region iv standard operating guidelines (sogs...

REGION IV STANDARD OPERATING GUIDELINES (SOGs)

Implemented: 8/25/2003

Revised: 4/05, 7/07

1

INSTRUCTIONS FOR USE OF STANDARD OPERATING GUIDELINES

The SOGs have been designed as patient care directives for Region IV prehospital care

providers.

Unstable patients or those receiving medications must have vital signs obtained and

documented every 5 minutes.

Intubation attempts should be limited to two attempts per intermediate, paramedic or

PHRN, per patient. If unsuccessful, insert oropharyngeal airway and ventilate via bag-

valve-mask. Laryngeal Mask Airway may also be inserted by trained individuals.

Following Endotracheal Intubation, tube placement should be verified by visualization of

cord passage and auscultation: End-tidal CO2 detectors, tube check detectors, or pulse

oximetry may be used as placement adjuncts and are to be documented as such.

MEDICATION THAT MAY BE ADMINISTERED VIA THE ENDOTRACHEAL

TUBE:

Narcan (Naloxone) Atropine

Epinephrine (Adrenalin)

On scene time greater than 20 minutes medical and 10 minutes trauma requires

documentation indicating why the scene time was extended.

Any medications given IV should be inserted into the tubing port closest to the needle

insertion site. Immediately following medication administration, a saline flush of 5-10ml

should be given.

IV fluids will be at keep open (TKO) rate or 30ml/hr, for adults 20 ml/hr for pediatrics,

unless condition indicates a need for higher flow rates or a saline lock may be utilized on

stable patients.

Treatment guidelines associated with medications and their administration are derived

from recommendations by: ACLS, ITLS, PALS, PEPP, and AHA.

If the SOGs are utilized, you must document on your Medical Records as to what

procedures/treatments were carried out utilizing SOGs.

PEDIATRICS: Parents/Primary caregivers should be included in all aspects of the

pediatric patient’s care.

Note: Biphasic defibrillation protocols may vary depending on the specific biphasic

waveform employed. The specific device may vary from service to service.

Providers need to base their defibrillation energy levels on the recommended

manufacturer’s guidelines appropriate for the type of device and for the type of

waveform used in the delivery of care.

Note: A prolonged extrication alone is not reason to call specialty transport. Serious

injury must accompany prolonged extrication.


Implemented/Revised: 8/25/2003

Revised: 4/05, 10/07, 3/08

2

APPROVED MEDICATION LIST

Medications

ALS BLS/ILS

Adenosine 6mg/ml (2ml) Aspirin 81mg chewable tablets

Amiodarone 150mg Epi Pen Auto Injector Adult 0.3mg

Aspirin 81mg chewable tablets Epi Pen Auto Injector Pedi 0.15mg

Atropine 1mg/10ml Oral Glucose 15grams

Calcium Chloride 10% in 10ml

Decadron 10mg IV

Dextrose 50%

Diazepam (Valium) 10mg/2ml IV’s

Diphenhydramine (Benadryl) 50mg Isotonic Solutions

Epinephrine 1:1,000 1mg/ml Dopamine 400mg/250ml

Epinephrine 1:10,000 1mg/10ml

Etomidate 20mg vial 2mg/ml

Furosemide (Lasix) 40mg & 100mg

Glucagon 1mg

Magnesium Sulfate 1-2grams Additional Transfer Medications

Morphine Sulfate (MSO4) 4mg or 10mg/ml Not to be titrated

Naloxone (Narcan) 2mg/ml Amiodarone Drip

Nitroglycerine Tablets 0.4mg Aggrastat pre mix

Nitroglycerine paste 1inch pre-packaged Antibiotics

Normal Saline flush Aminophylline premix

Oral Glucose 15grams Blood/Blood Products

Sodium Bicarbonate 50mEq/50ml Cardizem

Solu-Medrol 125mg/2ml Dobatamine

Thiamine 100mg/2ml Heparin Drip

Toradol 30mg Integrilin, ReoPro

Vasopressin 40 Units Lidocaine Drip 2gm/500ml

Versed 5mg or 10mg/2ml Magnesium Sulfate Drip

Zofran (Ondansetron) 4mg & 8mg Tabs Nitroglycerine drip (Tridil)

Zofran (Ondansetron) 4mg/2ml Potassium Chloride

Inhalants

Albuterol (Proventil, Ventolin)

Unit dose 2.5mg in 3ml



Revised: 4/05, 10/07, 3/08

3

PATIENT HISTORY

1. Age and gender

2. Chief Complaint

3. Obtain pulse oximetry (Capnography if available), on any patient at risk

for having or developing hypoxemia.

4. Rapid glucose determination should be obtained on any patient whose

condition is suspect of altered glucose levels and on any unstable or

injured infant or child with cardiorespiratory instability.

5. Any observations that are pertinent physically or environmentally

6. Assess patients pain level according to:

a. Onset

b. Provocation/preceding

c. Quality

d. Radiation

e. Symptoms

f. Time

7. Document all information on patient record.

Special Considerations:

Consider causes:

A Alcohol, abuse T Trauma, temperature

E Epilepsy, electrolytes, encephalopathy I Infection, intussusception, inborn

I Insulin errors

O Opiates, overdose P Psychogenic

U Uremia P Poison

S Shock, seizures, stroke,

occupying lesion, subarachnoid

hemorrhage, shunt



Revised: 4/05, 10/07, 3/08

4

PATIENT ASSESSMENT

Adult / Pediatric

BLS/ILS/ALS

GENERAL PATIENT ASSESSMENT:

1. Assess and assure scene safety.

2. BSI (Body Substance Isolation) precautions on all patients.

Adult Initial Assessment

3. a. Airway – establish and maintain an airway. Utilize cervical spine

precautions when indicated.

b. Breathing – provide or assist ventilations as indicated.

c. Circulation – check pulse and control hemorrhage as indicated.

d. Disability – neurologic exam.

1. A Alert

2. V responds to Verbal stimuli

3. P responds to Painful stimuli

4. U Unresponsive

e. Expose and examine as indicated.

f. Identify priority transports.

4. Focused History and Physical Exam

a. Systematic head-to-toe assessment including GLASGOW COMA SCALE

b. Allergies

c. Medications

d. Pertinent medical history

e. Last oral intake, Last menstrual period

f. Events leading to present condition

g. Initial set of Vital Signs

h. Rate pain 0-10 scale

5. Detailed Physical Exam (patient and injury specific when appropriate)

6. Ongoing Assessment

a. Reassess ABCD’s



Revised: 4/05, 10/07, 3/08

5

PATIENT ASSESSMENT (cont.)

Pediatric Initial Assessment

3. A. Airway Maintenance/Spinal Motion Restriction

1. Maintain patent airway

• head tilt-chin lift / or modified jaw thrust

• oral or nasal airway / or intubation

• suction / minimize risk of aspiration

2. Spinal Motion Restriction

• manual stabilization and full spinal motion restriction on

backboard or in car seat (if significant injury suspected, package

and immobilize on board).

B. Breathing

1. Observe for adequate breathing after airway is established

• rate, rhythm and effort of respirations

• chest expansion

• breath sounds

• positioning of body

2. Assist ventilations by

• mouth-to-mouth, mouth-to-nose breathing

• BVM and/or intubation if indicated

• translaryngeal jet ventilations age specific

3. Oxygen therapy

• nasal cannula or blow by

• non-rebreather mask

C. Circulation

1. Adequacy of circulation assessed by noting:

• heart rate, including quality of peripheral and central

pulses

• capillary refill and hydration status

• skin temperature and color

• blood pressure; use appropriate cuff size

2. Circulatory support

• control hemorrhage

• IV or IO fluid at 20ml/kg LACTATED RINGERS bolus

D. Disability

1. Brief Neuro exam including:

• assessment of mental status using AVPU and pupil assessment

E. Exposure

1. Expose patient as appropriate and prevent heat loss

F. Pain Assessment (0-10 Scale or Wong-Baker Faces Scale pg. 6)

Refer to Pain Protocol SOG (See pg. 11-12) for pain intervention.



Revised: 4/05, 10/07, 3/08

6

WONG BAKER’S FACES SCALE (PAIN SCALE)

A golden rule to follow in pain assessment

is:

Whatever is painful to an adult is painful to

an infant or child until proved otherwise.



Revised: 4/05, 10/07, 3/08

7

CONSIDERATION FOR CHILDREN WITH SPECIAL

HEALTHCARE NEEDS (CSHN)

Providers should be aware that within your community children with special

needs exist.

Refer to child’s emergency care plan formulated by their medical providers, if

available. Understanding the child’s baseline will assist in determining the

significance of altered physical findings. Parents or caregivers are the best source

of information regarding: medications, baseline vitals, functional level and

normal mentation, medical history, equipment operation, troubleshooting, and

emergency procedures.

Regardless of underlying conditions, assess in a systematic and thorough manner.

Use parents, caregivers, and home health nurses as medical resources.

Be prepared for differences in airway anatomy, physical development, cognitive

development, and possible existing surgical alterations or mechanical adjuncts.

Common home therapies include: respiratory support (oxygen, apnea monitors,

pulse oximeters, tracheostomies, mechanical ventilators), nutrition therapy

(nasogastric or gastrostomy feeding tubes), intravenous therapy (central venous

catheters), urinary catheterization or dialysis (continuous ambulatory peritoneal

dialysis), biotelemetry, ostomy care, orthotic devices, communication of mobility

devices, or hospice care.

Communicate with the child in an age appropriate manner. Maintain

communication with and remain sensitive to the parents/caregivers and the child.

The most common emergency encountered with these patients is respiratory

related and so familiarity with respiratory emergency interventions, adjuncts, and

treatment is to be considered.



Revised: 4/05, 10/07, 3/08

8

INITIAL MEDICAL CARE

Adult / Pediatric

BLS

1. Maintain patent airway via a head tilt/chin lift or modified jaw thrust.

2. Utilize oral or nasal airway as necessary.

3. Place on side (vomiting precautions) unless contraindicated.

4. Suction to minimize risk of aspiration.

5. Loosen tight clothing and reassure patient

6. Place patient in semi-Fowler’s position or position of comfort unless

contraindicated e.g. decreased blood pressure.

7. Adult: OXYGEN 4-6 LPM nasal cannula. Pediatric: Use blow-by oxygen.

If unstable, increase oxygen to 100% If patient symptomatic,

non-rebreather mask or assist with BVM increase oxygen to

. 100% non-rebreather mask or

assist with BVM.

8. Monitor oxygen saturation per pulse oximetry if available.

9. Pain management should be considered in the care of all patients. Ask patient to

rate their pain on a scale of 1-10 or use Wong Bakers Scale (See pg. 6).

10. If patient encountered with continuous infusion devices or home medication

devices an ALS unit is to be utilized and Medical Control will be contacted for

direction.

11. If altered mental status:

Place patient on side (vomiting precautions), unless contraindicated.

Check glucose level. If glucose < 80 adult, < 60 children and infants treat

per Diabetic/Glucose Emergencies SOG (See pg. 69) or Cold

Emergencies Frostbite and Hypothermia Guidelines (See pg. 88-89).

Contact Medical Control as soon as possible.

12. Transport as soon as possible.

13. Contact Medical Control as soon as possible



Revised: 4/05, 10/07, 3/08

9

INITIAL MEDICAL CARE (cont.)

Adult / Pediatric

ILS - In addition to BLS care:

14. If intubated, end tidal CO2 detector and/or esophageal intubation detection device

may be utilized in addition to auscultation and pulse oximetry. If unable to

intubate, consider use of Laryngeal Mask Airway.

15. Establish TKO (30 ml/hr) IV of Isotonic Solution for adults. Keep open pediatric

IV’s will be infused at 20ml/hr. For pediatric patients, use a dial-a-flow or infuse

at 20ml/hr when utilizing IV tubing without dial-a-flow. Establish vascular access

IV/IO. NORMAL SALINE/LACTATED RINGERS. Fluid bolus with 20ml/kg.

Repeat if no improvement to maximum of 60ml/kg. (Pediatric patient < 16 years

of age.)

ALS – In addition to BLS/ILS care.

16. If unable to intubate, consider use of Laryngeal Mask Airway or BVM to

ventilate. For adults: refer to the Intubation Using Versed SOG (See pg. 57-58).

If intubation continues to be unsuccessful, BVM to ventilate and refer to the

Translaryngeal Jet Ventilation SOG (See pg. 162-163)

17. Monitor cardiac rhythm.

18. Consider 12-Lead EKG in suspected cardiac patients with chest pain. Utilize

Risk Stratification for Chest Pain criteria sheet, when system applicable.

19. Pain management should be determined per Pain Protocol SOG (See pg. 11-12)

in the care of all patients. Ask patient to rate any pain on a scale of 0-10 or utilize

Wong-Baker’s Scale for pediatric patients.

20. Check and record VS and patient condition a minimum of every 15 minutes, For

unstable patients obtain vital signs and assessments every 5 minutes. Document

times and findings.



Revised: 4/05, 10/07, 3/08

10

GENERAL ILLNESS

Sick / Unknown / Nausea / Vomiting

Adult / Pediatric

BLS

1. Provide Initial Medical Care

NOTE: Pre-hospital personnel must be acutely aware of patients who present with

no specific complaints or minor complaints. These patients’ history and

assessment is to be closely evaluated to determine the most appropriate

care required. Female patients do not necessarily have classic symptoms

of MI; their symptoms may be diaphoresis and “not feeling right.”

2. Obtain blood glucose check

ILS – In addition to BLS care

3. Initiate an IV of Isotonic Solution at TKO for adults unless hypotensive, then

titrate to maintain the SBP >100. Pediatric IV of LACTATED RINGERS with

infusion rate of 20ml/hr.

ALS – In addition to BLS/ILS care

4. If signs of hypoperfusion, e.g. low B/P, tachycardia, delayed capillary refill etc.

infuse IV fluids for adult at 20ml/kg provided lungs are clear. In pediatric patients

1-8 years old infuse the LACTATED RINGERS at 20ml/kg. Neonates 0-1

month, obtain IV of LACTATED RINGERS, infuse at 10ml/kg. If unable to

obtain IV after one attempt seek direction from Medical Control.

5. Nausea and Vomiting

Assure that the patient receive nothing by mouth.

Obtain orthostatic vital signs if time allows

Adult & Children > 12 yrs of age Children 4-11 yrs of age

ZOFRAN 4mg IV/IM. ZOFRAN 4mg disintegrating tab

IVP ZOFRAN is given place on top of tongue. When

over 2 minutes. dissolved (in seconds) ask patient to

swallow saliva.

ZOFRAN 8mg disintegrating

tab place on top of tongue. When

dissolved (in seconds) ask

patient to swallow saliva.



Revised: 4/05, 10/07, 3/08

11

PAIN PROTOCOL

Adult / Pediatric

BLS


2. Obtain subjective measurement of patients pain using the:

Adults: Scale of 0-10

Pediatrics: Wong-Baker Faces Scale (See pg. 6)

3. Check patient’s allergies and current medications (prescription and over

the counter)

4. Use available methods to control pain (i.e. splint, pillow, positions of

comfort, etc)

ILS – in addition to BLS care

5. Establish IV of Isotonic Solution:

Adults: TKO – 30ml/hr

Pediatrics: TKO – 20ml/hr

ALS – in addition to BLS/ILS care

Adult: Peds:

6. TORADOL 30mg IV or IM TORADOL (Peds 2-16 yrs.)

(IM dosage should be reserved 0.5mg/kg IV - Max of 15mg’s

for longer transport times). OR 1mg/kg IM - Max of 30mg’s

Special Note: Do not mix TORADOL in syringe with any other medications.

Do not give TORADOL to patients with aspirin or ibuprofen allergies or

elderly patients with a cardiac history.

Do not give to patients with: Renal problems, GI Bleeding, ulcers, or

bleeding disorders.

7. MORPHINE SULFATE 1-4mg MORPHINE SULFATE

IV push if indicated. 0.05-0.10 mg/kg IV. Maximum

Maximum 4mg IVP single dose of 2mg.

Use 0.05 mg/kg dose in infant

younger than six months. Maximum

dose of 0.5 mg’s IVP.



Revised: 4/05, 10/07, 3/08

12

PAIN PROTOCOL (cont.)

Adult / Pediatric

8. Following the initial administration of MORPHINE contact Medical

Control.

9. Obtain vital signs following administration of pain medication and

document.

10. Patients received analgesics should remain on oxygen.

11. Discontinue narcotic use if:

Adult: respiratory efforts less than 12 per minute

Pediatrics (< 8 years): respiratory efforts less than 16 per minute.

12. Protect the airway and assist ventilatory efforts as required.

Remember if respiratory depression occurs, consider NARCAN:

Adults: Peds:

NARCAN 2mg IV. May NARCAN

repeat to maximum of <20kg-0.1mg/kg IV/IO/ETT

10mg’s IV. >20kg-2mg IV/IO/ETT

maximum of 2mg’s.



Revised: 4/05, 10/07, 3/08

13

INITIATION OF ALS CARE

ALS should be initiated according to the following guidelines:

1. Patient with abnormal vital signs – regardless of complaints. The following

guidelines for adults:

a. Pulse < 60 or > 130; or irregularity.

b. Respiration < 10 or > 28; or irregularity.

c. Systolic Blood Pressure < 90 or > 200

2. Any patient with a potentially life-threatening condition which exists or has

potential to develop during transport. Examples of situations in which ALS care

is usually indicated include, but are not limited to:

a. Altered Mental Status and/or Unconsciousness

b. Chest Pain

c. Palpitations

d. Seizures

e. Neurologic Deficit/Stroke

f. Syncope or Near Syncope

g. Abdominal Pain

h. Shortness of Breath/Difficulty Breathing

i. Vaginal Bleeding

j. Complication of Pregnancy or Emergency Childbirth

k. GI Bleeding

l. Multiple Trauma

m. Overdose/Poisoning

n. Burns

o. Cyanosis

p. Failure of child to recognize parents

q. Petichiae (small purplish hemorrhagic spots on skin – seen in many febrile

illnesses)

WHEN IN DOUBT, CONSULT WITH MEDICAL CONTROL.



Revised: 4/05, 10/07, 3/08

14

WITHHOLDING OR WITHDRAWING OF RESUSCITATIVE EFFORTS

EMTs/Prehospital RN’s will withhold resuscitation measures when:

1. Obvious sign of death

a. Rigor mortis without profound hypothermia

b. Decomposition

c. Decapitation

d. Profound dependent lividity

2. Patient has been declared dead by a coroner or a physician.

3. Document pronouncement time and physician or coroners’ name.

4. Contact Medical Control as soon as possible

BLS/ILS

1. If there is question whether CPR is to be initiated. Begin CPR and contact

Medical Control as soon as possible.

2. Emotional support should be provided to significant others.

3. Disposition of the patient will be handled according to local and county

requirements.

4. Resuscitative efforts may be withdrawn if ordered by Medical Control. The time

of pronouncement should be documented on the run sheet.

5. Document thoroughly all circumstances surrounding the use of this procedure.

ALS – in addition to BLS/ILS care.

