cooke county emergency medical services … · cooke county emergency medical services patient...

COOKE COUNTY EMERGENCY MEDICAL

SERVICES Patient Treatment Protocols

For use by Cooke County Emergency Medical Services

These protocols are not valid unless signed by medical director in red ink on this page

Douglas T. Lewis, M.D. Medical Director

Effective Date: April, 2014

These protocols are unique to Cooke County EMS per Medical Director Page 1

Table of Contents

Geographical and Status Personnel… ........................................................................................................... 5

Protocol Definitions … ................................................................................................................................... 6

Trauma Section 5 – 37

Introduction ................................................................................................................................................... 8

Initial Scene Survey ...................................................................................................................................... 9

Decision to Attempt Resuscitation .............................................................................................................. 10

Initial Trauma Assessment and Treatment ......................................................................................... 11 – 14

Traumatic Arrest ......................................................................................................................................... 15

Traumatic Shock ......................................................................................................................................... 16

Penetrating Injuries:

Truncal Wounds .......................................................................................................................................... 17

Neck wounds ............................................................................................................................................... 18

Head/Face Wounds .................................................................................................................................... 19 Isolated Extremity Wounds ......................................................................................................................... 20

Impaled Objects .......................................................................................................................................... 21

Sucking Chest Wound ................................................................................................................................ 22

Traumatic Brain Injury ......................................................................................................................... 23 – 24

Eye Injuries:

Corneal Burns and Abrasions ..................................................................................................................... 25

Blunt or Penetrating Eye Injuries ................................................................................................................. 26

Burn Injuries:

Chemical Injuries to Eye .............................................................................................................................. 27

Thermal Burns .................................................................................................................................... 28 – 29

Chemical Burns .......................................................................................................................................... 30

Electrical Burns / Electrocutions ................................................................................................................. 31

Amputation ................................................................................................................................................. 32

Pregnant Trauma Patient ............................................................................................................................ 33

Pediatric Trauma ................................................................................................................................ 34 – 35

Isolated Musculo-Skeletal Injury ................................................................................................................. 36

Acute Blunt Spinal Cord Injury .................................................................................................................... 37

Domestic Violence ...................................................................................................................................... 38


Medical Section 40 – 81

Abdominal Pain .......................................................................................................................................... 40 Allergic Reaction – Mild .............................................................................................................................. 41 Allergic Reaction – Moderate ...................................................................................................................... 42 Allergic Reaction Severe - Anaphylaxis ...................................................................................................... 43 Cardiac Arrest ............................................................................................................................................. 44 Asystole ...................................................................................................................................................... 45 Pulseless Electrical Activity (PEA) .............................................................................................................. 46 VF / Pulseless VT ....................................................................................................................................... 47 Post Resuscitation ...................................................................................................................................... 48 Bradycardia ................................................................................................................................................ 49 PSVT: Stable .............................................................................................................................................. 50 PSVT: Unstable .......................................................................................................................................... 51 VT: Stable ................................................................................................................................................... 52 VT: Unstable ............................................................................................................................................... 53 Acute Coronary Syndrome (Chest Pain - Suspect MI) ........................................................................ 54 – 55 STEMI ................................................................................................................................................. 56 – 57 Induced Hypothermia .......................................................................................................................... 58 – 59 Cardiogenic Shock ...................................................................................................................................... 60 Hypotension / Shock – unexplained ............................................................................................................ 61 Hypertensive Crisis ..................................................................................................................................... 62 Stroke ......................................................................................................................................................... 63 Asthma ....................................................................................................................................................... 64 CHF and Pulmonary Edema ....................................................................................................................... 65 COPD ......................................................................................................................................................... 66 Pneumonia / Bronchitis ............................................................................................................................... 67 Seizures ...................................................................................................................................................... 68 Dehydration ................................................................................................................................................ 69 Diabetic Emergencies ................................................................................................................................. 70 Altered Mental Status ................................................................................................................................. 71 Overdose / Poisoning ................................................................................................................................. 72 Behavioral/ Emotionally Disturbed .............................................................................................................. 73 Chemical Restraint ..................................................................................................................................... 74 Carbon Monoxide Poisoning ....................................................................................................................... 75 Heat Cramps / Exhaustion .......................................................................................................................... 76 Heat Stroke ................................................................................................................................................. 77 Hypothermia ............................................................................................................................................... 78 Radiation Exposure .................................................................................................................................... 79 Snakebite .................................................................................................................................................... 80 Sexual Assault ............................................................................................................................................ 81


OB / GYN Section 82– 90

Vaginal Bleeding ......................................................................................................................................... 83 Pre-Eclampsia / Eclampsia ......................................................................................................................... 84 Labor .......................................................................................................................................................... 85 Delivery ....................................................................................................................................................... 86 Breech Presentation ................................................................................................................................... 87 Cord Presentation ....................................................................................................................................... 88 Limb Presentation ....................................................................................................................................... 89

Pediatric Section 90 – 115

Post Delivery .............................................................................................................................................. 91 Neonatal Resuscitation ............................................................................................................................... 92 Meconium Staining ..................................................................................................................................... 93 Asystole ...................................................................................................................................................... 94 PEA ............................................................................................................................................................ 95 VF / Pulseless VT ....................................................................................................................................... 96 Post Resuscitation ...................................................................................................................................... 97

Unstable Narrow Complex Tachycardia ..................................................................................................... 98

Bradycardia ................................................................................................................................................ 99

Abdominal Pain ........................................................................................................................................ 100

Allergic Reaction – Mild ............................................................................................................................ 101 Allergic Reaction –Moderate ...................................................................................................................... 102 Allergic Reaction Severe- Anaphylaxis ...................................................................................................... 103 Altered Mental Status ............................................................................................................................... 104 Hypoglycemia ........................................................................................................................................... 105 Hyperthermia ............................................................................................................................................ 106 Hypothermia ............................................................................................................................................. 107 Near Drowning .......................................................................................................................................... 108 Overdose / Poisoning ................................................................................................................................ 109 Asthma ..................................................................................................................................................... 110 Bronchiolitis .............................................................................................................................................. 111 Croup ........................................................................................................................................................ 112 Epiglottitis ................................................................................................................................................. 113 Obstructed Airway / Foreign Body ............................................................................................................ 114 Seizures .................................................................................................................................................... 115


Appendix: Procedure Protocols 114 – 153

Pain Management ..................................................................................................................................... 117 Medication Assisted Intubation (MAI) ....................................................................................................... 118 Rapid Sequence Induction for Intubation (RSI) ............................................................................... 119 – 120 Continued Sedation / Paralysis ................................................................................................................. 121 Airway Management for the Burn Victim ................................................................................................... 122 Air Evacuation Protocol ............................................................................................................................ 123 Pacing Protocol ........................................................................................................................................ 124 DNR Protocol .................................................................................................................................. 125 – 126 Transtracheal Jet Ventilation .................................................................................................................... 127 Surgical Cricothyroidotomy ....................................................................................................................... 128 Nasotracheal Intubation ............................................................................................................................ 129 Orotracheal Intubation .............................................................................................................................. 130 King Airway ............................................................................................................................................... 131 Needle Chest Decompression .................................................................................................................. 132 Mucosal Atomization device (MAD) .......................................................................................................... 133 Portable Ventilator .................................................................................................................................... 134 Tidal Volumes (Pedi & Adult) ..................................................................................................................... 135

Blood Administration ................................................................................................................................. 136

Continuous Positive Pressure ................................................................................................................... 137

EZ – IO Intraosseous Infusion .................................................................................................................. 138

Rule of Nine’s Adult Burn Chart ................................................................................................................ 139

Rule of Nine’s Child Burn Chart ................................................................................................................ 140

Lund & Browder Burn Chart ...................................................................................................................... 141

Classification of Burn Severity Reference ................................................................................................. 142

Pediatric Drug Chart ................................................................................................................................. 143

Drug Calculations ...................................................................................................................................... 144

Dopamine Drip Chart ................................................................................................................................ 145

Levophed Drip Chart ................................................................................................................................. 146

Nitroglycerin Drip Dosage Chart ............................................................................................................... 147

Dobutamine Drip Chart ............................................................................................................................. 148

Nasogastric Tube ..................................................................................................................................... 149

12 – Lead Placement Reference .............................................................................................................. 150

Termination of Pre-hospital Resuscitation ................................................................................................. 151

Spinal Immobilization Clearance .............................................................................................................. 152

Orthostatic BP Measurement .................................................................................................................... 153

Start – Triage Guide System .................................................................................................................... 154

Rapid NIHSS form .................................................................................................................................... 155

Drug Guide Section 155 – 200

Pregnancy Category for Drugs ................................................................................................................. 156 Drugs A – Z .................................................................................................................................... 157 – 205


Geographical and Status of Personnel

Geographical Responsibility and Status of Personnel

Cooke County Emergency Medical Services covers 874 Sq. Miles of Cooke County. We are a rural EMS provider with

pockets of dense population. This protocol is to clarify when an EMT, EMT-P, Licensed Paramedic or Critical Care

Paramedic may perform his or hers protocols and in what areas they may utilize these protocols.

It is intended that these protocols are for on duty personnel. It is understood that there are times the off duty personnel

respond to major incidents, and in this case, the off duty personnel may utilize their skills. It is further understood that off

duty personnel may come across incidents that may require for them to utilize their skills. Within the operating area of

Cooke County, the personnel may utilize their skills, but all must be documented on the Patient Care Report.

Off Duty personnel that are traveling outside of Cooke County, that come across an incident, may utilize all their skills

within the guidelines of these protocols. An incident report must be completed and turned into the Administrator, and a copy

must go to the Medical Director for review.

On Duty personnel that are out of Cooke County EMS’ operating area and come across and incident, may utilize their

skills to the certified level. All appropriate patient care documentation must be completed.


Protocol Definitions

Definitions

1. Vital signs

For the purposes of these protocols, vital signs will be defined as follows:

a. Pulse b. Respirations c. Blood Pressure d. Pulse Oximetry e. Temperature f. Blood Glucose (as Indicated) g. End Tidal Co2 numbers and Charted waveforms on the following types of patients:

1) All intubated patients

2. Multi-Casualty Incident: Any incident that overwhelms local response capabilities

3. Verified intubation tube placement

A successful endotracheal intubation will be verified and documented by at least 4 of the following criteria:

a. Direct Visualization of tube passing through the cords b. Auscultation of six lung fields with positive air return c. Auscultation of an absence of air in the epigastrium d. Fogging of the tube e. Positive initial ETCO2 return f. Continuous ETCO2 return g. Charting of ETCO2 waveform h. Proper use of Bougie Stylet device

4. Pediatric Limits

a. Any patient < 18 years of age and < 40 kg or b. Any patient < 12 years of age.


Trauma

Protocols


Trauma Introduction

The initial assessment and treatment of a trauma patient must be performed in a rapid, systematic, and thorough fashion. Evaluation of the patient according to established priorities will help one to identify serious life-threatening situations quickly, so that intervention can take place, possibly preventing further deterioration in the patient’s status. The systematic evaluation of the trauma patient should be performed on all injured patients, even those with minor trauma. The most important priorities in the evaluation and treatment of the trauma patient are found in the primary survey of the patient. Frequently, patient assessment must occur simultaneously with patient treatment during this phase of the patient’s evaluation. At times, invasive procedures (e.g., intubation with in-line cervical stabilization) or initiation of rapid transport may be required before the complete, overall patient assessment is achieved.

The primary survey in a trauma patient includes assessment and treatment of the following:

1. Airway Evaluation, establishment, and maintenance of an airway using C-spine precautions; determination of the patient’s level of consciousness in order to provide additional information concerning the patient’s airway status.

2. Breathing Determination of whether or not a trauma patient is adequately breathing and oxygenating. Serious chest injuries may rapidly progress to cardio-respiratory arrest, and certain chest injuries

that may require immediate intervention (sucking chest wounds, tension pneumothorax).

3. Circulation Determination if a pulse is present, controlling external bleeding, and identification of injuries that may use significant blood loss. Initiation of rapid transport and intravenous fluids play a role in the treatment of the patient at this stage.

4. Disability Performance of a rapid neurological evaluation to establish a patient’s level of consciousness, and pupillary size and reaction.

5. Exposure The clothing is removed to identify all injured areas with special care to avoid hypothermia.

Return to Index


Trauma - Initial Scene Survey This guideline should be used in the initial assessment of the scene where a trauma patient is located.

1. Survey the scene for possible hazards and resurvey periodically. 3. Secure the scene. 4. Protect yourself first, then victims from hazards. 5. Identify mechanism of injury. 6. Identify all potential patients. Notify Medical Control of victim count. 7. Prioritize patients, if more than one, using the same ABC system. 8. If MCI, triage using START. 9. Notify Medical Control of victim count.

Return to Index


Trauma – Decision to Attempt Resuscitation

The following are guidelines regarding the decision to attempt resuscitation in the field. Good judgment and common sense shall be used in the application of these guidelines. 1. In all situations where there is any possibility that life exists, every effort should be made to resuscitate the patient and transport to the hospital. 2. The paramedic should be aware of the following facts:

a. Those persons in VF, PEA, and Asystole can potentially be resuscitated. b. That “time down” is an inaccurate parameter of resuscitation, as the patient could have been in bradycardia or

simply unconscious for all of that time, yet still perfusing blood to the brain. Additionally, information received from bystanders in regard to time is often inaccurate.

c. That pupil size and response to light can be inaccurate as medications taken orally or intraocular can affect them. Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia and yet be resuscitated without neurological deficit.

3. Resuscitation need not be attempted in the field in cases of:

a. Decapitation b. Decomposition c. Rigor mortis d. Dependent lividity e. Visual massive trauma to the brain or heart conclusively incompatible with life

f. Blunt mechanism of injury in cardiac arrest 4. Mass Casualty Incidents - In these situations, the acceptable triage protocol will apply.

5. Living Wills - The paramedic’s actions should not be changed by a Living Will described or produced by the family or bystanders. 6. “NO TRANSPORT” Decisions to not transport must be approved through MEDICAL CONTROL.

Note: Since it is usually not possible to predict no recoverability of a brain acutely insulted by cardiac arrest and attempts to do so increase anoxia time with the likelihood of further permanent brain damage, the responsible paramedic is usually obligated to start CPR. Paramedics should keep in mind that they may be held liable if they elect not to do so, on an arbitrary basis.

Return to Index


Trauma - Initial Assessment and Treatment

Clinical Definition: This guideline establishes priorities in the initial assessment and treatment of trauma patients. The trauma patient must be evaluated and treated in a rapid and orderly fashion in order to achieve the best patient outcome. When a life threatening problem is identified, treatment is initiated for that problem before proceeding with the next step in the guideline. Using this approach, life-threatening injuries are identified and treated in a stepwise manner.

NOTE: Assume the following in ALL severely injured patients:

a. The patient has a spinal injury until proven otherwise b. The patient has an immediate threat to life that has not yet been found. c. The patient is going to decompensate at any moment.

The only aspects of patient care that, in most cases, would be performed prior to the initiation of patient transport include:

a. Establish and maintain an adequate and appropriate airway with oxygenation and ventilation as required. b. Immobilize and protect the spine as indicated and required c. Initial attempts to control significant external hemorrhage

AIRWAY: Basic Life Support: 1. Assess level of consciousness 2. Assess, establish, and/or maintain an adequate airway, while also observing C-spine precautions. Apply cervical collar

if indicated and while doing so, note: a. Is trachea midline? b. Any bruising, swelling, or crepitus in the neck? c. Is carotid pulse present? If no pulse present, begin CPR and immediately refer to Traumatic Arrest Protocol.

(pg. 15) 3. Insert oral or nasopharyngeal airway as indicated. 4. Administer high flow oxygen (100% by face mask or BVM) and assist patient’s ventilation as needed. If the patient has a decreased level of consciousness, ventilate:

a. ≥ 13 y/o – 10 – 18 breaths/mi b. ≥ 5 – 12 y/o – 20 – 25 breaths/min c. 0 – 4 y/o – 30 – 40 breaths/min

If the patient has a decreased LOC or other signs of a traumatic brain injury: refer to Traumatic Brain Injury Protocol (pg. 23), after completion of the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14)

5. Reassess patient frequently including adequacy of ventilations. Intermediate and Paramedic I: 6. Establish need for in-line endotracheal intubation. Observe C-spine precautions. 7. If intubation is necessary, it should be performed using the two-man technique with one person stabilizing the cervical spine while the other person performs the intubation. Extreme care must be taken to avoid flexion or extension of the neck.

8. If intubation is performed, endotracheal tube placement should be assessed and documented using three or more of the


following techniques:

a. Visualization of endotracheal tube passing through vocal cords. b. Equal breath sounds. c. Absence of ventilated air in the epigastrium d. Rise and fall of chest wall. e. Use of a Bougie f. Fogging of the Endotracheal Tube g. Positive Initial Co2 return with EtCo2 (if available) h. Charting of ETCO2 waveform

9. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of 35 – 45 mmHg, otherwise ventilate at a rate of 12 – 20 breaths/minute for adults and children at a rate of 20 – 30 breaths/min for children less than 4 years of age. If the tube cannot be confirmed in the proper position, it should be removed and the patient re-intubated. When proper placement is confirmed, the tube should be properly secured with tube holder and c-collar and CID to minimize the chances of dislodgment. (If unable to fit patient with c-collar, secure head with CID).

10. Reassess patient’s airway/ventilation frequently. NOTE: Failure to provide and maintain an adequate airway is the most common cause of preventable pre-hospital morbidity and mortality. The airway should be carefully assessed initially and frequently reassessed to assure a competent airway is maintained during the pre-hospital phase of treatment. BREATHING: Basic Life Support:

1. Observe chest wall movement for symmetry and auscultate breath sounds on both sides of the chest. Rate, depth, and pattern of breathing as well as the integrity of the chest wall should be assessed. 2. Assist or deliver ventilations as required. All patients with a decreased level of consciousness ventilate:

a. ≥ 13 y/o – 16 – 18 breaths/min b. ≥ 5 – 12 – 20 – 24 breaths/min c. 0 – 4 y/o – 20 – 30 breaths/min

3. All patients with more than minor injuries (e.g., isolated extremity fractures, minor lacerations, etc.) should receive supplemental 100% oxygen by non-rebreather mask or BVM. 4. If sucking chest wound has been identified, apply dressing as described in Sucking Chest Wound Protocol. (pg. 22) Intermediate: 5. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube to maintain a EtCo2 of 35 – 45 mmHg. Paramedic I: 6. If signs of tension pneumothorax are present, refer to the Needle Chest Decompression Protocol (pg. 132) and contact MEDICAL CONTROL

CIRCULATION/ BLEEDING:


Basic Life Support: 1. Control serious external bleeding by direct pressure or pressure dressings. 2. If not already done, palpate for a pulse. If not present, initiate CPR and proceed to the Traumatic Arrest Protocol (pg. 15) 3. If pulse is present, then obtain pulse rate and BP. If systolic BP < 90, Heart Rate > 120, and/or clinical evidence of shock is present, refer to Traumatic Shock Protocol. (pg. 16) 4. Palpate abdomen for rigidity or tenderness and pelvis for pain or crepitus (identifying potential sources for significant blood loss). 5. Examine the patient’s back, if possible, for gross deformities or penetrating injuries prior to placing the patient on the backboard. 6. For penetrating injuries, also see Penetrating Injuries Protocol. (pg. 17)

Intermediate and Paramedic I: 7. If there is evidence of a significant mechanism of injury, external blood loss, or evidence of possible pelvic or femur fracture or other significant injuries, attempt to establish 2 large bore IVs with NS and run wide open if the patient’s SBP is less than 90 mmHg systolic. Run IV at TKO rates or at the direction of MEDICAL CONTROL. Attempts to establish IV access are usually made en route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If the patient has a SBP < 90 or heart rate > 120, see the Traumatic Shock Protocol. (pg. 16)

DISABILITY (Neurological Exam): All Levels: 1. Evaluate neurological status by noting the following:

a. Mental status/level of consciousness. b. Presence/absence of movement in extremities, either spontaneously or in response to pain c. Pupillary size and reactivity. d. Evidence of trauma to the head or neck.

2. If evidence of head trauma, have suction ready and observe for any seizure activity. 3. If altered level of consciousness, assist or ventilate patient (if patient will allow).

a. ≥ 13 y/o – 16 – 18 breaths/min b. ≥ 5 – 12 y/o – 20 – 26 breaths/min c. 0 – 4 y/o – 30 – 40 breaths/min

End-tidal CO2 monitor, ventilate to maintain an EtCo2 of 35 – 45 mmHg. 4. If evidence of closed head injury, see Traumatic Brain Injury Protocol. (pg. 23-24)

NOTE: The patient’s status must be reassessed at frequent intervals to detect changes and these changes should be immediately reported to Medical Control. The ABC’s including vital signs should be repeated every 15 minutes in potentially stable patients and every 5 minutes in unstable patients.

EXPOSE AND EXAMINE:


All Levels:

1. Examine for specific injuries – burns, chemicals, drowning, eye, etc. If present, see specific protocol.

2. Assess extremities by inspection and palpation for present of tenderness, gross deformity, soft tissue swelling, lacerations, or

abrasions. Also, note motor, sensory, and vascular integrity in each extremity. Appropriately dress and splint extremity injuries as

required and as time will allow. Elevate injured extremities when possible.

3. If possible, when patient is log rolled onto backboard, palpate and inspect back for evidence of trauma.

4. Calculate Glasgow Coma Score and Revised Trauma Score.

GLASGOW COMA SCORE

REVISED TRAUMA SCORE

Eye Opening

Spontaneously

To verbal Command

To Pain

No Response

Score:

Best Verbal Response

Oriented

Confused

Inappropriate words

Incomprehensible sounds

No Response

Score:

Best Motor Response

Obeys

Localized Pain

Withdraws to pain

Abnormal Flexion to pain

Extension to pain

No Response

Score:

Total

4

3

2

1

5

4

3

2

1

6

5

4

3

2

1

Score

_____

Respiratory Rate

10 – 29 =

> 29 =

6 – 9 =

1 – 5 =

0 =

Score:

Systolic Blood Pressure

> 89 =

76 – 89 =

50 – 75 =

1 – 49 =

0 =

Score:

Glasgow Coma Score

13 – 15 =

9 – 12 =

6 – 8 =

4 – 5 =

3 =

Score:

Total

4

3

2

1

0

4

3

2

1

0

4

3

2

1

0

Score

_____

Return to Index


Traumatic Arrest

Clinical Definition: This protocol should be used for the treatment of a patient who has suffered a traumatic cardiac arrest. Patients with a blunt mechanism of injury and who have a cardiac arrest have minimal, if any, chance of survival, and many pre-hospital providers do not attempt resuscitation. For those providers who attempt resuscitation, the following protocol should be used. Resuscitation should be attempted in all patients with a penetrating mechanism of injury. Basic Life Support: 1. If not already done, evaluate/treat ABC’s according to Trauma assessment and Treatment Protocol. (pg. 11-14) 2. Initiate CPR and prepare for rapid transport. Immobilize spine, if appropriate. Intermediate: 3. Establish patent airway using in-line cervical spine stabilization, if appropriate. 4. Identify correctable causes of hypoxia and initiate treatment:

a. Administer 100% oxygen. b. For sucking chest wounds, treat according to Sucking Chest Wound Protocol. (pg. 22)

5. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of 35 – 45 mmHg, otherwise ventilate at 12 – 20 breaths/minute for adults and children at 20 – 30 breaths/min for children less than 4 years of age. 6. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en-route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used.

Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm. 8. If rhythm other than PEA, treat cardiac arrhythmia per protocol during transport. 9. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg. 11-14)

10. Evaluate for tension pneumothorax, Contact Medical Control and refer to the Needle Chest Decompression Protocol. (pg. 132)

Note: PEA in a trauma patient is most likely due to hypovolemia from blood loss. Definitive therapy is usually required to

stop the source of hemorrhage and blood transfusions are needed usually ASAP. Hence rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume BUT DOES NOT CARRY OXYGEN.

