anchorage (ak) protocols (2008)

ANCHORAGE FIRE DEPARTMENT

Medical Operations Manual

MOM 3.0

Michael Levy, M.D., FACEP, FACP

Medical Director

Erich Scheunemann, MICP Assistant Chief, Operations

Anne Sigsworth, MICP

Battalion Chief, Operations

MOM 3.0 August 1, 2008

Anchorage Fire Department Medical Operations Manual

Introduction to MOM 3.0

Medical Operations Manual

The Medical Operations Manual (MOM) remains the basic document that describes the Anchorage Fire Department’s protocols and standing medication orders as directed by the Medical Director for pre-hospital care by AFD personnel. Version 3.0 introduces new and revised protocols and drug orders. In most cases, off-line medical control using this document’s content will allow for the care of the vast majority of our patients. On-line control, i.e. contact with medical control, is strongly encouraged in situations that are outside the scope of these protocols. The protocols in this document are based upon best available evidence for efficacy and safety. As new information becomes available, protocols may change and the electronic version of the MOM will be updated accordingly. AFD administration will make all personnel aware of the current standard version of MOM. Please contact me or Chief Scheunemann with any questions regarding the MOM. Michael Levy, MD Medical Director AFD Procedure and Instruction (Extracted from P&I 905-9, 7/08) Purpose The Medical Operations Manual (MOM) is the Anchorage Fire Department's core reference for medical protocols and medication standing orders. The MOM therefore defines the basic medical standard and boundaries for EMS practice within the department. Policy The policy of the Anchorage Fire Department is to provide personnel with a Medical Operations Manual. Maintenance 1.1 The Medical Operations Manual will be developed and maintained under the

direction of the Medical Director. 1.2 Any member who recognizes a situation for which an addendum to the MOM would

be appropriate may request through their EMS Battalion Chief an update to the Medical Operations Manual.

1.3 The Medical Operations Manual will be reviewed and updated as necessary. 1.4 The Medical Operations Manual will be maintained at each fire station and operations

work site.

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Contact Telephone Numbers Alaska Division of Family and Youth Services (Child Abuse/Neglect Reporting)

269-4000(fax) 269-3939

Alaska Native Medical Center Emergency Department

729-1729(fax) 729-1759

Alaska Regional Hospital Emergency Department 264-1222(fax) 264-2004

Elmendorf AFB Hospital Emergency Department 580-5555(fax) 580-2230

Providence Alaska Medical Center Emergency Department

212-3111(fax) 212-3647

Mat-Su Regional Medical Center Emergency Department

861-6620(fax) 861-6776

Oregon Poison Control Center (24 hour toxicology)

1-800-222-1222

Anchorage Emergency Operations Center Medical Operations Branch Fire/Rescue Operations Branch

343-1414343-1413

(fax) 343-1441AFD Dispatch 267-4950

(fax) 267-4989AFD EMS 1 (shift EMS Battalion Chief) 267-4912

(cell) 317-3353AFD Medical Director (pager) 762-2452

(cell) 632-0309(fax) 696-7385

AFD Assistant Chief (EMS), Operations 267-5090(pager) 792-0237

(cell) 223-4204(fax) 267-4977

AFD Battalion Chief (EMS), Editor 267-4912APD Non-Emergency Number 786-8500

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Table of Contents

Introduction to MOM 3.0 ......................................................................................................................................2 Medical Operations Manual ............................................................................................................ 2

Contact Telephone Numbers ..............................................................................................................................3 Table of Contents.................................................................................................................................................4 Section 1: Standing Medication Orders .............................................................................................................7

adenosine ....................................................................................................................................... 7 albuterol .......................................................................................................................................... 8 amiodarone ..................................................................................................................................... 9 aspirin ............................................................................................................................................10 atropine sulfate...............................................................................................................................11 calcium chloride .............................................................................................................................12 captopril .........................................................................................................................................13 (Capoten®) ....................................................................................................................................13 dextrose 50% .................................................................................................................................14 diphenhydramine............................................................................................................................15 dopamine .......................................................................................................................................16 Dopamine Drip Chart for Adults .....................................................................................................17 droperidol .......................................................................................................................................18 epinephrine 1:1000 ........................................................................................................................19 epinephrine 1:10,000 .....................................................................................................................20 epinephrine 1:100,000 ...................................................................................................................21 etomidate .......................................................................................................................................22 fentanyl ..........................................................................................................................................23 furosemide .....................................................................................................................................24 glucagon ........................................................................................................................................25 glucose, oral...................................................................................................................................26 HemCon® Bandage.......................................................................................................................27 lidocaine.........................................................................................................................................28 lorazepam ......................................................................................................................................29 magnesium sulfate .........................................................................................................................30 morphine sulfate.............................................................................................................................31 naloxone ........................................................................................................................................32 nitroglycerin....................................................................................................................................33 nitrous oxide...................................................................................................................................34 oxytocin..........................................................................................................................................35 phenylephrine HCL ........................................................................................................................36 sodium bicarbonate........................................................................................................................37 succinylcholine...............................................................................................................................38 tetracaine .......................................................................................................................................39 vasopressin....................................................................................................................................40 vecuronium bromide.......................................................................................................................41 (Norcuron®) ...................................................................................................................................41

Section 2: Treatment Protocols ........................................................................................................................42 Introduction ........................................................................................................................................42

General Guidelines for the Treatment and Transport of Patients...................................................42 General Guidelines for All EMS Providers .....................................................................................42 EMT-I/ETT Patient Care Protocol...................................................................................................43 EMT-II Patient Care Protocol .........................................................................................................43 EMT-III Patient Care Protocol ........................................................................................................44 Scope of Practice for EMT-II and EMT-III ......................................................................................44

Airway and Ventilation........................................................................................................................44 Administration of Oxygen ...............................................................................................................44 Airway Protocol ..............................................................................................................................45 Bag-Valve-Mask Ventilation (BVM) ................................................................................................45 Endotracheal Intubation .................................................................................................................45 Combitube or King LT-DTM Airway................................................................................................46 Cricothyrotomy...............................................................................................................................47 Eschmann Endotracheal Tube Introducer......................................................................................48

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Gastric Intubation ...........................................................................................................................49 Inspiratory Impedance Device........................................................................................................49 Rapid Sequence Intubation with Neuromuscular Blockade............................................................50

Cardiac...............................................................................................................................................51 CPR ...............................................................................................................................................51 Chest Pain .....................................................................................................................................52 Congestive Heart Failure and Acute Pulmonary Edema................................................................53 Cardiac Monitoring .........................................................................................................................54 12-Lead ECG .................................................................................................................................54 Revivant AutoPulse Device............................................................................................................55 Transcutaneous Pacing .................................................................................................................55

ACLS Algorithms and BLS Charts......................................................................................................56 Post Resuscitation Care.................................................................................................................56 Post Cardiac Arrest Cooling...........................................................................................................56 Post Resuscitation Care Algorithm.................................................................................................58 Pulseless Arrest Algorithm .............................................................................................................59 Bradycardia Algorithm....................................................................................................................60 NCT (Narrow Complex Tachycardia) Algorithm .............................................................................61 Perfusing WCT (Wide Complex Tachycardia) Algorithm................................................................62 Automatic External Defibrillator (AED) Algorithm ...........................................................................63 Basic Life Support Summary Sheet ...............................................................................................64 Foreign Body Airway Obstruction (FBAO) Summary Sheet ...........................................................65

Intravascular Access and Medication Administration .........................................................................66 Intravenous (IV) Therapy ...............................................................................................................66 Adult Intraosseous (IO) Therapy ....................................................................................................66 Medication Administration ..............................................................................................................67

General Medical .................................................................................................................................68 Asthma, Wheezing, COPD.............................................................................................................70 Carbon Monoxide (CO) Poisoning .................................................................................................71 Combative Patient..........................................................................................................................71 Diabetic Emergencies ....................................................................................................................72 Blood Glucose Determination ........................................................................................................73 Epistaxis.........................................................................................................................................73 Hyperkalemia .................................................................................................................................73 Hypertension..................................................................................................................................74 Hypotension ...................................................................................................................................74 Pain Management ..........................................................................................................................75 Seizures, Status Epilepticus and Postictal States ..........................................................................76 Seizure Algorithm...........................................................................................................................77 Stroke (CVA)..................................................................................................................................78 Tricyclic Antidepressant Overdose.................................................................................................78 Unconscious Patient Unknown Etiology.........................................................................................79

Trauma and Environmental Injuries ...................................................................................................80 General Trauma Guidelines ...........................................................................................................80 Amputations ...................................................................................................................................81 Burn Management..........................................................................................................................81 C-Spine Guidelines (Axial Spine Immobilization) ...........................................................................81 Clinical Criteria for Assessment of Spine Injury .............................................................................83 External Hemorrhage .....................................................................................................................85 Eye Injuries ....................................................................................................................................86 Hypothermia...................................................................................................................................86 Inflatable Lower-Body Splint (MAST/PASG) ..................................................................................87 Near Drowning ...............................................................................................................................87 Pelvic Fracture ...............................................................................................................................87 Traumatic Brain Injury (TBI) ...........................................................................................................91 Airway Management in TBI Patients ..............................................................................................91 TurkelTM Safety Thoracentesis Catheter ........................................................................................92

Appendix ............................................................................................................................................93 Triage (START Algorithm)..............................................................................................................93 Glasgow Coma Scale.....................................................................................................................94 FACES© Pain Rating Scale...........................................................................................................94 Adult Burn Chart.............................................................................................................................95

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Precordial Lead Placement ............................................................................................................96 12 Lead Waveforms .......................................................................................................................97 Capnography Waveform Elements ................................................................................................98 Capnography Waveform Analysis ..................................................................................................99 VentiSure™ ET CO2 Reference ...................................................................................................100

Section 3: Pediatric Treatment Protocols and Weight Pages ......................................................................101 Transporting the Pediatric Patient ................................................................................................101 Spinal Immobilization ...................................................................................................................101 Safeguard Transport Seat............................................................................................................101 Pediatric Intraosseous (IO) Therapy ............................................................................................102 Neonate/Small Infant Intraosseous (IO) Therapy.........................................................................103

Obstetrics and Neonatal Treatment Protocols .................................................................................104 Newborn Care..............................................................................................................................104 Obstetrics.....................................................................................................................................105 Third Trimester Hemorrhage........................................................................................................105 Pre-eclampsia and Eclampsia......................................................................................................106 Childbirth......................................................................................................................................106 Postpartum Hemorrhage..............................................................................................................107

Pediatric Weight Pages....................................................................................................................107 Appendix ..........................................................................................................................................125

APGAR Scores ............................................................................................................................125 Infant Burn Chart..........................................................................................................................125 Child Burn Chart...........................................................................................................................126

Section 4: Medical Operations........................................................................................................................127 EMS P&Is, SOGs, and Manuals ..................................................................................................127 EMS Incident Disposition .............................................................................................................128 Definition of Patient ......................................................................................................................128 Destinations for Hemodialysis (HD) and Peritoneal Dialysis (PD) Patients..................................128 Destination of Patients with Psychiatric Problems........................................................................129 Direct Admit Patients....................................................................................................................129 Dispatch Alerting to First Defibrillation .........................................................................................129 ePCR Completion ........................................................................................................................130 Hospital Alerts ..............................................................................................................................130 STEMI Alert..................................................................................................................................130 Trauma Alert ................................................................................................................................131 Stroke Alert ..................................................................................................................................131 Arrival Times at Hospital ..............................................................................................................131 Hospital Disposition of Code 99, Status 1 and Status 2 Pediatric Patients and Pre-term Labor ..131 Hospital Radio Report Format/Patient Status ..............................................................................132 Medical Consumables Expiration Dates.......................................................................................132 Medication Use and Patient Safety ..............................................................................................133 Patient Safety and EMS Medical Supplies ...................................................................................134 Utilizing ICS for Code 99 Resource Management........................................................................134 Perimortal Policy ..........................................................................................................................134 SUID (Sudden Unexpected Infant Deaths) ..................................................................................135 Obvious Death/Decision Not to Resuscitate ................................................................................135 Patients Unresponsive to CPR.....................................................................................................136 Traumatic Cardiac Arrests ...........................................................................................................136 Comfort One/Do Not Resuscitate.................................................................................................136 Public Inebriate Incident Disposition ............................................................................................137 Requesting APD Assistance ........................................................................................................137 Safety Modification to Mixed EMS Responses.............................................................................138 Transfer of Care/Return to Service Policy....................................................................................138 Transport Policy for the Mat-Su Regional Medical Center ...........................................................139

Appendix A: Approved Medical Abbreviations ............................................................................................140 Appendix B: MOM 3.0 ......................................................................................................................................148

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Section 1: Standing Medication Orders

adenosine (Adenocard®)

Actions A nucleoside found in all cells of the body. It slows conduction time through the AV junction, can interrupt reentry pathways through the AV junction, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT). Indications Conversion of PSVT. (Will not convert AFib, Aflutter or most VT). Contraindications • Known hypersensitivity. • Second or third degree block (except if functioning pacemaker). • Sick sinus syndrome (except if functioning pacemaker). Side Effects and Adverse Reactions • CV: Facial flushing, chest pain, occasional prolonged asystole. • RESP: Shortness of breath, chest pressure. May exacerbate active asthma (contact

physician if active wheezing). • CNS: Nausea. Warnings • Obtain 12-lead ECG prior to administration. Run continuous lead I, II, V2 printout during

adenosine administration. • Effect potentiated by dipyridamole (Persantine) and carbamezapine (Tegretol). • Effect antagonized by theophyllines. Adult Dose • IV/IO: 6.0 mg RAPID IVP at site as close to needle hub as possible followed immediately by

rapid flush. If after 2 minutes second dose is required, increase to 12.0 mg RIVP. May repeat once at 12.0 mg RIVP to a total of 30.0 mg.

o Option: NCT: If adenosine antagonists are present (Theophyllines), contact Physician for 3rd dose of 18 mg (total 36 mg).

• IM: NOT given IM. Protocol Reference • Narrow Complex Tachycardia Algorithm. • Perfusing Wide Complex Tachycardia Algorithm. Pediatric Dose IV/IO: 0.1 mg/kg, dilute 2 ml Adenosine with 4 ml NS to 6 mg/6 ml if patient < 6 kg. May repeat twice at 0.2 mg/kg. See specific pediatric weight page.

How supplied 60 mg in 20 ml vial.

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albuterol (Ventolin®, Proventil®)

Actions Primarily a beta-2 sympathomimetic, it produces bronchodilation. Because it is more specific for beta-2 adrenergic receptors than isuprel, it produces fewer cardiovascular side effects and more prolonged bronchodilation. Onset is within 15 minutes, and it peaks in 60-90 minutes. Therapeutic effects may last up to 5 hours. Indications Relief of bronchospasm in patients with reversible obstructive airway disease, including asthma. Contraindications History of hypersensitivity. Side Effects and Adverse Reactions • CNS: Nervousness, tremor, headache, dizziness, insomnia. • CV: Tachycardia, hypertension, angina. • GI: Drying of oropharynx, nausea, vomiting, and unusual taste. Warnings • Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and

diabetes. • Should not be used at the same time as epinephrine. However, either may be used after

failure of the other. • Administer cautiously to patients on MAO inhibitors or tricyclic antidepressants.

o Common MAO inhibitors include Nardil® (phenilizine) and Parnate® (tranylcypromine).

• Beta-blockers and albuterol will inhibit each other. Adult Dose 2.5-5 mg via nebulizer, as indicated by specific protocol. Add sodium chloride to medication to a total of 3ml volume of medication and dilutent in nebulizer. Protocol Reference • Asthma, Wheezing, COPD. • Congestive Heart Failure and Acute Pulmonary Edema. • Allergy/Anaphylaxis. Pediatric Dose 2.5-5 mg via nebulizer, blow by into face, PRN, transport. How Supplied 3 ml unit dose (2.5 mg albuterol sulfate in 3 ml), and/or 20 ml multi-use 0.5% (5 mg/ml).

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amiodarone (Cordarone®)

Actions Amiodarone is a very complex drug with actions upon sodium, potassium and calcium channels as well as alpha and beta-adrenergic blocking properties. Indications • Recurrent/Persistent Pulseless VT/VF after defibrillation and epinephrine. • Perfusing WCT (second-line to Lidocaine if chest pain or ischemia.) Contraindications • History of hypersensitivity. • Cardiogenic shock. • 2nd or 3rd degree AV block in absence of functioning pacemaker. • Sinus Bradycardia Side Effects and Adverse Reactions • CV: Hypotension / bradycardia. • Vessels: Can cause sclerosis / phlebitis. Warnings • Safety in pregnancy not established. May only be given in pregnancy if potential benefit

outweighs risk to fetus. • Torsade des pointes is an uncommon pro-arrhythmic effect usually associated with QTc>450

ms. Adult Dose • IV/IO: Pulseless VT/VF: 300 mg IVP. May repeat 150 mg after five minutes if necessary for

recurrent Pulseless VT/VF. • Perfusing WCT, Torsades with perfusion: 150 mg in 50 ml bag NS administered over

approximately 10 minutes (50 gtts/min using 10 gtts/ml dripset). • IM: NOT given IM Protocol Reference • Pulseless Arrest Algorithm. • Perfusing WCT. • Post Resuscitation Care Algorithm. Pediatric Dose • Physician contact required. • Pulseless VT/VF: 5 mg/kg IV, IO, SIVP. • Perfusing WCT, Torsades with perfusion: 5 mg/kg IV/IO over 10 min. Dilute 150 mg with 50

ml NS. and infuse with a volumetric infusion device. How Supplied 150mg in 3ml vial. The drug must be drawn slowly from the vial directly into the syringe without a needle to avoid foaming.

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aspirin (ASA, acetylsalicylic acid)

Actions Inhibits platelet aggregation. Indications Chest pain with suspicion of myocardial infarction or unstable angina. Contraindications • Active peptic ulcer disease. • Sensitivity to aspirin or other nonsteroidal anti-inflammatory. • Patient who has already taken aspirin within last 12 hours. Side Effects and Adverse Reactions • GI:Upper GI bleeding, upset stomach. • RESP:Acute bronchospasm in susceptible individuals. Warnings None. Adult Dose 162mg PO, chewed well. Protocol Reference • Chest pain. • Congestive Heart Failure and Acute Pulmonary Edema. • Post Resuscitation Algorithm. Pediatric Dose Not indicated. How Supplied 81 mg chewable tablets.

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atropine sulfate (Atropine)

Actions Potent parasympatholytic (anticholinergic). By reducing vagal tone it increases automaticity in the SA node and increases A-V conduction. Indications • Sinus bradycardia accompanied by hemodynamic compromise: hypotension (SBP < 90);

confusion; frequent PVCs; pale, cold, clammy skin. • Second- and third-degree AV blocks (unless accompanied by wide QRS). • Asystole. • Pre-medication for pediatric succinylcholine administration. • Pesticide exposure and organophosphate exposure (physician contact required). Contraindications None in emergency situations. Side Effects and Adverse Reactions • CNS:Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision,

headache. • CV: Increases heart rates; may worsen ischemia or increase area of infarction; ventricular

fibrillation. • GI:Dry mouth, difficulty swallowing. • GU: Urinary retention. • Other:Can worsen pre-existing glaucoma. Warnings • Too small a dose (< 0.02 mg/kg), or normal dose pushed too slowly, may initially cause the

heart rate to decrease. • Potentiated by antihistamines and antidepressants. • Do not use in tricyclic antidepressant overdose. • May worsen cardiac ischemia. • Do not exceed maximum dose of 3 mg IV. Adult Dose (IV/IO) • Perfusing bradycardias and blocks, 0.5 mg IV q 3-5 min. to max. 3 mg. • Asystole/PEA: 1 mg IV q 3-5 min, to max 3 mg. • Organophosphate poisoning may require large doses of atropine: contact medical control. • IM: This route may be used in organophosphate exposure: contact medical control. Protocol Reference • Pulseless Arrest Alogorithm. • Post Resuscitation Care Algorithm. • Bradycardia Algorithm. • Pediatric pre-medication for paralytic agent, field use. Pediatric Dose 0.02 mg/kg IV or I0. Minimum dose: 0.1 mg. Maximum single dose 0.5 mg for child, 1.0 mg for adolescent. How Supplied 1 mg in 10 ml pre-filled syringe.

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calcium chloride (CaCl)

Actions Has multiple membrane actions in conducting and muscular tissue. Stabilizes irritable myocardium in the setting of hyperkalemia. Indications • Unstable arrhythmia in a patient who may be hyperkalemic. • Calcium channel blocker overdose with hypotension. Contraindications None in the setting of confirmed hyperkalemia with a sinusoidal cardiac rhythm. Side Effects and Adverse Reactions Integument: Pain at injection site. Warnings • Rapid injection may cause bradycardia. • May worsen digoxin toxicity. • Co-administration with sodium bicarbonate will cause precipitation. Adult Dose • IV/IO: 1 gm SIVP. • IM: NOT given IM. Protocol Reference Hyperkalemia. Pediatric Dose Not indicated. How Supplied 1 gm in 10 ml vial.

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captopril (Capoten®)

Actions Angiotensin-coverting enzyme (ACE) inhibitor. The ACE converts inactive angiotensin I to biologically active angiotensin II. The blocking effect of captopril causes a decrease of the plasma levels of angiotensin II and aldosterone. ACE inhibitors decrease the peripheral resistance without causing a compensatory tachycardia. Captopril also has well documented efficiency for heart failure: it reduces the ventricular preload and afterload. Indications • Pulmonary edema. Second-line to Nitroglycerine. Use only if SBP remains > 110. • Hypertension (at physician request only). Contraindications: • Pregnancy: can cause renal failure in neonate • Relative contraindications:

o Breast feeding. o Dehydration (high renin state) may cause exaggerated lowering of BP.

Side Effects and Adverse Reactions Single dose therapy is not expected to cause any of the side effects typically associated with ACE inhibitors except for possible hypotension.

Adult Dose • SL: 25 mg SL is usual dose (may give 12.5 in small individuals or if concern about possible

excessive effect). Protocol Reference • Congestive Heart Failure and Acute Pulmonary Edema • Hypertension Pediatric Dose By direct medical control order only. How Supplied 25 mg tablets

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dextrose 50% (D50W, D50, D25, D10)

Actions A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. Indications Hypoglycemia or suspected hypoglycemia. Contraindications None. Side Effects and Adverse Reactions • CV: Thrombosis, sclerosis if given in small peripheral vein. • Integ: Tissue irritation if IV infiltrates. May cause skin necrosis. • Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia. Warnings • May theoretically cause Wernicke-Korsakoff syndrome in acute alcohol intoxication. • Theoretically may worsen cerebral edema if present. Adult Dose • IV/IO: 25 gm (50 ml). Obtain a Glucometer reading (if possible) before administering.

Administer with running IV fluid. May repeat once if required. • IM: NOT given IM. Protocol Reference • Unconscious patient unknown etiology. • Diabetic Emergencies. • Seizures. • Blood Glucose Determination. Pediatric Dose • 0.5 gm/kg SIVP/IO to max of 25 gm. • Give as D25 (1 ml/kg diluted with 1 ml/kg NS or sterile water) if weight less than 25 kg. • Give as D10 (1 ml/kg diluted with 4 ml/kg NS or sterile water) for neonate. Notes • Doses are the endpoint. If patient responds to smaller dose during a slow push, stop at that

level and reassess. • May dilute to D25 if needed for adult with fragile veins or small-bore IV catheter. How Supplied 25 gm in 50 ml pre-filled syringe.

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diphenhydramine (Benadryl®)

Actions An antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Prevents, but does not reverse, histamine mediated responses, particularly its effects on smooth muscle in the bronchial airways, GI tract, uterus, and blood vessels. Indications • Allergy symptoms. • Anaphylaxis, as an adjunct to epinephrine. • Dystonic (extrapyramidal) and dysphoric reactions associated with use or overdose of

phenothiazines and related drugs: droperidol, haloperidol, Thorazine, Compazine, Stelazine, metoclopromide (Reglan).

• Adjunct to use of morphine in potentially hypotensive patient (give 12.5-25 mg SIVP prior to morphine).

Contraindications • Newborn or premature infants. • Nursing mothers. • Lower respiratory tract symptoms, including asthma. Side Effects and Adverse Reactions • CNS: Drowsiness, confusion, insomnia, headache, vertigo, hyperactivity in children. • CV: Palpitations, tachycardia, PVCs, hypotension. • GI: Nausea, vomiting, diarrhea, dry mouth, constipation. • GU: Dysuria, urinary retention. • RESP: Thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness. Warnings • In infants and children especially, OD may cause hallucinations, convulsions, or death. • May diminish mental alertness in adults and children. In young children, may produce

excitation. • Have additive effects with alcohol and other CNS depressants (hypnotics, sedatives,

tranquilizers, etc). • More likely to cause dizziness, sedation, and hypotension in the elderly (>60 y/o). Adult Dose • IV/IO: 25–50 mg IV. • IM: 25–50 mg IM. Protocol Reference • Anaphylaxis. • Pain management. • Combative Patient Pediatric Dose • IV/IO: 1 mg/kg IV. Maximum: 50 mg per dose. • IM: 1 mg/kg deep IM. Maximum: 50 mg per dose. How Supplied 50 mg in 1 ml vial.

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dopamine (Intropin®)

Actions Stimulates dopaminergic, alpha-adrenergic and beta-adrenergic receptors. Inotropic effect increases cardiac output. Dilates renal and mesenteric vessels at low doses that may not increase heart rate or blood pressure. Therapeutic doses have predominantly beta adrenergic effects that increase cardiac output and vital organ perfusion without marked increases in pulmonary occlusive pressure. At high doses, alpha-receptor stimulation causes peripheral vasoconstriction and marked increases in pulmonary occlusive pressure. Indications Cardiogenic or vasogenic shock. Contraindications • Hypovolemia. • Pheochromocytoma. • Uncorrected tachyarrhythmias or ventricular fibrillation. Side Effects and Adverse Reactions • CNS:Headache. • CV: Ectopic beats, tachycardia, anginal pain, palpitations, hypotension. • GI: Nausea, vomiting. • Local:Necrosis and tissue sloughing with extravasation. • Other:Piloerection, dyspnea. Warnings • Inactivated in alkaline solutions. • Patients taking monoamine oxidase MAO inhibitors will require substantially reduced dosage.


Adult Dose • IV/IO: Mix 400mg of dopamine in 250 ml of NS to yield a concentration of 1600 mcg/ml.

Begin infusion at 5 mcg/kg/min and titrate to effect. Dosages of over 20 mcg/kg/min have occasionally been required. Refer to Dopamine Drip Chart.

• IM: NOT given IM. Protocol Reference • Pulseless Arrest Algorithm. • Bradycardia Algorithm • Hypotension. • Post Resuscitation Care Algorithm. Pediatric Dose • IV/IO: Mix 150 mg (3.75ml) of dopamine in 250 ml NS to yield a concentration of 600

mcg/ml. Start at 10 mcg/kg/min.If not effective in 3-5 minutes, consider physician contact for permission to increase to 20 mcg/kg/min.

• IM: NOT given IM How Supplied 200 mg in 5 ml vial.

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Dopamine Drip Chart for Adults

FOR A CONCENTRATION OF 1600 μg of DOPAMINE PER MILLILITER SOLUTION: 400 mg dopamine in 250ml NS.

Body Wt. lbs. 110 121 132 143 154 165 176 187 198 209 230 231 242

Wt. kgs. 50 55 60 65 70 75 80 85 90 95 100 105 110 μg/min. 5μg

10

11

11

12

13

14

15

16

17

18

19

20

21

6μg 11 13 14 15 16 17 18 19 21 22 23 24 25 7μg 13 15 16 17 19 20 21 23 24 25 27 28 29 8μg 15 17 18 20 21 23 24 26 28 29 31 32 34 9μg 17 19 21 22 24 26 28 29 31 33 34 36 38 10μg 19 21 23 25 27 29 31 32 34 36 38 40 42 11μg 21 23 25 27 29 32 34 36 38 40 42 44 46 12μg 23 25 28 30 32 34 37 39 41 44 46 48 50 13μg 25 27 30 32 35 37 40 42 45 47 50 52 55 14μg 27 29 32 35 37 40 43 45 48 51 53 56 59 15μg 29 32 34 37 40 43 46 49 52 54 57 60 63 16μg 31 34 37 40 43 46 49 52 55 58 61 64 67 17μg 32 36 39 42 45 49 52 55 58 62 65 68 71 18μg 34 38 41 45 48 52 55 58 62 65 69 72 76 19μg 36 40 44 47 51 54 58 62 65 69 73 76 80 20μg 38 42 46 50 53 57 61 65 69 73 76 80 84

FLOW RATE IN DROPS PER MINUTE BASED ON A MICRODRIP CALIBRATION OF 60 DROPS EQUAL 1.O MILLILITER.

