Prehospital Care Manual - Contra Costa CountyContra Costa County Prehospital Care Manual 12/2003 Page 1 4 Communications < RADIO COMMUNICATIONS Four radio channels are designated for

CONTRA COSTACOUNTY

PREHOSPITAL CAREMANUAL

December 2001

FOREWORD

This handbook was developed with the advice and assistance of many concerned participants in ContraCosta County's EMS System. The EMS Agency would like to thank all those involved for their effortsin creating this manual.

ALL INFORMATION CONTAINED HEREIN IS INTENDED ONLY FOR USE WITHIN THE

CONTRA COSTA COUNTY EMS SYSTEM. NO RESPONSIBILITY WILL BE ASSUMED FOR

ITS USE (OR THE CONSEQUENCES OF ITS USE) IN ANY OTHER CONTEXT.

Health Services DepartmentContra Costa County

Emergency Medical Services Agency1340 Arnold Drive, Suite 126

Martinez, CA 94553(925)646-4690

www.cccems.org

December 1, 2003

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TABLE OF CONTENTS

. . . . . . . . . . . . . . . . . . . . . GENERAL NOTES SECTION . . . . . . . . . . . . . . . . . .

Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Radio Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Base Hospital Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Base Hospital Report Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Receiving Facility Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Receiving Facility Report Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Contra Costa County Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Patient Destination Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Doctor’s Medical Center - San Pablo Campus . . . . . . . . . . . . . . . . . . . . . . . . . . 3Dialysis Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Load and Go Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Notes on Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Initial Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Pediatric Age Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Notes on OB/GYN Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Notes on Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5CRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Glasgow Coma Scale (GCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Helmet Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Cervical Collars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Spinal Immobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Notes on Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Notes on Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ii

. . . . . . . . . . . . . . . . . . . . . . . BLS NOTES SECTION . . . . . . . . . . . . . . . . . . . .

Emergency Medical Technician (EMT) Scope of Practice . . . . . . . . . . . . . . . . . . . . . . 13

BLS Management of Patients Encountered Prior to Activation of 9-1-1 . . . . . . . . . . . . . . 14

Administration of Oral Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

First Responder Defibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Shock Advisory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Defibrillator Cables/Pads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Verbal Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Patient Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Spinal Immobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

. . . . . . . . . . . . . . . . . . . . . . . ALS NOTES SECTION . . . . . . . . . . . . . . . . . . . .

Paramedic Scope of Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Local Optional Scope of Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Advanced Life Support Skills List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Notes on Advanced Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Endotracheal Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21End-tidal CO (ETCO ) Detection Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 2

Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Administration of Narcan (Naloxone) and Dextrose . . . . . . . . . . . . . . . . . . . . . 23Drug and Treatment Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Drug Supply Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Oral Endotracheal Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Stomal Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Esophageal/Tracheal Double Lumen Airway (ETDLA) . . . . . . . . . . . . . . . . . . . . . . . . 29

Needle Cricothyrotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Needle Thoracostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Saline Lock Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Intraosseous Infusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Blood Glucose Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

External Cardiac Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

. . . . . . . . . . . . . . . . . TREATMENT GUIDELINES SECTION . . . . . . . . . . . . . .

CARDIAC EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Shock (Non-Traumatic) C1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

First Responder Defibrillation C2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Non-transporting Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ventricular Fibrillation/Pulseless Ventricular Tachycardia C3 . . . . . . . . . . . . . . . 39Pulseless Electrical Activity C4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Asystole C5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Ventricular Tachycardia with Pulses C6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Ventricular Tachycardia with Pulses: Stable . . . . . . . . . . . . . . . . . . . . . 42Ventricular Tachycardias with Pulses: Unstable . . . . . . . . . . . . . . . . . . . 42

Paroxysmal Supraventricular Tachycardias C7 . . . . . . . . . . . . . . . . . . . . . . . . . 43Supraventricular Tachycardias: Stable . . . . . . . . . . . . . . . . . . . . . . . . . 43Supraventricular Tachycardias: Unstable . . . . . . . . . . . . . . . . . . . . . . . . 43

Bradycardia C8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Bradycardia: Asymptomatic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Bradycardia: Symptomatic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Other Cardiac Dysrhythmias C9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Sinus Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Chest Pain C10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

ENVIRONMENTAL EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Heat Illness/Hyperthermia E1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Heat Cramps/Heat Exhaustion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Heat Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Hypothermia E2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Moderate Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Severe Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

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Burns E3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Envenomation E4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Snake Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Bees/Wasps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

HAZARDOUS MATERIALS EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52General Priorities and Treatment H1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Hydrofluoric Acid H2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Pesticides — Carbamates and Organophosphates H3 . . . . . . . . . . . . . . . . . . . . . 54

MEDICAL EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Abdominal Pain M1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Systemic Allergic Reactions/ Anaphylactic Shock M2 . . . . . . . . . . . . . . . . . . . 56

Systemic Allergic Reaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Anaphylactic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Dystonic Reaction M3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Poisons/Drugs M4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Ingestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Narcotics/Sedatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Caustics and Corrosives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Tricyclic Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

NEUROLOGIC EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Coma/Altered Level of Consciousness N1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Seizures/Status Epilepticus N2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Acute Cerebrovascular Accident (Stroke) N3 . . . . . . . . . . . . . . . . . . . . . . . . . . 62Syncope/Near Syncope N4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

OB-GYN EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Vaginal Hemorrhage O1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Vaginal Bleeding Not in Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Imminent Delivery (Normal) O2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Imminent Delivery (Complications) O3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Breech Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Prolapsed Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Pre-Eclampsia/Eclampsia O4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

PEDIATRIC EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Routine Medical Care P1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Neonatal Resuscitation P2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Cardiac Arrest - Non-Traumatic P3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Pediatric Cardiopulmonary Arrest - Basic Therapy . . . . . . . . . . . . . . . . . 70Ventricular Fibrillation/Pulseless Ventricular Tachycardia . . . . . . . . . . . . 70Asystole/Pulseless Electrical Activity (PEA) . . . . . . . . . . . . . . . . . . . . . 70

Bradycardia P4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Tachycardia P5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

v

Stable Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Unstable Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Hypotension/Shock P6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Altered Level of Consciousness P7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Seizures P8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Poisoning P9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Anaphylaxis/Allergic Reaction P10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Systemic Allergic Reaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Anaphylactic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Acute Respiratory Distress P11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Infant/Child with Complete Airway Obstruction . . . . . . . . . . . . . . . . . . . 78Croup/Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Acute Asthma/Bronchospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Critical Trauma P12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Non-Critical Trauma P13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Minor Trauma P14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Traumatic Arrest P15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Burns P16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Apparent Life-Threatening Event (ALTE) P17 . . . . . . . . . . . . . . . . . . . . . . . . . 84

RESPIRATORY EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Airway Obstruction R1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Conscious Patient — Able to Speak . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Conscious Adult Patient — Unable to Cough or Speak . . . . . . . . . . . . . . . 85Adult Patient Who Becomes Unconscious . . . . . . . . . . . . . . . . . . . . . . . 85

Acute Respiratory Distress R2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Respiratory Distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . 86Acute Asthma/Bronchospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Respiratory Arrest R3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Acute Pulmonary Edema R4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Pneumothorax R5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Simple Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Tension Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

TRAUMATIC EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Critical Trauma T1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Non-Critical Trauma - T2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Minor Trauma - T3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Traumatic Arrest T4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Crush Injury/Crush Syndrome T5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

DOPAMINE DRIP RATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Pediatric Drug Dosage Chart (3-16 kg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Pediatric Drug Dosage Chart (17-50 kg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

vi

. . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . .

Instructions for completion of the Prehospital Patient Care Record . . . . . . . . . . . . . . . 101

. . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX B . . . . . . . . . . . . . . . . . . . . . . . .Treatment Guidelines for bi-phasic low energy difibrillators

CARDIAC EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Ventricular Fibrillation/Pulseless Ventricular Tachycardia C3 . . . . . . . . . . . . . . 109Ventricular Tachycardia with Pulses C6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Ventricular Tachycardia With Pulses: Stable . . . . . . . . . . . . . . . . . . . . 110Ventricular Tachycardias With Pulses: Unstable . . . . . . . . . . . . . . . . . . 110

Paroxysmal Supraventricular Tachycardias C7 . . . . . . . . . . . . . . . . . . . . . . . . 111Supraventricular Tachycardias: Stable . . . . . . . . . . . . . . . . . . . . . . . . 111Supraventricular Tachycardias: Unstable . . . . . . . . . . . . . . . . . . . . . . . 111

Other Cardiac Dysrhythmias C9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Sinus Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

GENERAL NOTES

SECTION

Contra Costa County Prehospital Care Manual 12/2003 Page 1

4 Communications

< RADIO COMMUNICATIONS

Four radio channels are designated for communication with hospitals in Contra Costa County. Receiving hospitalcommunications are done via MED 12, whereas paramedic base hospital communications may occur via MED 12or MED 13, depending on location.

MED 11 T: 491.4375 Use for Sheriff’s Dispatch-to-ambulance communication(formerly L9) R: 488.4375

MED 12 T: 491.9125 Primary channel for base contact for West County paramedic units. Also(formerly L19) R: 488.9125 used county-wide for BLS and helicopter radio traffic

MED 13 T: 491.6125 Primary channel for base contact for paramedic units operating south ofR: 488.6125 Ygnacio Valley Road and west of I-680 along Highway 24

Whenever possible, paramedic personnel should use the MED channel assigned to the area in which they areresponding for ambulance-to-base hospital communications. MED 12 is the county-wide backup ALS channel andshould be used if MED 13 is not available. Ambulance and helicopter personnel are to contact Sheriffs Dispatch onMED 11 to request the use of MED 12 prior to utilizing the channel. The dispatcher shall be given unitidentification, and a description of current traffic (Code 2, Code 3 or trauma destination decision).

No request for use is necessary for MED 13.However, each unit must monitor the channel prior to use, to ensurethat other units are not already using the channel. Radio identification procedures must be strictly followed, asmore than one call may be occurring at the same time. If traffic is in progress on a MED channel, otherambulance personnel may either wait until current traffic is finished, or find an alternate means of contacting thedesired hospital. Any unit may, in cases such as trauma destination decisions, request that Sheriff's Dispatchbreak into current traffic on MED 12 to request temporary use of the channel. Units using MED 13 may requestuse of the channel from a unit that is currently on that channel. When making base contact for trauma destinationonly, the initial transmission should make the purpose of the call clear. Cellular phones may also be used as ameans of communication.

< BASE HOSPITAL COMMUNICATIONS

CONTRA COSTA COUNTY BASE HOSPITAL

HOSPITAL ED PHONE BASE PHONE/MED 12 CODE

John Muir Medical Center1601 Ygnacio Valley Rd. (925)939-5800Walnut Creek, CA 94598

Taped: (925)939-5804Post Call-in: (925)947-3298

Rec. Fac. Notif: (925)947-3379MED 12 Code: 14524

The base hospital is on-call 24 hours per day.

Page 2 12/2003 Contra Costa County Prehospital Care Manual

< BASE HOSPITAL REPORT FORMAT

Base hospital contacts requesting base orders should contain the following information and follow the basic orderlisted below:

Hospital nameAgency nameUnit #Response code and ETAPatient age and sexPatient chief complaintPatient's current level of consciousnessVital signsPertinent past medical historyPrehospital treatment and patient response to treatmentSpecific request for additional orders or questions regarding care

< RECEIVING FACILITY COMMUNICATIONS

HOSPITAL CODES FOR USE ON MED 12

Contra Costa Regional Medical Center 14574 Kaiser - Walnut Creek 14284

Doctors Medical Center - San Pablo 13613 Mt. Diablo Medical Center 14214Campus

John Muir Medical Center 14524 San Ramon Regional Medical Center 13623

Kaiser - Richmond 13653 Sutter Delta Medical Center 14294

< RECEIVING FACILITY REPORT FORMAT

Receiving facility reports should contain the following information and follow the basic order listed below:

Hospital nameAgency nameUnit #Response code and ETAPatient age and sexPatient chief complaintPatient's current level of consciousnessVital signsPertinent physical findings (briefly)Presence of drugs/alcohol (for 5150 transports to Contra Costa Regional Medical Center)Prehospital treatment and patient response to treatment


CONTRA COSTA COUNTY HOSPITALS

HOSPITAL SERVICES ED PHONE #

Contra Costa Regional Medical Center Basic ED (925)370-51702500 Alhambra Avenue OB/NeonatalMartinez, CA 94533

Doctor’s Medical Center - San Pablo Campus Basic ED (510)232-66222000 Vale Road OB/NeonatalSan Pablo, CA 94806 BURN CENTER

John Muir Medical Center Basic ED (925)939-58001601 Ygnacio Valley Road OB/NeonatalWalnut Creek, CA 94598 TRAUMA CENTER

Kaiser Medical Center/Richmond Basic ED (510)307-1566901 Nevin AvenueRichmond, CA 94504

Kaiser Medical Center/Walnut Creek Basic ED (925)295-48201425 South Main Street OB/NeonatalWalnut Creek, CA 94596

Mt. Diablo Medical Center Basic ED (925)674-23332540 East StreetConcord, CA 94520

San Ramon Regional Medical Center Basic ED (925)275-83386001 Norris Canyon Road OB/NeonatalSan Ramon, CA 94583

Sutter/Delta Medical Center Basic ED (925)779-72733901 Lone Tree Way OB/NeonatalAntioch, CA 94509

4 Patient Destination Determination

< DOCTOR’S MEDICAL CENTER - SAN PABLO CAMPUS

When Doctor’s Medical Center - San Pablo Campus’ emergency department has initiated emergency departmentdiversion, women who are seeing an obstetrician on-staff at Doctor’s Medical Center - San Pablo Campus, andwho have arranged with obstetricians to deliver their babies at Doctor’s Medical Center - San Pablo Campus areconsidered "direct admits" and should be taken directly to the Labor and Delivery Unit.

< DIALYSIS PATIENTS

Patients with advanced renal disease requiring dialysis have special medical needs that may deserve specificattention in the pre-hospital setting. Problems that may occur include fluid overload and electrolyte imbalances.


Patients may be particularly prone to these problems if they should miss scheduled dialysis sessions.

Fluid overload may lead to pulmonary edema. The initial treatment of this is similar to other patients withpulmonary edema, and may include oxygen, nitroglycerin, furosemide and morphine. Definitive treatment at acenter that provides acute dialysis capabilities is often necessary. The preferable transport destination for this typeof patient is the hospital at which the patient has received dialysis care. Patients in extremis will need transport tothe closest emergency department.

Hyperkalemia is also common in renal failure patients, leading to arrhythmia or ventricular fibrillation. Treatment in the field, after base contact, may include sodium bicarbonate and calcium chloride.

4 Load and Go Procedures

Patients with severe medical conditions or traumatic injuries often need to be transported without delay. Fieldtreatment is to be minimized to essential stabilization and the emphasis is placed on prompt transport to anappropriate receiving facility.

Conditions to be considered for "Load and Go" transport include:

• unmanageable airways in any patient; • severe trauma, especially to the head, chest, or abdomen; and, • obstetrical emergencies including prolapsed cord, abnormal presentation, abnormal bleeding, or

maternal seizures.• patients in hypovolemic shock

4 Notes on Pediatric Patients

The causes of catastrophic events, such as cardiac arrest are most often related to respiratory failure, shock orcentral nervous system injuries. Early treatment is critical in this population.

< INITIAL APPROACH

• Remain calm and confident as the child may pick up on any anxiety. • DO NOT SEPARATE THE CHILD FROM THE PARENT unless absolutely necessary. • Establish a rapport with the parents as well as the child, and encourage the parents to touch, hold or

cuddle the child when appropriate. • Go from least intrusive to most intrusive in your initial assessment. • LOOK, then LISTEN, then FEEL• Always explain what you are doing as you proceed. • Avoid manipulating any area that appears to be painful until late in the examination, and always tell the

child before you touch those potentially painful areas.

< PEDIATRIC AGE DEFINITIONS

• Neonate is 0-1 month• Pediatric patient is < 14 years old


< VITAL SIGNS

Vital signs are valuable in the assessment of pediatric patients, but have significant limitations and can bedangerously misleading. Children can be in compensated shock with a normal blood pressure. However, they willexhibit signs of poor peripheral circulation. Blood pressure is maintained by increasing peripheral vascularresistance and heart rate. This will cause the skin to appear pale, dusky or mottled, and to feel cool, clammy ormoist. Capillary refill may also be delayed. Capillary refill greater than 2 seconds is a sign of poor circulation.Capillary refill time of 5 seconds or greater indicates impending circulatory failure.

Hypotension is a late and often sudden sign of cardiovascular decompensation. The systolic pressure may not dropuntil the patient has a decrease of 25-30% in blood volume, therefore, relatively little blood loss in an infant oryoung child may cause decompensation and cardiopulmonary arrest. Tachycardia (heart rate greater than 100) willpersist until cardiac reserve is depleted. Bradycardia (heart rate less than 60) in a distressed child is an ominoussign of impending cardiac arrest.

ABNORMAL VITAL SIGNS FOR AGEAge RR Pulse BP

Neonate (<1 month) <40 >60 <100 >160 Variable-use skin signsInfant (1 month - 1 year) >40 >160 <60

Toddler (1 - 4 years) >30 >140 <75

School age (5 - 13 years) >25 >120 <85

Adolescent (>13 years) >20 >110 <90

4 Notes on OB/GYN Emergencies

< VAGINAL BLEEDING

Vaginal bleeding that is not a result of direct trauma or a women's normal menstrual cycle may indicate a seriousgynecological emergency. Determining the specific cause of the bleeding may be impossible, therefore, allwomen who have vaginal bleeding should be treated as though they have a potentially life-threatening condition. This is especially true if the bleeding is associated with abdominal pain. The most serious complication of vaginalbleeding is hypovolemic shock due to blood loss.

< SEXUAL ASSAULT

Care of the patient who has been sexually assaulted must include both medical and psychological considerations. The best approach is to be nonjudgmental and to maintain a professional but compassionate attitude. Examine thevictim for injury that requires immediate stabilization. Though your responsibilities do not include lawenforcement, try wherever possible to preserve evidence. Field personnel are required to notify law enforcementpersonnel in these cases.

< CHILDBIRTH

Since childbirth is a natural process, the decision field personnel will need to make is whether there is time totransport the patient to the hospital or whether they should prepare for a field delivery. If delivery appearsimminent, immediately prepare to assist the delivery.


4 Notes on Trauma

Time is a critical factor and it must be emphasized. Critical trauma patients who receive definitive (in hospital)care at a time greater than one hour post injury have significantly greater rates of morbidity and mortality. On-scene times should be kept to less than 20 minutes, unless there are unusual circumstances such as patientextrication. All scene times greater than 20 minutes should have the reason for the extended time documented onthe patient care report.

< CRAMS

The CRAMS score reflects a patient's physiologic response to trauma and is the total of scores assigned to each ofthe following five categories:

C = Circulation

The capillary refill test is a quick measure of the adequacy of circulation. Capillary refill is determined bypressing on a finger or toe pad, then releasing the pressure. The time for normal color to return to the area is thennoted. Normal capillary refills occurs in two seconds or less. Delayed capillary refill is any time greater thantwo seconds. Capillary refill cannot be assessed without adequate light.

In the critical trauma patient, if a BP using the sphygmomanometer is not able to be obtained, a systolic BP (SBP)may be roughly estimated by location of palpable pulses:

* palpable radial pulse is equivalent to a SBP of 80 or greater;

* palpable femoral pulse is equivalent to a SBP of 70 or greater;

* palpable carotid pulse is equivalent to a SBP of 60 or greater.

R = Respirations

Respiration are evaluated as being normal, abnormal or absent. Abnormal respirations may be identified by:

* the inability to verbalize words;

* the use of accessory muscles of respiration;

* paradoxical or asymmetrical chest wall movement (flail);

* agonal respirations or excessive respiratory rates.

A = Abdomen/thorax (including Back)

The abdomen/thorax is evaluated as being non-tender, tender, or a third category which includes rigid abdomen,flail chest, or penetrating injuries to the abdomen or thorax, anteriorly and/or posteriorly. Only a patient who isable to respond to painful stimuli can manifest abdominal tenderness. In an unconscious patient, bruising orsignificant lacerations and abrasions on a patient's abdomen or thorax may indicate "assumed" tenderness.

M = Motor

Motor response is evaluated as normal, responds to pain (including decorticate posturing), or the third categorywhich is either decerebrate posturing (abnormal extension) or no response.

S = Speech

Speech is evaluated as normal, confused, or no intelligible words. Confused speech includes putting wordstogether in a disconnected manner as well as giving incorrect information in an organized manner. Moaning is anexample of no intelligible words.


CRAMS

CIRCULATION Normal capillary refill and BP >100 . . . . . . . . 2

Delayed capillary refill or BP 85 to 100 . . . . . . . 1

No capillary refill or BP < 85 . . . . . . . . . . . . . 0

RESPIRATION Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Abnormal (labored or shallow) . . . . . . . . . . . . . 1

Absent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

ABDOMEN Abdomen or thorax nontender . . . . . . . . . . . . . 2

Abdomen or thorax tender . . . . . . . . . . . . . . . . 1

Abdomen rigid, flail chest, or penetrating wounds toabdomen or thorax . . . . . . . . . . . . . . . . . . . . . 0

MOTOR Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Responds only to pain (or decorticate posturing) . . 1

No response (or decerebrate posturing) . . . . . . . . 0

SPEECH Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Confused . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

No intelligible words . . . . . . . . . . . . . . . . . . . 0

Glasgow Coma Scale (GCS)

EYES Open spontaneously . . . . . . . . . . . . . . 4

Open to verbal command . . . . . . . . . . . 3

Open to pain . . . . . . . . . . . . . . . . . . . 2

No response . . . . . . . . . . . . . . . . . . . 1

BEST Oriented and converses . . . . . . . . . . . . 5VERBAL

RESPONSEDisoriented and converses . . . . . . . . . . 4

Inappropriate words . . . . . . . . . . . . . . 3

Incomprehensible sounds . . . . . . . . . . 2

No response . . . . . . . . . . . . . . . . . . . 1

BEST Obeys verbal commands . . . . . . . . . . . 6MOTOR

RESPONSELocalizes pain . . . . . . . . . . . . . . . . . . 5

Flexion - withdraws from pain . . . . . . . 4

Flexion - abnormal (decorticate) . . . . . . . . 3

Extension (decerebrate) . . . . . . . . . . . . . 2

No response . . . . . . . . . . . . . . . . . . . 1

TOTAL 3 - 15


< HELMET REMOVAL

Patients wearing helmets present special management needs regarding airway maintenance and monitoring. There are generally two types of helmets, and the type of helmet determines how easily or difficult it may be tomaintain or monitor and airway with the helmet in place:

- Sports Helmets (football, hockey, etc) - these helmets are generally open anteriorly and allow for easyairway access. The face mask should be removed to facilitate easy airway access. If spinalimmobilization is required, the helmet should not be removed. If the helmet must be removed, theshoulder pads must also be removed to maintain neutral spinal alignment.

- Motorcycle Helmets - these helmets may have full face shields, which makes airway assessment andmanagement very difficult.

As a general guideline DO NOT REMOVE HELMETS, unless:

1) The helmet interferes with airway management.

2) The helmet has improper fit, which allows the head to move within the helmet.

3) The helmet interferes with proper spinal immobilization.

4) The patient is in cardiac arrest.

< CERVICAL COLLARS

The primary purpose of a cervical collar is to protect the cervical spine from compression. Cervical collars arean important adjunct to immobilization but must always be used in conjunction with manual immobilization or withmechanical immobilization provided by a suitable spine immobilization device. The rigid anterior portion of thecollar also provides a safe pathway for the lower head strap across the neck.

Proper sizing of a cervical collar is critical. The key dimension on a patient is the distance between an imaginaryline drawn across the top of the shoulders, where the collar will sit, and the bottom plane of the patient's chin. The key dimension on the collar is the distance between the black fastener and the lower edge of the rigid plasticencircling band, not the foam padding. When the patient is being held in a neutral position, measure the distancefrom the shoulder to the chin in finger widths. Then select the size collar that most closely matches the keydimensions of the patient. The tallest collar that does not hyperextend a patient should be used.

The most important step in application is the proper positioning of the chin piece. Position the chin piece bysliding the collar up the chest wall. Be sure that the chin is well supported by the chin piece and that the chinextends far enough onto the chin piece to at least cover the central fastener. Difficulty in positioning the chin piecemay indicate the need for a shorter collar.

