· TFPD EMS PROTOCOLS MISSION STATEMENT Telluride Mountain Village & Placerville EMS (The...

TFPD EMS PROTOCOLS

MISSION STATEMENT

Telluride Mountain Village & Placerville EMS (The Telluride Fire Protection District) will provide and maintain the highest quality pre-hospital care available in the industry, through individual patient compassion and a strong team approach to solving healthcare problems this service will be made available to any and all in need.

Telluride Fire District EMS Manual

Protocols, Guidelines, Policies, and Procedures

February 2002

Updated November 2002

Updated January 2008

Prepared Under the Direction of

Jane Reldan, M.D., Physician Advisor

Updated Under the Direction of

Peter Hackett, M.D.

Updated Under the Direction of

Diana Koelliker, MD

TFPD EMS PROTOCOLS

January 1, 2008 TABLE OF CONTENTS

Executive Summary

Definitions

Protocols: The forms of ceremony and etiquette observed by heads of state.

Medical: A written statement of the history and treatment of any particular patient, especially one made for medicolegal purposes.

Policy: A method or course of action adopted by a government, business organization, etc., designed to influence and determine decisions; a guiding principle or procedure.

Guideline: A statement of general policy.

Procedure: A manner of proceeding; a series of steps of course of action; a set of forms for conducting business or public affairs.

Base Physician: Physician at receiving facility.

Introduction

The Telluride Fire District EMS manual is a document to assist the provider in patient assessment and care. The users of this manual must understand that this manual is and will continue to be, a dynamic tool to guide patient care, to assist with initial and continuing education, and to set a baseline for continuous quality improvement in the Telluride Fire District EMS System. Medicine changes on a daily basis, thus this manual is subject to continual review and frequent updates.

The text is organized in three sections. The first seven sections, the Protocol Sections, should be understood and followed carefully. The eighth section, Operational Guidelines, gives general direction to care-givers. The ninth section, Policy and Procedures, includes the requirements set by the Physician Advisor for participation in the EMS System.

Much of this manual has been adopted directly from the Mesa County EMS manual; they, in turn had taken, with permission, much of their manual from the February 1996 issue of the Denver Metro Protocols. We extend our thanks. Many hours of labor were donated by the following Protocol Committee in reviewing, revising, rewriting, editing, and typing this manual.

Their Assistance and Persistence is Appreciated

Dr. Peter Hacket, M.D. Jill Masters NREMT-P Dr. David Dreitlein M.D.

Lee Roufa, R.N. John Cheroske EMT-I Eric Berg NREMT-P

Stacy Sheridan NREMT-P Dr.Jane Reldan, M.D. Heidi Attenberger NREMT-P

Emil Sante NREMT-P Joyce Kimball EMT-I Deb Neiberger EMT-B

TFPD EMS PROTOCOLS


TABLE ON CONTENTS

SECTION I: ASSESSMENT I-1

PEDIATRIC ASSESSMENT I-1 NEUROLOGIC ASSESSMENT I-5

SECTION II: MEDICAL TREATMENT II-1

ABDOMINAL PAIN II-1 ALLERGY/ANAPHYLAXIS II-3 DYSRHYTHMIAS II-5

GENERAL II-5 PREMATURE VENTRICULAR CONTRACTIONS II-8 VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA II-10 ASYSTOLE II-12 PULSELESS ELECTRICAL ACTIVITY II-13 BRADYCARDIA W/ PULSE II-14 TACHYCARDIA II-16 NARROW COMPLEX TACHYCARDIA W/ PULSE II-17 WIDE COMPLEX TACHYCARDIA W/ PULSE II-18

CARDIAC ARREST II-19 CHEST PAIN II-21 COMA / ALTERED MENTAL STATUS / NEUROLOGIC DEFICIT II-24 EYE INJURY II-26 HYPERTENSION II-28 OB/GYN / CHILDBIRTH II-30 POISONS / OVERDOSES II-33 PSYCHIATRIC / BEHAVIORAL II-35 RESPIRATORY DISTRESS II-37 SEIZURES II-40 SHOCK II-43 STROKE II-46 SYNCOPE II-48 VOMITING II-50

SECTION III: TRAUMA TREATMENT III-1

MULTIPLE TRAUMA OVERVIEW III-1 TRAUMA ALGORITHM III-4 ABDOMINAL TRAUMA III-5 AMPUTATIONS III-7 BURNS III-9 CHEST INJURY III-13 EXTREMITY INJURY III-16 FACE & NECK TRAUMA III-18 HEAD TRAUMA III-21

TFPD EMS PROTOCOLS


SPINAL TRAUMA III-24 SPINAL CLEARANCE III-26 TRAUMA ARREST III-27 MULTIPLE PATIENT INCIDENTS III-29 TRIAGE III-35 TRANSPORT III-37 TRIAGE / TRANSPORT – PEDIATRIC PATIENT III-38

SECTION IV: ENVIROMENTAL INJURIES IV-1

BITES & STINGS IV-1 DROWNING / NEAR DROWNING IV-3 HIGH ALTITUDE ILLNESS IV-5 HYPERTHERMIA IV-7 HYPOTHERMIA / FROSTBITE IV-9

HYPOTHERMIA ALGORITHM IV-11 SNAKE BITES IV-13

SECTION V: PEDIATRIC TREATMENT V-1

GENERAL GUIDELINES V-1 INFANT & CHILD RESUSCITATION V-3 PEDIATRIC PULSELESS ARREST V-6 PEDIATRIC SHOCK V-7 PEDIATRIC RESPIRATORY DISTRESS V-9

PEDIATRIC SEIZURES V-12 SUDDEN INFANT DEATH SYNDROME V-14 INFANT CHOKING V-16

SECTION VI: DRUG PROTOCOLS VI-1

ACTIVATED CHARCOAL VI-1 ADENOSINE (ADENOCARD) VI-2 ALBUTEROL SULFATE VI-3 AMIODARONE VI-4 AMMONIA INHALANTS VI-5 ASPIRIN VI-6 ASSISTING W/ NITROGLYCERINE VI-7 ASSISTING W/ PRESCRIBED INHALER VI-9

ATROPINE VI-11 CALCIUM CHLORIDE VI-13 CALCIUM GLUCONATE VI-14 DEXAMETHASONE (DECADRON) VI-16 DEXTROSE VI-17 DIAZEPAM (VALIUM) VI-19 DIAZEPAM, RECTAL VI-21 DILTIAZEM (CARDIZEM) VI-22 DIPHENHYDRAMINE (BENADRYL) VI-24

TFPD EMS PROTOCOLS


DOPAMINE (INTROPIN) VI-25 EPINEPHRINE VI-27 EPINEPHRINE – AUTO INJECTOR VI-30 ETOMIDATE VI-31 FENTANYL (SUBLIMAZE) VI-32 GLUCAGON VI-34 HALDOL (HALOPERIDOL LACTATE) VI-36 HEPARIN VI-37 IPRATROPIUM BROMIDE (ATROVENT) VI-38 IV SOLUTIONS VI-40 FLUID CHALLENGE VI-41 LIDOCAINE VI-42 MAGNESIUM SULFATE VI-44 METHYLPREDNISOLONE (SOLU-MEDROL) VI-45 MIDAZOLAM (VERSED) VI-47 MORPHINE SULFATE VI-49 NALOXONE (NARCAN) VI-51 NITROGLYCERIN VI-52 OXYGEN VI-55 PROMETHAZINE (PHENERGAN) VI-57 PHENYLEPHRINE (NEO-SYNEPHRINE) VI-58 PITOCIN (OXYTOCIN) VI-59 RACEMIC EPINEPHRINE (VAPONEPHRINE) VI-60 SODIUM BICARBONATE VI-62 SUCCINYLCHOLINE (ANECTINE) VI-64 TERBUTALINE VI-66 TOPICAL OPHTHALMIC ANESTHETICS (TETRACAINE) VI-67 VASOPRESSIN VI-69 VECURONIUM (NORCURON) VI-70 ZOFRAN (ONDANSETRON) VI-71

SECTION VII: PROCEDURE PROTOCOL VII-1

AIRWAY MANAGEMENT VII-1 GENERAL PRINCIPLES VII-1 OPENING THE AIRWAY VII-4 OBSTRUCTED AIRWAY VII-7 CLEARING & SUCTIONING VII-9

ASSISTING W/ VENTILATIONS VII-12 ADVANCED AIRWAY MANAGEMENT VII-14 OROTRACHEAL INTUBATION VII-14 NASOTRACHEAL INTUBATION VII-17 LARYNGEAL MASK AIRWAY VII-19 NEEDLE CRICOTHYROTOMY VII-21 SURICAL CRICOTHYROTOMY VII-23 VENTILATOR AIRWAY OPERATIONS VII-25

TFPD EMS PROTOCOLS


RAPID SEQUENCE INDUCTION INTUBATION VII-26 BANDAGING VII-29 CARDIOVERSION ALGORITHM VII-31 DENTAL PROBLEMS VII-33 TRANSCUTANEOUS CARDIAC PACING VII-34 DEFIBRILLATION VII-36 AUTOMATIC EXTERNAL MANUAL DEFIBRILLATION VII-38 VENOUS ACCESS TECHNIQUE VII-40 BUFF CAP OR EXTENSION SET VII-42 EXTERNAL JUGULAR VEIN VII-43 INJECTIONS – SUBCUTANEOUS / INTRAMUSCULAR VII-44 INTRAOSSEOUS PLACEMENT & INFUSION VII-45 FIELD DRAWN BLOOD SAMPLES VII-48 MEDICAL ADMINISTRATION (PARENTERAL) VII-49 NASOGASTRIC / OROGASTRIC TUBE PLACEMENT VII-53 PNEUMATIC ANTI-SHOCK GARMENT (PASG) VII-54 PHYSICAL RESTRAINTS VII-57 CHEMICAL RESTRAINTS VII-60 SPLINTNG VII-62

AXIAL VII-62 EXTREMITY VII-64 PELVIC FRACTURES VII-67

TENSION PNEUMOTHORAX DECOMPRESSION VII-69 URINARY CATHETERIZATION VII-71

SECTION VIII: OPERATIONAL GUIDELINES VIII-1

AUTOMATED EXTERNAL DEFIBRILLATION VIII-1 COORDINATION ON SCENE VIII-1 CONFIDENTIALITY VIII-2 CONSENT VIII-3 CPR DIRECTIVES VIII-6 RESUSCITATION & FIELD PRONOUNCEMENT VIII-9

HAZARDOUS MATERIALS VIII-13 BLOOD AND/OR BODY FLUID EXPOSURE VIII-15 INFECTIOUS / COMMUNICABLE DISEASES VIII-17 PHYSICIAN AT THE SCENE / MEDICAL DIRECTION VIII-21 TRANSPORT OF PATIENT VIII-22

AIR TRANSPORT VIII-23 NON-TRANSPORT VIII-24 NON-TRANSPORT ALGORITHM VIII-27

RADIO REPORT VIII-28

SECTION IX: POLICY PROCEDURE IX-1 REGISTRATION & RECORD KEEPING IX-1 RESCUER’S AGREEMENT W/ PHYSICIAN ADVISOR IX-2

TFPD EMS PROTOCOLS


TRIP & DATA REPORTS IX-4 APPROVED MEDICAL ABBREVIATIONS IX-6 QUALITY ASSURNCE / QUALITY IMPROVEMENT PLAN IX-8 TRIP REPORT REVIEWS IX-9

QA/QI MONTHLY REPORT IX-10 CONTINUING EDUCATION IX-11

TFPD EMS PROTOCOLS ASSESSMENT: PEDIATRICT PATIENT

January 1, 2008 I - 1

Pre-Hospital Patient Assessment

PEDIATRIC PATIENT ASSESSMENT B/I/P

Children can be examined easily from head to toe, or from toe to head in the non-critical pediatric patient, but lack of understanding by the patient, poor cooperation, and fright often limit the ability to assess completely in the field. Children often cannot verbalize what is bothering them, so it is important to do a systematic survey (see Secondary Survey) which covers areas that the patient may not be able to tell you about. Any observations about spontaneous movements of the patient and areas that the child protects are very important. In the patient with a medical problem, the more limited set of observations listed below should pick up potentially serious problems. A. General: 1. Level of alertness, eye contact, attention to surroundings 2. Muscle tone: Normal, increased, or weak and flaccid 3. Responsiveness to parents, care givers: Is the patient playful or irritable? B. Head: 1. Signs of trauma 2. Fontanels, if open: Abnormal depression or bulging C. Face: 1. Pupils: Size, symmetry, reaction to light 2. Hydration: Brightness of eyes: Is child making tears? Is the mouth moist? D. Neck: Note stiffness E. Chest: 1. Note presence of stridor, retractions (depressions between ribs on inspiration)

or increased respiratory effort 2. Auscultate the chest a. Breath sounds: Symmetrical, rales, wheezing? b. Heart: Rate, rhythm F. Abdomen: Distention, rigidity, bruising, tenderness


January 1, 2008 I - 2

G. Extremities: 1. Brachial pulse 2. Signs of trauma 3. Muscle tone, symmetry of movement 4. Skin temperature and color, capillary refill 5. Areas of tenderness, guarding or limited movement H. Neurological exam: See Neurological Assessment Equipment Guidelines According to Age and Weight

Age (50th Percentile Weight)

Equipment

Preemie (1-2.5 kg)

Neonate (2.5-4.0 kg)

6 Months (7.0 kg)

1-2 Years (10-12 kg)

5 Years (16-18 kg)

8-10 Years (24-30 kg)

Airway infant (oral)(00)

infant small (0)

small (1)

small (2)

medium (3)

medium large (4.5)

Breathing Self-inflating bag

infant

infant

child

child

child

child/adult

Endotracheal tube 2.5-3.0 (uncuffed)

3.0-3.5 (uncuffed)

3.5-4.0 (uncuffed)

4.0-4.5 (uncuffed)

5.0-5.5 (uncuffed)

5.5-6.5 (uncuffed)

Laryngoscope blade 0 (straight)

1 (straight)

1 (straight)

1-2 (straight)

2 (straight/curved)

2-3 (straight/curved)

Suction (F) 6-8/6 8/6 8-10/6 10/6 14/14 14/14

Venous access Angiocath

22-24

22-24

22-24

20-22

18-20

16-20

Butterfly needle 25 23-25 23-25 23 20-23 18-21

Orogastric tube (F) 5 5-8 8 10 10-12 14-18

Chest tube (F) 10-14 12-18 14-20 14-24 20-32 28-38


January 1, 2008 I - 3

APGAR Chart

Sign 0 1 2

A - Appearance Pale, Blue Body: Pink/Ext: Blue Fully Pink

P - Pulse Absent <100 >100

G - Grimace-(catheter in nares)