Note: Refer to the Pediatric Weight Pages for pediatric drip rates.

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droperidol (Inapsine®)

Actions Droperidol produces tranquilization and sedation with reduced motor activity and reduced anxiety. Additionally, droperidol produces alpha adrenergic blockade, which can lead to hypotension.

Indications Combative patient without any other obvious, reversible reason for the behavior who threatens the safety of the crew or who may him/herself be injured in our physical attempts to contain the behavior. Contraindications History of hypersensitivity to droperidol or haloperidol. Side Effects and Adverse Reactions • CNS:Extrapyramidal reactions, Dysphoric reactions. These may be treated with

Diphenhydramine. • CV:Hypotension; tachycardia. • Resp:Increased respiratory depression if baseline status is decreased (particularly by other

drugs). Warnings • Hypotensive effect potentiated by hypovolemia. • Hypotensive effect due to alpha blockade more likely to occur at IV doses > 2 mg. • This drug will generally be given IM! Be sure to reduce dose for IV. • Reduce dose for small body size, elderly, infirmity. • Prolonged effect may occur with renal or hepatic failure. Adult Dose Droperidol 1.25-5.0 mg IM or 1-2mg IV for combativeness. IM May repeat in 10 minutes if not effective. IV may repeat in 5 minutes if not effective. Protocol Reference Combative Patient. Pediatric Dose Not indicated; call medical control. How Supplied 5 mg in 2 ml vial.

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epinephrine 1:1000 (Epi 1:1000)

Actions A sympathomimetic that stimulates both alpha and beta-adrenergic receptors. Causes immediate bronchodilation, increase in heart rate, and increase in the force of cardiac contraction. Subcutaneous dose lasts 5-15 minutes. Indications • Asthma. • Allergy/Anaphylaxis • Angioneurotic edema. • Pediatric cardiac resuscitation second-line to IV/IO 1:10,000 only if IV/IO unobtainable. Contraindications • Hyperthyroidism. • Hypertension. • Elderly or debilitated patients with underlying cardiovascular disease. • Note: in anaphylaxis, there are no Contraindications. Side Effects and Adverse Reactions • CNS:Anxiety, headache, cerebral hemorrhage. • CV: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. • GI: Nausea and vomiting. Warnings • Asthmatic patients >55 years of age require Physician contact. • Inactivated by alkaline solutions; never mix with sodium bicarbonate. • Catecholamine action is depressed by acidosis; attention to ventilation and circulation is

essential. • Antidepressants potentiate the effects of epinephrine. • Causes hyperglycemia. • Cannot be given intravenously at this strength. Adult Dose • SC: 0.3-0.5 mg (0.3-0.5ml) SC. May be repeated every 15 minutes x 3 for asthma. May be

repeated every 10 mins as needed for anaphylaxis, but if multiple does are required consider moving to IV Epi 1:100,000. Can also be given SL.

• IV/IO: NOT given IV/IO. • IM: NOT given IM. Protocol Reference • Anaphylaxis. • Asthma. • Newborn Care. Pediatric Dose • SC: 0.01 mg/kg SC if patient > 4 kg. Maximum dose: 0.3 mg. Repeats same as adult • IV/IO: NOT given IV/IO. • IM: NOT given IM. • ET In cardiac resuscitation, 0.1 mg/kg flushed with 3-5 ml NS. How Supplied 1mg in 1 ml ampule.

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epinephrine 1:10,000 (Epi 1:10,000)

Actions A sympathomimetic that stimulates both alpha and beta-receptors. Increases myocardial and cerebral blood flow during ventilation and chest compression. Increases systemic vascular resistance and thus may enhance defibrillation. Indications • Asystole. • Ventricular fibrillation unresponsive to defibrillation. • Pulseless ventricular tachycardia (including pulseless WCT) unresponsive to defibrillation • PEA. • Additional pediatric Indications

o Hypotension with circulatory instability. o Bradycardia unresponsive to atropine. o Initial treatment of bradycardia in neonates.

Contraindications None in these situations. Side Effects and Adverse Reactions • CNS:Anxiety, headache, cerebral hemorrhage. • CV: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. • GI: Nausea and vomiting. Warnings • Inactivated by alkaline solutions; never mix with sodium bicarbonate. • Catecholamine action is depressed by acidosis; attention to ventilation and circulation is

essential. • Antidepressants potentiate the effects of epinephrine. • Causes hyperglycemia. Adult Dose • IV/IO: 1mg IV. May repeat every 5 minutes. • IM: NOT given IM. Protocol Reference • Pulseless Arrest Algorithm • Bradycardia Algorithm • Newborn Care. Pediatric Dose • IV/IO: 0.01 mg/kg (0.1 ml/kg) IV. Repeat every 5 minutes as necessary. • IM: NOT given IM.

How Supplied 1mg in 10 ml prefilled syringe.

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epinephrine 1:100,000 (Epi 1:100,000)

Actions Provides vascular tone, inotropic support, and bronchodilation in the setting of an acute hypersensitivity reaction with anaphylactic shock. Indications Anaphylactic shock. Contraindications None in this setting. Side Effects and Adverse Reactions • CNS: Anxiety, headache, cerebral hemorrhage. • CV: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. • GI: Nausea and vomiting. • Integ: Skin sloughing if IV extravasates. Warnings • Epinephrine is inactivated by alkaline solutions; never mix with sodium bicarbonate. • Catecholamine action is depressed by acidosis; attention to ventilation and circulation is

essential. • Antidepressants potentiate the effects of epinephrine. • Causes hyperglycemia. Adult Dose • Remove 9 ml from an epi 1:10,000 preload and draw up 9 ml of NS from a vial or IV bag. • Administer as slow, continuous IV/IO push, titrating against symptoms. • May repeat dose as needed. Protocol Reference Anaphylaxis. Pediatric Dose Same as for adults.

How Supplied See Adult Dose instructions.

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etomidate (Amidate®)

Actions Ultrashort acting non-barbiturate hypnotic. Indications • Sedation prior to paralytic assisted intubation. • Sedation prior to emergency synchronized cardioversion. Contraindications • Known allergy to etomidate. Side Effects and Adverse Reactions • CV: Usually no effect. • RESP:Usually no effect. • Neuro:Involuntary muscle movements. • Other: Pain on injection. • GI:May cause GI discomfort; hiccoughs. Warnings None. Adult Dose • IV/IO: 0.3 mg/kg SIVP over 15-60 sec. For procedures other than RSI, start with ½ dose and

titrate to desired effect up to full dose. • IM: not recommended. Protocol Reference • Rapid Sequence Intubation. • Narrow Complex Tachycardia Algorithm. • Perfusing Wide Complex Tachycardia Algorithm. Pediatric Dose • IV/IO: 0.3 mg/kg for age >7 weeks. For procedures other than RSI, start with ½ dose and

titrate to desired effect up to full dose. How Supplied 20 mg in 10 ml vial.

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fentanyl (Sublimaze®)

Actions Potent opiate analgesic with same mechanism of action as other narcotic analgesics. Onset of action is almost immediate, duration of action is 30-60 minutes.

Indications Patients suffering from severe pain in whom a shorter duration of narcotic effect is desired: • Multiple Trauma. • Head Injury. • Abdominal Pain. Contraindications • History of hypersensitivity to opiates. • Not to be used in patients taking MAO inhibitors.


Side Effects and Adverse Reactions • CNS: Sedation. • CV: Hypotension; bradycardia. • Resp: Respiratory depression, apnea. Warnings • Rapid infusion can lead to chest wall spasm, muscle rigidity. • Dosage units are MICROGRAMS. Adult Dose 1.0 microgram/kg SIVP. May repeat x 1 if ineffective after 5 minutes or effect wanes during transport. Protocol Reference Pain Management. Pediatric Dose IV/IO: 1.0 microgram/kg SIVP (titrate to 1.0 microgram/kg total dose). IN: 1.5 microgram/kg Intranasal via MAD (titrate to 1.5 microgram/kg total dose) How Supplied 100 microgram in 2 ml.

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furosemide (Lasix®)

Actions A sulfonamide derivative and potent diuretic that inhibits the re-absorption of sodium and chloride in the proximal and distal renal tubules, and in the Loop of Henle. With IV administration, onset of diuresis is within 5 minutes, peak is in 30 minutes; and duration is 2 hours. Indications • Pulmonary edema. • Hypertension (at physician request only). Contraindications • Anuria. • Relative Contraindications:

o Allergy to sulfa. If previous reaction was minor, consider the risks versus benefit to the patient.

o Pregnancy. Use only when benefits clearly outweigh risks. Side Effects and Adverse Reactions • CNS:Dizziness, tinnitus, hearing loss, headache, blurred vision, weakness. • GI:Anorexia, vomiting, nausea. • CV: Hypotension. • Other:Pruritus, urticaria, muscle cramping. Warnings • Rapid infusion and high doses (>100 mg) can cause tinnitus and inner ear damage. • Should be stored to protect it from light. • Dehydration and electrolyte imbalance can result from excessive dosages. • Rapid diuresis can lead to hypotension. Adult Dose • IV/IO: 0.5 mg/kg SIVP if not currently on furosemide; give 1.0 mg/kg SIVP if currently taking.

For repeat doses, physician contact required. • IM: NOT given IM. Protocol Reference • Congestive Heart Failure and Acute Pulmonary Edema. • Hypertension. Pediatric Dose • Not permitted without physician contact. • IV/IO: 0.5-1 mg/kg IV slowly over 1-2 minutes. • IM: NOT given IM. How Supplied 40 mg in 4 ml vial

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glucagon (Glucagon)

Actions Produced naturally in the pancreas by alpha cells in the islets of Langerhans. Acts only on liver glycogen, converting it to glucose. Increases blood glucose concentrations. Effective in small doses. No toxicity problems have been reported. Indications • Hypoglycemia when IV access is not available. • Symptomatic β-blocker overdose.* • Symptomatic Calcium-channel blocker overdose.* Contraindications Hypersensitivity to glucagon. Side Effects and Adverse Reactions GI: Occasionally causes nausea and vomiting. Warnings • Use caution in patients with a history of insulinoma or pheochromocytoma. • Response for hypoglycemia may take up to 20 minutes. • Depletes liver glycogen stores. Increased carbohydrate intake is important, as is transport

after administration. Adult Dose IV, IO, IM, SC: 1.0 unit of glucagon. Can be repeated once. * Protocol Reference • Diabetic Emergencies. • Asystole. . Pediatric Dose IV, IO, IM, SC: 0.05 mg/kg. Maximum:1 mg.* *Doses required for treatment of calcium channel blocker or β-blocker OD may be much higher than listed here. Start with above listed doses and if OD is strongly suspected, contact medical control. How Supplied 1 unit (1 mg) glucagon in dry powder form and 1ml diluting solution.

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glucose, oral (Insta-glucose ®)

Actions A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. Indications Hypoglycemia or suspected hypoglycemia in alert patient. Contraindications None. Side Effects and Adverse Reactions None. Warnings None. Dose Swallow one tube. If no improvement in 10 minutes, repeat. Protocol Reference • Diabetic Emergencies. • Blood Glucose Determination. How Supplied Insta-Glucose contains 24 grams of carbohydrate.

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HemCon® Bandage (HemCon®)

Actions The HemCon® Bandage is a hemostatic dressing made of chitosan, a natural substance that adheres when in contact with blood. The HemCon® Bandage is a freeze-dried chitosan-based dressing designed to optimize the mucoadhesive surface density and structural integrity of chitosan at the site of injury. There is evidence suggesting the HemCon® Bandage may also enhance platelet function and possibly incorporate red blood cells into the clot formed at the site of the wound. Indications • For uncontrolled external hemorrhage when conventional methods are unsuccessful or not

possible, for example, due to the anatomical area incompatible with a tourniquet or direct compression.

Contraindications • Known allergy to chitosan. Precautions • Once applied, do not attempt to reposition the bandage. A new bandage should be applied

to other exposed bleeding sites. • Care must be taken to avoid contact with the patient’s eyes. • If bandage is not effective in stopping bleeding, remove original and apply a new bandage.

Additional bandages cannot be applied over ineffective bandages. Use • The HemCon® Bandage works by adhering aggressively to tissue surfaces when in contact

with blood or moisture. This adhesive-like action forms a strong, flexible barrier that seals and stabilizes the wound.

• Initial approach to most external bleeding sources (lacerations, abrasions, puncture wounds) should be to apply pressure using a gauze bandage and elevated the bleeding area if possible. If the gauze bandage soaks through with blood, remove it and apply the HemCon® Bandage as directed

• For suspected arterial bleeding (large spurts of blood following deep lacerations), attempt direct pressure on a “pressure point”, i.e. pulsatile vessel proximal to the bleeding area if one can be found. If this is not effective proceed with the use of the HemCon® Bandage immediately. If the wound is causing potentially life threatening bleeding and the area is accessible a tourniquet may be used in concert with the HemCon® Bandage.

• Apply cream colored side towards the wound. • Apply directly to the lacerated vessel not to the surface of the wound. The bandage can be

cut into smaller pieces to fit into small wounds, or multiple bandages can be overlapped for large injuries.

• Apply pressure for 2-5 minutes or until the bandage adheres and bleeding stops. Use Kerlix or gauze to apply even pressure against wound.

• The bandage can be wrapped with gauze or a pressure dressing for transport. • Do not let moisture from your hand come in contact with the bandage. The moisture could

cause the bandage to become sticky. Removal • To remove, simply irrigate the area with saline. There is no need for wound debridement. Protocol Reference and How Supplied • General Trauma Guidelines. • 2” x 4” Bandage in a sterile foil sealed package.

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lidocaine (Xylocaine®)

Actions Decreases ventricular automaticity and raises the ventricular fibrillation threshold. Indications • PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more. • Perfusing ventricular tachycardia in setting of possible myocardial ischemia. • Ventricular fibrillation and pulseless WCT (second line to amiodarone). • Reduction of infusion discomfort in the conscious adult patient with whom IO vascular access

has been made in. Contraindications • Heart blocks:

o Second-degree, Mobitz II. o Complete AV block. o Stokes-Adams syndrome.

• Allergy to amide-type local anesthetics (not Novacaine [procaine]). Side Effects and Adverse Reactions • CV: Rarely with toxic levels, causes hypotension, QRS widening, bradycardia, cardiac arrest. • RESP:At toxic levels, respiratory depression or arrest. Warnings • If PVCs occur in conjunction with symptomatic sinus bradycardia, treat the bradycardia first. • Metabolized in the liver. Note dosage for liver failure, low cardiac output, and patients >70

years of age. Adult Dose • PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more or ventricular

tachycardia in setting of possible myocardial ischemia, 1.0 mg/kg IV/IO, repeat with 0.5 mg/kg every 5-10 minutes if necessary to a total of 3.0 mg/kg.

• Liver failure, low cardiac output, patient >70 y/o: give normal 1mg/kg IV/IO bolus dose, but repeats are at 0.25 mg/kg.

• IO Infusion Preparation: 20 mg to 50 mg slowly administered prior to fluid bolus and/or medication administration.

• IM: NOT given IM. Protocol Reference • Pulseless Arrest Algorithm. • Perfusing WCT Algorithm. • Post Resuscitation Care Algorithm. Pediatric Dose 1 mg/kg IV/IO bolus. Not allowed below 3 kg. Can be repeated twice. How Supplied 100mg in 5ml (2%) prefilled syringe.

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lorazepam (Ativan®)

Actions A benzodiazepine that depresses the limbic system, thalamus, and hypothalamus, resulting in calming effects. Produces an amnesic effect, suppresses seizures, is an antiemetic, and is also a muscle relaxant. Indications • Status epilepticus. • Adjunct to cardiac pacing to alleviate anxiety in conscious patient. • Post-intubation sedation. • Sedation of TBI patient. Contraindications (Relative): Alcohol or other sedatives may exaggerate and prolong sedative effect. Side Effects and Adverse Reactions • CNS: Confusion, muscular weakness, blurred vision, slurred speech, drowsiness. • CV: Respiratory depression can occur (1%). Hypotension is very rare (0.1%). Adult Dose • IV/IO: 1-2 mg diluted with 1 ml sodium chloride, SIVP. • Repeat up to additional 2 mg if seizure persists after 5 minutes. • Additional dose of 2 mg can be given in the intubated patient if required due to agitation

(must be first verified that agitation is not due to correctable hypoxemia or complication of tube placement). Total for the intubated patient not to exceed 4mg without physician contact.

• IM: 2 mg, may repeat x1 as above. Protocol Reference • Seizures. • Traumatic Brain Injury. • Post Resuscitation Care Algorithm. Pediatric Dose

• IV/IO: 0.05-0.1 mg/kg diluted 50% with NS, SIVP, titrated to effect (max 2 mg). o Repeat dose if seizure persists after 5 minutes.

• IM: 0.1 mg/kg, may repeat x1 as above. How Supplied 2 mg in 1 ml preload.

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magnesium sulfate (MgS04)

Actions The mechanisms of action in arrhythmias and eclampsia are not fully understood. They are thought to be caused in part by magnesium’s effect on chronotropy and smooth muscle tone. Indications • Refractory VFib or pulseless WCT: last line. • Torsade de pointes: first line if known hypomagnesemia or preexistent prolonged QT. • Perfusing WCT. • Eclampsia. Contraindications • Heart block. • Hypermagnesemia. Side Effects and Adverse Reactions CV: Heart block, flushing, bradycardia, hypotension. Warnings • May cause respiratory depression. • MgS04 is hyperosmolar and must be diluted to prevent red blood cell damage. Adult Dose • IV/IO:

o Torsades, refractory VF/WCT: 1gm of MgS04 in 100 ml of NS (Pre-mix). Run drip at full flow. May repeat x1 in 2 min.

o Eclampsia: 3 gms added to pre-mix (above) titrated to cessation or maximum of 4 gm.

• IM: painful; absorption may not be fast enough to effect arrhythmia. Contact medical control if this route is necessary.

Protocol Reference • Obstetrics: Pre-eclampsia and eclampsia. • Pulseless Arrest Algorithm. • Perfusing WCT Algorithm.

Pediatric Dose Not indicated. How Supplied • 1 gm in 100 ml pre-mix bag. • 5 gm in 10 ml vial.

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morphine sulfate (MS)

Actions A narcotic analgesic that depresses the central nervous system and suppresses pain by binding at opioid receptors in the brain. Increases venous capacitance, decreases venous return, and produces mild peripheral vasodilation. Also decreases myocardial oxygen demand. Indications • Pain from acute MI. • Pain from other sources. Contraindications • Acute abdomen. • Volume depletion or hypotension. • Head trauma (GCS<13). • Acute substance abuse. • Acute asthma. • History of hypersensitivity to opiates. • Multiple trauma: excluding isolated extremity fractures. Side Effects and Adverse Reactions • CNS:Euphoria, drowsiness, pupillary constriction, respiratory arrest. • CV:Bradycardia, hypotension. • GI:Decreases gastric motility; may cause nausea and vomiting. • GU:Urinary retention. • RESP:Bronchoconstriction, decreased cough reflex. Warnings • Detoxified by the liver. • Potentiated by alcohol, antihistamines, barbiturates, phenothiazines, and other sedatives. Adult Dose • IV/IO: 2-5 mg IV, slowly. Repeat with small increments every 5 minutes until desired

response is achieved. Adult maximum 15 mg. Physician contact required for larger doses.

• IM: 5 mg-15 mg IM. Adult maximum 15 mg. Physician contact required for larger doses. Protocol Reference • Chest Pain. • Pain Management. • Transcutaneous pacing. Pediatric Dose 0.1 mg/kg SIVP/IO. Can also be given IM or SC. Can be repeated once. Not given to patient under 4 kg in weight.

How Supplied 10 mg in 1 ml preload.

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naloxone (Narcan®)

Actions The mechanism of action is not fully understood. It does appear that Narcan antagonizes the effects of opiates by competing at the same receptor sites. When given IV, the action is apparent within two minutes. IM or SC administration is slightly less rapid. Indications • Respiratory depression secondary to narcotics or related drugs. • Suspected acute opiate overdose. Contraindications • Hypersensitivity. Warnings • Caution in newborns of mothers who are known or suspected to be physically dependent on

opiates; may precipitate an acute abstinence syndrome. • May precipitate acute narcotic withdrawal in opiate addicted patient. Symptoms could

include: o CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear

production, sweating. o CV: Hypertension, hypotension, ventricular tachycardia, pulmonary edema,

ventricular fibrillation. o GI: Nausea, vomiting.

• Duration of action of some narcotics may exceed that of Narcan; may need to be repeated. • Not effective for respiratory depression caused by non-opioid drugs. • Patient may become violent as level of consciousness increases. • Large doses may be required in propoxyphene overdose (Darvon ®, Darvocet ®). Adult Dose IV, IO, IN, IM, SC, SL: 2 mg injection. May repeat in 2-3 minutes. If no response after 10 mg, then condition probably not due to narcotic. Note If patient has a high likelihood a narcotic addiction (based upon physical stigmata, other informants at scene, etc) and the situation is stable, consider using smaller doses of naloxone (e.g., 0.4-0.8 mg) to stimulate respirations yet avoid abrupt withdrawal. Protocol Reference Unconscious patient unknown etiology. Pediatric Dose IV, IO, IM, SC: 0.1 mg/kg, max dose 2 mg. Can be repeated as needed if no improvement is noted. How Supplied • 2 mg in 2 ml preload (1 mg/ml).

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nitroglycerin (Nitrolingual® spray)

Actions A direct vasodilator that acts primarily on the venous system, although it also produces direct coronary artery vasodilation. Causes a decrease in venous return that also decreases workload on the heart and thus myocardial oxygen demand. Sublingual spray is preferred over tablets because it is more reliably absorbed and bio-available. Indications • Ischemic chest pain. • Pulmonary edema. • Severe hypertension (not generally recommended; physician contact required). Contraindications • Increased intracranial pressure. • SBP <90. • Children under 12. • Viagra® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) use in past 24 hours. Side Effects and Adverse Reactions • CNS: Headache, dizziness, flushing, nausea, and vomiting. • CV: Hypotension, reflex tachycardia. Warnings • Because of an easily developed tolerance, patients on chronic nitrate therapy may require

larger doses of nitroglycerin during acute anginal episodes. • Light, air and moisture inactivate Nitro tablets. Must be kept in amber glass containers with

tight-fitting lids. Do not leave cotton in container. Once opened, nitroglycerine has a shelf life of 3 months.

• Nitrospray has a shelf- life of 1 to 2 years. • Alcohol will accentuate vasodilating and hypotensive effects. Adult Dose 1 metered dose sublingually (0.4mg). May repeat PRN at 3-5 minutes intervals. Hold canister upright. Do not shake. At the onset of attack, 1 or 2 metered doses to be sprayed into mouth. Blood pressure and relief of pain limit dosing, otherwise no upper limit to number of doses. Notes: • Position the canister as close as possible, press button firmly to release spray onto or under

tongue. Advise patient not to inhale spray. • Establish IV access before or concurrent with NTG administration. Protocol Reference • Chest pain. • Congestive Heart Failure and Acute Pulmonary Edema. • Hypertension. Pediatric Dose Not indicated. How Supplied 0.4 mg (400 ug) per metered dose spray.

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nitrous oxide (Nitronox®, NO2)

Actions A colorless gas that acts on the central nervous system. When mixed with 50% oxygen and inhaled, it produces an effect similar to a mild intoxicant. The patient laughs and talks but does not go to sleep. When inhaled, nitrous has a potent analgesic effect that dissipates within 2-5 minutes after stopping administration.

Indications Moderate to severe pain, such as that caused by trauma, acute MI, burns, acute abdomen. Contraindications • Any altered state of consciousness, such as alcohol ingestion, drug OD. • Trapped gas conditions: COPD patients, acute pulmonary pneumothorax, or suspected

intestinal blockage. • Pregnancy. Side Effects and Adverse Reactions CNS: Light-headedness, confusion, drowsiness, nausea, vomiting. Warnings Since nitrous is heavier than air, it may accumulate on floor of ambulance. During transports of more than 15 minutes, it may affect ambulance personnel. Adult Dose Self-administered through inhalation. Also apply 02 cannula at 4 -6 LPM to maintain oxygen therapy when Nitrous is not being administered. Protocol Reference • Chest Pain. • Pain Management. • Transcutaneous Pacing. Pediatric Dose Same as adult. How Supplied Blended mixture of 50% nitrous oxide and 50% oxygen. One oxygen and one nitrous oxide cylinder fed into a regulator that maintains the appropriate concentration.

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oxytocin (Pitocin®)

Actions Selectively affects uterine smooth muscle. Stimulates rhythmic contractions of the uterus, increases the frequency of existing contractions, and raises the tone of uterine muscle. Indications • Uncontrolled postpartum hemorrhage. Contraindications • Not to be administered before delivery of both baby and placenta. • Cardiovascular disease. Side Effects and Adverse Reactions • CNS:Cerebral hemorrhage. • CV: Hypertensive crises. • OB: Uterine rupture. • Neon:Fetal death. Warnings None other than those above. Adult Dose • IV/IO:

o Hemorrhage: add 40 units to 1 liter NS and titrate to a firm uterus. Use second IV line for volume replacement.

• IM: 10 units. Protocol Reference • OB: Postpartum Hemorrhage. Pediatric Dose Not indicated. How Supplied 10 units in 1 ml vial.

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phenylephrine HCL (Neo-synephrine nasal spray)

Actions Topical vasoconstrictor. Indications • Epistaxis. • Pretreatment for nasal endotracheal intubation. Contraindications • Known sensitivity to the product. • Systolic BP>220 and/or Diastolic BP>110. • Severe coronary artery disease. • Use of MAOI medications within 14 days.


Side Effects and Adverse Reactions CV: Possible increase in blood pressure. Warnings None. Adult Dose • Sprays to nostril(s). Protocol Reference • Epistaxis. • Nasal endotracheal intubation. Pediatric Dose • Not indicated below age 12. Adult dose for age>12. How Supplied • 15 ml spray bottle.

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sodium bicarbonate (NaHCO3)

Actions An alkalizing agent used to buffer acids. Bicarbonate combines with excess acid (usually lactic acid) present in the body to form a weak, volatile acid. This acid is broken down into C02 and H20. Indications • Cardiac arrest, prolonged resuscitation. • Hyperkalemia (second line to CaCl2 if cardiac arrest or bizarre/sinusoidal rhythm). • Tricyclic overdose with cardiac manifestations. Contraindications None in these settings. Side Effects and Adverse Reactions Metabolic alkalosis, hypernatremia, cerebral acidosis, sodium and H20 retention that can lead to CHF. Warnings • May inactivate catecholamines given at the same time. • Will precipitate if mixed with calcium chloride. Adult dose (IV/IO) • Cardiac arrest:

o 1 mEq/kg IVP. Repeat at 0.5 mEq/kg every 10 minutes, to a maximum of 250 mEq. • Hyperkalemia:

o 50 mEq IVP. Limit to single dose in hyperkalemia. • TCA OD:

o 50 mEq IVP. Limit to single dose in TCA OD. Protocol Reference • Pulseless Arrest Algorithm. • Hyperkalemia. • Tricyclic OD. Pediatric Dose 1 mEq/kg IV/IO. Can repeat twice at 0.5 mEq/kg q 10 minutes. (Dilute to half strength in neonatal resuscitation). How Supplied 50 mEq in 50 ml prefilled syringe.

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succinylcholine (Organon®, Anectine®)

Actions A short acting neuromuscular blocking agent that acts at the motor endplate. Indications To establish an airway in a patient in imminent danger because of an uncontrolled airway or ventilatory insufficiency, in whom other methods for securing the airway have been unsuccessful or are obviously impractical or impossible. Contraindications • Upper airway obstruction. • Probable inability to intubate afterward because of very unfavorable anatomical

characteristics, or face or neck trauma. • History of malignant hyperthermia. • Patient who is 24 hours post-spinal cord injury, severe burn or crush injury. • Known hyperkalemia. • Known myopathy (personal or family history of disease of muscles). Side Effects and Adverse Reactions • CV: Bradycardia; may be severe in pediatrics. • Neuro:Prolonged paralysis will occur in persons lacking pseudocholinesterase. Warnings • A second dose of succinylcholine is more likely to cause bradycardia. • Succinylcholine must be administered per the Rapid Sequence Intubation Protocol. Adult Dose • IV/IO: 1.5 mg/kg IVP. Protocol Reference Rapid Sequence Intubation with Neuromuscular Blockade. Pediatric Dose IV/IO: 2 mg/kg (to 35 kg as per Peds SO), after pre-medication with atropine (.02 mg/kg IV). How Supplied 200 mg in 10 ml.