Return to Index


Trauma - Traumatic Shock

Clinical Definition: This protocol should be used for the treatment of patients with traumatic shock SBP < 90 & HR > 120, but with a palpable pulse. If no pulse is palpable, proceed to (Traumatic Arrest Protocol) (pg. 15). Frequently, shock in a trauma patient is due to internal or external bleeding. Hemorrhagic shock can be recognized by hypotension, tachycardia, diaphoresis, pallor, cyanosis, tachypnea, and other clinical signs of shock. Fluid resuscitation should be aimed at maintaining a SBP 70 – 90 mm/hg and no higher. Basic Life Support: 1. If not already done, evaluate/treat ABC’s according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11) 2. Prepare for rapid transport. Intermediate: 3. Establish a patent airway using C-spine precautions. Use End-tidal CO2 monitor to maintain an EtCo2 of 35 – 45

mmHg, otherwise ventilate at 12 – 20 breaths/minute for adults and larger children and at 20 – 30 breaths/min for children less than 4 years of age.

4. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used.

5. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Paramedic I: 6. Evaluate as to need for Tranexamic acid infusion. (pg. 136)

7. Apply ECG electrodes and determine cardiac rhythm. Note: Fluid resuscitation in children is performed according to weight. Definitive therapy is usually required to stop the

source of hemorrhage and blood transfusions are needed usually ASAP. Rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume; BUT DOES NOT CARRY OXYGEN.

MINIMIZE ON - SCENE TIME

Return to Index


Trauma – Penetrating Injuries (Truncal Wounds)

Clinical Definition: Any injury in which there is evidence for penetration of the skin by an object that could result in injury to underlying structures. Examples include gunshot wounds, stab wounds, ice pick wounds, impaled objects, sucking chest wounds, etc. Other protocols may apply in cases of penetrating injuries, such as traumatic shock and traumatic arrest. Refer to all of the appropriate protocols that apply.

General Guidelines: Truncal Wounds

Chest / Abdomen / Back / Proximal Extremities Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Treat open chest wounds according to guidelines for sucking chest wounds; refer to Sucking Chest Wounds Protocol (pg. 22) 5. Treat evisceration of abdominal contents by covering tissue with saline-moistened gauze sponges or sterile towels. DO NOT attempt to replace abdominal contents through the wound. Intermediate: 6. Attempt to establish 2 large bore IV’s with Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between 70 – 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm.


Return to Index


Trauma – Penetrating Injuries (Neck Wounds)

General Guidelines: Head / Neck / Face Wounds

Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury, tracheal injury, blood vessel injury, and lung injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Monitor closely for signs of soft tissue swelling in the neck that could lead to airway obstruction. 5. Have suction set up and ready to clear airway of blood or secretions. 6. Observe closely for signs of a tension pneumothorax. Intermediate: 7. Attempt to establish 2 large bore IV’s and Normal Saline and run at appropriate rate to be aimed at maintaining a SBP 70 – 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 8. Apply ECG electrodes and determine cardiac rhythm. Paramedic II: 9. Prophylactic intubation (MAI or RSI) may be required if airway compromise from neck swelling occurs.

Consult MEDICAL CONTROL. Contact Medical Control:

.

MINIMIZE ON - SCENE TIME Return to Index


Trauma – Penetrating Injuries (Head & Face Wounds)

General Guidelines: Head / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury, tracheal injury, and/or blood vessel injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Have suction set up and ready to clear airway of blood or secretions. 5. Elevate head of backboard 15 to 30 degrees - DO NOT elevate head by flexing neck! Intermediate:

6. If patient is unconscious or has a decreased LOC without a gag reflex and or rising ICP is suspected, an advance airway should be performed to secure the airway. Use End-tidal CO2 monitor with an advance airway.

Ventilate to maintain an EtC02 of 35 – 45 mmHg, otherwise ventilate at 12 – 20 breaths/minute for adults and larger children and at 20 – 30 breaths/min for children less than 4 years of age. 7. Attempt to establish 2 large bore IVS with Normal Saline and run at rate to be aimed at maintaining a SBP 70 – 90 mm/hg and no higher. 8. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL

CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm. Paramedic II: 10. Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. Contact Medical Control:

MINMIZE ON - SCENE TIME

Return to Index


Trauma – Penetrating Injuries (Isolated Extremity Wounds)

General Guidelines: Isolated Extremity Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Check neurovascular status distal to wound (presence of pulse, feeling, and movement). 2. If impaled object – do not remove; refer to Impaled Object Protocol. (pg. 21) 3. Control external bleeding with direct pressure first, then pressure dressings. 4. Splint affected extremity. 5. Elevate affected extremity 15 to 30 degrees. 6. Prepare for rapid transport, even if vital signs are stable. Intermediate: 7. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh

area, attempt to establish 2 large bore IV with Normal Saline and run at appropriate rate to be aimed at maintaining a systolic blood pressure between 70 – 90 mm/hg and no higher.

8. Attempts at IV access should be made en-route but may be attempted at the scene if approved by MEDICAL

CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm.

10. Refer to Pain Management Protocol. (pg. 117)

MINIMIZE ON – SCENE TIME

Return to Index


Trauma – Impaled Objects

Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. In general, do not remove impaled object. If impaled object is causing airway compromise resulting in respiratory

distress, and this distress cannot be corrected without removal of the foreign body, contact MEDICAL CONTROL immediately for further orders.

3. When possible, stabilize the impaled object on the body so that it does not move around and cause more internal injury. 4. Any impaled object to the torso (chest, abdomen, back, lower neck, or proximal extremities) should be considered a

potentially life-threatening injury and treated as such. Transportation should be initiated as soon as possible, even if the patient appears stable.

5. If manpower is available and time exists during transport, continue further evaluation and treatment of patient according

to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Intermediate: 6. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh

area, attempt to establish 2 large bore IV’S of Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between 70 – 90 mm/hg and no higher.

7. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL

CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 8. Apply ECG electrodes and determine cardiac rhythm. 9. Refer to Pain Management Protocol (pg. 117)


Return to Index


Trauma – Sucking Chest Wound

Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask 3. Seal the wounds as rapidly as possible, preferably with Vaseline-coated gauze or asherman chest seal, to prevent further collapse of the lung. * In general, the dressing should be sealed on two or three sides only. This allows it to act as a one-way valve allowing air in the pleural space (chest cavity) to get out when the lung expands, but preventing air on the outside from entering the chest cavity through the wound.* 4. Watch closely for signs and symptoms of a tension pneumothorax. If these signs develop, usually lifting one corner of the occlusive dressing will relieve the tension pneumothorax. 5. Prepare for rapid transport. 6. As time allows and manpower permits, continue evaluation and treatment of the patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Intermediate: 7. Attempt to establish 2 large bore IVS and Normal Saline and run at rate to maintaining a SBP between 70 – 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. *Note: If patient is awake and cooperative, have him/her cough (this removes as much air as possible from the chest

cavity), and then apply the Vaseline gauze or Asherman Chest Seal System immediately afterwards.

8. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or advanced airway. If an advanced airway is used, End-tidal CO2 monitor, ventilate to maintain an EtCo2 of 35 – 45 mmHg. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm.

Prophylactic intubation, MAI, may be required if airway compromise occurs Paramedic II:

Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs

Contact Medical Control:

Return to Index

MINIMIZE ON – SCENE TIME


Trauma – Traumatic Brain Injury

Clinical Definition: Any traumatic injury to the face or head which results in an injury to the brain, as manifested by some degree of impairment in mental function. Typically, these patients rage from being comatose to wild and combative. Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury. Provide supplemental oxygen. 2. If patient is hypoventilating, assist or provide ventilations (with supplemental oxygen) at a rate of 12 – 20. 3. Have suction hooked up and readily available. Be prepared to roll patient, if necessary, should vomiting occur. 4. Monitor EtC02 5. Monitor Oxygen Saturation 6. Take seizure precautions. 7. Prepare for rapid transport. 8. Elevate head of backboard 15 to 30 degrees. DO NOT elevate the head by flexing the neck! Intermediate: 9. Appropriate airway management may require endotracheal intubation while observing C-spine precautions. If patient is unconscious or has decreased LOC without a gag reflex, endotracheal intubation with in-line cervical spine stabilization and hyperventilation should be performed to decrease increased intracranial pressure.

If intubated, use, End-tidal CO2 monitor and ventilate to maintain an EtCo2 between 35 – 45 mmHg, otherwise ventilate at 12 – 20 breaths/minute for adults and larger children and at 20 – 30 breaths/min for children less than 4 years of age.

10. Attempt to establish 2 large bore IV’s of Normal Saline and run at appropriate rate to maintaining a SBP 70 – 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene only if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 11. Apply ECG electrodes and determine cardiac rhythm. 12. If seizures occur and are prolonged (greater than 15 – 30 seconds), administer Valium slow IV push in 2 mg increments, (10mg maximum for adult) until seizure stops. If intubation not performed prior to seizure, it should be performed after Valium has been administered so that hyperventilation may be more effectively performed and the airway is better protected.

Return to Index


13. If nausea / vomiting:

Ondansetron (Zofran):

4 mg IVP, IM or Oral ODT; (Max 8 mg Q 4 hours); may repeat in 15 minutes if no improvement

Pediatric Dosages of Ondansetron (Zofran):

Ages 2 – 7: 1 mg IVP / IM or Oral ODT; (Max 2 mg Q 4 Hours); may repeat in 15 minutes if no improvement

Ages 7 – 12: 2 mg IVP, IM or Oral ODT; (Max 4mg Q 4 Hours); may repeat in 15 minutes if no improvement

Under 2 years of age .15 mg/kg IVP or Oral ODT; may repeat in 15 minutes if no improvement 14. Prophylactic intubation, MAI, may be required if airway compromise occurs

Paramedic II: 15. Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs



Trauma – Eye Injuries (Corneal Burns & Abrasions)

Clinical Definition: These injuries usually occur when the eye is exposed to sources of high intensity light or ultraviolet radiation such as associated with tanning booths, or sun lamps, also corneal injuries may be produced by prolonged wearing of contact lenses. Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Lie patient down and have them close both eyes. 3. Bandage as necessary. Paramedic I: 4. Transport patient.

Return to Index


Trauma – Eye Injuries (Blunt or Penetrating Eye)

All Levels: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Have the patient lie flat or with the head slightly elevated. 3. DO NOT attempt to open the injured eye(s). 4. Instruct the patient to close both eyes. 5. Bandage as necessary. 6. DO NOT place any type of compressive dressing over the injured eye(s), and be careful not to apply pressure to the eye(s). 7. DO NOT REMOVE any penetrating object from the eye (unless ordered by medical control) 8. Transport the patient.

Return to Index


Trauma – Eye Injuries(Chemical Injuries to Eye) Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Flush the affected eye(s) with copious amounts of water or Normal Saline, using a minimum of 2 liters or more for each eye continued throughout transport. If the substance is alkaline in nature, perform continuous irrigation during transport. Contact lenses should be removed if present. Paramedic I: 3. Transport patient.

Return to Index


Trauma- Burns (Thermal)

Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Look closely for any evidence of inhalation injury (hoarseness, stridor, sooty sputum, facial burns, and singed facial hair). If present, provide supplemental oxygen, preferably humidified. 2. Prepare for air transport, if significant burn or inhalation injury. 3. Remove any jewelry, belts, shoes, etc. from areas of burns as these objects may retain heat and increase the burn; also swelling of burned areas may make subsequent removal difficult. In addition, remove any burned or singed clothing that is not stuck to the underlying skin of the patient. 4. Assess depth of burn (first, second, third) as well as the total area of the burn using “Lund & Browder burn chart / “rule

of nines” (pg. 139-141) or fact that palmar surface of the patient’s hand usually represents 1% of body surface area. Include only second and third degree burns in the percentage of body surface burnt.

5. Perform local burn care as follows:

a. Do not apply ice to burned area. b. Do not apply ointments or solutions to burns. c. Do not attempt to open blisters. d. Small burns (<10% of BSA):

1) If burn occurred less than 15 minutes prior to your arrival, cover burn with sterile towels or gauze sponges

soaked with saline.

e. Larger burns: a. Wear sterile gloves and mask until large burns are covered. b. Cover large burns with dry, sterile, or clean sheets. Do not use wet dressings since they may cause

hypothermia on large burns. c. Cover patients who have large burns with additional sterile or clean sheets or blankets to prevent loss of

body heat.

6. Treat any associated injuries (bandage and splint). 7. If eyes are affected, refer to Eye Injury Protocol. (pg. 25-27)

Intermediate: 8. IV therapy with Normal Saline should be initiated in patients with the following:

a. Evidence of inhalation injury. b. Elderly or underlying chronic illnesses or other associated injuries that require an IV. c. Burn exceeds 10% BSA. d. Electrical burns.

9. Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA).


Paramedic I: 10. Apply ECG electrodes and determine cardiac rhythm. 11. Monitor EtCo2 12. Consider Pain management:

Morphine 10 mg SIVP (Max Dose 40 mg)

AND

Valium 10 mg SIVP (Max Dose 20 mg)

May be repeated only if SBP is maintained >90 mmHg 13. If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL Paramedic III: 14. If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) or Prophylactic intubation (RSI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL


Return to Index


Trauma – Burns (Chemical)

Ensure Crew Safety! Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Remove

contaminated clothing and wash all exposed skin unless Lime exposure is suspected. DO NOT USE WATER ON LYE. Contact Poison Control and Medical Control for instructions on specific chemicals.

2. Splint any fractures or deformities as required. Intermediate: 3. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists. 4. Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA). Paramedic I: 5. Apply ECG electrodes and determine cardiac rhythm. Refer to appropriate arrhythmia protocol as required. 6. Consider Pain Management:


AND


May be repeated only if SBP is maintained >90 mmHg

Contact Medical Control

Return to Index


Trauma – Burns (Electrical & Electrocution)

Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Cover entrance and/or exit wounds with dry sterile dressings. 3. Splint any fractures or deformities as required. Intermediate: 4. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists 5. Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA). Paramedic I: 6. Apply cardiac monitor and determine rhythm. Refer to appropriate arrhythmia protocol as required. 7. Consider Pain Management:


AND


May be repeated only if SBP is maintained >90 mmHg


Return to Index


Trauma - Amputation

Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg.11-14) 2. Control bleeding with direct pressure or pressure points. Tourniquet is used only as a last resort. 3. Remove gross contaminants on part by rinsing with saline solution. No other attempt should be made to debride the part. 4. Wrap amputated part in moistened saline gauze and place in plastic bag or container. Seal the plastic tightly, so fluid cannot come in contact with the amputated part. Place sealed container in iced solution of water or saline. Intermediate: 5. Initiate IV Normal Saline if indicated. Run TKO unless hypotensive or clinical evidence of shock exists. Paramedic I: 6. Apply ECG electrodes and determine cardiac rhythm. 7. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control:

Return to Index


Trauma - Pregnant Trauma Patient

In order to adequately care for the mother and unborn child that have been traumatized, one MUST be aware of the following facts: 1. The average maternal heartbeat will increase by 10 to 15 beats per minute when compared to the non-pregnant patient. 2. The systolic and diastolic blood pressure of the pregnant patient will often decrease by 10 to 15 mmHg in the second trimester of pregnancy and then return to normal by term. 3. The pregnant patient undergoes a significant increase in circulating blood volume - about 40 to 50%. This represents as increase in both plasma and red blood cells. However, there is usually a greater increase in plasma compared to the increase in red blood cells, thereby resulting in a relative anemia for many pregnant patients. 4. The pregnant patient may lose 30% to 45% of her circulating blood volume before hypotension develops. 5. When the pregnant patient is lying flat on her back, the enlarged uterus can cause significant compression of the inferior vena cava, thereby reducing venous return to the heart by up to 25% or 30%. This can then result in hypotension. Therefore when possible, pregnant patients should be transported in the left lateral recumbent position. If it is necessary to immobilize the patient supine, then the backboard should be tilted upward 20 to 30 degrees towards the patient’s left. This will help to roll the pregnant uterus away from the inferior vena cava. 6. Gastric emptying and motility are decreased during pregnancy. This, combined with the compressive effects of the enlarging uterus on the stomach, increases the risk of aspiration in patients with a decreased level of consciousness. 7. Trauma to the pregnant patient can result in very significant amounts of occult bleeding - either intrauterine or retroperitoneal. 8. Abruptio placenta is the leading cause of traumatic fetal death. Vaginal bleeding is seen in about 75% of cases. Maternal hemorrhage that does not result in decreased blood pressure can still reduce fetal blood flow by 90-95%. Trauma significant enough to cause shock in the mother is associated with Fetal Death. Contact Medical Control: Consider: NG tube

Return to Index


Trauma - Pediatric Trauma Patient

Clinical Definition: This protocol applies to pediatrics < 18 y/o & <40 kg or any patient < 12 y/o. Individual protocols apply to all injured patients and should be applied to the pediatric patient with reference to this protocol. When the protocols differ, a special reference is noted in the general protocol. Pediatric Differences: Normal Pediatric Vital Signs: 1. Blood pressure: systolic 80 + two times age

Diastolic 2/3 systolic pressure 2. Pulse: Newborns 130 – 140

Infants 120 – 130 Preschool 100 – 120 School age 80 – 100

3. Respirations: Newborns 20 – 40

Infants 20 – 30 Preschool 20 – 25 School age 12 – 20

Blood Volume: The normal total blood volume of a child is about 80 – 85 ml/kg. Estimated Pediatric Endotracheal Tube Sizes:

Age Size Newborn 2.5 – 3.0 6 months 3.5 1 year 4.0 2-3 years 4.0 – 4.5 4-5 years 5.0 – 6.0 6-8 years 6.0 – 6.5 10-12 years 6.5 – 7.0 > 14 years 7.5 – 8


Shock: 1. Shock in a child is demonstrated by a faster than normal heart rate; cool and pale extremities; evidence of poor perfusion; and a systolic blood pressure less than 70 mmHg. Children have excellent compensatory systems and the appearance of a fall in blood pressure represents severe shock. 2. A child in traumatic shock has lost at least 25% of their total blood volume. 3. Treatment of shock: Basic: 4. High flow 100% oxygen. Intermediate: 5. At least one large bore IV with Normal Saline.

As with adults, attempts to establish IV access are usually made enroute but may be made at the scene, if long transport are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL

6. When replacing volume loss in a child suffering from hemorrhagic shock, give an initial fluid bolus of 20 cc/kg.

If the vital signs then stabilize and the child no longer appears to be in shock, run the IV at a TKO rate while continuing to transport. If the first fluid bolus of 20 cc/kg does not stabilize the child’s vital signs, then give a second fluid bolus of 20 cc/kg. This means that the child has probably lost at least one half of his/her total blood volume and will need blood transfusions upon arrival at a health care facility.

Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm.

Return to Index


Trauma - Isolated Musculo-Skeletal Injury

Clinical Criteria: Muscular skeletal injuries with absolutely no potential for head, abdominal, chest or multi-system injury. Examples, isolated extremity fracture, crush injury and / or burn. Mechanism of injury consistent of an isolated muscular skeletal event with deformity, swelling and ecchymosis to the injured site. Pain present upon movement or palpation of the injury site and is normotensive patient without allergies or other contraindications. Basic: 1. C-spine control ABC’s 2. Hemorrhage control 3. Oxygen as needed, SpO2 (if available) 4. Serial Vital signs 5. Splint/Immobilize appropriately 6. If the patient has no signs of the following, than C-Collar should be applied, but not placed on backboard:

a. No Neck or Back Pain b. No Numbness or Tingling c. No Weakness of Extremities d. No Pain upon Palpation of Neck or Back e. No Pain on Motion of Neck or Back

7. If the patient has any of the above sign and/or symptoms or if there is significant mechanism, FULL C-SPINE

PRECATIONS INCLUDING C-COLLAR AND BACKBOARD must be utilized.

Intermediate: 8. IV of Normal Saline, large bore if:

a. Open or closed femur Fracture b. Hypotension or other S/S of shock c. Obvious gross deformity

Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm. 10. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control:

If possible multi-system trauma, abdominal and / or head injury, must contact medical control for pain management

Return to Index


Trauma - Acute Blunt Spinal Cord Injury

Clinical Definition: This protocol should be used for treatment of the patient with acute blunt spinal cord injury

Basic:

1. Establish and maintain manual c-spine stabilization 2. Determine the nature of the injury. 3. Evaluate and treat ABC’s according to protocol. 4. Assess for defining characteristics of SCI including: Partial, complete or suspected Loss of sensory and / or motor function in the upper and / or lower Extremities. 5. Immobilize and stabilize spine. 6. Prepare for rapid transport. Intermediate: 7. Establish 2 large bore IV’s with NS, infuse at TKO rate. Paramedic I: 8. If indicated, intubate using C-Spine precautions.

9. Apply ECG electrodes and determine cardiac rhythm, treat per arrhythmia protocol if indicated.

10. Continue evaluation as per the Initial Trauma Assessment and Treatment Protocol (pg. 11-14), with frequent

neurologic assessments. 11. Prophylactic intubation (MAI) may be required if airway compromise occurs.

Paramedic II:

Prophylactic intubation (MAI/RSI) may be required if airway compromise occurs.


Return to Index


Trauma - Domestic Violence

1. Call for law enforcement support, stage if necessary until law enforcement secures the scene.

2. Assess the scene for safety. 3. Treat injuries per trauma protocol. 4. Talk to patient alone in a safe, private environment. Use direct simple questions such as: Who caused these injuries?

Are you in a relationship with someone who hurts or threatens you? 5. Look for history of domestic violence, behavioral and physical clues.

Return to Index


Medical

Protocols


Medical – Abdominal Pain / Nausea / Vomiting

Clinical Definition: Non-traumatic abdominal pain. Basic:

Assess and treat ABC’s

Oxygen per patient

VS, including SpO2

Consider Orthostatic VS (if possible) (pg. 153) Intermediate:

IV, Normal Saline Paramedic I:

EKG

For severe nausea and vomiting:

Ondansetron (Zofran): 4mg IVP, IM or Oral ODT (Max 8mg every 4 hours); May repeat in 15 minutes if no improvement

OR

Promethazine: 12.5 IVP; 25 mg IM; (do not use if patient is >65 years old)


Must contact medical control for pain management consideration

Return to Index


Medical – Allergic Reaction (Mild)

Clinical Definition: Urticaria and itching without dyspnea or hypotension.

Basic:


VS, including SpO2

Oxygen per patient Intermediate:

IV, Normal Saline

Paramedic I:

EKG, 12 lead

Benadryl: 25 mg IVP or 50 mg IM


Return to Index


Medical – Allergic Reaction (Moderate)

Clinical Definition: Urticaria, itching and dyspnea without hypotension. Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic:


VS, including SpO2

Oxygen per patient

EPIPEN, if patient prescribed.

Intermediate:


EKG, 12 lead & ETCO2

Epinephrine (1:1,000): 0.5 mg SQ


If patient is in moderate to severe dyspnea, initial medications may be given prior to IV access

Dexamethasone: 8 mg IVP

OR

Methylprednisolone: 125 mg IVP


Repeat Epinephrine (1:1,000): 0.3 mg SQ

Return to Index


Medical – Allergic Reaction Severe (Anaphylaxis)

Clinical Definition: Urticaria, edema, dyspnea and hypotension (BP < 90 systolic). Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic:


VS, including SpO2

Oxygen per patient

EPIPEN, if patient prescribed. Intermediate:



Epinephrine (1:10, 000): 0.5 mg IVP or IN; may repeat once during transport OR

Epinephrine (1:1000): 0.5 mg SQ; may repeat once during transport


Dexamethasone: 8 mg IVP OR

Methylprednisone: 125 mg IVP

Be prepared to intubate should patient’s condition decline. Contact Medical Control

Return to Index


Medical – Cardiac Arrest

Clinical Definition: Unresponsive, no respirations, no pulse Basic:

Assess ABCs

AED, as soon as available

CPR (Utilize Lucas as soon as available)

Maintain airway with appropriate adjunct and ventilate with 100% O2 Intermediate:

Establish vascular access, Normal Saline

Advanced airway, apply ETCO2 Paramedic I:

(Utilize Ventilator as soon as available) Refer to appropriate protocol:

Asystole PEA VF and Pulseless VT


Return to Index


Medical – Asystole

Paramedic I:

CPR (Utilize Lucas and Ventilator as soon as available)

Confirm asystole in two leads

Establish vascular access

Vasopressin: 40 units IVP; may repeat in 20 minutes

AND

Epinephrine (1:10,000): 1 mg IVP or IN; 3 – 5 minutes apart; 2 mg via ET; repeat every 3 – 5 minutes

Place an advanced airway and ventilate with 100% O2, apply EtC02 Consider and treat possible causes:

Hypoxia………………………… ventilate Acidosis………………………… ventilate very well, Sodium Bicarbonate 1 meq/kg IVP during prolonged CPR

Overdose………………………. Narcan if suspected narcotic overdose Diabetic reactions…………….. See diabetic emergencies Hyperkalemia………………….. Sodium Bicarbonate 1 AMP Hypokalemia Hypothermia……………………. Passive re-warming, warmed fluids Hyperthermia…………………... Aggressive external cooling, cooled fluids

End tidal CO2 monitoring maintain at 35 – 45 mmHg. Do not over ventilate

SpO2 may help confirm tube placement and adequate ventilations

Consider NG tube placement Contact Medical Control After 10 minutes of EtC02 Monitoring with persistent readings of less than 10 mmHg with confirmed tube placement;

Contact Medical Control to consider termination of efforts.

