. Placement of secondary access with an injection lock.

Equipment: Angiocaths of the appropriate gauge Alcohol preps. Injection lock (catheter cap). 3 cc syringe Sterile normal saline, 2 cc. Tape and Band-Aid or commercial securing device ("Venigaurd", "Opsite", etc.)

Procedure: 1. Assemble and prepare equipment. Don appropriate personal protective (infection control) items. 2. Select, prepare for, and establish IV with angiocath in usual manner. 3. Once stylet is removed, attach injection lock to IV catheter. 4. Flush lock and catheter with 1-2 cc of normal saline. 5. If patent, secure IV catheter in usual manner.

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Intraosseous Cannulation EZ IO Bone Drill & B.I.G

Procedural Protocol

PR08 Criteria:

CRITICALLY ill or injured child in whom IV access cannot be established in two attempts OR within 90 seconds.

General: Any medications or fluids that can be administered using IV infusion can be infused with an adult IO. IO medication dosages and fluid boluses are the same as those used in IV infusion, as both procedures route directly into the patient's bloodstream.

Indications:

A. Inability to obtain peripheral access in an adult patient that requires access in an emergency manner. B. Its use should be considered after two IV attempts have failed or if no peripheral IV sites are

found and exhibits one or more of the following: a) An altered mental status (GCS of 8 or less) b) Respiratory compromise (SaO₂ 80% after appropriate oxygen therapy) c) Hemodynamic instability (systolic BP <90)

C. The IO is not intended nor should it be considered for prophylactic use. Contraindications:

A. Fracture of the tibia or femur – consider alternate tibia. B. Previous orthopedic procedure at insertion site. C. Infection at injection site. D. Inability to locate landmarks (significant edema, obesity) E. Pre-existing medical condition (tumor near site or peripheral vascular disease) F. Excessive fatty tissue at the insertion site, obesity.

Paramedic or Intermediate Use: A. The EZ-IO or the B.I.G. (Bone Injection Gun) is the two adult IO devices approved by the for use. C. Pain, in alert patients, consider 20 to 50 mg of 2% Lidocaine IO, prior to saline infusion. Procedure:

A. Wear appropriate PPE. B. Determine EZ-IO/B.I.G. indications. C. Rule out contraindications and locate insertion site. D. Cleanse insertion site and prepare EZ-IO/B.I.G. driver and needle set. E. Stabilize leg and insert EZ-IO/B.I.G. needle. F. Remove stylet and confirm placement. G. Flush or bolus the catheter with 5 ml of normal saline. H. Connect IV tubing and begin infusion. I. Apply dressing and monitor the site and the patient condition.

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Intravenous Cannulation

Procedural Protocol

PR09 Criteria: Any patient requiring IV access for medication or fluid administration, either immediate or anticipated.

As directed by specific protocol. IV cannulation can be made on any patient upon the discretion of the Paramedic including but not limited to EJ, AC cannulations. Blood should be collected when:

Patient is going to receive dextrose

Patient is going to receive Phenytoin

Any other situation, at the EMS personnel's discretion Contraindications:

Only as noted in specific protocols. Treatment: Establishment of peripheral IV (see specific procedure for external jugular IV)

Administration of IV fluid as indicated in specific protocols. Collection of blood into clot tubes for laboratory analysis.

Equipment: IV catheter (over-the-needle type) of desired gauge Alcohol or povidine/iodine preps 4x4's Band-Aid and tape or commercial securing device ("Venigaurd", "Opsite", etc.) IV fluid bag of desired type Minidrip or volume administration set (60 gtt/ml or 10-12 gtts/ml) as indicated Extension set, if indicated Tourniquet (BP cuff may be used instead). IF DRAWING BLOOD:

10 cc syringe Blood Collection tubes Syringe needle, 18 ga.