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tetracaine (Alcaine®)

Actions A local anesthetic for topical ophthalmologic use. Indications Short-term relief of pain caused by corneal injuries such as flash burns, corneal abrasions, and chemical exposures. Contraindications • Penetrating eye injuries. • Allergy to local anesthetics. Side Effects and Adverse Reactions None. Warnings • Administer ONLY to patients who are being transported by AFD. • Use only on patients who can open the eye spontaneously. • Advise patient to avoid touching the eye while anesthetized. • Do NOT give unused portion to patient. Adult Dose 2 drops in affected eye. May repeat once. Protocol Reference • Eye injury. • Pain Management. Pediatric Dose 2 drops in affected eye. May repeat once. How Supplied 15 ml squeeze bottle of 0.5% solution.

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vasopressin (Vasopressin®)

Actions Vasopressin (arginine vasopressin, AVP; antidiuretic hormone, ADH) is a hormone released from the posterior pituitary. AVP has two principle sites of action: kidney and blood vessels. AVP increases water reabsorption by the kidneys. This is the antidiuretic effect of AVP. This hormone also constricts arterial blood vessels, contributing to an increase in systemic vascular resistance during heart failure, thus increasing coronary perfusion without the beta adrenergic effects of epinephrine. Indications Pulseless cardiac arrests including Asystole, PEA, Ventricular Fibrillation, and Pulseless Ventricular Tachycardia. Contraindications None in the above setting.

Side Effects and Adverse Reactions None in the above setting. Warnings None in the above settings.

Adult Dose 40 units IVP/IO. Not repeated. Protocol Reference Pulseless Arrest Algorithm.

Pediatric Dose Not recommended. How Supplied 20 units in 1 ml vial.

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vecuronium bromide (Norcuron®)

Actions Non-depolarizing neuro-muscular blocking agent of intermediate duration. Competes with cholinergic receptors at the motor endplate. Reversed by acetylcholinesterase inhibitors. Its onset to effective paralysis is on the order of 2-3 minutes but decreases with increased dose. Its clinical duration in normal doses is 25-40 to show signs of muscle activity and 45-65 minutes to recover 90% function. Indications Post cardiac arrest cooling. Contraindications • Known sensitivity to the agent. • History of Myasthenia Gravis. Side Effects and Adverse Reactions None in the above situation. Warnings • May have prolonged effect in patients with hepatic and renal disease. • Malignant hyperthermia: insufficient data, considered possible. • Not to be used for primary RSI. Adult Dose • IV/IO: Induction of paralysis (post-resuscitation cooling): 0.1mg/kg IVP. • Contact Medical Control if maintenance dose required. Protocol Reference • Endotracheal intubation. • Rapid sequence induction. • Post cardiac arrest cooling. How Supplied 10 ml vial with reconstitution fluid.

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Section 2: Treatment Protocols

Introduction General Guidelines for the Treatment and Transport of Patients

Critical Trauma The goal in critical trauma is the shortest possible scene time. To the extent possible, after initial scene assessment and necessary immobilization is performed, all other interventions are performed in the MICU enroute to the hospital. Early notification or Trauma Alert to the receiving facility is crucial. Cardiac Arrest The goal is to obtain a perfusing rhythm and then to transport. All Patients

• The offer of transport will be extended to every patient. • Transport offers will be extended in a neutral manner and without qualification. • Any refusal of medical assistance, and/or transport, must be informed and competent. • Informed and competent refusals of medical assistance, and/or AFD transport, must be

thoroughly documented in the PCR. Patient or guardian signatures must be obtained. In cases where this is not possible, then the reason(s) for the absence of a signature must be explained in the PCR.

• Patients will only be transported to a hospital. • The safest method of transporting the adult patient is using the gurney with restraint

belts. The practice of transporting a patient on the bench seat or a jump seat is strongly discouraged and acceptable only when multiple patients are being transported in one ambulance (and the additional patients can be secured properly with existing safety restraints).

• All patients transported on the gurney are to have the torso-to-waist restraints applied. If the patient condition allows, the headrest is to be elevated. There are situations that might require different techniques to restrain the patient safely to the gurney (e.g., a patient who is morbidly obese or lying left lateral recumbent), and every means should be utilized.

General Guidelines for All EMS Providers

Initial Size-up

1. Observe Body Substance Isolation precautions. 2. Ensure scene safety. 3. Determine number of patients. 4. Determine mechanism of injury/nature of illness. 5. Call for additional help or specialty resources as needed. 6. Consider need to provide spinal immobilization. 7. Form a general impression of the condition of the patient(s)

General Approach to the Patient

1. Establish patient responsiveness. If cervical spine trauma is suspected, manually stabilize the spine.

2. Assess the patient’s airway for patency, protective reflexes and the possible need for advance airway management. Look for signs of airway obstruction.

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3. Open the airway as necessary using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected.

4. Suction as necessary. 5. Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway

cannot be maintained with positioning. EMTs may use Combitube or King Airway in a patient with no gag reflex and immediate need for airway control.

6. Assess for signs of respiratory distress, failure, inadequate tidal volume or arrest. If present, refer to the appropriate protocol for treatment options.

7. If breathing is adequate, place the patient in a position of comfort and administer high-flow, 100%concentration oxygen as necessary. Use a partial nonrebreather mask.

8. Assess pulse/perfusion status. 9. Look for external hemorrhage if indicated and control using direct pressure or a pressure

dressing. 10. Immediately treat imminent life threatening problems as they are found during the initial

assessment. 11. Reassess the patient frequently.

EMT-I/ETT Patient Care Protocol

General • Follow General Patient Care as listed above. • Determine chief complaint and level of distress. • Measure and record vital signs. • Perform physical exam specific to chief complaint.

Medical Emergencies

• Code 99: Follow AED Protocol. • Diabetic Emergencies: Suspected hypoglycemia: check blood sugar with Glucometer, if

blood sugar <80 and patient has symptoms of hypoglycemia but is alert, administer oral glucose.

• Assist with patient’s nitroglycerin, metered dose inhaler, or epinephrine auto-injector per State of Alaska regulations.

• Chest Pain: ASA per Standing Medication Order and Chest Pain Protocol. • All other: Follow General Patient Care and Oxygen Therapy guidelines in this document.

Approved advanced airway is Combitube® or King Airway. Trauma Emergencies

• Stabilize spine when indicated by mechanism of injury or signs and symptoms (See C-Spine guidelines).

• Control external hemorrhage. • Perform rapid head-to-toe exam. • Follow General and Oxygen Therapy guidelines in this document. • Approved advanced airway is Combitube® or King Airway.

Multi-victim/Mass Casualty Incident Follow Start Protocol.

EMT-II Patient Care Protocol General Follow all guidelines per EMT-I/ETT Patient Care Protocol. Additional Authorized Activities

MOM 3.0 43


An AFD EMT-II who has been authorized by the Medical Director may: • Initiate peripheral IV therapy per IV Therapy Protocol. • Initiate IO therapy in unconscious adult patients per EZ-IO protocol under the direct

supervision of a MICP. • Administer D50W per Diabetic Emergencies Protocol and D50W Standing Medication

Order. • Administer naloxone HCL (Narcan ®) per Standing Medication Order. • Administer nebulized albuterol for bronchospasm per albuterol medication order when so

directed by an incoming MICP.

EMT-III Patient Care Protocol

General Follow all guidelines per EMT-II Patient Care Protocol. Additional Authorized Activities An AFD EMT-III who has been authorized by the Medical Director may:

• Apply electrodes and monitor cardiac activity. • Manually defibrillate ventricular fibrillation and pulseless ventricular tachycardia. • Administer specific medications according to Treatment Protocols and Standing

Medication Orders when trained to those specific medications and under the direct supervision of a state licensed and municipally certified MICP.

• Administer lidocaine per Pulseless Arrest Algorithm and lidocaine Standing Medication Order.

• Administer atropine per Pulseless Arrest and Bradycardia Algorithms and atropine Standing Medication Order.

• Administer epinephrine 1:10,000 per the Pulseless Arrest Algorithm and epinephrine 1:10,000 Standing Medication Order.

• Administer epinephrine 1:1000 per Anaphylaxis and Asthma Protocols and epinephrine 1:1000 Standing Medication Order.

• Administer morphine sulfate per Pain Management and Chest Pain Protocols and morphine sulfate Standing Medication Order.

• Administer NTG for chest pain per Chest Pain Protocol and NTG Standing Medication Order.

Scope of Practice for EMT-II and EMT-III

EMT-II and EMT-III providers are limited to the scopes of practice defined in the MOM and only when supervised by an MICP or in direct communication with an incoming MICP.

Airway and Ventilation

Administration of Oxygen Oxygen therapy Oxygen will be administered as the paramedic and/or EMT/ETT deems appropriate according to clinical signs and clinical situation. If pulse oximeter is used in addition to the clinical assessment, the Sa02 should be >95%.

• COPD: a relatively small number of patients with this condition will react to supplemental oxygen by slowing their respiratory rate and eventually becoming obtunded. These patients have at baseline a compensated hypoxemia. This must be considered in all COPD patients and 02 should not be used routinely in such patients unless they are

MOM 3.0 44


being treated for symptomatic hypoxemia. If a COPD patient is being treated for hypoxemia, carefully titrate oxygen to improve the patient’s clinical status. Carefully monitor these patients and if ventilatory drive is suppressed and the need for oxygen persists, then augment with BVM or other measures as required.

Airway Protocol

General Airway and Oxygenation 1. Head tilt/chin lift maneuver if unconscious; jaw thrust if suspected cervical spine injury or

trauma. 2. Oropharyngeal or nasopharyngeal airway as indicated. 3. Suction as needed to maintain clear airway but limit each event to 15 seconds with re-

oxygenation between attempts. 4. Oxygen will be delivered as deemed necessary. Use appropriate 02 delivery device and

flow rate to achieve Sp02 of> 95%. If Sa02 not available, use clinical judgment for delivery method and concentration.

• 2-6 liters by nasal cannula. • 10-15 liters by non-rebreather mask. • 15-25 liters by bag-valve mask (depends on oxygen resources).

Bag-Valve-Mask Ventilation (BVM)

Deliver breaths slowly over 1 second with a volume adequate to cause chest rise when ventilating the apneic patient.

• Limit ventilations to 10 per minute in the adult cardiac arrest patient.

Endotracheal Intubation Endotracheal intubation (oral or nasal) is recognized as the most direct and effective means of securing and maintaining the airway. Orotracheal intubation is generally preferable, but the nasal route allows for a definitive airway in persons who have a gag reflex (yet require an airway) or in whom an oral approach is not possible. Indications

• Unprotected airway with danger of aspiration. • Need to support ventilation due to patient's inability to generate adequate tidal volumes. • Apnea (relative indication). • Inability to ventilate by other means. • Occasionally as the only means of drug delivery.

Contraindications

• Orotracheal intubation: none if the proper indications are present. • Nasotracheal intubation:

o Possible mid-face fracture. o Nasal deformity or obstruction. o Possibility of nasopharyngeal foreign body that could be blindly pushed into

airway. o When there is any consideration of increased intracranial pressure.

Method - Orotracheal Intubation

1. One team member should oxygenate the patient with 100% 02. 2. If the patient is breathing spontaneously, DO NOT HYPERVENTILATE OR BVM

AUGMENT. If patient is apneic or ventilating inadequately, bag at appropriate rate.

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3. Assemble intubation equipment: check tube cuff, have suction ready, have Endostat® or other securing method ready.

4. Consider Eschmann Stylet for difficult airways. 5. Intubate. 6. Confirm placement in apneic patient with TubeChek®. 7. Apply capnography (if available). 8. Confirm placement in perfusing patient with VentiSure™ colormetric device (if no

capnography available). 9. Check breath sounds in both axillae and in the epigastrium, and check the tube’s

distance at the teeth. 10. ETT tube should be inflated until no air is heard to escape around the tube, or, to a

maximum of 10 ml of air in cuff. 11. Secure tube. 12. Intubation should be completed in no more than 2 attempts each by 2 providers

MAXIMUM in non-arrest patients. Move to alternative airway if unable to intubate.

Method - Nasotracheal Intubation 1. Check patient for the larger or more patent nare. 2. Instill Neo-synephrine: administer 3 squirts of 0.5% Neo-synephrine spray prior to

nasotracheal intubation when time and conditions permit. 3. Lubricate tube and/or nare and nasal passage well and insert the tube, advancing along the

slightly downward path of the nasal cavity. 4. Listen for the approach of the tube to the glottis. Advance tube on inhalation. Success is often

confirmed by a cough. 5. Check breath sounds, inflate cuff and secure tube. Notes

• While CPR is being performed, it is expected personnel will set up for or try ETT placement without interrupting compressions.

• In cardiac arrest, one attempt by one provider for ETT placement; if unsuccessful, move on to Combitube.

• Do not delay initial defibrillations for intubation. • Apply cricoid pressure when patient is being BVM ventilated (if personnel are available)

and release pressure only after cuff of endotracheal tube is inflated with position confirmed!

• The patient should be oxygenated prior to placement attempts. • ETT placement will be re-evaluated after each time patient is moved and

periodically throughout transport. This must be documented in the PCR. • Secure the neck of intubated unresponsive patients with c-collar or other method to help

avoid displacement of the tube by unintended head movement. • Measure pulse oximetry continuously. Pulse oximetry is a routine diagnostic tool used to

measure oxygen saturation and response to oxygen therapy. It is generally reliable but, as always, clinical impression is the final determinant in whether to believe a given reading.

• NGT may be placed in the intubated patient with distended abdomen as per Gastric Intubation Protocol.

Combitube or King LT-DTM Airway

The Combitube®, Combitube®SA or King Airway will be used by MICPs or EMTs when endotracheal intubation is not possible, technically difficult or when the Combitube® or King Airway is considered the best method to safely expedite airway management in a critical patient’s care.

MOM 3.0 46


Indications • Unprotected airway with danger of aspiration. • Need to support ventilation due to patient's inability to generate adequate tidal volumes. • Apnea (relative indication). • Inability to ventilate by other means. • In trauma: may be used initially as the most expedient method. Must be used if

unsuccessful endotracheal intubation after two attempts maximum. • General patient in need of airway intervention in which endotracheal intubation is

unsuccessful. Contraindications

• Gag reflex present. • Height less than 4 feet. • Known or suspected esophageal disease. • Caustic ingestion. • Suspected foreign body in airway.

King Airway The King Airway is a single lumen supraglottic airway device that occludes the esophagus and oropharynx providing isolation of laryngopharynx for ventilation of the trachea. Intubation of the trachea is nearly impossible and shouldn’t be considered an possibility as in the combitube. The King Airway accepts the Eschmann stylet to aid in endotracheal intubation. Placement and sizing:

Size Height Connector Color Inflation Volume 3 4-5 feet Yellow 45-60 ml 4 5 – 6 feet Red 60-80 ml 5 ≥ 6 feet Purple 70-90 ml

Method Refer to training document for the Combitube® and Combitube®SA, and King LT-D.

Cricothyrotomy Cricothyrotomy is a last resort intervention available to MICPs for unrelieved airway obstruction or a patient emergently requiring an airway who cannot be intubated. Indications Absolute need for an airway with no other practical option. Contraindications None in this setting. Method Refer to document: Melker™ Cuffed Emergency Cricothyrotomy Catheter Set.

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Eschmann Endotracheal Tube Introducer (Portex Endotracheal Tube Introducer; Eschmann Stylet; Gum Bougie)

The introducer is a 15 French, 60 cm long semi-rigid, resin coated, braided polyester instrument used as an adjunct to assist with oral endotracheal intubation. The first (distal) 2.5 cm is angled 35 degrees to facilitate placement within the trachea. Indications

• Any oral endotracheal intubation attempt involving poor vocal cord visualization. • Anatomic, traumatic, or pathologic conditions limiting laryngeal access.

Contraindications Patients requiring endotracheal tubes smaller than 6.0 mm. Precautions When passed blindly, the introducer should not be forced. Method

1. While this procedure can be performed by a single paramedic, preferably it requires two personnel: the intubating paramedic and an assistant.

2. Lubricate introducer with water-soluble lubricant. • Option: slide appropriately selected endotracheal tube over the introducer.

3. Perform laryngoscopy. 4. With the angled tip directed anteriorly, guide the introducer towards the epiglottis. 5. Advance the introducer posterior to the epiglottis and into the glottic opening.

• Cricoid pressure may facilitate correct placement and the introducer may be palpable when the angled tip passes the cricoid cartilage.

6. Tracheal placement of the introducer is indicated by palpable “clicking” of the introducer as the angled tip passes over tracheal rings. • If the angled tip stops advancing, it has reached the carina. • Failure to palpate “clicking” or to meet resistance after inserting nearly the full length

of the introducer indicates esophageal placement. 7. When the introducer is confirmed to be in the trachea, the intubating paramedic maintains

laryngoscopy and holds the introducer in position. • If the angled tip has been placed at the carina, withdraw the tip approximately 2 cm

and hold in position. 8. The assistant advances the endotracheal tube along the stationary introducer, holding

the proximal tip as it is exposed. 9. With the intubating paramedic continuing laryngoscopy, the paramedic (or assistant) then

advances the endotracheal tube along the stationary introducer past the larynx. 10. If any difficulty in passing the endotracheal tube is encountered, rotate the tube 90

degrees counter-clockwise to orient the bevel of the tube posteriorly. • The introducer may be allowed to rotate with the endotracheal tube but should not be

moved up or down the trachea. 11. Secure the endotracheal tube manually, remove the introducer, and verify tube

placement in the usual manner. • Placement depth is approximately 20-21 cm at the teeth for adult females and 22-23

cm at the teeth for adult males. 12. Fully secure endotracheal tube with commercial restraint device.

Notes

• The Eschmann Endotracheal Tube Introducer is not a disposable, single-use device. If undamaged, the introducer may be disinfected following standard procedures and reused to a maximum of five times (manufacturer’s recommendation).

MOM 3.0 48


• If the introducer is stored in a curled or shaped condition at less than body temperature it can develop cracks. The manufacturer recommends storage in its hard plastic sheath.

Gastric Intubation

Indications Gastric decompression Contraindications

• Ingestion of caustic substances. • Nasogastric: not used if there is facial trauma or significant head trauma.

Method - Nasogastric Insertion

1. Select tube size appropriate to patient size and age. 2. Examine for the more patent nare. 3. Measure the tube against the patient to get a rough idea of the length of tube that will be

necessary to intubate the stomach. 4. Lubricate the tube with water-soluble lubricant. 5. Place the tube following the natural downward slope of the nose, trying to keep the tube

on the floor of the nasal cavity. 6. The tube should move easily, do not use excessive force. 7. When the tube appears to be in position, place a stethoscope over the stomach,

insufflate 20 ml of air with a syringe and auscultate for air in the stomach. 8. Place the tube to suction.

Method - Orogastric Insertion

1. Select tube size appropriate to patient size and age. 2. Measure the tube against the patient to get a rough idea of the length of tube that will be

necessary to intubate the stomach. 3. Lubricate the tube with water-soluble lubricant. 4. Insert the tube into the mouth. 5. The tube should move easily, do not use excessive force. 6. When the tube appears to be in position, place a stethoscope over the stomach,

insufflate 20 ml of air with a syringe and auscultate for air in the stomach. 7. Place the tube to suction.

Inspiratory Impedance Device

(ResQPOD® Circulatory Enhancer) This device causes as brief impedance to inspiration and can lead to improved cardiac output in low flow states. Indications:

• For temporary increase in blood circulation in perfusing patients with persistent hypotension and spontaneous ventilations supported by ETT/Combitube or BVM.

• PEA cardiac arrest or cardiac arrest with a mixture of “promising” rhythms (organized rhythms intermixed with VF/VT/asystole) in which CPR is being performed.

Contraindications

• Known decompensated heart failure or CHF. • Pulmonary hypertension or aortic stenosis. • Flail chest. • Chest pain. • Patient with primary complaint of shortness of breath.

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• It is currently not indicated for pediatric use (<12 yo, <80lb). Method

1. Refer to appendix for graphics on use of device. 2. With facemask and BVM: apply ResQPOD between facemask and BVM. Provide

ventilations in customary manner 3. With ETT or Combitube: apply ResQPOD between airway device and BVM and ventilate

as per protocol. 4. Be sure that all pieces fit tightly 5. The device has a timing light that is activated by a switch on the upper face rim. This

light directs the timing for delivering 10 breaths per minute with each breath lasting 1.0 seconds, and will be used with cardiac arrest indications.

Note This is a relatively new technology with which our experience is not yet mature. This device may help improve blood pressure in the spontaneously ventilating patient. It also increases the work of breathing by causing a brief inspiratory increase in effort. Careful monitoring may be required to balance these two effects in any given patient. As an example, a patient who is mildly hypotensive and with respiratory difficulties may WORSEN with this intervention. Careful monitoring of the clinical effect will be necessary. As another example, a resuscitated cardiac arrest patient with a good pulse who begins to have spontaneous ventilation should have the device removed.

Rapid Sequence Intubation with Neuromuscular Blockade Indications To establish an airway in a patient in imminent danger because of an uncontrolled airway or ventilatory insufficiency, in whom other methods for securing the airway have been unsuccessful or are obviously impractical or impossible. Contraindications

• Upper airway obstruction. • Probable inability to intubate afterward because of very unfavorable anatomical

characteristics, or face or neck trauma. • History of malignant hyperthermia. • Patient who is 24 hours post-spinal cord injury, severe burn, or crush injury. • Known hyperkalemia. • Known myopathy (personal or family history of disease of muscles).

Note If unable to intubate or use Combitube® or King Airway and succinylcholine is contraindicated, proceed to cricothyrotomy. Guidelines

• Prior to initiating RSI, reevaluate the patient for any obvious contraindications for paralysis

• One paramedic and at least one other provider with advanced airway skills (approved by the medical director for field intubations) will directly attend the airway during and immediately after administration of the paralytic, until the following have been successfully completed:

o Intubation. o Confirmation of tube placement as per Airway Protocol. o Re-confirmation of tube placement with a C02 monitor or other recommended

adjunct (mandatory). o Tube is secured.

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Procedure

1. Assemble personnel and equipment: • 2 providers with airway skills. • Intubation tools, check ETT cuff, suction. • IV access with running IV. • Check label and draw up succinylcholine 1.5 mg/kg and etomidate 0.3 mg/kg (if

indicated) 2. Preoxygenate patient with 100% oxygen from BVM. If patient is spontaneously ventilating

with adequate volume, DO NOT VENTILATE. If patient requires BVM ventilation, apply cricoid pressure.

3. Give succinylcholine. If neuromuscular blockade is required in the conscious patient, use etomidate 0.3 mg/kg SIVP for sedation prior to succinylcholine.

4. Proceed with intubation as per Airway Protocol. 5. Maintain cricoid pressure from time of paralysis until tube is inflated. Must be fully

prepared to ventilate and suction prior to administration, and to establish a surgical airway if necessary.

6. For sedation of combativeness after successful intubation and end of paralytic action, lorazepam 2 mg (may give up to 4 mg) SIVP.

Pediatric Guidelines

• Pre-medicate with atropine (0.02 mg/kg) before giving succinylcholine (see atropine standing order).

Note Consider restraints during paralysis, after securing the airway and initiating ventilation, especially in restless head injury patients.

Cardiac

CPR Available evidence shows that high quality, uninterrupted cardiac compressions are of great importance to victims of cardiopulmonary arrest. Compressions using an external device (Revivant® Autopulse) show promise as an adjunct in this setting. AFD personnel are directed to institute CPR at the earliest possible moment and to limit all interruptions to continuous CPR. Early, high-quality CPR in unwitnessed cardiac arrests is the most important early activity that influences survival from a cardiac arrest.

• Compressions must be deep enough and fast enough to provide perfusion but also must be minimally interrupted for the positive benefit to be realized.

• CPR now is to occur BEFORE any other activity except to confirm the presence of cardiac arrest and the absence of airway obstruction.

• CPR will be done for 5 cycles of 30:2 compressions to ventilations ratio (about 2 minutes) before the first pause for any procedure.

o PUSH HARD and PUSH FAST at a rate of 100 compressions/minute and release completely.

o Ventilations are delivered over 1 second only; do not hyperventilate. • While CPR is being performed it is expected that personnel will apply monitor pads, BVM

mask, attempt IV and a MICP will set up for or try intubation without interrupting compressions.

• After an endotracheal tube or combitube has been successfully placed, continue CPR compressions without pauses at a rate of 100/minute with synchronized ventilations.

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• After this first complete CPR cycle, there will be a brief pulse check and a monitor rhythm check.

o If the rhythm is VF/VT without pulse, one defibrillation will be done at maximum output and compressions will be resumed WITHOUT pulse check and without rhythm check for another 5 cycles of CPR.

• Medications may be administered during this period.

Chest Pain The new era of fibrinolytics and emergency angioplasty requires that patients with signs and symptoms consistent with acute myocardial infarction be transported as quickly as possible. Indications All patients with chest pain of possible cardiac origin. These orders may also be applied to patients with symptoms that may represent an acute coronary syndrome including:

• Unexplained diaphoresis. • Pain in a typical cardiac referral pattern. • Indigestion in a suspicious clinical setting.

Guidelines

• ABC’s, Airway Protocol, Hypotension Protocol, ACLS Protocols as required. • Oxygen, cardiac monitor, IV or IO. • 12-Lead ECG Protocol with 12-Lead ECG performed within 5 minutes of first EMS

contact. • “OPQRST” and history of current events. • Be sure to ask about aspirin and Viagra, Levitra, Cialis usage. • Physical exam focusing on LOC, signs of pulmonary edema.

Medications

• Nitroglycerin, per standing orders. • Aspirin, 162 mg PO, per standing orders (do not re-administer if given within last 12h). • Morphine, per standing orders. • Nitrous oxide, per standing orders (may be helpful if morphine allergy or hypotension).

Management and Transport Considerations

• Patients that require an IV/IO or 12-Lead ECG should have those therapies initiated ASAP after arrival and at the initial contact point whenever practical.

• Short scene times for patients with potential myocardial infarction are a priority, and consideration shall be given to completing interventions on scene so as to comply with provider transport safety guidelines while maintaining the shortest practical scene times.

• Transport code appropriate to the patient’s need. • If patient is a potential acute MI, notify the hospital that you have a patient with chest pain

consistent with myocardial ischemia. • If the patient presents with contiguous lead ST segment elevations, initiate STEMI Alert

(See Medical Operations section). Note

• Treat chest pain aggressively. • Pain will increase the patient’s ischemia.

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Congestive Heart Failure and Acute Pulmonary Edema

The diagnosis of Congestive Heart Failure (CHF)/Acute Pulmonary Edema (APE) can be difficult and is easily confused with COPD exacerbation as well as infectious causes of respiratory distress. It is best made by considering medical history, risk factors, medications and physical exam with particular attention paid to blood pressure. Factors most associated with a dyspneic patient having CHF include:

• History of CHF. • Exam showing Jugular Venous Distention (JVD). • Atrial fibrillation on monitor. • History of cardiac disease: coronary disease, valvular or MI. • Hypertension. • Orthopnea, Dypnea on Exertion (DOE) and Paroxysmal Nocturnal Dyspnea (PND). • Blood pressure is typically quite high in APE. • Peripheral edema may be present. • Symmetric “moist” rales and pink frothy sputum.

Applies To All non-pediatric patients with respiratory symptoms consistent with CHF/APE, including those from various sources such as iatrogenic fluid overload or renal failure, as well as other more typical causes. Severity

• Asymptomatic: Dyspnea on exertion but no symptoms at rest. • Mild: Mild dyspnea at rest despite 02 treatment. Able to speak in full sentences. • Moderate: Moderate dyspnea. Sp02 < 93% on supplemental 02. Normal mental status. • Severe: Severe dyspnea, ventilatory failure, hypoxia (Sp02 < 90% on 02). Typically with

high systolic BP. Altered consciousness. Difficulty speaking due to dyspnea. Guidelines

• ABC’s, airway protocol, hypotension protocol, ACLS protocols as required. • Refer to ACLS monograph for treatment pathways for ACS • Oxygen, cardiac monitor, 12-lead-protocol, IV. EtC02 monitoring. • ”OPQRST” and history of current events. Be sure to ask about aspirin usage. Physical

exam focusing on LOC, signs of pulmonary edema. • Position the patient in high fowlers. Legs dependent off of the stretcher is often required. • Nitroglycerin is the most effective, fasting acting agent and should be used first and with

a frequency based upon the patient’s severity and response. • Captopril given sublingually is the second line drug following initial nitroglycerin therapy. It

effectively treats the afterload and makes the heart’s output more effective.

Drug Treatment • Severe with cardiogenic shock (patient with evidence of “Severe APE” and with

hypotension MAP <75 and/or SBP<100) o Dopamine 5 mcg/kg/min and titrate. o Alternative: consider 250 cc normal saline bolus prior to or concurrent with

initiation of dopamine. • Severe symptoms

o NTG 0.4 mg SL and repeat every 3 minutes with ultimate dosing determined by clinical response and SBP.

o Captopril 25 mg SL after initial NTG if SBP maintained at >110. o Albuterol 2.5 mg via nebulizer for wheezing. o Furosemide 0.5 mg/kg SIVP if not currently on furosemide; give 1.0 mg/kg SIVP

if currently taking.