A cervical collar must NOT inhibit the patient's ability to open his mouth or your ability to open the patient'smouth if vomiting occurs. A cervical collar must not obstruct or hinder ventilation in any way.


< SPINAL IMMOBILIZATION

Spinal immobilization is a critical procedure necessary in many, but not all patients suffering trauma. Properevaluation, including assessment of the mechanism of injury, assessment of the patient (particularly with regard toneurologic function) and assessment of confounding factors (drugs, pain, etc.) are necessary in order to make aproper decision about spinal immobilization.

One overriding principle is that if any doubt exists as to whether a patient has sustained a spinal injury,immobilization should be done. A poor neurologic outcome because immobilization was not performed faroutweighs the discomfort of immobilization for those without injuries. A systematic approach will allowappropriate evaluation of patients with potential for spinal injury and application of immobilization techniques forthose patients. Patients who do not meet criteria will avoid the discomfort, delay and additional unnecessarytesting that often accompanies spinal immobilization.

In all situations, airway and ventilation have the highest priority and must be addressed with minimal movement ofthe patient prior to full assessment.

A wide variety of devices and methods exist for immobilizing a patient. The specific method and equipment to beused should be based upon the situation, the patient's condition and available resources. Regardless of the specificdevice the focus should be on the patient and their needs.

< HEAD INJURY

Priorities for treatment of head-injury patients include maintenance of adequate oxygenation and blood pressure aswell as appropriate attention to possible cervical spine injury. Hyperventilation of head-injury patients should beavoided in all but the most severe cases, as it may worsen delivery of oxygen to the brain.

Patients with adequate ventilatory effort (12-16 breaths per minute in adults) should receive 100% oxygen by mask. Patients with poor ventilatory effort (either in terms of slow rate or shallow breathing) may need assisted ventilationsat normal rate. Deeply comatose patients may require intubation to assure an adequate airway.

In the prehospital setting, aggressive hyperventilation is to be avoided. Patients with a dilated pupil on oneside, or who have decerebrate or decorticate posturing likely have severe brain injury and swelling that may lead tobrain herniation. For these patients, an increase in respiratory rate of 2-4 per minute is appropriate to provide the smalldegree of hyperventilation advised for these most severe cases.

Fluid administration should not be withheld in hypotensive head injury patients, as hypotension also worsens braininjury. Rapid transport of trauma patients is essential, and it is appropriate to obtain IV access and administer fluidsduring transport.

< AMPUTATIONS

For partial amputations, splint in anatomic position and elevate the extremity. If the part is completely amputated,place the amputated part in a sterile, dry container or bag. Seal or tie off the bag, and place it in a secondcontainer or bag. Seal or tie off the second bag and place on ice. DO NOT PLACE THE AMPUTATED PARTDIRECTLY ON ICE OR IN WATER. Elevate the extremity involved and dress with dry gauze.


4 Notes on Hypothermia

Many patients seen in the prehospital setting may have predisposing factors that lead to hypothermia. Commonmedical conditions leading to hypothermia include hypoglycemia or stroke. Trauma with shock may also lead tohypothermia, and this can be worsened by exposure to a cold environment. Resuscitative efforts for these patientsare less effective in the setting of hypothermia. Newborns and infants as well as the elderly have an increasedpredisposition to hypothermia, as do some persons with drug and alcohol abuse.

For any patient with a predisposition to or suspected hypothermia, general treatment measures include removingwet clothing and drying the patient. Insulate against additional heat loss by covering the patient with a blanket. Innewborns and infants, the head should also be covered to prevent heat loss. Patients should be removed from coldenvironments as soon as possible.

Severe hypothermia leading to marked lowering of core body temperature is rare in our county. Severelyhypothermic patients may have impaired speech, memory, judgment, and coordination. Hypotension may also bepresent. Gentle handling of these patients, general warming/treatment measures listed above, and prompttransport (in a warmed ambulance) is appropriate.

4 Notes on Burns

After the patient has been removed from direct contact with the source of the burn, and the acute burning processhas been stopped, then the priorities for burned patients are the same as for any other type of injury or illness.

In the case of chemical burns (other than dry chemicals that may become more harmful when wet), remove thepatient's shoes, hose or shower over the clothes, and then remove the clothes. Remove potentially constrictingjewelry. Do not remove clothing that has stuck to the skin as a result of the burning. Protection should be affordedto prehospital personnel during this process.

Airway problems should be suspected whenever the patient was burned or otherwise exposed to smoke in anenclosed space, when there was exposure to toxic fumes, or when there are burns or evidence of soot or hairsinging to the face and/or upper airway. Pulmonary complications are usually delayed; however, if early airwayproblems are evident or likely, apply oxygen and transport immediately to the nearest appropriate facility. Furthercare can be given en route. All patients exposed to smoke should be treated for possible carbon monoxidepoisoning using high flow oxygen. Chronic lung patients will be more dramatically affected and should be moreclosely observed.

Shock from burns is usually delayed. If the patient is in shock, consider other causes. Associated injuries arelikely to be more acutely life threatening than the burn itself.

Initially, cool wet dressings should be used to stop the burning process and to limit the depth of injury. Wetdressings shall be left on burns. If patients have large burns (more than 10% of total body surface area), coolingmeasures and exposure may lead to hypothermia. Those patients should be covered with blankets to preserve bodyheat (can be placed over wet dressings). If less than 10% total body surface area (TBSA) has been burned, thatsmall area may be kept moist and cool during transport for pain relief.


Use the Rule-of-Nines to estimate the extent of the burn.

The following criteria are recommended in considering referral to a burn center:

-- Significant full thickness burns to hands, feet, face, or genitals;

-- Full thickness burns of more than 10% TBSA;

-- Partial thickness burns and /or full thickness burns adding up to more than 30% TBSA

Patients with other life threatening injuries may require stabilization at the closest appropriate receiving facilityprior to transfer to a burn center. Transporting units may be directed past closer facilities by the base hospitalphysician, once it has been determined that the patient is stable enough and that the burn center is prepared toreceive the patient.

Doctor’s Medical Center - San Pablo Campus is the designated BURN CENTER for Contra Costa County.


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BLS NOTES

SECTION


4 Emergency Medical Technician (EMT) Scope of Practice

"Emergency Medical Technician I" or "EMT-I" means a person who has successfully completed an EMT-Icourse which meets the requirements of this Chapter, has passed all required tests, and who has been certified bythe EMT-I certifying authority.

100063. Scope of Practice of Emergency Medical Technician-I (EMT-I).

(a) During training, while at the scene of an emergency, during transport of the sick or injured, or duringinterfacility transfer, a supervised EMT-I student or certified EMT-I is authorized to do any of thefollowing:

(1) Evaluate the ill and injured.

(2) Render basic life support, rescue and first aid to patients.

(3) Obtain diagnostic signs including temperature, blood pressure, pulse and respiration rates, level ofconsciousness, and pupil status.

(4) Perform cardiopulmonary resuscitation, including the use of mechanical adjuncts to basiccardiopulmonary resuscitation.

(5) Use the following adjunctive airway breathing aids:

(A) oropharyngeal airway;

(B) nasopharyngeal airway;

(C) suction devices;

(D) basic oxygen delivery devices; and

(E) manual and mechanical ventilating devices designed for prehospital use.

(6) Use various types of stretchers and body immobilization devices.

(7) Provide initial prehospital emergency care of trauma.

(8) Administer oral glucose or sugar solutions.

(9) Extricate entrapped persons.

(10) Perform field triage.

(11) Transport patients.

(12) Set up for ALS procedures, under the direction of an EMT-II or EMT-P.

(13) Inflate antishock trouser, under the direction of an EMT-II or EMT-P, if approved by the medicaldirector of the local EMS agency. (not currently used in Contra Costa County)

(14) Perform automated external defibrillation when authorized by an EMT AED service provider.

(b) In addition to the activities authorized by subdivision (a) of this section, the medical director of the localEMS agency may also establish policies and procedures to allow a certified EMT-I or a supervisedEMT-I student in the prehospital setting and/or during interfacility transport to:

(1) Monitor peripheral lines delivering intravenous glucose solutions or isotonic balanced salt solutionsincluding Ringer's Lactate for volume replacement.

(2) Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn offthe flow of intravenous fluid; and

(3) Transfer a patient who is deemed appropriate for transfer by the transferring physician, and whohas nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubesand/or indwelling vascular access lines, excluding arterial lines;


(4) Monitor preexisting vascular access devices and peripheral lines delivering intravenous fluids withadditional medications pre-approved by the Director of the EMS Authority (not currently allowedin Contra Costa County).

(5) Assist patients with the administration of physician prescribed devices, including but not limited to,patient operated medication pumps, sublingual nitroglycerin, and self-administered emergencymedications, including epinephrine devices.

(c) The scope of practice of an EMT-I shall not exceed those activities authorized in this Section, Section100064, and Section 100064.1 of the California Code of Regulations.

4 BLS Management of Patients Encountered Prior to Activation of 9-1-1

EMT-I's who encounter a patient where the 9-1-1 system has not been activated should assess the patient todetermine whether the care needed by that patient is beyond their scope of practice. If it is determined that thepatient may benefit from ALS level care, the 9-1-1 system should be activated. After assuring activation of the 9-1-1 system, EMT-I personnel should assess the patient and begin any care required that is allowed in the EMT-IScope of Practice.

If the EMT-I unit has transport capabilities, the personnel should determine if the ETA of the paramedic unit isgreater than the transport time to the closest appropriate receiving facility. If so, the EMT-I unit should proceedwith patient transport and cancel the ALS unit. If the ETA of the paramedic unit is less than the transport time tothe closest appropriate receiving facility, remain on scene and turn the patient over to the paramedic unit upontheir arrival.

Documentation of the patients chief complaint, history of present illness, past medical history, medications,allergies, vital signs, findings from the physical exam, and a general assessment and any treatment initiated is tobe completed. A copy of the patient documentation should be given to the transport unit prior to transport, ifpossible.

4 Administration of Oral Glucose

EMT-Is may administer an approved oral glucose agent by utilizing the following procedure:

1. Confirm altered level of consciousness in a patient with a known history of diabetes, and thatthe patient is conscious and able to sit in an upright position.

2. Dispense up to 30 grams of the oral glucose solution into the patient's mouth. Optimally, thepatient will self-administer the solution.

3. If the patient has difficulty swallowing the solution, discontinue the procedure. The first priorityis keeping an open airway.

4. Record the administration of the oral glucose solution with the time given and any changes inthe patients level of consciousness.


4 First Responder Defibrillation

< SHOCK ADVISORY SYSTEM

The Lifepak 500/CR Plus continuously assesses the patient's EKG signal for a potentially shockable rhythm. TheShock Advisory System (SAS) is designed to recommend a shock if it detects Ventricular Fibrillation orVentricular Tachycardia. If the LIFEPAK 500 detects a shockable rhythm, there will be an audible prompt, PushAnalyze, as well as a message on the screen. When this occurs, have the machine analyze the patient's rhythm. If the patient is in a shockable rhythm the defibrillator will state that a shock is advised and begin charging inpreparation for shocking the patient. With the LIFEPAK CR Plus, when the SAS detects a shockable rhythm theAED charges automatically. It then instructs the user to deliver the shock by pressing the shock button. The shockadvisory system has been turned off during CPR

< DEFIBRILLATOR CABLES/PADS

Do not use the defibrillation electrode if the gel is torn, separated or split from the foil. This may cause arcingand patient burns. Peel the protective backing from the electrode slowly to prevent damage to the gel.

Patients with implanted pacemakers or implantable defibrillators are treated just like any other patient. Ifpossible, do not place the electrodes on the pulse generator of the pacemaker. EMS personnel may feel the shockfrom an implantable defibrillator as a slight "buzz", but it will not harm them.

< VERBAL REPORT

Verbal reports are very important and should begin once the self check for the Lifepak 500 has cleared the screen. The initial report should include the name of the person reporting, engine company designation, status of thedefibrillator self-check (e.g., self-check ok), patient location, estimated patient age, patient sex, and findings fromthe initial assessment of the patient. Continue to verbally report events as they occur (e.g., insertion of oralairway, ventilating with demand valve, attaching electrodes, analyzing rhythm, paramedics (unit number) on-scene at...). If a shock is advised, verify that everyone (including the operator) is clear of the patient, andverbalize that everyone is clear.

< PATIENT ASSESSMENT

All patients are to be assessed upon arrival for level of consciousness and the presence or absence of a pulse andrespirations, even if CPR is being done. The results of this initial assessment are to be verbalized in the initialreport.




Ç SPINAL IMMOBILIZATION

Spinal immobilization is a critical procedure necessary in many, but not all patients suffering trauma. Properevaluation, including assessment of the mechanism of injury (high velocity motor vehicle crash, significant fall,penetrating trauma that may have potential spinal involvement, etc.), assessment of the patient (particularly withregard to neurologic function) and assessment of confounding factors (drugs, pain, etc.) are necessary in order tomake a proper decision about spinal immobilization.

If any doubt exists as to whether a patient has sustained a spinal injury, immobilization should be done. In allsituations, airway and ventilation have the highest priority and must be addressed with minimal movement of thepatient prior to full assessment.

» Indications

! Any patient with:

- acute motor or sensory deficit

- spine pain or tenderness

- trauma severe enough to qualify for trauma center disposition (with suitable mechanism or area ofinjury)

! Patients with potential injury mechanism who are unable to be assessed because of:

- head injury

- altered level of consciousness of any cause

- suspected presence of drugs or alcohol

- distracting painful or emotional (including psychiatric) conditions

» Equipment

- Rigid cervical collar - Long backboard

- Straps (for torso immobilization) - Head immobilization device

- Padding

» Procedure

1) Provide manual in-line immobilization immediately, moving the head into a proper in-line position, unlesscontraindicated*. Continue to support and immobilize the head without interruption.

2) Evaluate the patient's ABC's and provide any immediately required intervention.

3) Check motor, sensory and circulation in all four extremities.

4) If patient meets ALL of the following criteria, immobilization may be omitted:

a. Alert, fully oriented to person, place, time and situation

b. No evidence or suspicion of alcohol or substance abuse

c. Able to communicate effectively with prehospital personnel (other than language barrier)

d. Normal sensory and motor function in extremities


e. No areas of tingling, numbness or paresthesia

f. No neck or spinal tenderness on palpation

g. No neck or spinal pain with movement

h. No distracting painful or emotional conditions

5) If patient does not meet all criteria listed in #4, IMMOBILIZE:

a. Examine the neck and apply a properly fitting, effective cervical collar.

b. Pick the immobilization device that you will use, and immobilize the torso to the device so that thetorso cannot move up or down, left or right.

c. Evaluate and pad behind the head as needed.

d. After the torso straps have been tightened, immobilize the head, maintaining a neutral in-lineposition.

e. Tie the feet together and immobilize the legs so that they can not move anteriorly or laterally.

f. Fasten the arms to the immobilization device.

g. If patient is pregnant, elevate spine board on patient’s right side to approximately 15 degree angle(left lateral recumbent) to promote venous return.

g. Recheck the ABC's and motor, sensory, and circulation in all four extremities.

*In-line movement should not be attempted if the patient's injuries are so severe that the headpresents with such misalignment that it no longer appears to extend from the midline of theshoulders. Other contraindications would be if careful movement of the head and neck into aneutral in-line position results in neck muscle spasm, increased pain, the commencement orincrease of a neurological deficit such as numbness, tingling or loss of motor ability, orcompromise of the airway or ventilation.

ALS NOTES

SECTION


4 Paramedic Scope of Practice

California Code of Regulations, Title 22, Division 9, Chapter 4:

100139. Emergency Medical Technician-Paramedic (EMT-P)

"Emergency Medical Technician-Paramedic" or "EMT-P" or "paramedic" or "mobile intensive care paramedic"means an individual who is educated and trained in all elements of prehospital advanced life support; whose scopeof practice to provide advanced life support is in accordance with standards prescribed by this chapter, and whohas a valid license issued pursuant to this chapter.”

10014. Scope of Practice of Paramedic.

(a) A paramedic may perform any activity identified in the scope of practice of an EMT-I in Chapter 2 of theDivision, or any activity identified in the scope of practice of an EMT-II in Chapter 3 of this Division.

(b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform thescope of practice specified in this Chapter.

(c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring forpatients in a hospital as part of his/her training or continuing education under the direct supervision of aphysician, registered nurse, or physician assistant, or while at the scene of a medical emergency orduring transport, or during interfacility transfer, or while working in a small and rural hospital pursuantto section 1797.195 of the Health and Safety Code, may perform the following procedures or administerthe following medications when such are approved by the medical director of the local EMS agency andare included in the written policies and procedures of the local EMS agency.

(1) Basic Scope of Practice:

(A) Perform defibrillation and synchronized cardioversion.

(B) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps.

(C) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway,and adult endotracheal intubation.

(D) Institute intravenous (IV) catheters, heparin locks, saline locks, needles, or other cannulae (IVlines), in peripheral veins; and monitor and administer medications through pre-existing vascularaccess.

(E) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer'slactate solution.

(F) Obtain venous blood samples.

(G) Use glucose measuring device.

(H) Perform Valsalva maneuver.

(I) Perform needle cricothyroidotomy.

(J) Perform needle thoracostomy.

(K) Monitor thoracostomy tubes

(L) Monitor and adjust IV solutions containing potassium, equal to or less than 20 mEq/L.

(M) Administer approved medications by the following routes: intravenous, intramuscular, subcutaneous,inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical.

(N) Administer, using prepackaged products when available, the following medications:


(1) 25% and 50% dextrose;

(2) activated charcoal;

(3) adenosine;

(4) aerosolized or nebulized beta-2 specific bronchodilators;

(5) aspirin;

(6) atropine sulfate;

(7) bretylium tosylate;(not currently used in Contra Costa County)

(8) calcium chloride;

(9) diazepam;(not currently used in Contra Costa County)

(10) diphenhydramine hydrochloride;

(11) dopamine hydrochloride;

(12) epinephrine;

(13) furosemide;

(14) glucagon;

(15) midazolam

(16) lidocaine hydrochloride;

(17) morphine sulfate;

(18) naloxone hydrochloride;

(19) nitroglycerin preparations, except intravenous, unless permitted under (c)(2)(A) of this section;

(20) sodium bicarbonate; and

(21) syrup of ipecac (not currently used in Contra Costa County)

(2) Local Optional Scope of Practice:

(A) Perform or monitor other procedure(s) or administer any other medication(s) determined to beappropriate for paramedic use, in the professional judgement of the medical director of the localEMS agency, that have been approved by the Director of the Emergency Medical Services Authoritywhen the paramedic has been trained and tested to demonstrate competence in performing theadditional procedures and administering the additional medications.

4 Contra Costa Local Optional Scope of Practice

The following medications and procedures are approved for use in the Contra Costa County Local Optional Scopeof Practice:

T Pediatric Endotracheal Intubation

T Intraosseous Infusion

T Pulse Oximetry

T External Cardiac Pacing


4 Advanced Life Support Skills List

The following skills may be performed by Contra Costa County paramedics following treatment guidelines or basehospital orders:

1. Adult oral endotracheal intubation

2. Esophageal/Tracheal Double Lumen Airway (ETDLA)

3. Removal of foreign body obstruction with magill forceps

4. Needle cricothyrotomy

5. Defibrillation

6. Cardioversion

7. Intravenous therapy

8. Drug therapy (see drug list)

9. Needle thoracostomy

10. Intraosseous infusion**

11. Pediatric oral endotracheal intubation*

12. Use of pulse oximeter

13. Glucose Testing

14. External Cardiac Pacing

*Only paramedics who have completed the Contra Costa County advanced airway certification requirements mayperform these skills.

**Only paramedics who have completed the Contra Costa County pediatric skills training requirements mayperform these skills.

4 Notes on Advanced Airway Management

< ENDOTRACHEAL MEDICATIONS

The following medications may be administered via the endotracheal tube:

• Lidocaine

• Epinephrine

• Atropine

• Narcan (Naloxone)

In general, endotracheal doses should be doubled from the usual intravenous dosage. In pediatric patients (otherthan neonates), endotracheal doses of epinephrine are increased by ten-fold by usage of 1:1000 preparation forendotracheal administration.

In adult patients, there is no limit to the number of doses or total volume of fluid which may be administered.


Medications should be diluted to a volume of 10 ml prior to administration.

A maximum of 3 doses of medication may be instilled in pediatric patients (base physician may order additionaldoses). Medications in pediatric patients should be diluted to a volume of 3 - 5 ml prior to administration throughthe ETT. Several ventilations should be provided using BVM after medication administration.

< END-TIDAL CO (ETCO ) DETECTION DEVICES2 2

All intubated patients who are not in cardiac arrest require additional confirmation of tube placement by use of anETCO device. After intubation and confirmation of tube placement via esophageal detection device (bulb),2

patients should have an ETCO device placed (either in-line or using integrated device in bag-valve-mask.2

Use of an ETCO device in a pulseless patient is unreliable in assessing tube placement. Color change may or2

may not be present on initial intubation, and change in ETCO detection later may not be indicative of tube2

dislodgment. Use of other methods of detection (bulb initially, physical exam or direct laryngoscopic visualization)are needed in these patients.

Colorimetric devices will change color when carbon dioxide is detected. If no color change occurs after severalventilations in intubated patients with pulses, incorrect tube placement has likely occurred. The tube must beremoved and intubation may be reattempted if indicated.

Continuous observation of the colorimetric device is essential. If correct intubation occurs initially withappropriate color change, and later the device indicates no ETCO detected, the patient should be immediately2

reassessed. If the patient is confirmed to have a pulse, the tube has likely dislodged. The tube must be removedand intubation may be reattempted if indicated.

If the device becomes contaminated with fluids or emesis, it is no longer reliable and must be discarded andreplaced with another ETCO device.2

Waveform devices detect a "tracheal waveform." If the tracheal waveform is not detected, incorrect tubeplacement has likely occurred. The tube must be removed and intubation may be reattempted if indicated.

If an intubated patient without pulses regains pulses during resuscitation, an ETCO device should be placed as2

soon as practicable.

< PULSE OXIMETRY

Pulse oximetry is utilized for prehospital assessment and monitoring. Normal oxygen saturation is 96-99%. Agencies which utilize pulse oximetry have policies and procedures addressing use, testing, training, and qualityassurance concerning use.

Pulse oximetry should not be used in any circumstance to exclude use of supplemental oxygen. Field treatmentguidelines should be followed regardless of pulse oximetry readings. In situations such as anemia, low perfusion(shock), edema, carbon monoxide poisoning, or methemoglobinemia, inaccurate readings may occur. Incorrectapplication of sensors or patient movement may also lead to inaccurate readings.


Because pulse oximetry is limited to measurement of oxygen saturation of hemoglobin, it cannot detecthypoventilation or hypercarbia. Patients with respiratory insufficiency may be able to maintain adequateoxygenation in the face of hypoventilation, and pulse oximetry may not detect an impending respiratory disaster. As with all monitoring tools, patient physical assessment is critical in order to correctly interpret pulse oximetryfindings.

4 Drug Therapy

< ADMINISTRATION OF NARCAN (Naloxone) AND DEXTROSE

Administration of narcan and dextrose may not be appropriate for every patient with an altered level ofconsciousness. Dextrose should be administered only when there is evidence that the patient is suffering fromhypoglycemia. Narcan should be administered only when there is evidence that the patient is suffering from anarcotic overdose, and the patient is symptomatic (e.g., decreased respirations). Paramedics should be sensitive tothe fact that cancer patients lose all benefit of the pain relief provided by the medications the narcan is reversing,and should use narcan only when the patient has a depressed respiratory rate.

< DRUG AND TREATMENT ERRORS

Upon discovering an error in the administration of medications or treatments, the paramedic shall immediately:

1. verbally notify the receiving hospital physician and/or RN

2. verbally notify the base hospital physician and MICN that directed the call

3. verbally notify the paramedic provider agency supervisor

4. send an EMS Notification Form to the EMS Agency and Base Hospital Coordinator within 24 hours. Acopy shall be given to the paramedic provider agency supervisor.


4 Drug Supply Listing

DRUG CONCENTRATION DOSE NOTES

ACTIVATED 25 gm in slurry 50 gm PO Contraindicated in caustic or corrosive

CHARCOAL solution ingestions. Not effective in some overdoses(alcohol, sodium, potassium, iron, cyanide). Should not be given if patient has decreasedlevel of consciousness or potential rapiddeterioration (such as tricyclic antidepressantor benzodiazepine overdose).

