EMS Protocols - Thurston County

Thurston County

EMS Protocols

Medical Program Director Dr Larry Fontanilla, MD

May 2011

Thurston County

EMS Protocols

This document describes the methods by which the Thurston County EMS System will continue to provide the highest quality prehospital patient care available. We have incorporated evidence based guidelines with historically proven practices to produce this document. While it is impossible to address every possible variation of disease or traumatic injury, these policies, protocols, and procedures do provide a foundation for treating the vast majority of patients we encounter. Certainly our education, experience and clinical judgment will assist us as we provide the highest quality patient care available. Additionally, on-line medical control is available for those patient presentations that do not fall within the scope of the document.

Dr. Larry Fontanilla, MD Medical Program Director

General Patient Care 1

Universal ALS upgrade 8

Assessment and Treatment 9

ACLS - Appendix A A-1

BLS Transport to Nearest ALS - Appendix B B-1

Childbirth - Appendix C C-1

Death in the Field - Appendix D D-1

Infant Transfer - Appendix E E-1

Mandatory Reporting Criteria - Appendix F F-1

Medical Abbreviations - Appendix G G-1

Appendix H H-1

Medications - Appendix I I-1

Tools for EMS Providers - Appendix J J-1

Pre Hospital Communications - Appendix K K-1

Skills - Appendix L L-1

SOAP Written Report Format - Appendix M M-1

START Tool - Appendix N N-1

Toxindromes - Appendix O O-1

Wa State Trauma Triage Tool/SPH Trauma Criteria/Appendix P P-1

Appendix Q - Healthline Access Q-1

Glossary

PhoneFax Contacts for EMS Providers inside back cover

Index

Thurston County Medic One

1

General Patient Care

I. Airway – management shall be in accordance with American Heart Association (AHA) Standards

Head tilt – chin lift (not for trauma) Jaw thrust

Suctioning Finger sweep (no blind finger sweeps for infants

or children) Abdominal thrusts (chest thrusts for infants)

Direct laryngoscopy and removal of an obstruction with Magill forceps

Positioning Insertion of an oropharyngeal airway Insertion of a nasopharyngeal airway Orotracheal intubation

− Eschmann-type stylette Laryngeal mask airway Surgical intubation with cricothyroidotomy device

II. – shall be enhanced, assisted or maintained using the following equipment/techniques:

III. Ventilation – shall be enhanced, assisted or maintained using the following equipment/techniques:

rate of 15-25 lpm

General Patient Care Procedures

Bold Italics indicate an ALS procedure

2

Gene

ral P

atie

nt C

are

1. Used to assist a conscious seated patient 2. Used to assist or breathe for an unconscious patient

(*medical patients only)3. Used in conjunction with an endotracheal tube

IV. Circulation

Control bleeding with direct pressure. If unsuccessful, elevate and use pressure points. As a last resort,

1. All cardiac arrest patients who do not meet the Death in Field (DIF) criteria (Appendix D) will have resuscitation attempted.

2. If a patient does not meet the criteria in the DIF

personnel shall begin resuscitation and apply an AED.3. Cardiopulmonary resuscitation shall be performed in

accordance with current AHA guidelines.

1. The goal of fluid resuscitation in the setting of hypovolemia or uncontrolled bleeding is to obtain and maintain a systolic blood pressure of 90-100 mmHg.

2. Initial fluid resuscitation for children less than 8 y/o and presenting with signs or symptoms of shock should consist of a 20 ml/kg bolus of normal saline, repeat x2 prn.

3. who exhibits signs or symptoms of hypoperfusion.

following sites:


3

General Patient Care


a) Right internal jugular veinb) Right subclavian veinc) Right or left femoral vein

5. intraosseous infusion:a) Adult – Medial aspect of the proximal tibiab) Child – Medial aspect of the proximal tibia

V. Disability – evaluation of mechanism of injury (MOI) should be completed for every patient who is suspected of having a spinal injury

situation otherwise suggests a change in their health status, should receive a complete assessment.

and paramedics shall use the Spinal Immobilization Decision Tool (Appendix L) for those patients with uncertain mechanism or injury.

of spinal injury or who meet the exclusion criteria of the Spinal Immobilization Decision Tool shall have full spinal immobilization applied.

discomfort. Pregnant patients should have the

should be immobilized:1. Long bone: Immobilize joint above and below the

injury. Splint in gross anatomical alignment. Tension should be applied and the limb stabilized during realignment and splinting. If the fracture cannot be reduced because of severe pain or remains in a position incompatible with transport, an ALS upgrade is indicated.

4

Gene

ral P

atie

nt C

are


2. Joint: Immobilize long bone above and below the injury. Splint in the position found. If no pulse attempt to realign one time.

3. Distal PMS should be evaluated and recorded before and after splinting.

administration of pain medication.

VI. Pain management

of all patients in severe pain.

pain should be attempted such as placing the patient

immobilizing and splinting painful areas.

physiologic signs of severe pain including: diaphoresis, tachycardia, hypertension, tachypnea, pallor or significant grimacing.

management if they:

interventions, andshow physical or physiologic signs of pain, andrate their discomfort at 7 or greater, and

receive an IV opiate injection Any patient receiving opiate pain management, will

be transported by ALS and must:

measurements every 5 minutes

5

General Patient Care have code summary attached to their patient

care reportVII. Communication

accompanied by an explanation for the upgrade.

responding medic units.

are required to give a complete verbal report (Appendix

scene cannot cancel an EMT or higher-level response to the scene.

supervising physician when:1. Directed to do so by protocol.2. The paramedic has evaluated a patient and is

the scene. 3. The paramedic is on scene with a patient who meets

Steps 1-4 Washington State Trauma Triage Tool

for any critical patient is desirable. The base station physician is always available for

consultation with the paramedic.

the receiving facility to give a short verbal report. If patient condition changes significantly while en route (e.g. Section VIII, “Ground transport”), the receiving facility should receive an updated report as soon as possible.

1. A verbal report must be given at every handoff of a patient.


6

Gene

ral P

atie

nt C

are

2. The first-arriving unit will provide an initial written report of patient care to the transporting unit. The EMS provider who performs the hands-on exam is responsible for writing the report.

3. Each EMS unit that performs an assessment of the patient shall provide a written report that accompanies the patient to the hospital. The provider performing the examination shall complete the narrative (SOAP) portion of this report.

the elements of a complete SOAP note (Appendix M), including medications and vital signs.

replace or qualify as a written report.

VIII. Transport

1. In general, patients should be transported to the hospital of their choice. Patients in need of specialty care (e.g. pediatric center, trauma center) require consult with the base station physician.

en route to a hospital, a request for ALS upgrade should be made; the ALS unit dispatched should

1. Any field provider may request air transport via TCOMM. An ALS upgrade is required. Transport destination shall be determined by the ALS provider in consultation with medical control physician.

2. The primary provider of air transport services for


7

General Patient Care3. Use of air transport should be coordinated with the

incident commander.

with a report for any patient transported by air.ALL

should be afforded the best possible safety measures available while being transported:1. When possible, patients should be transported

sitting up. 2. Fasten all manufacturer-supplied gurney safety belts.

patient compartment during transport.

their seat belts whenever possible.5. Children should be restrained in a size-appropriate

child-restraint device whenever possible.

IX. Dispute resolution

disputes between personnel on the scene is preferred.

disagree about treatment, the most conservative

personnel on the scene disagree about whether an ALS upgrade is necessary, an ALS upgrade for evaluation will be requested.

a course of action for a particular patient, the most conservative approach (usually an ALS transport) will be followed.


Univ

ersa

l ALS

Upg

rade

s

8

Universal ALS Upgrades

I. An ALS evaluation is required if any of the conditions listed below are present:

compromise

radial pulse)

lung sounds

to vehicle)

9

Assessment and Treatm

entAssessment and Treatment

MedicalAbdominal / Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Allergic Reaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Animal Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Bleeding (Non-traumatic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Breathing Difficulty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Chest Pain / Discomfort / Heart Problems . . . . . . . . . . . . . . . . 21Choking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Diabetic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Environmental Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . 27Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Mental / Emotional / Psych. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Overdose / Poisoning (Toxic Exposure) . . . . . . . . . . . . . . . . . . 35Pregnancy / Childbirth / OB-GYN . . . . . . . . . . . . . . . . . . . . . . . 37Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Unconscious / Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

TraumaAbdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Chest Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Extremity Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Head and Neck Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Spinal Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Submersion Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

10

Asse

ssm

ent a

nd T

reat

men

tPertinent Subjective Findings

Pertinent Objective Findings

ALS Upgrade Required For

syncope or heavy vaginal bleeding

greater than 50

Abdominal / Back Pain

11


entAssessment / Differential Diagnosis

disease

Plan/Treatment

ALS

Abdominal / Back Pain

12

Asse

ssm

ent a

nd T

reat

men


and severity

possible allergens®


or tongue


AND has a history of anaphylactic reaction to this allergen

Allergic Reaction

13



Plan/Treatment

® (if indicated)

patient’s albuterol

it’s present

ALS

Allergic Reaction

14

Asse

ssm

ent a

nd T

reat

men



around site

− Altered or decreased mental status

− Hypotension − Tachycardia− Tachypnea

− Oral paresthesia or unusual tastes


Assessment / Differential Diagnosis

Animal Bites

15


entPlan/Treatment

Poison Center at 800-709-0911

ALS

Animal Bites

16

Asse

ssm

ent a

nd T

reat

men


diarrhea − Coumadin®

− Cancer− Ulcer− Alcoholism− Recent surgery



Bleeding (Non-traumatic)

17



Plan/Treatment

ALS

Bleeding (Non-traumatic)

18

Asse

ssm

ent a

nd T

reat

men


− Smoking− Asthma / Reactive

− COPD− Intubated previously

− Anxiety/hyperventilation


mental status

sentences

rhonchi)

10 or greater than 36

greater than 140

hypotension

peripheral)

edema)

Breathing Difficulty

19


entALS Upgrade Required For


syndrome

Plan/Treatment

the patient


20

Asse

ssm

ent a

nd T

reat

men

t

ALS

®

®

Ped


21


entPertinent Subjective Findings



Coronary Syndrome

Chest Pain / Discomfort / Heart Problems

22

Asse

ssm

ent a

nd T

reat

men

tAssessment / Differential Diagnosis

Syndrome

Plan/Treatment

chest discomfort

ALS

Ped

Chest Pain / Discomfort / Heart Problems

23






Plan/Treatment

Choking

24

Asse

ssm

ent a

nd T

reat

men

t

ALS

Peds

Choking Emergencies

25


entDiabetic Emergencies

Pertinent Subjective Findings

(Time last taken)− Oral hypoglycemic agents



− Signs or symptoms of shock


− Irregular respirations− Odor of ketones on breath− Dehydration (dry mucous

tachycardia)



