emsc partnership for children/national association of ems physicians model pediatric protocols*12003...

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SPECIAL CONTRIBUTIONS EMSC P ARTNERSHIP FOR CHILDREN/NATIONAL ASSOCIATION OF EMS PHYSICIANS MODEL PEDIATRIC PROTOCOLS: 2003 REVISION Pediatrics Committee, National Association of EMS Physicians THE NEED FOR STANDARDIZED PROTOCOLS Our emergency medical services (EMS) system is founded on the principle of delegated practice. Medical oversight establishes a certain standard of emer- gency patient care, which is then carried out by prehospital providers in the field. Broadly speaking, the term medical oversight encompasses both direct and indirect facets of medical control. Direct medical oversight is the online guidance provided by designated physicians to prehospital providers during emergency calls. Indirect medical oversight consists of training programs, patient care pro- tocols, and quality assurance measures that are initiated by local, regional, state, and agency medical directors or advi- sory boards. Throughout this document, the term medical direction represents all forms of medical oversight as applied by any state, region, or agency. To make a delegated system work, medical direction must ensure that all prehospital providers are equipped to meet appropriate standards of patient care. This requires education and train- ing, treatment protocols to guide re- scuers’ actions in the field, and support from qualified direct medical oversight physicians as needed. The responsibili- ties of medical direction include autho- rizing an accepted scope of practice for emergency medical technicians (EMTs) of varying skill levels; verifying that EMTs have received the necessary train- ing to render field care swiftly and skillfully; and developing and approv- ing protocols that delineate the proper steps in patient management. Protocols represent an important ele- ment in furthering the quality of pre- hospital care. Although they cannot replace sound clinical judgment, they facilitate rapid and effective treatment. They serve to standardize management actions so that prehospital providers will know how to proceed in a given patient presentation. They also provide an unambiguous gauge by which ad- herence to EMS practice standards may be measured. PUTTING THE PROTOCOLS TO USE EMS systems provide services under widely varying conditions. Current protocols therefore vary among agen- cies. The protocols developed and pres- ented in this document provide a basis for medical direction to create or refine existing protocols to meet local, re- gional, and state needs. In this manner, these protocols set forth a standardized approach to pediatric treatment that can be employed by a wide variety of EMS systems. The ultimate authority for prehospital patient care rests with medical direction and the state EMS agency. Each EMS jurisdiction must authorize each of these protocols before its use. Each EMS jurisdiction must review these protocols and further designate the following: interventions that are considered standing orders, requiring no con- sultation with direct medical over- sight interventions that are considered medical oversight options, to be carried out only after obtaining approval from an online physician interventions that are not applicable due to local conditions, training, and resources Because this is a highly individual de- termination, these model protocols do not designate these aspects of practice for any specific EMS system. In deciding which interventions should be standing orders and which will require authorization, EMS systems and medical direction should consider critical time factors. For certain lifesav- ing interventions, taking the time to consult a direct medical oversight phy- sician before initiating the action could have a detrimental effect on patient Received February 9, 2004, from the Pediat- rics Committee, National Association of EMS Physicians (NAEMSP), and the Division of Emergency Medicine, Children’s National Medical Center, Washington, DC (KB). Accepted for publication February 9, 2004. Approved by the NAEMSP Board of Direc- tors, December 2003. Supported initially by the Health Resources and Services Administration, Maternal and Child Health Bureau, and the Department of Transportation, National Highway Traffic Safety Administration EMSC Partnership for Children (purchase order #97-MCHB- HO763A). The authors thank MCHB’s EMSC Program and NHTSA for valuable staff assistance and funding for this effort. Address correspondence and reprint requests to: Kathleen Brown, MD, Division of Emer- gency Medicine, Children’s National Medical Center, 111 Michigan Avenue, Washington, DC 20010. e-mail: <[email protected]>. doi:10.1016/j.prehos.2004.03.009 343

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Page 1: EMSC partnership for children/National Association of EMS Physicians model pediatric protocols*12003 Revision

SPECIAL CONTRIBUTIONS

EMSC PARTNERSHIP FOR CHILDREN/NATIONAL ASSOCIATION OF EMSPHYSICIANS MODEL PEDIATRIC PROTOCOLS:

2003 REVISION

Pediatrics Committee, National Association of EMS Physicians

THE NEED FOR

STANDARDIZED PROTOCOLS

Our emergencymedical services (EMS)system is founded on the principle ofdelegated practice. Medical oversightestablishes a certain standard of emer-gency patient care, which is then carriedout by prehospital providers in the field.Broadly speaking, the term medical

oversight encompasses both direct andindirect facets of medical control. Directmedical oversight is the online guidanceprovided by designated physicians toprehospital providers during emergencycalls. Indirect medical oversight consistsof training programs, patient care pro-tocols, and quality assurance measures

Received February 9, 2004, from the Pediat-rics Committee, National Association of EMSPhysicians (NAEMSP), and the Division ofEmergency Medicine, Children’s NationalMedical Center, Washington, DC (KB) .Accepted for publication February 9, 2004.

Approved by the NAEMSP Board of Direc-tors, December 2003.

Supported initially by the Health Resourcesand Services Administration, Maternal andChild Health Bureau, and the Department ofTransportation, National Highway TrafficSafety Administration EMSC Partnershipfor Children (purchase order #97-MCHB-HO763A). The authors thank MCHB’sEMSC Program and NHTSA for valuablestaff assistance and funding for this effort.

Address correspondence and reprint requeststo: Kathleen Brown, MD, Division of Emer-gencyMedicine, Children’s NationalMedicalCenter, 111 Michigan Avenue, Washington,DC 20010. e-mail: <[email protected]>.

doi:10.1016/j.prehos.2004.03.009

that are initiated by local, regional, state,and agency medical directors or advi-sory boards. Throughout this document,the term medical direction represents allforms of medical oversight as applied byany state, region, or agency.To make a delegated system work,

medical direction must ensure that allprehospital providers are equipped tomeet appropriate standards of patientcare. This requires education and train-ing, treatment protocols to guide re-scuers’ actions in the field, and supportfrom qualified direct medical oversightphysicians as needed. The responsibili-ties of medical direction include autho-rizing an accepted scope of practice foremergency medical technicians (EMTs)of varying skill levels; verifying thatEMTs have received the necessary train-ing to render field care swiftly andskillfully; and developing and approv-ing protocols that delineate the propersteps in patient management.Protocols represent an important ele-

ment in furthering the quality of pre-hospital care. Although they cannotreplace sound clinical judgment, theyfacilitate rapid and effective treatment.They serve to standardize managementactions so that prehospital providerswill know how to proceed in a givenpatient presentation. They also providean unambiguous gauge by which ad-herence to EMS practice standards maybe measured.

PUTTING THE PROTOCOLS

TO USE

EMS systems provide services underwidely varying conditions. Current

343

protocols therefore vary among agen-cies. The protocols developed and pres-ented in this document provide a basisfor medical direction to create or refineexisting protocols to meet local, re-gional, and state needs. In this manner,these protocols set forth a standardizedapproach to pediatric treatment that canbe employed by a wide variety of EMSsystems.

The ultimate authority for prehospitalpatient care rests with medical directionand the state EMS agency. Each EMSjurisdictionmust authorize each of theseprotocols before its use. Each EMSjurisdiction must review these protocolsand further designate the following:

� interventions that are consideredstanding orders, requiring no con-sultation with direct medical over-sight

� interventions that are consideredmedical oversight options, to becarried out only after obtainingapproval from an online physician

� interventions that are not applicabledue to local conditions, training, andresources

Because this is a highly individual de-termination, these model protocols donot designate these aspects of practicefor any specific EMS system.

In deciding which interventionsshould be standing orders and whichwill require authorization, EMS systemsand medical direction should considercritical time factors. For certain lifesav-ing interventions, taking the time toconsult a direct medical oversight phy-sician before initiating the action couldhave a detrimental effect on patient

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344 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2004 VOLUME 8 / NUMBER 4

survival. Those interventions should bedesignated standing orders.Examples of such actions would in-

clude:

� any measure needed to establish ormaintain airway patency, includingadvanced airway procedures

� treatment for respiratory distress,failure, or arrest

� defibrillation or cardioversion forcardiopulmonary failure or arrest

� treatment for shock� treatment for active seizures� treatment for anaphylaxis

In addition to standing orders for life-threatening conditions, contingencyguidelines should be established toaddress circumstances in which a directmedical oversight physician is notavailable.Although these protocols address

both basic and advanced life supportmeasures, they do not attempt to differ-entiate between the two, nor do theyspecify which actions are appropriatefor EMS providers of varying certifica-tion levels. Proper patient care does notvary, regardless of the provider’s skillsor certification. Ideally, every necessaryaction should be carried out as specifiedin the protocol. Realistically, the EMT’sskill level will limit the actions that canbe provided in the field. Defining howthese limitations will be applied toproviders at different certification levelsis up to medical direction. However, it isimportant to emphasize that the basiclife support (BLS) steps of airway andbreathing are, in most cases, the onlyactions necessary to deliver a pediatricpatient safely to definitive care.Protocols require constant reevalua-

tion to ensure that they reflect advancesin EMS training, medical knowledge,science, and technology. Medical di-rection must continually evaluate pro-viders’ skills to ensure competencyand compliance with applicable EMSstandards. Implementing new protocolsmay necessitate that educational andtraining programs be updated in bothinitial and continuing prehospital edu-cation to ensure that providers have thenecessary skills and training to carryout their responsibilities. Medical di-rection must maintain an ongoing com-mitment to keep abreast of changes inmedical knowledge that may affect theprotocols. It is also essential for medical

direction to implement continual qual-ity improvement efforts that may leadto further clarification or revision of theprotocols and amended standards forprovider training.

PROTOCOL DEVELOPMENT

PROCESS

To develop these protocols, the processemployed by the writing team wasa combination of literature-based andexpert-consensus judgment. To start theprocess, the writing team reviewedmore than 250 representative protocolsselected from a national sample, thengenerated a list of commonly encoun-tered protocols and collated the in-dividual steps associated with each.To ensure compliance with accepted

national standards, the draft protocolswere comparedwith practices describedin the EMT-Basic and EMT-ParamedicNational Standard Curricula, theAmerican Heart Association (AHA)Pediatric Advanced Life Support pro-gram, the American Academy ofPediatrics (AAP) and AHA NeonatalResuscitation program, the AmericanCollege of Surgeons (ACS) AdvancedTrauma Life Support program, theCenter for Pediatric EmergencyMedicine’s Teaching Resource forInstructors in Prehospital Pediatrics, andthe National Association of EmergencyMedical Technicians (NAEMT) Pre-hospital Trauma Life Support program.The published literature was also re-viewed for prehospital pediatric studiesthat would provide additional guid-ance. If a point of controversy was notaddressed in the prehospital literature,a search of the literature in pediatricemergency medicine was conductedand conclusions were extrapolated forapplicability to the prehospital environ-ment. Further guidance was obtainedwhen needed from an expert-consensusgroup representing major national pro-fessional organizations in EmergencyMedical Services for Children (EMSC),EMS, pediatric emergency medicine,and emergency medicine.The resultant draft version of the

protocols was mailed to representativesnamed by major EMS and medicalprofessional organizations with a re-quest for written comments. Based onthe responses received, a second draftwas developed.

In August 1998, a meeting was heldin Washington, DC, at which in-dividuals representing the nationalEMS, EMSC, and medical professionalorganizations reviewed this seconddraft. Each protocol was evaluated tosee whether it was either supportedby a predominance of scientific litera-ture or based on accepted nationalstandards. All protocols that met oneof these criteria were considered ac-ceptable. Participants then reviewedthe remaining protocols and, basedon consensus judgment, decidedwhich would be accepted and whichwould be modified to meet specificrecommendations.

In addition to content decisions, thegroup also addressed formatting andoverall medical direction issues. Thegroup determined that the protocolsshould be constructed so that any singleprotocol could be used independently.Although this strategy necessitates re-peating many standard patient caresteps from one protocol to the next, itserves to stress the universal importanceof initial airway and breathing inter-ventions in pediatric care and highlightsthe concept that many children mayrequire only BLS measures, as delin-eated. Furthermore, establishing stand-alone protocols greatly facilitates theselection of individual protocols fromthe overall document, as appropriatefor various systems.