Procedure: 1. Select and prepare equipment. Don appropriate personal protective (infection control) items. 2. Select IV fluid. Check for expiration date and visually examine for contamination. 3. Connect administration set and extension set. 4. Clear air from IV tubing. 5. Apply constricting band. Confirm distal pulse after application. If using BP cuff, inflate cuff to 80% of patient's

systolic pressure. 6. Select site below constricting band. 7. Clean area with alcohol or povidone/iodine prep. 8. Inspect catheter/needle assembly for defects. 9. Stabilize vein at site. 10. Pierce skin with needle/catheter, keeping bevel up. 11. Enter lumen of vein with needle, as evidenced by blood return into catheter hub. 12. Very slightly advance assembly to ensure that catheter tip has entered lumen. 13. Stabilize needle and advance catheter into vessel lumen. 14. Withdraw needle from catheter. If needed, gentle pressure may be applied proximal to catheter to stop bleeding

from catheter. 15. IF drawing blood, attach syringe to catheter hub and gently draw required volume. Avoid hemolysis. 16. Attach IV tubing to catheter hub. Remove constricting band. 17. IF blood drawn, attach needle to syringe and insert into clot tube. Allow tube to draw blood from syringe. DO

NOT push blood into tube. 18. Open IV to wide open briefly, and check for good flow and lack of extravasation. 19. If IV patent, secure catheter/tubing with tape/bandaid or commercial device. 20. Set IV flow to desired rate.

21. Properly dispose of contaminated equipment/supplies.

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Nasogastric Tube Insertion

Procedural Protocol

PR10

Criteria: Cardio-pulmonary arrest with gastric distention Gastric distention secondary to near drowning Respiratory arrest/distress with assisted ventilations AND gastric distention. Poisoning and/or overdose requiring immediate gastric emptying WITH secure and patent airway. The Paramedic attendant can only perform Nasogastric Tube Insertion

Contraindications: Altered mental status WITHOUT secured airway Treatment: NG intubation in CPR, respiratory arrest/distress Equipment:

Nasogastric tube(s) of correct size 60 cc syringe, catheter-tip type Disposable cup Disposable straw Water soluble lubricant Sterile water 1/2 or 1 inch tape Suction equipment and supplies Stethoscope Oxygen

Procedure: 1. Assemble, prepare equipment. Don appropriate personal protective (infection control) items. 2. Inspect nares. If unconscious, place a nasal trumpet (airway) in most dilated nare. 3. Measure, using NG tube, the distance from the nare, across oropharynx, and down to navel. 4. With tip at navel, mark distance to nare on NG tube. 5. Remove nasal airway, if placed. Place tip of lubricated NG tube into most dilated nare. 6. Advance tube into posterior pharynx. If patient is conscious, have him/her swallow while advancing

tube through pharynx and into esophagus. Advance tube with each swallow. (Have patient use straw to drink and swallow water).

7. If patient is unconscious, position patient's head in a neutral or flexed position while advancing tube through pharynx and into esophagus.

8. If patient develops stridor or dyspnea, STOP. Remove tube, oxygenate patient, and attempt NG placement again.

9. Once tube is advanced to distance mark, stop and manually stabilize tube. 10. Attach syringe aspirate for gastric contents. 11. After aspirating, auscultate over epigastrium while re-injecting aspirate. 12. Tube placement is confirmed by auscultating air or aspirate entering stomach. The presence of gastric

contents on aspiration helps confirm placement, but its absence does not necessarily indicate improper placement.

13. Once placement is confirmed, secure tube with tape. 14. Attach to suction. Turn suction off every 3 - 5 mins. 15. If lavage is to be used, draw up sterile saline in the syringe and inject it into the NG tube. Attach tube to

suction for 3 - 5 mins or until all saline is recovered. Repeat this cycle as needed.

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Nasotracheal Intubation

Procedural Protocol

PR11

Criteria: Any patient requiring tracheal intubation (as in "Orotracheal Intubation" procedure) who cannot be intubated orally or has an intact Gag Reflex.

Contraindications:

Infants

USE WITH CAUTION IN:

Basilar skull fracture.

Severe maxillo-facial trauma.

Nasal fracture or deviated septum.