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• Moderate symptoms o Treatment modalities are the same as with severe but the intensity of dosing will

be less frequent. NTG is first line, captopril 25mg SL as above unless symptoms completely resolve with nitroglycerin therapy.

• Mild symptoms o Nitroglycerin SL. o Captopril should be considered depending on symptoms and blood pressure.

Medications

1. Nitroglycerin SL, per standing orders. 2. Captopril SL, per standing orders. 3. Furosemide SIVP, per standing orders. 4. Aspirin PO, per standing orders.

• Note: When an MI is suspected.

Cardiac Monitoring Initiate continuous monitoring in all of the following:

• First time seizures and patients over 30 y/o with seizures. • Chest pain of all causes (including symptoms suggestive of Acute Coronary Syndrome). • Unconscious patients of any etiology. • Patients with a neurological deficiency of unknown etiology. • Any blunt or penetrating chest trauma. • Irregular or abnormal peripheral pulses. • Syncope. • Suspected overdoses*. • Patients who are hemodynamically unstable. • Asthmatic patients over 35 y/o receiving epinephrine.

*Measure QRS and QT intervals.

12-Lead ECG

Purpose EMS-generated 12-lead ECG may hasten the restoration of vessel patency by speeding the acquisition of that vital piece of data. In rhythm disturbances, the 12-lead gives additional information as to the type of rhythm. Method EMS will obtain the 12-lead ECG for the indications listed below. In general, the leads will be applied by EMT while the paramedic takes history, obtains IV access etc. The goal is to add no more than one minute to scene time for ECG. Indications

• Narrow Complex Tachycardia - Obtain pre-adenosine 12-lead. Try to get continuous strip during conversion with adenosine (leads I, II and V2).

• Suspected AMI or acute coronary syndrome (symptoms may include indigestion, nausea, arm or jaw pain).

• CHF, pulmonary edema, acute respiratory distress that might be due to cardiac etiology. • Unexplained diaphoresis (age appropriate). • Unexplained tachycardia or hypoxemia in a patient with known coronary artery disease. • Unexplained syncope or near-syncope in non-pregnant patient greater than age 40.

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Contraindications Unstable patient. Reporting Paramedic will make a verbal report at earliest appropriate time alerting the receiving hospital of the patient’s history, physical exam, response to therapy and ECG findings (rate, rhythm and evidence of injury, ischemia or infarction). The paramedic shall report the findings by describing ST elevation or depression, q-waves and other abnormalities in each lead in which the abnormality is seen. Notes Try to get the 12-lead before giving nitroglycerin to patients with cardiac chest pain. If this will result in significant delay (>60sec), treat symptoms prior to 12-lead acquisition.

Revivant AutoPulse Device The Zoll AutoPulse is a battery operated, non-invasive mechanical CPR pump. The AutoPulse device is currently in limited use in the Municipality of Anchorage EMS system. Indications

• Non-traumatic cardiac arrest, to include PEA requiring CPR • >age 18 • >90 lbs body weight • <300 lbs body weight

Contraindications

• Cardiac arrest due to traumatic injury • Confirmed Comfort One or DNR order • Abdominal or chest surgery in previous 6 weeks

Usage guidelines

• The AutoPulse device automatically sizes to fit a 32 to 54 inch chest diameter. • The AutoPulse shall be used in accordance with the manufacturer’s recommendations. • At the current time, the AutoPulse device is to be incorporated as soon as feasible into

the treatment flow of a cardiac arrest without changing current Anchorage Fire Department protocols.

• The Autopulse is equipped with rate settings of: ° 30:2 ° Continuous

Transcutaneous Pacing

Indications • Witnessed asystole. • Consider as first approach to patient with anginal chest pain and symptomatic

bradycardia. • Any of the following rhythms when they are symptomatic and either not responsive to

atropine or are causing major instability requiring use before atropine. o Sinus or junctional bradycardia. o Sinus pause. o 2nd or 3rd degree AV block.

Current Settings

• Cardiac arrest or mentation that makes pain problems unlikely: 20mA increments.

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• Mentation suggesting potential pain problems: 5mA increments with brief pauses for the patient to adjust.

Procedure

• Pace @70/min. Increase current to electrical capture (consistent T waves) and check perfusion signs carefully for mechanical response.

• Discontinue and retry later if perfusion clearly does not improve. Pain control

• In conscious person pain control will most likely be paramount. • Morphine and Lorazepam preferred if neither is contraindicated; use Nitronox if neither is

practical. • Pain will increase the patient’s ischemia.

ACLS Algorithms and BLS Charts

Post Resuscitation Care

Indications Care of patients who have the return of spontaneous circulation after a no-flow cardiac arrest. Guidelines

• Work to optimize oxygenation and ventilation by reassessing these parameters frequently by clinical exam and monitoring of physiologic parameters such as oxygen saturation and capnography.

• Careful attention to the airway device regarding maintenance of its position and suctioning as necessary. Remove Airway Impedance Device (ResQPod).

• Work to optimize blood pressure while paying careful attention to the possibility of adversely increasing cardiac work. If there are no contraindications and rate is adequate, try bolus of 250 ml saline and reevaluate. If evidence of “pump failure” then begin with dopamine.

• Consider precipitating cause of arrest: Obtain 12 lead ECG if possible. • Treat bradycardia-associated hypotension with atropine, fluids, dopamine, or

transcutaneous pacing as per the algorithm. • Consider nasogastric tube. • Consider aspirin therapy. • If blood pressure adequate and ECG shows ST elevations, try to use NTG. • Lorazepam titrate to a maximum of 4 mg SIVP for agitation or post-arrest seizure.

Contact Medical Control for repeat doses if needed for long transport. • Maintain normothermic body temperature in trauma. • For ROSC after medical cardiac arrest refer to Post Cardiac Arrest Cooling protocol.

Note See Algorithm on page 59.

Post Cardiac Arrest Cooling Adult patients who suffer a cardiac arrest of presumed cardiac etiology and who experience a sustained return of spontaneous circulation (ROSC) have been shown to have improved outcomes when the body temperature is cooled to approximately 32° Celsius (90° Fahrenheit).

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Applies to: 1. All patients with cardiac arrest with sustained ROSC >5 minutes and who are:

a. Unable to follow verbal commands if intubated. b. Unable to open eyes and verbalize if not intubated.

2. The patient must be intubated or have a competent rescue airway (Combitube® or King Airway) in place prior to cooling.

Exclusions: 1. Age <18 years old. 2. Traumatic cardiac arrest. 3. “Significant” head trauma. 4. Actual or suspected significant hemorrhage (GI bleeding, AAA, for example). 5. Suspected hypothermia already present. 6. Frank pulmonary edema present.

Procedure:

1. If pulses are lost, stop cooling and treat underlying problem as per appropriate protocol. 2. Expose patient and apply ice packs to axilla and groin. 3. IV/IO: Pressure infuse 2.0 liters of chilled normal saline at maximum possible rate. The

goal is to achieve either prehospital or in ED a total of 30.0 ml/kg of cooled fluid. 4. Label saline bags with “Hypothermia Protocol” with date and time initiated. 5. Suppress shivering: Give vecuronium 0.1 mg/kg to maximum of 10.0 mg IVP/IO. If

SBP>100, give lorazepam 2.0 mg SIVP/IO. 6. Dopamine 10-20 mcg/kg/min IVPB/IO to MAP of 90-100 (see note below). 7. Monitor EtCO2 and maintain at 40 mmHg. Cooling and paralytic may decrease CO2

output. Note: Methods of Obtaining Mean Arterial Pressures (MAP) • MAP = [(2 x diastolic)+systolic] / 3 • Check the MAP on the LP 12

o WARNING: The importance of confirming the BP with manual checks should be emphasized. Studies have shown that NIBP readings are inaccurate in hypotensive patients. Since the patients that need this MAP calculation to be accurate are unstable, it will be that much more important. The MAP reading is on the screen in lower left corner BP box as well as on the printout of vitals on the code summary.

• Use this table:

Systolic Diastolic MAP

110 80 90

120 75-90 90-100

130 70-85 90-100

140 65-80 90-100

MOM 3.0 57


Post Resuscitation Care Algorithm

MOM 3.0 58


Pulseless Arrest Algorithm

MOM 3.0 59


Bradycardia Algorithm

Routine Medical Care

Monitor, IV, O2

Patient symptomatic?

YES NO

Definition of symptomatic bradycardia: HR<60 bpm with at least one of the following:

1. Chest pain. 2. Altered LOC. 3. Hypotension 4. Difficulty breathing.

OR

Atropine

0.5 mg IV q 3-5 min. to max. 3 mg.

Monitor and transport.

Transcutaneous pacing

Fluid challenge if no signs of CHF.

Dopamine 5-20 μgm/kg/min.

MOM 3.0 60


NCT (Narrow Complex Tachycardia) Algorithm


Monitor, IV, O2

Definition of unstable: 1. Chest pain 2. Altered LOC 3. Hypotension 4. Difficulty breathing

Patient stable? YES NO

Valsalva; 12-Lead ECG (Continual I, II, V2

printout during adenosine administration.)

Etomidate 0.3 mg/kg SIVP If situation allows.

Rhythm unchanged

Adenosine 6 mg RIVP

Adenosine 12 mg RIVP

Synchronized cardioversion

100j

Rhythm unchanged


200j

Rhythm unchanged


Option: If adenosine

antagonists are present (theophyllines), contact Physician for 3rd dose of

18 mg (total 36 mg).


300j

Rhythm unchanged


360j

MOM 3.0 61


Perfusing WCT (Wide Complex Tachycardia) Algorithm


Monitor, IV, O2 If Pt. becomes unstable,

move to appropriate point on “unstable” arm of

algorithm.

YES Patient Stable?

NO

WCT: Uncertain

Type Etomidate 0.3 mg/kg SIVP

If situation allows.

WCT: Monomorphic

VT

Rhythm unchanged

Ischemia: Lidocaine per protocol Otherwise: Amiodarone, 150 mg in NS

50 ml bag. 50 gtts/min. using 10 gtts/ml dripset.

Sensing Adequate? YES NO

Rhythm unchanged

Cardioversion 100j

Defibrillation 200j

Rhythm unchanged

Cardioversion 200j

Defibrillation 300j

Defibrillation 360j

Cardioversion 300j

Cardioversion 360j

Adenosine 6 mg RIVP


Adenosine 12 mg RIVP*

Definition of unstable: Chest Pain, altered LOC, hypotension, or difficulty breathing.

Magnesium 1 gm IVPB

SVT

WCT:

Suspected or known hypomagnesemia or prolonged QT (Torsades)

Polymorphic VT

*If adenosine antagonists are present (Theophyllines), contact Physician for 3rd dose of 18 mg (total 36 mg).

MOM 3.0 62


MOM 3.0 63

Automatic External Defibrillator (AED) Algorithm


Infa

nt (1

yea

r or l

ess)

1

Hea

d-til

t/chi

n-lif

t Ja

w th

rust

12

-20

brea

ths/

min

ute

Eac

h br

eath

1 s

econ

d

Bra

chia

l

1 fin

gerb

read

th b

elow

in

term

amm

ary

line

2 fin

gers

, or b

oth

thum

bs

with

han

ds a

roun

d ch

est

Abo

ut 1

/3 to

1/2

the

dept

h of

the

ches

t

100

per m

inut

e

30:2

, sin

gle

resc

uer

15:2

, tw

o re

scue

rs2

Yes

Chi

ld (1

-8 y

ears

)

Hea

d-til

t/chi

n lif

t Ja

w th

rust

12

-20

brea

ths/

min

ute

Eac

h br

eath

1 s

econ

d

Car

otid

Low

er h

alf o

f the

st

ernu

m

2 ha

nds

stac

ked

or

Hee

l of 1

Han

d A

bout

1/3

to 1

/2 th

e de

pth

of th

e ch

est

100

per m

inut

e

30:2

, sin

gle

resc

uer

15:2

, tw

o re

scue

rs2

Yes

Adu

lt

Hea

d til

t/chi

n-lif

t Ja

w th

rust

10

-12

brea

ths/

min

ute

Eac

h br

eath

1 s

econ

d

Car

otid

Low

er h

alf o

f the

st

ernu

m

2 ha

nds

stac

ked

1½ to

2 in

ches

100

per m

inut

e

30:2

, sin

gle

resc

uer

30:2

, tw

o re

scue

rs2

Yes

Bas

ic L

ife S

uppo

rt S

umm

ary

Shee

t

Proc

edur

e

Airw

ay m

aneu

ver

Res

cue

brea

thin

g ra

te

Pul

se lo

catio

n

Han

d po

sitio

n

Com

pres

sion

met

hod

Com

pres

sion

dep

th

Com

pres

sion

rate

CP

R ra

tio

Pau

se fo

r ven

tilat

ion?

3

____

____

____

____

____

____

____

____

____

____

This

sum

mar

y sh

eet m

ay b

e fre

ely

copi

ed a

nd d

istri

bute

d fo

r edu

catio

nal p

urpo

ses

but n

ot re

prin

ted

for s

ale.

2 N

eona

tal r

esus

cita

tion

shou

ld b

e pe

rform

ed a

t a ra

te o

f 120

com

pres

sion

s pe

r min

ute

and

a ra

tio o

f 3:1

. 3 If

end

otra

chea

l tub

e or

Com

bitu

be in

pla

ce, c

ontin

uous

com

pres

sion

s at

100

/min

with

ven

tilat

ions

syn

chro

nize

d.

4 A p

ause

is n

ot in

dica

ted

in th

e in

tuba

ted

or c

ombi

tube

d pa

tient

.

MOM 3.0 64


Visu

aliz

e M

outh

N/A

Yes

N/A

Yes

N/A

Yes

Blin

d Fi

nger

swee

p

No

No

No

No

No

No

Bac

kblo

ws

No

No

No

No

Yes,

5

Alte

rnat

e

No

Che

st

Com

pres

sion

s1

No

CPR

No

CPR

Yes,

5

Alte

rnat

e

CPR

Abd

omin

al

Thru

st

Rep

eate

d Th

rust

s

No

Rep

eate

d Th

rust

s

No

No

No

Fo

reig

n B

ody

Airw

ay O

bstr

uctio

n (F

BA

O) S

umm

ary

Shee

t

Con

ditio

n

Con

scio

us

Adu

lt

Unc

onsc

ious

A

dult

Con

scio

us

Chi

ld

(poo

r air

exch

ange

)

Unc

onsc

ious

C

hild

Con

scio

us

Infa

nt

(poo

r air

exch

ange

)

Unc

onsc

ious

In

fant

____

____

____

____

____

____

____

____

____

____

This

sum

mar

y sh

eet m

ay b

e fre

ely

copi

ed a

nd d

istri

bute

d fo

r edu

catio

nal p

urpo

ses

but n

ot re

prin

ted

for s

ale.

1 P

regn

ancy

obes

ity

MOM 3.0 65


Intravascular Access and Medication Administration

Intravenous (IV) Therapy Indications

• Patients in shock or impending shock requiring volume replacement. • Patients requiring IV drug therapy. • Pediatric IV placement at paramedic discretion. • Cardiac arrest.

o One attempt or one minute, then move to EZ-IO

Method • Apply venous tourniquet. • Prep site with alcohol. • Perform venous catheterization with appropriate gauge IV. • Appropriate disposal of sharps • Chart site, gauge and number of attempts.

Guidelines

• Volume replacement: Start 1-2 large-bore IVs and infuse NS to maintain systolic blood pressure above 90 (adult) or to maintain perfusion (improved mentation, color, or capillary refill) in pediatric patients. * Monitor vital signs and lung sounds frequently.

• Medications: Infuse medications through a running IV. • Saline lock: For stable patient with the potential to need IV access medication or fluid. • Cardiac arrest: large-bore IV.

*Vigorous fluid therapy in patients with internal bleeding may lead to further hemorrhage. Aim for SBP of 90 and signs of improved tissue perfusion (as above), then decrease rate. Refer to Traumatic Brain Injury Protocol for additional pressures.

Adult Intraosseous (IO) Therapy (EZ-IO)

Indications

• Adults > 40 kilograms in weight. • An alternate to peripheral IV access in any seriously ill or injured patient in which IV

access cannot be established in timely manner. • Cardiac arrest.

Contraindications

• Patients under 40 kilograms (with Adult needle). • Fracture of tibia or femur. • Previous orthopedic procedures (ie. knee replacement). • Infection at insertion site. • Inability to locate landmarks. • Excessive tissue at insertion site. • Previous attempts at IO insertion in same bone.

Considerations

• Any medication, fluid, or blood products that can be given intravenously can be given via IO.

• Due to anatomy of IO space flow rates may be slower than those achieved with IV catheters. Use of initial 10.0 ml NS bolus and continued use of a pressure bag may help.

MOM 3.0 66


• Insertion of EZ-IO in conscious patients causes mild to moderate discomfort and is usually no more painful than a large bore IV.

• IO infusion may cause severe discomfort for conscious patients. o Adults: Consider slow administration of 20mg to 50mg of 2% Lidocaine prior to

IO bolus or infusion. o Note: This is the same Lidocaine preparation as used in cardiac patients.

• The needle can remain in place for up to 24 hours. Method

1. Place patient into supine position. 2. Identify and locate bony landmarks:

a. The site of choice is the proximal tibia, just medial to the tibial tuberosity, on the flat portion of the proximal tibia (2 finger widths below the patella and 1 finger width medial).

b. Alternative site: i. Distal tibia. Locate the insertion site 2 fingerbreadths proximal to the

medial maleous. c. Alternative site:

i. Humeral head: Place patient’s hand on abdomen. The humeral head insertion site is found slightly anterior to the arms lateral midline on the greater tubercule of the humeral head.

3. Prep site with betadine or alcohol or chlorhexidine 4% (preferred). 4. Load the Adult needle onto driver. 5. Stabilize leg near (not under) the insertion site. 6. Press needle against the site at a 90 degree angle and operate the driver using firm,

gentle pressure. 7. Stop when the needle flange touches the skin or a sudden decrease in resistance is felt.

The black horizontal line on the shaft of the needle should be visible above the level of the skin surface prior to activation of the IO driver to assure adequate needle length to reach the marrow space.

8. Remove stylet and dispose in sharps container. 9. Do not aspirate bone marrow (may cause obstruction in needle). 10. Connect primed IV extension. 11. Consider use of Lidocaine for conscious patients unless contraindicated. 12. Flush or bolus EZ-IO catheter rapidly with 10.0 ml of normal saline. 13. Place a pressure bag on solution being infused when applicable. 14. Dress site, secure tubing and apply wristband. 15. Monitor EZ-IO site.

Medication Administration

Route In cardiac arrest or other critical resuscitation, IV is the preferred route when available. Give a 20 ml flush after each IV injection. Use IO when IV is not available. IO doses are equivalent to IV. Parental administration definitions

Route Method

IN Intra-nasal using mucosal administration device IM Intra-muscular using approved technique. IO Intraosseous. IVD IV drip. IVP IV push (bolus). IVPB IV piggy-back PO Per Os, Orally.

MOM 3.0 67


Rapid IV bolus Specific attention to rapid push and immediate follow up flush. RIVP Rapid IV push. SC Subcutaneous. SIVP Slow IV push, over 1-2 minutes unless specified otherwise. SL Sublingual.

Endotracheal administration of medications has been shown to be ineffective and should no longer be used. The only exception is 1:1000 Epinephrine in pediatric resuscitation, and then only if an IV/IO is unobtainable. Definitions – Restricted Situations

• Contraindication - the drug cannot be given without physician contact. Deviation without contact requires immediate Special Medical Report (FD-1). Note: all medications are understood to be contraindicated when the patient has a known sensitivity or allergy.

• Relative contraindication - the drug is not normally recommended; physician contact preferred.

Note Deviation in a restricted situation requires:

• Thorough charting of circumstances that support the decision. • Notification and explanation to the receiving physician upon hospital arrival. • FD-1 to be completed and submitted to EMS Battalion Chief and to Medical Director for

review.

General Medical

Anaphylaxis Anaphylaxis is a severe, generalized allergic reaction. By its nature, anaphylaxis is potentially life-threatening and involves more than one of the body’s systems. Anaphylaxis is triggered by the immune system which produces IgE (Immunoglobulin E- an anti body class produced in excess during allergic reaction) as a response to an allergen. IgE then attaches itself to the surface of Mast cells. Anaphylaxis occurs when a person is exposed to a trigger substance, to which they have already become sensitized. Minute amounts of allergens may cause a life-threatening anaphylactic reaction. Anaphylaxis may occur after ingestion, skin contact, injection of an allergen or, in rare cases, inhalation. Anaphylactic shock, the most severe type of anaphylaxis, occurs when an allergic response triggers a quick release from mast cells of large quantities of immunological mediators (histamines, prostaglandens, leukotrienes ) leading to systemic vasodilation (associated with a sudden drop in blood pressure) and edema of bronchial mucosa (resulting in bronchoconstriction and difficulty breathing). Anaphylactic shock requires agents to support vascular tone (epinephrine, IV fluids and in severe cases dopamine), bronchodilation (epi, albuterol) and membrane stabilizers (steroids) as well as antihistamines (diphenhydramine.) Anaphylactic shock can lead to death in a matter of minutes if left untreated. Reactions usually begin within minutes of exposure, but may be delayed. Sometimes symptoms will improve initially, only to recur or progress a few hours later – this is known as biphasic anaphylaxis. Symptoms of anaphylaxis commonly include those in the skin such as itch, hives or urticaria, swelling or angioedema and flushing. Respiratory symptoms might include wheeze, cough, shortness of breath and chest tightness, throat tightness, swelling in the throat, or change in voice. At times eyes itch and the nose will become congested. Rapid heart rate may occur and low blood pressure may cause dizziness. Nausea, vomiting and abdominal cramping indicate

MOM 3.0 68


involvement of the gastrointestinal tract. Symptoms may start mildly and rapidly progress to severe. Consider what may be causing the reaction and remove it from the patient or the patient from exposure, if possible. SC/IM Epinephrine is the medication of choice for first line treatment of anaphylaxis regardless of severity. Early and aggressive use of Epi in this setting leads to improved patient outcomes and reduces the chance for the patient to progress to anaphylactic shock. Note; EMT I can assist with the patient’s EpiPen or EpiPen Jr Autoinjector. Early Onset/Stable Reaction

1. Airway Protocol. * 2. Cardiac Monitoring Protocol. 3. Epinephrine: 1:1000 SC/IM (unless contraindicated)

• Adult: 0.3-0.5 mg SC/IM may repeat q10 as needed. • Ped: 0.01 mg/kg SC may repeat q10 as needed.

4. IV Protocol. 5. Diphenhydramine (Benadryl):

• Adult: 25 mg IV. • Ped: 1 mg/kg to a maximum 25 mg/dose.

Moderate to severe anaphylaxis- includes wheezing

1. Airway Protocol. * 2. Cardiac Monitoring Protocol. 3. Epinephrine**: 1:1000 SC/IM (unless contraindicated)

• Adult: 0.3-0.5 mg SC/IM may repeat q10 as needed. • Ped: 0.01 mg/kg SC may repeat q10 as needed.

4. IV Protocol. 5. Diphenhydramine (Benadryl):

• Adult: 25- 50 mg IV/IO. • Ped: 1 mg/kg (give IM if no IV available) to a maximum 50 mg/dose.

6. Albuterol: Nebulize per albuterol standing order if wheezing persists post epinephrine administration.

**Be prepared to move quickly to IV/IO epinephrine as per anaphylactic shock protocol if patient’s symptoms progress .

Anaphylactic shock 1. Airway Protocol. * 2. IV Protocol 3. Cardiac Monitoring Protocol. 4. Epinephrine: 1:100,000 IV/IO.

• Give as a slow push from a 10ml syringe and titrate to symptoms. No dose limits in this setting if heart rate remains stable with no ectopy.

• Ped administration same as adult. 5. Diphenhydramine (Benadryl):

• Adult: 50 mg IV/IO. • Ped: 1 mg/kg to a maximum 50 mg/dose.

6. Albuterol: Nebulize per albuterol standing order if wheezing persists post epinephrine administration.

* Be prepared to proceed directly to cricothyrotomy due to the potential for massive laryngeal edema in the setting of anaphylaxis / anaphylactic shock.

MOM 3.0 69


Asthma, Wheezing, COPD

Asthma, also referred to as reactive airway disease, and Chronic Obstructive Pulmonary Disease, are conditions of obstructed outward airflow. These patients require substantial expiratory time in their ventilatory cycle. If these patients require BVM or intubation with assisted breathing, it is crucial to give sufficient time for the expiratory phase. They also require small tidal volumes, delivered slowly. Neglecting this technique will result in a patient that is tight and “can’t be bagged.” Indications All patient being treated for known or presumed asthma (reactive airway disease), wheezing,or chronic obstructive pulmonary disease. Guidelines

1. Airway Protocol. 2. Supplemental oxygen by the method yielding the highest usable 02 delivery tolerated by

the patient. 3. Cardiac Monitoring Protocol if patient:

• Is in moderate to severe respiratory distress. • Has prior cardiac history. • Is >50 years old. • Patients >35 years old receiving epinephrine.

Mild Distress

1. Albuterol inhaler, 3 breaths; Note: EMT-I may assist with patient’s own inhaler/nebulizer. 2. Nebulized albuterol, 2.5 mg at 6-8 lpm.

Moderate Distress: Nebulized albuterol, 5 mg at 6-8 lpm, may repeat once.

Severe Distress: 1. Nebulized albuterol, 5 mg at 6-8 lpm.

• Note: Continuous administration. 2. Epi 1:1000: 0.3-0.5mg SC.

• Note: May repeat q15 min. x3. • Physician contact required for age >55.

3. Pediatric: Epi 1:1000: 0.01 mg/kg SC; max.0.3 mg/dose. • Note: May repeat q15 min. x3. • Nebulized albuterol, 5 mg at 6-8 lpm, blow by into face, PRN, in transport.

Note Epinephrine is not indicated in the patient with COPD.

Oxygen administration is indicated for all symptomatic, hypoxemic patients. Those with severe COPD and CO2 retention may be very sensitive to 02; high concentrations may cause further C02 retention. Nevertheless, if these patients are having severe respiratory distress, they should be treated with 02 and monitored carefully for changes in mental status. As they improve, the 02 should be titrated down to the lowest comfortable level. Assist ventilations if respiratory distress does not improve and level of consciousness deteriorates.

If a COPD patient is being treated for hypoxemia, carefully titrate oxygen to improve the patient¹s clinical status. If available, apply capnography and monitor C02 level. If it begins to increase,

MOM 3.0 70


consider decreasing oxygen concentration. If ventilatory drive is suppressed and the need for oxygen persists, then augment with BVM or other measures as required. All patients treated for asthma or COPD by AFD must be transported to a receiving facility.

Carbon Monoxide (CO) Poisoning Carbon Monoxide is an odorless, colorless, tasteless toxic gas resulting from incomplete combustion. Common sources of carbon monoxide include motor vehicles, structure and wild-land fires, gas powered machines operating in closed spaces, improperly functioning heaters or furnaces and industrial sites. Certain solvents can also cause CO poisoning. Carbon monoxide poisoning is often misdiagnosed as the flu, gastroenteritis, or psychiatric or other disorders and is the single leading cause of poisoning mortality in the United States. Headache is the most common symptom of CO poisoning. Other common symptoms include fatigue, dizziness, nausea and vomiting. More severe exposures can cause confusion, shortness of breath, and fainting. In severe cases, cardiac arrhythmias, hypotension, seizures, coma, and death may occur. Untreated carbon monoxide poisoning may result in short and long-term health consequences. Assessment

• Based on clinical presentation, environmental factors, clusters of patients, and/or a high index of suspicion.

• Do not rely on any machine reading over clinical suspicion. Transport to an emergency department if clinical suspicion of symptomatic CO exposure exists.

• Oximetry does not help in pure CO cases since the hemoglobin is typically fully saturated. CO-oximetry will non-invasively measure SpCO percentage ±3%.

Treatment

• Airway, Oxygen, IV, and ECG Protocols as appropriate. • All potential victims of CO poisoning should be placed on NRB 02 with tight fitting mask.

Measure SpCO. • SpCO 0-3%-no further evaluation of SpCO needed if low index of suspicion for CO

exposure. • SpCO > 3% and nonsmoker: provide O2 and any supportive measures and transfer to

emergency department for further evaluation. o If the patient is a smoker some judgement issues come into play. If the patient is

completely asymptomatic and the index of suspicion for significant exposure is low (based upon e.g. duration of exposure, status of others in the structure, etc) no further evaluation may be required up to a SpCO of 10% in a 2 pack/day smoker (rough rule : up to 5% CO /pack of cigarettes/day).

o Always transport if there is any uncertainty.