ADENOSINE 3 mg/ml 6 mg rapid IV, followed by 20 Contraindicated in 2nd or 3rd degree heartml NS rapid bolus; if no blocks. May cause transient heart blocks orconversion in 1-2 minutes, transient asystole. Side effects may includemay give 12 mg rapid IV, palpitations, chest pain/pressure,followed by 20 ml NS rapid hypotension, dyspnea, feeling of impendingbolus; if no conversion in 1-2 doom. Use caution when patient is takingminutes, may repeat carbamazepine, dipyridamole or

methylxanthines.

ALBUTEROL 2.5 mg of Albuterol 3 ml of 0.083% solution per This long acting Beta-2 stimulator should bein 0.083% inhalant unit dose ampule nebulized to used with caution in patients takingsolution per 3 ml deliver 2.5 mg of albuterol - monoamineoxidase (MAO) inhibitor drugsunit dose ampule may be delivered via ETT (e.g., Nardil, Parnate).

5 - 15 minutes per nebulizedtreatment (2 ampules)

ASPIRIN 81 mg/tablet 4 tablets to be chewed by Do not administer if patient has a history ofpatient allergy to aspirin or salicylates

ATROPINE 0.1 mg/ml 0.5 mg IV for bradycardia — Doses less than 0.5 mg can causemay repeat every 5 min to max paradoxical bradycardia. Atropine can dilate0.04 mg/kg; pupils, aggravate glaucoma, cause urinary

1.0 mg IV for asystole — mayrepeat every 3-5 min to max0.04 mg/kg;

2.0 mg via ETT — may repeatevery 3-5 min to max 0.04 Remove clothing of victim ofmg/kg; organophosphate poisonings, and flush skin

2.0 mg IV fororganophosphate poisoning —may repeat every 5 min

retention, confusion, and dysrhythmias,including V-tach and V-fib. Increasesmyocardial O consumption.2

to remove traces of poison.

CALCIUM 100 mg/ml 500 mg IV - May repeat once Use cautiously or not at all in digitalized

CHLORIDE patients. Avoid extravasation. Rapidadministration can cause dysrhythmias orarrest. Use for patients with suspectedhyperkalemia.

DEXTROSE 50% 500 mg/ml 25-50 gm IV

DIPHENHYDRAMINE 50 mg/ml 25-50 mg IV or IM (1mg/kg) Epinephrine is the first line drug for

(Benadryl) anaphylaxis

DOPAMINE 1600 mcg/ml By Microdrip: Mid dose(5–10 mcg/kg/min) increases cardiac

800 mg/500 ml D5W

15–60 gtts/min = 5–20mcg/kg/min x 70 kg

See DOPAMINE CHART —TABLE 1

output without increasing heart rate or BP -Higher dose(10–20 mcg/kg/min) causesperipheral vasoconstriction and increases BP -Doses higher than 20 mcg/kg/min may resultin decreased mesenteric and renal perfusion.Antecubital veins are preferred. Avoidextravasation. Avoid exposure to light. Cancause dysrhythmias.


DRUG CONCENTRATION DOSE NOTES

EPINEPHRINE 0.1 mg/ml 1.0 mg IV in cardiac arrest Alpha and beta sympathomimetic. May

1:10,000 2.0 mg ETT in cardiac arrest

May repeat every 3-5 min

0.1-0.5 mg slow IVP foranaphylaxis in 0.1 mgincrements

cause serious dysrhythmias and exacerbateangina. Its use in patients over 40, or with ahistory of heart disease should be avoidedunless the patient is severely symptomaticand there is absolute certainty that thedyspnea is due to asthmatic bronchospasm.Avoid exposure to light. IM or SCabsorption may be delayed in patients inshock.

EPINEPHRINE 1.0 mg/ml 0.3 – 0.5 mg IM, SC, or SL

1:1,000 (0.01 mg/kg)

FUROSEMIDE 10 mg/ml 0.5 - 1.0 mg/kg IV Inject slowly. Tinnitus and hearing loss have(Lasix) been associated with rapid injection, high

doses, and impaired renal function.

GLUCAGON 1 mg/ml 1 mg IM Effect may be delayed 5–20 minutes - ifpatient responds, give PO sugar

LIDOCAINE 20 mg/ml 1.5 mg/kg IV for cardiac Blood levels decline rapidly. When possible,

2% arrest bolus over 1-2 min. CNS toxicity manifested

3 mg/kg ETT in 10 mlincrements for cardiac arrest

1 mg/kg IV for hemodynamically significantventricular ectopy

Maximum dose – 3 mg/kg

by drowsiness, disorientation, decreasedhearing, paresthesia, twitching, agitation,seizures. Metabolism slowed by decreasedhepatic blood flow, cirrhosis, decreasedcardiac output. Treat rate first whenextrasystoles are secondary to bradycardia.

MIDAZOLAM 5mg/ml Adults For use if IV access is not readily available.(Versed) - 0.2mg/kg IM or 1-5mg IV

- Maximum dose - 10mg

Pediatrics

- 0.2 mg/kg IM or 0.1 mg/kgIV - Maximum dose - 5mg

Observe respiratory status. Use withcaution in patients over age 60.

Doses for sedation over 2mg require basecontact.

MORPHINE 10 mg/ml 2-10 mg IV (trauma) Can cause hypotension and respiratorySULFATE depression (which can be subtle).

To be stocked inampules only

2-20 mg IV (chest pain, burns)Hypotension is more common in patientswith low cardiac output or volumedepletion. Nausea is a frequent side effectrapid administration. Titrate in 2-4 mgboluses, rechecking VS between each dose.Reversible with Narcan (with possibleexception of vascular effects).

NARCAN varies 1.0–2.0 mg IV or IM Should be given IV whenever possible.(Naloxone) 1.0 mg diluted in 9.0 ml NS

ETT

Shorter duration of action than that of mostnarcotics. Higher doses may sometimes benecessary. May not reverse vasculareffects of narcotics. Consider effect onpatients using narcotics for pain relief.

NITROGLYCERIN 0.4 mg/tablet or 1-6 tablets or unit dose spray Can cause hypotension and headache.

1/150 unit dose spray SL Protect from heat and light. Do not use ifsystolic BP less than 90 or if patient hastaken Viagra within the past 24 hours.

SODIUM 1 mEq/ml 50–100 mEq (1 mEq/kg) Assure adequate ventilation. Can

BICARBONATE May repeat ½ initial dose

8.4% every 10 minutes

precipitate or inactivate other drugs. NOT AFIRST LINE DRUG FOR CARDIAC ARREST.


4 ALS Procedures

Ç ORAL ENDOTRACHEAL INTUBATION

In adults, oral endotracheal intubation is the optimal method of advanced airway control. Intubation allowsfor protection of the airway and decreases the chance of aspiration.

In pediatric patients, BLS maneuvers are the preferred method for initial airway management and arefrequently sufficient to maintain the airway. If BLS maneuvers appear ineffective or are unable to bemaintained, intubation should be considered. Gastric distention is common with use of BLS maneuvers, butaspiration frequency is similar in intubated and non-intubated patients.

Nasotracheal intubation is not an approved skill in Contra Costa County.

No more than three attempts at endotracheal intubation should be done. Unsuccessful intubations should bemanaged either with an EDTLA (Combitube) or via BLS maneuvers.

Base hospital physician consultation is recommended if there is any question concerning the need to intubatea patient. The Base Hospital physician may also approve extubation of a patient in the field (aside fromextubation for meconium aspiration of newborns).

» Indications• Patient in cardiopulmonary or respiratory arrest• Patient with severe respiratory distress (adults)• Patient with a respiratory rate of 6 or less, or with ineffective respiratory effort

» Contraindications• Isolated medical respiratory arrest with suspected hypoglycemia or narcotic overdose• Maxillo-facial trauma with unrecognizable facial landmarks• Patients experiencing seizures• Patients with an active gag reflex

» Equipment- OPA: sizes 000-6 - Water Soluble Lubricant - 12 cc Syringe- Laryngoscope handle - Magill Forceps (pedi/adult) - Stylets (pedi/adult)- Laryngoscope blades: 2 each - ET Tubes: 3 each, sizes 2.5-9.0 - Towels

- #2, 3, 4 MacIntosh blade - Extra Batteries - Suction- #0, 1, 2, 3, 4 Miller blade - Extra Bulbs - Stethoscope

- 1" Waterproof Tape/Tube Holder - Bag-Valve-Mask- Esophageal intubation detection bulb - End-tidal CO2 detector

» Procedure1) Assure an adequate BLS airway.2) Hyperventilate with 100% oxygen using a bag-valve-mask or demand valve.3) Select appropriate ET tube. If appropriate tube has a cuff, check cuff to ensure that it does not leak;

note the amount of air needed to inflate. Deflate tube cuff. Leave syringe attached.


a) Insert appropriate stylet, making sure that it is recessed at least one cm. from the distalopening of the ET tube. Lubricate the tip of the tube.

4) Assure c-spine immobilization with suspected trauma.5) Insert laryngoscope and visualize the vocal cords.6) Suction if necessary and remove any loose or obstructing foreign bodies.7) CAREFULLY pass the endotracheal tube tip past the vocal cords; remove the stylet; advance the

ET tube until the cuff is just beyond the vocal cords; then inflate the cuff with 5-7cc of air. Inuncuffed pediatric tubes, advance tube no more than 2.5 cm beyond vocal cords (use vocal cordmarker line if present on tube);a) Attach the compressed esophageal intubation detector bulb to the end of the ET tube and release

the bulb. If the bulb does not fully re-inflate, extubate the patient and repeat steps 2 through 7. b) If the patient is not in cardiac arrest, attach end-tidal CO detection device to the ET tube.2

Observe for presence or absence of color change in device after several ventilations. If there isno color change, extubate and repeat steps 2 - 7.

c) Auscultate the chest for air entry on the right and left sides equally. Look for symmetric chestwall rise.

8) Immediately assess tube placement with colorimetric end-tidal CO2 indicator:a) If the end-tidal CO2 indicator indicates exhaled carbon dioxide (changes from purple to yellow

color), the tube should be secured.b) If the end-tidal CO2 indicator does not change color (remains purple), no carbon dioxide is

being exhaled.C In a patient with pulses, no color change indicates incorrect endotracheal tube placement

(esophageal). The tube should be removed and reintubation attempted.C In a patient without pulses, this may represent correct placement but requires further

confirmation with esophageal detector bulb.< If the esophageal detector bulb rapidly inflates, this indicates tracheal placement, and

the tube should be secured.< If the esophageal detector bulb inflates slowly or there is no air return, the patient

should have the tube removed and reintubation should be attempted.9) Following successful confirmation of intubation, auscultation of lungs, epigastrium, and observation

of chest rise should be done. If chest does not rise, extubate and reintubate.10) Secure the tube with tape or ET holder and ventilate. Mark the TUBE at the level of the lips.11) Continued monitoring includes both physical exam findings and use of a colorimetric end-tidal CO2

indicator or capnometer. Reassessment should occur after any patient movement, and shouldinclude esophageal detector bulb in pulseless patients who are not exhaling carbon dioxide.

! If there is continued slow air return with the esophageal indicator bulb on the second attempt, thevocal chords and tube placement should be assessed by direct visualization. False results canoccasionally occur when patients have CHF or obesity (the bulb will not inflate despite being in thetrachea).

! Positive end-tidal CO2 readings (color change from purple to yellow) can occasionally occur with atube that is dislodged with the tip of the tube is lying just above the vocal cords. Capnometers willshow a different waveform in these instances, but a colorimetric device will not. Consistentobservation of the patient's perfusion, vital signs, and chest rise, along with monitoring of theend-tidal CO2 indicator or capnometer is essential.


STOMAL INTUBATION

For patients with existing tracheostomy without tube (mature stoma):1) Assure an adequate BLS airway.2) Hyperventilate with 100% oxygen using a bag-valve-mask. Do not use demand valve.3) Select the largest endotracheal tube that will fit through the stoma without force (it should not be

necessary to lubricate the tube).4) Check cuff, if applicable.5) Do not use a stylet.6) Pass endotracheal tube until the cuff is just past the stoma. Right mainstem bronchus intubation may

occur if the tube is placed further since the distance from tracheostomy to carina is less than 10 cm.The tube will protrude from the neck by several inches.

7) Inflate the cuff8) Immediately assess tube placement with colorimetric end-tidal CO2 indicator:

a) If the end-tidal CO2 indicator indicates exhaled carbon dioxide (changes from purple to yellowcolor), the tube should be secured.

b) If the end-tidal CO2 indicator does not change color (remains purple), no carbon dioxide isbeing exhaled.C In a patient with pulses, no color change indicates incorrect endotracheal tube placement

(esophageal). The tube should be removed and reintubation attempted.C In a patient without pulses, this may represent correct placement but requires further

confirmation with esophageal detector bulb.< If the esophageal detector bulb rapidly inflates, this indicates tracheal placement, and

the tube should be secured.< If the esophageal detector bulb inflates slowly or there is no air return, the patient

should have the tube removed and reintubation should be attempted.9) Auscultate the chest for air entry on the right and left sides equally. Look for symmetric chest wall

rise. Check neck for subcutaneous emphysema, which indicates false passage of tube. If the chestDOES NOT RISE, extubate and repeat steps 2-7.

10) Secure the tube with tape and ventilate.

Note: Do not attempt to reinsert a dislodged pre-existing tracheostomy tube


Ç ESOPHAGEAL/TRACHEAL DOUBLE LUMEN AIRWAY (ETDLA)

The Esophageal/Tracheal Double Lumen Airway (ETDLA) or Combitube is a secondary option toendotracheal intubation in providing a method of ventilating patients who are unconscious, apneic and pulseless.

The ETDLA does not require direct visualization of the airway or significant manipulation of the neck. It isrelatively simple to insert and can be used in patients 4 feet tall and up, including taller pediatric patients.

Indications:

• When attempts at intubation have failed (no more than three attempts should be made)

• Situations where the airway cannot be visualized for intubation

-Trauma/blood/vomit/other secretions

-Entrapment of the patient with limited access to the airway

Contraindications:

• Active gag reflex

• Caustic ingestion or extensive airway burn

• Known esophageal disease (e.g., cancer, varices, stricture, others)

• Laryngectomy with stoma (can place ET tube in stoma)

• Height less than 4 feet tall

Equipment:

-Adult ETDLA (Combitube) Rollup Kit- patients over 5 feet tall and

-SA Rollup Kit - patients between 4 feet tall and 5 feet 6 inches tall.

-Suction

-Water-soluble lubricant

-Bag-Valve-Mask

-Stethoscope

Procedure:

1) Assure an adequate BLS airway

2) Select appropriate “ETDLA.” Check cuffs to ensure that they do not leak. Deflate tube cuffs. Leave syringes attached. Lubricate the tip of the tube.

3) Attach “fluid deflector” elbow to tube #2.

4) Hyperventilate with 100% oxygen.

5) CAREFULLY insert the “ETDLA” into the mouth, keeping tube midline, advancing the tube until thedouble black line on the tube matches up to the teeth or the alveolar ridge.

6) Inflate #1 pilot balloon with 100cc of air (85cc for SA size)


7) Inflate #2 pilot balloon with 15cc of air (12cc for SA size)

8) Ventilate through tube #1 (blue)

9) Auscultate the chest for air entry on the right and left sides for equal air entry

10) If breath sounds present - continue to ventilate

11) If breath sounds absent

a. Ventilate tube #2

b. Auscultate the chest for air entry on the right and left sides for equal air entry

c. If breath sounds present – continue to ventilate

12) Secure the tube with tape

13) Continue to monitor the patient for proper tube placement throughout prehospital treatment andtransport.

14) Document “ETDLA” placement times and results of tube placement checks performed throughoutthe resuscitation and transport.

Troubleshooting:

• If air leak is heard, increase inflation slightly through pilot balloon #1 and recheck

• If no breath sounds are heard with ventilation through either tube #1 or tube #2, it is possible that thetube has been placed too far into the pharynx. Deflate the #1 pilot balloon and retract tube 2-3cm,then reinflate cuff. Recheck sounds.

• If placement is unsuccessful, remove tube, ventilate via BVM and repeat sequence of steps.

• If unsuccessful on second attempt, BLS airway management should be resumed.

• Most unsuccessful placements relate to failure to keep tube in midline during placement.

Additional Information:

• Medications can be given via the ETDLA only if the tube is in the trachea. Medications should notbe administered with esophageal placement.

• For patients with perfusing pulses, end-tidal CO2 detectors will work and should be used.

• Cuffs can be lacerated by broken teeth or dentures. Remove dentures before placing tube.

• Do not force tube, as airway trauma may occur.


Ç NEEDLE CRICOTHYROTOMY

This skill is to be performed on-scene with partner assistance. Once needle cricothyrotomy has beenperformed, percutaneous transtracheal ventilation (PTV) is to be used to provide oxygenation for the patient.

» Indications

• Respiratory arrest secondary to complete airway obstruction

• Failure to relieve obstruction with Heimlich or Magill Forceps

» Contraindications

• Any condition other than respiratory arrest secondary to complete airway obstruction

» Equipment

- 10 - 13 gauge 2 - 3" angiocath - 30 cc syringe

- Betadine and alcohol swabs - Sterile gauze pads

- Occlusive dressing/vaseline gauze - ½ inch tape

- Oxygen tubing - "Y" connector

- IV extension tubing - Scalpel with #11 blade (optional)

» Procedure

1) Attach 30 cc syringe to 10 - 13 gauge angiocath and attach IV extension tubing and oxygen tubing to"Y" connector, then connect oxygen tubing to oxygen source at 15 lpm.

2) Locate the cricothyroid space.

3) Cleanse site with betadine.

4) Using two fingers from non-dominant hand:

a) place one finger on thyroid cartilage and the other on the cricoid cartilage.

b) apply traction to the skin.

5) Make midline puncture with scalpel (optional).

6) Holding needle and syringe at a downward, 60E angle make puncture in midline using steady firmpressure.

7) Should feel a "give" when cricoid membrane is penetrated. When air can be freely aspirated,catheter is in the trachea.

8) Advance catheter downward until hub is seated against the skin and remove the needle.

9) Connect IV extension tubing to angiocath.

10) Ventilate by placing thumb over the open end of the "Y" connector — one second on, four secondsoff.

11) Observe lung inflation and auscultate chest for adequate ventilation.

12) Apply occlusive dressing, and sterile gauze pads to site and secure the catheter.


Ç NEEDLE THORACOSTOMY

Needle thoracostomy may be performed to relieve a tension pneumothorax.

» Indications

• altered level of consciousness

• decreased B/P; increased pulse and respirations

• absent breath sounds on the affected side

• hyperresonance to percussion on the affected side

• jugular vein distension

• increased dyspnea or difficulty ventilating

• tracheal shift away from the affected side(often difficult to assess)


• Any condition other than tension pneumothorax.

» Equipment

- 12 - 14 gauge 2 -3 " angiocath - 30 cc syringe

- One-way valve - Rubber connecting tubing

- Betadine and alcohol swabs - Sterile gauze pads

- Occlusive dressing/vaseline gauze - Tape

» Procedure

1) Locate the 2nd ICS in the midclavicular line on the same side as the pneumothorax (An alternatesite is the fourth or fifth intercostal space, in the mid-axillary line).

2) Prep site

3) Attach syringe to 10 - 12 gauge angiocath.

4) Make insertion on top of lower rib at a 90E angle.

5) Advance slightly superior to clear rib, then back to 90E angle, to make "Z" track puncture.

6) A "give" will be felt upon entering the pleural space. Air and/or blood should push the syringeplunger back.

7) Advance catheter superiorly, remove needle and allow pressure to be relieved.

8) Attach one-way valve.

9) Apply vaseline gauze/occlusive dressing to site.

10) Secure catheter and one-way valve.

a) criss-cross taping for catheter.

b) tape vaseline gauze down to prevent leakage.

c) tape one-way valve in dependent position.

11) Reassess - expect rapid improvement in clinical condition and breath sounds.


Ç SALINE LOCK PROCEDURE

A saline lock is used to provide IV access in patients who do not require continuous infusion of solutions andadministration of multiple medications is not anticipated. If a saline lock is in place, it may be used toadminister one to two medications in an emergent situation, prior to connecting a primed IV line.

» Indications

• Any patient where placement of a prophylactic IV line is appropriate.


• Patient presentations which may require IV fluid replacement or multiple IV medicationadministrations.

• Patients requiring administration of D50.

» Equipment

- IV start pak or equivalent

- Intravenous catheter of appropriate gauge (not to be used with 24 gauge catheters).

- Saline lock catheter plug with short extension

- 3cc syringe

- Sterile normal saline (3-5cc)

» Procedure

1. Explain the procedure to the patient.

2. Remove catheter plug and attached extension set from package and prime with normal saline.

3. Prepare the site for venipuncture.

4. After venipuncture, secure extension set to hub of catheter and affix to patient's skin.

5. Prep rubber stopper on saline lock, insert needle, and slowly flush with at least 3cc of normalsaline while observing for signs of infiltration.

6. While injecting the last .2cc of normal saline, continue exerting pressure on the syringe plungerwhile withdrawing the needle from the saline lock.

7. If a medication is administered via the saline lock, flush with at least 3cc of normal salinefollowing administration of the medication.

NOTE: If patient requires fluid bolus or administration of multiple medications, remove saline lock andsecure primed IV tubing to catheter.


Ç INTRAOSSEOUS INFUSION

Intraosseous infusion may be performed on pediatric patients by EMT-Ps who have successfully completed aContra Costa County EMS approved training course. This procedure may only be performed prior tobase MD contact (including disrupted communications) in situations where the child is in cardiac arrestor profound shock.

» Indications

• The child is under the age of seven (7) and has no obvious venous access;• One of the following conditions exists:

- cardiac or respiratory arrest, impending arrest, or unstable dysrhythmia- shock or evolving shock, regardless of cause

• After evaluation of potential IV sites, it is determined that an IV attempt would not be successful


• Suspected vascular or bony disruption of the pelvis or selected extremity• History of metabolic bone disease or congenital malformations • Skin infection or burn overlying the area of insertion

» Equipment

- Povodine based prep solution - Sterile gloves- IV of NS attached to volutrol - Intraosseous needle- 10/12cc syringe filled with normal saline - 3cc syringe

» Procedure

1) Place the child supine with a rolled towel under the knee, restrain if necessary.2) Use the flat surface of the proximal tibia, just distal to the tibial tubercle. Put on gloves and

thoroughly prep the area with the antiseptic solution.3) Introduce the intraosseous needle slightly angled from perpendicular at a 60° angle, directed

towards the foot.4) Pierce the bony cortex using a firm rotary or drilling motion (do not move needle side to side or up

and down). A distinct change in resistance will be felt upon entry into the medullary space.5) Remove the stylet and confirm intramedullary placement by injecting, without resistance, 10 cc

normal saline.6) Attach IV tubing to the intraosseous hub.7) Anchor needle to overlying skin with tape.8) If unable to establish on first attempt, make one attempt on opposite leg, no more than two (2)

attempts total.9) Monitor pulses distal to area of placement10) Monitor leg for signs of swelling or cool temperature which may indicate infiltration of fluids into

surrounding tissue.

» Possible Complications

• local infiltration of fluids/drugs into the subcutaneous tissue due to improper needle placement• cessation of the infusion due to clotting in the needle, or the bevel of the needle being lodged

against the posterior cortex• osteomyelitis or sepsis • fat or bone emboli• fluid overload • fracture


Ç BLOOD GLUCOSE TESTING

Glucose Testing is to be done on all patients presenting with an altered level of consciousness, from eithermedical or traumatic causes. Patients with known diabetes and suspected hypoglycemia (e.g., diaphoresis,weakness) should also be tested. Testing may be done from a digit blood sample or a venous sample.

» Indications

C Any patient with an altered level of consciousness.


C Any patient without an altered level of consciousness

» Equipment

- Alcohol Swabs- Finger lancets (for digit samples)- Cotton Balls/sterile gauze pads- Glucose Testing device and strips

» Procedure

1) If obtaining blood sample via finger stick:a. Cleanse finger with alcohol swab.b. Puncture finger tip with lancet.c. Place drop of blood on glucose test strip per manufacturer’s instructions.d. Place gauze/cotton ball on puncture site with pressure to stop bleeding.e. Use glucose testing device per manufacturer’s instructions.f. If blood sugar is less than or equal to 60mg/dl, give Dextrose as specified in field treatment

guidelines.2) If obtaining blood sample via venipuncture (e.g., at IV start), follow steps c-f above.