The group discussed the advisabilityof designating which actions should beconsidered standing orders for eachprotocol, but concluded that this shouldbe a regional decision, as it depends onmany variables, including the level ofmedical oversight, the training receivedby EMS providers at different certifica-tion levels, the clinical experience ofindividual EMS providers, and thefrequency with which the skills areperformed. The group ultimately estab-lished its recommendation that certainlifesaving procedures should be consid-ered standing orders in all regionsbased on critical time factors involved.Additional factors governing standingorders should be determined bymedical direction.

The group also discussed the advis-ability of designating separate BLS andadvanced life support (ALS) protocolsand designating which steps appliedto which EMS-provider certificationlevels. Although the Department of

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345CSHCN: MODEL PEDIATRIC PROTOCOLS, 2003 REVISION

Transportation’s National Highwayand Traffic Safety Administration hasestablished national training guidelinesfor Certified First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic, significant variations existamong EMS systems regarding theactual level of provider training, scopeof practice, and certification levels foreach of these designations. Therefore,the group concluded that, althoughthese protocols define the care to beprovided, regional EMS systems shoulddetermine which actions fall withinspecific providers’ scope of practice.Finally, the group noted that several

protocols include decision points atwhich more than one treatment optionor medication choice could be consid-ered medically acceptable. For thoseprotocols, all options would be listed,and medical direction could select theoption to be implemented. Similarly,when a useful treatment option existsthat might exceed providers’ cap-abilities, system resources, or systemneeds in certain regions, the step is listedwith the qualifier that it should beconsidered as permitted by medicaldirection.At the conclusion of this meeting,

a third draft was generated and distrib-uted to the writing team for comments,which were incorporated into the fourthdraft.This draft was copyedited, and then

forwarded to the review panel and allstate and territorial EMS directors. In aneffort to further broaden the input intothe development process and to be asinclusive as possible, the protocols werealso posted on the NAEMSP websitefor download, with a comment form tobe returned to the writing team. Thewebsite posting was also availablethrough links from other major EMSand EMSC websites. The commentsobtained from this draft were incorpo-rated into the final document. In addi-tion to review of the document, the stateEMS directors were asked to suggestmechanisms for distributing the fin-ished protocols nationally and withintheir individual states and territories.These protocols are intended to rep-

resent model treatment practices. TheEMS agencies can rely on them to directpatient care, whether they are im-plemented as standing orders or asoptions authorized by direct-medical-oversight physicians. In either case, the

protocols should serve as a qualitymeasure to ensure uniformity of care.The authors hope that individuals, EMSproviders, and medical directors willuse these protocols to help improve thecare children receive in emergencies.

2000 AND 2003 REVISION

PROCESS

Because medical knowledge is an ever-evolving subject, it was decided duringthe initial development process that itwould be necessary to create an ongoingreview and revision process for theseprotocols. The process and timeline thatwere chosen specify a review of theprotocols in September of each year todetermine whether any new researchdata or new peer-reviewed guidelinesmight necessitate a change in theprotocols. If such a change is needed,the protocols would be revised, withthe draft circulated for commentsto the organizations that were involvedin the original review process, thenedited based on those comments. Theedited draft would then be presented atthe annual NAEMSP meeting, first tothe Pediatric Task Force and then to theBoard of Directors for final approval.The approved and revised protocolswould then be distributed, as werethe original set of protocols, viathe NAEMSP and EMSC NRC websitesand via direct mailings to the state andterritorial EMS directors. Last, any re-vised protocols would be submitted toPrehospital Emergency Care for publication.The first major revision occurred in

the fall of 2000 and was largely a re-flection of the new Emergency CardiacCare Committee guidelines released inAugust 2000. A subsequent revisionemploying the process as describedwas conducted in 2003 and includedthe addition of protocols for childrenwith special health care needs(CSHCN).

THE MODEL PEDIATRIC

PROTOCOLS

General Patient Care

This protocol provides general guidelinesfor patient management. Refer to additionalprotocols as appropriate for treatment ofspecific conditions. A length-based resusci-tation tape is recommended to help EMS

personnel quickly determine appropriateequipment size, normal vital signs, andcorrect drug dosages.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury. Ifhazardous conditions are present(such as swift water, hazardousmaterials, electrical hazard, or con-fined space), contact an appropriateagency before approaching the pa-tient. Wait for the designated spe-cialist to secure the scene andpatient, as necessary.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess the patient’s breathing, in-cluding rate, auscultation, inspec-tion, effort, and adequacy ofventilation as indicated by chestrise. Obtain a pulse oximeterreading.

11. If chest rise indicates inadequateventilation, reposition airway andreassess.

12. If inadequate chest rise is notedafter repositioning airway, suspecta foreign body obstruction of theairway. Refer to the appropriateprotocol for treatment options.

13. Assess for signs of respiratorydistress, failure, or arrest. If pres-ent, refer to the appropriate pro-tocol for treatment options.

14. If the child is not breathing orbreathing is inadequate, initiateassisted ventilation using a bag-valve-mask device with high-flow,100% concentration oxygen. Beginwith two slow, deep breaths of

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346 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2004 VOLUME 8 / NUMBER 4

about 1.0 to 0.5 seconds’ duration,then ventilate at 20 breaths/min forall ages. If abdominal distentionarises, considerplacinganasogastrictube to decompress the stomach.

15. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administrationof pharmacologic adjuncts, such assedatives and paralytic agents, toaid with intubation, as permitted bymedical direction. Confirm place-ment of endotracheal tube usingclinical assessment and end-tidalcarbon dioxide (CO2) monitoring.

16. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-by,as tolerated.

17. Control hemorrhage using directpressure or a pressure dressing.

18. Assess circulation and perfusion bymeasuring heart rate and observingskin color and temperature, capil-lary refill time, and the quality ofcentral and peripheral pulses.Blood pressure should be measuredonly in children older than 3 years.

19. For children with absent pulses,initiate cardiopulmonary resuscita-tion at a combined rate of 120compressions/min for newborns(three compressions to each breath)or 100 compressions/min for infantsand children (15 compressions toeach 2 breaths for children greaterthan 8years of ageuntil the airway issecured with intubation; and 5compressions to each breath forpatients less than 8 years of ageand those over 8 years of age witha secured airway). Compressiondepth is 0.5 to 0.75 inch for neonates,0.5 to 1 inch for infants, and 1 to 1.5inches for children. There should bea pause in compressions for ventila-tion until the airway is secured withintubation.

20. Initiate cardiac monitoring. Forabsent pulses, initiate monitoringwith either a manual defibrillatoror an automated external defibril-lator (AED) and treat per appro-priate protocol.

21. If there is evidence of shock, obtainvascular access using an age-

appropriate large-bore catheter withlarge-caliber tubing. If intravenousaccess cannot be obtained, proceedwith intraosseous access. Administera fluid bolus of normal saline at 20mL/kg set to maximum flow rate (ata minimum , 20 minutes). Reassessthe patient after the bolus. If signs ofshock persist, the bolus may be re-peated at the same dose up totwo times for a maximum total of60 mL/kg.

22. Evaluate mental status, includingpupillary reaction, distal functionand sensation, and AVPU (alert,verbal, pain, unconsciousness)assessment.

23. If spinal trauma is suspected, con-tinue manual stabilization, placea rigid cervical collar, and immobi-lize the patient on a long backboardor similar device.

24. Expose the child only as necessaryto perform further assessments.Maintain the child’s body temper-ature throughout the examination.

25. If the child’s condition is critical orunstable, initiate transport. Performfocused history and detailed physi-cal examination en route to thehospital if the patient’s status andmanagement of resources permit.

26. If the child’s condition is stable,perform focused history and de-tailed physical examination on thescene, and then initiate transport.

27. Reassess the patient frequently.28. Contact direct medical oversight

for additional instructions.

Foreign Body AirwayObstruction

The following protocol applies to an un-conscious child or infant with a foreignbody obstruction of the airway.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Confirm that the patient is un-

responsive.6. Open the airway using a head tilt/

chin lift.7. Attempt assisted ventilation using

a bag-valve-mask device with high-

flow, 100% concentration oxygen. Ifunsuccessful, reposition airwayand attempt bag-valve-mask-assisted ventilation again.

8. Use age-appropriate techniques todislodge the obstruction (for infantsyounger than 1 year, apply backblows with chest thrusts; for chil-dren � 1 year, use abdominalthrusts).

9. If unsuccessful, establish a directview of the object and attempt toremove it with Magill forceps.

10. If unsuccessful, attempt endotra-cheal intubation and ventilate thepatient.

11. If unsuccessful, perform needlecricothyrotomy and needle jet in-sufflation.

12. Assess circulation and perfusion.13. Assess mental status.14. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

15. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

16. Reassess the patient frequently.17. Contact direct medical oversight

for additional instructions.

Respiratory Distress,Failure, or Arrest

A patient who presents with acute re-spiratory distress of sudden onset accompa-nied by fever, drooling, hoarseness, stridor,and tripod positioning may have a partialairway obstruction. Do nothing to upset thechild. Perform critical assessments only.Enlist the parent to administer blow-byoxygen. Place the patient in a position ofcomfort. Do not attempt vascular access.Transport immediately.

Definitions

Respiratory distress is indicated by thefollowing findings:

� alert, irritable, anxious� stridor� audible wheezing� respiratory rate faster than normal

for age� intercostal retractions� nasal flaring� neck muscle use

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347CSHCN: MODEL PEDIATRIC PROTOCOLS, 2003 REVISION

� central cyanosis that resolves withoxygen administration

� mild tachycardia� able to maintain sitting position

(children older than 4 months)

Respiratory failure involves thefindings above with any of the follow-ing additions or modifications:

� sleepy, intermittently combative, oragitated

� increased respiratory effort at sternalnotch

� marked use of accessory muscles� retractions, head bobbing, grunting� central cyanosis� marked tachycardia� poor peripheral perfusion� decreased muscle tone

Respiratory arrest involves thefindings above with any of the follow-ing additions or modifications:

� unresponsive to voice or touch� absent or shallow chest wall motion� absent breath sounds� respiratory rate slower than 10

breaths/min� weak to absent pulses� bradycardia or asystole� limp muscle tone� unable to maintain sitting position

(children older than 4 months)

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction. Signsinclude:

� absent breath sounds� tachypnea� intercostal retractions� stridor or drooling� choking� bradycardia� cyanosis

7. If foreign body obstruction of theairway is suspected, refer to theappropriate protocol for treatmentoptions.

8. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

9. Suction as necessary.10. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

11. Assess the patient’s breathing, in-cluding rate, auscultation, inspec-tion, effort, and adequacy ofventilation as indicated by chestrise. Assess for signs of respiratorydistress, failure, or arrest. Obtaina pulse oximeter reading.

12. If chest rise indicates inadequateventilation, reposition airway andreassess. If inadequate chest riseis noted after repositioning airway,suspect a foreign body obstructionof the airway. Refer to the appropri-ate protocol for treatment options.

13. If signs of respiratory arrest orrespiratory failure with inadequatebreathing are present, assist ven-tilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen.

14. If abdominal distention arises, con-sider placing a nasogastric tube todecompress the stomach.

15. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

16. If breathing is adequate and patientexhibits signs of respiratory dis-tress, administer high-flow, 100%concentration oxygen as necessary.Use a nonrebreather mask or blow-by as tolerated.

17. If bronchospasm is present, refer tothe appropriate protocol for treat-ment options.

18. Assess circulation and perfusion.

19. Initiate cardiac monitoring.20. If the patient shows signs of severe

respiratory failure or respiratoryarrest, consider establishing vascu-lar access and administering nor-mal saline at a sufficient rate to

keep the vein open. If intravenousaccess cannot be obtained, proceedwith intraosseous access. Do notdelay transport to obtain vascular

access.21. Assess mental status.22. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-ature throughout the examination.

23. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

24. Reassess the patient frequently.25. Contact direct medical oversight

for additional instructions.

Respiratory Distress in theChild on VentilatorySupport

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Open the airway using head tilt/chin lift.