Combative Patient

Indications All violent and combative patients thought to be a risk to themselves or AFD personnel during transport. The usual etiology of this behavior would be secondary to cocaine or methamphetamine use, but may be secondary to neuro-psychiatric disorders or other ingestions. It is important to exclude hypoglycemia, hypovolemia, hypoxia, or head injury as the cause of the behavior. Guidelines

• Protect yourself first, and then protect the patient from injury.

MOM 3.0 71


• Be sure that you have the right kind (e.g. law enforcement) and number of personnel to handle the problem.

• Always leave yourself, and the patient, escape routes. • Obtain vital signs, if possible.

Medical Support

• Maintain ABC’s. • Monitor vital signs, take history, and do physical assessment if possible.

Optional treatment modalities

• IV at a TKO rate. • Obtain glucometer reading if possible. If behavior is likely due to hypoglycemia (history or

clinical) treat as per Diabetic Emergencies Protocol. • Restraints may be needed for patient and/or medical staff protection. • Consider Droperidol 1.25-5.0 mg IM or 1-2mg IV. Extrapyramidal reactions may be

treated withDiphenhydramine. • For the intubated combative patient, refer to and utilize the Rapid Sequence Intubation

Protocol. Transport

• Maintain ABC’s (this may include physical restraints in intubated and combative patients). • Monitor vital signs. • Bring samples of drugs, plants or other causative agents. • Patient management may interrupt radio communication. • PROTECT PATIENT AND PERSONNEL FROM INJURY.

Diabetic Emergencies

Adult Guidelines

1. Provide general supportive care as required by patient’s status. 2. Check blood glucose with Glucometer. 3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral

glucose and monitor for improvement. 4. If patient has a significantly altered level of consciousness and blood glucose is <60,

administer D50W: 25 gm IV. A running IV line is required. 5. If unable to establish IV, give glucagon: 1 mg (1 unit) SC/IM. 6. If patient does not improve, repeat glucometer and may repeat D50 x1. Re-evaluate and

consider other etiologies. 7. All hypoglycemic patients taking an oral hypoglycemic must be transported and all others

should be strongly encouraged to allow transport. Pediatric Guidelines

1. Provide general supportive care as required by patient status. Septic neonates and young infants may become hypoglycemic with serious infections.

2. Check blood glucose with Glucometer. 3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral

glucose and monitor for improvement. 4. If patient has a significantly altered level of consciousness and glucose is <60:

a. Wt < 25kg: administer D25 IV or IO per Pediatric Weight Pages. b. Wt ≥ 25kg give as D50W per Pediatric Weight Pages.

5. If unable to establish IV, give glucagon 1 mg (1 unit) SC/IM if >20 kg; if less than 20 kg then use .05 mg/kg.*

6. If patient does not improve, repeat Glucometer and may repeat D50W x1.

MOM 3.0 72


*In neonates and infants, hypoglycemia may result from depletion of available liver glycogen due to physiological stress. Since glucagon uses glycogen as the energy source, it is less likely to be effective in this setting.

Blood Glucose Determination Indications

• Before and after D50 administration, when possible, to evaluate response to therapy. • Suspected abnormal blood sugar values: diabetes, possible hypoglycemia. • Unconsciousness of unknown etiology. • Status seizures. • Symptoms/signs suggestive of CVA.

Method Glucometer.

Epistaxis Epistaxis is a common problem and may arise spontaneously or from trauma. Although the lay public strongly correlates elevated blood pressure with epistaxis, scientific evidence is lacking. There are two basic types of epistaxis: those that arise from the anterior nasal cavity and those that arise from the posterior. Anterior bleeding is usually controlled with direct pressure or pharmacological agents. Posterior bleeding is generally incompressible in the prehospital setting and is often the result of significant arterial bleeding. Bleeding which does not respond to therapy for anterior epistaxis should be assumed to be of posterior origin. Significant nasal arterial bleeding in the elderly should be considered to likely be of posterior origin unless an anterior bleed is visualized. Procedure - Known or Presumed Posterior Bleeding

1. IV access. 2. Trial of compression of nares. 3. Trial of rolled 2x2 gauze firmly placed beneath upper lip(should resemble the size and

shape of cigarette filter) in the midline between lip and gum, with pressure then applied in a direction toward the nasal spine(either with pressure applied from the skin surface of the upper lip or directly on the gauze).

4. 3 squirts of neosynephrine to each nare. 5. Positioning to allow blood to be expectorated by patient or suctioned by EMS. 6. Airway control if necessary.

Procedure - Anterior Bleeding

1. If no current active bleeding, transport without further intervention. 2. Compression of nasal alae. This should include the entire cartilaginous area distal to

nasal bone. 3. If bleeding persists: see 3 above. 4. If bleeding persists: have patient gently blow nose to try to evacuate all clot and use 3

squirts of neosynephrine to affected side.

Hyperkalemia

Severe elevations of potassium cause progressive derangement of cardiac conduction. This eventually leads to VTach or VFib, often preceded by a sinusoidal ECG pattern. The prehospital provider will rarely have sufficient information to make this diagnosis since it generally requires lab confirmation. It should be strongly suspected in a dialysis-dependent renal

MOM 3.0 73


failure patient who demonstrates a sinusoidal cardiac rhythm, suffers cardiac arrest after missing a dialysis session, or is otherwise known to be hyperkalemic. Tall, peaked T waves in multiple leads are also suggestive, and often diagnostic in a patient who is known to be at risk for hyperkalemia. Indications Unstable patient who is at risk for hyperkalemia. Guidelines

1. Airway Protocol. 2. IV Protocol. 3. Cardiac Monitoring Protocol. 4. Administer calcium chloride, 1 gm (10 ml) SIVP. 5. Administer sodium bicarbonate, 50 mEq IVP.

Note Do not co-administer these agents because precipitation will occur.

Hypertension Severe hypertension requiring pre-hospital treatment is quite rare. Treatment is necessary only if the hypertension clearly is causing a clinical condition to evolve or if there is documented end-organ damage due to the hypertension (difficult to establish pre-hospital). The main examples of this are intracranial hemorrhage, myocardial ischemia, or renal failure associated with severe elevations of blood pressure (systolic >240,diastolic >140). This is a largely unstudied area. The danger in pre-hospital treatment is that an agent may cause a precipitous change in blood pressure that creates a new, and potentially worse, problem. Guidelines

1. Treat the underlying condition if it may be causing the elevated BP. 2. Pain: Pain Protocol. 3. Anxiety: Verbal calming techniques and reassurance. 4. Pulmonary edema: CHF and APE Protocol. 5. NTG: not generally recommended; physician contact required. 6. Captopril: at physician request only. 7. Furosemide: at physician request only.

Hypotension Patients who present with symptomatic hypotension should be categorized as to their probable intravascular volume status as well as the presumed mechanism for the hypotension (if known or presumed). Therapy should then be directed accordingly. Indications Symptomatic hypotension unrelated to trauma. Guidelines

• Consider volume status: Is patient “dry” (hypovolemic), normally hydrated(euvolemic), or “wet” (hypervolemic).

a. If the patient is hypovolemic: use repeat boluses of normal saline titrated against clinical exam.Potential situations: gastrointestinal illness, dehydration of other causes.

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b. Is the patient euvolemic? May need volume and dopamine.Potential causes: septic shock, neurogenic shock, anaphylactic shock.

c. Is the patient hypervolemic? Use dopamine. This situation is generally cardiogenic shock.

Pain Management

Many of our patients experience acutely painful conditions. We can help many of them with medications or other techniques. In general, we must balance our wish to ease their pain with the possibility of complicating their care.

Pediatric patients experience pain that is as real as in older persons and should be offered pain control when appropriate. General Guidelines

• A calm and supportive provider will help the injured person deal with the anxiety associated with an injury. Conversation used to distract from the situation is helpful.

• Fractures and sprains are generally more comfortable if splinted and iced. This is especially true for femur fractures that can be traction splinted.

Documentation • Document by means of the FACES© Pain Rating Scale the patient’s pain level at the

onset of EMS care. o The Pain Rating Scale is found within the Appendix of Section 2: Treatment

Protocols. • Document any change in that level after EMS intervention or at termination of EMS care.

Medical Therapy Patients with no contraindications who are experiencing moderate to severe pain should be offered pain relief.

Absolute contraindications • Allergy to proposed pain agent. • Hypotension. • Acute multi-system trauma with unstable vital signs. • Penetrating eye injury (tetracaine). • Significant impairment due to alcohol or other intoxicants.

Relative contraindications • Pregnancy (N02). • Pneumothorax (N02). • Bowel obstruction (N02).

Therapies

• Morphine sulfate, per standing orders. Note: See diphenhydramine regarding hypotension.

• Fentanyl, preferred for situations where short action desired e.g. abdominal pain, head injury, multiple trauma or if patient has morphine allergy.

• Nitrous oxide (NO2), per standing orders. • Tetracaine, per standing orders.

Note

• All patients given analgesics by AFD shall be transported to a receiving facility. • The patient must be aware of and agree to this before receiving therapy.

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Seizures, Status Epilepticus and Postictal States

Seizures are generally of short duration and, if self-limited, require no drug therapy in the field. Seizures that are not self-limited, or that last longer than a few minutes, do require drug therapy. Always consider possible etiologies, including hypoglycemia, hypoxemia, toxic ingestion, trauma, CNS infections, and subarachnoid hemorrhage.

Observe the type of seizure that is occurring. If it is a motor seizure, observe whether it is general or focal. If focal, communicate this to the receiving physician and record it on the PCR. Adult Guideline

• Control all further seizure activity with lorazepam 1-2 mg repeated in 5 minutes if necessary.

• Apply supplemental oxygen by NRB. • Oxygen may be discontinued if patient returns to normal mentation and has no more

indication for oxygen. • If further doses are required, physician contact required.

Pediatric Guideline

• Attention to ABCs and general supportive care. • Lorazepam 0.1 mg/kg SIVP. May give lorazepam IM 0.1 mg/kg. • Begin cooling if febrile.

Note Transport at the level appropriate to patient’s status.

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Seizure Algorithm


Stroke (CVA) A stroke is a focal neurological change that occurs as a result of lack of blood flow to the brain. This is typically the result of a clot in a blood vessel in or near the brain or from a bleeding blood vessel. EMS treatment is supportive emphasizing protection against secondary insults such as hypoxemia. Although blood pressure may be elevated in these patients, there is rarely (if ever) an indication for rapid blood pressure lowering in the field. Recent advances have lead to an opportunity to use clot-busting drugs in a select group of patients who are suffering an acute stroke. Interventions must be initiated within 3 hours of onset of symptoms so EMS time can be very critical. Guidelines

1. Airway Protocol. Attention to need for suctioning. 2. Apply O2. 3. Cardiac monitor. 4. IV saline lock. 5. If evidence of increased intracranial pressure, elevate head 15 degrees. 6. Perform 30 Second Stroke Exam. A positive on any of the three measures suggests

stroke: • Test upper extremity strength: have the patient close his/her eyes and extend both

arms. Ask him/her to maintain this for 10 seconds. Downward drift with one (but not both) indicates unilateral weakness.

• Test facial strength: have the patient smile. If this is equivocal, have the patient blow up both cheeks with air and then gently tap on either cheek to see if air is released. A facial droop with smiling or inability to keep air in only one side of the face indicates facial weakness.

• Test speech: have the patient repeat a saying such as “the sun shines on the fearless in Fairbanks”. Inability to repeat this due to lack of articulation or due to not being able to form the words is a positive finding.

7. If a Stroke Exam is positive and onset is within 3 hours, notify ED ASAP that patient may be a candidate for stroke intervention (Stroke Alert). See “Stroke Alert” in Operations Section for further criterea.

8. Continually reassess for, and document, any neurological changes during transport.

Tricyclic Antidepressant Overdose Tricyclic antidepressants (TCAs) are widely prescribed for a variety of conditions and are responsible for more intentional drug overdose deaths than any other group of prescribed medications. These agents act upon a number of physiologic systems and therefore have effects that are the net result of those actions. Pupillary findings, for example, may range from dilated to constricted depending upon whether the anticholinergic effects (dilation), or the adrenergic blockade (constriction) predominate. Dose Range Therapeutic ranges for most TCAs are 2-4 mg/kg. Life-threatening symptoms usually occur with ingestions greater than 10 mg/kg. Fatalities often occur within 2hours and rarely >24 hours post-ingestion. Serious toxicity is almost always seen within 6hours. Clinical Presentation

• CNS: Mild to moderate TCA toxicity may present as drowsiness, confusion, slurred speech, and ataxia with increasing TCA toxicity, CNS depression progresses to coma and respiratory depression. Seizures may occur and are usually brief and single (the tetracyclics, amoxapine and maprotiline may cause status epilepticus).

• Cardiovascular: cardiac conduction delays, supraventricular tachycardia, premature ventricular beats, ventricular tachycardia, hypotension, and respiratory depression.

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• Electrocardiographic abnormalities are common, especially prolongation of the PR, QRS, and QT intervals. Other ECG abnormalities include conduction blocks. The natural progression of ECG and cardiac abnormalities occurs in the following order: sinus tachycardia, widening of the QRS complex, decreased cardiac inotropy, increased PR interval, and finally, decreased heart rate.

Pre-Hospital Focus Points

• Consider TCA OD in all unconscious unknowns. • If the patient has decreased LOC, ECG findings of prolongation of QRS, or QT intervals,

and OD are conceivable, initiate therapy for TCA OD as listed below. • Death in TCA OD will be due to a lethal cardiac arrhythmia, poor peripheral perfusion due

to decreased cardiac output or respiratory embarrassment due to aspiration or decreased ventilatory effort.

• Progression of neurological deterioration can occur remarkably quickly: anticipate that the patient may require intubation.

Treatment

• Decreased LOC, poor gag reflex: intubate. • QRS abnormalities: QRS>.10 sec, QT>.35 sec at 100 bpm; or QT>.44 sec at 60 bpm: 50

mEq NaHCO3, hyperventilate. • Ventricular arrhythmias: bursts of VT or frequent PVCs: 50 mEq NaHCO3,

hyperventilate. • Hypotension: 50 mEq NaHCO3, hyperventilate, fluid bolus with careful attention to fluid

overload. Note

Overaggressive use of NaHCO3 may result in severe base excess, which is very difficult to correct. LIMIT TO: 50 mEq.

Tricyclic Antidepressants Generic Names Trade Names Comments

Amitriptyline Elavil, Endep, Etrafon, Limbritol, Triavil Amoxapine Asendin Clomipramine Anafranil Desipramine Norpramin Doxepin Adapin, Sinequan, Zonalon Imipramine Tofranil Maprotiline Ludiomil Nortriptyline Pamelor Protriptyline Vivactil Trimipramine Surmontil Cyclobenzaprine Flexeril Treat as TCA OD Carbamazepine Tegretol Treat as TCA OD.

Unconscious Patient Unknown Etiology

Guidelines

• Assess ABC’s. • Assess for signs of trauma. • Look for medic alert bracelet, pill bottles or other evidence for underlying medical

condition. • Look for signs of drug abuse. • Look for treatable causes.

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• Consider metabolic etiology: o Check glucose and treat if significantly low: see Diabetic Emergencies Protocol. o If evidence of opiate narcotic overdose (including propoxyphene): treat with

naloxone. o Observe for smells of alcohol, ketones, or other unusual odors.

Vital Signs

• Hypotension: see Hypotension Protocol. • Bradycardia: see Bradycardia Algorithm. • Tachycardia: see tachycardia algorithms in ACLS Algorithms.

Physical Exam Focus on potential causes including infection (fever, lung exam, skin etc), toxins (drugs, carbon monoxide, others). Neuro Exam Seizure, other? If evidence of focal findings on exam (and blood sugar within normal range): treat as TBI.

Trauma and Environmental Injuries

General Trauma Guidelines Victims of severe trauma benefit most from very rapid transport to a facility capable of caring for their injuries. Pre-hospital interventions that extend scene time, with the possible exception of those related to airway and spine management, are detrimental to patient well-being. Minimal scene times are more difficult to achieve in blunt trauma, which may require extrication and immobilization, and this is understood when applying the following standards. It is vital to give early notification to the receiving hospital so that they can assemble their trauma team. Applies To All victims of serious trauma resulting in an unstable or potentially unstable patient. Standards

• Airway at the scene if emergently required. • Control severe external hemorrhaging. • IV/IOs en route. • Scene time <8 minutes. • Early notification of the receiving hospital.

Guidelines

1. High-flow 02. 2. C-Spine and Spinal injury Protocol. 3. External Hemorrhage Protocol. 4. Cardiac monitor. 5. Two Large-bore IVs if possible (14 or 16 G) or IOs. 6. For shock, IV NS at rapid flow rates with initial goal reversal of symptoms of shock.

• Bleeding into body cavities may worsen with overly aggressive IV fluid therapy. In cases of suspected internal bleeding, limit fluids to the amount required to bring SBP to 90 and/or alleviate the shock state as demonstrated by mental status, skin signs, and vital signs.

7. Keep patient warm.

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Amputations Guidelines

1. Amputated part shall be wrapped in sterile dressing, slightly moistened with NS (dressing should be damp, not wet).

2. Place the part in a plastic bag and seal. 3. Place bag in a cool solution. 4. Never immerse the part or put it directly on ice. 5. Transport amputated part with patient to hospital. 6. Stump care:

• Apply bulky dressing. • Control extremity hemorrhage by direct pressure and elevation of the limb. • If these meausres are inadequate, consider HemCon® bandages. • Follow the Tourniquet Protocol if ongoing bleeding is uncontrolled by other

measures. 7. If tourniquet was applied in the field prior to EMS arrival, it is usually best to leave it in

place. Note in writing as accurately as possible the time of application.

Burn Management Thermal trauma presents significant diagnostic challenges. The possibility of multi-system injury is very high in patients rescued from burning structures, explosions, electrical burns or dermal chemical exposures. Initially subtle airway compromise may become acutely life threatening. An explosion or electrical injury may have thrown the victim some distance resulting in internal injuries, initially masked by painful burns. The EMS provider should try to get a rapid size-up of all potentially injuring mechanisms involved in the injury. Guidelines

1. Extinguish the fire. 2. Remember: Molten plastics/tar should be rapidly cooled to stop further burning. NEVER

try to pull such substances off of the skin. This can result in the loss of vital skin structures and convert the burn to one requiring a graft!

3. Airway Protocol. 4. Remove clothing and jewelry as needed. 5. Cover with burn sheet or dry dressings. 6. Estimate percentage of total body surface involvement. 7. Estimate thickness of burn. 8. For second and third degree burns over 20% total body surface area, start IV with NS

using large-bore catheter. • Refer to burn charts for estimation of BSA. • Use variation of Parkland formula: Fluids in 24h=TBSA burn x 4 ml x wt (kg)

with 1st half in first 8 hours. 9. Treat for shock. 10. Pain Management Protocol.

PREHOSPITAL REMEMBER: TBSA burned x 2 x Wt (kg) = mls NS in first 8hrs.

C-Spine Guidelines (Axial Spine Immobilization)

The proper and timely application of axial immobilization to a patient with an unstable injury of the spine is unquestionably one of the most important pre-hospital skills. It clearly reduces or eliminates the potentially devastating effects of a spinal injury if it is applied prior to compression or laceration of nervous structures by either active or passive movement.

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These guidelines are provided to set a uniform standard for all AFD personnel. They may be independently applied by ETT through MICP. Situations in which cervical and full spinal immobilization are indicated: Categories

• Patient complaint /clinical signs and symptoms. ° All patients c/o pain or tenderness on palpation of the neck or midline back, following

physical injury of sufficient magnitude that damage to ligaments or bone of the spinal column could have occurred.

° All patients with a cervical, thoracic or lumbar deformity or any form of neurological deficit following physical injury.

° All patients with altered or decreased level of consciousness and a major mechanism of injury, regardless of presence or absence of pain.

° Unconscious patients with significant penetrating trauma to the head, neck or trunk in which trajectory could include spinal column (T or L-spine).

° Any neurological deficit after penetrating trauma to the head, neck or trunk (T or L-spine)

° Any unconscious patient following significant trauma.

• Suspicious mechanism of injury: spinal immobilization indicated. ° Ejection from a vehicle. ° Fall >15 feet. ° Pedestrian struck by a moving vehicle with evidence of significant impact with vehicle

or upon impact with ground. ° Any seriously injured multiple trauma patient.

Notes

• Use these as guidelines. If there is any doubt, immobilize the patient. • In certain circumstances spinal immobilization may be omitted even though a potential

mechanism for spinal injury exists. The following algorithm, Clinical Criteria for Assessment of Spine Injury, explains the decision-making process for omitting spinal precautions in this setting.

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Clinical Criteria for Assessment of Spine Injury

Mechanism

YESSpine Pain/ Tenderness

Motor / Sensory Exam

Reliable Patient /Exam YES

NORMAL

Possible Spine Injury ABNORMAL

NO

Negative Spine Injury

Negative Positive / Uncertain

NO

• Calm • Cooperative • Sober • Alert

• Acute Stress Reaction (ASR)

• Brain Injury • Intoxication • Abnormal Mental

Status • Distracting Injuries • Communications • Age<12 • Advanced age?

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Spinal Immobilization Method

Notes

• The cervical collar should contact the shoulders and securely support the chin. • Head movement should be restricted by: the cervical collar, blanket-roll, and 2” tape. • The occipital padding should position the head in a neutral or very slightly flexed position. • The popliteal padding should provide some flexion to the knees. • The Spyder™ strap should be snug enough to prevent lateral displacement of the patient

if the board is tilted. • The chest strap should be high on the thorax so diaphragmatic movement is unrestricted. • Strap from the shoulders and chest working toward the feet. Secure the head last. • Use additional padding between legs or between legs and straps or flanks and straps as

needed to prevent lateral movement when board is tipped.

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External Hemorrhage

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Eye Injuries Chemical Exposures Copiously irrigate the eye(s)right away. Use available fluid. Examples: a kitchen sink with the depth to allow the patient to put the eye under running water; an eye wash station at an industrial site; irrigation with IV fluid through an 18g catheter held at the nasal or temporal canthus, or through a nasal cannula placed on the bridge of the nose. Tetracaine may be used to facilitate this process. Note Bring the MSDS, chemical agent, or name of the agent to receiving facility with the patient.

UV Exposure Manage pain with tetracaine and transport.

Blunt Trauma • Obtain basic visual acuity if possible (light/dark vision or ability to read newsprint or count

fingers). Do this in children as well as adults. • Protect eye from pressure or further injury, and transport. May apply eye shield if

available but DO NOT patch. • Elevate head and have patient avoid valsalva.

Penetrating

• As with blunt trauma. • Leave any penetrating object in place.

Hypothermia Assessment

• Severe hypothermia is present in a cold patient with any of the following signs: depressed vital signs, altered level of consciousness, core temperature of 90°F. (32°C) or lower, absence of shivering (less reliable in the presence of ETOH), or who has significant illness or injury.

o Mild to moderate hypothermia is assumed in the cold patient without any of these signs.

Basic Treatment

• Focus on preventing further heat loss. • Add heat to the core surface areas (head, neck, chest, and groin), or re-warm internally

with warm, moist air. • Caution: warm packs must be wrapped and monitored, especially in the perfusion-

impaired patient. • Treat and transport in very warm air (80°F. or warmer) if possible.

Specific Therapy • Indications for O2 are as usual for mild or moderate hypothermia.

o If severe, administer at 2-4 lpm via nasal cannula. • Indications for oral airways and ETT tubes are the same as in warm patients. • In severe patients attempt IV line of NS after other stabilization and give a 10 ml/kg bolus

followed by 5 ml/kg/hr infusion. (Example: 70 kg pt and 10 gtt/ml dripset =1 gtt/sec). • In mild to moderate hypothermia, indications for IVs and medications are as usual. • In severe hypothermia, pacing is not indicated, nor are medications unless specifically

ordered.

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• Intubation may be more difficult than usual and should be performed gently to reduce the risk of VF.

CPR Setting

• Do not resuscitate if: o Core temp is <60°F. o Patient has ice in airway. o Generalized or total-body frozen skin/tissue is present (such that it is obviously

more than localized frostbite). • Provide basic treatment and specific therapy as above. • Carefully assess absence of pulse and respirations for up to 45 seconds before

beginning CPR. • For patients with a core temperature >86°F, follow standing orders. • For patients with a core temperature <86° F, VF, one defibrillation only should be

performed as indicated. o If unsuccessful, transport with CPR.

• Asystole or other pulseless rhythms: transport with CPR.

Inflatable Lower-Body Splint (MAST/PASG) Indications

• To splint pelvic and/or multiple leg fractures. • Can be considered as an option to treat traumatic shock, particularly in the setting "1"

above or with suspected intra-abdominal bleeding but do not delay transport time to apply.

• Suspected ruptured abdominal aortic aneurysm.

Contraindications Pulmonary edema. Relative Contraindications

• Chest injury. • Evisceration. • Impaled object. • Pregnancy.

Near Drowning Treatment No Heimlich unless evidence of foreign body airway obstruction. The “up to” 45 second pulse check before CPR also applies here. Other therapy follows the hypothermia guidelines.

Pelvic Fracture

Stabilize an unstable pelvis by the application of moderate circumferential pressure around the pelvic girdle. This may be accomplished by the application of the abdominal section only of the MAST®, using the trunk portion of an inverted KED®, binding the pelvic girdle with a folded sheet, or using the long elastic straps packaged with the Sager® traction splint.

Tourniquet Indications:

• Amputation of an extremity with uncontrolled bleeding. • Failure to stop extremity bleeding with pressure dressing.

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• Failure to stop extremity bleeding with hemostatic agent. • Significant extremity hemorrhage in the face of any or all of the following requiring scene

resources being re-directed: o Need for airway management. o Need for breathing support. o Circulatory shock. o Need for other emergent interventions or assessment. o Bleeding from multiple sources. o Inability to specifically localize the source of severe hemorrhage.

• Impaled foreign body with ongoing extremity bleeding. • Danger presented to responding crew(s). • Total darkness or other adverse environmental factors. • Mass casualty events.

Contraindications:

• None if indication is present. Method:

• Application site will be the most prominent muscle mass on the extremity proximal to the injury. (EXAMPLE: forearm for injury at or about the wrist, biceps area for any other injury of the upper extremity, calf for ankle or lower, and thigh for all other lower extremity injury).

• Expose skin or ensure that article of clothing is absolutely flat to avoid pressure points. • Tighten the tourniquet ONLY to the point that bleeding stops. • Mark patient’s forehead with tourniquet time in military time (24hour clock). Marking will

be in large letters “TT ___” • The tourniquet should NEVER be placed out of site such as beneath a blanket. • The transferring medic will give verbal report to receiving physician that a tourniquet is in

place and will receive verbal confirmation of this information. • Tourniquet removal may be considered by provider. Follow “Tourniquet Reassessment

Algorithm” and “Tourniquet Removal Algorithm.”

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Traumatic Brain Injury (TBI) TBI is a significant cause of morbidity and mortality in trauma. Scientific evidence exists showing how pre-hospital care can improve outcome in TBI. Pre-hospital therapy should focus on limiting secondary brain injury that can result from hypoxemia, hypoventilation, and hypo-perfusion. EMS must also try to limit physical factors that can increase intracranial pressure.

Guidelines 1. Assess ABC’s. Stabilize spine. 2. Oxygenate with 100% 02, or highest concentration available. Monitor 02 saturation. 3. Secure airway. If intubation is required, it should be done with minimal gag stimulation.

Consider RSI if gag is present and patient requires airway. 4. Capnography if available. Maintain pC02 35-40 unless patient shows signs of herniation

(see below) 5. Establish IV with NS. Treat hypotension with fluid infusion. If normotensive, TKO.

AGE SBP 12-Adult <90 5-12 <80 1-5 <75 0-1 <65

Treatment • Elevate head of stretcher or backboard 15 degrees if possible while maintaining spinal

precautions. • Evaluate and record mental status; the patient’s level of consciousness is the best

indicator of brain function. Use the Glasgow Coma Scale to assess patient’s status on EMS arrival and document. Frequently reevaluate vital signs and GCS (q5 min.).

• Hyperventilation is indicated in an unconscious trauma patient who is deteriorating neurologically with:

o Decerebrate or decorticate posturing. o Significantly different pupil size (>2 mm difference) in a comatose, head injury

patient. o Cushing’s reflex (bradycardia and hypertension associated with acute head

injury). o Lateralizing signs (one-sided neurological changes elsewhere on the body, i.e.,

other than just pupil differences). o Decrease in GCS by 2 or more points.

Definition of Hyperventilation • Capnography reading of 32-35.

o Adult: 20 breaths per minute. o Child: 25 breaths per minute. o Infant: 30 breaths per minute.