6. Attach a copy of the EKG rhythm strip to the provider copy of the run sheet.

BLS/ILS/ALS

Power of Attorney for Healthcare

7. DNR requests can only be honored by EMS personnel if a written DNR Order,

signed by the patient’s physician, is presented.

8. Healthcare decisions other then DNR may be made by the Power of Attorney for

Healthcare, if the document provides for this. If in doubt, treat and contact

Medical Control.

9. Bring any documents presented to the hospital.

BLS/ILS/ALS

Living Will/Surrogates

10. DNR requests can only be honored by EMS personnel if a written DNR Order,

signed by the patient’s physician, is presented.



Revised: 4/05, 10/07, 3/08

15

WITHHOLDING OR WITHDRAWING OF RESUSCITATIVE EFFORTS (cont.)

11. A Living Will by itself may not be honored by field personnel. Begin or

continue treatment. Contact Medical Control, explain the situation, and follow

any orders received.

12. There are no situations in which a surrogate can directly give instructions to

field personnel. Begin or continue treatment. Contact Medical Control,

explain the situation and follow any orders received.

BLS/ILS/ALS

DNR Orders / Withholding Treatment

13. Confirm the validity of the DNR order according to system policy. Components

of a VALID DNR order:

Must be a written document that has not been revoked. It must at least contain the

following:

Name of patient

Name and signature of physician

Effective date.

The words “Do Not Resuscitate”, “Withhold Treatment”, or the equivalent

Evidence of consent – either:

Signature of the patient, or

Signature of Legal Guardian, or

Signature of Durable Power of Attorney for Health Care Agent, or

Signature of surrogate decision-maker under the Illinois Health

Care Surrogate Act.

14. If the DNR order is valid, resuscitative efforts will be withheld: follow any

specific orders found on the DNR order.

15. In the event the patient has a valid DNR order but IS NOT in cardiac or

respiratory arrest with a decompensating condition, begin Initial Medical Care

(See pg. 8-9). If intubation is indicated contact Medical Control for direction. If

unable to contact Medical Control, provide ventilatory assistance, follow

appropriate SOP and transport as soon as possible.

16. If resuscitative efforts were begun prior to the DNR form being present, contact

Medical Control and explain the situation: follow any orders received.

BLS/ILS/ALS

Hospice Patients Not in Arrest

If patients are registered in a hospice program, initiate BLS care request the

patient DNR orders and immediately contact Medical Control for orders on

treatment and disposition. Inform Medical Control of the presence of written

treatment orders and/or valid DNR orders.



Revised: 4/05, 10/07, 3/08

16

CARDIAC PROTOCOLS

ROUTINE CARDIAC CARE

BLS – Provide Initial Medical Care

1. Assess responsiveness

2. Sit patient upright and loosen clothing

3. Obtain pulse oximetry.

4. Oxygen per nasal cannula at 4-6 liters per minute or non-rebreather mask

at 12-15 liters per minute, if patient has respiratory compromise.

If patient has emphysema or COPD, provide oxygen at 2-4 liters per

minute via nasal cannula.

If patient is experiencing severe respiratory distress or is cyanotic initiate

oxygen per non-rebreather mask at 12-15 liters per minute and prepare to

assist ventilate.

5. Obtain initial pain scale, document and reevaluate frequently. Record any

changes.


6. Obtain IV access with saline lock or isotonic solution at TKO.


7. Capnography may be utilized.

8. Evaluate cardiac rhythm and document.

9. Obtain a 12-Lead EKG in suspected cardiac patients with chest pain.

Utilize Risk Stratification for Chest Pain criteria sheet, when system

applicable.

10. Transmit 12 Lead or lead II EKG to Medical Control. Monitor patient

closely for changes in cardiac rhythm.



Revised: 4/05, 10/07, 3/08

17

EMERGENCY CARDIAC CARE

� Arrhythmia treatment per ACLS guidelines

IF RESPONSIVE

1. Observe closely

2. Treat according to Routine Cardiac Care Protocol

IF NOT RESPONSIVE

1. Call for defibrillator

2. Assess for breathing (look, listen, feel)

3. If breathing and NO trauma:

a. Place in rescue position

4. If NOT breathing

a. Give 2 breaths

b. Assess for circulation

5. If pulse present:

a. Follow routine cardiac care

b. Consider causes:

i. Hypotension/Shock/Acute Pulmonary Edema

ii. Acute MI

iii. Arrhythmia

6. If NO pulse present:

a. Start CPR

b. Assess Cardiac Rhythm

c. Follow appropriate algorithm

7. Implement AED

a. Call for ALS assist

8. If Defibrillator is used:

a. Set monophasic according to algorithm

b. If biphasic is used set at energy levels clinically equivalent or superior

to monophasic.



Revised: 4/05, 10/07, 3/08

18

EMERGENCY CARDIAC CARE (cont.)

CONSIDER CONTRIBUTING CAUSES OR FACTORS FOR

UNRESPONSIVENESS AND/OR RHYTHM DISTRUBANCES

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypo-/hyperkalemia

• Hypothermia

• Toxins

• Tamponade, cardiac

• Tension pneumothorax

• Thrombosis (coronary or pulmonary)

• Trauma



Revised: 4/05, 10/07, 3/08

19

SUSPECTED CARDIAC PATIENT WITH CHEST PAIN

STABLE: Alert, Blood pressure within normal limits (SBP> 100 mmHg)

BLS – Provide Initial Medical Care

1. Special considerations:

Carefully inquire of patient’s use of Viagra (sildenafil citrate), Cialis, Levitra,

within 4 hours or the use of Cocaine within the past 24 hours. May potentiate the

effects of nitrates.

NOTE: Viagra (Sildenafil citrate) Revatio, Cialis, Levitra. . . is indicate for the

treatment of pulmonary hypertension to improve exercise ability.

2. Baby ASPIRIN 4-81mg tablets (324 mg’s) chewed and swallowed unless

contraindicated.

May assist the patient with their own NITROGLYCERINE tablets if patient has

not taken the maximum dose of NITROGLYCERINE, assist the patient to

administer one tablet of NITROGLYCERINE 0.4mg SL if the BP > 100 mm Hg

systolic. The NITROGLYCERINE may be repeated with the guidance of

medical control. Maintain the patient in a reclining position.

3. Contact Medical Control prior to providing additional treatment for patients with

chest pain who is < 18yrs. of age.


4. Provide Routine Cardiac Care

5. Obtain IV with saline lock or isotonic solution at TKO.


6. BP > 100 mm Hg and symptomatic: NTG 0.4mg SL.

NOTE: Initial NTG may be given prior to IV start

BP must be obtained and documented prior to each NTG administration

7. May repeat NTG x 1 in 5 minutes if. SBP > 100 mm Hg and IV established.

8. If NTG SL effective and SBP >100 mm Hg apply NTG paste 1 inch.

9. If pain persists

a. If SBP > 100 mm Hg and pain unrelieved by NITRO x 2: consider:

MORPHINE SULFATE 2mg’s IVP q 5 minutes prn unless

contraindicated. Maximum dose of 10mg.



Revised: 4/05, 10/07, 3/08

20

SUSPECTED CARDIAC PATIENT WITH CHEST PAIN (cont.)

10. Special Consideration:

a. Limit IV attempts to three per patient if patient is a candidate for

thrombolytic therapy

b. Obtain and transmit 12-lead or Lead II EKG to hospital. Continue to

monitor patient closely for significant changes in cardiac rhythm.

UNSTABLE: Altered mental status or signs of hypoperfusion (SBP<90 mmHg)


If Pulse < 60, treat per Bradycardia SOG (See pg. 22-23).

If Pulse > 60, treat per Cardiogenic Shock SOG (See pg. 51).

Treat dysrhythmias per appropriate Standard Operating Guidelines.



Revised: 4/05, 10/07, 3/08

21

NORMAL SINUS RHYTHM – Suspected Cardiac Patient

(Insert Rhythm Strip)

BLS


ILS/ALS - in addition to BLS care


FIRST DEGREE HEART BLOCK – Suspected Cardiac Patient


BLS


ILS/ALS - in addition to BLS care


3. Monitor the patient closely for any progression of heart block.



Revised: 4/05, 10/07, 3/08

22

SINUS BRADYCARDIA – Suspected Cardiac Patient

(Insert Cardiac Strip)

BLS




3. No additional treatment required if:

a. Alert and Oriented

b. Skin warm and dry

c. Blood pressure stable

4. Treatment necessary if pulse less than 60 BPM per minute and:

a. Deviation from patient’s normal level of consciousness

b. Diaphoretic

c. Blood pressure < 90 mmHg systolic

d. Frequent PVCs

e. Symptoms of angina or dyspnea

f. Or other signs of shock

ALS - in addition to BLS care

5. Medication options:

Pacing should be considered immediately for severely symptomatic patients.

Refer to Non-Invasive External Cardiac Pacing Guidelines SOG (pg. 29-30)

Use without delay for high degree blocks (Type II, Second-Degree Block, or

Third-Degree AV Block).

a. ATROPINE: 0.5mg IVP while awaiting pacer. May repeat to a total dose

of 3mg. If ineffective, begin pacing upon arrival. May be given per ETT at

twice the IV dose.



Revised: 4/05, 10/07, 3/08

23

SINUS BRADYCARDIA (cont.)

b. DOPAMINE: 400mg in 250ml D5W (1600mcg/ml). Titrate to maintain

systolic BP of 90-100 mmHg by slowly increasing drip rate. Dosing range

10-20mcg/kg/min.

6. Consider CPR if the heart rate is under 40 and the patient is unresponsive.



Revised: 4/05, 10/07, 3/08

24

SECOND DEGREE HEART BLOCK MOBITZ TYPE I


BLS


ILS - in addition to BLS care



3. Follow ACLS Bradycardic Algorithm.

________________________________________________________________________

SECOND DEGREE HEART BLOCK MOBITZ TYPE II


BLS

1. Initial Medical Care


2. Routine Cardiac Care


3. Consider sedation prepare for transcutaneous pacing. (Refer to Non-Invasive

External Cardiac Guidelines SOG pg. 29-30). Consider ATROPINE 0.5mg

IVP, may repeat to a total of 3mg’s. Consider DOPAMINE 10-20 mcg/kg/min.



Revised: 4/05, 10/07, 3/08

25

THIRD DEGREE HEART BLOCK (COMPLETE HEART BLOCK)


BLS





3. Consider sedation prepare for transcutaneous pacing. (Refer to Non-Invasive

External Cardiac Guidelines pg. 29-30). Consider ATROPINE 0.5mg IVP,

may repeat to a total of 3mg’s. Consider DOPAMINE 10-20 mcg/kg/min.

a. Never treat third degree heart block with ventricular escape beats with

AMIODARONE.



Revised: 4/05, 10/07, 3/08

26

PEDIATRIC BRADYARRHYTHMIAS

BLS

1. Provide Initial Medical Care:

Adequate airway and ventilation is essential.

Initiate CPR if, after adequate ventilation, the heart rate remains:

< 60 per minute in an infant or

A child < 8 years and associated with poor systemic perfusion

2. Assess for causative factors, such as hypoxemia, acidosis, and hypothermia.

3. Contact Medical Control as soon as possible.

Initiate corrective resuscitative measures for causative factors as necessary.



5. If signs of hypovolemia bolus with an IV of LACTATED RINGERS at 20ml/kg.

If symptomatic bradycardia persists despite effective oxygenation and ventilation

consider the following medications:


6. EPINEPHRINE (1:1,000) 0.1 mg/kg (0.1 ml/kg) ET or

EPINEPHRINE (1:10,000) 0.01 mg/kg (0.1 ml/kg) IVP/IO. Repeat q 3-5

minutes as long as dysrhythmia with hypoperfusion persists.

NOTE: If increase vagal tone or primary AV block, consider ATROPINE as

first line medication.

7. ATROPINE 0.02 mg/kg rapid IVP/IO or 0.02 mg/kg ET. Minimum dose

0.1 mg. Repeat q 3-5 minutes until maximum total dose administered.

Maximum single IV/IO dose is 0.5mg < 8 years, 1mg > 8 years.

Maximum total IV/IO dose is 1mg < 8 years, 2mg > 8 years.

8. Initiate external pacing at a rate of 100.

**Consider sedation, contact Medical Control as soon as possible.

Notes:

Flush all IV/IO drugs with 5ml NS.

Flush or dilute all ET drugs with 2ml NS.

Attempt to keep child warm with protected hot packs or blankets as possible.



Revised: 4/05, 10/07, 3/08

27

12 LEAD ELECTROCARDIOGRAM GUIDELINE (EKG)


1. Utilize in the event of a suspected Acute Coronary Syndrome or anginal

equivalents (dyspnea, syncope, weakness, diaphoresis and palpitations, DKA)

● pre and post cardioversion of patients

● patients experiencing dysrhythmias

● patients experiencing heart failure

2. Provide routine cardiac care

3. Prepare the patient

a. Explain the procedure

b. Place patient supine with the head of stretcher no higher than 30 degrees

c. Make sure patient does not chill, shivering causes artifact

d. Offer reassurance to the patient as tense muscles may cause artifact.

e. Prepare the chest make sure it is dry, free of debris and oil. Clip excessive

chest hair with scissors; do not shave in case of use of thrombolytics in the

Emergency Department.

4. Place the limb electrodes in the proper area according to the diagram on the

following page.

5. Place chest electrodes in proper place according to the following diagram.

6. Do not remove EKG electrodes once they have been placed.

7. Upon completion of the 12-Lead EKG transmit to the receiving facility if

possible.

8. Attach a copy of the 12-Lead EKG to EMS run sheets.



Revised: 4/05, 10/07, 3/08

28

With the positive electrode on the left arm &

the negative electrode on the right arm, the

Lead I provides a view of the left side of the

heart looking toward the right.

With the positive electrode on the left leg & the

negative electrode on the right arm, Lead II

provides a view of the bottom (inferior aspect)

of the heart, looking toward the right arm.

With the positive electrode on the left leg & the

negative electrode on the left arm, Lead III

provides another inferior aspect of the heart,

looking toward the left arm.

Lead V1 The electrode is at the fourth

intercostal space just to the right of the

sternum.

Lead V2 The electrode is at the fourth

intercostal space just to the

left of the sternum.

Lead V3 The electrode is at the line

midway between leads V2 and V4

Lead V4 The electrode is at the

midclavicular line in the fifth interspace.

Lead V5 The electrode is at the anterior

axillary line at the same level as lead V4

Lead V6 The electrode is at the

midaxillary line at the same level as lead

V4

I

LateralaVR

V1

Septal

V4

Anterior

II

Inferior

AVL

Lateral

V2

Septal

V5

Lateral

III

Inferior

AVF

Inferior

V3

Anterior

V6

Lateral



Revised: 4/05, 10/07, 3/08

29

NON-INVASIVE EXTERNAL CARDIAC PACING GUIDELINES

(Transcutaneous Cardiac Pacing)

Indications: 1. Symptomatic Bradycardic patients;

2. Pulseless idioventricular rhythms

3. Asystole that occurred following defibrillation.

ALS in addition to BLS/ILS care



If the patient is conscious or family members are present, explain procedure

Prepare the skin by cleaning it, clipping excess hair with scissors

Apply cardiac monitor

Apply pacer electrodes in the anterior-posterior locations (see diagrams)

Set pacer at approximately 80 stimuli per minute or to maintain BP of 90mmHg

a. If bradycardic increase the mA from lowest setting until capture

b. Start at 80 MA (milli-amps) if patient is asystolic

c. Run a continuous strip during initial pacing attempts

Once capture is noted, reassess your patient

a. Assure patient palpable pulse is synchronous to pacer

b. Obtain BP

c. Note LOC and peripheral perfusion

d. If electric capture occurs without mechanical capture, increase mA until

mechanical capture (palpable pulse) is verified.

If the patient is in great discomfort, call Medical Control for pain control direction.

Avoid using the carotid pulse to confirm pacer capture (electrical stimulation may

cause muscle contraction and may simulate a pulse)

If mechanical capture is unsuccessful (no palpable pulse) resume CPR and contact

Medical Control. Follow appropriate SOP for displayed cardiac rhythm.

If V-Fib or V-Tach occur at any time, turn TCP off immediately and treat per

appropriate SOG.



Revised: 4/05, 10/07, 3/08

30

NON-INVASIVE EXTERNAL CARDIAC PACING GUIDELINES (cont.)

(Transcutaneous Cardiac Pacing)

Contraindicated in:

a. Hypothermia due to decreased metabolic rate. Ventricles more prone to

fibrillation.

b. Prolonged bradyasystolic cardiac arrest

Documentation of TCP must include:

a. Vital signs

b. Time pacing initiated

c. Current mA that accomplished capture

d. Rate required to maintain 90mmHg of Blood Pressure.

e. Medications given



Revised: 4/05, 10/07, 3/08

31

ANTERIOR – POSTERIOR

ELECTRODE POSITIONS

Anterior Posterior

Anterior – posterior positioning of transcutaneous electrodes

Anterior-lateral positioning of transcutaneous electrodes



Revised: 4/05, 10/07, 3/08

32

SUPRAVENTRICULAR TACHYCARDIA

(NARROW COMPLEX TACHYCARDIA RATE > 150)

BLS





3. Consider and treat for possible underlying causes.

heart failure

cardiogenic shock

hypovolemia

side effects of drugs or overdose

STABLE: alert, blood pressure within normal limits

1. Valsalva maneuver while preparing medication

2. If no response, ADENOCARD 6mg rapid IVP

3. If no response in 2 minutes, ADENOCARD 12mg rapid IVP

4. If no response in 2 minutes, ADENOCARD 12mg rapid IVP

follow ADENOCARD doses with rapid 10cc NS flush

UNSTABLE: heart rate > 150, altered mental status, signs of hypoperfusion

1. Consider sedation with VALIUM 5-10mg or VERSED 2-4mg increments q 2

minutes up to 10mg.

2. SYNCHRONIZED CARDIOVERSION @ 100 Joules (or equivalent biphasic)

3. If no response, repeat SYNCHRONIZED CARDIOVERSION (200 Joules, 300

Joules, 360 Joules or equivalent biphasic in succession.) Check rhythm and pulse

between shocks.

4. If no response, refer to Cardiogenic Shock SOG (See pg. 51) or contact Medical

Control.

Note: ADENOCARD should not be given to irregular rapid rhythms.



Revised: 4/05, 10/07, 3/08

33

PEDIATRIC NARROW COMPLEX TACHYCARDIA (SVT)

Ventricular Rate > 220 and QRS < 0.08sec

Potential Causes: Anxiety, fear, pain, blood loss, sepsis, dehydration, shock, reentry

phenomenon.

Poor Perfusion (unstable)

BLS Provide Initial Medical Care

1. Administer 100% oxygen


2. Obtain IV/IO access – Do not delay cardioversion for vascular access

3. Fluid bolus of LACTATED RINGERS at 20ml/kg.


4. Consider sedation with VALIUM (Diazepam) 0.1mg/kg or VERSED

(Midazolam) 0.1mg-0.2mg/kg

5. Consider synchronized cardioversion: 0.5-1 joules/kg

a. If tachyarrhythmia persists increase to 1-2 joules/kg for 2nd cardioversion

Normal Perfusion (stable)

BLS Provide Initial Medical Care

1. Administer 100% oxygen


2. Obtain IV access of LACTATED RINGERS at 20ml/hr.

3. Fluid bolus of LR at 20mL/kg, neonates 10ml/kg. Contact Medical Control


4. Attempt vagal maneuvers (ice bag to top of head, blow through an occluded

straw).