− Insulin− Oral hypoglycemic agents− Alcohol− Aspirin− Beta blockers

26

Asse

ssm

ent a

nd T

reat

men

tPlan/Treatment

(Appendix I)AL

S

®

Peds −

−

−

Diabetic Emergencies

27


entEnvironmental Emergencies


prior to c/o symptoms

engaged in prior to c/o symptoms

hostile environment

is taking

− Cramps− Dizziness

− Has any attempt been made to

exposure accidental or

28

Asse

ssm

ent a

nd T

reat

men

tPertinent Objective Findings

mental status

− Skin irritation at contact site

− Respiratory distress

Salivation Lacrimation Urination Defecation Gastrointestinal Emesis

− Tachycardia− Tachypnea

or hard skin− Absence of

shivering− Bradycardia

− Hypotensive



hazardous materials

Environmental Emergencies

29


entEnvironmental Emergencies

Plan/Treatment

− Rest patient

inducing shivering

− Check rectal temperature

− Handle patient very gently− Check carotid pulse for a full minute before starting CPR

protocol as per normothermic patients

axilla and groin− Check rectal temperature

treatment recommendations

30

Asse

ssm

ent a

nd T

reat

men

t

ALS

Peds

Environmental Emergencies

31


entHeadache


mental status

side(s))

rigidity)


mental statussensation


or diastolic blood pressure greater than 110

32

Asse

ssm

ent a

nd T

reat

men


(SAH)

Plan/Treatment

ALS

Headache

33



illness or injury

disorders

the patient

attempts

abused substance

patient’s environment


substances


from the scene to the hospital

Mental / Emotional / Psych

34

Asse

ssm

ent a

nd T

reat

men


− Schizophrenia− Depression− Mania− Anxiety

− Alcohol/acidosis− Epilepsy/electrolytes/

endocrine− Insulin (hypo/

hyperglycemia)− Overdose− Uremia/underdose− Trauma− Infection− Psychosis− Pump/poison− Stroke/shock

Plan/Treatment

ALS

Mental / Emotional / Psych

35




status− Salivation− Lacrimation− Urination− Defecation− Gastrointestinal − Emesis

(See Appendix O for signs and symptoms of specific poisoning syndromes)


Overdose / Poisoning (Toxic Exposure)

36

Asse

ssm

ent a

nd T

reat

men


Plan/Treatment

treatment recommendations

ALS

Overdose / Poisoning (Toxic Exposure)

37



pregnancies

ultrasound)

− Number of pads/tampons used per hour

− Passing any tissue

abd/back pain

− Hypertension− Miscarriage


and duration)

prolapsed/nuchal cord)

vaginal discharge

Pregnancy / Childbirth / OB-GYN

38

Asse

ssm

ent a

nd T

reat

men

tALS Upgrade Required For

− Contractions 2 min apart (first pregnancy)− Contractions less than 5 min apart (other pregnancy)

uterine contractions

syncope or heavy vaginal bleeding

or greater than 90 mmHg diastolic


(miscarriage)

Pregnancy / Childbirth / OB-GYN

39


entPlan/Treatment

pregnancy or childbirth

side for transport

− Emergent transport

in birth canal

− Emergent transport

− Massage uterus− Encourage baby to nurse

− Supportive care− Treat for seizures as needed

ALS

Pregnancy / Childbirth / OBGYN

40

Asse

ssm

ent a

nd T

reat

men


medications

abstinence

seizure


bladder)

mental status


or abrupt onset of severe headache

Seizures

41



alcohol use

Plan/Treatment

ALS

Peds

Seizures

42

Asse

ssm

ent a

nd T

reat

men


or similar

− Anti-hypertensives− Blood thinners− Aspirin


mental status

sensation

or receptive)


Stroke

43


entStroke


Plan/Treatment

Transport Decision Tree

ALS

or difficulty speaking.

Routine transport to

closest stroke center or facility of

patient’s choice.

NO

YES

YES

NO

44

Asse

ssm

ent a

nd T

reat

men


rescue breathing


paraphernalia

hypoglycemic medications



− Alcohol/acidosis− Epilepsy/electrolytes/endocrine− Insulin (hypo/hyperglycemia)− Overdose− Uremia/underdose− Trauma− Infection− Psychosis− Pump/poison− Stroke/shock

− Cardiac dysrhythmia− Stroke− Hyperventilation − Orthostatic

Unconscious / Syncope

45


entPlan/Treatment

General patient care proceduresAL

SPe

ds

Unconscious / Syncope

46

Asse

ssm

ent a

nd T

reat

men


belts/airbag)


genitalia

distended abdomen

abdominal organs

the ribs


Abdominal Trauma

47


entAbdominal Trauma


Plan/Treatment

bulky dressing

ALS

Peds as high as the nipple line

pediatric trauma patients

48

Asse

ssm

ent a

nd T

reat

men


steam/smoke

hazardous materials

respiratory disease

electrical burn


mouth/nose area (BSA)


5 y/o

Burns

49


entBurns


Plan/Treatment

and then dry patient− Remove burnt or contaminated clothing (that is not melted

to the skin)

percent of BSA affected

blankets to prevent hypothermia

an enclosed space

50

Asse

ssm

ent a

nd T

reat

men

t

ALS

Peds

Burns

51


entChest Trauma


belts/airbag)


movement

neck and shoulders



52

Asse

ssm

ent a

nd T

reat

men

tPlan/Treatment

− Apply occlusive dressing and secure on three sides− If patient develops increased respiratory difficulty or tension

affected side

− Splint in position of comfort using patient’s body and

ALS

Peds

Chest Trauma

53


entExtremity Trauma


condition(s)


of shock

function or sensation

amputation



Non-accidental trauma

54

Asse

ssm

ent a

nd T

reat

men

tPlan/Treatment

– Distal PMS should be evaluated and recorded before and after splinting.

− Direct pressure to control bleeding

for bleeding− Immobilize

sterile normal saline

time placed in the container− Transport the amputated part to the same hospital as

the patient

ALS

Extremity Trauma

55


entHead and Neck TraumaPertinent Subjective Findings

belts/helmets)

status

condition(s)


retrograde)

consciousness

− Posturing− Abnormal pupillary

responses

pattern)

56

Asse

ssm

ent a

nd T

reat

men

tALS Upgrade Required For


− Alcohol/acidosis− Epilepsy/electrolytes/

endocrine− Insulin (hypo/hyperglycemia)− Overdose− Uremia/underdose

− Trauma− Infection− Psychosis− Pump/poison− Stroke/shock

Head and Neck Trauma

57


entPlan/Treatment

at 24 breaths per minute

care not to depress skull fractures− Remove objects impaled in cheeks and pack both inside

and outside to control bleeding

− Irrigate to remove non-impaled foreign substances

patient not to look around

avulsed tooth in saline and attempt to replace in its socket prior to transport

− Do not remove foreign objects

occlusive dressing.


58

Asse

ssm

ent a

nd T

reat

men

t

ALS


59


entSpinal Trauma


region of body affected (dermatome)

condition(s)

substances

belts/helmets)


to injury mental status



60

Asse

ssm

ent a

nd T

reat

men

tPlan/Treatment

− Unsafe scene

paramedics only

blanket roll under the backboard on the patient’s right side

ALS

Peds

Special attention should be placed on obtaining neutral

(shoulders to feet) because of the larger occipital portion of the head.

Spinal Trauma

61



of diving platform (MOI for spine injury)

compressions/rescue breathing

hours

− Depth of dive− Ascent rate

− Dyspnea


neurological exam

ears/nose


Submersion Injury

62

Asse

ssm

ent a

nd T

reat

men


Plan/Treatment

ALS

Peds

Submersion Injury

A-1

Appendix A – ACLS Algorithms

Pulseless Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-2Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-4Bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-5Pediatric Pulseless Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . A-6Pediatric Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-8Pediatric Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-10Neonatal Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-12


A-2

Appe

ndix

A –

ACL

S Al

gorit

hms

Pulseless Arrest

PULS

ELES

S AR

REST

VF/V

TAs

ysto

le/P

EASh

ocka

ble

Not S

hock

able

AC

Give

5 c

ycle

s of

CPR

*

Give

1 s

hock

Shoc

kabl

e

Shoc

kabl

e rh

ythm

?

Give

2 m

in o

f CPR

*

Shoc

kabl

e

Shoc

kabl

e rh

ythm

?

Shoc

kabl

e rh

ythm

?

Not S

hock

able

B

Resu

me

CPR

imm

edia

tely

for 2

min

Epin

ephr

ine

Re

peat

eve

ry 3

to 5

min

Or M

ay g

ive

1 do

se o

f vas

opre

ssin

40

U IV

/IO to

re

plac

e fir

st o

r sec

ond

dose

of e

pine

phrin

e

Give

1 s

hock

Resu

me

CPR

imm

edia

tely

for

2 m

in

A-3


Pulseless Arrest

Resu

me

CPR

imm

edia

tely

afte

r the

sho

ck

Re

peat

eve

ry 3

to 5

min

epin

ephr

ine

Give

5 c

ycle

s of

CPR

*

Shoc

kabl

eSh

ocka

ble

rhyt

hm?

Not S

hock

able

Not S

hock

able

A-4

Appe

ndix

A –

ACL

S Al

gorit

hms

Tachycardia

>

Identify and treat underlying cause

Yes

No

Persistent tachyarrhythmia causing:

No

Wide QRS?> 0.12 second

Sychronized cardioversion

adenosine

Yes

Doses/DetailsSynchronized Cardioversion

A-5


Monitor and

observe

Bradycardia

Identify and treat underlying cause

Yes

No Persistent bradyarrhythmia causing:

Atropine

orDopamine

orEpinephrine

Consider:

A-6

Appe

ndix

A –

ACL

S Al

gorit

hms

Pediatric Cardiac Arrest

VF/VT Asystole/PEA

Start CPR

Rhythmshockable?

Rhythmshockable?

Rhythmshockable?

Rhythmshockable?

Rhythmshockable?