Young children. Treatment: Nasotracheal intubation Equipment:

Endotracheal tube(s) of appropriate size Bag-valve-mask, complete 10 cc syringe Water-soluble lubricant Tape or commercial tube securing device Nasal airway of the appropriate size Nasal intubation "whistle" tip. Stethoscope Suction equipment and supplies Oxygen

Procedure:

1. Manually establish or secure airway. Pre-oxygenate and hyperventilate patient. 2. Assemble and prepare equipment. Lubricate ET tube, attach "whistle" tip. 3. While oxygenating, inspect nares. 4. Place nasal airway (lubricated) in most dilated or least obstructed nare. The airway will further dilate

nare. 5. Position patient's head as appropriate (neutral if cervical spine precautions indicated, It sniffing"

position otherwise). 6. Remove mask and nasal airway. 7. Place tip of ET tube into nare. 8. Advance tube through nare, keeping bevel to the floor of the nasal passage. Use a gentle twisting

motion to help advance the tube. If resistance is met, retreat a short distance and advance again using gentle twisting. If persistent resistance is met, withdraw tube, re-oxygenate, and try other nare.

9. Advance tube through pharynx and toward glottis. Listen for air movement at tip. 10. As glottis is approached, air noise at tip should become more sharply defined. 11. At either inhalation or exhalation, advance tube into glottis. Adapter hub should seat near or against

nare. 12. Listen for air at tip. If not present, withdraw and reattempt. If present, remove whistle tip. 13. Attach BVM. Confirm placement by auscultating epigastrium and lung fields with ventilation. If

placement confirmed, inflate cuff. 14. Reposition tube or re-intubate patient as needed. Each attempt must be preceded by 30-60 seconds of

oxygenation. 15. Secure tube. 16. RECONFIRM tube placement often, especially after moving patient or manipulating ET tube.

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Nebulized Brochodilation

Procedural Protocol

PR12

Criteria: Dyspnea WITH evidence of bronchospasm (wheezes, silence), due to asthma or COPD. WITH adequate mental status and respiratory effort to inspire mist. Can be performed by the EMT-Basic and Intermediate under the Direct Supervision and approval of the attending Paramedic

Contraindications:

CHF/Pulmonary Edema. Severely obtunded or unconscious patient.

Treatment:

Nebulized administration of approved medications.

Equipment: Medication for nebulization 3 cc syringes, 2 (if medication not premixed) Sterile normal saline, 2 cc (if medication not premixed) Oxygen-driven nebulizer Oxygen

Procedure:

1. Assemble, prepare equipment and medication. Don appropriate personal protective (infection control) items.

2. Explain procedure to patient. 3. If possible, encourage the patient to exhale as much as possible. 4. Place, or have the patient place, the mouthpiece in the patient's mouth OR direct the medication at

patient's nose/mouth. 5. Have the patient inhale to his/her maximum volume. 6. If possible, have the patient hold his/her breath for 1 - 2 seconds, then slowly exhale. 7. Repeat the process until all the mist is gone. 8. DISCONTINUE therapy if:

a) The patient's heart rate increases by 20 beats/min or more from baseline b) Cardiac dysrhythmias appear (or worsen, if already present)

9. In some cases, the patient will be too dyspneic to follow these directions. This is not a contraindication to this procedure. Nebulized bronchodilation will generally still be effective as long as the patient is able to inspire the mist. Modify the procedure as needed to administer the medication to the anxious or extremely dyspneic patient.

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Needle Chest Decompression

Procedural Protocol

PR13

Criteria: Signs/symptoms of a tension pneumothorax

Contraindications:

None Can only be performed by attending Paramedic

Treatment: Needle chest decompression for traumatic tension pneumothorax. Equipment:

Chest decompression kit, which includes: 10 or 12, 14, and 16 ga over-the-needle catheters (2 ea) One-way valve (X 2) Povidone-iodine prep Number 10 scalpel 10 cc syringe

Stethoscope ECG monitoring supplies and equipment Oxygen Appropriate ventilation equipment

Procedure:

1. Ensure that patient is being ventilated. It is important that patient also have a patent IV in place and be on the ECG monitor.

2. Assemble, prepare equipment. Don appropriate personal protective (infection control) items. 3. Locate second intercostal space at mid-clavicular line on affected side of chest. Alternatively, the third

space at mid-axillary line may be used. 4. Prepare area with povidone-iodine. 5. Attach the syringe to the over-the-needle catheter. 6. At the selected location, make a small stab incision with the scalpel. Incise only through the dermis,

superior to and longitudinally with the rib. 7. Insert the over-the-needle catheter assembly through the incision and into the chest, directing it just

over third rib (mid-clavicular) or fourth rib (mid-axillary). Direct the assembly slightly caudally. (I prefer the mid-axillary approach.)