Revised: 4/05, 10/07, 3/08

34

PEDIATRIC NARROW COMPLEX TACHYCARDIA (SVT) (cont.)

Ventricular Rate > 220 and QRS < 0.08sec

IF VAGAL MANEUVERS UNSUCCESSFUL:

5. ADENOSINE 0.1mg/kg rapid IVP – Followed by 3-5ml fluid bolus

6. If no effect repeat ADENOSINE at double the initial dose with maximum dose

not to exceed 12mg IVP.

7. Each ADENOSINE dose should be followed by a 3-5ml rapid fluid bolus



Revised: 4/05, 10/07, 3/08

35

VENTRICULAR ECTOPY


BLS


2. Apply 100% Oxygen

ILS – In addition to BLS Care


4. Rule out and treat other possible causes of ectopy (hypoxia, acidosis, hypotension,

dehydration)

ALS – In addition to BLS/ILS Care

5. Never treat third degree heart block with ventricular escape beats with

AMIODARONE.

6. If bradycardia present with PVCs treat per ACLS Bradycardic algorithm

7. Medication Options:

a. After obtaining verbal order for AMIODARONE 150mg IVP over 20-60

minutes IV.



Revised: 4/05, 10/07, 3/08

36

VENTRICULAR TACHYCARDIA (VENTRICULAR RATE >150)


BLS


2. Consider shock position.

3. Apply 100% Oxygen




5. If no pulse, treat as ventricular fibrillation.

6. Stable patient:

Adult Peds

a. AMIODARONE 150mg IV a. AMIODARONE 5mg/kg IV/IO

over 10 minutes. over 20 minutes.

b. If Ventricular Tachycardia persists

after AMIODARONE 150mg’s

consider cardioversion.

c. If AMIODARONE ineffective or

as signs and symptoms dictate it

may be necessary to proceed to

unstable algorithm.




Revised: 4/05, 10/07, 3/08

37

VENTRICULAR TACHYCARDIA (cont.)

UNSTABLE PATIENT: (rate >150, CP, SOB, CHF, hypotension)

BLS





3. Consider sedation with

Adult Peds

VALIUM 5-10mg IV or VALIUM 0.1mg/kg IV/IO for

children < 5 years max 5mg.

> 5 years max 10mg.

VERSED 2-4mg IVP after VERSED 0.1-0.2 mg/kg IV/IO

2 minutes up to 10mg. Max 0.2 mg/kg.

DO NOT sedate in presence of hypotension, pulmonary edema or

unconsciousness.

NOTE: Sedatives are commonly associated with respiratory depression.

Be prepared to assist ventilatory efforts.

4. Peds: For synchronized cardioversion, use an initial dose of 0.5 to 1 joule/kg for

unstable VT with a pulse and cardiovascular instability. Increase the dose to 2

joule/kg if the initial dose is ineffective.

5. Adult: SYNCHRONIZED CARDIOVERSION at 100 Joules (or equivalent

biphasic or manufacturer’s recommendation) and

Adult Peds

AMIODARONE 150mg IV AMIODARONE 5mg/kg IV/IO

Over 10 minutes. over 20-60 minutes IV/IO bolus.

Do not delay cardioversion for IV attempt. Assess pulse and rhythm after each

cardioversion. If rhythm converts, follow appropriate SOG.


biphasic or manufacturer’s recommendation) if ventricular tachycardia persists.



Revised: 4/05, 10/07, 3/08

38

VENTRICULAR TACHYCARDIA (cont.)


biphasic or manufacturer’s recommendation) if ventricular tachycardia persists.

8. Adult Peds

May repeat If V-tach persists contact Medical

AMIODARONE 150mg IVP bolus Control.

over 10 minutes if V-tach persists.


biphasic or manufacturer’s recommendation) after each AMIODARONE bolus,

if V-tach persists.

10. Call Medical Control for additional anti-arrhythemic orders.

NOTE: If V-tach is pulseless or deteriorates to V-fib, defibrillate at 360 Joules

(or equivalent biphasic) immediately and follow V-fib SOG.

Do not give AMIODARONE if rhythm is bradycardic with PVCs

Note If Torsades de Pointes suspected (not in cardiac arrest) MAGNESIUM

SULFATE “loading dose” 1 to 2 grams in 10 mL D5W over 2 minutes.



Revised: 4/05, 10/07, 3/08

39

VENTRICULAR FIBRILLATION / PULSELESS V-TACHAdult


BLS

1. Initiate CPR and resume after interventions as appropriate.



3. Intubate.

4. Obtain IV of Isotonic Solution.

ALS - in addition to BLS/ILS care

5. Unwitnessed arrest:

a. Maintain CPR until defibrillator available

b. Check cardiac monitor for ventricular fibrillation or pulseless VT:

c. Immediately defibrillate with monophasic at 360 joules or equivalent

biphasic or manufacturer’s recommendation.

d. Resume CPR.

e. EPINEPHRINE 1.0 mg IV/IO (repeat after 3-5 min.). VASOPRESSIN

one dose/40 units IV/IO may replace either the first or second dose of

EPINEPHRINE. If IV/IO access cannot be established or is delayed, give

EPINEPHRINE 1:10,000, 2-2.5 mg diluted in 5-10 ml of water or

NORMAL SALINE and injected directly into the ET tube.



Revised: 4/05, 10/07, 3/08

40

VENTRICULAR FIBRILLATION

Adult (cont.)

f. Defibrillate monophasic maximum joules or biphasic per manufacturer

guidelines.

g. Resume CPR immediately after each intervention.

h. AMIODARONE 300mg IVP.

Note: Consider MAGNESIUM SULFATE 1-2gm if rhythm Torsades De

Pointes.

i. Consider additional dose of AMIODARONE 150mg IVP.

j. Defibrillate monophasic maximum joules or biphasic per manufacturer

guidelines.

k. Call Medical Control for additional anti-arrhythmic orders.



Revised: 4/05, 10/07, 3/08

41

PEDIATRIC VENTRICULAR FIBRILLATION OR

PULSELESS VENTRICULAR TACHYCARDIA

BLS

1. Begin CPR and continue until AED available.

2. Refer to AED guidelines for 1-8 year olds. Transport as soon as possible.



4. Intubate.

5. Establish peripheral IV or intraosseous line as indicated. If dehydrated or

hypovolemic, IV FLUID BOLUS LACTATED RINGERS 20ml/kg IV/IO,

Neonates 10ml/kg.

ALS - in addition to BLS/ILS care

Use pediatric resuscitation tape if available (Broslow tape or an equivalent

pediatric wheel system)

6. DEFIBRILLATE at 2 joules/kg monophasic or biphasic.

7. Resume CPR for 2 minutes.

8. If VF/VT persists, DEFIBRILLATE at 4 joules/kg.

9. Resume CPR for 2 minutes after each defibrillation if indicated.

10. Provide a third DEFIBRILLATION if ventricular fibrillation persists.

11. If no change, resume CPR and INTUBATE. Establish vascular access IV/IO

12. EPINEPHRINE 1:1,000 0.1mg/kg (0.1 ml/kg)ET or

EPINEPHRINE 1:10,000 0.01 mg/kg (0.1 ml/kg) IVP/IO.

13. DEFIBRILLATE at 4 joules/kg after each medication administration.

14. EPINEPHRINE 1:1,000 0.1 mg/kg (0.1 ml/kg) IVP/IO/ET. Repeat

EPINEPHRINE q 3-5 min

15. AMIODARONE 5mg/kg IV/IO.



Revised: 4/05, 10/07, 3/08

42

PEDIATRIC VENTRICULAR FIBRILLATION OR PULSELESSVENTRICULAR TACHYCARDIA (cont.)

16. Consider MAGNESIUM SULFATE 25 to 50 mg/kg IV/IO (maximum dose; 2g)

for torsades de pointes.

Notes:

Flush all IV/IO meds with 5ml NS

Flush or dilute all ET meds with 2ml NS

Attempt to keep child warm with blankets and/or protected hot packs as

able.

17. Call Medical Control for additional anti-arrhythmic orders.



Revised: 4/05, 10/07, 3/08

43

ASYSTOLE / VENTRICULAR STANDSTILL

Adult

BLS

1. Begin CPR

2. Transport as soon as possible

(Insert Cardiac Strip)



4. Consider intubation and obtain IV access


5. Apply cardiac monitor, confirm Asystole in two (2) leads.

6. Consider transcutaneous pacemaker.

7. EPINEPHRINE 1.0 mg IV/IO (repeat after 3-5 min.). VASOPRESSIN one

dose/40 units IV/IO may replace either the first or second dose of


EPINEPHRINE 1:10,000, 2-2.5 mg diluted in 5-10 ml of water or NORMAL

SALINE and injected directly into the ET tube.

8. ATROPINE 1.0mg IVP. May repeat every 3-5 minutes (if asystole persists) to a

maximum of 3 doses (3mg). May be given by ETT at twice the IV dose or 2mg’s

diluted in a minimum of 10ml of NORMAL SALINE.

9. Search for and treat identified reversible causes.

10. Medical Control may order CALCIUM CHLORIDE 1gm for renal dialysis

patients.



Revised: 4/05, 10/07, 3/08

44

ASYSTOLE OR PULSELESS ELECTRICAL ACTIVITY

Pediatric

BLS

1. Begin CPR




4. Intubation and obtain IV/IO access


5. Monitor cardiac rhythm

6. Medication:

a. EPINEPHRINE IV/IO 0.01mg/kg 1:10,000 (0.1ml/kg)

1. ETT 0.1mg/kg 1:1,000 (0.1ml/kg)

7. Continue CPR

8. Consider causes and treat them accordingly:

a. Hypoxia Tension Pneumothorax

Hypovolemia Tamponade, cardiac

Hyper/Hypokalemia Toxins

Hydrogen Ion Acidosis Thrombosis, coronary or pulmonary

Hypothermia Trauma

Hypoglycemia

9. Check glucose. If altered refer to pediatric Diabetic/Glucose Emergency SOG

(See pg. 69).

10. Epinephrine subsequent doses IV/IO may be repeated every 3-5 minutes

a. Via ETT at twice the IV/IO dose



Revised: 4/05, 10/07, 3/08

45

PULSELESS ELECTRICAL ACTIVITY (PEA)

Adult

BLS

1. Begin CPR


ILS – in addition to BLS care.


4. Intubate and obtain IV access.


5. EPINEPHRINE 1.0 mg IV/IO (repeat after 3-5 min.). VASOPRESSIN one

dose/40 units IV/IO may replace either the first or second dose of


EPINEPHRINE 1:10,000, 2-2.5 mg diluted in 5-10 ml of water or NORMAL

SALINE and injected directly into the ET tube.

6. Consider ATROPINE 1.0mg IV or IO for PEA with rate less than 60. May

repeat every 3-5 minutes to a maximum of 3 doses (3mg). May be given by ETT

at twice the IV dose or 2mg’s diluted in a minimum of 10ml of NORMAL

SALINE.

7. Consider the possible underlying causes:

Hypoxia Tension Pneumothorax

Hypovolemia Tamponade, cardiac

Hyper/Hypokalemia Toxins

Hydrogen Ion Acidosis Thrombosis, coronary or pulmonary

Hypothermia Trauma

Hypoglycemia

8. CALCIUM CHLORIDE 1gm may be ordered by Medical Control for dialysis

patients.



Revised: 4/05, 10/07, 3/08

46

IMPLANTED CARDIAC DEFIBRILLATORS

(ICD, PCD, AICD)

BLS

1. Provide Initial Medical Care.

2. Any patient who has been shocked by his/her ICD should be encouraged to seek

medical attention.


3. Provide Routine Cardiac Care.


4. Treat dysrhythmias per appropriate SOG.

All defibrillation attempts should be at highest manufacturer

recommended energy level.

If no response, alter paddle/pad placement slightly and repeat shock.

Avoid direct placement of the defib pads/paddles over the ICD unit or path

of wires.

5. If ICD is repeatedly firing and patient is hemodynamically stable (B/P within

normal limits, absence of tachycardia and capillary refill within normal limits)

consider sedation. Contact Medical Control for orders.



Revised: 4/05, 10/07, 3/08

47

AUTOMATIC EXTERNAL DEFIBRILLATION (A.E.D.)

BLS


NOTE: If a patient has an automated internal defibrillator (AICD) or pacemaker,

do not place the electrode over the implanted device.

2. Initiate CPR and continue until Automatic External Defibrillator (AED)

has been made ready

3. Turn on the AED power (some devices will “power on” automatically

when lid is opened) and stop CPR

4. Choose the correct pads (adult vs. child) for size/age of victim. Use child

pads or child system for children less than 8 years of age if available. Do

not use child pads or child system for victims 8 years and older. Attach

AED electrodes to the pulseless, non-breathing patient

5. Assure that all rescuers have cleared the patient and allow the AED to

analyze the patients rhythm

6. If the AED advises “shock”, have all rescuers clear the patient and deliver

1 shock

7. Immediately resume CPR beginning with chest compressions. Do not

delay CPR to recheck the rhythm or pulse.

NOTE: Call for Advanced Life Support assistance

8. Transport should be initiated at this time

9. After 2 minutes (5 cycles) of CPR repeat steps 5 and 6 until the advanced

care providers take over or the victim starts to move

ILS – In addition to BLS care


ALS – In addition to BLS/ILS care

11. If AED is in use prior to arrival begin manual or hands off defibrillation if

indicated.

12. Continue per appropriate SOG

13. If recorded data available, transport with patient



Revised: 4/05, 10/07, 3/08

48

HYPERTENSIVE EMERGENICES

Symptoms: Sudden rise in BP > 200/130 mmHg, severe headache, nausea, vomiting,

weakness, dizziness, epistaxis and blurred vision.

BLS


2. Special Considerations:

Carefully inquire of patient’s use of Viagra (sildenafil citrate, Cialis, Levitra)

within 4 hours or the use of Cocaine within the past 24 hours. May potentiate the

effects of nitrates.



4. Obtain IV with saline lock.


5. Monitor cardiac rhythm

6. NITROGLYCERIN (NTG) gr 1/150 SL , If SBP > 150 may repeat every 5

minutes with maximum of 3 tablets.

7. Apply NTG topically 1 inch unless allergic or SBP < 100 mmHg

8. Reassess patient and vital signs every 5 minutes for changes.



Revised: 4/05, 10/07, 3/08

49

PULMONARY EDEMA

(DUE TO HEART FAILURE)

BLS

When the patient’s chief complaint is shortness of breath or the patient expresses the

inability to lie flat due to shortness of breath:

1. Place the patient in an upright position if the BP >100mmHg.

2. Give Oxygen supplement to maintain pulse oximetry:

If COPD retainer maintain Oxygen saturation at 90% to 93%.

Non-COPD patients maintain Oxygen saturation at 95% to 98%.

3. Provide Initial Medical Care.


4. Initiate physical exam with emphasis on is the patient exhibiting:

Rales (crackling in lungs) edema

cool extremities clammy skin

5. Does the patient have a history of:

COPD Asthma Heart Failure Hypertension

Acute Coronary Syndrome Pulmonary Embolism

Did the patient take their heart failure medication yesterday or today?


STABLE: Alert, normotensive

6. Place the patient on continuous cardiac monitor.

7. Administer ASPIRIN 324mg’s (4 baby ASA) if not allergic to it, if the patient is

not already taking and if the patient’s level of consciousness allows.

NOTE: If ASPIRIN has been taken in the past 12 hours withhold administration of the

ASPIRIN and document why the ASPIRIN was not given. Inform the receiving

hospital.



Revised: 4/05, 10/07, 3/08

50

PULMONARY EDEMA (DUE TO HEART FAILURE) (cont.)

8. Give the patient LASIX 0.5-1mg/kg IVP (or twice the patients daily dose). Not to

exceed 120mg’s.

9. If the patient complains of chest heaviness, tightness, aching, fullness, sharp pain

or chest pressure consider NTG 0.4mg SL or 1 metered dose if SBP >100mmHg.

May repeat the NTG 0.4mg SL or 1 metered dose in 5 minutes if SBP remains

>100mmHg for continued complaint of chest pain.

10. If SBP >100mmHg: and if SL NTG relieved pain, apply NTG paste 1(one) inch

topically.

For anxiety, if SBP >100mmHg: MORPHINE SULFATE 1-4mg slow IVP

(maximum 4mg’s). Contact Medical Control for further orders.

UNSTABLE: cardiac rhythm, altered mental status, hypotension signs/symptoms

of shock.

11. Follow ACLS protocols.

Pulse <60: treat per Bradycardia SOG (See pg. 22-23)

Pulse >60: treat per Cardiogenic Shock SOG (See pg. 51)



Revised: 4/05, 10/07, 3/08

51

CARDIOGENIC SHOCK

Sign and Symptoms of hemodynamic instability: Diaphoresis, Angina,

Tachycardia, rapid shallow respirations, deviation from patient’s “normal level of

consciousness”, nausea/vomiting, peripheral signs of shock e.g. cool extremities,

cyanosis. Ischemic EKG changes (e.g. elevated ST segments).

BLS





If hypovolemic and/or dehydrated and lungs are clear:

IV FLUID BOLUS OF 20mL/kg of isotonic solution. Reassess and repeat

as needed.

Reassess breath sounds after each 200cc increment.

3. Treat underlying dysrhythmias per appropriate SOG.

4. DOPAMINE DRIP starting at 10mcg/kg/min. with 60 drop tubing or Dial-a-

Flow as available. Titrate to SBP > 90mmHg



Revised: 4/05, 10/07, 3/08

52

AIRWAY OBSTRUCTION

Adult / Pediatric

BLS

1. Determine responsiveness and ability to speak.

2. Position patient to open airway:

If unconscious: use head tilt/chin lift

If possible c-spine injury: use modified jaw thrust.

3. Assess breathlessness/degree of airway impairment.

CONSCIOUS

ABLE TO SPEAK:

4. Complete Initial Medical Care

Note: Do not interfere with patient’s own attempts to clear airway

CANNOT SPEAK:

5. 5 abdominal thrusts (Heimlich maneuver) with patient standing or sitting.

5 chest thrusts if patient in 2nd-3

rd trimester of pregnancy or morbidly obese

Pedi: 5 back blows with head down, and 5 chest thrusts in infants < 1 year of age.

REPEAT IF NO RESPONSE.

6. If successful: complete Initial Medical Care and transport

7. Still obstructed:

Continue appropriate intervention

Note: Any time the efforts to clear the airway are successful, complete Initial Medical

Care and transport.

UNCONSCIOUS

8. Attempt to ventilate. If obstructed:

Look into mouth when opening the airway during CPR, use finger sweep only to

remove visible foreign body if unresponsive.

9. Continue CPR until ALS arrives.

ILS– in addition to BLS care

10. Visualize airway with laryngoscope and attempt to clear using forceps and/or

suction.