Go to 6 or 7

CPR 2 min

CPR 2 min

CPR 2 min

CPR 2 min

CPR 2 min

Yes No

Shock

Shock

Shock

Yes

Yes

No

No Yes

Yes

No

No

A

B

D

F

H

I

A-7


Shock Energy for Defibrilation

>

Drug TherapyEphinephrine IO/IV Dose:

Amiodarone IO/IV Dose:

Pediatric Cardiac Arrest

A-8

Appe

ndix

A –

ACL

S Al

gorit

hms

Iden

tify

and

treat

und

erly

ing

caus

e

Tach

ycar

dia

dura

tion

Prob

able

Sin

us T

achy

card

ia

Prob

able

Sup

rave

ntric

ular

Tac

hyca

rdia

Pediatric Tachycardia

No

Card

iopu

lmon

ary

com

prom

ise

A-9


Sync

hron

ized

ca

rdio

vers

ion:

0.5

to

aden

osin

e it

does

not

del

ay e

lect

rical

Expe

rt co

nsul

tatio

n ad

vise

dAm

ioda

rone

Cons

ider

vag

al

man

euve

rs

(No

dela

ys) If IV

acc

ess

read

ily a

vaila

ble:

Gi

ve a

deno

sine Or

Sync

hron

ized

car

diov

ersi

on:

Pediatric Tachycardia

Sear

ch fo

r and

tre

at c

ause

Cons

ider

ad

enos

ine

if rh

ythm

regu

lar

and

QRS

mon

omor

phic

Yes

A-10

Appe

ndix

A –

ACL

S Al

gorit

hms

Pediatric Bradycardia

Perfo

rm C

PR

Yes

No

No

Iden

tify

and

treat

und

erly

ing

caus

e

A-11


Repe

at e

very

3 to

5 m

inut

es

If in

crea

sed

vaga

l ton

e or

prim

ary

AV

bloc

k:

atro

pine

Puls

eles

s Ar

rest

Pediatric Bradycardia

Yes

A-12

Appe

ndix

A –

ACL

S Al

gorit

hms

Neonatal Resuscitation

Term

ges

tatio

n?Br

eath

ing

or c

ryin

g?Go

od to

ne?

Labo

red

brea

thin

g or

per

sist

ent

cyan

osis

?Rout

ine

care

Yes,

sta

yw

ith m

othe

r

No

Yes

No

War

m, c

lear

airw

ay if

nec

essa

ry,

dry,

stim

ulat

e

HR b

elow

100

,ga

spin

g, o

r apn

ea?

PPV,

Spo

, mon

itorin

g

Birth

30 s

ec

60 s

ec

Clea

r airw

aySp

o 2, m

onito

ring

Cons

ider

BiP

AP®

HR b

elow

100

?No

Yes

Yes

No

A-13


Neonatal Resuscitation

Yes

HR b

elow

60?

Take

ven

tilat

ion

corr

ectiv

e st

eps

Cons

ider

intu

batio

nCh

est c

ompr

essi

ons

Coor

dina

te w

ith P

PV

HR b

elow

60?

IV e

pine

phrin

e

Post

resu

scita

tion

care

Take

ven

tilat

ion

corr

ectiv

e st

eps

Intu

bate

if n

o ch

est r

ise!

Cons

ider

NoNo

Yes

A-14

Appe

ndix

A –

ACL

S Al

gorit

hms

B-1

Appendix B – BLS transport to Nearest ALS (Policy 27)Policy purposeTo ensure a mechanism for providing patients with the most rapid availability of ALS measures

Policy statementIn the event BLS is on scene with a patient requiring ALS upgrade, and the ALS unit has a prolonged response time, BLS personnel will stabilize the patient and:

1. Contact the responding ALS unit(s) to arrange for one of the following:a. Transport to a rendezvous point, orb. If a rendezvous with the ALS unit would take longer than

the transport to the hospital, consult the incoming ALS unit, then transport to the nearest hospital.

2. The ALS unit will be responsible for:a. Deciding the proper course of action (1.a. or 1.b. above)b. Calling base station to inform the base station physician

of decision if the ALS patient is going to be transported BLS (1.b. above)

3. Transporting unit will be responsible for calling the receiving facility to provide patient information

Appendix B – BLS Transport to Nearest ALS (Policy 27)

C-1

Appe

ndix

C –

Chi

ldbi

rth1. Perform risk assessment for field delivery:

a) If contractions are between 2 and 5 minutes apart, transport to the nearest facility

b) If contractions are greater than 5 minutes apart, transport to the patient’s hospital of choice

c) If contractions are less than 2 minutes apart, patient feels urge to push or have a bowel movement or the baby is crowning, plan for a field delivery unless contraindicated below:

position and expedite transport

unless the baby is crowning

unless the baby is crowning. If the decision to deliver in the field is made, call for an additional medic unit and plan to transport after the first child is delivered.

was told by her physician not to deliver vaginally, expedite transport, even if baby is crowning

2. If birth is not imminent then transport to appropriate facility:a) Place patient in left lateral recumbent position and provide

supplemental oxygen as neededb) Provide early notification of the patient’s status to

receiving facility

a) Prepare a delivery location (consider the modesty of the patient, the privacy of the family and the safety of the unborn child)

the delivery of the child

Appendix C – Childbirth

C-2

Appendix C – Childbirthnarrow, moves too easily and is top-heavy

b) Gather equipment and supplies:

regulators, etc.)

and ready

a) When the patient feels she needs to push, encourage her to push for as long as possible (usually 10 sec), then take a deep breath and bear down again

part of a gloved hand to prevent the baby from delivering too fast

membrane by pinching and remove it from baby’s head

nose using a bulb syringe. If meconium is present in

suction as necessary.

the back of the baby’s neck and feeling for the umbilical cord wrapped around the neck. If the cord is present, gently slip it over the head (cord could wrap multiple times).

baby’s head, apply both umbilical clamps and cut the cord between the two clamps


C-3

Appe

ndix

C –

Chi

ldbi

rthissues dealt with, have mother deliver the baby’s body:

the other as the shoulders prepare to deliver

gentle pressure to guide the head posteriorly (relative to mother) first, to deliver the anterior shoulder and then guide the head anteriorly to deliver the posterior

usually follows quickly

the baby and cut the cord in between the clamps

using towels

and cover to keep warm

status to facility of choice or nearest hospital

delivery of the baby. When the patient says she feels the

to the hospital with the patient

with blood.

nurse her baby to assist in controlling postpartum hemorrhaging.


D-1

Appendix D – Death in Field (DIF) and paramedics may withhold or terminate resuscitation

cases or if in doubt at any time, resuscitation should begin

d) Incineration

g) Evisceration of brain or heart

valid (signed)

resuscitation if the patient has been diagnosed with a terminal illness and there is a reasonable indication that the patient and his or her family did not want to have cardiopulmonary resuscitation performed.

personnel should perform all resuscitative measures regardless of any documentation.

start breathing with airway positioning

of trauma shall be determined to be dead in the field and not transported if:

Appendix D – Death in Field (DIF)

D-2

Appe

ndix

D–

Deat

h in

Fie

ld (D

IF)

the head and is pulseless and apneic after opening airway

trauma to the chest and is pulseless and apneic after opening airway

c) The patient presents in asystole

6. Medical cardiac arrest – The patient in non-traumatic (medical) cardiac arrest shall be determined to be dead in the field and not transported after consultation with the supervising physician in any of the following circumstances:a) The patient’s initial presenting rhythm is asystole and

no previous resuscitative efforts were initiatedb) At any time during the resuscitation, the patient stays

in an asystolic or agonal rhythm that is refractory to ACLS measures

c) After full ACLS resuscitative measures have been instituted and the patient’s ETCO2 remains at 10 mmHg or below for 10 minutes

d) A patient in PEA does not respond to appropriate ACLS measures

victims of electrocution, lightning and drowning should have resuscitative efforts begun and be transported to the nearest hospital unless the supervising physician orders otherwise

whether to discontinue or withhold resuscitation


D-3

Appendix D – Death in Field (DIF)b) All cases of non-resuscitation will have an ECG strip

documenting the cardiac rhythm, with the time and date recorded on the strip. If using a LP 12, attach it to the patient care report

c) All consultations with the supervising physician will be documented, including the time, physician’s name and instructions


E-1

Appe

ndix

E –

Infa

nt T

rans

fer

Appendix E – Infant Transfer

paid and volunteer firefighters and fire department-certified

72 hours old).

transfer custody of a child whether the child is less than 72 hours old as determined to a reasonable degree of medical certainty.

is a parent of the child.

identifying information as a condition of transferring custody of the newborn, and shall attempt to protect the anonymity of the parent.

history or information by providing the parent with the approved

department-approved pamphlet, which includes referral information regarding “adoption options, counseling, appropriate medical and emotional aftercare services, domestic

Procedures for infant transfers include:

accordance with protocols and provide the appropriate level

transferring person is a parent of the child, without requesting name, social security number or other identifying information.

E-2

Appendix E – Infant TransferAppendix E – Infant Transfer

time of birth of the child to ascertain whether the child is a

immediately try to attain completion of the family medical history questionnaire. When that is completed, the parent will be given the pamphlet with referral information, but such information shall be provided even if the parent refuses to provide any medical history or information.

statute, the qualified person shall attempt to obtain family medical history and address the immediate health and safety

9. In the event that employees or members of the department who do not meet the definition of qualified person are asked to accept transfer of a newborn from a parent, or any child from any person, they must ask the transferor to wait a few minutes while they summon a qualified person by

F-1

Appe

ndix

F –

Man

dato

ry R

epor

ting

Crite

ria

required to report:

1) When there is reasonable cause to believe that abandonment, abuse, financial exploitations, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to

2) If there is reason to suspect that sexual or physical assault has occurred, mandated reporters shall immediately report to the appropriate law enforcement agency (city police or

reasonable cause to believe that a child or adult dependent or developmentally disabled person has suffered abuse or neglect,

Reporting procedure

answering service will provide referral to the appropriate agency

or herself;

or his or her family’s home.

Appendix F – Mandatory Reporting Criteria

F-2


of adults can take several forms:

engages in self-destructive behavior)

noncommunicative, depressed or nonresponsive

participate in family or community activities

abuse in children can be different from in adults and vary somewhat with the age of the child.

of children can take several forms:


F-3

Appe

ndix

F –

Man

dato

ry R

epor

ting

Crite

ria1. Insure safety and provide medical aid as needed to save or

assist the child2. If child is clearly dead, do not move the body

stay at the scene or not)

of speakers

abilities and scene observations

interest or knowledge of sexual acts, reports or inappropriate touching, etc.

diaper rash; hungry; underweight; lack of food, formula or care; parent or child use of drugs or alcohol, etc.