Ç EXTERNAL CARDIAC PACING

External cardiac pacing may be performed for the treatment of symptomatic bradycardia. This procedure isrequired for transport providers and optionally available for first-responder paramedic providers.

Indications:• Symptomatic bradycardia (heart rate <60 and one or more signs or symptoms below)

Signs and symptoms:• Blood pressure <90 systolic;• Shock—Signs of poor perfusion, evidenced by:

P decreased level of consciousness or decreased sensorium;P prolonged capillary refill;P cool extremities or cyanosis;

• Chest pain, diaphoresis;• CHF or acute shortness of breath.

Contraindications:• Asystole• Brady-asystolic cardiac arrest• Hypothermia (relative contraindication) – patient warming measures have precedence• Children <14 years old (hypoxia/respiratory problems are most likely causes of bradycardia in children

and should be addressed.

Equipment• Cardiac monitor/defibrillator with pacing capability• Pacing electrodes

Procedure:1) Patient assessment and treatment per Symptomatic Bradycardia treatment guideline. If IV access

not promptly available, proceed to pacing (should not wait to administer atropine/wait for response totreatment).

2) Explain procedure to the patient.3) Place pacing electrodes and attach pacing cable to pacing device per manufacturer’s

recommendations.4) Set pacing mode to demand mode, pacing rate to 80 BPM, and current at zero milliamps (mA).5) As possible/if required, provide patient sedation/pain relief with midazolam or morphine sulfate IV or

IM. Patients with profound shock and markedly altered level of consciousness may not requiresedation/pain relief initially.

6) Activate pacing device and increase the current in 10 mA increments until capture is achieved(pacemaker produces pulse with each paced QRS complex).

7) Assess patient for mechanical capture and clinical improvement (BP, pulses, skin signs, LOC).8) Continue monitoring. Contact base for further orders if patient symptoms are not resolving

(consideration for dopamine, further alteration of pacer settings) or if further sedation /pain controlorders required.

NOTE: Patients with high grade AV block (second degree type II or third degree block) who do not havesymptoms do not require pacing. However, equipment should be immediately available if symptoms arise. Patients with symptoms who respond initially to atropine should have pacing equipment immediatelyavailable.

TREATMENT GUIDELINE

SECTION


CARDIAC EMERGENCIESShock (Non-Traumatic) C1

SHOCK

Signs and symptoms of shock with dry lungs, flat neck veins. May have poor skinturgor, history of GI bleeding, vomiting, diarrhea. May be warm and flushed, febrile. Mayhave history of high fever (SEPSIS).

1. Ensure a patent airway• OXYGEN - high flow. Be prepared to support ventilations as needed

2. Shock position, if tolerated3. Keep patient warm, but don't overheat4. Cardiac monitor - treat dysrhythmias per specific treatment guideline5. Consider early transport, CODE 36. IV ACCESS - two (2) large bore IVs en route, 250-500cc fluid challenge. Recheck vitals every

250cc to a maximum of 1 liter7. Test BLOOD GLUCOSE level8. Consider:

• NARCAN 1.0-2.0 mg per dose IVP or IM (if unable to establish IV) if patient has respiratorycompromise and narcotic overdose suspected

• DEXTROSE 50% 25 gm IVP if blood glucose level less than 609. Contact Base Hospital if any questions or if additional therapy is required10. Consider:

• DOPAMINE infusion beginning at 5 ug/kg/min if hypotension persists (see Table 1)

CARDIOGENIC SHOCK

Signs and symptoms of shock, history of congestive heart failure, chest pain, rales,shortness of breath, pedal edema.

1. Ensure a patent airway• OXYGEN - high flow. Be prepared to support ventilations as needed

2. Position of comfort3. Keep patient warm, but don't overheat4. Cardiac monitor - treat dysrhythmias per specific treatment guideline5. Consider early transport, CODE 36. IV ACCESS TKO7. Contact Base Hospital if any questions or if additional therapy is required8. Consider:



CARDIAC EMERGENCIESCardiac Arrest - First Responder Defibrillation C2

BASIC THERAPY - First Responder Defibrillation

NON-TRANSPORTING UNIT

1. CONFIRM: -unconscious, pulseless, and apneic or unconscious, pulseless with agonal respirations-adult patient-child weighing over 90 pounds

IF TRAUMA: Prepare patient for immediate transport. As time permits, prior toparamedic arrival, initiate defibrillation protocol

2. CPR until the defibrillator is attached3. Initiate Analyze/Defibrillation

-Clear bystanders and crew-Have the machine analyze rhythm

3.1 If the rhythm is NOT shockable-Check pulse and respirations-If absent, do one minute of CPR-Check pulse and respiration-If absent, have the machine analyze rhythm

3.2 If the rhythm is shockable-Clear bystanders and crew-Press button to deliver shock-Machine will reanalyze-If patient remains in a shockable rhythm after three shocks have been delivered:

-Check pulse and respirations-If absent, do one minute of CPR

4. If, at any point, there is a pulse with or without respirations:-maintain airway-assist ventilations, as needed-take a blood pressure (if the systolic blood pressure is less than 60, do CPR)

If the patient returns to a pulseless state:-Clear bystanders and crew-Have the machine analyze rhythm

5. If a paramedic unit arrives to transport the patient, turn the patient over to paramedic personnelwhen you reach the point where CPR is appropriate.If turn over is delayed, continue to provide care according to this protocol.

6. If a BLS unit arrives to transport the patient, accompany the patient to the hospital providing careen route. Deliver no more than nine (9) defibrillations on-scene prior to beginning transport.

7. Complete the Contra Costa County EMS Prehospital Care Report form.


CARDIAC EMERGENCIES

Cardiac Arrest - Ventricular Fibrillation/Pulseless Ventricular Tachycardia C3

VENTRICULAR FIBRILLATION & PULSELESS VENTRICULAR TACHYCARDIA(see appendix B for energy settings for bi-phasic low energy defibrillators)

1. DEFIBRILLATION at 200 W/S, if no response - DEFIBRILLATION at 200-300 WS, if noresponse - DEFIBRILLATION at 360 WS

- if return of spontaneous circulation from any defibrillation with narrow QRS complex:

• LIDOCAINE 1 mg/kg IVP if no prior Lidocaine dose has been administered

• LIDOCAINE 0.5-0.75 mg/kg IVP - repeat every 5-10 minutes to total dose of 3 mg/kg

2. Continue CPR

3. Advanced airway management and establish IV ACCESS TKO

4. EPINEPHRINE 1:10,000 1.0 mg IVP or 2.0 mg ETT - repeat every 3-5 minutes

5. DEFIBRILLATION at 360 W/S

6. LIDOCAINE 1.5 mg/kg IVP or 3.0 mg/kg ETT (max dose 3 mg/kg IVP)

7. DEFIBRILLATION at 360 W/S every minute

8. Prepare for transport

9. Consider:

• SODIUM BICARBONATE 1.0 mEq/kg IVP for suspected hyperkalemia, profound acidosisor prolonged down time with return of circulation.

10. Contact Base Hospital if any questions or if additional therapy is required


CARDIAC EMERGENCIES

Cardiac Arrest (Pulseless Electrical Activity) C4

PULSELESS ELECTRICAL ACTIVITY

1. Continue CPR

2. Consider causes:

• Hypovolemia

• Hypoxia - increase ventilations

• Cardiac Tamponade

• Tension Pneumothorax - NEEDLE THORACOSTOMY

• Hypothermia

• Massive Pulmonary Embolism

• Drug Overdoses (tricyclics, digitalis, beta-blockers, calcium channel blockers)

• Hyperkalemia - suspect in kidney dialysis patients

• Acidosis

• Massive Acute Myocardial Infarction



5. Consider:

• ATROPINE 1.0 mg IVP - repeat every 3-5 minutes total dose of 0.04 mg/kg if bradycardia isevident

• Fluid challenge 250-500 cc, reassess

6. Transport

7. Consider:

• SODIUM BICARBONATE 1.0 mEq/kg IVP for suspected hyperkalemia or profound acidosis

• CALCIUM CHLORIDE 500 mg (5 ml of 10% solution) if hyperkalemia is suspected.



CARDIAC EMERGENCIES

Cardiac Arrest (Asystole) C5

ASYSTOLE

1. Continue CPR unless patient meets criteria for determination of death


3. Consider causes:

• Hypoxia - increase ventilations

• Drug Overdoses

• Hyperkalemia - suspect in kidney dialysis patients

• Pre-existing Acidosis

• Hypokalemia

• Hypothermia


5. ATROPINE 1.0 mg IVP — 2.0 mg ETT repeat every 3-5 minutes to total dose of 0.04 mg/kg

6. Consider:

• SODIUM BICARBONATE 1.0 mEq/kg IVP for suspected hyperkalemia or profound acidosis


8. Consider termination of efforts

If rhythm is unclear and possibly ventricular fibrillation, defibrillate as for ventricularfibrillation.


CARDIAC EMERGENCIES

Ventricular Tachycardia with Pulses C6

VENTRICULAR TACHYCARDIA WITH PULSES: STABLE

1. Ensure a patent airway

• OXYGEN - high flow. Be prepared to support ventilation as needed.

2. IV ACCESS TKO

3. LIDOCAINE 1.0 mg/kg IVP

4. Consider:

• LIDOCAINE 0.5 - 0.75 mg/kg IVP every 5 minutes until ventricular tachycardia is resolvedor 3 mg/kg reached.

• If no response, then treat as unstable Ventricular Tachycardia


VENTRICULAR TACHYCARDIAS WITH PULSES: UNSTABLE(see appendix B for energy settings for bi-phasic low energy defibrillators)

Signs of poor perfusion, chest pain, dyspnea, hypotension, or CHF.



2. IV ACCESS TKO

3. Prepare for SYNCHRONIZED CARDIOVERSION. If sedation is needed, MIDAZOLAM 1-5mg IV (initial dose 1mg, titrate in 1-2mg increments - use caution in patients over age 60)

• SYNCHRONIZED CARDIOVERSION 100 W/S





5. Consider:

• If Ventricular Tachycardia recurs, SYNCHRONIZED CARDIOVERSION (use lowest w/slevel previously successful)

• LIDOCAINE 0.5 - 0.75 mg/kg IVP every 5-10 minutes to total dose of 3 mg/kg (with CHF,liver failure, age greater than 70 or shock, consider 10 minute time interval between doses)



CARDIAC EMERGENCIES

Paroxysmal Supraventricular Tachycardias C7

SUPRAVENTRICULAR TACHYCARDIAS: STABLE

Heart rate greater than 150 beats per minute - usually narrow QRS complex.



2. Cardiac monitor

3. IV ACCESS TKO

4. VALSALVA

5. Consider:

• ADENOSINE 6mg rapid IVP - followed by 20cc bolus of normal saline

• If patient has not converted, ADENOSINE 12mg rapid IVP - followed by 20cc bolus ofnormal saline, 1-2 minutes after initial dose. May repeat dose once.


SUPRAVENTRICULAR TACHYCARDIAS: UNSTABLE (see appendix B for energy settings forbi-phasic low energy defibrillators)

Signs of poor perfusion, chest pain, dyspnea, hypotension or CHF. Heart rate greaterthan 150 beats per minute - usually narrow QRS complex. If wide QRS complexconsider ventricular tachycardia.



2. Position of comfort. If decrease level of consciousness, position left lateral decubitus

3. Cardiac monitor

4. IV ACCESS TKO

5. Consider:


• If patient has not converted, ADENOSINE 12mg rapid IVP - followed by 20cc bolus ofnormal saline, 1-2 minutes after initial dose. May repeat dose once.

6. Prepare for SYNCHRONIZED CARDIOVERSION. If sedation is needed, MIDAZOLAM 1-5mg IV (initial dose 1mg, titrate in 1-2mg increments - use caution in patients over age 60)








CARDIAC EMERGENCIES

Bradycardia C8

BRADYCARDIA: ASYMPTOMATIC

Heart rate less than 60 with no other symptoms.


• OXYGEN therapy - low flow

2. Position of comfort.

3. Cardiac monitor

4. Consider IV ACCESS TKO

BRADYCARDIA: SYMPTOMATIC

Heart rate less than 60, chest pain, shortness of breath, decreased level ofconsciousness, low BP, shock, pulmonary congestion, and/or congestive heart failure.



2. Position of comfort. If decreased level of consciousness, position left lateral decubitus

3. Cardiac monitor

4. IV ACCESS TKO - if not promptly available, proceed to external cardiac pacing

5. ATROPINE 0.5 mg IVP

6. EXTERNAL CARDIAC PACING - start at zero milliamps and increase in 10 mA incrementsuntil capture is achieved

• MIDAZOLAM 1-2mg IVP or IM for sedation

• MORPHINE SULFATE 1-2mg IVP or IM for pain relief

7. Transport

8. Consider:

• Repeat ATROPINE 0.5-1.0 mg every 3-5 minutes to maximum of 0.04 mg/kg - use withcaution in patients with suspected ongoing cardiac ischemia.


10. Consider:

• DOPAMINE infusion beginning at 5 ug/kg/min if rhythm not responsive to atropine (see Table1)


CARDIAC EMERGENCIES

Other Cardiac Dysrhythmias C9

SINUS TACHYCARDIAHeart rate 100-160, regular.


• OXYGEN - low flow

2. Position of comfort. If decreased level of consciousness, position on left side

3. Cardiac monitor

4. Consider:

• IV ACCESS TKO if other vital signs abnormality exists

• Treat underlying cause

ATRIAL FIBRILLATION (see appendix B for energy settings for bi-phasic low energydefibrillators)



2. Cardiac monitor

3. IV ACCESS TKO

4. If well tolerated, transport with cardiac monitoring

5. If unstable:

S ventricular rate greater than 150 and;

S BP less than 80, or;

S unconsciousness or obtundation, or;

S severe chest pain or dyspnea

Consider: (if sedation is needed, MIDAZOLAM 1-5mg IV (initial dose 1mg, titrate in 1-2mgincrements - use caution in patients over age 60)

• SYNCHRONIZED CARDIOVERSION at 100 w/s






CARDIAC EMERGENCIES


ATRIAL FLUTTER (see appendix B for energy settings for bi-phasic low energydefibrillators)

Variable rate depending on block. Atrial rate between 250-350, "saw-tooth"pattern.



2. Cardiac monitor

3. IV ACCESS TKO


5. If unstable:













CARDIAC EMERGENCIES

Chest Pain C10

CHEST PAIN OR ASSOCIATED SYMPTOMS SUSPICIOUS OF CARDIAC ISCHEMIA

Substernal pain, discomfort or tightness radiation to jaw, left shoulder or arm, nausea,diaphoresis, dyspnea, anxiety.



2. Reassure patient and place in position of comfort

3. Restrict patient movement - loosen tight clothing

7. Allow patient to take their own Nitroglycerin, if systolic BP is greater than 90 mmHg and patienthas not taken Viagra within the previous 24 hours

5. Cardiac monitor - 12 lead EKG if available

6. IV ACCESS TKO

ASPIRIN 325mg (or four 81mg tablets) PO to be chewed by patient. DO NOT administer ifpatient has allergies to aspirin or salicylates, or has apparent active gastrointestinal bleeding

NITROGLYCERIN 0.4 mg(gr. 1/150) SL if systolic BP greater than 90 and patient has not takenViagra within the previous 24 hours - may repeat every 5 minutes until maximum of 6 dosesadministered, or pain subsides or BP less than 90 systolic

MORPHINE SULFATE 2-4 mg increments slow IV push - maximum 20 mg should beconsidered if pain not relieved by first three (3) doses of nitroglycerin. Consider earlieradministration to patients in severe distress from pain. Titrate to pain relief, systolic BP > 90 andadequate respiratory effort. CONTINUE ADMINISTRATION OF NITROGLYCERIN TO MAXSIX (6) DOSES.

7. Consider:

• For ventricular ectopy causing hemodynamic compromise (hypotension, confusion),LIDOCAINE 1.0 mg/kg IVP. Administer only if rate is greater than 60 and no evidence ofheart block exists. Ectopy that does not result in hemodynamic compromise should not betreated.

• Repeat LIDOCAINE 0.5 mg/kg IVP every 5-10 minutes until ectopy resolved or 3.0 mg/kgreached (with CHF, liver failure, age greater than 70 or shock, consider 10 minutes timeinterval between doses).

8. Contact Base Hospital if pain is not resolved or if hypotension develops


ENVIRONMENTAL EMERGENCIES

Heat Illness/Hyperthermia E1

HEAT CRAMPS/HEAT EXHAUSTION

Exhaustion, vague flu-like symptoms, normal/slightly elevated body temperature, normalmental status.



2. Move patient to a cool environment

3. Consider:

• IV ACCESS TKO

Suspect heat stroke in any patient with an altered level of consciousness in a hot environment, or anypatient with hot, dry skin.

HEAT STROKE

Triad of exposure to heat stress, altered level of consciousness and elevated bodytemperature, often associated with absence of sweating, tachycardia, and hypotension.


• OXYGEN - high flow

2. Move to cool environment and begin cooling measures:

- remove clothing and splash/sponge with water

- place cool packs on neck and in axilla and inguinal areas

- promote cooling by fanning

- be prepared for possible seizures

3. IV ACCESS TKO

4. FLUID CHALLENGE up to 500ml, repeat vital signs

5. Test BLOOD GLUCOSE level

6. DEXTROSE 50% 25 gm IVP if blood glucose level equal to or less than 60

7. NARCAN 1.0-2.0 mg per dose IVP or IM (if unable to establish IV) if patient has respiratorycompromise and narcotic overdose is suspected

8. Consider:

• repeat FLUID CHALLENGE 500ml, repeat vital signs


10. Consider:

• MIDAZOLAM 1-5mg IV (initial dose 1mg, titrate in 1-2mg increments - use caution forpatients over age 60) 0.2 mg/kg IM if IV route unavailable (maximum 10 mg)




Hypothermia E2

MODERATE HYPOTHERMIA

Conscious and shivering but lethargic, skin pale and cold (body temperature 84-95E F).



2. Gently move to sheltered area minimizing physical exertion or movement of the patient

3. Cut away wet clothing and cover patient with warm, dry sheets or blankets

4. IV ACCESS TKO

SEVERE HYPOTHERMIA

Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absentrespirations (body temperature below 84E F).

1. Handle gently, but ensure a patent airway - Be prepared to support ventilations as needed

• OXYGEN - high flow using warm, humidified oxygen if available. Avoid hyperventilating thepatient

2. Gently move to sheltered area minimizing physical exertion or movement of the patient

3. Cut away wet clothing and cover patient with warm, dry sheets or blankets

4. Consider:

• If spontaneous respirations are present, intubate only if absolutely necessary to preventaspiration or if ventilations are inadequate.

5. Cardiac monitor. Observe for organized rhythm and pulses for one minute. If organized rhythmpresent, move quickly but gently to warm environment.

6. IV ACCESS TKO, preferably en route




SEVERE HYPOTHERMIA PATIENTS MAY APPEAR DEAD. WHEN IN DOUBT, BEGIN

RESUSCITATION.



Burns E3

BURNS

Damage to the skin caused by contact with caustic material, electricity, or fire. Secondor third degree burns involving 20% of the body surface area, or those associated withrespiratory involvement are considered major burns.

1. Remove patient to a safe area

2. Stop the burning process:

• Remove contact with agent, unless it is adhered to skin

• Brush off chemical powders

• Identify chemical, if possible, then flush copiously with cool water

• Apply cool, wet dressings to wounds - Caution: large areas covered with cool, wet dressingsmay lead to hypothermia


• OXYGEN — high flow. Be prepared to support ventilation as needed

4. Protect the burned area:

• Do not break blisters

• Cover with clean dressings or sheets

• Remove restrictive clothing/jewelry if possible

5. Assess for associated injuries

6. Consider:

• IV ACCESS TKO

• For pain relief in the absence of hypotension (systolic BP < 100), significant other trauma,altered level of consciousness, MORPHINE SULFATE 2-20 mg IVP, titrated in 2 - 4 mgincrements to pain relief and BP




Envenomation E4

SNAKE BITES

If the snake is positively identified as non-poisonous, treat with basic wound care.

1. Keep patient calm

2. Identify type of snake, if possible

3. Splint affected extremity and restrict patient movement - immobilize the extremity at the level ofthe patient’s heart

4. Remove rings, bracelets, or other constricting items on the affected extremity

5. Monitor vital signs frequently

6. If patient has signs of shock:

• Ensure a patent airway

• OXYGEN – high flow. Be prepared to support ventilations as needed

7. Consider:

• Cardiac monitor

• IV ACCESS TKO

BEES/WASPS

Symptoms of stings usually occur at the site of injury and have no specific treatment. Reactions to allergens can be severe, and may lead to anaphylactic shock.

1. Keep patient calm

2. Remove stinger by flicking it off the skin with card or knife edge - Do not squeeze stinger

3. Apply cold pack

4. Remove rings, bracelets, or other constricting items on the affected extremity

5. Monitor vital signs

6. If patient has signs of allergic reaction:

• Ensure a patent airway


7. Consider:

• Cardiac monitor

• IV ACCESS TKO


HAZARDOUS MATERIALS EMERGENCIES

General Priorities and Treatment H1

Priorities

1. Recognize the call as a hazardous materials incident, or potential incident.

2. Stay upwind, uphill, upstream and upgrade of the incident

3. If first-in unit, isolate the scene and deny entry

4. Use Incident Command Structure (ICS). Consider Medical Advisory Alert or activation of theMulti-Casualty (MCI) plan.

5. Rescuer safety is critical. Do not become a victim. Stay out of “Exclusion” and “ContaminationReduction” zones unless trained, equipped and authorized to enter.

6. Decontamination generally takes priority over treatment or transport. If in doubt about the needfor, or adequacy of, decontamination, refer to DOT North American Emergency ResponseHandbook. In general, remove contaminated clothing and flush skin and eyes with water for 2-5minutes. Eye irrigation should continue with saline for 10-15 minutes.

7. Refer to field treatment guidelines for specific treatment.

8. Be aware of secondary contamination potential. Pesticides pose serious hazard due to ability ofthese chemicals to be absorbed through intact skin. Liquid irritant gases (such as acids, ammoniaor chlorine), solid or liquid cyanide compounds, petroleum distillates and hydrocarbons also posesecondary contamination hazards. Refer to DOT Handbook for specific agents.

General Treatment Guidelines



2. If patient with significant eye symptoms from exposure, irrigate with saline.

3. Cardiac monitor.

4. Transport

5. Consider:

• IV ACCESS TKO

• ACTIVATED CHARCOAL 50 gm PO (1.0 gm/kg for pediatrics) in oral ingestions such ascyanide, sulfur-containing compounds, petroleum distillates and hydrocarbons, or pesticides.

• ALBUTEROL 5 mg/6 ml saline via nebulizer if patient wheezing. Note: Cardiac arrhythmiasin patients with petroleum distillate or hydrocarbon exposure may be exacerbated.


Information about decontamination procedures may be obtained from the following sources:

- Department of Transportation North American Emergency Response Guidebook

- CHEMTREC - 1-800-424-9300

- County Hazardous Materials Agency - (925)646-2286 (contact Sheriff’s Dispatch at night or on weekends)

- Poison Center - 1-800-523-2222



Hydrofluoric Acid H2

HYDROFLUORIC ACID

1. Ensure provider safety - skin contact with hydroflouric acid MUST be avoided.



3. Continue decontamination initiated on scene

4. Cardiac monitor

5. IV ACCESS TKO

6. Transport

7. Consider:

• CALCIUM CHLORIDE 500mg (5 ml of 10% solution) IVP for tetany or cardiac arrest


Concentrated hydrofluoric acid burns are especially serious and warrant base hospitalcontact. The emphasis should be on continuous irrigation and rapid transport.

Background - This substance causes minimal burning sensation on initial contact, but is highly toxic andmay penetrate tissue to cause ulceration and bone destruction.

Signs and Symptoms - INHALATION exposure causes eye, nose, and throat irritation, cough,tracheobronchitis, and delayed onset of pulmonary edema. INGESTION will cause severe corrosiveburns. SYSTEMIC absorption causes hypokalemia, hypomagnesia, and can result in tetany and/orcardiac arrest. TOPICAL exposure may or may not exhibit redness to the skin.

Decontamination PRIOR to EMS management - Remove contaminated clothing and flush affected areasfor 1 to 2 minutes.

Secondary contamination - No risk after initial decontamination procedures completed.



