Yakima Co (WA) Protocols 2010

YAKIMA COUNTY

EMS SYSTEM

Operating Procedures & Guidelines

Yakima County EMS & Trauma Care Council

5110 Tieton Drive · Yakima WA 98908 · Phone (509) 966-5175 · Fax (509) 966-5176

COUNTY OPERATING PROCEDURE MANUAL

Section 7 TABLE OF CONTENTS

(1) GENERAL PROVISIONS COG Definitions COG Controlled Substances

COP Documentation of Prehospital Emergency Medical Care COP Destination of Patient without Hospital Preference

(2) DISPATCH/COMMUNICATIONS COP Interagency Radio Communications during Emergency Medical Incidents COG Prehospital to Hospital Communications

(3) MEDICAL DIRECTION COG Medical Direction, Supervision COG Provider Orientation & Skills Checklist COG Quality Improvement/Assurance Program

(4) MEDICAL CONTROL COG Medical Control

(5) PATIENT TREATMENT PROTOCOLS COP Helicopter Alert & Response COP Patients Warranting ALS Intervention and Transport COP Mass Casualty Incident COG Pandemic Flu

(6) TRAUMA SYSTEM COP Triage and Transport of Trauma Patients

Yakima County Prehospital Care Protocols

Effective Date: July, 2010 Version: #2010 – July

Approved by Juan Acosta, DO, MS, FACOEP, FACEP

Yakima County Medical Program Director

INTRODUCTION TO THE PROTOCOLS The Yakima County Prehospital Care Protocols for Basic, Intermediate and Advanced Life Support represent a compilation of accepted national standards and a historical perspective of prehospital care in Yakima County. They have been developed to ensure a standard of prehospital care throughout Yakima County by providing treatment guidelines for emergency medical service (EMS) providers certified under the scope of authority of the Yakima County Medical Program Director (MPD). They include those protocols necessary for EMS personnel certified as First Responders, EMT-B Technicians, EMT-IV Technicians, EMT-Airway Technicians, EMT-IV/Airway Technicians, EMT-Intermediates w/King Airway, Combitube, LMA and EMT-Intermediates w/Endotracheal, and EMT-Paramedics. EMS personnel are expected to commit the protocols to memory, and have thorough knowledge and understanding of each of the procedures and assorted pharmacological interventions. This document does not incorporate all conditions that may be encountered in the field. For situations not addressed in the protocols, prehospital providers should perform procedures in accordance with their level of training and currently accepted Washington State standards, or consult with the on-duty emergency physician at the designated medical control facility. Format of the Protocols Each protocol includes the certification level (FR, EMT-B, EMT-I, EMT-P) for which it is approved. Throughout the protocols, procedures requiring on-line medical control are preceded with the phrase “verbal order", which is in BOLD/ITALICS. These procedures can only be done after consultation and approval of the physician at the facility that will receive the patient, or the on-duty physician at the designated medical control facility. All other protocols are considered standing orders (off-line medical control), do not require a verbal order, and should be performed by all levels of training. Protocols that require the skill level of the First Responder are typed in black. The protocols that require the skill level of the EMT-Basic are typed in blue. The protocols that require the skill level of the EMT-Intermediate are typed in green. If an individual is ILS certified the protocols should be followed to their level of certification (i.e., IV, Airway, IV/Airway, and EMT-I). The protocols that require the skill level of the EMT-Paramedic are typed in red. 2010 Yakima County Prehospital Care Protocols Updated June 2010

YAKIMA COUNTY PREHOSPITAL CARE PROTOCOLS July 2010

GENERAL PROTOCOLS

REFUSAL OF TREATMENT AND/OR TRANSPORT FR, EMT-B, EMT-I, EMT-P A. It is necessary to obtain patient consent (or permission) before rendering emergency medical care. Expressed/informed consent must be received from competent adult patients. Implied consent is assumed in the case of life- threatening injury or illness when the patient is unconscious, disoriented, a mentally incompetent adult, or a minor whose parent or legal guardian is unavailable. B. A competent adult has the right to refuse treatment. 1. When a competent adult refuses treatment, you must inform the patient of the risks and consequences involved in refusing care, and be sure the patient understands you. 2. After you have explained, and are assured that they fully understand the risks and consequences, you must have the patient sign a "release from liability" form. 3. If the patient refuses to sign the form, obtain a witness signature of refusal to sign. C. When in doubt, always treat the patient. D. See the "Behavioral Emergencies" protocol regarding the use of force in treating a mentally incompetent patient. E. Contact medical control physician if refusal endangers the patient's safety. F. We recommend that an EMS provider give honest insight into his/her judgment of the patients’ condition when asked, however, avoid giving medical “advice” or “direction” in regard to what medications the patient should or should not take or home remedy recommendations. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Refusal of Treatment and/or Transport

ABUSE AND NEGLECT FR, EMT-B, EMT-I, EMT-P A. In the event of a known or suspected incident, EMS personnel are required to report any reasonable cause to believe that a child, dependent adult and/or developmentally disabled person who is not able to provide for their own protection, are being abused or neglected (required per RCW 26.44.030). B. If abuse or neglect is suspected, contact local law enforcement as soon as possible. Reporting an incident is regarded as a request for an investigation, and the individual reporting in good faith is immune from liability (in accordance with RCW 26.44.060). C. EMT-B – Transporting personnel will notify receiving emergency physician (in accordance with RCW 26.44.060). D. EMS personnel who fail to report, or cause failure of a report to be made, shall be guilty of a gross misdemeanor (in accordance with RCW 26.44.080). E. On the medical incident report, document known facts only. Include the name of the law enforcement personnel and agency contacted, along with the date and time notified.

2010 Yakima County Prehospital Care Protocols Updated July 2010

Abuse and Neglect

BEHAVIORAL EMERGENCIES FR, EMT-B, EMT-I, EMT-P A. Utilize verbal de-escalation techniques: 1. Begin by asking the patient to follow your orders. 2. Advise them of the consequences of not following your orders. 3. Finally, order them to do what you want them to do. B. Requirements for the use of force 1. You must have legitimate objectives: a. For your safety. b. For the safety of others. c. For the patient's safety. d. To facilitate treatment in a mentally incompetent patient. 2. It must be immediately necessary, and law enforcement must be notified. a. Request that law enforcement place patient in protective custody. b. Document officer's name and agency if they refuse to place patient in protective custody. 3. You must use the minimal amount of effective force initially. 4. It must immediately cease once the objective has been met. 5. EMT-P – Chemical Restraint - Versed 2.0 – 5.0 mg IM or IV. Verbal Order - for additional doses of Versed of 2mg IM or IV. C. Do not use any of the following restraining techniques that could impair breathing. 1. "Hog tying," where hands and feet are bound behind the patient. 2. Sandwiching the patient between two backboards. 3. Transporting the patient in the prone position. D. After a patient is under control, use humane techniques to restrain the patient. E. Once a patient is restrained, do not release him/her. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Behavioral Emergencies

F. EMT-B – If a patient is still in handcuffs, a police officer must accompany the patient during transport or remove the handcuffs. G. The patient's condition must be closely and continuously monitored. H. Contact the receiving hospital when feasible. I. Document all facts regarding the objectives of the restraint. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Behavioral Emergencies

DO-NOT-RESUSCITATE FR, EMT-B, EMT-I, EMT-P A. When the patient is determined to be "obviously dead", resuscitation measures shall not be initiated. Obviously deceased patients are victims who, in addition to the absence of respirations and cardiac activity, have suffered one or more of the following. 1. Decapitation. 2. Evisceration of the heart or brain. 3. Incineration. 4. Rigor mortis. 5. Decomposition. 6. Lividity. B. For patients who don't meet the criteria in "A," begin initial patient assessment and resuscitative procedures per normal protocols. Proceed until an EMS-No CPR form or bracelet is found or Physician Orders for Life-Sustaining Treatment (POLST) or an advanced directive, living will or DNR order signed by the patient’s physician is confirmed. 1. For traumatic death attempt initial resuscitation, then if no response, contact Medical Control. 2. If any of the above documents are found and believed to be current and expressing the patient’s wishes, stop resuscitation. 3. If intermediate or advanced life support personnel will be responding to the scene, allow them to make contact with the attending physician or Medical Control Facility physician. C. Provide emotional support to the family. D. Notify local law enforcement (at least one EMS provider should remain at the scene until an officer arrives). 2010 Yakima County Prehospital Care Protocols Updated July 2010

Do Not Resuscitate

E. The following individuals can revoke an advanced directive, DNR order, or EMS- No CPR form or bracelet or POLST form: 1. The patient (by destroying the form, bracelet, or advanced directive). 2. Attending physician. 3. Health care power of attorney. F. If there is an emotional confrontation over not providing resuscitation efforts, or the family insists; begin or continue resuscitation, even if a valid EMS-No CPR form or bracelet, or POLST form or advanced directive is located. Notify Medical Control Facility (MCF) as soon as possible once the patient is in the ambulance. G. For those patients suffering from a terminal illness who have not reached the point of cardiac and/or pulmonary arrest, and cannot expect to realize any long- term benefit from prehospital care, and who have a written DNR order, advanced directive, or EMS-No CPR form or bracelet or POLST form: 1. Do not perform the following measures (if any of the measures have begun and valid documentation is produced, the measure(s) should be discontinued): a. Cardiopulmonary resuscitation. b. Endotracheal intubation (leave ET tube in place, but discontinue ventilation). c. Defibrillation. d. Administration of resuscitative medications. e. Positive-pressure ventilation. 2. The following may be done: a. Position of comfort. b. Airway control and suction. c. IV, IV/Airway, EMT-I, EMT-P – IV line for hydration and/or analgesics. d. Oxygen for dyspnea. H. Clinical judgment and consultation with the patient, patient's family, the patient's physician, or the on-duty physician at the Medical Control Facility, should determine what procedures to perform. I. In such cases, the patient's comfort is of paramount interest to the prehospital care provider. Invasive and painful treatment modalities should be avoided if at all possible. J. In the event that a patient expires after life sustaining measures and transport began the transporting agency will notify the emergency department, preferably the Charge Nurse, of the situation and continue transport to the hospital. K. In any case that is questionable, proceed with appropriate protocols, and consult with the Medial Control Facility physician.

2010 Yakima County Prehospital Care Protocols Updated July 2010 Do Not Resuscitate

TASER REMOVAL/TREATMENT EMT-B, EMT-I & EMT-P Unlike other forms of penetrating foreign bodies, taser barbed darts because of their shot length (1/4”) may be safely removed by EMS personnel when requested by law enforcement. The darts should only be removed in the field if they do not involve the eye, face, neck, breast, or groin. Patients with retained darts in these areas should be transported to a hospital for removal by a physician. Prior to removal EMS personnel must be convinced the individual/patient must be in police custody and adequately restrained. A. Body substance isolation procedures must be taken. B. Ensure that wires are disconnected from the gun or the wires have been cut. C. Push on the body part that the barbed dart (straight #8 fish hook) is imbedded and simultaneously pull the dart straight out. D. Apply alcohol or iodine to the puncture area and dress the wound with a Band- Aid or other sterile dressing. Inform the patient and police that this may be removed in 24-48 hours. E. Treat the dart as a “contaminated sharp”. The dart should be placed in a biohazard sharps container and turned over to law enforcement. F. Patient must be thoroughly assessed to determine if other medical problems or injuries are present. G. EMT-P – Patient must be placed on a 4-lead cardiac EKG to check for irregular heart rates. A strip must be run and attached to patient care report. H. Patient must have a heart rate of <110 bpm, respiratory rate >12, O2 saturation >94%, systolic blood pressure >100mmHg and <180mmHg. I. Patient has no other acute medical or psychiatric condition requiring medical evaluation, such as: 1. Traumatic injury sustained in TASER induced fall or police encounter. 2. Hypoglycemia 3. Acute psychiatric disturbance or excited delirium. 2010 Yakima County Prehospital Care Protocols Updated July 2010 Taser Removal/Treatment

J. If the individual does not have any other presenting injuries/illness, they may be left in the custody/care of law enforcement. K. Patient has had tetanus booster in last ten years. If tetanus status is unknown, the patient may be taken to the hospital by police if all other treat and release criteria are met. (Police are to be informed that it is the responsibility of the police service to ensure that the patient receives a tetanus booster within 72 hours. This advice must be documented on the patient care report.) L. Ask the patient if they would like to be taken to the hospital. If the patient refuses, document the patient’s refusal as per refusal protocol. If the patient wishes to be transported to the hospital, transport is to be initiated. If the patient refuses transport, instruct the patient to seek medical attention immediately, if he/she develops any signs of infection around one or more of the wounds (fever, increased pain, redness, heat, swelling, purulent discharge). 2010 Yakima County Prehospital Care Protocols Updated July 2010

Taser Removal/Treatment

MEDICAL EMERGENCIES Introduction The following protocols are for use by FR, EMT-B, EMT-I, and EMT-P providers. If an individual is ILS certified the protocols should be followed to their level of certification (i.e., IV, Airway, IV/Airway, and EMT-I). In some cases, a protocol will be level specific, which will be preceded by the level in bold. PATIENT ASSESSMENT (perform on every patient) FR, EMT-B, EMT-I, EMT-P A. Conduct scene size-up, scene safety, BSI, and develop action plan. B. Perform Initial assessment. 1. Form general patient impression. 2. Determine level of consciousness using AVPU (alert, responds to verbal, responds to pain, unresponsive). 3. A – Assess airway. 4. B – Check for breathing. 5. C – Check circulation and control major bleeding. 6. If available, use pulse oximetry and record result, and then administer oxygen at 15L/min per non-rebreather mask (MRB) when indicated. Oxygen by nasal cannula may be used if patient unable to tolerate a mask. 7. EMT-I & EMT-P – Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. If pulse oximetry is not available, give oxygen when indicated, by mask or cannula. C. EMT-B – If patient is critical, perform a rapid medical assessment, and consider rapid transport. 1. Notify transporting agency or receiving hospital as soon as practical. 2. When transport is delayed, perform a detailed physical exam. 3. Contact transporting agency with patient's condition, vital signs and care rendered. 4. FR – Continue with ongoing assessment. D. FR – If the patient is not critical, perform a focused history. 1. History using S.A.M.P.L.E. (symptoms, allergies, medications, past history, last oral intake, events preceding). 2. Vital signs. 3. Perform a detailed physical exam. 4. Contact transporting agency with patient's condition, vital signs, and care rendered. 5. Continue ongoing assessment. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Patient Assessment

ALTERED MENTAL STATUS FR, EMT-B, EMT-I, ALS A. If patient has good gag reflex and adequate respiratory drive, maintain airway and administer oxygen. 1. EMT-B – If patient has an altered mental status of unknown origin, or has a history of diabetes and could have an abnormal glucose level, a glucose check may be performed in accordance with the Hypoglycemia Protocol. B. If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with pocket mask, BVM and supplemental oxygen at 15 L/min or more, or by OPVD (oxygen-powered ventilation device). C. EMT-B with Airway – If King Airway, LMA or Combitube technician on-scene, consider placement of King Airway, LMA or Combitube in accordance with Appendix A. EMT-I & EMT-P A. EMT-P - Consider ET intubation in accordance with Appendix A. B. Consider cause (i.e., overdose, hypoglycemia) and treat accordingly.


Altered Mental Status

ANAPHYLAXIS (ALLERGIC REACTIONS) FR, EMT-B, EMT-I, EMT-P A. Establish and maintain airway. B. Administer oxygen. C. EMT-B – If patient has a known history of allergic reactions, is displaying signs of rash, redness, or hives, and has his/her own antihistamine, the EMS provider may: 1. Encourage the patient to administer his/her own antihistamine. 2. Assist the patient in administering his/her own antihistamine. D. If patient has a known history of life-threatening anaphylactic reactions, is in respiratory distress and/or is hypotensive, and has a prescribed epinephrine auto-injector, the EMS provider may: 1. Encourage the patient to administer his or her own epinephrine auto- injector. 2. Assist the patient in administering his or her own epinephrine auto- injector. 3. Administer the epinephrine auto-injector for the patient. 4. Follow the Kristine Kastner Act a. If the patient is less than 18 years old, does not have a prescription Epi-Pen and gives permission or the parent or guardian gives written or verbal permission, and then EMS may administer the Epi- Pen from the unit. b. If the patient is over 18 years old, has no prescription, gives permission, and is having an anaphylactic reaction the EMS is allowed to administer the adult Epi-Pen without consulting Medical Control. E. Verbal Order – Contact medical control or receiving hospital physician prior to giving epinephrine to any normotensive patient who is elderly or has a history of hypertension or MI. F. Verbal Order – If patient has no relief from the epinephrine and has a dual-dose injector, contact medical control, or receiving hospital for further direction. G. If patient is in respiratory arrest, follow the Respiratory Emergencies protocol. H. Document all pertinent information.


Anaphylaxis (Allergic Reactions)

EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. B. Administer age appropriate auto-injector epinephrine. C. EMT-I – Establish cardiac monitor. D. IV, IV/Airway, EMT-I – Establish large-bore IV catheter with NaCl at a rate indicated by clinical findings and vital signs. E. EMT-P – If systolic blood pressure greater than 70: 1. Consider epinephrine, 1:1000, 0.3 – 0.5 mg, IM. Pediatric dose is 0.01 – 0.02 mg/kg, IM. 2. Administer diphenhydramine, 25 – 50 mg, IV or IM. 3. Solumedrol 125mg IV. F. EMT-P – If systolic blood pressure less than 70: 1. Administer epinephrine, 1:10,000, 0.3 – 0.5 mg, IV or ET. Pediatric dose is 0.01 – 0.02 mg/kg IV or ET. 2. Verbal Order—repeat epinephrine q 10 minutes as clinical situation dictates. G. EMT-I – If wheezing, administer Albuterol, 2.5 mg in 2.5 cc NaCl, per nebulizer mask.