Appendix F – Mandatory Reporting Criteria cont.

G1

Appendix G – Medical Abbreviations

G1


> Greater than

syndrome

immunodeficiency syndrome

Appearance, Pulse, Grimace, Activity, Respirations

unresponsive

isolation

c̄ With

2

pulmonary disease

resuscitation

accident

confinement (due date for delivery)

symptoms

2 End-tidal carbon dioxide

FemaleFx Fractureg Grams

GI Gastrointestinal

throat

illness

diabetes mellitusIM Intramuscular

G-2

Appe

ndix

G –

Med

ical

Abb

revi

atio

ns


distention

hypertrophy Male

(helicopter)

mEq Milliequivalentmg MilligramMI Myocardial infarction

ml Millilitermm Millimeter

diabetes mellitus

2

Onset, Provoker(s), Quality, Radiation, Severity, Time

contraction

tachycardia

PE Patient examPupils equal, round and reactive to light with accommodation

psi Pounds per square inch

supraventricular tachycardia

Pt Patient

contractionPx Painq Everyqd Every dayqh Every hourqid Four times a dayqod Every other day

G-3



s̄ Without

S Allergies, Medications, Pertinent past history Last oral intake, Events leading to 911 call

2

WPW Wolff-Parkinson-White syndrome

H-1

Appe

ndix

H

I-1

Appendix I – Medication

Generic name Other names PageActivated Charcoal Actidose® I-2Adenosine Adenocard® I-3Albuterol Proventil® and Ventolin® I-4Albuterol / Ipratropium Duoneb® I-5Amiodarone Cordorone® I-6Aspirin ASA I-7Atropine I-8Calcium Chloride Calcium I-9Dextrose D50W I-10Diltiazem Cardizem® I-11Diphenhydramine Benadryl® I-12Dopamine I-13Epinephrine Adrenalin® I-14Epinephrine Auto-injector Epi-Pen® and Epi-Pen® Jr. I-15Etomidate Amidate® I-16Fentanyl Citrate I-17Furosemide Lasix® I-18Glucose Glutose® and Insta-glucose® I-19Glucagon I-20Lidocaine I-21Magnesium Sulfate I-22Methylprednisoine Solu-Medrol® I-23Midazolam Versed® I-24Naloxone Narcan® I-25Nitroglycerin I-26Nitroglycerin Ointment I-27Normal Saline I-28Oxygen I-29Ondametron Zofran® I-30Promethazine Phenergan® I-31Proparacaine Alcaine®, Opthaine®, Opthetic® I-32Sodium Bicarbonate I-33Succinylcholine Anectine®, Quelicin® I-34Thiamine I-35Vasopressin Pitressin® I-36Vecuronium Norcuron® I-37

Bold indicates an ALS-only medication

Appendix I – Medications

I-2

Appe

ndix

I –

Med

icat

ion

Activated CharcoalEMTOther names: Actidose®

Class: Antidote

Indications: Treatment of patient who has ingested poisons by mouth, when recommended by the Washington Poison Center

Contraindications: Relative (without NG tube): Absent gag, unconscious patient, potential sedation from suspected overdose

Precautions/ adverse reactions:

Does not absorb iron, lithium, inorganic ions, ethanol, methanol or cyanide

Suggested dosage:

Adult

Pediatric

Notes:

at 800-709-0911 prior to administration

I-3


Adenosine

Other names: Adenocard®

Class: Anti-dysrhythmicIndications: Narrow complex SVTContraindications: Wide complex tachycardia, second-

syndrome; caution in patients with asthma and COPD


Severe bradycardia, VF, VT, afib,

bronchospasm; will cause temporary

and a general transient ill feelingSuggested dosage:

Adult

Pediatric

may repeat with 12 mg after 1-2 minutes

I-4

Appe

ndix

I –

Med

icat

ion

AlbuterolEMTOther names: Proventil®, Ventolin®

Class: Adrenergic beta-2 agonist Indications:

bronchospasm

symptoms of respiratory distress

Contraindications: NonePrecautions/ adverse reactions:

Arrhythmias, tachycardia, severe chest discomfort

Suggested dosage:

Adult

Pediatric

®: 5 puffs, repeat as necessary up to 20 puffs

if less than 2 y/o; otherwise use adult dose

asthma or COPD

allergic reaction

should connect it to an oxygen source at 6 lpm.

I-5


Albuterol / Ipratropium

Other names: Duoneb® , Combivent®

Class:bronchodilator

Indications: Initial treatment of moderate to severe bronchospasm

Contraindications: None


Arrhythmias, tachycardia, severe chest discomfort

Suggested dosage:

Adult/pedsrepeat as needed for persistent respiratory distress

®: 5 puffs

I-6

Appe

ndix

I –

Med

icat

ion

Amiodarone

Other names: Cordarone®

Class: Anti-dysrhythmic

Indications: For patients with recurrent VF or pulseless VT after one dose of lidocaine

Contraindications:

Precautions / adverse reactions:

None

Suggested dosage:

Adult

Pediatric

I-7


Aspirin EMTOther names: Generic

Class: Anti-platelet, non-narcotic analgesic, non-steroidal anti-inflammatory, antipyretic

Indications: Signs and/or symptoms of acute coronary syndrome

Contraindications: Allergy to Asprin


None

Suggested dosage:

Adult

Pediatric

I-8

Appe

ndix

I –

Med

icat

ion

Atropine

Other names: Generic

Class: Anticholinergic parasympatholytic

Indications:

Contraindications: HR: greater than 180

Precautions / adverse reactions:

Tachycardia, nausea, ventricular ectopy

Suggested dosage:

Adult

Pediatric

needed every 3-5 minutes up to 0.04 mg/

1.0 mg IVP, then2.0 mg IVP, then5.0 mg IVP, then10.0 mg IVP

Escalate the dose every 10 minutes until respiratory secretions dry up

repeat once

0.5 mg) for pre-medication in RSI

I-9


Calcium Chloride 10%

Other names: Generic

Class: Electrolyte replacementIndications:

arrhythmia thought to be secondary

supervising physician for administration regimen)

respiratory depression

Contraindications: Ventricular fibrillation, digitalis toxicity, hypercalcemia

Precautions/ adverse reactions: bradycardia, dysrhythmias, cardiac arrest;

can potentiate toxicity of digitalis on the heart

Suggested dosage:

Adult

Pediatricmin slow IVP)

tape for dose

I-10

Appe

ndix

I –

Med

icat

ion

Dextrose 50%

Other names: D50WClass: CaloricIndications: Symptomatic hypoglycemia Contraindications: Hyperglycemia, delirium tremensPrecautions/ adverse reactions:

Pre-treat hypoglycemic alcoholic patients with thiamine

Suggested dosage:

Adult

Pediatric

blood glucose remains less than

(1:1 D50W:NS)

(1:4 D50W:NS) for neonate

resuscitation tape for dosing

I-11


Diltiazem

Other names: ®

Class:Indications:

Contraindications: Wide complex SVT

Known WPW disease

Pulmonary congestionPrecautions/ adverse reactions:

Hypotension, arrhythmias, CHF

Suggested dosage:

Adult

Pediatric

unsuccessful after 10 mins follow-up 10 mg IVP

pediatric pts

I-12

Appe

ndix

I –

Med

icat

ion

Diphenhydramine

Other names: ®

Class: AntihistamineIndications:

Contraindications: Anticholinergic poisoningPrecautions/ adverse reactions:

Drowsiness, dilated pupils, tinnitus, dry mouth

Suggested dosage:

Adult

Pediatric

I-13


Dopamine

Other names: GenericClass: VasopressorIndications:

syndromes

and symptomsContraindications: Ventricular fibrillation, tachy-

dysrhythmias, pheochromocytomaPrecautions/ adverse reactions: with peripheral vascular disease.

Reduce dose by half in patients with significant renal disease.

Suggested dosage:

Adult

Pediatric

250 ml NS

greater than 90 mmHg

I-14

Appe

ndix

I –

Med

icat

ion

Epinephrine

Other names: Adrenalin®

Class: AdrenergicIndications:

due to anaphylactic respiratory distress or

VT, pediatric bradycardia


artery disease

Suggested dosage:

Adult

Pediatric

® or IV or SVN, 0.3-0.5 mg (3-5 ml 1:10,000)

- Drip IV, IO 4-8 mcg/min (1 mg in 250ml of saline = 4 microgram/ml)

length-based resuscitation tape)

I-15


Epinephrine Auto-injector Epi-Pen®, Epi-Pen® Jr. EMT

Other names:

Epinephrine

Class: AdrenergicIndications:

symptoms of anaphylaxis:

(hypotension) OR difficulty swallowing (throat edema), and consents to treatment

® Jr. is indicated in patients

(66 pounds)


coronary artery disease

Suggested dosage:

Adult

Pediatric

® ® Jr.