7. For a patient receiving invasiveventilation via a ventilator, assessthe patient to determine the possi-

ble cause of respiratory distress byremoving the patient from theventilator and assisting ventilationswith a bag-valve-mask via the

tracheostomy tube. Use the follow-ing reactions to assisted ventilationwith a bag-valve-mask to help de-termine the cause:

� If unable to ventilate the patient,there is significant resistance,or there is poor air entry withbag-valve-mask ventilation, theproblem is probably due to

the tracheostomy tube. Refer tothe ‘‘Respiratory Distress in the

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348 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2004 VOLUME 8 / NUMBER 4

Child with a Tracheostomy’’protocol.

� If able to ventilate through thetracheostomy tube and the pa-tient improves, or if the respira-tory distress is still present, theproblem is probably due toa medical problem. Refer to the‘‘Respiratory Distress, Failure, orArrest’’ protocol.

� If the patient improves and iseasy to ventilate with bag-valve-mask–assisted ventilation, theproblem is probably due to theventilator. In this situation, per-form the following actions:

A. Ensure that the ventilator isset to the correct settingsgiven to you by the parentsor other caregivers, the oxy-gen supply is not empty, andthe power supply is con-nected to the ventilator.

B. Confirm that the circuit issecurely connected.

C. Reconnect the patient to ven-tilator circuit. Ensure thatconnection between the cir-cuit and tracheostomy tube issecure.

D. If the tracheostomy tube hasa cuff, ensure that it is inflatedby checking the pilot balloon.If the pilot balloon is deflated,reinflate the cuff by attachinga syringe to the pilot balloonvalve and inflating with airuntil the pilot balloon isinflated.

E. Ask the parents or othercaregivers to perform anyprocedure they have beentaught to correct ventilatorproblems.

F. If the patient remains in dis-tress, disconnect the patientfrom the ventilator and assistventilations with a bag-valve-mask via the tracheostomytube and prepare for trans-port.

8. For a patient receiving noninvasiveventilation via either biphasic pos-itive airway pressure (BiPAP) orcontinuous positive airway pres-sure (CPAP), assess the cause ofthe problem:

A. Ensure that the device is set tothe correct settings given to

you by the parents or othercaregivers, the oxygen supplyis not empty, and the powersupply is connected to theventilator.

B. Confirm that the patient iscorrectly attached to thedevice.

C. Ask the parents or othercaregivers to perform any pro-cedure they have been taughtto correct device problems.

D. If the patient remains in dis-tress, disconnect the patientfrom the device and assistventilations with a bag-valve-mask.

E. If, despite assisted ventilationswith a bag-valve-mask, thepatient remains in distress, re-fer to the ‘‘RespiratoryDistress,Failure, or Arrest’’ protocol.

9. Assess the patient’s breathing, in-cluding rate, auscultation, inspec-tion, effort, and adequacy ofventilation as indicated by chestrise. Assess for signs of respiratorydistress, failure, or arrest. Obtaina pulse oximeter reading.

10. Record the ventilator settings,which may include respiratoryrate, tidal volume, pressure set-tings, inspired oxygen concentra-tion and positive end-expiratorypressure (PEEP).

11. If abdominal distention arises, con-sider placing a nasogastric tube todecompress the stomach.

12. If bronchospasm is present, refer tothe appropriate protocol for treat-ment options.

13. Assess circulation and perfusion.14. Initiate cardiac monitoring.15. If the patient shows signs of severe

respiratory failure or respiratoryarrest, consider establishing vascu-lar access and administering normalsaline at a sufficient rate to keep thevein open. If intravenous accesscannot be obtained, proceed withintraosseous access. Do not delaytransport to obtain vascular access.

16. Assess mental status.17. Expose the child only as neces-

sary to perform further assess-ments. Maintain the child’s bodytemperature throughout theexamination.

18. Initiate transport. Perform focusedhistory and detailed physical ex-

amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

19. Reassess the patient frequently.20. Contact direct medical oversight

for additional instructions.

Respiratory Distress in theChild with a Tracheostomy

The following protocol applies to a patientwith a tracheostomy who is experiencingrespiratory distress.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Open the airway using a head tilt/

chin lift.6. Assess the tracheostomy to make

sure that:

� Tracheostomy tube is in place� Obturator has been removed� If it is a double lumen, the inner

cannula is in place� For fenestrated tracheostomy

tube, the decannulation plug ortalk valve has been removed

7. Assess the patient’s breathing, in-cluding rate, auscultation, inspec-tion, effort, and adequacy ofventilation as indicated by chestrise. Assess for signs of respiratorydistress, failure, or arrest. Obtaina pulse oximeter reading.

8. If signs of respiratory arrest orrespiratory failure with inadequatebreathing are present, assist ventila-tion using a bag-valve-mask devicewith high-flow, 100% concentra-tion oxygen via the tracheostomy.If unsuccessful, reposition airwayand attempt bag-valve-mask–assisted ventilation again. If trache-ostomy tube is a double-lumen tube,the inner cannula must be in place toattach the bag-valve-mask device.

9. If unable to ventilate via the trache-ostomy, or if respiratory distresspersistswithpoorornoisy (gurgling,rhonchi) breath sounds, attempt tosuction through the tracheostomyusing the following procedure:

A. Ask the family and caregivers forthe patient’s suctioning supplies

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and for assistance, as they aremore familiar with suctioningthe patient. If the patient’ssupplies are not available, usea suction catheter of the samesize as normally used for thepatient. If knowledge of size ofcatheter is not available, the sizecan be estimated by doubling theinner diameter of the tracheos-tomy tube and rounding downto an available catheter size.

B. For double-cannula catheters,the inner cannula may be re-moved, suctioned directly, andthen reinserted.

C. Determine suction depth bycomparing the suction catheterwith either the obturator or thepatient’s spare tracheostomytube. If these are not available,then maximum suction depthfor catheter should be 3 to 6 cm.

D. Ensure that the suction device isset to 100 mm Hg for tracheos-tomy suctioning.

E. Preoxygenate the patient viaeither nonrebreather mask overthe face (partial tracheostomy)or tracheostomy tube, or viaassisted ventilations with bag-valve-mask if the patient hasineffective ventilations. If unableto ventilate, then proceed imme-diately to the next step.

F. Instill 2–3 mL of sterile normalsaline into the tracheostomytube.

G. Insert a suction catheter intothe tracheostomy to a pre-determined depth with the suc-tion off. Never force a catheterwhile inserting. Apply suctionwhile withdrawing the catheter.Limit suctioning to no morethan 10 seconds.

H. Suctioning following steps D toG may be repeated up to twotimes, if significant secretionsare removed and the patienttolerates the procedure.

I. If unable to pass the suctioncatheter and the patient remainsin distress despite assisted ven-tilations, proceed to step 10 tochange tracheostomy tube.

10. After suctioning, if the patient re-mains in distress with poor airmovement, again attempt assistedventilation using a bag-valve-mask

device with high-flow, 100% con-centration oxygen via the tracheos-tomy.

11. If unable to ventilate via the trache-ostomy and the patient remains indistress, change the tracheostomytube by either the facilitated or thedirect technique.

Facilitated technique

A. Ask the patient’s family or care-giver for a new tracheostomytube and for assistance withchanging the tracheostomy tube,as they may have more ex-perience than prehospital per-sonnel.

B. For a double-cannula trache-ostomy tube, remove theinner cannula and follow thistechnique to insert the outercannula. Once the outer can-nula is in place, insert the innercannula prior to confirmingcorrect placement via assistedventilation.

C. Insert a suction catheter througha new tracheostomy tube.

D. If the tracheostomy tube hasa cuff, deflate the cuff byconnecting a syringe to the valveon the pilot balloon and with-drawing air until the pilot bal-loon collapses.

E. Cut the tracheostomy ties orremove the tracheostomy holderdevice.

F. Gently remove the old tracheos-tomy tube in the anatomicaldirection (outward and towardthe patient’s feet).

G. Insert the suction catheter intothe stoma. Aim the suctioncatheter toward the patient’sfeet, and insert only 3 to 6 cminto the airway.

H. Gently advance the new trache-ostomy tube over the suctioncatheter while holding the cath-eter in place and using it asa guide.

I. Remove the suction catheterfrom the tracheostomy tube.

J. If unable to insert new tracheos-tomy, try the same procedurewith a smaller tracheostomytube.

K. If still unable to insert thetracheostomy tube, insert a sim-ilar internal-diameter size en-

dotracheal tube following thesame technique. The endotra-cheal tube should be insertedonly to a depth equal to thelength of the tracheostomytube that would have beeninserted.

L. Attach bag-valve-mask and pro-vide assisted ventilations.

M. Confirm placement of the newtracheostomy tube using clinicalassessment, including bilateralchest expansion with goodbreath sounds, improvement invital signs, and pulse oximetry.Secondary confirmation shouldbe via end-tidal carbon dioxide(CO2) monitoring.

Direct technique

A. Ask the patient’s family or care-giver for a new tracheostomytube and for assistance withchanging the tracheostomytube, as they may have moreexperience than prehospitalpersonnel.

B. For a double-cannula trache-ostomy tube, remove theinner cannula and follow thistechnique to insert the outercannula. Once the outer can-nula is in place, insert the innercannula prior to confirmingcorrect placement via assistedventilation.

C. If the tracheostomy tube hasa cuff, deflate the cuff byconnecting a syringe to the valveon the pilot balloon and with-drawing air until the pilot bal-loon collapses.

D. Cut the tracheostomy ties orremove the tracheostomy holderdevice.

E. Gently remove the old tracheos-tomy tube in the anatomicaldirection (outward and towardthe patient’s feet).

F. Gently insert the new tracheos-tomy tube in the anatomicaldirection. This will be with thecurve downward, the tubeaimed toward the patient’s feet,and in a curving motion. Makesure the obturator is in place forinsertion, and then remove itafter insertion.

G. If unable to insert new tracheos-tomy, try the same procedure

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with a smaller tracheostomytube.

H. If still unable to insert thetracheostomy tube, insert a sim-ilar internal-diameter size endo-tracheal tube following the sametechnique. The endotrachealtube should be inserted only toa depth equal to the length of thetracheostomy tube that wouldhave been inserted.

I. Attach bag-valve-mask and pro-vide assisted ventilations.

J. Confirm placement of the newtracheostomy tube using clinicalassessment, including bilateralchest expansion with goodbreath sounds, improvement invital signs, and pulse oximetry.Secondary confirmation shouldbe via end-tidal CO2monitoring.

12. If the patient remains in distresswith inadequate breathing, and thetracheostomy tube cannot be re-placed with a new tracheostomytube or an endotracheal tube, at-tempt to perform orotracheal in-tubation using standard technique.This should be attempted only forpatients with an intact airway prox-imal to the tracheostomy site (par-tial tracheostomy).

13. If the patient remains in distresswith inadequate breathing, and thetracheostomy tube cannot be re-placed and orotracheal intubationcannot be performed, assist ven-tilations with a bag-valve-maskover the mouth and nose whileoccluding the stoma (this shouldbe performed only on a patient withan intact airway proximal to thetracheostomy site) or over the stomawhile occluding the mouth andnose. Assess for adequate ventila-tion by clinical assessment, includ-ing bilateral chest expansion withgood breath sounds, improvementin vital signs, and pulse oximetry.

14. Continue with assisted ventilationsfor patients with continued respira-tory distress and inadequatebreathing.

15. If abdominal distention arises, con-sider placing a nasogastric tube todecompress the stomach.

16. If breathing is adequate and thepatient exhibits continued signs ofrespiratorydistress, administerhigh-flow, 100% concentration oxygen

as necessary. Use a nonrebreathermask or blow-by, as tolerated. In thepatient with respiratory distress andabsent breath sounds, consider ob-struction of the tracheostomy tubeand proceed with step 9.

17. If bronchospasm is present, refer tothe ‘‘Bronchospasm’’ protocol fortreatment options.

18. Assess circulation and perfusion.19. Assess mental status.20. Expose the child only as necessary

to perform further assessments.Maintain the child’s body tempera-ture throughout the examination.

21. Initiate transport. Perform focusedhistory and detailed physical exam-ination en route to the hospital if thepatient’s status and management ofresources permit.

22. Reassess the patient frequently.23. Contact direct medical oversight for

additional instructions.

Bronchospasm

A silent chest is an ominous sign, in-dicating that respiratory failure or arrest isimminent.