No Response Some Grimace or Avoidance

Cough, Cry, or Sneeze

A - Activity Limp Some Flexion Active, Good flexion

R - Respirations Absent Slow, Irregular, Ineffective

Crying, Rhythmic, Effective

*Infants with scores of 7 – 10 usually require supportive care only *A score of 4-6 indicates moderate depression Pediatric Vital Signs

Age

Weight (KG)

Heart Rate

Respiration

Blood Pressure (Systolic)

Newborn 3 100-160 30-60 50-70

1-6 Weeks 4 100-160 30-60 70-95

6 months 7 90-120 25-40 80-100

1 year 10 90-120 20-30 80-100

3 years 15 80-110 20-30 80-100

6 years 20 70-100 18-25 80-110

10 years 30 60-90 15-20 90-120

12 years 40 85-90 16-22 90-120

Pediatric IV Fluid Administration 20cc/kg over 5-20 minutes normal saline


January 1, 2008 I - 4

Glasgow Coma Score

Adult/Older Child Score Small Child/Baby

Eyes Opening Spontaneously To Verbal Command To pain No response

4 3 2 1

Spontaneously To speech To pain No Response

Best Verbal Response

Oriented Confused Inappropriate words Incomprehensible words None

5 4 3 2 1

Coos and babbles Irritable cries Cries to pain Moans to pain No response

Best Motor Response

Obeys command Purposeful movementWithdrawal Flexion Extension None

6 5 4 3 2 1

Spontaneous Withdraws to touch Withdraws to pain Abnormal flexion Abnormal No response

TFPD EMS PROTOCOLS ASSESSMENT: NEUROLOGIC

January 1, 2008 I - 5

Pre-Hospital Patient Assessment

NEUROLOGIC ASSESSMENT B/I/P

Management of patients with head injury or neurologic illness depends on careful assessment of neurologic function. Changes are particularly important. The first observations of neurologic status in the field provide the basis for monitoring sequential changes. It is, therefore, important that the first responder accurately observe and record neurologic assessment, using measures which will be followed throughout the patient’s hospital course. A. Vital Signs: Observe particularly for adequacy of ventilations; depth, frequency,

and regularity of respirations. B. Level of consciousness: Glasgow Coma Score

Adult/Older Child Score

Eyes Opening Spontaneously To Verbal Command To pain No response

4 3 2 1

Best Verbal Response Oriented Confused Inappropriate words Incomprehensible words

None

5 4 3 2 1

Best Motor Response Obeys command Purposeful movement Withdrawal Flexion Extension None

6 5 4 3 2 1

GSC = ≤ 3 coma or death

GCS = ≤ 8 Intubate GCS = Total (maximum 15)

A Quick Guide to Responsiveness (“AVPU”)

A= alert V= responds to voice P= responds to pain U= no response (unresponsive)

C. Eyes:

1. Direction of gaze, extraocular movement.

TFPD EMS PROTOCOLS ASSESSMENT: NEUROLOGIC

January 1, 2008 I - 6

2. Size and reactivity of pupils.

D. Movement: Observe whether all four extremities move equally well.

E. Sensation (if patient awake): observe for absent, abnormal, or normal sensation at different levels if cord injury is suspected.

Special Notes A. The Glasgow Coma Scale (GCS) used above has gained acceptance as one

method of scoring and monitoring patients with head injury. It is readily learned, has little observer-to-observer variability, and accurately reflects cerebral function. Always record specific responses rather than just the score (sum of observations). In areas where numerical assignment of scores is not a formal procedure, the observations of the GCS still provide an excellent basis for field neurologic assessment. Note also that the other parameters listed must be observed to assess fully the neurologically impaired patient.

B. Use your written report to follow and identify changes rapidly. C. At a minimum, AVPU and gross motor function must be noted/documented

before moving patient with suspected head/spinal injury. D. Note what stimulus is being used when recording responses. Applied noxious

stimuli must be adequate to the task but not excessive. Initial mild stimuli can include light pinch, dull pinprick, or light sternal rub. If these are unsuccessful at eliciting a pain response, pressure with a dull object to base of nail bed, stronger pinch (particularly in axilla), or sternal rub will be necessary to demonstrate the patient’s best motor response.

E. When responses are not symmetrical, use motor response of the best side for

scoring GCS and note asymmetry as part of neurologic evaluation. F. Use of restraints or intubation of patient will make some observations less

accurate. Be sure to note on chart if circumstances do not permit full verbal or motor evaluation.

G. Remember that a patient who is totally without response will have a score of 3,

not 0. H. In small children, the GCS may be difficult or impossible to evaluate. Children

who are alert and appropriate should focus their eyes and follow your actions, respond to parents or care givers, and use language and behavior appropriate to their age level. In addition, they should have normal muscle tone and a normal cry. Several observers should attempt to elicit a “best verbal response,” to avoid over or underestimation of level of consciousness. See pediatric assessment.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ABDOMINAL PAIN

January 1, 2008 II - 1

Treatment Protocols: Medical Treatment

ABDOMINAL PAIN

B/I/P Specific Information Needed A. Pain: Nature (crampy or constant), duration, location; radiation to back, groin, chest,

shoulder B. Associated symptoms: Nausea, vomiting (bloody or coffee-ground), diarrhea, constipation,

black or tarry stools, urinary difficulties, menstrual history, fever C. Past history: Previous trauma, abnormal ingestions, medications, known diseases, surgery Specific Objective Findings A. Vital signs B. General appearance: Restless, quiet, sweaty, pale C. Abdomen: Tenderness, guarding, distention, rigidity, pulsatile mass D. Emesis, stool, or urine; describe amount E. Check for equality of pulses Treatment A. Position of comfort (consider shock position) B. NPO (nothing by mouth) C. If BP < 90 systolic and signs of hypovolemic shock: 1. Administer O2 2. Establish venous access with saline, consider bolus if appropriate D. Establish venous access if vital signs normal, NS TKO E. Monitor vitals during transport F. Consider ECG / Monitor / 12 Lead to rule out cardiac event

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ABDOMINAL PAIN


Specific Precautions A. Causes of abdominal pain can rarely be determined in the field. Pain medication is seldom

indicated and may change details of the physical exam necessary to diagnose the patient in the Emergency Department. Pts previously assessed at TMC may require pain management enroute to MMH. Follow instructions of the attending physician.

B. The most important diagnoses to consider are those associated with catastrophic internal

bleeding: ruptured aneurysm, liver, spleen, ectopic pregnancy, etc. Since the bleeding is not apparent, you must think of the volume depletion and monitor patient closely to recognize shock.

C. Elderly patients may have significant hypovolemic shock with systolic blood pressures

above 90 mmHg. D. Upper abdomen and lower chest pain may reflect thoracic pathology such as myocardial

infarction, etc. Fluid resuscitation may be contraindicated. E. All patients receiving fluid bolus must have breath sounds evaluated for pulmonary edema

prior to fluids.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ALLERGY/ANAPHYLAXIS



ALLERGY/ANAPHYLAXIS B/I/P

Specific Information Needed A. History: Current sequence of events, exposure to allergens (bee stings, drugs, nuts,

seafood most common), prior allergic reactions B. Current symptoms: Itching, wheezing, respiratory distress, nausea, weakness, rash,

anxiety C. Medications, past medical history, medic alert tag Specific Objective Findings A. Vital signs, level of consciousness B. Respirations: Wheezing, upper airway noise (stridor), effort C. Mouth: Tongue or upper airway swelling, hoarse voice D. Skin: Hives, swelling, flushing Treatment A. B/P: Ensure airway. Prepare to assist ventilations I/P: Early endotracheal intubation may be advisable before swelling becomes severe.

Suction as needed B. Position of comfort (upright if respiratory distress predominates; supine if shock prominent) C. Administer high flow O2 D. Consider removing injection mechanism if still present (stinger, needle, etc.) E. Monitor cardiac rhythm F. If signs of shock and/or altered LOC (anaphylaxis), CONTACT BASE early while

considering: 1. Fluid bolus: IV, NS. 2. B/I/P: Epinephrine (EMT B may assist with any valid non-prescribed Epi-pen with

Medical Direction)

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ALLERGY/ANAPHYLAXIS


3. I/P: Diphenhydramine, slow IV or IM 4. I/P: Consider Albuterol or other nebulized medicines

5. I/P: Consider Solumedrol 125 mg IV. CONTACT BASE prior to administration 6. P: Consider Glucagon for patients on beta blockers unresponsive to Epinephrine

G. For respiratory distress and BP > 90 mmHg systolic (mild or moderate allergic reaction),

consider: 1. I/P: Epinephrine, 1:1,000, 0.3 mg - 0.5 mg SQ (EMT-B assists with Epi-pen). In extreme cases, IV administration of NO MORE THAN 0.3 mg OF 1:10,000 may

be appropriate. CONTACT BASE IF POSSIBLE 2. I/P: Diphenhydramine, 25 - 50 mg slow IV or IM H. For all other patients, CONTACT BASE to consider Diphenhydramine, slow IV I. Transport rapidly if patient unstable Specific Precautions A. Allergic reactions can take multiple forms! (ie. airway compromise with respiratory distress,

pulmonary edema, hypotension) Early consult with base physician is encouraged. B. Anxiety, tremor, palpitations, tachycardia, and headache are not uncommon with

administration of epinephrine. These may be particularly severe when given IV. In children, Epinephrine may induce vomiting. In elderly patients, angina, MI, or dysrhythmias may be precipitated.

C. Two forms of Epinephrine are carried as part of Paramedic equipment. The standard

ampules and self-administered preloaded syringes of aqueous Epinephrine contain a 1:1,000 dilution appropriate for SQ or IM injection. IV Epinephrine should be given in a 1:10,000 dilution. Use the 1:10,000 premix for IV dosing to avoid mistakes. Be sure you are giving the proper dilution to your patient, and give slowly.

D. Before treating anaphylaxis, be sure your patient has objective signs as well as subjective

symptoms and history. Patients with hyperventilation syndrome and even asthma will occasionally think they are having an allergic reaction. Epinephrine will just aggravate their anxiety. Anaphylaxis must have 2 out of three: skin, respiratory & cardiovascular collapse.

E. Lethal edema may be localized to the tongue, uvula or other parts of the upper airway.

Examine closely and be prepared for early intubation before swelling precludes this intervention.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - GENERAL



DYSRHYTHMIAS: GENERAL

B/I/P Specific Information Needed A. Present symptoms: Sudden or gradual onset, palpitations B. Associated symptoms: Chest pain, dizziness or fainting, trouble breathing, abdominal pain,

fever C. Prior history: Dysrhythmias, cardiac disease, exercise level, pacemaker D. Current medications, particularly cardiac Specific Objective Findings A. Vital signs B. Signs of poor cardiac output: 1. Altered level of consciousness 2. “Shocky” appearance: Cool/clammy skin, pallor 3. Blood pressure < 90 mmHg systolic C. Signs of cardiac failure (increased back-up pressure): 1. Neck vein distention - JVD 2. Lung congestion - rales 3. Peripheral edema: Sign of chronic failure, not acute D. Signs of hypoxia: Marked respiratory distress, cyanosis, tachycardia Treatment A. Administer O2, position of comfort B. Establish venous access C. Evaluate the patient. Is the patient perfusing adequately or are there signs of

inadequate perfusion? D. I/P: Apply cardiac monitor and evaluate dysrhythmia



1. Is there a pulse corresponding to monitor rhythm? 2. Rate: Tachycardia, bradycardia, normal? 3. Are the ventricular complexes wide or narrow? 4. What is the relation between atrial activity (P waves) and ventricular activity? 5. Is the dysrhythmia potentially dangerous to the patient? (See Specific

Precautions: D) 6. Consider 12 Lead if patient is asymptomatic E. Document the dysrhythmia by paper tape recording F. Treat if needed according to pulse rate. (See protocols) or as directed by base physician G. Document results of treatment (or lack thereof) by checking pulse and recording EKG on

paper tape H. Transport nonemergent if patient has stabilized. Monitor condition en route Specific Precautions A. Treat the patient, not the dysrhythmia! If the patient is perfusing adequately, he does not

need emergency treatment. This is true of bradydysrhythmias as well as tachydysrhythmias. What is normal for one person may be fatal to another.

B. Documentation of dysrhythmias is extremely important. Field treatment of a dysrhythmia

may be life-saving, but long-term treatment requires knowing what the problem was. Documentation also allows for learning and discussion after the case. These cases are not common, and should be reviewed and used as learning tools by as many persons as possible.

C. Correct dysrhythmia diagnosis based only on monitor strip recordings is difficult and often

not possible. Treatment must be based on observable parameters: Rate, patient condition and distance from the hospital.

D. Dangerous rhythms are those that do not necessarily cause poor perfusion, but are likely to

deteriorate. They require recognition and treatment to prevent degeneration to mechanically significant dysrhythmias. Among dangerous rhythms are: Multifocal PVCs, runs of PVCs, ventricular tachycardia, and Mobitz II 2nd degree block.

E. Cardiac arrest and life-threatening dysrhythmias can be successfully treated in the field,

and show the benefits of “stabilization before transfer” in prehospital care. The patient is better off when the duration of arrest or poor perfusion is minimized.



F. Remember, drugs may be administered by routes other than intravenous, including

intramuscular or intraosseous. Check individual drug protocols for dosages. G. Drug dosages vary in the pediatric and elderly populations. (See Drug Protocols for

details.)

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - PVCs



PREMATURE VENTRICULAR CONTRACTIONS (PVCs) I/P

INITIATE SUPPORTIVE MEASURES

• ABCs • Airway Management as indicated • Calm/reassure patient • Initiate high flow oxygen • Cardiac monitor • Establish venous access

Are there 3 or more PVCs seen together or in a “run?” YES NO See Wide Complex Tachycardia Is the patient complaining of chest pain w/ Pulse Protocol (presumed cardiac etiology)? YES NO Do you see: INITIATE Multifocal PVCs TRANSPORT Couplets Bigeminy or Trigeminy? YES NO CONSIDER See Chest Pain BASE CONTACT Protocol LIDOCAINE OR AMIODARONE 1.5 mg/kg IV push 150 mg slow IV (½ dose for elderly patients) INITIATE TRANSPORT AND CONTACT BASE

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - PVCs


Special Notes: A. Determine if atrial fibrillation/flutter or any conduction block exists (1st, 2nd, or 3rd degree).