Pesticides — Carbamates and Organophosphates H3

PESTICIDES — CARBAMATES AND ORGANOPHOSPHATES

1. Ensure provider safety - serious hazard prior to decontamination due to the ability of thesechemicals to be absorbed through intact skin.

2. DO NOT INDUCE VOMITING



4. Irrigate injured eyes

5. Cardiac monitor

6. Consider:

• IV ACCESS TKO

7. Transport

8. Consider:

• ATROPINE 1.0-2.0 mg IVP repeat as necessary until relief of symptoms

• ACTIVATED CHARCOAL PO

– Adult 50 gm

– Pediatric 1.0 gm/kg


Background - These products are widely used in home gardening and commercial agriculture.

Signs and Symptoms - Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscleweakness, small/pinpoint pupils, muscle twitching, and/or seizures may occur. Death is due torespiratory muscle paralysis.

Dizziness, nausea and vomiting, headache, and upper airway irritation (after inhalation exposure), maybe from the petroleum based solvent, and not due to cholinesterase inhibition from the carbamate ororganophosphate exposure.

Decontamination PRIOR to EMS management - If LIQUID contaminant remove clothing and flush for 1to 2 minutes - if SOLID or POWDER contaminant, brush powder off victim, then flush for 1 to 2minutes.

Secondary contamination - Serious hazard prior to decontamination due to the ability of these chemicalsto be absorbed through intact skin.


MEDICAL EMERGENCIES

Abdominal Pain M1

ABDOMINAL PAIN


2. Position of comfort

3. NOTHING BY MOUTH

4. Consider:

• IV ACCESS TKO


MEDICAL EMERGENCIES

Systemic Allergic Reactions/ Anaphylactic Shock M2

SYSTEMIC ALLERGIC REACTION

Reaction involving upper or lower respiratory tract - dyspnea, stridor, wheezing,tachycardia, anxiety, tightness in chest.


• OXYGEN - high flow. Be prepared to support ventilations as needed

2. Position of comfort - if decreased level of consciousness, left lateral decubitus

3. NOTHING BY MOUTH

4. Cardiac monitor - treat dysrhythmias per specific treatment guidelines

5. • IV ACCESS TKO

• EPINEPHRINE 1:1000 0.3 - 0.5 mg subcutaneously

• ALBUTEROL 5.0mg/6 ml saline via nebulizer. May repeat as needed

• DIPHENHYDRAMINE 25 - 50 mg slow IVP or IM if unable to establish IV access

6. Frequent reassessment of vital signs and respiratory status


ANAPHYLACTIC SHOCK

Serious progression for a reaction with respiratory/airway features to one which mayinclude hypotension, altered level of consciousness, cyanosis or severe respiratorydistress/arrest.




3. NOTHING BY MOUTH

4. Cardiac monitor — treat dysrhythmias per specific treatment guidelines

5. Consider early transport

6. IV ACCESS with large bore cannula wide open. Recheck vitals after every 250 cc.

7. EPINEPHRINE 1:10,000 titrate in 0.1mg doses slow IVP if BP less than 80 systolic up to a totalof 0.5 mg IV

• EPINEPHRINE 1:1,000 0.3-0.5mg IM if unable to establish IV access

8. ALBUTEROL 5.0 mg/6 ml saline via nebulizer. May repeat as needed

9. Consider:

• DIPHENHYDRAMINE 25 - 50 mg slow IVP




MEDICAL EMERGENCIES

Dystonic Reaction M3

DYSTONIC REACTIONS

Restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis, history ofingestion of phenothiazine or related compounds (primarily anti-psychotic medications).




3. IV ACCESS TKO

4. DIPHENHYDRAMINE 25-50mg IV

• DIPHENHYDRAMINE 50mg IM if unable to establish IV access



MEDICAL EMERGENCIES

Poisons/Drugs M4

INGESTIONS(Basic Therapy)

1. Ensure a patent airway• OXYGEN - low flow. Be prepared to support ventilations as needed

2. Position of comfort - if decreased level of consciousness, left lateral decubitus3. Identify substance and time ingested and bring sample to hospital4. Cardiac monitor5. Consider:

• IV ACCESS TKO6. Consider:

• Being careful not to contaminate yourself and others, remove contaminated clothing, brush offpowders, wash off liquids

• Treat specific ingestions/exposures according to specific treatment guidelines• ACTIVATED CHARCOAL 25-50 gm PO


NARCOTICS/SEDATIVES

1. Ensure a patent airway• OXYGEN - low flow. Be prepared to support ventilations as needed

2. Position of comfort - if decreased level of consciousness, left lateral decubitus3. IV ACCESS TKO4. If altered mental status is present, consider:

• NARCAN 1.0-2.0 mg IVP or IM (if unable to establish IV) if patient has respiratorycompromise

• NARCAN 0.1 mg increments IV (dilute 1:10 with saline) up to 2 mg total to address inadequaterespirations for patients who are receiving narcotics for terminal illness

5. Consider:• ACTIVATED CHARCOAL 25-50 gm PO, if alert and ingestion has occurred within the last

20 minutes6. Contact Base Hospital if any questions or if additional therapy is required

CAUSTICS AND CORROSIVES

Ingestion of substances that cause intra-oral burns, painful swallowing or inability tohandle secretions.

1. DO NOT INDUCE VOMITING2. Ensure a patent airway

• OXYGEN - low flow. Be prepared to support ventilations as needed3. Position of comfort - if decreased level of consciousness, left lateral decubitus4. Consider:

• PO water or milk5. IV ACCESS TKO


MEDICAL EMERGENCIES

Poisons/Drugs M4

TRICYCLIC ANTIDEPRESSANTS

Substances which cause anticholinergic crisis characterized by altered mental status,fever, dilated pupils, flushed skin, and dry mucous membranes. Frequently associated with respiratory depression, almost always accompanied by tachycardia. Widened QRScomplexes and associated ventricular arrhythmias are generally signs of a life-threateningingestion.




3. IV ACCESS TKO

4. For life-threatening dysrhythmias, hemodynamically significant supraventricular rhythms,ventricular dysrhythmias:

- hyperventilation if assisting ventilations or if intubated

- SODIUM BICARBONATE 1 mEq/kg slow IVP


6. For seizures:

• MIDAZOLAM 1-5mg IV (initial dose 1mg, titrate in 1-2mg increments - use caution forpatients over age 60) - 0.2 mg/kg IM if IV route unavailable (maximum 10mg)


NEUROLOGIC EMERGENCIES

Coma/Altered Level of Consciousness N1

COMA/ALTERED LEVEL OF CONSCIOUSNESS

Glasgow Coma Scale less than 15, etiology unclear (consider AEIOU TIPS).



2. If decreased level of consciousness, position patient on left side

3. Consider:

• ORAL GLUCOSE - if patient is a known diabetic, is conscious, able to sit in an uprightposition, and able to self-administer solution

4. Cardiac monitor


6. IV ACCESS TKO (wide open if in shock)


• GLUCAGON 1.0 mg IM if unable to establish IV access


• NARCAN 0.1 mg increments IV (dilute 1:10 with saline) up to 2 mg total to address inadequaterespirations for patients who are receiving narcotics for terminal illness

9. Consider:

• Test BLOOD GLUCOSE level if symptoms not resolved

• DEXTROSE 50% 25 gm IVP as a repeat dose if blood glucose level equal to or less than 60

10. Contact Base Hospital if ALOC is not resolved



Seizures/Status Epilepticus N2

SEIZURES

Tonic, clonic movements followed by a period of unconsciousness (post-ictal period). Usually history of prior seizures, on medication, or alcohol withdrawal. Most seizures areself-limiting and do not require field treatment. A continuous or recurrent seizure isseizure activity greater than 10 minutes or recurrent seizures without patient regainingconsciousness.



2. Left lateral position if no trauma

3. Protect patient from injury by placing padding appropriately - DO NOT FORCIBLYRESTRAIN THE PATIENT

4. Cardiac monitor


6. Consider:

• IV ACCESS TKO

• DEXTROSE 50% 25 gm IVP if blood glucose level equal to or less than 60

• NARCAN 1.0-2.0 mg IVP or IM (if unable to establish IV) if patient has respiratorycompromise and narcotic overdose suspected


8. For continuous or recurrent seizures, consider:

C MIDAZOLAM 1-5 mg IV (initial dose 1 mg, titrate in 1-2 mg increments). Use caution inpatients over age 60.

C MIDZOLAM 0.2 mg/kg IM (maximum 10 mg IM) if IV route unavailable.



Acute Cerebrovascular Accident (Stroke) N3

ACUTE CEREBROVASCULAR ACCIDENT (STROKE)

Sudden onset of weakness, paralysis, confusion, speech disturbances, may beassociated with headache.



2. Position of comfort - if decreased level of consciousness, left lateral decubitus position

3. Cardiac monitor

4. TRANSPORT


6. IV ACCESS TKO en route

7. Consider:

• DEXTROSE 50% 25gm IVP if blood glucose level equal to or less than 60

• NARCAN should be given only if patient has respiratory compromise and narcotic overdosesuspected.




Syncope/Near Syncope N4

SYNCOPE/NEAR SYNCOPE

Brief loss of consciousness, dizziness. Often postural following valsalva maneuver, orearly pregnancy. May have cardiac history.



2. Supine position, elevate legs if indicated

3. Cardiac monitor — treat dysrhythmias per specific treatment guidelines

4. Consider:

• IV ACCESS TKO

• Test BLOOD GLUCOSE level

• DEXTROSE 50% 25 gm IVP if blood glucose level equal to or less than 60


OB-GYN EMERGENCIES

Vaginal Hemorrhage O1

SHOCK

Profuse vaginal bleeding, signs of shock



2. Place patient on left side, if pregnant

3. Monitor vital signs frequently

4. If post-partum, perform firm uterine massage, put baby to breast

5. Save any tissue passed

6. IV ACCESS – two (2) large bore IVs en route - 250 - 500 cc fluid challenge. Recheck vitals afterevery 250 cc to maximum of one (1) liter.

7. Contact Base Hospital if any questions or additional therapy is required

VAGINAL BLEEDING NOT IN SHOCK

Abnormal (non-menstrual) vaginal bleeding, between menses, during pregnancy, postpartum or post operative.



2. Place patient on left side, if pregnant

3. If post-partum, perform firm uterine massage, put baby to breast

4. Save any tissue passed

5. Consider:

• IV ACCESS TKO


OB-GYN EMERGENCIES

Imminent Delivery (Normal) O2

IMMINENT DELIVERY, NORMAL PRESENTATION

Regular contractions, bloody show, low back pain, feels like bearing down, crowning.


2. Prepare for home delivery. Reassure mother, instruct during delivery

3. BLS - CONTINUE WITH DELIVERY — IF ALS AND TIME ALLOWS, CONSIDER:

• IV ACCESS TKO

4. As head is delivered, apply gentle pressure to prevent rapid delivery of the infant. Gently suctionbaby's mouth, then nose, keeping the head dependent. If cord is wrapped around neck and can't beslipped over the infant's head, double clamp and cut between clamps

5. Immediately clamp cord 6-8 inches from baby and cut between clamps

6. Assess baby by APGAR score at 1 and 5 minutes (see below)

7. Dry baby and keep warm, placing baby on mother's abdomen or breast

8. If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ONCORD TO DELIVER PLACENTA

9. Observe mother and infant frequently for complications. To decrease post-partum hemorrhage,perform firm fundal massage, put baby to mother's breast

10. Prepare mother and infant for transport

11. If delivery is premature (less than 36 weeks gestation), prepare for neonatal resuscitation


APGAR Chart

0 1 2

APPEARANCE Blue – Pale Body Pink – Limbs Blue Pink All Over

PULSE 0 Less Than 100 100 or Greater

GRIMACE No Response Grimace Cough, Cry, Sneeze

ACTIVITY Flaccid Some Flexion Active Movement

RESPIRATORY Absent Slow, Irregular Strongly CryingEFFORT


OB-GYN EMERGENCIES

Imminent Delivery (Complications) O3

BREECH PRESENTATION

Presentation of buttocks or feet.


2. Begin transport with early Base Hospital contact, if transporting unit; If non-transporting unit,prepare to assist delivery

3. Allow delivery to proceed passively until the baby's waist appears

4. Rotate baby to face down position (DO NOT PULL)

5. If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the vagina to create anair passage for the infant

6. If ALS and time allows, consider:

• IV ACCESS TKO

PROLAPSED CORD

Cord presents first and is compressed during delivery, compromising infantcirculation.


2. Insert gloved hand into vagina and gently push presenting part off of the cord. Do not attempt to re-position the cord. Cover cord with saline soaked gauze

3. Place mother in trendelenburg position with hips elevated

4. Begin transport with early Base Hospital contact, if transporting unit; If non-transporting unit,prepare to assist delivery

5. If ALS and time allows, consider:

• IV ACCESS TKO


OB-GYN EMERGENCIES

Pre-Eclampsia/Eclampsia O4

SEVERE PRE-ECLAMPSIA/ECLAMPSIA

Third trimester pregnancy with hypertension (BP greater than 160 systolic, greaterthan 110 diastolic), mental status changes, visual disturbances, peripheral edema(pre-eclampsia), seizures and/or coma (eclampsia).



2. Position mother in left lateral decubitus position

3. Maintain a quiet environment - darken the room

4. IV ACCESS TKO while en route


6. Treat seizures or coma per appropriate field treatment guidelines


PEDIATRIC EMERGENCIES

Routine Medical Care P1

PRIMARY/SECONDARY GENERAL SURVEY+ A pediatric patient is defined as age 14 or less. A neonate is 0-1 month of age.

Unless otherwise specified, pediatric protocols should be used to treat thesepatients.

+ Consideration of family anxieties during pediatric emergencies is essential.Whenever possible, given the situation encountered and condition of the child,provide family support through sensitivity to their concerns and emotions.

1. Establish level of consciousness

2. Evaluate airway

• Identify signs of airway obstruction and respiratory distress, including cyanosis, stridor,drooling, nasal flaring, choking, intercostal retractions, absent breath sounds, apnea or near-apnea, tachypnea, and/or grunting

3. Secure airway. Consider spinal immobilization.

• Open airway. Suction PRN.

• Consider placement of oropharyngeal airway if child is unconscious.

• Always begin with BLS airway maneuvers

S Establishment and maintenance of a patent airway and support of adequate ventilation are themost critical components of Basic Life Support.

S Proceed to intubation only when BLS airway maneuvers are ineffective.

4. Assess need for ventilatory assistance

• Use chest rise as an indicator of ventilation

• Pulse oximetry if available

• Demand valves are contraindicated in children

5. Evaluate and support circulation. Stop hemorrhage

• Assess perfusion using the following indicators: heart rate, skin signs, capillary refill, mentalstatus, quality of pulse, blood pressure.

6. Continue with secondary survey

• Perform head to toe assessment

• Obtain patient history

• Do an environmental assessment including consideration of intentional injury

7. Determine appropriate treatment protocols

• Use length based resuscitation tape to estimate patient weight, fluid volumes, defibrillationsettings, and equipment sizes. Use drug charts as references for dosages (page 97-100).

• For infants <3kg, children > 34 kg, and medications not listed on the tape, determineappropriate drug dose by using the standard dose listed on the drug chart.

• Pediatric patients are subject to rapid changes in body temperature. Steps should be taken toprevent loss for increase in body temperature.

• Compared to adults, a small amount of fluid loss can result in shock in children

• Compared to adults, a small amount of excess fluid administration can result in pulmonaryedema in children

• Scene time for treatment of pediatric patients should be kept to a minimum. Mosttreatment can be done en route.



Neonatal Resuscitation P2

NEONATAL RESUSCITATION

IF MECONIUM IS PRESENT:

• Presence of meconium requires thorough suctioning before other resuscitation. Suctioningshould occur after delivery of child's head (before delivery of the torso), if delivery is inprogress.

• Presence of thin meconium (watery) is not an indication (by itself) for intubation.

• If thick meconium is present, and the infant is not crying, intubation and direct suctioningthrough an endotracheal tube should be done immediately after delivery, before anystimulation or drying. The endotracheal tube should be withdrawn during each suctioningattempt. No more than three (3) intubation/suction/extubation sequences should be done.

• Ventilate with 100% oxygen

1. If infant has weak or gasping respirations, or is not breathing, initiate bag mask ventilation at arate of 40-60/minute with 100% oxygen

2. Heart rate less than 100:

• ventilate at 40 - 60/minute with 100% oxygen

3. Heart rate 80 and decreasing:

• begin chest compressions and ventilate

• use ratio of 3 chest compressions:1 ventilation (90 compressions and 30 ventilations per minute)

4. Consider:

• Intubation

5. Heart rate less than 80 after adequate ventilation and chest compressions:

• EPINEPHRINE 1:10,000, 0.01 mg/kg ETT, IV, IO

• repeat EPINEPHRINE 1:10,000, 0.01 mg/kg ETT, IV, IO every 3-5 minutes

• IV/IO ACCESS TKO using volutrol. Do not delay transport for IV or IO access

6. Heart rate is between 80- 100, stop compressions, continue ventilation.

7. Heart rate is 100 or above, stop compressions, evaluate respiration. If infant is breathingnormally at a rate of 40-60, stop ventilation.

• If pink, gradually decrease oxygen and discontinue if patient continues to remain well perfusedand pink.

• If cyanotic, continue 100% oxygen by mask.


Always keep infant warm and dry:

- skin to skin contact with mother if possible

- cover with blanket

- place hat on infant



Cardiac Arrest - Non-Traumatic P3

PEDIATRIC CARDIOPULMONARY ARREST - Basic Therapy

No spontaneous pulses or respirations in a non-traumatic setting.

1. CPR with airway management, until defibrillator available (for patients weighing more than 90lbs.)

2. Determine cardiac rhythm

3. Proceed to specific dysrhythmia treatment guidelines

VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIAIt is critical to defibrillate as early as possible if ventricular fibrillation is present

1. Advanced airway management

2. Continue CPR

3. DEFIBRILLATE 2 ws/kg Use Infant Paddles for patients up to 1 year old or 10kg

4. DEFIBRILLATE 4 ws/kg


6. IV or IO ACCESS TKO using volutrol

7. EPINEPHRINE 1:10,000 0.01 mg/kg IVP, IO, or EPINEPHRINE 1:1,000 , 0.1 mg/kg ETT

8. DEFIBRILLATE 4 ws/kg 30-60 seconds after each drug administration

9. LIDOCAINE 1.0 mg/kg IVP, IO, or LIDOCAINE, 2.0 mg/kg ETT


11. Repeat EPINEPHRINE 1:1,000 0.1mg/kg IVP, IO, ETT every 3-5 minutes

12. Consider:

• Base Hospital contact

• repeat LIDOCAINE, 1.0 mg/kg IVP, IO, or ETT

• DEFIBRILLATE 4 ws/kg

ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA)Causes of PEA: severe hypoxemia, severe acidosis, severe hypovolemia, tensionpneumothorax, cardiac tamponade, profound hypothermia.

1. Advanced airway management

2. Continue CPR

3. IV or IO ACCESS TKO using volutrol

4. EPINEPHRINE 1:10,000 0.01 mg/kg IVP, IO, or EPINEPHRINE 1:1,000 , 0.1 mg/kg ETT

S repeat EPINEPHRINE 1:1,000 0.1 mg/kg IVP, IO or ETT every 3-5 minutes

5. Consider:

• FLUID CHALLENGE NS 20 ml/kg bolus using volutrol, if hypovolemia is suspected. Mayrepeat boluses of 20 ml/kg X 2.




Bradycardia P4

BRADYCARDIA

90% of all pediatric bradycardias are related to respiratory depression and only requiresupport of ventilation. Only unstable, severe bradycardia causing cardiopulmonarycompromise will require further treatment. Signs of severe cardiorespiratory compromiseare poor perfusion, delayed capillary refill, hypotension, respiratory difficulty, alteredlevel of consciousness.



• Support ventilation as needed with appropriate airway management- usually bag maskventilation

• Demand valves are contraindicated in children.

2. If unstable, IV ACCESS TKO or IO access (Base physician order only) using volutrol

3. Begin CPR if evidence of poor perfusion

4. Be prepared to support airway with appropriate advanced airway management as indicated

5. EPINEPHRINE 1:10,000, 0.01 mg/kg IVP, IO - repeat every 3-5 minutes or EPINEPHRINE1:1,000, 0.1 mg/kg ETT - repeat every 3-5 minutes

6. Consider:

• ATROPINE 0.02 mg/kg IVP, IO, ETT (0.1 mg minimum dose) - may be repeated once forcontinued heart rate < 60 - maximum for single dose = 0.5 mg (5 ml) up to age 14




Tachycardia P5

STABLE TACHYCARDIA- Normal QRS Duration:Normal level of consciousness, normal capillary refill, able to palpate blood pressure thatis normal for patient's age.


• OXYGEN - low flow. Be prepared to support ventilation with appropriate airway management- Demand valves are contraindicated in children.

2. Cardiac Monitor


UNSTABLE TACHYCARDIAAltered level of consciousness, delayed capillary refill, abnormal skin signs and unable topalpate blood pressure.


• OXYGEN - high flow. Be prepared to support ventilations with appropriate airwaymanagement - Demand valves are contraindicated in children.

2. Cardiac Monitor

3. IV ACCESS TKO (must be rapidly available) or IO ACCESS (Base physician order only) usingvolutrol

4. FLUID BOLUS - 20 ml/kg if hypovolemia suspected

5. CONTACT BASE HOSPITAL

6. NORMAL QRS (0.08 or less):

- Rate > 180 in child or > 220 in infant, absent or abnormal 'P' waves:

A. If IV access is obtained, consider:

• ADENOSINE 0.1 mg/kg rapid IVP ( maximum dose 6mg) - followed by 10-20ml bolusof NS

• ADENOSINE 0.2 mg/kg IVP (maximum single dose 12mg) - followed by 10-20ml bolusof NS if patient has not converted. May repeat X 1

• Sedation with MIDAZOLAM 0.1 mg/kg IV (titrated in 1mg max increments - max dose5mg). Do not delay cardioversion if difficult IV access.

• CARDIOVERSION - 0.5-1.0 ws/kg

B. If IV access is NOT obtained, consider CARDIOVERSION 0.5-1.0 ws/kg

7. WIDENED QRS (>0.08):

A. If IV access is obtained:

• LIDOCAINE, 1 mg/kg IVP, IO

• Sedation with MIDAZOLAM 0.1 mg/kg IV (titrated in 1mg max increments - max dose5mg). Do not delay cardioversion if difficult IV access

• CARDIOVERSION 0.5-1.0 ws/kg, if Lidocaine is not rapidly effective

B. If IV access is NOT obtained:

• CARDIOVERSION 0.5-1.0 ws/kg

• Repeat CARDIOVERSION as needed



Hypotension/Shock P6

HYPOTENSION/SHOCK

Altered level of consciousness; cool, clammy, mottled skin; capillary refill > 2 seconds;tachycardia; blood pressure < 70 systolic. Listless infant or child with poor skin turgor,dry mucous membranes, history of fever may indicate sepsis, meningitis. Settings oftrauma may indicate hemorrhage, vomiting, diarrhea, dehydration.



2. Keep warm

3. IV ACCESS if readily available or IO ACCESS, using volutrol. Do not delay transport fordifficult access.

4. FLUID CHALLENGE 20 ml/kg over 10 minutes and re-assess. May repeat boluses of 20 ml/kgX 2.

5. Cardiac Monitor


7. Consider:

• DEXTROSE- 0.5 gm/kg IVP or IO if blood glucose level equal to or less than 60 in thefollowing concentrations & volumes:

- 25% - 2 ml/kg if 1 month or older

- 12.5% - 4 ml/kg if less than 1 month old. (Dilute D25 1:1 with sterile saline)




Altered Level of Consciousness P7

ALTERED LEVEL OF CONSCIOUSNESS

Identify and document neurological deficits. If Glasgow Coma Scale less than 15 andetiology unclear, consider AEIOU TIPS.

1. Ensure a patent airway - consider C-spine precautions


2. If decreased level of consciousness, position patient in left lateral decubitus position

3. Cardiac monitor - treat dysrhythmias per specific treatment guidelines


5. ORAL GLUCOSE if blood glucose equal or less than 60 and patient is known diabetic, isconscious, able to sit upright and swallow.