11. Still obstructed: Attempt forced ventilation

12. Still obstructed: INTUBATE and push foreign body into right mainstream

bronchus, then pull back tube and ventilate left lung.

13. Still obstructed: Adults: Consider Translaryngeal Ventilation.

Transport and ventilate with 100% oxygen/BVM.


14. Monitor for Cardiac dysrhythmia and/or cardiac arrest.



Revised: 4/05, 10/07, 3/08

53

RESPIRATORY DISTRESS

Pediatric

BLS

1. Perform rapid cardiopulmonary assessment

2. Obtain pulse oximetry.

3. Support infant’s head in neutral (sniffing) position. Allow older children to

assume position of maximum comfort to optimize airway.

4. High flow oxygen

5. Assist ventilations if necessary with 100% oxygen utilizing bag valve mask with

reservoir.

6. Maintain normal body temperatures. Give nothing by mouth.

7. Transport and notify receiving hospital as soon as possible.

8. If BLS unit and transport time is greater than 5 minutes, arrange an ALS intercept

enroute to the hospital


9. Intubate and obtain IV of LACTATED RINGERS at 20mL/hr.



11. Monitor for cardiac dysrhythmias and/or cardiac arrest.



Revised: 4/05, 10/07, 3/08

54

PEDIATRIC RESPIRATORY ARREST

BLS

1. Secure and maintain patent airway using:

jaw thrust or head tilt/chin lift

suction

oropharyngeal airway

2. C-spine immobilization as indicated

3. If airway obstructed, refer to Airway Obstruction SOG (See pg. 52)

4. If breathing resumed, continue with Initial Medical Care.

5. If not breathing; administer 100% O2 with BVM. Observe for increase in heart

rate and improved color. If pulse <60 initiate CPR refer to Bradycardia SOG

(See pg. 22-23)

6. Obtain glucose level – If Blood Sugar <60 children and infants, or signs and

symptoms of Insulin Shock/Hypoglycemia – follow Diabetes/Glucose

Emergencies SOG (See pg. 69) as appropriate.

7. Contact Medical Control.




10. If no improvement, secure airway per intubation or assist ventilate with BVM

11. Establish vascular access via IV/IO.

Special consideration:

Respiratory arrest may be a presenting sign of toxic ingestion or metabolic

disorder.


12. Consider NARCAN administration after airway control established.

13. Monitor for cardiac dysrhythmias and for cardiac arrest.



Revised: 4/05, 10/07, 3/08

55

ASTHMA / RESTRICTIVE DISEASE

Adult / Pediatric

BLS

1. Provide Initial Medical Care as indicated


2. Obtain IV of Isotonic Solution at TKO for adults. Pediatric IV of LACTATED

RINGERS with infusion rate of 20ml/hr.


3. Monitor cardiac rhythm.

4. Place patient in a position to facilitate breathing

5. Apply pulse oximetry. Capnography may be utilized.

6. Medication options:

ADULT:

a. ALBUTEROL 2.5mg (3 ml) into nebulizer treatment – May be repeated

immediately if partial response.

b. Contact Medical Control

c. SOLU-MEDROL 125mg IVP or DECADRON 10mg IVP

d. EPINEPHRINE 1:1,000 0.3-0.5mg sub-q.

PEDIATRIC:

a. ALBUTEROL 1.25mg (1.5 ml) into nebulizer treatment. May be repeated

immediately if partial response.

b. Contact Medical Control

c. EPINEPHRINE 1:1,000 0.01mg/kg with maximum of 0.3mg’s sub-q.

d. SOLU-MEDROL 2mg/kg IVP or DECADRON 0.25mg/kg IVP

7. Monitor vital signs and respiratory effort every 5 minutes and document.

** Note: Differential diagnosis should be considered. Asthma can be simulated by other

pulmonary problems which cause wheezing or shortness of breath. **

i.e. anaphylaxis, pulmonary embolism, croup, or pneumothorax.



Revised: 4/05, 10/07, 3/08

56

GUIDELINES FOR OROTRACHEAL INTUBATION

Policy:

Tracheal intubation is the preferred technique for controlling the airway in

patients who are unable to maintain an open airway.

Indications:

1. Unable to ventilate an unconscious patient with conventional methods.

2. The patient cannot protect his or her airway.

3. Prolonged artificial ventilation is needed.

Prior to Insertion:

1. Preoxygenate the patient for several minutes with 100% oxygen prior to

insertion attempt.

2. Ventilations should never be interrupted for more than 30 seconds for any

reason.

3. Trauma patient orotracheal intubation is done with the patient’s head and neck

stabilized in a neutral position.

4. Don protective equipment.

5. Prepare equipment.

Insertion Procedure:

1. Insert the laryngoscope blade into the right side of the patient’s airway to the

correct depth, sweeping toward the center of the airway while observing the

desired landmarks.

2. After identifying the desired landmarks, insert the endotracheal (ET) tube

between the patient’s vocal cords to the desired depth.

3. The laryngoscope is then removed while holding the ET tube in place; the

depth marking on the side of the ET tube is noted.

4. If a stylet has been used, it should be removed at this time.

5. Inflate the pilot valve with enough air to complete the seal between the

patient’s trachea and the cuff of the ET tube (usually 8-10mL).

6. Attach a BVM and ventilate while observing for chest rise and each delivered

breath.

7. To ensure proper ET tube placement bilateral breath sounds and absence of air

sounds over the epigastrium are indications that the ET tube is properly

placed.

8. Continue to manually stabilize or secure the ET tube in the determined proper

position and monitor for good oxygenation and ventilation.



Revised: 4/05, 10/07, 3/08

57

INTUBATION USING VERSED

Adult

Policy:

Intubation is indicated for newly unresponsive patients, those who cannot protect

their airway or in those needing assistance with breathing.

Indications:

When prolonged artificial ventilation is needed.

Patient cannot protect his/her own airway e.g. respiratory distress, imminent

respiratory arrest or no gag reflex.

Glasgow Coma Score <8.

Severe chest injury with cyanosis and a respiratory rate >30 or <10.

Imminent tracheal/laryngeal closure due to severe edema secondary to trauma,

burns, or allergic process.

Altered mental status with significant risk of vomiting and aspiration, as in head

injury, drug or alcohol intoxication and status epilepticus.

Contraindications:

Fractures of the midface e.g. maxilla, zygoma, floor of the orbit and nose, Leforte

fractures. Signs and symptoms specific to midface fractures include midfacial

edema, unstable maxilla, lengthening of the face (donkey face) epistaxis, numb

upper teeth, nasal flattening, and cerebrospinal fluid leakage.

ALS

Considerations:

Consider potential for hypoglycemia prior to implementing sedation and

intubation.

Adult


2. Continue to assist ventilations during preparation for intubation.

3. Do not allow the patient to become hypoxic, proceed immediately with

intubation.



Revised: 4/05, 10/07, 3/08

58

INTUBATION USING VERSED

Adult (cont.)

4. Administer VERSED 5mg’s IVP followed by VERSED 5mg’s IVP at two

minute intervals until sedation is achieved or to a maximum of 10mg’s total.

5. Apply cricoid pressure.

6. Attempt oral or oral in-line intubation as is case appropriate.

7. Intubation must be confirmed using cord visualization and auscultation (refer to

instructions on SOP page 1 for suggested confirmation techniques).

8. Utilize CO2 detectors or System specific tube placement devices as a method of

confirmation of appropriate endotracheal tube placement.

9. Secure ETT and reassess breath sounds.

10. When available, place the patient on an approved transport ventilator.

If additional sedation is necessary to reduce or eliminate a recurrent state of agitation

following intubation, administer VERSED 4mg’s (if BP >100/70). Immediately contact

Medical Control.

If the intubation attempt is unsuccessful, continue to assist ventilate with BVM, and

contact Medical Control immediately.

If unable to assist ventilate be prepared for Translaryngeal Jet Ventilation SOG

procedure implementation. (See pg. 162-163)



Revised: 4/05, 10/07, 3/08

59

INTUBATION USING ETOMIDATE

Policy:

This protocol is to be used for patients > 10 years of age.

Indications:

When prolonged artificial ventilation is needed.

Patient cannot protect his/her airway e.g. respiratory distress, imminent

respiratory arrest or no gag reflex.

Glasgow Coma Score < 8.

Severe chest injury with cyanosis and respiratory rate > 30 or < 10.

Imminent tracheal/laryngeal closure due to severe edema secondary to trauma,

burns, or allergic process.

Altered mental status with significant risk of vomiting and aspiration, as in head

injury, drug or alcohol intoxication and status epilepticus.

Contraindications:

Fractures of the midface e.g. maxillas, zygoma, floor of the orbit and nose,

Leforte fractures. Signs and symptoms specific to midface fractures include

midface edema, unstable maxilla, lengthening of the face (donkey face) epistaxis,

numb upper teeth, nasal flattening, and cerebrospinal fluid leakage.

ALS

Considerations:

Consider potential for hypoglycemia prior to implementing sedation and

intubation.

Adult


2. Continue to assist ventilations with 100% Oxygen via BVM during

preparation for intubation.

3. Do not allow the patient to become hypoxic, proceed immediately with

intubation.

4. Administer ETOMIDATE 0.3mg/kg rapid IVP.

5. Depress and hold cricoid pressure until tube passed.



Revised: 4/05, 10/07, 3/08

60

INTUBATION USING ETOMIDATE (cont.)

6. Attempt oral or in-line intubation as is case appropriate.

7. If proper muscle tone relaxation has not been achieved to allow for

intubation after 60 seconds, may repeat ETOMIDATE 0.3mg/kg rapid

IV.

8. Intubation must be confirmed using cord visualization and auscultation

(refer to instructions on SOG pg. 1 for suggested confirmation

techniques).

9. Utilize CO2 detectors or system specific tube placement devices as a

method of confirmation of appropriate endotracheal tube placement.

10. Secure ETT and reassess breath sounds.

11. When available place the patient on an approved transport ventilator.

12. Call Medical Control for post intubation sedation.

If unable to assist ventilate be prepared for Translaryngeal Jet Ventilation SOG

procedure. (See pg. 162-163).



Revised: 4/05, 10/07, 3/08

61

PEDIATRIC DRUG DOSES

May be determined by Broselow Tape or Pediatric wheel.

Adenosine (Adenocard) Must be given rapid bolus followed by 3-5ml flush

0.1mg/kg IV/IO. May double (0.2mg/kg) for second dose.

Maximum 1st dose 6mg

Maximum 2nd dose 12mg

Maximum 3rd dose 12mg

Albuterol

1.25mg (1.5ml) via nebulizer

Amiodarone

5mg/kg IV/IO; can repeat the 5mg/kg IV/IO bolus. Maximum single dose

of 300mg’s.

Atropine

0.02 mg/kg IV/IO or 0.03mg/kg ETT

minimum single dose 0.1mg

maximum doses:

<8 years single dose 0.5mg

<8 years total dose 1mg

8-16 years single dose 1mg

8-16 years total dose 2mg

Decadron

0.25 mg/kg

IV/IO

Dextrose 50% diluted 1:1 with NORMAL SALINE making a 25% solution

2-4ml/kg IV/IO > 2 month old

Dilute above 25% 1:1 with NORMAL SALINE to make 12.5%

< 2 month old use 2-4ml/kg IV/IO of 12.5%

Epinephrine 1:1,000

0.01ml (0.01mg)/kg SubQ (maximum dose 0.3ml)

Epinephrine

Bradycardia < 60 BPM or rapidly decreasing heart rate, Asystole or

Pulseless Arrest

First dose

IV/IO 0.01mg (0.1ml)/kg 1:10,000

ETT 0.1mg (0,1ml)/kg 1:1,000

Subsequent doses 0.1 mg/kg 1:1000 IV/IO repeat every 3-5

minutes for Asystole or PEA



Revised: 4/05, 10/07, 3/08

62

PEDIATRIC DRUG DOSAGES (cont)

*Glucagon

(0.5mg IM) is recommended for peds patients weighing < 25kg or

**younger than 6-8 yrs**.

*As per system protocol.

Morphine Sulfate (MSO4)

0.05-0.1mg/kg > 6 months old < 6 months 0.05mg/kg IV/IO

Naloxone (Narcan)

If < 20kg 0.1mg/kg IV/IO/ETT

If > 20kg 2mg IV/IO/ETT

Sodium Bicarbonate

1mEq/kg IV/IO

Valium (Diazepam)

0.1mg/kg IV/IO; <5 yrs single maximum dose 5mg

>5 yrs single maximum dose 10mg

Subsequent doses 0.25mg/kg IV/IO

Valium:

PER RECTUM 0.5mg/kg

Rectal Valium Procedure:

1. Compute dose per weight

2. Remove needle from TB syringe. If dosage is greater than 1ml

will required 2 TB syringes.

3. Pull plunger or syringe back to desired dose mark

4. Insert needle of Valium syringe into the hub of the TB syringe.

5. Inject the desired amount of Valium into the TB syringe.

6. Lubricate tip of the TB syringe

7. Insert TB syringe tip without the needle, into the patient’s

rectum (no further than the tip)

8. Push plunger to inject the Valium

Versed (Midazolam)

0.1-0.2mg/kg IV/IM

Maximum single dose 4mg

NOTE: Fluid Bolus for shock is Isotonic or LACTATED RINGERS Solution 20ml/kg

for pediatric> 28 days old.

NOTE: < 28 days old use 10ml/kg LACTATED RINGERS as fluid bolus.



Revised: 4/05, 10/07, 3/08

63

REACTIVE (LOWER) AIRWAY DISEASE

PEDIATRIC WHEEZING (< 8 yrs of age)

BLS

1. Provide Initial Medical Care; special considerations

If minimal-to-moderate distress: O2 at 4-6 L/nasal cannula or pediatric

mask at 10L per minute. (aim mask at face if child resistant)

If severe distress: 100% O2 with NRB or BVM at 10-12 liters/min.


2. Pediatric IV of LACTATED RINGERS with infusion rate of 20ml/hr.


3. ALBUTEROL 1.25mg (1.5ml) via nebulizer.

4. Partial response: repeat ALBUTEROL immediately.

5. No response to ALBUTEROL or patient in severe distress:

EPINEPHRINE 1:1,000

< 10 kg = 0.1mg or 0.1ml SQ

11 – 20 kg = 0.2mg or 0.2ml SQ

21 – 30 kg = 0.3mg or 0.3ml SQ

6. If imminent arrest, INTUBATE and use in-line ALBUTEROL 1.25mg (1.5ml).



Revised: 4/05, 10/07, 3/08

64

PARTIAL (UPPER) AIRWAY OBSTRUCTION

CROUP / EPIGLOTTITIS

Pediatric

BLS

1. Provide Initial Medical Care; special considerations:

Do not place anything in mouth to visualize pharynx.

CROUP

STABLE: No cyanosis, mild respiratory distress, no retractions

2. If wheezing transport as soon as possible.

UNSTABLE: Cyanosis, marked stridor, or respiratory distress, evidence of inadequate

airway exchange.


3. Do not start IV unless child presents in impending arrest


4. NS 6ml in nebulizer by mask or aim mist at child’s face (allow caregiver to hold

mask)

5. Monitor ECG for changes in heart rate. Bradycardia signals deterioration.

EPIGLOTTITIS

STABLE: No cyanosis, effective air exchange. Administer Oxygen by having

caregiver hold mask near patient.

UNSTABLE: Bradycardic, altered mental status, marked stridor/ventilatory distress,

retractions, ineffective air exchange, and/or actual or impending

respiratory arrest.

6. Position supine in sniffing position. Ventilate with 100% oxygen/Peds BVM

using slow compressions of bag.



Revised: 4/05, 10/07, 3/08

65

PARTIAL (UPPER) AIRWAY OBSTRUCTION

CROUP / EPIGLOTTITIS

Pediatric (cont.)


7. Do not start IV unless child presents in impending arrest


8. Monitor ECG for changes in heart rate. Bradycardia signals deterioration.

9. If unable to ventilate temporarily stop ambulance and attempt one oral

endotracheal intubation.

NOTE: In the event of cardiac arrest follow appropriate SOG.



Revised: 4/05, 10/07, 3/08

66

PEDIATRIC NEAR DROWNING

BLS

Beware of personal safety if victim is still in water.

1. Initiate ventilations while patient is still in the water if possible.

2. Remove the patient from the water as soon as possible.

Note: Patient is at high risk for vomiting.

3. Provide Initial Trauma Care.

4. Handle patient gently.

5. Remove wet clothing.

6. Dry off and wrap in blanket when possible.

7. Assess patient’s temperature.

• If normothermic, treat dysrhythmias per appropriate SOG

• If hypothermic, treat per Cold Emergencies Frostbite and

Hypothermia SOG (See pg. 88-89)

8. Treat other signs and symptoms per appropriate Regional SOG.


NOTE: All patients with low core body temperatures should be resuscitated.

ILS in addition to BLS care

10. Intubate if GCS < 8.

11. Obtain IV of LACTATED RINGERS with infusion rate of 20 mL/hr.

12. Obtain red or yellow top blood tube for hospital. Label with patient name, date of

birth (if available), time drawn and initial.

ALS in addition to BLS/ILS care


13. Apply cardiac monitor.




Revised: 4/05, 10/07, 3/08

67

ALLERGIC REACTION / ANAPHYLAXIS

Adult / Pediatric

BLS


2. Apply ice or cold pack to bite or injection site if appropriate.

Adult: Peds:

3. *EPINEPHRINE 1:1000 0.5mg SQ *EPINEPHRINE 1:1000

May repeat x 1 after 15 min. SQ 0.01mg/kg to maximum

if minimal response. of 0.3mg’s . To be considered for

children weighing 30 kgs or less. Not

for neonates.

OR *EPINEPRHINE PEN ADULT OR *EPINEPHRINE PEN

0.3mg into thigh muscle. PEDIATRIC 0.15mg into thigh

muscle. To be used for children < 30

kgs.





ALLERGIC REACTION (localized signs)

Adult: Peds:

5. BENADRYL 50mg IM or slow IVP BENADRYL 1mg/kg IM or slow

IVP not to exceed 50mg’s.

ANAPHYLAXIS (multisystem reaction with altered mental status or signs of

hypoperfusion, e.g., low B/P, tachycardia, ventilatory distress, delayed capillary refill)

Obtain IV access enroute

Adult: Peds:

6. If signs of hypoperfusion IV FLUID If signs of hypoperfusion, IV

BOLUS at 20mlkg FLUID BOLUS of 20ml/kg of

Lactated Ringers

7. EPINEPHRINE 1:1,000 0.5mg SQ EPINEPHRINE 1:1,000 SQ

may repeat x 1 after 15 minutes if 0.01 ml/kg to maximum of 0.3mg’s.

minimal response. To be considered for children

weighing 30 kgs or less Not for

Neonates

* As per system protocol.



Revised: 4/05, 10/07, 3/08

68

ALLERGIC REACTION / ANAPHYLAXIS

Adult / Pediatric (cont.)