8. Once the pleural space is entered (recognized by a change in resistance and/or air entry into the syringe), advance catheter into space until the hub is flush with the skin.

9. Remove needle and syringe while manually stabilizing catheter. 10. Attach the one way valve to the hub of the catheter. 11. Secure the assembly to the chest wall with tape. 12. Auscultate chest for improvement in breath sounds. 13. Contact Medical Control and advise them of procedure and results. 14. Monitor catheter and valve to insure continued correct functioning, and patient for need for additional

decompression.

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Oral Tracheal Intubation

Procedural Protocol

PR14

Criteria: An patient requiring mechanical ventilation, PEEP, or airway protection. As directed in the specific protocols

Contraindications: None Treatment: Orotracheal intubation. Equipment:

Endotracheal tube(s) of appropriate size Stylet for ET tubes Laryngoscope handle and batteries Laryngoscope blades of the appropriate sizes and desired type Bag-valve-mask, complete 10 cc syringe Water-soluble lubricant Tape or commercial tube securing device Oral airway of the appropriate size Stethoscope Suction equipment and supplies Oxygen

Procedure: 1. Manually establish or secure airway. Pre-oxygenate and hyperventilate patient. 2. Assemble and prepare equipment. 3. Position patient's head as appropriate (neutral if cervical spine precautions indicated, "sniffing" position

otherwise). 4. Remove mask and oral air-way. 5. Insert laryngoscope blade, moving tongue to the left and lifting epiglottis. DO NOT apply pressure to

teeth. 6. Visualize glottis and vocal cords. 7. Pass ET tube through pharynx and into glottis. Directly visualize passage of tube through cords. 8. Advance tube until cuff is just past cords. STOP advancing. 9. Manually stabilize/secure tube 10. Attach BVM to tube adapter and ventilate patient. 11. Confirm placement by auscultating over epigastrium FIRST, then bilaterally over anterior chest (use

lateral chest in pedi patients). 12. Reposition tube or re-intubate patient as needed. Each attempt must be preceded by 30-60 seconds of

oxygenation. 13. Once tube is confirmed to be in place, inflate cuff. 14. REASSESS tube placement. If still in correct position, place oral air-way as a bite block and secure

tube with tape or use a commercial device. 15. RECONFIRM tube placement often, especially after moving patient or manipulating ET tube.

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Positive End Expiratory Pressure

Procedural Protocol

PR15

Criteria: Any patient with evidence of moderate to severe atelectasis, aspiration, or alveolar infiltrate, especially: * Pulmonary edema

* Near drowning * Smoke or fume inhalation with severe respiratory distress

Contraindications:

None Treatment:

Provision of PEEP. Equipment:

PEEP valve, BVM, complete Intubation equipment ECG monitoring equipment and supplies Oxygen

Procedure:

1. ENDOTRACHEALLY INTUBATE PATIENT. 2. Attach PEEP valve to end adapter of BVM. 3. Attach BVM to ET tube in usual manner. 4. Ventilate patient as usual. 5. Observe ECG rhythm and vital signs closely. PEEP may cause dysrhythmias and/or changes in vitals.

Discontinue or decrease PEEP if significant adverse responses occur.

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Surgical Airway

Procedural Protocol

PR16

Criteria: CRITICAL patient in whom a patent airway cannot be maintained or established by oro-pharyngeal or naso-pharyngeal airway, BVM, or oro- or naso-tracheal intubation, due to maxillo-facial trauma, inflammation or swelling of the airway, or other mechanism resulting in a life-threatening airway compromise. Can only be done by a Paramedic. Must be the last resort in managing a patients airway

Contraindications: An airway obtainable by no other means.

Treatment: Establishment of a surgical airway in the patient with complete obstruction.

