Columbia Co (OR) Protocols (2009)

8/7/2019 Columbia Co (OR) Protocols (2009)

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01/02

Columbia County Emergency Medical Services Protocols

Table of Contents 1. Signature page

2. Introduction/Orientation 3. EMS Protocols

A. Treatment Protocols

T1. Abdominal Pain

T2. Airway

T3. Altered Mental Status/Coma

T4. AmputationT5. Anaphylaxis/Allergies

T6. Burns

T7. Cardiac Arrest T8. Cardiac Chest Pain

T9. Cardiac Dysrhythmias

T10. ChildbirthT11. Dental Avulsions

T12. Diabetic Emergencies

T13. Head traumaT14. Heat Illness

T15. Hypertensive Emergencies

T16. Hypothermia

T17. Musculoskeletal InjuriesT18. Near Drowning

T19. Neonatal Resuscitation

T20. Ob-Gyn EmergenciesT21. Poisons and Overdoses

T22. Psychiatric/Behavioral Emergencies

T23. Respiratory DistressT24. Seizures

T25. Shock

T26. Suspected Spinal Injuries

T27. Syncope T28. 12 Lead EKG and Thrombolysis

B. Medication Protocols

M1. Activated Charcoal (Actidose®) M2. Adenosine (Adenocard®)

M3. Albuterol (Proventil®)

M4. Amiodarone (Cordarone®) M5. Aspirin (acetylsalycilic acid or ASA)

M6. Atropine



01/02

Columbia County Emergency Medical Services ProtocolsTable of Contents

B. Medication Protocols (cont)M7. Benadryl® (diphenhydramine)

M8. CalciumM9. DextroseM10. Diltiazem (Cardiazem®)

M11. Dopamine

M13. Epinephrine

M14. GlucagonM15. Hanks Solution®

M16. Ipatropium (Atrovent® - Combivent®)

M17. IpecacM18. Ketorolac (Toradol®)

M19. Lasix® (furosemide)

M20. Lidocaine (xylocaine)M21. Magnesium

M22. Midazolam (Versed®)

M23. Morphine

M24. Naloxone (Narcan®) M25. Nitroglycerine (Nitrostat®, Nitrolingual® pump spray)

M26. Nubain

M27. OxygenM28. Properacaine (Alcaine®)

M29. Retavase

M30. Sodium Bicarbonate

M31. Succinylcholine (Anectine®)M32. Thiamine

M33. Vecuronium (Norcuron®)

C. Procedural/Operational Protocols

P1. Airway Management

P2. Control/Monitoring of IV SolutionsP3. Crime Scene Response

P4. Death in the Field

P5. Do Not ResuscitateP6. Documentation of Care

P7. Intraosseous InfusionsP8. Ocular ExposuresP9. OLMC-Hospital Communications



01/02

4.

Columbia County Emergency Medical Services ProtocolsTable of Contents

C. Procedural/Operational Protocols (cont)

P10. On-Scene Medical Control

P11. Patient RefusalP12. Patient Restraint

P13. Patient Treatment Rights

P14. Radiologic EmergenciesP15. Scope of Practice

P16. Slow Down/Cancellation

P17. Staging EMS UnitsP18. Time at the Scene

P19. Tension Pneumothorax Decompression

P20. Transcutaneous Pacing P21. Trauma

P22. Transport of the Chronically Ill

MCI/MPS Protocol



01/02


Signature Page EMT Basic/Intermediate/Paramedic Protocols

We recognize these protocols to be the written detailed procedures for medicaland trauma emergencies to be performed by the EMT Basic/Intermediate/Paramedic, as

issued by the supervising physician commensurate with the scope of practice and level of

certification of the EMT. This statement is applicable to all EMTs providing care for thefollowing agencies/districts:

Scappoose Rural Fire Protection District

St Helens Rural Fire Protection DistrictRainier Rural Fire Protections District

Clatskanie Rural Fire Protection District

Mist/Birkenfeld Rural Fire Protection District

Vernonia Rural Fire Protection District

This statement is intended to be consistent with the Oregon Administrative Rules

as they pertain to EMT Basic/Intermediate/Paramedic scope of practice

________________________________ ______________________________

Michael Greisen Brian BurrightFire Chief Division Chief/EMS Coordinator

Scappoose Rural Fire Protection District St Helens Rural Fire Protection District

________________________________ ______________________________

Vince Donner Robert Keyser

Division Chief/EMS Coordinator Medical Officer Rainier Rural Fire Protections District Clatskanie Rural Fire Protection District

________________________________ ______________________________

Ann Berg Paul Epler Medical Officer Fire Chief

Mist/Birkenfeld Fire Protection District Vernonia Rural Fire Protection District

Louis J Perretta MD, FACEPPhysician Supervisor

Columbia County Emergency Medical Services



01/02


Introduction/OrientationThese protocols were written for all Columbia county EMS providers that are

comprised of the following fire districts:Scappoose Rural Fire Protection District

St Helens Rural Fire Protection District

Rainier Rural Fire Protections DistrictClatskanie Rural Fire Protection District

Mist Birkenfeld Rural Fire Protection District

Vernonia Rural Fire Protection District

The protocols are written for all EMT providers and specific medications,

procedures and treatments that are limited to the EMT Intermediate level or EMT

Paramedic level will be indicated by an asterisk . The system is as follows: No asterisk or one asterisk means that the procedure, medication, or treatment

can be provided by all EMTs

Two asterisks means that the procedure, medication, or treatment can be provided

by EMT Intermediates or EMT Paramedics onlyThree asterisks means that the procedure, medication, or treatment can be

provided by EMT Paramedics onlyThe protocols are arranged into 3 sections, Treatment, Medications, and

Procedural/Operational. The protocols are labeled and ordered according to the

following classification:

T, M or P (indicating Treatment, Medication, or Procedural/Operationalrespectively) followed by:

The Number of the Protocol. These protocols will be numbered in alphabetical

order and pages within a protocol will be labeled by a period followed by a number toindicate the page of the protocol. For example:

The fourth page of the Trauma protocol will be labeled: P21.4… since it is the fourth page of the 21st

Procedural/ Operational protocol



01/02

Treatment

Protocols



07/01 T1.1

♦ ♦ ♦ ♦

ABDOMINAL PAINHISTORY

♦ Pain

• Nature

• Duration

• Location and Radiation

• Severity

• Time of onset

• Quality

♦ Associated Symptoms

• Nausea

• Vomiting (bloody or coffee- ground)

• Diarrhea

• Constipation

• Melena (red or tarry feces)

• Urinary difficulties

• Menstrual history

• Fever

• Shortness of breath

• Chest pain

♦ Past History

• Surgery, Recent trauma

• Abnormal ingestion

• Medical Illnesses, medications• History of similar pain in the past

PHYSICAL FINDINGS♦ Vital signs

♦ Abdominal Exam

• Tenderness, guarding, rebound tenderness, rigidity, bowel sounds,

distention, pulsatile mass

• Emesis

• Lower extremity pulses

TREATMENTPlace patient in a position of comfort

Keep patient NPO

Give O2*

Initiate IV access, Balanced Salt Solution, large bore, SL, or as needed**



7/01 T1.2

TREATMENT (cont)

♦ If shock is present (BP<90) and there is a history of a traumatic event, enter the

patient into the trauma system

♦ If there is no history of trauma and shock is present. Proceed with the shock (hypovolemia) protocol

♦ Obtain vital signs frequently

SPECIFIC PRECAUTIONS

♦ Abdominal pain may be the first warning of catastrophic internal bleeding(ruptured aneurysm, ischemic/infarcted bowel, ectopic pregnancy, perforated

viscous, etc.). Since the bleeding is not apparent, you must think of volumedepletion and monitor patient closely to recognize shock

♦ In upper abdominal pain, consider myocardial ischemia as an etiology



1/02 T2.1

♦

AIRWAY

PURPOSE

The purpose of this protocol is to define for the EMT, procedures which should beused to assure a PROTECTED airway and adequate ventilation of a patient (see

AIRWAY MANAGEMENT protocol)♦

♦

♦ ♦ ♦ ♦

1.

2. 3. 4.

5.

6.

Use of the bag valve mask and oropharyngeal airway is not considered sufficient

to provide and maintain a protected airway, except for limited time periods prior

to intubation or during drug administration in the Altered Mental Status Protocol.

Patients who are unconscious and need positive pressure ventilation should beendotracheally intubated as soon as possible.

INDICATIONS

Respiratory insufficiency or impending respiratory failure

Altered mental status with airway compromise (high risk of aspiration) e.g.

overdose, poisoning

Cardiac and/or Respiratory arrest

Situations requiring positive pressure ventilation

PROCEDURE

All unconscious patients who need positive pressure ventilation should beintubated unless they are immediately resuscitated or have a high probability of

rapidly regaining consciousness (i.e., drug overdose, hypoglycemia)

The intubation should take no longer than 5 minutes, with no more than 3attempts. Intubation should occur within 10 minutes of arrival at the scene.

The Sellick Maneuver should be used whenever the bag valve mask is used.

No individual intubation attempt should take longer than 30 seconds. However, if

the oximeter is being used, the alternative endpoint is an O2 saturation of 90 or less

Start by opening the airway with basic airway maneuvers and pre-oxygenate the

patient with 100% O2 via mask while maintaining cricoid pressure. This does notalways mean ventilating the patient since ideally the patient should be breathing

100% O2 on their own in this preparatory phase

If the patient is not in cardiac arrest or not completely relaxed for intubation, please see the Advanced Airway Management section of this protocol

7. 8. 9.

Intubate the patient and verify tube placement with a 5-point check and the end

tidal CO2 monitor ***Place an oral airway or bite block and secure the tube recording the tube depth

Recheck and redocument the ET tube placement after movement of the patient or a change in the vital signs



1/02 T2.2

ADVANCED AIRWAY MANAGEMENT (see AIRWAY MANAGEMENT protocol)

INDICATIONS

♦ • • • • •

1. 2. 3. 4.

Additional indications for ET tube placement are:

A clenched jawAn active gag reflex

Uncontrollable combative behavior

Head injured patients with a GCS of 8 or less

Clinical conditions requiring airway protection

PROCEDURE

Maintain opening the airway and pre-oxygenate with 100% O2 while maintainingcricoid pressure

Assemble your airway equipment and place the patient on a cardiac monitor and

pulse oximeter Start IV (if not already established)

Start the premedication phase and give:

• Lidocaine 1-1.5 mg/kg IV

• Midazolam 0.1mg/kg IV not to exceed an initial dose of 5mg

5. 6.

7. 8.

9.

Continue cricoid pressureAdminister the paralytic agent:

• Succinylcholine 1.5 mg/kg

• If the patient doe not relax completely within 1 minute, repeat the samedose

About 1 minute after the Succinylcholine is administered, paralysis should occur

and the patient should be intubated at this pointIf the patient desaturates during the intubation attempt (SaO2 less than 90%),

abort the attempt and ventilate with a BVM and 100% oxygen until the SaO 2

moves up into the mid to high 90% rangeIf all intubation attempts fail, ventilate with BVM and 100% O2 and insert a

Combi-Tube or perform a Cricothyroidotomy (see AIRWAY MANAGEMENT

PROTOCOL)10.

11.

12.

Intubate the patient and verify tube placement with a 5-point check and the end

tidal CO2 monitor. Place an oral airway or bite block and secure the tube,

recording the tube depth (consider c-collar for further stability)

Recheck and redocument the ET tube placement after movement of the patient or a change in the vital signs

If paralysis is needed during transport, give Vecuronium 0.1 mg/kg IV.

[ONLY TO BE DONE BY PARAMEDICS WHO HAVE DONE AN OR

ROTATION AND HAVE PASSED THE ADVANCED AIRWAY EXAM]



1/02 T2.3

♦ ♦ ♦

♦ ♦ ♦

PEDIATRIC CONSIDERATIONSAdminister Atropine 0.02 mg/kg IV for children under 2 years (minimum dose is

0.1 mg not to exceed the adult dose)

Administer Succinylcholine 2 mg/kg IV for children under 6 years. May repeatonce if there is inadequate relaxation

A formula that is helpful to remembering tube sizes for different age childrenyounger than 8 years:

Tracheal tube size (mm) = (age in years/4) + 4

Generally use an un-cuffed endotracheal tube until 8 years

Try to utilize a length based resuscitation tape (e.g. Broselow tape) whenavailable

DO NOT perform a Cricothyroidotomy in children under 8 years; consider a Needle Cricothyroidotomy procedure (see AIRWAY MANAGEMENT

protocol) if unable to intubate or ventilate



1/02 T3.1

ALTERED MENTAL STATUS/COMA HISTORY

♦ Onset (acute vs. gradual)

♦ History of trauma

♦ Description of the scene (pills found, notes present, syringes, unusual odors at the

scene e.g. Ammonia, Natural gas))♦ Recent emotional crisis (suicidal or homicidal ideations, abrupt or bizarre

behavioral changes)

♦ Drug or alcohol ingestion

♦ Environmental exposures (toxic, exertion or heat exposure)

♦ Psychiatric Disorders

♦ Medical history (diabetes, seizures, etc.)

♦ Medications and Allergies

PHYSICAL FINDINGS

♦ Vital Signs (including temperature)

♦ Level of Consciousness (GCS)

♦ Pupil size, reactivity, symmetry

♦ Breath odor (alcohol, ketones)

♦ Nuchal rigidity (suspect C spine injury with head trauma)

♦ Abnormal breathing patterns

♦ Presence of needle tracks

♦ Evidence of trauma

♦ Medical alert tags

TREATMENT

♦ Airway, Breathing, Circulation*

♦ Start oxygen and follow AIRWAY protocol as needed*

♦ ♦ ♦

Initiate IV access**

Attempt to establish rapport

Restrain if necessary (follow PATIENT RESTRAINT protocol

♦ Determine whole blood glucose level using glucometer. If blood glucose is less

than or equal to 80 mg%:

• Give D50W, orally if the patient is able to;* 50 ml of D50W in large veinif patient is unable to take sugar orally**

• Consider Thiamine 100 mg slow IV push if there is any question of

alcoholism or malnutrition*** • Give Glucagon 1.0 mg IM or SQ when unable to give glucose IV and

blood glucose level less than or equal to 80 mg%***



1/02 T3.2

TREATMENT (cont)

♦ Consider Narcan® for suspected opiate intoxication. Titrate in 0.4-2.0 mg

increments every 3-5 minutes to reverse coma up to 8 mg total (see

POISONING/OVERDOSE protocol** The end point of administration is to

have adequate respiratory effort.

♦ For patients who are suicidal:• Do not leave patient alone

• Remove or have someone remove dangerous objects (i.e., knives, guns, pills, etc.)

• Inquire specifically regarding depression, helpless or hopeless feelings and

thoughts of suicide.

• Question specifically about hallucinations or delusions

• Transport in calm, quiet manner; obtain, monitor vitals


♦ Psychiatric disorders almost never cause Organic Brain Syndrome. If patient isdisoriented, think of medical causes

♦ Do not attribute the patient’s behavior to alcohol without checking for other

etiologies

♦ In cases of dangerous environment, safety of personnel on scene is paramount

♦ Be particularly attentive to airway. Aspiration of secretions, vomiting andinadequate tidal volume are common. Transport in left lateral decubitus position

when possible

♦ When dealing with patients with an altered mental state, you should also consider

these other medical conditions:

• Seizures (see SEIZURE protocol)

• Stroke (CVA)

• Sepsis



7/01 T4.1

AMPUTATIONHISTORY

♦ Time of amputation

♦ Mechanism of amputation, care of severed part

♦ History of bleeding problems (also family history)

♦ Amputation at or proximal to wrist or ankle requires Trauma System entry♦ Medical history, medications, and allergies

PHYSICAL FINDINGS

♦ Vital signs

♦ Excessive bleeding, blood loss at scene, arterial bleeding

♦ Note structural attachments in partial amputations

♦ Distal neurovascular exam in partial amputations

TREATMENT

♦ Maintain appropriate body substance isolation precautions

♦ For Complete Amputations:

• Cover the stump (proximal part) with sterile dressing, moistened with aBalanced Salt Solution and cover with dry dressing (Chux, Kerlix, etc.).

• Control bleeding by direct pressure and elevation

• Retrieve the severed part and wrap it in a dry sterile dressing then place it

in a plastic bag.

• Place sealed bag into a ice cold water immersion. The ice cubes may be in

the water, however, no direct contact between injured tissue/part(s) and ice

should occur

♦ For Partial Amputations:

• Cover with sterile dressing, moistened with Balanced Salt Solution, cover with dry dressing, splint in anatomical position, avoid torsion and

angulation. Reduce any torsion into anatomical position

♦ If the patient has severe, incapacitating pain, consider Morphine Sulfate (see

MORPHINE protocol).*** Do not use if a patient has undiagnosed abdominal pain or head injury.

♦ If bleeding is excessive, consider starting an IV en route with a Balanced Salt

Solution.**

♦ If unable to control bleeding with direct pressure and elevation, use a pressure point (rarely effective). If you continue to have significant bleeding, use a BP

cuff as a tourniquet and inflate to 50 mm Hg above systolic BP. Do not apply for more than 6 minutes allowing the cuff to relax for a minute or two then re-inflate

if bleeding is still not controlled

♦ Oxygen (see AIRWAY Protocol)



7/01 T4.2


♦ Do not use dry ice.

♦ Time is of the greatest importance to assure viability. If the extrication or transport time will be prolonged, consider sending the amputated part ahead to be

surgically prepared for re-implantation.



1/02 T5.1

ANAPHYLAXIS AND ALLERGIC REACTIONS

HISTORY

• • • • • • • • • • • • • •

•

•

•

•

♦ ♦

♦ ♦

Symptoms

ItchingDifficulty breathing

Chest tightness

Nausea, vomiting

Abdominal cramps

Subjective airway impairment or swelling

Numbness and tingling

Rash, swelling

Syncope

Weakness

AnxietyChoking sensation

Cough.

Present history Exposure (orally, IM or IV) during past few hours to allergenic substances such as

drugs (antibiotics, allergy shots), insect bites, toxic substances, unusual foods(nuts, fish and fruit most common)

Also, with isolated angioedema, exposure to any of the group of medications

known as angiotensin converting enzyme inhibitors may be secondary to themedication and potentially life-threatening:

Benazepril (Lotensin®

), Captopril (Capoten®

), Enalapril (Vasotec®),

Fosinopril (Monopril®

), Lisinopril (Zestril®

), Losartan (Cozaar ®

), Moexipril(Univase

®), Quinapril (Accupril

®), Ramipril (Altace

TM)

As well as the combination agents:

Capozide®

, Hyzaar ®

, Lotensin®

HCT, Lotrel®

, Prinzide®, Vaseretic

®,

Zestoretic®

Past history

Known allergies, prior allergic reactions, current medications

PHYSICAL FINDINGS

Vital signs.

HEENT

• Periorbital edema, lip edema, tongue edema, sublingual/lingual edema,edema of posterior oropharynx, uvula, or soft palate.

Respiratory

• Stridor, wheezing, hoarseness, cough.

Skin

• Rash, urticaria, edema.



1/02 T5.2

PHYSICAL FINDINGS (CONT)

• ♦

♦ ♦ ♦ ♦

Neurological

Level of consciousness.

TREATMENT

Protect airwayFurther treatment may not be indicated if only hives and itching are present. Consider diphenhydramine 25 to 50 mg IM or IV slow push for adults

O2, high flow, by non-rebreather mask; Suction as needed

Advanced airway techniques (see AIRWAY protocol) may be required if unable to

intubate or ventilate by bag mask after Epinephrine has been administered.

Cricothyrotomy may be needed for larnygospasm (see AIRWAY MANAGEMENT

protocol

♦ ♦ Remove injection mechanism if still present

IV: Balanced Salt Solution, large bore; Treat for shock syndrome if BP less than 90mm Hg (see SHOCK protocol)

♦ ♦ Patient should be supine with legs elevated unless respiratory distress predominates

Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)

♦ IF THE PATIENT HAS SIGNS OF ANAPHYLAXIS

• With BP greater than 90 mm Hg systolic, administer Epinephrine 0.3 ml 1:1,000

SQ1

• With BP less than 90 mm Hg systolic, administer Epinephrine 3.0 ml 1:10,000

slow IV or 6.0ml ET in adult***

• If no improvement in the blood pressure noted after the Epinephrine and a 500ccfluid challenge, repeat Epinephrine 3.0 cc 1:10,000 IV in 10 minutes. Maximum

dose is 1.0 mg (10 cc of 1:10,000)***

• Use Albuterol®

(see RESPIRATORY DISTRESS protocol) if wheezing is

present**

SPECIFIC PRECAUTIONS:

♦ ♦ ♦ ♦ ♦

Epinephrine should only be given if there are signs or symptoms of cardiovascular collapse or significant respiratory distress

It is important to differentiate anaphylaxis from hyperventilation, since epinephrinewill aggravate anxiety in patients who are hyperventilating

Epinephrine increases cardiac work and may precipitate angina or MI in susceptibleindividuals

Common side effects include anxiety, tremor, vomiting, palpitations, tachycardia and

headache, particularly with IV administration.Two forms of Epinephrine are available; 1) 1:1,000 dilution appropriate for SQ

administration 2) 1:10,000 dilution for IV or ET administration***. BE SURE TOGIVE THE PROPER DILUTION TO YOUR PATIENT



1/02 T5.3

PEDIATRIC CONSIDERATIONS♦ ♦ ♦

Epinephrine can induce vomiting in children

For itching give diphenhydramine 1.0 mg/kg IM or slow IV push

If wheezing is present treat with inhaled albuterol (see RESPIRATORY DISTRESS

protocol)** ♦

• • •

For severe respiratory distress:

Epinephrine 1:1000, 0.01 mg/kg (0.01 cc/kg) SQ*1

maximum dose is 0.3 mg (0.3cc)**

Epinephrine, 1:10,000, 0.01 mg/kg (0.1 cc/kg) IV or IO; maximum dose is 0.1 mg

(1.0 cc)**

Epinephrine, 1: 1000, 0.1 mg/kg in 1-2 cc NS by ET***

1EMT Basics need to file a copy of the PCR with the Board of Medical Examiners in

each instance



1/02 T6.1

BURNSHISTORY

♦ Time elapsed since burn

♦ Was patient in an enclosed space with steam or smoke? How long?

♦ Loss of consciousness

♦ Accompanying explosion, trauma, toxic fumes

♦ Respiratory complaints

♦ Prior cardiac or pulmonary disease

♦ Medications/Allergies

PHYSICAL FINDINGS

♦ Vital signs.

♦ Evidence of respiratory burns:

• Soot or erythema of mouth

• Singed nasal hairs

• Cough, hoarseness

• Respiratory distress

• Carbonaceous sputum

♦ Extent of burns:

• Description of areas involved

• Use the “Rule of Nines” to estimate % total body surface area (TBSA)

♦ Depth of burns:

• Superficial - erythema only

• Significant - blistered, denuded, or charred areas.

• Associated trauma.♦ Level of consciousness - orientation to name, place, and date. Short-term memory.

TREATMENT

♦ Remove clothing which is smoldering or which is non-adherent to the patient.

♦ Remove rings, bracelets and other constricting items.

♦ O2, high flow, by non-rebreathing mask (see AIRWAY protocol)*

♦ If burn is moderate-to-severe, cool the area with saline saturated dressings; cover the burns wdry, clean dressings.

♦ Consider Morphine for pain control (see MORPHINE protocol) in combination with midazo per protocol (see MIDAZAOLAM protocol)***

♦ Leave unbroken blisters intact

♦ Types of Burns:



1/02 T6.2

TREATMENT (cont)

• Thermal Burns If more than about 20% significant burn or if respiratory distress or hypotensio

exist:

• Monitor airway and start oxygen (see AIRWAY protocol)

• Start IV: Balanced Salt Solution, large bore, at 10 cc/kg for adults and

cc/kg for children(see SHOCK protocol)**

• Monitor cardiac rhythm**

• Electrical Burns

These burns usually have an exit and entry burn and the patient has a greater riof cardiac dysrhythmias and internal organ damage; their treatment includes:

• •

Apply sterile dressings to entry and exit burns

Monitor cardiac rhythm and treat dysrhythmias (see CARDIACDYSRHYTMHIAS protocol)**

• Start IV: Balanced Salt Solution, large bore, TKO or as % burn (seeSHOCK protocol)**

• Chemical Burns With these burns there may be a chance of contamination to the rescuers and a

HAZMAT response should be considered if this is the case; remember to prote

yourself from contamination first; their treatment includes:

• • •

♦

Flush contaminated skin and eyes with copious amounts of water

If the chemical is dry, brush it off the skin and flush with water

During the washing process, wear rubber or latex gloves and control th

wash to avoid splashing

BURN CENTER CRITERIA The following patients should be transported to the Burn center directly; the exception would

for Clatskanie and Rainier, where the patient should be transported to the closest facility for stabilization:

• Total significant (second degree) burn which is 20% or more of body surface in an adu

10% in a child under 10 years or an adult over 50 years

• Full thickness (third degree) burn which is greater than 5% TBSA

• Electrical burns• Burns with Inhalation injuries

• Significant Chemical burns

• Burns to the face, hands, feet, genitalia, and circumferential

• Significant burns in patients with chronic medical problems

• Trauma system patients with burns meeting the criteria above



1/02 T6.3

♦ ♦ ♦ ♦

♦ ♦


Suspect airway burns in any facial burns or burns received in an enclosed space

Consider Carbon Monoxide and Cyanide poisoning in all closed space burns. If suspected, gO2, high flow, through non- rebreather mask

Consider Morphine Sulfate for pain***

Deaths in the first 24 hours after burn injury are due to either airway burns or fluid loss.