6. Consider:

• IV ACCESS TKO using volutrol

• DEXTROSE- 0.5 gm/kg IVP or IO if blood glucose level equal to or less than 60 in thefollowing concentrations & volumes:


- 12.5% - 4 ml/kg if less than 1 month old. (Dilute D 25 1:1 with sterile saline)

• GLUCAGON 0.1 mg/kg IM - if unable to establish IV - maximum of 1 mg

6. NARCAN - 0.1 mg/kg IVP or IM (if unable to establish IV) if patient has respiratory compromiseand narcotic overdose is suspected - maximum dose 2 mg

7. Consider:

• Re-test BLOOD GLUCOSE level, if not responsive to therapy

• DEXTROSE- 0.5 gm/kg IVP or IO as a repeat dose if blood glucose level equal to or less than60 in the following concentrations & volumes:






Seizures P8

SEIZURES

Tonic, clonic movements followed by a period of unconsciousness (post-ictal period).Usually febrile in nature, between ages of 6 months and 5 years. Most seizures are self-limiting and do not require field treatment. Continuous/recurrent seizures are seizure activitygreater than 10 minutes or recurrent seizures without patient regaining consciousness.



2. Left lateral decubitus position if no trauma

3. Protect patient from injury by placing padding appropriately - DO NOT FORCIBLY RESTRAINTHE PATIENT

4. Consider:

• Undress patient if febrile and heavily clothed


6. Consider:

• IV ACCESS TKO using volutrol

• DEXTROSE- 0.5 gm/kg IVP or IO if blood glucose level equal to or less than 60 in thefollowing concentrations & volumes: (may repeat if patient is not responding and re-test ofglucose is less than or equal to 60)



• NARCAN - 0.1 mg/kg IVP or IM (if unable to establish IV) if patient has respiratorycompromise and narcotic overdose suspected - maximum dose 2mg


8. For continuous or recurrent seizures, consider:

• MIDAZOLAM 0.1 mg/kg IV (titrated in 1mg increments - max dose 5mg)

• MIDAZOLAM IM 0.2 mg/kg (maximum 10mg) if IV route unavailable



Poisoning P9

POISONING

Determine type, amount time of material absorbed by the patient. Bring in the containerand/or label.




3. Identify substance and time ingested and bring sample to hospital

4. Consider:

• IV ACCESS TKO using volutrol, in unstable patients

• Cardiac monitor

• Treat dysrhythmias per specific treatment guidelines

• NARCAN- 0.1 mg/kg IVP or IM (if unable to establish IV) if patient has respiratorycompromise and narcotic overdose suspected - maximum dose 2mg

• ACTIVATED CHARCOAL 1gm/kg PO




Anaphylaxis/Allergic Reaction P10

SYSTEMIC ALLERGIC REACTIONReaction involving upper or lower respiratory tract - dyspnea, stridor, wheezing,tachycardia, anxiety, tightness in chest - the more rapid the onset, the more severethe reaction




3. NOTHING BY MOUTH

4. Cardiac monitor - treat dysrhythmias per specific treatment guideline

5. IV ACCESS TKO using volutrol

• EPINEPHRINE 1:1,000, 0.01 mg/kg SC - maximum dose 0.3 mg

• ALBUTEROL 5 mg/6 ml saline via nebulizer. May repeat once if no improvement afterinitial treatment

• DIPHENHYDRAMINE 1 mg/kg IVP, IM (maximum dose of 50 mg)



ANAPHYLACTIC SHOCKSerious progression from a reaction with respiratory/airway features to one which mayinclude hypotension, altered level of consciousness, cyanosis or severe respiratorydistress. RAPID Transport is essential in anaphylaxis.




3. NOTHING BY MOUTH

4. Cardiac monitor - treat dysrhythmias per specific treatment guideline

5. IV ACCESS or IO ACCESS (Base physician order only) using volutrol - 20 cc/kg NS fluidchallenge. May repeat X 2 to a maximum of 60 cc/kg.

6. EPINEPHRINE 1:10,000 0.01 mg/kg, maximum single dose 0.1 mg, slow IVP or IO -maximumtotal dose 0.3 mg

• If no IV or IO access - EPINEPHRINE 1:1000 0.01 mg/kg IM (maximum dose 0.3 mg) OREPINEPHRINE 1:1000 0.1 mg/kg ETT if intubated .

7. ALBUTEROL 5.0 mg/6 ml saline via nebulizer. May repeat once if no improvement after initialtreatment

8. Consider:

• DIPHENHYDRAMINE 1 mg/kg IVP, IO, IM (maximum of 50 mg)





Acute Respiratory Distress P11

Determine degree of physiologic distress: increased respiratory rate; use of accessorymuscles; inadequate ventilation; tired appearing; depressed level of consciousness;cyanosis. Determine which causes best fit patient signs and symptoms, initiate treatment.

INFANT/CHILD WITH COMPLETE AIRWAY OBSTRUCTION

1. In infants less than 1 year old, start with five (5) back blows. Then turn the infant over and deliverfive (5) chest thrusts in a manner similar to CPR (but slower). Finger sweeps are to be avoidedunless the foreign body can be seen and plucked from the infant's mouth.

2. In children 1 year of age or older, treatment follows the same sequence as in the adult, except thatfinger sweeps are to be avoided unless the foreign body can be seen and plucked from the child'smouth.

3. Prior to initiation of ALS, assure 2 cycles of BLS maneuvers. If patient is still obstructed,VISUALIZE THE AIRWAY WITH THE LARYNGOSCOPE AND REMOVE THEFOREIGN BODY, if visible, with Magill Forceps

4. If attempts with Magill Forceps are unsuccessful, and prepare for NEEDLECRICOTHYROTOMY.

CROUP/EPIGLOTTITISThe presence of upper respiratory infection or croupy cough, sore throat, fever, stridoror drooling.

1. Ensure a patent airway• Offer reassurance; keep patient calm - allow parent to hold child during transport, if feasible• OXYGEN therapy - high flow as tolerated

2. If patient deteriorates, or becomes completely obstructed, positive pressure ventilation via bag-valve-mask should be attempted.


ACUTE ASTHMA/BRONCHOSPASMAcute onset of respiratory difficulty usually with a history of prior attacks, wheezes,

coughing.

1. Ensure a patent airway• OXYGEN - high flow. Be prepared to support ventilation with appropriate airway

management - Demand valves are contraindicated in children.2. Position of comfort - left lateral decubitus if decreased level of consciousness3. Limit any physical exertion or movement - attempt to reduce patient anxiety4. Consider ALBUTEROL 5.0 mg/6.0ml NS via nebulizer - may repeat once 5. Contact Base Hospital if any questions or if additional therapy is required6. Consider:

• ALBUTEROL 5.0 mg/6.0ml NS via nebulizer• EPINEPHRINE 1:1000 0.01 mg/kg SC -maximum 0.3 mg/dose.



Critical Trauma P12

OBSERVE LOAD AND GO PROTOCOL

CRITICAL TRAUMAConfirmed critical trauma patients shall be transported directly to a trauma center -patients with unmanageable airways go to the closest appropriate facility.

Physiologic criteria:CRAMS of 7 or less in the presence of an anatomic factor and/or mechanism of injury

Anatomic Injury Factor Criteria:- Penetrating injury to the head, neck, thorax (chest, back) abdomen, pelvis, or groin- Evidence of two or more long bone fractures- Traumatic paralysis- Amputation above the wrist or ankle- Major burns in association with trauma- Patients who have a mechanism of injury (see listing in P13, Non-critical Trauma) likely to causemajor injury, but who are not exhibiting signs of physiologic deterioration are considered possiblecritical trauma patients. These patients require a trauma destination decision by the trauma basehospital prior to transport via air or ground, even if the injury was sustained several hours prior toambulance arrival.

Critical trauma patients may have signs and symptoms of shock due to traumatic injury.

1. Ensure a patent airway• Airway management/support with spinal immobilization/precautions. Needle cricothyrotomy

may be indicated in an unmanageable airway.• OXYGEN - high flow. Be prepared to support ventilations as needed.• Immobilization of the head, cervical/thoracic/lumbar spine with the body secured to the

backboard2. LOAD AND GO PROTOCOL3. Place splints/cold packs on injuries and dressings/pressure on bleeding sites as needed4. Address hypothermia5. IV or IO ACCESS using volutrol. Do not delay transport for difficult access6. Consider:

• FLUID CHALLENGE 20 ml/kg, recheck vitals.• Repeat FLUID CHALLENGE 20 ml/kg if continued poor perfusion X 2

7. Consider:• For relief of extremity pain in the absence of head or torso trauma, hypotension or poor

perfusion or altered level of consciousness, MORPHINE SULFATE 0.05-0.1 mg/kg IVP inup to 2 mg increments. Titrate to pain relief and age appropriate BP. Avoid use with patientswith drug or alcohol intoxication.

8. Contact Trauma Base Hospital - give a brief patient presentation9. Cardiac monitor



Non-Critical Trauma P13

Patients who have a mechanism of injury listed below, but who are not exhibiting signs of physiologicdeterioration are considered possible critical trauma patients. These patients require a trauma destinationdecision by the trauma base hospital prior to transport via air or ground, even if the injury was sustainedseveral hours prior to ambulance arrival.

Mechanism of injury criteria:

• Evidence of high-energy dissipation or rapid deceleration, which may include;

- Vehicle rollover with unrestrained occupant

- Major damage to vehicle

- Intrusion of passenger space by 12 or more inches

- Impact of 40 mph or greater

- Death of occupant in same passenger space

- Persons requiring disentanglement from a vehicle

• Child less than 14 ears old hit by vehicle

• Child ejected from a moving object ( motorcycle, bicycle, horse)

• Fall greater than or equal to 15 feet.

• Significant blunt injury to the head, neck ,thorax, abdomen, or pelvis as a result of any of theabove or as a result of assault or other forcible encounter with a blunt object

• Penetrating injury to the extremities (above the knee or elbow)


• Airway management/support with spinal immobilization/precautions

• OXYGEN - high flow. Be prepared to support ventilations as needed.

• Immobilization of the head, cervical/thoracic/lumbar spine with the body secured to thebackboard

2. Contact Trauma Base Hospital for trauma destination decision

3. Place splints/cold pack and dressings/pressure on bleeding sites as needed

4. Address hypothermia

5. IV ACCESS using volutrol. Do not delay transport for difficult access

6. Consider:

• FLUID CHALLENGE 20 ml/kg, recheck vitals

• Repeat FLUID CHALLENGE 20 ml/kg if continued poor perfusion X 2

7. Cardiac monitor

8. Consider:

• For relief of extremity pain in the absence of head or torso trauma, hypotension or poorperfusion or altered level of consciousness, MORPHINE SULFATE 0.05-0.1 mg/kg IVP inup to 2 mg increments. Titrate to pain relief and age appropriate BP. Avoid use with patientswith drug or alcohol intoxication.




Minor Trauma P14

MINOR TRAUMA

Patients with trauma not meeting critical trauma or non-critical trauma criteria.


• Airway management/support with spinal immobilization/precautions, if indicated


2 Assess extremities for pulses, circulation, motor function and sensation

3. Place splints, dressings, and pressure on bleeding sites as needed

4. Address hypothermia, remove wet clothing, keep warm

5. Consider:

• IV ACCESS -TKO

• For extremity pain (including hip), MORPHINE SULFATE 0.05 - 0.1 mg/kg IVP in up to 2mg increments to a maximum total dose 10 mg. Titrate to pain relief and age appropriatesystolic BP. Avoid use with patients with suspected significant head injury, drug or alcoholintoxication.

C MORPHINE SULFATE 0.1 mg/kg IM if IV route unavailable




Traumatic Arrest P15

CARDIOPULMONARY ARREST DUE TO TRAUMATIC INJURY

1. Begin CPR


• OXYGEN - ventilate with 100% O2

• Demand valves are contraindicated in children.

2. Cardiac monitor - defibrillate if in ventricular fibrillation

3. IV or IO ACCESS

4. FLUID CHALLENGE 20 ml/kg using volutrol. May repeat up to 60 ml/kg. Do not delaytransport for IV access or to administer fluid.

5. Contact Receiving Hospital with update of patient

6. Contact Trauma Base Hospital - give brief patient presentation, if time allows or via post call-inline.



Burns P16

Damage to the skin caused by contact with caustic material, electricity, or fire. Second orthird degree burns involving 10% of the body surface area, or those associated withrespiratory involvement are considered major burns.

1. Remove patient to a safe area

2. Stop the burning process:

• Remove contact with agent, unless it is adhered to skin

• Brush off chemical powders

• Identify chemical, if possible, then flush copiously with cool water

• Apply cool, wet dressings to burns if surface area is less than 10% - Caution: large areascovered with cool, wet dressings may lead to hypothermia. Remove wet clothing, keep as warm as possible.



4. Consider:

• IV or IO ACCESS TKO

• Pain relief (in the absence of hypotension or poor perfusion) MORPHINE SULFATE 0.1mg/kg IVP or IO in up to 2 mg increments, maximum total dose 10 mg. Titrate to pain reliefand age appropriate systolic BP.

5. Protect the burned area:

• Do not break blisters

• Remove restrictive clothing/jewelry if possible

• Cover with clean dressings or sheets

6. Assess for associated injuries




Apparent Life-Threatening Event (ALTE) P17

An Apparent Life-Threatening Event (ALTE) was formally known as a "near-miss SIDS"episode. This is an event that is frightening to the observer (may think the infant has died)and involves some combination of apnea, color change, marked change in muscle tone,choking, or gagging. It usually occurs in infants less than 12 months of age, though anychild with symptoms described under 2 years of age may be considered an ALTE. Mostpatients have a normal physical exam when assessed by responding personnel.

Approximately half of the cases have no known cause, but the other half do have asignificant underlying cause such as infection, seizures, tumors, respiratory or airwayproblems, child abuse, or SIDS. Because of the high incidence of problems and the normalassessment usually seen, there is potential for significant problems if the child's symptomsare not seriously addressed.

1. Obtain history and severity of event, whether patient awake or asleep at time of episode, andwhat resuscitative measures were done by the parent or caretaker

2. Obtain medical history, including history of chronic diseases, seizure activity, current or recentinfections, gastroesophageal reflux, recent trauma, medication history. Obtain history withregard to mixing of formula (appropriate/inappropriate)

3. Perform comprehensive exam, including general appearance, skin color, interaction withenvironment, or evidence of trauma

4. Treat identifiable cause if appropriate

5. Transport

6. If treatment/transport is refused by parent or guardian, contact base hospital to consult prior todocumentation of refusal of care.


RESPIRATORY EMERGENCIES

Airway Obstruction R1

Mechanical upper airway obstruction with history of food aspiration, alcohol abuse.

CONSCIOUS PATIENT — ABLE TO SPEAK

1. Leave the patient alone; offer reassurance

2. Encourage coughing


4. Frequent suctioning as needed to control secretions

5. Avoid agitating the patient

6. Cardiac monitor

CONSCIOUS ADULT PATIENT — UNABLE TO COUGH OR SPEAK

1. Ask the patient if s/he is choking

2. Administer abdominal thrusts until the foreign body is expelled or until the patient becomesunconscious

3. After obstruction is relieved, reassess the airway, lung sounds, skin color and vital signs


5. Cardiac monitor

ADULT PATIENT WHO BECOMES UNCONSCIOUS

1. Roll patient supine; open airway; perform finger sweep

2. Attempt ventilation; if unable, reposition airway

3. Attempt ventilation; if unable to ventilate, perform 5 abdominal thrusts

4. Perform the finger sweep and attempt to ventilate

5. If patient is still obstructed, repeat steps 3-4

6. If patient is still obstructed, VISUALIZE THE AIRWAY WITH THE LARYNGOSCOPEAND REMOVE THE FOREIGN BODY, if visible, with Magill Forceps

7. NEEDLE CRICOTHYROTOMY, if attempts with Magill Forceps are unsuccessful




Acute Respiratory Distress R2

RESPIRATORY DISTRESS

Increased respiratory rate, sensation of difficulty breathing not clearly due to theclinical entities specified below. May be due to pneumonia, inhalation of toxicsubstances, pulmonary embolus.



2. Position of comfort - if decreased level of consciousness, place in left lateral decubitus position

3. Cardiac monitor

4. Consider:

• IV ACCESS TKO

5. Contact Base Hospital if symptoms are not resolved

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic symptoms of pulmonary disease, wheezing, cough, decreased breath sounds,may have barrel chest.

1. Ensure a patent airway• OXYGEN – low flow and increase as indicated. Be prepared to support ventilations

as needed2. Position of comfort - if decreased level of consciousness, place in left lateral decubitus position3. Consider:

• Limit any physical exertion or movement• Loosen tight clothing• Keep patient warm, but not overheated

4. Cardiac monitor5. Consider:

• ALBUTEROL 5.0 mg/6 ml saline via nebulizer. May repeat as necessary .• IV ACCESS TKO




Acute Respiratory Distress R2

ACUTE ASTHMA/BRONCHOSPASM

Acute onset of respiratory difficulty usually with a history of prior attacks,wheezes, coughing.


• OXYGEN – low flow and increase as indicated. Be prepared to supportventilations as needed

2. Position of comfort - if decreased level of consciousness, place in left lateral decubitusposition

3. Consider:

• Allow patient to take his/her medications

• Limit any physical exertion or movement

• Attempt to reduce patient anxiety

4. Cardiac monitor

5. Consider:

• ALBUTEROL 5.0 mg/6 ml saline via nebulizer. May repeat as necessary

• IV ACCESS TKO

• For patients 35 years or younger, EPINEPHRINE 1:1,000 0.3-0.5mg SC, ifpatient’s respiratory status is deteriorating despite repeat doses of Albuterol.Avoid us in patients with history of coronary artery disease or hypertension.

• EPINEPHRINE 1:1,000 0.3-0.5mg IM if patient has sustained respiratoryarrest due to asthma/bronchospasm


7. Consider:

• EPINEPHRINE 1:1,000 0.3-0.5mg SC for patients over age 35, or with priorhistory of coronary artery disease or hypertension



Respiratory Arrest R3

RESPIRATORY ARREST

Absence of spontaneous ventilations without cardiac arrest. Consider narcoticoverdose.


• Support ventilations as needed

• OXYGEN – ventilate with 100% O2

2. Consider:

• IV ACCESS TKO

• NARCAN 1.0-2.0 mg IVP or IM (if unable to establish IV) initially if patienthas respiratory compromise and narcotic overdose suspected.

• EPINEPHRINE 1:1,000 0.3-0.5mg IM, if patient has sustained respiratoryarrest due to asthma/bronchospasm

• Cardiac monitor

3. Transport with further treatment as indicated by patient response or presence ofdysrhythmias



Acute Pulmonary Edema R4

ACUTE PULMONARY EDEMA

Acute onset of respiratory difficulty, may have history of cardiac disease, rales,occasional wheezes.



2. Position of comfort - if decreased level of consciousness, place patient in left lateral decubitusposition

3. Consider:

• Limit any physical exertion or movement by the patient

• Calm and reassure the patient

4. Cardiac monitor

5. IV ACCESS TKO

6. Consider:

• NITROGLYCERIN 0.4 mg (1/150 gr.) SL if BP greater than 90 systolic and patienthas not taken Viagra within the previous 24 hours - may repeat every 5 minutes untilmaximum of 6 doses administered, or:

- condition improves

- severe headache

- BP less than 90 systolic

• FUROSEMIDE 0.5 - 1.0 mg/kg slow IVP if

C patient in extremis with signs and symptoms of pulmonary edema, or

CC prior history of pulmonary edema or

C patient previously taking Lasix (furosemide) or Bumex (bumetanide).


8. Consider:

• MORPHINE SULFATE in 2mg increments IVP if BP greater than 90 - max dose 10mg. Titrate to reduction in symptoms

• DOPAMINE infusion beginning at 5 ug/kg/min (see Table 1) if BP is less than 100systolic

• FUROSEMIDE 0.5 - 1.0 mg/kg slow IVP if

C patient is NOT in extremis with signs and symptoms of pulmonary edema, or

CC has no prior history of pulmonary edema or

C patient has not previously taken Lasix (furosemide) or Bumex (bumetanide).



Pneumothorax R5

SIMPLE PNEUMOTHORAX

May be normotensive; absent or diminished breath sounds on one side with notracheal deviation, distended neck veins or history of trauma.



2. Cardiac monitor

3. Begin transport

4. Consider:

• IV ACCESS TKO

5. Contact Trauma Base Hospital if any questions or if additional therapy is required

6. Continuously monitor for signs of tension pneumothorax

TENSION PNEUMOTHORAX

Absent or diminished breath sounds on one side with some combination of fallingblood pressure, distended neck veins, hyperresonance on side without breath soundswith possible tracheal deviation to the opposite side, cyanosis.



2. Cardiac monitor

3. Begin transport

4. IV ACCESS TKO

5. NEEDLE THORACOSTOMY on affected side

6. Contact Trauma Base Hospital


TRAUMATIC EMERGENCIESCritical Trauma T1

TRAUMA PATIENTSConfirmed critical trauma patients shall be transported directly to a trauma center -patients with unmanageable airways go to the closest appropriate facility.

Physiologic Criteria:< CRAMS of 7 or less in the presence of an anatomic factor and/or mechanism of

injury.Anatomic Injury Factor Criteria:< Penetrating injury to the head, neck, thorax (chest, back), abdomen, pelvis or groin< Evidence of two or more long bone fractures (humerus and/or femur)< Traumatic paralysis< Amputation above the wrist or ankle< Major burns in association with traumaPatients who have a mechanism of injury (see listing in T2, Non-Critical Trauma Patients)likely to cause major injury, but who are not exhibiting signs of physiologic deterioration areconsidered possible critical trauma patients. These patients require a trauma destinationdecision by the trauma base hospital prior to transport via air or ground, even if the injurywas sustained several hours prior to ambulance arrival.

CONFIRMED CRITICAL TRAUMA PATIENTS1. Ensure a patent airway

• Airway management/support with spinal immobilization/precautions:Needlecricothyrotomy may be indicated in unmanageable airway.

• OXYGEN - high flow. Be prepared to support ventilations as needed• Immobilization of the head, cervical/thoracic/lumbar spine with the body secured to the

backboard/scoop stretcher2. LOAD AND GO PROTOCOL3. Place splints/cold packs on injuries and dressings/pressure on bleeding sites as needed4. Consider:

• Advanced airway management with in-line cervical immobilization• Evaluate for tension pneumothorax or pericardial tamponade

5. IV ACCESS – two (2) large bore IVs en route6. Consider:

• 250-500 cc fluid challenge, recheck vitals7. Consider: If GCS is less than 15

• Test BLOOD GLUCOSE level• DEXTROSE 50% 25 gm IVP if blood glucose level less than 60

8. Consider:• For relief of extremity pain in the absence of head or torso trauma, hypotension (BP <

100) or poor perfusion or altered level of consciousness, MORPHINE SULFATE 2-10mgIVP in 2-4 mg increments. Titrate to pain relief and systolic BP > 100. Avoid use withpatients with drug or alcohol intoxication.

9. Contact Trauma Base Hospital - give a brief patient presentation10. Cardiac monitor11. Trauma Base Hospital update of patient status, completion of patient assessment, repeat vital

signs


TRAUMATIC EMERGENCIES

Non-Critical Trauma - T2

NON-CRITICAL TRAUMA PATIENTSPatients meeting mechanism of injury criteria who are triaged by trauma base hospital as non-critical trauma patients.

Mechanism of Injury Criteria:< Evidence of high energy dissipation or rapid deceleration which may include:

C vehicle rollover with unrestrained occupantC major damage to vehicle

C intrusion of passenger space by 12 inches or moreC impact of 40 mph or greater

C death of occupant in same passenger spaceC persons requiring disentanglement from a vehicle

< Adult hit by vehicle traveling faster than 15 mph< Child less than 14 years old hit by vehicle

< Persons ejected from a moving object (motorcycle, horse, etc.)< Fall greater than or equal to 15 feet

< Significant blunt injury to the head, neck, thorax (chest/back), abdomen or pelvisas a result of any of the above, or as a result of assault or other forcibleencounter with a blunt object

< Penetrating injury to the extremities (above the knee or elbow)


• Airway management/support with spinal immobilization/precautions as needed


• Immobilization of the head, cervical/thoracic/lumbar spine with the body secured to thebackboard/scoop stretcher as needed

2. Contact Trauma Base Hospital for trauma destination decision

3. Assess extremities for pulses, circulation, motor function and sensation

4. Place splints/cold packs and dressings/pressure on bleeding sites as needed

5. IV ACCESS – TKO

6. Consider: If GCS is less than 15

• Test BLOOD GLUCOSE level

• DEXTROSE 50% 25 gm IVP if blood glucose level less than 60

7. Cardiac monitor

8. Consider:

• For relief of extremity pain in the absence of head or torso trauma, hypotension (BP < 100)or poor perfusion or altered level of consciousness, MORPHINE SULFATE 2-20mg IVPin 2-4 mg increments. Titrate to pain relief and systolic BP > 100. Avoid use with patientswith drug or alcohol intoxication.