Anaphylaxis (Allergic Reactions)

CEREBROVASCULAR ACCIDENT (STROKE) FR, EMT-B, EMT-I & EMT-P A. If patient has good gag reflex and adequate respiratory drive, maintain airway and administer oxygen. B. If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with pocket mask, BVM and supplemental oxygen at 15 L/min or more, or by OPVD. C. EMT-B with Airway – if King Airway, LMA or Combitube technician is on-scene, consider placement in accordance with Appendix A. D. If patient has a neurological deficit, place patient on affected side (recovery position). E. EMT-B – If patient has sign and symptoms consistent with a CVA transport

immediately and notify the receiving facility while enroute. You must include the following information in your radio report and in your MIR narrative:

1. Face: Is it symmetrical? YES or NO 2. Arm: Symmetrical strength? YES or NO 3. Speech: Is it slurred or abnormal? YES or NO 4. Time: What time was the patient last known to be normal? 5. Is the patient on Coumadin (Warfarin)? 6. Glucometry: Glucose should be over 60. (Severe hypoglycemia can

present like a stroke). 7. Glascow Coma Scale: See Appendix G. F. EMT-B – Determine capillary blood glucose. EMT-I & EMT-P A. Administer oxygen, titrate saturations to greater than 90% and suction PRN. B. If conscious without focal deficits, assess and transport. C. If unconscious or focal deficits: 1. If evidence of trauma, use cervical spine immobilization. 2. EMT-P – If airway not maintained with BLS procedures, place endotracheal tube, in accordance with Appendix A. D. IV, IV/Airway, EMT-I – Draw blood in accordance with Appendix B. E. IV, IV/Airway, EMT-I – Establish peripheral IV with saline lock or TKO NaCl. F. EMT-I – Establish cardiac monitor. G. EMT-I – Verbal order – If hypoglycemic, consider D50 W, 25 g IV bolus. 2010 Yakima County Prehospital Care Protocols Updated July 2010 Cerebrovascular Accident

Epistaxis FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Instruct patient to blow their nose to expel any clots that may have formed in the nasal cavity. C. Using thumb and index finger apply direct pressure to non-bony part of nose for 5 - 10 minutes or until bleeding has stopped. D. Reassess vital signs every 5 - 10 minutes. E. EMT- B – If patient is hypertensive or on anticoagulants the patient should be transported. EMT-I & EMT-P A. Spray Afrin Nasal Spray in both nostrils before applying pressure. B. IV, IV/Airway, EMT-I – Consider large bore IV for severe and persistent bleeding. C. Consider Nebulized 1:1,000 Epinephrine 2 mg (2 ml) in 1 ml of normal saline @ 8L/min Oxygen via nebulizer mask. 1. Verbal Order: For epistaxis in the presence of hypertension, hold on the Epinephrine and contact Medical Control for direction. 2010 Yakima County Prehospital Care Protocols Updated July 2010 Epistaxis

SUSPECTED HYPOGLYCEMIA (DIABETIC) FR, EMT-B, EMT-I & EMT-P A. If patient has a known history of hypoglycemia, a good gag reflex and adequate respiratory drive, maintain airway and administer oxygen. EMT-B Optional 1. If the patient has an altered mental status of unknown origin, or has a history of diabetes and could have an abnormal glucose level, then a glucose check should be performed. 2. The glucometer to be used must be in good working order and have a self-test and test-strip-verification performed monthly or more frequently if recommended by the manufacturer of the machine. Test strips shall NOT be out of date and all procedures shall follow the glucometer manufacturer’s instructions. 3. Utilizing universal precautions, the patient has a stick performed and the blood is tested in the glucometer. 4. Record the result on the patient report sheet (MIR). 5. If the glucose level is below 80, the patient is awake and has an intact gag reflex, administer oral glucose. B. EMT-B – If patient is conscious with a gag and has the ability to swallow, administer oral glucose or a large amount of (some type of) sugar solution. C. FR – If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with pocket mask, BVM and supplemental oxygen at 15 L/min or more, or by OPVD. D. EMT-B with Airway– if a King Airway, LMA or Combitube technician is on-scene, consider placement in accordance with Appendix A. EMT-I & EMT-P A. If the patient is conscious with a good airway, administer a large amount of (some type of) sugar solution, PO.

B. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. 1. Consider drawing blood, in accordance with Appendix B. 2. Determine capillary blood glucose. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Suspected Hypoglycemic (Diabetic)

C. EMT-I – If glucose is less than 80 and patient has signs and symptoms of hypoglycemia, administer D50W, 25 g IV bolus. D. EMT-P – If there is suspected alcohol abuse or malnutrition, administer Thiamine, 100 mg IV bolus prior to administration of D50W. E. EMT-P – If unable to establish peripheral IV, administer glucagon, 1.0 mg IM/SQ, pediatric dose: 0.05 – 0.1 mg/kg, up to 1.0 mg. F. If alert and competent, patient has the option of transport; thoroughly document refusal. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Suspected Hypoglycemia (Diabetic)

HYPOTENSION – UNKNOWN ETIOLOGY EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen and using pulse oximetry, titrate saturation to greater than 90%. C. Obtain serial vital signs every 5 minutes. D. EMT-I – Establish cardiac monitor. E. IV, IV/Airway, EMT-I – Consider drawing blood, in accordance with Appendix B. F. If hypotension is secondary to cardiac origin, refer to Cardiogenic Shock Protocol. G. IV, IV/Airway, EMT-I – Establish large-bore IV with NaCl, and fluid challenge in 200 mL increments to patient’s BP and clinical findings, up to a total of 1000 mL. H. IV, IV/Airway, EMT-I – If no improvement with first IV, and no signs of CHF, establish second large-bore IV with NaCl, and run both as approximately 200 mL per 5 minutes, up to 2000 mL, or as clinical situation dictates. I. IV, IV/Airway, EMT-I – Verbal Order – if an IV cannot be established, a Vidacare™ EZ-IO™ may be placed per manufacturer’s instructions. See Appendix B. J. EMT-P – If no response, or inadequate response to fluid challenge, and systolic BP < 90 mm Hg: 1. Verbal order – Administer dopamine 5 – 7 ug/kg/minute, IV piggyback, titrating up to 20 ug/kg/minute, or until blood pressure reaches 90 mm Hg or greater systolic. 2. Mix dopamine, 400 mg in 250 mL NaCl, for a concentration of 1600 ug/mL. 3. Use metered-flow tubing.


Hypotension (Unknown Etiology)

NARCOTICS OVERDOSE EMT-I & EMT-P A. Establish and maintain airway. B. If ventilating adequately, administer oxygen and using pulse oximetry, titrate saturation to greater than 90%. C. If patient is apneic or hypoventilating, assist ventilations with BVM and supplemental oxygen at 15 L/min or OPVD. D. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. E. EMT-I – If patient is apneic, or suspected to become uncooperative and/or violent, consider naloxone, administered by titrating to a return of respiratory drive and to a point where the patient can be managed. F. EMT-I – Administer naloxone, 0.4 - 4 mg, IV bolus or IM. Titrate to minimum respiratory rate of 10 min. G. EMT-P – Consider ET intubation. H. EMT-I – If no response to naloxone, refer to Unconscious Patient Protocol. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Narcotics Overdose

NAUSEA VOMITING EMT-P A. If the patient has, protracted or recurrent nausea/vomiting administer Zofran 4mg ODT or IV, or Anzemet 12.5 mg IV bolus - one time dose. A second dose of Zofran 4mg ODT or IV may be provided. B. If patient continues to have nausea/vomiting after administration of Anzemet, administer Zofran 4 mg IV. C. Pediatric dose of Zofran is 0.1mg/kg 2010 Yakima County Prehospital Care Protocols Updated July 2010

Nausea and Vomiting

OBSTETRICAL EMERGENCIES (CHILDBIRTH) FR, EMT-B, EMT-I & EMT-P A. Determine: 1. Date of expected birth. 2. Onset of contractions/pain. 3. Any bleeding or discharge. 4. Number of pregnancies/births. 5. Duration and frequency of contractions. B. If patient shows signs or symptoms of perineum bulging, the baby crowning, contractions < 2 minutes apart, or has a need to “push” or “bear down”, then prepare for imminent delivery. 1. Contact receiving hospital or medical control physician for instructions. 2. Have mother lie supine with knees drawn up and spread apart. 3. Administer oxygen by non-rebreather mask. 4. Prepare OB kit. 5. When the infant’s head appears during crowning, place fingers on bony part of skull and exert very gentle pressure to prevent explosive delivery. 6. When the head is delivered, suction infant’s nose and mouth with a bulb syringe. Do not let mother “push” or “bear down” until airway is suctioned. 7. Assist delivery of shoulders and body; do not pull on the infant. 8. When the baby is delivered: a. Wipe blood and mucus from mouth and nose, suction mouth and nose again. b. Assure patent airway, and stimulate breathing or crying by tapping soles of feet. c. Do APGAR assessment on infant one minute and then again five minutes after delivery. d. Wrap infant in a warm blanket and place on its side. e. Keep infant level with the vagina until the cord is cut. f. As pulsations cease, double-clamp or tie and cut the cord between two clamps. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Obstetrical Emergencies (Childbirth).

9. Let placenta deliver normally; do not pull on cord. a. Place in plastic bag and transport with mother. b. Massage mother’s lower abdomen until firm. c. Place a sterile pad over vaginal opening. 10. Estimate time of delivery and blood loss. Treat for shock as necessary. C. There are three situations where you do not attempt delivery in the field. 1. Prolapsed cord (cord presents through the birth canal before delivery). a. Place mother in knee-chest position. 2. Limb presentation (an arm or leg is first to protrude from the birth canal). 3. Breech birth (buttocks or extremities presents first during the delivery). D. Place patient on left lateral side or position of comfort – except as noted above. E. If bleeding from the vagina, cover with appropriate dressing. F. EMT-B – If transport time from the scene to Yakima is less than 30 minutes, transport all third-trimester pregnancy complications, traumas, or premature births to Yakima Valley Memorial Hospital. G. For those patients who suffer cardiopulmonary arrest, who are in the third trimester of pregnancy, full resuscitative measures should be continued, even if it is obvious that the mother will not survive. EMT-I & EMT-P A. Obtain history, to include: 1. Gravidity (number of times pregnant). 2. Parity (number of live births). 3. How many weeks pregnant. 4. Medical problems during this pregnancy; high-risk patient. 5. Taking medications regularly (e.g., insulin, seizure medications). 6. Recent use of drugs (e.g., cocaine, ETOH).

B. Detailed exam to include: 1. Vaginal bleeding? Fluid leaking? 2. Cramps? How often do they come? 3. Palpate fundus for contractions. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Obstetrical Emergencies (Childbirth)

C. Administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. D. Transport in left lateral decubitus position. E. If a multiparous patient, and contractions < 2 minutes apart, and transport time > 15 minutes, prepare to deliver. 1. When infant’s head begins to emerge, support it gently, to prevent explosive delivery. 2. Clear infant’s airway as soon as his/her face delivers. 3. Determine APGAR score, and record time of delivery. 4. Consider delivering the placenta while en route. a. Once the placenta has delivered, bleeding can be controlled by massaging the fundus. b. Clamp and cut the cord, save the placenta. 5. IV, IV/Airway, EMT-I – Establish large-bore peripheral IV with 1000 Ml bag of NaCl @ TKO. F. EMT-P – If severe vaginal hemorrhaging, administer oxytocin, 20 units in 1000 mL, and titrate to control uterine bleeding. G. EMT-P – If postpartum hemorrhage is profuse, and patient is exhibiting signs of shock – increase oxytocin IV rate. 1. IV, IV/Airway, EMT-I – Start a second line of NaCl and expedite transport. H. EMT-P – If eclamptic seizure, administer magnesium sulfate, 2 g in 10 mL NaCl, IV push. Contact receiving hospital ASAP.


Obstetrical Emergencies (Childbirth)

SEIZURES FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Prevent injury to the patient. C. Administer oxygen. D. Obtain history. E. If pediatric patient and temperature > 100 degrees, consider possibility of febrile seizure. Remove heavy clothing. F. EMT-B – Determine capillary blood glucose. EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. B. Determine capillary blood glucose. C. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. D. If a grand mal seizure that terminates spontaneously and patient has a history of previous seizures with ongoing medical management of those seizures, and the clinical situation dictates – patient has the option of not being transported to the hospital. If patient is alert, thoroughly document refusal. E. Witnessed, continuous grand mal seizures (unconsciousness, tonic/clonic movement of all extremities), lasting greater than 10 minutes, with respiratory compromise, or repetitive seizures without return of consciousness: 1. EMT-P – Administer lorazepam, 2 – 4 mg slow IV push, every 3 – 5 minutes until seizure ceases, systolic BP is < 100 mm Hg, or respiratory depression. If unable to establish an IV give midazolam, 2 – 5 mg IM. 2. EMT-P – Establish a cardiac monitor. 3. EMT-P – Continue monitoring and protecting airway. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Seizures

OVERDOSE/POISONING FR, EMT-B, EMT-I & EMT-P A. If there is evidence of an actual overdose/poisoning, contact receiving hospital or medical control for direction. 1. Remove pills, tablets or powder from patient’s mouth or skin. 2. EMT-B – If patient is alert, administer activated charcoal with sorbitol, 50 grams in aqueous base. 3. Do not use Ipecac. B. Gather all containers, bottles, labels, and etcetera, of poisonous agents for transport with patient to the hospital. C. If patient sustains a bite or sting (spider, snake, insect, etc.): 1. Scrape site to remove stinger; do not pull straight out. 2. Remove constricting items (e.g., rings) before swelling occurs. 3. Keep limb immobilized below the heart and apply a cold pack (notice). 4. If a snake bite, restrict patient’s movement (do not apply cold pack). D. In cases of suspected organophosphate poisoning, contact receiving hospital or medical control for instructions. EMT-I & EMT-P A. Do an initial assessment, to include signs of trauma. History to include search for evidence of toxins (pill bottles, drug paraphernalia, etc.); bring to the emergency department. B. If unconscious, chest pain, arrhythmia, or depressed level of consciousness, administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. C. If patient is alert, administer activated charcoal with sorbitol, 50 grams PO. D. If cardiac dysrhythmias are present, refer to Cardiac Dysrhythmias Protocol. E. If patient with depressed level of consciousness, and/or inadequate vital signs, refer to Hypotension and/or Unconscious Person Protocol. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Overdose and Poisonings

F. EMT-P – Treat tricyclic-induced rhythms with sodium bicarbonate 50 mEq (1 Amp), IV push. G. If a narcotic overdose, refer to Narcotics Overdose Protocol. H. If organophosphate (pesticide) overdose, refer to Organophosphate Protocol.


Overdose and Poisonings

ORGANOPHOSPHATE POISONING FR, EMT-B, EMT-I & EMT-P A. Attempt to decontaminate patient with water. B. EMT-B – Notify Medical Control Facility physician that you are transporting a patient contaminated with hazardous materials and DO NOT bring patient into the emergency department until told to do so by the emergency physician or qualified hospital staff. EMT-I & EMT-P A. Ensure the safety of EMS providers. B. Wear appropriate protective clothing, mask, gloves, until patient is adequately decontaminated. C. Ensure patient is properly decontaminated before being loaded into the ambulance. 1. Adequately ventilate ambulance. If there is a strong odor, do not transport; continue decontamination, and initiate treatment in the field. 2. Consider all body fluids potentially contaminated and hazardous. 3. Contact Medical Control Facility if transport will be delayed for decontamination. D. Administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. E. EMT-P – Ensure an adequate airway, intubate if indicated, and prepare to suction copious secretions. F. IV, IV/Airway, EMT-I – Establish intravenous access with a saline lock. G. EMT-I – Establish cardiac monitor. H. EMT-P – Verbal order – Administer atropine, 2.0 mg, IV, repeat doses 2 – 10 mg every 5 – 15 minutes for copious secretions, altered mental status, or cardiac dysrhythmias. I. EMT-P – Verbal order – Pediatric atropine dose, 0.5 – 0.1 mg every 5 – 15 minutes. J. If transport time is long, ingestion is likely and patient is alert, administer 50 gm of activated charcoal with sorbitol. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Organophosphate Poisoning

UNCONSCIOUS (Non-Traumatic/Unk. Etiology) EMT-B, EMT-I & EMT-P A. EMT-B – If patient has a good gag reflex and adequate respiratory drive, administer oxygen, and using pulse oximetry, titrate Saturation to greater than 90%. B. If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with BVM and supplemental oxygen at 15 L/min or OPVD. C. Look for underlying causes of unconsciousness. D. EMT-I – Establish cardiac monitor. E. IV, IV/Airway, EMT-I – Establish peripheral IV access with NaCl @ TKO. F. IV, IV/Airway, EMT-I – Consider drawing blood, in accordance with Appendix B. G. Determine capillary blood glucose. H. EMT-I – If hypoglycemia is determined, administer D50W, 25 g IV bolus. 1. EMT-P – If suspected chronic alcohol abuse or malnutrition, administer thiamine, 100 mg, IV bolus, prior to administration of D50W. I. EMT-I – If no response, administer naloxone, 0.4 – 4.0 mg, IV bolus or IM. J. EMT-P – If no response to naloxone or D50W, and airway or ventilation is compromised, consider endotracheal intubation, in accordance with Appendix A. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Unconscious (non-traumatic/unknown etiology)

ASTHMA FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway B. Administer oxygen. C. EMT-B – If patient has a known history of respiratory difficulties is conscious, and having difficulty breathing, and has a physician prescribed metered-dose inhaler, the EMS provider may: 1. Encourage the patient to administer his or her own metered-dose inhaler. 2. Assist the patient in administering his or her metered-dose inhaler. D. FR – If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with pocket mask, OPVD or BVM and supplemental oxygen at 15 L/min or more. E. EMT-B with Airway – If King Airway, LMA or Combitube technician on-scene, consider placement of in accordance with Appendix A. EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. B. EMT-I – Establish cardiac monitor and End-Tidal CO2 monitoring, if available. C. EMT-I – Consider albuterol, 2.5 mg in 2.5 cc NaCl, per nebulizer mask or ET; repeat immediately if indicated clinically. D. IV, IV/Airway, EMT-I – Consider peripheral IV with NaCl and administer 100 mL fluid bolus. E. EMT-P – Consider ET intubation. EMT-I – Consider positive-pressure ventilation if patient has a decreased LOC and is hypoventilating. F. Consider administration of Atrovent, 0.5 mg in 2.5 ml NaCl. Monitor heart rate for tachycardia. G. Consider use of CPAP, see Appendix A. H. Monitor Capnography, see Appendix A. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Asthma

I. EMT-P – If patients are not responding to Albuterol and, 1. patient has severe symptoms, 2. patient is not elderly, 3. patient is not hypertensive, 4. patient has no cardiac history. Consider epinephrine, 1:1,000, 0.01ml/kg, IM, up to a maximum of 0.3ml. Consider magnesium sulfate, 2 grams, by IV over 5 minutes. Administer Solumedrol 125mg IV. J. EMT-P – Verbal Order – If patients are not responding to Albuterol, symptoms are severe, and patient is elderly, hypertensive, or has a cardiac history, consult Medical Control Facility regarding epinephrine.


Asthma

CHRONIC OBSTRUCTIVE PULMONARY DISEASE EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen and using pulse oximetry, titrate saturation to greater than 90%. C. Monitor respiratory status closely for oxygen-induced hypoventilation. D. If hypoventilating, assist ventilations with BVM or OPVD. E. EMT-I – Administer albuterol, 2.5 mg in 2.5 cc NaCl per nebulizer mask, repeat immediately if clinically indicated. 1. EMT-P – Administer the albuterol as above, and ipratropium (atrovent) 0.5 mg in 2.5 cc NaCl per nebulizer mask. F. EMT-I – Establish cardiac monitor. G. IV, IV/Airway, EMT-I – Establish peripheral IV. H. EMT-P – Administer C-PAP (Continuous Positive Airway Pressure), as necessary. See Appendix A. I. EMT-P – Consider ET intubation and positive-pressure ventilation if patient has a decreased LOC and hypoventilation.


Chronic Obstructive Pulmonary Disease

CONGESTIVE HEART FAILURE WITH ACUTE PULMONARY EDEMA EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate saturation to greater than 90%. B. EMT-I – Establish cardiac monitor. C. IV, IV/Airway, EMT-I – Establish peripheral IV. D. EMT-P – If unconscious or decreased level of consciousness, and unable to maintain airway—consider ET intubation and assist ventilations with BVM and supplemental oxygen at 15 L/min or OPVD. E. EMT-P – If systolic blood pressure >100: 1. Administer furosemide, 40 mg (or double the patient’s daily dosage), IV or IM slow push, max dose 100 mg. 2. EMT-I – Administer nitroglycerin (tablet or spray), 0.4 mg sublingual, up to a total of 1.2 mg, unless systolic BP < 100 mmHg. 3. If symptoms continue, pulmonary edema is severe, and patient is not obtunded, administer morphine, 2.0 – 10.0 mg, IV slow push. F. EMT-P –Administer C-PAP (Continuous Positive Airway Pressure), as necessary. See Appendix A.