In a few instances, caution should be used with water flushing of chemical contaminants. In case of lime (CaCO3), brush off excess, and then flush with copious amounts of water. Do n

use water for phosphorus contamination

PEDIATRIC CONSIDERATIONSConsider child abuse in pediatric burns

Morphine dose for children under 30 kg (66 pounds) is 0.1 mg/kg IV for the first dose and titr

once with a repeated dose if needed***



1/02 T6.4

Rule of Nines

RULE OF NINES♦ In adults, most areas of the body can be divided into portions of 9% or multiples of 9. This is

useful technique for estimating the total body surface area (TBSA) of a burn. In a small child

the head takes more surface area and the rule of nines is modified. See diagram above.



7/01 T7.1

CARDIAC ARREST

HISTORY

♦ Preceding symptoms

♦ Onset

♦ Downtime (no CPR)

♦ Duration of CPR

♦ Witnessed arrest?

♦ Past history: cardiac disease, hypertension

♦ Medications/allergies

♦ Evidence of drug ingestion

♦ Evidence of penetrating or blunt injury

♦ Appropriateness of resuscitative efforts; DNR orders or advanced directives (see

DEATH IN THE FIELD protocol

PHYSICAL FINDINGS ♦ Determine presence of arrest

• Unresponsive

• Absent or terminal respirations

• Absent pulses over major arteries

• Pupil size

♦ Document:

• Dependent lividity

• Decomposition

• Rigor Mortis

TREATMENT ♦ Initiate CPR: Follow American Heart Association Basic Life Support Standards*

♦ Initiate airway management and intubate (either Combitube** or Endotracheal***)

♦ Initiate IV access**

♦ Check cardiac rhythm and follow appropriate arrest algorithm**

♦ Do not diagnose Cardiac Arrest solely on the basis of a monitor reading. Consider also the absence of respirations and pulse.



7/01 T7.2

TREATMENT (cont)

♦ These following algorithms were developed to treat a broad range of patients with

Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia (VT), Ventricular Asystole, and Pulseless Electrical Activity (PEA). Some patients may require care

not specified herein. These algorithms should not be construed as prohibiting such

flexibility. Flow of algorithms presumes that the dysrhythmia is continuing. If therhythm changes, move to the appropriate algorithm

CARDIAC ARREST ALGORITHM

FIRST RESPONDERS-EMT Basics

♦ For patients in cardiac arrest secondary to ventricular fibrillation or pulselessventricular tachycardia. In all cardiac arrest cases, ALS backup must be requested, if

not already responding.

Start ABC’s and set up/attach AED

Press “Analyze” and Defibrillate if recommendedIf no pulse, repeat the process

Press “Analyze” and Defibrillate if recommended

If no pulse, repeat the processPress “Analyze” and Defibrillate if recommended

Do CPR for one minute, if still no pulse



Press “Analyze” and Defibrillate if recommended

Do CPR for one minute, and if no pulse continue with 3 stacked shocks after pressing“Analyze” the defibrillate each time



7/01 T7.3

EMT INTERMEDIATES** ♦ For patients in cardiac arrest secondary to ventricular fibrillation or pulseless

ventricular tachycardia. In all cardiac arrest cases, ALS backup must be requested, if

not already responding.

ABC’s

Perform CPR until the defibrillator is attachedDefibrillate 200 Joules if needed

Defibrillate 300 Joules if neededDefibrillate 360 Joules if needed

Check pulse and rhythm

Ventricular Fibrillation Pulse Asystole

Ventricular Tachycardia PEA

(pulseless)Place Combi-tube High flow O2 Place Combi-tube

Initiate IV Initiate IV Initiate IV

1:10000 Epinephrine Lidocaine 1:10000 Epinephrine

1.0 mg IV; repeat every 1.5 mg/kg IV 1.0 mg IV; repeat every

3-5 minutes while 3-5 minutes while

patient is in arrest TRANSPORT patient is in arrest

Defibrillate 360 J Check Pulse & rhythm

within 30-60 seconds

Asystole PEA

Lidocaine 1.5 mg/kg if

Persistent VF/VT Atropine 1mg IV, repeat 500 cc Fluid

q 3-5 minutes up to challenge

0.04 mg/kg maximum If heart rate is

less than 60 BPMAtropine 1mg

IV q 3-5 min



7/01 T7.4

CARDIAC ARREST ALGORITHM

EMT PARAMEDIC*** ♦ These following algorithms were developed to treat a broad range of patients with

Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia (VT), Ventricular Asystole, and Pulseless Electrical Activity (PEA). Some patients may require care

not specified herein. These algorithms should not be construed as prohibiting such

flexibility. Flow of algorithms presumes that the dysrhythmia is continuing. If therhythm changes, move to the appropriate algorithm. Continue CPR between drug

doses and defibrillate within 30-60 seconds of the drug dose.

Ventricular Fibrillation and

Pulseless Ventricular Tachycardia

ABC’s

CPR until a defibrillator is availableCheck monitor for rhythm

Defibrillate 200 JDefibrillate 300 J

Defibrillate 360 JCPR

Check pulse and rhythm

IntubateInitiate IV access

1:10,000 Epinephrine 1.0 mg IV every 3-5 minutes

Defibrillate 360 JMagnesium 2 gms IV

Defibrillate 360 JAmiodarone 300 mg IV

3or Lidocaine 1.5 mg/kg IV (3 mg/kg ET)

1

Defibrillate 360 J

Amiodarone 150 mg IV3 or Lidocaine 1.5 mg/kg IV (3 mg/kg ET)1 Defibrillate 360 J

Consider Sodium Bicarbonate 1 mEq/kg IV2

Defibrillate 360J

1If successful in converting to a rhythm with a pulse with lidocaine, start a drip at 2 mg/min.

Be cautious with lidocaine if: a) systolic BP<90, b) pulse <50, c) periods of sinus arrest, d)the presence of AV block 2

Bicarbonate should be used early in cardiac arrest of known cyclic antidepressant overdoseor renal failure patients with hyperkalemia. If used, half the dose may be repeated every 10

minutes

3Amiodarone has a tendency to foam if it is withdrawn too rapidly from the vial into thesyringe. If successful conversion, start a drip at 1 mg/min.



7/01 T7.5CARDIAC ARREST ALGORITHM

EMT PARAMEDIC

Asystole

ABC’sCPR

Intubate

Confirm asystole in 2 leads

Initiate IV access1:10,000 Epinephrine 1.0 mg IV every 3-5 minutes

Atropine 1 mg IV every 3-5 minutes up to 0.04 mg/kg maximum

Consider and treat the possible causes:

Hypoxia-oxygenate and ventilate

Hyperkalemia (renal failure)- give sodium bicarbonate 1mEq/kg IV andcalcium chloride 10mg/kg IV

Acidosis- give sodium bicarbonate 1mEq/kg IV

Cyclic antidepressant OD- give sodium bicarbonate 1mEq/kg IV

Pulseless Electrical Activity

ABC’sCPR

IntubateInitiate IV access

1:10,000 Epinephrine 1.0 mg IV every 3-5 minutes

If the heart rate is less than 60/min give Atropine 1 mg IVevery 3-5 minutes up to 0.04 mg/kg maximum

Consider and treat the possible causes:Hypoxia-oxygenate and ventilate

Hyperkalemia (renal failure)- give sodium bicarbonate 1mEq/kg IV andcalcium chloride 10mg/kg IV

Acidosis- give sodium bicarbonate 1mEq/kg IV

Cyclic antidepressant OD- give bicarbonate 1mEq/kg IV

Tension pneumothorax- needle decompression

Cardiac tamponade-immediate transport

Massive pulmonary embolism- immediate transport

SPECIAL CONSIDERATIONS

♦ Intubation is preferable and should be performed as soon as possible. ***

♦ Endotracheal Epinephrine, Atropine, and Lidocaine may be used. Double the

recommended dose when given endotracheally.***



7/01 T7.6

PPEEDDIIAATTR R IICC CCOONNSSIIDDEER R AATTIIOONNSS ♦ Cardiac arrest in children is often secondary to respiratory failure. Aggressive airway support

with oxygenation and ventilation can lead to spontaneous return of the pulse and cardiac

rhythm

♦ In all the arrest algorithms, High Dose Epinephrine (0.1 mg/kg) is given after an initial

standard dose in children under the age of 18. ***

Quick Reference to Pediatric DrugsNEONATES

DRUG INDICATION DOSE

Atropine** Bradycardia, asystole 0.1 mg

Dextrose 25%** Hypoglycemia 0.5 gms/kg

(dilute D50 by ½ in NS) 2cc/kg

Epinephrine** Bradycardia, Cardiac 0.01 mg/kg

1:10,000 Arrest Don’t use

high dose

Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg

(dilute by ½ in NS)

INFANTS AND CHILDREN

DRUG INDICATION DOSE

Adenosine*** SVT 0.05 mg/kg

Atropine** Bradycardia, asystole 0.02 mg/kg

Min dose 0.1 mg

Don’t exceed adult dose

Dextrose 25%** Hypoglycemia 0.5 gm/kg(diluteD50 by ½ in NS) (2cc/kg)

Dopamine*** Low cardiac output 5-20 mcg/kg/min

Epinephrine** V fib, low cardiac output 0.01 mg/kg

Cardiac arrest then 0.1 mg/kg

Lidocaine** V tach, V fib 1.5 mg/kg bolus10-50 mcg/kg drip

Naloxone** Respiratory depression 0.1 mg/kg

20

to narcotics

Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg/dose

(dilute by ½ in NS) Cyclic antidepressant OD

Hyperkalemia

Midazolam (Versed)*** Sedation for Pacing, IV or IO 0.1 mg/kg

Cardioversion, Seizures to max of 2.5 mg

IM: 0.2 mg/kg to max 5mg



1/02 T8.1

CARDIAC CHEST PAINHISTORY

♦ Pain (may be heaviness, squeezing, indigestion or discomfort)

• Onset

• Duration

• Location and Radiation

• Aggravating and Alleviating Factors

♦ Associated Symptoms

• Nausea and/or Vomiting

• Diaphoresis

• Shortness of Breath

• Neck, jaw, shoulder or arm pain

• Generalized Weakness (in the elderly)♦ Past History

• Prior Myocardial Infarction

• Prior history of Angina

• History of PTCA or CABG

• Hypertension

• High Cholesterol

• Diabetes

• Cocaine/Methamphetamine use

• Smoking

• Family History of Coronary Artery Disease

PHYSICAL FINDINGS

♦ General Appearance

♦ Vital Signs

• Upon arrival and after every intervention, as well as before any interventionwhich may alter the blood pressure.

♦ Cardiac

• Neck vein distension, irregular pulse

♦ Respiratory

• Rales, wheezing, rhonchi, Chest wall tenderness

♦ Skin

• Diaphoresis, cyanosis, peripheral edema

TREATMENT

♦ Place the patient in a position of comfort

♦ Administer O2: 6 liters per minute via nasal cannula or to maintain oxygen saturationabove 95% (see AIRWAY PROTOCOL)*



1/02 T8.2

♦ Place cardiac monitor and pulse oximeter (see CARDIAC DYSRHYTHMIA protocol)**

♦ Initiate IV access, single large bore IV with Lactated Ringers in a microdrip at TKO**

♦ Administer nitroglycerin spray, one dose SL Q 5 minutes until pain relieved, you give a

total of 3 doses, or systolic BP < 90 mmHg***

♦ Be cautious with administering nitroglycerin to patients who have taken Viagra < 24hours prior to encounter as these patients are more likely to have hypotensive episodes

♦ Administer 81 mg baby ASA X 4, chew and swallow*

♦ You may administer Morphine Sulfate for relief of continued pain, as long as systolic blood pressure > 90 mmHg.***

♦ Complete the Thrombolytic Checklist*** and transport

♦ For St Helens Fire District (see 12 LEAD EKG AND THROMBOLYSIS

PROTOCOL)***



1/02 T9.1

CARDIAC DYSRHYTHMIASHISTORY

♦ Chief Complaint: sudden or gradual

♦ Related symptoms:

• Dizziness

• Weakness

• Chest pain (angina)

• Syncope

• Shortness of breath

• Palpitations

♦ Past medical/cardiac history


PHYSICAL FINDINGS

♦ Vital signs

♦ Level of consciousness

♦ Distended neck veins

♦ Peripheral edema

♦ Presence of rales or pulmonary congestion

♦ Irregular heart sounds; thready, irregular pulse

TREATMENT

♦ Start high flow O2 and apply the pulse oximeter (see AIRWAY protocol)*

♦ Monitor the cardiac rhythm**


♦ Dysrhythmias may not require treatment in the field if the patient is asymptomatic♦ If the patient has a BRADYDYSRHYTHMIA:

1.

2.

Determine if the patient is SYMPTOMATIC Hypotension (heart rate <60/min)

Shortness of Breath (pulmonary edema) (heart rate <60/min) Ventricular Ectopy (heart rate <60/min) Chest Discomfort (heart rate <40/min)

The patient is ASYMPTOMATIC if:

There is NO hypotension, shortness of breath, ventricular ectopy, and chest

discomfort and the patients systolic blood pressure is greater than 90 mmHg.



1/02 T9.2

TREATMENT (cont) For SYMPTOMATIC BRADYDYSRHYTHMIAS:

3. Apply the transcutaneous pacemaker and concurrently establish an IV if not already established (see TRANSCUTANEOUS PACING protocol). Do not delay pacing in

symptomatic patient while vascular access is being established.***4. 5. 6.

If no IV is established, begin pacing***If IV is established, administer 0.5 mg** mg or 1.0mg ***of Atropine IV. If there is

response to the Atropine, begin pacing*** If mechanical capture is achieved (see TRANSCUTANEOUS PACING protocol)

consider administering midazolam (Versed®

) 2.5 mg-5 mg IVP*** and transport. Yo

may repeat the dose of midazolam if the patient is still uncomfortable.

7. IF mechanical capture is not achieved, repeat the Atropine 1.0 mg IV**, repeating eve5 minutes, up to a maximum of 3.0 mg, as needed to maintain heart rate above 60/minand systolic BP >90 mmHg.***

♦ For patients with SUPRAVENTRICULAR TACHYCARDIA:• This includes Atrial fibrillation, Atrial flutter, and Paroxysmal Supraventricular

Tachycardia (PSVT) or any narrow complex heart rate greater than 150/min. These c be difficult to differentiate.

• If the heart rate is above 150/min, regardless of the cause and in the setting of a suspec

ischemic cardiac event, treatment of the tachycardia early in the course may preventimpending cardiovascular collapse

• If the patient is perfusing well (no chest pain, BP > 90 mmHG, no shortness of breath)

Administer O2 (see AIRWAY protocol)* Initiate IV access**

Cardiac monitoring**

Transport



1/02 T9.3

TREATMENT (cont)

♦ If the patient is unstable (chest pain, pulmonary edema, hypotension, altered mental statustreat according to the following:

_______UNCONSCIOUS***_________________________CONSCIOUS***_____ Synchronous Cardioversion Consider sedation with

100 Joules midazolam 2.5mg-5 mg IV***

Synchronous Cardioversion Synchronous Cardioversion200 Joules 100 Joules

Synchronous Cardioversion Synchronous Cardioversion300 Joules 200 Joules

Synchronous Cardioversion Synchronous Cardioversion

360 Joules 300 Joules

Synchronous Cardioversion

360 Joules

♦ If the patient is stable (no chest pain, no respiratory distress, blood pressure > 90mmHG)treat according to the following:

_______CONSCIOUS***_____________________________UNCONSCIOUS**_

Consider early transport Consider Altered Mental

Consider Valsalva Status/Coma protocol

Adenosine 6 mg IVP*** Adenosine 12 mg IVP***

Adenosine 12 mg IVP***

Diltiazem 0.25 mg/kg IV*** over 2 minutes



1/02 T9.6

PPEEDDIIAATTR R IICC CCOONNSSIIDDEER R AATTIIOONNSS ((ccoonntt))

♦ Wide Complex tachycardia-QRS>0.08 sec

• Ventricular Tachycardia

If stable treat as adults adjusting the dose of lidocaine for the child’s weight

If unstable, cardioversion starting with 1 Joule/kg followed by 2 Joules/kg andJoules/kg***

♦ Use pediatric paddles for children less than 10 kg

♦ Place paddles on chest in sternal apical position

If pediatric paddles are not available, use adult paddles placed anterior-posterior on the chest wallwith firm contact



7/01 T10.1

CHILDBIRTHHISTORY

♦ Last menstrual period or due date

♦ Bleeding (recent, within 1 week)

♦ Single or Multiple pregnancy

♦ Past medical history and past OB-GYN history (G?/P?)

♦ Hypertension

♦ Protein in the urine

♦ Edema

♦ Seizures

♦ Ruptured membranes (clear or meconium stained)

♦ Abdominal Pain/Contractions (timing and duration)


PHYSICAL FINDINGS

♦ Vital signs including fetal heart rate if possible♦ Abdominal exam

♦ Presence of vaginal bleeding

♦ Swelling in the face or extremities

♦ If the possibility of delivery exists, observe the perineum for blood, fluid, crowning, or anabnormal presentation (foot, arm, cord or breech)

TREATMENT

♦ If not pushing or bleeding, transport, left lateral decubitus

position.

♦ If bleeding is moderate to heavy:• O2, high flow*

• Start IV, Balanced Salt Solution, large bore, TKO, or as indicated if shock

syndrome is present. Start IV enroute unless shock syndrome present**

♦ Transport immediately: Previous cesarean section, multiple births, abnormal presenting parts, excessive bleeding, premature birth.

♦ If question of imminent delivery, observe briefly for frequency and quality of

contractions, then transport as indicated.



7/01 T10.3

SPECIAL PRECAUTIONS

♦ Placental Abruption can occur in the third trimester of pregnancy when the placenta

prematurely separates from the uterine wall causing intrauterine bleeding. Shock candevelop without significant vaginal bleeding

♦ Consider an ectopic pregnancy in any woman of child bearing age (15-55) with

abdominal pain or vaginal bleeding♦ Do not pull on the umbilical cord

♦ Bundle and keep infant near mother. Keep infant’s head covered.

♦ Remain cool and calm. The laboring mother may need your reassurance that all is well

until hospital arrival.

♦ Avoid performing digital exams except in cases of breech presentation delivery of cord prolapse

APGAR SCORE

SIGN 0 1 2

HEART RATE Absent Less than 100 Greater than 100

RESP. EFFORT Absent Slow, Irregular Good, CryingMUSCLE TONE Limp Some ext. flexion Active Motion

REFLEX No Response Grimace Cough or Sneeze

COLOR Blue, Pale Body Pink Completely Pink



7/01 T11.1

DENTAL AVULSIONSHISTORY

♦ Recent trauma to the face


♦ Other injuries?

PHYSICAL FINDINGS

♦ HEENT exam

♦ Complete Oropharyngeal exam

♦ Neck exam

♦ Vital signs

TREATMENT

♦ To aid in the successful re-implantation of avulsed adult teeth when they can be placed insolution within 1 hour of the time when they are avulsed. This increases probability of successful re-implantation by following this procedure:

• Open “Save-A-Tooth” container

• Peel off seal from container and basket

• Drop in tooth (teeth)

• Close lid tightly

• Label with patient’s name

• Transport in upright position

♦ The following are precautions to using the “Save-A-Tooth” container:

• Not to be used for teeth that has been broken off. The root needs to be intact.

• Not for use with baby teeth

• Do not place more than one person’s teeth in one container

• Do not attempt to rinse or clean teeth before placing them in solution

♦ If there are no other indications for transport, patient may seek out their own dentist for reimplantation. Avulsed teeth can be stored up to 24 hours in this solution.



1/02 T12.2

PHYSICAL FINDINGS (cont)

♦ For Hyperglycemia:

• Skin:

Warm, dry, flushed

• Respiratory:

Kussmaul, tachypnea, acetone or fruity breath odor • Neurological:

Drowsiness, stupor, coma

TREATMENT♦ Assess and support airway/breathing/circulation (see AIRWAY and/or SHOCK

protocols)

♦ Determine whole blood glucose level using glucometer *


♦ If whole blood glucose reading is less than or equal to 80 mg%:

• • • • • •

Administer D50 as an oral solution or equivalent if the patient is able to handle

an oral solution*Administer 50 ml of D50W IV if patient is comatose or unable to take oral sugar.

Repeated doses of D50W may be necessary**

Administer Glucagon 1.0 mg IM for hypoglycemia if unable to establish IV and

patient unable to take oral glucose***

Administer Thiamine 100 mg IV/IM if there is question of alcoholism or chronic

malnutrition***

If patient able to maintain airway and take orally, administer oral glucose

solution, fruit juice, or candy

♦ If whole blood glucose reading is greater than or equal to 300mg%:

Administer 100% O2 via NRBM or BVM (see AIRWAY protocol)

• • Administer 500 cc fluid bolus NS**

Check blood glucose Q 30 minutes during transport

♦ Transport all patients who are hyperglycemic; transport all hypoglycemic patients in

whom the mental status does not return to normal or baseline for them.

SPECIFIC PRECAUTIONS ♦ The diabetic will frequently know what is needed. Listen to the patient.

♦ Hypoglycemia can present as seizures, coma, behavior problems, intoxication, confusion

or stroke-like picture with focal deficits (particularly in elderly patients)

♦ Patients who are elderly or who have been hypoglycemic for prolonged periods of time

may be slower to awaken.

♦ If the diabetic is unconscious, if it is difficult to decide between Diabetic Coma

(Hyperglycemia) and Insulin Shock (Hypoglycemia). If the precise nature of the

patient’s condition is in question, SUGAR SHOULD BE GIVEN TO ANY DIABETIC

WHO IS UNCONSCIOUS OR HAS AN ALTERED MENTAL STATUS.



7/01 T13.1

HEAD TRAUMA

HISTORY

♦ Mechanism of injury (blunt vs. penetrating)

♦ Time of injury♦ Loss of or change in consciousness

♦ Protective devices: Helmet, seat belts

♦ Nausea, vomiting

♦ Headache, neck pain

♦ Medical illnesses

♦ Current medications/allergies

♦ Drug or alcohol use

♦ Attempt to obtain pertinent medical history from patient or family member, if

available.

PHYSICAL FINDINGS

♦ Evaluate airway patency, breathing capability, and gross injuries to extremitiesand trunk

♦ Evaluate level of consciousness, check for restlessness, pupil size and response to

light

♦ Document with Glasgow Coma Scale, orientation to person, place, time and purpose

♦ External evidence of head trauma, (e.g., blood/fluid from ears/nose, scalplacerations, deformities)

♦ Abnormal breath odor (especially ETOH), bleeding or CSF from nose and ears

TREATMENT

♦ Assure airway protection. Aggressive ventilatory support including high flow O2 and early use of ET tube is indicated. Endotracheally intubate patients with aGCS of 8 or less (see AIRWAY-ADVANCED AIRWAY protocol)***

♦ Maintain cervical spine alignment

♦ Use direct pressure to diminish or stop bleeding of scalp wounds. No direct pressure over skull fractures or brain tissue

♦ Start IV, Balanced Salt Solution, TKO. If shock syndrome is present proceed per

Shock Protocol**

♦ Continue to observe vital signs and changes in LOC.



7/01 T13.2


♦ Changes in the patient’s Glasgow Coma Score in relation to time intervals, is

most important for the treating physician.

♦ Always assume cervical spine injury in all patients with head trauma.♦ Shock syndrome findings do not occur in head injury in adults. Look elsewhere

for the cause of shock. However, head injury in infants may cause hemorrhagic

shock.

♦ Hypoventilation can cause cerebral edema.

♦ Mandatory transport for all patients with a head injury and altered level of

consciousness. If necessary, the patients may need chemical restraint (see

PATIENT RESTRAINT protocol)***.

♦ Avoid all medications which may alter mental status unless absolutely necessary,e.g. Midazolam

®in a seizing head trauma patient.***

♦ It is essential to realize that in a seriously head injured patient, the most effective

pre-hospital care that can be provided is:1. Aggressive airway management with adequate ventilation and

oxygenation

2. Avoidance of hypotension by aggressively resuscitating any BP less than100 or any signs of poor perfusion

An injured brain needs oxygenation and adequate cerebral perfusion to have any

chance of long-term recovery

PEDIATRIC CONSIDERATIONS♦ Children generally recover better than adults. However, children less than three

years of age have worse outcomes from severe head injuries than older children.

Secondary brain injury from hypoxemia and hypovolemia must be avoided

♦ Seizures occurring shortly after injury are more common in children. They are

usually self-limiting. Seizures will require investigation by CT scanning atappropriate facility

♦ The young child with an open fontanelle and mobile features is more tolerant of

an expanding intracranial mass. Other signs of expanding mass may be hiddenuntil rapid decompensation occurs

♦ Glasgow Coma Scale is useful but must be modified for the pediatric age group.The verbal response scores are as follows:

Score 5 social smile, fixes and followsScore 4 cries but consolable

Score 3 persistently irritableScore 2 breathless and agitated

Score l no response



7/01 T13.3

GLASGOW COMA SCALEScale Points

EYE OPENING: Spontaneous 4

To Speech 3

To Pain 2 None

BEST VERBAL RESPONSE: Oriented 5Confused Conversation 4

Inappropriate Words 3

Incomprehensible Sounds 2 None

BEST MOTOR RESPONSE: Obeys Commands 6

Localizes Pain 5Withdraws From Pain 4

Flexion To Pain 3Extension To Pain 2

None



1/02 T14.2

TREATMENT

Secure airway (see AIRWAY protocol); administer100% O2 via NRBM* ♦ Cooling techniques:♦

♦ ♦ ♦

♦ ♦

• Remove clothing, wet sheet if available

• Use the air conditioning in the ambulance

• Ensure adequate air flow over patient for evaporative loss; use a fan if possible

• A mist bottle is effective in exposed patient. A charged 1 ¾” line,

carefully used can rapidly cool a patient

Monitor vital signs*

Monitor cardiac rhythm**

Initiate IV access. Administer fluid bolus of 250-500 cc NS (20 cc/kg inchildren). Titrate additional fluids to maintain systolic blood pressure >100

mmHg** Check a glucose level. Administer 50 ml of D50W IV if < 80mg%***

If the patient is seizing, administer midazolam 2.5 to 5.0 mg IV for seizures or 5.0

mg IM if there is no IV access***


♦ Heat stroke, a true emergency, is characterized by altered level of consciousness.Heat stroke must be differentiated from heat exhaustion (although this may lead to

heat stroke) and heat cramps.

