Horry County Fire Rescuehorrycountyfirerescue.com/Portals/4/SiteImages/sop/SOP-709.pdf · Crime Scenes 11 Snake Bite 63 Reporting of a lost child, suspected abuse or neglect 13 Crush

Horry County Fire Rescue

Prehospital Medical Protocols

July 01, 2009

2

These Protocols are Approved for use by Authorized

Horry County Fire Rescue personnel only.

The Horry County Fire Rescue Medical Control Physician, Dr. Thomas J. Martel, is the authorizing physician of this document. Dr. Martel has chosen to allow use of these protocols to personnel who have successfully completed, or are actively engaged in a precept program as designed and administered by Horry County Fire Rescue.

Personnel who have not begun, successfully completed, or are engaged in the precept program but are unsupervised by a preceptor are not authorized to perform any of the

skills located within this document.

3

Page # Page # Administrative Section Trauma Section Control of the Advanced Life Scene 4 Burns 57 Transport Policy 5 Head Injury 58 Trauma Field Triage Decision Scheme 7 Jellyfish Sting 59 Approved Standards for Radio Communications 8 Paralysis/ Spinal Injury 60 Consent or Refusal of Care 9 Penetrating Trauma/ Hemorrhage 61 Field Resuscitation and Discontinuation of Resuscitation 10 Sting Ray Sting 62 Crime Scenes 11 Snake Bite 63 Reporting of a lost child, suspected abuse or neglect 13 Crush Injury 64 Do Not Resuscitate Orders 15 Pediatric Protocols Behavioral Section Abdominal Distress: Non-trauma 66 Altered Level of Consciousness 17 Altered Level of Consciousness 67 Psychiatric / Behavioral 18 Anaphylaxis 68 Overdose 19 Asystole / PEA 69 Ventricular Fibrillation / Tachycardia 71 Cardiac Section Bradycardia 73 Asystole / PEA 20 Cardiac Arrest due to Hypothermia 75 Bradycardia 22 Burns 76 Cardiogenic Shock 24 Fever 77 Chest Pain (of Suspected Cardiac Etiology) 25 Head Injury 78 Hypertensive Crisis 26 Hyperthermia 79 Premature Ventricular Contractions 27 Hypothermia 80 Narrow Complex Tachycardia 28 Multiple Trauma 81 Ventricular Fibrillation/Pulseless Ventricular Tachycardia 31 Near Drowning 82 Wide Complex Tachycardia 34 Newborn Resuscitation 83 Pain Management 85 Environmental Section Poisoning / Ingestion 86 Heat Exhaustion/ Heat Stroke 37 Respiratory Distress 87 Cold Exposure/ Hypothermia 38 Seizure 88 Hypotension / Shock 89 OB/GYN Section SVT / Narrow Complex Tachycardia 90 Eclampsia 39 Wide Complex Tachycardia 93 Gynecology & Miscarriage 40 Prehospital Information for Pediatric Care 96 OB Delivery 41 Post Partum 42 Procedures EKG Usage 98 “Other” Miscellaneous Medical Section Adult / Child Intraosseous Infusion 99 Abdominal Pain 43 Medication Administration 101 Stroke / TIA 44 Oxygenation 102 Diabetic 45 Intubation 104 General Illness 46 Impedance Threshold Device 105 Exposure to Confined Space Fire 47 King Laryngeal Tube Airway 106 Pain Management 48 End Tidal CO2 & Capnography 108 Poisoning 49 Plural Decompression 111 SCUBA Related Injury 50 Rapid Extrication 112 Seizure 51 Spinal Precautions 113 Vomiting/ G.I. Problems 52 CPAP Usage 114 Medication Infusions 116 Respiratory Section Stroke Scale 117 Anaphylaxis/ Allergic Reaction 53 Asthma/ Bronchospasm/ Dyspnea due to COPD 54 CHF / Pulmonary Edema 55 Near Drowning 56

4

Administrative Section

Introduction

The following treatment protocols are for the use of the EMT, EMT-I, and Paramedic in the field. They have been developed to ensure high-quality and standardized emergency care. While patient assessment, basic and advanced life support procedures have not been enumerated thoroughly here; they are always to be initiated as necessary. So that this may be achieved, the initial responding crew should bring all appropriate equipment into the emergency’s scene (minimum to include the medical bag), any additional response unit(s) shall bring in equipment as necessary. Patients who require advanced skills, whether interventions are performed or not (due to patient refusal of advanced procedures), remain ALS patients. It is the option of the on-line Physician to modify the treatment of a patient from that described in the protocols if the best interest of the patient is thereby served. Such modifications of treatment must be in accordance with the standard practice in pre-hospital care. Any deviation from procedures described herein is to be well documented for subsequent review by the Horry County Fire Rescue Medical Control Physician.

Control of Advanced Life Support at the Scene All medical personnel in the Horry County Fire Rescue system operate under the supervision of the Medical Director and obtain his/her immediate direction from the On-Line Medical Control Physician. If the patient's private physician is present and willing to assume responsibility for the patient's care, the patient care provider should defer to the orders of the private physician. The On-Line Medical Control Physician should be contacted for record keeping purposes. The provider’s responsibility reverts back to the On-Line Medical Control Physician at any time when the private physician is no longer in attendance. ANY INSTRUCTIONS VIA THE INTERVENER PHYSICAN SHOULD ONLY BE FOLLOWED AS LONG AS THEY ARE WITH-IN THE STATE APPROVED FORMULARY. If an intervener physician is present and willing to assume responsibility for the patient's medical care and signs the run report, he/she may request Medical Control of the emergency scene from the On-Line Medical Control Physician. The On-Line Medical Control Physician may transfer Medical Control to the intervener physician if he/she so chooses. The On-Line Medical Control Physician maintains the right of managing the case entirely, working with the intervener, or allowing him/her to assume responsibility. The intervener physician should sign the run sheet and must accompany the patient to the hospital in the emergency vehicle. However, in the event of a disaster, patient care needs may require that the intervener physician remain at the scene. The On-Line Medical Control Physician is ultimately responsible if there is any disagreement between the intervener physician and the On-Line Medical Control Physician, in which case the provider should take orders from the On-Line Medical Control Physician. 1. Intervener physician is a licensed physician (without a prior established patient/physician

relationship) wishing to take control of an emergency scene, who is willing to provide evidence of licensure and will accompany the patient to the hospital should such control be granted by the On-Line Medical Control Physician. Add the Intervener Doctor’s information to the comments section of the patient care report.

5


Transportation Policy

To ensure prompt and efficient response, all 9-1-1 requests for an ambulance will be answered in the Horry County Communications Center. Ambulances will be dispatched from there in accordance with the Horry County Fire Rescue Dispatch Policy. Horry County Fire Rescue transports patients to all area emergency departments. In general, when appropriate the patients will be transported to any of those hospitals as directed by the patient except in the following circumstances: • Grand Strand Regional and McLeod Regional Medical Center may be utilized as an interventional

cardiac catheterization facility. • If the patient does not have a preference of hospital and will, therefore, be transported to the nearest

hospital. • If the paramedic has any doubt that the patient is stable, the patient will be transported to the nearest

facility. • The receiving hospital diverts the ambulance to another hospital. The ambulance crew must also

give a radio report to the receiving facility. The ambulance crew must notify the Shift Medical Officer or his designee as soon as possible.

• Pregnant patients with vaginal bleeding or any other complication including labor should be transported to the nearest hospital with a Labor & Delivery Department.

• Intubated patients should be transported to the nearest hospital with an ICU unit and respiratory therapy support.

• All acutely psychotic and suicidal patients are to be transported to one of the following facilities: Loris Community Hospital, Conway Medical Center, Waccamaw Community Hospital or Grand Strand Regional Medical Center. Any other patients with psychiatric issues can be seen at any local area hospital.

Trauma Alert and Trauma Notification Patients All “Trauma Alert and Trauma Notification” patients will be transported to the nearest trauma center. Trauma Centers include Conway Medical Center, Loris Community Hospital and Grand Strand Regional Medical Center. Air medical transport service include Carolina Life Care, Airlink and Meducare. “Trauma Alert” patients are defined as patients with:

1. Revised trauma score (RTS) < 12 upon EMS evaluation 2. Age appropriate hypotension 3. Respiratory rate < 10 or > 29 (< 20 in infant less than 1 year)

“Trauma Notification” patients are defined with:

1. Penetrating injuries to head, neck, torso or extremity to elbow and knee 2. Flail Chest 3. Two or more proximal long bone fractures 4. Crush, de-gloved, or mangled extremity 5. Amputation proximal to wrist or ankle 6. Clinically apparent pelvic fracture 7. Paralysis 8. Severe burns with other traumatic injuries 9. Isolated severe burns (if available, triage to nearest burn center)

Transport guidelines continued next page…

6


Transport guidelines continued

Acute MI Suspected If the patient’s history, physical exam findings and 12 lead EKG are all positive for a possible AMI you will transmit a 12-Lead EKG to the closest Life Net receiving station at the hospital the patient wishes to be transported. If the patient does not have a hospital of choice, send the EKG to the closest Life Net receiving station. When the transmission is complete every attempt should be made to discuss patient findings with the emergency department physician. During this consultation the emergency department physician will determine the need for possible transport to an interventional cardiac care center. If the on-line medical control physician believes the EKG is consistent with an acute MI with ST elevation inform the patient of the following statement:

“After consultation with Dr. __________ it appears that you may be having a heart attack. You will have to be seen by a qualified emergency care physician to confirm

this. If you are having a heart attack, you may need specialized treatment and care at an interventional cardiac care facility. Would you like to be transported to the

closest interventional cardiac care facility?”

Allow the patient and/or family to make an informed decision. If the patient or family opts for transportation to any other hospital, simply advise them that the patient may have to be transferred to an interventional cardiac care facility at a later time, but that EMS will abide by the patient’s (or family) choice of hospital.

*** Advanced notification to the receiving facility along with a “transmitted” 12-lead EKG is mandated whenever possible! ***

Approved Advanced Interventional Cardiac Care Facilities: Grand Strand Regional Medical Center McLeod Regional Medical Center

7


Transport guidelines continued

Trauma Field Triage Decision Scheme If ground transport will exceed 30

minutes and no air transport is available, contact on-line medical control for appropriate transport destination.

Measure Vital Signs Revised Trauma Score (RTS) ≤ 12 upon EMS evaluation Age Appropriate hypotension Respiratory rate <10 or >29 per minute(<20 in infant less than 1 year) YES NO

Transport to closest designated trauma center available. Air transport or bypass of level 3 trauma center to level 1 or level 2 trauma center should be considered if distance and circumstances are appropriate and/or not level 3 trauma center is available.

Assess anatomy of injury

Penetrating injuries to head, neck torso or extremity to elbow and knee Flail Chest Two or more proximal long bone fractures Crush, de-gloved, or mangled extremity Amputation proximal to wrist or ankle Clinically apparent pelvic fracture Paralysis Severe burns with other traumatic injuries Isolated severe burns (If available, triage to nearest burn center) YES NO

Transport to closest designated trauma center available. Air transport or bypass of level 3 trauma center to level 1 or level 2 trauma center should be considered if distance and circumstances are appropriate and/or no level 3 trauma center is available.

Assess mechanism of injury and evidence of high-energy impact

Fall >20 ft. in adult (one story = 10 feet) Fall >10 ft. or two to three times the height of a child Intrusion >12 inches occupant side Intrusion > 18 inches on any side Ejection (partial or complete) from automobile Death in same passenger compartment Pedestrian struck by vehicle, thrown, run over, or with impact > 20 MPH Bicyclist thrown, run over, or with impact > 20 MPH Motorcycle crash > 20 MPH YES NO

Transport to closest available trauma center. A lower level trauma center should not be bypassed to transport to a higher-level trauma center. If no trauma center is available, transport to closest appropriate hospital emergency department for evaluation and transfer as necessary. Air transport from incident scene is rarely appropriate.

Assess special patient or system considerations

Older adults Children Patients with bleeding disorders or on anticoagulation medication End stage renal disease requiring dialysis Pregnancy > 20 weeks YES NO

Transport according to usual transport protocol

Contact medical control and consider transport to closest available trauma center. A lower level trauma center should not be bypassed to transport to a higher-level trauma center. If no trauma center is available, transport to the closest appropriate hospital emergency department for evaluation and transfer as necessary.

Decision to call for on-scene air transport should come from South Carolina certified personnel associated with a South Carolina licensed EMS or first responder agency.

EMS services must identify appropriate hospitals when no trauma center is available.

8


Approved Standards for Radio Communication

1. Radio contact will be made on all patients transported by ambulance. 2. Radio contact will be made at the decision of the primary attendant but prior to arriving at the

receiving facility.

3. Transported patients will be assigned a priority (1-4) based on acuity, level of support required and potential for decline in clinical status.

Condition Based Priority Codes

Priority 1: Minor traumatic injury or medical condition in a patient with normal vital signs will

not require immediate or specialized care, and normally not require transport at high speed.

Priority 2: More complex traumatic injury or medical condition requiring ALS intervention and

simple supportive or prophylactic care (i.e., oxygen, IV). These patients are expected to have an uneventful transport, but may need early treatment or specialized care.

Priority 3: Complex traumatic injury or serious medical condition requiring aggressive ALS

support (i.e., medication administration, ventilatory support). These patients are considered unstable and their clinical condition may change at any moment. There will be a definite need for immediate or specialized care.

Priority 4: Critical condition requiring maximal ALS support and or resuscitation. These

patients will require intensive support and physician involvement at the time of arrival.

Suggested Patient Report Content

4. Radio transmission should be concise and information and should include the following information

Priority 1: Identify the unit initiating the call. Give a brief statement identifying the nature of the

run. State estimated time of arrival. Vital signs and exact mechanism of injury can be obtained after arrival.

Priority 2 & 3 Identify the unit initiating the call. Give a brief statement identifying the nature of the

run, vital signs at the time of transport, and pertinent positive medical findings. List supportive and resuscitative measures taken. State the estimated time of arrival.

Priority 4: Identify the unit initiating the call. Identify the nature of the run. List the supportive

and or resuscitative measures taken with emphasis on type of airway and presence of IV access. State estimated time of arrival.