If so, avoid treatment and discuss options with base. B. PVCs are common in elderly patients who are seen for any reason. Treatment should only

be initiated in the presence of acute cardiac symptoms, and drug dosages may need to be modified with elderly patients. CONTACT BASE to discuss any other indications before initiating therapy.

C. First line therapy for PVC is high flow oxygen. D. After Lidocaine bolus, start a Lidocaine drip 2-4 mg/min. E. Lidocaine is metabolized in the liver; elderly patients and those with poor liver

function/perfusion are more likely to experience side effects.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS ~ V-FIB / V-TACH

January 1, 2008 II - 10


VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA B/I/P

• Assess ABC’s • Consider Precordial Thump if arrest was witnessed • Initiate CPR: 2 minutes of nonstop compressions before defibrillation • Defibrillate @ 120J – 200J biphasic energy

PUSLES PRESENT/NSR ASYSTOLE / P.E.A. Assess vitals See Asystole/P.E.A. Support ABC’s algorithm PULSELESS VT/VF

Continue CPR non-stop compressions for 2 minutes w/ intermittent ventilations

Defibrillate 120J – 200J

Rhythm unchanged? Continue CPR for 2 minutes Intubate – verify placement & secure Start IV/IO Epinephrine 1mg IV/IO - repeat every 3 to 5 minutes OR Vasopressin 40 u IV/IO - single dose only Defibrillate 120J – 200J

Rhythm unchanged? Continue CPR for 2 minutes Amiodarone 300 mg IV/IO – may repeat x1 150 mg in 5 minutes) OR Lidocaine 1 – 1.5 mg/kg IV/IO – may give 0.5 – 0.75 mg/kg in 5 minutes x3 OR max 3 mg/kg Defibrillate 120J – 200J Rhythm unchanged? Continue CPR for 2 minutes Consider Magnesium Sulfate 1 – 2 g IV/IO for Torsades de Pointes Consider Sodium Bicarbonate for prolonged down time >10 minutes Defibrillate 120J – 200J

Rhythm unchanged? Continue CPR for 2 minutes

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS ~ V-FIB / V-TACH

January 1, 2008 II - 11

Special Note:

• Each drug administration should be followed by a defibrillation within 30-60 seconds with CPR in progress

• If limited man power IV/IO should take priority over intubation

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - ASYSTOLE

January 1, 2008 II - 12


ASYSTOLE (Assess appropriateness of resuscitation attempts)

B/I/P INITIATE SUPPORTIVE MEASURES: · ABCs · CPR · Endotracheal intubation*(I/P) · Establish IV/IO *(I/P) · Confirm asystole in at least two leads, check gain (increase lead

size) (I/P) · Consider transcutaneous pacing (external pacer) (I/P) EPINEPHRINE (1:10,000) OR VASOPRESSIN 40 u

IV/IO (I/P) 1 mg IV/IO push, repeat every 3 - 5 min. Or 2 - 2.5 mg diluted in 10 ml saline ET tube ATROPINE (I/P) 1 mg IV/IO push, repeat every 3 - 5 min up to a total of 3 mg (.04

mg/kg) CONTACT BASE Consult for possible administration of Sodium Bicarbonate Or termination of efforts * NOTE: In some cases, the order of ET vs. IV may be reversed. Special Notes: A. Patients who convert from a viable rhythm into asystole should have transcutaneous pacing

instituted immediately. However, pacing should be withheld from that patient who presents in asystole.

B. The effectiveness of transcutaneous pacing is directly related to the speed with which this

therapy is initiated. C. When asystole is diagnosed, check the integrity of the leads and electrode patches and

confirm this interpretation in at least two leads. ACLS also calls for checking gain or increasing size in the lead button on Lifepack12’s.

D. In pediatric patients, after ABCs have been initiated, hyperoxygenate, give an IV fluid bolus,

reassess, consider Epinephrine

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - PEA

January 1, 2008 II - 13


PULSELESS ELECTRICAL ACTIVITY (PEA) B/I/P

INITIATE SUPPORTIVE MEASURES: · ABCs · CPR · Endotracheal intubation (I/P) · Establish IV/IO (B/I/P) CONSIDER POSSIBLE CAUSES: · Hypovolemia IV fluid bolus (B/I/P) (250 mg NS or 20

ml/kg in peds) · Tension pneumothorax Chest

decompression (per protocol)

· Hypoxia Check tube

placement · Acidosis Hyperoxygenation · Cardiac tamponade · Hypothermia · Pulmonary embolism · Myocardial infarction · Drug overdose EPINEPHRINE (1:10,000) OR VASOPRESSIN 40 u IV/IO (I/P) 1 mg IV/IO push, repeat every 3 - 5 min Or 2 - 2.5 mg in 10 ml ET tube IF BRADYCARDIA ATROPINE (I/P) 1 mg IV/IO push, every 3 - 5 min; max .04 mg/kg Or 2 - 3 mg in 10 ml ET tube INITIATE TRANSPORT CONTACT BASE EARLY Special Notes: In pediatric patients, hyperoxygenate, give fluid bolus (20 ml/kg), reassess, and consider Epinephrine. CONTACT BASE

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - BRADYCARDIA

January 1, 2008 II - 14


BRADYCARDIA WITH PULSE B/I/P

INITIATE SUPPORTIVE MEASURES: ABCs Airway management as indicated Initiate oxygen therapy (B/I/P) Establish venous access (B/I/P) Is the patient conscious, alert, HR < 60 beats/min., without serious signs or symptoms? (cx pain, SOB, ↓ LOC, ↓BP, pulmonary congestion, CHF, AMI)

YES NO INITIATE TRANSPORT PREPARE FOR AND CONTACT BASE TRANSCUTANEOUS PACING (I/P) CONSIDER ATROPINE (I/P) 0.5 - 1 mg IV push EVALUATE RESPONSE CONSIDER EPINEPHRINE 2 - 10 mg/min BP > 90 mmHg Heart rate normal Bradycardia persists BP < 90 mmHg CONTACT BASE Fluid bolus to 250 ml REPEAT maximum and ATROPINE (I/P) INITIATE TRANSPORT CONTACT BASE TO INTIATE CONTACT BASE TRANSCUTANEOUS For possible approval PACING (TCP) (I/P) to administer Dopamine HCl (P) INITIATE TRANSPORT AND CONTACT BASE to administer

Epinephrine (I/P)

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - BRADYCARDIA

January 1, 2008 II - 15

Special Notes: A. Do not delay TCP while awaiting IV access or for Atropine to take effect if the patient is

showing signs of poor perfusion. B. When pacing, verify mechanical capture and patient tolerance. Consider MS or Valium for

analgesia and CONTACT BASE. C. Differentiate premature ventricular beats from escape beats. Escape beats are beneficial to

the patient and should be treated by increasing the underlying rate and conduction, not by suppressing the escape beats with Lidocaine.

D. In pediatric patients, after therapy for the ABCs has been initiated, hyperventilate, give fluid

bolus, reassess, consider Epinephrine. Epinephrine should be the first medication utilized (see protocol for dosage).

TFPD EMS PROTOCOLS MEDICAL TREATMENT: DYSRHYTHMIAS - TACHYCARDIA

January 1, 2008 II - 16


TACHYCARDIA B/I/P

INITIATE SUPPORTIVE MEASURES: · ABCs · Airway management as indicated · Initiate oxygen therapy · Establish venous access

· Obtain 12Lead ECG · Obtain history · Is patients Stable or Unstable with serious signs & symptoms (CP, SOB, ↓LOC, ↓BP, Shock, CHF, AMI)?

STABLE UNSTABLE Is QRS narrow (<0.12 sec.)? See pg. II-17 Patient has serious S/S: Is QRS wide (≥0.12 sec.)? See pg. II-18 i.e.: chest pain, dyspnea ↓LOC, ↓BP, HR > 150, shock, pulmonary congestion, CHF, AMI

Immediate synchronized cardioversion, sedation if possible ~ DO NOT delay biphasic cardioversion.

75J – 120J – 150J – 200J Atrial fibrillation

30J – 50J – 75J – 120J Atrial flutter/PSVT 30J – 50J – 75J – 120J


January 1, 2008 II - 17


NARROW COMPLEX TACHYCARDIA WITH PULSE

B/I/P INITIATE SUPPORTIVE MEASURES: · ABCs · Airway management as indicated · Initiate oxygen therapy · Establish venous access

· Obtain 12Lead ECG

Rhythm is REGULAR OR IRREGULAR Attempt vagal maneuvers Probable Atrial Fibrillation Give Adenosine 6mg RAPID IV push Possible Atrial Flutter or MAT May repeat once in 1 – 2 min Consider Expert consultation Control rate with Diltiazem If rhythm CONVERTS If rhythm DOES NOT CONVERT Likely re-entry SVT Possible Atrial Flutter, Ectopic Atrial Tachycardia Consider Expert consultation or Junctional Tachycardia

Treat reoccurrence with Adenosine, Diltiazem Control rate with Diltiazem Treat underlying causes Special Notes A. A narrow QRS complex is less than 0.12 seconds in duration. B. Tachycardia is most likely a secondary problem when the pulse is less than 160. Treat

hypoxia, hypovolemia, pain, and other problems first. C. Valsalva maneuvers can be achieved by asking the patient to blow the plunger out of a

syringe or placing a hand on the abdomen of a seated or supine patient and asking the patient to apply enough pressure to lift your hand from them.


January 1, 2008 II - 18


WIDE COMPLEX TACHYCARDIA WIDE QRS W/ PULSE

B / I / P

INITIATE SUPPORTIVE MEASURES: · ABCs · Airway management as indicated · Initiate oxygen therapy · Establish venous access

· Obtain 12Lead ECG

Rhythm If ventricular tachycardia If atrial fibrillation If pre-excited atrial fibrillation Torsades de Pointes or uncertain rhythm with aberrancy (AF+WPW) Amiodarone 150 mg IV Control rate with: Amiodarone Magnesium 1-2 g IV over 10 minutes Diltiazem 150 mg IV over 10 min over 5 – 60 minutes Repeat as needed (avoid Adenosine/Diltiazem) followed by infusion Max dose 2.2 g/24 hrs. Special Notes A. A wide QRS complex is defined as a complex with a width greater than 0.12 seconds in

duration. B. A wide complex tachycardia is usually ventricular in origin, but may on occasion be a

supraventricular rhythm with aberrant conduction. C. CONTACT BASE to consider sedation in conscious patients. Consider Diazepam. D. If delays in synchronization occur and patient is critical, administer immediate

unsynchronized shocks.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: CARDIAC ARREST

January 1, 2008 II - 19


CARDIAC ARREST B/I/P

Specific Information Needed A. CPR directives or DNR orders B. History of arrest: Onset, preceding symptoms, bystander CPR, other treatment, duration of

arrest C. Past history: Diseases, medications D. Surroundings: Evidence of drug ingestion, trauma, other unusual presentations Specific Objective Findings A. Absence of consciousness B. Agonal or no respirations C. Absence of pulse D. Signs of trauma, blood loss E. Air temperature; skin temperature Treatment A. Check surroundings for safety to rescuers B. Initiate CPR C. Call for back-up if needed D. B/I/P: Check rhythm with monitor; treat rhythm by protocol Specific Precautions A. Cardiac arrest in a trauma situation is not treated according to this protocol (See Trauma

Arrest protocol). B. Survival from cardiac arrest is related to the time to both BLS and ALS treatment. Don’t

forget CPR in the rush for advanced equipment. A call for back-up should be initiated promptly by any BLS unit. Likewise, standing order administration of the first steps in treatment is recommended to minimize time delays to ALS.

C. See Infant and Child Resuscitation protocol for special pediatric details.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: CARDIAC ARREST

January 1, 2008 II - 20

D. Large peripheral veins (antecubital or external jugular) are preferred IV sites in an arrest. After 2 attempts at IV access consider IO access. E. I/P Remember that rhythm can’t be read in anything other than lead II without monitoring

electrodes in place. Also check lead size for asystole as well as other leads. F. Be sure to recheck for pulselessness and unresponsiveness upon arrival, even if CPR is in

progress. This will avoid needless and dangerous treatment of “collapsed” patients who are inaccurately diagnosed initially, or who have spontaneous return of cardiac function after a dysrhythmia or vasovagal episode.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: CHEST PAIN

January 1, 2008 II - 21


CHEST PAIN B/I/P

Specific Information Needed A. Pain: Nature, onset, duration, location, radiation, aggravation, alleviation, relationship to

exertion and respirations B. Associated symptoms: Nausea, vomiting, diaphoresis, respiratory difficulty, cough, fever.

Be aware of unusual presentation of AMI patients, especially in women C. Past history: Previous cardiac or pulmonary problems, medications, drug allergies Specific Objective Findings A. Vital signs B. General appearance: Color, apprehension, sweating C. Signs of heart failure: Neck vein distention, peripheral edema, respiratory distress D. Lung exam by auscultation: Rales, wheezes or decreased sounds E. Chest wall tenderness, abdominal tenderness Treatment A. Calm and reassure patient (and others) and place patient at rest, position of comfort

(usually semi-fowlers) B. Administer O2 C. If patient’s history suggests a cardiac origin to the chest pain:

1. Expose chest and prep as necessary (i.e. dry and shave) 2. Acquire 3 and 12Lead and if RCA involvement acquire 15Lead.

a. Apply chest and limb leads using the following markers

i. RA – right arm

ii. LA – left arm

iii. RL – right leg


January 1, 2008 II - 22

iv. LL – left leg

v. V1 – forth intercostals at the right sternal border

vi. V2 – forth intercostals space at the left sternal border

vii. V3 – directly between V2 and V4

viii. V4 – fifth intercostals space at midclavicular line

ix. V5 – level with V4 at left anterior axillary line

x. V6 – level with V5 at left midaxillary line

b. Attach patient cable to electrodes c. Instruct patient to remain still d. Press the 12Lead ECG button on monitor

e. Enter patient age into device when prompted f. If the monitor detects signal noise, such as patient movement or disconnected

lead, the 12Lead acquisition will be suspended until the noise is removed

g. Once acquired, retain the ECG data and deliver it to physician upon arrival at ED

h. Contact the receiving facility and advise them 12Lead has been acquired ant that transmission is in process if requested

3. I/P: Monitor cardiac rhythm and acquire 12Lead and record strip to leave with hospital.

4. I/P: Administer up to four chewable baby aspirin. B: May CONTACT BASE for verbal to give chewable 81 mg ASA. 5. Establish venous access (consider two patent lines) and blood draw (blue, purple &

green tops) for lab work. 6. I/P: Normalize pulse by treating symptomatic dysrhythmias, according to protocols. 7. I/P: Administer Nitroglycerin SL if BP > 100 systolic. Repeat until pain relieved: Every 5

minutes up to 3 doses, or systolic BP < 100 (includes patient administered Nitroglycerin within last 15 minutes). EMT may assist patient taking his/her own NTG (EMT-B by direct order). IV access must be in place.