♦ Do not delay transport for cooling in the field.

PPEEDDIIAATTR R IICC CCOONNSSIIDDEER R AATTIIOONNSS • For children administer 20 cc/kg of NS for the fluid bolus, and re-bolus at

10cc/kg**

• For hypoglycemia (blood glucose<60) give 1.0 cc/kg of 25% solution**

• For seizures, administer midazolam 0.1 mg/kg IV or 0.2 mg/kg if IM or IO***



1/02 T15.2

TREATMENT (cont)

♦ If the patient is exhibiting signs or symptoms of hypertensive emergency, such aschest pain (see CARDIAC CHEST PAIN protocol) or pulmonary edema (see

RESPIRATORY DISTRESS protocol):

• Administer O2 (see AIRWAY protocol)* • • •

Monitor the cardiac rhythm**

Initiate IV access and saline lock **

For systolic blood pressure greater than 200 mm Hg and/or diastolic blood

pressure greater than 120 mmHg, administer Nitroglycerine 0.4 mg SL or one dose of nitroglycerine spray, q 5 minutes until blood pressure is less

than 200 mm Hg systolic, 100 mmHg diastolic, or symptoms resolve***

Be cautious with administering nitroglycerin to patients who have takenViagra

®< 24 hours prior to encounter as these patients are more likely to

have hypotensive episodes

♦ Transport the patients expeditiously to the hospital


♦ Hypertensive encephalopathy often takes a few hours or even a day or two todevelop. There is no nuchal rigidity, and focal neurological deficits, if present,

are often transient and migratory.

♦ Nuchal rigidity should cause one to suspect intracerebral or sub-arachnoidhemorrhage

♦ Rapid onset of symptoms (coma, hemiparesis) often indicates intracranialhemorrhage or cerebral infarction

♦

Toxemia of pregnancy is best treated by emptying the uterus. Transport the patient to a hospital with OB facilities

♦ Remember to treat the symptoms and not the blood pressure and recognize thesymptoms that need to be treated



7/01 T.17.3

HYPOTHERMIA

HISTORY

♦ Length of exposure

♦ Wet or dry♦ Air/water temperature

♦ Wind

♦ Drug/alcohol use

♦ Extremity pain, paresthesia (frostbite), shivering

♦ History and timing of changes in mental status

♦ Past History:

• Cold injuries

• Medications

• Medical illness

PHYSICAL FINDINGS

♦ Define categories of accidental hypothermia by physical findings (patient will be

categorized by lowest physiological variable):

• APNEA - put metal or glass slide under nostrils for 60 seconds

• PULSE - palpate carotid pulse for 60 seconds

• EKG - attach EKG leads and interpret rhythm**

• LOC - determine LOC by verbal and motor responsiveness.

♦ Categorize the hypothermic patient according to the following:

• MODERATE HYPOTHERMIA• Respirations >12/min, palpable pulses, organized EKG rhythm, and

responds to commands

• COLD ALIVE

• Respirations < or = 12/min, no palpable pulse, organized EKG rhythm,responsive to verbal or motor stimuli

• COLD LIFELESS (see DEATH IN THE FIELD protocol)

• Apneic, pulseless, disorganized EKG rhythm, no response

• FROZEN LIFELESS (see DEATH IN THE FIELD protocol)

• Apneic, pulseless, major trauma, head or trunk frozen



7/01 T.17.4

TREATMENT

♦ Determine temperature of patient as possible

♦ Allow patient to breathe humidified 100% O2 NRB

♦ Remove wet, cold, or constricting clothing; wrap patient in blankets. Protect from further exposure

♦ Handle patient gently; the hypothermic heart is irritable, and roughness may result inventricular arrhythmias

♦ Treat according to the category of hypothermia:

• MODERATE HYPOTHERMIA

Supportive care, warm O2, EKG monitoring, IV if feasible**, transport assoon as possible

• COLD ALIVE

Warm O2, EKG monitoring, IV if feasible**, transport as soon as possible

• COLD LIFELESS (see DEATH IN THE FIELD protocol) ACLS protocols, warm O2, start peripheral IV **

• FROZEN LIFELESS (see DEATH IN THE FIELD protocol) Transport only if the risk to rescue personnel is acceptable

♦ Use warmed IV fluids if possible; 10 cc/kg bolus and 5 cc/kg per hour**

♦ If hypothermia injury is local (frostbite):

• Handle injured part gently; leave uncovered

• Do not allow injured part to thaw if chance exists for refreezing before arrival at

definitive care facility

• Maintain core temperature of patient with blankets


♦ Do not force oral intubation

♦ Consider other protocols as appropriate (i.e.ALTERED MENTAL STATUS/COMA)

♦ Severely hypothermic patients may appear dead. When in doubt begin CPR. Fielddetermination of death should not be considered until the patient is evaluated by a

physician

♦ Patients who are profoundly hypothermic (COLD LIFELESS) may require pumprewarming and should be transported to hospitals with that capability (cardiac bypass)

♦ Do not consider the patient dead unless they are warmed first!



7/01 T1.5

MUSCULOSKELETAL INJURIES

HISTORY

♦ Mechanism of injury

o Locationo Time


♦ Past medical history


PHYSICAL FINDINGS

♦ Vital signs

♦ Level of consciousness (GCS score)

♦ Cervical exam for tenderness

♦ Localized pain, tenderness♦ Swelling, discoloration, angulation, crepitus

♦ Deep lacerations, exposed bone fragments

♦ Loss of function, limitation of motion, guarding

♦ Quality of distal pulses, capillary refill

♦ Paralysis, numbness, incontinence

TREATMENT

♦ Assure airway, breathing, circulation, control hemorrhage

♦ Immobilize cervical spine if appropriate:

o Major or consistent mechanism of injury

o Potential C spine injury and: Altered LOC or intoxication Neck Pain New neurologic deficits

♦ Examine for additional injuries, evaluate, and treat, if necessary, those with higher priority

♦ For highly suspected pelvic or femur fractures, consider large bore IV with Balanced SaltSolution (see SHOCK protocol)**

♦ For open fractures:

o

Control bleeding with direct pressure and/or elevationo Apply sterile dressing saturated with Normal saline

♦ Splint all fractures in the normal anatomic position, applying axial traction as needed

♦ Elevate simple fractures. Apply ice or cold packs if time and extent of other injuries

allow

♦ If the patient has severe pain, consider Morphine Sulfate 2-5 mg IV slowly (see

MORPHINE protocol)***. Do not use if a patient has undiagnosed abdominal pain or head injury



7/01 T1.6

TREATMENT (cont)

♦ Transport as necessary, monitor circulation (pulse and skin temperature), sensation, and

motor function distal to site of injury


♦ Fractures do not necessarily lead to loss of functions, e.g., impacted fractures may cause pain but little or no loss of function

♦ Extremity injuries benefit from appropriate care, but are of low priority in a multiple-

injured patient

PPEEDDIIAATTR R IICC CCOONNSSIIDDEER R AATTIIOONNSS

♦ Small children require extra padding under the shoulders when immobilizing the C-spine

♦ The dose of morphine for children <30kg is 0.1 mg/kg***. This dose may be repeated in

5 minutes if there continues to be severe pain



7/01 T18.1

NEAR DROWNINGHISTORY

♦ How long patient was submerged

♦ Approximate temperature of water

♦ Fresh or salt water ♦ Contamination of water

♦ Depth of recovery

♦ Trauma

• MVA

• Scuba

• Diving

• Child abuse

♦ Drug/alcohol use

♦ Symptoms:

• Cough, dyspnea, vomiting, pleuritic chest pain


PHYSICAL FINDINGS

♦ Vital signs; especially temperature, respiratory rate

♦ Neurologic status:

o Mental status, pupillary exam, Seizures

♦ Respiratory

o Rales, wheezing, frothy sputum

♦ HEENT

o Signs of head and/or neck trauma, neck tenderness

TREATMENT

♦ Clear upper airway

♦ Assist ventilation as needed; if unsuccessful, patient may need intubation and positive pressure or suction

♦ Stabilize neck prior to removing from water if any suggestion of neck injury

♦ O2, 15 LPM via non-rebreather mask *


♦ Monitor cardiac rhythm (see CARDIAC ARREST and CARDIAC DYSRHYTHMIAS protocols**



7/01 T18.2


♦ Be prepared for vomiting

♦ ALL NEAR-DROWNINGS SHOULD BE TRANSPORTED. Even if patients initiallyappear fine, they can deteriorate. Monitor closely. Pulmonary edema is likely, and can

occur after a long normal interval♦ Hypothermia may be a problem (see HYPOTHERMIA protocol)

♦ Be aware of other injuries in near drowning associated with trauma (MVA’s, jumping or diving)

♦ Do not resuscitate patients in cardiac arrest if submerged for more than 30 minutesEXCEPT:

• Resuscitate if the patient is recovered after being submerged for 60 minutes if:

1. The patient may have been trapped in an underwater air pocket2. The water is less than 40

oF at recovery depth



7/01 T19.2

SPECIAL PRECAUTIONS

♦ Meconium Aspiration

• Because meconium aspiration is a major cause of neonatal morbidity andmortality, preventing this is very important and could save an infants life.

• Close to 60% of all neonates with meconium staining of the amniotic fluidaspirate. In order to prevent aspiration the hypopharynx must be thoroughly

suctioned before initiation of respirations

• This is done by using a 10 F or larger catheter to suction the mouth, nose, and

pharynx of a meconium stained neonate as soon as the head is delivered

• After delivery, endotracheally intubate and suction the neonate if there is thick

meconium with particulates in it or they continue to have depressed respirations

• In a neonate with severe asphyxia, the full clearance of meconium need to be

weighed against the need to start resuscitation



7/01 T20.2

TREATMENT

♦ O2, moderate flow (see AIRWAY protocol)*

♦ Consider IV: Balanced Salt Solution as needed (see SHOCK protocol)**

♦ In the third trimester, transport on the left side unless delivery is imminent

♦ If patient is post-partum:1. Massage uterus, have mother nurse infant to aid in uterine contraction to stop or

slow down bleeding

♦ If the patient is near term and has signs of Preeclampsia (blood pressure greater than160/110 mmHG, peripheral edema, headaches, seizures):

1. If seizures, see SEIZURES protocol2. Transport immediately

3. Magnesium Sulfate can be used as a preventative agent in women with

preeclampsia for seizures. Contact OLMC to consider using Magnesium.***

♦ Obtain vital signs during transportation.

SPECIAL PRECAUTIONS

♦ Always consider pregnancy, or ectopic pregnancy particularly as a cause of vaginal

bleeding or abdominal pain in any female of child bearing age

♦ Patients in shock from vaginal bleeding should be treated the same as any patient withhypovolemic shock (see SHOCK protocol)



7/01 T21.5

TREATMENT (cont)

♦ For Chlorine Gas Inhalation:

3. 4.

♦ ♦ ♦ ♦

Nebulize Normal Saline via face mask or hand held nebulizer for duration of transport**

Inhalation poisoning is particularly dangerous to rescuers. Recognize an

environment with continuing contamination and extricate rapidly by properlytrained and equipped personnel

♦ Obtain and document vital signs during transport.


♦ Some hydrocarbon ingestions may benefit from emesis. Contact Poison Control on all

hydrocarbon ingestions

♦ Do not try to neutralize acids with strong alkalis. Do not try to neutralize alkalis with

acids♦ Activated Charcoal may be ineffective in ingestions such as mineral acids, alkalies,

petroleum products, Iron, and Lithium

♦ SLUDGE syndrome consists of Salivation, Lacrimation, Urination, Defecation,Gastrointestinal distress (cramping, abdominal pain), Emesis.

♦ Intubate patient with compromised airway and/or ineffective respiratory effort who isunresponsive to Narcan

®.**

PEDIATRIC CONSIDERATIONS

IV glucagon dose is 50-75 µg/kg over 1 minute for ß Blocker OD***

Naloxone dose is 0.1 mg/kg IV, IM, SL or SQ**

The atropine dose may be very high in children with organophosphate poisoning***

Consider the possibility of abuse or neglect



7/01 T22.1

PSYCHIATRIC/BEHAVIORAL EMERGENCIES

HISTORY

♦ Recent crisis

♦ Emotional trauma♦ Bizarre or abrupt changes in behavior

♦ Suicidal/homicidal ideation

♦ Visual/auditory/tactile hallucinations

♦ Alcohol/drug ingestion

♦ Past medical/psychiatric history


PHYSICAL FINDINGS

♦ Vital signs

♦ Pupillary exam, focal neurologic deficits

♦ Mental status/orientation

TREATMENT

♦ If there is immediate danger to medical personnel and/or the patient:

a. Protect yourself and others

b. Summon law enforcement

c. Enter the scene after law enforcement clears the area and deems it safe

♦ If there is no evidence of immediate danger to medical personnel and/or the patient:

a. Assess ABC’s (see AIRWAY protocol)*

b. Assess their orientation and level of consciousness (see ALTERED MENTAL

STATUS/COMA protocol)c. Convey concern for the patient at the same time establishing rapport

d. Do not stay alone with the patient; have help available if there is a need to restrain the

patient (see PATIENT RESTRAINT protocol)

♦ If there is no evidence of immediate danger to medical personnel and/or the patient and the

patient is suicidal:

a. Do not leave patient alone

b. Remove or have someone remove dangerous objects (i.e., knives, guns, pills, etc.)

c. Inquire specifically regarding depression, helpless or hopeless feelings and thoughts of

suicide

d. Question specifically about hallucinations or delusions

♦ Transport in calm, quiet manner; obtain, monitor vitals



7/01 T22.2


♦ Psychiatric disorders almost never cause Organic Brain Syndrome. If patient is disoriented, think

of medical causes

♦ Alcohol withdrawal can sometimes mimic a psychiatric disorder. It is manifested in the first

stage by:

• Weakness and tremulousness possibly accompanied by anxiety, headache, nausea, andcramps

• Disturbance in gait, speech, mentation, drowsiness, erratic behavior

• Restless and agitated, craves alcohol or sedative drugs

• Patient may begin to "see" and "hear" things

♦ The second stage of withdrawal is manifested by:

• Same symptoms as first stage with the addition of convulsive seizures. The seizures may

begin as early as 12 hours after beginning of abstinence, but more often during the second

or third day

♦ The third Stage or Delirium Tremens is manifested by:• Symptoms may include vivid and frequently terrifying auditory, visual and tactile

hallucinations, profound confusion, insomnia, disorientation, hypertension, severe

agitation, restlessness, fever, and an abnormally rapid heartbeat

• Withdrawal is a medical emergency and the patient should be hospitalized

♦ Prolonged abuse of alcohol makes the alcoholic more prone to certain illnesses, i.e. subdural

hematoma, pneumonia, cirrhosis, upper gastrointestinal hemorrhage, hypoglycemia, pancreatitis,

central nervous system disorders and heart problems.

♦ In attempting to obtain a history on the alcoholic patient there will be difficulty, because of

patient denial and family reluctance, to discuss the problem. Make the patient and/or family

aware of the seriousness of the medical situation and the possible outcome of their denial.

♦ POLICE ASSISTANCE: If the patient is in a public place and because of his/her intoxication

and/or withdrawal symptoms presents a danger to him/herself or to others, the police are

authorized by ORS to transport or arrange transport of the individual to a place of treatment.

♦ If the patient has a history of alcohol or drug abuse, consider the possibility of intervention with

the attending physician.


♦ Pediatric patients who are intoxicated may be hypoglycemic. Remember; always check a glucose

in any patient with altered mental status (see ALTERED MENTAL STATUS/COMA protocol)



1/02 T23.2

TREATMENT

Put patient in position of comfort♦ ♦ Start O2 and be prepared to assist ventilation (see AIRWAY protocol)*

Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)** ♦ Use O2, low flow if patient history of COPD obtained and condition not emergent. CAUTION:

In these patients, higher O2 flows may precipitate respiratory arrest. Low flow O2 is adequate in

most clinical situations but can be safely increased in the absence of chronic lung disease.*

♦

Identify and treat UPPER AIRWAY OBSTRUCTION, if present:♦ • Partial or complete foreign body

2. 3.

4. 5.

6.

If patient is coughing or shows evidence of air exchange, encourage patient in

these efforts*

If patient exhibits inadequate air exchange, perform abdominal thrusts (taking the

fist, place it thumb side toward the patient in the epigastrium; wrapping the fist

with the other hand, squeeze forcibly in and upwards) until obstruction clears or

patient loses consciousness*

If patient loses consciousness (or is found unconscious), position the head andattempt to ventilate. If unable to ventilate, reposition the head and try again. If

still unable to ventilate, start CPR .*

If still unable to ventilate patient, perform direct laryngoscopy***. Remove any

foreign material noted with Magill forceps***. Again attempt to ventilate patient. If unsuccessful, place Combitube** or endotracheally intubate***

If unable to perform endotracheal intubation and still unable to ventilate patient

by any means, perform cricothyrotomy*** and ventilate with 100% oxygen

• Infectious/inflammatory (croup, epiglottitis, anaphylaxis):1. O2,highflow, blow-by for pediatrics (see PEDIATRIC CONSIDERATIONS)*

2. 3.

Allow patient to sit in position of comfort. Parent may be allowed to hold the

pediatric patientCroup with stridor at rest: 0.5ml/kg of Epinephrine 1:1,000 (1mg/ml), in 3.0 cc

NS nebulized via hand held nebulizer. For child < 20 kg; may repeat X 1; for

child > 20 kg; may give continuously for child in danger of respiratory

collapse.***

Croup without stridor at rest: Nebulized Normal Saline*** 4. 5. Consider anaphylaxis and treat if appropriate (see

ANAPHYLAXIS/ALLERGIES protocol).

♦ Consider treatment for specific problem if field assessment can be made by history and physical

findings

♦ If wheezing or bronchospasm is present (Asthma, COPD):

1. Administer oxygen by most appropriate means to maintain oxyhemoglobin

saturation >92%. Measure and document initial room air oxyhemoglobin

saturation if possible prior to use of oxygen therapy***



1/02 T23.3

TREATMENT (cont)

2. Inhalation therapy with nebulized albuterol (2.5-5.0 mg); may repeat as

needed.** Stop treatment if:

• The heart rate increases by 20 beats/minute

• Ventricular ectopy occurs

3. If a second treatment is needed or if the patient is normally on a combinationof Albuterol and Atrovent® for COPD, administer Ipatropium*** along with

the Albuterol. Administer 1 unit dose (0.5 mg) of Ipatropium.*** 4. Consider early use of SQ Epinephrine in children (see PEDIATRIC

CONSIDERSATIONS)*

5. If the patient with bronchospasm is unresponsive to treatment and is

deteriorating, who is less than 40 years old, not diabetic and has no history of

cardiac disease, consider epinephrine 1:1,000 O.3 cc SQ***

6. Initiate IV access, Balanced Salt Solution if respiratory distress is severe**

7. Monitor cardiac rhythm**

♦ IF symmetrical rales present (Pulmonary Edema):

1. Administer O2, high flow (see AIRWAY protocol)* 2. Sit patient upright, dangle legs if possible

3. Initiate IV access, Balanced Salt Solution**

4. Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)**

5. If BP is less than 100 mmHG, consider cardiogenic shock (see SHOCK

protocol)6. Nitroglycerin 0.4 mg SL q 5 minutes, if systolic BP greater than 100 mg

Hg**; Be cautious with administering nitroglycerin to patients who have

taken Viagra® < 24 hours prior to encounter as these patients are more likely

to have hypotensive episodes

7. Furosemide (Lasix®) according to the following dosage schedule***:

• If the patient is not currently taking, give 40 mg IV

• Give the patient the same dosage that they are currently taking IV (e.g. if the patient takes 40 mg/day, give 40 mg IV)

• Do not give more than 80 mg

8. Consider Morphine Sulfate, 2.0 mg increments to a maximum of 8.0 mg***

9. Consider nebulized Albuterol treatment, 2.5 mg for severe respiratory

distress with bronchospasm**

♦ Consider a Combitube** or endotracheal intubation*** in a rapidly deteriorating patient (see

AIRWAY protocol)

♦ If pneumothorax is present, watch for signs of tension. Consider decompression.*** (see

TENSION PNEUMOTHORAX DECOMPRESSION protocol)



1/02 T23.4


♦ If you are unable to differentiate the cause of the respiratory distress, the proper course is to

administer Oxygen and transport.

♦ Wheezing in older persons is frequently due to pulmonary edema, not asthma. Your patient may

make the wrong diagnosis. Consider also pulmonary embolus.

♦ Do not over-diagnose "hyperventilation" in the field. Your patient could have a pulmonary

embolus or other serious problem, give him/her the benefit of the doubt. Treatment with oxygen

will not harm the hyperventilator, and it will protect you from underestimating the problem


♦ Children with croup, epiglottitis or laryngeal edema usually have respiratory arrest due to

exhaustion or spasm. You will still be able to ventilate with mouth-to-mouth, pocket mask or

bag/valve/mask technique. Do not attempt intubation, even after several attempts at

repositioning, unless you are unable to ventilate the patient with non-invasive methods.

♦ Transport in a parents arms if the child is conscious

♦ Do not dilute or reduce the dose of albuterol

♦ Use "blow-by" technique with mask or nebulizer in children unable to properly use nebulizer

♦ Dose of epinephrine for children with asthma:

• Epinephrine 1:1000, 0.01 mg/kg (0.01 cc/kg) SQ***



7/01 T24.1

SEIZURES

HISTORY

♦ Onset

♦ Time interval♦ Type of seizure (focal, febrile, grand mal, petit mal)

♦ Previous history of seizures

♦ Medical history

• Medications and compliance

• Head trauma

• Diabetes

• Headaches

♦ Drugs or alcohol withdrawal

♦ Pregnancy (eclampsia)

PHYSICAL FINDINGS

♦ Vital signs

♦ Seizure activity

♦ Level of consciousness

♦ Head and oral trauma

♦ Incontinence. (Urinary or fecal)

♦ Focal neurologic signs

♦ Headache.

TREATMENT

♦ Airway: Ensure patency and start O2 (see AIRWAY protocol)*

♦ Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)**

♦ Continue assessing and document level of consciousness every 5 minutes

♦ Obtain and document vitals.

♦ Transport on the left side

♦ Medical personnel are often called to assist epileptics who seize in public. If patientclears completely, is taking his medications, has his own physician and is experiencing

his usual frequency of seizures, transport may be unnecessary. Document patient'smental status and have patient sign a refusal form. If under the age 18, have a parent or

guardian sign.



7/01 T24.2

TREATMENT (cont)

♦ If patient is in status seizures upon arrival, (status seizures are defined as: a continuous

seizure lasting more than 5 minutes, or repetitive seizures without regaining

consciousness):

1. Do not FORCE anything between the teeth; suction as needed2. Initiate IV access**

3. Determine whole blood glucose level using glucometer. If the blood glucoselevel is less than or equal to 60 mg %:

D50W, 50 ml IV into secure vein.** Give Thiamine 100 ml IV after

giving glucose if alcoholism or malnutrition is suspected.*** Administer Glucagon 1.0 mg IM if unable to administer dextrose***

4. Administer midazolam 2.5 mg IV and may repeat once for continued seizure. If no IV access, give midazolam 5mg IM and repeat once for continued seizure***

SPECIAL PRECAUTIONS

♦ Don't forget to check for a pulse. Seizure activity may be the first sign of cerebralhypoxia from cardiac arrest

♦ Seizures in patients over the age of 50 are frequently caused by dysrhythmias

♦ Move hazardous material away from patient. Restrain the patient only if needed to prevent injury. Protect patient's head.

♦ Focal motor seizures are generally not treated in the pre- hospital setting

♦ New onset seizure in any patient needs medical evaluation

♦ New onset seizures in a pregnant woman, in the third trimester may be indicative of

eclampsia (see OB-GYN EMERGENCIES protocol)


♦ Febrile seizures are found in children between the ages of 1 and 6; there is usually a

history of recent fever or illness and the seizures are usually short in duration

♦ The midazolam dose for children is:

o o

0.1mg/kg IV for a continuous or repetitive seizure up to a maximum of 2.5 mg;

may repeat once***

If there is no IV access, give 0.2 mg/kg IM or IO to a maximum of 5 mg; mayrepeat once***



7/01 T25.1

SHOCK

PHYSICAL FINDINGS

♦ Shock is defined as inadequate organ perfusion ♦ Signs and Symptoms may include, but are not limited to:

• Tachycardia (Pulse over 120)

• Hypotension (systolic BP <90 mm Hg)

• Skin cold and clammy. (May be absent in early septic shock).

• Mental status: Confusion, restlessness, apathy.

• Other: Marked thirst, syncope

CLASSIFICATION OF SHOCK

♦ Hypovolemic Shock: Shock characterized by the loss of circulating blood volume. Thismay be due to direct hemorrhage or through loss of fluids from severe vomiting, diarrhea,

burns, or peritonitis.

♦ Cardiogenic Shock: Pump failure.

♦ Distributive Shock: Characterized by abnormal vascular tone. Includes anaphylaxis,

early sepsis, neurogenic shock.

♦ Obstructive Shock: Mechanical obstruction to blood flow to or from the heart. Includescardiac tamponade, tension pneumothorax, dissecting aneurysm, massive pulmonary

embolism.

TREATMENT

♦ HYPOVOLEMIC SHOCK 1. Stop exsanguinating hemorrhage, if present.