Content continued next page…

9


Suggested Patient report content continued

5. A full history with primary and secondary survey is expected but it would be rare that information

such as family physician, medications, allergies and other past medical information would be required in a radio contact. This information can be obtained after arrival, unless the information affects subsequent orders given by radio by the on-line Medical Control (e.g., Lidocaine allergy).

6. Essential information in any presentation includes:

a. Priority status of patient, b. Patient’s age, c. Patient’s sex, d. Nature of run, e. Revised Trauma Score (if applicable) f. List of supportive/resuscitative measures, g. Vital signs at the time of transport (if abnormal) and h. Estimated time of arrival.

Consent and Refusal of Care

Valid consent shall be obtained from the patient prior to the initiation of evaluation and treatment as time and patient condition allow. Consent may be verbal or written, or may be implied in the incapacitated patient. Patients refusing treatment and/or transportation against medical advice will be made fully aware of the possible consequences of refusing care and should sign the Transport Waiver Form. For example, near drowning patients refusing transport must be informed about the possibility of secondary drowning. The signature of a family member is also highly desirable. The On-Line Medical Control Physician may be contacted prior to obtaining a signature on the refusal form in order to allow the physician to talk directly with the patient if he/she so desires. Patients under 16 years of age will be treated as minors. Patients 16 years of age or older, those under 16 years of age with children, or those that have been legally emancipated will be treated as adults. Therefore, these individuals have the right to refuse treatment and transportation. If the patient is under 16 years of age, it is the intention of HCFR to transport these patients to the proper emergency facility. If the patient adamantly refuses treatment and or transport, the ambulance crew should: Try to contact the patient’s parent(s) or legal guardian by telephone or other means and explain the situation. When the parent(s) or legal guardians voice a decision, have your partner witness this decision and document the decision in the comment section of the Patient Care Report. The crew should transport or not transport in accordance with the parent(s) or the legal guardian’s decision. If unable to contact the parent(s) or legal guardian, contact On-Line Medical Control (OLMC) for consultation. The patient care provider should then abide by the OLMC’s order. Thorough documentation is required on the Patient Care Report.

10


Field Resuscitation and Discontinuation of Resuscitation

1. Resuscitation need not be attempted in the field if any of the following conditions are met: a) There is evidence of massive trauma that is absolutely incompatible with life, such as

decapitation, severe crushing injury of the skull, incineration, etc. b) Rigor mortis, profound lividity, or bodily decomposition is present. c) The patient has already been pronounced dead by an authorized official, such as the Medical

Examiner, Coroner, or by a Physician who is licensed to practice medicine in South Carolina. d) A valid EMS DNR (Do Not Resuscitate) order bearing original signatures is found by or

presented to the EMS Crew. e) Patient in cardiac arrest with a confirmed down time of greater than 20 minutes.

2. If the above conditions are not met, and there is any possibility that life exists or can be restored,

every effort should be made to resuscitate the patient. 3. Once resuscitation has been initiated, it is to be continued until one of the following occurs:

a) Effective spontaneous circulation and ventilation are restored. b) Resuscitation efforts are transferred to others of at least equal skill, training and experience. c) The rescuers are exhausted and are physically unable to continue resuscitation efforts. d) On-Line Medical Control issues an order to discontinue resuscitation on a pulseless and apneic

patient.

4. Medical Control Order to Discontinue Resuscitation a) Paramedics are permitted to accept an order in person, by radio, or by telephone from a

licensed South Carolina Physician to discontinue resuscitation in a pulseless and apneic patient. b) When an order is issued by telephone or radio, a second crewmember must confirm the order

to avoid any chance of misunderstanding. The second crew member (confirming member) does not have to be a certified paramedic.

c) Should resuscitation be terminated before the patient is placed in the ambulance, disposition will be the same as if the patient were found dead on the scene.

d) When resuscitation is discontinued after the patient is placed in the ambulance, the deceased will be transported to the Medical Control Hospital for disposition.

e) The signature of the Physician who orders termination must be obtained on the Patient Care Report in a timely fashion.

f) In spite of an order to discontinue resuscitation, the Paramedic may, at his or her discretion, elect to continue resuscitative measures and transport to the hospital in response to mitigating circumstances.

Physicians Signatures If a transporting or non-transporting unit of the HCFR performs an advanced skill under standing order by protocol you may write in the space provided for the Physician’s signature: Per Protocol /Standing Order.

♦The ordering physician’s signature is required for all controlled substance administration♦

11


Crime Scenes

Response When called to respond to a violent or potentially violent scene that has not been secured by the governing police authority for the location of the call, HCFR apparatus responding to the call will proceed to the call in an uninterrupted non-emergent mode. If, by the time of an apparatus’s arrival in the general area of the call, the scene has not been secured, all responding HCFR apparatus will halt their response and wait in an area that can not be seen from the incident location and that does not prohibit or endanger the normal flow of traffic on a public road Extreme caution should be exercised if the responding apparatus becomes aware that the perpetrator (s) may still be in the vicinity. This information should be immediately and discreetly relayed to the communications center, who in turn can notify responding law enforcement units. This action may dictate law enforcement to modify their response.

Arrival Upon arrival of initial apparatus, if the patient is found to be in a condition compatible with life, the minimum of manpower needed to extract the patient from the scene will be utilized. All manpower utilized on the scene will remain on scene with the officer or at the hospital of treatment until registered with the governing police authority as having been “on scene”. Also any persons who took place in initial moving of the patient from the position in which they were found on scene will immediately make themselves available to the governing police authority for the purpose of an incident report in the regards to the moving of the patient. Upon arrival on scene personnel should limit their presence to only that area (s) where it is necessary to render aid and treatment. Personnel on scene are encouraged to prevent entry into a scene by those individuals who may contaminate the scene. This would include such parties as; family members, other residents of the scene, members of the media, and bystanders. Those individuals who react in an uncooperative manner should be asked to consult with law enforcement personnel. Upon arrival of initial apparatus, if the patient is found not to be in a condition compatible with life, the highest medically certified person on scene should confirm death of the patient. Responding Paramedics should apply an ECG monitor to the patient and register an asystolic rhythm. Responding Basic and Intermediate EMT’s should apply an AED to confirm that a shock is not recommended and assess the patient for standard obvious signs and symptoms of death. This person should not proceed with application of the LP-12 if death can be assumed. Death can be assumed if the patient exhibits any of the following three signs:

1. Rigor/livor Mortis 2. Decapitation 3. Decomposition.

12

Administrative Section If death can be assumed from the above signs, the personnel on scene should exit and secure the inner crime scene. No foreign objects should be introduced to the crime after life saving aid has been administered and the patient has been found to be in a condition not compatible with life.

If in order for the patient electrode to adhere to the skin the patient must have fluids wiped from the skin, the responder will use the following process:

• Any area of the patient that is wiped by a HCFR responder to enable adhesion of ECG pads will be wiped with a new sterile gauze for each area and the gauze will be left next to the area for which it was used. (i.e. gauze used on the left shoulder will be left at the left shoulder) This is to maintain evidence preservation and tracking.

A HCFR responder will not remove ECG electrode applied to the patient. Electrode may be removed at the time of autopsy if needed.

• Clothes that must be cut from the patient will be cut along a seam or in a manner as to not contact any known potential evidence. Said cut should not involve those places where a weapon, or other instruments, may have penetrated or altered the clothing.

If the patient is found to be viable, the minimum of manpower needed to extract the patient from the scene will be utilized. All manpower utilized on the scene will remain on scene with the officer or at the hospital of treatment until registered with the governing police authority as having been “on scene”. HCFR personnel may provide a valuable service to law enforcement if the patient makes any unsolicited and spontaneous statements outside of law enforcement’s presence. This is especially true if the patient believes they are dying. Documenting these statements should be in a manner that can withstand future scrutiny of the courts. Some suggested methods are, in descending order; tape recording, written notes (by HCFR personnel) or prompt notification to law enforcement personnel and repeating the statement while recall is still fresh. Any witnesses to these statements should be noted as well. If the patient is not found to be viable, the verifying responder will make themselves immediately available to the governing police authority for the purpose of an incident report in regards to the moving of the patient. All manpower utilized on the scene will remain on scene with the officer until registered with the governing police authority as having been “on scene”. Also any persons who took place in initial moving of the patient from the position in which they were found on scene will immediately make themselves available to the governing police authority for the purpose of an incident report in the regards to the moving of the patient Any object that is moved from its initial location within the crime scene must be reported to the governing police authority prior to responders leaving the incident location unless this process would impede patient care. If the process of reporting the movement of objects within the crime scene would impede patient care the responder will make immediate notification to the governing police authority upon releasing the care and transport of the patient to a higher level of medical care.

13


Reporting of a lost child, Suspected Abuse, or Neglect

Lost Child Pursuant to Title 20, Chapter 7, Article 1, Subarticle 5 (20-7-610) of South Carolina Law, any child found to be lost will be reported to the governing police authority for placement in emergency protective custody.

Suspected Abuse Pursuant to Title 20, Chapter 7, Article 7, Subarticle 1 (20-7-490) of South Carolina Law, Child Abuse or Neglect is defined as: "Child abuse or neglect", or "harm" occurs when the parent, guardian, or other person responsible for the child's welfare:

(a) inflicts or allows to be inflicted upon the child physical or mental injury or engages in acts or

omissions which present a substantial risk of physical or mental injury to the child, including injuries sustained as a result of excessive corporal punishment, but excluding corporal punishment or physical discipline which:

(i) is administered by a parent or person in loco parentis; (ii) is perpetrated for the sole purpose of restraining or correcting the child; (iii) is reasonable in manner and moderate in degree; (iv) has not brought about permanent or lasting damage to the child; and (v) is not reckless or grossly negligent behavior by the parents.

(b) commits or allows to be committed against the child a sexual offense as defined by the laws of

this State or engages in acts or omissions that present a substantial risk that a sexual offense as defined in the laws of this State would be committed against the child;

(c) fails to supply the child with adequate food, clothing, shelter, or education as required under

Article 1 of Chapter 65 of Title 59, supervision appropriate to the child's age and development, or health care though financially able to do so or offered financial or other reasonable means to do so and the failure to do so has caused or presents a substantial risk of causing physical or mental injury. However, a child's absences from school may not be considered abuse or neglect unless the school has made efforts to bring about the child's attendance, and those efforts were unsuccessful because of the parents' refusal to cooperate. For the purpose of this chapter "adequate health care" includes any medical or non-medical remedial health care permitted or authorized under state law;

14

Administrative Section Suspected Abuse Continued… (d) abandons the child; (e) encourages, condones, or approves the commission of delinquent acts by the child and the

commission of the acts are shown to be the result of the encouragement, condonation, or approval; or

(f) has committed abuse or neglect as described in subsections (a) through (e) such that a child who subsequently becomes part of the person's household is at substantial risk of one of those forms of abuse or neglect.

A. When adult / child abuse or neglect is suspected on the scene of an emergency, regardless if

the patient is transported or not, the local governing police authority should be summonsed to the patient. The request for police should be made through the Horry County E 911 system either by radio or cell phone.

B. If the patient is not transported, remain on the scene and wait for responding police

department representative’s arrival, unless your safety is threatened. C. If the patient is transported, request that the responding police department representative

respond to the hospital that you are transporting the patient too. D. If the Police are on the scene, notify the officer(s) of the suspected abuse or neglect. E. Notification to Hospital staff of suspected abuse or neglect should be made but will not

substitute the notification of law enforcement. F. Immediate documentation of the patient’s physical and mental status during the period of

your treatment should be completed. If the governing police authority is present at the hospital of treatment, a copy of the Patient Care Report may be furnished to the police authority upon request. A Patient Care Report may only be furnished to law enforcement without a subpoena in cases in which you are the initiator of a complaint of abuse/ neglect. Included within your documentation should be the name of the governing police authority that was notified, name of the officer who responded, and date and time the report was made to the responding officer.

Documentation (Additional) When making a report of suspected abuse/neglect the provider should provide the responding officer with the following information, upon their arrival at the patient, for follow up purposes:

• Your name • Work telephone number • The station at which you are working when the report was made • Your job title • Be prepared to make a full written or audio recorded statement

15


Do Not Resuscitate Orders 1. Any patient over the age of eighteen (18) years of age, who has a terminal disease, may request that

his/her physician complete a DHEC EMS Do Not Resuscitate (DNR) Order form. In the event that the patient is incapacitated, the patient’s surrogate (next of kin) or agent (physician) may request a DHEC EMS DNR order. The patient’s physician must complete a DHEC compliant DNR form. A DHEC compliant DNR Order states: The order must specifically state that it is a EMS Do Not Resuscitate Order, the patient’s name and signature, that the patient has a terminal illness, the name of the physician issuing the DNR Order and physician’s signature with contact information, and how the patient may revoke the DNR Order. A properly formatted EMS DNR must also contain the follow exact wording: NOTICE TO EMS PERSONNEL This notice is to inform all emergency medical personnel who may be called to render assistance to that (Patient’s name) he/she has a terminal condition which has been diagnosed by me and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest.

2. The patient or the patient’s family must keep this form near the patient, so that HCFR personnel will

see the form upon contact with the patient. 3. If the DHEC EMS DNR Order form is completed and has not been altered or defaced the HCFR

employee must withhold resuscitative efforts. A reasonable attempt should be made to view the DNR Order form containing the original signatures of the patient and ordering physician, however, you may honor a photocopied DNR Order form under good faith if the original cannot be located. If the employee has already begun resuscitative efforts when the form is discovered, the employee must discontinue such efforts.

4. The patient may wear a marker device such as a bracelet or necklace. The marker must be

distinctive and bear the patient’s name as well as the words “Do Not Resuscitate” or “DNR”. If the employee discovers such a marker, he/she should make a reasonable effort to find the DNR form. If the form can not be found, the employee must initiate or continue resuscitative efforts.

5. If the patient is transported by HCFR, the employee must also transport the DHEC EMS DNR

orders with the patient. 6. In the event that the patient has a valid DHEC EMS DNR order, the following procedures will be

withheld or withdrawn:

A. CPR B. Intubation or other advanced airway maneuvers

C. Artificial ventilation

16


D. Defibrillation E. Administration of cardiac resuscitation medications

F. Cardiac diagnostic monitoring (Rhythm strips or EKGs)

7. In the presence of a DHEC EMS DNR order, the employee may still render supportive care to ease

the suffering and/or relieve pain for the patient. Supportive care includes, but is not limited to, suction, oxygen, airway assistance that does not include intubation, hemorrhage control, administering pain medication, etc.

