1 2006 protocol update central shenandoah ems council
TRANSCRIPT
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2006 Protocol Update2006 Protocol Update
Central Shenandoah EMS CouncilCentral Shenandoah EMS Council
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BackgroundBackground
• Release of the American Heart Association 2005 Guidelines for CPR and ECC
• CSEMS Council Medical Control Review Committee
• Protocol Sub-committee• Peer Review
• Release of the American Heart Association 2005 Guidelines for CPR and ECC
• CSEMS Council Medical Control Review Committee
• Protocol Sub-committee• Peer Review
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Summary of Major AHA Changes
Summary of Major AHA Changes
2006 Protocol Update2006 Protocol Update
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Basic Life SupportBasic Life Support
• Focus on providing high-quality CPR with special attention to chest compression depth and rate, permitting complete chest wall recoil and minimal interruptions to compressions.
• Focus on providing high-quality CPR with special attention to chest compression depth and rate, permitting complete chest wall recoil and minimal interruptions to compressions.
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Basic Life SupportBasic Life Support
• All rescuers acting alone should use a 30:2 ratio of compressions-to-ventilations for all victims except newborns.
• Health-care providers performing two-rescuer CPR for adults should use a 30:2 compression-to-ventilation ratio when there is no advanced airway in place.
• Health-care providers performing two-rescuer CPR for infants and children should use a 15:2 compression-to-ventilation ratio when there is no advanced airway in place.
• All rescuers acting alone should use a 30:2 ratio of compressions-to-ventilations for all victims except newborns.
• Health-care providers performing two-rescuer CPR for adults should use a 30:2 compression-to-ventilation ratio when there is no advanced airway in place.
• Health-care providers performing two-rescuer CPR for infants and children should use a 15:2 compression-to-ventilation ratio when there is no advanced airway in place.
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Basic Life SupportBasic Life Support
• Compressions are given at a rate of 100 per minute with complete relaxation of pressure on the chest wall after each compression.
• Once an advanced airway is in place, continuous chest compressions are given at 100/minute with one ventilation every six to eight seconds (8–10 ventilations per minute). The ventilations are given without pausing chest compressions.
• Compressions are given at a rate of 100 per minute with complete relaxation of pressure on the chest wall after each compression.
• Once an advanced airway is in place, continuous chest compressions are given at 100/minute with one ventilation every six to eight seconds (8–10 ventilations per minute). The ventilations are given without pausing chest compressions.
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Basic Life SupportBasic Life Support
• Each rescue breath should be given over one second.
• If a jaw thrust without head extension does not open the airway for an unresponsive trauma victim with suspected cervical spine injury, use the head tilt–chin lift maneuver.
• Avoid over-ventilation: too many breaths per minute or breaths that are too large or too forceful.
• Each rescue breath should be given over one second.
• If a jaw thrust without head extension does not open the airway for an unresponsive trauma victim with suspected cervical spine injury, use the head tilt–chin lift maneuver.
• Avoid over-ventilation: too many breaths per minute or breaths that are too large or too forceful.
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Basic Life SupportBasic Life Support
• Use a child dose-reduction system with AEDs (e.g. pediatric pads/cable), when available, for children from one to eight years old.
• When two or more health-care providers are present during CPR, rescuers should rotate the compressor role every two minutes.
• Use a child dose-reduction system with AEDs (e.g. pediatric pads/cable), when available, for children from one to eight years old.
• When two or more health-care providers are present during CPR, rescuers should rotate the compressor role every two minutes.
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Basic Life SupportBasic Life Support
• For victims of ventricular fibrillation (VF) cardiac arrest, use a single shock, followed by immediate CPR for two minutes, starting with compressions first.
• For victims of ventricular fibrillation (VF) cardiac arrest, use a single shock, followed by immediate CPR for two minutes, starting with compressions first.
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Basic Life SupportBasic Life Support
• Actions for foreign body airway obstruction (FBAO) relief were simplified.
• For adult out-of-hospital cardiac arrest that is not witnessed by the EMS provider, rescuers give a period of CPR (about two minutes) before checking the rhythm and attempting defibrillation.