2. Place patient on stretcher, in Trendelenburg or shock position as tolerated.3. O2, high flow with ventilatory assistance as required.* Consider early

intubation*** (see AIRWAY protocol)4. IV, Balanced Salt Solution, large bore, x 2 if time and sites permit**

5. If no signs of fluid overload are present, give 500 ml Balanced Salt Solution IV as

rapidly as possible (10 ml/kg); monitor and document changes in patient status**

6. Repeat fluid bolus can be given if improvement is transient; withoutimprovement, may be repeated if the EMT believes it is in the patient’s bestinterest and the patient shows no signs of pulmonary edema

7. Monitor and document cardiac rhythm**, if possible and vital signs as well as

level of consciousness during transport.

8. DO NOT DELAY TRANSPORT. PATIENTS IN PROFOUND SHOCK MUSTBE TRANSPORTED IMMEDIATELY WITH AS MANY OF THE ABOVE

STEPS AS POSSIBLE ACCOMPLISHED ENROUTE.



7/01 T25.2

TREATMENT (CONT)

♦ CARDIOGENIC SHOCK

1. O2, high flow; assist ventilation as necessary. Consider placing a Combitube** or

endotracheal intubation*** 2. Monitor cardiac rhythm**. Evaluate and treat (see CARDIAC

DYSRHYTHMIAS protocol. Remember that shock itself can be a cause of dysrhythmias

3. IV, balanced salt solution, large bore**

• Administer fluid challenge of 250 ml. ** If the systolic blood pressuredoes not increase to 90 mm Hg or greater:

Administer Dopamine (see DOPAMINE INFUSION)*** 4. Consider Tension Pneumothorax as a cause and treat accordingly

5. Obtain vital signs frequently, watch level of consciousness and transportWITHOUT DELAY.

♦ DISTRIBUTIVE SHOCK

1. Give a 500 cc fluid challenge IV and repeat once if no response (BP systolic > 90mmHg)**

2. If shock persists, consider Dopamine (see DOPAMINE INFUSION)*** 3. If anaphylaxis is suspected, see ANAPHYLAXIS/ALLERGIES protocol

♦ OBSTRUCTIVE SHOCK 1. Apply the cardiac monitor (see CARDIAC DYSRHYTHMIAS protocol)**

2. Consider a fluid challenge of 500cc Balanced salt solution**

3. Treat underlying causes:

• Tension Pneumothorax- needle thoracentesis***

• Cardiac Tamponade- pericardiocentesis in the hospital

• Massive Pulmonary Embolus- Hospital surgery• Dissecting Aneurysm- Hospital surgery

DOPAMINE INFUSION***

♦ Mix Dopamine in a Volutrol®

type device (60 gtts/cc)

♦ For Adults:1. Mix 400 mg in 250 cc of BSS or 800 mg in 500 cc BSS giving a concentration of

1600 mcg/cc2. Take the patients weight in POUNDS, round to the nearest ten, drop the zero, and

that number is the number of drops/minute that equals 5 mcg/kg/min

3. An example of this is: Patient weight 174 pounds, round to 170 Drop the zero and you get 17 17 gtts/min=5 mcg/kg/min



7/01 T25.3


• Initial pediatric fluid bolus is 20 cc/kg IV or IO**

• Additional fluid boluses of 20 cc/kg can be given up to 60 cc/kg total**

• Determine the blood glucose level for shock in children and treat (see DIABETIC

EMERGENCIES protocol)** • For CARDIOGENIC SHOCK and DISTRIBUTIVE SHOCK, consider Dopamine if no

improvement in BP or perfusion after 60 cc/kg fluid challenge***

• The Dopamine formula for Pediatrics is***:

o Mix 80 mg in 250 cc BSS or 160 mg in 500 cc BSS giving a concentration of 320mcg/cc

o 1 gtt/kg/min of this solution equals 5 mcg/kg/min

o If the patient weighs 10 kg, run the infusion at 10 gtts/min to get 5 mcg/kg/min



7/01 T26.1

SUSPECTED SPINAL INJURY

HISTORY

♦ Violent mechanism of injury (witness, scene, situation)

♦ High-energy transfer (ejection, helmet damage, starred windshield, etc.)♦ Spinal cord injury may be the result of direct blunt and/or penetrating trauma, compression forces

(axial loading), abnormal motion (hyper flexion, hyperextension, hyper rotation, lateral bending

and distraction, i.e., hanging)

PHYSICAL FINDINGS

♦ Significant injury above the clavicles and around the head

♦ Significant multiple trauma

♦ Prior or present altered mental status

♦ Paralysis, weakness, numbness, or tingling with violent mechanism of injury or high energy

transfer

♦ Pain of the spine with or without movement

♦ Point tenderness, deformity, or guarding of the spine.

TREATMENT

♦ The following treatment will be used when any or all of the above PHYSICAL FINDINGS are

present, or when in the EMTs best judgment, the patient needs spinal support:

1. Temporarily immobilize cervical spine with rigid extrication collar, and continuous

manual in-line support. Immobilize thoracic and lumbosacral spine to long spine boardwhen possible, and/or other appropriate device as patient condition allows (KED,

orthopedic, etc.).

2.

Place 1 - 2" of soft material behind head to cushion head and preserve neutral position of head on backboard. Secure head and cervical spine to long spine board using dense, soft,

support material on both sides of the head, and tape. Straps affixed directly to the long

board will securely immobilize patient’s entire body. During this procedure the patient

should be moved as little as possible, and always as a unit.

3. Administer O2 as indicated (see AIRWAY protocol)*

4. Initiate IV if appropriate (see SHOCK protocol)**


♦ Vomiting should be expected in head injury patients. Therefore, patient should be securely

strapped to long board to enable board and patient to be turned as a unit. EMT should be aware

that additional help may be necessary during transport to turn patient and manage airway whilemaintaining C-spine integrity.

♦ Chin straps that could compromise the airway should be removed as the patient is immobilized to

the long board.

♦ Most patients require 1 to 1 1/2 inches of firm padding behind the head to assume standardneutral anatomic position.



7/01 T26.2

SPECIFIC PRECAUTIONS (CONT)

♦ In the severely traumatized patient requiring immediate life saving intervention and rapid

transport, rigid C-collar, continuous manual in-line support during rapid extrication onto a long

spine board and transport should be substituted for more time consuming methods.

♦ Airway problems, respiratory difficulty, and Shock are common in the traumatized patient.

Alternative techniques for performing airway procedures should be used in spinal injury patients.

To maintain proper control of the C-spine, 2 EMTs must perform a Combitube** or endotracheal

intubation*** with in-line stabilization.

♦ If any immobilization techniques cause an increase in pain or neurologic deficit, the patient

should be immobilized in position found or position of greatest comfort.

♦ Geriatric patients (over 55) should cause a higher index of suspicion for the EMT due to

physiologic aging changes. The EMTs awareness of the need to provide for C-spine

immobilization should be more acute in these patients.



7/01 T27.1

SYNCOPE

HISTORY

♦ Onset♦ Duration

♦ Seizure activity

♦ Precipitating factors; was the patient sitting, standing or lying

♦ Patient pregnant?

♦ Recent trauma

♦ Past medical history:

o Prior syncope

o Cardiac disease

o CVA

♦ Medications (newly prescribed)/allergies

♦ Symptoms: Vertigo, nausea, palpitations, chest or abdominal pain.

PHYSICAL FINDINGS

♦ Vital signs: Orthostasis (significant if pulse change > 30 bpm or systolic BP change > 15

mmHg from lying to sitting or standing)

♦ Neurologic exam: decreased level of consciousness, coma (see ALTERED MENTAL

STATUS/COMA protocol)

♦ Cardiovascular: presence of dysrhythmias (see CARDIAC DYSRHYTHMIAS protocol)

♦ HEENT: Signs of head trauma

♦ Incontinence

TREATMENT

♦ Assess the airway and administer O2 (see AIRWAY protocol)*

SHOCK ♦ Initiate IV access (see protocol)**

♦ Determine whole blood glucose level using glucometer. If blood glucose is less than or equal to 60 mg%:

• Give D50W orally if possible* or 50 ml in large vein if patient is unable to take

sugar orally**

♦ Cardiac monitor (see CARDIAC DYSRHYTHMIAS protocol)** ♦ Obtain and document vital signs during transport



7/01 T27.2


♦ Most syncope is vasovagal, not cardiac. Recumbent position should be sufficient torestore vital signs and level of consciousness to normal.

♦ Syncope in a recumbent position is almost always cardiac in etiology.

♦ Syncope of recent onset in middle-aged or elderly patients is often cardiac and deservesspecial concern. Occult GI bleeds, dissecting aneurysms, and ectopic pregnancy may

also present with syncope.

♦ Syncope by definition is a transient state of unconsciousness from which the patient hasrecovered. If the patient is still unconscious, follow the ALTERED MENTAL

STATUS/COMA Protocol or SHOCK protocol.



7/01 T28.1

12 LEAD EKG AND THROMBOLYSIS***

St Helens Only

♦ Follow CARDIAC CHEST PAIN protocol

♦ Obtain 12-lead EKG, transmit to Good Samaritan Emergency Department.Telephone/radio link with Emergency physician for confirm/deny "Acute Myocardial

Infarction" as EKG diagnosis. Emergency physician will not order thrombolytic therapy;

that is a paramedic decision. Notify Emergency Physician of your destination so that the12-lead EKG can be faxed to the receiving hospital.

♦ If confirmed, review the checklist to insure there are no YES or questionable responses.

♦ Mix and administer Retavase® using sterile technique:

1. Inject 10 ml of Sterile Water for Injection into the vial of Retavase®.2. Swirl gently to dissolve. DO NOT SHAKE.

3. Withdraw 10 ml of the solution from the vial, and inject into a patent, running IVover a 2 minute period.

4. Repeat steps 1-3, timing the administration of the second bolus to begin thirty(30) minutes after the start of the first bolus.

♦ Initiate Code 3 transport to the receiving hospital



7/01 M1.1

ACTIVATED CHARCOAL

CLASS

♦ Absorbent

PHARMACOLOGY AND ACTIONS:

♦ Activated charcoal is a fine black powder that binds and absorbs ingested toxinsthat may still be present in the GI tract

♦ Once bound to the activated charcoal, the combined poison-charcoal in excreted

from the body

INDICATIONS

♦ Effective in the management of poisoning or overdose of many substances.

PRECAUTIONS/CONTRAINDICATIONS

♦ Poison Control must be contacted before administering Activated Charcoal.

♦ Activated Charcoal should NOT be given to patients who are unconscious or whomay have a rapidly diminishing level of consciousness.

♦ Activated Charcoal may be ineffective in ingestions such as mineral acids,

alkalies, petroleum products, Lithium, or Iron.

♦ Administration of Activated Charcoal can result in aspiration.

♦ Activated charcoal may cause constipation

ADMINISTRATION

♦ Poison Control must be contacted.

♦ 1.0 gm/kg of Activated Charcoal in an aqueous- based solution. Dosage may be

higher as directed.



7/01 M2.1

ADENOSINE (ADENOCARD®)***

CLASS

♦ Endogenous nucleoside

PHARMACOLOGY AND ACTIONS

♦ Adenosine is a naturally occurring nucleoside that has the ability to slow conduction

through the AV node.

♦ Since most cases of PSVT involve AV nodal re-entry, Adenosine is capable of

interrupting the AV nodal circuit and stopping the tachycardia, restoring normal sinus

rhythm. It is not associated with hypotension and can be used safely in both wide and

narrow complex tachycardias.

♦ It is eliminated from the circulation rapidly, having a half life in the blood of less than 10seconds. This allows for the use of repeated doses in rapid succession if needed.

INDICATIONS

♦ To convert PSVT to normal sinus rhythm, including PSVT that is associated with

accessory bypass tracts (e.g. WPW).

PRECAUTIONS /CONTRAINDICATIONS

♦ When doses larger than 12 mg are given by infusion, there may be a decrease in blood

pressure secondary to a decrease in the peripheral vascular resistance.

♦ The effects of Adenosine are antagonized by the methylxanthines, such as Caffeine or

Theophylline. This would mean that larger doses of Adenosine may be required in the

presence of methylxanthines.

♦ Adenosine effects are potentiated by dipyridamole, thus requiring smaller doses of

Adenosine in the presence of dipyridamole.

♦ In the presence of Carbamazepine (Tegretol®), higher degrees of heart block may be

produced.

♦ Inhaled Adenosine has been shown to produce bronchospasm in asthmatic patients but IV

Adenosine has not. One should be aware of the possibility that Adenosine may produce

bronchoconstriction in patients with asthma

♦ Adenosine is not effective in converting Atrial Fibrillation, Atrial Flutter, or Ventricular

Tachycardia.

♦ Adenosine may “expose” atrial flutter in a patient who is being treated for presumed

PSVT in that the flutter waves become apparent during the administration of Adenosine.



7/01 M2.2

PRECAUTIONS /CONTRAINDICATIONS (CONT)

♦ Contraindicated in :

1. 2nd or 3rd degree AV block, sick sinus syndrome.

2. Known hypersensitivity.

3. Pregnancy is a relative contraindication.

ADMINISTRATION

♦ Adenosine is administered in less than 5 seconds via a rapid IV bolus, preferable through

a large bore IV in an antecubital vein.

♦ The medication should be administered through as IV port as close to the patient as possible so it is not diluted in the tubing.

♦ ADULT DOSE:

6 mg should be administered as an initial bolus followed by a 20 ml saline

flush.

A second bolus of 12 mg should be administered in 1 - 2 minutes if the first

bolus did not convert the patient to a normal sinus rhythm. A third 12 mg

bolus may be administered in 1 - 2 minutes if the two previous boluses were

unsuccessful.

♦ PEDIATRIC DOSE:

0.1 mg/kg IV push; increase to 0.2 mg/kg if necessary. May repeat X 1

SIDE EFFECTS/SPECIAL CONSIDERATIONS

♦ The most common side effects include facial flushing, dyspnea, chest pressure, nausea,

headache, and lightheadedness. These side effects are transient and usually last for only5 - 10 seconds.

♦ Transient 3rd degree heart block is common.

♦ If the patient becomes hemodynamically unstable at any point in time, cardioversionshould occur.



7/01 M3.1

ALBUTEROL SULFATE (PROVENTIL®)**

CLASS

♦ Sympathomimetic, bronchodilator


♦ Albuterol Sulfate is a potent, relatively selective ß2 adrenergic agonist and bronchodilator.

♦ The onset of improvement in pulmonary function is within 2 - 15 minutes after the initiation of

treatment and the duration of action is from 4 - 6 hours.

♦ As a ß2 agonist, Albuterol induces bronchial dilatation, but has occasional ß1 overlap with

clinically significant cardiac effects. Clinically significant arrhythmias may occur especially in

patients with underlying cardiovascular disorders such as Coronary Insufficiency andHypertension.

INDICATIONS

♦ Bronchial Asthma

♦ Reversible bronchial spasms that occur with Chronic Pulmonary Disease

♦ Wheezing secondary to allergic reactions.


♦ The patient's rhythm should be observed for arrhythmias. Stop treatment if:

1. Pulse increases by 20 BPM.

2. Frequent PVC's develop.

3. Any tachyarrhythmias other than Sinus Tachycardia appear.

♦ Paradoxical brochospasm may occur with excessive administration.

ADMINISTRATION

♦ The usual dosage for adults and children is 2.5 mg of Albuterol administered 3 - 4 times daily by

nebulization.

♦ Albuterol Sulfate solution for inhalation comes premixed in 3.0 ml unit dose containing total 2.5

mg at a concentration of 0.83 mg/ml. Refrigeration is not necessary with this medication.



7/01 M3.2

ADMINISTRATION (CONT)

♦ Patients in significant respiratory distress after the first treatment may require another treatment

immediately. If necessary, continue with sequential treatments.

♦ THE TECHNIQUE FOR ADMINISTERING ALBUTEROL IS AS FOLLOWS:

1. Nebulization should be accomplished using the supplied kit.

2. Oxygen flow should be set at 6 LPM. Patients with COPD should be monitored carefully for

CO2 retention.

3. Patients should be instructed to breathe as follows:

4. Inhale slowly.

5. Hold breath.

6. Exhale passively through nose.


♦ Albuterol may precipitate angina pectoris and dysrhythmias

♦ Albuterol should only be administered via inhalation

♦ Should be used with caution in patients with diabetes mellitus, hyperthyroidism, prostatic

hypertrophy or seizure disorders

♦ Safe to use in Pregnancy

♦ May be used with Ipatropium*** in selected patients with COPD. (see RESPIRATORY

DISTRESS protocol)

1. Skeletal muscle tremors are a common side effect



7/01 M5.1

ASPIRIN*1

CLASS

♦ Anti-inflammatory agent, platelet aggregation inhibitor.

PHARMACOLOGY/ACTIONS

♦ Aspirin has a plethora of actions through its inhibition of the production of prostaglandins, leukotrienes, and thromboxane. Aspirin acts as a potent anti-

inflammatory, analgesic, antipyretic, and inhibitor of platelet function.

INDICATIONS

♦ As an antiplatelet agent in patients with chest pain of suspected ischemic cardiacetiology.


♦ Contraindicated in patients with a known hypersensitivity to aspirin.

♦ Contraindicated in patients with active GI bleeds. Long term use can lead to GI bleeds in patients without other risk factors for ulcers. Overdose can be fatal.

♦ A history of asthma and nasal polyps may indicate an unknown hypersensitivity to

aspirin.

♦ Patients who have taken aspirin within the past twenty-four (24) hours do not need repeataspirin administration. When in doubt, treat.

♦ Multiple products and OTC preparations contain aspirin. When in doubt, read the label.

♦ Aspirin administration decreases mortality an equivalent amount as thrombolytics inacute myocardial infarction, with substantially less risk.

ADMINISTRATION

♦ Chew and swallow four 81 mg aspirin tablets.

1Basics may administer after completing a board approved course



7/01 M6.1

ATROPINE SULFATE

CLASS

♦ Anticholinergic


♦ Atropine is a muscarinic-cholinergic blocking agent. As such, it has the following effects:

a. Increases heart rate (by blocking vagal influences). b. Increases conduction through A-V node (i.e., increases ventricular sensitivity to atrial

impulses).

c. Reduces motility and tone of GI tract.

d. Reduces action and tone of the urinary bladder (may cause urinary retention).

e. Dilates pupils.f. This drug blocks cholinergic (vagal) influences already present. If there is little

cholinergic stimulation, effects will be minimal.

INDICATIONS

♦ To increase the heart rate in Bradycardias or pacemaker failure.

♦ To improve conduction in 2nd and 3rd Degree Heart Block.

♦ As an antidote for some insecticide exposures (anti- cholinesterases, e.g. organophosphates andcarbamates and nerve gases.

♦ To counteract excessive vagal influence responsible for some bradysystolic and asystolic arrests.

PRECAUTIONS

♦ Contraindicated in Atrial Fibrillation and Atrial Flutter because increased conduction may speed

ventricular rate excessively

♦ Bradycardias in the setting of an acute MI are common and probably beneficial Don't treat themunless there are signs of poor perfusion (low blood pressure, mental confusion). Chest pain could

be due to an MI or to poor perfusion caused by the Bradycardia itself. When in doubt, watchyour patient.



7/01 M6.2

ADMINISTRATION

♦ Adult: 1.0 mg IV, repeated in 0.5 mg increments if needed at 3 - 5 minute intervals to a total dose

of 0.04 mg/kg (usually 3.0 mg and titrated to a ventricular rate of about 60/min.). 1.0 to 2.0 mg

IV or 1.0 mg (10 cc) per ET tube in asystolic arrest.

♦ Pediatric: 0.02 mg/kg IV.

SIDE EFFECTS AND SPECIAL NOTES

♦ 2nd and 3rd degree block may be chronic and without symptoms. Symptoms occur mainly with

acute change. Treat the patient not the arrhythmia.

♦ Remember in cardiac arrest situations that Atropine dilates pupils.



7/01 M8.1

CALCIUM CHLORIDE

CLASS

♦ Electrolyte


♦ Calcium Chloride 10%, supplies free calcium immediately on an intravascular basis.

Calcium is an essential component for functional integrity of the nervous and muscular systems, normal cardiac contractility, and the coagulation of blood.

INDICATIONS

♦ Treatment of symptomatic calcium channel blocker overdose (bradycardia, hypotension).♦ Treatment of documented hypocalcemia.

♦ Treatment of presumed severe hyperkalemia (slow, wide complex, “sine wave” rhythmwith hypotension).


♦ Extremely tissue toxic. Should only be used in an IV that is freely flowing.

Extravasation will cause necrosis requiring extensive grafting.

ADMINISTRATION

♦ Bolus 10 cc of 10% Calcium Chloride ever 10 minutes in a freely flowing IV.



1/02 M9.1

DEXTROSE 50%*1

CLASS

♦ A simple sugar


♦ Glucose is the body's basic fuel. It produces most of the body's quick energy. Its use isregulated by insulin, which stimulates storage of excess glucose from the bloodstreamand glucagon which mobilizes stored glucose into the bloodstream.

INDICATIONS

♦ Hypoglycemic states usually associated with insulin shock in diabetes.

♦ The unconscious patient with a documented blood sugar below 80mg%

♦ In hypoglycemic patients with a focal or partial neurologic deficit or altered state of

consciousness.

♦ In hypothermia patients with a documented blood sugar below 80mg%


♦ Extravasation of D50W will cause necrosis of tissue. IV should be secure, and free returnof blood into the syringe or tubing should be checked 2 - 3 times during administration.

If extravasation does occur, immediately stop administration of drug. Report

extravasation of the drug to receiving hospital personnel and document.

ADMINISTRATION

♦ 50 ml amp (1.0 ml/kg) IV into secure vein, if patient unable to tolerate oral fluids.

♦ Give solution orally (or sugared juice, honey, molasses, Karo Syrup) if patient is awake

and able to maintain own airway.

♦ Dilute to 25% Dextrose in newborns and give 2.0 ml/kg.



1/02 M9.2


♦ D50W is remarkably free of side effects and should be used whenever Hypoglycemia

exists.

♦ D50W may worsen myocardial infarctions and strokes.

♦ Do not draw blood for glucose determination from site proximal to an IV containingGlucose or Dextrose.

♦ Dextrose may precipitate Wernicke's Encephalopathy in alcoholics. Should be givenwith caution and followed by 100 mg Thiamine*** in suspected alcoholic or malnourished patients.

1Basics may administer orally only



7/01 M10.2


♦ Hypotension occurs in 8% of patients. Symptomatic hypotension occurs in 3.2% of patients, and usually responds to Trendelenburg Position and/or infusion of crystalloid

solution.



7/01 M11.1

DOPAMINE (INTROPIN®)***

CLASS

♦ Alpha and Beta receptor stimulating agent


♦ Chemical precursor of nor-epinephrine which occurs naturally in man and which has bothalpha- and beta- receptor stimulating actions. Its actions differ with dosage given:

1-2 mcg/kg/min - dilates renal and mesenteric blood vessels (no effect on heart

rate or blood pressure). 2-10 mcg/kg/min - beta effects on heart which usually increase cardiac output

without increasing heart rate or blood pressure. 10-20 mcg/kg/min - alpha peripheral effects cause peripheral vasoconstriction and

increased blood pressure. 20-40 mcg/kg/min - alpha effects reverse dilation of renal and mesenteric vessels

with resultant decreased flow.

INDICATIONS

♦ Primary indication is Cardiogenic Shock.

♦ May be useful for other forms of shock, except hypovolemic.


♦ May induce tachyarrhythmias, in which case infusion should be decreased or stopped.

♦ High doses may cause extreme peripheral vasoconstriction. Conversely, low doses maycause a decreased blood pressure due to peripheral dilation.

♦ MAO inhibitors (Monamine Oxidase) potentiate the effects of this drug. Check for medications and contact Physician Supervisor or Medical Resource Hospital if patient is

taking Nardil®, Marplan®, or Parnate®.

♦ Should not be added to Sodium Bicarbonate or other alkaline solutions since Dopamine

will be inactivated in alkaline solutions.

ADMINISTRATION

♦ Mix Dopamine in a Volutrol®

type device (60 gtts/cc)




7/01 M11.2

♦ For Adults:

1. Mix 400 mg in 250 cc of BSS or 800 mg in 500 cc BSS giving a concentration of 1600 mcg/cc

2. Take the patients weight in POUNDS, round to the nearest ten, drop the zero, and

that number is the number of drops/minute which equals 5 mcg/kg/min3. An example of this is: Patient weight 174 pounds, round to 170 Drop the zero and you get 17

17 gtts/min=5 mcg/kg/min

• The Dopamine formula for Pediatrics is***:

o Mix 80 mg in 250 cc BSS or 160 mg in 500 cc BSS giving a concentration of 320

mcg/cc.

o 1 gtt/kg/min of this solution equals 5 mcg/kg/min If the patient weighs 10 kg, run

the infusion at 10 gtts/min to get 5 mcg/kg/min.


• The most common side effects include ectopic beats, nausea and vomiting. Angina has been reported following treatment. (Tachycardia and arrhythmias are less likely than

with other catecholamines.)

• Can precipitate hypertensive crisis in susceptible individuals, i.e. patients on MAOinhibitors (Parnate

®, Nardil

®, Marplan

®).

• Consider hypovolemia and treat this with appropriate fluids before administration of Dopamine. Dopamine is contraindicated for hypovolemic shock.

• Dopamine is best administered by an infusion pump to accurately regulate rate. For thisreason, it is hazardous when used in the field. Monitor closely.



1/02 M13.1

EPINEPHRINE*1

CLASS

♦ Sympathetic agent


♦ Catecholamine with alpha and beta effects.

♦ In general, the following cardiovascular responses can be expected:

1. Increased heart rate.2. Increased myocardial contractile force.

3. Increased systemic vascular resistance.

4. Increased arterial blood pressure.5. Increased myocardial O2 consumption.

6. Increased automaticity.

♦ Potent bronchodilator.