8. If the patient has expired, the employee must retain the DHEC EMS DNR order form. The form

must be returned to the administrative office to be filed with the patient’s record. 9. The patient may revoke the DHEC EMS DNR order, verbally or by mutilating, obliterating, or

destroying the document. Verbal revocation of an EMS DNR can only be made by the patient. Mutilation or obliteration destruction can be made by the patient’s surrogate (next of kin) or agent (physician).

17

Altered Level of Consciousness

NEMSIS – 6780 (Altered Mental Status)

Significant Findings (*Automatic ALS)

Medic Alert Tags *Altered Level of Consciousness Hyper / Hypotension *Evidence of Drug Use Breath Odor *Diaphoresis, Chest Pain *Evidence of Trauma *Abnormal / Unusual Breathing

BLS Treatment 1. C-spine control if indicated, ABC, History,

Physical Exam, Vital Signs, Pulse oximeter. 2. Administer oxygen– Manage airway as

necessary. 3. Check blood glucose level. 4. Administer oral glucose (1 tube) if less than 70

mg/dl in a conscious patient with a secure airway.

5. Perform pre-hospital stroke test. 6. Treat other associated signs and symptoms per

appropriate protocol.

***Contact Receiving Facility***

**Request Paramedic Evaluation if** Unconscious / not breathing Combined drugs and/or alcohol overdose Respiratory distress Syncope associated with headache, chest pain / discomfort / palpations, diabetes, GI / vaginal bleeding or abdominal pain. Alcohol intoxication

ILS Treatment 7. Obtain IV access. 8. D50 (25 grams) IV if blood glucose is < 70

mg/dl.A


** Request Paramedic Intercept When ** On-Line Medical Control Orders

ALS Treatment Standing Orders Physician Orders

9. ECG. 12 lead as needed. 10. Thiamine (100 mg) IV if history of

alcoholism with blood sugar < 70 mg/dl. 11. After 2 IV attempts administer Glucagon (1

mg) IM if blood glucose is < 70 mg/dl 12. Naloxone (2 mg) IV/IO/IM if respiratory

depression is present. 13. Treat other associated signs and symptoms

per appropriate protocol.


1. Second or third doses of Glucagon (1 mg) IM every 15-30 minutes.

Note; A. D50 (25 grams) can only be administered by the EMT-I that has successfully completed the SC DHEC dextrose administration bridge course – Reminder: Patient must be older than 14 years of age.

18

Psychiatric / Behavioral

NEMSIS-6810 (Behavioral)


Tries to hurt self or others Profuse sweating Rapid speech Crying or hysterical Flushed appearance Anxious and fearful Not responding to people of environment Hyperventilation Hostile or aggressive behavior


Physical exam, Vital signs, Pulse oximeter. 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Check blood glucose level. 4. Administer oral glucose (1 tube) if < 70 mg/dl

in a conscious patient with a secure airway. 5. Restrain patient as needed for safety.A B C

6. Treat other associated signs and symptoms per appropriate protocol.


**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Unusual behavior associated with diabetes Suicidal Gun shot wound / Stab wound(s)

ILS Treatment 7. Obtain IV access.




8. ECG. 12 lead as needed. 9. Treat other associated signs and symptoms per



1. Valium (hysteria) IV/IM/IO/PR 5 mg repeat to a maximum of 15 mg.

Note: a. Restraints are to be taken off when clinically appropriate. b. Check pulses every 5 minutes distal to the restraints to ensure adequate perfusion, if adequate perfusion is not present reposition restraints to allow for adequate perfusion. c. Never restrain a patient in a prone position. If handcuffs are used the key must be in your possession or the officer must accompany you in the ambulance.

19

Overdose

NEMSIS – 7030 (Overdose / Toxic Ingestion)


*Unresponsive *Altered level of consciousness *Depressed respirations



airway as necessary. 3. Check blood glucose level. 4. Administer oral glucose (1 tube) if < 70 mg/dl

in a conscious patient with a secure airway. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Altered level of consciousness Intentional / accidental with Rx medications. Ingestion of household cleaners Difficulty swallowing Acute alcohol intoxication age < 17 years Combined alcohol and drug overdose Cocaine / crack with chest pain Seizure secondary to drug overdose





7. ECG. 12 lead as needed. 8. Consider the following treatments in known

overdoses: Symptomatic Tricyclic Anti-Depressants

Sodium Bicarbonate (1mEq/kg) IV Calcium Channel Blockers

Consider TCP 9. Naloxone (2 mg) IV/IO/IM if respiratory

depressed. 10. Treat other associated signs and symptoms



1. Tricyclic Anti-Depressant Overdose Repeat Sodium Bicarbonate (1mEq/kg) IV.

2. Calcium Channel Blockers Calcium Gluconate (10 ml) IV.

20

Asystole / PEA

NEMSIS – 6790 (Asystole) 7150 (PEA) 7214 (Trauma Arrest)


*Unresponsive *Apenic *Pulseless

BLS Treatment 1. ABC, Initiate CPR / AED 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Once an advanced airway is placed monitor

CO2 with capnography, if available. 4. History and physical exam as time permits. 5. Check blood glucose level.


**Request Paramedic Evaluation if** Automatic ALS response

ILS Treatment 6. Obtain IV access– Insert EZ-IO after 2

unsuccessful IV attempts. 7. D50 (25 grams) IV if blood glucose is < 70

mg/dl. A




8. ECG. 12 lead as needed. 9. Search for and treat possible contributing

factors. 10. Epinephrine 1:10,000 (1 mg) IV/IO every 3-5

minutes. 11. Atropine (1 mg) IV/IO every 3-5 minutes –

maximum dose 3 mg. 12. Sodium Bicarbonate (1 mEq/kg) IV/IO 13. Consider termination of efforts if appropriate.



21

22

Bradycardia

NEMSIS – 6830 (Bradycardia)


*Slow pulse rate *Pale, grey skin color *Altered level of consciousness *Hypotension *Cyanosis *Nausea / vomiting *Diaphoresis Radiation of pain *Irregular pulse Frightened appearance *Difficulty breathing Restlessness / anxiety


Physical exam, Vital signs, Pulse oximeter. 2. Administer oxygen– Manage airway as

necessary. 3. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Chest pain or signs of shock Chest pain with drug use Implanted defibrillator shock





5. ECG with 12 lead. 6. Immediate transcutaneous pacing (TCP) if 2nd

degree type II or 3rd degree heart block is present.

7. Atropine (0.5 mg) IV/IO if blood pressure is < 90 mm/Hg systolic.



1. If unable to gain IV access – consider EZ-IO with OLMC.

2. Dopamine (2-20 mcg/kg/min.) IV infusion. 3. Epinephrine (2-10 mcg/min) IV infusion.

23

2

24

Cardiogenic Shock

NEMSIS – 6970 (hypotension / Shock (Non-Trauma)


*Rapid Pulse *Nausea / Vomiting *Cyanosis Restlessness / anxiety *Pale, grey skin color *Difficulty breathing / Shortness of breath *Irregular pulse Radiation of pain *Hypotension Frightened appearance






**Request Paramedic Evaluation if** Unconscious / not breathing Rapid heart rate with chest pain or signs of shock. Chest pain with drug use Implanted defibrillator shock

ILS Treatment 4. Obtain IV access. 5. Fluid bolus 250cc repeated as needed if lung

sounds are clear.




6. ECG with 12 lead. 7. Treat other associated signs and symptoms per



1. If unable to gain IV access – Consider EZ-IO with OLMC.

2. Dopamine (5-20 mcg/kg/min) titrate to systolic blood pressure > 90 mm/Hg.

25

Chest Pain

NEMSIS – 6860 (Cardiac Chest Pain)


*Bradycardia *Pale / grey skin color *Tachycardia *Cyanosis *Altered Level of Consciousness *Hypotension *Difficulty breathing *Irregular pulse *Nausea / vomiting Restlessness / anxiety *Diaphoresis Radiation of pain Frightened appearance



necessary. 3. Aspirin (324 mg) chewable PO. 4. Nitroglycerin per patient’s prescription if

systolic blood pressure is >100 mm/Hg every 5 minutes – 3 total doses. A



**Request Paramedic Evaluation if** Suspected cardiac origin Implanted defibrillator shock





7. ECG with 12 lead. 8. Nitroglycerin (0.4 mg) SL, No more than 3

metered doses should be administered in a 15 minute period. A 4th and subsequent doses may be administered, every 5 minutes, if chest pain persists and as long as systolic BP remains 100 mm/Hg or greater.



1. Morphine (4 mg) IV, may be repeated every 5 minutes to a total dose of 16 mg.

Note: A. Remember to ask the patient if they have taken any erectile dysfunction medication within the last 48 hours. If so, do not administer nitroglycerin.

26

Hypertensive Crisis NEMSIS – 6950 (Hypertension)


*Slow pulse rate *Unconscious *Altered level of consciousness *Cyanosis *Difficulty breathing *Hypotension *Diaphoresis Frightened appearance *Irregular pulse Radiation of pain *Nausea / vomiting Restlessness / anxiety *Pale grey skin color






**Request Paramedic Evaluation if** Blood pressure greater than 150 mm/Hg systolic and / or 100 mm/Hg diastolic. Any of the above automatic ALS items.








1. If blood pressure is above 220 mm/Hg systolic or 120 mm/Hg diastolic: Labetalol (10mg) IVP over 2 minutes –

repeat 10 mg every 10 minutes as needed. (Contraindicated for cocaine induced hypertension.)

27

Premature Ventricular Contractions

NEMSIS – 7232 (Ventricular Ectopy)


*Slow pulse rate *Unconscious *Altered level of consciousness *Cyanosis *Difficulty breathing *Hypotension *Diaphoresis Frightened appearance *Irregular pulse Radiation of pain *Nausea / vomiting Restlessness / anxiety *Pale grey skin color






**Request Paramedic Evaluation if** Unconscious / not breathing Age >25 years with symptoms of shortness of breath, nausea or diaphoresis. Rapid heart rate with chest pain or signs of shock. Chest pain with drug use. Implanted defibrillator shock








If the Patient is Symptomatic: 1. Lidocaine (1.0 mg/kg) IV, repeated (0.5

mg/kg) IV every 5 minutes until ectopy is suppressed or maximum of 3 mg/kg. After PVC’s are suppressed, initiate infusion (2-4 mg/min). A

Note: A. For infusions, reduce doses by 50% if the patient is in CHF, Shock, or over 70 years old.

28

Narrow Complex Tachycardia

(Rate Greater than 150 beats per minute) NEMSIS – 7190 (SVT) 6791 (Atrial Fibrillation)


*Slow pulse rate *Pale / grey skin color *Altered level of consciousness *Hypotension *Cyanosis *Nausea / vomiting *Diaphoresis *Difficulty breathing *Irregular pulse Frightened appearance Restlessness / anxiety Radiation of pain











5. ECG with 12 lead. Narrow Regular Stable

6. Vagal maneuvers 7. If unresolved, Adenosine (6 mg) rapid IV push

– if no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once.

8. Contact medical control for further recommendations.


Narrow Regular Unstable 10. Consider sedation, Valium (5mg) IV to

maximum dose of 15 mg. 11. Synchronized cardioversion.

CONTINUED ON THE NEXT PAGE


29

12. If unresolved, Adenosine (6 mg) rapid IV

push – if no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once.

13. Contact medical control for further recommendations.

Narrow Irregular Stable

14. Probable atrial fibrillation, possible atrial flutter or multifocal atrial tachycardia – contact medical control for further direction.

Narrow Irregular Unstable

15. Consider sedation, Valium (5mg) IV to maximum dose of 15 mg.

16. Synchronize cardioversion. 17. Contact medical control for further recommendations. 18. Treat other associated signs and symptoms



30

31

Ventricular Fibrillation /

Pulseless Ventricular Tachycardia NEMSIS – 7230 (Ventricular Fibrillation) 7240 (Ventricular Tachycardia)



BLS Treatment 1. ABC, Initiate CPR / AED 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Once an advanced airway is placed monitor

CO2 with capnography, if available. 4. History and physical exam as time permits. 5. Check blood glucose level. 6. Treat other associated signs and symptoms per




ILS Treatment 7. Obtain IV access– Insert EZ-IO after 2

unsuccessful IV attempts. 8. D50 (25 grams) IV if blood glucose is < 70

mg/dl. A ***Contact Receiving Facility***



9. Electrical therapy – If arrest is witnessed by fire/rescue, provide immediate defibrillation, otherwise provide 5 cycles or about 2 minutes of CPR prior to defibrillation.

10. Search for and treat possible contributing factors.

11. Epinephrine 1:10,000 (1 mg) IV/IO every 3-5 minutes.

12. Electrical therapy after each drug. 13. Amiodarone (300 mg) IV/IO. 14. After 5 minutes consider second dose of

Amiodarone (150 mg) IV/IO. 15. Magnesium Sulfate (2 grams in 50ml) IV

infusion given over 1 minute. 16. Sodium Bicarbonate (1 mEq/kg) IV/IO.


2. Calcium Gluconate (10 ml) IV – if known dialysis patient.

32




33

34

Wide Complex Tachycardia

(rate greater than 150 beats per minute) NEMSIS – 7240 (Ventricular Tachycardia)


*Altered level of consciousness *Pale / grey skin color *Irregular pulse *Difficulty breathing *Implanted defibrillator shock *Restlessness / anxiety *Cyanosis *Nausea / vomiting *Hypotension Radiation of pain *Diaphoresis






**Request Paramedic Evaluation if** Unconscious / not breathing Rapid heart rate with chest pain or signs of shock.


***Contact Receiving Facility*** ** Request Paramedic Intercept When ** On-Line Medical Control Orders


5. ECG with 12 lead. Stable Regular:

6. If Ventricular Tachycardia or uncertain rhythm: • Amiodarone (150 mg) IV/IO infusion over

10 minutes. If SVT with aberrancy:

• Adenosine (6 mg) rapid IV push – if no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once.