Return to Index


Medical – Pulseless Electrical Activity (PEA)

Paramedic I:

CPR (Utilize Lucas and Ventilator as soon as available)

Establish vascular access

Vasopressin: 40 units IVP; may repeat in 20 minutes AND

Epinephrine (1:10,000): 1 mg IVP or IN; 3 – 5 minutes apart; 2 mg via ET, may repeat every 3 – 5 minutes

Place an advanced airway and ventilate with 100% O2, Apply EtC02

Consider and treat cause:

Hypovolemia…………………………………… fluids and position Hypoxia…………………………………………. oxygenation and airway management Tension Pneumothorax……………………….. needle chest decompression Hypothermia……………………………………. re-warming with warmed fluids Acidosis…………………………………………. ventilation and Sodium Bicarbonate 1 meq/kg IVP Massive acute myocardial infarction…………. TCP Cardiac Tamponade

Hyperkalemia…………………………………… Sodium Bicarbonate 1 AMP Massive pulmonary embolism Drug overdoses such as………………………Tricyclics, digitalis, beta-blockers, and calcium channel blockers. Refer to Poisoning and Overdose. (pg. 72)


Return to Index


Medical – VF / Pulseless VT

Paramedic I: o EKG, quick look with paddles o V-Fib / V-Tach defibrillation immediately o LP12 Defibrillation 200j; followed by 2 full minutes of CPR

MRx Defibrillation 150j; followed by 2 full minutes of CPR CPR (Utilize Lucas and Ventilator as soon as available)

o Establish vascular Access

Vasopressin: 40/U IV; repeat every 20 minutes

AND

Epinephrine (1:10,000): 1 mg, IVP or IN; 3 – 5 minutes; 2 mg via ET, may repeat every 3 – 5 minutes

o Place an advanced airway and ventilate with 100% O2 (without delay in chest compressions). Apply EtC02

LP12 Defibrillation: 300j 30 – 60 seconds after each administration.

MRx Defibrillation: 150j 30 – 60 seconds after each administration.

Cordarone: 300 MG IVP

Consider 2nd dose of:

Cordarone: 150 mg IVP in 3 – 5 min

LP12 Defibrillation: 360j 30 – 60 seconds after each administration. o MRx Defibrillation: 150j 30 – 60 seconds after each administration.

Magnesium Sulfate: 1 – 2 g IV or IO (dilute in 10 ml of D5W for IV bolus) (For Torsades de Pointe only)

LP12 Defibrillation: 360j 30 – 60 seconds after each administration

MRx Defibrillation: 150j 30 – 60 seconds after each administration.

Consider NG tube Contact Medical Control:

Return to Index


Medical – Post Resuscitation (ROSC)

NOTE: If patient in bradycardia, refer to bradycardia protocol. DO NOT treat post – resuscitation narrow complex tachycardia, which may be caused by medications given during resuscitation. Basic:


VS, including EtC02 and SpO2 & O2 Intermediate:

IV, Normal Saline, D5W Paramedic I:

EKG, 12 lead & ETCO2, If converted after defibrillation or cardioversion ONLY: Watch closely for lethal dysrhythmias

If converted after medication, follow bolus with appropriate drip:

Cordarone: 150 mg in 100 cc D5W, run at 50 ml/hour

If patient hypotensive (BP < 90 systolic) after 5 min:

Fluid challenge: 250 cc IV Normal Saline

Dopamine: 10 mcg/kg/min IVPB to raise BP > 100 systolic; titrated to effect MUST USE IV PUMP (Drip Chart)

OR

Levophed: 0.1 – 0.5 mcg/kg/min IVB; >100 mmHg; <120 mmHg; titrate to effect (Max 3 mcg/min) MUST USE IV PUMP (Drip Chart)

Consider NG tube


Return to Index


Medical – Bradycardia

Clinical Definition: HR < 60 with one or more of the following: SBP < 90, PVC’s, altered LOC, chest pain and dyspnea

Basic:


VS, including SpO2

Oxygen per patient

Intermediate:

IV, Normal Saline

Paramedic I:

EKG, 12-lead

Atropine: 1.0 mg Rapid IVP; repeat every 3 – 5 min to Max 0.04 mg/kg or 3 mg If suspected beta-blocker overdose administer:

1 mg Glucagon IM and 1 g 10% Calcium Chloride SIVP, may repeat, every 2 minutes max. dose 5 mg

If suspected calcium channel blocker overdose administer:

1 gram 10% Calcium Chloride IVP

TCP (external pacing) highly recommended if available.

Pre-medicate if time permits Valium: 2 – 10 mg IVP or IN

OR

Ativan: 1 – 2 mg IVP or IN

OR

Versed: 5 mg IVP or IM If hypotensive:

Dopamine: 10 mcg/kg/min IVPB titrated to raise BP > 100 Systolic; MUST USE IV PUMP

(Drip Chart) Contact Medical Control: Return to Index


Medical – PSVT – Stable

Clinical Definition: BP > 90 without serious signs and symptoms and a pulse of at least 150 Basic:


VS, including SpO2

Oxygen per patient

Vagal maneuvers Intermediate:

IV, Normal Saline, antecubital vein or higher Paramedic I:

EKG, 12-lead Adenosine: 6 mg rapid IVP followed by a flush; repeat at 12 mg every 1 – 2 min (Max 30 mg)

*Adenosine is contraindicated in patients taking TEGRITOL and PERSANTIN* Contact Medical Control: If wide complex PSVT:

Cordarone: 150 mg bolus slowly over 10 minutes; Diluted in 20cc of D5W

Return to Index


Medical – PSVT – Unstable

Clinical Definition: SBP < 90, a pulse of at least 150, chest pain, dyspnea, decreased LOC, pulmonary congestion, CHF and MI Basic:


VS, including SpO2

Oxygen per patient

Vagal maneuvers Intermediate:

IV, Normal Saline, antecubital vein Paramedic I:

EKG, 12-lead if available Synchronized cardioversion: 100j, 200j

Premedicate if time permits

Valium: 2 – 10 mg IVP,IM or IN OR

Ativan: 1 – 2 mg IVP, IM or IN OR

Versed: 5 mg IVP or IM


Cordarone: 150 mg over 10 minutes; Diluted in 20 cc of D5W; max 300 mg

May repeat in 10 minutes if needed

Return to Index


Medical – VT- Stable

Clinical Definition: BP > 90 without serious S/S Basic:


Cough version

Oxygen per patient

VS, including SpO2 Intermediate:


EKG, 12-lead

Cordarone: 150 mg over 10 minutes; Diluted in 20cc of D5W; Max 300 mg May repeat in 10 minutes if needed

OR

Magnesium Sulfate: 1 – 2 grams IVP (For Torsades de Pointes only)

Synchronized cardioversion: 100j, 200j

Premedicate if time permits

Valium: 2 – 10 mg IVP, IM or IN OR


Versed: 5 mg IVP or IM Contact Medical Control

Return to Index


Medical - VT – Unstable

Clinical Definition: BP < 90 systolic altered LOC, dyspnea, diaphoresis or chest pain Basic:


VS, including SpO2



EKG, 12-lead if available Synchronized cardioversion: 100j, 200j

Pre-medicate if time permits:

Valium: 2 – 10 mg IVP, IM or IN OR


Versed: 5 mg IVP or IM

If ventricular rate >150 Immediate cardioversion is indicated. Medications listed below are relatively low priority. If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks.

Cordarone: 150 mg over 10 minutes; Diluted in 20cc in D5W (120 ml/hr) OR

Magnesium Sulfate: 1 – 2 g IVP (For Torsades de Pointes only) Contact Medical Control

Return to Index


Acute Coronary Syndrome (Chest Pain)

Clinical Definition: Chest, back, neck, jaw pain indicative of myocardial ischemia, dyspnea, diaphoresis, syncope, and cyanosis with nausea, vomiting and dizziness. Basic:


VS, including SpO2 and EtC02

O2 per pt ASA 324 mg PO

NOTE: If the patient has taken 325 mg within the last twelve (12) hours, do not give more ASA Intermediate:


15 Lead EKG

If ST elevation in two or more contiguous leads with reciprocal changes or a new onset LBBB move to STEMI protocol

Serial EKGs to identify trends.

Symptoms with a TIMI Score of 5 or greater Transport directly to the closest hospital with a CARDIAC CATH LAB.

Nitroglycerin: 0.4 mg SL; repeat every 5 minutes x 3 doses

*Nitrates are given for venous dilation not for Analgesia*

If hypotensive with SBP < 90 250 – 500 cc Bolus

If patient is anxious may consider:

Ativan: 1 – 2 mg SIVP

OR

Valium: 2 – 10 mg

Continued on next page

TIMI Score

Age 65-74 2 Age 75 or greater 3 DM/HTN or angina 1 SBP<100 3 HR>100 2 Weight<67kg 1


For Vasodilation / Pain consider:

Morphine: 2 – 10 mg IVP; repeat @ 2 mg increments every 5 min (Max dose of 10 mg)

Pain Management

Fentanyl: 25 – 50 mcg IVP; repeat @ 25 mcg increments every5 minutes (Max 100 mcg)

For Nausea and / or vomiting

Ondansetron: 4 mg IVP, IM or Oral ODT (Max 8 mg; every 4 hours) OR

Promethazine: 12.5mg IVP; 25 IM; start with lowest dose

Cardiac Chest Pain

Metoprolol: 5 mg SIVP; repeat every 5 minutes x3; Hold if SBP <100 and/or HR <55 OR

Nitro Drip: 2 – 20 mcg/min; Maintain Systolic >90 mmHg; titrate to effect MUST USE IV PUMP (Drip Chart)


Dopamine: 10 mcg/kg/min to raise BP > 100 systolic; titrated to effect MUST USE IV PUMP (Drip Chart)

Dobutamine 10 – 20 mcg/kg/min; start at 10 mcg/kg/min MUST USE IV PUMP (Drip Chart)

Return to Index


Medical - STEMI

Clinical Definition: Patients with non-traumatic chest, back, neck and /or jaw pain with ST-segment elevation in 2 or more contiguous leads and reciprocal changes are present, a new onset LBBB or a bifascular block. Basic:

ABC’s

VS q 5 minutes

SpO2 and EtC02

Oxygen per patient (maintain a Sp02 of 94 mmHg) ASA 324 mg PO

Intermediate:

2 large bore IV’s and / or lock; at least one antecubital vein; preferably in the same arm. Paramedic I:

Transport directly to the closest hospital with a CARDIAC CATH LAB

Transmit 12-Lead immediately and contact appropriate HOSPITAL FOR STEMI ALERT

Nitroglycerine 0.4 mg SL; repeat every 5 minutes x 3 doses

(WITHOUT right ventricular involvement)

For Vasodilation/Pain consider

Morphine: 2 – 10 mg IVP; may repeat every 5 minutes (Max dose of 10 mg)

For Pain Management

Fentanyl: 25 – 50 mcg IVP; may repeat every 5 minutes (Max 100 mcg)

Continued on next page


For nausea and / or vomiting

Ondansetron: 4 mg IVP, IM or Oral ODT (Max 8 mg; Q 4 hours) OR

Promethazine: 12.5 mg IVP; 25 IM Cardiac Chest Pain

Metoprolol: 5 mg SIVP; repeat every 5 minutes x3; Hold if SBP <100 and/or HR <55

OR

Nitro Drip: 10 mcg/min; Maintain Systolic >90 mmHg; titrate to effect Max 20 mcg; MUST USE IV PUMP (Drip Chart)


IF SBP <90 consider

Dobutamine: 2 – 20 mcg/kg/min IVPB; must start at 10 mcg/kg/min

MUST USE IV PUMP (Drip Chart)

Dopamine: 10 mcg/kg/min to raise BP >100 systolic; titrate to effect

MUST USE IV PUMP (Drip Chart)

Return to Index


Medical - Induced Hypothermia

Clinical Indication: Return of spontaneous circulation after cardiac arrest. Intubated patients that are well ventilated with ETCO2 > 30. Contraindications:

Traumatic Arrest

Apparent Pregnancy

< than 18 years old PARAMEDIC LEVEL ONLY:

Assure patent airway

Place patient on ventilator

MUST maintain continuous cardiac, O2 saturation and ETCO2 monitoring at all times.

Ensure vascular access with a minimum of 2 large bore IV’s

Document an initial rectal temperature INVASIVE COOLING PROCEDURE: Medicate for sedation (also for continued sedation) and shivering

Versed: 5 mg; may repeat only once in 20 minutes; maintain SBP ≥ 100

OR

Ativan: 1 – 2 mg SIVP OR

Valium: 10 mg SIVP OR

Etomidate: 0.3 mg/kg IVP, over 30 seconds OR

Ketamine 1 – 2 mg SIVP, over 1 minute

Remove clothing (Ensure privacy)

Apply Ice/cold packs directly on skin, axilla and groin for maximum cooling effects.


Rapidly Infuse Cold Saline: 30 ml/kg IV/IO: max 2 Liters (2000 ml)

If hypotensive may consider:

Levophed: 0.1 – 0.5 mcg/kg/min IVPB; SBP ≥ 100 (Max dose 3 mcg/kg/min) MUST USE IV PUMP (Drip Chart)

Temperature goal 32 – 34 C (89.6 to 93.2 F)

Reassess rectal temperature Discontinue cooling measure if < 33C (91.4 F) Continue to monitor temperature > 33C (91.4 F) and no shivering


If the patient has return to spontaneous circulation while enroute to NTMC-ED; Contact Medical Control immediately.

DO NOT DELAY TRANSPORT TO COOL!!!!!!!

If patient becomes pulseless again, discontinue cold saline infusion follow proper protocol. Ice packs may remain in place.

Remember: Patient may develop metabolic alkalosis with cooling. DO NOT HYPERVENTLIATE.

Patient must be transported to a hospital that will continue induced hypothermia; must transport to one of the following facilities:

Denton Regional Medical Center - Denton

Texas Health Presbyterian – Denton

Wise Regional Medical Center – Decatur Wilson and Jones – Sherman

Return to Index


Medical – Cardiogenic Shock

Clinical Definition: BP < 90 systolic in the absence of trauma, altered LOC, tachycardia or other arrhythmias, diaphoresis, pulmonary congestion and tachypnea. Basic:



Oxygen per patient

Intermediate:



Dobutamine 2 – 20 mcg/kg/min IVPB; must start at 10 mcg/kg/min; If known cardiogenic shock use 1st; MUST USE IV PUMP (Drip Chart)

OR

Levophed: 0.1 – 0.5 mcg/kg/min IVPB; SBP >100; titrate to effect (MAX dose 3 mcg/kg/min) MUST USE IV PUMP (Drip Chart)

OR

Dopamine: 10 mcg/kg/min IVPB; titrated to raise BP > 100 systolic; MUST USE IV PUMP (Drip Chart)


Return to Index


Medical – Hypotension /Shock – Unexplained

Clinical Definition: BP < 90 systolic, with S/S: pale, cold, clammy skin, syncope, vomiting and/or diarrhea with ↓ intake and output. Basic:


VS, including SpO2 & EtC02

O2 per patient

Place patient in Trendelenberg Position

Consider orthostatic VS (if possible) Intermediate:

IV, Normal Saline

Fluid challenge: 250 – 500 cc Normal Saline If hypotensive after 10 minutes, repeat fluid challenge Discontinue fluid challenge if S/S of Pulmonary Edema arises Second IV optional.

Paramedic I:

EKG, 12 Lead If still hypotensive after adequate volume resuscitation:

Levophed: 0.1 – 0.5 mcg/kg/min IVPB; titrate to raise SBP >100; Titrate to effect (Max dose 3 mcg/kg/min) MUST USE IV PUMP (Drip Chart)


If sepsis is suspected then consider:

Vasopressin Drip: 10 units in 250cc D5W run at 15 ml/hr; titrated to maintain SBP < 100

Dopamine: 10 mcg/kg/min IVPB; titrate to raise SBP > 100 (Drip Chart)

Return to Index


Medical – Hypertensive Crisis

Clinical Definition: Systolic BP > 200 or Diastolic > 120, headache, blurred vision, numbness and chest pain Basic:


VS, including SpO2

Oxygen per patient

Evaluate arm drift, facial droop, and speech impairment for stroke. If present, refer to Stroke Protocol. (pg. 63) Intermediate:


EKG, 12 lead

Nitroglycerine: 0.4 mg SL; repeat every 5 minutes x 3 doses Contact Medical Control:

Nitro Drip: 2 – 20 mcg/kg/min; SBP >90 mmHg; titrate to effect;

MUST USE IV PUMP (Drip Chart) OR

Labetalol: 10 mg IVP; repeat after 10 minutes for a total of 20 mg

OR

Metoprolol 5 mg; repeat every 5 minutes x 3; Hold if SBP >100 and/or HR <55

Return to Index


Medical – Stroke

Clinical Definition: Unilateral weakness, paralysis, facial droop and speech impairment

Basic:

Assess and treat ABC’s.

VS, including SpO2

O2 per patient.

Intermediate:

IV, Normal Saline

Dextrose stick: if <80 or signs of Hypoglycemia:

Thiamine: 100mg

D50: 25 g IVP

Paramedic I:

Confirm the presence of stroke type symptoms.

Determine the time of last known normal(LKN)

Perform the Rapid NIH Stroke Score exam.

If the LKN is less than 4.5 hours with an NIHSS of 8 or less and no absolute contraindications to

thrombolytic therapy transport to closest Skilled Stroke Facility.

If the LKN is greater than 4.5 hours or NIHSS greater than 8 or the patient has an absolute contraindication

to thrombolytic therapy and the patient will arrive at a Comprehensive Stroke Center in less than 12 hours

from the LKN utilize air transport.

If air transport is not available transport to closest Skilled Stroke Facility.

If air transport is used, send copy of completed Rapid NIHSS form with patient.

EKG, 12 lead

*Contact Medical Control:

Metoprolol: 5mg q 5 minutes x3; Hold if SBP>100 and/or HR <55

OR

Labetolol: 10mg IVP; repeat after 10 minutes for a total of 20mg

Return to Index


Medical – Asthma

Clinical Definition: Respiratory distress, wheezing on expiration, coughing, tripod positioning and / or accessory muscle use. Basic:


VS, including SpO2 & O2 per patient

Albuterol: 2.5 mg nebulized updraft; may repeat once in 10 min Intermediate:

IV, Normal Saline. Fluid bolus 250cc; may repeat once Paramedic I:

EKG, 12 lead

ETCO2

Terbutaline 0.25 mg SQ

Magnesium Sulfate 1 gram IVP

Decadron 4 mg IVP OR

Solu-medrol 125 mg IV

If IV unobtainable:

Decadron 4 mg; can be added to nebulized treatment

Morphine 4 mg; can be added to nebulized treatment

Continuous updraft

Epinephrine (1:1,000) 0.3 mg SQ

Consider CPAP Contact Medical Control:

IF STATUS ASTHMATICUS BE PREPARED TO INTUBATE Return to Index


Medical – CHF and Pulmonary Edema

Clinical Definition: Severe respiratory distress, cyanosis, diaphoresis, adventitious lung sounds, JVD, altered LOC and, chest pain. Basic:


VS, including SpO2, and EtC02

Oxygen per patient, consider BVM

Elevate head 30 degrees from supine Intermediate:


EKG, 12 Lead

Nitroglycerin: 0.4 mg SL; repeat every 5 minutes x 3 doses

Consider CPAP

Consider, with severe dyspnea and pulmonary edema:

Morphine: 2 – 5 mg IVP; repeat @ 2 mg increments every 5 minutes (Max dose of 10 mg)

Lasix: 0.5 – 1 mg/kg IVP

BE PREPARED TO INTUBATE


Dopamine: 10 mcg/kg/min to raise BP > 100 systolic; titrate to effect Must use a pump (Drip Chart)

Nitro Drip: 2 – 20 mcg/kg/min; maintain SBP >90 mmHg; titrate to effect; MUST USE IV PUMP

(Drip Chart)

Return to Index


Medical – COPD

Clinical Definition: Dyspnea with history of chronic bronchitis and / or emphysema Basic:



Oxygen per patient Mild dyspnea: 1 – 2 LPM via NC Severe dyspnea: 10 – 15 LPM via NRB or BVM

Albuterol: 2.5 mg nebulized updraft, may repeat once in 10 min

OR

DuoNeb: 3 ml nebulized updraft; may repeat once in 10 min

Intermediate:


EKG, 12 lead

Terbutaline: 0.25 mg SQ

Dexamethasone 4 mg IVP OR

Solu-medrol: 125 mg IV

NOTE: Epinephrine is not an alternate drug!

Consider CPAP

For Anxious Patient’s may consider: (must use with caution)

Ativan 1 mg SIVP OR

Valium 2 – 5 mg SIVP Contact Medical Control Return to Index


Medical- Pneumonia/ Bronchitis

Clinical Definition: Dyspnea with adventitious breath sounds and history of respiratory infection, productive purulent cough, fever, chest wall pain, and no evidence of CHF (pedal edema, JVD, pertinent cardiac history). Basic:



Oxygen per patient

Encourage productive coughing. Suction as needed.

Albuterol: 2.5 mg nebulized updraft; may repeat once in 10 min

With EtC02 presentation indicating bronchospasms

DuoNeb 3ml nebulized updraft; may repeat in 10 min. Intermediate:

IV, Normal Saline 250 cc/hour Paramedic I:

EKG, 12 lead

Consider CPAP Contact Medical Control

Return to Index


Medical - Seizure

Clinical Definition: Active seizures (tonic/ clonic) and / or postictal Basic:


VS, including SpO2 & O2 per patient Intermediate:

IV, Normal Saline

Dextrose stick: if < 80 or signs of Hypoglycemia:

Thiamine: 100 mg

D50: 25 g IVP

Paramedic I:

EKG, 12 lead

If seizures are prolonged or recurrent consider:

Valium: 5 mg IVP, IN, or rectal; may repeat as needed every 5 minutes until Max dose of 20 mg

OR

Ativan: 1 mg SIVP or IN, may repeat as needed or 2 mg every 5 minutes (MAX 8 mg) OR

Versed 3 – 5 mg IVP or IN; may repeat in 20 minutes

Contact Medical Control: NOTE: If Valium is given to patients suspected of using alcohol, ensure and monitor airway

Return to Index


Medical – Dehydration

Clinical Definition: Normotensive with tachycardia and other signs/symptoms including poor skin turgor with little or no urine output, dry mucous membrane and evidence of a dehydration mechanism (vomiting, diarrhea, fever, poor oral intake) Basic:

Assess and treat ABC’S

VS including SpO2

Oxygen per patient

Consider orthostatic VS (if possible) (pg. 153) Intermediate:

IV Normal Saline 250 – 500cc fluid bolus; may consider repeating bolus (Max 1000cc)

Paramedic I:

EKG, 12 Lead Contact Medical Control:

Return to Index


Medical – Diabetic Emergencies

Clinical Definition: Symptoms related to altered blood glucose levels Basic:



If alert, and suspected hypoglycemia, administer Oral Glucose Intermediate:

IV, Normal Saline

Dextrose stick If < 80 or signs of Hypoglycemia:

If alert, administer Oral Glucose If altered LOC:

Thiamine: 100 mg

D50: 25 g IVP

Repeat dextrose stick in 3 – 5 minutes

If BGL > 250 and S/S of DKA: IV infusion of NS 250 cc/hr Paramedic I: If IV unobtainable:

Glucagon: 1 mg IM or IN

EKG, 12 lead Contact Medical Control: NOTE: Diabetic emergencies are sometimes mistaken for other illnesses such as: (CVA, substance abuse, ETOH abuse or withdrawal) Be sure to thoroughly assess patient and treat all symptoms. If there is any doubt, consult medical control.