• Actions for foreign body airway obstruction (FBAO) relief were simplified.
• For adult out-of-hospital cardiac arrest that is not witnessed by the EMS provider, rescuers give a period of CPR (about two minutes) before checking the rhythm and attempting defibrillation.
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Advanced Life Support - AdultsAdvanced Life Support - Adults
• Therapy for acute coronary syndrome (ACS):– Emphasis on 12-lead ECG acquisition by EMT-Bs
and all ALS providers.
• Therapy for acute coronary syndrome (ACS):– Emphasis on 12-lead ECG acquisition by EMT-Bs
and all ALS providers.
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Learn More…Learn More…
• www.americanheart.org• Click on…
– CPR & ECC AHA Guidelines for CPR & ECC
• www.americanheart.org• Click on…
– CPR & ECC AHA Guidelines for CPR & ECC
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2006 BLS Protocol Review2006 BLS Protocol Review
CSEMS CouncilCSEMS Council
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Level DesignationLevel Designation
• First Responder… A• EMT-Basic… B• EMT-Shock Trauma… C• EMT-Enhanced… J• EMT-Cardiac… D• EMT-Intermediate… I• EMT-Paramedic… E
• First Responder… A• EMT-Basic… B• EMT-Shock Trauma… C• EMT-Enhanced… J• EMT-Cardiac… D• EMT-Intermediate… I• EMT-Paramedic… E
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Table of ContentsTable of Contents
• Each item is linked to the heading.• Each item is linked to the heading.
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General Patient ManagementGeneral Patient Management
• Scene size-up• Scene size-up
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Initial AssessmentInitial Assessment
• Breathing– Breaths delivered over 1 second.– Rescue breathing at 10 to 12 breaths/min (adult),
12 to 20 breaths/min (infant/child).
• Breathing– Breaths delivered over 1 second.– Rescue breathing at 10 to 12 breaths/min (adult),
12 to 20 breaths/min (infant/child).
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BLS ManeuversBLS Maneuvers 9
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General Patient ManagementGeneral Patient Management
• History and Examination– OPQRST-ASPN
• Associated symptoms• Pertinent negatives
• On-going Assessment
• History and Examination– OPQRST-ASPN
• Associated symptoms• Pertinent negatives
• On-going Assessment
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Cardiac Arrest – AdultCardiac Arrest – Adult13
More…More…
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Cardiac Arrest – AdultCardiac Arrest – Adult13
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Cardiac Arrest – AdultCardiac Arrest – Adult
• Follow manufacturer’s recommendations for shock energies.
• Arrest witnessed defibrillate as soon possible.• Arrest not witnessed 5 cycles of CPR
defibrillation.• Provide CPR while the defibrillator charges.• Give the shock as quickly as possible.• Immediately after shock delivery,
– Resume CPR (beginning with chest compressions)– Continue for 5 cycles (about 2 minutes) – Then check the rhythm.
• Follow manufacturer’s recommendations for shock energies.
• Arrest witnessed defibrillate as soon possible.• Arrest not witnessed 5 cycles of CPR
defibrillation.• Provide CPR while the defibrillator charges.• Give the shock as quickly as possible.• Immediately after shock delivery,
– Resume CPR (beginning with chest compressions)– Continue for 5 cycles (about 2 minutes) – Then check the rhythm.
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Cardiac Arrest – AdultCardiac Arrest – Adult
• Push hard and fast (100/min).• Ensure full chest recoil.• Minimize interruptions in chest
compressions.• One cycle of CPR: 30 compressions then 2
breaths; 5 cycles 2 min.• Rotate compressors every cycle.• Resuscitation can be terminated by BLS or
ALS providers under the direction of [Medical Control].
• Push hard and fast (100/min).• Ensure full chest recoil.• Minimize interruptions in chest
compressions.• One cycle of CPR: 30 compressions then 2
breaths; 5 cycles 2 min.• Rotate compressors every cycle.• Resuscitation can be terminated by BLS or
ALS providers under the direction of [Medical Control].