D. I/P: Consider if PVCs are significant (see Lidocaine protocol):


January 1, 2008 II - 23

1. Lidocaine bolus. 2. CONTACT BASE. 3. Administer second bolus Lidocaine 10 minutes after first bolus. E. Consider Morphine Sulfate if pain persists after second Nitroglycerin. F. If patient is in shock or has dysrhythmias refractory to treatment, CONTACT BASE,

consider rapid transport. G. Monitor cardiac rhythm and vitals en route. H. I/P: Consider fluid challenge, NS, or Dopamine (with medical control input) if hypotensive. Specific Precautions A. Suspicion of an acute MI is based on history. Do not be reassured by a “normal” monitor

strip. Conversely, “abnormal” strips (particularly ST and T changes) can be due to technical factors or non-acute cardiac diseases. ST elevation that changes after nitroglycerin administration can be significant and should be documented.

If ST ↑ goes away administer NTG, repeat 12Lead B. Constant monitoring is essential. As many as 50% of patients with acute MI who develop

ventricular fibrillation may have no warning of dysrhythmias. C. Lidocaine should NOT be given if: 1. Blood pressure < 90 mmHg systolic, or 2. Heart rate < 50 beats/min., or 3. Periods of sinus arrest or any A-V block are present D. If patient develops depressed respirations following morphine sulfate administration, be

prepared to actively support airway and ventilations; administer Naloxone E. Remember there are many causes for chest pain. Consider pulmonary embolus,

pneumonia, aneurysm, pneumothorax, and trauma F. Beware of IV fluid overload in the potential cardiac patient G. IV mandatory prior to NTG administration

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ALTERED CONSCIOUSNESS

January 1, 2008 II - 24


COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT B/I/P

Specific Information Needed A. Present history: Duration of illness, onset and progression of present state; antecedent

symptoms such as headaches, seizures, confusion, trauma, etc. B. Past history: Previous medical or psychiatric problems C. Medications: Use or abuse D. Surroundings: Check for pill bottles, syringes, etc., and bring with patient. Note odor in

house. Are others in the house sick? Carbon Monoxide reading? Specific Objective Findings A. Safety to rescuer: Check for gases or other toxins B. Vital signs C. Level of consciousness and neurological status D. Signs of trauma: Head, body E. Breath odor F. Needle tracks G. Medical alert tag Treatment A. Airway: Protect as needed (positioning, nasopharyngeal or oropharyngeal airway,

suctioning, endotracheal) B. Administer O2 C. Establish venous access and fluid bolus as indicated D. Draw appropriate tubes; test for blood glucose E. B/I/P: Administer Dextrose 50%, if blood glucose reading < 60, and if clinically indicated

(consider oral glucose/glucose gel)

TFPD EMS PROTOCOLS MEDICAL TREATMENT: ALTERED CONSCIOUSNESS

January 1, 2008 II - 25

F. I/P: Administer Naloxone, if clinically indicated; intravenous, intramuscular B: Administer Naloxone IN, if clinically indicated G. Monitor cardiac rhythm H. Transport in lateral recumbent position. (If trauma suspected, transport supine with cervical

collar and backboard; logroll as necessary) I. Monitor vitals during transport Specific Precautions A. Be particularly attentive to airway. Difficulty with secretions, vomiting, and inadequate tidal

volume are common. B. Hypoglycemia may present as focal neurologic deficit or coma (stroke-like picture). C. Coma in the diabetic may be due to hypoglycemia or to hyperglycemia (diabetic

ketoacidosis). IV dextrose should be given to all unconscious diabetics, as well as patients with coma of unknown origin unless a blood glucose reading in the high range is obtained. The treatment may be life-saving in hypoglycemic patient, and will do no harm in the normal or hyperglycemic patient.

D. Stroke patients may be alert but unable to respond (aphasic); therefore, communicate with

the patient and explain what you are doing. Avoid inappropriate comments. E. Naloxone is useful in any potential overdose situation, but be sure the airway and the

patient are controlled before giving Naloxone to a known drug addict. The acute withdrawal precipitated in an addict may result in violent combativeness and/or vomiting.

F. Remember accidental narcotic overdose often occurs in the elderly and others taking

prescription medications (even if used as prescribed). Overdose may not be apparent on history or exam.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: EYE INJURY

January 1, 2008 II - 26


EYE INJURY B/I/P

Specific Information Needed A. Obtain history of event; inquire about onset, duration mechanism, environment, etc. B. Obtain past history; inquire about medications, previous visual problems, contact lenses,

etc. C. Determine associated symptoms; inquire about any relative environmental exposure

symptoms Specific Physical Findings A. Note foreign body “sensation” B. Note secretion and discharge of tears C. Note infected conjunctiva, ciliary congestion D. Note any twitching or spasm of muscles of the eye E. Note decreased blinking F. Note ruptured or lacerated globe (See Special Considerations: C) G. Note presence or absence of contact lenses Treatment A. Remove patient from any compromising environment and treat coexistent injuries/problems

as indicated B. P: Administer local anesthetic, Tetracaine 1 - 2 drops (see Drug Protocols) C. B/I/P: If chemical (i.e., acid or alkali) or other irritant, provide saline irrigation, one liter each

eye D. Transport to appropriate emergency department

TFPD EMS PROTOCOLS MEDICAL TREATMENT: EYE INJURY

January 1, 2008 II - 27

Special Considerations A. Removal of an obvious foreign body in conjunctival sac can be usually undertaken with

irrigation. If the foreign body appears to be embedded in the cornea or globe, DO NOT attempt to remove.

B. If patient has blood in the anterior chamber (hyphema) or an obvious open eye injury,

transport in the sitting position as this assists in decreasing intraocular pressure. C. If the globe appears to be lacerated or ruptured, NO further exam or treatment should be

performed and no pressure applied to the orbit in any fashion (including patching or dressing); transport immediately.

DO NOT administer local anesthetic if globe open.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: HYPERTENSION

January 1, 2008 II - 28


HYPERTENSION B/I/P

Specific Information Needed A. History of hypertension and current medications B. New symptoms: Dizziness, nausea, confusion, visual impairment, paresthesia, weakness C. Drug use: Amphetamines, cocaine, ephedrine, or many over-the-counter health food and

dietary supplements D. Other symptoms: Chest pain, breathing difficulty, abdominal/back pain, severe headache Specific Objective Findings A. Evidence of brain dysfunction: Confusion, seizures, coma, stroke symptoms B. Presence of associated findings: Pulmonary edema, neurologic signs, neck stiffness,

unequal peripheral pulses, vomiting Treatment A. Administer O2 B. Place patient at rest in position of comfort C. Recheck BP, with special attention to diastolic pressure, correct cuff size and placement D. Treat chest pain, pulmonary edema, seizure activity as per usual protocols E. Establish venous access F. If diastolic remains above 130 on repeated readings AND patient has symptoms of

encephalopathy (brain dysfunction), chest pain, pulmonary edema, CONTACT BASE to consider:

1. I/P: Nitroglycerin 2. I/P: Morphine Sulfate G. Monitor cardiac rhythm H. Monitor vital signs and mental status during transport. DO NOT TREAT NUMBERS –

ONLY SYMPTOMS

TFPD EMS PROTOCOLS MEDICAL TREATMENT: HYPERTENSION

January 1, 2008 II - 29

Specific Precautions A. Secondary hypertension (high BP in response to stress or pain) is commonly seen in the

field. It does not require field treatment, and may not even mean the patient has chronic hypertension requiring ongoing treatment.

B. Hypertensive encephalopathy is rare, but can be treated with nitroglycerin or morphine.

Hypertension is more common in association with other problems (pulmonary edema, seizures, chest pain, coma, or altered mental states). It should be managed by treating the other problem, which is usually primary.

C. Diastolic pressures and mean arterial pressures are much more important in determining

danger of severe hypertension than is systolic pressure. These are poorly measured in the field. The diagnosis of “malignant” hypertension is not based on numerical levels, but rather on microscopic changes in blood vessels and damage to organs, which place this disease beyond the scope of prehospital care.

D. Don't forget that false elevation of BP can result from a cuff that is too small for the patient.

The cuff should cover 1/3 to 1/2 of the upper arm, and the bladder should completely encircle the arm.

E. Hypertension is seen in severe head injury, intracranial bleeding and ischemic CVA and is

thought to be a protective response that increases perfusion to the brain. Treatment should be directed at the intracranial process, not the blood pressure.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: CHILDBIRTH

January 1, 2008 II - 30


OB/GYN - CHILDBIRTH B/I/P

Specific Information Needed A. Symptoms: Pain, cramping, passage of clots or tissue, dizziness, weakness; if pregnant,

inquire about swelling of face and extremities, urge to push, contractions (regularity and timing), ruptured membranes

B. Obtain menstrual history: Last normal menstrual period, duration of period, amount of flow,

birth control method C. If pregnant, inquire about due date, prior problems with pregnancy (ie. breech, prev. c-sxn) D. Past and present history of hypertension (pre-eclampsia/eclampsia) E. Past history: Bleeding problems, pregnancies, medications, allergies Specific Objective Findings A. Vital signs and orthostatic changes B. Evidence of blood loss, clots or tissue fragments (bring tissue to the ED) C. Signs of hypovolemic shock, altered mental status, hypotension, tachycardia, sweating,

pallor D. Fever E. If pregnant, observe for uniform contraction and relaxation of uterus. Where privacy is

possible, examine perineum by observation only for: 1. Vaginal bleeding or fluid (note color) 2. Crowning (check during contraction) 3. Abnormal presentation (i.e., foot, arm, or cord) Treatment A. If patient is bleeding vaginally (moderate to heavy): NOTE: CONTACT BASE EARLY—FOR MEDICAL DIRECTION AND FOR ADEQUATE PREP

TIME AT HOSPITAL 1. Administer O2


January 1, 2008 II - 31

2. Establish venous access 3. If hypotensive, give fluid bolus, further fluids as directed and consider a second line 4. If hypotensive and pregnant, position onto left side B. If patient is in late pregnancy and there is crowning or other indication of imminent delivery,

deliver or transport. Be prepared to stop ambulance if delivery occurs en route. C. Transport immediately any pregnant patient with an abnormal presenting part or vaginal

bleeding. D. If patient is delivering: 1. Use clean or sterile technique 2. Guide and control, but do not retard or hurry the delivery 3. Suction the mouth (not throat), then nose with a bulb syringe on perineum See Airway Management for Meconium Protocol 4. Protect the infant from fall and temperature loss; wipe off amniotic fluid and wrap in a

clean or sterile blanket, check vital signs, provide artificial respiration or CPR as indicated. Assign APGAR score - see next page

5. Clamp the umbilical cord in two places approximately 8 - 10” from the infant 6. Cut the cord between the clamps 7. Establish venous access in mother and monitor vital signs 8. Transport. Do not wait for or attempt delivery of placenta; if placenta delivers

spontaneously, bring to the hospital E. If patient is bleeding in the postpartum period (within 24 hours of delivery): 1. Firmly massage uterus and have mother nurse infant to aid in uterine contractions. 2. Establish venous access. F. PIH (pregnancy induced hypertension) a.k.a. pre-eclampsia. This may occur pre or post-

partum.

1. Lay patient supine with right side elevated. 2.. P: If patient is having seizure, administer Magnesium Sulfate 2 gms/IV Contact Medical

Control. Mag can cause respiratory depression or hypotension.


January 1, 2008 II - 32

Specific Precautions A. Amount of vaginal bleeding is difficult to estimate. Try to get an estimate of number of

saturated pads in previous 6 hours. B. A patient in shock from vaginal bleeding should be treated like any other patient with

hypovolemic shock. C. If patient is pregnant, bring in any tissue which was passed. Laboratory analysis may be

important in determining status of pregnancy. D. Always consider pregnancy as a cause of vaginal bleeding. The history may contain

inaccuracies, denial, or wishful thinking. E. If the patient is pregnant, ask if she feels as though she is delivering. Particularly with prior

deliveries, most mothers will know. F. The primary enemy of newborns is hypothermia, which can occur within minutes due to

increased evaporative heat loss resulting from the infant’s large body surface area and the presence of amniotic fluid.

G. APGAR score is not predictive of later clinical course. Frequent monitoring of infant's vital

signs is more important. H. Suction mouth, pharynx, and nose immediately as head delivers.

APGAR Scoring Chart

Sign 0 1 2

A- Appearance

Pale, Blue

Body: Pink Ext: Blue Fully Pink

P- Pulse Absent

< 100 > 100

G- Grimace

(catheter in nares)

No Response

Some Grimace or avoidance

Cough, Cry, or Sneeze

A- Activity Limp Some Flexion Active, Good Flexion

R- Respirations

Absent

Slow, Irregular, or Ineffective

Crying, Rhythmic, Effective

TFPD EMS PROTOCOLS MEDICAL TREATMENT: POISONS/OVERDOSES

January 1, 2008 II - 33


POISONS AND OVERDOSES B/I/P

Specific Information Needed A. Type of ingestion: What, when, and how much was ingested? Bring the poison, the

container, description of emesis, all medications and everything questionable in the area with the patient to the Emergency Department.