8. BENADRYL 50mg slow IVP. If no BENADRYL 1mg/kg slow IVP. If

IV, give IM. No IV, give IM. Not to exceed

50mg’s

9. SOLU-MEDROL 125mg IVP SOLU-MEDROL 2mg/kg IVP

or DECADRON 10mg IVP or DECADRON 0.25mg/kg IVP

10. If wheezing; ALBUTEROL 2.5mg If wheezing; ALBUTEROL 1.25mg

(3ml) nebulizer per Asthma SOG (1.5 ml) via nebulizer per Asthma

(See pg. 55) SOG (See pg. 55)

Pediatric note: Flush all IV/IO meds with 5ml NS.



Revised: 4/05, 10/07, 3/08

69

DIABETIC / GLUCOSE EMERGENCIES

Adult / Pediatric

BLS


Obtain medical history and last oral intake

Monitor for vomiting and seizures.

2. Administer high flow O2 with humidification

3. Obtain and record blood glucose level, and vital signs

4. NOTE: If blood sugar <80 adult, <60 children and < 60 infants, and patient is

alert with an intact gag reflex, consider the administration of ORAL GLUCOSE.

Refer to Oral Glucose Guideline (See pg. 70-71).



RINGERS with infusion rate of 20mL/hr.

6. If unable to obtain IV site refer to Oral Glucose Guideline (See pg. 70-71).

7. Draw red or yellow top blood tube for hospital use. Label tubes with: patient’s

name, date of birth (if available), time of draw and your initials.


8. Blood sugar <80 adult, <60 children and < 60 infants or signs and symptoms of

Insulin Shock/Hypoglycemia

Adults and children > 8 years Peds:

DEXTROSE 50% 25Gm (50ml) IVP 1-8 years: DEXTROSE 25%

2-4ml/kg IVP

< 1 year: DEXTROSE 12.5%

2-4ml/kg IVP

*GLUCAGON 1mg IM *GLUCAGON half adult dose

If after 15 min. the patient (0.5mg IM) is recommended for

remains unconscious, may give an peds patients weighing < 25kg or

additional 1mg of GLUCAGON IM **younger than 6-8 yrs**.

9. Blood sugar > 180 with signs and symptoms of hyperglycemia/ketoacidosis

Adult: Peds:

IV FLUID BOLUS of isotonic BOLUS (20ml/kg) with

solution consecutive 20ml/kg LACTATED RINGERS.

increments, unless contraindicated. Contact Medical Control

Reassess the patient after each bolus




Revised: 4/05, 10/07, 3/08

70

ORAL GLUCOSE PROCEDURE

Adult / Pediatric

BLS/ILS/*ALS


Obtain medical history and last oral intake

Vomiting and seizure precautions.

2. Administer high flow O2

3. Obtain and record blood glucose level, if available

4. Obtain vital signs

5. Call Medical Control regarding patient condition and request oral glucose order.


Indications: Glucose gel acts to increase blood glucose levels and is given to any

patient with an altered level of consciousness who has a history of

diabetes.

Contraindications: Patients inability to swallow or is unconsciousness

Side Effects: None, however the risk for aspiration in a patient who does not have a gag

reflex is a significant danger.

ILS/ALS – in addition to BLS care

Procedure

A. Wear gloves

B. Confirm the patients LOC, the presence of a gag reflex and the ability to swallow

C. Examine the tube for intactness

D. Check the expiration date

E. Squeeze the entire tube onto the bottom third of a bite stick or tongue depressor

F. Open the patients mouth

G. Place the tongue depressor on the mucous membranes between the cheek and

gum, gel side next to cheek



Revised: 4/05, 10/07, 3/08

71

ORAL GLUCOSE PROCEDURE (cont.)

NOTE: Once the gel is dissolved, patient loses consciousness or has a seizure, remove

the tongue depressor.

Following administration

A. Reassess the patient frequently for:

1. airway problems

2. sudden loss of consciousness

3. seizures

*ALS will utilize oral glucose in the event of an inability to obtain IV access.



Revised: 4/05, 10/07, 3/08

72

SYNCOPE / NEAR SYNCOPE

Non-traumatic loss of consciousness

Adult / Pediatric

BLS


2. Obtain and record blood glucose level, if available. If <80 adult, <60 children and

infants, treat per Diabetic/Glucose Emergencies SOG (See pg. 69)

3. Obtain and document a Glascow Coma Scale.



5. Obtain an IV of Isotonic Solution at TKO for adults. Pediatric IV of

LACTATED RINGERS with infusion rate of 20ml/hr.


STABLE: Alert, blood pressure within normal limits

6. Apply cardiac monitor ECG.

Document changes in Glasgow Coma Scale

7. Anticipate underlying etiologies and treat according to appropriate SOG:

Metabolic - Diabetes or Poisoning/Overdose SOGs

Cardiac - Dysrhythmia or Cardiogenic Shock SOGs

Hypovolemic - Fluid Resuscitation

CNS Disorder - See appropriate Medical or Trauma SOG

e.g.: Toxicology Emergencies or Head Injury

SOG

Vasovagal - Provide Initial Medical Care

UNSTABLE: Altered mental status and/or signs of hypoperfusion, e.g., low B/P,

tachycardia, ventilatory distress, delayed capillary refill.

Note: Potential exists for underlying etiologies as indicated above.



Revised: 4/05, 10/07, 3/08

73

SEIZURES / STATUS EPILEPTICUSNon-traumatic origin

Adult / Pediatric

BLS

1. Provide Initial Medical Care; special considerations:

Clear and protect airway. Vomiting/aspiration precautions.

Protect the patient from injury. Do not place anything in mouth if seizing.

Position patient on side unless contraindicated.

Obtain vital signs

2. Obtain pulse oximetry. Capnography may be utilized.

3. Obtain and record blood glucose level, if available. If <80 adult, <60 child, <40

infant, treat per Diabetic/Glucose Emergencies SOG (See pg. 69).

FEBRILE SEIZURES:

Cool patient by removing clothing. Place towel or sheet moistened with

tepid (room temperature) water over patient and fan the child. DO NOT

induce shivering. DO NOT rub with alcohol or place in cold/ice water.

Give nothing by mouth, including any anti-fever medications unless

approved by Medical Control.




5. Obtain red or yellow top blood tube for hospital testing, label with patient name,

date of birth (if available), time of draw and initial.



7. If actively seizing, administer VALIUM or VERSED as follows:

Adult: Peds:

8. May give VALIUM 5mg VALIUM IV/IO 0.1mg/kg; <5 slow

IVP. Rectal VALIUM yrs (max dose 5mg), >5 yrs (max

2mg/min until seizure resolves or dose 10mg). Refer to Rectal

maximum dose of 10mg’s Valium Administration SOG

OR VERSED 4mg IVP as initial (See pg. 74). OR VERSED

dose. May be repeated in 2mg 0.1-0.2mg/kg IVP

increments to maximum of 10mg’s.

Refer to Rectal Valium Administration

SOG (See pg. 74)

9. Provide on going assessment of vital signs and respiratory status.

NOTE: If suspected that seizure is secondary to narcotic overdose, see Toxicologic

Emergencies SOG (See pg. 80-82).



Revised: 4/05, 10/07, 3/08

74

RECTAL VALIUM ADMINISTRATION

Adult / Pediatric

Policy

ALS

In the emergency setting you may give VALIUM rectally if you cannot establish an

intravenous line. Rectal administration of VALIUM may prove advantageous with the

unconscious or pediatric patient or when IV access is impractical or not possible.

Procedure for Rectal VALIUM

1. Compute dosage

2. Confirm the indication for administration and dose

3. Remove the needle from the TB syringe for children or the 3ml syringe for adults.

4. Pull the plunger back to the desired amount

5. Insert the VALIUM needles into the hub (the part the needle connects with) of the

TB syringe for children or the 3ml syringe for adult dosing.

6. Inject the desired amount of VALIUM into the appropriate syringe (2) e.g. an older

child may exceed greater than the 1ml TB syringe can hold, a second TB syringe may

be required to accurately measure a dose of greater then 2ml.

7. Lubricate the tip of the syringe to be used for rectal administration.

8. Insert the syringe without the needle into the rectum.

NOTE: A 3-5ml syringe may be used for dosage greater then the 1mL that a

tuberculin syringe allows. It is acceptable in this circumstance to attach an over-the-

needle catheter (plastic portion only) and lubricate the catheter prior to rectal

insertion. Administration of diazepam too high into the rectum, may decrease its

anticonvulsant effect, because the drug may be absorbed differently and broken down

more quickly in the liver.

9. Push the plunger to expel the VALIUM into the rectum.

10.Withdraw the catheter and hold the patient’s buttocks together thus permitting

retention and absorption.



Revised: 4/05, 10/07, 3/08

75

STROKE

Adult / Pediatric

BLS


Limit scene time

C-spine control for unconscious patients with suspected trauma.

2. Protect airway, suction as necessary.

3. Maintain head and neck in neutral alignment. Do NOT flex the neck.

If BP >90 mmHg, elevate head of bed 15-30 degrees.

4. Obtain pulse oximetry. Capnography may be utilized.

5. Monitor and record neurological status using GCS and note any changes.

6. Assess patient for:

Facial Drop (have patient show teeth or smile)

Arm Drift (patient closes eyes and holds both arms out for 10 sec)

Speech (have patient say “you can’t teach an old dog new tricks”)


7. Obtain IV of Isotonic Solution at TKO for adults. Pediatrics IV of LACTATED


8. Obtain red or yellow top blood tube for hospital. Label with patient name, date of

birth (if available), time drawn, and initial.

9. INTUBATE if GCS < 8.



11. In the event of seizure activity, contact Medical Control immediately to determine

if sedation is required.



Revised: 4/05, 10/07, 3/08

76

COMA OF UNKNOWN ORIGIN / DRUG OVERDOSE

INTOXICATION

Adult / Pediatric

BLS

1. Ensure scene and personal safety.

2. Secure and maintain airway. Support ventilations with 100% Oxygen.

3. Pulse oximetry.

4. Obtain a thorough history from patient, family or friends.

5. Consider hypoglycemia in an unconscious or convulsing patient.

6. Safely obtain any substance or substance container of a suspected poison and

transport with the patient.


7. Obtain blood glucose level and draw a red or yellow top blood tube for hospital

testing. Label all blood tubes drawn with patient’s name, the date of birth (if

available), time of draw and your initials.

9. Intubate if necessary.




11. Adults: If intubation attempt is unsuccessful refer to the Intubation Using

Versed SOG (See pg. 57-58). If intubation continues to be unsuccessful, BVM to

ventilate and refer to the Translaryngeal Jet Ventilation SOG

(See pg. 162-163).





Revised: 4/05, 10/07, 3/08

77

COMA OF UNKNOWN ORIGIN / DRUG OVERDOSE / INTOXICATION


14. Medications:

If patient is conscious and can maintain gag reflex, administer ORAL

GLUCOSE.

a. Infants < 1 year old: hypoglycemia; DEXTROSE 12.5% 2-4ml/kg IVP

Note: Refer to pediatric drug dosing for DEXTROSE 25% and 12.5%

direction.

Pediatrics (1-8 years): DEXTROSE 25% 2-4ml/kg IVP or *GLUCAGON

half adult dose (0.5mg IM) is recommended for peds patients weighing

< 25kg or **younger than 6-8 yrs**.

NARCAN < 20kg 0.1mg/kg IV/IO

> 20kg 2mg dose IV/IO

Consider Sodium Bicarbonate for tricyclic ingestions.

SODIUM BICARBONATE 1 mEq/kg

c. Adults:

THIAMINE 100mg IV or IM

DEXTROSE 50% 50ml SLOW IVP

NARCAN 2mg IVP

SODIUM BICARBONATE 1mEq/kg IVP for tricyclic ingestion.




Revised: 4/05, 10/07, 3/08

78

SICKLE CELL EMERGENCIES

Adult / Pediatric

Sickle cell anemia is an inherited disorder of red blood cell production, so named because

the red blood cells become sickle-shaped when oxygen levels are low. Sickle cell crisis

can be life threatening.

Signs and symptoms of sickle cell disease may include, but is not limited to:

Increased weakness Aching Chest pain with shortness of breath

Bony deformities Fever Sudden severe abdominal pain

Arthralgia (joint pain) Icteric (jaundice of sclera)

BLS


2. Place on high flow oxygen to saturate hemoglobin.

ILS – in addition of BLS care

3. Initiate an IV of NORMAL SALINE at 100ml/hr unless contraindicated


4. Adults: Peds:

MORPHINE SULFATE 2-5mg’s MORPHINE SULFATE 0.05-0.10mg/kg

IV or SQ IV or SQ

Following the initial administration of Morphine contact Medical Control regarding

patient’s condition.

Adults: If respiratory depression occurs, consider NARCAN 2mg’s IV(preferred route),

may be repeated - 2mg dose IV to total of 10mg’s IVP. SQ/IM administration of

NARCAN may be considered in the event that an IV site is not obtained.

Child: If respiratory depression occurs following morphine administration give

NARCAN 0.01mg/kg initially. A subsequent dose of 0.1mg/kg may be administered if

the initial dose does not result in the desired degree of clinical improvement.



Revised: 4/05, 10/07, 3/08

79

ACUTE ABDOMINAL PAIN

Adult / Pediatric

BLS

1. Initial Medical Care:

STABLE: Alert, blood pressure within normal limits.

2. Contact Medical Control for pain intervention.

UNSTABLE: Altered sensorium and signs of hypoperfusion, e.g., low B/P, tachycardia,

ventilatory distress, delayed capillary refill. Transport as soon as possible.


3. Obtain large bore IV of LACTATED RINGERS or NORMAL SALINE:

Adult infuse at TKO

Pediatric infuse at 20ml/hr.

NOTE: Pediatrics: If shock present and unable to establish IV access with 3 sticks or

within 90 seconds initiate IO.

4. Contact Medical Control for additional direction.


5. Establish cardiac monitor

6. If suspected abdominal aortic aneurysm or ectopic pregnancy, contact Medical

Control as soon as possible.

7. If signs and symptoms of shock present, establish second IV.



Revised: 4/05, 10/07, 3/08

80

TOXICOLOGIC / POISONING EMERGENCIES

Adult / Pediatric

BLS

STABLE: Alert, blood pressure within normal limits


2. Consult Medical Control or Poison Control 1-800-222-1222 for specific treatment

to prevent further absorption.




4. Adults: If intubation attempt is unsuccessful refer to the Intubation Using

Versed SOG (See pg. 57-58). If intubation continues to be unsuccessful, BVM to


(See pg. 162-163).

UNSTABLE: Altered mental status, airway compromise, and/or hypoperfusion, e.g., low

B/P, tachycardia, ventilatory distress, delayed capillary refill.

BLS




3. GCS < 8 and evidence of airway compromise, INTUBATE.


4. Respiratory compromise or altered LOC:

Adult: Peds:

NARCAN 2mg IVP, May < 20kgNARCAN 0.1mg/kg IV/IO

repeat after 5 min. or 0.2 mg/kg ET

> 20kgNARCAN 2.0mg IV/IO

SODIUM BICARBONATE maximum dose of 2mg’s

1 mEq/kg for tricyclic ingestions SODIUM BICARBONATE 1 mEq/kg

IVP for tricyclic ingestion.



Revised: 4/05, 10/07, 3/08

81

TOXICOLOGIC / POISONING EMERGENCIES (cont.)

5. ORGANOPHOSPHATE POISONING Excessive body secretions:

S – Salivation (Excessive production of saliva)

L – Lacrimation (Excessive tearing)

U – Urination (Uncontrolled urine production)

D – Defication (Uncontrolled bowel movements)

G – Gastrointestinel Distress (Cramps)

E – Emesis (Excessive vomiting)

B – Breathing difficulty

A – Arhythmias

M – Myosis (Pinpoint pupils)

Adult: Peds:

ATROPINE 2mg rapid IVP. ATROPINE 0.02mg/kg (min 0.1mg)

Repeat every 5-15 min until rapid IV/IO. Repeat every 5-15 min

condition improves until condition improves.

6. Following medication administration bolus with 10mL NORMAL SALINE.

7. CARBON MONOXIDE POISONING

100% oxygen/NRB or BVM

Do not rely on pulse oximetry

Keep patient as quiet as possible to minimize tissue oxygen demand.

8. DO NOT INDUCE VOMITING, ESPSCIALLY IN CASES WHERE CAUSTIC

SUBSTANCE INGESTION IS SUSPECTED.

9. Contact medical control for specific information about individual toxic exposures

and treatments.

10. Treatment for toxic exposure may be instituted as permitted by medical control,

including the following:

• High-dose atropine for organophosphates

• Sodium bicarbonate for tricyclic antidepressants

• Glucagon for calcium channel blockers or beta-blockers

• Diphenhydramine for dystonic reactions

• Dextrose for insulin overdose

POTENTIAL EXPOSURES

● Burning overstuffed furniture = Cyanide

● Old burning buildings = Lead fumes and Carbon monoxide

● Pepto-Bismol like products = Aspirin

● Pesticides = Organophosphates & Carbamates

● Common Plants = Treat symptoms and bring plant/flower to ED



Revised: 4/05, 10/07, 3/08

82

TOXICOLOGIC / POISONING EMERGENCIES (cont.)

SMELLS

● Almond = Cyanide

● Fruit = Alcohol

● Garlic = Arsenic, parathion, DMSO

● Mothballs = Camphor

● Natural gas = Carbon monoxide

● Rotten eggs = Hydrogen sulfide

● Silver polish = Cyanide

● Stove gas = Think CO (CO and methane are odorless)

● Wintergreen = Methyl salicylate



Revised: 4/05, 10/07, 3/08

83

State of Illinois

Nerve Gas Auto-Injector Guidelines

________________________________________________________________________

Purpose

To provide Illinois EMS agencies with guidelines on the appropriate use of Mark 1 kits.

The Mark 1 kit contains antidotes to be used in instances of exposure to nerve agents

(Sarin, Soman, Tabun, VX) or to organophosphate agents (lorsban, Cygon, Delnav,

malathion, Supracide parathion, Carbopenthion).

Equipment

Each Mark 1 kit consists of two auto-injectors containing

Atropine Sulfate 2 mg in 0.7 ML

Pralidoxime Chloride (2 PAM) 600 mg in 2 ML

Key Provisions

Only those licensed EMS providers that are governed by the State of Illinois EMS Act

(210 ICLS 50 are authorized by any EMS Medical Director to utilize the special

equipment and medications needed in WMD incidents, including Mark 1 auto-injectors.

When appropriate conditions warrant, contact Medical Control. Other organized response

teams not governed by the EMS Act may use the Mark 1 auto-injectors on themselves or

other team members when acting under the Illinois Emergency Management Agency Act

(20 ILCS 3305).

Guidelines

The guidelines for the use of the Mark 1 kits were developed by the EMS Cap

Committee of the Illinois College of Emergency Physicians (ICEP). They were then

adopted by the Illinois Medical Directors, Illinois Department of Public Health and the

Mutual Aid Box Alarm System (MABAS) in the Illinois Terrorism Task Force to provide

guidance to EMS agencies and providers who are part of an EMS system.