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Cardiac Arrest – AdultCardiac Arrest – Adult
• Avoid hyperventilation.• Secure airway and confirm placement.• After an advanced airway is placed,
rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. – Give 8 to 10 breaths/minutes.
• Check rhythm every 2 minutes.• Rotate compressors every 2 minutes with
rhythm checks.
• Avoid hyperventilation.• Secure airway and confirm placement.• After an advanced airway is placed,
rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. – Give 8 to 10 breaths/minutes.
• Check rhythm every 2 minutes.• Rotate compressors every 2 minutes with
rhythm checks.
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Cardiac Arrest – AdultCardiac Arrest – Adult
• Search for and treat possible contributing factors:– Hypovolemia– Hypoxia– Hydrogen ion (acidosis)– Hypo-/hyperkalemia– Hypoglycemia– Hypothermia
• Search for and treat possible contributing factors:– Hypovolemia– Hypoxia– Hydrogen ion (acidosis)– Hypo-/hyperkalemia– Hypoglycemia– Hypothermia
– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary or
pulmonary)– Trauma
– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary or
pulmonary)– Trauma
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Cardiac Arrest - ChildCardiac Arrest - Child25
More…More…
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Cardiac Arrest - ChildCardiac Arrest - Child22
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Medical & Trauma ProtocolsMedical & Trauma Protocols
2006 Protocol Update2006 Protocol Update
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Altered Mental StatusAltered Mental Status
• Most protocols contain introductory section with a background on the condition.
• AMS protocol directs provider to new sections.– Hypoglycemia– Hyperglycemia
• AEIOUTIPS
• Most protocols contain introductory section with a background on the condition.
• AMS protocol directs provider to new sections.– Hypoglycemia– Hyperglycemia
• AEIOUTIPS
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BurnsBurns
• Essentially unchanged.• Classification of burn severity table.• ABA burn unit referral criteria table.
• Essentially unchanged.• Classification of burn severity table.• ABA burn unit referral criteria table.
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Chest Pain (Non-traumatic)Chest Pain (Non-traumatic)
• Nitroglycerin to a total of 3 doses.• Emphasis on 12-lead acquisition.
– Notification of hospital.– Patient disposition.
• Nitroglycerin to a total of 3 doses.• Emphasis on 12-lead acquisition.
– Notification of hospital.– Patient disposition.
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Environmental (Snake Bite)Environmental (Snake Bite)
• No constricting bands.• Every 15 minutes, use a pen to mark the
border of the advancing edema and document the time.
• No constricting bands.• Every 15 minutes, use a pen to mark the
border of the advancing edema and document the time.
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Obstetrics – Normal DeliveryObstetrics – Normal Delivery
• Expanded, more detailed guidelines.• Expanded, more detailed guidelines.
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Obstetrics – Normal DeliveryObstetrics – Normal Delivery
• Essentially unchanged.• Ensure preservation of newborn warmth.• APGAR score.
• Essentially unchanged.• Ensure preservation of newborn warmth.• APGAR score.
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Obstetrics – Newborn ResuscitationObstetrics – Newborn Resuscitation• Respirations adequate, HR >100, centrally
cyanotic:– Blow-by oxygen.– No response in 30 seconds BVM 40 to 60 breaths per
minute.
• Respirations inadequate or HR <100:– Ventilation with a BVM.– Continue until HR >100.
• HR <60 after 30 seconds of BVM:– Chest compressions at a rate of 120/min.– Compression to ventilation ratio of 3:1.– Continue until HR >60.
• Respirations adequate, HR >100, centrally cyanotic:– Blow-by oxygen.– No response in 30 seconds BVM 40 to 60 breaths per
minute.
• Respirations inadequate or HR <100:– Ventilation with a BVM.– Continue until HR >100.
• HR <60 after 30 seconds of BVM:– Chest compressions at a rate of 120/min.– Compression to ventilation ratio of 3:1.– Continue until HR >60.
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Respiratory – Airway ObstructionRespiratory – Airway Obstruction 1 year of age
– “Are you choking?”
• Less than 1 year of age– Deliver 5 back blows (slaps) followed by 5 chest
thrusts
1 year of age– “Are you choking?”