Definition

Bronchospasm is usually accompaniedby respiratory distress with the follow-ing findings:

� wheezing� prolonged expiration� increased respiratory effort (de-

creased effort may be noted aspatient’s condition approaches respi-ratory failure)

� severe agitation, lethargy� suprasternal and substernal retrac-

tions� tripod positioning

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, and

the possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess breathing. Obtain a pulseoximeter reading.

11. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

12. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administrationof pharmacologic adjuncts, such assedatives and paralytic agents, toaid with intubation, as permitted bymedical direction. Confirm place-ment of endotracheal tube usingclinical assessment and end-tidalcarbon dioxide (CO2) monitoring.

13. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. If the patient shows signs of re-spiratory failure with inadequateventilation or respiratory arresttogether with clinical evidence ofbronchospasm or a history ofasthma, administer one of thefollowing systemic agents for bron-chodilation:

� Epinephrine, 1:1,000 at 0.01 mg/kg (maximum individual dose:0.3 mg), via subcutaneous route

� Terbutaline, 0.01 mg/kg (maxi-mum individual dose: 0.4 mg),via subcutaneous route

15. If the patient shows signs of re-spiratory distress or respiratoryfailure together with clinical evi-dence of bronchospasm or a historyof asthma, administer one of the

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following inhaled beta-2-agonistbronchodilators:

� Albuterol, 2.5 mg via nebulizerover a 10- to 15-minute period or4 puffs via metered-dose inhaler(MDI) with spacing device

� Levalbuterol, 0.625–1.250 mg vianebulizer over a 10- to 15-minuteperiod

� If these respiratory findingspersist, repeat the inhaled beta-2-agonist bronchodilator vianebulizer at 15-minute inter-vals throughout transport. Donot delay transport to administermedications.

16. If the patient shows signs of re-spiratory distress or respiratoryfailure together with clinical evi-dence of bronchospasm or a historyof asthma, consider administering500 mg of ipratropium bromide vianebulizer over a 10- to 15-minuteperiod. Ipratropium bromide andeither albuterol or levalbuterol maybe mixed together and adminis-tered simultaneously.

17. Assess circulation and perfusion.18. Initiate cardiac monitoring.19. If the patient shows signs of severe

respiratory failure or respiratoryarrest, consider establishing vascu-lar access and administering nor-mal saline at a sufficient rate tokeep the vein open. If intravenousaccess cannot be obtained in a pa-tient with respiratory arrest, pro-ceed with intraosseous access. Donot delay transport to obtain vas-cular access.

20. Consider administration of steroidsin one of the following prepara-tions, as permitted by medicaldirection:

� Prednisone, 2.0 mg/kg (maxi-mum individual dose 60 mg)orally

� Methylprednisolone, 2.0 mg/kg(maximum individual dose 125mg), via intravenous/intramus-cular route

� Hydrocortisone, 4.0 mg/kg(maximum individual dose 250mg), via intravenous/intramus-cular route

21. Assess mental status.22. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-ature throughout the examination.

23. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

24. Reassess the patient frequently.25. Contact direct medical oversight

for additional instructions.

Newborn Resuscitation

This protocol describes procedures for theresuscitation of a newly delivered infant.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions.3. Observe standard precautions.4. Suction the infant’s airway using

a bulb syringe as soon as theinfant’s head is delivered and be-fore delivery of the body. Suctionthe mouth first, and then thenasopharynx.

5. Once the body is fully delivered,dry the baby, replace wet towelswith dry ones, and wrap the babyin a thermal blanket or dry towel.Cover the infant’s scalp to preservewarmth.

6. Open and position the airway. Suc-tion the infant’s airway again usinga bulb syringe. Suction the mouthfirst, and then the nasopharynx.

7. If thick meconium is present and thepatient exhibits absent or depressedrespirations, heart rate less than 100beats/min, or poor muscle tone,initiate endotracheal intubation be-fore the infant takes a first breath.Suction the airway using an appro-priate suction adapter while with-drawing the endotracheal tube.Repeat this procedure until the en-dotracheal tube is clear ofmeconium.If the infant’s heart rate becomesbradycardic, discontinue suctioningimmediately andprovide ventilationuntil the infant recovers. Note: If theinfant is already breathing or crying,this step may be omitted.

8. Assess breathing and adequacy ofventilation.

9. If ventilation is inadequate, stimu-late the infant by gently rubbingthe back and flicking the soles ofthe feet.

10. If ventilation is still inadequateafter brief stimulation, begin assis-

ted ventilation at 40 to 60 breaths/min using a bag-valve-mask devicewith high-flow, 100% concentrationoxygen. If the ventilation remainsinadequate despite assisted ven-tilation, perform endotrachealintubation.

11. If ventilation is adequate and theinfant displays central cyanosis,administer high-flow, 100% concen-tration oxygen via blow-by. Holdthe tubing 1 to 1.5 inches from theinfant’s mouth and nose, and cupa hand around the end of thetubing to help direct the oxygenflow toward the infant’s face.

12. Assess heart rate by auscultation orby palpation of the brachial arteryor umbilical-cord stump.

13. If the heart rate is slower than 60beats/min after 30 seconds of as-sisted ventilation with high-flow,100% concentration oxygen, initiatethe following actions:

A. Continue assisted ventilation.B. Perform endotracheal intuba-

tion, if not already done.C. Begin chest compressions at

a combined rate of 120/min(3 compressions to each ventila-tion with a pause for ventilationuntil the airway is secured withintubation).

D. If there is no improvement inheart rate after intubation andventilation, administer 1:10,000epinephrine solution at 0.01mg/kg (maximum individualdose 1.0 mg) via endotrachealtube, or establish vascular accessand administer the same dose.In the neonate, vascular accessmay be obtained intraosseously,intravenously, or through theumbilical vein (if medical di-rection permits). Repeat epi-nephrine at the same doseevery 3 to 5 minutes as needed.

E. Initiate transport. Reassess heartrate and respirations en route.

14. If the heart rate is faster than 100beats/min, initiate the followingactions:

A. Assess skin color. If centralcyanosis is still present, continueblow-by oxygen.

B. Initiate transport. Reassess heartrate and respirations en route.

15. Reassess the patient frequently.

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16. Contact direct medical oversightfor additional instructions.

Bradycardia

Bradycardia generally arises from hypoxia.Therefore, airway, ventilation, and oxygen-ation are the highest management priorities.The cause of the hypoxia should be identifiedand corrected.

Definition

Severe cardiorespiratory compromise isindicated by:

� poor perfusion as evidenced bydelayed capillary refill, and weak orabsent peripheral pulses

� altered mental status� hypotension� respiratory difficulty

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess breathing. Obtain a pulseoximeter reading.

11. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

12. If the airway cannot be maintainedby other means, including attempts

at assisted ventilation, if prolongedassisted ventilation is anticipated, orthe patient continues to have severecardiorespiratory compromised de-spite oxygenation and ventilation,perform endotracheal intubation.Consider administration of pharma-cologic adjuncts, such as sedativesand paralytic agents, to aid withintubation as permitted by medicaldirection. Confirm placement ofendotracheal tube using clinicalassessment and end-tidal carbondioxide (CO2) monitoring.

13. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. Assess circulation and perfusion.15. Initiate cardiac monitoring and de-

termine rhythm.16. If signs of severe cardiopulmonary

compromise are present in an in-fant or neonate and the heart rateremains slower than 60 beats/mindespite oxygenation and ventila-tion, initiate chest compressions.

17. If the patient shows signs of severecardiopulmonary compromise, es-tablish vascular access and admin-ister normal saline at a sufficientrate to keep the vein open. Ifintravenous access cannot be ob-tained in a child younger than 6years, proceed with intraosseousaccess. Do not delay transport toobtain vascular access.

18. Check blood glucose.19. If signs of severe cardiopulmonary

compromise persist, administerepinephrine using the first avail-able route as follows: 1:1,000 solu-tion at 0.l mg/kg (maximumindividual dose: 10 mg) via endo-tracheal tube or 1:10,000 solution at0.0l mg/kg (maximum individualdose: 1.0 mg) via intravenous orintraosseous route. Repeat the doseevery 3 to 5 minutes until either thebradycardia or severe cardiopul-monary compromise resolves.

20. If signs of severe cardiopulmonarycompromise and bradycardia per-sist despite epinephrine, administeratropine at 0.02 mg/kg via intra-venous route, intraosseous route, orendotracheal tube. The minimumdose is 0.1 mg; the maximumindividual dose is 0.5 mg for a child,

and 1.0 mg for an adolescent.Atropine may be repeated onceafter 3 to 5 minutes and may bedoubled. The minimum doubleddose is 0.1 mg; the maximumdoubled individual dose is 1.0 mgfor a child, and 2.0 mg for anadolescent. Note: If the bradycardiais due to increased vagal tone orprimary atrioventricular block, at-ropine should be given beforeepinephrine.

21. For persistent bradycardia withsevere cardiopulmonary compro-mise, consider external pacing aspermitted by medical direction.

22. Assess mental status.23. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

24. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

25. Reassess the patient frequently.26. Contact direct medical oversight for

additional instructions, including:

� initiation of external pacing� repeated administration of epi-

nephrine� repeated administration of

atropine

Tachycardia

Definitions

Poor perfusion is indicated by:

� delayed capillary refill� weak or absent peripheral pulses� altered mental status� hypotension

The three types of tachycardia may bedistinguished by the following signs:

1. Sinus tachycardia is usually presentwhen

� An infant exhibits tachycardia inwhich the heart rate is slowerthan 220 beats/min, or a childexhibits tachycardia in which theheart rate is slower than 180beats/min.

� There is a normal QRS durationfor age (# 0.08 seconds).

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� Normal P waves are present, theR-R interval is variable, and thePR interval is constant.

� Heart rate varies with activity.

2. Supraventricular tachycardia is usu-ally present when

� An infant exhibits tachycardia inwhich the heart rate is faster than220 beats/min, or a child exhibitstachycardia in which the heartrate is faster than 180 beats/min.

� There is a normal QRS durationfor age (# 0.08 seconds).

� P waves are abnormal or absent.� Abrupt changes occur in heart

rate.

3. Presumptive ventricular tachycardia ispresent when

� The QRS duration is wide for age(> 0.08 seconds).

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions and

mechanism of illness or injury.3. Form a first impression of the

patient’s condition.4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,

manually stabilize the spine.6. Assess the patient’s airway for

patency, protective reflexes, and

the possible need for advanced

airway management. Look for

signs of airway obstruction.7. Open the airway using head tilt/

chin lift if no spinal trauma is

suspected, or modified jaw thrust

if spinal trauma is suspected.8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunct

if the airway cannot be maintained

with positioning and the patient is

unconscious.10. Assess breathing. Obtain a pulse

oximeter reading.11. If breathing is inadequate, assist

ventilation using a bag-valve-mask

device with high-flow, 100% con-

centration oxygen. If abdominal

distention arises, consider placing

a nasogastric tube to decompressthe stomach.

12. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

13. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. Assess circulation and perfusion.15. Initiate cardiac monitoring and de-

termine rhythm.16. Establish vascular access and ad-

minister normal saline at a sufficientrate to keep the vein open. Ifintravenous access cannot be ob-tained and the patient shows signsof poor perfusion, proceed withintraosseous access. Do not delaytransport to obtain vascular access.

17. Check blood glucose.18. For probable sinus tachycardia,

identify and treat possible causes,such as hypovolemia, shock, hyp-oxia, or pneumothorax.

19. For probable supraventriculartachycardia with signs of poorperfusion, the following stepsshould be taken:

A. Administer adenosine at 0.1mg/kg (maximum individualdose 6.0 mg) via rapid intrave-nous bolus at the port closest tothe intravenous hub. Adenosinemay be repeated twice at 0.2mg/kg (maximum individualdose: 12 mg) as needed.orPerform synchronized car-dioversion at 0.5 to 1.0 J/kg. Ifthe patient remains in supraven-tricular tachycardia, repeat car-dioversion at double the energy(maximum: 360 J). Sedate thepatient before cardioversion, aspermitted by medical direction.Sedation may be accomplished

by administering midazolam at0.1 mg/kg (maximum individualdose: 2.0 mg) or diazepam at 0.2mg/kg (maximum individualdose: 5.0 mg) via intravenousroute.