7. If unsuccessful consider sedation valium (5 mg) IV/IO every 5 minutes to a maximum dose of 15 mg.

8. Synchronized Cardioversion

Stable Irregular: 10. Transmit EKG to closest ER and speak to

OLMC. CONTINUED ON THE NEXT PAGE


35

Unstable (Critical):

10. Consider sedation valium (5 mg) IV every 5 minutes to a maximum dose of 15 mg.

11. Synchronized Cardioversion. 12. Treat other associated signs and symptoms



36

37

Heat Exhaustion / Heat Stroke

NEMSIS – 6960 (Hyperthermia)


*Altered level of consciousness *Dizziness / faintness *Seizures *Weakness *Hot / dry skin Severe muscular cramps / pain *Pale / clammy skin Rapid / weak pulse *Rapid / shallow breathing



necessary. 3. Remove patient from heat source. 4. Check blood glucose level. 5. Cooling measures. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Signs of shock Respiratory distress Syncope or near syncope Pale, clammy skin

ILS Treatment 7. Obtain IV access. 8. If Hypotensive, fluid bolus as needed (250 cc)

repeated as needed if lung sounds are clear. ***Contact Receiving Facility***



9. ECG with 12 lead. 10. Treat other associated signs and symptoms



38

Hypothermia

NEMSIS – 6890 (Hypothermia)


*Altered level of consciousness Rapid pulse and breathing *Depressed vital signs Poor muscle coordination *No shivering despite being very cold Shivering *Cold / pale skin



necessary. 3. Remove wet clothing and keep warm. 4. Check blood glucose level. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Signs of shock Respiratory distress Syncope or near syncope Pale, clammy skin Diaphoresis

ILS Treatment 6. Obtain IV access. 7. If hypotensive, warm fluid bolus as needed

(250 cc) repeated as needed if lung sounds are clear.







39

Pre-Eclampsia / Eclampsia NEMSIS – 7020 (Obstetrical Emergencies)


*Altered level of consciousness Edema of extremities *3rd trimester blood pressure >140/90 Significant, sudden weight gain *Blood pressure 15 mm/Hg above normal blood pressure *Unresponsive *Seizures



airway as necessary. 3. Place in left lateral recumbent position. 4. Transport gently. 5. Check blood glucose level. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Increase of systolic blood pressure 15 mm/Hg above normal. Seizures





8. ECG with 12 lead. If seizure occurs: 9. Magnesium Sulfate (2 grams) IV infusion over

2 minutes. 10. Valium (5 mg) repeated to a maximum of 15

mg. 11. Treat other associated signs and symptoms



40

Gynecology & Miscarriage

NEMSIS – 6935 (Gynecologic Emergencies)


*Altered level of consciousness *Heavy vaginal bleeding *Rapid / weak pulse Passage of tissue *Cool / clammy skin Paleness *Low blood pressure Cramp-like pains in lower abdomen Patients knowledge of pregnancy



airway as necessary. 3. Check blood glucose level 4. Treat other associated signs and symptoms per











41

OB Delivery / Childbirth NEMSIS – 6870 (Childbirth / Labor)


*Altered level of consciousness *Vaginal bleeding > 100cc *Labor before 38 weeks Abdominal pain *Urge to have a bowel movement Nausea / vomiting *Seizures Contractions after first infant is born *Meconium staining Weakness / dizziness *Signs of shock *Edema in the face or extremities



airway as necessary. 3. Place in left lateral recumbent position and

transport unless birth is imminent. 4. If childbirth is imminent prepare for delivery

and request a second ambulance. 5. Initiate post-partum care. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Vaginal bleeding Signs of shock Premature labor > 4 weeks early. Delivery Seizure Suspected drug use.








42

Pregnancy / Childbirth Post Partum

NEMSIS – 7010 (Newly Born)


*Altered level of consciousness Weakness / dizziness *Seizures Vaginal bleeding > 100c *Signs of shock Abdominal pain


Physical exam, Vital signs, Pulse oximeter. 2. Suction as needed, warm and dry. 3. Obtain APGAR score at 1 & 5 minutes. A

4. Administer oxygen as necessary– Manage airway as necessary.

5. Massage the fundus if bleeding continues. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Vaginal bleeding Signs of shock Premature labor > 4 weeks early. Delivery Seizure Suspected drug use.





8. ECG. 12 lead as needed. 9. If the infant is in cardiac arrest refer to

“Pediatric Protocols”. 10. Treat other associated signs and symptoms



Note: A.

Category 0 1 2 Appearance Blue Pink body with blue extremities Completely pink

Pulse Absent Below 100 100 or above Grimmace None Grimace Crying or sneezing

Activity Non / Flaccid Poor Active and crying Respirations None Slow or irregular Regular or crying

43

Abdominal Pain NEMSIS – 6720 (Abdominal Pain)


*Distended or rigid abdomen *Pulsating abdominal mass *Unequal / absent femoral pulses *Altered level of consciousness *Diaphoresis Tender abdomen



airway as necessary. 3. NPO 4. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Vomiting red blood Black, tarry stools Upper abdominal pain Lower abdominal pain, women age 12-50 with dizziness, syncope or heavy vaginal bleeding. Abdominal / back pain with syncope or near syncope when sitting.


repeated as needed if lung sounds are clear.







44

Stroke / TIA

NEMSIS – 7200 (Stroke / TIA)


*Altered level of consciousness Drooping on one side of the face *Coma Headache *Difficulty breathing Confusion / dizziness Impaired vision Paralysis of facial muscles Personality change Loss of expression on face Loss of function to extremities Mouth drawn to one side of the face

BLS Treatment 1. C-spine control if indicated, ABC, History, Physical

exam, Vital signs, Pulse oximeter. 2. Administer oxygen– Manage airway as

necessary. 3. Check blood glucose level 4. Perform prehospital stroke test. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Stroke symptoms age <50 Altered level of consciousness Respiratory distress Chest pain Seizure Severe headache Onset of symptoms < 3 hours Positive stroke test


mg/dl. A




8. ECG. 12 lead as needed. 9. Thiamine (100 mg) IV if history of alcoholism

with blood sugar < 70 mg/dl. 10. After 2 IV attempts administer Glucagon (1

mg) IM if blood glucose is < 70 mg/dl.




45

Diabetic Emergencies

NEMSIS – 6965 (Hypoglycemia) 6945 (Hyperglycemia)


*Altered level of consciousness Abdominal pain and vomiting Dry mouth & intensive thirst Weak / rapid pulse Restlessness Dry / Red / Warm skin Abnormal hostile or aggressive behavior Dizziness / headache Full, rapid pulse Skin pale / cold / clammy


Physical exam, Vital signs, Pulse oximeter, Check blood glucose level.


3. Position in left lateral recumbent position if altered level of consciousness.

4. Instant Glucose (1 tube) PO if blood sugar is < 70 mg/dl in a conscious patient with a secure airway.

5. Repeat blood glucose level 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Signs of shock Chest pain Unusual behavior Seizures


mg/dl. A





alcoholism with blood sugar < 70 mg/dl.. 11. After 2 IV attempts administer Glucagon (1

mg) IM if blood glucose is < 70 mg/dl. 12. Treat other associated signs and symptoms





46

General Illness

NEMSIS – 7220 (Universal Patient Care)

Significant Findings (*Automatic ALS) *Altered level of consciousness Nausea / vomiting *Non-descriptive pain Dizziness *Diaphoresis Weakness *Signs & symptoms of septic shock Increased temperature *Difficulty breathing increased / decreased BP


Physical exam, Vital signs, Pulse oximeter.. 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Check blood glucose level. 4. Perform prehospital stroke test. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Diaphoresis Syncope or near syncope when sitting Pale / clammy skin Respiratory distress

ILS Treatment 6. Obtain IV 7. If Hypotensive, fluid bolus as needed (250 cc)








47

Exposure to Confined Space Fire

NEMSIS – 6911 (Exposure – Airway Irritants)

Significant Findings (*Automatic ALS) *Altered level of consciousness Confusion / dizziness *Coma Red skin *Difficulty breathing Headache Impaired vision



airway as necessary. 3. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Chest pain Severe headache Seizures










48

Pain Management

NEMSIS – 7040 (Pain Control)


Severe Pain in isolated incidents BLS Treatment

1. C-spine control if indicated, ABC, History, Physical exam, Vital signs, Pulse oximeter..


3. Splint / position of comfort as needed. 4. Elevate affected body part. 5. Apply ice to affected area. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if**





8. ECG. 12 lead as needed. 9. If available and no IV access – Nitrous Oxide

self administration. 10. Treat other associated signs and symptoms




49

Poisonings



*Unconscious / Unresponsive Consider calling poison control: 1-800-222-1222 *Respiratory distress *Altered level of consciousness



airway as necessary. 3. Check blood glucose level. 4. Contact OLMC with nature of toxic exposure. 5. Activated Charcoal (1 gram/kg) PO with

OLMC or 6. Syrup of Ipecac (30 ml) followed by several

glasses of warm water with OLMC. 7. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Altered level of consciousness Intentional / accidental with Rx medications Ingestion of household cleaners Difficulty swallowing Acute alcohol intoxication, age <17 years old. Combined alcohol and drug overdose Cocaine / crack with chest pain Seizure secondary to drug overdose





9. ECG. 12 lead as needed. For Organophosphate Overdoses

10. Atropine (2 mg) IV every 5 minutes as needed – maximum dose of 6 mg.



50

SCUBA Diving Related – Decompression Illness

NEMSIS – 6892 (Diving Emergencies)


*Absent respirations or pulse *Pink / frothy sputum *Signs of respiratory distress *Seizures *Altered level of consciousness Cough


Physical exam, Vital signs, Pulse oximeter. – C-spine control if indicated.


3. Remove wet clothing and keep warm. 4. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Submersion confirmed > 1 minute. SCUBA diving accident.





6. ECG. 12 lead as needed. 7. If seizures occur, Valium (5 mg) repeated to a

total dose of 15 mg. 8. Treat other associated signs and symptoms per



51

Seizures

NEMSIS – 7170 (Seizure)


*Ongoing seizure activity – more than 5 minutes Incontinence *Pregnancy Medic Alert Tag *Altered level of consciousness Head or mouth trauma

BLS Treatment 1. Consider c-spine control, ABC, History,

Physical exam, vital signs, Pulse. 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Protect patient from injury. 4. Check blood glucose level. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Seizure > 5 minutes First time seizures Diabetic Pregnant > 20 weeks Secondary to illicit drugs. Secondary to recent head injury. Seizure, unknown history, age > 50 years old.

ILS Treatment 6. Obtain IV access. 7. D50 (25 grams) IV if blood glucose is < 70 mg/dl. A




8. ECG. 12 lead as needed. 9. Thiamine (100 mg) IV if history of alcoholism

with blood sugar < 70 mg/dl. 10. After 2 IV attempts administer Glucagon (1

mg) IM if blood glucose is < 70 mg/dl. 11. Valium (5 mg) repeated to a total dose of 15

mg or Valium (10 mg) PR may be repeated once.



1. Second or third doses of Glucagon (1 mg) every 15-30 minutes.


52

Nausea / Vomiting NEMSIS – 7251 (Vomiting)


*Altered level of consciousness *Vomiting blood *Coma Confusion / dizziness *Difficulty breathing

BLS Treatment 1. ABC, History, Physical exam, Vital signs,

Pulse. 2. Administer oxygen as necessary– Manage

airway as necessary. 3 Check blood glucose level. 4 Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Chest pain Dehydration





6. ECG. 12 lead as needed. 7. Zofran (2 to 4 mg) IV/IM for Nausea /

Vomiting. 8. Treat other associated signs and symptoms per



53

Allergic Reaction / Anaphylaxis NEMSIS – 6770 (Allergic Reaction / Anaphylaxis)


*Absent respirations or pulse *Blueness around lips *Low blood pressure *Weak / rapid pulse *Painful / squeezing sensation in chest *Abdominal cramps *Difficulty breathing *Swelling of face & tongue Nausea / vomiting Paleness Itching / hives Anxiety / dizziness Flushing around face and chest



airway as necessary. 3. Administer patient’s Epinephrine auto injector.4. If the patient’s prescribed auto-injector is not

available, begin immediate preparations for administering the Epinephrine auto injector from the fire apparatus stock.



**Request Paramedic Evaluation if** Unconscious / not breathing Cannot speak in full sentences. Swelling in throat or difficulty swallowing Diaphoresis Syncope History of anaphylactic reactions.






8. ECG. 12 lead as needed. 9. Epinephrine 1:1000 (0.3 mg) SQ may be

repeated once after 5 minutes. 10. Diphenhydramine (50 mg) IV/Deep IM. 11. If wheezing administer Albuterol (5 mg) in

nebulizer. Repeat 1 dose as needed. 12. Treat other associated signs and symptoms



1. In association with hypotension: Administer Epinephrine 1:10,000 (0.5 mg) IV

2. Second dose Diphenhydramine (50mg) IV/Deep IM with OLMC only.

54

Asthma / Bronchospasms / Shortness of Breath

NEMSIS – 7160 (Respiratory Distress)


*Extreme difficulty breathing *Altered level of consciousness *Wheezing *Chest pain *Rapid pulse and/or respirations *Cyanosis *Diaphoresis *Tripod position *Pink / frothy sputum *Hypertension Cough *Use of accessory muscles



necessary. 3. Administer Patient’s inhaler per prescription. 4. Consider CPAP usage if applicable. 5. Place in position of comfort (probably upright). 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Dyspnea with chest pain Inhaled toxic substances Unable to speak in full sentences. Recent childbirth / trauma / immobilization (2-3 months) without respiratory history. Drooling / difficult swallowing.






9. ECG. 12 lead as needed. 10. Albuterol (5 mg) nebulized may be repeated

as needed. 11. Treat other associated signs and symptoms



1. Epinephrine 1:1000 (0.3 mg) SQ may be repeated every 15 minutes to a total of 3 doses.

55

Congestive Heart Failure / Pulmonary Edema

NEMSIS – 7140 (Pulmonary Edema)


*Extreme difficulty breathing *Altered level of consciousness *Diaphoresis *Tripod position *Pink / frothy sputum *Hypertension *Audible wheezing *Use of accessory muscles *Rapid pulse and/or respirations *Hypotension *Chest pain Cough


Physical exam, Vital signs, Pulse oximeter.. 2. Administer oxygen– Manage airway as

necessary. 3. Consider CPAP usage if applicable. 4. Administer patient’s inhaler per prescription. 5. Place in position of comfort (probably upright). 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Dyspnea with chest pain Inhaled toxic substances Unable to speak in full sentences. Recent childbirth / trauma / immobilization (2-3 months) without respiratory history. Drooling / difficult swallowing.