I-16

Appe

ndix

I –

Med

icat

ion

Etomidate

Other names: Amidate®

Class: General anestheticIndications:

succinylcholine during RSI

Contraindications: None in emergent settingPrecautions/ adverse reactions: nausea, vomitingSuggested dosage:

Adult

Pediatric

given over 30-60 seconds; may repeat

occur within 2 minutes

10 y/o

I-17


Fentanyl Citrate

Other names: GenericClass: Narcotic analgesicIndications: Severe painContraindications:

head injuryPrecautions/ adverse reactions: with evidence of alcohol or sedative

intoxication

ill patients

who use narcotics chronicallySuggested dosage:

Adult

Pediatric

300 mg

consult supervising physician for repeat dosing

Notes:

supervising physician is mandatory

Sp02to the patient report

I-18

Appe

ndix

I –

Med

icat

ion

Furosemide

Other names: ®

Class:Indications:

120 mmHg) with volume overloadContraindications: Hepatic coma, suspected electrolyte

disturbances, hypotension, patients with allergies to sulfonamides


Efficiency goes down in patients with renal failure

Suggested dosage:

Adult

Pediatric

slow IVP

resuscitation tape

I-19


Glucose

Other names: Glutose®, Insta-glucose®

Class: CaloricIndications: Patient with an altered or decreased

of diabetesContraindications:

unable to swallowPrecautions/ adverse reactions:

Use caution to prevent aspiration of the glucose paste

Suggested dosage:

Adult

PediatricNotes:

EMT

I-20

Appe

ndix

I –

Med

icat

ion

Glucagon

Other names: GenericClass: EndocrineIndications:

establish IV access

relatively contraindicated by age or

++

supervising physician for dosing regimen)

supervising physician for dosing regimen)

Contraindications: NonePrecautions/ adverse reactions: may return

Zofran® concurrentlySuggested dosage:

Adult

Pediatricmin (max 1 mg/dose)

I-21


Lidocaine

Other names: GenericClass: Anti-dysrhythmicIndications:

uncertain type

Contraindications:atrial fibrillation with rapid aberrant ventricular response

Precautions/ adverse reactions: 70 y/o or if patient presents with acute

jaundice

Suggested dosage:

Adult

Pediatric

I-22

Appe

ndix

I –

Med

icat

ion

Magnesium Sulfate

Other names: GenericClass: Anti-convulsant, mineralIndications:

Contraindications:treated with paralytic agents


Will lower calcium; observe for hypotension, paralysis and CNS depression; will tend to reverse the effect of digitalis, pulmonary edema

Suggested dosage:

Adult

Pediatric

ml given IV over 4 minutes

20 ml given rapid IVP

2 g diluted with NS to 20 ml given IV over 5-20 minutes

I-23


Methylprednisolone

Other names: ®

Class: GlucorticoidIndications:

severe bronchospasm

Contraindications: Known hypersensitivity to the product or its constituents


None in emergent setting

Suggested dosage:

Adult

Pediatric(12 years

or less)

I-24

Appe

ndix

I –

Med

icat

ion

Midazolam

Other names: Versed®

Class:Indications:

Contraindications: None in emergent settingPrecautions/ adverse reactions: especially when mixed with narcotics,

Suggested dosage:

Adult

Pediatric

mins to max of 10 mg

mg prn

or IN

3 min to max 5 mg

I-25


Naloxone

Other names: Narcan®

Class: Narcotic antagonistIndications: Narcotic overdoseContraindications: Neonate with possible drug dependencePrecautions/ adverse reactions: overdosesSuggested dosage:

Adult

Pediatrictape for proper weight-based dosing

I-26

Appe

ndix

I –

Med

icat

ion

Nitroglycerin EMTOther names: Nitrotab, Nitrostat®

Class: Vasodilator, anti-anginalIndications:

cardiac event

Hypertensive pulmonary edemaContraindications: ® or Cialis® or

® in past 48 hours

Tachycardia (HR>100/min)


Hypotension, headache

Suggested dosage:

Adult

Pediatric

100 mmHg systolic

I-27


Nitroglycerin Ointment

Other names: Nitrobid®

Class: Vasodilator, anti-anginalIndications: Symptoms suggestive of ACS or CHF

cardiac event

Contraindications: ® or Cialis® or ® in past 48 hours

Tachycardia (HR>100/min)


Hypotension (additive effect with

tachycardia, headacheSuggested dosage:

Adult

Pediatric

Apply as soon as possible along with first sublingual nitro)

remains above 100 mmHg, increase to 2 inches

above 100 mmHg after 10 minutes, increase to 2 inches

I-28

Appe

ndix

I –

Med

icat

ion

Normal Saline

Other names:Class: Isotonic crystalloidIndications:

Contraindications: Pulmonary edemaPrecautions/ adverse reactions: of fluid overloadSuggested dosage:

Adult

Pediatric

I-29


OxygenEMTFIRST RESPONDER

Other names: GenericClass:Indications:

respiratory distress, respiratory arrestContraindications: NonePrecautions/ adverse reactions:

None

Suggested dosage:

I-30

Appe

ndix

I –

Med

icat

ion

Other names: Zofran®

Class: Anti-emeticIndications: Nausea, vomitingContraindications:Precautions/ adverse reactions:

Caution in liver disfunction

Suggested dosage:

Adult

Pediatric

Ondansetron

I-31


Promethazine

Other names: Phenergan®

Class: Anti-emeticIndications:

of medications such as fentanyl and glucagon

Contraindications: Age less than 2 yearsPrecautions/ adverse reactions:

Dystonia, sedation; consider lower end of dosing range in elderly patients

Suggested dosage:

Adult

Pediatric

elderly), repeat once as needed; always dilute in 10 ml saline

up to adult dose

I-32

Appe

ndix

I –

Med

icat

ion

Proparacaine

Other names: Alcaine® and Opthetic® and Opthaine®

Class: AnestheticIndications: Temporary ophthalmic anesthesia for

eye injuriesContraindications: NonePrecautions/ adverse reactions:

None

Suggested dosage:

Adult

Pediatric

I-33


Sodium Bicarbonate

Other names: GenericClass: Electrolyte (acid/base)Indications:

with calcium and albuterol (consult supervising physician)

Contraindications: Hypertension, hypertensive pulmonary edema


None

Suggested dosage:

Adult

Pediatricresuscitation tape

I-34

Appe

ndix

I –

Med

icat

ion

Succinylcholine

Other names: Anectine® and Quelicin®

Class:Indications: Intubation in patients with intact gag

reflex or whose degree of pharyngeal muscle tone prevents intubation

Contraindications:history of malignant hyperthermia, pseudocholinesterase deficiency, organophosphate poisoning


of throat cancer, non-arrested croup or epiglottitis

myasthenia gravis, muscular

(burns or other in previous three to 10 days)

Suggested dosage:

Adult


I-35


Thiamine

Other names:Class: VitaminIndications: Hypoglycemic patients with a history

of alcoholism; given prior to the administration of dextrose


None

Suggested dosage:

Adult

Pediatric

I-36

Appe

ndix

I –

Med

icat

ion

Vasopressin

Other names: Pitressin®

Class: EndocrineIndications: VF, pulseless VTContraindications: None in the setting of cardiac arrestPrecautions/ adverse reactions:

None

Suggested dosage:

Adult

Pediatric

minutes as substitute for epinephrine in cardiac arrest

I-37


Vecuronium

Other names: Norcuron®

Class:Indications:

than 15 min) of intubated patients who are combative enough to extubate themselves or otherwise harm themselves

Contraindications: Hypersensitivity to vecuronium or bromides


Respiratory insufficiency, apnea,

Suggested dosage:

Adult


I-38

Appe

ndix

I –

Med

icat

ion

J-1

Appendix J – Other Tools for EMS Providers

Appendix J – Other Tools for EMS ProvidersI. Normal vital signs

AGE PULSE RESPIRATIONSBLOOD PRESSURE

AVERAGE SYSTOLIC

AVERAGE DIASTOLIC

Newborn (1-28 days)

110-150 60 80 46

3 months 110-140 40 90 606-12 months 100-140 40 90 60

1 year 100-140 26 90 602 years 90-100 20 98 64

3-5 years 80-100 20 100 7010 years 70-100 16 114 60

Adolescent 70-100 12 118 60Adult 60-100 12 120 70

II. Rule of Nines for burn victims

AREA OF THE BODY ADULT CHILD9 percent 18 percent

Entire arm, each 9 percent 9 percentChest 9 percent 9 percentAbdomen 9 percent 9 percent

9 percentpercent9 percent

Front of leg, each 9 percent Entire leg is 14 percent9 percent

Genitalia 1 percent 1 percent

III. APGAR score for newborns

after delivery.

Clinical sign 0 points 1 point 2 pointsAppearancePulse Absent Above 100Grimace No response Grimaces CriesActivity Some flexion Active motionRespiratory Absent Slow, irregular Good cry

J-2

Appe

ndix

J –

Oth

er T

ools

for E

MS

Prov

ider

sIII. Glasgow Coma Scale and Pediatric Glasgow Coma ScaleThe GCS is scored between 3 and 15, 3 being the worst and 15

given below:

1 point 2 points 3 points 4 points 5 points 6 pointsBest Eye Response (4)

No eye opening

Eye opens to pain

Eye opens to verbal command

Eyes open spon-taneously

–– ––

Best Verbal Response (5)

No verbal response

Incompre-hensible sounds

Inappro-priate words

Confused Orientated––

Best Motor Response (6)

No motor response

Extension to pain

Flexion to pain

Withdrawal from pain

Localizing pain

Obeys commands

PEDS 1 point 2 points 3 points 4 points 5 points 6 pointsBest Eye Response (4)

No eye opening

Eye opens to pain

Eye opens to speech

Eyes open spon-taneously

–– ––

Best Verbal Response (5)

No verbal response

Infant moans to pain

Infant cries to pain

Infant is irritable and continually cries

Infant coos or babbles (normal activity)

––

Best Motor Response (6)

No motor response

Extension to pain (decerebrate response)

Abnormal flexion to pain for an infant (decorticate response)

Infant withdraws from pain

Infant withdraws from touch

Infant moves spon-taneously or purposefully

A GCS or PGCS score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less is a severe brain injury.

Appendix J – Other Tools for EMS Providers

K-1

Appendix K – Pre-hospital Verbal Comm

unicationsAppendix K – Pre-hospital Verbal Communications

if possible)

All reports should be given in this format and should be less than

completed in less than 60 seconds.

2. Hospital notification report format:

if possible)

All reports should be given in this format and should be less than 60 seconds.

This report should contain more detail than the radio report and should be accompanied by a copy of the initial written report.