Equipment: Surgical Airway Kit, which includes: Povidone-iodine prep. One-quarter inch wide umbilical tape ties. Cricothyroidotomy device, adult and pediatric Number 10 scalpel. Suction equipment and supplies. BVM complete. Stethoscope Oxygen

Procedure: 1. Prepare, assemble equipment. 2. If at all possible, hyperventilate patient. 3. Prepare the anterior neck with povidone-iodine. 4. Locate the cricothyroid membrane. Place finger on thyroid cartilage ("Adam's apple")and move finger

down into soft depression between thyroid cartilage and cricoid cartilage (next firm "bump"). 5. Leave finger on membrane. 6. Stabilize tissue by applying finger pressure bilaterally to membrane with hand that is marking site. 7. Place the tip of the scalpel on the skin in the center of the membrane. 8. Make a horizontal incision (approx. 2-4 cm across) through the epidermis and adipose tissue over the

membrane, exposing the membrane. 9. Stabilize the cricoid cartilage with thumb and forefinger, while identifying (if possible) and exposing the

cricoid membrane. 10. Once the cricoid membrane is exposed and identified make a horizontal incision (approx 2-4 cm across

the membrane). 11. Insert hemastats into the incision and spread incision open and introduce a 5.0 cuffed ET Tube

caudally and medially through the incision. Inflate the cuff. 12. Confirm proper placement by the ease of ventilating of air into the ET tube with BVM. 13. Remove syringe. 14. Ventilate and confirm placement with auscultation and observation of chest wall movement. 15. Secure airway with umbilical tape. 16. Apply dressing (if bleeding) to site. 17. Contact Medical Control and advise physician of procedure and results.

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Vagal Stimulation

Procedural Protocol

PR17

Criteria: STABLE SVT as defined in the specific protocols.

Contraindications:

For Carotid Sinus Massage * Unequal carotid pulses. * Bruit to either carotid artery. * History of CVA. * History of carotid or neck surgery. * Patient age greater than 50 years.

For Valsalva's Maneuver

None Treatment:

Applications of vagal maneuvers for stable SVT.

Equipment: ECG monitor and monitoring supplies. Equipment and supplies for IV.

Procedure: FOR VALSALVA MANEUVER:

1. Ensure that patient in on continuous ECG monitoring, is receiving O2, and has a patent IV in place. 2. Reconfirm that patient is still in SVT and that patient's clinical status is appropriate for vagal

maneuvers. 3. Briefly explain the overall procedure to the patient. 4. Have the patient take a deep breath. 5. Have the patient "bear down" against a closed glottis, as if trying to "clear" or "pop" his or her ears.

Have the patient perform this for as long as he or she can. 6. If no conversion, have the patient take another deep breath and repeat the procedure, up to three

attempts total. 7. If still no conversion and not contraindicated, move to carotid sinus massage.

FOR CAR0TID SINUS MASSAGE

1. Place the patient supine or semi-Fowler's with neck extended. 2. Separately palpate each carotid artery for pulse quality, and auscultate each for bruits. 3. Ensure that patient in on continuous ECG monitoring, is receiving O2, and has a patent IV in place. 4. Tilt the patient's head to one side. 5. Place the index and middle fingers over the carotid artery just below the angle of the jaw, as high on the

artery as possible. 6. Press the artery firmly back against the vertebral column and massage the artery. 7. Massage the artery until the first indication of conversion or heart block, but no longer than 20

seconds. 8. If no conversion after the first attempt, repeat the procedure once.

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Protocol Description Page RF01 Burn Reference 176

RF02 Trauma and Glascow Scoring 177

RF03 Multi Lead ECG 178

RF04 Guide to Drips 179

RF05 Anatomical Positions 181

RF06 Anatomical Reference to Movement 182

RF07 Cardiac Muscle Reference 183

RF08 Skull Bone Reference 184

RF09 Eye Anatomy Reference 185

RF10 Renal and Hepatic Reference 186

RF11 Head and Neck Anatomy Reference 187

References and Guides

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Burn References

Reference Protocol

RF01

Rule of Nines

Parkland Burn Formula: (IV fluids for first 8 hours)

(% Burn Area) X (Pt. Wt. in Kg) ______________________________________ = cc/hr 4

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Trauma and Glascow Come Score