Congestive Heart Failure

UPPER AIRWAY OBSTRUCTION EMT-P A. If there is partial obstruction and patient is breathing satisfactorily, or if hypoxic after removing the obstruction, administer oxygen at 15 L/min per non-rebreather mask, and transport ASAP in a position of comfort. B. If there is complete foreign body obstruction, first perform basic life support procedures for removal. C. If manual attempts are unsuccessful, perform direct laryngoscopy and attempt removal with Magill forceps, Kelly clamp, or other appropriate instrument. 1. Forceps-removal of the foreign matter must only be attempted with direct visualization of the obstruction. 2. If spontaneous respirations resume within 5-10 seconds, remove laryngoscope blade, monitor status, and administer oxygen at 15 L/min per non-rebreather mask. 3. If spontaneous respirations do not resume within 5-10 seconds, insert an ET tube as per protocol. D. If attempts at removal are unsuccessful and ventilation is still not possible, perform cricothyroidotomy per Appendix A. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Upper Airway Obstruction

CARDIAC EMERGENCIES If a biphasic defibrillator is used, the energy level should be set in accordance with the manufacturer’s recommendation for defibrillation and cardioversion or as listed below. Suspected ACUTE MI/CHEST PAIN EMT-B, EMT-I & EMT-P A. If patient has known cardiac history, is suffering from chest pain, has a systolic blood pressure at least 100, and has his/her own physician prescribed nitroglycerin (spray or tablet), the EMS provider may: 1. Encourage patient to administer his or her own nitroglycerin. 2. Assist patient in administering his or her nitroglycerin. 3. Verbal Order – Administer the nitroglycerin for patient. a. IV, IV/Airway, EMT-I – If a blood pressure of 110 systolic or less establish a large-bore IV catheter with NaCl at a rate indicated by clinical findings and vital signs prior to administration of nitroglycerin. b. Administer 1 dose of Nitroglycerin, sublingually, every 5 minutes, up to 3 doses. 4. Contraindications for use of Aspirin. a. Patient is allergic to aspirin. b. Active bleeding. 5. Administer 4 baby aspirin (324mg), or 1 adult aspirin (325mg) PO. a. Be sure that the patient is alert and responsive. b. If the patient has his/her own nitroglycerin and meets the criteria for administration, do not delay in administering nitroglycerin. c. Have the patient chew 4 baby aspirin or 1 adult aspirin. d. Record your actions, including the dosage and the time of administration. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Acute Myocardial Infarction (AMI)/Chest Pain

STEMI EMT-B, EMT-I & EMT-P

Upper Valley Acute MI – Perform a 12-Lead ECG and read for signs of Acute MI (1mm of ST elevation in two or more leads in typical MI pattern), if diagnostic of MI then proceed with the following: A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. B. EMT-I – Establish cardiac monitor and perform 12-lead. C. Notify receiving hospital immediately that you are transporting an acute MI patient who will need emergent cardiac catheterization. If possible, transmit EKG to hospital. D. EMT-B - Administer aspirin 324 - 325 mg orally, unless allergic. E. Heparin 70 units/kilogram IV bolus up to a maximum of 5000 units (hold for concern about recent or ongoing bleeding problems). F. Plavix 600 mg PO for patients with confirmed ST elevation (it is recommended that the EKG is transmitted and read by the ED physician delegate). G. EMT-I – Blood tubes for NSTEMI and STEMI patients shall be drawn in the following order: Blue, Green, Purple, and Red.

Lower Valley Acute MI – Perform 12-lead ECG and read for MI as listed above. If ECG is diagnostic of MI, and patient has already requested transport to a Yakima hospital, then proceed as above. If patient initially requested transport to a Lower Valley hospital, advise patient of the following: A. ”Your ECG shows that you are having a myocardial infarction, commonly known as a heart attack. This occurs because of a blocked artery going to your heart. The main treatment for an MI is opening this blockage either with medications or with a procedure called angioplasty, where a wire is put in the artery to open the blockage. Current medical studies show that angioplasty carries less risk of bleeding complications and has better short-term results in preventing death and heart muscle damage. Angioplasty is currently available only at Yakima hospitals. You have the choice of continuing transport to a Lower Valley hospital or-if you wish to have emergency angioplasty performed-being transported to a Yakima hospital of your choice.” The patient should then be transported to the hospital they choose. If this is a Yakima hospital, then proceed as above. B. If the patient has unstable vital signs, altered mental status or airway or respiratory compromise, he/she should be transported to the closest appropriate hospital. 2010 Yakima County Prehospital Care Protocols Updated July 2010

STEMI

NSTEMI EMT-B, EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. B. EMT-I – Establish cardiac monitor and perform 12-Lead. C. EMT-B - Administer aspirin 324 – 325mg orally, unless allergic. D. If pain unrelieved by NTG, and BP> 100 mmHg systolic, administer Morphine, 4 mg IV. Subsequent doses to be given in 2 mg increments, until pain is relieved or hypotension occurs, up to a total of 10.0 mg. 1. Should hypotension occur, consider fluid challenge. 2. If allergic to morphine, administer Fentanyl, 50 micrograms IV. 3. Subsequent doses of Fentanyl at 50 micrograms, up to a total of 500 micrograms. 4. If nauseated after analgesic, administer Anzemet 12.5mg IV bolus, or Zofran 4mg IV bolus over 2-5 min, or Zofran 4mg ODT (if unable to obtain an IV). a. A repeat dose of Zofran 4mg ODT or IV may be given. E. Administer 1 dose of Nitroglycerin, sublingually, every 5 minutes, up to 3 doses. F. For prolonged transport, consider nitro paste 1”. Remove for systolic blood pressure less than 100. G. It is recommended that providers work toward a patient who is free from pain. If pain is not relieved it is recommended that an attempt be made to transport the patient straight to a facility with catheterization capability and into the cath. lab directly when possible. H. EMT-I – Blood tubes for NSTEMI and STEMI patients shall be drawn in the following order: Blue, Green, Purple, and Red.


NSTEMI

CARDIAC DYSRHYTHMIAS EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. B. EMT-I – Establish cardiac monitor, perform 12-lead ECG if stable. C. IV, IV/Airway, EMT-I – Establish peripheral IV access with NaCl @ TKO. D. EMT-P – Medications administered via peripheral IV access should be followed by 20 mL bolus of IV fluid and elevation of the extremity. E. EMT-P – Metered-flow IV tubing should be used when administering Lidocaine or Dopamine drips. ATRIAL FIBRILLATION/FLUTTER EMT-P A. If patient unstable with serious signs and symptoms (e.g., chest pain, shortness of breath, decreased level of consciousness, low BP, shock, pulmonary congestion, CHF, acute MI): 1. Initiate synchronized cardioversion @ 100 J, biphasic defibrillation @ 100 J. If patient conscious & no delay would result, consider Midazolam, 2.0 – 10.0 mg, slow IV push. 2. If no conversion, initiate a second synchronized countershock @ 200 J, biphasic defibrillation @ 150 J. 3. If no conversion, initiate a third synchronized countershock @ 300 J, biphasic defibrillation @ 200 J. 4. If no conversion, initiate a fourth synchronized countershock @ 360 J, biphasic defibrillation @ 200 J. B. If pain develops consider Fentanyl 50 micrograms or Morphine 4 mg IV PRN. C. If patient is stable, administer diltiazem, 0.25 mg/kg (usual dose 15 – 20 mg) IV slowly over 2 minutes, watch for possible hypotension. Rebolus 15 minutes later if needed, 0.35mg/kg IV over 2 minutes. 1. Verbal order – If hypotension occurs after diltiazem dose, consider calcium gluconate 10ml vial slow IV push over 5 minutes. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cardiac Dysrhythmias/Atrial Fibrillation/Flutter

BRADYARRHYTHMIAS/AV BLOCKS EMT-P A. If ECG shows 2nd degree AV block, 3rd degree block, junctional rhythm, or bradycardia, with a heart rate < 60 per minute, and patient is symptomatic (e.g., chest pain, shortness of breath, decreased level of consciousness, low BP, shock, pulmonary congestion, CHF, acute MI)—administer atropine, 0.5, IV bolus, repeat 0.5 mg every 3-5 minutes, up to a total of 3.0 mg. B. Initiate external cardiac pacing. Discuss the need for sedation and analgesia. C. Verbal order – If pacing without capture, administer dopamine, 5 – 20 mcg/kg/minute, IV piggyback. CARDIOGENIC SHOCK EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen and using pulse oximetry, titrate Saturations to greater than 90%. C. Obtain serial vital signs throughout the incident. D. EMT-I – Establish cardiac monitor. E. IV, IV/Airway, EMT-I – Establish large-bore IV with NaCl and administer fluid challenge of 200 mL. Do not administer fluid challenge if patient displays signs and symptoms of pulmonary edema. F. Verbal Order - EMT-P – If no response, or inadequate response to fluid challenge, and systolic BP < 90 mm Hg: 1. Mix dopamine, 400 mg in 250 mL NaCl, for a concentration of 1600 mcg/mL. 2. Use metered flow IV tubing. 3. Administer dopamine, 5 – 7 mcg/kg/minute, IV piggyback, titrating up to 20 mcg/kg/minute; or until blood pressure 90 mm Hg or greater systolic. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Bradyarrhythmias/AV Blocks/Cardiogenic Shock

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT) EMT-P A. If patient is unstable with serious signs and symptoms (e.g., chest pain, shortness of breath, decreased level of consciousness, low BP, shock, pulmonary congestion, CHF, acute MI): 1. Initiate synchronized cardioversion @ 50 J, biphasic defibrillation @ 100 J. If patient is conscious, systolic BP > 90 mm Hg and no significant delay would result; consider midazolam, 2.0 – 10.0 mg, slow IV push. 2. If no conversion, initiate a second synchronized countershock @ 100 J, biphasic defibrillation @150 J. 3. If no conversion, initiate a third synchronized countershock @ 200 J, biphasic defibrillation @ 200 J. 4. If no conversion, initiate a fourth synchronized countershock @ 300 J, biphasic defibrillation @ 200 J. 5. If no conversion, initiate a fifth synchronized countershock @ 360 J, biphasic defibrillation @ 200 J. B. If patient is stable: 1. Establish cardiac monitor and perform 12-lead. 2. Have patient perform Valsalva maneuver (deep breath & hold). A carotid massage may be performed in patients less than 40 years old, to one side of neck only. 3. Administer adenosine, 6.0 mg, rapid IV bolus, over 1-3 seconds. 4. If no conversion after 2 minutes, administer a second rapid IV bolus of adenosine, 12.0 mg, over 1-3 seconds. 5. Administration of adenosine must be followed by an immediate flush of 20cc of IV fluid. If PSVT is irregular, or confirmed as atrial fibrillation or atrial flutter, do not administer adenosine. 6. Verbal Order – If no conversion after second dose of adenosine, and QRS complex is still narrow, consider diltiazem, 0.25 mg/kg, (usual dose 15 – 20 mg) IV slow push, over 2-5 minutes. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Paroxysmal Supraventricular Tachycardia (PSVT)

VENTRICULAR TACHYCARDIA EMT-P A. In the conscious, stable patient, administer amiodarone 150 mg mixed in 100 mL of NaCl. 1. Consider repeat dose if tachycardia persists. B. In the unstable patient with serious signs and symptoms (e.g., chest pain, shortness of breath, decreased level of consciousness, low BP, shock, pulmonary congestion, CHF, acute MI): 1. Initiate immediate synchronized cardioversion @ 100 J, biphasic defibrillation @ 100 J. If patient is conscious, BP is greater than 90 mm Hg and no significant delay would result, consider midazolam, 2.0 – 10.0 mg, slow IV push. 2. In no response, initiate synchronized cardioversion @ 200 J, biphasic defibrillation @ 150 J, with subsequent shocks @ 300 J, biphasic defibrillation @ 200 J, then 360 J, biphasic defibrillation @ 200 J as indicated. 3. After conversion, administer amiodarone 150 mg mixed in 100 mL of NaCl over 10 minutes, if not already given. WIDE-COMPLEX TACHYCARDIA (uncertain type stable) EMT-P A. Administer amiodarone 150 mg mixed in 100 mL of NaCl over 10 minutes. B. If no conversion, administer a rapid IV bolus of adenosine, 6.0 mg, over 1-3 seconds. C. Verbal Order – If no conversion after 10 minutes, call MEDICAL CONTROL to administer a second rapid IV bolus of adenosine, 12.0 mg, over 1-3 seconds.


Ventricular Tachycardia/Wide-Complex Tachycardia

CARDIOPULMONARY ARREST Initial Resuscitation FR, EMT-B, EMT-I & EMT-P A. Verify cardiopulmonary arrest. B. Downtime is 4 minutes or less; initiate the Automated External Defibrillator (AED) by turning on the AED and beginning a verbal report while connecting to patient; begin rhythm analysis immediately. 1. If "shock advised" – defibrillate once followed by cycles of 30 compressions and 2 breaths for approximately 2 minutes. 2. After two minutes re-analyze and if possible, switch compressors. C. Downtime greater than 4 minutes; begin cycles of 30 compressions and 2 breaths for approximately 2 minutes. 1. Connect AED; after two minutes and analyze. 2. If a shock is indicated, shock once followed immediately by 30 compressions and 2 breaths for approximately 2 minutes. 3. EMT-I & EMT-P – Upon arrival, if BLS providers, equipped with an automated defibrillator, are already at the scene and defibrillation is indicated allow them to complete the shock, before disconnecting their device. D. Initiate CPR and ventilate per pocket mask or BVM with supplemental oxygen at 15 L/min. or by OPVD. E. In cases of severe hypothermia, and patient is unconscious, assess pulses for 30-60 seconds. If indicated a shock can be delivered. If unsuccessful, CPR should be initiated and begin re-warming as best as possible. Defibrillation should be re-attempted when core temperature is above 86 degrees Fahrenheit. F. EMT-B with Airway– If King Airway, LMA, or Combitube technician is on-scene, placement of the device may be done after the first shock, or after a "no shock" is indicated. Place in accordance with Appendix A. Defibrillation takes precedence over placement of the Airway device. Every effort should be paid to continuous chest compressions, including during the placement of an advanced airway. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cardiopulmonary Arrest

1. EMT-P - If an ETC has been placed prior to arrival and the device is in the esophageal position, an endotracheal tube may be placed, if transport to the hospital from the scene will exceed 30 minutes, the patient is not adequately ventilating, or medication administration cannot be given any other route. This may be accomplished by leaving the ETC in position while placing the ET tube. Every effort should be paid to continuous chest compressions, including during the placement of an advanced airway. 2. EMT-P – See Appendix A, Advanced Airway Management Protocol. G. Once an advanced airway is in place provide ventilations at a rate of 8 to 10 breaths a minute without pause in chest compressions. 1. Minimize the number and length of interruptions in chest compressions. Interruptions should be limited to less than 10 seconds, except for defibrillation, or moving a victim from danger. The maximum interruption of ventilations should be 30 seconds. H. EMT-P – If placement of an ET is unsuccessful after two attempts allow for placement of a King Airway, LMA, or Esophageal Tracheal Combitube (ETC). I. Perform resuscitation efforts until patient is breathing and has a pulse, care is released to a higher authority, or you become too exhausted to continue. If prolonged time in the field, contact Medical Control for advice. EMT-B, EMT-I & EMT-P J. EMT-I – Establish cardiac monitor, and defibrillate as necessary. Biphasic defibrillation @ 200 J for all shocks. K. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. 1. EMT-P – If unsuccessful, attempt external jugular cannulation. 2. IV, IV/Airway, EMT-I – Verbal Order – if an IV cannot be established, a Vidacare™ EZ-IO™ may be placed per manufacturer’s instructions. See Appendix B. 3. EMT-P – If IV and IO access is delayed, administer appropriate medications via endotracheal tube. L. EMT-P – Medications administered via peripheral IV access should be followed by a 20 mL bolus of IV fluid and elevation of the extremity. M. EMT-P – If time allows, insert NG tube for gastric decompression. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cardiopulmonary Arrest

ASYSTOLE (or pulseless idioventricular) EMT-P A. Confirm asystole clinically, and in more than one lead. B. If in question as to whether the rhythm is fine ventricular fibrillation or asystole, and downtime is 4 minutes or less, defibrillate at 360 J. Biphasic defibrillation at 200 J. C. Consider immediate transcutaneous pacing if: 1. Short down time. 2. Bystander CPR had been initiated. 3. Witnessed rhythm change to asystole. D. Administer epinephrine, 1:10,000, 1.0 mg, q 3-5 minutes, IV (2.0 mg if administered ET). E. Administer atropine, 1.0 mg, IV (2.0 mg if administered ET), may repeat q 3-5 minutes, up to a maximum of 3.0 mg. F. Consider Sodium Bicarbonate 50 mEq (1 amp) IV bolus for prolonged downtime. G. Verbal order – Consider discontinuing resuscitation efforts. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Asystole

PULSELESS ELECTRICAL ACTIVITY (PEA) EMT-P A. Consider correction of underlying cause (e.g., hypovolemia, cardiac tamponade, tension pneumothorax, acidosis, hypoxemia, hypothermia, drug overdose, hyperkalemia, or massive acute MI). B. Administer epinephrine, 1:10,000, 1.0 mg, q 3-5 minutes, IV (2.0 mg if administered ET). C. If rate < 60/minute, administer atropine, 1.0 mg, IV (2.0 mg if administered ET) bolus. May repeat q 3-5 minutes, up to 3.0 mg. D. If intubated, and a drug overdose of tricyclic antidepressant, similar compounds or suspected hyperkalemia—hyperventilate patient, and consider administration of 2 Amps of sodium bicarbonate, IV bolus (not to be used unless one of the above criteria exists). E. Consider sodium bicarbonate, 50 mEq (1 Amp), IV bolus for prolonged downtime. 1. WARNING: If administrating Calcium Gluconate to a patient who has or may receive sodium bicarbonate, start a 2nd line and administer the drugs in separate IV lines. F. Consider 1 Amp Calcium Gluconate for suspected hyperkalemia. G. Verbal order – Consider discontinuing resuscitation efforts.


Pulseless Electrical Activity (PEA)

VENTRICULAR FIBRILLATION (or pulseless ventricular tachycardia) EMT-I & EMT-P A. If downtime is 4 minutes or less, defibrillate ASAP at 360 J (prior to ET and/or IV attempt). Biphasic defibrillation @ 200 J for all shocks. B. If downtime is greater than 4 minutes initiate cycles of 30 compressions and 2 breaths for approximately 2 minutes. 1. Attach AED, after 2 minutes and analyze. If shock is indicated, shock once @ 360 J. Biphasic defibrillation @ 200 J. C. EMT-P - Administer vasopressin 40 units IV, after 10 minutes administer epinephrine, 1:10,000, 1.0 mg, q 3-5 minutes, IV (2.0 mg if administered ET). D. Defibrillate @ 360 J as necessary. Biphasic defibrillation @ 200 J. E. EMT-P - Administer amiodarone 300 mg IV. 1. If no IV access is available, administer lidocaine 3.0 mg/kg ET. F. Defibrillate @ 360 J, as necessary. Biphasic defibrillation @ 200 J. EMT-P G. If intubated and a drug overdose of tricyclic antidepressant, similar compounds or suspected hyperkalemia then hyperventilate patient and consider administration of sodium bicarbonate, 1 mEq/kg IV bolus. H. Continue defibrillation therapy, check for pulses intermittently, and maintain a pattern of drug-2 min compressions-shock, drug-2 min compressions-shock. I. In refractory VF or suspected torsades de pointes, consider magnesium sulfate, 2 g diluted in 10 mL of NaCl IV push. J. After conversion, administer amiodarone 150 mg mixed in 100 mL of NaCl over 10 minutes, if not already given. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Ventricular Fibrillation (or Pulseless V-Tach)

DISCONTINUING RESUSCITATION FR, EMT-B, EMT-I & EMT-P A. If signs of obvious death, or patient has an advance directive or EMS-No CPR directive, refer to the Do-Not-Resuscitate Protocol. B. EMT-P – Verbal Order – Consult with Medical Control Facility for patients that have not responded to an initial cycle of advanced cardiac life support in accordance with protocols. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Discontinuing Resuscitation

TRAUMA EMERGENCIES

Introduction The following protocols are not intended to encompass all traumatic incidents the EMS provider may encounter in the field, but to provide general guidelines for the often- encountered trauma case. The basic philosophy of prehospital trauma care is RAPID assessment, RAPID treatment and RAPID transport. Trauma is a surgical disease and it would be inappropriate to spend much time in the field attempting to stabilize the patient. Rapid transport should be initiated within 10 minutes of arriving at the scene, unless extenuating circumstances exist (e.g., prolonged extrication, difficult access, multiple- casualty incident). Protocols that require the skill level of the First Responder are typed in black. The protocols that require the skill level of the EMT-Basic are typed in blue. The protocols that require the skill level of the EMT-Intermediate are typed in green. If an individual is ILS certified the protocols should be followed to their level of certification (i.e., IV, Airway, IV/Airway, EMT-I). The protocols that require the skill level of the EMT-Paramedic are typed in red. In some cases, a protocol will be level specific, which will be preceded by the level in bold.