8. ECG with 12 lead. 9. Nitroglycerin (0.4 mg) SL, No more than 3

metered doses should be administered in a 15 minute period. A 4th and subsequent doses may be administered, every 5 minutes, if chest pain persists and as long as systolic BP remains 100 mm/Hg or greater.

11. Furosemide (40 mg or 40 mg plus the patients usual dose – total dose 120 mg) IV.




56

Drowning / Near Drowning

NEMSIS – 6890 (Drowning / Near Drowning)






3. Consider CPAP usage if applicable. 4. Remove wet clothing and keep warm. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Submersion confirmed > 1 minute. SCUBA diving accident.








57

Burns

NEMSIS – 6840 (Burns)


*Altered level of consciousness *Singed nasal hairs or mouth *Rapid weak pulse *Hoarseness *Low blood pressure *Difficulty breathing Burned areas 1st, 2nd, 3rd degree Secondary trauma

BLS Treatment 1. Remove patient from burning source. 2. ABC, History, Physical exam, vital signs,

Pulse Oximeter. 3. Administer oxygen as necessary– Manage

airway as necessary. 4. Determine burned body surface area 5. Remove any jewelry equal or distal to the burn. 6 Treat burns as needed. 7. Treat other associated signs and symptoms per

appropriate protocol. ***Contact Receiving Facility***

**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Burns to airway, nose or mouth. Hoarseness, difficulty talking / swallowing. Burns to neck, hands, feet or genitalia. Burns over 20% body surface area. Electrical burns / electrocution greater than or equal to 220 volts.







per appropriate protocol. ***Contact Receiving Facility***


2.

Rule of Nines Adult Body Part Child

9% Head 18% 9% Chest 9% 9% Abdomen 9% 9% Arm 9% 18% Back 18% 18% Legs 13.5% 1% Genitalia 1% 1% Palm 1%

58

Head Injury

NEMSIS – 6940 (Head Trauma)


*Altered level of consciousness *Rapid / weak pulse *Signs of internal bleeding *Low blood pressure *Decreased capillary refill Neck or spinal cord injury / pain Obvious bleeding Paleness Penetrating wounds Diaphoresis Pain / trauma to the head / neck or extremities

BLS Treatment 1. Consider c-spine control, ABC, History,

Physical exam, Vital signs, Pulse Oximeter 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Control bleeding 4. Stabilize deformed extremities 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Chest pain prior to the accident Patient ejection Patient trapped, extrication > 20 minutes MCI criteria


repeated as needed if lung sounds are clear. 8. D50 (25 grams) IV if blood glucose is < 70 mg/dl. A





alcoholism with blood sugar < 70 mg/dl.. 11. After 2 IV attempts administer Glucagon (1

mg) IM if blood glucose is < 70 mg/dl. 12. Treat other associated signs and symptoms

per appropriate protocol. ***Contact Receiving Facility***



59

Jelly Fish Sting

NEMSIS – 6820 (Bites & Envenomations)


*Altered level of consciousness *Difficulty breathing *Chest tightness *Weakness or collapse *Anaphylactic shock *Constricted upper airway *Abnormal pulse rate rhythm Burning sensation at site Headache / dizziness Muscle Cramps Localized pain Swelling at site Nausea / vomiting Joint pain



airway as necessary. 3. Remove jewelry or other constricting items

distal to the site. 4. Pour white vinegar over the sting site. 5. Scrape away stingers, taking care not to inject

more venom (use a tongue depressor only once per scrape).

6. Immobilize extremity. 7. Identify organism if possible – Do NOT

transport. 8. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Uncontrolled bleeding Respiratory distress Serious face and neck bites Signs of shock










60

Paralysis / Spinal Injury NEMSIS – 7175 (Spinal Cord Trauma)


*Altered level of consciousness *Rapid / weak pulse *Signs of internal bleeding *Low blood pressure *Decreased capillary refill Neck or spinal cord injury / pain Obvious bleeding Paleness Penetrating wounds Diaphoresis Pain / trauma to the head / neck or extremities Numbness/Tingling


Physical exam, Vital signs, Pulse oximeter, C-spine control if indicated.


3. Check blood glucose level 4. Control bleeding 5. Stabilize deformed extremities 6. Treat other associated signs and symptoms per








9. ECG. 12 lead as needed. 10. Treat other associated signs and symptoms



61

Penetrating Trauma

NEMSIS – 7000 (Trauma – Multisystem) 6920 (Extremity Trauma) 7215 (Trauma-Amputation) 6925 (Eye Trauma)


*Altered level of consciousness *Low blood pressure *Rapid / weak pulse *Decreased capillary refill *Signs of internal bleeding Obvious bleeding Paleness Diaphoresis Pain or trauma to the head, back, neck or extremities


Physical exam, Vital signs, Pulse oximeter., Control C-spine if indicated.


3. Cover open chest wounds with occlusive dressing and control bleeding.

4. Stabilize deformed extremities. 5. Treat other associated signs and symptoms per








8. ECG. 12 lead as needed. 9. If signs and symptoms of a Tension

Pneumothorax are present do a pleural decompression. A



1. Morphine (4 mg) IV, may be repeated every 5 minutes to a total dose of 16 mg. Can not be administered to patients with thoracic & abdominal trauma.

Note: A. Mid-clavicular approved by standing orders. Mid-axillary requires orders from medical control.

62

Stingray Sting



*Altered level of consciousness *Difficulty breathing *Chest tightness *Weakness or collapse *Anaphylactic shock *Constricted upper airway *Abnormal pulse rate rhythm Burning sensation at site Headache / dizziness Muscle Cramps Localized pain Swelling at site Nausea / vomiting Joint pain



airway as necessary. 3. Pour hot water over the site. (This also works

for sea urchins, starfish, and sea cucumbers). 4. Stabilize the barbs with bulky dressing. 5. Immobilize extremity. 6. Identify and do not transport the organism. 7. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Uncontrolled bleeding Respiratory distress Serious face and neck bites Signs of shock









63

Snake Bite


Significant Findings (*Automatic ALS) *Altered level of consciousness *Difficulty breathing *Chest tightness *Weakness or collapse *Anaphylactic shock *Constricted upper airway *Abnormal pulse rate rhythm Burning sensation at site Headache / dizziness Muscle Cramps Localized pain Swelling at site Nausea / vomiting Joint pain



airway as necessary. 3. Control bleeding 4. Remove jewelry or other constricting items

distal to the site. 5. Immobilize extremity and keep level with the

heart. No elevation – No cold packs. 6. Identify snake if possible – do not transport to

the hospital. 7. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Uncontrolled bleeding Respiratory distress Serious face and neck bites Signs of shock Bite from poisonous animals








64

Crush Syndrome

NEMSIS – 7000 (Trauma-Multisystem)

Significant Findings (*Automatic ALS) Crush syndrome (also traumatic rhabdomyolysis or Bywaters’ syndrome) is a serious medical condition characterized by major shock and renal failure following a crushing to skeletal muscle. 3 Criteria: (1) Involvement of a muscle mass. (2) Prolonged compression (1 hour or greater definitely after 4 hours). (3) Compromised blood circulation.



airway as necessary. 3. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Automatic ALS Call

ILS Treatment 4. Obtain IV access – 2 sites are preferred. 5. Prior to or during extrication, fluid bolus (250

cc) repeated as needed if lung sounds are clear.




6. ECG. 12 lead as needed. Monitor closely for widening of QRS > 0.12 seconds, presence of PVC’s and peaked T waves.

7. Consider air transport to a hyperbaric chamber 8. Cardiac arrest post extrication administration

Sodium Bicarbonate (1 mEg/kg) IV/IO. 9. Treat other associated signs and symptoms per



Decreased level of consciousness or significant drop in blood pressure after extrication with no obvious cause:

1. Sodium Bicarbonate (50 mEq) mixed in 1 liter of NS – run at 200 cc/hour.

2. Albuterol (5 mg) nebulizer as needed.

65

Pediatric Protocols

These protocols are to be used for children from birth until 8 years of age or less than 90 pounds. For patients older than 8 years of age or greater than 90 pounds follow the appropriate protocol in the adult

section of this document.

When providing pediatric care always refer to your length based tape (ie. Broselow tape) for appropriate emergency care in the pediatric

patients.

66

Pediatric Abdominal Distress: Non-Trauma NEMSIS – 6720 (Abdmoninal Pain)


*Tachycardia *Capillary refill time greater than 2 seconds *Cool / clammy skin *Poor pulses *Altered level of consciousness



airway as necessary. 3. NPO, position of comfort. 4. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Vomiting red blood Black, tarry stools Signs of shock

ILS Treatment 5. Obtain IV access. 6. If hypotensive, fluid bolus (20 cc/kg) repeated as needed per OLMC.







67

Pediatric Altered Level of Consciousness

NEMSIS – 6780 (Altered Mental Status)


*Evidence of trauma *Abnormal breathing *Altered level of consciousness Breath odor Hypertension / Hypotension



necessary. 3. Determine blood glucose level. 4. Instant Glucose (1 tube) PO if blood sugar is <

70 mg/dl in a conscious patient with a secure airway.



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Alcohol ingestion





8. ECG. 12 lead as needed. 9. D25W (0.5 gram/kg) IV slow administration if

blood glucose level < 70 mg/dl. D50W (1.0 gm/kg) PR. 10. Glucagon IM (0.1 mg/kg – maximum dose =

1.0 mg) after 2 IV attempts. 11. Narcan IV/IO/IM if respiratory depression is

present. Doses as follows: (0.1 mg/kg up to 5 years old) (2.0 mg > 5 years old) 12. Treat other associated signs and symptoms



1. Second or third doses: Glucagon (0.1 mg/kg – maximum dose = 1.0 mg) every 15-20 minutes.

68

Pediatric Anaphylaxis

NEMSIS – 6770 (Allergic Reaction / Anaphylaxis)


*Cyanosis around the lips *Swelling of the face and tongue *Hypotension *Weak / rapid pulse *Altered level of consciousness *Abdominal cramps *Difficulty breathing Itching / hives Nausea / vomiting Anxiety / dizziness



airway as necessary. 3. May administer patients own Epinephrine pen. 4. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress Difficulty swallowing Diaphoresis History of anaphylaxis reaction





7. ECG. 12 lead as needed. 8. If respiratory distress administer Epinephrine

1:1000 SQ (0.01 mg/kg up to 0.3 mg). 9. If wheezing administer Albuterol (5 mg) in

nebulizer. Repeat 1 dose as needed. 10. Diphenhydramine IV/IM (1 mg/kg) 11. Treat other associated signs and symptoms



1. Second or third doses: Epinephrine 1:1000 SQ (0.01 mg/kg up to 0.3 mg). 2. If hemodynamically unstable Epinephrine 1:10,000 IV (0.01 mg/kg – maximum dose 0.5 mg IV)

69

Pediatric Asystole / Pediatric PEA

NEMSIS – 6790 (Asystole) 7150 (PEA)





necessary. 3. CPR 4. As time permits obtain history / physical exam. 5. Determine blood glucose level. 6. Treat other associated signs and symptoms per




ILS Treatment 7. Obtain IV access – Insert EZ-IO after 2 unsuccessful IV attempts.




8. ECG – confirm cardiac rhythm in > 1 lead. 9. Search for and treat possible contributing

factors. 10. Epinephrine IV/IO: (0.01 mg/kg 1:10,000)

every 3-5 minutes. 11. Administer saline bolus 20 cc/kg. 12. If blood glucose < 70 mg/dl administer D25W

(0.5 gram/kg) IV/ IO slow administration. 13. Treat other associated signs and symptoms



1. Sodium Bicarbonate (1 mEq/kg) – dilute 1:1 with NS if age < 2 years old.

70

71

Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia

NEMSIS – 7230 (Ventricular Fibrillation) 7240 (Ventricular Tachycardia)









ILS Treatment 7. Obtain IV access– Insert EZ-IO after 2 unsuccessful IV attempts.




8. ECG 9. Defibrillate 1 time at 2 J/kg. 10. Give 5 cycles of CPR. 11. Check rhythm – if VF/VT then give 1 shock

at 4 J/kg. 12. Epinephrine (0.01 mg/kg 1:10,000) IV/IO

every 3-5 minutes. 13. Defibrillate 4 J/kg after 5 cycles of CPR. 14. Administer Amiodarone (5 mg/kg) IV/IO –

may be repeated once in 5 minutes. 15. If torsades de pointe administer Magnesium

Sulfate (25 mg/kg) IV/IO – maximum of 2 grams over 2 minutes.

16. If blood glucose < 70 mg/dl administer D25W (0.5 gram/kg) IV/ IO slow administration.

17. Search for and treat possible contributing factors.



1. Sodium Bicarbonate (1 mEq/kg) – dilute 1:1 with NS if age < 2 years old.

72

73

Pediatric Bradycardia

NEMSIS – 6830 (Bradycardia)


*Unresponsive *Hypotension *Apenic *Nausea / vomiting *Diaphoresis *Altered level of consciousness *Slow pulse rate *Cyanosis



necessary. 3. If signs of decreased perfusion and HR < 80 in

infants or HR < 60 in < 5 years old perform CPR.








6. ECG 7. Administer Epinephrine – repeat every 3-5

minutes at same dose: IV/IO: (0.01 mg/kg 1:10,000) 8. Administer Atropine – May repeat once. IV/IO: (0.02 mg/kg) Minimum single dose: 0.1 mg Maximum single dose: 0.5 mg child / 1.0 mg adolescence

9. Consider cardiac pacing. 10. Consider administer saline bolus 20 cc/kg. 11. If blood glucose < 70 mg/dl administer D25W

(0.5 gram/kg) IV/ IO slow administration. 12. Treat other associated signs and symptoms



1. Sodium Bicarbonate (1 mEq/kg) – dilute 1:1 with NS if age < 2 years old. 2. If unable to gain IV access – Consider EZ-IO with OLMC.