INDICATIONS

♦ Ventricular Fibrillation.

♦ Asystole.

♦ Pulseless Electrical Activity.

♦ Systemic allergic reactions.

♦ Asthma in patients under 40 years


♦ Epinephrine increases cardiac work and can precipitate angina, MI, or major dysrhythmias in an individual with ischemic heart disease.

♦ Wheezing in an elderly person is pulmonary edema or pulmonary embolus until provenotherwise.



1/02 M13.2


♦ Anxiety, tremor, headache, Tachycardia, palpitations, PVC’s, angina and HTN may becommon side effects.

♦ Can cause vomiting in children

ADMINISTRATION

♦ IN ADULTS:1. Cardiac arrest: 1.0 mg (10 ml of 1:10,000) IV initially during arrest, then every

three (3) minutes. **

2. Allergic reaction (Anaphylaxis): With BP greater than 90 mm Hg systolic, administer Epinephrine 0.3 ml

1:1,000 SQ * With BP less than 90 mm Hg systolic, administer Epinephrine 3.0 ml

1:10,000 slow IV **

♦ IN PEDIATRICS:

1. Cardiac arrest: 0.01 mg/kg (0.1 ml/kg of 1:10,000) IV ** initially during arrest,

then every three (3) minutes.

2. Allergic reaction (Anaphylaxis): Respiratory distress with good perfusion: Epinephrine 1:1000, 0.01 mg/kg

(0.01 cc/kg) SQ *1

if no IV or ET; maximum dose is 0.3 mg (0.3 cc)

If poor perfusion: Epinephrine 1:10,000, 0.01 mg/kg (0.1 cc/kg) IV *** or IO; maximum dose is 0.1 mg (1.0 cc)

3. Croup: 0.5 ml/kg of Epinephrine 1:1,000 (1.0 mg/ml) in 3.0 cc NS *** nebulizedvia hand held nebulizer.

1Basics may use by SQ or injection device (e.g. Epi-pen) and a report to the board must follow

each use



7/01 M14.1

GLUCAGON***

CLASS

♦ Antihypoglycemic agent


♦ Glucagon is a hormone which causes glucose mobilization in the body. It works oppositeto insulin, which causes glucose storage, and it is present normally in the body. It is

released at times of insult or injury when glucose is needed and mobilizes glucose from

body glycogen stores. Return to consciousness should be within 20 minutes of IM dose

of patient who is hypoglycemic.

INDICATIONS

♦ Known hypoglycemia when patient is stuporous or comatose, and D50W is not availableor an IV line cannot be established.

♦ May be useful in treating life-threatening beta-blocker overdoses.


♦ IV Glucose or Dextrose is the treatment of choice for insulin shock. Use of Glucagon is

restricted to patients who are seizing, combative, or with collapsed veins and in whom an

IV cannot be established. In these rare situations, it may be invaluable.


♦ Nausea and vomiting may occur as side effects.

♦ Persons with no liver glycogen stores (malnutrition, alcoholism) may not be able tomobilize any glucose in response to Glucagon.

ADMINISTRATION

♦ ADULTS-1.0 mg IM or SQ. May repeat in 20 minutes.

♦ PEDIATRICS-0.1 mg/kg IM or SQ in children or neonates. Maximum of 1.0 mg.



7/01 M15.1

HANK'S SOLUTION*

CLASS

♦ Cell growth solution


♦ "Save-A-Tooth" contains sterile Hank's Solution, which is a cell growth solution used in biology

to supply cells with all of the nutrients they need so that they can be grown in solution.

♦ Placing avulsed teeth into Hank's Solution before replantation has been shown to increase the rate

of successful replantation. Avulsed teeth can be stored up to 24 hours in this solution.

INDICATIONS

♦ To aid in the successful replantation of avulsed adult teeth when they can be placed in solution

within 1 hour of the time when they are avulsed.

PRECAUTIONS

♦ Not to be used for teeth that have been broken off. The root needs to be intact.

♦ Not for use with baby teeth.

♦ Do not place more than one person's teeth in one container.

♦ Do not attempt to rinse or clean teeth before placing them in solution.

ADMINISTRATION

a. Open "Save-A-Tooth" container.

b. Peel off seal from container and basket.

c. Drop in tooth (or teeth).

d. Close lid tightly.

e. Label with patient's name.

f. Transport in upright position.

g. If there are no other indications for transport, patient may seek out their own dentist for

replantation.



7/01 M17.1

IPECAC

CLASS

♦ Emetic agent


♦ Ipecac alkaloids act both locally on the gastric mucosa and centrally on thechemoreceptor trigger zone to induce vomiting. Usually effective within 20 - 30 minutes.

INDICATIONS

♦ To induce vomiting for patients who have ingested poisons or drugs (other than strong

acids, alkalis, hydrocarbons, or phenothiazine.)


♦ EMT must contact Poison Control Center before administering Ipecac.

♦ Ipecac should NOT be given to patients who are unconscious or who have a rapidly

diminishing level of consciousness.

♦ Should NOT be given to patients who are seizing.

♦ Ipecac should NOT be used to induce vomiting in the field in patients who have ingestedacids, alkalis (lye), silver nitrate, iodides, strychnine, hydrocarbons, tri-cyclics, camphor,

INH (Isoniazid), phenothiazenes, or short acting sedatives.

♦ Ipecac Syrup should not be confused with Ipecac Fluid Extract. The latter is veryconcentrated and has caused death.

♦ Ipecac should NOT be given to women in the third trimester of pregnancy.

ADMINISTRATION

♦ Poison Control must be contacted.

♦ Adult: 30 ml p.o., followed by 2 - 3 glasses of water.

♦ Pediatric (over 1 year): 15 ml p.o., followed by 1 - 2 glasses of water.

♦ The emetic action is improved if fluids are given orally just before or after the Ipecac (2 -3 glasses of water in adults).



7/01 M17.2


♦ Emetic action may be enhanced by ambulation.

♦ The gag reflex may be an unreliable indicator of whether or not someone will be able to

protect his/her airway in the event of emesis. Additionally, testing for a gag reflex in a patient with depressed level of consciousness may actually cause aspiration. USECAUTION.

♦ Always stand by with suction. Patient should be in lateral decubitus position, or sitting.

♦ May not be successful in phenothiazine overdose due to strong antiemetic action of

phenothiazine.



7/01 M18.1

KETOROLAC (TORADOL®)***

CLASS

♦ Nonsteriodal Anti-inflammatory . (NSAID)

MECHANISM OF ACTION

♦ Ketorolac (Toradol®

) is an injectable nonsteroidal anti-inflammatory drug (NSAID) thatdemonstrates analgesic, anti-inflammatory, and antipyretic activity. Ketorolac (Toradol

®)

inhibits prostaglandin synthesis, and appears to relax ureteral spasm (and thus pain) in patients with kidney stones. Usually effective in 20-30 minutes.

INDICATIONS

♦ In patients with known kidney stones and/or patients who have classic symptoms for

passage of a kidney stone (e.g. acute onset of unilateral back pain with radiation to lower quadrant/groin/testicles/ labia).


♦ Ketorolac (Toradol®) is contraindicated in patients with known hypersensitivity and

patients with previously demonstrated allergic manifestations to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).


) inhibits platelet function and is, therefore, contraindicated in

patients with high risk for bleeding.

♦ Ketorolac (Toradol®) should be used with caution in patients with impaired hepatic

function or a history of liver disease.


) is contraindicated in nursing mothers because of the potentialadverse effects on neonates.

ADMINISTRATION

♦ 30 mg IV or IM over 15 seconds.

♦ 15 mg IV over 15 seconds in geriatric patients and those weighing less than 50 kgs (110lbs).



7/01 M20.1

LIDOCAINE®

(XYLOCAINE)

CLASS

♦ Antiarrhythmic


♦ Depresses automaticity of Purkinje fibers; therefore, raises stimulation threshold in the

ventricular muscle fibers (makes ventricles less likely to fibrillate).

♦ Little antiarrhythmic effect at sub-toxic levels on atrial muscle.

♦ CNS stimulation: tremor, restlessness and clonic convulsions followed by depression andrespiratory failure at higher doses.

♦ Cardiovascular effect: decreased conduction rate and force of contraction, mainly at toxiclevels.

♦ The effect of a single bolus on the heart disappears in 10-20 minutes due to redistribution

in the body. Metabolic half-life is about 2 hours and, therefore, toxicity develops withrepeated doses.

INDICATIONS

♦ Stable Ventricular Tachycardia or recurrent Ventricular Tachycardia if clinical conditionis not rapidly deteriorating.

♦ Recurrent Ventricular Fibrillation.

♦ Pulseless Ventricular Tachcardia and Ventricular Fibrillation

♦ Following successful defibrillation or cardioversion from Ventricular Tachycardia or chemical conversion from magnesium sulfate.


♦ Use with extreme caution in presence of advanced AV Block unless artificial pacemaker

is in place.

♦ In Atrial Fibrillation or Flutter, quinidine-like effect may cause alarming ventricular acceleration.



7/01 M20.3


• PEDIATRICS-1 mg/kg IV or IO per dose; Infusion: 20 - 50 mcg/kg/min.

3. If cardioversion is successful, an infusion at 2.0 - 4.0 mg/min should be started.


• Side effects are as follows:

1. CNS disturbances: sleepiness, dizziness, disorientation, confusion, convulsions.

2. Hypotension: decreased myocardial contractility and increased AV Block at toxic

levels only.

3. Rare instances of sudden cardiovascular collapse and death.

• Drug is metabolized in the liver and, therefore, patients with Hepatic Disease, Shock or

Congestive Heart Failure will have impaired metabolism. All doses must be decreased by 50% in patients over 70 and those referred to above.

• Toxicity is more likely in elderly patients.

• As high as 50% of patients who develop Ventricular Fibrillation in the setting of an

Acute Myocardial Infarction may have no warning arrhythmias.



7/01 M22.1

MAGNESIUM SULFATE

CLASS

♦ Naturally occurring cation


♦ Magnesium is the second most common cation of the intracellular fluids.

♦ It plays a critical role in many enzyme systems, acts in neuromuscular transmission, andacts as a membrane stabilizer.

♦ Magnesium has been used to treat pre-term labor, eclampsia and pre-eclampsia, statusasthmaticus, seizures, alcohol withdrawal, torsades de pointes, ventricular fibrillation andventricular tachycardia.

INDICATIONS

♦ As an antiarrhythmic in the treatment of ventricular fibrillation and ventricular

tachycardia.

♦ Treatment of Torsade de pointes.

♦ Eclampsia with seizures.

PRECAUTIONS

♦ Administration of magnesium to patients with preexisting hypermagnesemia (typically

patients in renal failure) or the administration of excessive amounts of magnesium to any patient may lead to weakness, hypotension, loss of deep-tendon reflexes, and, at very

high levels, respiratory arrest.

ADMINISTRATION

♦ Pulseless ventricular tachycardia/ventricular fibrillation - 2.0 grams rapid IV push/IO.

♦ Stable/Unstable ventricular tachycardia - 2.0 grams IV slowly over 2 minutes.

♦ Eclampsia: 4.0 grams IV slowly over 5 minutes.


♦ Administration may be accompanied by a sensation of generalized warmness, with a

visible flushing being noted. This is associated with a peripheral vasodilation.



7/01 M22.2

MIDAZOLAM (VERSED®)

CLASS

♦ Benzodiazepine


♦ Midazolam acts as a central nervous system depressant, anticonvulsant, and

causes retrograde amnesia.

INDICATIONS

♦ Status seizures

♦ Produce amnesia during cardioversion, pacing, or burn treatment

♦ As an induction agent for paralytic intubation (see AIRWAY and AIRWAY

MANAGEMENT protocols)


♦ Allergy to midazolam or benzodiazepines

♦ Midazolam can cause respiratory depression and/or hypotension

♦ Midazolam is most likely to cause respiratory depression in patients who have

take alcohol or other depressant drugs

ADMINISTRATION

♦ For status seizures: Adults- 2.5 mg IV or 5 mg IM. May repeat the dose once in 1-2 minutes

if the seizure continues, up to 5 mg IV or 10 mg IM

Pediatrics- 0.1 mg/kg IV (maximum 2.5 mg) or 0.2 mg/kg IM (maximum

5 mg)

♦ For Cardioversion/Pacing: 2.5-5.0 mg IV (maximum 5 mg IV)

♦ For Rapid Sequence Intubation: 0.1 mg/kg IV (maximum 5 mg IV)



7/01 M22.3


♦ Midazolam should not be administered without having a BVM ready to use.

♦ In burn patients in which pain control is not adequate with morphine at 10 mg IV

alone, you may add midazolam at a dose of 2.5 mg IV. If there is a need toexceed this dosage, contact OLMC.

♦ The patient must be monitored closely for hypotension



7/01 M23.1

MORPHINE SULFATE

CLASS

♦ Opioid Analgesic


♦ Morphine Sulfate is a narcotic with potent analgesic and hemodynamic properties. It exerts its

analgesic effects on the central nervous system, simultaneously inducing drowsiness, mental

clouding and mood changes.

♦ Morphine has several hemodynamic actions of considerable importance:

1. It increases venous capacitance and thereby pools blood peripherally and decreases its

return (reduced preload). This assists in relieving pulmonary congestion and reduces left

ventricular and diastolic dimensions and myocardial wall stress. These all result in

decreased myocardial oxygen requirement.

2. Reduces systemic vascular resistance at the arteriolar level (reduced afterload). This

reduction in afterload also tends to decrease myocardial oxygen requirement. Central

sedative effects of morphine also will reduce myocardial oxygen requirements and the

chance of malignant arrhythmias due to reduction of apprehension and fear in patients.

The hemodynamic effects of morphine are probably mediated through the central nervous

system by a sympatholytic mechanism. Given intravenously, the onset of action is

prompt (2 - 3 minutes), peaks at 7 - 10 minutes, and lasts 3 - 5 hours.

INDICATIONS

♦ Severe chest pain unaffected by respirations or body movements with suspected ischemic cardiac pain unresponsive to Nitroglycerine.

♦ Severe pain (do not use if a patient has undiagnosed abdominal pain or head injury - see contra-

indications).

♦ Congestive heart failure/Pulmonary Edema

PRECAUTIONS /CONTRAINDICATIONS

♦ Contraindications to the use of Morphine:

Known allergy to morphine.

Volume depletion.

Hypotension or blood pressure less than 90 mmHg

Undiagnosed head or abdominal pain.

Trauma or suspected trauma to abdomen or head.



7/01 M23.2

PRECAUTIONS /CONTRAINDICATIONS (CONT)

♦ Morphine Sulfate causes predictable respiratory depression. This is quickly reversible with

Narcan®. Respiratory depression is much more likely to occur in patients with pre-existing

respiratory insufficiency (COPD).

♦ Narcan® and respiratory support should always be at hand when administering Morphine.

ADMINISTRATION

♦ Morphine should be given by titration of small intravenous doses at frequent intervals until the

desired response is achieved.

♦ There is considerable variation from patient to patient is the amount of drug required to acquire

the given effect. Give up to 20 mg maximum per patient; call OLMC if more is required

♦ Patients in respiratory distress with presumed congestive heart failure should receive a maximum

of 10 mg.

♦ A dose of 2.0 - 5.0 mg given intravenously is repeated every 5 - 30 minutes until the desired

effect has been achieved.

♦ Vital signs should be taken with particular attention to blood pressure and respiratory rate after

every incremental dose is administered.

♦ The end points of administration should be:

1. Achievement of desired effects. This may mean the dulling of sharp pain without

complete dissolution of the pain

2. Blood pressure less than 90 mm Hg.

3. Respiratory rate of less than 12 per minute.


♦ Respiratory depression, nausea and vomiting are all common side effects

♦ The analgesic effect of morphine should not be gauged solely by the total elimination of pain.

More importantly, morphine reduces the perception of pain by the patient while he/she still may

recognize the painful stimulus.

♦ Hypotension may develop as a consequence of the hemodynamic effect of Morphine especially inolder patients, volume depleted patients, or patients who have required elevated systemic vascular

resistance for the maintenance of their blood pressure. The value of small, frequent, incremental

doses is evident in this situation. Hypotension is usually responsive to Narcan® administration

and the Trendelenburg Position; if not, a cautious fluid challenge with 250 ml of Balanced Salt

Solution is indicated.



7/01 M23.3

SIDE EFFECTS/SPECIAL CONSIDERATIONS (CONT)

♦ In burn patients in which pain control is not adequate with morphine at 10 mg IV alone, you may

add midazolam at a dose of 2.5 mg IV. If there is a need to exceed this dosage, contact OLMC.



1/02 M24.1

NALOXONE (NARCAN®)

CLASS

• Synthetic Opiod Antagonist


• Narcan is a narcotic antagonist which competitively bonds to narcotic sites, but whichexhibits almost no pharmacologic activity of its own.

• Onset within 2 minutes with duration of action lasting 1 - 4 hours.

INDICATIONS

• Reversal of narcotic effects, particularly respiratory depression, due to narcotic drugs

either ingested, injected or administered in the course of treatment. Narcotic drugs

include Morphine, Demerol, Heroin, Dilaudid, Percodan, Codeine, Lomotil,Propoxyphene (Darvon

®), Pentazocine (Talwin

®).

• Diagnostically in coma of unknown etiology to rule out or reverse narcotic depression.

PRECAUTION/CONTRAINDICATIONS

• In patients physically dependant on narcotics, frank and occasionally violent withdrawal

symptoms may be precipitated.

• Be prepared to restrain the patient. May become violent as the Narcan reverses thenarcotic effect.

• Do not give if patient is older than 40 and on Clonidine (Catapress®). This may

precipitate malignant hypertension and induce or worsen hemorrhagic strokes or

myocardial infarcts.

• The duration of some narcotics is longer than Narcan®

and the patient must be monitored

closely. Repeated doses of Narcan®

may be required. Patients who have received thisdrug must be transported to the hospital because coma may re-occur when Narcan

®wears

off.

• May need large doses to reverse Propoxphene (Darvon®) overdoses.



1/02 M24.2

ADMINISTRATION

• ADULTS-0.4 to 2.0 mg slowly injected every 2 minutes IV, IM, SQ, SL, or by ET tube.IV administration is preferred.

• If no response is observed, this dose may be repeated at 3 - 5 minute intervals up to 5times (10 mg total) in patients suspected of having narcotic overdose.

• PEDIATRICS-0.1 mg/kg to 5 years of age or 20 kg weight, then adult dose IV, IM, SQor ET.

• In suspected opiate addicted patients, titrate doses until ventilations are adequate.



1/02 M25.1

NITROGLYCERIN1

CLASS

♦ Vasodilator and Antianginal agent


♦ Cardiovascular effects include:

1. Reduced venous tone - this causes pooling of blood in peripheral veins and decreased

return of blood to the heart. (Preload and afterload)

2. Decreased peripheral resistance.

3. Dilation of coronary arteries (if not already at maximum).

♦ General smooth muscle relaxation.

INDICATIONS

♦ Angina

♦ Chest, arm or neck pain thought possible to be related to coronary ischemia; may be useddiagnostically as well as therapeutically.

♦ Control of Hypertension in Angina or Acute Myocardial Infarction.

♦ Pulmonary edema; to increase venous pooling, lowering cardiac preload and afterload.

♦ Hypertensive crisis.

♦ Because NTG causes generalized smooth muscle relaxation, it may be effective in

relieving chest pain caused by esophageal spasm.

PRECAUTION/CONTRAINDICATIONS

♦ Generalized vasodilation may cause profound Hypotension and reflex Tachycardia,

particularly orthostatic.

♦ Nitroglycerin loses potency easily, it should be stored in a dark glass container with atight lid and not exposed to heat.



1/02 M25.2

PRECAUTION/CONTRAINDICATIONS (CONT)

♦ Be cautious with administering nitroglycerin to patients who have taken Viagra®

less than

24 hours prior to encounter as these patients are more likely to have hypotensiveepisodes.

♦ Avoid administration if blood pressure is less than 90 mmHG systolic,

SIDE EFFECTS

♦ Common side effects include throbbing headache, flushing, dizziness and burning under the tongue (if these side effects are noted, the pills may be assumed potent, not outdated).

ADMINISTRATION

♦ O.4 mg or 1 dose of Nitro spray SL. May be repeated every 5 minutes.Maximum 3 doses ** . If Nitro is controlling the chest pain, it may be repeated for more

than 3 doses ***.

1

EMT Basics can assist patients who are taking their own nitroglycerine



1/02 M26.1

NALBUFINE HYDROCHLORIDE (NUBAIN®)***

OPTIONAL

CLASS

♦ Synthetic narcotic agonist/antagonist


♦ Nubain®

(Nalbufine Hydrochloride) is a synthetic narcotic agonist/antagonist analgesic.It is an analgesic equivalent, milligram for milligram, to morphine.

♦ Its onset of action is 2-3 minutes after IV administration, and less than 15 minutes after SQ/IM administration.

♦ The respiratory depression associated with increasing doses of narcotics is not seen with Nubain

®, as it plateaus at a low dosage.

INDICATIONS

♦ Severe pain (do not use in patients with undiagnosed abdominal pain or head injury - seecontraindications)

♦ Substitute for pain management in morphine allergic patients.


♦ Known allergy to Nubain®

, Numorphan®

, Oxymorphan®

, or Narcan®.

♦ Volume depletion, hypotension, undiagnosed head or abdominal pain.

♦ Trauma or suspected trauma to abdomen or head.

♦ Chronically addicted to narcotics, to include patients on methadone (will precipitate acutewithdrawal).

ADMINISTRATION

♦ May be administered IV/IM/SQ. Usual IM/SQ dose is 10 mg.



1/02 M26.2

ADMINISTRATION (cont)

♦ Titrate IV doses (only) to desired effect, with usual starting dose being 5.0 mg.Endpoints of administration are:

o Achievement of desired effects.

o

Blood pressure less than 90 mm Hg.o Respiratory rate less than 12.


♦ Precipitation of withdrawal in narcotics addicts.

♦ Nausea, vomiting, respiratory depression, hypotension. Treat respiratory depression with

Narcan®

, hypotension with IV fluids/Trendelenburg position/Narcan®. (see ALTERED

MENTAL STATUS/COMA and SHOCK protocols)



1/02 M27.1

OXYGEN

CLASS

♦ Element

PHARMACOLOGY AND ACTION

♦ Oxygen added to the inspired air raises the amount of oxygen in the blood and therefore,

the amount delivered to the tissues. Tissue hypoxia causes cell damage and death.Breathing in most persons is regulated by small changes in acid/base balance and CO2

levels. It takes relatively large drops in blood oxygen concentration to stimulate

respiration.

INDICATIONS

♦ Suspected hypoxemia or respiratory distress from any cause.

♦ Acute chest pain in which a myocardial infarction is suspected.

♦ Shock (decreased oxygenation of tissues) from any cause.

♦ Major trauma.

♦ Carbon Monoxide poisoning.

PRECAUTIONS/CONTRAINDICATIONS:

♦ If the patient is not breathing adequately on his/her own, the treatment of choice isventilation, not just O

2. A nasal cannula without a breath is a waste of O2 (and

patients!!).

♦ A small percentage of patients with chronic lung disease breathe because they arehypoxic. Administration of O

2will shut off their respiratory drive. DO NOT

WITHHOLD OXYGEN BECAUSE OF THIS POSSIBILITY. BE PREPARED TOASSIST VENTILATION IF NEEDED. Initial O2 flow should be no greater than 2 LPM

in these patients.

ADMINISTRATION

DOSAGE INDICATIONS

Low 1-2 LPM) Patients with chronic lung disease.

Moderate (4-6 LPM) Precautionary use for trauma, abdominal pain, etc.

High (10-15 LPM) Severe respiratory distress, either medical or traumatic.



1/02 M27.2


♦ Non-humidified O2 is drying and irritating to mucous membranes.

♦ Restlessness may be an important sign of hypoxia.

♦ Oxygen supports combustion.

♦ Oxygen toxicity (overdose) is not a hazard from acute administration.

♦ Nasal prongs work equally well on nose and mouth breathers.

♦ Most hypoxic patients will feel quite comfortable with an increase of inspired O2 from 21

- 24%.

METHOD FLOW RATE O2

%

NASAL CANNULA 1 LPM

2 LPM6 LPM

24%

28%40%

FACE MASK 8 LPM 50-60%

OXYGEN RESERVOIR 10-12 LPM 90%

MOUTH TO MASK 10 LPM15 LPM

30 LPM

50%80%

100%

BAG-VALVE MASK ROOM AIR

12 LPM

INFLATE BAG

21%

40%

90+%



7/01 M28.1

PROPARACAINE HYDROCHLORIDE (ALCAINE®)OPTHALMIC SOLUTION, 0.5%***

CLASS

♦ Topical anesthetic agent.


♦ Alcaine®

contains a local anesthetic agent and is administered topically to the cornea toinduce corneal anesthesia.

INDICATIONS

♦ To induce corneal anesthesia to relieve pain before ocular lavage and from cornealforeign bodies not requiring ocular lavage.


♦ Penetrating ocular trauma.

♦ Allergy to Procainamide or to all amide type anesthetics (e.g. lidocaine, Marcaine®

)

ADMINISTRATION

♦ Administer two drops to the cornea or inferior conjunctival sac.

♦ May be repeated in fifteen minutes by the administration of two more drops topically.

♦ In a patient who is undergoing ocular lavage with a Morgan Lens, instill the rest of the bottle of Alcaine

®into the liter of crystalloid being used to lavage the eye using a syringe

and needle.



7/01 M29.1

RETAVASE™ (RECOMBINANT RETAPLASE)

St Helens OnlyCLASS

♦ Thombolytic.


♦ Retavase™ is a sterile, purified protein of 355 amino acids which represents the active portions of native TPA. It is synthesized using recombinant DNA technology.