PATIENT ASSESSMENT (must be performed on every patient) FR, EMT-B, EMT-I & EMT-P A. Conduct scene size-up, scene safety, BSI, and develop action plan. B. Perform initial assessment. 1. Form general patient impression. 2. Determine level of consciousness using AVPU. 3. A – Assess airway while protecting c-spine. 4. B – Check for breathing. 5. C – Check circulation and control major bleeding. 6. If available, use pulse oximetry and record result, and then administer oxygen at 15 L/min per non-rebreather mask (NRB) when indicated. Oxygen by nasal cannula may be used if patient unable to tolerate a mask. C. IV, Airway, IV/Airway, EMT-I – Administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. If pulse oximetry is not available, give oxygen when indicated by mask or cannula. D. If patient is critical, perform a rapid trauma assessment, extricate as necessary, and consider rapid transport. 1. Treat for hypoperfusion (shock). 2. Activate trauma system by calling a “Trauma Alert” in accordance with County Operating Procedures. 3. Contact the responding ambulance with patient status/vital signs. 4. Total on-scene time should be limited to 10 minutes. 5. When transport is delayed, perform a detailed physical exam. 6. Continue with ongoing assessment. E. If the patient is not critical, perform a focused history. 1. If indicated, immediately stabilize the cervical spine and apply appropriate sized cervical collar, consider short board vs. long backboard, secure to the board with straps, and immobilize head to the board using a proper head immobilizer. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Patient Assessment (Trauma)

2. Obtain history, using S.A.M.P.L.E. (symptoms, allergies, medications, past history, last meal, and events preceding). 3. Obtain vital signs. 4. Perform a detailed physical exam. 5. Treat for hypoperfusion (shock). 6. Contact the transporting agency with patient’s condition, vital signs, and care rendered. 7. Continue ongoing assessment. F. In the event of a Mass Casualty Incident (MCI) involving multiple patients or limited resources, utilize the Simple Triage and Rapid Transport (S.T.A.R.T.) triage method (R=Respirations, P=Pulse, M=Mental Status) in accordance with the County Operating Procedures. EMT-I & EMT-P A. IV, IV/Airway, EMT-I – Establish an IV of NaCl, TKO, as indicated by patient’s condition and injuries. Establish two IVs, if possible, for severely injured patients or patients with hypotension.


Patient Assessment (Trauma)

TRAUMA ALERT(S) FR, EMT-B, EMT-I & EMT-P Conduct scene size-up, scene safety, BSI, and develop action plan. The first certified EMS provider (or agency) on-scene will determine whether a patient(s) meets the trauma triage criteria by using the State of Washington Prehospital Trauma Triage (Destination) Procedures (WSPTTP), refer to Appendix D. In the event that there is more than one person that qualifies as a Trauma Alert patient the first arriving paramedic unit will remain on-scene. In the event that there is more than one EMS transporting agency responding, utilize OSCCR frequency for inter-ambulance communications regarding, for example, a Trauma Alert patient’s location, transport destination, or to give a short report. (For larger incidents, radio frequencies will be determined by the on-scene Incident Command.)

A. Perform initial assessment 1. Determine level of consciousness using AVPU and GCS 2. A – assess airway while protecting c-spine (where indicated) 3. B – check for breathing 4. C – check circulation and control major bleeding 5. Perform a Rapid Trauma Assessment 6. Activate the Trauma System – reference letter “C.” below on this protocol. 7. Extricate as necessary, package patient(s) for immediate transport by next arriving transport unit. 8. Attach a Washington State Trauma Registry Band to the patient’s wrist or ankle. B. Total on-scene time should be limited to 10 minutes (with the exception of extended extrication). Do not delay on-scene time for patient intubation, oxygen saturations, splinting, bandaging of minor lacerations, and etc. In the event of ambulance delay consider immediate transport, rendezvous, or air transport (Utilize air transport in accordance with County Operating Procedures). C. Activate the trauma system by contacting the highest-level designated trauma facility within 30 minutes transport time via ground or air transport from the incident scene. (The highest-level designated trauma facility in Yakima County rotates between Yakima Regional Medical Center and Yakima Valley Memorial Hospital, with the exception of some locations in the southern part of the County where Sunnyside Community Hospital may be the closest and highest-level within 30 minutes). 2010 Yakima County Prehospital Care Protocols Updated July 2010

Trauma Alert(s)

1. This must be done immediately upon determining the patient(s) condition, and via the H.E.A.R. frequency or cellular phone (or other means as conditions dictate). 2. Radio contact with the designated trauma facility will be preceded with the phrase: “This is a Trauma Alert.” The initial on-scene report must include the following: 1. Mechanism of injury. 2. Total number of patients’ and the number that qualify as Trauma Alerts. 3. Using Appendix D state how each patient qualifies as a Trauma Alert (i.e. patient #1 has a penetrating injury to the chest; patient #2 was ejected and is unresponsive). 4. Later radio reports refer to County Operating Procedures. If time permits proceed with the following care (acceptable delay exists i.e., extended extrication time). D. EMT-B with Airway – Consider placement of a King Airway, LMA or Combitube. E. IV, IV/Airway, EMT-I – Establish an IV of NaCl, TKO, as indicated by patient’s condition and injuries. Establish two IVs, if possible, for severely injured patients or patients with hypotension. F. EMT-P – Consider endotracheal intubation only if an acceptable delay exists, BLS measures are not sufficient and placement of an ETC, King or LMA has failed. G. The on-scene paramedic unit will advise the second arriving transport unit of its transport destination be it the Trauma Center for Yakima County, a landing zone for air transport, the closest Trauma Center by ground transport or the facility recommended by the Trauma Center that was contacted. H. While en route to the hospital, the transporting agency must provide a complete patient status report, via radio or other means, to the receiving trauma facility.

I. In Upper Yakima County (and in Lower Yakima County, if transport time from the scene to Yakima would be 30 minutes or less, despite the proximity to SCH or TCH), for the conditions described below, patient destination should be as follows: 1. Pregnant patients – Yakima Valley Memorial Hospital 2. Pediatric patients less than the age of 10 years – Yakima Valley Memorial Hospital 3. Hemodynamically stable patients with a severe head injury and a Glasgow Coma Score of 13 or below – either Yakima Regional Medical Center or Yakima Valley Memorial Hospital per rotation. 2010 Yakima County Prehospital Care Protocols Updated July 2010 Trauma Alert(s)

ABDOMINAL TRAUMA FR, EMT-B, EMT-I & EMT-P A. If patient has an evisceration, cover the exposed abdominal organs with saline or sterile water-soaked dressings. B. Open wounds should be covered with occlusive or moist dressings. C. Penetrating objects should be left in place and secured for transport. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Abdominal Trauma

BURNS FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen. C. Remove patient from a hazardous environment and remove constricting items and smoldering or non-adherent clothing. 1. Brush any dry solids off patient. 2. Dilute and rinse any chemicals with water. D. Stop the burning process. E. Determine the location, extent and depth of burns, and any associated trauma or complications. F. Cover minor burns with sterile dressings moistened with normal saline, and consider cooling if painful. G. Cover moderate to severe burns with dry sterile dressings. Clean non-sterile sheets may be used for large BSA. H. If hands or feet are involved, separate digits with sterile gauze pads. I. Cover patient to conserve body heat and to keep him/her warm. J. If chemical burns, brush off any dry chemicals and irrigate appropriately. K. Obtain history to include: mechanism or source of burn; time elapsed since burn; whether patient was in a confined space with smoke or steam, and how long; and whether there was a loss of consciousness. EMT-I & EMT-P A. Administer high flow O2. B. Obtain history to include: mechanism or source of burn; time elapsed since burn; whether patient was in a confined space with smoke or steam, and how long; and whether there was a loss of consciousness. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Burns

C. If there are critical burns, such as partial-thickness (2ndº) or full-thickness (3rdº) involving greater than 10% of the body surface area; facial burns; or respiratory involvement: 1. EMT-I – Establish cardiac monitor. 2. IV, IV/Airway, EMT-I – Establish large-bore IV with NaCl and run at appropriate rate (avoid placing IV catheter in burned areas). 3. Continue to monitor airway status, and treat as indicated. 4. EMT-P – Consider morphine sulfate, 4.0 – 10.0 mg IV, every 5 minutes, as needed, for pain up to 40 mg. EMT-P D. If allergic to morphine, consider fentanyl, 50 micrograms IV. Subsequent doses fentanyl at 50 micrograms, up to a total of 500 micrograms.

E. If nauseated after analgesic, administer Anzemet, 12. 5 mg IV bolus or IM. F. If unable to establish an IV, consider administration of morphine, 10 mg IM one time or fentanyl, 100 micrograms IM one time. G. Verbal order – If fire in an enclosed space, oropharyngeal soot, or burn is present and patient has stridor, consider early prophylactic intubation before significant airway edema develops. H. If there is a chemical burn with hydrofluoric acid (HF), cover with gauze dressing saturated with calcium gluconate. I. If patient’s hand is burned with HF, fill a glove with calcium gluconate, place the burned hand in the glove and tape to wrist. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Burns

CHEST TRAUMA FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen. C. Penetrating objects should be left in place and secured for transport. D. Flail or fractured ribs should be stabilized with bulky dressings. EMT-I & EMT-P A. Administer oxygen and using pulse oximetry, titrate Saturation to greater than 90%. B. EMT-P – Place endotracheal tube when indicated. Watch for signs of tension pneumothorax. C. EMT-I – Establish cardiac monitor. D. IV, IV/Airway, EMT-I – If BP <90 mm Hg establish two large-bore peripheral IVs with NaCl and titrate fluids to systolic BP of 90. 1. Consider additional IV lines. E. IV, IV/Airway, EMT-I – If BP ≥ 90 mmHg, establish large-bore peripheral IV with NaCl, and run at an appropriate rate. F. EMT-P – If tension pneumothorax develops, perform needle thoracostomy in accordance with “Suspected Tension Pneumothorax” protocol. G. If present, stabilize flail chest segment with a pillow splint or other appropriate splinting device. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Chest Trauma

SUSPECTED TENSION PNEUMOTHORAX EMT-P A. In the event of a suspected tension pneumothorax, and the patient is deteriorating rapidly, perform the following: 1. Prepare all necessary equipment. 2. Identify the second intercostal space at the mid-clavicular line. 3. Prepare the site with providone-iodine swabs. 4. Use a 12-gauge catheter over-the-needle (16-gauge for pediatric patients) device, attached to a one-way flutter valve, or an MPD-approved commercial device. 5. Insert the needle above the third rib, into the second intercostal space, until a “pop” is heard. 6. Advance the catheter an additional 1 – 2 cm, and withdraw the needle (or as recommended by the manufacturer, if using a commercial device). 7. Secure with tape and a bulky dressing. B. Continually monitor lung sounds and respiratory status. 2010 Yakima County Prehospital Care Protocols Updated July 2010 Suspected Tension Pneumothorax

C-SPINE TRAUMA FR, EMT-B, EMT-I & EMT-P A. Do not place patient in c-spine precautions if communication is possible and all of the following conditions are met. 1. Patient is conscious, alert, and oriented. 2. Patient is not under the influence of drugs or alcohol. 3. Patient has no complaints of neck pain. 4. Patient has no complaints of arm or leg numbness. 5. Exam reveals non-tenderness. 6. NO distracting injury. B. If all of the above conditions are not met: 1. Provide immediate, manual, in-line head and c-spine stabilization in the neutral position. 2. Apply appropriate sized cervical collar, consider short board vs. long backboard, secure to the board with straps, and immobilize head to board using a head immobilizer. C. Do not use mechanism alone to determine whether c-spine precautions and immobilization are utilized. D. In the event that standard c-collar sizes are not appropriate for your patient(s) the following may be utilized: 1. Blocks and tape. 2. Towel rolls on either side of patients head and tape. 3. Other approved device for c-spine immobilization. E. DO NOT place a towel around the patient’s neck, as this does not provide adequate c-spine immobilization. F. Once patient is placed in c-spine precautions, they must be removed only by a physician. You may not “clear” c-spine in the field; you may follow the guidelines listed above. 2010 Yakima County Prehospital Care Protocols Updated July 2010

C-Spine Trauma

HEAD TRAUMA FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway using c-spine precautions. B. Administer oxygen. C. Cover open wounds with sterile dressings. D. If patient has good gag reflex and adequate respiratory drive, maintain airway and oxygen. E. If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway, and assist ventilations with pocket mask, BVM and supplemental oxygen at 15 L/min or more, or by OPVD. F. EMT-B with Airway– If a King Airway, LMA or Combitube technician is on- scene, consider placement of device in accordance with Appendix A. EMT-I & EMT-P A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than 90%. B. Control external hemorrhage and provide c-spine immobilization. C. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. D. EMT-P – If Glasgow Coma Scale ≤ 8 or unconscious: 1. Place an endotracheal tube and ventilate with BVM and supplemental oxygen at 15 L/min or OPVD (do not hyperventilate unless patient is exhibiting signs of herniation syndrome with rapid deterioration). 2. EMT-P – If patient requires paralysis, perform rapid sequence intubation (RSI) in the following order: a. Administer lidocaine, 1 mg/kg IV. b. Administer etomidate, 0.3 mg/kg per IV push. c. Administer succinylcholine, 1.5 mg/kg IV. 3. If a pediatric patient: a. Administer lidocaine, 1 mg/kg IV. b. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.5 mg (minimum of 0.1 mg). c. Administer etomidate 0.3 mg/kg per IV push. d. Administer succinylcholine, 1.5 mg/kg IV. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Head Trauma

E. If patient has signs/symptoms of hypovolemia secondary to other trauma – treat shock as per protocols. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Head Trauma

MULTISYSTEM TRAUMA FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Provide spinal immobilization. C. Administer oxygen. D. Control severe external hemorrhage as indicated. E. Treat life-threatening conditions as indicated. If patient meets “Trauma Alert” criteria do not delay transport for the following procedures. Patient should be transported within 10 minutes. In this case, the following procedures would be performed during transport. F. Cover open wounds with sterile dressings. G. Splint fractures with appropriate device. H. Apply an approved pelvic splint device if pelvic fracture is suspected. EMT-I & EMT-P A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than 90%. B. EMT-P – Consider endotracheal intubation in accordance with Appendix A. C. IV, IV/Airway, EMT-I – If BP < 90 mm Hg, establish two or more large-bore peripheral IVs with NaCl, and titrate fluids to a systolic blood pressure of approximately 90. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Multi-System Trauma

MUSCULOSKELETAL TRAUMA FR, EMT-B, EMT-I & EMT-P A. Assess pulses, motor function, and sensation before and after immobilization. B. Consider alignment with gentle traction if distal pulses are absent or gross deformity is noted. C. Immobilize other possible fractures using an appropriate splinting device (e.g., cardboard, pillow, etc.) making sure to splint above and below the joints. D. Cover open fractures with sterile dressings prior to immobilization. E. EMT-B – Immobilize adult ankle injuries using a pillow splint. F. EMT-B – Immobilize mid-shaft femur fractures using a traction splint (Apply the splint whether an open or closed fracture.) If a pelvic fracture exists, do not apply the traction splint, immobilize patient to a long-spine board. G. EMT-B – Apply an approved pelvic splint device if pelvic fracture is suspected. EMT-I & EMT-P A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than 90%. B. Immobilize fracture(s) in accordance with above (BLS, B. – G.). C. In the presence of severe long-bone fractures, open fractures or multiple fractures, and complaint of severe pain: 1. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. If hypotensive, run at wide-open rate. 2. EMT-P – Administer morphine, 2.0 – 10.0 mg IV for pain control. Subsequent doses to be given in 2.0 – 10 mg increments until pain is relieved, hypotension occurs, hypoventilation occurs, or decrease in mental status, up to 40 mg. 3. EMT-P – If allergic to morphine, administer fentanyl, 50 micrograms IV. Subsequent doses fentanyl at 50 micrograms, up to a total of 500 micrograms. 4. EMT-P – If nausea follows analgesics, administer Anzemet 12. 5 mg IV bolus or IM. 5. EMT-P – If unable to establish an IV, consider administration of morphine 10 mg IM one time or fentanyl 100 micrograms IM one time. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Musculoskeletal Trauma

SOFT TISSUE TRAUMA FR, EMT-B, EMT-I & EMT-P A. Penetrating objects should be left in place and secured for transport. B. Control hemorrhaging. C. If patient sustains an amputation, wrap severed body part in sterile moist dressing, place in a plastic bag on ice, and transport. Do not allow severed body part to freeze.


Soft Tissue Trauma

ENVIRONMENTAL EMERGENCIES COLD EMERGENCIES FR, EMT-B, EMT-I & EMT-P A. Remove patient from inclement environment, move to a warm place, and remove wet clothing. B. Handle patient with care, and wrap in blankets to prevent further heat loss. C. Apply heat packs to the neck, groin, and armpits and attempt to re-warm. D. Do not massage extremities to re-warm or allow patient to walk or exert him/herself. E. In cases of severe hypothermia, in which patient is unconscious, assess pulses for 30-60 seconds. If indicated, a shock can be delivered. If unsuccessful, CPR should be initiated and re-warming begun.

HEAT EMERGENCIES FR, EMT-B, EMT-I & EMT-P A. Remove patient from hot environment, move to a cool place and loosen or remove clothing. B. Moisten skin to allow for evaporative cooling while fanning patient. C. EMT-B – If patient is conscious and responsive, allow him/her to drink fluids. D. EMT-B – If patient is unconscious with pulses, place on left side and transport immediately. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cold and Heat Emergencies

NEAR-DROWNING/DROWNING FR, EMT-B, EMT-I & EMT-P A. Assure safety of rescue personnel. B. Contact medical control physician with age of victim, time in water and temperature of the water, to determine the need for rescue vs. body recovery. C. If unconscious or a spine injury is suspected, provide in-line stabilization and remove patient from the water using a long backboard. D. If no spinal injury is suspected, remove patient from the water, place patient on left side and allow water, vomitus and secretions to drain from the upper airway. E. If patient has good gag reflex and adequate respiratory drive, maintain airway and administer oxygen. F. If patient has no gag reflex, establish oropharyngeal or nasopharyngeal airway and assist ventilations with pocket mask, BVM, and supplemental oxygen at 15 L/min or more or by OPVD. G. EMT-B with Airway– If a King Airway, LMA or Combitube technician is on- scene, consider placement of device in accordance with Appendix A. H. In cases of severe hypothermia, and patient is unconscious, assess pulses for 30-60 seconds. If indicated, a shock can be delivered. If unsuccessful, CPR should be initiated and re-warming begun. EMT-P A. Consider ET intubation in accordance with Appendix A. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Near Drowning/Drowning

PEDIATRICS CARDIOPULMONARY ARREST FR, EMT-B, EMT-I & EMT-P INITIAL RESUSCITATION A. Establish and maintain airway. B. Verify cardiopulmonary arrest. C. Initiate cycles of 30 compressions and 2 breaths with a single rescuer. Two rescuer CPR, utilize 15 compressions and 2 breaths for patients < 1 year of age. D. Ventilate with a pediatric BVM, with supplemental oxygen at 15 L/min or more. E. EMT-I – Establish cardiac monitor. F. If heart rate is < 60/minute in an infant or a child, despite oxygenation and ventilation, begin CPR. G. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. H. IV, IV/Airway, EMT-I – If peripheral route is not obtained within two attempts or 90 seconds (whichever comes first), attempt intraosseous (IO) route, using the Vidacare™ EZ-IO™. I. EMT-P – Place an endotracheal tube and continue ventilations with pediatric bag- valve-device. J. Once an advanced airway is in place, provide chest compressions without pause for ventilation. Provide ventilation at a rate of 8 to 10 breaths a minute. K. EMT-P – If time allows, insert NG tube for gastric decompression.