Return to Index


Medical – Altered Mental Status

Clinical Definition: Unresponsive or disoriented patient without a clear mechanism for altered mental status. Refer to appropriate protocols as needed (diabetes, head injury, etc.) Basic:


VS, including SpO2


IV, Normal Saline

Dextrose stick: if < 80 or signs of hypoglycemia:

Thiamine: 100 mg

D50: 25 g IVP Paramedic I: If pupils are constricted and/or respiratory depression:

Narcan: 0.5 - 2 mg IVP or IN, to improve respiratory status; may repeat as needed

EKG, 12 lead Contact Medical Control

Return to Index


Medical – Overdose / Poisoning

Clinical Definition: Known/ suspected ingestion, injection, inhalation, or absorption of harmful substance Basic:


Oxygen per patient

If contact poisoning, brush off or flush with H2O NOW




If altered mental status; refer to Altered Mental Status Protocol. (pg. 71)

If known organophosphate poisoning:

Atropine: 2 mg IVP or IM may repeat in 5 min. if needed. (organophosphate)

Charcoal 50 g PO (only if alert)

Benadryl: (Dystonic reaction): 25 mg; 50 IM

Sodium Bicarbonate: 1 mEq/kg (adult minimum 50 mEq) IVP (Tricyclic antidepressant)

If suspected ETOH poisoning: 250cc NS fluid bolus given over 20 minutes

If suspected/known narcotic overdose:

Narcan 0.5 - 2 mg IVP or IN, to improve respiratory status; may repeat as needed

Contact Medical Control: If patient refuses transport and / or is in potential danger, contact Medical Control and law enforcement.

Return to Index


Medical – Behavioral / Emotionally Disturbed

Assess patient, scene, and contact control hospital.

Treat life-threatening injuries.

Assess the situation and call for law enforcement support. If the patient appears dangerous or has lethal weapons, or appears in danger of losing control, or has violent disruptive or self-destructive impulses, the law enforcement personnel may aid in providing the necessary physical restraints.

Approach the patient in a direct, honest manner:

o Maintain continuous contact with the patient. o Encourage the patient to discuss situational stresses. o Check for emotional instability (mood swings), paranoid delusions, and depression.

Avoid restraining the patient, if possible, but once restraints are applied, DO NOT REMOVE until accepted by receiving facility.

Treat non-life-threatening injuries as the patient allows.

Refer to Chemical Restraint Protocol. (pg. 74)

Return to Index


Medical – Chemical Restraint

For patients with agitation, severe anxiety, and, or with violent aggressive appearance. Note: It is imperative to maintain the safety of the crew first. Basic:

If patient is approachable, VS including SpO2

Contact Law Enforcement if Pt is not approachable. Consider takedown options

Oxygen if tolerated Intermediate:

IV Normal Saline, large bore if tolerated Paramedic I:

EKG/12 Lead if tolerated

Geodon 20 mg IM ONLY; DO NOT REPEAT OR

Haldol: 5 mg SIVP, over 1 minute or 10 mg IM

Ativan: 1 mg SIVP or 2 mg IM; (If normotensive, no respiratory distress)

OR

Versed: 5 mg Slow IVP or IM (for severe agitation) May repeat Haldol and / or Ativan in 10 minutes if not controlled

Thiamine: 100 mg IV or IM

VS, O2, IV, EKG, Blood Glucose as soon as tolerated Contact Medical Control:

For notification and/or if not effective with 2nd dose Return to Index


Medical – Carbon Monoxide

Basic:

Remove victim from source


VS, including SpO2

High flow oxygen Intermediate:

IV, Normal Saline. Paramedic I:

EKG, 12 lead & ETCO2 If patient is in severe respiratory distress then may consider

CPAP


Return to Index


Medical – Heat Cramps / Exhaustion

Clinical Definition: Hot and humid weather with cramping in the extremities with associated nausea, vomiting, syncope episode with profuse sweating and tachycardia. Basic:



External cooling: o Remove to cool environment o Remove excessive clothing o Cover with wet sheet o Fan patient o Ice packs to groin, axilla, and neck o Ice packs around IV tubing

Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient

Intermediate:

IV, Normal Saline 250 – 500 cc Bolus; may repeat bolus (Max 1000cc)

Dextrose stick: If < 80 or signs of Hypoglycemia:

If alert, administer Oral Glucose If altered LOC:

Thiamine: 100 mg

D50: 25 g IVP

Paramedic I:

EKG, 12 lead Contact Medical Control:

If available, and if the patient is not nauseated, give fluids PO (H2O with a little salt or Gatorade). Do not massage cramping muscles.

Return to Index


Medical – Heat Stroke

Clinical Definition: Absence of sweating, reddened skin altered LOC, seizures and core temp > 105. Basic:



Aggressive external cooling: o Remove to cool environment o Remove excessive clothing o Cover with wet sheet o Fan patient o Ice packs to groin, axilla, and neck o Ice packs around IV tubing

Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient.

Intermediate:

IV, Normal Saline 250 – 500cc Bolus; may repeat bolus (Max 1000cc)

Dextrose stick: if < 80 or signs of Hypoglycemia:

Thiamine: 100 mg

D50: 25 g IVP Paramedic I: If the patient is having seizures or if shivering consider:

Valium: 5 – 10 mg IVP (Max 10 mg)

OR

Ativan: 1 – 2 mg SIVP OR

Versed: 5 mg IVP or IM; may repeat after 20 minutes

EKG, 12 lead


Return to Index


Medical – Hypothermia

Mild to Moderate: Core temperature (rectal) of 90º - 95º, shivering and possible altered LOC. Basic:


VS, including SpO2

Oxygen per patient

Begin external warming: o Remove wet clothing o Wrap in blanket o Heat packs to groin, axilla, neck, lateral chest o Heat packs around IV tubing

Intermediate:

IV, Normal Saline

Dextrose stick: if < 80 or Signs of hypoglycemia:

Thiamine: 100 mg

D50: 25 g IVP Paramedic I:

EKG, 12 lead if available

Consider Pain management; refer to Pain Management Protocol. (pg. 117) Contact Medical Control to consider:

Severe: core temp < 90º, no shivering, cyanosis, altered LOC and apnea

Treat as mild or moderate except, if pulseless or BP < 60 systolic, begin CPR. Maintain good basic life support. Contact MEDICAL CONTROL as to whether to begin advanced life support.

Return to Index


Medical – Radiation

Notify nearest HAZMAT team

The vast majority of accidents involving radioactive materials occur in facilities in which these materials are used daily. In these circumstances, rescue squads should seek and follow the professional advice that is readily available to them in these centers. For accidents involving radioactive materials where professional guidance is unavailable, the following guidelines should be followed: 1. Assess scene, patient, and contact controlling hospital, which is expected to coordinate this care and control with law enforcement, fire control, and state agencies. 2. If victims without serious injury are involved in the accident:

a. Do not enter the area suspected of having radioactive material present. b. Do not permit spectators to enter the area. c. Do not allow the victim(s) to leave the area d. After conferring with the emergency physician, treat the victim’s other injuries. e. Notify the hospital that a patient exposed to radiation is being transported.

3. If victims with serious injury are involved in the accident:

a. Treat life-threatening injuries. b. Remove the patient from the hazard area as soon as possible. c. Remove contaminated outer clothing and wash all exposed skin. d. Obtain vital signs every 10 minutes. e. Search for and treat other injuries. f. Wrap the patient in a blanket. g. Notify the hospital that a patient exposed to radiation is being transported.

Return to Index


Medical – Snake Bite

Basic:


VS, including SpO2

Oxygen per patient

Keep victim quiet

Remove all jewelry and tight clothing from the affected limb which is maintained at heart level

Treat for shock

Immobilize the affected part at heart level

If available, the dead snake should be transported to the hospital for proper identification

Consider outlining the effective site to and note the time of outline to assists with watching for swelling Intermediate:


EKG, 12 lead

Consider Pain management; refer to Pain Management Protocol. (pg. 117) Contact Medical Control

Return to Index


Medical – Sexual Assault

Assess scene, patient, contact control hospital, and contact law enforcement with patient permission or to protect crew safety.

Treat life-threatening injuries.

Offer emotional support. Concentrate history of medical aspects of the case.

Search for and treat other injuries. (If possible, do not disturb the scene of assault or remove any clothing.)

When contacting law enforcement and the control hospital, do not identify the victim by name. Do your utmost to protect the patient’s privacy.

Before transporting the patient to the hospital, discourage them from taking a shower, bath or douche, brush teeth or changing their clothing.

Arrangements may need to be made for additional clothing that the patient can wear home.

Patients 16 years of age and older can be seen by a SANE nurse at NTMC Patients less than 16 years of age must be transported to DRMC

Return to Index


OB / GYN

Protocols


OB / GYN Vaginal Bleeding

Clinical Definition: Non-traumatic vaginal bleeding in the absence of labor. Basic:


Oxygen per patient

VS, including SpO2

If severe bleeding, examine vaginal area and retain any tissue or clots. Place a sterile dressing over vaginal opening and leave loose.

Intermediate:

IV Normal Saline; may increase IV rate or multiple IV’s should be established if shock is present. Paramedic I:

EKG Contact Medical Control:

For severe nausea and vomiting:

Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; may repeat (Max 8 mg Q 4 hours)

OR

Promethazine: 12.5 mg IVP; 25 mg IM

Possible causes:

Abruptio Placenta: pain, uterine contractions, may appear to be normal labor.

Placenta Previa: Placentia Previa: painless, bright red hemorrhaging, usually at end of second trimester.

Spontaneous Abortion: abdominal cramps, vaginal hemorrhage, back pain, presence of tissue of fetus. Do not attempt placental delivery.

Return to Index


OB/GYN – Pre – Eclampsia / Eclampsia

Clinical Definition: Gestation > 20 weeks and hypertension (BP > 140 systolic and/or > 90 diastolic) with peripheral edema, moderate to severe nausea/vomiting, severe headache, and hyperreflexia. Basic:


Oxygen per patient

Assess VS, including SpO2, with patient on left side, every 5 minutes Intermediate:


EKG

Magnesium sulfate: 4 - 6 g in 50 cc of Saline over 20 min IVPB; or 2 g IM, If unable to obtain IV Contact Medical Control: Consider repeating:

Magnesium sulfate: 2 grams IV

Consider if hypertensive:

Labetalol: 20 mg IVP

For seizures refractory to Mag Sulfate consider:

Valium: 2 - 10 mg IVP OR

Ativan: 1 mg IVP, IN; repeat as needed every 5 minutes until to 2 mg

Return to Index


OB/GYN - Labor

Clinical Definition: Back and /or abdominal cramping or pain with gestation > 20 weeks. Basic:


Perform visual exam; check for crowning (if present, prepare for delivery)

Oxygen per patient


IV Normal Saline Paramedic I:

EKG Contact Medical Control: For severe nausea and vomiting:

Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; may repeat (Max 8 mg q 4 hours)

Transport as soon as possible, if delivery not imminent

If preterm labor less than 34 weeks gestation then consider:

Terbutaline: .25 mg SQ

Magnesium sulfate: 4 – 6 g / 50 cc over 20 min IVPB OR 2 grams IM; if unable to obtain IV

Morphine: 2 – 10 mg IVP; repeat every 5 minutes at 2 mg increments (Max 10 mg)

Return to Index


OB/GYN - Delivery

Clinical Definition: Active labor with presentation of fetus, delivery of infant and placenta. NOTE: Refer to the Labor Protocol (pg. 85) to prepare patient for delivery.

All Levels: Preparations:

Open OB kit.

Place mom supine with knees bent.

Place clean sheet under buttocks.

Put on sterile gloves, if possible.

Have mom pant between contractions.

Inspect for crowning.

Provide supplemental Oxygen to all delivery patients. Procedure:

As crowning begins, apply gentle pressure to infant’s head (take caution of fontanelle).

Continue gentle pressure as head delivers.

With bulb syringe, suction infant’s mouth then nose.

Check for umbilical cord around neck. If present, gently slip cord from around neck. If unable to slip around head, apply clamps 2" apart and cut in between, then unwrap cord from around neck.

Gently guide head downward to assist shoulder delivery. Be prepared to support infant, delivery is quicker at this point.

Suction again, mouth then nose.

Note time of delivery.

Dry infant and wrap in infant insulating blanket to keep warm.

Clamp cord at 6" from infant and another at 2" distal from the first clamp. Cut cord.

Perform APGAR scoring at 1 and 5 minutes (treat infant per score). Refer to Pediatric Post Delivery Protocol. (pg.91) Placenta:

Placenta will deliver approximately 20 minutes after birth.

If severe bleeding persists: Treat for shock to level of training. Gently massage abdominal area over uterus to cause contractions and placenta delivery. Transport.

Retain placenta and transport to hospital. Contact Medical Control

Return to Index


OB/GYN – Delivery (Breech Presentation)

Clinical Definition: Presentation of buttocks or feet first. NOTE: Best delivered in hospital, however if delivery is imminent assist as follows: Basic:

Assess and treat ABCs

VS, including SpO2 & O2 per patient Intermediate and Paramedic I:

IV, Normal Saline Procedure:

Prepare mother for delivery as described in the Delivery Protocol. (pg. 86)

Allow fetus to deliver spontaneously up to the level of the umbilicus. If the fetus is in a front presentation, gently extract the legs downward after the buttocks are delivered.

After the legs are clear, support the baby’s body with the palm of the hand and volar surface of the arm.

After the umbilicus is visualized, gently extract 4 to 6 inch loop of cord to allow delivery without traction on the cord. Gently rotate the fetus to align the shoulders in an anterior-posterior position. Continue with gentle traction until the axilla is visible.

Gently guide the infant upward to allow delivery of the posterior shoulder then gently guide the infant downward to deliver the anterior shoulder.

Be aware that the head often is delivered without difficulty. If the head is not delivered in 2 – 3 minutes, use two fingers in a “V” on either side of the nose to provide an airway and transport immediately.

Complete delivery procedure as described in the Delivery Protocol. (pg. 86) Contact Medical Control

Return to Index


OB/GYN – Delivery (Cord Presentation)

Clinical Definition: Umbilical cord presents with or before presenting part of fetus. NOTE: Transport Immediately. Basic:


Oxygen via non-rebreather

VS, including SpO2

Intermediate and Paramedic I:

IV, Normal Saline

Procedure:

Place mother in knee-chest or Trendelenberg position on left side.

TRANSPORT IMMEDIATELY.

Instruct mother to “pant” with each contraction to prevent bearing down.

Apply moist sterile dressing to the exposed cord to minimize temperature changes that may cause umbilical artery spasm.

With a gloved hand, gently push the fetus back into the vagina and elevate the presenting part to relieve pressure on the cord. The cord may spontaneously retract, but NO ATTEMPT SHOULD BE MADE TO REPOSITION THE CORD. DO NOT REMOVE HAND.


Return to Index


OB/GYN – Delivery (Limb Presentation)

Clinical Definition: Presentation of extremity. NOTE: Transport Immediately. Basic:


Oxygen via non-rebreather

VS, including SpO2 Intermediate and Paramedic I:

IV, Normal Saline Procedure:

Place mother in knee-chest or Trendelenberg position on left side.

TRANSPORT IMMEDIATELY.


Return to Index


Pediatric

Protocols


Pediatric – Post Delivery

Clinical Definition: Care and evaluation of the newborn infant. All Levels:

Ensure patent airway, suctioning mouth and nose.

Prevent heat loss. Dry neonate and keep warm. Cover with dry wrappings. Be sure to cover the head.

Place infant on the back or side with the neck slightly extended in the sniffing position.

Provide tactile stimulation to induce respirations if necessary. Appropriate methods are slapping or flicking the soles of the feet and rubbing the infant’s back.

Perform APGAR scoring at 1 and 5 minutes.

If Respiratory Distress: Rate > 80 consistently, nasal flaring, grunting or retractions and SpO2 < 96%, consistently:

Blow – by O2 @ 10 LPM

Sat < 90, apnea: O2 via BVM @ 20 – 30 minute

If Bradycardia: Rate 81 - 100: Blow – by O2 at 10 LPM Rate < 80: CPR, O2 via BVM at 20 – 30 minute


The APGAR SCORE

Sign

0

1

2

1 min

5 min

Appearance (skin color)

Blue, pale

Body pink, extremities blue

Completely pink

Pulse rate (heart rate)

Absent

Below 100

Above 100

Grimace (irritability)

No response

Grimaces

Cries

Activity (muscle tone)

Limp

Some flexion of extremities

Active motion

Respiratory (effort)

Absent Slow and irregular

Strong cry

Total Score:

Return to Index


Pediatric – Neonatal Resuscitation

Clinical Definition: Resuscitation of the depressed neonate (infant born at >38 weeks gestation, less than 30 days old).

NOTE: Transport immediately

Basic:

Assess and treat ABCs.

Dry and keep infant warm.

Place infant on back with neck in sniffing position.

If meconium is present refer to the Meconium Staining Protocol.

After delivery, use mild stimulation (drying, warming, suctioning) to induce respirations.

If respiratory response is slow, shallow, or absent begin positive-pressure ventilation (40 – 60) with pediatric bag – valve – mask and supplemental oxygen.

If heart rate <100, initiate positive-pressure ventilation with supplemental oxygen if not already done.

If heart rate < 80, begin chest compressions

If central cyanosis is present in an infant with spontaneous respirations and an adequate heart rate, administer blow-by oxygen at 5 L/min.

Intermediate:

Endotracheal intubation is indicated if BVM ventilation is ineffective.

ETCO2 ventilate at 20 – 30 breaths/min to maintain an EtCo2 between 35 – 45 mmHg.

IV/IO Normal Saline. Paramedic I:

EKG. Refer to appropriate protocol

If shock present: 10 cc/kg fluid bolus, repeat at 10 cc/kg Contact Medical Control

Return to Index


Pediatric – Meconium Staining

Clinical Definition: Presence of fetal stool in amniotic fluid. Basic:

Suction mouth, pharynx, and nose in that order.

Provide blow-by oxygen. Intermediate and Paramedic I:

Suction hypopharynx under direct visualization.

If the neonate is depressed or the meconium is thick or particulate, perform direct endotracheal suctioning using the ET tube as a suction catheter. Quickly intubate the trachea and apply suction to the proximal end of the endotracheal tube while withdrawing the tube.

Repeat the intubation-suction-extubation cycle until no further meconium is obtained. Do not ventilate between intubations.

Continue resuscitative measures as needed. Contact Medical Control

Return to Index


Pediatric - Asystole

Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest

ENSURE PROPER VENTILATIONS

Basic:

Determine pulselessness

Begin CPR with good ventilations and supplemental O2 Intermediate:

Intubate

EtCo2 then ventilate at 20 – 30 breaths/min to maintain an EtCo2 between 35 – 45 mmHg

IV or IO, Normal Saline Paramedic I: Determine cardiac rhythm (confirm Asystole in 2 leads)

Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 – 5 minutes

Consider the causes Hypoxemia Tension Pneumothorax Acidosis Cardiac Tamponade Hypovolemia Hypothermia Hypoglycemia


Return to Index


Pediatric – Pulseless Electrical Activity (PEA)

Basic:

Determine pulselessness.

Begin CPR with good ventilations and supplemental O2.

Determine possible causes: if TRAUMA, transport NOW. Intermediate:

Intubate.

EtCo2 then ventilate to maintain an EtCo2 between 35 – 45 mmHg

IV or IO, Normal Saline Paramedic I:

Determine cardiac rhythm

Epinephrine (1:10,000): .01 mg/kg IV/IO/ET/IN; repeat every 3 – 5 minutes Contact Medical Control:

Possible causes: Hypoxemia Tension Pneumothorax Acidosis Cardiac Tamponade Hypovolemia Hypothermia Hypoglycemia

Return to Index


Pediatric – VF / Pulseless VT

Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest.

ENSURE PROPER VENTILATIONS Basic:

Determine pulselessness

Begin CPR with good ventilations and supplemental O2 Intermediate:

Intubate

EtCo2 then ventilate at 20 - 30 breaths/min to maintain an EtCo2 between 35 – 45 mmHg

IV/ IO, NS Paramedic I:

Determine cardiac rhythm (quick look)

If un-witnessed V-Fib / V-Tach perform 1 minute of CPR prior to Intubation and Defibrillation

Defibrillate: 2 j/kg

Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 – 5 minutes

Defibrillate: 4j/kg after each dose.

Cordarone: 5 mg/kg IV bolus

Defibrillate: 4j/kg after each dose.


Return to Index


Pediatric – Post Resuscitation (ROSC)

Basic:

Continue 100% O2 via NRB or BVM

VS, including SpO2

Intermediate:

IV, Normal Saline, or D5W.

Paramedic I:

If bradycardic, see Bradycardia Protocol (pg. 99)

Up to one year: rate < 80

One to eight years: rate < 60


If converted from ventricular rhythm and no previous medications given and patient hypotensive after 5 minutes

Dopamine: 5.0 – 10 mcg/kg/min IVPB; titrated to effect Must use a Pump (Drip Chart)

Return to Index


Pediatric – Unstable Narrow Complex Tachycardia

Clinical Definition: Narrow complex Tachycardia (<0.08 sec) infants > 220 bpm, children >180 bpm with signs and symptoms of hypoperfusion. Consider underlying causes of tachydysrhythmias. Do not treat sinus tachycardia in pediatric patients. Basic and First Responder:

Ensure airway patency

Oxygen per patient

Complete VS, SpO2 monitor if available Intermediate:

IV/IO of Normal Saline, or saline lock

Dextrose-stick if < 80 see hypoglycemia protocol (pg. 105) Paramedic I:

ECG 12 lead if practical

Vagal Maneuvers ( if this can be done in a timely manner)

Synchronous Cardioversion at 0.5 – 1.0 j/kg, may repeat at 2 j/kg

May pre-medicate with Ativan or Valium if time permits. Dosing per Broselow tape

Adenosine: 0.1 mg/kg rapid IV push (max first dose 6 mg); may double the dose once and then may

repeat

Cordarone: 5 mg/kg IV over 20 – 60 minutes


Return to Index


Pediatric - Bradycardia

Clinical Definition: Up to one year with ventricular rate < 80. One to eight years with ventricular rate < 60.

Basic:

Ensure patent airway

VS, including SpO2

Intermediate:

IV or IO, Normal Saline

Paramedic I:

Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 – 5 min

Consider possible causes: Hypoglycemia Respiratory Compromise Acidosis Medical History

Atropine: 0.02 mg/kg IV/IO/ET/IN; repeat in 3 – 5 min Max of 0.04 mg/kg; Minimum single dose: 0.1 mg; Maximum single dose: 0.5 mg

Fluid challenge: 10 cc/kg of Normal Saline

If severe respiratory compromise, intubation may be necessary. ETCO2, if available.


Return to Index


Pediatric – Abdominal Pain (Vomiting)

Clinical Definition: Non-traumatic abdominal pain. Basic:


Oxygen per patient



EKG For severe nausea and vomiting:

Ondansetron (Zofran):

Ages 2 and under: 0.15 mg/kg; Contact Medical Control

Ages 2 – 7: 1 mg IVP, IM or Oral ODT (Max 2 mg Q 4 Hours); May repeat in 15 minutes with no improvement

Ages 7 – 12: 2 mg IVP, IM or Oral ODT (Max 4 mg Q 4 Hours); May repeat in 15 minutes with no improvement


Return to Index


Pediatric – Allergic Reaction (Mild)

Clinical Definition: Urticaria, itching, without dyspnea or hypotension Basic and Intermediate:


VS, including SpO2

Oxygen per patient Paramedic I:

EKG

Benadryl: 1.0 mg/kg IM; MAX 25 mg


Return to Index


Pediatric – Allergic Reaction (Moderate)

Clinical Definition: Urticaria, itching, dyspnea without hypotension. NOTE: If significant wheezes: see Pediatric Asthma Protocol. (pg. 110) Basic:



EPIPEN, if patient prescribed. Intermediate:


Benadryl: 1.0 mg/kg IV/IM; MAX 25 mg

Epinephrine (1:1,000): 0.005 mg/kg SQ; MAX 0.3 mg

EKG

If patient has moderate to severe dyspnea, meds may be given prior to IV access

Dexamethasone: 0.1 mg/kg IVP

OR

Methylprednisolone: 1 mg/kg IVP

Contact Medical Control: Repeat the Epinephrine (1:1,000): 0.01 mg/kg SQ

Return to Index


Pediatric – Allergic Reaction Severe (Anaphylaxis)

Clinical Definition: Urticaria, edema, dyspnea and hypotension. NOTE: If significant wheezes: refer to Pediatric Asthma Protocol. (pg. 110) Basic:



EPIPEN, if patient prescribed.