B. Reason for exposure: Think of child neglect, depression, etc. C. Symptoms: Respiratory distress, sleepiness, nausea, agitation or decreased level of

consciousness D. Past history: Medications, diseases E. Action taken by bystanders: Induced emesis? “antidote” given? Specific Objective Findings A. Vital signs B. Airway: Patency and adequacy of ventilation C. Level of consciousness and neurologic status: Check and document frequently D. Breath odor, increased salivation, oral burns E. Skin: Sweating, cyanosis F. Systemic signs: Vomitus, arrhythmias, lung findings Treatment

CAUTION: SCENE AND RESCUER SAFETY IS PRIORITY ONE A. Assess and support ABCs B. Administer O2 C. Support patient on side and protect airway D. Establish venous access. CONTACT BASE E. B/I/P: Test for blood glucose. Administer Dextrose 50%, IV in secure vein, if clinically

indicated

TFPD EMS PROTOCOLS MEDICAL TREATMENT: POISONS/OVERDOSES

January 1, 2008 II - 34

F. I/P: Administer Naloxone in patients with decreased respiratory effort and observe patient

for improved ventilations G. B: Administer Naloxone IN in patients with decreased respiratory effort and observe patient

for improved ventilations H. Monitor cardiac rhythm I. I/P: May need to administer Sodium Bicarbonate if widened QRS or ventricular

dysrhythmias on monitor after excessive tricyclic antidepressant(s) ingested B/ I/P: Most medication overdoses (as well as NSAIDs, aspirin and Tylenol) will respond to

activated charcoal. If LOC is normal, administer 50g of activated charcoal with Sorbitol. CONTACT BASE prior to administration

P: Consider nasogastric insertion and charcoal administration P: Consider suctioning stomach contents through nasogastric tube P: Initial treatment for Cocaine overdose will be Valium. Consider Nitro to prevent coronary

spasm. Beta blockers are contraindicated in Cocaine use. CONTACT BASE prior to administration in hypertensive patients with CP. J. Frequent monitoring of vital signs during transport. Specific Precautions A. Watch the ABCs: These are important and can quickly change. B. There are few specific “antidotes.” Product labels and home kits can be misleading and

dangerous. Contact poison center or base as appropriate. C. Do not neutralize acids with alkalis. Do not neutralize alkalis with acids. These “treatments”

cause heat-releasing chemical reactions that can further injure the GI tract. D. Inhalation poisoning is particularly dangerous to rescuers. Recognize an environment with

continuing contamination and extricate rapidly.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: PSYCHIATRIC/BEHAVIORAL

January 1, 2008 II - 35


PSYCHIATRIC/BEHAVIORAL B/I/P

Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol,

physical trauma, emotional trauma, suicidal ideations B. Obtain past history; inquire about previous psychiatric and medical problems, medications Specific Objective Findings A. Evaluate vital signs B. Note medic alert tags, odor to breath C. Determine ability to relate to reality D. Note hallucinations and behavior Treatment A. Attempt to establish rapport. Utilize family if available and helpful B. Assure airway C. Restrain if necessary (See Restraints Protocol) D. Monitor vital signs E. If altered mental status or unstable vital signs: 1. Administer O2 2. Establish venous access 3. Draw appropriate blood tubes and check blood glucose 4. B/I/P: Consider D50 5. BI/P: Consider Narcan

6. I/P: Consider Haloperidol

TFPD EMS PROTOCOLS MEDICAL TREATMENT: PSYCHIATRIC/BEHAVIORAL

January 1, 2008 II - 36

Specific Precautions A. Psychiatric patients often have an organic basis for mental disturbances. Beware of

hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion. B. If emergency treatment is unnecessary, do as little as possible except to reassure while

transporting. Try not to violate the patient’s personal space. C. If the situation appears threatening, consider a show of force involving police before

attempting to restrain. D. Beware of weapons. These patients can become very violent. E. Mental health holds are not placed in the field by EMS personnel. F. Be aware of rescuer/scene safety. G. Consider early involvement of base and/or law enforcement.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: RESPIRATORY DISTRESS

January 1, 2008 II - 37


RESPIRATORY DISTRESS B/I/P

Specific Information Needed A. History: Acute change or injury, slow deterioration B. Past history: Chronic lung or heart problems or known diagnosis, medications, home O2,

past allergic reactions, recent surgery, and recent illness C. Associated symptoms: Chest pain, cough, fever, hand or mouth paresthesias Specific Objective Findings A. Vital signs B. Oxygenation: Level of consciousness, cyanosis C. Ventilatory effort: Accessory muscle use, forward position, pursed lips D. Neurologic signs: Slurred speech, impaired consciousness, evidence of drug/alcohol

ingestion E. Signs of upper airway obstruction: Hoarseness, drooling, exaggerated chest wall

movements, inspiratory stridor F. Signs of congestive failure: Neck vein distention (JVD) in upright position, rales, peripheral

edema G. Breath sounds: Clear, decreased, rales, wheezing, or rhonchi H. Hives, upper airway edema I. Evidence of trauma: Crepitus of neck or chest, bruising, steering wheel damage,

penetrating wounds Treatment A. Put patient in position of comfort (usually upright). If patient is immobilized due to trauma

and a respiratory event also exists allow patient to sit up to breathe easier. But attempts should be made to maintain cervical spine immobilization.

B. Identify and treat upper airway obstruction if present (suctioning, nasopharyngeal airway,

endotracheal intubation, etc.) C. Administer O2


January 1, 2008 II - 38

D. Assist ventilation with pocket mask or bag valve mask if necessary E. Assess and consider treatment for the following problems if respiratory distress is severe

and patient does not respond to proper positioning and administration of O2 1. Asthma: a. Establish venous access b. Monitor cardiac rhythm, SaO2, ETCO2 c. I/P: Albuterol via nebulizer (through BVM if needed). Consider Albuterol/Atrovent

neb d. CONTACT BASE station if repeated Albuterol nebulizer required. e. I/P: CONTACT BASE for Epinephrine or Magnesium Sulfate. 2. Cardiogenic pulmonary edema: a. Sit patient up, legs dangling if possible b. Establish venous access c. Monitor cardiac rhythm, SaO2, ETCO2 d. CONTACT BASE to consider: 1. I/P: Nitroglycerin 2. I/P: Morphine Sulfate 3. I/P: Albuterol e. I/P: Assist ventilations and consider intubation if patient has altered mentation

3. High Altitude pulmonary edema:

a. Position of comfort b. High flow O2 c. Monitor cardiac rhythm, SaO2, ETCO2 d. Albuterol nebulizer if any wheezing is present


January 1, 2008 II - 39

4. Chronic lung disease with deterioration: a. Administer O2 as per Oxygen protocol (see following Precaution). b. Monitor cardiac rhythm, SaO2, ETCO2 c. Establish venous access d. IP: Albuterol via nebulizer 5. P: Pneumothorax: Watch for signs of tension. If patient deteriorates rapidly, consider

chest decompression 6. Consider possibility of pulmonary embolism F. If diagnosis unclear, place patient in position of comfort, and administer oxygen, transport G. Prepare to assist ventilations if patient fatigues or develops altered mentation, or if

respiratory arrest occurs Specific Precautions A. Don’t over diagnose “psychogenic” in the field. Your patient could have a pulmonary

embolus or other serious problem; give him/her the benefit of the doubt. Treatment with oxygen will not harm the patient with hyperventilation syndrome, and it will keep you from underestimating the problem.

B. Wheezing in older persons may be due to pulmonary edema (“cardiac asthma”). Pulmonary

embolus is an uncommon cause of wheezing. C. Provide supplemental Oxygen. 1. Vital signs within normal limits: titrate to maintain SaO2 > 90%. 2. Altered LOC, abnormal vital signs: titrate to maintain SaO2 > 90%. 3. History of COPD TREAT COMPLICATIONS OF COPD AS ANY OTHER RESPIRATORY

EMERGENCY, KEEPING IN MIND THAT PROLONGED EXPIRATION TIME MUST BE ALLOWED FOR WHEN ASSISTING VENTILATIONS (AS WITH ASTHMATICS). INTUBATED PATIENTS SHOULD BE VENTILATED AT SLOWER RATES TO ALLOW FOR EXHALATION AND TO PREVENT BAROTRAUMA (or auto-PEEP).

a. If high flow oxygen is inadequate, assist ventilations with BVM, see above. 4. Strongly consider base contact prior to intubation. 5. ETCO2 may be an additional helpful vital sign to obtain.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: SEIZURES

January 1, 2008 II - 40


SEIZURES

B/I/P Specific Information Needed A. Seizure history: Onset, time interval, previous seizures, type of seizure B. Medical history: Especially head trauma, diabetes, headaches, drugs, alcohol, medications,

pregnancy Specific Objective Findings A. Vital signs B. Description of seizure activity C. Level of consciousness D. Head and mouth trauma E. Incontinence to urine and/or fecal F. Air temperature; patient temperature G. Skin color and moisture Treatment A. Airway: Ensure patency—nasopharyngeal airways are useful NOTE: Do not force anything between the teeth B. Administer O2 C. Suction as needed D. Protect patient from injury E. Check pulse immediately after seizure stops F. Keep patient on side G. Establish venous access if hospital transport is anticipated H. I/P: Administer Diazepam (5-10 mg), IV slowly, for status seizures rectal Versed may be used for pediatric patients (2.5 mg)


January 1, 2008 II - 41

P: If IV access cannot be obtained: alternatives are 5 mg Versed IM or 2.5 mg per nare IN I. Test for blood glucose J. B/I/P: Administer Dextrose 50%, if clinically indicated K. I/P: Administer Naloxone, if clinically indicated L. Monitor cardiac rhythm M. Keep in lateral recumbent position for transport N. Monitor vitals O. Status Epilepticus are status seizures. Status, meaning multiple back to back seizures.

These patients are postictal often with no postictal state after they have stopped. IV/IO or rectal Versed or Valium should be considered.

Specific Precautions A. Move hazardous materials away from patient. Restrain the patient only if needed to prevent

injury. Protect patient’s head. B. Trauma to tongue is unlikely to cause serious problems however, trauma to teeth may.

Attempts to force an airway into the patient’s mouth can completely obstruct airway. Do not use bite sticks.

C. Seizure can be due to lack of glucose or oxygen to the brain, as well as to the irritable

focus associated with epilepsy. Hypoxia from transient dysrhythmia or cardiac arrest (particularly in younger patients) may cause seizure and should be treated promptly. Don’t forget to check for pulse once a seizure terminates.

D. Hypoxic seizures can also be caused by simple faint, either when the tongue obstructs the

airway in the supine position, or when overly helpful bystanders prop the patient or elevate the head prematurely.

E. Alcohol-related seizures are common w/ withdrawal, but cannot be differentiated from other

causes of seizure in the field. Assessment in the intoxicated patient should still include consideration of hypoglycemia and all other potential causes. Field management is as for any seizure.

F. Seizures may be due to dysrhythmias or stroke. Of these, dysrhythmia is the most

important to recognize in the field. G. Medical personnel are often called to assist epileptics who seize in public. If patient clears

completely, is taking his/her medications, has his/her own physician, and is experiencing his/her usual frequency of seizures, transport may be unnecessary. Consult base.


January 1, 2008 II - 42

H. Valium has a tendency to decrease respiratory effort. Monitor respiratory status. I. Seizures in pregnant patients (or even those who are recently delivered) may be the

presenting sign of eclampsia or toxemia of pregnancy. Seizures in those patients will respond better to administration of Magnesium Sulfate.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: SHOCK

January 1, 2008 II - 43


SHOCK: MEDICAL B/I/P

Specific Information Needed A. Onset: Gradual or sudden; precipitating cause or event B. Associated symptoms: Itching, peripheral or facial edema, thirst, weakness, respiratory

distress, abdominal or chest pain, dizziness on standing C. History: Allergies, medications, bloody vomitus or stools, significant medical diseases,

history of recent trauma, last menstrual period, vaginal bleeding, fever Specific Objective Findings A. Vital signs: Pulse > 120 (occasionally < 50); BP < 90 systolic B. Mental status: Apathy, confusion, restlessness, combativeness C. Skin: Flushed, pale, sweaty, cool or warm, hives, or other rash D. Signs of trauma E. Signs of cardiogenic shock: jugular venous distention in upright position, rales, peripheral

edema Treatment A. Administer O2 B. Place patient supine, legs elevated C. Cover patient to avoid excess heat loss. Do not over bundle—the goal is to maintain normal

body temperature D. Assess for cardiogenic cause: 1. I/P: If HR > 150, treat tachyarrhythmia according to protocol. 2. I/P: If HR < 60, treat bradyarrhythmia according to protocol. 3. If distended neck veins, chest pain, or other evidence of cardiac cause: a. Position of comfort b. Be prepared to assist ventilations or initiate CPR c. Establish venous access


January 1, 2008 II - 44

d. Monitor cardiac rhythm e. Evaluate for possible tension pneumothorax. Treat according to protocol E. P: Consider Dopamine F. Transport rapidly for definitive diagnosis and treatment G. If no evidence of cardiogenic cause, institute general treatment measures: 1. Place patient supine; elevate legs 10-12 inches. (If respiratory distress results, leave

patient in position of comfort.) 2. Fluid bolus: IV, NS H. Assess and treat for specific cause, such as anaphylaxis, if this can be determined I. Monitor VS, cardiac rhythm, and level of consciousness during transport Specific Precautions A. Shock in a cardiac patient may be caused by hypovolemia; however, CONTACT BASE

prior to administering fluid boluses. B. Mixed forms of shock are treated as hypovolemia, but the other factors contributing to the

low perfusion should be considered. Neurogenic shock is caused by relative hypovolemia as blood vessels lose tone as in spinal cord trauma. Cardiac depressant factors can also be involved. Anaphylaxis is a mixed form of shock with hypovolemic, neurogenic, and cardiac depressant components. Epinephrine is used in addition to fluid load.

C. Cardiogenic shock from various causes is difficult to treat even in a hospital setting. Rapid

transport is recommended. D. Consider the four underlying sources of hypoperfusion (shock) and the types of shock that

are related to these. Pump Problem Container Problem Volume Problem Respiratory

Problem Cardiogenic Neurogenic hypovolemic/hemorrhagic All respiratory

complications Septic Trauma & Medical Anaphylaxis Psychogenic


January 1, 2008 II - 45

E. Shock presents in a succession of three phases: Compensatory Progressive Irreversible The first two phases present opportunity for positive intervention, the third phase offers no opportunities. Mechanism/Causes HYPOVOLEMIA (volume) Differential/Symptoms Dehydration suggestive illness Vomiting, diarrhea Diabetes with hyperglycemia diabetes; acute illness, increased urine or blood loss, thirst, fever Ectopic pregnancy female, 12-50 years, abdominal pain GI bleed vomitus; black or red stool Ruptured abdominal aneurysm severe back/abdomen pain, age, history

of high blood pressure, pulsatile abdominal mass, tearing pain

Vaginal bleeding suggestive history, miscarriage, abortion or delivery Intra-abdominal bleeding minor trauma, abdomen, back or shoulder pain CARDIOGENIC (pump) Arrhythmia palpitations Pericardial tamponade chest area cancer, blunt or penetrating trauma Tension pneumothorax respiratory distress, COPD, trauma Myocardial failure chest pain, history of congestive failure Pulmonary embolus sudden respiratory distress, chest pain CHF MIXED (container) Sepsis symptoms fever, elderly, urinary symptoms Drug overdose suggestive history Anaphylaxis SOB, itching, mouth swelling, dizziness, exposure to allergen

TFPD EMS PROTOCOLS MEDICAL TREATMENT: STROKE

January 1, 2008 II - 46


STROKE (SUSPECTED) Indications Patient exhibits altered mental status, weakness, blindness, anisocoria, sensory loss, aphasia, syncope, vertigo, serious headache, seizure, respiratory pattern change, and hypertension. Patients with a history of CVA, TIA, previous cardiac/ vascular surgery, diabetes, CAD, hypertension, atrial fibrillation, or history of trauma Treatment A. Ensure ABC’s B. Vital Signs C. Ensure one or more IV lines D. Acquire blood samples E. Acquire ECG and 12Lead F. Check blood glucose G. Consider C-Spine if mechanism indicates H. If appropriate, initiate Cincinnati Prehospital Stoke Scale:

1. facial droop (have patient show teeth or smile)

a. normal – both sides of face move equal

b. abnormal – one side of face does not move as well as the other 2. sidearm drift (patient closes eyes and extends both arms straight out with palms up for

10 seconds

a. normal – both arms move the same or both do not move at all

b. abnormal – one arm does not move or one arm drifts down compared with the other

3. abnormal speech (have patient “You can t teach an old dog new tricks”)

a. normal – patient uses correct words with no slurring

b. abnormal – patient slurs words uses wrong words or is unable to

speak

TFPD EMS PROTOCOLS MEDICAL TREATMENT: STROKE

January 1, 2008 II - 47

Interpretation: If any one of these signs is abnormal, the probability of stoke is 72%. Contact Medical Control to advise of potential thrombolytic candidate

Thrombolytic check list should be completed for any patient suspected of stroke with symptoms lasting longer than 90 minutes.