There are 10 provisions in the guidelines:

1. To utilize these kits you must be an EMS agency or provider within an Illinois

EMS system and participate within an EMS disaster preparedness plan.

2. The decision to utilize the Mark 1 antidote is authorized by this State protocol.

3. At a minimum and EMS provider must be an Illinois EMT at any level including

First Responder with additional training in the use of the auto-injector.



Revised: 4/05, 10/07, 3/08

84

State of IllinoisNerve Gas Injector Guidelines

________________________________________________________________________

4. The Mark 1 kit is not to be used for prophylaxis. The injectors are antidotes, not a

preventative device. The Mark 1 kit may be self-administered if you become

exposed and are symptomatic. Exit immediately to the Safe Zone for further

medical attention.

5. Use of the Mark 1 kit is to be based on signs and symptoms of the patient. The

suspicion or identified presence of a nerve agent is not sufficient reason to

administer these medications.

6. Atropine may be administered IV or IM in situations where Mark 1 kits are not

available.

7. Auto-injectors are not to be used on children under 88 pounds (40 kg).

Pediatric Mark 1 injectors are currently being reviewed by the FDA.

8. If available, diazepam (Valium) or midazolam (Versed) may be cautiously given

under Medical Control direction or by Standard Operating Procedures (ALS see

pg. 73 Seizure/Status Epilepticus), if convulsions are not controlled.

9. When the nerve agents have been ingested exposure may continue for some time

due to slow absorption from the lower bowel. Fatal relapses have been reported

after initial improvement. Continual medical monitoring is mandatory.

10. If dermal exposure has occurred decontamination is critical and should be done

with standard decontamination procedures. Patient monitoring should be directed

to the signs and symptoms as with all nerve organophosphate exposures.

Continual medical monitoring and transport is mandatory.

RADIATION INJURIES



Revised: 4/05, 10/07, 3/08

85

Adult / Pediatric

BLS/ILS/ALS

1. FOLLOW DIRECTIONS OF THE HAZMAT COMMAND ON SCENE.

2. Pain management per appropriate medical or trauma SOG.

3. Contact Medical Control as soon as possible and indicate the following:

number of victims

medical status of victims.

source of radiation

amount and kinds of radioactivity present.

For assistance, 24-hour hotline numbers are available:

Argonne National Laboratory – Department of Energy

24-hour call – 630-252-4800

Illinois Department of Nuclear Safety

24-hour call – 217-785-0600

CHRONIC RENAL FAILURE



Revised: 4/05, 10/07, 3/08

86

DIALYSIS PATIENT EMERGENCIES

Adult / Pediatrics

BLS


2. No BP’s in same arm as graft or fistula

3. Control obvious hemorrhage from graft or fistula (arterial bleeding) with direct

pressure.


IVs should not be attempted on the extremity with a graft or fistula

When emergencies occur during dialysis, the staff may leave access needles in

place, clamping the tubing. If this is the only accessible site, request their

assistance to connect your IV tubing.

UNSTABLE: Altered mental status or signs of hypoperfusion, e.g., low B/P,

tachycardia, ventilatory distress, delayed capillary refill

1. If lungs clear, and hypotensive adults infuse 200ml fluid bolus. May repeat one

time if lungs clear and hypotension persists.

2. For pediatric patient contact Medical Control for fluid orders.


3. If signs of hypoperfusion, e.g. low B/P, tachycardia, delayed capillary refill, with

widened QRS complex:

DEXTROSE 50% 25Gm (50mL) IVP (potential hyperkalemia)

SODIUM BICARBONATE 1mEq/kg IVP (potential acidosis)

4. If unresponsive to fluid challenge or pulmonary edema present, treat per

Cardiogenic Shock SOG (See pg. 51).

CARDIAC ARREST:

5. Treat patient condition per appropriate medical SOP, with the following

additions:

DEXTROSE 50% 25Gm (50mL) IVP (potential hyperkalemia)

SODIUM BICARBONATE 1 mEq/kg IVP (potential acidosis)

CALCIUM CHLORIDE 10%/10ml IVP (potential hyperkalemia).

HEAT EMERGENCIES



Revised: 4/05, 10/07, 3/08

87

Adult / Pediatric

BLS/ILS/ALS

HEAT CRAMPS


2. Move patient to cool environment. Do NOT massage cramped muscles.

HEAT EXHAUSTION / HEAT STROKE

BLS/ILS/ALS

1. Remove as much clothing as possible to facilitate cooling.

2. Initiate rapid cooling.

Cold packs to lateral chest wall, groin, axilla, carotid arteries, temples,

behind knees.

Sponge or mist with cool water, and fan or cover body with wet sheet and

fan body.

Discontinue cooling if shivering occurs.

3. Check blood glucose level if available. If <80 adult, <60 children and infants,

treat per Diabetic/Glucose Emergencies SOG (See pg. 69.)

ALS/ ILS – in addition to BLS/ILS care

4. Obtain IV.

5. Adult: Peds:

IV FLUID BOLUS IV FLIUD BOLUS of LR 20ml/kg

of Normal Saline at 20ml/kg

6. If seizures occur, refer to Seizure SOG (See pg. 73).



Revised: 4/05, 10/07, 3/08

88

COLD EMERGENCIES

Frostbite and Hypothermia

Adult / Pediatric

BLS/ILS/ALS


2. Check blood glucose level if available. Treat per Diabetic/Glucose Emergencies

SOG (See pg. 69).

FROSTBITE:

3. Rapidly rewarm frozen areas with tepid water. Hot packs wrapped in a towel may

be used. Do NOT rub. Do NOT thaw if there is a chance of refreezing.

4. HANDLE SKIN LIKE A BURN. Protect with light, dry sterile dressings. Do not

let affected skin surfaces rub together.


5. Contact Medical Control for pain control intervention

BLS/ILS/ALS

MILD/MODERATE HYPOTHERMIA: Conscious or altered sensorium, shivering

6. Rewarm patient

a. Place patient in warm environment. Remove wet clothing.

b. Apply hot packs wrapped in towels to axilla, groin, neck, thorax. Wrap

patient in blankets.

7. Treat per Diabetic/Glucose Emergencies SOG (See pg. 69).

SEVERE HYPOTHERMIA: Poor muscle control or rigidity, simulating rigor mortis.

There will be NO shivering.

Sensorium: Confused, withdrawn, disoriented, or comatose.

BLS


2. Avoid unnecessary manipulation and rough handling.

3. Check pulse for 30-60 seconds. Anticipate bradycardia. If no pulse, begin CPR

and implement AED if available. Give one shock if advised.



Revised: 4/05, 10/07, 3/08

89

COLD EMERGENCIES: Frostbite and Hypothermia


4. Resume CPR.

5. Transport patient very gently to avoid precipitating Ventricular Fibrillation.

Maintain in supine position.

6. Check blood glucose level if available. Treat per Diabetic/Glucose Emergencies

SOG (See pg. 69).


7. INTUBATION, if indicated.

8. Obtain IV of NS TKO if veins accessible. (IO with NS for Peds at 20ml/hr if

unable to obtain IV access).


9. If rhythm V-fib defibrillate once at 360 Joules (or equivalent biphasic

manufacturer recommendation)

10. Pediatric patients – Defibrillation at 2/Joules/kg.

11. If conversion refer to appropriate cardiac rhythm procedure.



Revised: 4/05, 10/07, 3/08

90

PSYCHOLOGICAL EMERGENCIES

Adult and Pediatrics

BLS/ILS/ALS

1. Assess SCENE AND PERSONAL SAFETY. Call law enforcement personnel to

scene, if needed. Above all, DO NOTHING TO JEOPARDIZE YOUR OWN

SAFETY.

2. Provide Initial Medical Care; as situation warrants.

Determine and document if patient is a threat to self or others, or if patient

is unable to care or provide for self. Do not leave patient alone.

Exception: caregiver is in jeopardy.

Protect patient from harm to self or others.

ALS care may be waived in favor of basic transport if patient is

uncooperative or dangerous to self or provider.

3. Verbally attempt to calm and reorient the patient to reality. Do not participate in a

patient’s delusions or hallucinations.

4. If patient is combative, contact Medical Control to obtain restraint order.

5. Consider medical etiologies of behavioral disorder and treat according to

appropriate SOG:

Hypotension

Hypoxia

Substance Abuse/Overdose

Neurologic disease (Stroke, intracerebral bleed, head injury, etc.)

Metabolic imbalance (hypoglycemia, thyroid disease, etc.)

Seizure/postictal

6. Consult Medical Control physician from the scene in ALL instances where a

refusal of transport is being considered.



Revised: 4/05, 10/07, 3/08

91

START TRIAGE PLAN

Adult / Pediatric

The START plan (Simple Triage & Rapid Treatment) was developed to be used in the

event of a mass casualty incident (MCI). This plan allows Rescuers, EMTs &

Paramedics to triage a patient at a MCI in 60 seconds or less. The plan is based on three

observations of each patient:

1. Respiration

2. Circulation

3. Mental Status

START principles:

The START plan calls for rescuers to correct the main threats to life, obstructed airways

and severe arterial bleeding. The START plan utilizes the METTAG Triage Card which

classifies patients into four different areas for treatment. It is a system that quickly and

accurately categorizes victims into treatment groups. The plan is simple to learn and

simple to retain. It is extremely useful in the MCI setting by maximizing the efficiency

of the rescuers.

The Triage Team must evaluate and place the patients into one of four categories.

Deceased (BLACK) – No ventilations present even after attempting to reposition the

airway.

Immediate (RED) – Ventilations present only after repositioning the airway. Also place

into this category if respiratory rate is greater than 30 per minute. Delayed capillary refill

(greater than two seconds) or the patient is unable to follow simple commands.

Delayed (YELLOW) – Any patient who does not fit into either the immediate or minor

categories.

Minor (Green) – Separate from the general group at the beginning of the triage

operation. Also known as the “walking wounded”. Direct patients away from the scene

to a designated safe area. Use these patients to control bleeding and assist in airway

maintenance of immediate patients.



Revised: 4/05, 10/07, 3/08

92

START Procedures:

RESPIRATORY

Every patient will be assessed for ventilatory rate & adequacy.

If a patient is not breathing, check for foreign objects causing obstruction in the

mouth. Remove loose dentures.

Reposition the head, using cervical spine precautions if this does not delay

assessment.

If the above efforts do not initiate respiratory efforts, TAG THE PATIENT

BLACK.

If the victim’s respiratory rate is greater then 30 per minute, TAG THE PATIENT

RED.

Victims who have respirations less than 30 per minutes are NOT TO BE

TAGGED AT THIS TIME. ASSESS THESE PATIENTS FOR PERFUSION.

PERFUSION

The best method to assess perfusion is capillary nail bed refill.

Press nail beds or lips, then release. Color should return to the area within two

seconds.

If it takes more than two seconds, the patient is showing signs of inadequate

perfusion and MUST BE TAGGED RED.

If the color returns within two seconds, the patient is NOT TAGGED UNTIL

THE MENTAL STATUS IS ASSESSED.

If capillary refill can not be assessed, palpate the radial pulse. In most cases, if

the radial pulse can not be felt, the systolic blood pressure will be below 80

mmHg.

Hemorrhage control techniques will be incorporated into this section. Control

significant bleeding by direct pressure and elevate the lower extremities.

Utilize the “walking wounded” to assist the hemorrhage control on himself or

another patient.



Revised: 4/05, 10/07, 3/08

93

MENTAL STATUS

The mental status evaluation is used for patient whose respirations and perfusion

are adequate. To test mental status, the rescuer should ask the victim to follow a

simple command such as, “open and close your eyes”, or “squeeze my hands”.

If the patient can not follow these commands, then TAG THE PATIENT RED.

If the patient can follow these commands, TAG THE PATIENT GREEN.

Only after all patient have been triaged can patients be treated. The above

procedures should take no more than 60 seconds per patient.

TRIAGE TAGS

Triage tags are completed during transportation to the hospital or in the treatment

area if there is time. To fill out the tag properly, follow these instructions:

• enter time of triage

• enter date

• enter other important information (history, treatment, etc….)

• enter vital signs and the time taken in indicated areas

• enter injuries on the diagram

• enter name (if able to obtain)

• enter address with city and state (if able to obtain)

• EMT’s rendering treatment will enter IV’s, drugs, and other treatments

• tear off all colored areas below the determined priority and retain

• attach tag SECURELY and in a CLEARLY VISIBLE area.

The corner of the tag marked with a cross is removed in the treatment section

prior to moving to a medical facility. These should be given to the Sector Officer

in that area.

The corner marked with an ambulance is to be removed prior to the actual

removal of the patient from the treatment area to a medical facility. It is to

retained by the crew until the end of the MCI. These are then given to the Sector

Officer in charge of Transportation.



Revised: 4/05, 10/07, 3/08

94

INITIAL TRAUMA CARE

Adult / Pediatrics

BLS

SCENE SIZE-UP

Assess and secure scene safety

Universal blood and body secretion precautions (BSI) on all patients.

If a potential crime scene, make efforts to preserve integrity of possible

evidence

Anticipate potential injuries based on the mechanism of energy transfer.

INITIAL ASSESSMENT:

1. AIRWAY/C-SPINE: Spinal motion restriction in age appropriate device as

indicated. Chin lift or modified jaw thrust. Oral airway as necessary and suction

as needed. Vomiting and seizure precautions.

2. BREATHING/VENTILATION: expose chest. Observe for adequate breathing

After airway is established.

Auscultate breath sounds

Note respiratory rate, rhythm & efforts of respiration

Chest expansion

Oxygen 4-6 L/NC. If acute, altered mental status, hemodynamically

Unstable (low B/P, Tachycardia and delayed capillary refill) or signs of

Hypoxemia.

Criteria:

100% oxygen/NRM or assist with BVM.

3. CIRCULATION: assess cardiovascular status.

Assess heart rate, peripheral and central pulses

Apparent hydration

Skin color and temperature

Obtain BP with appropriate size cuff

If no carotid pulse – Traumatic Arrest SOP

Control all external hemorrhage

Determine if load and go situation

NOTE: Evaluate using Glasgow Coma Scale, AVPU and pupil assessment

Obtain and record Blood Glucose level.

4. EXPOSURE:

Expose patient as appropriate as assessment

Prevent heat loss



Revised: 4/05, 10/07, 3/08

95

INITIAL TRAUMA CARE

Adult / Pediatrics (cont.)

5. Pain assessment (0-10 scale or Wong Baker Face Scale pg. 6)


6. If ILS/ALS and intubation is required, utilize in-line or nasotracheal technique

unless contraindicated.

7. If circulatory support required, NORMAL SALINE IV/IO fluid bolus of 20

ml/kg.


8. Adults: If unable to secure airway by other means, Refer to the Intubation Using

Versed SOG (See pg. 57-58). If intubation continues to be unsuccessful BVM


(See pg. 162-163).

STABLE

IVs: Inadequate perfusion: Obtain large bore IVs enroute. Infusion rate: Adults

infuse Isotonic Solution at TKO. Pediatric infuse LACTATED

RINGERS at 20ml/hr. Consider IO if pediatric patient and criteria met.

UNSTABLE

Adequate perfusion: Attempt large bore IV enroute. Fluid bolus of

Isotonic Solution to maintain BP 90-100 systolic.

Consider PASG if pelvic or bilateral femur fracture

Pediatric: If there is evidence of shock (low B/P, tachycardia and delayed

capillary refill) 20mL/kg bolus should be administered x1. Neonate IV

infuse LACTATED RINGERS at 10ml/kg. Contact Medical Control as

soon as possible for additional orders.


Monitor ECG as required per ITLS/PHTLS guidelines

If tension pneumothorax, perform CHEST DECOMPRESSION to affected side

per Chest Decompression SOG (See pg. 164).



Revised: 4/05, 10/07, 3/08

96

INITIAL TRAUMA CARE

Adult / Pediatrics (cont.)

LOAD & GO SITUATIONS

There are circumstances that demand hospital care to allow stabilization of a patient. It

may be necessary for the prehospital provider to abridge certain procedures described in

Region 4 Standard Operating Guidelines. When critical circumstances require urgent

transport, it is necessary to document thoroughly the rationale for leaving the scene and

deviating from Region 4 Standard Operating Guidelines. The emphasis is on rapid patient

packaging and limited on-scene times as is possible. Prolonged extrication times greater

than 10 minutes should be accounted for in the patient documentation.



Revised: 4/05, 10/07, 3/08

97

PEDIATRIC TRAUMA

< 16 YEARS OF AGE

BLS

I. ASSESSMENT

1. Provide rapid cardiopulmonary assessment.

2. Assess adequacy of airway and breathing with simultaneous cervical spine

immobilization.

3. Assess cardiopulmonary system with attention to adequacy of perfusion

(i.e., mental status, presence, location, and character or pulses; skin

moisture, temperature, and capillary refill)

4. Briefly assess neurologic function (i.e., level of consciousness, pupils,

gross motor function)

5. Obtain brief history of incident and mechanism of injury

6. If patient is stable, obtain vital signs and SAMPLE history.

II. TREATMENT

1. Initial Trauma Care

2. Contact Medical Control


If signs of shock, refer to Hypovolemic and Distributive Shock SOG (See pg.

98-99) or Asystole or Pulseless Electrical Activity SOG (See pg. 44) (e.g.

hypotension, tachycardia, poor capillary refill), initiate:

IV fluid bolus 20ml/kg of LACTATED RINGERS

Neonates 10ml/kg of LACTATED RINGERS

Repeat fluid bolus per ITLS/PHTLS guidelines


Monitor ECG as required per ITLS/PHTLS guidelines.



Revised: 4/05, 10/07, 3/08

98

HYPOVOLEMIC AND DISTRIBUTIVE SHOCK

Adult / Pediatric

A. ADULT: Signs and Symptoms

a. Pulse > 100 (except in neurogenic shock)

b. Systolic BP < 90 mmHg (late sign of shock)

c. Diaphoresis, restlessness, anxiety and thirst

d. Rapid, shallow respirations (except if neurogenic shock)

e. Patient deviation from “normal” mental state.

f. Peripheral signs of shock (pale/cool/clammy/mottling/cap refill >2 sec.)

g. Obvious signs of bleeding: external or internal

h. Oxygen saturation < 94%

B. PEDIATRIC: Signs and Symptoms

a. Normal Pediatric Vital Signs (EMSC)

Newborn 1 year 3 years 6 years 10 years 15 years

Pulse 100-160 90-140 80-120 70-115 60-110 70-90

Resp rate 30-60 20-30 20-30 18-25 15-20 15-20

Systolic BP 50-90 80-100 80-110 80-110 90-120 100-130

b. Signs of distress:

i. Respiratory rate > 60

ii. Heart rate < 5yrs. old: < 80 or > 180

> 5yrs. old: < 60 or > 160

iii. Indicators of Hypoperfusion in Children

Respiratory difficulty

Cyanosis despite Oxygen administration

Central pallor/cyanosis or coolness

Hypotension (Late/Ominous sign)

Bradycardia (late sign)

Weak, thready or absent peripheral pulse

No palpable BP

Decreasing LOC

Oxygen saturation < 94%

C. Treatment

a. Control HEMMORHAGE

- Apply direct pressure

- Elevate the bleeding extremity.