B. Consider treatment with alter-native antiarrhythmic medi-cations, including:

� Amiodarone, 5 mg/kg intrave-nously over 20 to 60 minutes

� Procainamide, 15 mg/kg over 30to 60 minutes

� Lidocaine, 1 mg/kg intravenousbolus

20. For probable ventricular tachycar-

dia with a pulse and poor perfu-

sion, the following steps should be

taken:

A. Perform synchronized car-dioversion at 0.5 to 1.0 J/kg. Ifthe patient remains in ventricu-lar tachycardia with a pulse, re-peat cardioversion at double theenergy (maximum: 360 J).Sedate the patient before car-dioversion, as permitted bymedical direction. Sedationmay be accomplished by admin-istering midazolam at 0.1 mg/kg (maximum individual dose:2.0 mg) or diazepam at 0.2 mg/kg (maximum individual dose:5.0 mg) via intravenous route.

B. Consider treatment with antiar-rhythmic medications, includ-ing:

� Amiodarone, 5 mg/kg intrave-nously over 20 to 60 minutes

� Procainamide, 15 mg/kg over 30to 60 minutes

� Lidocaine, 1 mg/kg intravenousbolus

21. For probable ventricular tachycar-

dia with a pulse and adequate

perfusion, the following steps

should be taken:

A. Consider treatment with antiar-rhythmic medications, includ-ing:

� Amiodarone, 5 mg/kg intrave-nously over 20 to 60 minutes

� Procainamide, 15 mg/kg over 30to 60 minutes

� Lidocaine, 1 mg/kg intravenousbolus

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B. Perform synchronized car-dioversion at 0.5 to 1.0 J/kg. Ifthe patient remains in ventricu-lar tachycardia with a pulse, re-peat cardioversion at doublethe energy (maximum: 360 J).Sedate the patient before car-dioversion, as permitted bymedical direction. Sedation maybe accomplished by administer-ing midazolam at 0.1 mg/kg(maximum individual dose: 2.0mg) or diazepam at 0.2 mg/kg(maximum individual dose: 5.0mg) via intravenous route.

22. Assess mental status.23. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

24. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

25. Reassess the patient frequently.26. Contact direct medical oversight

for additional instructions.

Nontraumatic CardiacArrest

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Confirm apnea, and provide assis-ted ventilation using a bag-valve-mask device with high-flow, 100%concentration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

7. Confirm absent pulse, and beginchest compressions at age-appro-priate rate and ratio.

8. Initiate cardiac monitoring and de-termine rhythm. This can be ac-complished with either a manualdefibrillator or an automated exter-nal defibrillator (AED).

9. Refer to appropriate protocols forfurther management actions:

� Ventricular Fibrillation/PulselessVentricular Tachycardia for BasicLife Support Providers with anAutomated External Defibrillator(AED)

� Ventricular Fibrillation/PulselessVentricular Tachycardia

� Asystole or Pulseless ElectricalActivity

Ventricular Fibrillation/Pulseless VentricularTachycardia for Basic LifeSupport Providers with anAutomated ExternalDefibrillator (AED)

For children 8 years of age or older,a standard AED with adult energy settingsshould be used. For children younger than 8years of age, the preferred device is onedesigned for children younger than 8 yearsof age and approved by the Food and DrugAdministration for this indication. Ingeneral, devices approved for childrenyounger than 8 years of age have softwarethat can accurately detect ventricularfibrillation or ventricular tachycardia andemploy technology to reduce the energydelivered.For children younger than 8 years of age,

and when a device specifically designed andapproved for children younger than 8 yearsof ages is not available, one must recognizethat, although using a fixed-energy AED insome children may have the potential forharm, not treating ventricular fibrilla-tion has the potential for even greaterharm—death of the child. As such, de-fibrillation should not be withheld based onweight and size criteria alone, and a stan-dard AED delivering adult energy levelsshould be used if protocols and medicaloversight permit.

1. Turn on the AED.2. Apply the appropriate AED pads

to the child’s bare, dry chest. Peelone pad at a time off the backing,and, following the diagram, pressthe pad firmly to the child’s bareskin. Place one pad on the child’supper right chest and the other padon the child’s lower left side (apicaland sternal placement), ensuringthe pads do not touch each other.If the child’s chest is too small foruse of this location, then the pads

should be placed in an anterior andposterior position.

3. Plug in connector (if necessary).4. Tell everyone to stand clear.5. Let the AED analyze the heart

rhythm (or push the button marked‘‘analyze’’).

6. Deliver a shock by pushing theshock button if prompted by theAED. Let the AED reanalyzeand provide additional shock ifprompted by the AED. FollowAED prompts; recheck for signs ofcirculation, when indicated.

7. If no shock is indicated or afterthree shocks have been delivered,recheck for the presence of a pulse.

8. If pulse is still absent perform CPRfor 1 minute and then repeat steps4–7.

9. Check for presence and adequacyof ventilation.

10. If the patient is still apneic, con-tinue to provide assisted ventila-tion using a bag-valve-mask devicewith high-flow, 100% concentrationoxygen.

11. Initiate transport.12. Perform focused history and de-

tailed physical examination enroute to the hospital if the pa-tient’s status and management ofresources permit.

13. Reassess the patient frequently.

Ventricular Fibrillation orPulseless VentricularTachycardia

Throughout the following resuscitationsequence, check pulses and cardiac rhythmafter each sequence of shocks and drugadministration.

1. Perform steps 1–9 of the ‘‘Non-traumatic Cardiac Arrest’’ protocol.Confirm the presence of ventricularfibrillation (VF) or pulseless ven-tricular tachycardia (VT).

2. Defibrillate at 2.0 J/kg (maximum200 J).

3. Defibrillate at 4.0 J/kg (maximum360 J).

4. Defibrillate at 4.0 J/kg (maximum360 J).

5. Perform endotracheal intubation.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

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6. Obtain vascular access. If intrave-

nous access cannot be obtained,proceed with intraosseous access.

7. Using the most readily available

route, administer epinephrine1:1,000 solution at 0.1 mg/kg (max-

imum individual dose: 10 mg) viaendotracheal tube or 1:10,000 solu-

tion at 0.01 mg/kg (maximumindividual dose: 1.0 mg) via

intravenous or intraosseous route.Subsequent doses of epinephrine

should be administered every 3 to5 minutes for the remainder of

resuscitation. Consider higherdoses of epinephrine for the secondor subsequent doses.

8. Flush the medication port with 10to 20 mL of intravenous fluid after

each dose of intravenous medica-tion to aid entry of drugs into

central circulation.9. Defibrillate at 4.0 J/kg (maximum:

360 J) 30 to 60 seconds after each

medication bolus. From this point,the pattern should be compres-

sions, followed by medicationadministration and then an attempt

at defibrillation.10. Administer an antiarrhythmic

agent(s) from the following:

� Amiodarone, 5 mg/kg intrave-nous/intraosseous bolus

� Lidocaine, 1 mg/kg intrave-nous/intraosseous bolus

� Magnesium, 25–50 mg/kg intra-venous/intraosseous bolus fortorsade des pointes or hypomag-nesia (maximum dose: 2 grams)

11. Defibrillate at 4.0 J/kg (maximum:360 J), followed by compressions.

12. Continue compressions and repeatsteps 8–9.

13. If VF or pulseless VT recurs aftersuccessful defibrillation, repeat de-fibrillation using the last energylevel that restored perfusingrhythm.

14. Contact direct medical oversightfor additional instructions.

15. Initiate transport.16. Assess mental status.17. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

18. Perform focused history and de-tailed physical examination enroute to the hospital if the pa-

tient’s status and management ofresources permit.

19. Reassess the patient frequently.

Asystole and PulselessElectrical Activity

Potentially treatable causes of asystole andpulseless electrical activity include severehypoxemia, severe acidosis, severe hypo-volemia, tension pneumothorax, cardiactamponade, profound hypothermia, toxicingestion, severe bradycardia, and hyper-kalemia (renal failure).

Definition

Pulseless electrical activity (PEA) ap-pears upon cardiac monitoring as ab-sent pulses with organized QRScomplexes. The following dysrhythmiasmay present as PEA:

� electromechanical dissociation(EMD)

� pseudo-EMD� idioventricular rhythms� ventricular escape rhythms� bradyasystolic rhythms� postdefibrillation idioventricular

rhythms

1. Perform steps 1–9 as listed in the‘‘Nontraumatic Cardiac Arrest’’protocol. Confirm the presence ofasystole in two leads.

2. Perform endotracheal intubation.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

3. Obtain vascular access. If intrave-nous access cannot be obtained,proceed with intraosseous access.

4. Using the most readily availableroute, administer epinephrine1:1,000 solution at 0.1 mg/kg (max-imum individual dose: 10 mg) viaendotracheal tube or 1:10,000 solu-tion at 0.01 mg/kg (maximum in-dividual dose: 1.0 mg) viaintravenous or intraosseous route.

5. Repeat epinephrine every 3 to 5minutes. Consider higher doses ofepinephrine for second or subse-quent doses.

6. Flush the medication port with 10–20 mL of intravenous fluid aftereach dose of intravenous medica-tion to aid entry of drugs intocentral circulation.

7. Contact direct medical oversightfor additional instructions.

8. Initiate transport.9. Assess mental status.

10. Expose the child only as necessaryto perform further assessments.Maintain the child’s body temper-ature throughout the examination.

11. Perform focused history and de-tailed physical examination enroute to the hospital if the patient’sstatus and management of resour-ces permit.

12. Asystole that does not respond tothe above treatment sequence maybe considered refractory. It may beappropriate to discontinue resusci-tative efforts in refractory asystoleas permitted by medical direction.

13. Reassess the patient frequently.

Vascular Access ViaCentral Catheter

The following protocol is intended forpatients with a central catheter who requirevascular access as defined by other patientcare protocols and for whom peripheralaccess cannot be obtained. If there is anyquestion of the need to access these devices,contact direct medical oversight beforeaccessing a central catheter.

1. Observe standard precautions.2. If peripheral intravenous access

cannot be obtained, proceed withcentral access. Do not delay trans-port to obtain vascular access.

3. Ask parents or caregivers for sup-plies and assistance at attempt-ing central access.

4. Determine the type of central cath-eter present. This will usually beeither a tunneled catheter (Broviac),implanted catheter (Medicport), orperipherally inserted catheter(PICC).

5. Access the central catheter using thefollowing techniques.

Tunneled Catheter (Broviac)

A. Prepare the intended intrave-nous solution, tubing, and nec-essary syringes (empty 10-mLsyringe and 10-mL syringe filledwith normal saline).

B. Remove the cap on the end ofthe catheter. If there is more thanone lumen available (tunneledcatheters can come as single-,double-, or triple-lumen), choose

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the largest diameter lumen ba-sed on the markings; or, if thereare no markings, choose anylumen.

C. Clean the end of the selectedlumen with alcohol.

D. Attach an empty 10-mL syringe.E. Unclamp the selected lumen.F. Aspirate 3–5 mL of blood with

the syringe. If unable to aspirateblood, immediately reclamp theselected lumen; if another lumenis present, attempt to use itbeginning with step A. If clotsare present, immediately contactdirect medical oversight.

G. Reclamp the selected lumen.H. Attach the 10-mL syringe filled

with normal saline, and flushwith 3–5 mL of normal saline. Ifthe catheter does not easilyflush, reclamp the elected lu-men; if another lumen is present,attempt to use it beginning withstep A.

I. Attach the intravenous tubing,and unclamp the selected lu-men.

J. Observe for free flow of theintravenous fluid.

K. Adjust the flow rate.L. Tape the catheter and tubing in

place.

Implanted Catheter (Mediport)

A. Prepare the intended intra-venous solution, tubing,Habermann needle, and neces-sary syringes (empty 10-mL sy-ringe and 10-mL syringe filledwith normal saline).

B. B. Attach an empty 10-mL sy-ringe to the tubing at the endof the Habermann needle (inan emergency, if Habermannneedle is unavailable, use a stan-dard 20–21-gauge needle).

C. Identify the access site. It willusually be located in the chestand can be found with palpa-tion.

D. Clean the access site withBetadine.

E. Remove the Betadine with analcohol swab.

F. Hold the access point under theskin firmly between two fingers.

G. Insert a Habermann needle intothe access site until it is felt toenter the lumen. This will be

indicated by a lack of resistance.Avoid inserting too deep andstriking the base of the accesspoint.