74

75

Pediatric Cardiac Arrest Due to Hypothermia

NEMSIS – 6980 (Hypothermia) 6850 (Cardiac Arrest)









ILS Treatment 7. Obtain IV access– Insert EZ-IO after 2 unsuccessful IV attempts. 8. Fluid bolus (20 cc/kg) repeated with OLMC.




9. ECG. 10. Defibrillate VF/VT to total of 1 time (2 J/kg) 11. Withhold IV medications and any further

defibrillations – Continue CPR & support of the airway.

12. Contact OLMC for further treatment decisions.



76

Pediatric Burns NEMSIS – 6840 (Burns)


*Hoarseness *Singed mouth *Altered level of consciousness *Rapid / weak pulse *Hypotension *Difficulty breathing Burned areas 1st, 2nd, 3rd Trauma



airway as necessary. 3. Remove jewelry and clothing. 4. Treat burns as needed. 5. Obtain history / physical exam as time permits. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / Apenic. Altered level of consciousness. Burns to airway, nose or mouth. Burns to neck, hands or genitalia. Burns over 20% BSA. Electrical burns / electrocution.





8. ECG 9. Nitrous oxide (self administration) if no IV

access. 10. Treat other associated signs & symptoms per



1. Morphine IV/IM/IO (0.2 mg/kg) OLMC.

Pediatric Rule of Nines

Body Part Percent Head 18% Chest 9%

Abdomen 9% Arm 9% Back 18% Legs 13.5%

Genitalia 1% Palm 1%

77

Pediatric Fever NEMSIS – 6930 (Fever)


*Unresponsive *Hypotension *Apenic *Nausea / vomiting *Altered level of consciousness *Diaphoresis *Cyanosis *Slow pulse rate



airway as necessary. 3. If the patient is unstable or having a seizure

treat per the appropriate algorithm. 4. Transport in position of comfort lightly

wrapped. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unresponsive Seizures Altered level of consciousness Apenic / respiratory distress

ILS Treatment




6. If the temperature is above 100.6 degrees Fahrenheit and the child has not received acetaminophen in the past 6 hours administer Acetaminophen (10 mg/kg) PO.



.

78

Pediatric Head Injury NEMSIS – 6940 (Head Trauma)


*Altered level of consciousness *Rapid / weak pulse *Signs of internal bleeding *Low blood pressure *Decreased capillary refill Neck or spinal cord injury / pain Obvious bleeding Paleness Penetrating wounds Diaphoresis Pain / trauma to the head / neck or extremities


Physical exam, Vital signs, Pulse oximeter. C-spine precautions.


3. Control bleeding. 4. Stabilize deformed extremities. 5. Assess Glasgow Coma Score. 6. Treat other associated signs and symptoms per


**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Patient ejection Patient trapped, extrication > 20 minutes MCI criteria

ILS Treatment 7. Obtain IV access. 8. If hypotensive, fluid bolus (20 cc/kg) repeated

as needed per OLMC. ***Contact Receiving Facility***



9. ECG. 12 lead as needed. 10. D25W (0.5 gram/kg) slow administration if

blood glucose level < 70 mg/dl. D50W (1.0 gm/kg) PR. 11. After 2 IV attempts administer Glucagon IM

(0.1 mg/kg – maximum dose = 1.0 mg). Signs of Increased Intracranial Pressure Present?

12. Ventilate as follows: > 1 year old @ 20-25 times minute 1 month -1year old @ 40 times a minute 0-1 month @ 40-50 times a minute

13. If available - once intubated monitor CO2 with capnography.



1. Second or third doses: Glucagon (0.1 mg/kg – maximum dose = 1.0 mg) IM every 15-20 minutes.

79

Pediatric Hyperthermia*

NEMSIS – 6960 (Hyperthermia)


*Altered level of consciousness Dizziness / faintness *Seizures Weakness *Hot / dry skin Severe muscular cramps / pain *Pale / clammy skin Rapid / weak pulse *Rapid / shallow breathing

BLS Treatment 1. Remove patient from heat source. 2. ABC, History, Physical exam, Vital signs,

Pulse Oximeter 3. Administer oxygen as necessary– Manage

airway as necessary. 4. Check blood glucose level. 5. Cooling measures – do not induce shivering. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Signs of shock Respiratory distress Syncope or near syncope Pale, clammy skin








Note: *Hyperthermia does not refer to physiologic temperature elevation in normal children with acute minor illness, nor to those who have febrile seizures.

80

Pediatric Hypothermia

NEMSIS – 6980 (Hypothermia)


*Altered level of consciousness Rapid pulse and breathing *Depressed vital signs Poor muscle coordination *No shivering despite being very cold Shivering *Cold / pale skin



airway as necessary. 3. Remove wet clothing and warm. 4. Check blood glucose level. 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Signs of shock Respiratory distress Syncope or near syncope Pale, clammy skin Diaphoresis








81

Pediatric Multiple Trauma NEMSIS – 7000 (Trauma – Multisystem)


*Altered level of consciousness *Low blood pressure *Rapid / weak pulse *Decreased capillary refill *Signs of internal bleeding Obvious bleeding Paleness Diaphoresis Pain or trauma to the head, back, neck or extremities


Physical exam, Vital signs, Pulse oximeter., Control C-spine if indicated.


3. Cover open chest wounds with occlusive dressing and control bleeding.

4. Stabilize deformed extremities. 5. Treat other associated signs and symptoms per


**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Capillary refill > 2 seconds Patient ejection Patient trapped, extrication > 20 minutes MCI criteria

ILS Treatment 6. Obtain IV/IO access – 2 sites is preferred. 7. If Hypotensive, fluid bolus as needed (20

cc/kg) repeated with OLMC. ***Contact Receiving Facility***



8. ECG. 12 lead as needed. 9. If signs and symptoms of a Tension

Pneumothorax are present do a pleural decompression with an 18g needle. A

Signs of Increased Intracranial Pressure Present?

10. Ventilate as follows: > 1 year old @ 20-25 times minute 1 month -1year old @ 40 times a minute 0-1 month @ 40-50 times a minute

11. If available - once intubated monitor CO2 with capnography.



Note:A. Mid-clavicular approved by standing orders. Mid-axillary requires orders from medical control.

82

Pediatric Near Drowning

NEMSIS – 6890 (Drowning / Near Drowning)






3. Remove wet clothing and warm. 4. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Submersion confirmed > 1 minute.


as needed per OLMC.




7. ECG. 12 lead as needed. 8. Ensure proper airway control & ventilation 9. Treat other associated signs and symptoms per



83

Newborn Resuscitation

NEMSIS – 6850 (Cardiac Arrest)


*Absent respirations or pulse *Signs of respiratory distress *Altered level of consciousness

BLS Treatment 1. If meconium is present suction the mouth, then

the nose thoroughly before stimulation. 2. Clamp cord, cut. 3. Warm, dry, stimulate. 4. Place in flat position and assess airway,

breathing & circulation. 5. Heart rate < 100 or pale tone & color continue

to dry, warm and stimulate. Suction as needed and provide blow by 100% oxygen.

6. Reassess in 1 minute – if no improvement provide positive pressure ventilation with 100% oxygen.

7. Reassess in one minute – if no improvement and heart rate is < 80 begin chest compressions.

8. Check blood glucose level. 9. Treat other associated signs and symptoms per



ILS Treatment 10. Obtain IV access– Insert EZ-IO after 2 unsuccessful IV attempts. 11. Consider fluid bolus as needed (10 cc/kg)

repeated with OLMC. ***Contact Receiving Facility***



12. ECG 13. Epinephrime (0.01 mg/kg) 1:10,000 IV/IO

repeated every 3-5 minutes. 14. D10W (0.2 gram/kg) IV/IO if blood glucose is

< 70 mg/dl. 15. Naloxone (0.1 mg/kg) IV/IO. 16. Treat other associated signs and symptoms



84

85

Pediatric Pain Management

NEMSIS – 7040 (Pain Control)


BLS Treatment

1. C-spine control if indicated, ABC, History, Physical exam, Vital signs, Pulse oximeter.


3. Splint / position of comfort as needed. 4. Elevate affected body part. 5. Apply cold pack to affected area. 6. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if**









1. Morphine (0.2 mg/kg) IV/IM/IO, may be repeated.

86

Pediatric Poisoning / Ingestion



*Abnormal breathing Breath odor *Altered level of consciousness



airway as necessary. 3. Determine blood glucose level. 4. Instant Glucose (1 tube) PO if blood sugar is <

70 mg/dl in a conscious patient with a secure airway.



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress





8. ECG. 12 lead as needed. 9. D25W (0.5 gram/kg) slow administration if

blood glucose level < 70 mg/dl. D50W (1.0 gm/kg) PR. 10. Glucagon IM (0.1 mg/kg – maximum dose =

1.0 mg) after 2 IV attempts. 11. Narcan IV/IO/IM if respiratory depression is

present. Doses as follows: (0.1 mg/kg up to 5 years old) (2.0 mg > 5 years old)



1. Second or third doses Glucagon (0.1 mg/kg – maximum dose = 1.0 mg) IM every 15-20 minutes.

87

Pediatric Respiratory Distress

NEMSIS – 7160 (Respiratory Distress)


*Extreme difficulty breathing *Altered level of consciousness *Wheezing *Use of accessory muscles *Rapid pulse and/or respirations *Cyanosis *Diaphoresis *Tripod position



necessary. 3. Administer Patient’s inhaler per prescription. 4. Place in position of comfort (probably upright). 5. Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Respiratory distress


as needed per OLMC.




8. ECG. 12 lead as needed. 9. Albuterol (5 mg) nebulized may be repeated as

needed. 10. Treat other associated signs and symptoms



1. Epinephrine 1:1000 (0.01 mg/kg – maximum 0.3 mg) SQ may be repeated every 15 minutes to a total of 3 doses.

88

Pediatric Seizures NEMSIS – 7170 (Seizure)


*Ongoing seizure activity – more than 5 minutes Medic Alert Tag *Altered level of consciousness Head or mouth trauma

BLS Treatment 1. ABC, History, Physical exam, Vital signs,

Pulse. 2. Administer oxygen as necessary– Manage

airway as necessary. 3. Protect patient from injury. 4 Check blood glucose level. 5 Treat other associated signs and symptoms per



**Request Paramedic Evaluation if** Unconscious / not breathing Seizure > 5 minutes First time seizures Diabetic Secondary to recent head injury.





7. ECG. 12 lead as needed. 8 D25W (0.5 grams/kg) IV or D50W (1 gram/kg)

PR if blood glucose is < 70 mg/dl 9 After 2 IV attempts administer Glucagon (0.1

mg/kg – maximum 1mg) IM if blood glucose is < 70 mg/dl.

10. Valium (0.2 mg/kg) IV/IO maximum dose 10 mg or 0.75 mg/kg – whichever is less

or 11. Valium (0.5 mg/kg) PR may be repeated (0.25

mg/kg) in 10 minutes. 12. Treat other associated signs and symptoms




89

Pediatric Hypotension / Shock

NEMSIS – 6970 (Hypotension / Shock (Non-Trauma)


*Altered level of consciousness *Low blood pressure *Rapid / weak pulse *Decreased capillary refill *Signs of internal bleeding Obvious bleeding Paleness Diaphoresis


Physical exam, Vital signs, Pulse oximeter. Control C-spine if indicated.




**Request Paramedic Evaluation if** Unconscious / not breathing Altered level of consciousness Respiratory distress Capillary refill > 2 seconds


as needed per OLMC.







90

Narrow Complex Tachycardia* NEMSIS – 7190 (SVT) 6791 (Atrial Fibrillation)


*Slow pulse rate *Pale / grey skin color *Altered level of consciousness *Hypotension *Cyanosis *Nausea / vomiting *Diaphoresis *Difficulty breathing *Irregular pulse Frightened appearance Restlessness / anxiety










5. ECG. 12 lead as needed.

Stable (Symptomatic) 6. Vagal maneuvers 7. Adenosine (0.1 mg/kg) maximum dose 6 mg

rapid IV. 8. If unresolved, Adenosine (0.1 mg/kg) rapid IV

– may repeat once max 12 mg/dose. 9. Contact medical control for further direction. 10. Treat other associated signs and symptoms


Unstable (Critical) 11. Consider sedation, Valium (0.2 mg/kg) IV/IO

maximum dose 10 mg or 0.75 mg/kg – whichever is less.


mg/kg) in 10 minutes. Continued on the Next Page

1. Amiodarone (5 mg/kg) IV infusion over 20 minutes.

91

13. Synchronize cardioversion – (0.5-1 J/kg doubled up to 2 J/kg)

14. Contact medical control for further direction. 15. Treat other associated signs and symptoms


***Contact Receiving Facility*** Note: • SVT rate may be > 220 beats per minute in infants • >180 in children > 2 years old.