Reference Protocol

RF02

Adult Glasgow Coma Score Adult Revised Trauma Score

Eye Opening Respiratory Rate/Min

Spontaneous 4 14-36/Minute 4

To Voice 3 11-14/Minute 3

To Pain 2 >36/Minute 2

None 1 <10/Minute 1

Verbal Response Systolic BP

Oriented 5 >90 4

Confused 4 70-89 3

Inappropriate Words 3 50-70 2

Incomprehensible Words 2 <50 1

No Response 1 Neurological (Glasgow)

Motor Response Score is 14-15 4

Obeys Commands 6 Score is 11-13 3

Localizes Pain 5 Score is 8-10 2

Withdraws from Pain 4 Score is <8 1

Flexes from Pain 3

Extension on Pain 2

No Response 1

Glasgow Total Score ATS Total Score

The Sum of Eye+Verbal+Motor = 3-15 Sum of Respiratory+BP+Neurological = 3-12

Mild Injury is 13 through 15 points

Moderate Injury is 9 to 12 points

Severe Injuries 3 through 8 points

Report GCS as 3 numbers: Report ATS as 3 Numbers:

Example: E2+V3+M5 = GCS of 10 Example: R2+BP3+N4 = ATS of 9

Eye opening tests indicate the function of the brain's activating centers. The patient's eyes may open spontaneously, only on verbal request, or only with painful stimulation.

Best verbal response indicates the condition of the central nervous system within the cerebral cortex. The patient may be able to speak normally and be oriented to time and place, or he or she may be disoriented and use inappropriate words. At the other end of the scale, the patient may only make incomprehensible sounds or no sound at all.

Best motor response tests examine a patient's ability to move arms and legs. Responses may vary from the ability to move about on command to the ability to move only in response to pain. Each element of the Glasgow Coma Scale is rated using "1" as the lowest possible score in each category. Physicians classify brain injuries as mild, moderate, or severe, using these scores.

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Multi-Lead ECG Interpretation

Reference Protocol

RF03

For our purposes, "multilead ECG" is considered to be the use of 5 or more ECG leads. It is required on all stable patients who are thought to be in SVT or VT. Additionally, it should be used routinely on all patients who display signs or symptoms of myocardial ischemia or those with an unclear or potentially significant dysrhythimia. Since ECG leads are actually electrical "angles of vision", utilizing more than one lead to evaluate the ECG provides the paramedic with a more complete picture of the electrophysiology of the patient's heart. To use just one lead to evaluate the ECG is akin to trying to view a whole room through the peephole on the door. Routinely using multiple leads will allow the paramedic to: * More accurately evaluate and interpret unclear or unusual rhythms. * Rapidly and accurately differentiate a wide complex SVT from VT. * Consistently identify crucial ECG changes, such as ST elevation (which often does not appear in

Lead II). The first step to proper ECG interpretation is good lead placement. The location of the lead attachment points on the patient significantly affects the accuracy of the ECG image. Leads placed too closely to one another distort the ECG we see, especially the QRS morphology and the relative positions of the ST and T wave. For diagnostic quality ECG'S, the electrode patches should be placed as follows:

1. One on each arm, in the mid humerus area. The patches should be even with the heart, either on the lateral or anterior aspects of the biceps.

2. One on the left leg, as far away from the arm leads as practical. A good place is on the lower, lateral calf. To run leads I, II, and III, simply attach the lead wires to the arm and leg patches as usual. The only real disadvantage to this placement of the patches is that it increases patient movement artifact considerably. When running a diagnostic ECG, you will need to have the patient hold as still as possible to minimize the artifact. If you do not need a diagnostic quality ECG and are merely monitoring the patient for general evaluation or gross changes (e.g. tachycardia vs. bradycardia, NSR vs. VT), you will get a more clear "picture" with the patches placed near the right and left shoulders and on the lower left torso. You must realize, however, that in this "standard" placement, you will not be able to evaluate ST and T changes accurately. The multilead ECG consists of Leads I, II, 111, MCL1 (modified chest lead 1), and MCL6 (modified chest lead 6). MCL1 and MCL6 are rough equivalents of VI and V6 on a 12 lead ECG. If running a multilead ECG, run at least a six (6) second strip each in leads I, II, and III using patches in the diagnostic positions. Then run six (6) second strips in leads MCL1 and MCL6 as described in the "Electrocardiogram" procedure in this protocol. If patient movement artifact is a problem, you may now move your electrode patches in to the more standard placement.