H. Unclamp the tubing, and aspi-rate 3–5 mL of blood with thesyringe. If unable to aspirateblood, immediately reclamp thecatheter and do not use it fur-ther. If clots are present imme-diately, contact direct medicaloversight.

I. Reclamp the tubing.J. Attach the 10-mL syringe filled

with normal saline, and flushwith 3–5 mL of normal saline. Ifthe catheter does not easilyflush, reclamp catheter and donot use further.

K. Attach the intravenous tubing,and unclamp the tubing.

L. Observe for free flow of theintravenous fluid.

M. Adjust the flow rate.N. Secure the needle in place.

Peripherally Inserted CentralCatheter (PICC)

A. Prepare the intended intrave-nous solution, tubing, and nec-essary syringes (empty 10-mLsyringe and 10-mL syringe filledwith normal saline).

B. Remove the cap on the end ofthe catheter. If there is more thanone lumen available (PICCs cancome as single-, double-, or tri-ple-lumen), choose the largestdiameter lumen based on themarkings; or, if there are nomarkings, choose any lumen.

C. Clean the end of one lumen withalcohol.

D. Attach an empty 10-mL syringe.E. Unclamp the selected lumen.F. Aspirate 3–5 mL of blood with

the syringe. If unable to aspirateblood, immediately reclamp thelumen; if another lumen is pres-ent, attempt to use it beginningwith step A. If clots are present,immediately contact direct med-ical oversight.

G. Reclamp the lumen.H. Attach the 10-mL syringe filled

with normal saline, and flushwith 3–5 mL of normal saline. Ifthe catheter does not easilyflush, reclamp the selected lu-men; if another lumen is present,

attempt to use it beginning withstep A.

I. Attach the intravenous tubing,and unclamp the selected lu-men.

J. Observe for free flow of theintravenous fluid.

K. Adjust the flow rate.L. Tape the tubing in place.

6. If shock is not present, allow thefluid to run at a rate of 10 mL/hourto prevent the central catheter fromclotting.

Altered Mental Status

This protocol is intended for patients withan altered mental status of unknownetiology.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess breathing. Obtain a pulseoximeter reading.

11. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

12. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-

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tion of pharmacologic adjuncts,such as lidocaine, sedatives, andparalytic agents, to aid with in-tubation, as permitted by medicaldirection. Confirm placement ofendotracheal tube using clinicalassessment and end-tidal carbondioxide (CO2) monitoring.

13. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. If signs of respiratory distress, re-spiratory failure, or respiratoryarrest are present, refer to theappropriate protocol for treatmentoptions.

15. Assess circulation and perfusion.16. Initiate cardiac monitoring.17. Obtain vascular access. If intrave-

nous access cannot be obtained,proceed with intraosseous access.

18. Determine blood glucose level.19. If blood glucose level is lower than

80 mg/dL or cannot be deter-mined, administer dextrose via in-travenous or intraosseous route asfollows:

� D50W at 1.0 mL/kg for childrenolder than 2 years

� D25W at 2.0 mL/kg for childrenyounger than 2 years

� D10W at 5.0 mL/kg for neonates

If vascular access is unavailable, admin-ister 1.0 mg of glucagon via intramus-cular injection.

20. Repeat blood glucose determina-tion 1 to 2 minutes after dextrose isadministered.

21. Dextrose may be repeated once atthe same dosage if the bloodglucose level remains lower than80 mg/dL or if the blood glucoselevel cannot be determined andthere is no change in the patient’smental status after the initial dose.

22. Administer naloxone at 0.1 mg/kg(maximum individual dose: 2.0mg) via intravenous or intraoss-eous route. Naloxone may be givenvia endotracheal tube or intramus-cular injection at the same dose ifvascular access is not available.

23. If there is evidence of shock ora history of dehydration, adminis-ter a fluid bolus of normal saline at20 mL/kg set to maximum flow

rate (at a minimum, 20 minutes).Reassess the patient after the bolus.If signs of shock persist, the bolusmay be repeated at the same doseup to two times for a maximumtotal of 60 mL/kg.

24. Assess mental status.25. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

26. If the child’s condition is critical orunstable, initiate transport. Performfocused history and detailed phys-ical examination en route to thehospital if the patient’s status andmanagement of resources permit.

27. If the child’s condition is stable,perform focused history and de-tailed physical examination on thescene, and then initiate transport.

28. Consider causes of altered mentalstatus, such as chemical or drugintoxication, toxic exposure, headtrauma, or seizure.

29. Reassess the patient frequently.30. Contact direct medical oversight

for additional instructions.

Seizures

This protocol is intended for patients whoare experiencing status epilepticus. Tomanage seizures in patients who are notexperiencing status epilepticus, contact di-rect medical oversight for instructions.

Definition

In status epilepticus, the patient will beexperiencing an active seizure whenrescuers arrive, with:

� a single episode of seizure activitylasting longer than 5 minutes or

� two or more episodes of seizureactivity between which the patientdoes not regain consciousness

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness.

Protect the patient from injuryduring the involuntary muscularmovements.

6. Assess the patient’s airway for

patency, protective reflexes, andthe possible need for advanced

airway management. Look for

signs of airway obstruction.7. Open the airway using head tilt/

chin lift if no spinal trauma is

suspected, or modified jaw thrust

if spinal trauma is suspected.8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintained

with positioning and the patient is

unconscious.10. Assess breathing. Obtain a pulse

oximeter reading.11. If breathing is inadequate, assist

ventilation using a bag-valve-mask

device with high-flow, 100% con-

centration oxygen. If abdominaldistention arises, consider placing

a nasogastric tube to decompressthe stomach.

12. If the airway cannot be maintainedby other means, including attempts

at assisted ventilation, or if pro-

longed assisted ventilation is antic-ipated, perform endotracheal

intubation. Consider administra-tion of pharmacologic adjuncts,

such as sedatives and paralytic

agents, to aid with intubation aspermitted by medical direction.

The actively seizing patient shouldnot be intubated without the usage

of pharmacologic agents. Confirm

placement of endotracheal tubeusing clinical assessment and

end-tidal carbon dioxide (CO2)monitoring.

13. If breathing is adequate, place thechild in a position of comfort and

administer high-flow, 100% concen-tration oxygen as necessary. Use

a nonrebreather mask or blow-by

as tolerated.14. Assess circulation and perfusion.15. Initiate cardiac monitoring.16. Establish vascular access. Adminis-

ter normal saline at a sufficient rate

to keep the vein open.17. Determine blood glucose level.18. If blood glucose level is lower than

80 mg/dL or cannot be deter-

mined, administer intravenous dex-trose as follows:

� D50W at 1.0 mL/kg for childrenolder than 2 years

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� D25W at 2.0 mL/kg for childrenyounger than 2 years

� D10W at 5.0 mL/kg for neonates

If vascular access is unavailable, admin-ister 1.0 mg glucagon via intramuscularinjection.

19. Repeat blood glucose determina-

tion 1 to 2 minutes after dextrose is

administered.20. Dextrose may be repeated once at

the same dosage if the blood

glucose level remains lower than

80 mg/dL or if the blood glucose

level cannot be determined and the

patient is still in status epilepticus

after the initial dose.21. Administer an anticonvulsant(s),

as chosen by medical direction;

all intravenous anticonvulsants

should be given slowly (over 1 to

2 minutes) to avoid apnea.

� Diazepam 0.1–0.2 mg/kg (maxi-mum individual dose: 10 mg) viaintravenous route or 0.5 mg/kg(maximum individual dose: 10mg) via rectal route

� Lorazepam, 0.1 mg/kg (maxi-mum individual dose: 5.0 mg)via intravenous or intramuscularroute

� Midazolam, 0.1–0.15 mg/kg(maximum individual dose: 5.0mg) via intravenous or intramus-cular route

� Fosphenytoin, 20 phenytoinequivalents/kg (maximum indi-vidual dose: 1,000 phenytoinequivalents) via intravenous orintramuscular route

22. If seizures persist, repeat any listed

anticonvulsant except fosphenytoin

at the same dose, or contact direct

medical oversight for further

instructions.23. Assess mental status.24. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-

ature throughout the examination.25. If the child’s condition is critical or

unstable, initiate transport. Perform

focused history and detailed phys-

ical examination en route to the

hospital if the patient’s status and

management of resources permit.26. If the child’s condition is stable,

perform focused history and de-

tailed physical examination on thescene, and then initiate transport.

27. Reassess the patient frequently.28. Contact direct medical oversight

for additional instructions.

NontraumaticHypoperfusion (Shock)

Definition

Shock may be categorized as hy-povolemic, distributive, obstructive, orcardiogenic. Manifestations of shockinclude:

� altered mental status� tachypnea� tachycardia� absent peripheral pulses� cool, clammy, mottled skin� capillary refill time longer than 2

seconds� hypotension and/or bradycardia

(late findings)

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess breathing. Obtain a pulseoximeter reading.

11. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placing

a nasogastric tube to decompressthe stomach.

12. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

13. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

14. Assess circulation and perfusion.15. Initiate cardiac monitoring.16. Establish vascular access using an

age-appropriate large-bore catheterwith large-caliber tubing. If intra-venous access cannot be obtained,proceed with intraosseous access.Do not delay transport to obtainvascular access.

17. If there is still evidence of shock,administer a fluid bolus of normalsaline at 20 mL/kg set to maximumflow rate (at a minimum, 20minutes). Reassess the patient afterthe bolus. If signs of shock persist,the bolus may be repeated at thesame dose up to two times fora maximum total of 60 mL/kg.

18. Assess mental status.19. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

20. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

21. Reassess the patient frequently.22. Contact direct medical oversight

for additional instructions.

Anaphylactic Shock/Allergic Reaction

The following protocol is intended forpatients with allergic reaction or anaphy-lactic shock. For patients with generalized

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allergic manifestations that do not meet thecriteria listed below, contact direct medicaloversight before treatment.

Definitions

The patient with an allergic reactionwill have:

� generalized allergic manifestations,such as urticaria (hives)

� a history of allergic exposure

To meet the criteria for anaphylacticshock, the patient must have thefindings listed above plus one of thefollowing:

� partial or complete airway obstruc-tion

� signs of shock, such as altered mentalstatus, respiratory distress, weak orabsent peripheral pulses, and/orcyanosis

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions and

mechanism of illness or injury.3. Form a first impression of the

patient’s condition.4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,

manually stabilize the spine.6. Assess the patient’s airway for

patency, protective reflexes, and

the possible need for advanced

airway management. Look for

signs of airway obstruction.7. Open the airway using head tilt/

chin lift if no spinal trauma is

suspected, or modified jaw thrust

if spinal trauma is possible.8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunct

if the airway cannot be maintained

with positioning and the patient is

unconscious.10. If the patient meets criteria for

anaphylactic shock, administer epi-

nephrine, a 1:1,000 solution at 0.0l

mg/kg (maximum individual dose:

0.3 mg), via subcutaneous injection;

or epinephrine, a 1:10,000 solution

at 0.5 mg/kg (maximum individual

dose: 25 mg), via intravenous or

intraosseous route.

11. Assess breathing. Obtain a pulseoximeter reading.

12. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

13. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

14. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

15. If bronchospasm is present in a pa-tient with adequate ventilation,administer one of the followinginhaled beta-2-agonist bronchodila-tors:

� Albuterol, 2.5 mg, via nebulizerover a 10- to 15-minute period or4 puffs via metered-dose inhaler(MDI) with spacing device

� Levalbuterol, 0.625–1.25 mg, vianebulizer over a 10- to 15-minuteperiod

16. Assess circulation and perfusion.17. Reassess patient for signs of ana-

phylactic shock. If criteria are stillpresent, repeat the epinephrine,a 1:1,000 solution at 0.0l mg/kg(maximum individual dose 0.3mg), via subcutaneous injection; orepinephrine, a 1:10,000 solution at0.5 mg/kg (maximum individualdose of 25 mg), via intravenous orintraosseous route.

18. Initiate cardiac monitoring.19. If the patient meets criteria for

anaphylactic shock, and intrave-nous or intraosseous access hadnot yet been obtained, establishvascular access using an age-appropriate large-bore catheter

with large-caliber tubing. If intra-

venous access cannot be obtained,

proceed with intraosseous access.