Combative patients with TBI may suffer an increase in ICP if forcibly restrained. Such patients may require chemical sedation if verbal calming methods are not effective. EMS providers must have some certainty that the combativeness is not due to correctable causes such as hypoglycemia or hypoxemia before initiating sedation. Lorazepam is the preferred agent (doses titrated to 4 mg SIVP).

Airway Management in TBI Patients

• Patients with TBI who are unable to be oxygenated or ventilated by other measures will have an airway established by EMS in compliance with protocols previously established in the MOM.

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• Patients whose airway can be adequately managed with basic measures will preferentially be managed in this fashion even if it is apparent that intubation will ultimately be required. Intubation in this case will be deferred to the emergency department.

• End-tidal C02 will be monitored whenever possible with a goal of 35-40 mmHg. Low EtC02 is associated with a worse outcome.

• Regardless of the airway method chosen, goals are: o Short scene time o No episodes of hypoxemia o Avoiding hypotension o Early notification of the receiving hospital

Destination Issues The receiving facility must have a functioning CT scanner available as well as neurosurgeon on staff; (as of this writing EAFB is the only receiving facility without a neurosurgeon). Note

• Evaluation of a patient with mental status changes is often complicated. • The EMS provider must consider TBI in cases without apparent mechanism and must

also consider toxic/metabolic causes in cases in which there is a trauma mechanism that does not seem sufficient to explain the patient’s exam.

• Blood glucose determination should be used liberally when the cause of the change in mental status is not obvious.

TurkelTM Safety Thoracentesis Catheter Pleural decompression will be performed on patients with life threatening, progressive respiratory distress due to suspected tension pneumothorax by inserting a TurkelTM Thoracentesis Catheter into the second intercostal space on the mid-clavicular line on the affected side.

Method See the training document TurkelTM Safety Thoracentesis Catheter.

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Appendix

Triage (START Algorithm)

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Glasgow Coma Scale

Components Value Score Best eye opening Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal Oriented 5 Confused 4 Inappropriate 3 Moans / unintelligible 2 None 1 Best motor Obeys commands 6 Purposeful movement (pain) 5 Withdraw (pain) 4 Decorticate 3 Decerebrate 2 None 1

FACES© Pain Rating Scale

From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

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Adult Burn Chart

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Precordial Lead Placement

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12 Lead Waveforms

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Capnography Waveform Elements

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Capnography Waveform Analysis

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VentiSure™ ET CO2 Reference

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Section 3: Pediatric Treatment Protocols and Weight Pages

Transporting the Pediatric Patient Spinal Immobilization The pediatric patient that requires spinal immobilization must be packaged with as much care as adult patients. Due to their decreased size, and the limitations of equipment designed and tested for adults, additional care must be made to properly ensure correct fit and stabilization of the pediatric patient. Long Backboard / KED – Used in accordance to the standard of care for spinal immobilization. Additional padding will be need to be used to ensure patient’s stabilization. Child Passenger Restraint Seats (CPRS) – “Car Seats” can be used with pediatric patients who have a potential for neck or back trauma. The patient’s head and torso is to be padded. The use of a properly sized and placed c-collar is recommended in addition to padding stabilization. The CPRS is then secured to the gurney using both the knee and waist straps. This is done by placing the CPRS in a rear facing position, elevating the back of the gurney to full upright position, then running the gurney straps through both belt positions on the CPRS. Exceptions: Belt-positioning boosters and infant only (rear facing) seats cannot be utilized. Non-Spinal Immobilized (Medical or Isolated Trauma) Acceptable Adjuncts

Patient-fitted Child Passenger Restraint Seat (CPRS) – “Car Seat;” fitted as above

AFD Ferno Pedi-Mate: Patients from 10-40 lbs AFD Safeguard Transport Seat: Patients from 22-100 lbs

Ferno Pedi-Mate

a. The Ferno Pedi-Mate must be attached securely to the stretcher utilizing the

upper black strap behind the stretcher and the lower black straps around the frame of the stretcher.

b. The head portion of the stretcher may be adjusted to any angle for the comfort of the patient.

c. The fully adjusting 5-point harness must be used when transporting patients and must rest snugly against the patient. The retainer clip must be used on the patient at armpit level.

d. Weight limits will be strictly adhered to using the Ferno Pedi-Mate, which are 10 – 40 lbs.

e. If in doubt of proper fitting and installation when using the Ferno Pedi-Mate, consult an AFD-certified Child Passenger Safety Technician.

Safeguard Transport Seat

a. The Safeguard Transport seat must be attached securely to the stretcher utilizing the upper brown strap behind the stretcher and the lower black straps around the frame of the stretcher.

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b. The head portion of the stretcher may be adjusted to any angle for the comfort of the patient.

c. The fully adjusting 5-point harness must be used when transporting patients and must rest snugly against the patient. The retainer clip must be used on the patient at armpit level.

d. Weight limits will be strictly adhered to using the SafeGuard, which are 22 – 100 lbs. e. If in doubt of proper fitting and installation when using SafeGuard, consult an AFD-

certified Child Passenger Safety Technician. f. Additional installation instruction can be found at SafeGuard EMS Seating g. The SafeGuard Transport seat is not to be used with patients who have potential

spinal compromise.

Pediatric Intraosseous (IO) Therapy (EZ-IO)

Indications

• Pediatric patients in the 3 - 39 kilogram weight range. • An alternate to peripheral IV access in any seriously ill or injured patient in which IV

access cannot be established in timely manner. • Cardiac arrest.

Contraindications

• Patients under 3 kilograms or over 39 kilograms (with Pediatric needle). • Fracture of tibia or femur. • Previous orthopedic procedures (ie. knee replacement). • Infection at insertion site. • Inability to locate landmarks. • Excessive tissue at insertion site. • Previous attempts at IO insertion in same bone.

Considerations

• Any medication, fluid, or blood products that can be given intravenously can be given via IO.

• Due to anatomy of IO space flow rates may be slower than those achieved with IV catheters. Use of initial 5.0 ml NS bolus and continued use of a pressure bag may help.

• Insertion of EZ-IO in conscious patients causes mild to moderate discomfort and is usually no more painful than a large bore IV.

• IO infusion may cause severe discomfort for conscious patients. o Pediatric: 0.5 mg/kg of 2% Lidocaine prior to IO bolus or infusion o Note: This is the same Lidocaine preparation as used in cardiac patients.

• The needle can remain in place for up to 24 hours. Method

1. Place patient into supine position. 2. Identify and locate bony landmarks: 3. The site of choice is the proximal tibia, just medial to the tibial tuberosity, on the flat

portion of the proximal tibia (2 finger widths below the patella and 1 finger width medial). 4. Alternative site:

• Distal tibia. Locate the insertion site 1 fingerbreath proximal in the midline of the tibial shaft.

5. Alternative site:

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http://www.safeguardseat.com/ems


• Humeral head: Place patient’s hand on abdomen. The humeral head insertion site is found slightly anterior to the arms lateral midline on the greater tubercule of the humeral head.

6. Prep site with betadine or alcohol or chlorhexidine 4% (preferred). 7. Load the Pediatric needle onto driver. 8. Stabilize leg near (not under) the insertion site. 9. Press needle against the site at a 90 degree angle and operate the driver using firm,

gentle pressure. 10. Stop when the needle flange touches the skin or a sudden decrease in resistance is felt.

The black horizontal line on the shaft of the needle should be visible above the level of the skin surface prior to activation of the IO driver to assure adequate needle length to reach the marrow space.

11. Remove stylet and dispose in sharps container. 12. Do not aspirate bone marrow (may cause obstruction in needle). 13. Connect primed IV extension. 14. Consider use of Lidocaine for conscious patients unless contraindicated. 15. Flush or bolus EZ-IO catheter rapidly with 5.0 ml of NS. 16. Place a pressure bag on solution being infused when applicable. 17. Dress site, secure tubing and apply wristband. 18. Monitor EZ-IO site.

Neonate/Small Infant Intraosseous (IO) Therapy (Jamshidi Needles)

Indications

• An alternative to venipuncture in infants <3 kilograms when peripheral IV access cannot be quickly achieved within 2 attempts or 90 seconds.

• Drug and fluid resuscitation in the infant who is unconscious and unresponsive, and in need of immediate life saving intervention.

• Cardiac arrest. Contraindications

• Insertion of an IO into a fractured bone. • Insertion of an IO distal to a fractured bone (i.e., tibial placement with a femur fracture). • Previous attempts at IO insertion in the same bone.

Relative Contraindications Infection or burns at the intended site (physician contact required) Precautions

• The infusion rate may not be adequate for resuscitation of ongoing hemorrhage or severe shock. It is a good alternative route when venous access is difficult.

• Extravasation of fluid is the most common problem secondary to improper initial placement or dislodgement of needle.

• Other complications reported in the literature are rare, including fat embolism and osteomyelitis.

Method

1. Infant is placed in the supine position. 2. Identify and locate the bony landmarks:

• The site of choice is in the proximal tibia 1-2 finger breadths below the tibial tuberosity on the anteromedial surface.

• Alternate sites are: o The distal femur 2 finger breadths above the external condyles in the midline;

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o The distal tibia 1-2 finger breadths above the medial malleolus at the ankle. 3. Prep the site with betadine. 4. Direct and insert the needle with the stylet in place perpendicular to the bone or angled

away from the joint, avoiding the epiphyseal plate. 5. Insert with pressure and a boring or screwing motion until penetration into the marrow,

which is marked by a sudden lack of resistance. 6. Remove the stylet.

a) Appropriate disposal of sharps. 7. Attach a 5 ml syringe filled with saline. The IO is appropriately placed if the following are

present: • Aspiration with syringe yields blood with marrow particulate matter. • Attempt at infusion of saline in syringe is not met with resistance or infiltration at the

site. • Needle stands without support.

8. Attach stopcock to IO; attach IV tubing or use syringes directly to the stopcock for medication flushes/fluid replacement. • IV flow rates to gravity may be unacceptably slow. • Use 60 ml syringes for fluid boluses. • Medications administered by IO must be followed by a flush of at least 5 ml to ensure

that the drug is infused into the marrow. 9. Stabilize needle on both sides with sterile gauze and secure with tape.

• Avoid tension on the needle. 10. Chart site, gauge and number of attempts.

Obstetrics and Neonatal Treatment Protocols

Newborn Care

1. Suction the infant’s airway using a bulb syringe as soon as the infant’s head is delivered and before delivery of the body. Suction the mouth first, then the nasopharynx.

2. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the infant’s scalp to preserve warmth.

3. Open and position the airway. Re-suction the infant’s airway. Suction the mouth first, then the nasopharynx.

4. If thick meconium is present, initiate endotracheal intubation before the infant takes a first breath.

5. Suction the airway using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers. Note: If the infant is already breathing or crying, this step may be omitted.

6. Assess breathing and adequacy of ventilation. 7. If ventilation is inadequate, stimulate the infant by gently rubbing the back and flicking

the soles of the feet. 8. If ventilation is still inadequate, after brief stimulation, begin assisted ventilations at

40 to 60 breaths per minute using a bag-valve-mask device with high-flow, 100% concentration oxygen.

9. If ventilation is adequate and the infant displays central cyanosis, administer high-flow, 100% concentration oxygen via blow-by. Hold the tubing 1 to 1-1/2 inches from the infant’s mouth and nose and cup a hand around the end of the tubing to help direct the oxygen flow toward the infant’s face.

10. Assess heart rate by auscultation or by palpation of the umbilical cord stump. 11. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted

ventilation with high-flow, 100% concentration oxygen, initiate the following actions:

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• Continue assisted ventilation. • Begin chest compressions at a combined rate of 120/minute (three compressions

to each ventilation). • If there is no improvement in heart rate after 30 seconds, perform endotracheal

intubation. • If there is no improvement in heart rate after intubation and ventilation, administer

Epi. 1:1000 solution at 0.1 mg/kg (maximum individual dose 1 mg) via endotracheal tube, or establish vascular access and administer 0.01mg/kg Epi 1:10,000 IVP (maximum individual dose 1 mg). Repeat epinephrine at the same dose every 3 to 5 minutes PRN.

• Initiate transport. Reassess heart rate and respirations en route. 12. If the heart rate is between 60 and 80 beats per minute, initiate the following actions:

• Continue assisted ventilation with high-flow, 100% concentration oxygen. • If there is no improvement in heart rate after 30 seconds, initiate management

sequence described in step 11b. • Initiate transport. Reassess heart rate and respirations en route.

13. If the heart rate is between 80 and 100 beats per minute, initiate the following actions: • Continue assisted ventilation with high-flow, 100% concentration oxygen. • Stimulate as previously described. • Initiate transport. Reassess heart rate after 15 to 30 seconds.

14. If the heart rate is faster than 100 beats per minute, initiate the following actions: • Assess skin color. If central cyanosis is still present, continue blow-by oxygen. • Initiate transport. Reassess heart rate and respirations en route. • Clamp umbilical cord securely 8-10 inches from the infant. • Do APGAR scores at one and five minutes, if possible. This can be done later.

Do not delay resuscitative or warming measures to obtain APGAR. • Reassess the patient frequently.

NOTE Assess and support temperature (warm and dry), breathing (stimulate to cry), circulation (heart rate and color).

Obstetrics

All EMS encounters with pregnant patients will proceed with the care directed toward the maternal-fetal unit; all interventions are to be performed with an understanding of their potential effect on both the mother and fetus. Provide supplemental O2 in all cases of trauma or hypoxemia. Position the mother to maximize blood flow (15 degree left lateral tilt or manually displace the uterus).

Third Trimester Hemorrhage

Indications All patients known or believed to be in the third trimester of pregnancy that is experiencing vaginal bleeding. Possible causes of third trimester bleeding include placenta previa, abruptio placentae*, and uterine rupture.

*In the presence of abruptio placentae, shock is likely to be out of proportion to the apparent volume of blood loss.

Guidelines 1. O2. 2. Position left lateral recumbent. 3. Begin emergency transport, code red.

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4. Notify receiving facility immediately. 5. Establish at least one, preferably two, large-bore IVs. Titrate fluid rate to patient’s status.

IV should be deferred until transport is underway. 6. Under no circumstances attempt to examine the patient internally

Pre-eclampsia and Eclampsia

Pre-eclampsia, characterized by hypertension, edema, and proteinuria develops after the twentieth week of gestation, and may occur up to 3 weeks postpartum. Eclampsia is pre-eclampsia with seizures.

Indications All patients with eclampsia, or one with symptoms of pre-eclampsia who appears likely to have a seizure. These patients are expected to meet the minimum criteria of systolic BP >140 and peripheral edema.

Guidelines 1. ABC’s: Airway Protocol as required, supplemental 02, large bore IV, TKO. 2. Monitor. 3. Minimize lights, noise or other stressors. 4. Position left lateral recumbent. 5. Magnesium sulfate 1-4 gm IVPB.* Carefully monitor for respiratory depression. 6. Unstable pre-eclamptic: handle and transport gently.

* Add 3 gm magnesium sulfate (50% solution) to a 1 gm/100ml bag (total 4 gm/100ml). Magnesium sulfate is hyperosmolar and will cause damage to red blood cells if not diluted, or if injected too quickly even when properly diluted.

Childbirth

Indications Women in active labor who desire transport to a hospital.

Policy 1. Complications of delivery that require immediate emergency transport are prolapsed

cord, breech, limb breech, shoulder, or face presentation. 2. Specific history should include prenatal care, expected complications, para, gravida, due

date, personal MD, high risk factors, whether water has broken, color of amniotic fluid, previous c-section, medical history, medications and allergies.

Guidelines – Imminent Delivery 1. Prepare for delivery. 2. Establish one large-bore IV. 3. Deliver at home. 4. Assess baby and mother. 5. Attend to neonatal needs: ABCs, warmth, APGARs. (See Newborn Care Protocol). 6. If uncomplicated and neonate is OK, place at mother’s breast. 7. If delivery is uncomplicated and mother and baby are stable, transport code yellow.

Normal blood loss during delivery is 250-500 cc. If on-going, severe hemorrhage occurs, follow Postpartum Hemorrhage protocol below. Guidelines - Active Labor, Delivery NOT Imminent

1. Exam and history. 2. Saline lock. 3. Transport left lateral recumbent to hospital of choice, code yellow.

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Postpartum Hemorrhage Indications Postpartum patient with more than 500 ml of blood loss. Guidelines:

1. Establish large bore IV with 40u Pitocin in 1000 cc NS. 2. Check perineum for any obvious source of bleeding from birth trauma. Apply direct

pressure if site found. 3. Perform vigorous external uterine massage. 4. Give Pitocin solution by rapid infusion (titrate to firm uterus) or 10u by IM injection. 5. Establish second unmedicated large bore IV of NS for volume replacement. 6. Treat for shock. 7. Rapid transport with frequent vital signs.

Pediatric Weight Pages

2.2 pounds 1kg Adenocard Dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.1 mg = 0.1 ml of dilute mix. rpt q 3 min x 2 @ 0.2 mg = 0.2 ml Albuterol-neb not allowed Amiodarone 5 mg = 0.1 ml. Physician contact required. Atropine not allowed Benadryl not allowed D50W Give as D10. Dilute 0.5 g = 1 ml D50 with 4 ml NS. Rpt x 1 after 10 min. Dopamine 10 mcg/min = 1 gtt/60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy not allowed 0.1 mg = 0.1 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.01 mg = 0.1 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 0.3 mg = 0.15 ml for age > 7 weeks Fentanyl not allowed Glucagon 0.05 mg = 0.05 ml Lidocaine not allowed Lorazepam IV/IO: Dilute 50%. 0.05-0.1 mg = 0.05-0.1 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.1 mg = 0.05 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine not allowed Narcan 0.1 mg = 0.1 ml q 3 min prn Nitronox not allowed Sodium Bicarb dilute 50%, Give 1 mEq = 2ml of dilute mix. May repeat 0.5 mEq = 1 ml of dilute mix q 10

minutes x 2 Sux 2 mg = 0.1ml Tetracaine not allowed Fluid Bolus 10 ml q 5-10 min x 2 rpt Synch CV not allowed Defib 2 joules rpt @ 4 joules Pacing 140/min; begin @ 60 mA ET tube 2.5 / ETCO2 Detector: not allowed Gastric tube: orogastric only

VS --> HR: 110 - 160 BP: 36 /14 - 58/36 R: 30 - 60

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4.4 pounds 2 kg Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.2 mg = 0.2 ml of dilute mix rpt q 3 min x 2 @ 0.2 mg = 0.4 ml Albuterol-neb not allowed Amiodarone 10 mg = 0.2 ml. Physician contact required. Atropine not allowed Benadryl not allowed D50W Give as D10. Dilute 1 g = 2 ml D50 with 8 ml NS. Rpt x 1 after 10 min. Dopamine 20 mcg/min = 1 gtt/ 30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy not allowed 0.2 mg = 0.2 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.02 mg = 0.2 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 0.6 mg = 0.3 ml for age > 7 weeks Fentanyl not allowed Glucagon 0.1 mg = 0.1 ml Lidocaine not allowed Lorazepam IV/IO: Dilute 50% 0.1-0.2 mg = 0.1-0.2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.2 mg = 0.1 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine not allowed Narcan 0.2 mg = 0.2 ml q 3 min prn Nitronox not allowed Sodium Bicarb dilute 50%. Give 2 mEq = 4ml of dilute mix, may repeat 1 mEq = 2 ml of dilute mix q 10

minutes x 2 Sux 4 mg = 0.2 ml Tetracaine not allowed Fluid Bolus 10 ml/kg = 20 ml q 5-10 min prn x 2 rpt Synch CV not allowed Defib 4 joules rpt @ 8 joules Pacing 140/ min; begin @ 60 mA ET Tube 2.5 or 3.0 / ETCO2 Detector: Not allowed Gastric tube orogastric only VS --> HR: 110 - 160 BP: 44/22 - 66/42 R: 30 - 60

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7 pounds 3 kg Adenocard Dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.3 mg = 0.3 ml of dilute mix rpt q 3 min x 2 @ 0.6 mg = 0.6 ml Albuterol-neb not allowed Amiodarone 15 mg = 0.3 ml. Physician contact required. Atropine not allowed Benadryl not allowed D50W Give as D10. Dilute 1.5 g = 3 ml D50 with 12 ml NS. Rpt x 1 after 10 min. Dopamine 30 mcg/min = 1 gtt/20 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy not allowed 0.3 mg = 0.3 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.03 mg = 0.3 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 0.9 mg = 0.45 ml for age > 7 weeks Fentanyl not allowed Glucagon 0.15 mg = 0.15 ml Lidocaine 3 mg = 0.15 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.15-0.3 mg = 0.15-0.3 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.3 mg = 0.15 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine not allowed Narcan 0.3 mg = 0.3 ml q 3 min prn Nitronox not allowed Sodium Bicarb dilute 50%. Give 3 mEq = 6 ml of dilute mix, may repeat 1.5 mEq = 3ml of dilute mix q 10

minutes x 2 Sux 6mg = 0.3ml Tetracaine not allowed Fluid Bolus 10 ml /kg = 30 ml q 5-10 min prn x 2 rpt Synch CV not allowed Defib 6 joules rpt @ 12 joules Pacing 140/ min; begin @ 60 mA ET Tube 3.0 / ETCO2 Detector: not allowed Gastric tube: orogastric only

VS --> HR: 110 - 160 BP: 42/26 - 66/48 R: 30 - 60

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9 pounds 4 kg Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.4 mg = 0.4 ml of dilute mix, rpt q 3

min x 2 @ 0.8 mg = 0.8 ml Albuterol-neb not allowed Amiodarone 20 mg = 0.4 ml. Physician contact required. Atropine 0.1 mg = 1.0 ml q 5 min x 1 rpt Benadryl not allowed D50W Give as D10. Dilute 2 g = 4 ml D50 with 16 ml NS. Rpt x 1 after 10 min. Dopamine 40 mcg/min = 1 gtt/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1000 Asthma/Allergy not allowed 0.4 mg = 0.4 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.04 mg = 0.4 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 1.2 mg = 0.6 ml for age > 7 weeks Fentanyl 4 mcg IV/IO (0.08 ml); 6 mcg IN (0.12 ml) Glucagon 0.2 mg = 0.2 ml Lidocaine 4 mg = 0.2 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.2-0.4 mg = 0.2-0.4 ml dilute mix SIVP titrated to effect; rpt in 5 min

if seizure persists. IM: 0.4 mg = 0.2 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 0.4 mg = 0.04 ml q 20 min x 1 rpt Narcan 0.4 mg = 0.4 ml q 3 min prn Nitronox not allowed Sodium Bicarb dilute 50%. Give 4 mEq = 8 ml of dilute mix, may repeat 2 mEq = 4 ml of dilute mix q 10

minutes x 2 Sux 8 mg = 0.4 ml Tetracaine not allowed Fluid Bolus 80 ml q 5-10 min x 2 rpt Synch CV not allowed Defib 8 joules rpt @ 16 joules Pacing 140/ min; begin @ 60 mA ET Tube 3.0 or 4.0 / ETCO2 Detector: not allowed Gastric tube: orogastric only

VS --> HR: 110 - 160 BP: 56/30 - 80/50 R: 30 - 60

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11 pounds 5 kg Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.5 mg = 0.5 ml of dilute mix, rpt q 3 min x

2 @ 1.0 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 25 mg = 0.5 ml. Physician contact required. Atropine 0.1 mg = 1.0 ml q 5 min x 1 rpt Benadryl 5 mg = 0.1 ml q 5 min x 1 rpt D50W Give as D10. Dilute 2.5 g = 5 ml D50 with 20 ml NS. Rpt x 1 after 10 min. Dopamine 50 mcg/min = 1 gtt/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.05 mg = 0.05 ml SC q 10 min x 2 rpt 0.5 mg = 0.5 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.05 mg = 0.5 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 1.5 mg = 0.75 ml for age > 7 weeks Fentanyl 5 mcg IV/IO (0.1 ml); 7.5 mcg IN (0.15 ml) Glucagon 0.25 mg = 0.25 ml Lidocaine 5 mg = 0.25 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.25-0.5 mg = 0.25-0.5 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min. if seizure persists. IM: 0.5 mg = 0.25 ml undiluted; rpt x 1 in 5 min. if seizure persists. Morphine 0.5 mg = 0.05 ml q 20 min x 1 rpt Narcan 0.5 mg = 0.5 ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 5mEq = 5 ml, may repeat 2.5 mEq q 10 min x 2 Sux 10 mg = 0.5 ml Tetracaine not allowed Fluid Bolus 100 ml q 5-10 min x 2 rpt Synch CV 3 joules rpt @ 5 joules rpt @ 10 joules Defib 10 joules rpt @ 20 joules Pacing 120/ min; begin @ 60 mA ET Tube 3.0 or 4.0 / ETCO2 Detector: not allowed Gastric tube: orogastric only

VS --> HR: 110 - 160 BP: 56/30 - 80/50 R: 30 - 60

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13 pounds 6 kg Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.6 mg = 0.6 ml of dilute mix. rpt q 3 min x 2 @ 1.2 mg = 1.2 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 30 mg = 0.6 ml. Physician contact required. Atropine 0.12 mg = 1.2 ml q 5min x 1 rpt Benadryl 6 mg = 0.12 ml q 5 min x 1 rpt D50W Give as D10. Dilute 3 g = 6 ml D50 with 24 ml NS. Rpt x 1 after 10 min. Dopamine 60 mcg / min = 1 gtt/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.06 mg = 0.06 ml SC q 10 min x 2 rpt 0.6 mg = 0.6 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.06 mg = 0.6 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 1.8 mg = 0.9 ml for age > 7 weeks Fentanyl 6 mcg IV/IO (0.12 ml); 9.0 mcg IN (0.18 ml) Glucagon 0.3 mg = 0.3 ml Lidocaine 6 mg = 0.3 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.3-0.6 mg = 0.3-0.6 ml dilute mix SIVP titrated to effect; rpt in 5 min

if seizure persists. IM: 0.6 mg = 0.3 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 0.6 mg = 0.06 ml q 20 min x 1 rpt Narcan 0.6 mg = 0.6 ml q 3min prn Nitronox not allowed Sodium Bicarb (do not dilute) 6 mEq = 6 ml, may repeat 3 mEq q 10 min x 2 Sux 12 mg = 0.6 ml Tetracaine not allowed Fluid Bolus 120 ml q 5- 10 min x 2 rpt Synch CV 3 joules rpt @ 6 joules rpt @ 12 joules Defib 12 joules rpt @ 24 joules Pacing 120/ min; begin @ 60 mA ET Tube 3.0 or 4.0 / ET CO2 Detector: not allowed VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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15 pounds 7 kg Adenocard 0.7 mg = 0.23 ml rpt q 3 min x 2 @ 1.4 mg = 0.46 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 35 mg = 0.7 ml. Physician contact required. Atropine 0.14 mg = 1.4 ml q 5 min x 1 rpt Benadryl 7 mg = 0.14 ml q 5 x 1 rpt D50W Give as D10. Dilute 3.5 g = 7 ml D50 with 28 ml NS. Rpt x 1 after 10 min. Dopamine 70 mcg/ min = 7 gtts/ 60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.07 mg = 0.07 ml SC q 10 min x 2 rpt 0.7 mg = 0.7 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.07 mg = 0.7 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 2.1 mg = 1.05 ml for age > 7 weeks Fentanyl 7 mcg IV/IO (0.14 ml); 10.5 mcg IN (0.21 ml) Glucagon 0.35 mg = 0.35 ml Lidocaine 7 mg = 0.35 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.35-0.7 mg = 0.35-0.7 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.7 mg = 0.35 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 0.7 mg = 0.07 ml q 20 min x 1 rpt Narcan 0.7 mg = 0.7ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 7 mEq = 7 ml, may repeat 3.5 mEq q 10 min x 2 Sux 14 mg = 0.7 ml Tetracaine not allowed Fluid Bolus 140 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 4 joules rpt @ 7 joules rpt @ 14 joules Defib 14 joules rpt @ 28 joules rpt @ 50 joules Pacing 120/ min; begin @ 60 mA ET Tube 3.0 or 4.0 VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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17 pounds 8 kg Adenocard 0.8 mg = 0.27 ml rpt q 3 min x 2 @ 1.6 mg = 0.54 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 40 mg = 0.8 ml. Physician contact required. Atropine 0.16 mg = 1.6 ml q 5 min x 1 rpt Benadryl 8 mg = 0.16 ml q 5 min x 1 rpt D50W dilute 50%, 4 g = 16 ml D25W q 10 min x 1 rpt Dopamine 80 mcg/min = 2 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.08 mg = 0.08 ml SC q 10 min x 2 rpt 0.8 mg = 0.8 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.08 mg = 0.8 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 2.4 mg = 1.2 ml Fentanyl 8 mcg IV/IO (0.16 ml); 12 mcg IN (0.24 ml) Glucagon 0.4 mg = 0.4 ml Lidocaine 8 mg = 0.4 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.4-0.8 mg = 0.4-0.8 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.8 mg = 0.4 ml undiluted; rpt x 1 in 5 min. if seizure persists.Morphine 0.8 mg = 0.08 ml q 20 min x 1 rpt Narcan 0.8 mg = 0.8 ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 8 mEq = 8 ml, may repeat 4 mEq q 10 min x 2 Sux 16 mg = 0.8 ml Tetracaine not allowed Fluid Bolus 160 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 4 joules rpt @ 8 joules rpt @ 16 joules Defib 16 joules rpt @ 32 joules Pacing 120/ min; begin @ 60 mA ET Tube 3.0 or 4.0 VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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20 pounds 9 kg Adenocard 0.9 mg = 0.3 ml rpt q 3 min x 2 @ 1.8 mg = 0.6 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 45 mg = 0.9 ml. Physician contact required. Atropine 0.18 mg = 1.8 ml q 5 min x 1 rpt Benadryl 9 mg = 0.18 ml q 5 min x 1 rpt D50W dilute 50%, 4.5 g = 18 ml D25W, q 10 min x 1 rpt Dopamine 90 mcg/min = 3 gtts/20 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.09 mg = 0.09 ml SC q 10 min x 2 rpt 0.9 mg = 0.9 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.09 mg = 0.9 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 2.7 mg = 1.35 ml Fentanyl 9 mcg IV/IO (0.18 ml); 13.5 mcg IN (0.27 ml) Glucagon 0.45 mg = 0.45 ml Lidocaine 9 mg = 0.45 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.45-0.9 mg = 0.45-0.9 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.9 mg = 0.45 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 0.9 mg = 0.09 ml q 20 min x 1 rpt Narcan 0.9 mg = 0.9 ml q 3 min prn Nitronox not allowed Sodium Bicarb