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Guide to Drips

Reference Protocol

RF04

Amiodarone Infusion

3 Phase Dosing over First 24 Hours Infusion Mix Concentration Dose (mg/min) Rate (ml/hr)

Goal 1000mg

over 24 hrs

Rapid Loading Phase 150mg in 100ml D5W 1.5mg/ml 15 600 150mg over 10

mins

Slow Loading Phase 900mg in 500ml D5W 1.8mg/ml 1 33.3 360mg over

6hrs

Maintenance Infusion Phase 900mg in 500ml D5W 1.8mg/ml 0.5 16.6 520mg over 18

hrs

Anectine Infusion

Preparation 1 gram into 250ml NS yields a concentration of 4mg/ml

Dose Range 2.5-4.0 mg/min μg/min 1 1.5 2.0 2.5 3.0 3.5 4.0

gtts/min 15 22.5 30 37.5 45 52.5 60

Dopamine Infusion ggts/minute (60 ggt set) or ml/hr:

Preparation 400mg in 250ml D5W yields a concentration of 1600 ug/ml

Dose Range 2-20 ug/kg/min Patient kg 2.5 5 10 20 30 40 50 60 70 80 90 100 105 110

2μg/kg/min * * * 1.5 2 3 4 5 5 6 7 8 9 10

5μg/kg/min * 1 2 4 6 8 9 11 13 15 17 19 20 21

10μg/kg/min 1 2 4 8 11 15 19 23 26 30 34 38 40 42

15μg/kg/min 1.4 3 6 11 17 23 28 34 39 45 51 56 59 65

20μg/kg/min 2 4 8 15 23 30 38 45 53 60 68 75 79 83

Lidocaine Infusion Preparation 1 Gram in 250ml NS yields 4mg/ml

Dose Range 2-4 mg/min μg/min 1 2 3 4

gtts/min 15 30 45 60

Procainamide Infusion Preparation 1 Gram in 250ml NS yields 4mg/ml

Dose Range 1-6 mg/min μg/min 1 2 3 4 5 6

gtts/min 15 30 45 60 75 90

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Must use In-Line Filter

Mannitol Infusion Preparation 25%/50ml (250mg/ml) in 250ml NS yields 1Gr/ml

Dose Range Adult: 1.5-2.0 Gr/kg of 25% solution over 30-60 minutes

Children: 1.0-2.0 Gr/kg over 30-60 minutes Milileters to Administer over 30-60 minutes

Patient kg 2.5 5 10 20 30 40 50 60 70 80 90 100 105 110

1.0 g/kg 2.5 5 10 20 30 40 50 60 70 80 90 100 105 110

1.5 g/kg 3.75 7.5 15 30 45 60 75 90 105 120 135 150 157 165

2.0 g/kg 5 10 20 40 60 80 100 120 140 160 180 200 210 220

Bretylium

Dose: 5-10 mg/kg over 10 minutes for V-Tach and 5mg/kg Bolus for V-Fib

Maintenance Drip: 2mg/minute

Mix: 500mg Bretylium in 250-ml D5W yields 2mg/ml

Drip 1 ggt/second=2mg/minute

Drug Administration Formulas

D (desired dose) x V (vehicle)

H (dose on hand) = Amount to Give

Infusion Rate (mL/h) = Weight (kg) x Dose (ug/kg/min) x 60 min/h

Concentration (ug/mL)

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Anatomical Reference

Reference Protocol

RF05

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Anatomical Reference Movements

Reference Protocol

RF06

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Cardiac Muscle

Reference Protocol

RF07

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Skull Bone Reference

Reference Protocol

RF08

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Eye Anatomy Reference

Reference Protocol

RF09

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Renal and Hepatic Anatomy Reference

Reference Protocol

RF10

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Neck and Head Anatomy Reference

Reference Protocol

RF11

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Protocol Description Page RX01

RX02

RX03

RX04

RX05

RX06

RX07

RX08

RX09

RX10

RX11

Medication Reference/Guide

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Acetaminophen

Reference Medications

RX01

update to protocols

Documents