♦ When introduced in pharmacologic concentrations into the human body, Retavase™ produces a systemic lytic state, breaking down clots throughout the body.

INDICATIONS

♦ For the treatment of the acute myocardial infarction, as defined in the Cardiac Chest PainProtocol.


♦ Age less than 18 years.

♦ Pain lasting less than 15 minutes or longer that 12 hours.

♦ No confirmation of acute myocardial infarction.

♦ Systolic blood pressure less than 90 or greater than 200.

♦ Systolic blood pressure difference greater than or equal to 20 mm Hg between right and

left arm.

♦ Pregnant or lactating.

♦ History of stroke, brain tumor, or aneurysm.

♦ Recent (less than 2 months) intracranial or intraspinal surgery or trauma.

♦ Active internal bleeding.

♦ Active GI/GU bleeding within 10 days.

♦ Taking coumadin (Warfarin®).

♦ Major surgery within 2 months.



7/01 M29.2

PRECAUTIONS/CONTRAINDICATIONS(CONT)

♦ CPR longer than 10 minutes.

♦ Significant trauma within the last 10 days.

♦ Terminal/DNR patient.

♦ No informed consent.

ADMINISTRATION

♦ Mix and administer Retavase™ using sterile technique:

1. Inject 10 ml of Sterile Water for Injection into the vial of Retavase™.2. Swirl gently to dissolve. DO NOT SHAKE.

3. Withdraw 10 ml of the solution from the vial, and inject into a patent, running IV

over a 2 minute period.4. Repeat steps 1-3, timing the administration of the second bolus to begin thirty

(30) minutes after the start of the first bolus.


♦ Death.

♦ Hemorrhagic stroke.

♦ Internal bleeding.

♦ Time is of the essence. Early identification facilitates rapid thrombolysis.



7/01 M30.1

SODIUM BICARBONATE

CLASS

♦ Alkalyzing agent


♦ Acidosis depresses cardiac contractility, depresses the cardiac response to catecholaminesand makes the heart more likely to fibrillate and less likely to defibrillate.

♦ Acids are increased when body tissues become hypoxic due to cardiac or respiratoryarrest. Sodium Bicarbonate reacts with hydrogen ions (acids) to form water and CO 2,

acting as a buffer in metabolic acidosis

INDICATIONS

♦ To control arrhythmias in Tricyclic Antidepressant overdose (see POISONING AND

OVERDOSE protocol).

♦ Cardiac arrest- see Cardiac Arrest protocol.

♦ Treatment of presumed severe hyperkalemia (slow, wide complex “sine wave” rhythm

with hypotension).


♦ Addition of too much NaHCO3 may result in alkalosis which is difficult to reverse and

can cause as many problems in resuscitation as acidosis.

♦ May increase cerebral acidosis, especially in diabetics who are ketotic.

ADMINISTRATION

♦ For Cardiac Arrest:

• Adult and Pediatric: 1.0 mEq/kg initially (approximately 2 amps for adults) Then

0.5 mEq/kg or 1.0 amp every 10 minutes until pulse restored.

♦ For Cyclic Antidepressant overdose or hyperkalemia:

• Administer 1 mEq/kg slow IVP



7/01 M30.2


♦ Each amp of Sodium Bicarbonate contains 44 or 50 mEq of Na+. This may increaseintravascular volume and hyperosmolarity conditions which result in cerebral

impairment.

♦ In the presence of a Respiratory Arrest without Cardiac Arrest, the treatment of choice isventilation to correct the respiratory acidosis. No NaHCO3 should be given unless

Cardiac Arrest has also occurred and then only after other first line interventions such asdefibrillation and other pharmacological interventions.

♦ Consider NaHCO3 in patients with renal failure who are on dialysis and may have

unstable cardiac activity secondary to hyperkalemia



7/01 M31.1

SUCCINYCHOLINE (ANECTINE®)

CLASS

♦ Depolarizing type neuromuscular blocking agent.

MECHANISM OF ACTION

♦ Succinylcholine (Anectine®

) is an ultra short acting depolarizing- type skeletal muscle

relaxant for IV or IM administration. The depolarization may be observed asfasiculations.

♦ Onset of flaccidity occurs within one minute of IV administration and within two to three

minutes of IM administration and lasts for four to six minutes.

INDICATIONS

♦ As an agent to provide skeletal muscle relaxation to facilitate endotrachael intubation incombative or tightly clenched patients.


♦ Penetrating ocular injury.

♦ History of stroke, paralysis, or existing neuro-muscular disease which has been present

for more than seven days.

♦ Extensive burns or crush injury more than seven days old.

♦ Family history of problems with general anesthesia.

♦ Personal or family history of malignant hyperthermia.


) is contraindicated in patients with known hypersensitivity.

ADMINISTRATION

♦ See AIRWAY and AIRWAY MANAGEMENT protocols

♦ The dosages are as follows:

• Adult - 1.5 mg/kg IV push for ages > 8.

• Pediatric - 2.0 mg/kg IV push for ages < 8.

• IM dose - 4.0 mg/kg for all ages. Maximum 150 mg.



7/01 M31.2



) has no known effect on consciousness, the pain threshold or cerebration. Administration must be accompanied by adequate anesthesia and/or

sedation.


) may increase intragastric pressure, which could result inregurgitation and possible aspiration of stomach contents. This result may also occur due

to the loss of esophageal parastaltic effect.


) causes a slight, transient increase in intraocular pressureand therefore should not be used in the presence of penetrating or open ocular injuries.


) has no direct effect on the myocardium, however, changes

in rhythm may result from vagal stimulation resulting in bradycardia, particularly in

pediatric patients.


) may cause muscle fasiculations which may cause additional

muscle trauma and be potentially deleterious to head injured patients. Consider pre-treatment with Vecuronium (Norcuron

®) (see AIRWAY and AIRWAY

MANAGEMENT protocol).


) may cause cardiac arrhythmias including bradycardia,tachycardia and cardiac arrest.


) may cause or exacerbate malignant hyperthermia.

♦ The paralytic effect of Succinylcholine (Anectine®

) may be prolonged, particularly in

pregnant women.


) should be administered by adequately trained individualsfamiliar with its actions, characteristics and hazards.

♦ Paramedics must be approved to use this medication. An OR rotation and successful

passing of the RSI exam is required for approval.



7/01 M32.1

THIAMINE

CLASS

♦ Vitamin


♦ Thiamine is a B-vitamin (B1) found in adequate amounts in the normal diet, butfrequently deficient in alcoholics. In alcoholics the deficiency causes Wernicke's

Syndrome, an acute and reversible encephalopathy characterized by ataxia, eye muscleweakness (diplopia and nystagmus), and mental derangements.

♦ Of more serious concern is Korsakoff's Psychosis, also caused by Thiamine deficiencyand characterized by memory disorder. Korsakoff's Psychosis may be irreversible once it

becomes established.

♦ For this reason, treatment with Thiamine is indicated if Wernicke's or Korsakoff'sSyndrome is recognized in an alcoholic. Since Thiamine is utilized in carbohydrate

metabolism, the syndromes may be precipitated by the administration of D50W in the

alcoholic, who often has already depleted Thiamine stores.

INDICATIONS

♦ In suspected alcoholics or malnourished patients after the administration of D50W.

♦ In suspected Wernicke's or Korsakoff's Syndrome.


♦ Allergic reactions occur but are extremely rare.(see ALLERGIES/ANAPHYLAXIS

protocol)

♦ Rapid IV administration has been associated with Hypotension.

ADMINISTRATION

♦ 100 mg IV (IM if necessary).



7/01 M33.2

VECURONIUM (NORCURON®)

CLASS

♦ Non-depolarizing type neuromuscular blocking agent

MECHANISM OF ACTION

♦ Nondepolarizing neuromuscular blocking agent of intermediate duration which

paralyzes skeletal muscle.

INDICATIONS

♦ As a defasiculating agent prior to the administration of Succinylcholine for suspected head injured patients.

♦ As an agent for the maintenance of paralysis which was initiated for airwaycontrol. Should only be used after endotracheal intubation has been confirmed.


♦ Since vecuronium (Norcuron®) causes prolonged paralysis, careful confirmation

of endotracheal tube placement should be undertaken before administration.

♦ Vecuronium (Norcuron®) is contraindicated in patients with known

hypersensitivity.

ADMINISTRATION

♦ Defasiculating dose: Adult: 1.0 mg IVP. Pediatric: 0.01 mg/kg IVP.

♦ After confirming correct endotracheal tube placement, administer vecuronium(Norcuron

®) 0.1 mg/kg IV push. (Standard adult dose - 7.0 mg).


♦ Vecuronium (Norcuron®) has no known effect on consciousness, the pain

threshold or cerebration. Administration must be accompanied by adequate

anesthesia and/or sedation.

♦ Repeated administration of maintenance doses of vecuronium (Norcuron®) has

little or no cumulative effect on the duration of neuromuscular blockade. Repeat

doses can be administered at relatively regular intervals with predictable results.



7/01 M33.3

SPECIAL CONSIDERATIONS (CONT)

♦ Patients with Hepatic Disease such as cirrhosis may experience a prolongedrecovery time in keeping with the role played by the liver in vecuronium

(Norcuron®) metabolism and excretion.

♦ Vecuronium (Norcuron®) should be administered by adequately trained

individuals familiar with its actions, characteristics and hazards.

♦ Paramedics must be approved to use this medication. An OR rotation andsuccessful passing of the RSI exam is required for approval.



7/01

Procedural/Operation

Protocols



1/02 P1.1

AIRWAY MANAGEMENT

PURPOSE

♦ To enable proper airway management for the EMT/Paramedic, assuring airwaycontrol and protection, as well as provide adequate ventilation and oxygenation

PROCEDURE

♦ Oxygenation, Ventilation, Airway Maintenance:

o Nasal Cannula (NC)* Useful for giving small amounts of supplemental oxygen (e.g. 2-4

liters)

o Partial Rebreather Mask (PRB)*

Needed when higher flow and concentrations of oxygen need to begiven (e.g. 5-10 liters)

o Blow-by Oxygen*

Used for infants and toddlers to deliver supplemental oxygen

and/or bronchodilators

o Nasopharyngeal/Oropharyngeal Airway (NPA/OPA)*

Used in patients who are unable to maintain an open airway on

their own

o Bag-Valve Mask (BVM)* Used when inadequate ventilation is present



1/02 P1.2

COMBI-TUBE**

The Combi-tube is a two-tube device with one distal tube and one proximal tube. When

it is inserted blindly, the distal (blue) tube enters the esophagus 90% of the time andenters the trachea 10% of the time. Depending on where the distal tube enters, the distal

tube will ventilate the esophagus or the trachea

INDICATIONS

♦ As an airway adjunct for EMT Intermediates

♦ When endotracheal intubation cannot be performed because of inadequate

visualization of the larynx

PROCEDURE

♦ Hyperventilate to prepare the patient for Combi-tube placement

♦ Place the head in a neutral position

♦ Insert the Combi-tube using the jaw lift maneuver to a depth showing the black

ring between the patient teeth

♦ Inflate the blue pharyngeal cuff (#1) with 100 cc’s of air and the clear distal cuff (#2) with 15 cc’s of air

♦ Ventilate through the longer blue tube (#1) and listen for sounds in the both lungs

and the stomach

♦ If breath sounds (instead of gastric sounds) are clearly heard through tube #1,ventilate through tube #1

♦ If you hear gastric sounds, ventilate through tube #2, the shorter clear tube

♦ Ventilate with 100% O2



1/02 P1.3

CRICOTHYROIDOTOMY***

DEFINITION

A cricothyroidotomy is the creation of a passage between the external

environment and the trachea through the cricothyroid membrane.

INDICATIONS

This technique should be used only when other attempts at establishing an airwayhave been unsuccessful, such as the inability to intubate or ventilate using BVM or

combi-tube and respiratory obstruction exists, such as:

• Foreign body obstruction

• Facial/laryngeal trauma

• Inhalation, thermal or caustic injury to the upper airway

• Angioneurotic edema

• Upper airway bleeding

• Epiglottitis

PROCEDURE

1. Place the patient in a supine position with the head secured; place two towels

under the shoulders and hyperextend the head (if not contraindicated by cervicalspine trauma)

2. Identify the cricothyroid membrane, the soft spot between the thyroid cartilage

and the cricoid ring

3. Prep the skin with betadine4. Insert the needle trough the membrane at a 45-degree angle toward the feet. Stop

when air is aspirated.

5. Stabilize the needle, remove the syringe, and pass the wire through the needle

until several inches are within the trachea6. Stabilize the wire; remove the needle and make a vertical incision in the skin next

to the wire with a scalpel

7. Pass the dilator with the cricothyroidotomy tube over the wire and through themembrane and remove the wire

8. Ventilate the patient, perform a 5 point check, and secure the tube in place



1/02 P1.4

SPECIAL PRECAUTIONS

♦ Advance the needle slowly making sure to stay in the midline; there are major vessels to either side of the membrane

♦ The vocal cords can be damaged if the puncture is made too high

♦ If the puncture is made too deeply, penetrating the posterior wall of the trachea, itcould lead to mediastinitis or inadvertent esophageal cannulation

♦ Cricothyroidotomy should not be used in children under 8 years. The cricoidcartilage is easily damaged in small children. If unable to endotracheally

intubate, a Needle Cricothyroidotomy with jet ventilation should be considered(see below)


♦ Administer Atropine 0.02 mg/kg IV for children under 2 years (minimum dose is

0.1 mg not to exceed the adult dose)

♦ Administer Succinylcholine 2 mg/kg IV for children under 6 years. May repeatonce if there is inadequate relaxation

♦ A formula that is helpful for remembering tube sizes for different age childrenyounger than 8 years:

Tracheal tube size (mm) = (age in years/4) + 4

♦ Generally use an un-cuffed endotracheal tube until 8 years

♦ Try to utilize a length based resuscitation tape (e.g. Broselow tape) whenavailable

Needle Cricothyroidostomy

♦ In children under the age of 8, if an endotracheal tube is not possible, consider Needle Cricothyroidostomy*** if you are unable to ventilate due to upper

airway obstruction or major trauma to the head and face:1. Find the cricothyroid membrane and prep the area

2. Use a 14 gauge angiocath connected to a 5 cc syringe , stabilize

the trachea with the nondominant hand and puncture the

cricothyroid membrane with the angiocath at a 30o-45

oangle

toward the feet

3. Verify placement with the aspiration of air and take special

care to avoid penetrating the posterior wall of the trachea4. Slide the catheter over the needle when placement is

confirmed, stabilize the needle with your hand and tape

securely5. Use O2 with jet ventilation tubing connected directly to a high

pressure source of O2 . Start with a PSI of 5 and adjust upward

until adequate chest rise is observed



1/02 P1.5

RAPID SEQUENCE INTUBATION with PARALYTIC

AGENTS

This procedure is reserved only for the paramedics that have passed the airway

exam and have spent a least one day in the operating room with ananesthesiologist (See OR ANESTHESIA REQUEST FORM)

INDICATIONS

♦ Respiratory insufficiency or impending respiratory failure

♦ Altered mental status with airway compromise (high risk of aspiration) e.g.overdose, poisoning

♦ Cardiac and/or Respiratory arrest

♦ Situations requiring positive pressure ventilation

♦ IN ADDITION TO:

A. A clenched jaw

B. An active gag reflexC. Uncontrollable combative behavior D. Head injured patients with a GCS of 8 or less

E. Clinical conditions requiring airway protection

♦ No contraindications exist (see SUCCINYLCHOLINE protocol)

EQUIPMENT

♦ Bag Valve mask apparatus

♦ NPA/OPA airways

♦ Oxygen

♦ Suction

♦ Larygoscope with blades, including Miller forceps

♦ A full array of endotracheal tube sizes and stylets

♦ Cardiac monitor

♦ Pulse Oximeter

♦ End-tidal CO2 monitor

♦ IV line

♦ Cook ®

Cricothyroidotomy kit

MEDICATIONS

Midazolam (Versed

®

) 0.1 mg/kg IV push not to exceed 5 mg in a singledoseLidocaine 1 –1.5 mg/kg IV

Succinylcholine (Anectine®) 1.5 mg/kg IV adults

2.0 mg/kg IV children less than 8 Y

4.0 mg/kg IM (if no IV access available)

Atropine 0.01 mg/kg IV in children less than 8 Y



1/02 P1.6

MEDICATIONS (cont)

Vecuronium 0.1 mg/kg IV for paralysis

1.0 mg IV for adult defasiculating dose

0.01 mg/kg IV for children less than 8 Y

PROCEDURE

1. Maintain opening the airway and pre-oxygenate with 100% O2 while maintaining

cricoid pressure

2. Assemble your airway equipment and place the patient on a cardiac monitor and pulse oximeter

3. Start IV (if not already established)

4. Start the premedication phase and give:a. Lidocaine 1-1.5 mg/kg IV

b. Midazolam 0.1mg/kg IV not to exceed an initial dose of 5mg

c. Atropine 0.01 mg/kg IV push for all children less than 8 years (minimumamount is 0.1 mg)

5. Continue cricoid pressure (Sellick maneuver)

6. Administer the paralytic agent:

a. Succinylcholine 1.5 mg/kg adults, 2.0 mg/kg children <8 b. If the patient doe not relax completely within 1 minute, repeat the same

dose

7. About 1 minute after the Succinylcholine is administered, paralysis should occur and the patient should be intubated at this point

8. If the patient desaturates during the intubation attempt (SaO2 less than 90%),

abort the attempt and ventilate with a BVM and 100% oxygen until the SaO 2

moves up into the mid to high 90% range

9. If the intubation attempts are repeatedly unsuccessful you can:

a. Ventilate with the BVM and 100% O2 until spontaneous respirationsreturn in 6-8 minutes IF you are able to ventilate and Cricoid pressure is

applied

b. If you are unable to ventilate with the BVM and 100% O2, tryrepositioning the head and/or using oro/nasopharyngeal airways (use

caution in potential C spine patients)

c. If you are still unable to ventilate, insert a Combi-tube and ventilate with100% O2 or perform a Cricothyroidotomy

10. Verify tube placement with a 5-point check and the end tidal CO2 monitor, place

an oral airway or bite block and secure the tube recording the tube depth

11. Recheck and redocument the ET tube placement after movement of the patient or

a change in the vital signs

12. If paralysis is needed during transport, give Vecuronium 0.1 mg/kg IV.



1/02 P1.7


♦ For Head Injury Patients (see HEAD TRAUMA protocol):a. Consider using a defasiculating dose of Vecuronium to prevent

fasiculations when Succinylycholine is administered. Fasiculations may

lead to increased intracranial pressure which should be avoided in patientswith head injuries and intracranial bleeding or swelling

b. Use the following dose of Vecuronium one minute before administering

the Succinylcholine (this dose will not cause paralysis): In adults, 1.0 mg IV push

In Children, 0.01 mg/kg IV push

c. Remember that head injury patients need early (pre-hospital) airway

management ensuring adequate oxygenation throughout their treatmentand transport

♦ When using the end-tidal CO2 monitor, monitor for color changes which may

indicate misplacement of the ET tube. In cardiac arrest situations, end tidal CO2 monitoring will not be a reliable method of confirming tube placement

♦ You should use the Pulse Oximeter in addition to the end-tidal CO2 monitor to

monitor tube placement and oxygenation

♦ It is recommended that there should be at least 2 rescuers proficient in intubation,when possible, before attempting RSI. It is up to the discretion of the Paramedic

on scene as to whether to proceed with RSI with only an EMT Basic or EMT

Intermediate present

♦ Do not rely just on the monitors, continually observe the patient



01/02 P2.1

CONTROL AND MONITORING OF IV SOLUTIONS**

PURPOSE

• To prevent the inadvertent administration of excess fluid volume or medications such as

lidocaine or dopamine or if there is a need to administer a specific amount of fluid to a

child

PROCEDURE • Initiate IV access

• If there is a need to maintain IV access, a SALINE LOCK should be placedexcept when there is a need to administer fluids:

1. Initiate the IV and after confirmation place the extension set1

over the IV

hub.

2. Flush with 10-15cc of normal saline through the adapter (or 2-3 cc if justusing a hub without extension tubing) and observe the area around the IV

to observe for any infiltration3. The system must be flushed after the administration of each medication

• If there is a small controlled amount of fluid needing to be administered, utilize a

Volutrol or Soluset type device1. Prepare the solution2. Connect the Volutrol between the solution bag and the IV tubing

3. Place the amount of fluid that you want to administer over 1 hour in the

Volutrol bag and close the connection to the solution bag

4. Infuse the amount in the Volutrol at the desired rate

• If there is a need to administer IV fluids for replacement of fluid volume lossessuch as trauma, burns, dehydration, or shock:

1. Initiate an IV and connect to IV tubing and a solution bag with Normal

Saline or a Balanced Salt Solution.2. Administer the fluid according to the specific protocol


• Balanced Salt Solutions should be used with caution in patients with renalimpairment (hyperkalemia), cardiac and respiratory disorders (fluid overload), or

extremes of age.1The extension set should at least be standard bore hub and it is preferred to be at least 5 inches long containing one

or more injection sites and a slide clamp



7/01 P3.1

CRIME SCENE RESPONSE*

PURPOSE: Law enforcement agencies stress that their first interest on any crime scene is the

preservation of life. Effective reconstruction of the crime scene must follow. EMS personnel can be of

assistance by adhering to the following guidelines regarding crime scene response.

PROCEDURE:

♦ Response and Arrival:

2. EMS units responding to the scene of a reported crime should obtain information from

their communications center about the nature of the incident and whether staging is

advised (see STAGING for HIGH RISK RESPONSE protocol)

3. As EMS and Fire units move into location, there should be a conscious evaluation of

physical and weather conditions around the site. Tire tracks of suspect vehicles are often

located in or adjacent to the driveway. Driving your unit over these tracks can obliterate

potentially significant evidence4. In any crime scene response, it is important to limit the number of personnel allowed into

the scene. It may be advantageous to have one of the EMS personnel consult with police

on the scene and direct the placement of vehicles and personnel response into the scene.

♦ Access and Treatment:

1. When entering the area where the victim is located, it is of great importance for EMS

personnel to select a single route to the victim. Maintaining a single route decreases the

chance of altering or destroying evidence or tracking blood over a suspect's footprints.

2. When moving toward the victim, it is important to note the location of furniture,

weapons, and other articles, and avoid disturbing them. If they need to be moved,

someone should note the location the article was moved from, by whom it was moved,and where it was placed.

3. Attempt to clean up medical debris left at the scene. This material often confuses the

investigators and leaves unanswered questions.

4. Be conscious of any statements made by the victim or other persons at the crime scene.

As soon as possible, write down what these statements were and report to the

investigating officers.

5. In treating the victim of a crime, it is important to note the specific garments worn by the

patient at the time of treatment. It is also VERY important that EMS personnel do not, if

at all possible, tear the clothing off or cut through any holes, whether made by a knife, bullet, or other object.

6. The victim should be placed on a clean sheet when ready for transport. At the hospital,

please try to obtain the sheet once the victim is moved off of it, fold it carefully in on

itself, and give it to the investigating officers. This is especially important in close

contact crimes such as rape or serious assault and death cases.



7/01 P3.2

DOCUMENTATION

♦ A detailed report that covers all aspects of your involvement at the crime scene is important in

case you are later called to testify in court

♦ These narratives should cover your observations and conversations with the family or persons

present at the scene, locations of response vehicles and equipment, furniture, weapons, or

clothing that has been moved, items that were handled by EMS responders, and your route to the

victim

♦ This narrative should be a separate report from your Patient Care Form

♦ EMS personnel should consider the following potential crime scenes:

• Domestic violence, suicide attempts

• Fires, MVAs,

• Assaults, near drowning

♦ If EMS personnel feel that there is a potential crime at the scene, report the suspicion to the

police.



7/01 P4.1

DEATH IN THE FIELD

PROCEDURE

♦ Determining Death in the Field (DIF) without initiating resuscitative efforts should be consideredunder the following conditions:

• If a bystander, family member, or First Responder has started BLS, these conditions maystill be used to determine DIF without Medical Resource Hospital contact. ORS allows a

layperson, EMT, or Paramedic to pronounce "Death in the Field"

Patient qualifies as a "DNR" patient (see DO NOT RESUSCITATE Protocol)

A pulseless, apneic patient in a Mass Casualty Incident or Multiple Patient Scene

where the resources of the system are required for the stabilization of living

patients

Decapitation

Rigor Mortis in a warm environment

Decomposition

Venous pooling in dependent body parts (dependent lividity)♦ In traumatic cardiac arrest, in addition to the conditions listed above under Withholding

Resuscitative Efforts, a victim of trauma should be determined to be Dead in the Field if:

The patient is a victim of blunt trauma and has no vital signs in the field

(pulseless, apneic, fixed and dilated pupils). These patients should not be

transported

If opening the airway does not restore the vital signs, the patient should not be

transported unless:

• There is a narrow complex rhythm, suggesting hypovolemia which may

respond to fluid resuscitation**

• There is ventricular fibrillation which would suggest a preceding medical

event.**

♦ In cardiac medical arrest: The victim of a medical (non-traumatic) Cardiac Arrest should be determined to

be Dead in the Field if:

• The patient's ECG shows Asystole or Agonal Rhythm upon initial

monitoring (and after at least one (1) repositioning of the paddles or

confirm in at least 2 leads), and the patient, in the Paramedic or

Intermediates best judgment, is not resuscitatable.**

• The Paramedic who is the PIC should determine DIF and notify the

Medical Examiner.***

• The patient who has been shown to be unresponsive to appropriate

advanced cardiac resuscitative measures by declining during

resuscitation to Asystole or Agonal Rhythm (after checking all leads,electrodes, may be determined to be Dead in the Field by the Paramedic

who is PIC.***

♦ All patients in Ventricular Fibrillation should in general be transported, except when DNR or

other withholding resuscitative efforts apply (if in doubt, contact Medical Resource Hospital).