(do not dilute) 9 mEq = 9 ml, may repeat 4.5 mEq q 10 min x 2

SUX 18 mg = 0.9 ml Tetracaine not allowed Fluid Bolus 180 ml q 5-10 x 2 rpt (l. ringers) Synch CV 5 joule rpt @ 9 joules rpt @ 18 joules Defib 18 joules rpt @ 36 joules Pacing 120/ min; begin @ 60 mA ET Tube 3.0 or 4.0 VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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22 pounds 10 kg Adenocard 1.0 mg = 0.33 ml rpt q 3 min x 2 @ 2.0 mg = 0.67 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 50 mg = 1 ml. Physician contact required. Atropine 0.2 mg = 2 ml q 5 min x 1 rpt Benadryl 10 mg = 0.2 ml q 5 min x 1 rpt D50W dilute 50%, 5 g = 20 ml D25W q 10 min x 1 rpt Dopamine 100mcg/min = 1 gtt/6 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.1 mg = 0.1 ml SC q 10 min x 2 rpt 1.0 mg ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.1 mg = 1 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 3.0 mg = 1.5 ml Fentanyl 10 mcg IV/IO (0.2 ml); 15 mcg IN (0.30 ml) Glucagon 0.5 mg = 0.5 ml Lidocaine 10 mg = 0.5 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.5-1 mg = 0.5-1 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if

seizure persists. IM: 1 mg = 0.5 mlundiluted; rpt x 1 in 5 min. if seizure persists. Morphine 1 mg = 0.1 ml q 20 min x 1 rpt Narcan 1 mg = 1 ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 10 mEq = 10 ml, may repeat 5 mEq q 10 min x 2 Sux 20 mg = 1.0 ml Tetracaine not allowed Fluid Bolus 200ml q 5-10 min x 2 rpt (l. ringers) Synch CV 5 joules rpt @ 10 joules rpt @ 20 joules Defib 20 joules rpt @ 40 joules Pacing 120/ min; begin @ 60 mA ET Tube 4.0 or 5.0 VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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26 pounds 12 kg Adenocard 1.2 mg = 0.4 ml rpt q 3 min x 2 @ 2.4 mg = 0.8 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 60 mg = 1.2 ml. Physician contact required. Atropine 0.24 mg = 2.4 ml q 5 min x 1 rpt Benadryl 12 mg = 0.24 ml q 5 min x 1 rpt D50W dilute 50%, 6 g = 24 ml D25W q 10 min x 1 rpt Dopamine 120 mcg/ min = 1 gtt/ 5 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.12 mg = 0.12 ml SC q 10 min x 2 rpt 1.2 mg = 1.2 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.12 mg = 1.2 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 3.6 mg = 1.8 ml Fentanyl 12 mcg IV/IO (0.24 ml); 18 mcg IN (0.36 ml) Glucagon 0.6 mg = 0.6 ml Lidocaine 12 mg = 0.6 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.6-1.2 mg = 0.6-1.2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 1.2 mg = 0.6 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 1.2 mg = 0.12 ml q 20 min x 1 rpt Narcan 1.2 mg= 1.2 ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 12 mEq = 12 ml, may repeat 6 mEq q 10 min x 2 Sux 24 mg = 1.2 ml Tetracaine not allowed Fluid Bolus 240 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 6 joules rpt @ 12 joules rpt @ 24 joules Defib 24 joules rpt @ 48 joules Pacing 120/ min; begin @ 60 mA ET Tube 4.0 or 5.0 VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60

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31 pounds 14 kg Adenocard 1.4 mg = 0.47 ml rpt q 3 min x 2 @ 2.8 mg = 0.94 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 70 mg = 1.4 ml. Physician contact required. Atropine 0.28 mg = 2.8 ml q 5 min x 1 rpt Benadryl 14 mg = 0.28 ml q 65 min x 1 rpt D50W dilute 50%, 7 g = 28 ml D25W, q 10 min x 1 rpt Dopamine 140 mcg/min = 7 gtts/30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.14 mg = 0.14 ml SC q 10 min x 2 rpt 1.4 mg = 1.4 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.14 mg= 1.4 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 4.2mg = 2.1 ml Fentanyl 14 mcg IV/IO (0.28 ml); 21 mcg IN (0.42 ml) Glucagon 0.7 mg = 0.7 ml Lidocaine 14 mg = 0.7 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.7-1.4 mg = 0.7-1.4 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min

if seizure persists. IM: 0.7 mg = 0.35 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 1.4 mg = 0.14 ml q 20 min x 1 rpt Narcan 1.4 mg = 1.4 ml q 3 min prn Nitronox not allowed Sodium Bicarb (do not dilute) 14 mEq = 14 ml, may repeat 7 mEq q 10 min x 2 Sux 28 mg = 1.4 ml Tetracaine not allowed Fluid Bolus 280 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 7 joules rpt @ 14 joules rpt @ 28 joules Defib 28 joules rpt @ 56 joules Pacing 120/ min; begin @ 60 mA ET Tube 4.0 or 5.0 VS --> HR: 90 - 140 BP: 80/50 - 112/80 R: 24 - 40

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35 pounds 16 kg Adenocard 1.6 mg = 0.53 ml rpt q 3 min x 2 @ 3.2 mg = 1.06 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 80 mg = 1.6 ml. Physician contact required. Atropine 0.32 mg = 3.2 ml q 5 min x 1 rpt Benadryl 16 mg = 0.32 ml q 5 min x 1 rpt D50W dilute 50%, 8 g = 32 ml D25W, q 10 min x 1 rpt Dopamine 160 mcg/min = 4 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.16 mg = 0.16 ml SC q 10 min x 2 rpt 1.6 mg = 1.6 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.6 mg = 1.6 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 4.8 mg = 2.4 ml Fentanyl 16 mcg IV/IO (0.32 ml); 24 mcg IN (0.48 ml) Glucagon 0.8 mg = 0.8 ml Lidocaine 16 mg = 0.8 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.8-1.6 mg = 0.8-1.6 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 1.6 mg = 0.8 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 1.6 mg = 0.16 ml q 20 min x 1 rpt Narcan 1.6 mg = 1.6 ml q 3 min prn Nitronox prn Sodium Bicarb (do not dilute) 16 mEq = 16 ml, may repeat 8 mEq q 10 min x 2 Sux 32 mg = 1.6 ml Tetracaine 1-2 gtts max Fluid Bolus 320 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 8 joules rpt @ 16 joules rpt @ 32 joules Defib 32 joules rpt @ 64 joules Pacing 100/ min; begin @ 60 mA ET Tube 5.0 or 6.0 VS --> HR: 80 - 110 BP: 82/50 - 112/78 R: 22 - 34

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40 pounds 18 kg Adenocard 1.8 mg = 0.6 ml rpt q 3 min x 2 @ 3.6 mg = 1.2 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 90 mg = 1.8 ml. Physician contact required. Atropine 0.36 mg = 3.6 ml q 5 min x 1 rpt Benadryl 18 mg = 0.36 ml q 5 min x 1 rpt D50W dilute 50%, 9 g = 36 ml D25W, q 10 min x 1 rpt Dopamine 180 mcg/min = 9 gtts/30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.18 mg = 0.18 ml SC q 10 min x 2 rpt 1.8 mg = 1.8 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.18 mg = 1.8 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 5.4 mg = 2.7 m Fentanyl 18 mcg IV/IO (0.36 ml); 27 mcg IN (0.54 ml) Glucagon 0.9 mg = 0.9 ml Lidocaine 18 mg = 0.9 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 0.9-1.8 mg = 0.9-1.8 ml dilute mix SIVP titrated to effect; rpt x 1 in 5

min if seizure persists. IM: 0.9 mg = 0.45 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 1.8 mg = 0.18 ml q 20 min x 1 rpt Narcan 1.8 mg = 1.8 ml q 3 min prn Nitronox prn Sodium Bicarb

(do not dilute) 18 mEq = 18 ml, may repeat 9 mEq q 10 min x 2

Sux 36 mg = 1.8 ml Tetracaine 1-2 gtts max Fluid Bolus 360 ml q 5-10 x 2 rpt (l. ringers) Synch CV 9 joules rpt @ 18 joules rpt @ 36 joules Defib 36 joules rpt @ 72 joules Pacing 100/ min; begin @ 60 mA ET Tube 5.0 or 6.0 VS --> HR: 80 - 110 BP: 82/50 - 112/78 R: 22 - 34

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44 pounds 20 kg Adenocard 2.0 mg = 0.7 ml rpt q 3 min x 2 @ 4.0 mg = 1.4 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 100 mg = 2 ml. Physician contact required. Atropine 0.4 mg = 4 ml q 5 min x 1 rpt Benadryl 20 mg = 0.4 ml q 5 min x 1 rpt D50W dilute 50%, 10 g = 40 ml D25W, q 10 min x 1 rpt Dopamine 200 mcg/min = 5 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi1:1,000 Asthma/Allergy 0.2 mg = 0.2 ml SC q 10 min x 2 rpt 2.0 mg = 2.0 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.2 mg = 2 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 6.0 mg = 3.0ml Fentanyl 20 mcg IV/IO (0.4 ml); 30 mcg IN (0.6 ml) Glucagon 1.0 mg = 1.0 ml Lidocaine 20 mg = 1 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 1-2 mg = 1-2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if

seizure persists. IM: 2 mg = 1 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 2 mg = 0.2 ml q 20 min x 1 rpt Narcan 2 mg = 2 ml q 3 min prn Nitronox prn Sodium Bicarb

(do not dilute) 20mEq = 20 ml, may repeat 10 mEq q 10 min x 2

Sux 40 mg = 2.0 ml Tetracaine 1-2 gtts max Fluid Bolus 400 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 10 joules rpt @ 20 joules rpt @ 40 joules Defib 40 joules rpt @ 80 joules Pacing 100/ min; begin @ 60 mA ET Tube 5.0 or 6.0 VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30

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55 pounds 25 kg Adenocard 2.5 mg = 0.8 ml rpt q 3 min x 2 @ 5.0 mg = 1.6 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 125 mg = 2.5 ml. Physician contact required. Atropine 0.5 mg = 5 ml q 5 min x 1 rpt Benadryl 25 mg = 0.5 ml q 5 min x 1 rpt D50W (do not dilute) 12.5 g =25ml D50W, q 10 min x 1 rpt Dopamine 250 mcg / min = 5 gtts/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.25 mg = 0.25 ml SC, q 10 min x 2 rpt 2.5 mg = 2.5 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.25 mg= 2.5 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 7.5 mg = 3.5 ml Fentanyl 25 mcg IV/IO (0.5 ml); 37.5 mcg IN (0.75 ml) Glucagon 1.0 mg = 1.0 ml Lidocaine 25 mg = 1.25 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 1-2 mg = 1-2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if

seizure persists. IM: 2 mg = 1 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 2.5 mg = 0.25 ml q 20 min x 1 rpt Narcan 2 mg = 2 ml q 3 min prn Nitronox prn Sodium Bicarb (do not dilute) 25 mEq = 25 ml, may repeat 12.5 mEq q 10 min x 2 Sux 50 mg = 2.5 ml Tetracaine 1-2 gtts max Fluid Bolus 500 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 13 joules rpt @ 25 joules @ 50 joules Defib 50 joules rpt @ 100 joules Pacing 100/ min; begin @ 60 mA ET Tube 5.0 or 6.0 VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30

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66 pounds 30 kg Adenocard 3.0 mg = 1.0 ml rpt q 3 min x 2 @ 6.0 mg = 2.0 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 150 mg = 3 ml. Physician contact required. Atropine 0.5 mg = 5 ml q 5 x 1 rpt Benadryl 30 mg = 0.6 ml q 5 min rpt x 1 @ 20 mg = 0.4 ml D50W (do not dilute) 15 g = 30 ml D50W, q 10 min x 1 rpt Dopamine 300 mcg / min = 5 gtts/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.3 mg = 0.3 ml SC q 10 min x 2 rpt 3.0 mg = 3.0 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.3 mg = 3 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 9.0 mg = 4.5 ml Fentanyl 30 mcg IV/IO (0.6 ml); 45 mcg IN (0.9 ml) Glucagon 1.0 mg = 1.0 ml Lidocaine 30mg = 1.5 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 1-2 mg = 1-2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if

seizure persists. IM: 2 mg = 1 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 3 mg = 0.3 ml q 20 min x 1 rpt Narcan 2 mg = 2 ml q 3 min prn Nitronox prn Sodium Bicarb

(do not dilute) 30 mEq = 30 ml, may repeat 15 mEq q 10 min x 2

Sux 60 mg = 3.0 ml Tetracaine 1-2 gtts max Fluid Bolus 500 ml q 5-10 min x 2 rpt (l. ringers) Synch CV 15 joules rpt @ 30 joules rpt @ 60 joules Defib 60 joules rpt @ 120 joules Pacing 100/ min; begin @ 60 mA ET Tube 6.0 or 7.0 VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30

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77 pounds 35 kg Adenocard 3.5 mg = 1.2 ml rpt q 3 min x 2 @ 7.0 mg = 2.4 ml Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms. Amiodarone 175 mg = 3.5 ml. Physician contact required. Atropine 0.5 mg = 5 ml q 5 x 1 rpt Benadryl 35 mg = 0.7 ml q 5 min x 1 rpt @15 mg = 0.3 ml D50W (do not dilute) 17.5 g =35ml D50W, q 10 min x 1 rpt Dopamine 350 mcg/min = 7 gtts/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS) Epi 1:1,000 Asthma/Allergy 0.3 mg = 0.3 ml SC q 10 min x 2 rpt 3.5 mg = 3.5 ml ET dose in arrest q 3-5 min if IV/IO unobtainable Epi 1:10,000 0.35 mg = 3.5 ml IV/IO q 5 min in arrest and bradycardia Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms. Etomidate 10.5 mg = 5.25 ml Fentanyl 35 mcg IV/IO (0.7 ml); 52.5 mcg IN (1.05 ml) Glucagon 1.0 mg = 1.0 ml Lidocaine 35 mg = 1.75 ml q 10 min x 2 rpt Lorazepam IV/IO: Dilute 50%. 1-2 mg = 1-2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if

seizure persists. IM: 2 mg = 1 ml undiluted; rpt x 1 in 5 min if seizure persists. Morphine 3.5 mg = 0.35 ml q 20 min x 1 rpt Narcan 2 mg = 2 ml q 3 min prn Nitronox prn Sodium Bicarb (do not dilute) 35 mEq = 35 ml, may repeat 17.5 mEq q 10 min x 2 Sux 70 mg = 3.5 ml Tetracaine 1-2 gtts max Fluid Bolus 500 ml q 5-10 x 2 rpt ( LR ) Synch CV 18 joules rpt @ 35 joules rpt @ 70 joules Defib 70 joules rpt @ 140 joules Pacing 100/ min; begin @ 60 mA ET Tube 6.0 or 7.0 VS --> HR: 60 - 90 BP: 94 /62 - 140/88 R: 12 - 16

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Appendix

APGAR Scores

Sign 0 1 2 Heart rate Absent <100 >100 Resp effort Absent Weak cry Strong cry Hypoventilation Good effort Muscle tone Limp Some flexion Active Reflex None Some motion Crying/active irritability Color Blue/pale Body pink All pink Extremities blue

Infant Burn Chart

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Child Burn Chart

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Section 4: Medical Operations The Medical Operations section is not intended to be a complete guide to all AFD documents; however, it provides a ready reference for certain specific information not contained elsewhere. Hyperlinks to EMS-relevant Procedures and Instructions (P&Is), Standard Operating Guidelines (SOGs) and manuals is found below. The documents can be found on the G Drive in the AFD Documents Folder. It is expected all personnel are familiar with the departmental documents listed and included below, as well as those that are not.

EMS P&Is, SOGs, and Manuals C-4 Contagious Disease, Epidemic, and Pandemic Emergencies

C-5 Concealed and Unsecured Weapons

M-4 Multi-Victim Incidents (MVI)

M-4 Multi-Victim Incidents (MVI) Reinforced Table

N-3 Notifications of Death of a Patient

R-3 Roles and Responsibilities of MICU Personnel on Non-EMS Incidents

900-35 Education and Special Duty Pay (Appendix 6: EMS)

900-41 Private Ambulance Service Dispatch

901-2 Infectious Disease Prevention and Control

901-4 Epidemic or Pandemic Emergencies

902-7 Continuing Medical Education

903-3 Biomedical Equipment

903-5 Controlled Substances

905-7 Medical Control

905-8 Operation Quickstart

905-9 Medical Operations Manual

AFD Metropolitan Medical Response System Manual (includes 905-11 MMRS MMST)

AFD EMS CQI Manual

AFD HIPAA Manual

State of Alaska EMS Mandatory Reporting Requirements

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EMS Incident Disposition Use the following procedures when radioing dispatch with EMS incident dispositions:

• When transporting a patient, the MICU should notify dispatch of the hospital transporting to, the transport status, and the number of patients being transported. The dispatcher must be certain to enter all of these data points, particularly the number of patients.

• If a patient refuses transport, the unit responsible for the patient report should notify dispatch of “patient refused transport”. The dispatcher should select this choice for the unit disposition.

• If the unit arrives and finds no patient, then they should notify dispatch of “location, no patient”. The dispatcher should select this choice for the unit disposition. Personnel are reminded to review below for the definition of a “patient”. It is a violation of department policy to report “location, no patient” to avoid completion of a PCR.

• If the units are cancelled en route, the dispatcher should select as the disposition “canceled by agency on-scene” and include which agency canceled and the reason for the cancellation in the comments.

Definition of Patient

A patient is defined as:

• Anyone who makes a first party call to 911 for EMS, • anyone who claims to have an illness or injury to whom we have responded or otherwise

encountered, • and anyone who on examination either by the significance of mechanism or findings may

have an injury or illness. Note: A multi-person event will require best judgment of PM or EMS provider. A Patient Care Report (PCR) is required for all patients except for a Public Assist that does not involve an injury or potential for injury given mechanism or situation. Destinations for Hemodialysis (HD) and Peritoneal Dialysis (PD)

Patients There are a number of medical problems experienced by HD and PD patients that can be treated only by very timely dialysis. Any delay in the appropriate treatment for these patients can result in worse patient outcomes. It is often very difficult for the field provider to exclude the patient’s need for dialysis. It is therefore policy that HD and PD patients are delivered to the appropriate facility of either Alaska Regional Hospital (ARH) or Providence Alaska Medical Center (PAMC.) These are the two local hospitals that provide in-house hemodialysis. It is the policy of the Anchorage, Girdwood, and Chugiak EMS systems that: • Municipality of Anchorage Area Wide EMS providers will identify all patients being

transported who are actively receiving either HD or PD. • ALL HD and PD patients with a medical complaint or serious medical or traumatic problem

must be transported to one of the two local dialysis hospitals regardless of the hospital’s diversion status if both are on diversion.

• During times of EMS diversion it is desirable that a pre-alert be given to the receiving hospital via AFD Dispatch and that the reason for destination choice is because of a dialysis patient.

• The ONLY exclusion to this policy is if the receiving hospital has declared an “internal disaster.”

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Destination of Patients with Psychiatric Problems Providence Hospital now has a psychiatric emergency department. All non-native patients who are transported by AFD for problems of a purely psychiatric nature should preferentially be taken to Providence Hospital. Included problems:

• Severe depression with or without suicidal ideation. • Severe anxiety not associated with substance abuse. • Pure behavioral or emotional problems including apparent psychosis, mania, delusions, etc. • Stable suicide attempts.

Excluded problems:

• Drug dependency or withdrawal. • Acute intoxication. • Possible medical problem or trauma thought possibly responsible for an altered

sensorium. ANMC would still like its beneficiaries to be transported preferentially to ANMC. Providence Hospital, Alaska Regional and ANMC ER’s will still handle the patients with “excluded problems” as before.

Direct Admit Patients The care of most patients will be transferred to hospital staff in the receiving facility Emergency Department. This policy allows the MICU crew to rapidly return to service and be available for an emergency response. There are situations, however, when it is in the best interest of the patient to proceed directly to a specific area of the hospital other than the Emergency Department and effect the transfer of patient care at that location. These situations include the following patient dispositions:

• Patients directly admitted to Intensive Care or Coronary Care Units. • Obstetric patients greater than 16 weeks gestation who are in active labor or where there

is any indication of fetal distress will be taken directly to Labor and Delivery. • Patients being directly admitted to other units whose comfort would be significantly

compromised from excessive movement, e.g., multiple orthopedic injuries or extensive burns.

• Cardiac cath lab patients when it can be determined either through AFD Dispatch or the receiving facility Emergency Department that the cath lab is ready to receive the patient without excessive delay (< 10 minutes).

Exceptions to this policy can be granted by the EMS Battalion Chief on a case by case basis. Any question regarding interpretation of this policy will be immediately referred to the EMS Battalion Chief.

Dispatch Alerting to First Defibrillation All personnel are required to notify dispatch immediately of the first defibrillation of a ventricular fibrillation/pulseless ventricular tachycardia delivered by an AFD crew during a Code 99. It is anticipated that this should occur after the radio declaration of a Code 99, and will be tracked as statistical data. An example of an appropriate radio notification would be: “Alarm, Engine 1, first shock delivered.”

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ePCR Completion

• All ePCRs including non-transports will be completed prior to the end of the shift. • Transport ePCRs will be completed prior to leaving the hospital. Call Dispatch via

landline for extension of out-of-service time. • The only exception is when the ambulance is dispatched prior to report completion. • Personnel will respond to all dispatches without delay. • When dispatched prior to ePCR completion, the report will be completed and faxed to the

receiving hospital as soon as possible after the response. This will take a priority over all other activities.

• Any exception requires prior approval of an EMS Battalion Chief.

Hospital Alerts The disruption which is caused by an alert which is inappropriate or inaccurate may be more than an inconvenience suffered by the hospital; it may lead to complications in patient care. The hospital alert system was intended to be another adjunct in emergency patient care which should be a benefit for the whole team – both pre-hospital providers and in-hospital providers. The alert system should not be used when only a high index of suspicion is present. Care should be taken to only use the alert system when the proper criteria are met. Alert status is given to the hospital based on the AFD paramedic’s impression that a patient has a high likelihood of requiring an intervention at the hospital due to the presence of a new stroke, severe trauma or acute coronary syndrome with elevated ST segments. Radio reports to the hospital will start with the type of alert, followed by the patient transport status.

STEMI Alert STEMI: S-T Segment Elevation Myocardial Infarction

• Age 35 or greater • Acute onset of symptoms • Symptoms consistent with acute coronary syndrome (ACS) that must include the

following: o “Visceral” chest pain: squeezing, pressure, aching, band-like, etc and may have

associated jaw or arm pain, diaphoresis, SOB • 12 lead ECG showing >1mm of ST-segment elevation in at least 2 contiguous limb leads

or >2mm in 2 or more contiguous precordial leads and that must have a “tombstone” or other convex morphology

o Flat, concave or other patterns are no longer sufficient to justify this alert. • ALL FOUR INDICATORS ABOVE ARE REQUIRED • Note the presence of Q-waves if seen. • QRS MUST be <0.12 (i.e. NO BUNDLE BRANCH BLOCK) unless it is definitively known

in a timely manner that the BBB is new. • LVH must be absent: measure largest major deflections at V1 or V2 (S wave) and V5 or

V6 (R wave). If >35, possible LVH: do not call STEMI alert • Dispatch pre-notification: alert dispatch at the earliest time to pre-alert the hospital that

they will be receiving a STEMI unless you are ready to give a report. • Dispatch prenotification information:

o ECG shows STEMI and patient meets the criteria in 1-5 above o Note if cardiogenic shock or other severe symptomatolgy present o Gender o Age o Weight

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o Approximate ETA • Maximize use of scene time: in patients with likely ACS and STEMI, use your team to

rapidly acquire data as you are treating the patient. Move to MICU as quickly as is deemed safe for the patient.

• Help minimize transfer to cath lab times: changeover in the ED take a surprising amount of time. Simple maneuvers such as EMS removing the patient’s shirt prior to starting an IV shaves off time and lessens the chance of losing the IV. Other ways that we can help with a smooth handoff will be explored.

Trauma Alert

• Victim of a penetrating or blunt trauma that by mechanism of injury and/or physical

findings suggesting a high likelihood of requiring immediate surgery or admission to the ICU for stabilization.

• Isolated head injuries, particularly those due to penetrating trauma will not usually require trauma alert.

Stroke Alert

• Field neurological exam is positive for focal neurological deficit suggestive of cerebrovascular accident (CVA).

• Strong evidence that symptoms began within the preceding 3 hours. • Pt had no severe neurological conditions preceding this event. • The patient is alert. • There are no obvious signs of contraindications to the use of fibrinolytic agents such as:

o Age less than or equal to 18 y/o o CVA or head trauma within the preceding 3 months o Major surgery in the last 14 days o History of intracranial hemorrhage o Rapidly resolving symptoms of stroke o GI or GU bleeding within the preceding 21 days o No seizure at onset of stroke

Arrival Times at Hospital

All Anchorage Area Wide EMS providers engaged in the transport of a patient to an area hospital will notify AFD Dispatch of MICU arrival at hospital only at the point when:

1. They have actually arrived on the ‘ramp’ at the ED.

2. The hospital garage doors, when used, are fully open.

This policy adjustment is a result of ongoing dialogue regarding the STEMI policy, and is part of an area wide statistical effort to capture accurate times in all incidents involving patients suffering from Myocardial Infarction. It is important to note that this shall apply to all patients transported by EMS providers and shall be strictly adhered to. Questions may be directed to an on duty AFD EMS Battalion Chief. Hospital Disposition of Code 99, Status 1 and Status 2 Pediatric

Patients and Pre-term Labor Pediatric patients 12 years old and under who are stable enough to bypass the closest hospital but who are expected to require admission to a Pediatric Intensive Care Unit (PICU) should be

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transported to either Providence Alaska Medical Center Hospital or to Alaska Native Medical Center, as appropriate, rather than to Alaska Regional Hospital or Elmendorf Hospital. This also applies to any OB patient less than 34 weeks gestation who is in pre-term labor. Critical care pediatric resources are concentrated at Providence and ANMC and are thus more capable of providing the best in-patient care for this patient population. Early notification of the receiving facility is crucial to allow them to assemble the needed resources in the ER. Pediatric or OB patients requiring immediate life-saving interventions will, as per existing policy, be taken to the closest appropriate Emergency Department. The exercise of good paramedic clinical judgment will be the determining factor in distinguishing the proper disposition of these patients on a case-by-case basis.

Hospital Radio Report Format/Patient Status

1. Report MICU designator and estimated time of arrival. 2. Report patient status*. 3. Report patient age and sex. 4. Report chief/complaint/mechanism of injury and brief pertinent history. 5. Report level of consciousness. 6. Report respiratory rate, depth and effort. 7. Report pulse rate and, if applicable, ECG rhythm. 8. Report blood pressure. 9. Report physical exam findings. 10. Report treatment provided and patient response. 11. State patient physician preference, if any.