92

93

Wide Complex Tachycardia NEMSIS – 7240 (Ventricular Tachycardia)


*Altered level of consciousness *Pale / grey skin color *Irregular pulse *Difficulty breathing *Diaphoresis *Restlessness / anxiety *Cyanosis *Nausea / vomiting *Hypotension Radiation of pain





**Request Paramedic Evaluation if** Unconscious / not breathing Rapid heart rate with chest pain or signs of shock.





5. ECG. 12 lead as needed.

Stable: 6. Vagal maneuvers 7. Adenosine (0.1 mg/kg) maximum dose 6 mg

rapid IV. 8. If unresolved, Adenosine (0.1 mg/kg) rapid IV

– may repeat once max 12 mg/dose. 6. Amiodarone (5mg/kg) IV infusion over 20

minutes. 7. Consider sedation, Valium (0.2 mg/kg) IV/IO

maximum dose 10 mg or 0.75 mg/kg – whichever is less

8. Synchronize cardioversion – (0.5-1 J/kg, if not effective, increase to 2 J/kg)


94

Unstable (Critical):

9. Consider sedation, Valium (0.2 mg/kg) IV/IO maximum dose 10 mg or 0.75 mg/kg – whichever is less.


mg/kg) in 10 minutes. 11. Synchronize cardioversion – (0.5-1 J/kg, if

not effective, increase to 2 J/kg) 12. Consult with medical control for further

direction. 13. Treat other associated signs and symptoms



95

96

Pediatric Information for Prehospital Care

Vital Signs Age Mean HR Mean RR Mean BP

Preemie 125 +/- 50 30 - 60 35 - 56 systolic Newborn 140 +/- 50 30 - 60 75/50

1-6 months 130 +/- 45 30 - 40 80/46 6-12 months 115 +/- 40 24 - 30 96/65

12-24 months 110 +/- 40 20 - 30 99/65 2-6 years 105 +/- 35 20 - 25 100/60

6-12 years 95 +/- 30 16 - 20 110/60 > 12 years 82 +/- 25 12 - 16 120/60

Average Body Weight Birth 6 months 12 months 23 months 36 months 5 years 10 years 3.5 kg 7 kg 10 kg 12 kg 15 kg 20 kg 30 kg

99th Percentile Blood PressureAge Systolic Diastolic

< 7 days 106 7-30 days 110

1 mo - 2 years 118 82 3 - 5 years 124 84 6-9 years 130 86

10-12 years 134 90

97

Glasgow Coma Scale Response Adults & Children Infants Points

No response No response 1 To pain To pain 2 To voice To voice 3 Ey

e O

peni

ng

Spontaneous Spontaneous 4 No response No response 1 Incomprehensible Moans to pain 2 Inappropriate words Cries to pain 3 Disoriented Irritable 4 Ve

rbal

Spontaneous Coos, babbles 5 No response No response 1 Decerebrate posturing Decerebrate posturing 2 Decorticate posturing Decorticate posturing 3 Withdraws to pain Withdraws to pain 4 Localizes pain Withdraws to touch 5

Mot

or

Obeys commands Normal spontaneous movement 6 Total Score 3-15

Pediatric Trauma Score +2 +1 -1

Patient Size > 20 kg 10-20 kg < 10kg

Airway Normal

Maintainable without invasive procedures Not Maintainable

CNS Awake Obtunded Comatose Systolic BP (or Pulse) > 90 mm/Hg (radial) 50-90 mm/Hg(femoral) < 50 mm/hg (no pulse)

Open Wounds None Minor Major or penetrating Skeletal None Closed Fracture Open / Multiple Fracture

98

Procedure Index

EKG Use

Overview Field use of 12 Lead EKGs will allow EMS paramedics to have a greater capacity to assess chest

pain patients for possible acute myocardial infarctions (AMI). Combined with these abilities will be the capability to alert the receiving hospital of the patient’s condition and allow them to better prepare for the patient’s arrival. The use of diagnostic 12 lead monitors will allow for earlier diagnosis of AMI’s to be made. When this is coupled with early hospital notification, a significant reduction in the delivery time of thrombolytics (“door to drug time”) and/or interventional catheterization (“door to cath time”) can be achieved, thus reducing mortality and morbidity from AMI’s.

Appropriate Use of Monitoring Devices

EKG evaluation by 3-lead equipped ALS first responder

ALS equipped first responder apparatus should record and evaluate cardiac rhythm and treat any irregularities per protocol until patient can be transported to ER/ED via “12-lead” equipped ALS ambulance. **If 12-lead equipped transport is unavailable or significantly delayed and BLS transport unit is available, ALS responder should not delay transport of patient and may transport utilizing 3-lead monitor. **

EKG evaluation by 12-lead capable equipped ALS responders

ALS equipped apparatus with 12-lead capabilities should initiate EKG monitoring via limb leads. Patients with a primary complaint other than “chest pain” with no irregularities noted in EKG may be transported to ER/ED on limb leads at the discretion of the paramedic. Patients with chest pain or irregularities should be monitored and recorded via 12-lead and transmit of EKG to the receiving facility ER/ED via fax capability should be attempted if possible.

General Information

The only devices that will be used by Horry County Fire Rescue for diagnostic 12 lead EKGs will be the Physio Control LP-12 cardiac monitor. Diagnostic 12 lead EKGs are considered to be lab studies. As with any other hospital or lab test, these results are to be kept strictly confidential. Do not make extra copies of 12 lead EKGs, share these EKGs with anyone else or discuss the interpretation of any 12 lead EKG with anyone. Copies of 12 lead EKGs will be left only on the patient’s ED chart and attached to the EMS run report. If you feel that a certain 12-lead test has clinical teaching value, bring that to the attention of your shift supervisor. Copies of 12 lead EKGs for CQI review will be obtained by members of the Training Division or designee. Remember patient confidentiality at all times! Horry County Fire Rescue will not turn LP-12 monitors or equipment over to rescue squad paramedics. Rescue squad paramedics are not covered under our liability insurance to use Fire Rescue equipment. This is the case even if it is an off-duty Fire Rescue employee who is working or volunteering for a rescue squad or other agency. If the patient requires 12 Lead EKG monitoring, a Horry County Fire Rescue paramedic will ride in with the patient and assume primary patient care duties for the patient enroute. All LP-12 monitors will have a third charged battery carried in the protective carry case at all times.

99

Procedure Index

Adult / Child Intraosseous (IO) Protocol

Training The EZ-IO AD® and EZ-IO PD® infusion systems require specific training prior to use.

Indications EZ-IO AD® (40 kg and over) and EZ-IO PD® (3 – 39 kg). 1. Intravenous fluid or medications are needed and a peripheral IV cannot be established in 2 attempts in the following situations:

A. Cardiac Arrest (medical or trauma). B. Any other circumstance with an on-line medical control order.

Contraindications

1. Fracture of the bone selected for IO infusion (consider alternate site). 2. Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site). 3. Previous significant orthopedic procedure (IO within 24 hours, prosthesis – consider alternate sire). 4. Infection at the site selected for insertion (consider alternate site).

Considerations Flow Rate: 1. Due to the anatomy of the IO space you will note flow rates to be slower than those achieved with IV catheters.

• Ensure the administration of an appropriate rapid syringe bolus (flush) prior to infusion NO FLUSH = NO FLOW

o Rapid syringe bolus (flush) the EZ-IO AD® with 10 ml of normal saline. o Rapid syringe bolus (flush) the EZ-IO PD® with 5 ml of normal saline. o Rapid syringe bolus (flush) as needed.

• To improve continuous infusion flow rate always use a syringe or pressure bag. Pain: 1. Insertion of the EZ-IO AD® and EZ-IO PD® in conscious patients has been noted to cause mild to moderate discomfort (usually more painful than a large bore IV). However, IO infusion for conscious patients has been noted to cause severe discomfort.

• Prior to IO syringe bolus (flush) or continuous infusion in alert patients, SLOWLY administer Lidocaine 2% through the EZ-IO hub.

o EZ-IO AD® slowly administer 20 mg Lidocaine 2%. o EZ-IO PD® slowly administer .5 mg/kg Lidocaine 2%.

Precautions

The EZ-IO AD® and EZ-IO PD® are not intended prophylatic use.

Continued on the Next Page

100

Procedure Index Adult / Child Intraosseous (IO) Protocol

Equipment

1. EZ-IO® Driver 2. EZ-IO AD® and EZ-IO PD® Needle Set 3. Alcohol & Betadine Swab 4. EZ-Connect 5. 10 ml syringe 6. 2% Lidocaine 7. EZ-IO® Yellow wristband

Procedure

Note: If the patient is conscious – with on-line medical control orders, advise of EMERGENT NEED for this procedure and obtain informed consent. 1. Wear appropriate BSI equipment. 2. Determine EZ-IO AD® and EZ-IO PD® indications. 3. Rule out contraindications. 4. Locate appropriate insertion site. 5. Prepare insertion site using aseptic technique. 6. Prepare the EZ-IO® driver and appropriate needle set. 7. Stabilize site and insert appropriate needle set. 8. Remove EZ-IO® driver from needle set while stabilizing catheter hub. 9. Remove stylet from catheter, place stylet in shuttle or approved sharps container. 10. Confirm placement. Connect primed EZ-Connect. Syringe bolus (flush) the EZ-IO catheter with the appropriate amount of normal saline. Utilize pressure for continuous infusions where applicable. Begin Infusion. Dress site, secure tubing and apply the wristband as directed. Monitor EZ-IO site and patient condition.

101

Procedure Index

Medication Administration

Narcotic Administration

Morphine Sulfate / Valium Contact On-Line Medical Control to request orders for Morphine Sulfate 4 mg every five (5) minutes (do not exceed a total of 16 mg). Carefully monitor respirations and Blood Pressure. Administer Valium two to five (2-5) mg with a maximum dose of fifteen mg (15 mg). On-Line Medical Control Order needs to be obtained for total dose exceeding 15mg. Qualifications for the use of Morphine Sulfate in pain relief in specific situations 1. The patient must be conscious 2. The patient’s systolic blood pressure (systolic) must be above one hundred 100mm HG 3. The patient should be checked for known allergies to Morphine Sulfate, or other opiates 4. The patient must have a transport time greater than five (5) minutes to the receiving ED If these conditions are met, the paramedic may call On-Line Medical Control via VHF, 800MHz, or telephone and request orders from the medical control physician to administer Narcotic. 1. Contact On-Line Medical Control for orders for Morphine Sulfate at appropriate dose. 2. The patient’s LOC, B/P, and lung sounds should be carefully assessed and noted 3. The patient should be transported to the ordering facility and be accompanied by the paramedic who

administered the Valium/Morphine Sulfate. 4. Valium/Morphine Sulfate or other scheduled medications will not be “handed-off” or given to

paramedics from any other agency.

Endotracheal Drug Administration

Although many drugs can be absorbed via the trachea, the IV and IO route of administration is preferred. For this reason, the endotracheal doses of resuscitation medications are not listed in the ACLS pulseless arrest algorithm or these procotols, although they may be used if no IV/IO access is available. Only the following four drugs can be administered via an endotracheal tube: L - Lidocaine A - Atropine Sulfate N - Naloxone E – Epinephrine

Special Information

When administering drugs via the endotracheal tube, administer 2.0 - 2.5 times the IV dose. In addition, dilute the drug in enough Normal Saline to result in a total volume of at least 10-ml. This will facilitate endotracheal instillation and aid in increased drug delivery to the respiratory tissues. Due to these requirements, endotracheal administration of medications will be allowed only after all other routes of medication administration have been tried.

102

Procedure Index Oxygenation

Guidelines for Care

It should be stressed that these are guidelines. As Emergency Care Providers our best tools are our judgment and intuition. Special Notes: 1. All “on-board” oxygen cylinders are to be properly secured in their mounts during the operation of the vehicle. 2. All “portable” oxygen cylinders are to be transported in an upright and secured position unless being transported in manner previously approved by the department. 3. All oxygen cylinders are to be replaced when they reach 300-500 PSI. Indications 1. Any patient deemed necessary by the medical care provider 2. Especially those with a chief complaint of:

• Chest Pain • Shortness of Breath • Moderate to Severe Trauma • Moderate to Severe Hemorrhage • Childbirth

Evaluate Patient’s Oxygen Saturation with Pulse-Oximeter

Administration Guidelines for COPD Patients

95% - 100% No increase in oxygen needed above their normal “home O2”, or ambient room air if the patient is not on “home O2” levels, unless the patient is specifically stating shortness of breath or chest pain as their chief complaint. O2 increases are best decided by the ALS care provider in conjunction with OLMC of the receiving facility if any questions exist. 88% - 94% Minor increase in oxygen needed above their normal “home O2”, or ambient room air if the patient is not on “home O2”levels, (these increases can normally accomplished by increasing the liters per minute the patient is normally on or placing the patient on a nasal cannula at a liter flow from 1-6 liters per minute) unless the patient is specifically stating shortness of breath or chest pain as their chief complaint. O2 increases are best decided by the ALS care provider in conjunction with OLMC of the receiving facility if any questions exist. Below 88%. Consider patient’s current condition and physical assessment. The patient may need to be placed on a non-rebreather or oxygenated with bag-valve-mask attached to a high flow oxygen delivery device. When delivering high flow rates of oxygen to COPD patients be prepared to intubate should you “knock out” their hypoxic drive. Whenever situation allows high flow oxygenation of COPD patients is best discussed with OLMC


103

Procedure Index

Oxygenation Oxygenation

Administration Guidelines for Non-COPD Patients 92% - 100% Administer oxygen via nasal cannula at 1 to 6 liters per minute. Use discretion as to the patient’s chief complaint and physical findings of your assessment. Patients with a chief complaint of severe chest pain, severe hemorrhage, major trauma, or dyspnea or physical findings of shock, diaphoresis, pale skin, inadequate breathing or circulation should all be given increased oxygen flows.

Below 92% Administer high flow oxygen. Nebulized treatments are be flowed at 6-10 liters per minute.

104

Procedure Index

Intubation Intubation Endotracheal intubation is ONLY to be performed by the Paramedic. The most experienced paramedic should be the individual performing the advanced airway management procedure. The placement of a Combitube, King Airway or LMA are still acceptable adjuncts for all levels of the prehospital provider. Intubation Confirmation After performing endotracheal intubation or successfully placing a Combitube, King of LMA device documentation of correct tube placement is paramount. Documentation should include, but is not limited to the following:

1. Breath sounds in all lung fields when artificial respirations are being performed. 2. No gurgling in the stomach when artificial respirations are being performed. 3. Condensation in the advanced airway device. 4. Visualization of the endotracheal tube passing through the vocal cords. 5. Chest rise and fall when artificial respirations are being performed. 6. Waveform capnography reading values. (Attach as soon as possible if not initially available.) 7. Oxygen saturation values.

Intubation and Cardiac Arrest Multiple trials evaluating resuscitation attempts by basic and advanced life support providers have not clearly established a link between long-term outcome and advanced skills such as medication administration and tracheal intubation. Tracheal tube insertion in the field has been shown to produce unacceptably high misplacement or unrecognized esophageal placement rates in many systems. Tracheal tube insertion has also been demonstrated to produce excessive interruptions in chest compressions decreasing the likelihood of a successful outcome. For all of these reasons, proper ventilation with a BVM is the ventilation method of choice during the first five minutes of cardiac arrest.

105

Procedure Index

Impedance Threshold Device The ResQPOD Circulatory Enhancer is an impedance threshold device (ITD) that utilizes a valve to limit air entry into the lungs during chest recoil between chest compressions. It is designed to reduce intrathoracic pressure and enhance venous return to the heart. Indications:

1. Cardiac Arrest Contraindications:

1. Patients where CPR is not indicated Equipment: (To be used in conjunction with)

1. Bag Valve Mask 2. King Tube, Combitube, LMA & ET Tube 3. ETCO2 Sensor

Procedure:

1. Attach ResQPOD ventilation port to ETCO2 Sensor. 2. Attach ResQPOD ventilation port to Bag/valve. 3. Slide ventilation timing assist light switch to on when using the ResQPOD in conjunction with

an advanced airway. 4. DO NOT hyperventilate.