7/01 P4.2

DOCUMENTATION

♦ All patient care provided should be documented with procedure and time

♦ In non-traumatic deaths or any time a cardiac monitor is used to determine death in the field, all

non-resuscitation or stopped resuscitation cases should have an ECG strip which shows

calibration of the ECG machine and the patient's rhythm. This does not apply to conditions listed

under A (Determining Death in the Field).***


♦ All conversations with physicians or Medical Resource Hospital should be fully documented with

physician's name, times, and instructions

♦ Most victims of electrocution, lightning, and drowning should have resuscitative efforts begun

and be transported to the hospital

♦ Hypothermic patients should be treated per the HYPOTHERMIA protocol

♦ Consider the NEEDS OF SURVIVORS when discontinuing a code. The following are some

guidelines:

o Calmly remove children from the resuscitation area

o If the emotional state of the family is appropriate, they may be allowed to watch or

participate in a limited and appropriate way by gathering medicines and providing history

o If family or friends were doing CPR prior to your arrival, commend their efforts

o If family or friends are disruptive, remove them as gently as possible

o If the resuscitation is occurring in the patients home, be respectful of those who live there

by making requests and not giving orders

o Give factual information to survivors regarding an explanation of the resuscitative effort

and why it may have failed.

o Genuine warmth and compassion are most helpful to grieving families; listening provides

grieving people with the most comfort

o Try to see to it that the survivors have a support system in place prior to leaving. Call

friends, family, neighbors, or clergy to be with them.♦ For the death of a child:

o Suspect SIDS between 1 month and 1 year of age

o Make every effort to resuscitate the child

o Do not accuse the parents of abuse or neglect

o Mottling on a baby’s body and bloody froth around the nose and mouth with a contorted

face may be present in SIDS deaths

♦ After death has been pronounced, contact the Columbia County Medical Examiner before

moving or altering the body unless released to do that by the Medical Examiner



7/01 P5.1

DO NOT ATTEMPT RESUSCITATE

PURPOSE

♦ The goal is to provide comfort and emotional support with the highest quality medical care to

patients in conformity with the highest ethical and medical standards. The patient with decision-making ability has the right to specify, in advance, their preferences when they may no longer be

able to communicate those preferences. The EMS system will honor “DNR” orders and advanced

directives.

DEFINITIONS

♦ DNR (Do Not Resuscitate) Order

• An order issued by a physician directing that in the event the patient suffers a

cardiopulmonary arrest, (i.e. clinical death)

♦ Clinical death exists when a patient is pulseless and not breathing.

♦ Biological death has occurred when no CNS signs of life exist.

♦ Advanced Directives convey a patient’s wishes regarding their treatment options near the end of

life

♦ Physicians Orders for Life-Sustaining Treatment (POLST) is a form signed by the patient’s

physician indicating treatment and care preferences. It includes a section for documenting DNR

orders but is also specific about various treatment preferences such as diet and comfort care.

When signed by a physician, the form becomes a physician’s order

♦ Attorney in fact is an adult appointed to make health care decisions for the patient

♦ Oregon Death with Dignity Act is a legislative act, which allows for physician-assisted suicide

for individuals who may be terminally ill.

PROCEDURE

• Unless a "DNR" order is issued, any patient who sustains a cardiopulmonary arrest will receive

full cardiopulmonary resuscitation with the objective of restoring life

• Resuscitation includes attempts to restore failed cardiac and/or ventilatory function by procedures

such as endotracheal intubation, mechanical ventilation, closed chest massage, and defibrillation

• BLS protocols at the EMT-B level will be followed while attempts to determine if a written DNR order from the patient's physician is in the patient's medical file

• If a DNR order is issued, BLS resuscitation efforts will continue until one of the following

occurs:

1. There is a written and signed DNR order produced

2. The patient’s physician directs the EMT/Paramedic not to continue resuscitation



7/01 P5.2

PROCEDURE (CONT)

3. There is a valid Advanced Directive or POLST order directing providers not to

resuscitate

4. The patients Attorney in fact directs the providers not to resuscitate

5. The person, who is terminally ill, has ingested medication under the provisions of the

Oregon Death with Dignity Act and has a DNR order and/or documentation that theingestion was an action under the provisions of the Death with Dignity Act. If 911 wascalled, make sure that the patient no longer wishes to end their life.

• The EMT must document the DNR order in the Patient Care Report

• It is always appropriate to provide comfort care measures

• The following procedures should NOT be performed on a patient who is the subject of a

confirmed DNR order and who is PULSELESS AND NONBREATHING:

CPR Endotracheal Intubation*** Defibrillation**

Oral/Nasal Airways Suctioning IV lines**

Fluids** Medications *** EKG monitoring.**

Oxygen Assistance with respiratory efforts Combi-Tube**



7/01 P6.1

DOCUMENTATION OF CARE

PURPOSE

• The purpose of this procedure is to describe what documentation is required onmedical responses.

PROCEDURE

• A Patient Care Report should be written for each patient seen, treated, or transported by an ALS or BLS ambulance. The patient care report should be

completed on the EMS Patient Care Form. Documentation will be in the SOAPformat.

• Documentation should include at least:

1. Patient problem presented2. Vital signs with time3. Treatment provided and time

4. EKG strip, if monitored**

5. Any change in condition of patient

6. OLMC (Medical Resource Hospital or receiving hospital) contact7. Any deviation from protocol.

• A copy of the Patient Care Report or an abbreviated report should be left at thehospital whenever a patient is transported. The completed Patient Care Report

must reach the hospital as soon as possible within 12 hours of the call.

• If a patient refuses treatment or transport, documentation should include at least(see PATIENT REFUSAL protocol):

1. Name of patient2. Reason for ambulance response

3. Reason for patient refusal4. Vital signs and time

5. Any other physical signs or symptoms

6. Competency of patient7. Level of consciousness – detailed

8. Any witnesses.

9. A completed Patient Refusal Form



7/01 P7.1

INTRAOSSEOUS INFUSIONS**

DEFINITION

This is an alternative technique for establishing IV access in pediatric patients in whom

peripheral IV access is difficult and time consuming.

INDICATIONS

♦ Intraosseous infusion is indicated in emergencies when life saving fluids or drugs should

be administered and IV cannulation is either too difficult or time consuming to perform

♦ In the pre-hospital setting, intraosseous infusion is generally considered in a child three

years of age or less, in cardiac arrest or shock with a decreased level of consciousness

and with an inability to establish peripheral IV access

♦ This procedure should not delay transport time and airway management should be the

therapeutic priority in all these cases (see AIRWAY and AIRWAY MANAGEMENT

protocols)♦ May be used on patients older than 3 years as a last resort for vascular access

PROCEDURE

1. Prepare the equipment:

a. Approved bone marrow type needles 15 and 18 gauge size

b. Betadine swabs

c. Two 5 cc syringes

d. Flush solution

e. Sterile gauze pads

f. Tape

g. Tee connector with a 3-way stopcock

2. Select the site over the proximal tibia, avoiding a leg which has been traumatized or

infected

3. Prepare the site by palpating the landmarks and note the entry point which is the

anteromedial flat surface 1-3 cm below the tibial tuberosity. Prep that area with betadine

and dry with a sterile gauze pad.

4. Insert the needle at the proximal tibial site, directing the needle caudally (toward the foot

and away from the knee joint to avoid damaging the growth plate)

a. The needle should penetrate the skin and subcutaneous tissue and be pushed

through the cortex by rotating until a “pop” or loss of resistance is felt. (do notrock the needle to get it through the cortex)

b. Confirm the placement of the needle in the marrow by:

i. The free aspiration of blood/marrow after the removal of the stylet (take

the blood/marrow sample to the ED) OR



7/01 P7.2

PROCEDURE (CONT)

ii. Infusion of 2-3 cc of sterile solution, palpating for extravasation or

noting significant resistance. If extravasation occurs, all further attempts

at the site and extremity should be avoided

5. Start the infusion:

a. Although gravity infusion may suffice, pressurized infusions (using a 3-waystopcock and 60 cc syringe or infusion pump) may be needed during

resuscitation.

b. When infusing medications through the IO site, pressure must be applied to the

fluid bag in order to maintain flow rates to ensure delivery of the medication


♦ Do not place an IO where there is cellulitis, burns, or a fracture proximal to the site

♦ Potential complications include osteomyelitis, growth plate injury, or extravasation of

fluid with compression of the popliteal vessels or the tibial nerve

♦ An alternate site for infusions is at the ankle at the medial surface of the distal tibia at the

junction of the medial malleolus and the shaft of the tibia.



7/01 P9.1

OCULAR EXPOSURES***

HISTORY

♦ Type of chemical exposure to the eyes:• Gas (e.g. Chlorine)

• Solid (e.g. Drano or lye)

• Liquid (e.g. battery acid)

♦ When the exposure occurred

♦ Contact lens use

♦ Visual changes

PHYSICAL FINDINGS

♦ Eye exam looking for:

• Pupil size, reactivity and shape

• Presence of redness to the conjunctiva or lids

• Presence of foreign material

INDICATIONS

♦ To treat chemical exposures to the eyes which could continue to cause damage to

the cornea (this does not include foreign bodies such as glass, dirt, rocks, or

grinding materials; it also does not include welding exposures or exposures to thesun.

PROCEDURE

1. Explain the eye irrigation procedure to the patient.

2. Place 2-3 drops of the Alcaine®

anesthetic solution into the inferior conjunctival

sac of the affected eye. May use 2-3 more drops if the eye is not completelynumbed.

3. Remove the contact lens if present and place the Morgan Lens.

4. Instill the remainder of the Alcaine®

solution into a1000 ml bag of NS.

5. Attach the 1000 ml bag of NS to the Morgan Lens and run it in over 30 minutes.


♦ DO NOT instill any drops into an eye which has an irregular pupil or blood in theanterior chamber (hyphema) These are signs of penetrating ocular injuries; if that

is the case, an eye shield should be placed and they should be transported.



7/01 P9.1

RECEIVING HOSPITAL COMMUNICATIONS

ON LINE MEDICAL CONSULTATION

PURPOSE

• The purpose of contacting the receiving hospital is to provide notification to thefacility prior to the arrival of an emergency patient. There will also be a need to

consult a physician if questions or conflicts arise in the course of providing care.This protocol will review the procedure for both of these

PROCEDURE

• EMTs should contact the receiving hospital at least 5 minutes before arrival bytelephone or the HEAR system

• The format of the report to the receiving hospital is as follows:

1.

Unit identification2. Age and sex of patient3. Condition of patient

4. Chief complaint or reason for transport5. Very brief pertinent medical history (one sentence)

6. Vital signs

7. Pertinent treatment rendered8. Request for additional information or treatment

9. ETA

• In order to minimize airtime, all reports should be given in this order and in a

maximum of 60 seconds. The HEAR report is not meant to be a full patient

report. The report should relay only patient care information. Patientidentification information, as well as HIV status, is inappropriate to be given onthe HEAR frequency.

• For all OLMC (On Line Medical Consultation):

1. If the receiving hospital is Washington, Columbia, Cowlitz or Clatsopcounties, try to contact the receiving hospital first and speak to a receiving

physician. If that is not possible, contact OHSU-Medical ResourceHospital (MRH).

2. If the receiving hospital is in Multnomah or Clackamas counties, contact

OHSU-Medical Resource Hospital (MRH).

3. You may call the GSH emergency department and speak to Dr. Wiens or

Dr. Perretta, if they are available, at any time regarding a case.



7/01 P10.1

ON-SCENE MEDICAL CONTROLFormerly Medical Professional at the Scene

PURPOSE

♦ To describe who is in charge of patient care at the scene of medical emergencies and howto resolve potential conflicts with other medical professionals who may be at the scene.

PROCEDURE

♦ For EMTs/ Paramedics On-Scene:

a. The first arriving and highest certified EMT will be the person in charge (PIC)

and will take responsibility for directing overall patient care.

b. The PIC will be responsible and accountable for patient care activities performed

at the scene and will be identified on all patient care reports

c. If there is a transfer of care to another service (e.g. Lifeflight) , the transfer of

patient care will be turned over to the transporting agency when:

The patient is placed on the transporting agencies gurney OR

At a time agreed upon by both EMTs (or EMT-flight nurse

♦ EMTs/Paramedics may take direction in the field from the following:

a. Physician Advisor

b. Regional protocols

c. On-line medical control (OLMC) (see OLMC-HOSPITAL

COMMUNICATION protocol)

d. Licensed physicians on scene as allowed in this protocol. Only physicians

(M.D./D.O.) with a valid license in the State of Oregon, as evidenced by their

wallet card license in their immediate possession, are recognized as physicians

under this section.

♦ EMTs/Paramedics in a physicians office or clinic:

a. When EMS is called to an office, paramedics and EMTs should receive

information and attempt to provide the assistance requested by the physician or

their staff while in the office.

b. While in the physicians office, the physician shall remain in charge of the patient

and can direct the EMT providing it is within the scope and protocols of the PIC

c. Once the patient is in the ambulance, the EMTs and paramedics shall follow the

protocols and the PIC is responsible for the patient care. The exception here

would be if the physician accompanies the patient to the hospital

d. If there are any conflicts between the protocols and the physician’s orders at the

scene, contact OLMC for direction (see

protocol

OLMC-HOSPITAL

COMMUNICATION



7/01 P10.2

PROCEDURE (cont)

♦ EMTs/Paramedics with physicians at a scene:

a. Medical professionals at the scene of an emergency may provide assistance to paramedics and shall be treated with professional courtesy

b. Medical professionals who offer their assistance at the scene should be asked to

identify themselves and their level of training. The EMT should request that the

medical professional provide proof of his/her identity if he/she wishes to assist

with care given to the patient after the arrival of the EMS Unit.

• The physicians should be thanked by the PIC and informed that the

EMTs/Paramedics work under county protocols

• If the physician requesting medical control is not the patient’s

“physician of record”:

1. The physician should accompany the patient to the hospital

2. The physician should complete and sign the prehospital care

report.3. OLMC is contacted (see OLMC-HOSPITAL

COMMUNICATION protocol) and agrees to transferring

patient care to the physician from the PIC

4. EMTs/Paramedics must provide care only according to approved

Columbia county protocols. The protocols need to be sharedwith any physician requesting medical control.

• If the physician requesting medical control is caring for the patient

prior to arrival of EMS:

1. The physician must accompany the patient to the hospital to

maintain continuity of patient care.

2. The physician on the scene shall have made available to him/her the services and equipment of the EMS Unit, if requested.

3. There should be full documentation of these events, includingthe physician's name.

4. If a conflict arises about patient care or treatment protocols, the

paramedic should contact the Physician Supervisor, the Medical

Resource Hospital, or the receiving hospital for assistance.

c. Nurses working in the aeromedical environment and physicians are the onlymedical professionals who may assume control of the patient. The EMT should

recognize the knowledge and expertise of other medical professionals and use

them for the best outcome of the patient.

♦ CONTACT OLMC IF THERE ARE ANY DISPUTES BETWEENEMTs/PARAMEDICS AND OTHER MEDICAL PROVIDERS (see OLMC-

HOSPITAL COMMUNICATION protocol)



7/01 P11.1

PATIENT REFUSAL

PURPOSE

♦ To describe the procedure used when obtaining and documenting a patient refusalafter an EMS response

PROCEDURE

♦ Determine if the patient initiated the 911 call for themselves

♦ Determine if the patient is an adult (18 YO or older) or a legally emancipatedminor (see PATIENT TREATMENT RIGHTS protocol)

♦ Determine if the patient is competent with Decision Making Capacity:

• Is oriented to Person, Place, Time, and Situation

• Exhibits no visual evidence of:

Altered level of consciousness Alcohol or drug ingestion that impairs judgment Injury, illness or trauma mechanism of injury

• Understands the nature of the medical condition, and the risks andconsequences of refusing care

♦ In the Patient with Competent Decision Making Capacity:

1. Explain the risks and possible consequences of refusing care and/or

transport2. If a serious medical need exists, contact OLMC

3. Enlist family, friend, and/or law enforcement to help convince the patient

that medical care is needed4. If the person continues to refuse, complete the REFUSAL

INFORMATION FORM5. Give the patient a copy of the form and keep the other copy for the

agencies file with the Pre-hospital Care report

♦ In a person with Impaired Decision Making Capacity:

1. An impaired patient should not sign the Refusal Information Form

2. Treat and transport any patient who is impaired and has a potentially lifethreatening condition

3. If the person meets criteria for NO PATIENT IDENTIFIED1

but is

impaired, make efforts to leave the person with a responsible individual4. If there is any medical need, make a reasonable effort to assure that the

patient receives appropriate care by contacting family, friends, and/or law

enforcement to help5. On cases that the patient is impaired, and there are no responsible

individuals to assure that they receive appropriate care, contact OLMC

(see OLMC-HOSPITAL COMMUNICATION protocol)



7/01 P11.2

PROCEDURE (cont)

6. If transport is needed in the impaired patient who is in need of restraint,

attempt restraint only if this can be done safely

♦ Document:1. General appearance

2. Vital signs

3. History and physical exam4. Mental status

5. Presence of drugs and/or alcohol

6. Assessment of decision making capacity

7. Risks explained and advice offered8. Response to efforts by EMTs to provide care

9. All communications with the patient, family, friends, law enforcement and

OLMC

10. Complete the Refusal Information Form

♦ Remember the EMERGENCY RULE:

• EMTs may treat and/or transport, under the doctrine of implied consent, a

person that requires immediate treatment to save a life or prevent seriousinjury

♦ Suggested reasons to contact OLMC:

• Suspected impaired decision making capacity

• Suspected serious medical conditions where transport is advised

• Conflicts at the scene

• If the EMT is uncertain of the risks a patient might encounter by refusing

No patient identified means:

• No significant mechanism of injury

• No significant signs of trauma

• No acute medical conditions

• The individual is 18 years or older

• The individual did not call 911 for themselves



7/01 P11.3

Columbia County Refusal Information Form

Name: ____________________________________Date of Birth: ________________

Run Number: ____________________Date: _________________________________

PLEASE READ AND KEEP THIS FORM!

This form has been given to you because you do not want treatment and/or transport by

_______________________Emergency Medical Services. Your health and safetyconcern us. Please remember the following:

1. Your condition may not seem as bad as it actually is. Without treatment your

condition could become worse.2. Our help cannot replace treatment by a doctor. You should obtain treatment by

going to an Emergency Department, or by calling your doctor. You may be seen

at an Emergency Department without an appointment.3. If you change your mind or your condition worsens, do not hesitate to call 911.

4. If this number has been circled, you have been advised to go to the hospital by

ambulance for evaluation and treatment.5. If this number has been circled, we have discussed your condition with a doctor

who agrees that you should go the hospital by ambulance for evaluation and

treatment.

6. Other: ____________________________________________________________

I have received a copy of this information sheet

Patient or Guardian Signature_______________________________Date_____________

• Patient or Guardian Assessment (circle)

1. Oriented to Person? Y N Place? Y NTime? Y N Event? Y N

2. Altered level of consciousness? Y N

3. Head Injury? Unknown Y N

4. Alcohol, drug or psychiatric impairment? Unknown Y N5. Does the person understand the advice given an the risks of refusing? Y N

• OLMC Contacted? Y No, not able No , not indicated

• Patient advised? Medical treatment needed Ambulance transport needed

(circle all that apply)Further harm could result without treatment

• DISPOSITION Patient would not accept the Refusal Information form(circle all that apply)

Patient refused all EMS services Refused field treatment Refused transportPatient left in the care or custody of :

NAME _________________________________________ RELATIONSHIP __________________

PIC Signature________________________________________________Date____________

ATTACH TO THE PATIENT CARE REPORT



7/01 P12.1

PATIENT RESTRAINT

PURPOSE

Patient restraints (physical and/or chemical) should be utilized only when necessary and

in those situations where the patient is exhibiting behavior that the EMT believes presentsa danger to the patient and/or others. This procedure should not be used on patients

refusing treatment unless they are on a police hold or after consulting with a physician

on-line. This procedure does apply to patient being treated under implied consent.

PROCEDURE

♦ Guidelines for physical restraint

♦ Use the minimal physical restraint required to accomplish necessary patient careand ensure safe transportation to the hospital:

1. Soft restraints may be sufficient

2. If law enforcement or additional personnel are needed, call for it before attempting any restraint procedures

3. Do not endanger yourself or your crew in attempting to apply

restraint

♦ Avoid placing restraints in such a way as to preclude evaluation of the patient’s

medical status (airway, breathing, circulation). Consider whether restraints will

interfere with necessary patient care activities or will cause further harm

♦ Physical restraints procedure:a. Ensure sufficient personnel are present to control the patient while

restraining him/her: USE POLICE ASSISTANCE WHEN AVAILABLE

b. Place patient face up on a long backboardc. Secure all extremities to the backboard:

1. Try to restrain lower extremities first using Flexcuffs®

around bothankles

2. Next, restrain the patients arms at the side using one Flexcuff ®

on

each wristd. If necessary, utilize cervical spine precautions (tape, foam bags, etc.) to

control violent head or body movements

e. Place padding under the patients head and wherever else needed to preventthe patient from further harming him/herself or restricting circulation

f. Secure the backboard to the gurney for transport using additional straps if

necessary; remember to secure additions straps to the upper part of thegurney to avoid restricting the wheeled carriage

g. Check the neurovascular status of each limb, distal to the site or restraint,

every 15 minutes and document the exam

h. Physical restraints must be used any time a potentially violent or unstable patient (i.e. head injury, altered mental status for any reason, or the patient

is under the influence of intoxicants) is transported by air ambulance or

helicopter



7/01 P12.2

PROCEDURE (cont)

i. In situations where the patient is under arrest and handcuffs are applied by

law enforcement officers:

1. The patient will not be cuffed to the stretcher and a law

enforcement officer shall accompany the patient in the ambulance,if the handcuffs are to remain applied

♦ Chemical restraint guidelines:a. b.

a.

b.

c.

d.

e.

Sedative agents can be used to provide a safe method of restraining the

violent, combative patient, preventing injury to the patient and/or others

These patients include but are not limited to:

1. Alcohol and/or drug intoxicated patients2. Restless, combative head injury patients

♦ Chemical restraint procedure:

Assess the possibility of using physical restraints first and the personnelavailable to safely attempt restraining the patient.

Prepare the sedative medications for injection and prepare for potentialhypotensive side effect.

Give 1-2 mg of Versed®

IM or IV push. Assess vital signs within the first5 minutes and thereafter. Repeat the dose if the patient is still combative

15 minutes after the initial injection.***

Assess the need for sedation carefully; the violent combative patient has a

lesser chance of injury while sedated. Any patient who is fighting their physical restraints and compromising their airway or cervical spine is a

candidate for sedation.

Side effects of Versed®

include hypotension. Midazolam should not be

administered without having a BVM ready to use.



7/01 P13.1

PATIENT TREATMENT RIGHTS

PURPOSE

♦ The Columbia County Protocols are intended for use with a conscious,consenting patient, minors, or an unconscious (implied consent) patient.

♦ If a conscious adult patient who is rational refuses treatment, you should complywith the patient's request and document the refusal (see PATIENT REFUSAL

protocol)

♦ If a conscious patient who is irrational or may harm him/herself refuses treatment,you should contact OLMC (see OLMC-HOSPITAL COMMUNICATION

protocol)(see PSYCH/BEHAVIORAL EMERGENCIES protocol).

♦ If a patient's family, patient's physician, or nursing home refuses treatment for a patient, protocols are contained herein to deal with those situations. (see

TRANSPORT OF THE CHRONICALLY ILL PATIENT protocol)

♦ A patient has the right to select a hospital (within reason) to which to betransported if he/she is rational, and if in your best judgment, transport to thathospital will not cause loss of life or limb. Code 3 ambulance should transport the

patient to the nearest appropriate facility.

♦ The age of consent and refusal in Oregon is 18. Exceptions to this rule arelawfully married patients under the age of 18, and legally emancipated minors

(age 16 and over) who have their “Order of Emancipation” from the court in their possession. Of critical importance to the EMT is the exception in the law where

the EMT may treat and/or transport under the doctrine of implied consent, a minor

who requires immediate care to save a life or prevent serious injury. This consentis also provided by these protocols (off-line medical direction).

♦ In situations with no injury, or a relatively insignificant injury involving minorswhere no parental contact can be obtained, contact with the Medical Resource

Hospital is mandatory. To err on the side of treatment is the safe approach.

Careful documentation is important.

♦ In addition to the above, all patients are entitiled to be treated at all times withconsideration and full recognition of human dignity and individuality. This

includes:

1. To have access to pre-hospital emergency medical care and transportationregardless of race, color, creed, national origin, age, sex, disability, or

ability to pay for the service provided.



7/01 P13.2

2. To have a reasonable response to a request for service once the

ambulance/EMS service is engaged.

3. To have reasonable privacy with respect to emergency care andtransportation.

4. To be treated with respect, dignity and compassion

5. To know the names and certification level of all personnel involved intheir care.

6. To be able to talk openly with the ambulance personnel involved and

know that the information will be held in confidence and only shared withthe individuals providing further medical care.

7. To know why each medical procedure needs to be performed, as well as

the alternatives to performing it and the risks involved.

8. To refuse portions of care or revoke consent for procedures after consentwas previously given.

9. To provide reasonable continuity of care once EMS is engaged to provide

service

10. To voice a concern regarding any aspect of the emergency medical careand transportation received, with the ability to call the district to discuss

the concern, which will not affect any future use of EMS services

11. To be transported in an environment that is safe from recognized hazards

and unreasonable annoyances



7/01 P14.3

PRE-HOSPITAL RESPONSE

TO RADIOLOGICAL MEDICAL EMERGENCIES

PURPOSE

♦ To create a set of procedures and guidelines for dealing with a potential radiologicalemergency at the defunct Trojan Nuclear power plant

PROCEDURE

♦ IF THERE IS NO DECLARED EMERGENCY AT TROJAN - AMBULANCE

DISPATCHED TO TROJAN:

A. "Zero" the pocket dosimeter from the radiation kit. Attach the pocket dosimeter and TLD to your shirt/jacket.

B.