L-1

Appe

ndix

L –

Ski

llsACS Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-2Airway – Difficult Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . L-12 Insertion of Nasopharyngeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-32 Insertion of Oropharyngeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-35Bag Valve Mask Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-6Bleeding Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-8Blood, Obtaining a Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-34Cannulation – Internal Jugular Intravenous . . . . . . . . . . . . . . . . . . . . . . . L-21 Femoral Intravenous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-16 Peripheral Intravenous . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-40 Subclavian Intravenous . . . . . . . . . . . . . . . . . . . . . . . . . . . L-52Capnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-9Cricothyrotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-10Defibrillation – Automated External Defibrillation. . . . . . . . . . . . . . . . . . . . L-3 Automated External Defibrillator Algorithm . . . . . . . . . . . . L-5 Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-28ECG set-up, 12-lead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-14Electrical Cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-13Epi-Pen® Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-15Glucometery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-18Helmet Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-19Hypothermia (Therapeutic). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-20Immobilization – Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-26 Long Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-27 Pelvic Wrap Splint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-38 Spinal Immobilization Decision Tool . . . . . . . . . . . . . . . L-48 Spinal Immobilization Decision Algorithm . . . . . . . . . . L-49 Spinal Immobilization . . . . . . . . . . . . . . . . . . . . . . . . . . L-50 Traction Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-54Introsseous Infusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-26Intravenous Line Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-28Intubation – Nasogastric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-34Intubation – Orotracheal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-22Melker® Cricothyrotomy Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-31Metered Dose Inhaler (MDI) Assist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-29Mouth-to-Mask Ventilation with Supplemental Oxygen . . . . . . . . . . . . . . . . L-30Needle Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-33Nasogastric. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-31Oxygen Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-37Orotracheal Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-36Pericardiocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-39Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-41Rapid Sequence Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-42Restraint Guidelines – Patients with Altered LOC. . . . . . . . . . . . . . . . . . . . . L-44Restraint Guidelines – Patients who are Violent/Combative. . . . . . . . . . . . . L-46Suctioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-53Transcutaneous Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-55Ventilation Mechanical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-56Ventilation Non-Invasive BiPAP® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-57

Appendix L – Skills

L-2

Appendix L – SkillsProvider level:

Indications:− Uncomfortable “pressure,” “fullness,”

“squeezing” or discomfort in the chest or neck that lasts more than a few minutes, or that goes away and comes back

− Discomfort that radiates to shoulders, neck or arms

− Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath

-OR-Patient exhibits any of the following signs or symptoms believed to be of cardiac origin:− Atypical chest, stomach or abdominal discomfort − Unexplained nausea (without vomiting)

or lightheadedness (not vertigo) without chest discomfort

− Shortness of breath and difficulty breathing (without chest discomfort)

− Unexplained anxiety, weakness or fatigue− Palpitations, cold sweat or paleness


Equipment: DefibrillatorProcedure:

Capture 12-lead prior to moving patient and prior to ALS NTG administration

Attach 12-lead to patient care report Prior to sending 12-lead, include patient name

and age If evidence of STEMI exists, consult base station

physician as early as possible Establish IV access (Appendix L) Administer fentanyl (Appendix I) as appropriate Treat rhythm disturbances as appropriate

(Appendix A)

Acute Coronary Syndrome Management

L-3

Appe

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L –

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llsProvider level:

Indications: Patients 1 > year of age who have confirmed circulatory arrest

Contraindiations: See Death in Field criteria, Appendix DEquipment: DefibrillatorProcedure: 1. Immediately upon arrival, verify respiratory

and circulatory arrest by the absence of consciousness, normal respirations and a carotid pulse.

2. Initiate CPR and resuscitation protocols. If it is an unwitnessed cardiac arrest, perform CPR for 2 minutes before initiating defibrillation protocol.

3. Turn the defibrillator power on and begin a verbal report.

4. Immediately attach the defibrillation pads with

a. If a shock is indicated, immediately charge and deliver a single shock. After the single shock, immediately begin 2 minutes of CPR (see algorithm).*

b. If no shock is indicated, immediately begin 2 minutes of CPR (see algorithm).*

c. After 2 minutes of CPR, reanalyze the rhythmi. If a shock is indicated, immediately charge

and deliver a single shock. After a single shock, begin 2 minutes of CPR.*

ii. If no shock is indicated, immediately check pulse. 1. If no pulse, then begin 2 minutes of

CPR. 2. If a pulse is detected, provide other care

per algorithm.

Automated External Defibrillation

*compression should be continued through charging cycle if possible

L-4

Appendix L – SkillsSpecial patient and pediatric guidelines:

A. Pediatric arrest: For children < 1 year old, verify cardiac arrest and begin effective CPR. DO NOT initiate defibrillation protocol.

B. For children 1 to 8 years use pediatric pads

C. For children 8 years of age and over: Follow adult defibrillation protocols

D. Traumatic arrest: Defibrillation is ineffective in traumatic cardiac arrest. If major blood loss/ trauma is obvious, initiate basic life support. If major blood loss/trauma is NOT obvious, initiate defibrillation protocols.

E. Patients attached to a public access defibrillator (PAD): If EMS Defibrillation providers arrive to find the patient attached to a PAD device, that device should be removed and replaced with the

initiated. This should be accomplished with minimal interruption of CPR.

F. Documentation Submittal: Review of any event in which the defibrillator is attached in cardiac arrest is mandatory. The complete event data and the medical incident report MUST be transmitted to Thurston County Medic One within 4 days of the event.

Automated External Defibrillation

L-5

Appe

ndix

L –

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llsVerify Pulselessness

AED Algorithm

Witnessed Unwitnessed

CPR until ready to defib 2 min CPR

Analyze

2 min CPR

Analyze/shock

- CPR while charging- immediately resume CPR after shock

etc.

1) Compressions 30:2 ventilations2) Asynchronous ventilations every 10 compressions after patient is intubated3) Narrate resuscitation into recorder4) Call 704-2785 to report cardiac arrest (include date, FD, patient name)5) Provide MIR, download to Medic One within 96 hours

L-6

Appendix L – Skills Bag Valve Mask Ventilation

Provider level:

FATS technique (non-trauma patient)

L-7

Appe

ndix

L –

Ski

lls: Two-person bag valve mask

Seated bag valve mask

Bag Valve Mask Ventilation Cont.

L-8


Bleeding Control

L-9

Appe

ndix

L –

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llsProvider level: Paramedic

Indications:

hyperventilating

Contraindications: Colormetric devices are not used to monitor non-intubated patients who have spontaneous respirations

Equipment:

2 measuring device® or Nonin®)

Preparation: Assemble necessary equipment

Procedure:

2 in a patient who is in cardiac arrest is not itself an indication for extubation but should cause the paramedic to further investigate the placement of the ETT

Pediatric considerations:

Colormetric devices must be specified for pediatric size and are not used with spontaneously breathing patients

Capnography

L-10

Appendix L – SkillsProvider level: Paramedic

Indications:techniques are not effective

Contraindications: Ventilation possible by less invasive means

Equipment:

Povidone-iodineScalpelTracheal hook

Endotracheal or tracheostomy tubeEschmann styletteMelker Kit

Preparation: Prep neck with Providone-iodineProcedure: Melker approach:

incision in membrane with scapel

angled toward feet, draw back on syringe plunger until air easily aspirated

“floppy” end first

is through skin

against skin

correct placement

Cricothyrotomy

L-11

Appe

ndix

L –

Ski

llsProcedure:

the membrane

and expose membrane

the membrane

handle of scalpel

tracheal hook

stylette into trachea

using Eschmann

and auscultate breath sounds to confirm placement


Cricothyrotomy Continued

L-12


Indications:orotracheal intubation unlikely to be successful

by each of two providers)

Contraindications: None in the setting of patients needing positive airway control

Equipment:

Catheter Set

Preparation: Gather and prepare proper equipment

Procedure:with or without prism, for situations where cords cannot be visualized

tube using Eschmann stylette

situations where orotracheal intubation or use

Pediatricconsiderations:

Size-appropriate equipment should be used

Difficult Airway Management

L-13

Appe

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L –

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llsProvider level: ParamedicIndications:

Contraindica-tions: needed if heart rate is less than or equal to 150

Equipment:

Preparation:

(sternum/apex)

Procedure:not unconscious

“sync” control button

the patient

clinical condition is critical, go immediately to

according to the tachycardia algorithm (Appendix A)


Electrical Cardioversion

L-14


12-lead ECG Setup

L-15

Appe

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L –

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llsProvider level:

Epi-Pen® Administration

L-16


Indications: Emergency venous access when peripheral access is not available in the setting of: - Shock - Cardiac arrest

Contraindications:

Equipment:

Preparation:flush tubing

Procedure:

to ensure the catheter is patent

dressing

of attempts and fluid given in the patient care report

Femoral Intravenous Cannulation

L-17

Appe

ndix

L –

Ski

llsPediatric considerations: pediatric patients

be used to administer fluid in infants requiring fluid resuscitation

Volutrol) to prevent unintentional fluid boluses

Femoral Intravenous Cannulation Cont.

L-18

Appendix L – SkillsGlucometery

Provider level:

*Note: Glucometry is a tool that should be used to supplement an ALS assessment; although it can safely be performed by ALS or EMTs. It is not a decision point in determining either upgrade or method of transport. BLS units should not carry glucometers, nor base any decision to upgrade or downgrade a patient based on a blood sugar reading. This skill should be performed under ALS supervision.

L-19

Appe

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llsProvider level:

Helmet Removal

L-20

Appendix L – SkillsProvider level: ParamedicIndications:

movement after 2 minutesContraindications:

to withhold or terminate resuscitative measuresoC)

Equipment: oC) saline

Preparation: Establish and secure IV if not already established

Procedure: open bolus

measures per protocol

as possible

Pediatric Considerations:

Hypothermia (Therapeutic)

L-21

Appe

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llsProvider level: ParamedicIndications: Emergency venous access when peripheral access is

not available in the setting of:

Contraindications:Equipment:


Procedure:

being cannulated

sternocleidomastoid and clavicle

triangle, lateral to the palpated carotid artery, and advance toward the ipsilateral nipple

the plunger on the syringe until blood is freely aspirated

ensure the catheter is patent

over site

attempts and fluid given in the patient care report

Internal Jugular Intravenous Cannulation

L-22

Appendix L – SkillsPediatricconsiderations: pediatric patients

used to administer fluid in infants requiring fluid resuscitation

Volutrol) to prevent unintentional fluid boluses

Internal Jugular Intravenous Cannulation Cont.

L-23

Appe

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L –

Ski

llsProvider Level: ParamedicIndications: Emergency circulatory access when peripheral access is

not available in the setting of:- Shock- Cardiac Arrest

Contraindications: RELATIVE- Peripheral access is available

Equipment: ®

® ® Needle Set

® or Standard Extension Set

Preparation:

flush tubing

Procedure:® driver and appropriate needle set

® driver from needle set while stabilizing catheter hub

or approved sharps container

®

® catheter with the

continuous infusions where applicable

as directed® site and patient condition

Introsseous Infusion EZ-10®

L-24

Appendix L – SkillsIntrosseous Infusion Cont.