Cardiopulmonary Arrest (Pediatrics)

BRADYARRHYTHMIAS EMT-P A. Symptomatic, including unconsciousness and hemodynamic instability: 1. Reassess adequacy of airway and ventilation. 2. Administer epinephrine, 1:10,000, 0.1 ml/kg IV or Vidacare™ EZ-IO™. 3. If ET only route available, administer epinephrine, 1:1000, 0.2 ml/kg. 4. Second, and subsequent doses of epinephrine, 1:1000, 0.1 ml/kg, IV, Vidacare EZ-IO™, or ET, q 3 minutes. 5. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.1 – 0.5 mg, IV, ET, or Vidacare EZ-IO™ (double dose for ET route). B. Consider initiating external cardiac compressions and ventilations.

ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) EMT-P A. In PEA, identify and treat the following causes: severe hypoxemia, severe acidosis, severe hypovolemia, tension pneumothorax, cardiac tamponade, profound hypothermia. B. Administer epinephrine, 1:10,000, 0.1 ml/kg, IV or Vidacare EZ-IO™. C. If ET only route available, administer epinephrine, 1:1000, 0.2 ml/kg. D. Second, and subsequent doses of epinephrine, 1:1000, 0.1 ml/kg, IV, Vidacare EZ-IO™, or ET, q 3 minutes. E. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.1 – 0.5 mg, IV, ET, or Vidacare EZ-IO™ (double dose for ET route). F. In PEA, consider fluid challenge of NaCl @ 20 ml/kg, re-warming, or needle thoracentesis. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Bradyarrhythmias/Asystole/PEA (Pediatrics)

VENTRICULAR FIBRILLATION (Pulseless Ventricular Tachycardia) EMT-P A. Defibrillate ASAP, at 2 J/kg. Second and subsequent shocks shall be at 4 J/kg. Same joules shall be used for biphasic defibrillation. 1. 1 initial shock may be delivered followed immediately by CPR and drug therapy. 2. Minimize interruptions in chest compressions. B. Initiate cycles of 15 compressions and 2 breaths for 2 rescuer CPR. 1. Once an advanced airway is in place, provide chest compressions without pause for ventilation. Provide ventilation at a rate of 8 to 10 breaths a minute. C. Administer epinephrine, 1:10,000, 0.1 ml/kg (IV, Vidacare EZ-IO™, or ET). D. If ET only route available, administer epinephrine, 1:1000, 0.2 ml/kg. E. Second, and subsequent doses of epinephrine, 1:1000, 0.1 ml/kg q 3 – 5 min. F. Immediately following the first dose of epinephrine above, defibrillate at 4 J/kg 30-60 seconds after epinephrine. Same joules shall be used for biphasic defibrillation. G. Administer lidocaine, 1 mg/kg. H. Repeat defibrillation at 4 J/kg as necessary. Same joules shall be used for biphasic defibrillation. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Ventricular Fibrillation and Pulseless V-Tach (Pediatrics)

RESPIRATORY EMERGENCIES FR, EMT-B, EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen @ 15 L/min. If mask is not tolerated, administer blow-by oxygen. C. Allow the patient to assume a position of comfort. D. Frequent vital signs. E. If decreased LOC, assist ventilations with BVM.

EMT-I & EMT-P A. If obstruction is present, treat as per Appendix A. B. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than 90%. If mask is not tolerated, administer blow-by oxygen. C. Allow the patient to assume a position of comfort. D. Frequent vital signs. E. If decreased LOC, assist ventilations with BVM. F. EMT-P – If patient does not respond to BVM ventilations, consider placement of an ET tube. G. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. If indicated, consider intraosseous (IO) route, using the Vidacare EZ-IO™. H. EMT-I – Establish cardiac monitor. I. EMT-P – Insert NG tube for gastric decompression. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Respiratory Emergencies (Pediatrics)

ASTHMA EMT-I & EMT-P A. Transport ASAP, and monitor status. B. EMT-I – Administer albuterol unit dose, (2.5 mg albuterol, 2.5 ml NaCl) by nebulizer mask, mouth piece, or blow-by. C. EMT-I – In severe asthma, administer dose via mask. Doses may be repeated immediately. D. EMT-P – Verbal order – If no response to albuterol, and condition becomes worse, consider epinephrine, 1:1000, SQ, at 0.01 ml/kg, not to exceed 0.3 ml. CROUP/EPIGLOTTITIS EMT-B, EMT-I & EMT-P A. Transport ASAP, allow patient to assume a position of comfort, minimize agitation, and monitor status. B. IV, Airway, IV/Airway, EMT-I – Administer nebulized saline via blow-by or nebulizer mask. C. EMT-P – For severe stridor, consider nebulized epinephrine, 1:1000, 2.5 mg mixed with 2.5 cc NaCl, via nebulizer mask. D. If a child loses consciousness, or develops periods of apnea, with respiratory depression, initiate BVM ventilation. E. EMT-P – If BVM unsuccessful, place ET tube using one size smaller than normal for his/her age. F. EMT-P – If attempts at ET intubation are unsuccessful, consider needle cricothyroidotomy. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Asthma/Croup/Epiglottitis (Pediatrics)

PEDIATRIC SEIZURES EMT-I & EMT-P A. Establish and maintain airway. B. Administer oxygen, titrate Saturation to 90% or greater. If not tolerated, administer blow-by oxygen. C. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. D. Determine if seizure is febrile in etiology. E. A physician must evaluate all pediatric seizure patients. Consider family transport only if a febrile seizure, and patient is awake and alert. F. EMT-I – Check blood glucose. If low, administer D25W, 0.5 – 1.0 g/kg. G. Witnessed, continuous grand mal seizures (unconsciousness, tonic/clonic movement of all extremities), lasting greater than 10 minutes, with respiratory compromise, or repetitive seizures without return of consciousness: 1. IV, IV/Airway, EMT-I – Establish peripheral IV with NaCl @ TKO. 2. EMT-P – Administer lorazepam 0.1 mg/kg mg slow IV push, every 3-5 minutes until seizure ceases, systolic BP is < 100 mmHg, or respiratory depression. 3. EMT-I – Establish a cardiac monitor. 4. EMT-I – Continue monitoring and protecting airway. H. EMT-P – If an IV cannot be established, administer midazolam, 0.2 mg/kg IM to a maximum of 5 mg. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Pediatric Seizures

APPENDIX A – Airway SUPRAGLOTTIC AIRWAYS USE OF THE KING LTS-D™ AIRWAY EMT-B, EMT-I & EMT-P A. Use of the KING LT(S)-D Airway is indicated in the following situations: 1. Cardiopulmonary arrest. a. In cardiopulmonary arrest the King LT(S) – D Airway may be used as the primary airway. i. Assess ABCs, defibrillation, when indicated, takes precedence over placement of the King LT(S)-D airway. ii. Begin chest compression and do not interrupt compressions for placement of the King LT(S)-D airway. iii. Follow the Cardiopulmonary Arrest protocol. 2. Respiratory arrest. B. Airway protection in critical patients with a loss of protective gag reflex when access to endotracheal intubation is not available. C. Contraindications for use of the KING LT(S)-D Airway are: 1. Responsive patients with an intact gag reflex. 2. Patients with known esophageal disease. 3. Patients who have ingested caustic substances. 4. Airway obstruction. 5. Patients under 4 feet in height – EMT-B Contraindication only D. EMT-B - Determining patient's height, choose the correct KING LT(S)-D size. 1. Patients 4 – 5 feet, tube size 3, yellow in color. 2. Patients 5 – 6 feet, tube size 4, red in color. 3. Patients greater then 6 feet, tube size 5, purple in color E. EMT-I & EMT-P – Determining patient’s height for patients less than 4 feet in height: 1. Patients 3.5 – 4 feet, tube size 2.5, orange in color. 2. Patients 3 – 3.5 feet, tube size 2, green in color. F. Attach a pulse oximeter, and monitor oxygen saturation. 2010 Yakima County Prehospital Care Protocols Updated July 2010 King LTS-D

G. If vomitus, blood or other foreign material is present in the hypopharynx, rapid and aggressive suctioning and/or manual removal must be done prior to attempting intubation with the King LT(S)-D Airway. H. Test the cuff inflation system by injecting the maximum recommended volume of air into the cuffs. Remove all air from cuffs prior to insertion. 1. Refer to Sizing Information chart for the maximum recommended volume of air. I. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings. J. Have a spare KING LT(S)-D ready and prepared for immediate use. K. Ventilate, patient with a bag-valve-mask (BVM) prior to insertion of the King LT(S)-D airway for 1-2 minutes prior to intubation attempt and ensure gag reflex is not intact. L. Position the patient’s head. The ideal head position for insertion of the KING LT(S)-D is the “sniffing position”. 1. However, the angle and shortness of the tube also allows it be inserted with the head in a neutral position. M. Hold the KING LT(S)-D at the connector with dominant hand. With non-dominant hand hold mouth open and apply chin lift unless contraindicated by C-spine precautions or patient position. N. With the KING LT(S)-D rotated laterally 45-90° such that the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue. 1. Never force the tube into position. O. As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin). P. Without exerting excessive force, advance KING LT(S)-D until base of connector aligns with teeth or gums. Q. Fully inflate cuffs using the maximum volume of the syringe included in the kit. 1. For KING LT(S)-D typical inflation volumes see Sizing Information chart.


King LTS-D

R. Attach the BVM to the 15 mm connector of the KING LT(S)-D. While gently bagging the patient to assess ventilation, simultaneously withdraw the airway until ventilation is easy and free flowing (large tidal volume with minimal airway pressure). 1. Depth markings are provided at the proximal end of the KING LT(S)-D that refer to the distance from the distal ventilatory openings. When properly placed with the distal tip and cuff in the upper esophagus and the ventilatory openings aligned with the opening to the larynx, the depth markings give an indication of the distance, in cm, to the vocal cords. S. Confirm proper position by auscultation, chest movement and verification of CO2 by capnography. T. Readjust cuff inflation to seal any air leaks. U. Secure KING LT(S)-D to patient using tape or other accepted means. A bite block can also be used, if desired. 1. DO NOT COVER THE PROXIMAL OPENING OF THE GASTRIC ACCESS LUMEN OF THE KING LTS-D. V. EMT-P – KING LTS-D ONLY – The gastric access lumen allows the insertion of up to an 18 Fr diameter gastric tube into the esophagus and stomach. Lubricate gastric tube prior to insertion. X. If patient regains consciousness or begins to fight the tube, restrain if necessary, and immediately remove the KING LT(S)-D Airway as follows: 1. Turn patient on his/her side. 2. Completely deflate cuffs. 3. Gently remove the KING LT(S)-D Airway. 4. Be prepared for the patient to vomit, and suction as needed. 5. Assure that patient's airway is patent and respirations are adequate, and assist ventilations as necessary. 6. Administer oxygen at 15 L/min per non-rebreather mask. 2010 Yakima County Prehospital Care Protocols Updated July 2010

King LTS-D

USE OF THE LMA SUPREME™ AIRWAY EMT-B, EMT-I & EMT-P A. Use of the LMA Supreme™ airway is indicated in the following situations: 1. Cardiopulmonary arrest a. In cardiopulmonary arrest the LMA Supreme™ Airway may be used as the primary airway. b. Assess ABCs, defibrillation, when indicated, takes precedence over placement of the LMA Supreme™ airway. c. Begin chest compressions and do not interrupt compressions for placement of the LMA Supreme™ airway. d. Follow the Cardiopulmonary Arrest protocol. 2. Respiratory arrest 3. Airway protection in critical patients with a loss of protective gag reflex when access to endotracheal intubation is not available. B. If vomitus, blood or other foreign material is present in the hypopharynx, rapid and aggressive suctioning and/or manual removal must be done prior to attempting intubation with the LMA Supreme™ Airway. C. Contraindications for use of the LMA Supreme™ Airway are: 1. Responsive patients with an intact gag reflex. 2. Patients with known hiatal hernia. 3. Patients who have ingested caustic substances. 4. Patients with pharyngeal trauma. 5. Airway obstruction. D. Determining patient’s weight, choose the correct LMA Supreme™ Airway size. 1. Adults below 70 kg or 160 pounds size 4 2. Adults above 70 kg or 160 pounds size 5 3. EMT-P – Children 30 – 50 kg or 66 – 110 pounds size 3 E. The LMA Supreme™ airway may be inserted with the patient in virtually any position. 1. Open sterilized pack and remove cuff protector. 2. Tightly deflate cuff to form a smooth wedge shape, without any wrinkles. a. Complete deflation promotes a better seal once inflated in place. 3. Generously lubricate the posterior cuff and curve of airway tube. 4. Hold the LMA Supreme© Airway at the fixation tab, with the distal end pointing downwards. 5. Press tip of cuff against hard palate, behind the incisors. 6. Rotate device inward with a circular motion, pressing against the contours of the hard and soft palate. 2010 Yakima County Prehospital Care Protocols Updated July 2010

LMA Supreme™

7. Continue to advance airway into hypopharynx until a definite resistance is felt. a. If the distance of the fixation tab falls between 1.5v cm – 2.5 cm this indicates the device is sized optimally and placed correctly. 8. Without holding the LMA Supreme©, inflate the cuff with just enough air to achieve a seal. a. A small outward movement is sometimes noticed as the device seats itself. 9. Use the fixation tab to secure the LMA Supreme© to the patient’s face with tape or an approved airway fixation device. F. Attach a bag-valve-mask to the standard connector to ventilate the patient. 1. Confirm proper position by auscultation and chest movement. a. EMT-P – verification of CO2 by capnography. 2. The drain tube is designed to passively channel fluid and gas safely away from the airway of the patient. a. When the LMA Supreme© is properly placed it creates two seals at the tracheal inlet and at the upper esophageal sphincter. These two seals are designed to separate the esophagus from the trachea for safer airway management. G. EMT-P – If active suctioning of the stomach is needed: 1. Pass an oral gastric tube through the gastric port on the LMA Supreme™. a. Oral gastric tube should be well lubricated. b. Pass the oral gastric tube slowly and carefully. c. Attach suction to the end of the oral gastric tube to clear stomach. H. If patient regains consciousness and/or gag reflex and/or begins to fight the tube, restrain if necessary, and immediately remove the LMA Supreme™ Airway as follows: 1. Turn patient on his/her side. 2. Completely deflate cuff. 3. Gently remove the LMA Supreme™ Airway. 4. Be prepared for the patient to vomit, and suction as needed. 5. Assure that the patient’s airway is patent and respirations are adequate. a. Assist ventilations as necessary. 6. Administer oxygen at 15 L/min per non-rebreather mask. 2010 Yakima County Prehospital Care Protocols Updated July 2010

LMA Supreme™

ESOPHAGEAL & TRACHEAL AIRWAYS USE OF THE ESOPHAGEAL TRACHEAL COMBITUBE (ETC) EMT-B, EMT-I & EMT-P A. Use of the Esophageal Tracheal Combitube (ETC) is indicated in the following situations: 1. Cardiopulmonary or Respiratory arrest. 2. Airway protection in critical patients with a loss of protective gag reflex when access to endotracheal intubation is not available. B. Defibrillation, when indicated, takes precedence over the Combitube. C. Ventilate, in accordance with protocols, 1-2 minutes prior to ETC intubation attempt. D. Determining patient's height, place head in a neutral position. E. Apply a water-soluble lubricant to the distal shaft of the tube and insert ETC into the mouth and direct it along the midline. Advance gently until the teeth (or gums) are aligned between the two black rings on the tube. F. For patients greater than 5 feet in height, use the regular adult size ETC as follows: 1. Using the large syringe, inflate Line 1 through the pilot balloon with 100 mL of air. 2. Using the small syringe, inflate Line 2 through the pilot balloon with 15 mL of air. G. For patients between 4 feet and 5 feet in height, use the small adult (SA) size ETC as follows: 1. Using the large syringe, inflate Line 1 through the pilot balloon with 85 mL of air. 2. Using the small syringe, inflate Line 2 through the pilot balloon with 12 mL of air. H. Attach a bag-valve-device with supplemental oxygen or OPVD to Tube No. 1, and begin ventilations. I. Using a stethoscope, listen for lung sounds in both lateral lung fields and over the epigastrium. 1. If lung sounds are present and there are no gastric sounds, continue ventilations. 2. If lung sounds are absent and gastric sounds are present, tracheal placement may have been accomplished. a. Remove the bag-valve-device or OPVD from Tube No. 1 and continue ventilations through Tube No. 2. 2010 Yakima County Prehospital Care Protocols Updated July 2010

ETC

b. Listen for lung sounds in both lateral lung fields and over the epigastrium. c. If lung sounds are absent and air exchange is heard over the epigastrium – deflate both cuffs, remove the ETC, and continue ventilations. d. If neither lung sounds nor gastric sounds are heard, deflate the oropharyngeal cuff and gently withdraw the ETC approximately 2-3 cm, and attempt to ventilate through Tube Number 1. J. The entire procedure should be accomplished within 30 seconds or less. K. If unsuccessful after the second attempt to insert the ETC, discontinue the procedure and continue ventilations using an alternative method. L. If esophageal intubation has occurred, consider attaching the mask elbow to Tube Number 2 to deflect the potential flow of stomach contents. M. Periodically check for appropriate placement of the ETC and adequate ventilations. N. If patient regains consciousness or begins to fight the tube, restrain if necessary, and immediately remove the ETC as follows: 1. Turn patient on his/her side. 2. Deflate both the pharyngeal and esophageal cuffs through Lines 1 and 2. 3. Gently remove the ETC. 4. Be prepared for the patient to vomit, and suction as needed. 5. Assure that patient's airway is patent and respirations are adequate, and assist ventilations as necessary. 6. Administer oxygen at 15 L/min per non-rebreather mask. O. If patient is to have an endotracheal tube placed by ALS or ILS personnel: 1. When the ALS or ILS provider is ready to intubate, deflate the pharyngeal cuff through Line 1. 2. Move the ETC to the left side of the patient's mouth. 3. After the endotracheal tube has been successfully placed, deflate the esophageal cuff through line 2 and gently remove the ETC. 2010 Yakima County Prehospital Care Protocols Updated July 2010

ETC

P. The Combitube is contraindicated, and should not be used with patients in the following situations: 1. An intact gag reflex. 2. Airway obstruction. 3. Patients under 4 feet in height. 4. Cases of known or suspected caustic ingestion. 5. Known esophageal disease. 6. Conscious or unconscious breathing patients. Q. Before releasing a patient, with an ETC in place, to another level of care (e.g., emergency physician, nurse, paramedic), the EMT performing the procedure must be certain that the receiving person is knowledgeable about the proper use and function of the device, and is aware that it is in place.