Contraindications: The following 12 questions should all be answered NO:

1. History of stroke or TIA in last 6 months 2. Recent head trauma or intercranial mass 3. Surgery or severe trauma in the past 2 weeks 4. Prior angioplasty or thrombolytic therapy 5. Blood pressure > 200 mmHg systolic or > 110 mmHg diastolic after NTG

6. Non compressible venous or arterial puncture 7. CPR performed for > 10 minutes 8. Acute pulmonary edema or cardiogenic shock 9. Current or prior pericarditis 10. Pregnant, recent delivery or abortion 11. Witnessed seizure at stroke onset 12. Recent acute myocardial infarction

Inclusion Criteria: The following 3 questions must be answered YES:

1. Age 18 years or older?

2. Clinical diagnosis of ischemic stroke w/ a measurable neurological deficit

3. Time of symptom onset (when patient was last seen normal) is well established as <

180 minutes (3 hours) before treatment would begin? If patient awoke in AM with seizure then they

are not a candidate because time of onset cannot be clearly determined.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: SYNCOPE

January 1, 2008 II - 48


SYNCOPE

B/I/P Specific Information Needed A. History of the event: Onset, duration, seizure activity, precipitating factors. Was the patient

sitting, standing, or lying? Pregnant? Arrival at high altitude? B. Past history: Medications, diseases, prior syncope C. Associated symptoms: Dizziness, nausea, chest or abdominal/back pain, headache,

palpitations Specific Objective Findings A. Vital signs B. Neurological status: Level of consciousness, residual neurological deficit C. Signs of head trauma, mouth trauma, incontinence D. Neck stiffness Treatment A. If trauma suspected consider CTLS protocol B. Position of comfort: DO NOT sit patient up prematurely if not completely alert or

hypotensive C. Acquire pulse oximetry prior to oxygen therapy to rule out hypoxia for new arrival to altitude D. Monitor vital signs and level of consciousness closely for changes or recurrence. E. Consider hypoglycemia. If signs of hypoglycemia are present: 1. Establish venous access 2. Draw appropriate blood tubes 3. Check blood glucose reading ≤ 60 4. Administer oral Dextrose or IV bolus of dextrose 50% in secure vein

TFPD EMS PROTOCOLS MEDICAL TREATMENT: SYNCOPE

January 1, 2008 II - 49

F. If vital signs unstable or age > 40 years: 1. Administer O2 2. Keep patient supine, elevate legs 10-12 inches 3. Establish venous access 4. Monitor cardiac rhythm Specific Precautions A. Syncope is by definition a transient state of unconsciousness from which the patient has

recovered. If the patient is still unconscious, treat as Coma. If the patient is confused, treat according to Coma/Altered Mental Status/Neurologic Deficit Protocol.

B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes.

Recumbent position should be sufficient to restore vital signs and level of consciousness to normal.

C. Syncope, which occurs without warning or while in a recumbent position or while

exercising, is potentially serious and often caused by arrhythmia. D. Patients over the age of 40 with syncope, even though apparently normal, should be

transported. In middle-aged or elderly patients, syncope can be due to a number of potentially serious problems. The most important of these to monitor and recognize are: dysrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm.

E. Any elderly patient with syncope and back pain should be considered to have a ruptured

abdominal aortic aneurysm until proven otherwise. F. High altitude syncope occurs in the first 24 hours of altitude exposure, usually in healthy

persons, and happens only once. The event is usually preceded by an alcoholic beverage and/or a meal.

TFPD EMS PROTOCOLS MEDICAL TREATMENT: VOMITING

January 1, 2008 II - 50


VOMITING B/I/P

Specific Information Needed A. Frequency, duration of vomiting B. Presence of blood in vomitus C. Associated symptoms: Abdominal pain, weakness, confusion D. Medication ingestion E. Past medical history: Diabetes, cardiac disease, abdominal problems, alcoholism Specific Objective Findings A. Vital signs B. Color of vomitus: Presence of blood C. Abdomen: Tenderness, guarding, rigidity, distention D. Signs of dehydration: Poor skin turgor, dry mucous membranes, confusion Treatment A. Position patient: Left lateral recumbent or semi-fowlers if vomiting; otherwise, supine B. Administer O2 C. Nothing by mouth D. If BP < 90 systolic and signs of hypovolemic shock, consider vagal influence; 1. Elevate legs 10-12 inches 2. Establish venous access, and give fluid bolus E. I/P: Consider Phenergan or Zofran F. Monitor vital signs during transport

TFPD EMS PROTOCOLS MEDICAL TREATMENT: VOMITING

January 1, 2008 II - 51

Specific Precautions A. Vomiting may be a symptom of a more serious problem. The most serious causes are GI

bleed or other intra-abdominal catastrophe. A rare cardiac patient may also present with vomiting as the predominant symptom.

B. Consider drug overdose; a patient who does not call the ambulance for medication

ingestion may call later when GI symptoms become severe. C. The vast majority of persons with vomiting have become sick over days, not minutes.

Unless severely ill, they do not require lights-and-siren transport or advanced field treatment.

D. Dehydration may be particularly severe in children with simple vomiting. IVs may be very

difficult to start, particularly with infants. Transport for definitive treatment is usually best.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: OVERVIEW

January 1, 2008 III - 1

Treatment Protocols: Trauma Treatment

MULTIPLE TRAUMA OVERVIEW B/I/P

Specific Information Needed A. Mechanism of injury: 1. Cause, precipitating factors, weapons used 2. Trajectories and forces involved to patient 3. For vehicular trauma: Condition of vehicle, windshield, steering wheel, compartment intrusion,

airbag deployment, type and use of seat belts. Specific description of mechanism (i.e., auto vs. pole, rollover, auto vs. pedestrian)

4. Helmet use, if sports related B. Patient complaints C. Initial position and level of consciousness of patient from witnesses, first responders D. Patient movement, treatment since injury E. Other factors such as drugs, alcohol, medications, diseases, pregnancy Specific Objective Findings A. Scene evaluation: 1. Note potential hazard to rescuers and patient 2. Identify number of patients; organize triage operations if appropriate 3. Observe position of patient, surroundings, probable mechanism, vehicle condition B. Patient evaluation: See treatment below Treatment Initial assessment in multiple trauma is performed at the same time as treatment A. Airway with C-spine immobilization B. Breathing C. Circulation, with control of major bleeding



D. Transport decision

1. If patient unstable, transport immediately. Treat enroute

2. Assess for potentially life-threatening injuries (see Assessment) and treat accordingly

E. Monitor vital signs, neurologic status and cardiac rhythm enroute F. P/ER Doctor: May request air transport at any time immediately followed by situational briefing with

other party (ER Doctor and P must communicate with each other when Special Transports are required)

Specific Precautions A. Assessment and management of trauma in the field has changed considerably in the past 5 years.

We now understand that there are patients who cannot tolerate a full assessment before life-saving intervention. Likewise, splinting, bandaging, and even the secondary survey are luxuries which may need to be bypassed in the critical patient. The need for blood, x-rays, operating room, and even specialized treatment centers makes time and in-hospital resources critical elements in resuscitation. For the special category of severely injured patients, the enlightened “load and go” is more appropriate than either the extended stabilization or the old “grab and run,” with no medical stabilization or care.

B. Critical injuries involve: 1. Difficulty with respiration 2. Difficulty with circulation (shock) 3. Decreased level of consciousness Any trauma patient with one or more of these conditions is a “load and go” and call for air

transport. C. Even in the noncritical patient with significant injury, “stabilization in the field” does not occur. With

major injuries, the very most you can do is to buy time. If the initial bolus of fluids results in improved vitals, do not become complacent. This patient frequently needs blood and an operating room to truly “stabilize” the traumatic process. Rapid transport is still of the highest priority.

D. Serial vital signs and observations of neurologic status in the field and during transport are critical. E. The trauma patient is probably the greatest risk to the rescuer for exposure to “bodily fluids.”

Observe Universal Precautions!



INDICATORS OF SIGNIFICANT INJURY MULTISYSTEM BLUNT OR PENETRATING TRAUMA WITH UNSTABLE VITAL SIGNS · Hemodynamic Compromise · Respiratory Compromise · Altered Mentation ANATOMICAL INJURY · Penetrating injury of head, neck, torso, groin · Combination of burns > 20% or involving face, airway, hands, feet or genitalia · Amputation above wrist or ankle · Paralysis · Flail chest · Two or more obvious proximal longbone fractures (upper arm or thigh) · Open or suspected depressed skull fracture · Unstable pelvis or suspected pelvic fracture HIGH ENERGY EVENT—RISK FOR SEVERE INJURY · Ejection from vehicle · Death of occupant in same vehicle · Auto crash with significant vehicular body damage · Significant fall · Significant auto rollover · Bent steering wheel · Auto - Pedestrian impact · Significant motorcycle, ATV or bicycle impact · Significant assault or altercation

TFPD EMS PROTOCOLS TRAUMA TREATMENT: ALGORITHM



ALGORITHM

TRAUMA B/I/P

Primary Exam

Immediate intervention for airway management and bleeding

“LOAD & GO” CRITERIA

Airway compromise

Clinical signs of shock Altered mental status

Positive indicators of significant injury YES NO

Rapid extrication Secondary survey for access on scene

“Load & Go” Splint all fractures on scene

INITIATE TRANSPORT AND CONTACT BASE Routine transport

Secondary survey enroute to trauma center

Repeat exam if any change in condition or after any interventions.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: ABDOMINAL TRAUMA



ABDOMINAL TRAUMA B/I/P

Specific Information Needed A. Patient complaints B. For penetrating trauma: Weapon, trajectory C. For auto: Condition of steering wheel, dash, vehicle; speed, patient trajectory; seatbelts in use,

type? D. Past history: Medical problems, medications, pregnancy Specific Objective Findings A. Observe: Distention, bruising, entrance/exit wounds B. Palpate: Areas of tenderness, guarding; pelvis stability to lateral and suprapubic compression Treatment A. Stabilize life-threatening airway and circulatory problems first B. Administer O2 C. Establish venous access D. For penetrating injuries: Cover wounds and eviscerations with moist saline gauze to prevent further

contamination and drying and heat loss. Do not attempt to replace. E. Observe carefully for signs of blood loss. If signs of shock: 1. Rapid transport 2. Second IV, large bore 3. Administer fluid bolus, NS; further fluids as directed a. Attempt to maintain a systolic BP ≥ 90 mmHg 4. CONTACT BASE. F. Monitor vital signs during transport.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: ABDOMINAL TRAUMA


Special Precautions A. The extent of abdominal injury is difficult to assess in the field. Be very suspicious; with significant

blunt trauma, injuries to multiple organs are the rule. B. Patients with spinal cord injury or altered sensorium due to drugs, alcohol, or head injury may not

complain of tenderness and may lack guarding in the face of significant intra-abdominal injury. C. Seat belts, steering wheels, and other blunt objects may cause occult intra-abdominal injury which

is not apparent until several hours after the trauma. You must consider forces involved to properly treat a trauma victim.

D. In children, significant intra-abdominal injury, which may lead to shock, may be present without any

external signs of injury, such as abrasions or hematomas. E. In penetrating abdominal injury, the impaled object should be left in place (manipulate only if

necessary to shorten for extrication), bleeding should be controlled by direct pressure around the object, and the object should be stabilized with bulky dressings.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: AMPUTATIONS



AMPUTATIONS

B/I/P Specific Information Needed A. History: Time and mechanism of amputation; care for severed part prior to rescuer arrival B. Past history: Medications, bleeding tendencies, medical problems Specific Objective Findings A. Vital signs B. Other injuries C. Blood loss at scene D. Structural attachments in partial amputations if identifiable Treatment A. Resuscitate and treat other more urgent injuries. B. Control hemorrhage with direct pressure, elevation. C. If hypotension or signs of shock: 1. Establish venous access 2. Fluid bolus: IV, NS D. Pain Management: as appropriate I/P: Morphine / Fentanyl E. Patient: Gently cover stump with sterile dressing. Saturate with sterile saline. Cover with dry

dressing. Elevate F. Severed part: Wrap in sterile gauze, preserving all amputated material. Moisten with sterile saline.

Place in watertight container (specimen cup, plastic bag, etc.). Place container in cooler with ice (do not freeze and do not float severed part in sterile saline).

G. CONTACT BASE.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: AMPUTATIONS


Specific Precautions A. Partial amputations should be dressed and splinted in alignment with extremity to ensure optimum

blood flow. Avoid torsion in handling and splinting. B. Do not use dry ice to preserve severed part. C. Control all bleeding by direct pressure and/or tourniquet. The most profuse bleeding may occur in

partial amputations, where cut vessel ends cannot retract to stop bleeding. CONTACT BASE if efforts are not successful.

D. Many factors enter into the decision to attempt re-implantation (age, location, condition of tissues,

other options). A decision regarding treatment cannot be made until the patient and part have been examined by a physician—and may not be made at the primary care hospital. Try to help the family and patient understand this, and don't falsely elevate hopes.

Amputation DON’Ts Amputation DOs

1.

Do not freeze the part by placing it directly on ice or by adding any other coolant such as dry ice.

1.

Wash parts thoroughly in sterile saline.

2.

Do not float the part in a bag of solution. 2.