Intermediate:


Benadryl: 1.0 mg/kg IV/IM; MAX 25 mg

Epinephrine (1:10,000): 0.01 mg/kg slow IV/IO/IN; MAX 0.3 mg

EKG

Repeat Epinephrine (1:10,000): 0.01 mg/kg IV/IO/IN If patient has moderate to severe dyspnea, meds may be given prior to IV access

Dexamethasone: 0.1 mg/kg IVP

OR

Methylprednisolone: 1 mg/kg IVP


Return to Index


Pediatric – Altered Mental Status

Clinical Definition: Unresponsive or disoriented patient without a clear mechanism for altered mental status. Refer to appropriate protocols as needed (diabetes, head injury, etc.) Basic:


VS, including SpO2

High flow oxygen, assist respirations via BVM, if needed Intermediate:

IV, Normal Saline

Dextrose stick: if < 80 or if signs and symptoms of hypoglycemia:

Preterm infants: D10: 5 – 10 cc/kg IV Children under 3 years: D25: 2 – 4 cc/kg IV, slowly Children 3 years or older: D50: 1 cc/kg IV

Glucagon for confirmed hypoglycemia: 1 mg IM/IN, if IV not available Paramedic I:

EKG


Narcan: 0.1 mg/kg IV/IO/IN; MAX SINGLE DOSE 2.0 mg

* D10 may be prepared with D50 diluted 1:4 with sterile NS.


Return to Index


Pediatric – Hypoglycemia

Clinical Definition: Symptoms related to altered blood glucose levels. Basic:


VS, including SpO2

Oxygen as tolerated

If alert, and suspected hypoglycemia, administer Oral Glucose Intermediate:

IV, Normal Saline

Dextrose stick: if < 80: Preterm infants: D10: 5 – 10 cc/kg IV Children under 3 years: D25: 2 – 4 cc/kg IV, slowly Children 3 years or older: D50: 1 cc/kg IV

Glucagon for confirmed hypoglycemia: 1 mg IM/IN, if IV not available Paramedic I:

EKG


*D10 may be prepared with D50 diluted 1:4 with sterile NS.


Return to Index


Pediatric – Hyperthermia(Environmental) Basic:


VS, including SpO2

High flow oxygen

Rapid external cooling: o Remove to cool environment. o Remove all clothing. o Sponge with cool water. o If shivering occurs, stop cooling. o Avoid large amounts of fluid PO o Fan patient.

Intermediate:

IV, Normal Saline at 15 – 20 cc/kg/hour, wrap ice packs around IV tubing. Paramedic I:

Valium: to stop shivering or seizure activity. 0.2 – 0.3 mg/kg slow IVP Ativan (if available) if Valium unavailable: 0.005 – 0.1 mg/kg SIVP; Rectal 0.1 – 0.2 mg/kg

CONTACT MEDICAL CONTROL FOR ORDERS TO REPEAT: MAX 4 mg


Return to Index


Pediatric - Hypothermia

Clinical Definition: Core temperature < 90 degrees, cessation of shivering activity and / or altered mental status.

Basic:


VS, including SpO2

Oxygen at highest concentration, assist with BVM if necessary.

Warm oxygen by wrapping heat packs around tubing

Cardiac arrest should be treated with CPR only

External warming: o Move to warm environment. o Remove wet clothing. o Wrap in blankets. o Heat packs to neck, groin, and axilla.

Intermediate:

IV, NS; Warm fluids by wrapping tubing with heat packs or pre-warmed fluids Paramedic I:

EKG

Dextrose stick: if < 80 or sign and symptoms of hypoglycemia:



Use cardiac drugs only on medical control order. Minimize rough handling or agitation of patient.

Return to Index


Pediatric – Near Drowning

Clinical Definition: Near Drowning refers to injuries, after partial or complete submersion, in which the child did not die or

where the death occurred more than 24 hours after the incident. Basic:

C-spine precautions


Suction as needed

VS, including SpO2

High flow oxygen Intermediate:

IV, Normal Saline

Airway management as necessary. ETCO2, if available Paramedic I:

EKG (see appropriate protocol) Contact Medical Control

Consider water temperature and possible hypothermia.

Transportation is necessary due to complications that may arise later.

Return to Index


Pediatric – Overdose / Poisoning Clinical Definition: Known / suspected ingestion / injection/inhalation / absorption of harmful substance. Basic:


Determine overdose substance

VS, including SpO2

If contact poisoning, brush off or flush with H2O NOW

High flow oxygen, assist respirations via BVM, if needed

If altered mental status see Pediatric Altered Mental Status Protocol (pg. 104)

Contact Poison Control: 1-800-222-1222 Intermediate:


EKG If ingested poisoning:

Activated Charcoal:

< 1 year: 1 g/kg > 1 year: 25 - 50 g


Return to Index


Pediatric - Asthma

Clinical Definition: Respiratory distress, wheezing on expiration, coughing, tripod positioning and / or accessory muscle use. Basic:


VS, including SpO2

Oxygen per patient

Albuterol: 2.5 mg nebulized updraft; ONLY HALF dose if under 2 years; may be repeated once in 10 minutes; only with Medical Control Permission

Intermediate


EKG, 12 lead & ETCO2 Monitor

If steroid dependent:

Dexamethasone .25 – 1.0 mg/kg IV/IO/IM OR nebulized updraft

Continuous updraft

Epinephrine (1:1,000): 0.01 mg/kg SQ MAX single dose SQ 0.3 mg OR nebulize updraft .5 mg;

Terbutaline: 0.25 mg SQ OR nebulized in 2 cc saline


Return to Index


Pediatric - Bronchiolitis

Clinical Definition: History of upper respiratory infection, rapid onset, hacking cough, audible wheezing, lethargy and, may be febrile. Under 2 years of age. Basic:


VS, including SpO2

Oxygen, humidified (blow-by if delivery device not tolerated)

Position of comfort

If febrile:

Tylenol Suspension: 15 mg/kg PO or RECTAL

Albuterol: 2.5 mg nebulized updraft; ONLY HALF dose if under 2 years; may be repeated once in 10 minutes; only with Medical Control Permission

Intermediate:

IV Normal Saline Paramedic I:

EKG

Epinephrine (1:1000) .5 mg nebulized updraft; may repeat after 10 min Contact Medical Control:

Epinephrine (1:1,000): 0.01 mg/kg SQ

Return to Index


Pediatric - Croup

Clinical Definition: History of upper respiratory infection, “barking” cough, most common at night, ages 6 months to 4 yrs. Do not examine throat Basic and Intermediate:


VS, including SpO2


Position of comfort If febrile:

Tylenol Suspension: 15 mg/kg PO OR RECTAL

Paramedic I:

EKG

Dexamethasone 0.1 mg/kg IVP OR nebulized updraft

Consideration:

Epinephrine (1:1000) .5 mg nebulized updraft; may repeat after 10 min Contact Medical Control

Return to Index


Pediatric - Epiglottis

Clinical Definition: Rapid onset, high fever, sore throat, drooling, inspiratory stridor, tri-pod positioning. Less than 5 y/o, do not examine throat or place anything in mouth. These patients require rapid transport. Basic and Intermediate:


VS, including SpO2


Position of comfort Paramedic I:

EKG

Dexamethasone 0.1 mg/kg, nebulized updraft Contact Medical Control:

If complete airway obstruction: Attempt intubation or Cricothyroidotomy

Agitation can increase edema or swelling.

*AVOID IV IF POSSIBLE*

Return to Index


Pediatric – Obstructed Airway / Foreign Body

Basic:

If patient able to cough, allow patient to relieve obstruction on his / her own

If patient unable to relieve obstruction, perform Heimlich maneuver appropriate to age Intermediate

Attempt to visualize obstruction and remove with Magill Forceps

Oxygen and intubation, as needed

Transport immediately Paramedic I:

IV Normal Saline only in deteriorating patients Contact Medical Control:

*Cricothyroidotomy, only if all other efforts fail……*

Return to Index


Pediatric - Seizures

Clinical Definition: Active seizures (tonic/ clonic) or postictal. Basic:

Ensure patent airway.

Determine possible cause: Elevated Temperature; Head Injury; Medical History

Protect patient from injury.

VS, including SpO2.

Oxygen as tolerated. Intermediate:

IV, Normal Saline

Dextrose stick: if < 80 or signs and symptoms of hypoglycemia:


Paramedic I:

EKG

Valium: 0.1 mg/kg IV/IO/IN, or 0.5 mg/kg RECTAL; may repeat in 5 min

OR

Ativan 0.05 – 0.1 mg/kg SIVP over 2 minutes; Rectal 0.1 – 0.2 mg/kg CONTACT MEDICAL CONTROL FOR ORDERS TO REPEAT: MAX 4 mg

Tylenol ` 15mg/kg Rectal (If Febrile)

Narcan: 0.1 mg/kg IVP, or 2 mg IM (If suspected narcotic overdose)

Glucagon: 1 mg IM/IN; if IV not available


* D10 may be prepared with D50 diluted 1:4 with sterile H20. * D25 may be prepared with D50 diluted 1:1 with sterile H20.

Return to Index


Appendix:

Procedure

Section


Pain Management (General Protocol)

Evaluate Pain Scale: 0 - 10, with 10 being the worst; Ask about Patient allergies to medications and, ask the patient if they

want pain management.

Verify no neurological deficits indicating head injury. If a possibility of a head injury or multi-systems trauma,

contact Medical Control prior to medication administration.

Administer one of the following:

Morphine: Adult: 2 – 5 mg increments Slow IVP, Q 5 minutes (MAX dose of 20mg)

Pediatric < 2 years: 0.1mg/kg Slow IVP Q 5 minutes (MAX of 10 mg)

Fentanyl: Adult: 25 – 50 mcg Slow IVP; May repeat after 5 minutes (MAX of 100 mcg)

Pediatric < 2 years: .5mcg/kg Slow IVP, may repeat after 5 minutes (MAX of .5mcg/kg)

Valium: Adult: 2 – 10 mg SLOW IVP

Pediatric: 0.1 mg/kg Slow IVP (MAX does of .5mg/kg)

Ativan Adult: 1 – 2 mg SIVP

Pediatric: Dose per Broselow

For severe nausea and vomiting due the effect of pain meds:

Ondansetron: Adult: 4 – 8 mg IVP, IM or Oral ODT

Pediatric: Age: 2 – 7; 1 mg IVP, IM or Oral ODT (MAX dose of 2 mg Q 4 hours)

Age: 7 – 12; 2 mg IVP, IM or Oral ODT (MAX dose of 4 mg Q 4 hours);

May repeat in 15 min if no improvement

Promethazine: Adult: 12.5 IVP; 25 mg IM

Pediatric: Contact Medical Control for Dosage

Pain Management for Burn patients:

Morphine 10 mg (Max Dose 40 mg)

AND


May repeat if SBP is maintained > 90 mmHg

Return to Index


Medication Assisted Intubation (MAI)

Clinical Definition: In the patient in whom intubation is required and has an Altered Level of Consciousness (LOC) with

Glasgow Coma Score of < 8, impending respiratory failure/arrest or airway obstruction, or an intact gag reflex consider

Medically Assisted Intubation (MAI), for contraindications see RSI Protocol.

Recommendations:

If no contraindications to the oral tracheal intubation approach, it will be your best choice.

Procedure:

Patient preparation as described in the RSI protocol is standard. Refer to RSI Protocol. (pg. 119 – 120)

In lieu of Succinylcholine/ Administer (may consider):

Ketamine: 1 – 2 mg/kg SIVP, over 1 minute

OR

Etomidate: .3 mg/kg

OR

Fentanyl 50 – 100 mcg

Consider Hurricane Spray

*If sedation is adequate then proceed with intubation*

Consideration:

If at any time you feel you are losing control of the airway with this protocol, you may consider repeating:

Etomidate: 0.3 mg/kg IVP

OR

Fentanyl: 50 – 100 mcg IVP

If still no success, then return to traditional RSI Protocol. Refer to RSI Protocol. (pg. 119 – 120)

Return to Index


Rapid Sequence Induction for Intubation (RSI)

Clinical Indications: Altered Level of Consciousness (LOC) with Glasgow Coma Score of < 8, impending respiratory failure and,

respiratory arrest , and/or airway obstruction.

Contraindications: Inability to ventilate the patient if paralyzed as in acetyl cholinesterase Disorders,

neuromuscular disorders (muscular dystrophies, MG, etc…)

Only personnel credentialed by the Medical Director (Paramedic II and above) are to attempt RSI in the field.

.

If patient is bradycardia, pre-medicate with:

Atropine: 0.5 – 1.0 mg IV

Prepare for endotracheal intubation :( have the needle Cricothyroidotomy kit & suction prepared and at the patient’s side)

For Sedation:

Ketamine 1 – 2 mg/kg SIVP, over 1 minutes

OR

Etomidate: 0.3 mg/kg IPV, over 30 seconds OR

Versed: 5 mg IVP

When sedation is achieved:

Succinycholine: 1 – 1.5mg/kg IVP

When patient is paralyzed and unable to intubate; place alternate airway (King Airway, TTJV, Cricothyroidotomy) and

Ventilate with use of pulse ox and ETCO2.

Effective ventilation of some form MUST BE ACHIEVED!!!!!

Secure and confirm tube placement and transport

(Continued on next page)


For continued sedation:

Versed: 1 – 5 mg IVP, every10 minutes for a total of 20 mg in 1 hour; (Pediatric dose 0.1 mg/kg)

OR

Fentanyl: 25 – 50 mcg every 5 minutes

For continued pain management:

Morphine: 2 – 5 mg IVP, every 5 minutes or until pain is relieved; (Pediatric dose 0.1 mg/kg)

For continued paralysis: Continued paralysis is only to be used when adequate sedation cannot be achieved.

Rocuronium (ROC): 1 - 1.5 mg/kg

Return to Index


Continued Sedation / Paralysis

Clinical Indications: For use in the intubated patient who demonstrates a lack of tolerance for the presence of the ET tube

and must remain sedated and paralyzed for airway protection during transport.

Under no circumstances should a paralytic be administered to any patient who is not appropriately pain medicated

and sedated.

PARAMEDIC ONLY

Verify tube placement via ETCO2 monitoring, auscultation of lung fields, and absence of air in the

epigastrium during ventilation. Findings must be documented.

Verify patency of IV

For continued sedation:

Ketamine: 1 – 2 mg/kg SIVP over 1 minutes

OR

Versed: 2.5 – 5 mg IVP

OR

Ativan: 1 – 2 mg IVP

For continued paralysis:

Rocuronium (ROC): 1 – 1.5 mg/kg IVP

Ensure Adequate and Effective Ventilation is ongoing for Duration of Transport

Return to Index


Airway Management for the Burn Victim

Clinical Definition: In the patient in which intubation is required and who likewise is the victim of a burn, this requires some

unique considerations. These are based on the physiologic considerations that these patients are predisposed to electrolyte

shifts and may have depressed cardiovascular reserves. These are some of the reasons we should do our best to avoid the

traditional agents which include Succinylcholine.

Recommendations: If no contraindications to the nasotracheal approach, this might be your first line of choice.

If you need patient cooperation and relaxation and nasotracheal is not possible or fails, then a “modified” RSI should be

utilized.

Procedure: Patient preparation as described in the RSI protocol is standard. (See RSI Protocol pg. 119)

In lieu of Succinylcholine and Etomidate:

Administer :

morphine 10 mg IVP (Max Dose 40 mg)

OR

Ativan 4 mg SIVP (Max 20 mg)

OR

Valium 10 mg IVP (Max 20 mg)

May repeat the above regimen but, SBP must remain < 90 mmHg

Consideration: If you feel you are losing control of the airway with this protocol, you may consider other options to include:

Ketamine 1 – 2 mg/kg SIVP

OR

Etomidate: 0.3 mg/kg IVP

OR

Fentanyl: 50 – 100 mcg IVP

If still no success, then return to traditional RSI Protocol. Refer to RSI Protocol. (pg. 119 – 120) Return to Index


Air Evacuation Protocol

The following criteria justify but do not require air evacuation for adult trauma patients: 1. Estimated ground transport to the nearest Level I/II Trauma Center is greater than the response and transport time for the

helicopter and the patient has one of the following injuries or conditions (The helicopter may carry blood, if requested. If so, only the response time should be considered.):

a) Multisystem blunt or penetrating trauma with unstable vital signs. b) Penetrating injury to head, neck, chest, abdomen, or groin. c) Burns > 20% TBSA (2nd or 3rd degree) or involving face, airway, hands, feet or genitalia. d) Amputations with the potential for reimplantation. e) Paralysis or other signs of spinal cord injury. f) Flail chest. g) Open or suspected depressed skull fracture. h) Open or unstable pelvis fracture. i) Two or more proximal bone fractures

2. Patient extrication time greater than 20 minutes 3. Number of critically injured patients exceeds capabilities of local EMS agencies. 4. Closest hospital is on diversion for trauma patients. 5. Ambulance access to the scene, or away from the scene, is impeded by road conditions, weather conditions, or traffic.

The following criteria justify air evacuation for pediatric trauma patients: 1. Experienced or at risk for developing acute respiratory failure or respiratory arrest and is not responsive to initial therapy. 2. Invasive airway procedure with assisted ventilation. 3. Respiratory rate less than 10 or greater than 60 breaths per minute. 4. Systolic blood pressure:

Neonate: less than 60 mmHg Infant (< 2 yr): less than 65 mmHg Child (2 - 5 yr): less than 70 mmHg Child (6 - 12 yr): less than 80 mmHg

5. Near drowning with signs of hypoxia or altered mental status.

The following criteria justify air evacuation for Medical Patients: 1. Acute MI with Cardiogenic shock or patient not eligible for TPA 2. Acute CVA which is defined as onset less than 3 hours 3. Other acute medical conditions that require immediate specialized treatment

Return to Index


Pacing (Transcutaneous)

Clinical Indication: For temporary pacing in patients with symptomatic bradycardia.

1. Attach lead wires to the adhesive electrode pads.

2. Apply anterior adhesive electrode on left side of sternum over the point of maximum intensity; posterior electrode just below

the left scapula. If possible, place pads on clean dry skin. If necessary, trim hair.

3. Turn pacer on. DO NOT start current flow.

4. Set pacer rate to 80.

5. Increase milliamp setting by 5's until capture is obtained or up to the maximum energy available.

Electrical capture: wide QRS and tall, broad T-waves.

Mechanical capture: palpable pulse, rise in BP, improved LOC, skin color/temp.

6. Confirm mechanical capture.

7. If no response is obtained from maximum pacing output, interrupt pacing and continue with the appropriate cardiac protocol.

Intermittently check for possible capture using maximum pacer setting.

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

5 – 10 seconds.

Return to Index


DNR Protocol

A. Pursuant to Title 25, Part I, Chapter 157.25, certified EMS personnel shall honor out of hospital DNR orders encountered during

their official duties.

B. Procedures that shall be withdrawn or withheld pursuant to these orders are:

1. Cardiopulmonary resuscitation;

2. Endotracheal intubation or other advanced airway management;

3. Artificial ventilation;

4. Defibrillation;

5. Transcutaneous cardiac pacing; and

6. Administration of cardiac resuscitation medications.

C. Patient Identification:

1. For purposes of identification a patient under this section may be wearing a Texas Department of Health bracelet or

necklace bearing the standardized DNR logo; and/or

2. An official DNR form may be present and completed in its entirety with appropriate legible signatures.

D. On-Site DNR Dispute Resolution Process:

1. If EMS personnel encounter a patient that is wearing an official DNR bracelet or necklace and is not presented with an

official DNR order form, said EMS personnel shall honor such bracelet or necklace as if the DNR form is present;

2. Should EMS personnel encounter a patient wearing an official DNR bracelet or necklace and/or is presented with an official

DNR order form and is instructed by a person identifying themselves as family member or the legal guardian of the patient to

resuscitate the patient, said EMS personnel shall begin normal resuscitative measures:

a. If there is conflicting instructions between family members, resuscitative measures will be begun and medical control

shall be contacted for instructions; and

b. If medical control cannot immediately be contacted, resuscitative measures will be continued and transport expedited;

and

c. The family member(s) or legal guardian will be required to accompany the crew to the hospital.

3. Circumstances of the DNR dispute shall be fully documented to include the full name(s), address (es), phone number(s), and

relationship(s) to the patient of those persons involved in the dispute.

E. Recordkeeping - Records shall be maintained on each incident in which an out-of-hospital order or DNR identification device is

encountered by EMS personnel, and the number of cases in which there is an on-site revocation of the DNR order shall be

recorded.

Return to Index


1. The data documented shall include:

a. An assessment of the patient's condition;

b. Whether an identification device and a DNR form was used to confirm DNR status and patient identification number;

c. Any problems relating to the implementation of the DNR order;

d. The name of the patient's attending physician; and

e. The full name, address, telephone number, and relationship to the patient of any witness used to identify the patient.

2. A photocopy of the original DNR form shall be made and retained with patient's EMS run report.

3. Annually, the EMS administration shall provide a report to the EMS Medical Director and the Bureau of Emergency

Management with the following information:

a. Number of times personnel have been presented with DNR documentation;

b. Number of times there was a problem and the DNR order could not be honored; and

c. Any problems that were encountered using the standardized form.

F. Out of State DNR orders - EMS Personnel may accept an original out-of-hospital DNR order that has been executed in any other

state if there is no reason to question the authenticity of the order.

1. EMS personnel may not accept any out-of-state identifying devices to include bracelets or necklaces.

2. If there is any question of validity of the DNR order, the responding EMS personnel shall attempt to contact medical control.

a. If medical control cannot be immediately contacted for direction, the responding EMS personnel shall begin resuscitative

measures.

G. Failure to honor a DNR order:

1. If there are any indications of unnatural or suspicious circumstances, the EMS personnel shall begin resuscitation efforts until

such time as a physician directs otherwise.

2. The indications of unnatural or suspicious circumstances shall be fully documented.

H. Pregnant persons - EMS personnel may NOT withhold resuscitation efforts from a person known by them to be pregnant.


Transtracheal Jet Ventilation

Clinical Indications: Inability to open and maintain the airway and all other methods to obtain an airway have failed.

Contraindications:

Transection of the trachea with significant damage to the cricoid cartilage; and the inability to palpate landmarks.

Procedure (if equipment available):

1. Maintain ventilation and airway clearance attempts while preparing equipment.

2. Assemble appropriate equipment, 13G cannula with 10ml syringe attached, oxygen tubing firmly connected to flow meter then

connect with 10 – 15 LPM flow, Y piece regulator oxygen flow.

3. Identify the cricothyroid membrane in the midline between the thyroid cartilage (Adams Apple) and the cricoid cartilage (Next

Prominent Cartilage down from the Thyroid Cartilage)

4. Cleanse site with alcohol prep.

5. Insert cannula tip through the skin and membrane in one firm push in the “Midline”, Angled at 45 degrees downward until a “give”

is felt.

6. Aspirating on the syringe as the cannula is inserted; air will freely enter the syringe as the cannula enters the trachea, confirming

tracheal entry.

7. Slide cannula over the needle into the trachea and secure. Attach the high pressure tubing to the catheter and oxygen source at

50 psi. Ventilate patient with 1 – 5 second burst at a rate of 12 – 20 per minute.