- If wound continues to bleed despite use of direct pressure and

elevation. Apply pressure over the proximal pressure point (pulse

point).



Revised: 4/05, 10/07, 3/08

99

HYPOVOLEMIA AND DISTRIBUTIVE SHOCK


NOTE: As long as a fracture remains unstable, the bone ends will

move and continue to injure partially clotted vessels, therefore,

stabilizing a fracture and decreasing movement is a high priority for

bleeding control associated with fractures.

b. Oxygen high flow per non-rebreather or intubation if necessary. Must

administer 100% to all patients and be prepared to assist ventilations.

MAINTAIN C-SPINE IN THE TRAUMA PATIENT BEFORE

ATTEMPTING INTUBATION. Adults: If ALS refer to the

Intubation Using Versed SOG (See pg. 57-58). If intubation

continues to be unsuccessful BVM ventilate and refer to the

Translaryngeal Jet Ventilation SOG (See pg. 162-163).

c. Consider MAST/PASG contact Medical Control for order to inflate. If

order to inflate is received inflate to maintain systolic BP of 90-

100mmHg. DO NOT use abdominal section in pediatric patients.

d. Transport immediately.

e. ENROUTE TO HOSPITAL:

1. Adult: Obtain 2 large bore IVs with NS/LR. Rapidly infuse a

bolus of 20ml/kg and reassess the patient.

2. Repeat bolus as necessary reassessing the patient after each

bolus.

3. PEDIATRIC: Obtain IV access with LR

i. Fluid bolus for shock is 20ml/kg of LR and reassess for

peripheral perfusion. This may be repeated and

followed by reassessment.

ii. Maintain IV at approximately 20ml/hr between boluses.

Neonates 10ml/kg

iii. If shock is present and IV access cannot be

accomplished within 3 sticks or 90 seconds, IO route

should be obtained.

f. Check vital signs frequently and monitor cardiac rhythm.

g. Watch closely for changes

h. Notify Medical Control and/or receiving hospital as soon as possible.

i. Document Glasgow Coma Scale/Revised Trauma Score on EMS

report.

**** NOTE: If a critical trauma situation is found and rapid transport is indicated,

contact Medical Control for guidance.****



Revised: 4/05, 10/07, 3/08

100

GLASGOW COMA SCALE

ADULT GLASGOW COMA SCALE

Spontaneous 4

To voice 3

To pain 2EYE OPENING

None 1

Oriented 5

Confused speech 4

Inappropriate words 3

Incomprehensive sounds 2

VERBAL RESPONSE

None 1

Obeys commands 6

Localizes pain 5

Withdraws to pain 4

Abnormal flexion to pain 3

Abnormal extension 2

MOTOR RESPONSE

None 1

TOTAL GLASGOW COMA SCORE: (3-15)

ADULT REVISED TRAUMA SCORE

GCS 13-15 4

GCS 9-12 3

GCS 6-8 2

GCS 4-5 1

Glasgow Coma Score

Conversion Points

GCS 3 0

10-29 4

> 29 3

6-9 2

1-5 1

Respiratory Rate

0 0

> 89 4

76-89 3

50-75 2

1-49 1

Systolic Blood Pressure

0 0

TOTAL REVISED TRAUMA SCORE: 0-12 Points



Revised: 4/05, 10/07, 3/08

101

PEDIATRIC COMA SCALE / TRAUMA SCORE

PEDIATRIC GLASGOW COMA SCALE (PGCS)

> 1 Year < 1 Year Score

Spontaneously Spontaneously 4

To verbal command To shout 3

To pain To pain 2

EYE

OPENING

No response No response 1

Obeys Spontaneous 6

Localizes pain Localizes pain 5

Flexion-withdrawl Flexion-withdrawl 4

Flexion-abnormal (decorticate rigidity) Flexion-abnormal (decorticate rigidity) 3

Extension (decerebrate rigidity) Extension (decerebrate rigidity) 2

MOTOR

RESPONSE

No response No response 1

> 5 Years 2-5 Years 0-23 months

Oriented Appropriate

words/phrases

Smiles/coos appropriately 5

Disoriented/confused Inaappropriate

words

Cries and is consolable 4

Inappropriate words Persistent cries

and screams

Persistent inappropriate crying and/or

screaming

3

Incomprehensible

sounds

Grunts Grunts, agitated, and restless 2

VERBAL

RESPONSE

No response No response No response 1

TOTAL PEDIATRICE GLASGOW COMA SCORE: (3-15)

PEDIATRIC TRAUMA SCORE (PTS)Component + 2 + 1 - 1

Size Child/adolescent > 20 kg Toddler 11-20 kg Infant < 10 kg

Airway Normal Maintainable Unmaintained or

Intubated

Systolic BP > 90 mmHg 50 – 90 mmHg < 50 mmHg

CNS Awake Obtunded/Lost consciousness Coma/Unresponsive

Skeletal Injury None Closed Fracture Open/Multiple Fractures

Open Wounds None Minor Major/Penetrating

If a proper sized blood pressure cuff is not available, blood pressure can be rated as:

+2 = palpable at wrist, +1 = palpable at groin, -1 = no pulse palpable

A PTS of < 8 indicates the need for evaluation at a Trauma Center.

Score range is from -6 to +12.



Revised: 4/05, 10/07, 3/08

102

RAPID CARDIOPULMONARY ASSESSMENT TOOL

I. Airway patency

1. Able to maintain independently

2. Requires adjuncts/assistance to maintain

II. Breathing

1. Rate

2. Mechanics

a. Retractions

b. Grunting

c. Accessory muscles

d. Nasal flaring

3. Air Entry

a. Chest expansion

b. Breath sounds

c. Stridor

d. Wheezing

e. Paradoxical chest movement

4. Color

III. Circulation

1. Assess for signs of circulation

2. Heart rate

3. Blood Pressure

a. volume/strength of central pulses

4. Peripheral Pulses

a. present/absent

b. volume/strength

5. Skin Perfusion

a. cap refill time

b. temperature

c. color

d. mottling

6. CNS perfusion

a. responsiveness

1. awake

2. responds to voice

3. responds to pain

4. unresponsive

b. recognizes parents

c. muscle tone

d. pupil size

e. posturing



Revised: 4/05, 10/07, 3/08

103

HEAD AND SPINE INJURIES

Adult / Pediatric

BLS


Apply cervical spine immobilization

Keep patient flat

Take vomiting and seizure precautions

Evaluate using Glasgow Coma Scale (GCS)

2. If glucose is <80 adult, <60 children and infants: Treat per Diabetic/Glucose

Emergencies SOG (See pg. 69).

3. Special Consideration: Mild hyperventilation is 4 ventilations above the normal

rate. Consider performing mild hyperventilation ONLY IF suspected impending

herniation (non-reactive/unequal pupils or posturing).

HEAD INJURIES

4. Ventilate with 100% oxygen

Adults: Peds:

16-20 adequate breaths Infants < 12 months 24-28 BPM

Children 1yr-15 yrs 20-24 BPM

5. Rapid transport and contact Medical Control enroute




ALTERED SENSORIUM

7. If GCS < 8, INTUBATE using in-line procedure. If unable to intubate, follow

Laryngeal Mask Airway procedure or assist ventilate per BVM.

8. Obtain and record blood glucose level, if available. Refer to Diabetic/Glucose

SOG (See pg. 69) for treatment guidelines.


9. Adults: If intubation attempt is unsuccessful refer to the Intubation using Versed

SOG (See pg. 57-58). If intubation continues to be unsuccessful, BVM ventilate

and refer to the Translaryngeal Jet Ventilation SOG (See pg. 162-163).

10. If seizure activity, treat per Seizure SOG (See pg. 73).



Revised: 4/05, 10/07, 3/08

104

HEAD AND SPINE INJURIES


SPINAL INJURIES

11. If signs of neurogenic shock.

Adults: Peds:

BP < 90 mmHg systolic and IV bolus LR 20ml/kg

pulse < 60 IV fluid challenge Contact Medical Control for additional

in 20ml/kg increments as needed. fluid orders



Revised: 4/05, 10/07, 3/08

105

CHEST INJURIES

Adult / Pediatric

BLS


Increase oxygen to 100% by NRB mask or assist with BVM.

2. Rapid transport to closest facility.

SUCKING CHEST WOUND/OPEN PNEUMOTHORAX

3. Apply occlusive dressing taped on three sides to create a flutter valve

4. If patient deteriorates, remove dressing temporarily to allow air to escape


5. Obtain IV of Isotonic Solution at TKO for adults. Pediatrics IV of LACATED

RINGERS with infusion rate of 20 ml/hr.

NOTE: Adults: If ALS and unsuccessful intubation refer to the Intubation Using

Versed SOG (See pg. 57-58). If intubation continues to be unsuccessful BVM


(See pg. 162-163).

FLAIL CHEST

6. If respiratory distress, appropriately ventilate with 100% oxygen via BVM to

provide internal splinting.




8. Intubate per ITLS/PHTLS guidelines.

TENSION PNEUMOTHORAX






Revised: 4/05, 10/07, 3/08

106

CHEST INJURIES (cont.)

Adult / Pediatric

10. Suspect a tension pneumothorax when patient presents with severe respiratory

distress or difficulty ventilating, hypotension, distended neck veins, absent breath

sounds on the involved side, and/or tracheal deviation.

11. Assess for need of pleural decompression on affected side

Adult:

14-16 ga x 2”-2 ¼ “ angiocath or use chest decompression kit as available.

Refer to Chest Decompression SOG (See pg. 164).

Pediatric Chest Decompression Chart

Procedure

Age (Yr) Size (kg) IV Needle Decompression

< 1 < 10 20g 20g

1-5 10-20 18g 18g

5-12 20-40 18-16g 16g

> 12 > 40 14-16g 14g

12. Monitor for Pulseless Electrical Activity, if present refer to Pulseless Electrical

Activity SOG (See pg. 44-45).



Revised: 4/05, 10/07, 3/08

107

TRAUMATIC ARREST

Adult / Pediatric

BLS

1. Provide Initial Medical and Trauma Care

2. If obviously dead, e.g., pulseless, apneic, contact Medical Control immediately

for direction.

3. If injury is incompatible with life, initiate treatment (i.e., massive brain matter

visible, multiple amputations, exsanguination) contact Medical Control

immediately.





5. If patient experiences loss of pulses under direct paramedic observation while

enroute to hospital; evaluate for need of:

1. Pleural decompression in accordance with ITLS/PHTLS guidelines for

Tension Pneumothorax

2. Refer to appropriate cardiac arrest SOG (e.g. PEA, V-Tach, etc.)



Revised: 4/05, 10/07, 3/08

108

OPHTHALMIC EMERGENCIES

Adult / Pediatric

BLS/ILS/ALS

1. Provide Initial Trauma Care

Assess pain on a scale of 0-10 or Wong Baker’s Face Scale (See pg. 6)

Quickly obtain gross visual acuity in each eye: light

perception/motion/acuity.

Discourage patient from sneezing, coughing, straining, or bending at

waist.

Elevate head of cot or backboard semi-Fowlers unless contraindicated

Suction must be available for vomiting precautions

Call Medical Control for pain management orders

CHEMICAL SPLASH/BURN

2. Immediately irrigate affected eye(s) using copious amounts of saline. Continue

irrigation while enroute to hospital.

3. Do not contaminate the uninjured eye during eye irrigation.

CORNEAL ABRASIONS

4. Patch both eyes

PENETRATING INJURY/RUPTURED GLOBE

Do not remove impaled objects; do not irrigate eye

Avoid any pressure on injured eye. Cover with cup, metal or plastic protective

shield.

Patch both eyes.



Revised: 4/05, 10/07, 3/08

109

BURNS

Adult / Pediatric

BLS


2. Evaluate depth of burn and estimate extent using rule-of-nines or palmar method

(patient’s palm = 1% of BSA). Assess need for transport to Burn Center.





4. For pain control refer to Pain Protocol SOG (See pg. 11-12).

THERMAL BURNS

5. If burned area < 10% BSA:

Cool burned area for no longer than 2 minutes with water or saline if burn

occurred within past 15 minutes.

6. DO NOT break blisters. Cover burn wounds with DRY sterile dressings.

7. Open dry sheet on stretcher before placing patient for transport. Cover patient

with dry sheets and blanket to maintain body temperature.

INHALATION BURNS

Note presence of wheezing, hoarseness, stridor, carbonaceous (black)

sputum/cough, singed nasal hair, eyebrows/lashes.

Oxygen at 100% non-rebreather mask or assist ventilations with BVM. If ILS,

INTUBATE if respiratory distress. Adults: If ALS, and unsuccessful intubation,

refer to the Intubation Using Versed SOG (See pg. 56-57). If attempted

intubation remains unsuccessful refer to Translaryngeal Jet Ventilation SOG

(See pg. 162-163) for adults.

For wheezing, if ALS consider:

Adults: Peds:

ALBUTEROL 2.5mg (3mL) Age 8 or < ALBUTEROL 1.25

May repeat x 1 (1.5mL) May repeat x 1.

ELECTRICAL BURNS

Immobilize as indicated.

If ALS assess ECG for dysrhythmias and treat according to appropriate SOP

Assess for wounds, including neurovascular status.

Cover wounds with dry sterile dressings (cooling not necessary)

BURNS (cont.)



Revised: 4/05, 10/07, 3/08

110

Adult / Pediatric

CHEMICAL BURNS

Wear protective covering

If powdered chemical, brush away excess. Remove clothing if possible.

Irrigate with copious amounts of water or saline ASAP and continue irrigation

during transport.

MUSCULOSKELETAL INJURIES



Revised: 4/05, 10/07, 3/08

111

Adult / Pediatric

BLS/ILS/ALS


2. Immobilize and/or splint above and below the injury. If pulses are lost after

applying a traction splint, leave the splint in place. Do not release traction.

Notify Medical Control of the change in status.

3. Elevate extremity and/or apply cold pack after splinting when appropriate.





4. For relief of pain: Refer to pain management protocol.

AMPUTATIONS/DEGLOVING INJURIES


2. If amputation is incomplete, stabilize with bulky dressing.

3. If uncontrolled bleeding continues after attempting to control with direct pressure

consider tourniquet above amputation as close as possible to the injury. Note time

of tourniquet application. DO NOT release tourniquet once applied.

4. Care of amputated parts:

Clean wound surface. DO NOT pick out embedded particles. Remove

large particles from the surface with sterile dressing when possible.

Wrap in saline-moistened gauze or towel. Place in plastic bag and seal.

DO NOT submerge tissue in water or saline without plastic covering.

Place plastic bag in second container filled with ice water or cold water.

OR, place on cold packs and bring with patient to the hospital, if unable to

place in plastic and immerse.

Label bag with name, date and time.





6. For relief of pain: Refer to Pain Protocol SOG (See pg. 11-12).



Revised: 4/05, 10/07, 3/08

112

MUSCULOSKELETAL INJURIES


CRUSH SYNDROME

BLS


2. Assess for injury and immobilize as needed. Check for distal vascular, motor and

sensory function.

3. Monitor for tachycardia, restlessness, and increased respiratory rate.


4. Obtain IV of Isotonic Solution at

Adults: Peds:

IV fluid bolus in 20ml/kg IV fluid bolus LR 20ml/kg

Repeat bolus until symptoms Contact Medical Control for additional fluid

resolved, unless contraindicated. orders


5. Apply ECG monitor prior to extrication and obtain baseline strip.

Signs and symptoms of crush syndrome may include:

Tachycardia, restlessness, increased respiratory rate, widened QRS, PR interval,

or peaked T waves.

6. For relief of pain: Refer to Pain Management SOG (pg.11-12)



Revised: 4/05, 10/07, 3/08

113

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden Infant Death Syndrome is the sudden, unexpected death of an apparently healthy

infant under one year of age, which remains unexplained after a thorough postmortem

evaluation. Including performance of a complete autopsy, examination of the death scene,

and review of the clinical history.

A. What SIDS is not:

1. Not caused by external suffocation

2. Not caused by vomiting or choking

3. Not contagious

4. Does Not cause pain or suffering to the infant

5. Can Not be predicted

6. Can Not be prevented

B. How to distinguish between SIDS and Child Abuse or Neglect

SIDS CHILD ABUSE/NEGLECT

Incidence:

Deaths: 3,000/year in the US

When: More frequent in winter months

Incidence:

Deaths: 2000 to 5000 die annually in the

US

When: No Seasonal Difference

Physical Appearance:

No external signs of injury

“Natural” appearance of death

- Lividity-settling of blood: Frothy

drainage from nose/mouth

- Small marks (e.g. diaper rash) look

more severe

- Cooling/rigor mortis-takes place

quickly in infants (approx. 3 hours)

Purple mottled markings on the head and

facial area

Appears to be well-developed baby, though

may be small for age

Other siblings appear to be normal and

healthy

Normal hydration and nutrition

Physical Appearance:

Visible signs of injury (Fx., bruises, burns,

cuts, head trauma, scars, welts, wounds)

May be obviously malnourished

Other siblings may show patterns of

injuries

NOTE: As a Healthcare Provider you are considered a mandated provider. What this

means is that you are required by law to report suspected child abuse and maltreatment

immediately when you have reasonable cause to believe that a child known to you in

your professional or official capacity may be abused or neglected child. You may do this

by calling the DCFS hotline at: 1-800-252-2873 or 1-800-25ABUSE.



Revised: 4/05, 10/07, 3/08

114

SUDDEN INFANT DEATH SYNDROME (SIDS) (cont.)

May Initially Suspect SIDS When: May Initially Suspect Abuse:

All the above characteristics appear All of the above characteristics appear

to be accurate to be accurate

PLUS PLUS

Parents say that the infant was well Parents’ story does not “sound right” or

and healthy when put to cannot account for all injuries on

sleep (last time seen alive) infant

NOTE: THE DETERMINATION OF WHETHER THE CHILD IS OR IS NOT A

SIDS VICTIM IS THE RESPONSIBILITY OF THE MEDICAL

EXAMINER OR MEDICAL CORONER. IT IS NOT THE

RESPONSIBILITY OF THE FIRST RESPONDER.

ONLY AN AUTOPSY CAN CONCLUSIVELY DETERMINE SIDS.

C. When a child is apneic and pulseless:

1. All resuscitation measures should be carried out immediately.

2. Obtain accurate information in a non-threatening manner.

3. Note how the child was found and the surroundings.

D. Keep in mind the parent’s reactions may range from a numb silence to a violent

hysteria.



Revised: 4/05, 10/07, 3/08

115

SUSPECTED ABUSE OR NEGLECT

CHILD, DOMESTIC, SEXUAL, ELDER

Adult / Pediatric

BLS/ILS/ALS

1. Provide Initial Medical/Trauma Care

2. Treat obvious injuries per appropriate SOG

3. Perform history, physical exam, scene survey as usual.

4. Document findings on run sheet:

Child interactions with parents and/or caregivers

Note: Discrepancies in parents history of injuries and child(s).