*Patient Status The patient status code is determined by the following guidelines:

• Code 99-Cardiac Arrest • Status One- Unstable, immediate threat to life or limb. • Status Two- Stable at this time, potential threat to life or limb. • Status Three- Stable with no potential threat to life or limb.

Radio reports should be as brief as possible while still conveying necessary information.

Medical Consumables Expiration Dates During daily and Monday apparatus inventory checks of medical consumables, please be aware that most if not all of these supplies have expiration dates and need to be exchanged with replacements from EMS Supply when expired. Checks of medical consumables found in station storage lockers should be made weekly as well, if not on Monday then another day identified by the station Senior Captain. If a parenteral medical consumable is in an undamaged and unopened package with a printed expiration date, it should be considered sterile and should remain unopened until used or rotated out upon expiration (e.g., IV catheters, IV tubing, and medications). Expiration dates are determined as follows:

1. If a medical consumable or date sensitive medical device has an expiration date which shows only the month and year (e.g., 5/07), it expires on the last day of that month.

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2. If a medical consumable or date sensitive medical device has an expiration date which lists day, month and year (e.g., 5/15/07), it expires on that day.

All expired or damaged medical consumables should be removed from AFD inventory.

Medication Use and Patient Safety Patient safety is the highest priority for the prehospital care providers of the Anchorage Fire Department EMS. As part of a more comprehensive Error Free Drug Program, the Medication Use and Patient Safety protocol will be one of several initiatives aimed at eliminating the chance of errors during the course of drug administration to patients within the Anchorage Area Wide EMS System. General

• Medication errors are a preventable cause of harm to patients. • Many medications including intravenous (IV) solutions appear similar and it is imperative

that one confirm the name, concentration and expiration date found on the label. • The AFD will strive to avoid all medication and IV infusion errors through education,

training and strict adherence to the best-demonstrated practice of medication administration and IV solution infusion.

Guidelines

• All personnel authorized to administer a given medication or IV infusion will be familiar with its indications, warnings and contraindications.

• All personnel who are involved in patient care and in assisting providers with medication administration including IV infusions will be familiar with medications used by AFD and be able to accurately identify these agents and their packaging.

• Such personnel will periodically demonstrate competence in this activity. Administration of Medications and IV Infusions

• Select medication and IV infusion fluid based upon clinical setting as per the MOM. • Select proper dose. • Reconfirm that proper medication and IV infusion fluid, and proper dose and drip rate, is

to be given. • Review allergies and medication list to confirm that no contraindication to the medication

exists. • If more than one provider is involved in drawing up medications, it is the responsibility of

the provider administering the medication to visually reconfirm the safety checks listed above as well as to confirm that the medication in a syringe is the desired medication by checking the label of the bottle from which it was drawn.

• Prior to attaching a properly assembled IV infusion set to a properly catheterized patient, the individual starting the IV will visually confirm that the IV has been assembled utilizing the proper IV fluid solution.

Errors

• If a medication is given or an IV infused in error, the first priority is to assess any immediate adverse reaction to the patient as well as to anticipate other potentially delayed consequence.

• Depending on the circumstance it may be appropriate to notify the patient at the time of the incident or later.

• Notify the receiving physician of the error and any corrective action. • Notify your shift EMS Battalion Chief.

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• Complete a FD-1 to the AFD Medical Director with a carbon copy to the EMS Battalion Chiefs and the Assistant Chief of EMS.

Patient Safety and EMS Medical Supplies

Patient safety is the responsibility of all Municipality of Anchorage EMS providers regardless of department affiliation, rank, or medical certification/licensure. In the interest of patient safety the Anchorage Fire Department is instituting the following procedures for all departments and personnel maintaining and restocking medical supplies from AFD EMS supply sources (area hospitals, EMS Supply, and in-station stores):

• It is the responsibility of the individual restocking medical supplies to confirm the contents of all supplies including but not limited to the correct medications and concentrations, IV solutions, expiration dates and compatibility with other medical supplies.

• Any member who discovers a discrepancy or incompatibility involving medical supplies within the station or during apparatus inventory checks will immediately notify their company officer (or designated officer or EMS Supply Officer for the Chugiak and Girdwood departments).

o The on-duty AFD EMS Battalion Chief will be immediately notified of this event. • Any member who discovers a discrepancy or incompatibility involving AFD medical

supplies at the area hospitals or with EMS Supply will immediately notify the on-duty AFD EMS Battalion Chief.

• The EMS Supply room will be secured after each access for restocking unless the EMS Supply Technician is present within the room.

• The supply room at Providence Alaska Medical Center and the supply cabinets at Alaska Regional Hospital will be secured after each access for restocking.

Utilizing ICS for Code 99 Resource Management In order to comply with P&I 905-2 and SOG I-2, personnel are instructed to establish a command structure to manage resources during the course of a Code 99 response. The initial dispatch will assign the responding resources to a tactical channel for cardiac arrest and respiratory arrest responses. Upon confirmation of Code 99 by the first arriving unit(s), command will be established and named, and a tactical channel will be requested if one has not already been assigned. Command may be assumed by the EMS Battalion Chief upon arrival on scene.

Perimortal Policy

This section shall define AFD policy regarding situations that involve patients that have been determined to be beyond resuscitation. Included are guidelines and information pertaining to SUID, obvious death, those patients that do not respond to advanced life support resuscitation efforts, and expected home death/Comfort-One patients It is the policy of the AFD to assume that a reasonable chance of resuscitation exists unless otherwise addressed in this document.

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SUID (Sudden Unexpected Infant Deaths) Policy In recognition of CDC guidelines concerning death scene investigation for victims of SUID it shall be the policy of the Anchorage Fire Department not to transport those patients under twelve months of age believed to have expired as a result of sudden infant death syndrome in circumstances when no resuscitation efforts have been undertaken.

Obvious Death/Decision Not to Resuscitate Policy It is AFD policy for the first arriving crew to begin resuscitation on any patient without pulse or respiration unless one or more of the following signs are present. If there is any doubt whether or not the patient meets this criterion, then CPR with BLS adjuncts shall be initiated. Resuscitative efforts shall continue until the first arriving MICP or EMT determines that the patient is beyond resuscitation and/or an emergency department physician is contacted and consulted.

• Evidence of non-recent death: o Rigor mortis (NOTE: only valid if hypothermia clearly not a factor). o Dependent lividity (NOTE: area to check depends upon position of patient). o Any evidence of decomposition.

• Explosive gunshot wound(s) to the head. • Severe injury obviously incompatible with life. • Submersion greater than one hour. • Suspected death due to hypothermia with the following signs:

o Core temp < 60 degrees. o Patient has ice in the airway. o Generalized or total body frozen skin/tissue which is more than localized

frostbite. Procedure The first arriving apparatus that determines the patient to be beyond resuscitation based upon the above criteria shall advise dispatch of an “11-29“ and recommend the closest ALS unit amend to code yellow; all other responding units shall be in service. The first arriving MICP or EMT will confirm the initial assessment and complete all required documentation. In the case of dispatch advising 11-29 per APD/AST then only the closest ALS unit will continue code yellow. Documentation The first arriving MICP or EMT shall complete a patient care report, specifically recording the physical findings which support the decision not to resuscitate based on the criteria established in this policy (NOTE: The assessment/impression portion of the narrative should be documented as “Beyond resuscitation“ or “No chance of resuscitation“). Any decisions not to resuscitate made upon consultation with a physician must have the time of contact and the name of the physician included in the documentation. Exceptions to this policy

• Triage decisions in multiple patient incidents. • An inability to gain access to the patient. This would include:

o Entrapment o APD/AST denying access to the scene or patient. If this is the case attempt to

obtain the name and badge number of the officer for documentation. o Situations that would place rescuers/AFD personnel in grave danger.

• Decisions based upon direct consultation with an emergency room physician, or with an identified MD on scene. Delays in Physician contact must be fully documented.

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Patients Unresponsive to CPR Policy Decisions by paramedics or EMTs to discontinue advanced life support resuscitation efforts outside the hospital, once those efforts are underway, require consultation with an emergency department physician. Contact must be made prior to discontinuing resuscitative efforts. Documentation The name of the consulted MD and the time of contact must be clearly documented on the completed patient care report.

Traumatic Cardiac Arrests

• Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life:

o Decapitation. o Hemicorporectomy. o Significant time lapse since pulselessness, including dependent lividity, rigor

mortis, and decomposition. • Blunt Trauma - Resuscitation efforts may be withheld in any blunt trauma patient who,

based upon a MICPs thorough primary patient assessment, is found: o Pulseless and apneic. o Asystolic in ECG leads I - III.

• Penetrating Trauma - Resuscitation efforts may be withheld in any penetrating trauma patient who, based upon a MICPs thorough primary patient assessment, is found:

o Pulseless and apneic. o Absence of papillary reflexes or spontaneous movement. o Asystolic in ECG leads I – III.

• Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a non-traumatic cause of the arrest, should have standard resuscitation initiated.

• Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiac arrest and 15 minutes of unsuccessful resuscitation and CPR.

• Traumatic cardiac arrest patients with a transport time to an emergency department of more than 15 minutes after the arrest is identified may be considered non-salvagable, and termination of resuscitation should be considered.

Comfort One/Do Not Resuscitate

Policy When AFD is called to respond to a confirmed expected home death or Comfort-One patient, the nearest ALS engine or MICU will respond code yellow to confirm that the patient is without signs of life. If another call of an emergency nature is received, and the unit responding is the closest available, that unit will divert to the emergency call and an additional ALS Engine or MICU will be dispatched to the original call. It is the responsibility of the EMT or MICP to assess the needs of the family for emotional support and ascertain whether logistical assistance in dealing with the deceased is required. The APD chaplain may be contacted through AFD dispatch to assist the family or caregivers of the patient at the discretion of the AFD EMT or MICP. Procedure The responding EMT or MICP will carefully evaluate pulse and respiration before verbal confirmation of death is reported to APD or the patient’s family. It should be noted that an ECG is not required nor is it preferred. Physical findings must be documented completely on the patient care report. If upon arrival, the family requests resuscitation or if there is a conflict among the

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family, resuscitation may be undertaken if no signs of non recent death are present. Additionally, if the patient still has measurable vital signs and the family requests transport without resuscitation an AFD MICU will transport to a receiving facility. Contact the patient’s personal physician or the receiving emergency department physician if special requests are made or if there are questions regarding treatment.

Public Inebriate Incident Disposition

• All persons encountered during incidents that meet the criteria of a patient per the MOM may only be transported to an area hospital. Transports to the CSP Transfer Station, Brother Francis Shelter or Beans Café are not authorized destinations.

• Customer service rides of public inebriates that EMS providers deem to not meet the definition of a patient per the MOM to the CSP Transfer Station, Brother Francis Shelter and Beans Café are prohibited per P&I 900-32 (Customer Service Rides), section 1.4:

At no time will any person professionally deemed to be inebriated (or otherwise incapable of maintaining responsibility for his or her actions) be permitted to ride in fire department vehicles under this Procedure or its associated Policy.

• All patients that meet the MOM definition of a patient shall be documented via a Patient Care Report, regardless of disposition. 911 responses to Man Down calls involving patient contact with public inebriates are not Public Assists.

• EMS providers that triage a public inebriate to APD or CSP for transport to the CSP Transfer Station, Brother Francis Shelter or Beans Café shall document the encounter in the Advanced EMS tab in FireRMS, to include an EMS narrative.

Requesting APD Assistance

From this point forward, the term “10-34 Code” is to be used when requesting the assistance of a couple of APD officers, code red. As always, immediately provide a brief reason of the need if at all possible.

• The purpose of this change is to have AFD personnel use the same vernacular as APD, in order to minimize any miscommunication or delay in summoning their assistance. This should be particularly beneficial when AFD personnel are being physically assaulted and don’t have time to elaborate the reason for the request. Although this scenario rarely occurs, when it does AFD dispatchers will notify APD dispatch of the “10-34 code” and will provide any pertinent information they have such as the location and type of call.

• In situations where the assistance of many APD officers is needed code red, continue to use the term “10-33” to make the request as outlined in P&I 905 -10: Fire/EMS Communications. This will send every available APD Officer.

• When requesting APD code yellow, continue to use plain language terminology. Note that for verbal assaults, it’s APD’s policy to send responding units code yellow.

• In summary: AFD’s communications policy now allows the use of two “10” codes, both of which are used to summon APD assistance code red. For your safety, memorize and use them appropriately.

Examples

• “Alarm, Engine 7, 10-34 code for a combative patient” (assumes AFD dispatch knows E-7’s location).

• “Alarm, Medic 9, 10-34 code” (crew is unable to provide a reason for the request and assumes AFD dispatch knows M-9’s location. As soon as possible, M-9 must provide more information).

• “Alarm, Medic 3, 10-33 for shots fired” (assumes AFD dispatch knows M-3’s location). • “Alarm, Engine 1, 10-33 for a riot at the Egan Center.”

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Safety Modification to Mixed EMS Responses Company Officers and MICU Firefighter/Paramedics should make every effort to avoid causing accidents as a result of Code Red/Yellow responses. Two apparatus of different response codes following closely together can cause confusion to civilian drivers, potentially causing accidents and other driving hazards. If both apparatus are responding from the same location, here are some suggestions for avoiding this situation: Both Units Respond Code Yellow

• If no significant delays are anticipated and the patient information provided by Dispatch indicates a stable situation, then a Code Yellow response is acceptable.

• Studies by other organizations reveal that the time saved between an emergent and non-emergent response has little, if any, impact on patient outcomes.

• In some cases, responding Code Red disrupts the flow of traffic so much that it is actually faster to respond non-emergent with the flow of traffic.

Don’t Follow so Close

• It is permissible for the second apparatus to slow their response out of the station when responding together.

• Let the first apparatus clear the station, get into traffic and depart the immediate area. • After traffic has returned to a reasonable normal flow, then depart. • 30% of engine companies are cancelled while enroute to mixed responses and the vast

majority of patients fall within the Status 3 category. • For those rare, but more critical patients, life-saving interventions are going to be

performed by the first arriving Code Red unit. Both Units Respond Code Red

• If you’re still uncomfortable responding both units Code Yellow or providing adequate spacing between units, then respond Code Red.

• Under no circumstances should two apparatus respond together at different response levels.

If you are responding from different locations and intersect along the way, make sure to follow the above rules.

Transfer of Care/Return to Service Policy MICU crews delivering a patient to a receiving facility have the following responsibilities:

• Continue all necessary patient care until a full transfer of information has been made to ensure patient safety and continuity of care. This occasionally involves a short interim period if an emergency department is very busy.

• Give a full, face-to-face verbal report to the receiving employee who will accept and continue care.

• Deliver a written copy of the Patient Care Report before leaving, unless another response interrupts completion. Return or fax a completed copy of the PCR at the earliest opportunity when it is not possible to leave one at the time of transfer.

• Return the MICU to response-ready condition as soon as possible after completing necessary patient care and verbal reporting duties, and place the unit in service.

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Transport Policy for the Mat-Su Regional Medical Center The Mat-Su Regional Medical Center (MSRMC) is located at 2500 S. Woodworth Loop off of Trunk Road, at Mile 35.5 of the Parks Highway (near the Parks and Glenn Highway interchange). Per recent updates in policy, MOA employees are allowed to drive MOA vehicles into the Kenai or Mat-Su Boroughs, at their own discretion and without securing prior permission, provided they are on MOA business.

EMS providers should use the following guidelines when faced with the issue of transporting patients to the Mat-Su Regional Medical Center (MSRMC):

• EMS providers who transport to MSRMC must make contact with MSRMC Emergency Department prior to initiating transport. MSRMC must accept the patient prior to the transport.

• Contact with MSRMC Emergency Department must be made via cell/landline phone at (907) 746-5123 (or -5124). MSRMC does not have radio capabilities.

• MOA EMS providers who may transport to MSRMC will not be able to complete an ePCR at MSRMC. An ePCR should be completed as soon as possible and faxed to MSRMC Emergency Department at: (907) 861-6851.

Patient Status AFD

MICU’s operating in Anchorage

AFD MICU’s operating in Eagle River/Chugiak

Chugiak Girdwood

1 (inc. code 99)

Anchorage Area Hospitals Closest Hospital* ** Closest Hospital* ** Anchorage Area

Hospitals

2 Anchorage Area Hospitals

Anchorage Area Hospitals

1. Anchorage Area Hospitals 2. MSRMC**


3 Anchorage Area Hospitals


1. Anchorage Area Hospitals 2. MSRMC**


* The determining line for proximity to MSRMC vs. AK. Regional Hospital is the Glenn Hwy, approximately Chugiak High School ** MSRMC must be consulted as to patient acuity/condition, and accept the patient before transport is initiated to MSRMC

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Appendix A: Approved Medical Abbreviations A- a before AAOx3 awake, alert, oriented x 3 [person/place/time] A&O x 4 - alert and oriented to person, place, time and event ab abortion ,*SAB spontaneous AB abd. abdomen ABG arterial blood gas abs. absent ACLS advanced cardiac life support ACS acute coronary syndromes admin. administer AED automatic external defibrillator AICD automatic implanted cardioverter-defibrillator AIDS acquired immune deficiency syndrome ALS advanced life support AMA against medical advice AMI acute myocardial infarction amp ampule Amp. amputation amt. amount ant anterior A & O alert and oriented AOS arrived on scene APAP acetominophen (Tylenol) ASA aspirin (acetylsalicylic acid) ASAP as soon as possible AV atrial/ventricular B- BBP blood borne pathogen BCP birth control pills BG blood glucose b.i.d twice a day bilat. bilateral BLS basic life support BM bowel movement BOW: bag of water BP blood pressure B/S breath sounds BS blood sugar BVM bag valve mask (Ambu Bag™) C- c with CA cancer Ca calcium CABG coronary artery bypass graft ("cabbage") CAD coronary artery disease cal. caliber

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CC chief complaint cc cubic centimeter CCU Cardiac Care Unit CHF congestive heart failure cl. clear cm. centimeter cm3 cubic centimeter CT CAT scan CNS central nervous system CO2 carbon dioxide CO carbon monoxide C/O complains of conc. concentration cond. condition COPD chronic obstructive pulmonary disease CPR cardiopulmonary resuscitation CSF cerebral spinal fluid CSM circulation, sensation and movement. CVA cerebrovascular accident D- d day D5W 5% dextrose in water D50 50% dextrose DBP diastolic blood pressure DC disconnect D/C discontinue D&C Dilation and curettage Defib. defibrillation Deform. deformity DI diabetes insipidus DIC disseminated intravascular coagulation dig. digtalis disloc. dislocated DM diabetes mellitus DNR do not resuscitate DOB date of birth DOE dyspnea on exertion dsg. dressing DTR deep dendon reflexes DT's delerium tremens Dx diagnosis E- ea. each EBL estimated blood loss ECG electrocardiogram ED Emergency Department EDC estimated date of confinement EEG electroencephalogram EENT ears, eyes, nose and throat e.g. for example EKG electrocardiogram (old, from German electrokardiogram) EMD Emergency Medical Dispatcher

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EMS Emergency Medical Services EMS-C Emergency Medical Services for Children EMT Emergency Medical Technician EMT-P Paramedic Epi. epinephrine ER Emergency Room ET endotracheal (tube) ETA estimated time of arrival ETCo2 end-tidal Co2 (detector) ETOH ethanol (ethyl alcohol) ETT endotracheal tube exam examination F- F Fahrenheit FB foreign body FD fire department fem. femoral FF firefighter FH family history FHT fetal heart tones fl. fluid flex. flexion freq. frequency FROM full range of motion ft. foot, feet Fx fracture G- gm gram ga. gauge gal. gallon GB gallbladder GC gonorrhea gd. good gen. general gluc. glucose GI gastrointestinal GM seizure grandmal seizure gr. grain G 0 1,2, etc. gravida (must have number following) grav. gravida GOA gone on arrival GSW gunshot wound gtts drops GU genito-urinary H- h hour HA H/A headache Hb hemoglobin HEENT head, eyes, ears, nose, and throat HEPA high efficiency particulate aspirator

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Hep-B,HBV Hepatitis B (or A, C, D) Hg mecury HIV human immunodeficiency virus H & P history and physical HPI history of present illness HR heart rate h.s. at bedtime HTN hypertension Hx history I- ICP intracranial pressure ICS Incident Command System ICU Intensive Care Unit IM intramuscular info. information inj. injury irreg. irregular iu international units IUD intrauterine device IV intravenous IVD IV drip IVDA IV drug abuse IVP intravenous push IVPB intravenous piggy back J- J. joule jct. junction JVD juglar venous distension K- K potassium KCL potassium chloride KED Kendricks Extrication Device™ kg kilogram KVO keep vein open L- L. liter L left lac. laceration lat. lateral lb. pounds LBBB left bundle branch block LBP low back pain L&D labor and delivery lg. large lig. ligament liq. liquid LLQ left lower quadrant LMP last menstrual period

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LOC level of consciousness (in Glasgow scale) LOC loss of consciousness LPM liters per minute (oxygen) LPN Licensed Practical Nurse LR lactated Ringers (IV solution) L. left LUQ left upper quadrant M- m. meter mA milliamps MAE moves all extremities mand. mandible MAST Medical Anti Shock Trousers™ (see PASG) mcg microgram MCI mass casualty incident MCL1 modified chest lead 1 MCL 6 modified chest lead 6 MD medical doctor mEq milliequlivants mg milligram Mg magnesium MI myocardial infarction MICP Mobile Intensive Care Paramedic MICU Mobile Intensive Care Unit misc. miscellaneous ml. milliliters mm. millimeter mo month M/O months old mod. moderate MOI mechanism of injury MRI magnetic resonance imaging MS Morphine Sulfate M/S motor and sensory (i.e.; M/S intact x4 ext) MSDS Material Safety Data Sheet multip. multiparous musc. muscle MVA motor vehicle accident MVI multi-victim incident N- NA not applicable (available) Na sodium NaCl sodium chloride NAD no acute (apparent) distress NaHCO3 sodium bicarbonate narc. narcotic NC nasal cannula NCT narrow complex tachycardia neg. negative Neuro. neurological NG nasogastric NKDA no known drug allergies

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norm. normal NP Nurse Practitioner NPO nil per os (nil per mouth) NRB non-rebreathing (mask) NS normal saline NSAID non-steroidal anti-inflammatory drug NSR normal sinus rhythm NTG nitroglycerin N&V nausea and vomiting O- O2 oxygen OB obstetrics Ob/Gyn obstetrics/gynecology occ. occasional OCP oral contraceptive pill OD. overdose OTC over the counter oz. ounce P- p after (superscript hyphen over p) P 1,2, etc. parity (must be followed by # and used with gravida) PA, PA-C Physician Assistant palp. palpation parox. paroxysmal PASG pneumatic anti-shock garment PAC premature atrial contraction/complex PAT paroxysmal atrial tachycardia PCN penicillin PCR patient care record/report PD police department PE pulmonary embolus, or physical exam PEA pulseless electrical activity (cardiac) PERL pupils equal and reactive to light PERLA pupils equal and reactive to light and accommodation PERRL pupils equal, round, and reactive to light PERRLA pupils equal, round, and reactive to light and accommodation peds. pediatrics PID pelvic inflammatory disease PIH pregnancy induced hypertension PMH past medical history PMS pulse, motor, sensory PMS premenstrual syndrome PND paroxysmal nocturnal dyspnea pneumo.,ptx pneumothorax p.o. by mouth post. posterior POV privately owned vehicle PPE personal protective equipment preg. pregnant prep. prepare PRN as necessary/needed PROM premature rupture of membranes

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prox. proximal PT patient PTCA percutaneous transluminal coronary angioplasty PTOA prior to our arrival PVC premature ventricular contraction Q- q each, every q.d. each day q.h. each hour q.i.d. four times a day qt. quart R- R rate R right RBBB right bundle branch block resp. respirations RL Ringer’s lactate (IV solution) RLQ right lower quadrant Rm room RMA refuse[s] medical assistance RN Registered Nurse ROM range of motion RSI rapid sequence intubation RT Respiratory Therapist RUQ right upper quadrant Rx prescription/medication S- s without SABA supplied air breathing apparatus sal. saline SAR search and rescue SBP systolic blood pressure SCBA self contained breathing apparatus SCUBA self contained underwater breathing apparatus SUIDS sudden unexpected infant death syndrome SA sinus node (sinoatrial) SIVP slow intravenous push SL sublingual SOB shortness of breath SOP standard operating procedure SpO2 oxygen saturation (peripheral/pulse) SQ subcutaneous S&S signs and symptoms SR sinus rhythm STAT immediately STD sexually transmitted disease std. standard sup. superior supp. suppository Surg. surgery or surgeon

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SVT supraventricular tachycardia Sx symptoms/signs T- T temperature tab. tablet TB tuberculosis TCA tricyclic anti-depressant TIA transient ischemic attack t.i.d. three times a day TKO to Keep Open TM tympanic Membrane tol. tolerate(d) TPR temperature, Pulse, Respirations trach. tracheostomy tract. traction Tx treatment U- ug micrograms UOA upon our arrival URI upper respiratory infection UTI urinary tract infection V- Vv. vein VA Veteran's Administration (US Government) VD venereal disease VF ventricular fibrillation VFD volunteer fire department V-fib ventricular fibrillation vol. volume vs vital signs VT,V-tach ventricular tachycardia W- WBC white blood count WCT wide complex tachycardia WD warm/dry wk. week WNL within normal limits WPD warm, pink, dry (skin signs) WPW Wolf-Parkinson-White wt. weight X- X-fer transfer Y- Y/O, y.o. years old

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Appendix B: MOM 3.0 This revision table recognizes the major changes and additions that have occurred in AFD EMS between the electronic versions of the MOM 2007 v. 2.0 (September 21, 2005) and this new edition.

MOM 3.0

MOM 3.0 Change, Addition -Changes to and additions of new protocols and medications. -Overall layout changed with decreased size and use of hyperlinks.

Cover Change Revision and date added. Introduction Change -Updated intro from Dr. Levy.

-Updated language from P&I Contact Telephone Numbers

Change Updated contact numbers for Providence Hospital.

Table of Contents Change Updated to reflect changes. Section 1: Adenosine Change Reversed to MOM 2007 dosage. Section 1: Vecuronium Change New medication added. Section 2: Adult IO Therapy Change Updated protocol. Section 2: AED Algorithm Change Updated algorithm. Section 2: Amputations Change Updated to reference Tourniquet

Protocol. Section 2: Anaphylaxis Addition New protocol and guidelines added. Section 2: Chest Pain Change Updated. Section 2: EMT-II and EMT-III Patient Care Protocol

Addition Added EZ-IO use in unconscious adult patients.

Section 2: External Hemorrhage

Addition New algorithm added.

Section 2: General Trauma Guidelines

Change Updated with new language.

Section 2: Pediatric IO Therapy

Change Updated and moved to Section 3.

Section 2: Post Cardiac Arrest Cooling

Addition New protocol added.

Section 2: Post Resuscitation Care Algorithm

Change Updated algorithm.

Section 2: Pulseless Arrest Algorithm

Change Updated algorithm.

Section 2: Tourniquet Addition New equipment and protocol added. Section 2: Triage (START Table)

Addition Moved from Appendix A.

Section 2: Appendix Change -Removed APGAR table, Child, and Infant Burn Tables; moved to Section 3. -Removed equipment-specific information; hyperlinked from protocols.

Section 3: Pediatric IO Therapy

Addition Added new protocol.

Section 3: Neonate/Small Infant IO Therapy

Addition Updated protocol to reflect treatment on patients <3 kg.

MOM 3.0 148


MOM 3.0 149

Section 3: Transporting the Pediatric Patient

Addition New equipment and transport guidelines added.

Section 3: Appendix Addition Added APGAR table, Child, and Infant Burn Tables.

Section 4: Medical Operations

Addition Modified contents of Section 5: Administrative moved to this section.

Section 4: ePCR Completions

Change Updated with new language.

Section 4: Medication Expiration Dates

Change Removed and updated (see next line).

Section 4: Medical Consumables Expiration Dates

Added New guideline.

Section 4: Patient Transports

Change Removed and update is found in P&I 900-41 Private Ambulance Service Dispatch

Section 5: Administrative Change State of Alaska Mandatory Reporting updated with material from ADM 07-18 Reporting Requirements; moved to Section 4: Medical Operations.

Appendix A: Multi-Victim Incident (MVI) and START Triage

Change START table moved to Section 2; MVI contents hyperlinked in Section 3.

Appendix B: MMRS Change Moved to document and hyperlinked in Section 4.

Appendix C: Approved Medical Abbreviations

Change Moved to Appendix A.

Appendix D: MOM 3.0 Change, Addition Update and add; changed to Appendix B.

anchorage (ak) protocols (2008)

Documents

medical protocols

medical control

basic medical standard

operations anne sigsworth

afd assistant chief

afd personnel

afd administration

chief scheunemann