8. Secure Transtracheal Jet Ventilation device securely.

Return to Index


Surgical Cricothyroidotomy

Contraindications:

There are no absolute contraindications in the patient who will not survive without a definitive airway, but remember that a patient who

has sustained a trauma to the neck area may have a hematoma and incision into this area can result in significant bleeding.

Procedure:

1. Patient should be placed in the supine position with the neck maximally exposed.

2. Locate the cricothyroid membrane utilizing anatomical landmarks.

3. Surgically prep the area with alcohol/Betadine. Use aseptic technique if possible.

4. Stabilize thyroid cartilage with one hand, make a 2.5 cm vertically oriented incision and identify the membrane, it is imperative this

entire procedure maintain itself in the midline of the neck.

5. Puncture the membrane with the scalpel and then place either a hemostat or trouseau dilator in the incised site.

6. Pass an ET tube of at least 6.0 in size, and attach to BVM.

7. Ventilate and check for correct placement with chest rise, breath sounds, end tidal CO2, and tube humidification.

8. If possible inflate cuff and secure the tube in place.

Complications

1. Bleeding at the site

2. Aberrant placement of the tube into pre-tracheal fascia and dissection of subcutaneous air into soft tissues of neck.

Return to Index


Nasotracheal Intubation

Note: This procedure requires a spontaneous breathing patient. Remember that this procedure is unpleasant, and the patient will want to resist so cervical spine movement should be anticipated.

Indications: 1. Inability to open the mouth (e.g. clenching teeth) 2. Suspected cervical spine injury IF ability to perform in-line technique oral tracheal is in doubt! 3. Dental Injuries and/or gagging or resisting laryngoscope placement

Contraindications: 1. Basilar skull fracture and severe nasal or mid-facial deformity 2. Apnea, upper Airway Obstruction and acute epiglottitis 3. Care should be taken with patients on anticoagulants and with patients with known or suspected coagulopathies and

are potential candidates for thrombolytic agent (cardiac or CNS). 4. Children under 8 years of age

Complications: 1. Nasal Trauma and turbinate fractures 2. Epistaxis and/or perforation of pharyngeal wall 3. Brain Intubation and infection Procedure without paralysis:

1. Select the largest and least obstructed nostril, may consider inserting a lubricated nasal airway to help dilate the nasal

passage.

2. Appropriately position and secure patient provide emotional support and explain procedures. 3. Premedicate with hurricane spray. 4. Appropriately pre-oxygenate the patient.

5. Administer Lidocaine 1.5mg/kg before intubating patient’s with suspected Closed Head Injury. 6. Administer appropriate sedation as needed unless contraindicated. 7. Select appropriate sized ET tube (may need a size small then used for oral intubation). 8. Lubricate ET Tube liberally with water soluble gel.

9. Insert the tube bevel inward. The tube is designed to insert into the right nare. If inserting into the left nare invert the tube and insert then rotate 180 degrees upon reaching the hypopharynx. The tube should be inserted perpendicular to the horizontal plane, along the floor of the nasopharynx and not toward the frontal sinus. NEVER FORCE THE TUBE. 10. Gently pass the tube while listening to breath sounds or for a positive whistle if using a BAAM. 11. Pass the tube on inspiration, confirm placement by: auscultation of breath sounds, observing for symmetrical chest wall movement, patient’s inability to speak, presence of vapor in the tube, Positive end tidal CO2, improved oxygen saturation and then secure the tube in place.

Return to Index


Orotracheal Intubation

Advantages:

1. To provide controlled, precise oxygenation and ventilation.

2. To protect against aspiration and is a route for drug administration?

Indications:

1. Apnea, respirations <8 and/or GCS < 8

2. CHI with increased ICP

3. Pulse Oximetry <90% with respiratory Distress

4. COPD with Altered Level of Consciousness and/or evidence of airway burns

Contraindications:

1. Cervical Spine injury unless using in-line stabilization

2. Severe Facial Trauma, fracture of the larynx and/ or upper Airway Obstruction

Complications:

1. Cervical Strain, neurologic injury

2. Soft tissue injuries to the mouth, lips, tongue or pharynx.

3. Dental Injuries, vocal Cord Spasm or Injury and/or Tracheal / Bronchial rupture

4. Right main-stem intubation, esophageal intubation, vomiting and aspiration

5. Vasovagal responses such as bradycardia, tachycardia, dysrhythmias

6. Cardiac Arrest with interruption of CPR

Procedure without paralysis:

1. Position the patient to optimize glottis visualization. For trauma patient’s maintain in-line stabilization.

2. Pre-oxygenate the patient for 3 minutes

3. Atropine 0.01 – 0.02 mg/kg for patients <8 years, or 0.5mg for bradycardic adults.

4. Lidocaine 1.5 mg/kg for potential closed head injuries.

5. If indicated utilize Benzocaine spray to reduce the activity of the gag reflex.

6. Administer sedation as needed unless contraindicated

7. Apply a Nasal Cannula at 15 lpm

8. Apply traction in an anterior direction displacing the tongue and the epiglottis until the glottic opening is visualized.

9. Insert the endotracheal tube from the right corner of the mouth and watch it pass through the vocal cords.

10. Inflate the cuff with 5 – 10 cc of air.

11. Confirm tube placement by checking for bilateral chest rise, bilateral breath sounds, vapor and condensation in the tube, absence of

gurgling over the epigastrium, improved oxygen saturation, presence of ETCO2 , improvement in color.

12. Secure the tube in place.

Return to Index


King Airway

Clinical Indications: Following two (2) unsuccessful attempts to place an endotracheal tube, or if it appears additional endotracheal intubation

attempts would be unsuccessful, use of the King Airway should be considered.

Contraindications:

1. Patients who are conscious or who have an intact gag reflex

2. Patients under four (4) feet in height

3. Patients with known esophageal disease (varicese, alcoholism, cirrhosis etc.) or ingestion of caustic substances

Precautions:

1. The KING LT-D does not protect the airway from the effects of regurgitation and aspiration.

2. High airway pressures may divert gas either to the stomach or to the atmosphere.

3. Intubation of the trachea cannot be ruled out as a potential complication of the insertion of the KING LT-D.

4. After placement, perform standard checks for breath sounds and utilize an appropriate carbon dioxide monitor as required by protocol.

5. Lubricate only the posterior surface of the KING LT-D to avoid blockage of the ventilation apertures or aspiration of the lubricant.

6. The KING LT-D is not intended for re-use.

7. During transition to spontaneous ventilation, airway manipulations or other methods may be needed to maintain airway patency.

Procedure:

1. Test cuff inflation system by injecting the maximum volume of air into the cuffs. Remove all air from both cuffs prior to insertion.

2. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near

the ventilatory openings.

3. Pre-oxygenate patient with 100% oxygen for at least 1 minute.

4. Position the head. The ideal head position for insertion of the KING LT-D is the "sniffing position". The angle and shortness of

the tube also allows it to be inserted with the head in a neutral position.

5. Hold the KING LT-D at the connector with dominant hand, hold mouth open and apply chin lift.

6. With the KING LT-D rotated laterally 45-90o such that the blue orientation line is touching the corner of the mouth, introduce tip

into mouth and advance behind base of tongue. Never force the tube into position.

7. As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin).

8. Without exerting excessive force, advance KING LT-D until proximal opening of gastric access lumen is aligned with the teeth or gums.

9. With a syringe inflate the KING LT-D; inflate cuffs with the minimum volume necessary to seal the airway at the peak ventilatory pressure

employed (just seal volume).

10. Attach the BVM to the 15 mm connector of the KING LT-D. While gently bagging the patient to assess ventilation, simultaneously withdraw the

airway until ventilation is easy and free flowing (large tidal volume with minimal airway pressure).

11. Depth markings are provided at the proximal end of the KING LT-D which refers to the distance from the distal ventilatory openings. When

properly placed with the distal tip and cuff in the upper esophagus and the ventilatory openings aligned with the opening to the larynx, the depth

markings give an indication of the distance, in cm, from the vocal cords to the upper teeth.

12. Attach ETCO2 monitoring device to adaptor and follow guidelines for its use.

13. Confirm proper position by auscultation, chest movement and verification of CO2 by capnography. Do not let go of tube until secured. Secure

KING LTS-D to patient using tape or an approved commercial device. DO NOT COVER THE PROXIMAL OPENING OF THE GASTRIC

ACCESS LUMEN.

14. Immediately following successful placement of the King Airway, apply an appropriately sized cervical collar. If the C-collar doesn’t fit; manual

inline stabilization should be utilized if transported; blankets, towels and tape should be used appropriately to restrict cervical spinal motion.

No exceptions.

15. If an Adult or pediatric patient is to be transported, they must be secured to a backboard.

ONCE INSERTED SUCCESSFULLY, DO NOT REMOVE

Return to Index


Needle Chest Decompression Protocol

Indication: Patient in respiratory distress with at least 4 of the following clinical signs of tension pneumothorax:

a. Dyspnea with use of accessory muscles of respiration b. Marked decrease or absent breath sounds in the axilla on affected side* c. Hypertympany to percussion of anterior chest on affected side* d. Deviation of trachea away from affected side e. Pulse oximetry below 92% despite 100% O2 by mask f. High or increasing resistance to ventilation in the intubated patient g. Penetrating or blunt trauma to the chest h. Subcutaneous emphysema

Procedure:

ABC’s, if patient not ventilating secure airway

1. ECG

2. Obtain a size 10 – 16 IV catheter at least one and one half inches long 3. Locate the second intercostal space at the mid-clavicular line on the affected side of the chest 4. Prepare the skin with antiseptic solution 5. Align the needle with the top if the third rib and press the needle through the chest wall at a 90 degree angle to the

anterior chest wall 6. Once in the pleural space stabilize the catheter and advance the catheter over the needle 7. Leave the catheter open to the air as long as air can be felt coming from the catheter flutter valve and stop cock optional

if available or asherman chest seal.

Reassess ABC’s and contact Medical Control and report results

Return to Index


Intra – Nasal Mucosal Atomization Device (MAD)

1. Disconnect MAD from the included syringe

2. Fill syringe with the desired volume of solution and eliminate remaining air.

3. Connect MAD to the syringe. If using MAD with 6” extension, eliminate air in tubing and bend into position. Tubing will remain in

fixed position.

4. Place MAD tip in the nostril or oropharyngeal cavity.

5. Compress the syringe plunger to spray atomized solution into the nasal or oropharyngeal cavity.

6. Re-use the MAD on the same patient as needed, and then discard.

7. Do not place the MAD tip within the trachea.

8. Do not use the MAD on more than one patient.

Return to Index


Portable Ventilator

Criteria for use: Paramedic Only with Medical Director Approval (Check-off) 1. Any patient that has been successfully intubated with an endotracheal tube.

2. Any patient that is in severe respiratory distress requiring the use of a BVM or endotracheal intubation.

3. Any Patient in cardiac arrest that needs ventilator support. 4. Transfer of ventilated patients from an acute care facility. Procedure for use: 1. Connect ventilator oxygen supply tubing to wall mounted oxygen.

2. Connect flexible vent circuit to vent and test lung. Adjust end-tidal and respirations per minute. Approximately 5 – 10ml/kg (Ideal

Body Weight) initially for tidal volume and 12 – 14 breaths per minute on Assist-Control setting. Titrate tidal volume as necessary to deliver adequate ventilations. I-times should be at about 1.5 seconds. For in-field use, PEEP will generally not be used. With test lung in place, verify acceptable ventilator operation.

3. If patient is a hospital transfer, utilize hospital vent settings as a guideline. 4. Verify proper tube placement prior to connecting to ventilator. 5. If patient is intubated, connect flexible vent circuit to patient. Verify positive lung sounds and adequate chest rise and fall. Observe

for fogging in tube. Ensure that ETCO2 device is connected (if available). 6. Monitor pulse oximetry and ETCO2 for verification of tube placement as well as proper ventilatory support. Adjust vent settings as

necessary to maintain SPO2 above 93% and ETCO2 in a range of 35 – 45mmHg. Precautions: 1. As with any mechanical device, failure is possible. Always have a BVM ready for use. Monitor the patient continuously. In the

event of ventilator failure, disconnect patient from ventilator and provide respiratory support with BVM.

2. Monitor Patient for pneumothorax. If pneumothorax is present see pneumothorax protocol and discontinue use of ventilator.

Return to Index


Tidal Volumes Chart

Pediatric Ventilator Tidal Volumes

Dose Preterm New Born 6 Months 1 Year 3 Years 6 Years 10 Years 11 Years 12 Years 14 Years

Pounds 3 lbs 7 lbs 15 lbs 22 lbs 33 lbs 44 lbs 66 lbs 77 lbs 88 lbs 110 lbs

Kilograms 1.5 kg 3 kg 7 kg 10 kg 15 kg 20 kg 30 kg 35 kg 40 kg 50 kg

7ml/kg 10.5 21 ml 49 ml 70 ml 105 ml 140 ml 210 ml 245 ml 280 ml 350 ml

8ml/kg 12 ml 24 ml 56 ml 80 ml 120 ml 160 ml 240 ml 280 ml 320 ml 400 ml

9ml/kg 13.5 ml 27 ml 63 ml 90 ml 135 ml 180 ml 270 ml 315 ml 360 ml 450 ml

10ml/kg 15 ml 30 ml 70 ml 100 ml 150 ml 200 ml 300 ml 350 ml 400 ml 500 ml

Adult Ventilator Tidal Volumes

Dose

Pounds 121 lb 132 lb 143 lb 154 lb 165 lb 176 lb 187 lb 198 lb 209 lb 220 lb 231 lb 242 lb

Kilograms 55 kg 60 kg 65 kg 70 kg 75 kg 80 kg 85 kg 90 kg 95 kg 100 kg 105 kg 110 kg

7 ML/KG 385 ml 420 ml 455 ml 490 ml 525 ml 560 ml 595 ml 630 ml 665 ml 700 ml 735 ml 770 ml




Return to Index


Blood Administration

Indications: Trauma patients who upon assessment present with signs and symptoms of hypovolemic shock

Procedure (Paramedic Level Only):

1. Evaluate patient for signs/symptoms of hypovolemic shock maintaining considerations for mechanism and site of injury, distance

from nearest emergency facility, time to receive packed red cells to scene, time of extrication (if applicable), estimated time of

arrival to Level 1 or Level 2 trauma facility (if available).

2. Notify supervisor of need for packed red cells at scene. Supervisor will contact Medical Control and appropriate facility and arrange

for transport of 2 units of O negative packed red cells and appropriate blood tubing.

3. Initiate bilateral large bore IV therapy with Normal Saline (preferably warmed fluids). Try to verify medical history and possible

allergies including prior transfusion reactions if any. Verify and closely monitor vital signs including temperature.

4. Upon arrival of packed red cells, verify that blood units are O negative. Verify with a second paramedic. Record unit ID numbers

along with patient name and appropriate demographic information.

5. Initiate blood infusion via large bore IV line with Normal Saline. Record infusions start time.

6. Monitor patient vital signs including temperature every five minutes. Maintain continuous assessment for transfusion reaction

(i.e.: signs/symptoms of anaphylaxis, increased temperature above normal, sudden onset of nausea/vomiting, continued

hypotension, angina, dyspnea, coagulopathies). If possible transfusion reaction noted, discontinue blood therapy and treat

presenting symptoms via appropriate protocol (Notify Medical Control).

7. Upon completion of transfusion, record time and vital signs.

8. Upon transfer of care, provide receiving personnel complete report regarding transfusion.

9. Upon completion of written patient care report; supervisor is to immediately provide a complete copy to either the lab/blood bank

supervisor or nursing supervisor at facility that provided the packed red cells. Patient care report should specifically have all

pertinent transfusion information including complete vital signs, unit numbers of packed red cells, to whom care was transferred and

name of receiving facility.

Return to Index


Continuous Positive Pressure

Indications:

1. Respiratory Distress indicated by low O2 saturation, high CO2 on capnography, RR>20 or RR<10 sustain or significantly

increased work of breathing.

2. Patient’s condition does not respond to supplemental oxygen.

3. Patient’s respiratory distress is likely from COPD, CHF, asthma or pneumonia.

4. Patients on CPAP or Bi-Pap at site of transfer.

Inclusion Criteria:

1. Awake and alert patients able to maintain airway.

2. Age >13 years

3. Medical patient with SBP >90 mmHg

Exclusion Criteria:

1. Uncooperative, confused or significantly agitated patient

2. Unable to properly protect airway

3. Suspected Pneumothorax or Hemothorax

4. Significant chest wall trauma

5. RR<8

6. Hypotension not responsive to minimal fluid resuscitation

7. Near respiratory arrest

8. Unable to obtain proper seal of face mask

Treatment:

1. Follow initial steps in appropriate protocol

2. Apply CPAP per manufacture procedure with initial setting of 0 – 1 cm H2O, FIO2 with 100% and titrate to effect.

3. Select proper mask.

4. Explain procedure to patient. Ask patient hold mask to face initially to confirm tolerance; after at least 3 minutes, patient can then

be converted to straps.

5. Monitor closely for deterioration in condition: decreased mental status, increased work of ventilation, decreased O2 saturation,

increased O2 concentration, drop in SBP to <95 mmHg or increased agitation.

6. Pressure can be decreased for stable patients without signs of respiratory distress to basic levels of pressure of 3 – 5 cm H2O and

O2 concentration of 100%.

7. May use inline nebulizer if needed: see specific protocol.

8. If patient is deteriorating contact medical control or Captain regarding RSI or medically assisted intubation and BVM ventilation.

Return to Index


EZ – IO – Intraosseous Infusion

The EZ IO device consists of a battery powered driver; a special needs assembly, right-angle extension tubing, and a wrist band.

Indications:

Patients where rapid, regular IV access is unavailable with any of the following

Cardiac and / or respiratory arrest / respiratory failure

Multi-system trauma with severe hypovolemia

Severe dehydration with vascular collapse and / or loss of consciousness

Contraindication:

Fractures proximal to proposed insertion site

Inability to locate landmark (significant edema)

Excessive tissue at insertion site (obesity)

Current or prior infection at proposed site

Previous IO insertion or joint replacement at the proposed site

Procedure:

1. Locate insertion site a. Proximal Tibia b. Distal Tibia c. Distal Femur d. Humeral Head

2. Clean insertion site with aseptic technique 3. Prepare EZ-IO driver and needle 4. Stabilize site and insert EZ-IO needle 5. Stabilize catheter hub and remove EZ-IO driver from needle set 6. Confirm placement 7. Flush with Lidocaine then with 10 ml of NS 8. Connect extension set and/or IV tubing 9. Place a pressure bag on solution (if needed) 10. Begin infusion (watch carefully for infiltration) 11. Apply dressing 12. Monitor EZ-IO site and patient condition

Return to Index


Rule of Nine’s Adult

Return to Index


Rule of Nine’s Child

Return to Index


Lund and Browder Burn Chart

Parkland Burn Formula for fluid replacement: 4 ml x % BSA x kg 50% calculated in 1st 8 hours

Age in years 0 1 5 10 15 Adult

A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½

B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾

C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½

Return to Index


Classification of Burn Severity Reference

Major Burns

1. Partial-thickness burns greater than 25% of body surface area in adults or greater than 20% in children or the elderly. 2. Full-thickness burns greater than 10% of BSA 3. All burns involving the face, eyes, hands, feet or perineum that may result in functional or cosmetic impairment. 4. Burns caused by caustic chemical agents. 5. Burns complicated by inhalation injury, major trauma or poor-risk patients.

Moderate Burns

1. Partial-thickness burns 15% - 25% BSA in adults and 10% - 20% BSA in children or the elderly. 2. Less than 10% of BSA full-thickness burns. 3. Not involving the risk to specialized function such as the face, eyes, ears, hands, feet or perineum.

Minor Burns

1. Burns less than 15% of BSA in adults or 10% of BSA in children or the elderly. 2. Less than 2% full-thickness burns. 3. No functional or cosmetic risk to special functional areas.

Return to Index


Pediatric Drug Chart NEW 6 1 3 6 10 11 12 14

DOSE PRETERM BORN MONTHS YEAR YEARS YEARS YEARS YEARS YEARS YEARS

WEIGHT POUNDS 3 7 15 22 33 44 66 77 88 110

KG 1.5 3 7 10 15 20 30 35 40 50

Heart Rate 100 - 160 100 - 160 90 - 120 90 - 120 80 - 120 70 - 100 60 - 90 60 - 90 60 - 90 60 - 90

Respiratory Rate 30-60 30-60 25-40 20-30 20-30 18-25 15-20 15-20 15-20 15-20

Systolic BP 50-70 50-70 80-100 80-100 80-100 80-110 80-110 90-120 90-120 90-120

ET Blades 0-1 0-1 1 1-2 1-2 2 2 2 2-3 3

ET Tube 2-2.5 3.0-3.5 3.5 4.0 4.5 5.0 6.0 6.0 – 6.5 6.5 7.0

Defibrillation 2 J / KG 3j 6j 14j 20j 30j 40j 60j 70j 80j 100j

4 J / KG 6j 12j 28j 40j 60j 80j 120j 140j 160j 200j

Adenocard .1 MG /KG 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg

.2 MG / KG 0.3mg 0.6mg 1.4mg 2mg 3mg 4mg 6mg 7mg 8mg 10mg

Atropine .02 mg/kg 0.03mg 0.06mg 0.14mg 0.2mg 0.3mg 0.4mg 0.6mg 0.7mg 0.8mg 1mg

Benadryl 1mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 25mg 25mg 25mg 25mg

Charcoal <1yr: 1 g/kg 1.5g 3g 7g

>1 yr: 25-50g 25g 25g 25g 25g 50g 50g 50g

D10 5cc/kg 7.5cc

10cc/kg 15cc

D25 2cc/kg 6cc 14cc 20cc

4cc/kg 12cc 28cc 40cc

D50 1cc/kg 15cc 20cc 30cc 35cc 40cc 50cc

Dexamethasone 0.1 mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 4mg

Epi 1:1000 .005mg/kg 0.0075mg 0.015mg 0.035mg 0.05mg 0.075mg 0.1mg 0.15mg 0.175mg 0.2mg 0.25mg

Epi 1:10000 .01mg/kg 0.015mg 0.03mg 0.07mg 0.1mg 0.15mg 0.2mg 0.3mg 0.35mg 0.4mg 0.5mg

Fluid Challenge 20cc/kg 30cc 60cc 140cc 200cc 300cc 400cc 600cc 700cc 800cc 1000cc

Glucagon 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg

Lidocaine 2% 1.0mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg

Methylprednisolone 1.0mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg

30mg/kg 45mg 90mg 210mg 300mg 450mg 600mg 900mg 1050mg 1200mg 1500mg

Narcan .1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5 mg 4mg 4mg

Terbutaline .25mg .25mg .25mg .25mg .25mg .25mg .25mg .25mg .25mg .25mg .25mg

Valium .1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg

.5mg/kg 0.75mg 1.5mg 3.5mg 5mg 7.5mg 10mg 15mg 17.5mg 20mg 25mg

Sync Cardioversion .5j/kg 0.75j 1.5j 3.5j 5j 7.5j 10j 15j 17.5j 20j 25j

2j/kg 3j 6j 14j 20j 30j 40j 60j 70j 80j 100j

Tylenol 15mg/kg 22.5mg 45mg 105mg 150mg 225mg 300mg 450mg 525mg 600mg 750mg

Etomidate .3mg/kg 0.45mg 0.9mg 2.1mg 3mg 4.5mg 6mg 9mg 10.5mg 12mg 15mg

Succinylcholine 1mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg

1.5mg/kg 2.25mg 4.5mg 10.5mg 15mg 22.5mg 30mg 45mg 52.5mg 60mg 75mg

Versed .1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg

Return to Index


Drug Calculations

Calculating Drops per Minute

gtts / min = volume to be infused X gtts/mL of administration set

total time in minutes

Calculating Solution Concentration

mg in solution divided by mL in solution

Calculating mg/min OR Calculating mcg/min (Lidocaine / Norepinephrine)

gtts / min = volume on hand X drip factor X desired dose

Dosage on hand

Calculating mcg/kg/min

gtts / min = desired dose X weight (kg) X drip factor

Solution concentration

Return to Index


Dopamine Drip Chart

400 mg Dopamine / 250 mL D5W Concentration: 1600 mcg/mL Infusion Dose: 2 – 20 mcg/kg/min