Pediatric Considerations: pediatric patients

be used to administer fluid in infants requiring fluid resuscitation

to prevent unintentional fluid boluses

L-25

Appe

ndix

L –

Ski

llsProvider level:

IV Line Setup

L-26


Joint Immobilization

L-27

Appe

ndix

L –

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llsProvider level:

Long Bone Immobilization

L-28


Contraindications:

Equipment:

Preparation: on the patient (sternum-apex)

Procedure:

(through leads or paddles)

charge the defibrillator

the patient


Manual Defibrillation

L-29

Appe

ndix

L –

Ski

llsProvider level:

Metered Dose Inhaler (MDI) Assist

L-30


Mouth-to-Mask Ventilation with Supplemental Oxygen

L-31

Appe

ndix

L –

Ski


Indications:

activated charcoal

Contraindications:suspected skull fracture

during insertion

Equipment:

Preparation: Gather equipment

Procedure:the ear and then to a midpoint between the xiphoid and the umbilicus

soluble lubricant

continue to insert until the measured depth is reached

air while auscultating over the epigastrium

stomach contents


In the pediatric patient, use the length-based tape

Nasogastric Tube Insertion (NG Tube)

L-32


Nasopharyngeal Airway

L-33

Appe

ndix

L –

Ski


Indications: Tension pneumothorax

Contraindications: None in setting of tension pneumothorax

Equipment:

Preparation:iodine solution

Procedure:catheter in the mid-clavicular line at the second intercostal space at a 90-degree angle by walking the needle over the top of the third rib

air is freely aspirated, do not advance needle

in place

the catheter

Needle Thoracentesis

L-34


Indications:

Contraindications: None in the emergency setting

Equipment: - Lancet

- Alcohol wipe - Adhesive bandage - Glucometer

- IV start equipment - 10 ml syringe - Vacutainer holder with female adapter - 7 ml purple-top blood tube (or law enforcement-

provided kit)

Preparation: - Clean the site - Prepare the glucometer

- Start IV and remove needle from catheter

Procedure: Glucose testing:

lock tubing)

and flush

date and your initials on the blood band

blood tube

Obtaining Blood Specimens

L-35

Appe

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L –

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llsProvider level:

Oropharyngeal Airway

L-36


Contraindications:

Appendix L)

Equipment:

tube holder

2 monitoring equipment/device

Preparation: Assemble and check required equipment

Procedure:

30 seconds, with re-oxygenation between attempts

(total of four attempts) before implementing alternative

2 monitoring

(every 5 minutes) measurement by the defibrillator

Pediatricconsiderations:

equipment sizes

2 monitoring

Orotracheal Intubation

L-37

Appe

ndix

L –

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llsProvider level:

Oxygen Administration

L-38


Pelvic Wrap Splint

L-39

Appe

ndix

L –

Ski


Indications: Signs and symptoms of cardiac tamponade

Contraindications: None in setting of tamponade

Equipment:

Preparation:prepped with povidone-iodine

Procedure:and the left costal margin at a 30- to 45-degree angle to the skin

advance the needle while aspirating constantly

possible (30-50 ml)


Use shallower angle of approach in children with small chests

Pericardiocentesis

L-40


Indications:

administration

Contraindications: None in emergent setting

Equipment:

or 1,000 ml)

Preparation:saline solution and flush tubing

Procedure:

sample, release the tourniquet

or IV fluid bag

occlusive dressing over the site

receive ALS transport

Pediatricconsiderations: Volutrol) to prevent unintentional fluid boluses

Peripheral Intravenous Cannulation

L-41

Appe

ndix

L –

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Indications: Patients with signs of respiratory distress or dyspnea

Contraindications:

Equipment:

Preparation:

Procedure:

reading must correlate with heart rate)

Pediatric considerations: possible (ear lobe, toes, foot, hand)

Pulse Oximetry

L-42

Appendix L – SkillsRapid Sequence Induction

Provider level: Paramedic

Indications: 2 less than 88 percent refractory to other interventions)

respiratory compromise

burns, neck or midfacial trauma, or anaphylaxis

gag reflex

Contraindications: − Very fat or short neck− Severe arthritis of neck with minimal mobility− Known anatomical deformities

− Non-arrested croup or epiglottitis

Equipment:

2 monitoring equipment/device

tracheal tube holder

Preparation:

sedative and paralytic

2 to at

L-43

Appe

ndix

L –

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llsProcedure:

mg/kg

attempt(s)

immediately following intubation2 monitoring

tracheal tube holder

administer midazolam 5 mg IV, 2 mg IV prn Notify supervising physician as soon as possible

is necessary following intubation, contact the supervising physician to discuss administering


important as in adults

equipment sizes and calculate drug doses

Rapid Sequence Induction Cont.

L-44


Restraint Guidelines for Patients with Altered LOC

L-45

Appe

ndix

L –

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llsRestraint Guidelines for Patients with Altered LOC Cont.

L-46


Restraint Guidelines for Violent/Combative Patients

L-47

Appe

ndix

L –

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lls

Chemical restraint:

Indications:– Patients who are so violent and combative that

they cannot reasonably be placed in medical restraint without causing physical injury to the patient or EMS providers, OR

– Patients who continue to struggle after placed in full body medical restraint

IF SITUATION ALLOWS, contact supervising physician for orders for midazolam 10 mg IN or IM

Restraint Guidelines for Violent/Combative Patients Cont.

L-48


Spinal Immobilization Decision Tool

L-49

Appe

ndix

L –

Ski

lls Spinal Immobilization Decision Algorithm

Proceed with complete spinal immobilization

L-50

Appendix L – SkillsSpinal Immobilization

Provider level:

L-51

Appe

ndix

L –

Ski

llsSpinal Immobilization Cont.

L-52

Appendix L – SkillsSubclavian Intravenous Cannulation (Infraclavicular Approach)Provider level: ParamedicIndications: Emergency venous access when peripheral access is not

available in the setting of:

Contraindications:Equipment:


Procedure:

the clavicle

advancing the needle toward the suprasternal notch

on the syringe until blood is aspirated

the catheter is patent

dressing over the site

and fluid given in the patient care reportPediatric considerations: pediatric patients

to administer fluid in infants requiring fluid resuscitation

prevent unintentional fluid boluses

L-53

Appe

ndix

L –

Ski

llsProvider level:

Endotracheal (paramedics only)

endotracheal tube

endotracheal tube to moisten secretions as necessary to facilitate suctioning

*Note: if patient is in cardiac arrest you may suction airway while performing chest compressions.

Suctioning

L-54


Traction Device

L-55

Appe

ndix

L –

Ski


Indications:cardiac output that is unresponsive to atropine

who has a transplanted heart

Contraindications:

Equipment:

Preparation:

(sternum/apex) fashion

Procedure:rhythm

capture is obtained

lowest effective level


Use pediatric pacing pads

Transcutaneous Pacing

L-56


Indications:


Equipment:

Preparation:

Mode: CMV - Assist

Trigger [L/min] 52] 5

Tplat

VtPmax 2 2

Procedure:

Auto-PEEP


Contraindicated in patients requiring

Ventilation Mechanical

L-57

Appe

ndix

L –

Ski


Indications:

Contraindications: Patient is unconscious/obtunded/absent gag reflexPatient is suspected/potential upper airway

or burns

Equipment:

Preparation:

®”)

Trigger [L/min] 52] 5

PS 10

Vt

Pmax 2 2

Procedure:


Contraindicated in patients less than 10 years

Ventilation Non-Invasive (“BiPAP®”)

M-1

Appendix M – SOAP W

ritten Report Format

The narrative section of the Medical Incident Report should provide a comprehensive yet as brief as possible “snapshot” of

In Thurston County, the narrative section of a pre-hospital MIR is organized using the SOAP format. SOAP stands for Subjective, Objective, Assessment and Plan.

Subjective (hx present, past): This is information told to the examiner that he or she could not directly observe. The information required in this section is easily remembered by two mnemonics: SAMPLE (Signs and symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, and Events leading to the 911 call) and OPQRST (Onset, Provokers, Quality, Radiation, Severity and Time).

Objective (findings): The objective portion of the narrative section contains details the examiner observed directly. This is where the patient assessment is documented.

Assessment (findings):

not a diagnosis. The assessment should be written as a two-part statement. The first part should state simply whatever the examiner found wrong with the patient: “Chest discomfort,” for example. The second part of the assessment is the “Rule Out” section, which is written in a

problem should be preceded by the abbreviation “R/O” (“Rule Out”). For example, the assessment of a patient with chest discomfort and shortness of breath might look like this: A/Chest Discomfort 1) R/O ACS 2) R/O CHF.

Plan (care events): This section of the narrative should detail the care the patient received and his or her response to the treatment. This Washington state-approved tool is designed to help emergency medical service providers prioritize treatment and transport during a mass casualty incident.

Appendix M – SOAP Written Report Format

M-2

Appe

ndix

M –

SOA

P W

ritte

n Re

port

Form

atPatients have the right to participate in and guide their medical care including the ability to refuse any given treatment or transport. However, in order to exercise this right a patient must demonstrate to the EMS provider that they have ‘decision making

person is able to stand trial, and is not a relevant term in medical

provider determining that a patient has the ability to understand his/her choices and the possible outcomes of their decisions.

A patient with decision making capacity must:

1. Have fluency in English2. Be over the age of 183. Be oriented to person, place and time and not show any

obvious cognitive deficit4. Be free of the influence of alcohol, drugs, or any mind

altering substances5. Not have any injury or medical condition affecting their

judgement6. Not have threatened or attempted suicide during this episode7. Demonstrate the ability to explain the decision they are

making and the possible negative outcomes including death and devastating disability

If a patient that meets these standards wishes to refuse any aspect of medical care or transport, the Thurston County EMS provider will use the following procedure:

intoxicant, medical condition, or injury that may impair their judgement

to accept

Refusal of Care

M-3

Appendix M – SOAP W

ritten Report Format

death or devastating disability due to current, subsequent or undiagnosed conditions, or deterioration of their condition caused by deviation from Thurston County standards and protocols

negative outcomes that may entail

have the patient sign the “Against Medical Advice” form

encourage the patient to seek medical attention or call 911 if conditions change or they decide they would like evaluation and care

Refusal of Care

N-1

Appe

ndix

N –

STA

RT T

ool

Notbreathing

Positionairway

Notbreathing

Breathing

Approach patient

AirRespirations

Normal

Assessradial Pulse

Present

AssessMentation

FollowsCommands

Tag Yellow,save end

Tag Black,save end

Give 5rescue

breaths; ifstill not

breathing, tag black.