SUSPECTED CHILD ABUSE/NEGLECT:

5. Transport. Report your suspicion to ED staff upon arrival

Contact Medical Control if parent or legal guardian refusing care

6. Notify Department of Children and Family Services (DCFS) at 1-800-25-ABUSE

(24 hour phone line)

SUSPECTED DOMESTIC/SEXUAL:

Provide victims of suspected abuse information on services available.

Encourage them to seek medical attention.

If patient is victim of suspected sexual abuse and < 18 years of age, DCFS must

be contacted.

SUSPECTED ELDER ABUSE HOTLINE:

Notify Department of Aging 1-800-252-8966 (daytime hours) or 1-800-279-0400

(after hours, weekends/holidays).

Nursing Home patients IDPH 1-800-252-4343

SUSPECTED SEXUAL ASSAULT:

A. Assess and prioritize and treat the patients medical needs.

B. When the sexual assault has occurred at the location of the call treat the

site as a crime scene and preserve any evidence.

C. Notify law enforcement.

D. Encourage the victim to allow transport to a hospital and provide the

emergency department a medical treatment history.

E. Document the patients history, physical exam and scene survey on the run

sheet. Do not document suppositions.



Revised: 4/05, 10/07, 3/08

116

RAPE / SEXUAL ASSAULT

Sexual assault is an attack against a person that is sexual in nature, the most common of

which is rape.

EMS personnel may be called on to treat a victim of sexual assault, molestation, or actual

or alleged rape cases. Such cases mandate professionalism, tact, kindness and sensitivity.

Patient Care

1. Whenever possible a female rape victim should be given the option of being

treated by a female paramedic to abate the hindrance of an assessment and for the

patient’s psychological well-being.

2. Determine if the victim is physically injured and treat accordingly (limit physical

exam to a brief survey for life threatening injuries.

3. Do not attempt to elicit information regarding the assault.

4. Do not present as judgmental.

5. Protect the victim from the judgment of others on scene.

6. Remember the location is considered a crime scene. Preserve evidence.

7. Do not cut through any clothing or throw away anything from the scene.

8. Place bloodstained articles in separate paper-not plastic bags (if possible obtain an

evidence bag from police).

9. Gently persuade the patient to not clean themselves up.

10. Should the victim decline transport offer to call a friend or relative who can stay

with them.

11. Keep documentation concise and record only what the patient stated in their own

words. Use quotation marks to indicate that the report is the patient’s version of

events.

12. Do not insert your own opinion or offer any conclusions regarding the event.

13. Record all observations that the physical exam elicits and the condition of

clothing.

ILS/ALS

Follow appropriate Regional SOG as physical exam dictates.



Revised: 4/05, 10/07, 3/08

117

TRAUMA IN PREGNANCY

BLS

1. Provide Initial Trauma Care

2. Be aware that the mother may appear stable, but the fetus may be in jeopardy.

3. Visualize externally for vaginal bleeding, leaking amniotic fluid, or crowning.

Assess for fetal movements and uterine contractions.

4. Elevate the right side of backboard 20-30°. This allows placement of the patient

on left side to reduce pressure in inferior vena cava.

5. If CPR indicated, place patient flat on back with right hip elevated with blanket or

pillows to reduce pressure on the inferior vena cava. Follow appropriate SOG or

guidelines per ITLS/PHTLS.

7. Notify Medical Control ASAP to allow mobilization of appropriate hospital

personnel.


7. Obtain IV of Isotonic Solution at TKO unless condition indicates the need for

fluid bolus. (e.g. signs of shock).





Revised: 4/05, 10/07, 3/08

118

HEMORRHAGE IN PREGNANCY / OBSTETRICAL COMPLICATIONS

A pregnant woman does not have to be in labor to have excessive bleeding. Bleeding in

early pregnancy may be due to miscarriage. If the bleeding occurs in late pregnancy it

may be due to problems involving the placenta.

BLS

1. Provide Initial Medical Care:

Oxygen at 100% by NRB mask or assist with BVM

2. Treat for shock as indicated by signs and symptoms.

Keep patient warm

Massage the fundus (uterus)

Allow infant to nurse

Monitor vital signs at least every 5 minutes

3. Note type, color and amount of any vaginal discharge or bleeding.

4. Retain expelled tissue or large blood clots and give to the emergency department

personnel.

5. Provide emotional support to parents.

Third Trimester Bleeding: should be attributed to either placenta previa or abruptio

placenta until proven otherwise. Consider patient to be at high risk for hemorrhage and

treat as indicated for hemorrhagic shock. Including positioning her on the left side.


6. If altered mental status or signs of hypoperfusion (e.g. low B/P, Tachycardia,

delayed capillary refill), IV FLUID BOLUS of 20 ml/kg

titrated to patient response.

7. Palpate abdomen and note presence of contractions.

8. Insert second IV line if no improvement in peripheral perfusion repeat fluid bolus.



TOXEMIA IN PREGNANCY OR PREGNANCY INDUCED HYPERTENSION

BLS

1. HANDLE PATIENT GENTLY. Minimize Central Nervous System stimulation

(avoid lights and siren). DO NOT check pupillary response.

2. Monitor for potential seizures.



Revised: 4/05, 10/07, 3/08

119

HEMORRHAGE IN PREGNANCY / OBSTETRICAL COMPLICATIONS (cont.)


3. Obtain IV of Isotonic Solution at TKO.


4. If seizure occurs: Contact Medical Control as soon as possible for treatment

orders.




Revised: 4/05, 10/07, 3/08

120

EMERGENCY CHILDBIRTH

BLS

UNCOMPLICATED LABOR

1. Obtain history and determine if there is adequate time to transport.

a. Gravida (# of pregnancies) and Para (#of live births)

b. Number of miscarriages, stillbirths, multiple births

c. Due date (EDC) or date of LMP (last menstrual period)

d. Onset, duration, and frequency of contractions (time from beginning of one to

the beginning of the next)

e. Length of previous labors, in hours

f. Status of membranes; intact or ruptured. If ruptured, inspect for prolapsed

cord or evidence of meconium. Note time since rupture.

g. HIGH RISK CONCERNS: drug abuse in mother, teenage pregnancy, hx of

diabetes, HTN, cardiovascular disease, and other pre-existing disease that may

compromise mother and/or fetus: preterm labor (< 37 weeks), previous

breech, or C-section

2. Inspect for bulging perineum, crowning, or whether patient is involuntarily

pushing with contractions. If contractions are two minutes apart with crowning or

any of the above are present, prepare for delivery. If delivery is not imminent,

transport on left side. DO NOT ATTEMPT TO DELAY DELIVERY

UNLESS PROLAPSED CORD IS NOTED.

IF DELIVERY IS IMMINENT:


a. If mother is hyperventilating, encourage slow deep breathing


4. If mother becomes hypotensive (e.g. B/P < 110’s) or lightheaded at any time, IV

FLUID BOLUS of 20ml/kg and apply 100% oxygen by non-rebreather mask or

assist with BVM.

5. Position mother on back if possible. Appropriate Body Substance Isolation.

6. Open OB pack. Place drapes over mother’s abdomen and beneath perineum.

Prepare bulb syringe, cord clamps, and towel to receive infant. Have neonatal

BVM and oxygen supply ready.



Revised: 4/05, 10/07, 3/08

121

EMERGENCY CHILDBIRTH (cont.)

DELIVERY

7. Allow head to deliver passively. Control rate of delivery by placing palm of one

hand over occiput. Protect perineum with pressure from other hand.

8. If amniotic sac is still intact, gently twist or tear the membrane. Note presence or

absence of meconium.

9. If meconium is present in amniotic fluid: See Delivery Complications –

Meconium Staining SOG (pg. 126-127).

10. Once the head is delivered, allow it to passively turn to one side. This is

necessary for the shoulders to deliver. Suction mouth and nose with bulb syringe

as soon as head delivers.

11. Feel around the infant’s neck for umbilical cord. If present, attempt to gently lift

it over the baby’s head. If unsuccessful, double clamp and cut the cord between

the clamps.

12. To facilitate delivery of the upper shoulder, gently guide the head downwards.

Once the upper shoulder is delivered, support and lift the head and neck slightly

to deliver the lower shoulder.

13. The rest of the baby should deliver quickly with one contraction. Firmly grasp

the infant as it emerges, since baby will be wet and slippery.

14. Keep newborn level with vagina until the cord stops pulsating and is double

clamped.



Revised: 4/05, 10/07, 3/08

122

EMERGENCY CHILDBIRTH (cont.)

CARE OF THE NEWBORN

15. Assess the airway, breathing, and circulatory status of the neonate. If in distress,

refer to the Neonatal Resuscitation SOG (See pg. 124-125)

16. Initial Care immediately after delivery:

Keep infant level with mother’s uterus; hold in a 15-degree head-down

position.

Note the date and time of delivery in documentation.

Suction mouth and nose using the neonatal bulb syringe; repeat as

necessary

Dry and warm the neonate; wrap in blanket or dry cloth.

Stimulate the infant by gently rubbing the back or feet.

Spontaneous respirations should begin in 30 seconds. If they do not, refer

to Neonatal Resuscitation SOG (See pg. 124-125).

17. Clamp the cord at 6” and 8” from the infant’s body, 45 seconds after the birth (or

when the cord stops pulsating); cut between the clamps. Check the cord ends for

bleeding. If no sterile implement is available, leave cord clamped, but not cut.

Place infant on mother’s abdomen for transport.

18. Obtain the 1 minute APGAR score. If < 6: refer to the Neonatal Resuscitation

SOG (See pg. 124-125).

19. Transport together, if possible.

POST-PARTUM CARE

20. Placenta should deliver in 20-30 minutes. If delivered, collect in bag from OB kit

and transport to hospital for inspection. Do NOT pull on cord to facilitate

delivery of the placenta. DO NOT DELAY TRANSPORT AWAITING

DELIVERY OF PLACENTA.

21. If perineum is torn and/or bleeding, apply direct pressure with sanitary pads, and

have patient bring her legs together. Apply cold pack (ice bag) to perineum (over

pad) for comfort and to reduce swelling.

22. If blood loss > 500cc:


23. IV FLUID BOLUS in 20ml/kg, repeat according to patient response

Massage top of uterus (fundus) until firm

Breast feeding may increase uterine tone. Allow newborn to nurse.

If signs of hypoperfusion e.g. low B/P, tachycardiac and delayed capillary

refill, despite above treatment, start second IV enroute and run wide open.



Revised: 4/05, 10/07, 3/08

123

APGAR

SCORING 0 1 2 1 min 5 min

Appearance (color) BLUE

PALE

BLUE HANDS

& FEET

ENTIRELY

PINK

Pulse (heart rate)ABSENT < 100/min > 100/min

Grimace (reflex

irritability)NO

RESPONSEGRIMACE

COUGH

OR

SNEEZE

Activity (muscle

tone) LIMP

SOME

FLEXION OF

EXTREMITY

ACTION/

MOTION

Respiratory effortABSENT

WEAK CRY/

HYPOVENT-

ILATION

STRONG

CRY

TOTALS



Revised: 4/05, 10/07, 3/08

124

NEONATAL RESUSCITATION

BLS

The majority of newborn infants require no resuscitation beyond maintenance of

temperature, mild stimulation, and suctioning of the airway. Transport is indicated as

soon as an airway is secured and resuscitative interventions have been initiated. If

APGAR is <6 at 1 minute, or meconium present, start resuscitation.

1. Leave at least 6 inches of umbilical cord when cutting the cord on an infant in

obvious distress. One team member should note the 1 minute and 5 minutes

APGAR scores. Do not interrupt resuscitation efforts to obtain APGAR.

2. Rapidly warm and dry the neonate and provide tactile stimulation by flicking the

soles of the feet and/or rubbing the back. Wrap the infant in dry linens and cover

head. Note: Infants born with meconium staining require thorough suctioning

(mouth first, then nares) immediately upon delivery of the head and BEFORE

stimulation or initiation of artificial ventilation.

3. Place the newborn supine, with the head in the neutral position.

4. Suction the mouth then nose with a bulb syringe. Deep suctioning of the

oropharynx using an 8-10FR catheter, if indicated, should be limited to 5 seconds

at a time; ventilate between suctioning attempts.

NOTE: If meconium is present proceed to #9.

5. Ventilate the child between suctioning using 100% oxygen with a neonatal BVM

at a rate of 40-80/minute, if adequate spontaneous ventilations do not begin in 10-

15 seconds. Use only enough tidal volume to see the chest rise. The first

ventilation will require a little more pressure to begin lung inflation. Continue to

suction the nose and oropharynx periodically to remove secretions that emerge

from the lungs.

6. Evaluate the heart rate. MONITOR FOR decrease in heart rate (e.g. < 100 beats

per minute)

8. If apnea, heart rate < 100, or central cyanosis is present: continue to ventilate at

40/60 ventilations per minute with 100% oxygen and neonatal BVM.

9. If, despite adequate assisted ventilation for 30 seconds, the heart rate is < 60 beats

per minute and not increasing: continue assisted ventilation and begin chest

compressions interposed with ventilation in a 3:1 ratio at a combined rate of

120/minute.

9. ILS: If meconium is present in the oropharynx, visualize the cords.

If the infant is depressed (poor respiratory efforts, decreased muscle tone,

or heart rate < 100) and meconium is present at the cords, perform direct

endotracheal suctioning.

10. INTUBATE using a 3.0-4.0 ET tube (2.5 for preemie) and a straight laryngoscope

blade. Carefully check tube placement by listening to bilateral breath sounds. If

the ET attempt is unsuccessful, transport with ventilation per BVM.

11. Establish vascular access IV/IO NS/LR at TKO.

12. ALS: Apply cardiac monitor.

13. ALS: If the heart rate remains < 60/minute despite warming, stimulation,

adequate ventilation with 100% oxygen, initiate CPR and consider

EPINEPHRINE (1:10,000) 0.01 mg/kg IVP/IO or (1:10,000) 0.2-0.3 mg/kg ET.



Revised: 4/05, 10/07, 3/08

125

NEONATAL RESUSCITATION (cont.)

Special Considerations per medical control:

● D12.5% 1-2 ml/kg IV/IO (Dilute D50 into ½ then ½ again to make D12.5%)

● Fluid Bolus 10 ml/kg NS/LR

● NARCAN 0.1 mg/kg IV/IO/ET



Revised: 4/05, 10/07, 3/08

126

DELIVERY COMPLICATIONS

BLS

Provide Initial Medical Care

100% O2 with NRB mask or assist ventilations with BVM.

LOAD-AND-GO SITUATION with care enroute.

SHOULDER DYSTOCIA:

Place mother supine with knees to shoulder and reattempt delivery.

If unsuccessful, return to supine position. Supplemental O2 to baby and protect

head.

BREECH BIRTH:

NEVER ATTEMPT TO PULL THE INFANT FROM THE VAGINA BY THE

LEGS OR TRUNK.

As soon as the legs are delivered, support the baby’s body wrapped in a towel.

After the shoulders are delivered, if face down, gently elevate the legs and trunk

to facilitate delivery of the head.

Head should deliver in 30 seconds with the next contraction. If NOT, reach two

gloved fingers into birth canal to locate baby’s mouth. Push vaginal wall away

from baby’s mouth to form an airway. Keep fingers in place and transport

immediately. Alert receiving hospital ASAP.

Apply gentle pressure to the fundus. If head does NOT deliver in 2 minutes, keep

your fingers in place to maintain the airway. Keep exposed part of newborn

warm and dry.

If head delivers, anticipate neonatal distress. Refer to Neonatal Resuscitation

SOG.

PROLAPSED CORD:

Put mother in Trendelenburg in knee-chest position.

DO NOT push cord back into vagina.

Place gloved hand into vagina between pubic bone and presenting part with cord

between two fingers to monitor cord pulsations and exert counter-pressure on

presenting part.

Cover exposed cord with moist dressing and keep warm.

Maintain hand placement until relieved at Emergency Department.

MECONIUM-STAINED AMNIOTIC FLUID:

Suctioning of the mouth, nose, and posterior pharynx should be performed before

delivery of the shoulders and again after delivery when the infant has been

warmed.

Use of an 8-10FR catheter is recommended, although a bulb syringe may

be adequate.



Revised: 4/05, 10/07, 3/08

127

DELIVERY COMPLICATIONS (cont.)


If meconium is present in the oropharynx, visualize the cords. If meconium is

present at the cords, and if the infant is depressed (poor respiratory efforts,

decreased muscle tone or heart rate less than 100) delay drying and stimulating

and suction the trachea before taking other resuscitate steps. Place the infant in a

warm environment and perform the following actions immediately:

A. Open the hypopharynx with a laryngoscope

B. Intubate the trachea.

C. Set the mechanical suction no higher than –100 mm Hg.

D. The endotracheal tube is used as a suction catheter and suction is applied

as the tube is slowly withdrawn.

E. If a significant amount of meconium is obtained the procedure should be

repeated x 1, using a new ET tube for each suctioning.

Note: if the heart rate is decelerating, resuscitation must proceed without

delay.

F. Rapid transport is imperative.


G. Monitor for cardiac arrhythmias, bradycardia or cardiac arrest.



Revised: 4/05, 10/07, 3/08

128

PEDIATRIC RESUSCITATION GUIDELINES

CPR FOR INFANTS AND CHILDREN

Maneuver Child

1 year to Puberty

Infant

Under 1 year of age

AIRWAY Head tilt-chin lift (suspected trauma, use jaw thrust)

BREATHING Initial 2 effective breaths at 1 second/breath

Rescue breathing without

chest compressions12 to 20 breaths/min (approximately)

Rescue breaths for CPR with

advanced airway8 to 10 breaths/min (approximately)

Foreign-body airway

obstructionAbdominal thrusts Back slaps and chest thrusts

CIRCULATION:

Pulse check (<10 sec)Carotid Brachial or femoral

Compression landmarks Lower half of sternum,

between nipples

Just below nipple line (lower

half of sternum)

Compression method

Push hard and fast

Allow complete recoil

Heel of one hand or as for

adults

2 or 3 fingers

(2 rescuers):

2 thumb-encircling hands

Compression depth Approximately one third to one half the depth of the chest

Compression rate Approximately 100/min

Compression-ventilation ratio 30:2 (single rescuer)

15:2 (2 rescuers)

Defibrillation AED Use AED after 2 min’s or 5

cycles of CPR.

Use pediatric system for child

1 to 8 years if available

For sudden collapse (out of

hospital) or in-hospital

arrest use AED as soon as

available.

No recommendations for

infants

< 1 year of age

SUGGESTED SIZES FOR INTUBATION & SUCTION EQUIPMENT

AGE ET TUBE BLADE SIZE SUCTION

CATHETER

Newborn 3.0 O S 6 – 8 FR

6 months 3.5 1 S 8 FR

18 months 4.0 1 – 2 S 8 FR

3 years 4.5 2 S 8 – 10 FR

5 years 5.0 2 S 10 FR

6 years 5.5 2 S 10 FR

8 years 6.0 2 S / C 10 Fr

12 years 6.5 3 S / C 12 FR

Note: Select a tube or blade size based on the size of the child, not his or her

chronological age. Prepare tubes that are one size larger and one size smaller than

the one you select. Fast reference: size of little finger nail, or use formula: 16 +

age in years / 4.

region iv standard operating guidelines (sogs...

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