Body

lbs

77

88

99

110

121

132

143

154

165

176

187

198

209

220

231

242

Weight Kg:

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

mcg/kg/min D R O P S P E R M I N U T E

2 3 3 4 4 4 5 5 5 6 6 6 7 7 8 8 8

3 4 5 5 6 6 7 7 8 8 9 10 10 11 11 12 12

4 5 6 7 8 8 9 10 11 11 12 13 14 14 15 16 17

5 7 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21

6 8 9 10 11 12 14 15 16 17 18 19 20 21 23 24 25

7 9 11 12 13 14 16 17 18 20 21 22 24 25 26 28 29

8 11 12 14 15 17 18 20 21 23 24 26 27 29 30 32 33

9 12 14 15 17 19 20 22 24 25 27 29 30 32 34 35 37

10 13 15 17 19 21 23 24 26 28 30 32 34 36 38 39 41

Return to Index


Levophed (Norepinephrine)

4 mg in 500 ml D5W (8 mcg/ml)

Initial Rate 1 mcg/min

Maximum Rate 30 mcg/min

Desired Dose (mcg/min) Rate in ml/hr 1 mcg/min 7 ml/hr

2 mcg/min 15 ml/hr

3 mcg/min 22 ml/hr

4 mcg/min 30 ml/hr

5 mcg/min 37 ml/hr

6 mcg/min 45 ml/hr

7 mcg/min 52 ml/hr

8 mcg/min 60 ml/hr

9 mcg/min 67 ml/hr

10 mcg/min 75 ml/hr

11 mcg/min 82 ml/hr

12 mcg/min 90 ml/hr

13 mcg/min 97 ml/hr

14 mcg/min 105 ml/hr




Return to Index


Nitroglycerin Drip Chart

25mg in 250 ml / Concentration 100 mg/mL

50 mg in 250 mL / Concentration 200 mg/mL

Milliliter per hour

Milligram per minute

Milliliter per hour

Milligram per minutes

3 5 1 3.3 5 8 2 6.7

6 10 3 10 9 15 6 20 12 20 7 23 15 25 9 30 18 30 12 40 21 35 15 50 24 40 18 60 30 50 21 70 36 60 24 80 42 70 27 90 48 80 30 100 54 90 33 110 60 100 36 120 66 110 39 130 72 120 42 140 78 130 45 150 84 140 48 160 90 150 54 180 96 160 60 200

105 175 66 220 114 190 72 240 120 200 78 260

Return to Index


Dobutamine Drip

250mg Dobutamine / 500 cc D5W

Body lbs: 77 88 99 110 121 132 143 154 165 176 187 198 209 220 231 242

Weight kgs: 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110

mcg/kg/min D R O P S P E R M I N U T E

2 8 10 11 12 13 14 16 17 18 19 20 22 23 24 25 26

3 13 13 13 13 20 22 23 25 27 29 31 32 34 36 38 40

4 17 19 22 24 26 29 31 34 36 38 41 43 46 48 50 53

5 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66

6 25 29 32 36 40 43 47 50 54 58 61 65 68 72 76 79

7 29 34 38 42 46 50 55 59 63 67 71 76 80 84 88 92

8 34 38 43 48 53 58 62 67 72 77 82 86 91 96 101 106

9 38 43 49 54 59 65 70 76 81 86 92 97 103 108 113 119

10 42 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132

11 46 53 59 66 73 79 86 92 99 106 112 119 125 132 139 145

12 50 58 65 72 79 86 94 101 108 115 122 130 137 144 151 158

13 55 62 70 78 86 94 101 109 117 125 133 140 148 156 164 172

14 59 67 76 84 92 101 109 118 126 134 143 151 160 168 176 185

15 63 72 81 90 99 108 117 126 135 144 153 162 171 180 189 198

16 67 77 86 96 106 115 125 134 144 154 163 173 182 192 202 211

17 71 82 92 102 673 122 133 143 153 163 173 184 194 204 214 224

18 76 86 97 108 119 130 140 151 162 173 184 194 205 216 227 238

19 80 91 103 114 125 137 153 160 171 182 194 205 216 228 239 251

20 84 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264

Return to Index


Nasogastric Tube (NG Tube)

Clinical Indications: Gastric decompression for intubated patients.

Contraindications: Complications: 1. Suspected basilar skull fracture. 1. Nasal tissue trauma/hemorrhage 2. Facial trauma 2. Passage of tube into the trachea 3. Recent nasal surgery 3. Perforation of the esophagus 4. Known or suspected esophageal varicese 4. GI bleeding 5. Ingestion of caustic poisonings 5. Coiling of the tube into posterior pharynx

6. May induce gagging or vomiting; Aspiration

Equipment: All necessary equipment should be prepared, assembled and available prior to starting the NG tube. Basic equipment should include:

1. Personal protective equipment (gloves, mask, face shield) 2. NG tube, 60 ml catheter tip syringe 3. Water-soluble lubricant 4. Adhesive tape 5. Suction 6. Stethoscope Procedure: 1. Prepare and assemble all equipment 2. Inspect the nares for deformity or obstructions to help determine best side for insertion of the NG tube. 3. Measure length of tube by placing the tip over the stomach area and extend it to the patient’s ear lobe

a. Note the marks on the tube used to measure.

4. Flex the neck if not contraindicated 5. Liberally lubricate the distal tip with water-soluble lubricate (KY Jelly) 6. Insert the tube along the floor of the nasal passage 7. Do not orient the tip upward into the turbinate’s. 8. Continue to advance the tube until the appropriate distance is reached. 9. Confirm placement by injecting 20 cc of air and auscultating the epigastric region for the swish or bubbling of the air

over the stomach. a. Gastric content may also be used to confirm placement

10. Secure the tube with tape to the nose and forehead or cheek 11. Decompression of the stomach of air and food can be done by connecting the tube to suction

Documentation should include the following:

1. The procedure and any complications that may have occurred 2. Time of procedure and the results successful / unsuccessful.

Return to Index


Placement for 12 Lead Reference

Precordial lead placement: 1. V – 1: 4th intercostal space just to the right of the sternum 2. V – 2: 4th intercostal space just to the left of the sternum 3. V – 3: between V2 and V4 4. V – 4: 5th intercostal space mid clavicular line 5. V – 5: anterior axillary line level with V4 6. V – 6: mid axillary line level with V4 and V5 7. V4R: 5th intercostal space in right mid-clavicular line

The area the leads are looking at:

1. Leads I, AVL, V5, V6: lateral wall of left ventricle 2. Leads II, III, AVF: inferior wall of left ventricle 3. Leads V1, V2: septal wall of left ventricle 4. Lead V3, V4: anterior wall of the left ventricle 5. Lead V4R: right ventricle The following 12 lead variations should raise suspicion for Ischemia, Injury or infarction:

Ischemia: ST depression, possible T wave inversion

Injury: ST elevation, possible T wave inversion

Infarction: ST elevation, possible T wave inversion, possible abnormal Q wave

Acute Myocardial Infarction Location

Location: Leads: Reciprocal Changes:

Inferior (RCA): II, III, aVF I, aVL

Septal (LAD): V1, V2

Anterior (LAD): V3, V4 II, III, aVF

Lateral (CIRC): I, aVL, V5, V6 II, III, aVF

Posterior: V7, V8, V9 ST, V1 – V4

Right Ventricle V4R None seen

Return to Index


Termination of Prehospital Resuscitation

Policy: To establish criteria by which resuscitative efforts may be discontinued in the field. The initial and ending rhythm must be Asystole.

Purpose: The purpose of this policy is to:

Allow for discontinuation of prehospital resuscitation after delivery of adequate and appropriate ALS therapy.

Allow for discontinuation of prehospital resuscitation for patients that show signs of obvious death. Procedure:

CPR and ALS therapy may be discontinued by EMS personnel when the following criteria are met:

The initial and ending rhythm must be Asystole with no change during resuscitative efforts.

Patient is >18 years of age.

Patient is not pregnant.

Situation is not related to hypothermic cause

ETCO2 remains < 10 mmHg after early successful advanced airway placement and 10 minutes of Advanced Life Support.

There has been absolutely no return of pulse, spontaneous respirations, eyes opening or movement, no motor response and no neurological activity.

Determination of resuscitation efforts must be determined prior to transport!!!!

MEDICAL CONTROL MUST BE CONTACTED PRIOR TO TERMINATION EFFORT!!!!!

Note: Documentation should include initial rhythm, time ALS was started and stopped. These events will be

needed to record time of death.

Return to Index


Spinal Immobilization Clearance

Clinical Indications: This protocol is to be used only on patients that alert and oriented to person, place and event.

These patients must have a positive neurological exam without any evidence of intoxication and no significant traumatic

mechanism.

Consider immobilization in any patients with arthritis, cancer or any underlying spinal or bone disease.

Any patient involved in any mechanism that includes high-energy events such as ejection, high falls and abrupt deceleration crashes should be considered for spinal immobilization even in the absence of signs and/or symptoms.

May use the acronym “NSAIDS” to help remember this protocol:

“N”: Neurologic exam; Look for focal deficits such as tingling, reduced strength or numbness in any extremity. Does the

patient present with one or more of these symptoms?

“S”: Significant mechanism; was this a high energy event that may cause significant injuries?

“A”: Alertness; is the patient oriented to person, place, time and event? Any changes in level of consciousness or was

there a positive loss of consciousness?

“I”: Intoxication; is there an indication that the patient may be intoxicated? Do they have decision making capabilities?

“D”: Distracting injury; does the patient have an injury which is capable of producing significant pain causing distraction of

possible neck or back pain?

“S”: Spinal exam; is there a point of tenderness in the spinal process or tenderness with range of motion?

The decision not to implement spinal immobilization precautions for patients is your responsibility.

You must remember a normal exam may not be sufficient to rule out a spinal injury in children and the elderly.

IF THE PATIENT HAS ANY COMPLAINTS OF THE ABOVE SIGNS AND / OR SYMPTOMS OR IF THERE IS SIGNIFICANT MECHANISM, FULL C-SPINE PRECAUTIONS INCLUDING C-COLLAR AND BACKBOARD MUST BE UTILIZED.

Return to Index


Orthostatic Blood Pressure Measurement Clinical Indications: Patients with suspected blood or fluid loss or dehydration with no indication for spinal immobilization

This procedure should be considered while still inside the residence and/or before moving the ambulance. Safety of our patients always comes 1st.

Procedure:

1. Gather standard BP cuff and stethoscope. 2. With the patient supine, obtain pulse and blood pressure. 3. Place the patient in upright position. 4. Then with assistance ask patient to stand. (may need to assist pt in standing position) 5. If the systolic BP falls more than 10 mmHg or the pulse raises more than 10 bpm, the patient is considered to have

positive orthostatic vital signs. 6. If the patient is experiencing dizziness upon sitting up or is obviously dehydrated based on history or physical exam,

formal orthostatic examination should be omitted and fluid bolus initiated.

Return to Index


Start - Triage Guide System

SIMPLE TRIAGE AND RAPID TRANSPORT

Primary Triage Guidelines (Use triage bags with tape for rapid assessment)

1. Can the Patient Walk? Yes= Green; No = Go to Question 2

2. Can the Patient Obey? Yes= Go to Question 3; No= Go to Question 4 (Skip 3)

3. Does Patient Have Radial Pulse? Yes=Yellow; No=Red

4. Does Patient Breathe with open Airway? Yes=Red; No=Black

Secondary Triage Guidelines (Use Mettags or equivalent)

Return to Index


NIHSS Form

Patient:___________________________________________NIHSS Date:_____________Initial NIHSS Time:_____________Last Known Normal:__________________

Family contact number:____________________________ Visual Fields Normal 0 Partial Hemianopia 1 Emergency Thrombolytic Checklist Complete Hemianopia 2 ____ Absolute Contraindications Present Left Arm No Drift 0 Mild Drift 1 Major Drift 3 No Movement 4 ____ Right Arm No Drift 0 Mild Drift 1 Major Drift 3 No Movement 4 ____ Left Leg No Drift 0 Mild Drift 1 Major Drift 3 No Movement 4 ____ Right Leg No Drift 0 Mild Drift 1 Major Drift 3 No Movement 4 ____ Relative Contraindications Sensory Normal 0 Present Impaired 1 ____ Language Normal 0

Mild Aphasia 2 Severe Aphasia 3 Complete Aphasia 4 ____

LOC Oriented to Person, Place, & Time 0

Confused to Person, Place, or Time 1 Unable to answer ANY correct 4 ____ Total (27 possible) ____

Uncontrollable Bleeding

History of CVA or CNS damage

Major surgery within the last 2 weeks

Major trauma within the last 10 days

Diabetic Hemorrhagic Retinopathy or Ophthalmic Hemorrhage

Pregnancy

Recent non-compressible vascular puncture

History of B/P > 180 systolic after initial treatment

Age over 75

Recorded B/P of 180/110 or greater

GI or GU bleeding within 6 weeks

Obstetric delivery within 6 weeks

Cancer diagnosis

Active peptic ulcer

Known bleeding diathesis or use of anticoagulants

Streptococcal infection in last 6 months, or exposure to Streptokinase or Eminase

PFI Assessment (Cerebellar Infarct)

Finger to Nose Test

Right Hand (Normal/Missed)

Left Hand (Normal/Missed)

Vertical Nystagmus (Positive/Negative)

Criteria for Transport to Comprehensive Stroke Center

Surgery within last 14 days

MI or previous Stroke

Hemorrhage within last 21 days

NIHSS greater than 8

PFI Assessment Failure

Stroke Symptoms with Severe Headache

Cooke County

Emergency Medical Services

305 South Chestnut

Gainesville, Tx. 76240

940-668-5561

Fax 940-665-5287

Return to Index


Drug

Guide


Pregnancy Category Rating for Drugs

Category A Controlled studies in women fail to demonstrate a risk to the fetus in the 1st trimester and no significant risk in later trimester. The possibility of fetal harm appears to be remote.

Category B

Either (1) animals reproductive studies have not demonstrated a fetal risk, but there no controlled studies in pregnant women, or (2) animal reproductive studies have shown an adverse effect that (other than decreased fertility) that was not confirmed in controlled studies on women in the 1st trimester, but there is no evidence of risk in later trimesters.

Category C

Either (1) studies in animals have revealed adverse effects on the fetus, but there are no controlled studies in women or (2) studies in women and animals are not available. Drugs in this category should be given only if the potential benefits justify the risk to the fetus.

Category D

Positive evidence of human fetal risk exist, but the benefits for pregnancy women may be acceptable despite the risk, as in life-threatening diseases for which safer drugs cannot be used or are ineffective. An appropriate statement must appear in the “WARNINGS” section of the labeling of drugs in this category.

Category X

Studies in animals or human beings have demonstrated fetal abnormalities, there is evidence of fetal risk based on human experience or both; the risk of using the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. An appropriate statement must appear in the “CONTRINDICATIONS” section of the labeling of drugs in this category.


Activated Charcoal

Class: Adsorbent Actions: Absorbs toxins by chemical binding and prevents GI absorption.

Onset: Immediate Duration: Continual while in GI tract Indications: Many oral poisonings and medication overdoses Contraindications: Corrosives, caustics, petroleum distillates (relatively ineffective, and may induce vomiting), GI bleeding Side Effects: May indirectly induce nausea & vomiting and may cause constipation or mild transient diarrhea Drug Interactions: Syrup of ipecac (adsorbed by activated charcoal, and will result in vomiting of the charcoal) Dosage: See Protocols Route: PO Pregnancy safety: Category C

Return to Index


Adenosine (Adenocard)

Class: Antidysrhythmic Actions: It slows the conduction through AV node of the heart.

It is cleared very rapidly, having a half-life of < 10 seconds. Onset: Immediately Duration: 10 seconds Indications: Symptomatic PSVT Contraindications: Sick sinus syndrome and second or third degree heart block Side Effects: Light-headedness, HA; Diaphoresis; Palpations; Chest pain; Flushing; Hypotension

Shortness of breath; Nausea, metallic taste Precautions: A reduced dose must be used in heart transplant recipients. BP, pulse and EKG should be monitored Dosage: See Protocol Route: IV Pregnancy Safety: Category C

Return to Index


Albuterol (Proventil; Ventolin)

Class: Sympathomimetic (B2 selective) Actions: Bronchodilator Onset: 5 – 15 minutes after inhalation Duration: 3 – 4 hours after inhalation Indications: Relief of bronchospasm in patient with reversible obstructive airway disease. Prevention of exercise-induced bronchospasm; Asthma Contraindications: Patient with known hypersensitivity; Symptomatic tachycardia Precautions: BP, Pulse and EKG result should be monitored Use caution in patients with known heart disease Side Effects: Palpations; Anxiety; Headache; Dizziness; Sweating Dosage: See Protocols Route: Inhalation Pregnancy safety: Category C

Return to Index


Amiodarone (Cordarone)

Class: Class III Antidysrhythmic Actions: Prolongs action potential after refractory period; slows the sinus rate; increases PR and QT

intervals; decreases peripheral resistance Onset: within minutes Duration: Variable Indications: Life-threatening cardiac dysrhythmias, such as V-Tach and V-Fib Contraindications: Hypersensitivity to drug; severe sinus node dysfunction; cardiogenic shock

2nd & 3rd degree heart block; hemodynamically significantly bradycardia Side Effects: Hypotension; Headache; Dizziness; Bradycardia; AV conduction abnormalities

Flushing; Abnormal salivation Dosage: See Protocols Route: IVP Pregnancy Safety: Category D

Return to Index


Ammonia Ampule / Inhalants

Class: Respiratory stimulant Actions: Elicits a response in a conscious patient be irritating mucous membranes of upper respiratory tract.

It stimulates the vasomotor center of medulla causing an increase in blood pressure. Indications: Syncope; to determine level of consciousness Contraindications: None Side Effects: None Special Information: Use with caution in patients with COPD or asthma - may cause bronchospasm Be sure patient has inhaled sufficient vapor to elicit a response Dosage: 2 – 3 inhalants; break ampule and hold close to patient's nostrils Route: Inhalation

Return to Index


Aspirin (Acetylsalicylic acid)

Class: Platelet inhibitor / anti-inflammatory Actions: Blocks platelet aggregation

Onset: 15 – 30 minutes Duration: 4 – 6 hours Indications: Cardiac chest pain; Acute Myocardial Infarction Contraindications: Hypersensitive to salicylates; GI bleeding; Active ulcer; Hemorrhagic strokes; Bleeding disorders

Side Effects: Stomach irritation; heartburn or indigestion; Nausea / Vomiting; Allergic Reaction Drug Interactions: Decreased effects with antacids and steroids

Increased effects anticoagulants, insulin, oral hypoglycemic, fibrinolytic agents Dosage: Adult: 324 Route: PO Pregnancy Safety: Category D

Return to Index


Atropine

Class: Anticholinergic (Para-sympatholytic) Actions: Blocks acetylcholine receptors; increase heart rate; reduces GI secretions Onset: Rapid Duration: 2 – 6 hours Indications: Hemodynamically significant bradycardia; Organophosphate poisoning; Pediatric RSI Contraindications: Tachycardia; Unstable cardiovascular status in acute hemorrhage with myocardial ischemia Narrow-angle glaucoma Side Effects: Tachycardia: Palpations; Dysrhythmias; Headache; Dizziness; Nausea / Vomiting

Anticholinergic effects: Blurred vision, dry eyes, dilated pupils Flushed, hot, dry skin

Dosage: See Protocols Route: IV Pregnancy Safety: Category C

Return to Index


Benadryl (Diphenhydramine)

Class: Antihistamine Actions: Blocks histamine receptors; some sedative effects. Onset: Max effects 1 – 3 hours Duration: 6 – 12 hours Indications: Anaphylaxis; Moderate to severe allergic reactions; Dystonic reactions Contraindications: Pt taking MOA inhibitors; Hypersensitivity; Narrow – angle glaucoma Side Effects: Sedation; Dries secretions; Blurred vision; Hypotension; Palpations

Dosage: See Protocols Route: IV / IM

Pregnancy Safety: Category C

Return to Index


Benzocaine Spray 20% (Hurricane Spray)

Class : Topical anesthetic

Actions: When applied to the posterior region of the oropharynx, reduces the activation of the gag reflex.

Used as a numbing agent to reduce sensation

Onset: 15 – 30 seconds

Duration: 15 Minutes

Indications: When the patient needs intubation, gag reflex is present, but patient has no need or

contraindications for use of narcotics or benzodiazepines.

Contraindications: Hypersensitivity

Side Effects: Tingling or burning may occur

Precautions: Patients will have little or no gag reflex post use; Have suction prepared and ready.

Dose: Spray posterior oropharynx with 1 – 2 metered sprays (50 – 100mg), to reduce gag reflex, in order

to facilitate intubation.