Tag Red,save end

Tag Red,save end

Absent

Tag Red,save end

Fast, slow or noisyFast, slow or noisy

Breathing

Pediatricnot breathing

Appendix N – START Tool

O-1

Appendix O – Toxindromes

Substance BP HR RR T Mental status Signs/symptoms

Adrenergic agonists

Agitation, psychosis Mydriasis, diaphoresis

Antihistamines

Variable – Agitation to coma, psychosis

Dry mouth, blurred vision, mydriasis, flushing, urinary retention

Beta blockers Lethargy, coma

Dizziness, cyanosis, seizures

Cholinergic agents

Lethargy, coma

Salivation, lacrimation, urination, diarrhea, miosis, diaphoresis, seizures

Cyclic antidepressants

Lethargy, coma

Dry mouth, blurred vision, mydriasis, flushing, urinary retention

Ethanol & sedatives

Lethargy, coma

Slurred speech, ataxia, hyporeflexia

Ethanol or sedative withdrawal

Agitation, psychosis

Mydriasis, diaphoresis, tremor, seizures

Hallucinogens

Variable – Agitation to lethargy, psychosis

Mydriasis

Opioid compounds

Lethargy, coma

Slurred speech, ataxia, hyporeflexia

Opioid withdrawal

Normal to agitated

Nausea, vomiting, abdominal cramping, hyperactivity

Salicylate compounds

Variable – Agitation to coma

Tinnitus, nausea, vomiting, diaphoresis

Appendix O – Toxindromes

P-1

Appe

ndix

P –

Was

hing

ton

Stat

e Tr

aum

a Tr

iage

Too

l

Appendix P – Washington State Trauma Triage Tool

Measure vital signs and level of consciousness

Access anatomy of injury

Access mechanism of injury and evidence of high-energy impact

Falls

High-Risk Auto Crash

Auto v. Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20 mph) Impact Motorcycle Crash > 20 mph

Age

Anticoagulation and Bleeding Disorders Burns

Time Sensitive Extremity Injury End-Stage Renal Disease Requiring Dialysis Pregnancy > 20 Weeks EMS Provider Judgement

NO

NO

Access special patient or system considerations

NO

Transport according to protocol

NO

When in doubt, transport to a trauma center.For more information on the Decision Scheme, visit: www.cdc.gov/FieldTriage

1

2

3

4

P-2

Appendix P – Washington State Traum

a Triage ToolAppendix P – Washington State Trauma Triage Tool

Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.

YES

Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.

YES

Transport to closest appropriate trauma center, which depending on the trauma system, need not be the highest level trauma center.

YES

Contact medical control and consider transport to a trauma center or a specific resource hospital.

YES

U.S. DEPATMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR DISEASE CONTROL AND PREVENTION

P-3

Appe

ndix

P –

Was

hing

ton

Stat

e Tr

aum

a Tr

iage

Too

lSt. Peter Hospital

Full Trauma Team Activation (FTT) Requirement

2<90% with associated chest injury

pelvic fracture

Trauma Surgeon must be called in to see these patients

*Neurosurgeon may be called in place of general surgeon for isolated penetrating head injuries ONLY*

Q-1

Appendix Q – Healthline Access

BLS Uniton scene BLS

eval done

Call HealthLinethrough CAPCOM

704-2740

Nurse recommends EMS transport to ED?

(Nurse may want to speak to patient directly)

Patient to followHealthLine

recommendations

Appropriate EMS treatment and

transport to ED

EMS unsure ifEMS transportis necessary

EMS assists with follow-up asnecessary

Yes

Healthline Access Procedure for On-scene EMS personnel

Q-2

Appe

ndix

Q –

Hea

lthlin

e Ac

cess

1

GLOSSARYACS acute coronary syndrome – refers to any

group of clinical symptoms caused by acute myocardial ischemia

adrenergic resembling adrenaline, especially in physiological action

akisthesia a feeling of restlessness and an urgent need of movement, side effect of phenothiazines

antegrade forward (e.g. from the time of injury)

anticoagulant substance that hinders the clotting of blood; a blood thinner

aphasia absence or impairment of the ability to communicate through speech, writing, or signs due to dysfunction of brain centers

barotrauma any injury caused by a change in atmospheric pressure between a potentially closed space and the surrounding area

Bell’s palsy paralysis of the facial nerve producing distortion on one side of the face

carbonaceous sputum

sputum tinged black or charcoal secondary to exposure to fire and or a smoky environment

carpopedal spasms

involuntary flexion of the hands and feet, usually secondary to carbon dioxide deficiency

cholinergic liberating, activated by or involving acetylcholine; resembling acetylcholine, especially in physiologic action

CID cervical immobilization device

clonic reflexes rhythmic, involuntary muscle contractions

colormetric devices

end-tidal carbon dioxide detectors that rely on a litmus type paper to change color in the presence of carbon dioxide

consent definitions

expressed consent means the patient was advised of the treatment being offered and has given permission; implied consent means consent is assumed to exist (i.e., the patient has not refused)

cricoid pressure application of digital pressure to cricoid cartilage in neck of an unconscious patient to permit visualization of the glottic opening during endotracheal intubation

Glossary

2

GLOS

SARY

Cushing’s triad the triad of hypertension, bradycardia and changing respiratory pattern in patients with head injuries; sign of increasing intracranial pressure

DAN Divers Alert Network, an international support network that can provide specialized information and assistance in the area of dive medicine (similar to poison control or CHEMTREC)

dermatome an area of skin that is mainly supplied by a single spinal nerve; useful for finding the site of damage to the spine

DTs delirium tremens is a disorder involving sudden and severe mental (psychosis) or neurological (seizure) changes caused by abruptly stopping the use of alcohol

dysrhythmia a disordered rhythm exhibited in a record of electrical activity of the brain or heart

dysphagia difficulty in swallowing

dyspnea the sensation of shortness of breath

dystonia involuntary muscle contractions often involving lateral rotation of the neck and lateral gaze

eclampsia seizure occurring around the time of childbirth; often associated with hypertension or edema

epistaxis nosebleed

evisceration protrusion of the internal organs

FATS Technique Face and Thigh Squeeze is a technique for manually maintaining an open airway while using a bag valve mask to ventilate a nontraumatic patient

GCSlevel of consciousness by assigning a point value to best eye-opening response, best verbal response and best motor response

hydrofluoric acid acid used for glass etching

incontinence inability of the body to control the bladder or bowel

intubation attempt tip of laryngoscope passing the lips

lacrimation the secretion of tears, especially when abnormal or excessive

Glossary Cont.

3

GLOSSARYlateralizing signs signs that occur on one side of the body

miosis very small pupils

mydriasis pronounced or abnormal dilation of the pupil

normothermic normal body temperature

nuchal of or relating to the region of the neck

pallor deficiency of color, especially of the face

palpitations a sensation of an unduly rapid or irregular heart beat

paresthesia sensation of numbness, prickling or tingling

petechial hemorrhaging

small, purplish hemorrhagic spots on the skin

polypharmacy ingestion of more than 1 drug together

POLST Physician Ordered Life Sustaining Treatment, or end-of-life treatment documentation

postictal period that follows the clonic phase of a generalized seizure

pre-syncope signs and symptoms experienced by a patient prior to having a syncopal event

priapism persistent, abnormal erection of the penis accompanied by pain and tenderness

procedure describes the sequence of actions in medical protocols or policies

prodrome symptom(s) that may indicate the onset of a disease

protocol defines field treatments, or the order and type of medical interventions for specific illness and injury conditions

pseudoseizure seizurelike behavior that may or may not be voluntary

retrograde going backward (i.e., loss of memory before injury)

Glossary Cont.

4

GLOS

SARY

rule of palm method used to measure the body surface area of a burn patient: the palm of the person who is burned (not fingers or wrist area) is about 1 percent of the

surface area burnedsalicylate a group of aspirin-like compounds (i.e., Pepto

Bismol, Alka Seltzer)sclera the white part of the eyeball

semi-Fowler’s position for patient, with the back raised 45 degrees from horizontal

sonorous respirations

snoring respirations

sublingual beneath the tonguestatus seizure multiple seizure without return to baseline level of

sublingual consciousness

subcutaneous emphysema

the presence of a gas and especially air in the subcutaneous tissue

tachypnea abnormally rapid breathing (36-40 breaths per minute for an adult)

Torsades de Pointes

ventricular tachycardia that is characterized by rhythmic fluctuation in amplitude of the QRS complexes

tonic involuntary muscular contraction

toxindrome a syndrome associated with a certain toxic substance

trismus total contraction of the muscles of the jaw

unilateral affecting only one side

vertigo the sensation that the environment is moving

WPW Wolff-Parkinson-White syndrome is an autonomic defect of the heart that is associated with severe or difficult-to-control tachycardias

Glossary Cont.

Phone/Fax Contacts for EMS Providers CONTACT AC NUMBER MAIN NUMBER FAX

Capital Medical Center ER 360 956‐2596 754‐5858 956‐2564

Providence Centralia ER 360 330‐8515 877‐736‐2803 330‐8684

Childrens Seattle ER 206 987‐8899 866‐987‐2000 987‐3945

Divers Alert Network (DAN) 919 684‐9111

Harborview Med Ctr “Trauma Doc” 206 731‐3074 731‐3000 731‐2655

Madigan Army Medical Center 253 968‐1396 968‐1110 968‐3190

Madigan Gate for Entrance 253 968‐1396

Mary Bridge Childrens ER 253 403‐1476 403‐1400 403‐1406

Providence St. Peter Hospital ER 360 491‐8888 491‐9480 493‐7663

Tacoma General ER 253 627‐8500 403‐1000 403‐1517

Virginia Mason ER & Hyperbaric 206 583‐6450 624‐1144 223‐6677

END HARM Reporting 866 363‐4276 END‐HARM

Area Agency on Aging 360 664‐2168 664‐2168 664‐0791

Thurston County Coroner 360 586‐2091 586‐2091 357‐2485

Washington Poison Center 800 709‐0911 800‐222‐1222

Washington State Patrol 360 586‐1999 586‐4443 (Tacoma

24hrs)

OTHER IMPORTANT RESOURCES

Red Cross (24 hrs) 360 352‐8575 352‐0861

Safeplace (Emergency Shelter) 360 754‐6300

(Will return voice mail within 20

minutes)

Salvation Army (Emergency Shelter) 360 352‐8596

CYS Shelter Project (11‐17 yrs) 360 943‐0780

Crisis Clinic 360 586‐2800 800‐627‐2211

Domestic Violence Hotline 800 562‐6025

Haven House Youth Shelter (24hrs) 360 754‐1151

EMS Protocols - Thurston County

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