Wrap in sterile gauze moistened with solution of normal saline.

3.

Do not use any antiseptics or other solutions.

3.

Place in a sterile container, e.g., a sterile urine analysis jar.

4.

Do not allow the tissue to dry. 4.

Place this container into a second container filled with crushed ice. DO NOT place the severed part directly on ice.

Time is of the essence. Cooling is essential to maintain the viability of the amputated part.

1-800-262-LIMB Information courtesy of Institute for Limb Preservation

TFPD EMS PROTOCOLS TRAUMA TREATMENT: BURNS



BURNS B/I/P

Specific Information Needed A. History of injury: Time elapsed since burn. Was patient in a closed space with steam or smoke?

Electrical contact? Loss of consciousness? Accompanying explosion, toxic fumes, other possible trauma?

B. Past history: Prior cardiac or pulmonary disease, medications? Specific Objective Findings A. Vital signs B. Extent of burns: Description or diagram of areas involved C. Depth of burns: Superficial - erythema only; partial or full thickness circumferential- blistered or

charred areas. (Extent of burn; one patient palm = 1% burn) D. Evidence of CO poisoning or other toxic inhalation: Altered mental state, headache, vomiting,

seizure, coma E. Evidence of inhalation burns: Respiratory distress, cough, hoarseness, singed nasal or facial hair,

soot or erythema of mouth F. Entrance and exit wounds for electrical burns G. Associated trauma Treatment General: Assure scene/rescuer safety. THERMAL BURNS: A. Extinguish fire and/or hot/smoldering area on patient with sterile or clean water (cold, but not ice-

cold) to cool skin and stop the burning process. (Do not use ice, snow, or any ointment) B. Remove clothing which is smoldering or which is non-adherent to the patient. Cut adhered

clothing. Melted synthetic fabrics can be soaked in cold water to stop burning C. Administer O2 if indications from history or physical of respiratory burns, toxic inhalation, or

significant flame or smoke exposure. Humidified oxygen is recommended in severe burns D. Assess and treat for associated trauma (blast or fall)



E. Remove rings, bracelets, and other constricting items F. If significant burn is moderate-to-severe (over 15% of body surface area), cover wounds with dry

clean sterile dressings G. Use cool, wet dressings in smaller burns (less than 15%) for patient comfort H. Establish venous access. Two large bore IV’s in unaffected extremities. If IV must be obtained

through burned tissue, use dressing to secure IV (Coban), as tape will not hold when skin begins to leak fluid

I. For pain relief, prn: I/P: Morphine Sulfate / Fentanyl J. Transport, monitoring vital signs K. I/P: Watch for airway compromise and be prepared to intubate INHALATION INJURY: A. Assure scene safety B. Administer O2 during full time of transport. Humidified O2 is recommended is severe burns C. Be prepared to ventilate or assist if respirations inadequate D. Monitor cardiac rhythm CHEMICAL BURNS: A. Assure scene safety B. Protect rescuer from contamination. Wear appropriate gloves and clothing C. Remove all clothing and brush off any remaining powdered chemical D. Assess and treat for associated injuries E. Decontaminate patient using running water for 15 min. prior to transport if patient stable F. Check eyes for exposure and rinse with free-flowing water for 15 min. Both eyes can be irrigated

with a nasal cannula attached to an IV set and normal saline. Single eyes should be irrigated medial to lateral aspect to avoid contaminating the unaffected eye

G. Evaluate for systemic symptoms which might be caused by chemical contamination. CONTACT

BASE for possible treatment



H. Remove rings, bracelets, constricting bands I. Wrap burned area in clean, dry cloths for transport. Keep patient as warm as possible after

decontamination J. CONTACT BASE for special treatment or procedures as needed ELECTRICAL INJURY: A. Protect rescuers from continued live electric wires B. Separate victim from electrical source when area safe for rescuers C. Consider c-spine immobilization D. Initiate CPR as needed. Defibrillation (as per protocol) E. Prolonged respiratory support may be needed F. Immobilize cervical spine, assess for other injuries G. Monitor patient for possible arrhythmias. Treat as per Arrhythmia protocol H. Establish venous access with two large-bore IVs in extremities without entry or exit wounds. Early

fluid resuscitation is important in the management of electrical burns Specific Precautions A. Leave blisters intact when possible. B. Suspect airway burns in any facial burns or burns received in closed places. Edema may become

severe, but not be immediately apparent. Avoid unnecessary trauma to the airway. Humidified O2 is useful if available.

C. Assume carbon monoxide poisoning in all closed space burns. The RAD-54 will help determine

level of exposure. Treatment is 100% O2 continued for at least 2 hours and at least 20 minutes with hyperbaric oxygen. In addition, other toxic products of combustion are more commonly encountered than realized. CONTACT BASE for special instructions if other toxic inhalations are suspected.

D. Consider suicide attempt as cause of burn, and child abuse in pediatric burns. E. Lightning injuries can cause prolonged respiratory arrest. Prompt, continuous respiratory

assistance (sometimes for hours to days) can result in full recovery.



F. Field decontamination of chemical exposures has been shown to significantly reduce extent of

burn. It is rare to encounter a chemical which is not properly decontaminated by copious water. Unless a specific contraindication is known, do not waste time before initiating treatment to find the specific culprit.

G. EMS personnel should not participate in decontamination unless trained and equipped to do so.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: CHEST INJURY



CHEST INJURY

B/I/P Specific Information Needed A. Patient complaints: Chest pain (type), respiratory distress, neck pain, other areas of injury B. Mechanism: Amount of force involved (particularly deceleration), speed of impact, seat belt

use/type C. Penetrating trauma: Size of object, caliber of bullet D. Past medical history: Medications, prior medical problems Specific Objective Findings A. Observe: Wounds, air leaks, chest wall movement, neck veins, tidal volume B. Palpate: Tenderness, crepitus, tracheal position, tenderness on sternal compression, pulse

pressure C. Auscultate: Breath sounds, heart sounds (quality) D. Surroundings: Vehicle, steering wheel condition Treatment A. Clear and open airway. Stabilize neck if indicated B. Assist breathing if patient is apneic or respirations depressed (<10, >30) C. Administer O2 D. If penetrating injury present, transport rapidly with further stabilization enroute E. For open chest wound with air leak, use occlusive dressing taped on three sides only, to allow air

to escape but not enter the chest F. Observe chest for paradoxical movements G. Intubate for respiratory insufficiency as manpower and time allow H. Control exsanguinating hemorrhage with direct pressure I. Obtain baseline vital signs, neurologic assessment



J. Evaluate neck veins and blood pressure: 1. If neck veins flat and patient in shock, transport rapidly and treat hypovolemia en route: a. Establish venous access b. Fluid bolus: IV, NS c. Monitor cardiac rhythm 2. If patient in shock with neck veins distended, also transport rapidly, and consider: a. Tension pneumothorax if respiratory status markedly deteriorating with clinical findings of

pneumothorax w/ circulatory collapse (hypotension, deviated trachea, AMS): i. Release occlusive dressings on open chest wounds ii. I/P: Needle decompression b. Pericardial tamponade, if mechanism of injury suspicious (may have distant heart sounds,

narrow pulse pressure): i. Establish venous access ii. Fluid bolus: IV, NS c. Cardiac contusion with typical ischemic chest pain or severe chest wall contusion: i. Monitor cardiac rhythm ii. I/P: Lidocaine IV for significant PVCs (see Chest Pain Protocol). 3. If patient stable without signs or symptoms of shock: a. Complete secondary survey b. If significant injury present: i. Establish venous access ii. Monitor cardiac rhythm enroute iii. I/P: Lidocaine IV for significant PVCs (see Chest Pain Protocol) K. Immobilize impaled objects in place with dressings to prevent movement.



L. Monitor vitals and level of consciousness every five minutes with significant injury. Specific Precautions A. Chest trauma is treated with difficulty in the field and prolonged treatment before transport is not

indicated if significant injury is suspected. If patient is critical, transport rapidly and avoid treatment of non-emergent problems at the scene. Penetrating injury particularly should receive immediate transport with minimal intervention in the field.

B. Consider medical causes of respiratory distress such as asthma, pulmonary edema or COPD that

have either caused trauma or been aggravated by it. C. Chest injuries sufficient to cause respiratory distress are commonly associated with significant

blood loss. Look for hypovolemia. D. Myocardial contusion can occur, particularly with anterior chest wall injury, as from a steering

wheel. Pain is similar to myocardial infarct pain. Monitor the patient and treat dysrhythmias as in a medical patient, but think first of hypoxia and hypovolemia as potential causes of dysrhythmias.

E. Don’t forget to check the back for injuries, especially the patient in shock, where a cause is not

evident (check the back, axillary region and base of neck). F. Significant intrathoracic injuries can exist without any external signs of injury.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: EXTREMITY INJURIES



EXTREMITY INJURIES B/I/P

Specific Information Needed A. Mechanism of injury: Direction of forces, if known B. Areas of pain or limited movement C. Treatment prior to arrival: Realignment of open or closed fracture, movement of patient D. Past medical history: Medications, medical illnesses Specific Objective Findings A. Vital signs B. Observe: Localized swelling, discoloration, angulation, lacerations, exposed bone fragments, loss

of function, guarding C. Palpate: Tenderness, crepitus, instability, quality of distal pulses, sensation D. Note estimated blood loss at scene Treatment A. Treat airway, breathing, and circulatory problems as first priorities (see Multiple Trauma Overview) B. Immobilize cervical spine when appropriate C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with

higher priority first D. If patient unstable, transport rapidly, treating life-threatening problems en route. Splint patient by

securing to long board to minimize fracture movement E. If patient stable, or isolated extremity injury exists: 1. Check distal pulses and monitor/sensory functions prior to immobilization of injured extremity 2. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate

with bone 3. Before splinting consider analgesics - IV / IM / IN

TFPD EMS PROTOCOLS TRAUMA TREATMENT: EXTREMITY INJURIES


4. Splint areas of tenderness or deformity: apply gentle traction throughout treatment and try to immobilize the joint above and below the injury in the splint (see Splinting: Extremity). Repeat pulse check after splinting

5. Realign fractures/dislocations by applying gentle axial traction if indicated: a. To restore circulation distally b. To immobilize adequately (i.e., realign femur fracture) c. If femur fracture suspected with mid shaft angulations or bump apply traction splint 6. Check distal pulses and sensation after reduction and splinting 7. Elevate simple extremity injuries. Apply ice if time and extent of injuries allow 8. Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of

injury during transport Special Precautions A. Patients with multiple injuries have a limited capacity to recognize areas which have been injured.

A patient with a femur fracture may be unable to recognize that he has other areas of pain. Be particularly aware of missing injuries proximal to the obvious ones (e.g., a hip dislocation with a femur fracture, or a humerus fracture with a forearm fracture).

B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels or leave cooling

for hospital setting. C. Do not attempt to realign dislocations in the field unless circulation is compromised. Splint in the

position of comfort. D. Injuries around joints may become more painful and circulation may be lost with attempted

realignment. If this occurs, stabilize the limb in the position of most comfort with the best distal circulation.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: FACE & NECK TRAUMA



FACE AND NECK TRAUMA B/I/P

Specific Information Needed A. Mechanism of injury: Impact to steering wheel, windshield, etc., clothesline-type injury to face or

neck B. Management before arrival by bystanders, first responders C. Patient complaints: Areas of pain; trouble with vision, hearing; neck pain; abnormal bite; short of

breath D. Past medical history: Medications, medical illnesses Specific Objective Findings A. Vital signs B. Airway: Jaw or tongue instability, loose teeth, vomitus or blood in airway, other evidence of

impairment or obstruction C. Neck: Tenderness, crepitus, hoarseness, bruising, swelling, stridor D. Blood or drainage from ears, nose E. Level of consciousness, evidence of head trauma F. Injury to eye: Lid laceration, blood anterior to pupil, abnormal pupil, abnormal globe position Treatment A. Control airway with C-spine immobilization if indicated: 1. Open airway using jaw thrust, keeping neck in alignment with in-line cervical immobilization 2. Use finger sweep to remove oral foreign bodies 3. Suction blood and other debris 4. Stabilize tongue and mandible with chin lift. Maitain airway with oral and nasal (in absence of

suspected midface or basilar skull fracture) adjuncts 5. Note evidence of laryngeal injury and transport immediately if signs present



6. I/P: Intubate if bleeding severe or airway cannot be maintained. Consider nasotracheal

intubation in patients over 8 years of age without evidence of midface fracture. Abandon procedure if resistance is met and proceed with orotracheal intubation and in-line cervical immobilization

7. If intubation cannot be performed due to severe facial injury, attempt to manage with

suctioning and bag-valve-mask

8. P: If necessary, consider cricothyrotomy (see Advanced Airway Management: Cricothyrotomy Protocol)

B. Support oxygenation as needed C. Administer supplemental O2 D. Stop hemorrhage; check pulse and circulation E. Establish venous access: 1. TKO if stable 2. With signs of hypovolemia: i. Fluid bolus, further fluids as directed. ii. CONTACT BASE. F. Obtain vital signs, assess neurologic status. G. Complete secondary survey if no life-threatening injuries present. H. Cover injured eyes with protective shield or cup—avoid pressure or direct contact to eye. I. Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing to avoid

contamination. J. Bring avulsed teeth with you. Keep moist in saline-soaked gauze or in milk if available. K. Monitor airway closely during transport for development of obstruction or respiratory distress.

Suction and treat as needed. Transport in position of comfort.



Specific Precautions A. Fracture of the larynx should be suspected in patients with respiratory distress, abnormal voice,

and history of direct blow to neck from steering wheel, rope, fence wire, etc. Both intubation and cricothyrotomy may be unsuccessful in the patient with a fractured larynx, and attempts may precipitate respiratory arrest. Transport rapidly for definitive treatment if you suspect this potentially lethal injury. Do not attempt intubation or cricothyrotomy unless the patient is in severe respiratory distress.

B. Airway obstruction is the primary cause of death in persons sustaining head and face trauma.

Meticulous attention to suctioning, and stabilization of tongue and mandible may be the most important treatment rendered.

C. Remember that the apex of the lung extends into the lower neck and may be injured in penetrating

injuries of the lower neck, resulting in pneumothorax or hemothorax. D. Do not be concerned with contact lens removal in the field.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: HEAD TRAUMA



HEAD TRAUMA B/I/P

Specific Information Needed A. History: Mechanism of injury, estimate of force involved; with motorcycle or bicycle, was helmet

worn? B. History since injury: Loss of consciousness (duration), change in level of consciousness, memory

loss for events before and after trauma, movement (spontaneous or moved by bystanders), seizure activity

C. Past history: Medications (esp. insulin), medical problems, seizure history, alcohol or drug use Specific Objective Findings A. Vital signs (note respiratory pattern and rate) B. Neurologic assessment: Including pupils, response to stimuli and level of consciousness C. External evidence of trauma: Contusions, abrasions, lacerations, bleeding from nose, ears Treatment A. Assess airway and breathing; treat life-threatening difficulties: (see Multiple Trauma Overview).