Return to Index


Calcium Chloride 10%

Class: Electrolyte Actions: Increases cardiac contractility Onset: 5 – 15 minutes Duration: Dose dependent (effects may persist up to 4 hours) Indications: Acute Hyperkalemia; Calcium Channel blocker toxicity Contraindications: Patients receiving digitalis Side Effects: Bradycardia (may cause asystole); Hypotension; Metallic taste Severe local necrosis and sloughing following IM or IV infiltration Dosage: See Protocols Route: IVP Pregnancy Safety: Category C

Return to Index


Dexamethasone (Decadron, Hexadrol)

Class: Glucocorticoid (Steroid) Actions: Decreases cerebral edema; Anti-inflammatory; Suppresses the immune system Onset: 4 – 8 hours after parenteral administration Duration: 24 – 72 hours Indications: Anaphylaxis (after epinephrine & diphenhydramine); Asthma; Chronic inflammation Contraindications: Active untreated infections; Hypersensitivity to the product Side Effects: Decreased wound healing and HTN; GI bleeding and Hyperglycemia Drug Interaction: Barbiturates and phenytoin can decrease dexamethasone effects Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C

Return to Index


Dextrose 50%

Class: Carbohydrate, hypertonic solution Actions: Elevates blood glucose rapidly Onset: 1 minute Duration: Depends on the degree of hypoglycemia Indications: Suspected or known hypoglycemia (BS < 60 mg/dL); Altered level of consciousness Coma or seizure of unknown origin Contraindications: None in emergency setting Precautions: Blood sample should be drawn prior to administering D50 (if possible) Dosage: See Protocols Route: IVP Pregnancy Safety: Category C

Return to Index


Diazepam (Valium)

Class: Benzodiazepine (Schedule IV Drug) Actions: Anticonvulsant; Skeletal muscle relaxant; Sedative Onset: (IV) 1 - 5 min; (IM) 15 - 30 min Duration: (IV) 15 min – 1 hour (IM) 15 min – 1 hour Indications: Major motor seizure; Status epilepticus; Premedication before cardioversion; Skeletal muscle relaxant; acute anxiety Contraindications: Hypersensitivity to the drug; Substance abuse; Shock; CNS depression as a result of head injury Respiratory depression Side Effects: Hypotension; Respiratory depression; Ataxia; Psychomotor impairment Confusion and Nausea Drug Interactions: May precipitate CNS depression and psychomotor impairment when the patient is taking other

CNS depressant medications and should not be administered with other drugs because of possible precipitation (Incompatible with most fluids; should be administered into and IV of normal saline solution)

Dosage: See Protocols Route: IV / IM

Pregnancy safety: Category D

Return to Index


Dobutamine (Dobutrex)

Class: Sympathomimetic Actions: Primarily stimulates Beta-adrenergic receptors and less significant effects on beta and alpha adrenergic receptors Onset: 1 – 2 min; Peak after 10 Duration: 10 – 15 minutes Indications: Inotropic support for patients with left ventricular dysfunction Contraindications: Tachydysrhythmias (A-fib / Atrial flutter); Severe Hypotension with signs of shock Drug Interaction: Incompatible with Sodium Bicarbonate and Lasix in same IV line Side Effects: Headache; dose related tachydysrhythmias; HTN, ventricular ectopy Dosage: See Protocols Route: Infusion Pregnancy Safety: Category C

Return to Index


Dopamine (Intropin)

Class: Sympathomimetic Actions: Increased cardiac contractility; Causes peripheral vasoconstriction Onset: 2 – 4 minutes Duration: 10 – 15 minutes Indications: Hemodynamically significant hypotension not resulting from hypovolemia Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred Side Effects: Ventricular tachyarrhythmia’s; hypertension; palpations Precautions: Should not be administered in the presence of severe tachyarrhythmia’s, V-fib and ventricular irritability; beneficial effects lost when dose exceeds 20 mcg/kg/min Dose: See Protocols Route: Infusion Pregnancy Safety: Category C

Return to Index


DuoNeb/ Combivent (albuterol / ipratropium)

Class: Bronchodilator Actions: Prevention of bronchospasm Onset: 5 – 15 minutes after inhalation Duration: 3 – 4 hours after inhalation Indications: COPD; Emphysema Contraindications: Patients with known hypersensitivity to Albuterol, Proventil, Atrovent or Atropine Precautions: Use with cautious for patients with HTN; Coronary artery disease and seizures Monitor BP, Pulse and EKG when administering Side Effects: Palpations; Anxiety; HA; Dizziness; Sweating; Chest pain; Irregular heart beat Dosage: See Protocol Route: Inhalation Pregnancy Safety: Category C

Return to Index


Epinephrine 1:1000

Class: Sympathomimetic Actions: Bronchodilator Onset: 5 – 10 minutes SQ Duration: 5 – 10 minutes Indications: Severe asthma and allergic reaction; Anaphylactic shock Contraindications: Patients with underlying cardiovascular disease; Hypertension Side Effects: HA: Nausea; Restlessness; Weakness; Palpitations; Tachycardia Precautions: Protect from light; BP, pulse and EKG should be constantly monitored Dosage: See Protocols Route: SQ / Inhalation Pregnancy Safety: Category C

Return to Index


Epinephrine 1:10,000

Class: Sympathomimetic Actions: Increases heart rate and automaticity and cardiac contractile force; Increases myocardial electrical activity and systemic vascular resistance; Increases blood pressure Onset: 1 – 2 minutes IV / ET Duration: 5 – 10 minutes Indications: Cardiac Arrest; Anaphylactic shock Contraindications: None in emergency setting Side Effects: None in cardiac arrest Dosage: See Protocols Route: IV / ET Pregnancy Safety: Category C

Return to Index


Etomidate (Amidate)

Class: Nonbarbiturate sedative / hypnotic, anesthetic Actions: Short – acting hypnotic used to induce anesthesia; has a minimal effect on myocardial activity Onset: within 30 seconds Duration: 3 – 5 minutes Indications: Premedication for tracheal intubation Induction agent for rapid-sequence intubation for patients with BP ≥80 Contraindications: Hypersensitivity; Systolic BP < 80 (adults) Side Effects: Respiratory depression; Hypotension; Involuntary muscle movement Precaution: Make sure all RSI medications are prepared prior to induction Dosage: See Protocols Route: IVP Pregnancy Safety: Category C

Return to Index


Fentanyl (Sublimaze)

Class: Opioid analgesic (Schedule II Drug) Actions: CNS depressant; decreases sensitivity to pain Onset: 7 – 8 minutes Duration: ½ hour – 1 hour Indications: Severe Pain; Adjunct to rapid-sequence induction / sedation Contraindications: Respiratory depression; hypotension; Head Injury; hypersensitivity to opioids

Shock and hemorrhage Side Effects: Nausea / Vomiting; Bradycardia; Hypotension / HTN Drug Interactions: Effects may be increased when given with other CNS depressants or skeletal muscle relaxants Dosage: See Protocol Route: IV / IM Pregnancy Safety: Category C

Note: 50 – 100 times more potent than Morphine

Return to Index


Furosemide (Lasix)

Class: Loop diuretic Actions: Inhibits reabsorption of sodium chloride; Promotes prompt diuresis; vasodilation Onset: 5 – 20 minutes IV; Vascular effects within 5 minutes Duration: 2 hours Indications: CHF; Pulmonary edema Contraindications: Hypersensitivity; Pregnancy; Dehydration; Hypotension (BP < 90 systolic); Hypokalemia Side Effects: EKG changes; Hypotension; Dry mouth Dosage: See Protocols Route: IVP Pregnancy Safety: Category C

Return to Index


Geodon (ziprasidone)

Class: Antipsychotic Actions: Changes the effects of chemicals in the brain Onset: Unknown Duration: Unknown Indication: Rapid control of acute agitation Contraindications: Recent Myocardial Infarction; Uncompensated heart failure; History of Prolonged QT syndrome Side Effects: Dizziness; HA; Bradycardia; Anxiety / Agitation; Insomnia; HTN; Vasodilation Dosage: 20 mg Route: IM ONLY Pregnancy Safety: Category C NOTE: DO NOT USE with elderly patients with dementia – related psychosis, because of risk of death

from cardiovascular events or infection.

Return to Index


Glucagon

Class: Pancreatic hormone, insulin antagonist Actions: Causes breakdown of glycogen to glucose; Inhibits glycogen synthesis; Elevates blood glucose

levels; Increases cardiac contractile force; Increases heart rate Onset: within 1 minute Duration: 60 – 90 minutes Indications: Hypoglycemia without IV access (unable to take oral); Beta – blocker overdose Contraindications: Hypersensitivity Side Effects: Few in emergency Drug Interactions: Effects of anticoagulants may be increased if given with glucagon Precautions: Only effective if there are sufficient stores of glycogen within the liver

Dosage: See Protocols Route: IM Pregnancy Safety: Category B

Return to Index


Haldol (Haloperidol)

Class: Major tranquilizer (Antipsychotic) Actions: Blocks dopamine receptors in the brain therefore altering mood and behavior Onset: 30 – 60 minutes IM Duration: 12 – 24 hours Indications: Acute psychotic episodes; Emergency sedation for severely agitated or delirious patients Contraindications: CNS depressant; coma; hypersensitivity

Side Effects: Physical and mental impairment Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C

Return to Index


Ketamine (Ketalar) Class: Nonbarbiturate anesthetic Actions: Produces short – acting amnesia without muscular relaxation Onset: within 30 sec Duration: 5 – 10 minutes Indication: Rapid Sequence Induction: Medically Assisted Intubation Contraindications: Stroke; Increased Cranial Pressure (ICP) Side Effects: HTN, Elevated heart rate, Hallucinations, Delusions, Explicit dreams Dosage: 1 mg/kg Route: Slow IV Push Pregnancy Safety: Category C NOTE: For Pediatric patients, MUST USE ATROPINE to help in prevention of hypersalvation

Return to Index


Labetalol (Normodyne)

Class: Sympathetic Blocker

Actions: Selectively blocks alpha receptors; non-selectively blocks beta receptors

Onset: within 5 minutes

Duration: 3 – 6 hours

Indications: Hypertensive Crisis

Contraindications: Hypersensitivity; Bronchial asthma; CHF; 2nd / 3rd degree heart blocks;

Bradycardia; Cardiogenic shock; Pulmonary Edema

Side Effects: Bradycardia; heart block; CHF; bronchospasm; hypotension

Dosage: See Protocols

Route: Slow IVP

Pregnancy Safety: Category C

Return to Index


Levophed (Norepinephrine)

Class: Sympathomimetic Actions: Causes peripheral vasoconstriction Onset: 1 – 3 minutes Duration: 5 – 10 minutes Indications: Acute hypotension; cardiogenic and neurogenic shock Post resuscitation with systolic <90mmHg Contraindications: Hypersensitivity; V-Fib; Tachy – dysrhythmias Side Effects: Dizziness; Palpitations; Tachycardia; HTN, PVC’s; Angina; Nausea / Vomiting

Necrosis; Decreased urine output

Dosage: See Protocols Route: Infusion; MUST USE IV PUMP Pregnancy Safety: Category D

Return to Index


Lidocaine (Xylocaine)

Class: Antidysrhythmic (Class 1-B), local anesthetic Actions: Suppresses ventricular ectopic activity; increases ventricular fibrillation threshold Reduces velocity of electrical impulse through conductive system; Decreases ICP in head injuries Onset: 30 – 90 seconds Duration: 10 – 20 minutes Indications: Ventricular tachycardia / fibrillation

Contraindications: Hypersensitivity; High degree heart blocks; PVC’s in conjunction with Bradycardia Side Effects: Anxiety; Drowsiness; Confusion; Nausea / Vomiting; Widening of QRS Dosage: See Protocols Route: IV Pregnancy Safety: Category B

Return to Index


Lorazepam (Ativan)

Class: Benzodiazepine (Schedule IV Drug) Actions: Anticonvulsant; Sedative Onset: 20 – 30 minutes Duration: 6 – 8 hours Indications: Seizures; Sedation; Anxiety states; Premedication for cardioversion;

Prevention of shivering in induced hypothermia Contraindications: Hypersensitivity; Respiratory depression; Hypotension Side Effects: Drowsiness; Respiratory depression; Hypotension; Apnea Precautions: Emergency resuscitation equipment should be available Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category D

Return to Index


Magnesium Sulfate

Class: Anticonvulsant / Antiarrhythmic / Reduces bronchospasm (Electrolyte) Actions: CNS depressant; Anticonvulsant; Antidysrhythmic Onset: (IV) Immediate; (IM) 3 - 4 hours Duration: (IV) 30 minutes; (IM) 3 – 4 hours Indications: Seizures of Eclampsia (toxemia of pregnancy); Torsades de pointe Contraindication: Shock; Heart Block Side Effects: Respiratory depression; Drowsiness Precaution: Use with caution in patients receiving digitalis and patients in renal failure; Calcium chloride should

be readily available as an antidote if respiratory depression occurs Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category B

Return to Index


Methylprednisone (Solu-Medrol)

Class: Glucocorticoid (Steroid) Actions: Anti-inflammatory; Suppresses immune response Onset: 1 – 2 hours Duration: 8 – 24 hours Indications: Severe anaphylaxis; Asthma; COPD Contraindication: None in emergency setting Side Effects: GI bleeding; Prolonged wound healing; Suppression of natural steroids Precaution: Onset of action may be 2 – 6 hours and thus should not be expected to be of use in the critical first

hour following anaphylactic reaction; may raise blood sugars (caution in diabetes) Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C

Return to Index


Metoprolol (Lopressor)

Class: Beta – blocking agent Action: Selectively blocks beta 2 adrenergic receptors (cardio-protective) Onset: 1 – 2 minutes Duration: 3 – 4 hours Indications: To reduce myocardial ischemia and damage in patients with AMI; PSVT;

A - flutter and / or fibrillation Contraindications: Heart Failure; 2nd / 3rd degree heart block; Cardiogenic shock; Hypotension Side Effects: Bradycardia; AV conduction delays; Hypotension Precaution: BP, Pulse and EKG must be constantly monitored Dosage: See Protocol Route: Slow IV Push Pregnancy Safety: Category C

Return to Index


Midazolam Hydrochloride (Versed)

Class: Benzodiazepine (Schedule IV Drug) Actions: Hypnotic; Sedative Onset: 1 – 3 min IV; dose dependent Duration: 2 – 6 hours; dose dependent Indications: Seizure; sedation; Pre-medication for tracheal intubation and cardioversion To help prevent shivering for induce hypothermia patients Contraindications: Hypersensitivity; Narrow-angle glaucoma; Respiratory depression; Hypotension Side Effects: Drowsiness; Hypotension; Amnesia; Respiratory depression; Apnea Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category D

Return to Index


Morphine Sulfate

Class: Narcotic Analgesic (Schedule II Drug) Actions: CNS depressant; Causes peripheral vasodilation; Decreases sensitivity to pain Onset: 1 – 2 minutes Duration: 2 – 7 hours Indications: Chest pain associated with myocardial infarction; Pulmonary edema with / without associated pain Moderate to severe acute / chronic pain Contraindications: Hypersensitivity; Respiratory insufficiencies; Asthma; Bronchospasm; Intracranial pressure (ICP) Side Effects: Dizziness; Altered level of consciousness; Hypotension; Respiratory depression

Nausea / Vomiting Precautions: Should have naloxone (Narcan) available in case of respiratory depression and hypotension Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category B

Return to Index


Naloxone (Narcan)

Class: Narcotic Antagonist Actions: Reverses narcotic effects Onset: within 2 minutes Duration: 30 – 60 minutes Indications: Narcotic overdoses; to rule out narcotic of unknown origin Contraindication: Hypersensitivity Side Effects: None Precaution: Use with caution in narcotic – dependent patients who may experience withdrawal symptoms Dosage: See Protocols Route: IV / IM / ET (ET dose is 2.0 – 2.5 more than IV dose) Pregnancy Safety: Category B

Return to Index


Nitroglycerin (Sublingual Spray)

Class: Vasodilator (Nitrate) Actions: Smooth muscle relaxant; Reduces cardiac work; Dilates coronary arteries and systemic arteries Onset: 1 – 3 minutes Duration: 30 – 60 minutes Indication: Angina; Chest pain associated with myocardial infarction; Hypertension emergencies Contraindication: Hypersensitivity; Hypotension; Head injury; CVA

Recent use (within 24 – 48 hours) of Cialis, Levitra and/or Viagra Side Effects: Hypotension; HA; Nausea / Vomiting; Dizziness Precaution: Use caution with suspected / known inferior MI; BP must be constantly monitored; must be

protected from light; expires quickly once opened Dosage: 1 spray SL every 3 – 5 minutes for a total of 3 doses Route: SL Pregnancy Safety: Category C

Return to Index


Nitroglycerin Drip

Class: Vasodilator Actions: Smooth muscle relaxant; Reduces cardiac work; Dilates coronary arteries and systemic arteries Indications: Chest pain of suspected cardiac origin (hospital transport time > 15 minutes) HTN; CHF with acute pulmonary edema Contraindications: Hypersensitivity; Hypotension; Head injury; CVA

Recent use (within 24 – 48 hours) of Cialis, Levitra and/or Viagra Precautions: Monitoring of all vital signs and EKG must be monitored.

Once administration starts, may drastically drop blood pressure (if hypotension occurs. administer a fluid bolus of 250cc); Consider having a 2nd IV line (for fluid bolus if needed)

Suspected / known inferior MI When piggybacking with other solutions, place nitro line as close to IV site as possible

Consider: Contact medical control prior to administration; Must be in glass bottle with low sorb tubing Dosage: 2 – 20 mcg/kg/min; titrated to effect; CONTACT MEDICAL CONTROL PRIOR TO STARTING

INFUSION; MUST USE IV PUMP Route: Infusion Pregnancy Safety: Category C

Return to Index


Oxygen

Class: Gas Actions: Necessary for cellular metabolism; increases arterial oxygen tension and hemoglobin saturation Indications: Hypoxia; SpO2 < 95%; Ischemic chest pain; respiratory insufficiency;

Confirmed or suspected carbon monoxide poisoning Contraindications: None Side Effects: Drying of mucous membranes Consider: Obtain SpO2 readings before and after O2 administration Dosage: Low concentrations via NC @ 1 – 6 LPM High concentrations via NRB @ 10 – 15 LPM High concentrations via BVM @ 15 LPM Route: Inhalation

Return to Index


Promethazine (Phenergan)

Class: Phenothiazine, antihistamine (Anti-emetic) Actions: Antiemetic; mild anticholinergic activity; potentiates actions of analgesics Onset IV – rapid Duration: 4 – 6 hours Indications: Nausea / Vomiting; to potentiate the effects of analgesics; may be used for sedation Contraindications: CNS depression from alcohol, barbiturates or narcotics Side Effects: May impair mental and physical ability; Sedation; Dizziness; Nausea / Vomiting Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C

Return to Index


Rocuronium Bromide (Zemuron)

Class: Non-depolarizing neuromuscular blocker (Paralytic Agent) Actions: Paralyzes skeletal muscles including respiratory muscles Onset: 30 – 45 seconds Duration: 30 – 45 minutes Indications: To achieve paralysis to facilitate endotracheal intubation / ventilation Contraindications: Hypersensitivity Side Effects: Prolonged paralysis; Tachycardia; Apnea Precautions: Should not be administered unless skilled in endotracheal intubations are present, intubation

equipment must be available, O2 and resuscitative drugs must be available; must be stored in refrigerator

Dosage: See Protocol Route: IVP Pregnancy Safety: Category C

Return to Index


Sodium Bicarbonate

Class: Buffer, alkalinizing agent, electrolyte supplement Actions: Combines with excessive acids to form a weak volatile acid Onset: 2 – 10 minutes Duration: 30 – 60 minutes Indications: Late in the management of cardiac arrest; Tricyclic antidepressant OD; Severe refractory to

hyperventilation Contraindications: Hypersensitivity Side Effects: Alkalosis Dosage: See Protocols Route: IV Pregnancy Safety: Category C

Return to Index


Succinycholine (Anectine)

Class: Neuromuscular blocker (Paralytic Agent) / (depolarizing) Actions: Skeletal muscle relaxant; Paralyzes skeletal muscles including respiratory muscles Onset: Less than 1 minute Duration: 5 - 10 minutes after single dose Indications: To achieve paralysis to facilitate intubation Contraindications: Hypersensitivity Side Effects: Prolonged paralysis; Hypotension; Bradycardia Precautions: Should not administered unless skilled in endotracheal intubation; must have all intubation

equipment readily available; must have O2 and emergency resuscitative drugs available Dosage: See Protocols Route: IVP Pregnancy Safety: Category C

Return to Index


Terbutaline (Brethine)

Class: Sympathomimetic Actions: Relaxes bronchial smooth muscles by stimulating beta2 receptors; Bronchodilator

Onset: 15 minutes SQ Duration: 1 1/2 – 4 hours Indications: Reversible bronchospasm associated with chronic COPD; Asthma; Preterm labor Contraindications: Hypersensitivity Side Effects: Nervousness; Tremors; Dizziness; Weakness; Headache; Nausea / Vomiting;

Increases heart rate Precaution: Use with caution in patients with hyperthyroidism, diabetes and seizure disorder Dosage: See Protocols Route: SQ Pregnancy Safety: Category B

Return to Index


Thiamine (Vitamin B1) Class: Vitamin (B1) Actions: Cofactor / coenzymes in glucose metabolism Onset: Rapid Duration: Depends on the degree of deficiency Indications: Coma of unknown origin; Alcoholism; Malnutrition Contraindication: None in emergency setting Side Effects: Rare Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category A

Return to Index


Tranexamic Acid

Class: Anti-Fibrinolytic

Actions: Promotes clot formation in the setting of massive hemorrhage

Onset: Onset of action within 4 hours after IV administration, exact time of onset unclear and

variable.

Duration: Delayed effects up to 48 hours consistent with anti-inflammatory actions.

Indications: Adults in traumatic hemorrhagic shock from trauma less than 3 hours old with suspected

need for massive blood transfusion due to marked blood loss internal or external. Wounds and/or force typically sustained from neck to mid-thigh.

Adult trauma patient must have sustained tachycardia110 beats per minute or greater AND sustained hypotension systolic blood pressure less than 90 mmHg not responsive to fluid bolus.

Contraindications: Non-hemorrhagic shock, Non-traumatic hemorrhagic shock. Hemorrhagic shock stabilized with other hemostatic agents/measures

Side Effects: While a theoretical concern, TXA has not been shown to cause significant increase in

deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke in published trials to date.

Dosage: Loading dose: 1G in 100ml D5W, infuse at 825 ml/hr (infusion will complete in 10 minutes) Maintenance dose: 1G in 250ml D5W, infuse at 33 ml/hr (infusion will complete in 8 hours)

Route: IVPB

Pregnancy Safety:

Return to Index


Tylenol Suspension (Acetaminophen) Class: Analgesic / Antipyretics Actions: Fever reducer Onset: ½ - 2 hours Duration: 2 – 4 hours Indications: Fever Contraindication: Hypersensitivity Side Effects: Hemolytic anemia; Rash / Urticaria Precautions: Use cautiously in patient with any type of liver disease and / or long term alcohol use because

therapeutic doses may cause hepatotoxicity Dosage: See Protocols Route: PO / Rectally Pregnancy Safety: Category B

Return to Index


Vasopressin (Pitressin)

Class: Posterior pituitary hormone (ADH) Actions: Potent peripheral vasoconstrictor Onset: Immediately Duration: Variable Indications: Cardiac Arrest Contraindications: None used in emergency setting Side Effects: Ischemic chest pain; Abdominal distress; Sweating Dosage: See Protocols Route: IV / IO/ ET Pregnancy Safety: Category C

Return to Index


Zofran (Ondansetron)

Class: Selective Serotonin (Anti-emetic) Actions: Causes interruption of the Serotonin 5 - HT3 receptors responsible for vomiting in the brain Onset: Immediate Duration: Unknown Indications: Active nausea and vomiting and as an adjunct to prevent nausea / vomiting associated with

narcotic analgesic Contraindications: Hypersensitivity Side Effects: Headache; constipation and dizziness Dosage: See Protocols Route: IV / IM / Orally Pregnancy Safety: Category B

Return to Index


EMT EMT-I Paramedic I Paramedic II Paramedic III

Skill - Airway

Ventilation/Oxygenation

Airway-Orpharyngeal X X X X X

Airway-Nasopharyngeal X X X X X

Airway-Supraglotic X X X X

BVM X X X X X

BiPAP/CPAP X X X X

Chest Decompression X X X

Cricothyrotomy-needle

X X X

Cricothyrotomy-surgical X X

EtC02 monitoring X X X X X

Gastric decompression-NG

tube

X X X

Head tilt chin lift X X X X X

Intubation-Nasotracheal X X X X

Intubation-Orotracheal X X X X

Jaw thrust X X X X X

Modified jaw thrust X X X X X

Obstruction-direct

laryngoscopy

X X X X

Obstruction-manual X X X X X

Oxygen therapy-Humidifiers X X X X X

Oxygen therapy-Nasal

cannula

X X X X X

Oxygen therapy-non

rebreather mask

X X X X X

Pulse oximetry X X X X X

Suctioning-Upper airway X X X X X


EMT EMT-I PARAMEDIC I PARAMEDIC II PARAMEDICIII

Suctioning-Trachebronchial X X X X

Ventilator operations X X X

Rapid sequence induction X X

Medically assisted intubation X X X

Skill-

Cardiovascular/Circulation

Cardiac monitoring X X X

CPR X X X X X

Cardioversion X X X

Vagal Maneuvers X X X

Defibrillation X X X

Hemorrhage control-direct

pressure

X X X X X

Hemorrhage control-

Tourniquet

X X X X X

Mechanical CPR-Lucas X X X X X

Transcutaneous pacing X X X

12 lead placement, capture

and transmission

X X X X X

Skill-Immobilization

Spinal Immobilization-

Manual

X X X X X


Cervical collar

X X X X X


Kendrick extrication device

X X X X X

Spinal Immobilization-Long

spine board

X X X X X


EMT EMT-I PARAMEDIC I PARAMEDIC II PARAMEDIC III

Spinal Immobilization-Adult

vacuum mattress

X X X X X


Pediatric vacuum mattress

X X X X X

Spinal Immobilization-Rapid

manual extraction

X X X X X

Extremity stabilization-

manual

X X X X X

Extremity stabilization-Rigid

splint

X X X X X


Vacuum splint

X X X X X


Traction splint

X X X X X

Mechanical patient restraints X X X X X

Emergency moves for

endangered patients

X X X X X

Skill Medication

administration-Routes

Assisting patient with

prescribed medications

X X X X X

Aerosolized/nebulized X X X

Buccal X X X

Endotracheal X X X

Inhaled X X X

Intranasal X X X

Intramuscular X X X

Intravenous X X X

Intravenous piggyback X X X


EMT EMT-I PARAMEDIC I PARAMEDIC II PARAMEDIC III

Oral X X X X X

Rectal X X X

Sublingual X X X

Ophthalmic X X X

Intraosseous X X X X

Skill-IV

initiation/Maintenance

Intraosseous-Initiation X X X X

Intravenous-Initiation X X X X

Fluid infusion-Nonmedicated X X X X

Fluid infusion-Medicated X X X

Maintenance of blood

products

X X X

tpa infusion maintenance X

Skill-Miscellaneous

Assisted delivery(childbirth) X X X X X

Blood glucose monitoring X X X X X

Blood pressure-manual X X X X X

Blood pressure-Automated X X X X X

cooke county emergency medical services … · cooke county emergency medical services patient...

Documents