Enter the Trojan plant access road from Highway 30. Drive to the main gate. Themain gate will be open and the security guard will let you go through.

C. Drive to the upper gate. It will be open. Stop at this gate. An armed securityguard will get on the ambulance to escort you to the patient.

D. Is there radiation contamination? A Radiation Protection Technician (RPTEC) or Rainier Paramedic will determine. If there is a contamination, skip to

CONTAMINATION below. If there is no contamination:

E. Perform medical assessment and treatment. Package and load the patient.

F. When leaving, stop at the upper gate to let the escort get off.

♦ IF THERE IS CONTAMINATION FOUND:

A. Simple decontamination measures may be taken, i.e., removing contaminated

clothing, or moving a patient away from a radiation source. However, do not

delay medical treatment of the patient - it is more important to perform life savingmeasures than to decontaminate the person!

B. If there is no RPTEC present and the Paramedic determines that there is a

contamination, call a RPTEC in to provide radiation protection coverage.

C. When you transport the patient use your radiation monitoring instruments to

provide radiation protection coverage to you and the patient.

D. Request C-COM call the Oregon Health Division, Radiation Protection Services

at 1-503-731-4014, and request assistance.



7/01 P14.4

♦ FOR PATIENTS NEEDING TRANSPORT TO THE HOSPITAL:

• IF THERE IS NO CONTAMINATION

If this is not a trauma patient, transport to either St. John's Hospital inLongview, Good Samaritan Hospital, or St. Vincent Hospital in Portland.

If this is a trauma patient, follow your procedures for entry into theTrauma System.

Tell the hospital if the patient is contaminated. Additional directions may be given to you by the RPTEC depending on

the radiological condition of the patient

• IF THERE IS CONTAMINATION

An RPTEC will ride with you to provide radiation protection coverage.

When you transport the patient use your radiation monitoring instruments

to provide radiation protection coverage to you and the patient. Transport the patient to a hospital. If appropriate, consider a travel route

that avoids potential radiation release areas. When the transport is completed, and the hospital accepts responsibility

for patient treatment, a radiation survey of yourself, the other ambulance

staff, the equipment and ambulance must be done. You must remain at thehospital until this survey is completed. The hospital staff, the state

radiation team, or the RPTEC can do this survey. If the hospital staff, thestate radiation team, or the RPTEC cannot do the survey, you will have to

do the survey yourself. Any decontamination should be done before

leaving the hospital. Tell the state radiation team your pocket dosimeter reading and give them

your TLD. If the state radiation team is not there, return to your station,

contact them by phone and request their assistance.



7/01 P15.1

SCOPE OF PRACTICE

PARAMEDIC

• THE PARAMEDIC FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICE

SHALL NOT EXCEED:a. Perform all procedures at the Intermediate level.

b. Initiate the following airway management techniques: Endotrachael Intubation/Retrograde Intubation. Tracheal suctioning techniques.

Cricothyrotomy. Transtracheal jet insufflation which may be used when no other

mechanism is available for establishing an airway.

c. Initiate a nasogastric tube.

d. Initiate electrocardiographic monitoring and interpret presenting rhythm.

e. Provide advanced life support in the resuscitation of patients in cardiac arrest.

f. Perform emergency cardioversion in the compromised patient.

g. Attempt external transcutaneous pacing of bradycardia that is causinghemodynamic compromise.

h. Initiate or administer any medications or blood products under specific written

protocols authorized by the supervising physician, or a direct order from alicensed physician.

i. Initiate needle thoracentesis for tension pneumothorax in the field.

j. Initiate placement of a femoral intravenous line when a peripheral line cannot be

placed.

k. Initiate placement of a urinary catheter for trauma patients in the field who havereceived diuretics and where the transport time is greater than 30 minutes.



7/01 P15.2

INTERMEDIATE

• THE EMT-INTERMEDIATE FOR COLUMBIA COUNTY EMS SCOPE OFPRACTICE SHALL NOT EXCEED:

a. Perform all procedures at the Basic level.

b. Initiate and maintain peripheral IV lines and initiating saline locks

c. Initiate and maintain intraosseous infusions

d. Infuse isotonic crystalloid solution

e. Draw peripheral blood specimens

f. Initiate and administer the following medications: Epinephrine 1:10,000

Atropine Lidocaine Naloxone Hypertonic glucose Nitroglycerine

ß-2 specific nebulized bronchodilators1

g. Insert a Pharyngeal Esophageal Airway device (e.g. Combi-tube, EOA,Pharyngeal Tracheal Lumen airway)

h. Insert an orogastric tube

i. Maintain IV medication infusions initiated at the sending medical facility, under their direction, during transport

j. Perform defibrillation with a manual defibrillator 2

1 After completing a Health Division of the Department of Human Resources approved course in

the administration of nebulized bronchodilators

2 After completing a Health Division of the Department of Human Resources approved trainingcourse and in the service of an agency that has been granted a “EMT-Intermediate Manual

Defibrillation Waiver” by the Division



7/01 P15.3

BASIC

THE EMT-BASIC FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICE SHALL NOT EXCEED:

a. Conduct primary and secondary patient exams

b. Take and record vital signs

c. Open and maintain airways using Oropharyngeal and nasopharyngeal airways and pharyngeal suctioning devices

d. Administer O2 by nasal cannula or by partial or non-rebreather mask

e. Operate BVM ventilation device with reservoir

f. Provide standard CPR and obstructed airway care for infants, children, and adults

g. Provide care for soft tissue injuries and fractures

h. Provide care for suspected shock including the pneumatic anti-shock garment

i. Provide care for suspected medical emergencies, including:

Obtaining a peripheral blood glucose specimen for monitoring obtained via

fingerstick, heelstick or earlobe puncture

Administer oral glucose for hypoglycemia

Administer epinephrine by SQ or automatic injection device for anaphylactic

shock 1

Administer activated charcoal for poisonings

Administer aspirin for suspected myocardial infarction2

j. Assist with pre-hospital childbirth care

k. Perform cardiac defibrillation with an automatic or semi-automatic defibrillator

l. Transport stable patients with saline locks, heparin locks, foley catheters, or in-dwelling vascular devices

m. Perform other emergency tasks as requested if under the Direct Visual supervision of

a physician, under order of that physician.

n. Complete a clear and accurate pre-hospital care report form on all patient contacts,leaving a copy of the form with the medical facility receiving the patient

o. Assist patients with the administration of their own Nitroglycerine and metered doseinhalers that have been prescribed by their own physician



7/01 P15.4

FIRST RESPONDER

THE FIRST RESPONDER FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICESHALL NOT EXCEED:

a. Open and maintain airways using Oropharyngeal and nasopharyngeal airways and pharyngeal suctioning devices

b. Administer O2 by nasal cannula or by partial or non-rebreather mask

c. Operate BVM ventilation device with reservoir

d. Perform cardiac defibrillation with an automatic or semi-automatic defibrillator 3

1 A copy of the pre-hospital care report form needs to be sent to the Board of Medical Examiners

each time epinephrine is administered

2After completing a Health Division of the Department of Human Resources approved course in

the administration of aspirin

3Only when the FIRST RESPONDER is certified by the Health Division of the Department of

Human Resources as a FIRST RESPONDER and:

Has completed successfully a Division approved course on the use of the automatic and

semi-automatic defibrillator Complies with periodic re-qualification requirements for automatic and semi-automatic

defibrillators as established by the Health Division of the Department of Human

Resources



7/01 P16.1

SLOW DOWN/CANCELLATION

PURPOSE

♦ The purpose of this protocol will be to describe the situations when EMS responding

units might be slowed down in their response or cancelled by other EMS units or law

enforcement agencies.

♦ It is in the best interest of patient care and the public safety to cancel or slow down units(from emergency to non-emergency priority) responding to low priority emergency

medical calls when it is determined that the patient or situation does not require an

emergency response.

PROCEDURE

♦ BLS first responders may slow down ALS responders when they determine, after patientassessment, that the patient does not require ALS treatment or is refusing treatment

and/or transport (see PATIENT REFUSAL protocol).

♦ BLS first responders may cancel ALS responders if there is nothing found or the patientrequires only first aid. (bandaging or simple splinting)

♦ Law enforcement agencies may slow down EMS response if a patient requires only first

aid (bandaging or simple splinting) or the patient is refusing treatment and/or transport

(see PATIENT REFUSAL protocol).

♦ ALS first responders, BLS first responders, and law enforcement units should not cancel

or slow down EMS response because an air ambulance (Lifeflight) has been activated.Only after an air ambulance has landed, and the ALS/BLS responders or law enforcement

agent has conferred with the flight personnel, should they cancel or slow down further

EMS response



7/01 P17.1

STAGING EMS UNITS

PURPOSE

♦ To establish guidelines for the response of EMS providers to incidents that involve

violence, or are anticipated to be potentially violent in nature, or place EMS providers in jeopardy

♦ These incidents include (but may not be limited to):

1. Assaults (shooting, stabbing)

2. Hazardous materials incidents (see HazMat protocol)

PROCEDURE

♦ The following are the reasons for a unit to consider staging:

1. If the unit recognizes a violent situation or scene that could expose EMS providers to danger.

2. If the scene is a hazardous materials situation, the unit should stage and wait for

the hazardous material personnel to declare the scene safe.

3. If there is a previous unit at the scene that has staged.

4. If the unit is dispatched to a MPS/MCI incident and receive no assignment from

command or operations, they should proceed to the established staging area, or, if

one is not established, do so.(see MCI/MPS protocol)

5. If dispatch advises the unit of a known violent scene

♦ When staging, the unit should:1. Stage about 2 blocks from the incident and out of the line of sight.

2. Announce the staging location and that the unit is staging.

3. When staging, turn off the headlights and warning devices unless there is a traffic

hazard.

4. Once staged, the unit will not enter the scene until the scene is declared safe andsecure by the police or dispatch.



7/01 P18.1

TIME AT THE SCENE

PURPOSE

♦ The purpose of this protocol is to delineate on-scene time limitations.

PROCEDURE

♦ If at any time an EMT cannot provide or protect a patent airway to a patient within 5minutes after patient encounter and initiating emergency medical care, he/she is required

to transport the patient immediately.

♦ For TRAUMA cases, time spent on the scene should be 10 minutes or less whereextrication has been accomplished and the patient can be moved away from the site.

♦ Scene time should be limited to evaluating the need for ambulance transport and

immediate stabilization of the patient. Most procedures should be performed in theambulance.

Revised 04-96



7/01 P19.1

TENSION PNEUMOTHORAX DECOMPRESSION***

DEFINITION

• The emergent decompression of a tension pneumothorax using an over the needlecatheter and a Heimlich

®type valve.

INDICATIONS

• Tension Pneumothorax as defined by the following signs and symptoms:a. History (e.g. chest trauma, COPD, patient who is deteriorating on positive

pressure ventilation)

b. Hypoxia (low oxygen saturation)

c. Progressive respiratory distress along with agitation and restlessnessd. Jugular venous distension or distended neck veins

e. Asymmetrical movements on inspiration

f. Shift of the trachea toward the unaffected sideg. Shock with a low or rapidly decreasing blood pressure

• A simple pneumothorax or non-tension pneumothorax should NOT be decompressed.

Signs and symptoms of this include:

a. Mild to severe respiratory distress b. Chest pain

c. Decreased or absent breath soundsd. Subcutaneous air or crepitus

PROCEDURE

1. Expose the chest and clean with alcohol, Betadine®

, or soap.

2. Locate the mid clavicular line and the third rib on the affected side.

3. Insert a large gauge over the catheter needle (10-14 G) with a syringe attached, over thetop of the third rib. Hit the rib and slide OVER IT.

4. If the air is under tension, the barrel of the syringe will easily pull out or may even “pop”

out. If that happens, advance the catheter.5. Attach a Heimlich

®type valve to the catheter and keep the closed end pointed away from

the patient.

6. Tape the catheter and the valve securely.



7/01 P19.2


• The patients chest should be auscultated often to diagnose the return of the tension or other possible complications. (e.g. bleeding)

• Oxygenate these patients with 100% O2.

• Tension pneumothorax can result as a complication of CPR or aggressive positive pressure ventilation, the latter causing the progression to tension rapidly.

• Complications of needle thoracostomy:o Creation of a pneumothorax (where one did not exist)

o Lung laceration

o Bleeding or hemothorax (avoid going under the rib since that is where the

neurovascular bundle is located)

o Skin or lung infection

• Tension pneumothorax can be caused by completely covering an open chest wound;

always leave one side of the dressing open or un-taped when covering an open chestwound.



7/01 P20.1

TRANSCUTANEOUS PACING***

DEFINITION

♦ This is the technique of electronic cardiac pacing achieved by using skin

electrodes to pass repetitive electrical impulses through the thorax to the heart,stimulating the heart to contract

INDICATIONS

♦ Should be considered in cases of symptomatic bradycardia defined as:

8. 9. 10.

11.

Hypotension (heart rate <60/min)Shortness of Breath (pulmonary edema) (heart rate <60/min)

Ventricular Ectopy (heart rate <60/min)

Chest Discomfort (heart rate <40/min)

PROCEDURE

1. Ensure that the pacemaker leads are attached and the monitor is displaying thecardiac rhythm.

2. Attach the pacing electrodes to the anterior and posterior chest just to the left of the sternum and spinal column respectively.

3. Begin pacing at a heart rate of 80 beats per minute and zero current output.

Increase the current in increments of 20 mAs while observing the cardiac monitor for evidence of capture (see diagram) and confirm mechanical capture by

checking pulse and blood pressure.

4. If the patient is comfortable, continue pacing; if the patient is uncomfortable,

decrease the current output in increments of 5 mAs to a level just above capturethreshold.

5. If the patient continues to complain of pain during pacing despite decreasing thecurrent output, consider the administration of midazolam (see MIDAZOLAM

protocol) 6. If the patient is or becomes unconscious during pacing, assess capture by

observing the monitor and evaluating pulse and blood pressure changes. If the patient has electrical capture but no pulses, treat according to the PEA protocol

(see CARDIAC ARREST protocol)

7. If there is no response to pacing or ACLS protocols, consult OLMC (see

OLMC/HOSPITAL COMMUNICATION protocol)


♦ Transcutaneous pacing should not be used in the following situations:1. Asystole

2. Patients under the age of 143. Patients meeting death in the field criteria

4. Patients with signs of penetrating or blunt trauma



7/01 P21.1

TRAUMA PROTOCOL

Patients are to be entered into the Trauma System in ATAB I (Multnomah,

Washington, Clackamas, Columbia, Tillamook, and Yamhill Counties) when they meet

the following criteria and have been involved in a trauma incident. The EMT is required

to report the exact reason for patient entry to MRH and document the incident fully,including the reason(s) for entry:

ENTRY CRITERIA

♦ Physiological Criteria:

A systolic blood pressure of less than 90 mm/Hg.

Respiratory distress as evidenced by a respiratory rate of less than 10 or

greater than 29.

Altered Mental Status as evidenced by a Glasgow Coma Scale of 13 or less.

♦ Mechanism of the patient injury:

Extrication from a motor vehicle which takes greater than 20 minutes and uses

heavy tools.

Death of an occupant in the same car as the patient.

Ejection of the patient from an enclosed vehicle.

♦ Anatomical criteria:

The patient has a flail chest.

The patient has two or more obvious proximal long bone fractures (humerus,

femur).

The patient has a penetrating injury of the head, neck, torso, or groin

associated with an energy transfer.

The patient has in the same body area a combination of trauma and burns(partial and full thickness) of 15 percent or greater, or burns involving theface and/or airway.

The patient has an amputation proximal to the wrist or ankle.

The patient has numbness or paralysis in one or more limbs.



7/01 P21.2

♦ EMT Discretion:

If in the EMT's judgement, the patient has been involved in a trauma incident,which, because of a high energy exchange, causes the EMT to be highly

suspicious that the patient is severely injured, the patient should be entered into

the Trauma System.

The EMT's suspicion of trauma injury may be raised by the following factors:

a. Age greater than 60.

b. Age less than 12.

c. Extremes of environment (hot/cold).

d. Patient's previous medical history.e. Pregnancy.

f. Communication with the patient is impaired.

MEDICAL DIRECTION

♦ Off-line medical direction for trauma patients is controlled by the BLS/ALS

Protocols as adopted by ATAB I, the EMS agencies, and the PhysicianSupervisors.

♦ On-line medical direction within radio range of Medical Resource Hospital is

controlled by Medical Resource Hospital.

♦ On-line medical direction in areas where radio communications with MedicalResource Hospital is impossible are the responsibility of the Level III or Level IV

designated centers in their service areas. These areas are: Tillamook Hospital for Tillamook County, Columbia Memorial for Clatsop County, St. John's for Columbia County, and Newberg Hospital for Yamhill County.

♦ On-line medical direction may override off-line medical direction. Any instances

of this will be reported to ATAB QA.

COMMUNICATIONS

♦ Emergency Medical Technician at Scene to destination Trauma Center:

♦ IT IS ESSENTIAL THAT EARLY RADIO COMMUNICATIONS BEESTABLISHED CONCERNING THE TRAUMA VICTIM. After assessing a

trauma situation and making the determination that the patient should enter the

Trauma System, the EMT certified to the highest level should contact thedestination Trauma Center at the earliest time practical and provide the following:

1. Number of patients (age and sex).

2. Mechanism of injury.



7/01 P21.3

COMMUNICATIONS (CONT)

3. Anatomic site of injury.

4. Vital signs (blood pressure, respiratory rate, level of consciousness).

5. Geographic location of incident.

6.

Estimated time of departure from the scene/ETA.7. Unit number of transporting unit and mode of transport.

♦ In case of radio failure with medical direction, contact the EMS dispatch point for hospital information.

TRANSPORT PROTOCOL

♦ Patient to Level I hospital if 30 minutes or less transport time.

♦ Designated Trauma Center destination from the scene, if by ground transport, to be determined by the EMT based upon the following criteria:

Columbia County-Scappoose, St Helens: Emanuel Hospital Service Area. Columbia County-Rainier, Clatskanie, Mist-Birkenfeld: St Johns-

Longview or Columbia Memorial in Astoria

♦ Designated Trauma Center destination from the scene if by air transport to be

determined by flight personnel based upon the following criteria:

Regardless of patient origin, the patient destination to be alternated

between the Designated Trauma Centers.

If two patients are transported in the same transport, patient destinations to be same Designated Trauma Center.

In the event that the Designated Trauma Center which is to be the patient

destination, is unable to accept the patient, Medical Resource Hospital will

assist the flight crew in determining patient destination.

♦ In Columbia County, existing patient referral trends which use out-of-statehospitals are to be maintained until the ATAB plan addresses out-of-statehospitals.

MODE OF TRANSPORT♦ Ground vs. Air (Level I):

An air ambulance should be used when it would reduce total pre-hospital

time of a Trauma System by 10 minutes or greater. The EMT must

recognize that any patient entered in the Trauma System should receive

the most rapid transportation mode possible. The air ambulance can be put on stand-by and/or activated by request

through C-COM.



7/01 P21.4

PATIENT EVALUATION PROTOCOL:

♦ Treatment priority should be approached in this order:

1. Airway maintenance including control of the cervical spine. If unable to

establish and maintain an adequate airway, the patient should betransported to the nearest acute facility to obtain definitive airway control

by a qualified individual

2. Breathing3. Control of circulation

4. Control of hemorrhage

5. Treatment of shock

6. Splinting of fractures7. Neurological examinations

8. Secondary patient assessment

TRAUMA CARE PRIORITIES FOR PRE HOSPITAL CARE PERSONNEL

♦ Assess and maintain the airway; protect the cervical spine

1. Chin lift/jaw thrust

2. Clean airway of foreign bodies

3. Oropharyngeal/ nasopharyngeal airway4. Bag valve mask with oxygen supplementation as indicated

5. Endotracheal intubation*** or needle cricothyroidotomy***.

Endotracheal intubation is the preferred method of maintaining a patent

and protected airway. (see AIRWAY and AIRWAY MANAGEMENT

protocols)

♦ Breathing Control

1. Assessment

a. Expose the chest and neck.

b. Measure the rate and depth of respirations.c. Inspect and palpate for unilateral and bilateral chest movement,

subcutaneous emphysema, and sucking chest wounds.

d. Look for distended neck veins or a deviated trachea.e. Auscultate the lungs.

2. Management

a. Cover an open pneumothorax with a 3 way occlusive dressing.

b. Start oxygen therapy.

c. Alleviate tension pneumothorax (see TENSION

PNEMOTHORAX DECOMPRESSION protocol

d. Support ventilation.



7/01 P21.5

TRAUMA CARE PRIORITIES FOR PRE HOSPITAL CARE PERSONNEL

(CONT)

♦ Circulatory Control

1. Identify exsanguinating hemorrhage

a. Apply direct pressure b. Apply a tourniquet if there is uncontrolled bleeding from an

extremity

c. Open PASG on the stretcher and place the patient on the stretcher-

apply if necessary (see SHOCK protocol)

2. Assess for pulses

Generally if:1. The radial pulse is present, the systolic pressure is 80 mmHG

2. The femoral pulse is present, the systolic pressure is 70 mmHG3. The carotid pulse is present, the systolic pressure is 60 mmHG

3. Evaluate perfusion

a. Pulse rate and character b. Capillary refill

c. Skin Color (i.e. pink, pale, cyanotic, mottled)

4. Initiate 2 large bore IVs with a balanced Salt Solution during transport

5. Obtain blood pressure. This is a low priority, consider during transport.

♦ Assess Neurologic Status per Glascow Coma Scale

1. Eye opening

2. Best verbal response

3. Motor response

• Standardized pain stimulus is either supraorbital ridge pressure or

fingernail pressure

SCENE TIME

After gaining access to the patient, scene time should not exceed ten

minutes for any patient who is entering the Trauma System. Plan to

start IVs and initiate other care once en route to the hospital if necessary



7/01 P21.6

Patient transfer from a Level 3 or 4 hospital to a Level 1 hospital

The following guidelines shall be utilized to identify patients who are at a particularlyhigh risk of dying from multiple and severe injuries. Ideally, such patients should be

treated at a Level 1 Trauma Center when continued exposure to such problems by multi-disciplinary team systems may afford the patient an optimum outcome. Such patients

shall be transferred to Level 1 centers from Level 3 or 4 centers. The transfer should take place only after the receiving physician in the Level 3 or 4 center has conferred with the

Level 1 receiving trauma surgeon.

♦ Central Nervous System a. Head Injury

1. Penetrating injury

2. Depressed skull fracture3. Open injury

4. CSF leak 5. GCS less than or equal to 136. Deterioration in GCS of 2 or more score points

7. Lateralizing signs

b. Spinal Cord Injury

♦ Chest a. Wide superior mediastinum

b. Major chest wall injuryc. Cardiac injury

d. Patients who may require protracted ventilation

♦ Pelvis

a. Pelvic ring disruption with shock, more than 5 units transfused, evidence

of continued hemorrhage, and compound (open) pelvic injury or pelvicvisceral injury

♦ Multiple System Injury a. Severe face injury with head injury b. Chest injury with head injury

c. Abdominal or pelvic injury with head injury

d. Second degree or greater burns with head injury

♦ Secondary Deterioration (late sequelae in trauma system patients who were

not transferred) a. Patients requiring mechanical ventilation b. Sepsis

c. Single or multiple organ system failure (deterioration in CNS, cardiac,

pulmonary, hepatic, renal, or coagulation system)d. Osteomyelitis



7/01 P21.7

Patient transfer from a non-trauma hospital to a designated trauma hospital

♦ In the event that a non-trauma designated hospital receives a trauma patient whomeets Trauma System entry criteria, or the trauma patient is unstable, or the

hospital does not have the resources to take care of the patient, the non-traumahospital should:

a. Stabilize and care for the patient to the best of the facility’s ability b. The non-trauma hospital emergency physician or surgeon should contact

the Level 1 or 2 trauma surgeon and mutually agree on whether patient

transfer is needed

c. Report all cases to ATAB 1 Quality Assurance

Patient transfer between non-trauma designated hospitals

♦

For all trauma patients meeting trauma system entry criteria and/or inter-hospitaltransfer criteria (with possible exceptions), the non-trauma hospital should

consider transfer of these patients to a Level 1 trauma hospital

♦ Trauma patient transfers who meet entry or transfer criteria and are also

transferred from one non-trauma hospital to another should have reports of thesetransfers sent to ATAB 1 Quality Assurance

Patient transfer between trauma designated hospitals and a non-designated hospital

♦ When the HMO patient is treated at a designated trauma facility, the HMO facility

will be notified within 48 hours of patient arrival. The stabilized patient can be

transferred to a HMO hospital when the trauma surgeon and the HMO physicianmutually agree that transfer is in the patient’s best interest



7/01 P22.1

TRANSPORT OF THE CHRONICALLY ILL PATIENT

PURPOSE

• Informed consent process for the alert, conscious patient who requests notransport or treatment. The EMT shall:

1. Contact the attending physician for advice and try to establish

communication between the patient and physician. If communicationcannot be established:

Contact OLMC (see OLMC-HOSPITAL COMMUNICATION

protocol) and try to establish communication between the patientand the physician, or

The EMT shall explain the risks and benefits of transport andtreatment but the EMT shall accept the right of the patient to refuse

treatment and transport.

2. In all events the EMT shall follow the patient's directions regarding

Columbia Co (OR) Protocols (2009)

Documents

Transcript of Columbia Co (OR) Protocols (2009)