R. In the event an ETC has been placed, and the ambulance that will transport the patient is not staffed with personnel trained to use the device, then the EMT who performed the procedure will remain with the patient throughout transport, or until personnel with an equal or higher level of certification can assume patient care. S. EMT-P – ETC in esophageal position. 1. If an ETC has been placed prior to arrival of the EMT-Paramedic or ILS- Airway Technician, and the device is in the esophageal position, an endotracheal tube may be placed if transport to the hospital will exceed 30 minutes. 2. Continue ventilations while preparing for ET intubation. 3. Deflate the pharyngeal cuff through Line 1 and move the tube to the left side of the patient's mouth. 4. Perform direct laryngoscopy and endotracheal intubation. 5. After correct placement of the ET tube has been confirmed, deflate the distal cuff of the ETC through Line 2, and gently remove it. T. ETC in tracheal position. 1. If the ETC is in the tracheal position and functioning properly, it should be left in place. 2. If it is necessary to place a standard endotracheal tube, follow procedures as in Section S.2-5 above. 2010 Yakima County Prehospital Care Protocols Updated July 2010

ETC

ADVANCED AIRWAY MANAGEMENT EMT-P ENDOTRACHEAL INTUBATION The following is meant to provide a general protocol for endotracheal intubation (ET) and other advanced airway management procedures performed by the EMT- Paramedic. This procedure should be initiated in a short period of time, to prevent delay in the provision of adequate ventilation. A. Prior to deciding to intubate, the following questions concerning the patient must be considered. 1. Is there an immediate failure of maintenance of the airway? 2. Is there an immediate failure of protection of the airway? 3. Is there an immediate failure of ventilation? 4. Is there an immediate failure of oxygenation? 5. Is there a condition present, or is there a therapy required, that mandates intubation? B. Ensure open airway. C. Ventilate and preoxygenate for approximately 1-2 minutes with pocket mask or BVM and supplemental oxygen at 15 L/min or more, or OPVD. D. Using a laryngoscope and proper sized blade, perform direct laryngoscopy. 1. Consider having an assistant apply cricoid pressure using the Sellick's maneuver to occlude the esophagus (mandatory when performing RSI with succinylcholine). 2. Visualize the vocal cords and/or glottic opening, and advance endotracheal tube to the appropriate depth. E. If unable to accomplish endotracheal intubation within 30 seconds, withdraw and continue ventilations prior to a second attempt. F. Continue ventilations and confirm tube placement by: 1. Watching for chest rise. 2. Auscultation of the lateral lung fields and epigastrium with a stethoscope. 3. Capnography reading. 4. ET tube placement must be verified by a paramedic.


ET-Tube

G. Once ET tube placement has been confirmed, secure tube and continue ventilations with a bag-valve-device or flow-restricted OPVD (oxygen-powered ventilation device). H. Proper tube placement must be reassessed following any point at which a patient is moved (e.g., floor to stretcher; ambulance to emergency department, etc). I. A maximum of two total attempts at ET intubation on a single patient may be done prior to abandoning the procedure and using other alternatives. 1. If unsuccessful after two attempts at ET intubation, place an appropriate sized King Airway, Esophageal Tracheal Combitube (ETC) or LMA. 2. Do not use the ETC in patients under 4 feet in height. J. If a difficult airway is suspected an airway bougie may be helpful if available. 2010 Yakima County Prehospital Care Protocols Updated July 2010

ET-Tube

C-PAP (Continuous Positive Airway Pressure) EMT-P A. Indications for use of C-PAP are a patient who is in respiratory distress with signs and symptoms consistent with asthma, COPD, pulmonary edema, CHF, or pneumonia and who is: 1. Awake and able to follow commands. 2. Is over 12 years old and is able to fit the C-PAP mask. 3. Has the ability to maintain an open airway. 4. And exhibits two or more of the following: a. a respiratory rate greater than 25 breaths per minute. b. SPO2 of less than 94% at any time. c. use of accessory muscles during respirations. B. Contraindications for use of C-PAP are: 1. Patient is in respiratory arrest/apneic. 2. Patient is suspected of having a pneumothorax or has suffered trauma to the chest. 3. Patient has a tracheostomy. 4. Patient is actively vomiting or has upper GI bleeding. C. The following is the procedure for use of the C-PAP: 1. EXPLAIN THE PROCEDURE TO THE PATIENT. 2. Ensure adequate oxygen supply to ventilation device. 3. Place the patient on continuous pulse oximetry. 4. Place the patient on cardiac monitor (if available) and record rhythm strips with vital signs. 5. Place the delivery device over the mouth and nose. 6. Secure the mask with provided straps or other provided devices. 7. Use 5 cm H2O of PEEP valve. 8. Check for air leaks. 9. Monitor and document the patient’s respiratory response to treatment. 10. Check and document vital signs every 5 minutes. 11. Administer appropriate medication as certified (continuous nebulized Albuterol for COPD/Asthma and repeated administration of nitroglycerin spray or tablets for CHF). 12. Continue to coach patient to keep mask in place and readjust as needed. 13. Contact medical control to advise them of C-PAP initiation. 14. If respiratory status deteriorates, remove device and consider intermittent positive pressure ventilation via BVM and/or placement of King Airway or Combitube or endotracheal intubation. 2010 Yakima County Prehospital Care Protocols Updated July 2010

C-PAP

D. Removal procedure for C-PAP is as follows: 1. C-PAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences respiratory arrest or begins to vomit. 2. Intermittent positive pressure ventilation with a BVM, placement of a King Airway or Combitube and/or endotracheal intubation should be considered if the patient is removed from C-PAP therapy. E. Special Considerations 1. Do not remove C-PAP until hospital therapy is ready to be placed on patient. 2. Watch patient for gastric distention, which can result in vomiting. 3. Procedure may be performed on patient with Do Not Resuscitate Order. 4. Due to changes in preload and after load of the heart during C-PAP therapy, a complete set of vital signs must be obtained every 5 minutes.


C-PAP

CAPNOGRAPHY EMT-P A. Capnography (PETCO2 monitoring) is a non-invasive method that measures CO2 in exhaled gases, thus providing an evaluation of ventilatory status. Capnography may be used as an additional tool to compliment sound clinical skills and patient assessment and may be used on intubated patients. 1. Capnography is not affected by administering medications via endotracheal tube. 2. Water of secretions accumulating in the sensor may cause inaccurate readings. 3. The sensor is very easily damaged. Replace if inaccurate readings occur. 4. Capnography is a good clinical indicator of successful resuscitation and/or effective CPR, because readings within the normal values indicate organ perfusion. B. For patients who are intubated: 1. Provide ventilatory assistance to maintain CO2 readings at 38-45 mmHg (3.5% to 5.5%). 2. Confirm tube placement by auscultating breath sounds. 3. Attach the sensor into the locking bracket on the micro stream cable. 4. Attach the sensor to the endotracheal tube. a. CO2 readings (<0.5%) and no waveform would indicate a possible misplaced ET tube. C. Causes of increased ETCO2: 1. fever. 2. sepsis. 3. Sodium Bicarbonate administration. 4. increased metabolic rate. 5. seizures. 6. respiratory depression. 7. muscular paralysis. 8. hypoventilation. 9. COPD. 10. rebreathing. 11. leak in ventilator circuit. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Capnography

D. Causes of decreased ETCO2: 1. hypothermia. 2. pulmonary hypoperfusion. 3. cardiac arrest. 4. pulmonary embolism. 5. hemorrhage. 6. ventilator disconnect. 7. misplaced tube. 8. complete airway obstruction. 9. poor sampling. 10. leak around ET tube and cuff. 11. hypotension. 12. hyperventilation. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Capnography

CRICOTHYROIDOTOMY EMT-P A. The following situations may warrant the use of needle or surgical Cricothyroidotomy: 1. Acute upper airway obstruction not relieved by advanced airway maneuvers, and unable to ventilate by BVM. 2. Patients in respiratory arrest secondary to massive facial injuries, which prevents orotracheal or Combitube intubation, or BVM ventilation. 3. Patients with neck/tracheal injury, where endotracheal or King Airway or Combitube intubation attempts have been unsuccessful, and unable to ventilate by BVM. B. While continuing attempts to ventilate, place the patient in a supine position and hyperextend the head and neck. If a spinal injury is suspected, the head and neck should be maintained in a neutral, in-line position. C. Locate the patient's cricothyroid membrane and prep the area with providone- iodine swabs. D. To perform a needle cricothyroidotomy: 1. Attach a 12-gauge catheter over-the-needle (16-gauge for pediatric patients) device to a 10 cc syringe; fill the syringe with 1 – 2 cc NaCl. 2. Insert the needle/catheter in the midline, through the skin and membrane. Direct the needle posterior and caudally at a 45° angle to the trachea. 3. Advance the needle and catheter while maintaining negative pressure with the syringe. Air should readily fill the syringe when the trachea is entered. 4. Advance the catheter over the needle until the hub is flush with the skin, and then remove the needle and syringe. 5. Connect a #3.0 ET tube adapter to the catheter, then attach a bag-valve device and begin ventilations. 6. Check for adequacy of ventilations. 7. Dress and secure the wound site. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cricothyroidotomy

E. If long transport time and unable to maintain the airway, perform surgical cricothyroidotomy as follows: 1. Make a horizontal incision, approximately 2-3 cm long, cutting through the skin and membrane with a #11 scalpel blade angled away from the head. 2. Using one hand on the larynx to stabilize it (use an assistant if necessary), insert the scalpel handle, and rotate 90° to spread the cartilage. 3. Insert a small-cuffed ET tube (5.0-6.0 mm) into the cricothyroid membrane, directing the tube distally into the trachea. 4. Inflate the cuff, attach a bag-valve-device, and ventilate. 5. Check for adequacy of ventilations. 6. Dress and secure the wound site. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Cricothyroidotomy

NASAL INTUBATION EMT-P This protocol is meant as a guideline to highlight essential steps in the intubation process. The key factor to successful nasal intubation is picking the right patient and circumstances to perform the maneuver. The ideal patient is comatose, profoundly lethargic or potentially sedated. The patient must be breathing spontaneously and have no potential midface of nasal fractures or significant trauma. Ideal patients for this procedure would include drug overdoses, strokes/bleeds, and nearly obtunded COPD/CHF patients. A. The patient should be assessed for the need of intubation, including: 1. Impending airway closure 2. Inability to protect airway 3. Impending respiratory failure 4. Profound hypoxemia despite oxygen therapy B. The patient must be breathing spontaneously, have a patent nasal passage, no evidence of significant nasal or midface trauma or factures, be cooperative or obtunded. C. The straightest and least congested nasal passage should be identified and prepped with Afrin® nasal spray if possible. D. A 6.5 or 7.0 endotracheal tube should be coated with Lidocaine jelly and bent into a “C” shaped curve. E. The patient may be sedated with midazolam 2 – 10mg IV or morphine sulfate 2 – 10 mg IV. F. Insert the endotracheal tube into the nasal passage and attempt to push it into the lower pharynx. Do not force the tube if substantial resistance is met. G. Position the head in the sniffing position if spine injury is not a concern. H. Listen over the endotracheal tube opening and watch for rise and fall of the chest, then advance tube into the trachea at the beginning of a spontaneous breath, and advance it as far as possible. I. Confirm placement by breath sounds, fog in tube, oximetry and ETCO2 if available. J. If not successful after three attempts then proceed to a different airway management technique. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Nasal Intubation

RAPID SEQUENCE INTUBATION (RSI) WITH NEUROMUSCULAR BLOCKADE EMT-P A. Ensure that a functioning and secure IV line is in place. B. Establish a cardiac monitor. C. In adult patients with the potential for an elevated ICP (e.g., head injury; IC bleed; hypertensive crises), or those with ventricular dysrhythmias, premedicate with lidocaine, 1 mg/kg IV, prior to administration of succinylcholine. D. Administer etomidate, 0.3 mg/kg, IV push, unless unconscious and unresponsive. E. In children and adolescents, administer atropine, 0.02 mg/kg (minimum of 0.1 mg, and a maximum of 0.5 mg) IV push. F. Approximately 45-60 seconds following administration of etomidate, administer succinylcholine, 1.5 mg/kg IV push. G. Proceed with ET intubation in accordance with applicable protocol. H. If patient becomes combative or requires additional sedation during transport, administer repeated doses of midazolam 2 – 10mg IV or morphine sulfate 2 – 10 mg IV or fentanyl at 50 micrograms, up to a total of 500 micrograms. If still unable to control patient, administer vecuronium 0.1 mg/kg IV push. I. Place NG, if time allows, for decompression. Rapid Sequence Intubation Addendum Paralytic agents (Succinylcholine) may be used without medical control contact in the following circumstances: 1. Any trauma patient with a GCS score of 8 or less. 2. Any patient in which the loss of a patent airway could occur in less than 5 minutes (burn patient with airway edema, anaphylaxis, epiglottitis). For all other circumstances and conditions, paralytic agents may only be used with the authorization of Medical Control. 1. If Medical Control leaves the intubation to the discretion of the paramedic, the paramedic may use paralytics to intubate. 2. Intubation of patients not requiring paralysis may still be performed without Medical Control contact. 2010 Yakima County Prehospital Care Protocols Updated July 2010

RSI

RETROGRADE TRACHEAL INTUBATION EMT-P A. Indications for retrograde intubation: 1. Moderate to severe maxillofacial trauma. 2. High index of suspicion for cervical spine injury. 3. Inability to intubate patient orally due to anatomy, injury, etcetera. B. Remember to preoxygenate the patient using a BVM, it is possible to continue ventilating the patient during placement of the needle and guide wire. C. To perform a retrograde tracheal intubation: 1. Locate the cricothyroid membrane and clean the area with providone- iodine. 2. Puncture the cricothyroid membrane with the needle, aiming upwards toward the head at a 45° angle; once through the membrane, aspirate air to verify placement. 3. Pass guide wire through the cricothyroid needle aimed so that distal end of the wire may be retrieved from the mouth of patient. Withdraw needle off the wire. 4. Load ETT over oral end of the wire, passing the wire into the tube through Murphy's eye. 5. Pull the wire relatively taught and straight. 6. Advance ETT over the wire into the trachea to cricoid area, gradually relaxing the cricothyroid end of the wire, advance ETT to appropriate intratracheal location. 7. Release the cricothyroid end of the wire and withdraw the wire out of ETT. 8. Verify placement by use of the EDD and confirm bilateral breath sounds, then secure the tube. D. If using the Cook™ retrograde intubation tray, follow the directions included in the kit. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Retrograde Tracheal Intubation

APPENDIX B – IV THERAPY AND BLOOD DRAWS INTRODUCTION EMT-I & EMT-P The following protocol is meant to serve as a general procedural guideline when performing venipunctures, venous cannulations, intraosseous using the Vidacare™ EZ- IO™ and blood draws. ASEPTIC TECHNIQUE A. Whenever possible, sterile procedures must be used when performing venipuncture and venous cannulation. 1. Prepare the venipuncture site with a providone-iodine solution (Betadine©), and allow to dry prior to initiating the procedure. 2. If necessary in order to facilitate visualization of the vein, the providone- iodine solution may be wiped away (after drying) with an alcohol swab. B. In the rare circumstance that it becomes necessary to use a limited or non- sterile technique, due to the emergent nature of the patient's illness or injury, or environmental conditions: 1. Notify the attending emergency physician or nurse after arriving at the hospital. 2. On the medical incident report, document both the lack of aseptic technique, and the name of the individual at the hospital who was notified of such. GENERAL PROCEDURES A. Venipunctures may be performed only when clinically indicated and in accordance with applicable protocols. B. In the conscious, non-critical patient, no more than two attempts at peripheral venipuncture should be performed before the procedure is abandoned. C. If the patient is critical and unconscious, and venipuncture attempts in the upper extremities have been unsuccessful, consider cannulation of the external jugular vein. D. Also, if patient already has a central line, consider use of the central line.

E. Consider use of Vidacare EZ-IO™. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Aseptic Technique, General Procedures

BLOOD DRAWS A. Blood may be drawn as indicated in the protocols, and must occur at the time intravenous procedures are being performed. B. Prior to connecting IV tubing and fluid, attach a Vacutainer® or syringe and fill one blue-top, one green-top, and one lavender-top, and one red-top blood tube. C. Label blood tubes appropriately (patient’s name, the date, time, EMS provider's initials) and tape to the IV bag. D. Legal Alcohol Determination: 1. Blood may be drawn for legal alcohol determination at the request of law enforcement, as provided by RCW 46.61.520, RCW 46.61.522. This may be done only if: a. The patient's condition indicates the need for IV therapy as required per protocol. b. The procedure would not result in a delay that could potentially be detrimental to the patient. c. The patient is unconscious. d. The patient is under arrest for the crime of vehicular homicide or vehicular assault. e. The patient is under arrest for the crime of driving while under the influence of intoxicating liquor or drugs, which arrest results from an accident in which another person is injured and there is a reasonable likelihood that such a person may die as a result of the injuries sustained in the accident. 2. Law enforcement must complete and sign the Yakima County Direction to Take Blood Test form and return it to the provider while at the scene. 3. Attach the completed form to your agency's copy of the medical incident report (a copy may also be attached to the patient's hospital chart). 4. Document the procedure on the medical incident report form. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Blood Draws

INTERFACILITY TRANSPORT OF PATIENTS EMT-P A. Paramedics may transport patients with blood or other blood products running, if the blood products have been running for at least a 1/2 hour before the interfacility transport. 1. If there is the possibility that the blood product bag will need to be changed during the transport, then a nurse must accompany the patient. 2. Paramedics may not start a blood transfusion. B. Paramedics may transport patients without a nurse on board when the medication drips include those drugs listed on the “Prehospital Medication List”, which is located inside this document. 1. If the drug a patient is receiving is not listed in the “Prehospital Medication List” the drug should be discontinued or a nurse must accompany the patient during transport. 2. If the drug cannot be discontinued or you are in any doubt contact your Medical Program Director. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Interfacility Transports

FLUID THERAPY EMT-I & EMT-P A. Indications for IV fluid therapy include: 1. There is a high risk of internal hemorrhage (i.e., signs & symptoms, MOI) 2. Signs of shock exist (i.e., hypotension, tachycardia, pale or cool skin) 3. Hypotension 4. Hypovolemia (i.e., dehydration) 5. Hyperglycemia 6. Alcohol Withdrawals with Delirium Tremens B. Special Considerations 1. Avoid extremities where a dialysis shunt is present. This may be used as a last and final option if access is important to the patients’ survival. 2. Avoid extremities where a fracture exists. If multiple extremity fractures exist place IV above the fracture site. C. The amount of fluid given to a patient will vary based on the patients’ condition and needs for fluid, their size, weight and age. The following is meant to be utilized as a guideline and is not meant to replace the judgment of the EMT- Intermediate or Paramedic providing care. 1. Trauma Patients a. Give 1000ml bolus of Normal Saline, repeat at 500ml of NS. i. Monitor blood pressure every 5 minutes, maintain a systolic blood pressure of 90. 2. Medical Patients a. 200ml bolus of Normal Saline, followed by repeat vital signs including lung sounds i. Until improved mentation is achieved. ii. The patient has relief in symptoms (i.e., decreased DT’s, increased BP or decrease in heart rate if tachycardic) 3. Pediatric patients a. 20ml/kg bolus of Normal Saline, followed by repeat vital signs i. It is recommended that a Buretrol 60 drop set containing a 150ml chamber, be utilized on infants & children less than 7.5 kg or 15 lbs. ii. Any infant or child who is classified as “Pink” or “Grey” inside the Broselow tape (2007 Version B). 2010 Yakima County Prehospital Care Protocols Updated July 2010