106

Procedure Index

King Laryngeal Tube Airway King Laryngeal Tube Airway The King Laryngeal Tube Airway is a supralaryngeal device with oropharyngeal and esophagus low-pressure cuffs, a ventilation outlet between the two cuffs, and a blind distal tip. The King Tube is designed for positive pressure ventilation over 30 cm H2O and spontaneously breathing patients. The anatomically shaped distal tip and cuff assist in the airway’s passage behind the larynx and into the normally collapsed esophagus. Indications:

1. Primary airway management in cardiac arrest 2. Failed intubation 3. Difficult airway case 4. Upper gastrointestinal or airway hemorrhage that threatens airway patency.

Contraindications:

1. Responsive patient with intact airway – protective reflexes 2. Patients with known esophageal disease 3. Caustic ingestion 4. Upper airway obstructions due to foreign bodies or pathology

Equipment

1. BVM 2. Lubricant 3. 60-90 cc syringe 4. ET Tube Holder 5. ETCO2 Sensor

Procedure 1. Select the appropriate size tube, based on the patient’s height

a. Size 2: 35-45 inches or 12-25 kg’s b. Size 2.5: 41-51 inches or 25-35 kg’s c. Size 3: 4 to 5 feet d. Size 4: 5 to 6 feet e. Size 5: > than 6 feet

2. Apply lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings.

3. Pre-oxygenate via BVM

107

Procedure Index King Laryngeal Tube Airway

4. Position the head. The ideal head position for insertion of the KING LTS-D is the “sniffing position”.

However, the angle and shortness of the tube also allows it to be inserted with the head in a neutral position. For obese patients, elevation of the shoulders and upper back should be considered. • Hold the KING LTS-D at the connector with dominant hand. With non-dominant hand, perform a tongue-

jaw lift and insert tube into corner of mouth. • With the KING LTS-D rotated laterally 45-90 degrees, such that the blue orientation line is touching the

corner of the mouth. Introduce tip into mouth and advance behind base of tongue. • As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin). • Without exerting force, advance tube until base of connector is aligned with teeth or gums. • Using the syringe provided, inflate the cuffs of the KING LTS-D with the appropriate volume:

• Size 2 - 25-35 ml • Size 2.5 – 30-40 ml • Size 3 -50 ml • Size 4 -70 ml • Size 5- 80 ml

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

ventilation is easy and free flowing (large tidal volume with minimal airway pressure). • Depth markings are provided at the proximal end of the KING LTS-D which refers to the distance from

the distal ventilatory opening. • When properly placed, with the distal tip and cuff in the upper esophagus, and the ventilatory openings

aligned with the opening to the larynx. • The depth markings give an indication of the distance, in centimeters, from the vocal cords to the teeth. • Confirm proper position by auscultation, chest movement and EtCO2 wave form verification.

108

Procedure Index

End Tidal CO2 Monitoring / Capnography

1. INDICATIONS: Intubated applications (Mainstream) ● Verification of ETT placement ● ETT surveillance during transport ● CPR: compression efficacy & early sign of ROSC . ● Optimize ventilation of patients * Objective data to terminate resuscitation 2. PROCEDURE: ● Select EtCO2 setting on monitor if not set to default ● Assure nasal cannula or sensor to E.T. tube is correctly placed ● Check for wave forms ● Record wave form ● Capnography device should remain in place for continuous monitoring, with frequent checks to

ascertain that the tube does not migrate. ● At hospital, record waveform again 3. DOCUMENTATION: ● Upon confirmation of successful endotracheal intubation (positive wave form), print a strip and

document the initial reading on the abbreviated report. ● Document any airway or pharmacologic interventions based on capnography readings. ● Upon arrival to the emergency department and after transferring the patient to the hospital’s

bed/gurney; obtain a second strip demonstrating a continued positive wave form.

● Attach both strips to the completed run report. A code summary should accompany all cardiac arrest reports.

109

Procedure Index

End Tidal CO2 Monitoring / Capnography CAPNOGRAPHY WAVEFORM ANALYSIS: NORMAL – 35-45 mm Hg MANAGEMENT: Monitor

DISLODGED ETT: Loss of waveform, Loss of EtCO2 MANAGEMENT: Replace ETT

ESOPHAGEAL INTUBATION: Absence of waveform MANAGEMENT: Re-intubate

HYPOVENTILATION: ↓ RR, EtCO2 > 45 mm Hg MANAGEMENT: Assist ventilations/intubate

HYPERVENTILATION: ↑RR, EtCO2 < 35 mm Hg MANAGEMENT: ↓ventilations

BRONCHOSPASM: “Sharkfin” MANAGEMENT: Bronchodilators

4 5

0

45

0

4 5

0

4 5

0

4 5

0

4 5

0

110

Procedure Index

End Tidal CO2 Monitoring / Capnography CAPNOGRAPHY WAVEFORM ANALYSIS: ET cuff problem or partial tube obstruction MANAGEMENT: Re-access tube CPR – goal to maintain minimum of 10 mm Hg Sudden increase in EtCO2 - Return of spontaneous circulation

45

0

45

0

45

0

111

Procedure Index

Pleural Decompression

Indications When clinical findings reveal a tension pneumothorax (severe respiratory distress, diminished breath sounds on the affected side, tracheal deviation) with rapidly deteriorating vital signs. Symptoms of a Tension Pnuemothorax:

o Diminished or absent breath sounds. o Tracheal deviation. o Tachycardia. o Hypotension o Anxiousness (secondary to shock) o Subcutaneous emphysema. o Distended neck veins. o Pale and/or cyanotic o Diaphoretic.

Equipment needed for a pleural decompression: Betadine Preps, 14 or 16 gauge IV Needle –Catheter, One- way- valve Procedure: Select approved site (2nd or 3rd intercostal space, mid-clavicular line). Identify landmarks. Mid-clavicular line (MCL) / Midaxillary line (MAL). Second or third intercostal space (ICS) - feel for rough area on sternum at 3/4" below

suprasternal notch. This is the Angle of Louis and should correspond to the area of the second or third rib. Also, count the ribs to assure proper location. Prep site with Betadine. Firmly but carefully insert the needle with one-way-valve attached at a 90-degree angle just over the superior aspect (superior border) of the rib, through the skin and pleura until air escapes or a distinct "give" is felt. The undersurface of the rib should be avoided to limit injury to the neurovascular bundle. Air should be freely aspirated (if not, you are not in the pleural space). Remove needle while leaving catheter and one-way-valve in place. Reassess breath sounds and patient's condition (condition of patient should improve almost immediately). Secure catheter with tape. Recheck breath sounds and continuously monitor cardio-respiratory status.

Complications:

Lung laceration Pneumothorax Hemorrhage secondary to damage to the intercostal artery or vein Note: Standing orders for Pleural Decompression are for Mid-Clavicular decompression only. Mid-Axillary decompression requires an On-Line Medical Control Order.

112

Procedure Index Rapid Extrication

Conditions requiring Rapid Extrication

1. Fire or immediate danger of fire 2. Danger of explosion (Including danger of secondary explosion at terrorist incident.) 3. Rapidly rising water 4. Danger of structural collapse 5. Hostile environments such as riot conditions 6. Patient with an airway obstruction that cannot be relieved by jaw thrusts or finger sweeps 7. Chest pain, cardiac arrest 8. Inability to adequately ventilate patient while entrapped, respiratory arrest 9. Chest or airway injuries 10. Shock or uncontrolled bleeding 11. Patient position prevents access to or treatment of another patient that meets criteria for rapid

extrication.

Exclusion Criteria Any patient who does not meet the above criteria

Treatment

One rescuer initiates and maintains manual stabilization of the cervical spine. Another rescuer applies a rigid cervical collar. Rescuers assist with rotating the patient as a unit into a position where he/she can be laid supine on the long backboard. Rescuers place a long backboard next to the buttocks of the patient on the seat. The first rescuer maintains manual stabilization of the cervical spine or relinquishes it to another rescuer as appropriate while the patient is being maneuvered. Rescuers lower patient from a sitting position to a lying position on the long backboard. Rescuers slide the patient onto the long backboard, sliding the patient 1-foot at a time until the patient is completely on the board. Still maintaining manual stabilization of the cervical spine, the rescuers move the patient to the litter or away from the dangerous scene. Immobilize the patient to the backboard appropriately.

113

Procedure Index Spinal Precautions

Guidelines for care:

Clinical Criteria for Initial Assessment of Spinal Injury

Mechanism of Injury

All patients subjected to the following mechanisms of injury are to be placed in Spinal Precautions

* High speed MVA * Falls of 10 feet or greater * Cranial/ Facial Injuries * Selected penetrating wounds with possible spinal involvement

Negative or Uncertain Mechanism of Injury

Patients with contributing factors to be placed in Spinal Precautions * Spinal pain or tenderness * Abnormal Motor or Sensory examinations * Unreliable Patient Examination (including):

Acute Stress Reaction Head injury Intoxication Abnormal mental status Distracting injuries Communication barriers

*** Patients not included in one or more of the previous categories may be transported to the hospital with out spinal precautions***

When in doubt, Choose Spinal Precautions!!!

114

Procedure Index

Continuous Positive Airway Pressure (CPAP) Guidelines for usage: Indications: Dyspnea / hypoxemia secondary to congestive heart failure, acute cardiogenic pulmonary edema, pneumonia, chronic obstructive pulmonary disease (asthma, bronchitis, and emphysema) and:

A. Any patient who is complaining of shortness of breath for reasons other than pneumothorax. B. Is awake and oriented. C. Has the ability to maintain an open airway (GCS>10). D. Has a respiratory rate greater than 25 breaths per minute. E. Has a systolic blood pressure above 90 mmHg. F. Uses accessory muscles during respirations.

Contraindications:

1. Pneumothorax 2. Respiratory arrest 3. Agonal respirations 4. Unconscious 5. Shock associated with cardiac insufficiency 6. Penetrating chest trauma 7. Persistent chest trauma 8. Facial anomalies / stroke obtundation / facial trauma 9. Has active upper GI bleeding or history of recent gastric surgery

Procedure: 1. Make sure the patient does not have a pneumothorax!

2. Place patient in a sitting position. 3. Assess vital signs and SpO2 every 5 minutes. 4. Attach heart monitor and pulse oximeter. 5. If BP <90 systolic contact Medical Control prior to beginning CPAP. 6. Titrate to effect.

I. As a general rule, most patient’s airways are managed from the 2 to 5 setting. II. Increase the setting until the indicator levels out in the green area without falling

back in the black. 7. Explain the procedure to the patient:

I. Patient requires “verbal sedation” to be used effectively. a. Example: “You are going to feel some pressure from the mask but this will

help you breath easier.” II. Place delivery device over mouth and nose. III. Instruct patient to breath in through their nose slowly and exhale through their

mouth as long as possible (count slowly and aloud to four then instruct to inhale slowly.)


115

Procedure Index

Continuous Positive Airway Pressure (CPAP)

8. Check for air leaks. 9. Treatment should be given continuously throughout transport to ED. 10. Continue to coach patient to keep mask in place and readjust as needed. 11. If respiratory status / level of consciousness deteriorate, remove and consider bag valve mask

ventilation and / or endotracheal intubation. 12. Document on the patient care record should include but not limited to:

a. CPAP Level ___> (10 cm H2O) b. FiO2 - (100%) c. SpO2 every 5 minutes d. Vital signs every 5 minutes e. Response to treatment f. Any adverse reactions

Special Notes:

1. CPAP should not be used in children under 8 years of age. 2. Advise receiving hospital as soon as possible so they can prepare for patient’s arrival. 3. Do not remove CPAP until hospital therapy is ready to be placed on the patient to prevent

flash pulmonary edema. 4. Monitor for gastric distention - which may lead to vomiting. 5. If albuterol is indicated it can be administered in line with the T piece. 6. Application of ETCO2 is indicated.

116

Procedure Index

Medication Infusions

Amiodarone Infusion Mixing Instructions use a 10 drop set Dosing Information

1. Put 150 milligrams in a 50 cc bag of D5W. 50 gtts/min until 2. Yields a 3 mg/cc concentration. totally administered.

Dopamine Infusion Mixing Instructions Dosing Information

1. Put 400 mg in a 250 cc bag of D5W. Weight in pounds / 10 2. Yields a 1600 mcg/cc concentration. Subtract 2 = 5 mcg/kg/min 3. Dose: 2-20 mcg/kg/minute **Only works for 5 mcg/kg/min**

Epinephrine Infusion Mixing Instructions Dosing Information

1. Put 1 mg in a 250 cc bag of D5W. 2 mcg/min = 30 gtts/min 6 mcg/min = 90 gtts/min 2. Yields a 4 mcg/cc concentration. 3 mcg/min = 45 gtts/min 7 mcg/min = 105 gtts/min 3. Dose: 2-10 mcg/minute. 4 mcg/min = 60 gtts/min 8 mcg/min = 120 gtts/min 4. Start at 30 gtts/min and titrate. 5 mcg/min = 75 gtts/min 9 mcg/min = 135 gtts/min 10 mcg/min = 150 gtts/min

Lidocaine Infusion Mixing Instructions Dosing Information

1. Put 1 gram in a 250 cc bag of D5W. 2 mg/min = 30 gtts/min 2. Yields a 4 mg/cc concentration. 3 mg/min = 45 gtts/min 3. Dose: 2-4 mg/minute 4 mg/min = 60 gtts/min 4. Infuse at a rate of total bolus plus 1 mg

Magnesium Sulfate

Mixing Instructions use a 10 drop set Dosing Information 1. Put 2 grams in a 50 cc bag of D5W. 2. Yields a 40 mg/cc concentration. Given over 2 minutes.

117

Documents

Horry County Fire Rescuehorrycountyfirerescue.com/Portals/4/SiteImages/sop/SOP-709.pdf · Crime Scenes 11 Snake Bite 63 Reporting of a lost child, suspected abuse or neglect 13 Crush