• Less than 1 year of age– Deliver 5 back blows (slaps) followed by 5 chest
thrusts
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Respiratory – Airway ObstructionRespiratory – Airway Obstruction• Start CPR in all ages.
– No longer perform abdominal thrusts in age 1 year.
– Higher sustained airway pressures can be generated using the chest thrust rather than the abdominal thrust.
• Each time the airway is opened during CPR, look for an object and remove if found with a finger sweep.
• Start CPR in all ages.– No longer perform abdominal thrusts in age 1
year.– Higher sustained airway pressures can be
generated using the chest thrust rather than the abdominal thrust.
• Each time the airway is opened during CPR, look for an object and remove if found with a finger sweep.
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Respiratory – Pulmonary EdemaRespiratory – Pulmonary Edema
• Assist the patient with prescribed nitroglycerin, if available.
• Assist the patient with prescribed nitroglycerin, if available.
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Spinal ImmobilizationSpinal Immobilization
• New protocol.• “o” indicates First Responders trained to
perform spinal immobilization.• Applies to patient 14 years of age or older.
• New protocol.• “o” indicates First Responders trained to
perform spinal immobilization.• Applies to patient 14 years of age or older.
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“Selective Spinal Immobilization”“Selective Spinal Immobilization”
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ToxicologyToxicology
• 4.25.1 – GENERAL– No syrup of ipecac.– No activated charcoal.– Charcoal still in the Virginia OEMS Regulations.
• 4.25.1 – GENERAL– No syrup of ipecac.– No activated charcoal.– Charcoal still in the Virginia OEMS Regulations.
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Trauma TriageTrauma Triage
• UN-ENTRAPPED “PRIORITY” PATIENTS– Patient is located within 15 minutes of the
closest hospital:• Transport the patient directly to the closest hospital. • Summon a helicopter to rendezvous at the hospital.
– Patient is located more than 15 minutes from the closest hospital:
• Attempt to rendezvous with a helicopter at a location between the incident scene and the closest hospital.
• Set the rendezvous site such that the ambulance does not have to wait on the helicopter.
• UN-ENTRAPPED “PRIORITY” PATIENTS– Patient is located within 15 minutes of the
closest hospital:• Transport the patient directly to the closest hospital. • Summon a helicopter to rendezvous at the hospital.
– Patient is located more than 15 minutes from the closest hospital:
• Attempt to rendezvous with a helicopter at a location between the incident scene and the closest hospital.
• Set the rendezvous site such that the ambulance does not have to wait on the helicopter.
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Trauma TriageTrauma Triage
• UN-ENTRAPPED “PRIORITY” PATIENTS– Do not delay transport to wait on higher trained
personnel.– If a helicopter has been dispatched to the scene
and the patient is ready for transport, divert the helicopter to the closest hospital and transport the patient to that hospital.
– If ALS support is en route for a rendezvous, do not wait on the ALS personnel.
• UN-ENTRAPPED “PRIORITY” PATIENTS– Do not delay transport to wait on higher trained
personnel.– If a helicopter has been dispatched to the scene
and the patient is ready for transport, divert the helicopter to the closest hospital and transport the patient to that hospital.
– If ALS support is en route for a rendezvous, do not wait on the ALS personnel.
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Trauma TriageTrauma Triage
• ENTRAPPED “PRIORITY” PATIENTS– Provide care to the extent the entrapment
permits. – Request ALS personnel to the incident scene. – Summon helicopter support to the scene.– Notify [Medical Control] of the incident.– As soon as the entrapped person is freed,
• Follow the protocol on for un-entrapped patients.• Do not wait on ALS personnel or a helicopter• Initiate transport and rendezvous if possible.
• ENTRAPPED “PRIORITY” PATIENTS– Provide care to the extent the entrapment
permits. – Request ALS personnel to the incident scene. – Summon helicopter support to the scene.– Notify [Medical Control] of the incident.– As soon as the entrapped person is freed,
• Follow the protocol on for un-entrapped patients.• Do not wait on ALS personnel or a helicopter• Initiate transport and rendezvous if possible.