Fluid Therapy

VIDACARE EZ-IO™ PROCEDURES IV, EMT-I & EMT-P A. The EZ-IO™ AD should be used on adult patients (greater than 40 kg or 16 years of age) or the EZ-IO™ PD should be used on pediatric patients (3 -39 kg) who: 1. Need IV fluids or medications and a peripheral IV cannot be established in 2 attempts or 90 seconds and exhibit 1 or more of the following: a. An altered mental status (GCS of 8 or less). b. Respiratory compromise (SpO2 < 80% after appropriate oxygen therapy, respiratory rate < 10/min or > 40/min). c. Hemodynamic instability (Systolic BP < 90 mmHg) 2. EZ-IO™ may be considered PRIOR to peripheral IV attempts in the following situations: a. Cardiac arrest (medical or traumatic). b. Profound hypovolemia with alteration of mental status. B. Contraindications for use of the EZ-IO™ are as follows: 1. Fracture of the tibia or femur (consider alternate tibia). 2. Previous orthopedic procedures (IO within 24 hours, knee replacement) (consider alternate tibia). 3. Pre-existing medical condition involving that extremity. 4. Infection at insertion site (consider alternate tibia). 5. Inability to locate landmarks (significant edema). 6. Excessive tissue at insertion site (obesity). C. Special Considerations with use of the EZ-IO™: 1. Flow rates: a. Due to the anatomy of the intraosseous space, flow rates will be slower than those achieved with IV catheters. b. Initially infuse a rapid bolus of 10 mL of normal saline. c. Use a pressure bag to ensure continuous infusion. 2. Pain: a. Insertion of the EZ-IO™ in conscious patients causes mild to moderate discomfort but is usually no more painful than a large bore IV. b. IO infusion can cause severe discomfort for conscious patients. c. EMT-P - Prior to IO flush on alert patients, SLOWLY administer 40 mg (or 2ml) 2% IV Lidocaine through the EZ-IO™ hub. 2010 Yakima County Prehospital Care Protocols Updated July 2010

EZ-IO

D. The following is the procedure for using the EZ-IO™. If the patient is conscious, advise him/her of the EMERGENT NEED for this procedure and obtain consent. 1. Wear approved body substance isolation. 2. Locate and cleanse insertion site using aseptic technique. 3. Prepare the EZ-IO™ driver and needle set. 4. Stabilize leg. 5. Insert EZ-IO™ needle set. 6. Remove EZ-IO™ driver from needle set while stabilizing catheter hub. 7. Remove stylet from needle set and dispose in sharps container. 8. Confirm placement. 9. EMT-P - If the patient is conscious, administer 40 mg (2ml) 2% Lidocaine IO and wait 15 seconds. 10. Bolus the EZ-IO™ catheter with 10ml of normal saline. 11. Connect the IV tubing. 12. Place a pressure bag on solution being infused and adjust the flow rate, as desired. 13. Monitor EZ-IO™ site and patient condition. 14. Document use of EZ-IO™ in the medical incident report. 2010 Yakima County Prehospital Care Protocols Updated July 2010

EZ-IO

APPENDIX C - PREHOSPITAL MEDICATIONS LIST Activated charcoal (Charcola®) Adenosine (Adenocard®) Afrin Nasal Spray Albuterol (Proventil®) Amiodarone Aspirin (ASA) Atropine sulfate Calcium Gluconate D5-1/2 NS D25W (Dextrose) D50W (Dextrose) Diphenhydramine (Benadryl®) Diltiazem (Cardizem®) Dolasetron Mesylate (Anzemet) Dopamine (Intropin®) Epinephrine, 1:10,000 Epinephrine, 1:1000 EpiPen Injector (Adult/Junior) Etomidate Fentanyl Furosemide (Lasix®) Glucagon Haloperidol (Haldol) Heparin Ipratropium (Atrovent) Lactated Ringers Lidocaine, 100 mg (Xylocaine®) Lidocaine Drip, 1 gm, Vial or Pre-load (Xylocaine®) Lorazepam (Ativan®) Magnesium sulfate Methylprednisolone (Solu-Medrol) Midazolam (Versed) Morphine sulfate Naloxone (Narcan®) Nitroglycerin (Nitro Stat®) NitroPaste Oxytocin (Pitocin®) Oral Glucose Plavix (Clopidogrel Bisulfate) Promethazine (Phenergan) Sodium bicarbonate (NaHCO3) Succinylcholine (Anectine®) Thiamine (Betalin®) Vasopressin Vecuronium Zofran (ondansetron) 2010 Yakima County Prehospital Care Protocols Updated July 2010

Prehospital Medication Drug List

APPENDIX D STATE OF WASHINGTON PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURE

Purpose The purpose of the Triage Procedure is to ensure that major trauma patients are transported to the most appropriate hospital facility. This procedure has been developed by the Prehospital Technical Advisory Committee (TAC), endorsed by the Governor’s EMS and Trauma Care Steering Committee, and in accordance with RCW 70.168 and WAC 246-976 adopted by the Department of Health (DOH). The procedure is described in the schematic with narrative. Its purpose is to provide the prehospital provider with quick identification of a major trauma victim. If the patient is a major trauma patient, that patient or patients must be taken to the highest level trauma facility within 30 minutes transport time, by either ground or air. To determine whether an injury is major trauma, the prehospital provider shall conduct the patient assessment process according to the trauma triage procedures. Explanation of Process A. Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma system. This may include requesting more advanced prehospital services or aero-medical evacuation. B. The first step (1) is to assess the vital signs and level of consciousness. The words “Altered mental status” mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to painful stimuli only, or a verbal response which is confused, or an abnormal motor response. The “and/or” conditions in Step 1 mean that any one of entities listed in Step 1 can activate the trauma system. Also, the asterisk(*) means that if the airway is in jeopardy and the on-scene person cannot effectively manage the airway, the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit. These factors are true regardless of the assessment of other vital signs and level of consciousness. C. The second step (2) is to assess the anatomy of injury. The specific injuries noted require activation of the trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence of any of the specific anatomical injuries does require activation of the trauma system. Please note that steps 1 and 2 also require notifying Medical Control. D. The third step (3) for the prehospital provider is to assess the biomechanics of the injury and address other risk factors. The conditions identified are reason for the provider to contact and consult with Medical Control regarding the need to activate the system. They do not automatically require system activation by the prehospital provider. Other risk factors, coupled with a “gut feeling” of severe injury, means that Medical Control should be consulted and consideration given to transporting the patient to the nearest trauma facility. Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate transport or referral to a burn center/unit. Patient Care Procedures To the right of the attached schematic you will find the words “according to DOH-approved regional patient care procedures.” These procedures are developed by the regional EMS and Trauma council in conjunction with local councils. They are intended to further define how the system is to operate. They identify the level of medical care personnel who participate in the system, their roles in the system, and participation of hospital facilities in the system. They also address the issue of inter-hospital transfer, by transfer agreements for identification, and transfer of critical care patients. In summary, the Prehospital Trauma Triage Procedure and the Regional Patient Care Procedures are intended to work in a “hand in glove” fashion to effectively address EMS and Trauma patient care needs. By functioning in this manner, these two instruments can effectively reduce morbidity and mortality. If you have any questions on the use of either instrument, you should bring them to the attention of your local or regional EMS and Trauma council or contact 1-800-458-5281. 2010 Yakima County Prehospital Care Protocols Updated July 2010

Trauma Triage Tool

STATE OF WASHINGTON PREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURE EFFECTIVE DATE 1/95

Prehospital triage is based on the following 3 steps: Steps 1 and 2 require prehospital EMS personnel to notify Medical

Control and activate the Trauma System. Activation of the Trauma System in Step 3 is determined by Medical Control.** STEP 1 ASSESS VITAL SIGNS & LEVEL OF CONSCIOUSNESS • Systolic BP <90* • HR >120* *for pediatric (<15y) pts. use BP <90 or capillary refill >2 sec. *for pediatric (<15y) pts. use HR <60 or >120 • Any of the above vital signs associated with signs and symptoms of shock • and/or • Respiratory Rate <10 >29 associated with evidence of distress and/or • Altered mental status

**If prehospital personnel are unable to effectively manage airway, consider rendezvous with ALS, or intermediate stop at nearest facility capable of immediate definitive airway management.

YES

1. Take patient to the highest level trauma center within 30 minutes transport time via ground or air transport according to DOH approved regional patient care procedures.

NO

STEP 2

ASSESS ANATOMY OF INJURY • Penetrating injury of head, neck, torso, groin; OR • Combination of burns ≥20% or involving face or airway; OR • Amputation above wrist or ankle; OR • Spinal Cord injury; OR • Flail chest; OR • Two or more obvious proximal long bone fractures.

YES

2. Apply “Trauma ID Band” to patient.

NO

STEP 3

1. Take patient to the highest level trauma center within 30 minutes transport time via

ASSESS BIOMECHANICS OF INJURY AND OTHER RISK FACTORS

• Death of same car occupant; OR • Ejection of patient from enclosed vehicle; OR • Fall ≥20 feet; OR • Pedestrian hit at ≥20 mph or thrown 15 feet • High energy transfer situation • Rollover • Motorcycle, ATV, bicycle accident • Extrication time of > 20 minutes • Extremes of age <15 or >60 • Hostile environment (extremes of heat or cold) • Medical illness (such as COPD, CHF, renal failure, etc.) • Second/third trimester pregnancy • Gut feeling of EMS provider

YES

CONTACT MEDICAL CONTROL FOR DESTINATION DECISION

YES

ground or air transport according to DOH approved regional patient care procedures.

2. Apply “Trauma ID Band” to patient.

NO NO

TRANSPORT PATIENT PER REGIONAL PATIENT CARE PROCEDURE

Appendix E – DRUG REFERENCE Activated Charcoal Class: Adsorbent Actions: Adsorbs toxins by chemical binding and prevents gastrointestinal adsorption. Indications: Poisoning following emesis or when emesis is contraindicated. Contraindications: None in severe poisoning. Precautions: Should only be administered following emesis, in cases in which it is so indicated. Use with caution in patients with altered mental status. May adsorb Ipecac before emesis; If Ipecac is administered, wait at least 10 minutes to administer activated charcoal. Side Effects: Nausea, vomiting, and constipation. Dosage: 1 g/kg (typically 50-75 grams) mixed with a glass of water to form a slurry. Routes: Oral Pediatric Dosage: 1 g/kg mixed with a glass of water to form a slurry Adenosine (Adenocard) Class: Antiarrhythmic Actions: slows AV conduction Indications: symptomatic PSVT Contraindications: second- or third-degree heart block, sick-sinus syndrome, known hypersensitivity to the drug. Precautions: Arrhythmias, including blocks, are common at the time of cardioversion. Use with caution in patients with asthma. Side Effects: Facial flushing, headache, shortness of breath, dizziness, and nausea. Dosage: 6 mg given as a rapid IV bolus over a 1-2 second period; if, after 1-2 minutes, cardioversion does not occur, administer a 12-mg dose over 1-2 seconds. Routes: IV; should be administered directly into a vein or into the medication administration port closest to the patient and followed by flushing of the line with IV fluid. Pediatric Dosage: Safety in children has not been established. Afrin Nasal Spray Class: Vasoconstrictor Actions: Decongestant Indications: Patient meets the indications for nasal intubation. Contraindications: Recent monoamine oxidase (MAO) inhibitor use such as Marplan, Nardil, Parnate. Precautions: Use caution if patient is pregnant, has hypertension, heart disease, diabetes, liver or kidney disease Side Effects: Allergic Reaction, dizziness, hypertension, headache, irregular or fast heartbeat Dosage: Metered Dose Inhaler: 1-2 sprays

Routes: Nasal Spray Pediatric Dosage: Do not use with children. Albuterol (Proventil) (Ventolin) Class: Sympathomimetic (ß2 selective) Actions: Bronchodilation Indications: Asthma reversible bronchospasm associated with COPD Contraindications: Known hypersensitivity to the drug, symptomatic tachycardia Precautions: Blood pressure, pulse, and EKG should be monitored use caution in patients with known heart disease Side Effects: Palpitations, anxiety, headache, dizziness, and sweating Dosage: Metered Dose Inhaler: 1-2 sprays (90 micrograms per spray) Small-Volume Nebulizer: 0.5 ml (2.5 mg) in 2.5 ml normal saline over 5-15 minutes Rotohaler: one 200-microgram rotocap should be placed in the inhaler and breathed by the patient Routes: Inhalation Pediatric Dosage: 0.15 mg (0.03 ml)/kg in 2.5 ml normal saline by small volume nebulizer Amiodarone Class: Anti-arrhythmic agent Actions: Anti-dysrrhythmia Indications: Ventricular and supraventricular arrhythmias. Contraindications: Patients with history of hypersensitivity to the drug, sinus nodal bradycardia, AV block, 2nd & 3rd degree heart blocks. Precautions: Use with caution if the patient is pregnant or nursing. Not to be given with Lidocaine, increases risk of Asystole. Amiodarone can worsen the cardiac arrhythmia brought on by Digitalis poisoning Side Effects: Pulmonary toxicity, exacerbation of arrhythmia, and rare serious liver injury Dosage: 300mg cardiac arrest, 150mg over 10 minutes for ventricular dysrhythmias Routes: IV, IO Pediatric Dosage: 5mg/kg Aspirin (Bufferin) Class: Platelet inhibitor/anti-inflammatory. Actions: Blocks platelet aggregation. Indications: New-onset chest pain suggestive of MI signs and symptoms suggestive or recent CVA. Contraindications: Patients with history of hypersensitivity to the drug. Precautions: GI bleeding and upset. Side Effects: Heartburn, nausea and vomiting, wheezing. Dosage: 150-325 mg PO or chewed.

Routes: PO. Pediatric Dosage: not recommended. Atropine Class: Parasympatholytic (anticholinergic). Actions: Blocks acetylcholine receptors, increases heart rate, decreases gastrointestinal secretions. Indications: Hemodynamically-significant bradycardia, hypotension secondary to bradycardia, asystole, organophosphate poisoning. Contraindications: None when used in emergency situations. Precautions: Dose of 0.04 mg/kg should not be exceeded except in cases of organophosphate poisonings, tachycardia, hypertension. Side Effects: Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation, and blurred vision, urinary retention (especially older males). Dosage: Bradycardia: 0.5 mg every 5 minutes to maximum of 0.04 mg/kg. Asystole: 1 mg. Organophosphate poisoning: 2-5 mg. Routes: IV, ET (ET dose is 2 - 2.5 times IV dose). Pediatric Dosage: Bradycardia: 0.02 mg/kg Maximum single dose (child 0.5 mg) (adolescent 1.0 mg) Maximum total dose (child 1.0 mg) (adolescent 2.0 mg) Calcium Chloride (CaCl) Class: Electrolyte. Actions: Increases cardiac contractility. Indications: Acute hyperkalemia (elevated potassium), acute hypocalcemia (decreased calcium), calcium channel blocker (Nifedipine, Verapamil, etc.), overdose, abdominal muscle spasm associated with spider bite and portuguese man-o-war stings, antidote for magnesium sulfate. Contraindications: Patients receiving digitalis. Precautions: IV line should be flushed between calcium chloride and sodium bicarbonate administration. Extravasation may cause tissue necrosis. Side Effects: Arrhythmias (bradycardia and asystole), hypotension. Dosage: 2-4 mg/kg of a 10% solution; may be repeated at 10-minute intervals. Routes: IV. Pediatric Dosage: 5-7 mg/kg of a 10% solution. Dextrose 50% Class: Carbohydrate. Actions: Elevates blood glucose level rapidly.

Indications: Hypoglycemia. Contraindications: None in the emergency setting. Precautions: A blood sample should be drawn before administering 50% dextrose. Side Effects: Local venous irritation. Dosage: 25 grams (50 ml). Routes: IV. Pediatric Dosage: 0.5 g/kg slow IV; should be diluted 1:1 with sterile water to form a 25% solution. Diltiazem (Cardizem) Class: Calcium channel blocker. Actions: Slows conduction through the AV node, causes vasodilation, decreases rate of ventricular response, decreases myocardial oxygen demand. Indications: To control rapid ventricular response associated with atrial fibrillation and flutter. Contraindications: Hypotension, wide complex tachycardia, conduction system disturbances. Precautions: Should not be used in patients receiving intravenous ß blockers. Hypotension. Must be kept refrigerated or discarded one month after removal from refrigeration. Side Effects: Nausea, vomiting, hypotension, and dizziness. Dosage: 0.25 mg/kg bolus (typically 20 mg) IV over 2 minutes. This should be followed by a maintenance infusion of 5-15 mg/hour. Routes: IV, IV drip. Pediatric Dosage: Rarely used. Dolasetron Mesylate (Anzemet) Class: Serotonin 5HTe receptor antagonist Actions: Used to treat nausea and vomiting after chemotherapy. Its main effect is to reduce the activity of the vagus nerve, which is a nerve that activates the vomiting center in the medulla oblongata. Indications: Contraindications: Precautions: Side Effects: Headache, dizziness, constipation, prolonged QT interval can occur as well. Dosage: 12.5 mg Routes: IV Pediatric Dosage: 1.2mg/kg Diphenhydramine (Benadryl) Class: Antihistamine. Actions: Blocks histamine receptors, has some sedative effects. Indications: Anaphylaxis, allergic reactions, dystonic reactions due to phenothiazines.

Contraindications: Asthma, nursing mothers. Precautions: Hypotension. Side Effects: Sedation, dries bronchial secretions, blurred vision, headache, palpitations. Dosage: 25-50 mg. Routes: Slow IV push deep IM. Pediatric Dosage: 2-5 mg/kg. Dopamine (Intropin) Class: Sympathomimetic. Actions: Increases cardiac contractility, causes peripheral vasoconstriction. Indications: Hemodynamically significant hypotension (systolic BP of 70-100 mmhg) not resulting from hypovolemia, cardiogenic shock. Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred. Precautions: Should not be administered in the presence of severe tachyarrhythmias. Should not be administered in the presence of ventricular fibrillation, ventricular irritability. Beneficial effects lost when dose exceeds 20 µg/kg/min. Side Effects: Ventricular tachyarrhythmias, hypertension, palpitations. Dosage: 2-20 µg/kg/minute. Start low and increase as needed. Method: 800 mg should be placed in 500 ml of D5W giving a concentration of 1600 µg/ml. Routes: IV drip only. Pediatric Dosage: 2-20 µg/kg/minute. Epinephrine (Adrenalin): Description: A hormone produced by the adrenal gland (attached to the kidneys) and synthesized commercially. It is employed therapeutically as a vasoconstrictor, as a cardiac stimulant, and to relax bronchioles. It is also used to treat asthmatic attacks and treat anaphylactic shock. Epinephrine 1:1,000 Class: Sympathomimetic. Actions: Bronchodilation. Indications: Bronchial asthma, exacerbation of COPD, allergic reactions. Contraindications: Patients with underlying cardiovascular disease, hypertension, pregnancy, patients with tachyarrhythmias. Precautions: Should be protected from light. Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations and tachycardia, anxiousness, headache, tremor. Dosage: 0.3-0.5 mg. Routes: Subcutaneous (IV and ET for pediatric cardiac arrest). Pediatric Dosage: 0.01 mg/kg up to 0.3 mg.