Minor Trauma - T3

MINOR TRAUMA

Patients with trauma not meeting critical trauma or non-critical trauma criteria.


• Airway management/support with spinal immobilization/precautions as needed

• OXYGEN - low flow.

2. Assess extremities for pulses, circulation, motor function and sensation

3. Place splints/cold packs and dressings/pressure on bleeding sites as needed

4. IV ACCESS – TKO

5. Consider:

C For extremity pain (including hip), MORPHINE SULFATE 2-20 mg IVP, titrated in 2-5mg increments to pain relief and systolic BP >100, for pain relief in the absence ofhypotension or altered level of consciousness. Avoid use with patient with suspectedsignificant head injury, drug, or alcohol intoxication.

C MORPHINE SULFATE 5-10 mg IM if IV route unavailable.




Traumatic Arrest T4

CARDIOPULMONARY ARREST DUE TO TRAUMATIC INJURY

1. Begin CPR


• OXYGEN - ventilate with 100% oxygen

2. Advanced airway management with spinal immobilization

3. Cardiac monitor - defibrillate if in ventricular fibrillation

4. Transport

5. IV ACCESS – two (2) large bore IVs en route, 250-500 cc challenge

6. Place splints, dressings and pressure on bleeding sites

7. Contact Receiving Hospital with update of patient

8. Contact Trauma Base Hospital - give brief patient presentation, if time allows or via post call-inline.

Once the patient is prepared for transport, if time permits, initiate defibrillationprotocol.



Crush Injury/Crush Syndrome T5

CRUSH INJURY/CRUSH SYNDROME

Hypovolemia and hyperkalemia may occur, particularly in extended entrapments. Release ofcompression may release cellular toxins and potassium.


• Airway management/support with spinal immobilization/precautions, if indicated

• OXYGEN - high flow - support ventilations as required

2. Place splints, dressings and pressure on bleeding sites as needed

3. Consider:

• IV ACCESS - two large bore IV’s

• Cardiac monitor

• If wheezing, ALBUTEROL 5.0 mg/6 ml saline via nebulizer

• FLUID RESUSCITATION - 20ml/kg NS prior to release of compression

4. Consider:

• MORPHINE SULFATE 2-10 mg IVP (in 2 - 4 mg increments) or IM - titrate to painrelief and systolic BP greater than 100 - caution if major traumatic injuries suspected

5. Release compression/patient extrication

6. Additional splints and dressings as needed

7. Contact Trauma Base Hospital

8. If hyperkalemia suspected (entrapment greater than 4 hours, suspicion on ECG monitor withpeaked ‘T’ waves, absent ‘P’ waves or widened QRS complexes)

• ALBUTEROL 5.0mg/6ml saline continuously via nebulizer

• CALCIUM CHLORIDE 1 gm slow IVP over 60 seconds

Note: Flush tubing after administration of CALCIUM CHLORIDE to avoid precipitationwith SODIUM BICARBONATE

• SODIUM BICARBONATE 1 mEq/kg IVP

9. Consider:

• SODIUM BICARBONATE 1 mEq/kg added to NS - use second IV line as othermedications may not be compatible

TABLE 1 DOPAMINE DRIP RATES: Dopamine 1600 ug/ml solution — 400mg in 250 ml D5W. Chart based in 60 gtt/mltubing.

Pt. Weight

kg/lb 10 gtt 15 gtt 20 gtt 25 gtt 30 gtt 35 gtt 40 gtt 45 gtt 50 gtt 55 gtt 60 gtt 70 gtt 80 gtt

35/77 7.6 11 15 1940/88 6.7 10 13 17 2045/99 5.9 8.9 12 15 1850/110 5.3 8.0 11 13 16 1955/121 4.9 7.3 9.7 12 15 17 1960/132 6.6 8.9 11 13 16 18 2065/143 6.1 8.2 10 12 14 16 1870/154 5.7 7.6 9.5 11 13 15 17 1975/165 5.3 7.1 8.9 11 12 14 16 18 2080/176 5.0 6.7 8.4 10 12 13 15 17 18 2085/187 6.3 7.8 9.4 11 13 14 16 17 1990/198 5.9 7.4 8.9 10 12 13 15 16 1895/209 5.6 7.0 8.4 9.8 11 13 14 15 17 20100/220 5.3 6.6 8.0 9.3 11 12 13 15 16 19105/231 5.1 6.3 7.6 8.9 10 11 13 14 15 18 20110/242 4.9 6.0 7.3 8.5 9.7 11 12 13 15 17 19

Find patient weight in left column. Move right to desired dose. Drip rate is at top of chart.

Example: 70 kg patient - desired flow rate of 5.7 ug/kg/min - drip rate is 15 drops/minute.


Pediatric Drug Dosage Chart (3-16 kg)

Use Length-based Resuscitation Tape To Estimate If Weight Is Not Known

Chart Valid Only If Concentration Is Same As Listed

Drug

Dose

Activated Adenosine Adenosine Atropine Dextrose Dextrose Diphen- EpinephrineCharcoal Sulfate 12.5% 25% 1:1,000

200 mg/ml 0.1 mg/ml (Dilute D25 1 mg/ml3 mg/ml 3 mg/ml hydramine

1:1)50 mg/ml

1 gm/kg 0.1 mg/kg 0.2 mg/kg 0.02 mg/kg 1 mg/kg 0.01 mg/kg0.5 g/kg

(under 1 mo)0.5 g/kg

(> 1 mo)

For asthma,

subcutaneous

3 kg0.3 mg 0.6 mg 0.1 mg 1.5 g 1.5 g 3 mg 0.03 mg

(0.1 ml) (0.2 ml) (1 ml) (12 ml) (6 ml) (0.06 ml) (0.03 ml sc)

4 kg0.4 mg 0.8 mg 0.1 mg 2 g 2 g 4 mg 0.04 mg


5 kg0.5 mg 1 mg 0.1 mg 2.5 g 2.5 g 5 mg 0.05 mg


6 kg0.6 mg 1.2 mg 0.12 mg 3 g 3 g 6 mg 0.06 mg

(0.2 ml) (0.4 ml) (1.2 ml) (24 ml) (12 ml) (0.12 ml) (0.06 ml sc)

7 kg0.7 mg 1.4 mg 0.14 mg 3.5 g 3.5 g 7 mg 0.07 mg


8 kg0.8 mg 1.6 mg 0.16 mg 4 g 4 g 8 mg 0.08 mg


9 kg0.9 mg 1.8 mg 0.18 mg 4.5 g 9 mg 0.09 mg

(0.3 ml) (0.6 ml) (1.8 ml) (18 ml) (0.18 ml) (0.09 ml sc)

10 kg10 g 1 mg 2 mg 0.2 mg 5 g 10 mg 0.1 mg

(50 ml) (0.33 ml) (0.67 ml) (2 ml) (20 ml) (0.2 ml) (0.1 ml sc)

11 kg11 g 1.1 mg 2.2 mg 0.22 mg 5.5 g 11 mg 0.11 mg

(55 ml) (0.36 ml) (0.73 ml) (2.2 ml) (22 ml) (0.22 ml) (0.11 ml sc)

12 kg12 g 1.2 mg 2.4 mg 0.24 mg 6 g 12 mg 0.12 mg


13 kg13 g 1.3 mg 2.6 mg 0.26 mg 6.5 g 13 mg 0.13 mg


14 kg14 g 1.4 mg 2.8 mg 0.28 mg 7 g 14 mg 0.14 mg


15 kg15 g 1.5 mg 3 mg 0.3 mg 7.5 g 15 mg 0.15 mg

(75 ml) (0.5 ml) (1 ml) (3 ml) (30 ml) (0.3 ml) (0.15 ml sc)

16 kg16 g 1.6 mg 3.2 mg 0.32 mg 8 g 16 mg 0.16 mg






Drug

Dose

Epinephrine Epinephrine Glucagon Lidocaine 2% Midazolam Midazolam Morphine Naloxone1:1,000 1:10,000 Sulfate

1 mg/ml 0.1 mg/ml 10 mg/ml1 mg/ml 100 mg/5 ml 5 mg/ml 5 mg/ml

For arrest(repeat IV

doses)

or via

ETT if >1mo

0.1 mg/kg

For arrest,ETT neonate

0.01 mg/kg0.1 mg/kg 1 mg/kg 0.1 mg/kg

0.2 mg/kg

IM0.1 mg/kg 0.05 mg/kg to

IV 0.1 mg/kg

3 kg0.3 mg 0.03 mg 0.3 mg 3 mg 0.6 mg 0.15-0.3 mg 0.3 mg

(0.3 ml) (0.3 ml) (0.3 ml) (0.15 ml) (0.12 ml) (0.02-0.04 ml)

4 kg0.4 mg 0.04 mg 0.4 mg 4 mg 0.8 mg 0.2-0.4 mg 0.4 mg

(0.4 ml) (0.4 ml) (0.4 ml) (0.2 ml) (0.16 ml) (0.02-0.04 ml)

5 kg0.5 mg 0.05 mg 0.5 mg 5 mg 1 mg 0.5 mg 0.25-0.5 mg 0.5 mg

(0.5 ml) (0.5 ml) (0.5 ml) (0.25 ml) (0.2 ml) 0.1 ml (0.03-0.05 ml)

6 kg0.6 mg 0.06 mg 0.6 mg 6 mg 1.2 mg 0.5 mg 0.3-0.6 mg 0.6 mg

(0.6 ml) (0.6 ml) (0.6 ml) (0.3 ml) (0.24 ml) 0.1 ml (0.03-0.06 ml)


(0.7 ml) (0.7 ml) (0.7 ml) (0.35 ml) (0.28 ml) 0.1 ml (0.04-0.07 ml)


(0.8 ml) (0.8 ml) (0.8 ml) (0.4 ml) (0.32 ml) 0.1 ml (0.04-0.08 ml)


(0.9 ml) (0.9 ml) (0.9 ml) (0.45 ml) (0.36 ml) 0.1 ml (0.04-0.08 ml)

10 kg1 mg 0.1 mg 1 mg 10 mg 2 mg 1 mg 0.5-1 mg 1 mg

(1 ml) (1 ml) (1 ml) (0.5 ml) (0.4 ml) 0.2 ml (0.05-0.1 ml)

11 kg1.1 mg 0.11 mg 1 mg 11 mg 2.2 mg 1.1 mg 0.55-1.1 mg 1.1 mg

(1.1 ml) (1.1 ml) (1 ml) (0.55 ml) (0.44 ml) 0.22 ml (0.06-0.11 ml)


(1.2 ml) (1.2 ml) (1 ml) (0.6 ml) (0.48 ml) 0.24 ml (0.06-0.12 ml)


(1.3 ml) (1.3 ml) (1 ml) (0.65 ml) (0.52 ml) 0.26 ml (0.07-0.13 ml)


(1.4 ml) (1.4 ml) (1 ml) (0.7 ml) (0.56 ml) 0.28 ml (0.07-0.14 ml)

15 kg1.5 mg 0.15 mg 1 mg 15 mg 3 mg 1.5 mg 0.75-1.5 mg 1.5 mg

(1.5 ml) (1.5 ml) (1 ml) (0.75 ml) (0.6 ml) 0.3 ml (0.08-0.15 ml)


(1.6 ml) (1.6 ml) (1 ml) (0.8 ml) (0.64 ml) 0.32 ml (0.08-0.16 ml)





Drug

Dose

Activated Adenosine Adenosine Atropine Dextrose Diphen- EpinephrineCharcoal Sulfate 25% 1:1,000

200 mg/ml 0.1 mg/ml 1 mg/ml3 mg/ml 3 mg/ml hydramine

50 mg/ml

1 gm/kg 0.1 mg/kg 0.2 mg/kg 0.02 mg/kg 1 mg/kg 0.01 mg/kg0.5 gm/kg

(>1 mo)

For asthma,

subcutaneous

17 kg17 gm 1.7 mg 3.4 mg 0.34 mg 8.5 gm 17 mg 0.17 mg


18 kg18 gm 1.8 mg 3.6 mg 0.36 mg 9 gm 18 mg 0.18 mg


19 kg19 gm 1.9 mg 3.8 mg 0.38 mg 9.5 gm 19 mg 0.19 mg


20 kg20 gm 2 mg 4 mg 0.4 mg 10 gm 20 mg 0.2 mg











(150 ml) (1 ml) (2 ml) (5 ml) (60 ml) (0.6 ml) (0.3 ml sc)



34 kg34 gm 3.4 mg 6.8 mg 0.5 mg 17 gm 34 mg

(170 ml) (1.13 ml) (2.27 ml) (5 ml) (68 ml) (0.68 ml)0.3 mg

(0.3 ml sc)



45 kg45 gm 4.5 mg 9 mg 0.5 mg 22.5 gm 45 mg 0.3 mg

(225 ml) (1.5 ml) (3 ml) (5 ml) (90 ml) (0.9 ml) (0.3 ml sc)

50 kg50 gm 5 mg 10 mg 0.5 mg 25 gm

(250 ml) (1.67 ml) (3.3 ml) (5 ml) (100 ml)50 mg 0.3 mg

(1 ml) (0.3 ml sc)





Drug

Dose

Epinephrine Epinephrine Glucagon Lidocaine 2% Midazolam Midazolam Morphine Naloxone1:1,000 1:10,000 Sulfate

1 mg/ml 0.1 mg/ml 10 mg/ml1 mg/ml 100 mg/5 ml 5 mg/ml 5 mg/ml

For arrest(repeat IV

doses)

or via

ETT if >1mo

0.1 mg/kg

For arrest,ETT neonate

0.01 mg/kg0.1 mg/kg 1 mg/kg 0.1 mg/kg

0.2 mg/kg 0.1 mg/kg

IM IV0.05 mg/kg to

0.1 mg/kg


(1.7 ml) (1.7 ml) (1 ml) (0.85 ml) (0.68 ml) 0.34 ml (0.09-0.17 ml)


(1.8 ml) (1.8 ml) (1 ml) (0.9 ml) (0.72 ml) 0.36 ml (0.09-0.18 ml)


(1.9 ml) (1.9 ml) (1 ml) (0.95 ml) (0.76 ml) 0.38 ml (0.1-0.19 ml)

20 kg2 mg 0.2 mg 1 mg 20 mg 4 mg 2 mg 1-2 mg 2 mg

(2 ml) (2 ml) (1 ml) (1 ml) (0.8 ml) 0.4 ml (0.1-0.2 ml)

22 kg2.2 mg 0.22 mg 1 mg 22 mg 4.4 mg 2.2 mg 1.1-2.2 mg 2 mg

(2.2 ml) (2.2 ml) (1 ml) (1.1 ml) (0.88 ml) 0.44 ml (0.11-0.22 ml)


(2.4 ml) (2.4 ml) (1 ml) (1.2 ml) (0.96 ml) 0.48 ml (0.12-0.24 ml)


(2.6 ml) (2.6 ml) (1 ml) (1.3 ml) (1.04 ml) 0.52 ml (0.13-0.26 ml)

28 kg2.8 mg 0.28 mg 1 mg 28 mg 5.6 mg 2.8 mg 1.4-2 8 mg 2 mg

(2.8 ml) (2.8 ml) (1 ml) (1.4 ml) (1.12 ml) 0.56 ml (0.14-0.28 ml)

30 kg3 mg 0.3 mg 1 mg 30 mg 6 mg 3 mg 1.5-3 mg 2 mg

(3 ml) (3 ml) (1 ml) (1.5 ml) (1.2 ml) 0.6 ml (0.15-0.3 ml)


(3.2 ml) (3.2 ml) (1 ml) (1.6 ml) (1.28 ml) 0.64 ml (0.16-0.32 ml)


(3.4 ml) (3.4 ml) (1 ml) (1.7 ml) (1.36 ml) 0.68 ml (0.17-0.34 ml)

40 kg4 mg 0.4 mg 1 mg 40 mg 8 mg 4 mg 2-4 mg 2 mg

(4 ml) (4 ml) (1 ml) (2 ml) (1.6 ml) 0.8 ml (0.2-0.4 ml)

45 kg4.5 mg 0.45 mg 1 mg 45 mg 9 mg 4.5 mg 2.25-4.5 mg 2 mg

(4.5 ml) (4.5 ml) (1 ml) (2.25 ml) (1.8 ml) 0.9 ml (0.23-0.45 ml)

50 kg5 mg 0.5 mg 1 mg 5 mg 10 mg 5 mg

(5 ml) (5 ml) (1 ml) (2.5 ml) (2 ml) 1 ml2.5-5 mg 2 mg

(0.25-0.5 ml)

APPENDIX A

Instructions for completion ofthe Prehospital Care Report


Contra Costa County

Emergency Medical Services

Instructions for completion of the Prehospital Patient Care Record

Field Abbreviation Explanation Directions

A

Date Date of call

MTN # Message Transmission Network Number assigned by dispatch computers

Agency Name of response agency

Unit ID Identification number of responding unit

Response # Agency specific response number (if applicable)

Pt. __ of __ Patient __ of __ Enter patient number (e.g. Pt. 1 of 2)

Resp Code: 2 3 Response Code Circle appropriate number

Location Enter street address/location of incident

City Enter city where incident occurred

Map Page Thomas Bros. map coordinates

Name Patient first and last name

Age _________ D M Y Age ____ Day Month Year Patient age - circle appropriate age unit

M F U Male Female Unknown Patient sex

Wt ______kg Weight ____ kilograms Patient weight in kilograms

SS# Social Security Number Patient social security numberB

Transport Code: 2 3 Circle appropriate number (transport units only)

Destination Patient destination

ETE: Estimated Time En route Transport time, in minutes to destination facility

Base Contact: Y N Circle to indicate whether base contact was madeTime: and time of base contact

MDMC JMMC Mt. Diablo Medical Center Circle to indicate base contactedJohn Muir Medical Center

C

Medical Responsive Check if patient is a responsive medical patient

Medical Unresponsive Check if patient is an unresponsive medical patient

Trauma Low M.O.I. Mechanism of Injury Check if patient has M.O.I. associated with minortrauma

D

Trauma High M.O.I. Mechanism of Injury Check if patient has M.O.I. associated with majortrauma

Cardiac Arrest Check if patient is in cardiac arrest

Airway: Clear Noisy Obstructed Circle appropriate choice to indicate initial statusof patient airway

Respirations: <30 >30 Circle appropriate choice to indicate initialrespiratory rate

Capillary Refill: <2 sec >2 sec Circle appropriate choice to indicate initialcapillary refill

Radial Pulse: Yes No Circle appropriate choice to indicate initialpresence or absence of radial pulse

Loss of Con: Yes No Unk Loss of consciousness Circle appropriate choice to indicate whetherUnknown patient had a loss of consciousness



Oriented To: Person Time Place Circle appropriate choice(s) to indicate patient'sEvent initial level of orientation

Responds to: Verbal Pain Unresponsive Circle appropriate choice to indicate patient'sUnresp initial level of responsiveness

Suspect: ETOH DRUGS Circle appropriate choice if there is an indicationthat the patient has been using drugs or alcohol

Skin Color: Normal Pale Circle appropriate choice to indicate patient'sCyanotic Flushed Jaundice initial skin color

Temp: Warm Hot Cool Cold Temperature Circle appropriate choice to indicate patient'sinitial skin temperature

Moisture: Dry Clammy Circle appropriate choice to indicate patient'sDiaphoretic initial skin moisture

E

Chief Complaint Enter patient's chief complaint

Signs/Symptoms O - onset Enter patient's signs/symptoms - use OPQRST forP - provocationQ - qualityR - radiationS - severity (1-10)T - time

P - progressionA - associated chest painS - sputumT - tirednessE - exercise tolerance

pain, PASTE for respiratory difficulty. Includenarrative of call and patient presentation. Explainany abnormalities noted elsewhere on the PCR.

Allergies Enter patient's allergies

Last Oral Intake Enter time and what patient last ate or drank

Medications: Enter patient's medications

Events leading to call: Enter significant events leading to reason forpatient calling

Past History: Enter patient's past medical historyF

Time Enter time initial vital signs were taken

Blood pressure Enter initial blood pressure

Pulse Enter initial pulse rate

Resp Respirations Enter initial respiratory rate

Pupils: PERL Unequal R__mm Pupils Equal Reactive Light Circle appropriate choice - indicate pupil size ifL__mm pupils are not equal

VS Done By Vital Signs Enter name of provider that obtained initial vitalsigns

G



Head/Face: N D C A P B T L S N - Normal Circle appropriate letter to indicate any injuries orD - deformityC - contusionA - abrasionP - punctureB - burnT - tendernessL - lacerationS - swelling

abnormalities to head/face - describe in thesigns/symptoms narrative section

Neck: N D C A P B T L S Circle appropriate letter to indicate any injuries orabnormalities to neck - describe in thesigns/symptoms narrative section.

Trachea: Mid Dev: L R Midline Indicate whether the trachea is in the midline, orDeviated: Left Right deviated (if so, to which side).

JVD: Y N Jugular Venous Distention: Yes No Indicate the presence or absence of jugular venousdistention

Chest: Nontender Tender Circle to indicate whether chest is tender orExpansion: = Ö nontender and whether chest expansion is equal or

not equal

Breath Sounds: = Ö Clr Rales clear Circle to indicate whether breath sounds are equalRhonchi Wheezes or not equal and whether lungs are clear or noisy

Abdomen: N D C A P B T L S Circle appropriate letter to indicate any injuries orabnormalities to abdomen - describe in thesigns/symptoms narrative section.

Pelvis: N D C A P B T L S Circle appropriate letter to indicate any injuries orabnormalities to pelvis - describe in thesigns/symptoms narrative section.

Extremities: N D C A P B T L S Circle appropriate letter to indicate any injuries orabnormalities to extremities - describe in thesigns/symptoms narrative section.

Back: N D C A P B T L S Circle appropriate letter to indicate any injuries orabnormalities to back - describe in thesigns/symptoms narrative section.

General Assessment (see back): Enter general assessment code and text from liston back of PCR

H

Time Enter time vital signs were taken

Blood Pressure Enter patient's blood pressure

Pulse Enter patient's pulse rate

Resp Respirations Enter patient's respiratory rate

EKG ElectroCardioGram Enter patient's EKG rhythm

CRAMS Score Enter components of CRAMS and total - see backof PCR for explanation of score

Glasgow Enter components of Glasgow score and total - seeback of PCR for explanation of score

I

Time Enter time patient interventions were performed

ID Identification Enter ID of person performing patientinterventions

Management Enter patient intervention performed

Response Enter patient response to intervention



J

Condition on Arrival: Arrested Patient condition upon arrival - circle appropriateNot Arrested choice

Witnessed? Yes No Unk Unknown Circle appropriate choice to indicate whetherarrest was witnessed or not

CPR By: Police Family Cardio Pulmonary Resuscitation Circle appropriate choice to indicate whether CPRBystander Other None was being performed and by whom

Cause: Cardiac Trauma Other Circle appropriate choice to indicate cause ofarrest

Location: Home Work Public Circle appropriate choice to indicate location ofPlace Car Sports Other arrest

Est. Downtime: Estimated Downtime Enter estimated downtime of patient in cardiacarrest

Total Shocks: Enter total number of shocks delivered to patient

Regain Consciousness: Y N Yes No Circle appropriate choice to indicate whetherPulse: Y NBreathing: Y N

patient regained consciousness, pulse and/orbreathing in field

First Analysis: __:__ Enter time of first Lifepak 500 patient analysis

First Shock: __:__ Enter time of first Lifepak 500 patient shockK

Reason: Respiratory Distress Circle appropriate choice to indicate reason forFull Arrest Respiratory Arrest intubation

Blade Used: Straight Curved Circle appropriate choice to indicate laryngoscopeblade used

# Attempts Enter number of intubation attempts

Airway Prior to Intubation: OPA Oropharyngeal airway Circle appropriate choice to indicate airway beingNPA EOA None used prior to intubationNasopharyngeal airway

Esophageal obturator airway

Tube Size: Enter endotracheal tube size

Intubator ID Identification Enter name of person performing intubation

Environment: En route Floor Circle appropriate choice to indicate environmentBed Gurney Ground where intubation was performed

Obstructions: Vomitus Blood Circle appropriate choice to indicate obstructionsAnatomy Other: to intubation - explain Other obstructions

L

Dest. Dec.? Y N Time: Destination Decision? Yes No Was trauma destination made? If so, what time.