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Trauma TriageTrauma Triage
• CARDIAC ARREST IN TRAUMA PATIENTS:– Adult and pediatric patients found dead at the
scene of a trauma are not to be resuscitated unless they are:
• Hypothermic• recently drowned• Electrocuted
– BLS airway and ventilation procedures.– Patients who lose vital signs while care is being
administered. are to be resuscitated. Prompt consultation with [Medical Control] is mandatory.
– Blunt vs. penetrating trauma.
• CARDIAC ARREST IN TRAUMA PATIENTS:– Adult and pediatric patients found dead at the
scene of a trauma are not to be resuscitated unless they are:
• Hypothermic• recently drowned• Electrocuted
– BLS airway and ventilation procedures.– Patients who lose vital signs while care is being
administered. are to be resuscitated. Prompt consultation with [Medical Control] is mandatory.
– Blunt vs. penetrating trauma.
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Trauma TriageTrauma Triage
• LANDING ZONES– Pre-designated landing zones are preferred.– Landing zone should be selected in such a way
that the helicopter would be expected to arrive before the ambulance that is transporting the patient.
• LANDING ZONES– Pre-designated landing zones are preferred.– Landing zone should be selected in such a way
that the helicopter would be expected to arrive before the ambulance that is transporting the patient.
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ProceduresProcedures
2006 Protocol Update2006 Protocol Update
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12-Lead ECG12-Lead ECG
• All levels of training except First Responder.• Agency-based monitor-specific training.• CSEMS will be working with Phillips Medical
Systems to sponsor 12-lead classes in region.
• All levels of training except First Responder.• Agency-based monitor-specific training.• CSEMS will be working with Phillips Medical
Systems to sponsor 12-lead classes in region.
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CombitubeCombitube
• Procedure now recognized the two Combitube sizes.– 37 French– 41 French
• Procedure now recognized the two Combitube sizes.– 37 French– 41 French
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PASGPASGX
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Suctioning, Adult/PediatricSuctioning, Adult/Pediatric
• Expanded procedure description.• Expanded procedure description.
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PharmacologyPharmacology
2006 Protocol Update2006 Protocol Update
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AspirinAspirin
• Blood-thinning drugs, such as Coumadin, are no longer contraindications.
• Blood-thinning drugs, such as Coumadin, are no longer contraindications.
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EpiPen, EpiPen Jr. EpiPen, EpiPen Jr. 140
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Metered Dose InhalerMetered Dose Inhaler145
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Nitroglycerin, AssistedNitroglycerin, Assisted153
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Nitroglycerin, AssistedNitroglycerin, Assisted153
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Oral GlucoseOral Glucose154
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Abbreviations and SymbolsAbbreviations and Symbols
• Approved medical abbreviations. • Limit use of abbreviations to those that
appear on this list.
• Approved medical abbreviations. • Limit use of abbreviations to those that
appear on this list.
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Abbreviations and SymbolsAbbreviations and Symbols
• Dangerous abbreviations and dosage designations– DO NOT USE!– Problem Term– Intended meaning– Reason for Problem(s)– Suggested remedy
• Dangerous abbreviations and dosage designations– DO NOT USE!– Problem Term– Intended meaning– Reason for Problem(s)– Suggested remedy
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Deceased Patient Guidelines
Deceased Patient Guidelines
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Glasgow Coma ScaleGlasgow Coma Scale167
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Pediatric ReferencesPediatric References169
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Telephone NumbersTelephone Numbers170
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Triage, JumpSTARTTriage, JumpSTART171
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Triage, STARTTriage, START172
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AppendixAppendix173
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ReferencesReferences176
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ConclusionConclusion
• Protocols in two formats– Field guide.
• Reference only.
– Text-like document available electronically.• Complete protocol document.
• Field guides are being printed.• Distribution of field guides.
– First part of August.
• Effective date will be announced when printing of the field guides is completed.
• Protocols in two formats– Field guide.
• Reference only.
– Text-like document available electronically.• Complete protocol document.
• Field guides are being printed.• Distribution of field guides.
– First part of August.
• Effective date will be announced when printing of the field guides is completed.
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QuestionsQuestions