Do not delay transport to obtain

vascular access.20. If evidence of shock persists, ad-

minister a fluid bolus of normal

saline at 20 mL/kg set to maximum

flow rate (at a minimum, 20 mi-

nutes). Reassess the patient after

the bolus. If signs of shock persist,

the bolus may be repeated at the

same dose up to two times for

a maximum total of 60 mL/kg.21. Administer diphenhydramine at

1.0 mg/kg (maximum individual

dose 50 mg) via intravenous route

or deep intramuscular injection.22. Consider administering steroids

(such as methylprednisolone at 2.0

mg/kg) via intravenous route, as

permitted by medical direction.23. Assess mental status.24. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-

ature throughout the examination.25. If the child’s condition is critical or

unstable, initiate transport. Perform

focused history and detailed phys-

ical examination en route to the

hospital if the patient’s status and

management of resources permit.26. If the child’s condition is stable,

perform focused history and de-

tailed physical examination on the

scene, and then initiate transport.27. Reassess the patient frequently.28. Contact direct medical oversight

for additional instructions.

Anaphylactic Shock Treatedwith Auto-injector Device

The following protocol is intended forpatients in anaphylactic shock andproviders whose only epinephrine route isas an auto-injector. For other instances ofpatients with generalized allergic man-ifestations or anaphylaxis, refer to the‘‘Anaphylactic Shock/Allergic Reaction’’protocol.

Definitions

The patient with anaphylactic shockwill have evidence of an allergic re-action including

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� generalized allergic manifestations,such as urticaria (hives)

� a history of allergic exposure

And evidence of airway or circulatorycompromise as evidenced by

� partial or complete airway obstruc-tion

� signs of shock, such as altered mentalstatus, respiratory distress, weak orabsent peripheral pulses, and/orcyanosis

Procedure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is possible.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. If patient meets criteria for anaphy-lactic shock, administer epineph-rine via auto-injector device.Massage the injection site vigor-ously for 30 to 60 seconds. Use a 0.3-mg auto-injector for children over30 kg, and a 0.15-mg auto-injectorfor children less than 30 kg.

11. Assess breathing. Obtain a pulseoximeter reading.

12. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

13. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-

longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon-dioxide (CO2)monitoring.

14. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

15. Assess circulation and perfusion.16. Reassess patient for signs of ana-

phylactic shock. If criteria are stillpresent, repeat the autoinjector atthe same dosage.

17. Assess mental status.18. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

19. If the child’s condition is critical orunstable, initiate transport. Performfocused history and detailed phys-ical examination en route to thehospital if the patient’s status andmanagement of resources permit.

20. If the child’s condition is stable,perform focused history and de-tailed physical examination on thescene, and then initiate transport.

21. Reassess the patient frequently.22. Contact direct medical oversight

for additional instructions.

Trauma

The priorities in pediatric trauma manage-ment are to prevent further injury, providerapid transport, notify the receiving facility,and initiate definitive treatment. On-scenetime for a traumatic injury should be nolonger than 10 minutes unless there areextenuating circumstances, such as extri-cation, hazardous conditions, or multiplevictims. Document these circumstances onthe patient record. Inform the receivinghospital as early as possible about thepatient’s status and condition. This willallow hospital personnel extra time tomobilize resources.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions and

mechanism of injury. If hazardousconditions are present (such asswift water, hazardous materials,electrical hazard, or confinedspace), contact an appropriateagency before approaching the pa-tient. Wait for the designated spe-cialist to secure the scene andpatient as necessary.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness.

Manually stabilize the spine.6. Assess the patient’s airway for

patency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using a modifiedjaw thrust.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious. Note that the naso-pharyngeal airway is contraindi-cated in the presence of facialtrauma.

10. Evaluate breathing. Assess for sym-metry of chest expansion, equalbreath sounds, and adequate chestrise. Inspect the chest wall for signsof trauma. Obtain a pulse oximeterreading.

11. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach. If facial trauma ispresent or a basilar skull fractureis suspected, use an orogastric tubeinstead.

12. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, if respiratoryfailure is present, or if prolongedassisted ventilation is anticipated,perform a Sellick maneuver fol-lowed by endotracheal intubation.Consider administration of phar-macologic adjuncts, such as seda-tives and paralytic agents, to aidwith intubation, as permitted bymedical direction. Confirm place-ment of endotracheal tube usingclinical assessment and end-tidalcarbon dioxide (CO2) monitoring.

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13. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. If absent breath sounds or signs ofsevere respiratory distress arenoted together with a mechanismof injury that could cause a tensionpneumothorax, perform needledecompression. Use an 18- or 20-gauge over-the-needle catheter. In-sert the needle in the midclavicularline at the second intercostal space,just above the third rib (someprotocols provide for an alternativeinsertion location of fifth intercostalspace midaxillary line).

15. Control hemorrhage using directpressure or a pressure dressing.

16. Assess circulation and perfusion.17. Initiate cardiac monitoring.18. Assess mental status.19. Continue manual stabilization

while placing a rigid cervical collar.Immobilize the patient on a longbackboard or similar device.

20. Expose the child only as necessaryto perform further assessments.Maintain the child’s body temper-ature throughout the examination.

21. Initiate transport to an appropriatetrauma facility no more than 10minutes after arriving on the scene,unless extenuating circumstancesexist or medical direction directsotherwise.

22. Obtain vascular access using anage-appropriate large-bore catheterwith large-caliber tubing and ad-minister normal saline at a sufficientrate to keep the vein open. Ifextenuating circumstances delaytransport, obtain vascular accesson the scene, but do not delaytransport to obtain vascular access.

23. If there is evidence of shock, initiatevascular access in two sites. Ifintravenous access cannot be ob-tained, proceed with intraosseousaccess. Administer a fluid bolus ofnormal saline at 20 mL/kg set tomaximum flow rate (at a mini-mum, 20 minutes). Reassess thepatient after the bolus. If signs ofshock persist, the bolus may berepeated at the same dose up totwo times for a maximum total of60 mL/kg.

24. Splint obvious fractures of longbones.

25. Perform focused history and de-tailed physical examination enroute to the hospital if the pa-tient’s status and management ofresources permit.

26. Reassess the patient frequently.27. Contact direct medical oversight

for additional instructions.

Burns

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury. Ifhazardous conditions are present(such as swift water, hazardousmaterials, electrical hazard, or con-fined space), contact an appropriateagency before approaching the pa-tient. Wait for the designated spe-cialist to secure the scene andpatient as necessary.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Stop the burning process. If a dry

chemical is involved, brush it off,then flush with copious amountsof water. If a caustic liquid is in-volved, flush with copious amountsof water. Remove all of the patient’sclothing before irrigation. Be pre-pared to treat hypothermia, whichmay arise secondary to these inter-ventions. For chemical burns witheye involvement, immediately beginby flushing the eye with normalsaline.Continueflushing throughoutassessment and transport.

6. Establish patient responsiveness. Ifcervical spine trauma is suspected,manually stabilize the spine. Re-move the patient’s clothing andjewelry in any affected area.

7. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

8. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

9. Suction as necessary.10. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintained

with positioning and the patient isunconscious.

11. Assess breathing. Obtain a pulseoximeter reading. Refer to theappropriate protocol for manage-ment of respiratory distress.

12. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

13. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. This step should alsobe undertaken if inhalation injury issuspected. Consider administrationof pharmacologic adjuncts, such assedatives and paralytic agents, toaid with intubation as permitted bymedical direction. Confirm place-ment of endotracheal tube usingclinical assessment and end-tidalcarbon dioxide (CO2) monitoring.

14. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask for potentialinhalation injury or any seriousthermal burn.

15. Assess circulation and perfusion.16. For electrical burns, initiate cardiac

monitoring and determine rhythm.If a dysrhythmia is present, refer tothe appropriate protocol for treat-ment options.

17. If there is evidence of shock ina patient with major thermal burns,obtain vascular access using anage-appropriate large-bore catheterwith large-caliber tubing. If intra-venous access cannot be obtained,proceed with intraosseous access.Administer a fluid bolus of normalsaline at 20 mL/kg set to maximumflow rate. Reassess the patient afterthe bolus. If signs of shock persist,the bolus may be repeated at thesame dose up to two times fora maximum total of 60 mL/kg.

18. Assess mental status.19. If spinal trauma is suspected, con-

tinue manual stabilization, placea rigid cervical collar, and immobi-lize the patient on a long backboardor similar device.

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362 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2004 VOLUME 8 / NUMBER 4

20. Expose the child only as necessaryto perform further assessments.Maintain the child’s body temper-ature throughout the examination.

21. Apply a burn sheet or dry steriledressings to burned areas. To pre-vent hypothermia, avoid moist orcool dressings, and do not leavewounds or skin exposed.

22. Initiate transport. Perform focusedhistory and detailed physical ex-amination en route to the hospital ifthe patient’s status and manage-ment of resources permit.

23. Pain management is usually in-dicated. Refer to the ‘‘Pain Manage-ment’’ protocol for treatment options.

24. Reassess the patient frequently.25. Contact direct medical oversight

for additional instructions.

Toxic Exposure

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury. Ifhazardous conditions are present(such as swift water, hazardousmaterials, electrical hazard, or con-fined space), contact an appropriateagency before approaching the pa-tient. Wait for the designated spe-cialist to secure the scene andpatient as necessary.

3. Look for the source of the toxicexposure. Collect any containers ormedication bottles to transportwith the patient to the hospital.Consult a local poison controlcenter as appropriate.

4. Form a first impression of thepatient’s condition.

5. Observe standard precautions.6. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

7. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

8. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

9. Suction as necessary.10. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintained

with positioning and the patient isunconscious.

11. Assess breathing. Obtain a pulseoximeter reading.

12. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

13. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

14. If breathing is adequate, place thechild in a position of comfort andadminister high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-by,as tolerated.

15. Assess circulation and perfusion.16. Initiate cardiac monitoring.17. Obtain vascular access as indicated.18. If respiratory depression is present

and a narcotic overdose is sus-pected, administer naloxone at 0.1mg/kg (maximum individual dose:2.0 mg) via intravenous, intraoss-eous, or intramuscular route.

19. Treatment for other toxic exposuresmay be instituted as permitted bymedical direction, including thefollowing:

� High-dose atropine for organo-phosphates

� Sodium bicarbonate for tricyclicantidepressants

� Glucagon for calcium channelblockers or beta-blockers

� Diphenhydramine for dystonicreactions

� Dextrose for insulin overdose

Contact direct medical oversight forspecific information about individualtoxic exposures and treatments.

20. Assess mental status.21. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-ature throughout the examination.

22. If the child’s condition is critical orunstable, initiate transport. Performfocused history and detailed phys-ical examination en route to thehospital if the patient’s status andmanagement of resources permit.

23. If the child’s condition is stable,perform focused history and de-tailed physical examination on thescene, and then initiate transport.

24. Reassess the patient frequently.25. Contact direct medical oversight

for additional instructions.

Near-drowning

Hypothermia may offer some degree ofcerebral protection in a near-drowningincident, but it also increases cardiacirritability. Refractory dysrhythmias mayarise during assessment and treatment.Contact direct medical oversight as earlyas possible.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury. Ifhazardous conditions are present(such as swift water, hazardousmaterials, electrical hazard, or con-fined space), contact an appropriateagency before approaching thepatient. Wait for the designatedspecialist to secure the scene andpatient as necessary.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. Assess breathing. Obtain a pulseoximeter reading.

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363CSHCN: MODEL PEDIATRIC PROTOCOLS, 2003 REVISION

11. If breathing is inadequate, assist

ventilation using a bag-valve-mask

device with high-flow, 100% con-

centration oxygen. If abdominal

distention arises, consider placing

a nasogastric tube to decompress

the stomach.12. If the airway cannot be maintained

by other means, including attempts

at assisted ventilation, or if pro-

longed assisted ventilation is antic-

ipated, perform endotracheal

intubation. Consider administration

of pharmacologic adjuncts, such as

sedatives and paralytic agents, to

aid with intubation as permitted by

medical direction. Confirm place-

ment of endotracheal tube using

clinical assessment and end-tidal

carbon dioxide (CO2) monitoring.13. If breathing is adequate, place the

child in a position of comfort and

administer high-flow, 100% concen-

tration oxygen as necessary. Use

a nonrebreather mask or blow-by,

as tolerated.14. Assess circulation and perfusion.15. Initiate cardiac monitoring and

determine rhythm. Consult the

appropriate protocol for treatment

of specific dysrhythmias.16. Obtain vascular access. Administer

normal saline at a sufficient rate to

keep the vein open.17. Assess mental status.18. If spinal trauma is suspected, con-

tinue manual stabilization, apply

a rigid cervical collar, and immobi-

lize the patient on a long backboard

or similar device.19. Expose the child only as necessary

to perform further assessments.