John Muir on bypass: Y N Yes No Was John Muir on bypass?

Est. time to T.C.: Estimated time to trauma center: Enter estimated number of minutes to transport totrauma center

Other T.C. available? Y N Trauma Center Yes No Was another trauma center available?

Meets flight criteria? Y N Yes No Does patient meet criteria for using a helicopter?

Helo Agency: Helicopter: Which helicopter agency was used for transport?

Released to Helo: : Helicopter What time was patient released to the helicopterfor transport?

Ext. Time: Extrication Time: Enter minutes needed for extrication

Est. Blood Loss: Estimated Blood Loss Enter estimated amount of blood lost

Reason for Extended Scene Enter reason for scene time greater than 20Time: minutes

M



TCR Time Call Received Enter time dispatch center received call

Disp Dispatch Enter time unit was dispatched

En route Enter time unit went en route on call

On-scene Enter time unit went on-scene of call

Pt. Contact Patient contact Enter time patient contact was made

Transport Enter time transport was started

At Dest At Destination Enter time of arrival at transport destination

To Rend To rendezvous Enter time of departure to rendezvous site

At Rend At rendezvous Enter time of arrival at rendezvous site

Released to Grnd Released to Ground Enter time patient was released to groundtransport unit from helicopter

Type of Service No Transport Circle appropriate level of service providedALS BLS NOTRANS

N

AMA block Against Medical Advice Enter name of provider agency and have patientand witness sign and date

Release block Have patient sign authorizing release of data toEMS Agency for quality improvement purposes

Name: ID# Identification Number Enter prehospital personnel name and ID number: State license number for ALS, county certificationnumber for BLS

O

Medicare MediCal Kaiser Contra Costa Health Plan Circle type of insurance patient hasBlue Cross CCHP HMO Health Maintenance Organization

Ins #: Insurance #: Enter insurance numbers

Ins #: Insurance #: Enter insurance numbers

Address: Enter patients home address

City: Enter patients home city

State: Enter patients home state

Zip: Enter patients home zip code

DOB: Date of Birth Enter patients date of birth

Phone: Enter patients phone number

Drv. Lic #: Drivers License # Enter patients drivers license number

Beg. Mile: Beginning Mileage: Enter beginning transport mileage

End Mile: Ending Mileage: Enter ending transport mileage

Employer: Enter patients employer

Circle appropriate items in each category on the back of the patient care report





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APPENDIX B

Energy settings for bi-phasic lowenergy defibrillators


CARDIAC EMERGENCIES

Cardiac Arrest - Ventricular Fibrillation/Pulseless Ventricular Tachycardia C3

VENTRICULAR FIBRILLATION & PULSELESS VENTRICULAR TACHYCARDIA

1. DEFIBRILLATION at 120 W/S (bi-phasic low energy defibrillator only)



4. Continue CPR




8. LIDOCAINE 1.5 mg/kg IVP or 3.0 mg/kg ETT (max dose 3 mg/kg IVP)

9. DEFIBRILLATION at 200 W/S every minute (bi-phasic low energy defibrillator only)

10. Prepare for transport

11. Consider:

• SODIUM BICARBONATE 1.0 mEq/kg IVP for suspected hyperkalemia, profound acidosis orprolonged down time with return of circulation.

• LIDOCAINE 1 mg/kg IV as initial dose, if spontaneous circulation returns after defibrillation andno prior Lidocaine dose has been administered

• LIDOCAINE 0.5-0.75 mg/kg IV - may be repeated every 5-10 minutes to a maximum of 3.0mg/kg for all patients with return of spontaneous circulation after defibrillation



CARDIAC EMERGENCIES

Ventricular Tachycardia with Pulses C6

VENTRICULAR TACHYCARDIA WITH PULSES: STABLE



2. IV ACCESS TKO


4. Consider:

• LIDOCAINE 0.5 - 0.75 mg/kg IVP every 5 minutes until ventricular tachycardia is resolved or 3mg/kg reached.

• If no response, then treat as unstable Ventricular Tachycardia


VENTRICULAR TACHYCARDIAS WITH PULSES: UNSTABLE

Signs of poor perfusion, chest pain, dyspnea, hypotension, or CHF.



2. IV ACCESS TKO

3. Prepare for SYNCHRONIZED CARDIOVERSION. If sedation is needed, MIDAZOLAM 1-5mgIV (initial dose 1mg, titrate in 1-2mg increments - use caution in patients over age 60)

• SYNCHRONIZED CARDIOVERSION 75 W/S (bi-phasic low energy defibrillator only)





5. Consider:

• If Ventricular Tachycardia recurs, SYNCHRONIZED CARDIOVERSION (use lowest w/slevel previously successful)

• LIDOCAINE 0.5 - 0.75 mg/kg IVP every 5-10 minutes to total dose of 3 mg/kg (with CHF, liverfailure, age greater than 70 or shock, consider 10 minute time interval between doses)



CARDIAC EMERGENCIES

Paroxysmal Supraventricular Tachycardias C7

SUPRAVENTRICULAR TACHYCARDIAS: STABLE

Heart rate greater than 150 beats per minute - usually narrow QRS complex.



2. Cardiac monitor

3. IV ACCESS TKO

4. VALSALVA

5. Consider:


• If patient has not converted, ADENOSINE 12mg rapid IVP - followed by 20cc bolus of normalsaline, 1-2 minutes after initial dose. May repeat dose once.


SUPRAVENTRICULAR TACHYCARDIAS: UNSTABLE

Signs of poor perfusion, chest pain, dyspnea, hypotension or CHF. Heart rate greater than150 beats per minute - usually narrow QRS complex. If wide QRS complex considerventricular tachycardia.



2. Position of comfort. If decrease level of consciousness, position left lateral decubitus

3. Cardiac monitor

4. IV ACCESS TKO

5. Consider:


• If patient has not converted, ADENOSINE 12mg rapid IVP - followed by 20cc bolus of normalsaline, 1-2 minutes after initial dose. May repeat dose once.

6. Prepare for SYNCHRONIZED CARDIOVERSION. If sedation is needed, MIDAZOLAM 1-5mgIV (initial dose 1mg, titrate in 1-2mg increments - use caution in patients over age 60)








CARDIAC EMERGENCIES


SINUS TACHYCARDIAHeart rate 100-160, regular.



2. Position of comfort. If decreased level of consciousness, position on left side

3. Cardiac monitor

4. Consider:

• IV ACCESS TKO if other vital signs abnormality exists

• Treat underlying cause

ATRIAL FIBRILLATION



2. Cardiac monitor

3. IV ACCESS TKO


5. If unstable:






• SYNCHRONIZED CARDIOVERSION at 75 w/s (bi-phasic low energy defibrillator only)






CARDIAC EMERGENCIES


ATRIAL FLUTTER

Variable rate depending on block. Atrial rate between 250-350, "saw-tooth" pattern.



2. Cardiac monitor

3. IV ACCESS TKO


5. If unstable:













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INDEX

"load and go" . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

- A - bradycardia . . . . . . . . . . . . . 5, 24, 25, 36, 40, 44, 71

ABC's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17, 18

abdominal pain . . . . . . . . . . . . . . . . . . . . . . . . . 5, 55

acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

acute asthma . . . . . . . . . . . . . . . . . . . . . . . . . . 78, 87

acute cerebrovascular accident (stroke) . . . . . . . . . . 62

acute pulmonary edema . . . . . . . . . . . . . . . . . . . . 89

acute respiratory distress . . . . . . . . . . . . . . . 78, 86, 87

adenosine . . . . . . . . . . . . 20, 24, 43, 72, 97, 99, 111

adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

advanced life support skills list . . . . . . . . . . . . . . . . 20

airway obstruction . . . . . . . . . . . . . . . . 31, 68, 78, 85

albuterol . . . . . . . . . . . 24, 52, 56, 77, 78, 86, 87, 95

allergic reactions . . . . . . . . . . . . . . . . . . . . . . . . . 56

allergies . . . . . . . . . . . . . . . . . . . . . . . . . 14, 47, 102

ALOC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

ALS procedures . . . . . . . . . . . . . . . . . . . . . . . . 13, 25

altered level of consciousness . . . . . . . 14, 17, 23, 32,

35, 36, 48, 50, 56, 60, 71-74, 77, 79, 80, 91-93 cardiogenic shock . . . . . . . . . . . . . . . . . . . . . . . . . 37

ambulance . . . . . . . . . . . . . . . . . . . . 1, 10, 79, 80, 91

ammonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . 79, 91

anaphylactic shock . . . . . . . . . . . . . . . . . . . 51, 56, 77

anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . 24, 25, 77

angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

APGAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68, 84

assessment . . . . . . . . . . . . . 4, 5, 8, 9, 14, 15, 17, 22,

23, 36, 68, 84, 91, 103 childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

asystole . . . . . . . . . . . . . . . . . . . . . . . 24, 36, 41, 70

atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . 45, 112

atrial flutter . . . . . . . . . . . . . . . . . . . . . . . . . . 46, 113

atropine . . . 20, 21, 24, 36, 40, 41, 44, 54, 71, 97, 99

- B - CO2 . . . . . . . . . . . . . . . . . . . . . . . . . .22, 26-28, 30

base hospital . . . . . 1, 2, 11, 21, 23, 26, 37,39-48, 50,

52-54, 56-62, 64-67, 69-87, 89-95, 109-113 Contra Costa Regional Medical Center . . . . . . . . . . 2, 3

basic therapy - first responder defibrillation . . . . . . . 38

bees/wasps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

benadryl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

benzodiazepine . . . . . . . . . . . . . . . . . . . . . . . . . . 24

bleeding . . . . . . . . 4, 5, 35, 37, 47, 64, 79-81, 91-95

blood pressure . . . . . . . . . 5, 9, 13, 36, 38, 68, 72, 73,

90, 102, 103

bradycardia: asymptomatic . . . . . . . . . . . . . . . . . . 44

bradycardia: symptomatic . . . . . . . . . . . . . . . . . . . 44

breech presentation . . . . . . . . . . . . . . . . . . . . . . . 66

bretylium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

bronchospasm . . . . . . . . . . . . . . . . 25, 54, 78, 87, 88

burn center . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 11

burns . . . . . . . . 10, 11, 15, 25, 50, 53, 58, 79, 83, 91

- C -

calcium chloride . . . . . . . . . . . . . . . . 4, 20, 40, 53, 95

capillary refill . . . . . . . . . . . . . 5-7, 36, 68, 71-73, 101

carbon dioxide . . . . . . . . . . . . . . . . . . . . . . 22, 27, 28

carbon monoxide . . . . . . . . . . . . . . . . . . . . . . . 10, 22

cardiac arrest . . . . . 4, 5, 8, 22, 25, 27, 34, 36, 38-41,

53, 70, 88, 101, 104, 109

cardiac emergencies . . . . . . . . . . . 36, 38-47, 109-113

cardiac tamponade . . . . . . . . . . . . . . . . . . . . . . 40, 70

cardiopulmonary arrest . . . . . . . . . . . . . . 5, 70, 82, 94

caustics and corrosives . . . . . . . . . . . . . . . . . . . . . 58

cervical collar . . . . . . . . . . . . . . . . . . . . . . . . 8, 17, 18

cervical spine . . . . . . . . . . . . . . . . . . . . . . . . . . . 8, 9

chemical burns . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Chemtrec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

chest pain . . . . . . 24, 25, 36, 37, 42-47, 102, 110-113

chief complaint . . . . . . . . . . . . . . . . . . . . . 2, 14, 102

child abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

chlorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

choking . . . . . . . . . . . . . . . . . . . . . . . . . . . 68, 84, 85

chronic obstructive pulmonary disease . . . . . . . . . . 86

circulatory failure . . . . . . . . . . . . . . . . . . . . . . . . . . 5

clammy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 73, 102

communications . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 34

complete airway obstruction . . . . . . . . . . . . . . . 31, 78

cool . . . . . . . . . . . 5, 10, 34, 36, 48, 50, 73, 83, 102

CRAMS . . . . . . . . . . . . . . . . . . . . . . . . 6, 79, 91, 103

cricoid cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . 31

cricoid membrane . . . . . . . . . . . . . . . . . . . . . . . . . 31

cricothyroid space . . . . . . . . . . . . . . . . . . . . . . . . 31


critical trauma . . . . . . . . . . . . . . . . 5, 6, 79-81, 91-93

croup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

cyanide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24, 52

cyanosis . . . . . . . . . . . . . . . . . 36, 56, 68, 77, 78, 90

- D - - H -

decerebrate posturing . . . . . . . . . . . . . . . . . . . . . 6, 7

decontamination . . . . . . . . . . . . . . . . . . . . . . . . 52-54

decorticate posturing . . . . . . . . . . . . . . . . . . . 6, 7, 9

defibrillation . . . . . 13, 15, 19, 21, 38, 39, 68, 94, 109

destination determination . . . . . . . . . . . . . . . . . . . . 3

determination of death . . . . . . . . . . . . . . . . . . . . . 41

dextrose 50% . . . . . . . . 24, 37, 48, 49, 60-63, 91, 92

diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14, 35

disrupted communications . . . . . . . . . . . . . . . . . . . 34

Doctor’s Medical Center - San Pablo Campus 78, 84, 85, 87, 89, 90, 102. . . . . . . . . . . . . . . . . . . . . . . . . 3, 11

documentation . . . . . . . . . . . . . . . . . . . . . . . . . 14, 84

dopamine . . . . . . . . . . 20, 24, 36, 37, 44, 48, 89, 96

dopamine drip rates . . . . . . . . . . . . . . . . . . . . . . . 96

drug and treatment errors . . . . . . . . . . . . . . . . . . . 23

dusky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

dysrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . 34, 70

- E -

eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

edema . . . . . . . . . . . . . . . . 4, 22, 37, 53, 67, 68, 89

EMT-I . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 14, 19

EMT-I scope of practice . . . . . . . . . . . . . . . . . . . . 14

endotracheal intubation . . . . . . . . . . . . . 19-21, 26, 29

endotracheal medications . . . . . . . . . . . . . . . . . . . 21

environmental emergencies . . . . . . . . . . . . . . . . 48-51

EOA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

epinephrine 1:1,000 . . . 56, 70, 71, 77, 87, 88, 97-100

epinephrine 1:10,000 . . . . . . . . . . . 39-41, 56, 69-71,

77, 98, 100, 109

esophageal obturator airway . . . . . . . . . . . . . . . . 104

extubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26, 69

eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 52, 54

- F -

first responder defibrillation . . . . . . . . . . . . . . . . 15, 38

fluid challenge . . . . . . . 37, 40, 48, 64, 70, 73, 77, 79,

80, 82, 91

foreign body obstruction . . . . . . . . . . . . . . . . . . . . 21

full arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

- G -

glucagon . . . . . . . . . . . . . . . . 20, 25, 60, 74, 98, 100

heart rate . . . . 5, 24, 36, 43-45, 68, 69, 71, 111, 112

heat cramps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

heat exhaustion . . . . . . . . . . . . . . . . . . . . . . . . . . 48

heat stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

heimlich . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

helicopter . . . . . . . . . . . . . . . . . . . . . . . . 1, 104, 105

helmet removal . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

heparin locks . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 19

history . . . . 2, 14, 24, 25, 34, 37, 57, 61, 63, 68, 73,

hydrofluoric acid . . . . . . . . . . . . . . . . . . . . . . . . . 53

hyperresonance . . . . . . . . . . . . . . . . . . . . . . . . 32, 90

hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . 9, 59

hypotension . . . . . . . 5, 9, 10, 24, 25, 37, 42, 43, 47,

48, 50, 56, 71, 73, 77, 79, 80, 83, 91-93, 110, 111

hypothermia . . . 10, 36, 40, 41, 49, 50, 70, 79-81, 83

hypovolemic shock . . . . . . . . . . . . . . . . . . . . . . . 4, 5

hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . . 36, 40, 41

- I -

ice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

imminent delivery (normal) . . . . . . . . . . . . . . . . . . . 65

immobilization . . 8, 9, 13, 17, 18, 26, 68, 79-82, 91-95

implantable defibrillators . . . . . . . . . . . . . . . . . . . . 15

incident command structure (ICS) . . . . . . . . . . . . . . 52

infant . . . . . . . . . . . 5, 65, 66, 69, 70, 72, 73, 78, 84

inhalation . . . . . . . . . . . . . . . . . . . . . . 19, 53, 54, 86

intraosseous infusion . . . . . . . . . . . . . . . . . 20, 21, 34

- J -

John Muir Medical Center . . . . . . . . . . . . . . . 1-3, 101

jugular vein distension . . . . . . . . . . . . . . . . . . . . . . 32

- K -

Kaiser Medical Center/Richmond . . . . . . . . . . . . . . . 3

Kaiser Medical Center/Walnut Creek . . . . . . . . . . . . . 3

laryngoscope . . . . . . . . . . . . . . . . 19, 26, 78, 85, 104

lasix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25, 89

level of consciousness . . 2, 13-15, 17, 23, 24, 32, 35,

36, 43-45, 48, 50, 56, 58-60, 62, 68, 71-74, 76-80,


86, 87, 89, 91-93, 111, 112 pediatric cardiopulmonary arrest . . . . . . . . . . . . . . . 70

- M - pesticides . . . . . . . . . . . . . . . . . . . . . . . . . . . .52, 54

magill forceps . . . . . . . . . . . . . . . . 21, 26, 31, 78, 85

mechanism of injury . . . . . . 9, 17, 79, 80, 91, 92, 101

MED 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

MED 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2

MED 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

medical director . . . . . . . . . . . . . . . . . . . . . 13, 19, 20

medications . . . 14, 19-23, 30, 33, 57, 68, 87, 95, 102

midazolam . . . . . . . . . . . . . . . . 20, 25, 36, 42-46, 48,

59, 61, 72, 75, 98, 100, 110-113 pulmonary embolism . . . . . . . . . . . . . . . . . . . . . . . 40

moist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 10

morphine sulfate . . . . . 20, 25, 36, 44, 47, 50, 79-81,

83, 89, 91-93, 95, 98, 100 pulseless ventricular tachycardia . . . . . . . . . 39, 70, 109

motorcycle helmets . . . . . . . . . . . . . . . . . . . . . . . . 8

mottled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 73

Mt. Diablo Medical Center . . . . . . . . . . . . . . . 2, 3, 101

- N - report . . . . . . . . . . . . . . . . . . . . .1, 2, 6, 15, 38, 105

narcan . . 21, 23, 25, 37, 48, 49, 58, 60-62, 74-76, 88

narcotics/sedatives . . . . . . . . . . . . . . . . . . . . . . . . 58

nasotracheal intubation . . . . . . . . . . . . . . . . . . . . . 26

near syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

needle cricothyrotomy . . . . . . . . 21, 31, 78, 79, 85, 91

needle thoracostomy . . . . . . . . . . . 19, 21, 32, 40, 90

neonatal resuscitation . . . . . . . . . . . . . . . . . . . . 65, 69

- O - school age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

OB/neonatal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

oral glucose . . . . . . . . . . . . . . . . . . . . . 13, 14, 60, 74

organophosphate poisoning . . . . . . . . . . . . . . . . . . 24

oropharyngeal airway . . . . . . . . . . . . . . . . 13, 68, 104

overdose . . . . 23, 24, 26, 37, 48, 49, 60-62, 74-76, 88

oxygen . . . . . . . . . . . . . 4, 9, 10, 13, 22, 26, 28, 29,

31, 37, 42-54, 56-64, 67, 69, 71-83, 86-95, 110-113 shockable rhythm . . . . . . . . . . . . . . . . . . . . . . . 15, 38

- P - sinus tachycardia . . . . . . . . . . . . . . . . . . . . . .45, 112

pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

pale . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 49, 65, 102

paramedic scope of practice . . . . . . . . . . . . . . . . . 19

past medical history . . . . . . . . . . . . . . . . . . 2, 14, 102

PASTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

pediatric endotracheal intubation . . . . . . . . . . . . . . 20

pediatric patients . . . . . . . 4, 5, 21, 22, 26, 29, 34, 68

percutaneous transtracheal ventilation (PTV) . . . . . . 31

peripheral vascular resistance . . . . . . . . . . . . . . . . . . 5

petroleum distillates . . . . . . . . . . . . . . . . . . . . . . . 52

pneumothorax . . . . . . . . . . . . . . . . 32, 40, 70, 90, 91

poisons/drugs . . . . . . . . . . . . . . . . . . . . . . . . . 58, 59

post call-in . . . . . . . . . . . . . . . . . . . . . . . . . 1, 82, 94

pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64, 67

pre-eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

pre-existing vascular access . . . . . . . . . . . . . . . . . . 19

prolapsed cord . . . . . . . . . . . . . . . . . . . . . . . . . 4, 66

pulmonary edema . . . . . . . . . . . . . . . . . . 4, 53, 68, 89

pulse oximetry . . . . . . . . . . . . . . . . . . . 20, 22, 23, 68

pulseless electrical activity . . . . . . . . . . . . . . . . . 40, 70

- R -

radio channels . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

respiratory arrest . . . . . . . . . . 26, 31, 34, 87, 88, 104

respiratory distress . . . 26, 56, 68, 77, 78, 86, 87, 104

respiratory emergencies . . . . . . . . . . . . . . . . . . . 85-90

rule-of-nines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

- S -

saline lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

San Ramon Regional Medical Center . . . . . . . . . . . 2, 3

scoop stretcher . . . . . . . . . . . . . . . . . . . . . . . . 91, 92

seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . 61, 75, 84

sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34, 37, 73

sexual assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Sheriffs Dispatch . . . . . . . . . . . . . . . . . . . . . . . . . . 1

shock . . . . . . . . . 4, 5, 10, 15, 22, 25, 34, 36-38, 42,

44, 47, 51, 56, 60, 64, 68, 73, 77, 79, 104, 110

simple pneumothorax . . . . . . . . . . . . . . . . . . . . . . 90

skin signs . . . . . . . . . . . . . . . . . . . . . . . 5, 36, 68, 72

snake bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

spinal immobilization . . . . . . 8, 9, 17, 68, 79-82, 91-95

sports helmets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

stable . . . . . . . . . . . . . . . . . 11, 42, 43, 72, 110, 111

stridor . . . . . . . . . . . . . . . . . . . . . . . . . 56, 68, 77, 78


stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10, 48, 62

suctioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69, 85

supraventricular tachycardias: stable . . . . . . . . . 43, 111

supraventricular tachycardias: unstable . . . . . . . 43, 111

synchronized cardioversion 19, 42, 43, 45, 46, 110-113

syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

- T -

tachycardia . . . . . . . . . 5, 15, 39, 42, 43, 45, 48, 56,

59, 70, 72, 73, 77, 109-112

tension pneumothorax . . . . . . . . . . . 32, 40, 70, 90, 91

toddler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

tracheal shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

traction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

trauma . . . . . . . . . . 1, 3-6, 9, 10, 13, 17, 25, 26, 29,

30, 38, 50, 61, 73, 75, 79-82, 84, 90-95, 101, 104

trauma center . . . . . . . . . . . . . . . . 3, 17, 79, 91, 104

trauma destination . . . . . . . . . . 1, 79, 80, 91, 92, 104

trauma destination decision . . . . . . . . 1, 79, 80, 91, 92

traumatic arrest . . . . . . . . . . . . . . . . . . . . . . . . 82, 94

triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

- U -

unmanageable airways . . . . . . . . . . . . . . . . . 4, 79, 91

unstable . . . . 34, 42, 43, 45, 46, 71, 72, 76, 110-113

- V -

vaginal bleeding . . . . . . . . . . . . . . . . . . . . . . . . 5, 64

ventricular ectopy . . . . . . . . . . . . . . . . . . . . . . . 25, 47

ventricular fibrillation . . 4, 15, 39, 41, 70, 82, 94, 109

ventricular tachycardia with pulses: stable . . . . . 42, 110

ventricular tachycardias with pulses: unstable . . 42, 110

vital signs . . . 2, 4, 5, 14, 27, 45, 48, 51, 56, 64, 77,

85, 91, 102, 103, 112

- W -

wheezing . . . . . . . . . . . . . . . . . . . 52, 56, 77, 86, 95

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Prehospital Care Manual - Contra Costa CountyContra Costa County Prehospital Care Manual 12/2003 Page 1 4 Communications < RADIO COMMUNICATIONS Four radio channels are designated for