Epinephrine 1:10,000 Class: Sympathomimetic. Actions: Increases heart rate and automaticity. Increases cardiac contractile force. Increases myocardial electrical activity. Increases systemic vascular resistance. Increases blood pressure. Causes bronchodilation. Indications: Cardiac arrest, anaphylactic shock severe reactive airway disease. Contraindications: Epinephrine 1:10,000 is for intravenous or endotracheal use; it should not be used in patients who do not require extensive resuscitative efforts. Precautions: Should be protected from light. Can be deactivated by alkaline solutions. Side Effects: Palpitations, anxiety, tremulousness, nausea and vomiting. Dosage: cardiac arrest: 0.5-1.0 mg repeated every 3-5 minutes. severe anaphylaxis: 0.3-0.5 mg (3-5 ml); occasionally and Epinephrine drip is required. Routes: IV, IV drip, ET. Pediatric Dosage: 0.01 mg/kg initially with subsequent doses, Epinephrine 1:1,000 should be used at a dose of 0.1 mg/kg. Epinephrine Autoinjector Class: Adrenaline Actions: Bronchodilator, vasoconstrictor Indications: Severe allergic reactions or anaphylactic shock Contraindications: Precautions: Side Effects: Rapid heart rate, ventricular tachycardia, decreased blood flow to the injection site. Dosage: 0.3mg-0.5mg 1:1000 Routes: IM Pediatric Dosage: 0.15mg 1:1000 Etomidate Class: Intravenous anesthetic agent, hypnotic Actions: General anesthesia, sedative Indications: Rapid sequence intubation, conscious sedation Contraindications: Precautions: Quick acting, patient will become unresponsive in 30-60 seconds after administration. Side Effects: Adrenal crisis, seizure,

Dosage: 0.3 mg/kg IV, with a typical dose ranging from 20-40 mg, give over 30-60 seconds. Routes: IV. Pediatric Dosage: Not recommended Fentanyl Class: Opioid, narcotic analgesic Actions: Fentanyl is 100 times more potent than morphine, with 100 micrograms of Fentanyl approx. equivalent to 10 mg of morphine. Indications: Pain management, pain associated with cancer Contraindications: Hypersensitivity to medication Precautions: CNS depressant, respiratory depressant, desation Side Effects: Diarrhea, nausea, constipation, dry mouth, somnolence, confusion, asthenia (weakness), and sweating Dosage: 25-100mcg slow IVP over 2-3 minutes Routes: IV, IO Pediatric Dosage: 2mcg/kg slow IVP Furosemide (Lasix) Class: Potent diuretic. Actions: Inhibits reabsorption of sodium chloride, promotes prompt diuresis, vasodilation. Indications: Congestive heart failure, pulmonary edema. Contraindications: Pregnancy, dehydration. Precautions: Should be protected from light, dehydration. Side Effects: Few in emergency usage. Dosage: 40-80 mg. Routes: IV. Pediatric Dosage: 1 mg/kg. Glucagon Class: Hormone (antihypoglycemic agent). Actions: Causes breakdown of glycogen to glucose. Inhibits glycogen synthesis. Elevates blood glucose level. Increases cardiac contractile force. Increases heart rate. Indications: Hypoglycemia. Contraindications: Hypersensitivity to the drug. Precautions: Only effective if there are sufficient stores of Glycogen within the liver. Use with caution in patients with cardiovascular or renal disease. Draw blood glucose before administration.

Side Effects: Few in emergency situations. Dosage: 0.25-0,50 mg (unit) IV 1.0 mg, IM. Routes: IV, IM. Pediatric Dosage: 0.03 mg/kg. Haloperidol (Haldol) Class: Major tranquilizer. Actions: Blocks dopamine receptors in brain responsible for mood and behavior has antiemetic properties. Indications: Acute psychotic episodes. Contraindications: Should not be administered in the presence of other sedatives. Should not be used in the management of dysphoria caused by Talwin. Precautions: Orthostatic hypotension. Side Effects: Physical and mental impairment, Parkinson-like reactions have been known to occur, especially in children. Dosage: 2-5 mg. Routes: IM. Pediatric Dosage: Rarely used. Heparin Class: Anticoagulant. Actions: Functions as an anticoagulant by accelerating neutralization of activated clotting factors. Indications: Situations where a hypocoaguable state is required (i.e. post MI, post-CVA, pulmonary embolism). Contraindications: Should not be used unless there is a medical reason to anticoagulate the patient. Precautions: Sever, urticaria, and anaphylaxis have been reported following heparin administration skin necrosis can develop at site of subQ injections. Side Effects: Fever, bruising, oozing of blood. Dosage: Loading dose: 5,000 iu IV is a typical loading dose although large patients and patients with heparin resistance may receive larger doses. Maintenance dose: Infusion therapy is typically started at 800 - 1,000 iu/hour. the dosage is modified based upon the patient's prothrombin (pt) time. Routes: IV subQ (for prophylaxis). Pediatric Dosage: Rarely used. Ipatropium (Atrovent) Class: Anticholinergic. Actions: Causes bronchodilation, dries respiratory tract secretions. Indications: Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema. Contraindications: Patients with history of hypersensitivity to the drug, should not be used as primary agent in acute treatment of bronchospasm.

Precautions: Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations, dizziness, anxiety, tremors, headache, nervousness, dry mouth. Dosage: Small-volume nebulizer: 500 µg should be placed in small volume nebulizer (typically administered with a ß agonist). Routes: Inhalation only. Pediatric Dosage: Safety in children has not been established. Lidocaine (Xylocaine) Class: Antiarrhythmic. Actions: Suppresses ventricular ectopic activity, increases ventricular fibrillation threshold, reduces velocity of electrical impulse through conductive system. Indications: Malignant PVCs, ventricular tachycardia, ventricular fibrillation, prophylaxis of arrhythmias associated with acute myocardial infarction and thrombolytic therapy, premedication prior to rapid sequence induction. Contraindications: High-degree heart blocks, PVCs in conjunction with bradycardia. Precautions: Dosage should not exceed 300 mg/hr. Monitor for CNS toxicity. Dosage should be reduced by 50% in patients older than 70 years of age or who have liver disease in cardiac arrest, use only bolus therapy. Side Effects: Anxiety, drowsiness, dizziness, and confusion, nausea and vomiting, convulsions, widening of QRS. Dosage: Bolus: Initial bolus of 1.5 mg/kg; additional boluses of 0.5 - 0.75 mg/kg can be repeated at 8-10-minute intervals until the arrhythmia has been suppressed or until 3 mg/kg of the drug has been administered; reduce dosage by 50% in patients older than 70 years of age. Drip: after the arrhythmia has been suppressed a 2-4 mg/minute infusion may be started to maintain adequate blood levels. Routes: IV bolus, IV infusion. Pediatric Dosage: 1 mg/kg. Lorazepam (Ativan) Class: Benzodiazepine Actions: Anziolytic, amnesic, sedative/hypnotic, anticonvulsant and muscle relaxant. Indications: Anziety, insomnia, acute seizures including status epilepticus and sedation of aggressive patients Contraindications: Allergy or hypersensitivity, severe respiratory failure, acute intoxication, ataxia, acute narrow-angle glaucoma, sleep apnea, myasthenia gravis, pregnancy and breast feeding. Precautions: Use caution when administering to children or the elderly, and liver or kidney failure patients. Side Effects: Ataxia, sedation, anterograde amnesia and hangover effects. Dosage: 0.5-2.0 mg IV or 1.0- 4.0 IM Routes: IV, IM, IO Pediatric Dosage: 0.05-0.1mg/kg

Magnesium Sulfate Class: Anticonvulsant/Antiarrhythmic. Actions: CNS depressant, anticonvulsant, antiarrhyhmic. Indications: Obstetrical eclampsia (toxemia of pregnancy), pre-eclampsia/PIH, cardiovascular severe refractory ventricular fibrillation, pulseless ventricular tachycardia, post-MI as prophylaxis for arrhythmias, torsades de pointes (multi-axial ventricular tachycardia). Contraindications: Shock, heart block. Precautions: Caution should be used in patients receiving digitalis. Hypotension. Calcium Chloride should be readily available as an antidote if respiratory depression ensues. Use with caution in patients in renal failure. Side Effects: Respiratory depression, drowsiness. Dosage: 1-4 g. Routes: IV, IM. Pediatric Dosage: Not indicated. Methylprednisolone (Solu-Medrol) Class: Steroid. Actions: Anti-inflammatory, suppresses immune response (especially in allergic reactions). Indications: Severe anaphylaxis, asthma/COPD, possibly effective as an adjunctive agent in the management of spinal cord injury. Contraindications: None in the emergency setting. Precautions: Must be reconstituted and used promptly. Onset of action may be 2-6 hours and thus should not be expected to be of use in the critical first hour following an anaphylactic reaction. Side Effects: GI bleeding, prolonged wound healing, suppression of natural steroids. Dosage: General usage: 125-250 mg. Spinal cord injury: Initial bolus of 30 mg/kg administered over 15 minutes, followed by a maintenance infusion of 5.4 mg/kg/hr. Routes: IV, IM. Pediatric Dosage: 30 µg/kg. Midazolam (Versed) Class: Benzodiazepine tranquilizer. Actions: Hypnotic, sedative. Indications: Premedication prior to cardioversion/RSI, acute anxiety states. Contraindications: Patients with known hypersensitivity to the drug, narrow-angle glaucoma, shock. Precautions: Emergency resuscitation equipment should be available. Flumazenil (Romazicon) should be available. Dilute with normal saline or D5W prior to intravenous administration. Respiratory depression more common with Midazolam than with other Benzodiazepines.

Side Effects: Drowsiness, hypotension, amnesia, respiratory depression, apnea. Dosage: 1.0- 2.5 mg IV. Routes: IV, IM, intranasal. Pediatric Dosage: 0.03 mg/kg. Morphine Class: Narcotic. Actions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to pain. Indications: Severe pain, pulmonary edema. Contraindications: Head injury, volume depletion undiagnosed abdominal pain, patients with history of hypersensitivity to the drug. Precautions: Respiratory depression (narcan should be available), hypotension, nausea. Side Effects: Dizziness, altered level of consciousness. Dosage: IV: 2-5 mg followed by 2 mg every few minutes until the pain is relieved or until respiratory depression ensues. IM: 5-15 mg based on patient weight. Routes: IV, IM. Pediatric Dosage: 0.1-0.2 mg/kg IV. Naloxone (Narcan) Class: Narcotic antagonist. Actions: Reverses effects of narcotics. Indications: Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone, Morphine, Paregoric, Percodan, Tylox, Vicodin, synthetic analgesics, Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma, To rule out narcotics in coma of unknown origin. Contraindications: Patients with a history of hypersensitivity to the drug. Precautions: Should be administered with caution to patients dependent on narcotics as it may cause withdrawal effects. Short-acting, should be augmented every 5 minutes. Side Effects: none. Dosage: 1-2 mg. Routes: IV, IM. ET (ET dose is 2.0-2.5 times IV dose). Pediatric Dosage: < 5 years old > 5 years old 0.1 mg/kg 2.0 mg. Nitroglycerin Spray (Nitrolingual Spray) Class: Antianginal. Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries.

Indications: Angina pectoris, chest pain associated with myocardial infarction. Contraindications: Hypotension. Precautions: Constantly monitor vital signs. Syncope can occur. Side Effects: Dizziness, hypotension, headache. Dosage: One spray administered under the tongue; may be repeated in 10-15 minutes; no more than three sprays in a 15-minute period; spray should not be inhaled. Routes: Sprayed under tongue on mucous membrane. Pediatric Dosage: Not indicated. Nitropaste (Nitro-Bid) Class: Antianginal. Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries. Indications: Angina pectoris, chest pain associated with myocardial infarction. Contraindications: Children younger than 12 years of age, hypotension. Precautions: Constantly monitor blood pressure, syncope, drug must be protected from light, expires quickly once bottle is opened. Side Effects: Dizziness, hypotension. Dosage: 1/2 to 3/4 inches. Routes: Topical. Pediatric Dosage: Not indicated. Oxygen (O2) Class: gas. Actions: Necessary for cellular metabolism. Indications: Hypoxia. Contraindications: None. Precautions: Use cautiously in patients with COPD, humidify when providing high-flow rates. Side Effects: Drying of mucous membranes. Dosage: Cardiac arrest: 100%. Other critical patients: 100%. COPD: 35%. Routes: Inhalation. Pediatric Dosage: 24-100% as required. Oxytocin (Pitocin) Class: Mammalian hormone (polypeptide hormone) Actions: The peripheral actions of oxytocin mainly reflect secretion from the pituitary gland. In lactating mothers, oxytocin acts at the mammary glands, causing milk to be ‘let down’ into subareolar sinuses, from where it can be excreted via the

nipple. Oxytocin release during breastfeeding causes mild but often painful uterine contractions. This serves to assist the uterus in clotting the placental attachment point postpartum. Indications: Post-partum hemorrhage Contraindications: verify that baby and the placenta have been delivered and that there is not an additional fetus in the uterus Precautions: overstimulation of the uterus, uterine rupture, hypertension, cardiac dysrhythmias, anaphylaxis Side Effects: subarachnoid hemorrhage, seizures, increased heart rate, decreased blood pressure, over stimulated uterus. Dosage: 10-20 Units in 1000ml NaCl Routes: IV Pediatric Dosage: not recommended. Plavix (Clopidogrel) Class: Antiplatelet agent Actions: Inhibits blood clots in coronary artery disease, peripheral vascular disease, and cerebrovascular disease. Indications: Prevention of vascular ischaemic events, acute coronary syndrome without ST-segment elevation (NSTEMI), ST elevation MI (STEMI) Contraindications: In patient already taking clopidogrel due to increased risk of digestive tract hemorrhage. Precautions: Side Effects: Severe neutropenia (low shite blood cells), hemorrhage (increased if co-administration of aspirin) Dosage: 75 mg oral tablets Routes: PO Pediatric Dosage: Promethazine (Phenergan) Class: Antihistamine (h1 antagonist). Actions: Mild anticholinergic activity, antiemetic, potentiates actions of analgesics. Indications: Nausea and vomiting, motion sickness, to potentiate the effects of analgesics, sedation. Contraindications: Comatose states, patients who have received a large amount of depressants (including alcohol). Precautions: Avoid accidental intra-arterial injection. Side Effects: May impair mental and physical ability, drowsiness. Dosage: 25 mg. Routes: IV. Pediatric Dosage: 0.5 mg/kg. Sodium Bicarbonate Class: Alkalinizing agent. Actions: Combines with excessive acids to form a weak volatile acid, increases ph.

Indications: Late in the management of cardiac arrest, if at all, tricyclic antidepressant overdose, severe acidosis refractory to hyperventilation. Contraindication: Alkalotic states. Precautions: Correct dosage is essential to avoid overcompensation of ph. Can deactivate catecholamines. Can precipitate with calcium preparations. Delivers large sodium load. Side Effects: Alkalosis. Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes as indicated by blood gas studies. Routes: IV. Pediatric Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes. Succinylcholine (Anectine) Class: Neuromuscular blocking agent (depolarizing). Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles. Indications: To achieve paralysis to facilitate endotracheal intubation. Contraindications: Patients with known hypersensitivity to the drug. Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available. Paralysis occurs within 1 minute and lasts for approximately 8 minutes. Side Effects: Prolonged paralysis, hypotension, bradycardia. Dosage: 1-1.5 mg/kg (40-100 mg in an adult). Routes: IV. Pediatric Dosage: 1 mg/kg. Vasopressin Class: Peptide hormone, antidiuretic hormone Actions: Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue’s permeability. It also increases peripheral vascular resistance, which in turn increases arterial blood pressure. Indications: increase peripheral vascular resistance during CPR (as an alternative to epinephrine or after epinephrine has been used) Contraindications: Chronic nephritis, ischemic heart disease, PVC’s, advanced arteriosclerosis Precautions: epilepsy, migraine, asthma, heart failure, and angina Side Effects: Blanching of the skin, abdominal cramps, nausea, hypertension, bradycardia, and minor dysrhythmias Dosage: 40 units Routes: IV, IO Pediatric Dosage: Not recommended

Thiamine (Vitamin B1) Class: Vitamin. Actions: Allows normal breakdown of glucose. Indications: Coma of unknown origin, alcoholism, delirium tremens. Contraindications: None in the emergency setting. Precautions: Rare anaphylactic reactions have been reported. Side Effects: Rare, if any. Dosage: 100 mg. Routes: IV, IM. Pediatric Dosage: Rarely indicated. Vecuronium (Norcuron) Class: Neuromuscular blocking agent (non-depolarizing). Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles. Indications: To achieve paralysis to facilitate endotracheal intubation. Contraindications: Patients with known hypersensitivity to the drug. Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available. Paralysis occurs within 1 minute and lasts for approximately 30 minutes. Side Effects: Prolonged paralysis, hypotension, bradycardia. Dosage: 0.08-0.10 mg/kg. Routes: IV. Pediatric Dosage: 0.1 mg/kg. Zofran (Ondansetron) Class: Serotonin, receptor antagonist Actions: antiemetic Indications: nausea and vomiting, often followed by chemotherapy, or due to chronic medical illness or acute gastroenteritis. Contraindications: Allergy to Zofran Precautions: HA, Dizziness, Diarrhea Side Effects: Constipation, dizziness and headache Dosage: 4-8mg IV Routes: IV, IO, IM, PO, ODT Pediatric Dosage: <1 yr 1mg, 1-8yr 2mg, >8yr 4mg 2010 Yakima County Prehospital Care Protocols Updated July 2010

APPENDIX F ‐ DRIP CHART & CONVERSIONS 1.2 lbs = 1 kg (patient weighs 150lbs, 150/2.2 = 68kg) 5 cc = 1 tsp 15 cc = 1TBS or 3 tsp Gtts/ml = Drops per milliliter Gtts/min = Drops per minute Convert grams to milligrams: __gm X 1000 = ___mg Convert liters to milliliters: __L X 1000 = ___ml Convert milligrams to grams: __mg divided by 1000 = ___gm Convert milliliters to liters: __m l X 1000 = ___L

Dopamine 5 – 7 mcg/kg/min

Using a 250ml bag of NS and 400mg vial of Dopamine with a

220lbs (100kg) patient.

5 mcg/kg/min 19 gtts/min



The Math: 7 X 100 X 60 = 4200/1600 = 26 gtts/min

Lidocaine 2 – 4 mg/min

Using a 500 ml of NS and 2 Grams of Lidocaine X 1000 = 2000 mg.

2 mg/min 30 gtts/min or 1 drop every

other second.

4 mg/min 60 gtts/min or 1 drop every

second.

The Math: 2000 mg of Lidocaine divided by 500 ml of NS = 4mg/ml

For every 60 drops = 4mg of Lidocaine (a drop a second)

For every 15 drops = 1 mg of Lidocaine (a drop every 0.5 seconds)

For every 30 drops = 2 mg of Lidocaine ( a drop every other second)

For every 45 drops = 3mg of Lidocaine (a drop every 1.5 seconds)

Drip Set How many time

periods does the drip set have in one hour?

Calculation

60 ml/hour

60 gtts/ml 1 (there is 1 ‐ 60 minute

period in an hour)

60 /1 = 60 gtts/min

20 gtts/ml 3 60/3 = 20 gtts/min



APPENDIX G – Glasgow Coma Scale, APGAR, START GLASCOW COMA SCALE ‐ For Head Injury Patients

Eye Opening

Spontaneous 4

To loud voice 3

To pain 2

None 1

Verbal Response

Oriented 5

Confused, disoriented 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Best Motor Response

Obeys 6

Localizes 5

Withdraws (flexion) 4

Abnormal flexion posturing 3

Extension posturing 2

None 1

APGAR – For Newborn Infants at Time of BirthTo be checked at 1min and 5min after birth.

Score 0 1 2

Heart Rate Absent Less Than 100 Over 100

Respiratory Effort

Absent Slow, Irregular Good Cry

Muscle Tone Limp Some Flexion Active Motion

Reflex Irritability

No Response Grimace Cry Cry

Color Pale Body Pink,

Extremities Blue

All Pink

Reference Yakima County Operating Procedure for MCI.

Documents

Yakima Co (WA) Protocols 2010