Maintain the child’s body temper-

ature throughout the examination.20. If the child’s condition is critical or

unstable, initiate transport as

quickly as possible. Perform fo-

cused history and detailed physical

examination en route to the hospi-

tal if the patient’s status and man-

agement of resources permit.21. If the child’s condition is stable,

perform focused history and de-

tailed physical examination on the

scene, and then initiate transport.22. Reassess patient frequently.23. Contact direct medical oversight

for additional instructions.

Pain Management

This protocol is intended for patients whorequire pain management in addition toother clinical interventions. Pain medica-tion often causes sedation and affectsa patient’s mental status. As a result,analgesia should not be administered ina patient with head trauma.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness. If

cervical spine trauma is suspected,manually stabilize the spine.

6. Assess the patient’s airway forpatency, protective reflexes, andthe possible need for advancedairway management. Look forsigns of airway obstruction.

7. Open the airway using head tilt/chin lift if no spinal trauma issuspected, or modified jaw thrustif spinal trauma is suspected.

8. Suction as necessary.9. Consider placing an oropharyngeal

or nasopharyngeal airway adjunctif the airway cannot be maintainedwith positioning and the patient isunconscious.

10. If the airway cannot be maintainedby other means, including attemptsat assisted ventilation, or if pro-longed assisted ventilation is antic-ipated, perform endotrachealintubation. Consider administra-tion of pharmacologic adjuncts,such as sedatives and paralyticagents, to aid with intubation aspermitted by medical direction.Confirm placement of endotrachealtube using clinical assessment andend-tidal carbon dioxide (CO2)monitoring.

11. Assess breathing. Carefully noteadequacy of ventilation. Obtaina pulse oximeter reading.

12. If breathing is inadequate, assistventilation using a bag-valve-maskdevice with high-flow, 100% con-centration oxygen. If abdominaldistention arises, consider placinga nasogastric tube to decompressthe stomach.

13. If breathing is adequate, place thechild in a position of comfort and

administer high-flow, 100% concen-tration oxygen as necessary. Usea nonrebreather mask or blow-byas tolerated.

14. Assess circulation and perfusion.Obtain baseline blood pressure.

15. Obtain vascular access. Administernormal saline at a sufficient rate tokeep the vein open.

16. Assess mental status.17. Expose the child only as necessary

to perform further assessments.Maintain the child’s body temper-ature throughout the examination.

18. If the child’s condition is critical orunstable, initiate transport. Performfocused history and detailed phys-ical examination en route to thehospital if the patient’s status andmanagement of resources permit.

19. If the child’s condition is stable,perform focused history and de-tailed physical examination on thescene, and then initiate transport.

20. Assess the patient’s pain usinga numerical scale or visual analogscale as appropriate to the child’sabilities.

21. Administer an analgesic agent(s)from the following:

� Morphine, 0.1 mg/kg (maxi-mum individual dose: 10 mg),via intravenous or subcutaneousroute

� Fentanyl, 1.0 mg/kg (maximumindividual dose: 100 mg), viaintravenous route

� Ketoralac, 1.0 mg/kg (maximumindividual dose: 30 mg), via in-travenous route

� Nitrous oxide via inhalationsystem

22. After drug administration, reassessthe patient using the appropriatepain scale. Carefully note adequacyof ventilation and perfusion.

23. Reassess the patient frequently.24. Contact direct medical oversight

for further instructions.

Death of a Child

There is no normal parental reaction tothe death of a child. Individual responsesmay range from emotional outbursts toapparent withdrawal. Rescuers shouldnot make any assumptions or judg-ments. Maintain a professional demeanorat all times. Perform the initial assessment,

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364 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2004 VOLUME 8 / NUMBER 4

environmental assessment, and focusedhistory as part of the clinical process.Observe, assess, and document accuratelyand objectively.

1. Ensure scene safety.2. Perform a scene survey to assess

environmental conditions andmechanism of illness or injury.

3. Form a first impression of thepatient’s condition.

4. Observe standard precautions.5. Establish patient responsiveness.6. Assess airway and breathing. Con-

firm apnea.7. Assess circulation and perfusion.8. Initiate cardiac monitoring. Con-

firm absent pulse.9. Determine whether to perform fur-

ther resuscitation measures:

� If patient does not exhibit lividityor rigor, proceed with cardiopul-monary resuscitation as permit-ted by medical direct ion,following the ‘‘NontraumaticCardiac Arrest’’ protocol. Duringresuscitation, perform steps 11and 12 below. Initiate transport.

� If patient exhibits lividity andrigor, do not resuscitate, as per-mitted by medical direction.Proceed with step 10.Note: Livid-ity can be mistaken for bruisingand evidence of abuse. Do notmake any assumptions or judgments.

10. Provide supportive measures forparents and siblings:

� Explain the resuscitation process,transport decision, and furtheractions to be taken by hos-pital personnel or the medicalexaminer.

� Reassure parents that there wasnothing they could have done toprevent death.

� Allow the parents to see the childand say goodbye.

� Maintain a supportive, profes-sional attitude, no matter howthe parents react.

� Whenever possible, be responsiveto parental requests. Be sensitiveto ethnic and religious needs orresponses, and make allowancesfor them.

11. Obtain patient history using a non-judgmental approach. Ask open-ended questions as follows:

� Has the child been sick?� Canyoudescribewhat happened?� Who found the child? Where?� What actions were taken after

the child was discovered?� Has the child been moved?� When was the child last seen

before this occurred, and bywhom?

� How did the child seem whenlast seen?

� When was the last feeding pro-vided?

12. Reassess the environment. Docu-ment findings, noting the following:

� Where the child was locatedupon arrival

� Description of objects locatednear the child upon arrival

� Unusual environmental condi-tions, such as a high temperaturein the room, abnormal odors, orother significant findings

13. If the parents interfere with treat-ment or attempt to alter the scene,initiate the following actions:

� Remain supportive, sympathetic,and professional.

� Avoid arguing with the parentsor exhibiting anger.

� Do not restrain the parents orrequest that they be restrainedunless scene safety is clearlythreatened.

14. Document the emergency call, in-cluding the following information:

� Time of arrival� Initial assessment findings and

basis for resuscitation decision� Time of resuscitation decision� Time of arrival at hospital if

resuscitation and transport wereinitiated

� Parental support measures pro-vided if resuscitation was notinitiated

� History obtained (note who pro-vided the information)

� Environmental conditions� Time law enforcement personnel

arrived on scene� Time that scene responsibility

was turned over to law enforce-ment personnel

The committee acknowledges the work ofDr. David Markenson in coordinating therevision process of these protocols.

It is important to note the significant effort,time, insight, and knowledge brought to theoriginal protocol process by the project direc-tors of the original purchase order, DeborahMulligan Smith, MD, and Robert O’Connor,MD.Without their foresight and tireless effort,this process would never have begun.

The authors particularly thank Jean Athey,PhD, whose vision, insight, and dedicationhelped to initiate this effort and guide itthrough its development and completion.They also thank Dan Kavanaugh, whoseconstant support and insight were instru-mental to the continuation of this project. Inaddition, they thank the members of theEMSC National Resource Center for theirguidance, review, and support. They thankDr. Jane Ball, who provided general guid-ance and assistance throughout the originalproject; Renee Barrett, PhD, who assistedwith the protocol review process, directedthe contract, and managed administrativeaspects for the first edition; and RobertWaddell, who spent many hours evaluatingthese protocols and providing additionaldirection. At NAEMSP, a great deal ofinvaluable support was offered by leader-ship members of the organization, particu-larly past presidents Robert A. Swor, DO,Jon R. Krohmer, MD, and Richard Hunt,MD, and current president Robert Bass, MD.In addition, the authors acknowledge theefforts of Jeff Andrews, EMT-P, who spentseveral tireless days helping to collect,collate, and review over 300 representativeprotocols used as part of the initial docu-ment development process.

The authors recognize the detailed evalu-ations and comments provided by membersof the review panel appointed as liaisonsfrom the national EMS and medical pro-fessional organizations. Their commentsrepresent the opinions of individual re-viewers on behalf of their organizationsbut do not necessarily constitute organiza-tional approval of protocol content. Reviewpanel members, preceded by the organiza-tions they represent, are as follows: Amer-ican Academy of Family Physicians,Douglas Long, MD; American Academy ofPediatrics, Joseph Wright, MD, MPH; Amer-ican Ambulance Association, Karen Old-ham, MD; American College of EmergencyPhysicians, Craig Warden, MD, MPH;American College of Osteopathic Emer-gency Physicians, Gregory Frailey, DO;American College of Surgeons, Arthur Coo-per, MD; Emergency Nurses Association,Sherri-Lynn Almeida, DrPH, RN; Interna-tional Association of Fire Chiefs, MarkThorp, RN, CEN, EMT-P; National Associ-ation of EMTs, Tommy Loyacono, EMT-P;National Association of State EMS Directors,Mark King; National Council of State EMS

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365CSHCN: MODEL PEDIATRIC PROTOCOLS, 2003 REVISION

Training Coordinators, Alonzo Smith; Soci-ety for Academic Emergency Medicine, EricGlasser, MD; Joint Review Committee onEducational Programs for the EMT-Para-medic, Peter Glaeser, MD; National Registryof EMTs, Charles O’Neal; National PediatricTrauma Registry, Carla DiScala, PhD; EMSCNational Resource Center, Renee Barrett,PhD; and HRSA MCHB EMSC Program,Jean Athey, PhD.

The authors also thank the state andterritorial EMS directors, all of whomprovided their expert review of the initialdraft protocols. They appreciate the effortsof every individual and extend a specialacknowledgment to the following persons,who returned detailed analyses and in-sightful comments on behalf of their states:Alaska, Matt Anderson and Doreen Risley;California, Richard Watson (EMSC AdvisoryCommittee); Connecticut, Philip Stent, MD,and Cheryl Mayeran, MPH; Illinois, Leslee

Stein-Spencer; Kentucky, Mary Fallat, MD;Louisiana, Nancy Bourgeois and MaryStewart, RN (EMSC Committee); Maryland,Joseph Wright, MD, MPH; New Jersey,Gerard Muench; New Mexico, KeithMausner, MD, Robert Sapien, MD,and Jim Flaherty, MD (Navaho NationEMS); New York, Richard Hunt, MD;Rhode Island, Peter Leary and KenethWilliams, MD; Washington, Janet Griffith;and West Virginia, Mark King and LeePyles, MD.The authors acknowledge the contribu-

tions of several individuals who reviewedthe protocols on behalf of their organiza-tions: American Academy of Pediatrics NRPSteering Committee, Susan Niermeyer, MD,and John Kattwinkel, MD; Center forPediatric Emergency Medicine, George Fol-tin, MD, and Michael Tunik, MD; andNational Association of EMS Physicians,Dave Cone, MD, Richard Hunt, MD, Jon

Krohmer, MD, Robert Swor, DO, and BrianZachariah, MD.

In addition, the authors thank the follow-ing individuals who took the time to reviewthe protocols on their own recognizance andprovided us with their comments: MarianneGausche, MD, Arthur Hsieh, EMT-P, andAndrew Stern, EMT-P.

The authors also acknowledge John To-daro, REMT-P, RN, the Florida Associationof EMS Educators, and the Florida SIDSAlliance for providing the committee withthe SIDS protocol that served as the basisfor the creation of the original Death ofa Child and SIDS protocol included in thisdocument.

Finally, the authors acknowledge theexceptional assistance of their copyeditor,Tamia Karpeles, whose skill created the well-structured, uniform, and well-written firstset of protocols that served as the templatefor the revised protocols.