Use assistant to provide in-line cervical immobilization when indicated while managing respiratory difficulty

B. Administer O2 C. Control hemorrhage. Stop scalp bleeding with direct pressure. Continued pressure may be needed D. TRANSPORT RAPIDLY if patient has unstable neurologic, respiratory, or circulatory status.

Notify base to initiate air transport E. Obtain initial vital signs, neurologic assessment F. If patient is unconscious and showing signs of neurological deterioration (e.g., dilated pupil, rising

BP, slowing pulse, posturing): P: Consider rapid sequence intubation Remember GCS under eight, intubate 1. DO NOT BAG. Assist ventilations and hyperoxygenate at a rate of 8-16/per minute. ETCO2 &

SaO2 are the most definitive tools for determining efficacy of artificial ventilation. 30 mmHg is the suggested value to maintain normal ETCO2 & 95 - 100% for SaO2. Necessary tidal volume can be estimated using the 10cc/kg rule.



2. I/P: Consider intubation. Intubation (particularly nasal) increases ICP so…… 3. I/P: If time allows, administer Lidocaine (1.5 mg/kg.) IV 1 minute prior to intubation 4. Intubated patients should absolutely have ETCO2 in place and be ventilated to 30 mm/hg. Start at 12-15 bags/per minute and adjust accordingly.

5. Consider elevating the backboard at the head to reduce ICP

G. Immobilize cervical, thoracic and lumbosacral spine in ALL head trauma. H. If signs of hypovolemic shock are present initiate treatment en route: 1. Establish venous access 2. Fluid bolus: IV, NS 3. Look carefully for possible sources of bleeding (abdomen, pelvis, chest) 4. CONTACT BASE. I. If patient stable (respiratory, circulatory, neurologically): 1. Establish venous access TKO. Be judicious with fluids 2. Complete secondary survey 3. Splint fractures and dress wounds if time permits J. Monitor airway, vitals, and level of consciousness repeatedly at scene and during transport. Status

changes are important. Use GCS early and often Specific Precautions A. When head injury patients deteriorate, check first for airway, oxygenation and blood

pressure. These are the most common causes of “neurologic” deterioration. If the patient has tachycardia or hypotension, evaluate for hypovolemia from associated injuries.

B. The most important information you provide for the base physician is level of consciousness and

its changes. Is the patient stable, deteriorating or improving? C. Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent cause of death in

head injury. D. If active airway ventilation is needed then RSI should be indicated. Ventilate to an ETCO2 of 30

mm/hg. Intubate when possible.



E. If patient is combative from head injury, consider sedation. CONTACT BASE for orders. The airway and C-spine can be more appropriately managed with a relaxed patient and the effects can be reversed at the receiving facility if desired.

F. Scalp lacerations can cause profuse bleeding, and are difficult to define and control in the field. If

direct local pressure is insufficient to control the bleeding, evacuate any large clots from flaps and large lacerations with sterile gauze, and use direct hand pressure to provide hemostasis. If the underlying skull is unstable, pressure should be applied to the periphery of the laceration over intact bone.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: SPINAL TRAUMA



SPINAL TRAUMA B/I/P

Specific Information Needed A. Mechanism of injury and forces involved: 1. Positive mechanisms include high speed vehicle accident, a fall from 20 feet or gun shot

wound near the spine 2. Negative mechanisms include rock dropped onto foot, twisted ankle while running or a gun

shot wound to the extremity 3. Uncertain mechanisms include tripping and falling to the floor, low speed motor vehicle

accident in parking lot B. Clinical criteria are used to further assess patients who have uncertain or positive mechanism of

injury C. If patient complains of spinal pain or if patient has spinal tenderness, immobilize D. Clinical assessment criteria include documenting motor and sensory exam and reliability of patient 1. Patient must be calm, cooperative, sober, and alert 2. Examples of unreliable patient include those having acute stress reaction, brain injury,

intoxication, abnormal mental status, distracting injuries, communication barriers Specific Objective Findings A. Assessment of patient’s reliability B. Test and document motor and sensory exam. If any abnormalities, exam is positive and spinal

immobilization applied C. If local injury precludes motor or sensory exam, the exam is considered unreliable and spinal

immobilization is advised Treatment A. Assess airway and breathing; treat life-threatening difficulties. Use controlled ventilation for high

cervical cord injury associated with abdominal breathing. Use assistant to provide in-line cervical immobilization while managing ABCs

B. Administer O2

TFPD EMS PROTOCOLS TRAUMA TREATMENT: SPINAL TRAUMA


C. Control hemorrhage D. Immobilize cervical, thoracic and lumbosacral spine. Use firm cervical collar, foam blocks/towel

rolls, tape and spine board E. Obtain initial vital signs and neurologic assessment F. Establish venous access. If signs of hypovolemia: Fluid bolus, NS, further fluids as directed G. Monitor airway, vitals, and neurologic status frequently at scene and during transport H. Extended care: Serially examined and refer to algorithm for extended care Specific Precautions A. Be prepared to turn entire board on side if patient vomits (patient must be secured to spine board

or vacuum mattress). B. Neurogenic shock is likely with significant spinal cord injury. Raise the foot of the spine board. Be

sure respirations remain adequate. C. If hypotension is unresponsive to simple measures, it is likely due to other injuries. Neurologic

deficits make these other injuries hard to evaluate. Cord injury above the level of T-8 removes tenderness, rigidity, and guarding as clues to abdominal injury.

D. Spinal immobilization in patients with penetrating trauma should be accomplished only when

neurologic deficit or impaled foreign body is present.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: SPINAL CLEARANCE



SPINAL CLEARANCE

B/I/P Specific Information Needed

A. Any YES answer to the following questions: patient is to be fully CTLS immobilized

1. Any drugs or alcohol taken today

2. Any loss of consciousness – or if patient is NOT AAO x 4 3. Any pain or point tenderness along spine noted after two complete exams at 5 minutes apart 4. Any distracting injuries ie: 10/10 pain, high levels of anxiety, amputation, exposed bone, etc.

5. Any paresthesia involving any extremities

B. Consider age, behavioral status, and overall reliability of patient before definite clearance C. After trauma, give ample time for cessation of patient’s adrenaline levels to reveal more

reliable test results Specific Objective Findings

A. Test and document motor and sensory response; any abnormalities require spinal immobilization

Treatment A. Aside from above questions a thorough spinal palpation should be given from top to bottom. If

patient asymptomatic a second spinal exam/palpation should follow five minutes after initial palpation

Specific Precautions

A. If there is any question / concern after exam EMT should take full CTLS precautions

B. Be VERY clear in documentation of exam

C. Mechanism should give you a heightened sense of caution, despite overt physical findings. When a mechanism defies common logic (ie. falls of 30+ ft., MVA rollover x8) be conservative and err on the side of caution

TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRAUMA ARREST



TRAUMA ARREST B/I/P

Specific Information Needed A. Time of arrest B. Mechanism: Blunt vs. penetrating C. Signs of irreversible death (decapitation, dependent lividity) Specific Objective Findings A. Vital signs B. Evidence of massive external blood loss C. Evidence of massive blunt head, thorax or abdominal trauma Treatment A. Blunt trauma arrest: 1. Initiate basic life support 2. Manage airway. Consider needle decompression of chest cavities 3. If no vital signs or other signs of life present after above treatments, consider field

pronouncement 4. When possible, airway and venous access should be established en route, minimizing on-

scene time and any other delays in transporting patient 5. CONTACT BASE. 6. I/P: If cardiac activity returns with above treatment, treat arrhythmias per ACLS protocols and

transport rapidly B. Penetrating trauma arrest: 1. Initiate basic life support 2. Manage airway. Consider needle decompression 3. Rapid transport

TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRAUMA ARREST


4. Establish venous access, fluid bolus: IV, NS 5. CONTACT BASE to report patient status 6. I/P: If cardiac activity returns with above treatment, treat arrhythmias per ACLS protocols 7. Consider field pronouncement (see Resuscitation and Field Pronouncement Guidelines

protocol) for the following: a. Signs of irreversible death b. ALS has been unavailable for at least 20 minutes from the time EMS personnel initiate on-

scene assessment and there is no return of vital signs or signs of life Specific Precautions A. Victims of blunt trauma arrest without vital signs at the scene after initiation of ALS have a mortality

rate approaching 100%. B. Trauma arrests secondary to penetrating truncal injuries can be resuscitated and saved. There is a

higher rate of survival in victims of low velocity penetrating injuries versus victims of high velocity injuries.

TFPD EMS PROTOCOLS TRAUMA TREATMENT: MULTI-PATIENT INCIDENTS



MULTIPLE PATIENT INCIDENTS

FR/B/I/P Specific Information Needed A. History of incident: Nature of incident, mechanism B. Exact location C. Presence of hazardous conditions D. Has Incident Command System been initiated? E. Estimate number of patients initially. Later estimate number of Level red, yellow, green, and black

patients F. Additional Resources needed Specific Objective Findings A. Observe: Weather conditions, hazards, condition of patients B. Access to patients, severity of injuries MCI Incidents; Course of action A. Initiate Incident Command System (ICS) B. Designate Incident Command (IC) C. Designate Operations Officer D. Notify dispatch of nature of incident, exact location, estimated number of patients additional

resources needed, and consider implementation of San Miguel County Disaster Plan E. Develop a management plan F. Delegate authority and responsibility to subordinates, in order to accomplish goals and objectives G. Assign units as required and provide specific operating objectives for these units 1. After an incident commander is determined, the following EMS sectors are established as

needed: a. EMS Officer



b. Triage Unit c. Extrication Unit (establish by fire department) d. Patient Transportation Unit e. Treatment Unit H. Provide effective command, until relieved by more qualified personnel I. Review and evaluate the effectiveness of operations and revise as needed J. As an incident winds down, return units to service and terminate command when appropriate INCIDENT COMMAND SYSTEM Roles and Responsibilities of EMS A. EMS Officer: 1. Implements assigned incident objectives 2. Works within the Incident Command System and reports to the Operations Officer 3. Designates triage, treatment, and patient transportation unit officers and treatment area

locations 4. Requests additional personnel and resources sufficient to handle the magnitude of the

incident

ICS

OPERATIONS

EMS EXTRICATION

TRIAGE TREATMENT TRANSPORTATION



5. Ensures notification of hospitals 6. Monitors safety of personnel B. Triage Officer: 1. Works within the Incident Command system and reports to the EMS Officer 2. Determines location of triage areas (triage may take place either in the extrication area or at

the entry to the treatment area) 3. Requests personnel as needed from the EMS Branch Director 4. Assigns available personnel and equipment to patients 5. Initial Triage will be done using the START System (see addition) 6. Responsible for determining number of total patients, number of Levels red, yellow, green ,

and black patients and relaying that information to the EMS Division Officer 7. Triage is a continuous process from 1st contact with the patient through treatment,

transportation, and into the hospital 8. Assigns personnel to triage the “walking wounded” 9. Manages the distribution and use of Triage Tags (see addition) 10. Coordinates movement of patients from the triage area to the treatment area 11. Collects and assembles the “walking wounded” separate from the treatment and extrication

areas for later triage C. Extrication Officer (establish by Fire Department): 1. Responsible for managing the rescue of entrapped victims 2. Works within the Incident Command system and reports to Incident Command 3. Coordinates with the treatment unit for patient care during the rescue operation 4. Coordinates with the triage unit for patient transportation to the triage or treatment area 5. Determines resources needed 6. Allocates and supervises assigned resources



7. Ensures safety of personnel operating in the area D. Treatment Officer: 1. Works within the Incident Command System and reports to the EMS Division Officer 2. Locates a suitable treatment area and reports that location to the extrication officer and EMS

Division Officer 3. Determines resources needed for patient treatment and requests through EMS Division

Officer 4. Sets up separate “immediate,” “delayed,” and “walking wounded” treatment areas 5. Assigns, supervises, and coordinates personnel within the sector 6. Ensures that patients received in the treatment areas are: a. Separated by triage category b. Reassessed and retriaged appropriately (continual) c. Receive prompt and efficient treatment 7. Directs movement of patients to ambulance loading areas E. Patient Transportation Officer: 1. Works within the Incident Command System and Reports to the EMS Division Officer 2. Is the hospital contact person on scene? As soon as possible, contact Telluride Medical

Center to advise of the following: (using cell phone or EMS channel.) a. Type of incident b. Location c. Estimate of total number of patients d. Estimate of number of Level I, Level II, and walking wounded (Level III) e. Estimated time of initial patient arrival 3. Report resource needs to EMS Division Officer 4. Establishes an ambulance staging (if Command has not done so) and patient loading areas



5. Establishes a “route map” for vehicle travel from staging through the incident site and to the

hospitals. (“One way” traffic is preferred with clearly marked routes. Let staging know the “route” so that incoming units can be advised of it)

6. Establishes and operates a helicopter landing site (radio traffic with flights to be conducted

over frequency) 7. Coordinates directly with staging, delivery of ambulances to ambulance loading zone 8. Coordinates with Telluride Medical Center for transport priority 9. Notifies Telluride Medical Center of number of incoming patients, destination, and their status

(i.e., Level I, II or III) and whether male/female, infant, child, or adult. (All radio communication with hospitals will be done through the transportation officer and not by individual ambulances unless conditions make this impossible)

10. Telluride Medical Center and the transportation officer will coordinate patient destination

needs 11. Updates EMS Division Officer and Telluride Medical Center of changes in number of patients

and their status 12. Coordinates with other sectors as needed 13. Reports when the last patient has been transported, to EMS Division Officer and TMC 14. It is recommended that an assistant be assigned to the Transportation Officer early in the

incident.

Notes: The Medical Center has requested that they be notified as soon as possible with accurate information in multiple casualty incidents. This applies to any incident which has the potential to stress the system, whether it is the full disaster with 60 victims, the auto accident with four critical patients, or a single patient for whom the air transport may be necessary. Recommendation: When an agency arrives on scene on these incidents and does size up, a radio report to TMC should keep both the clinic and dispatch apprised of the situation.

Example: 1. 911 receives the call from a reporting party of an “auto accident with people all over the road” 2. 911 initiates page to responding agency



3. The Incident Commander or personnel requests additional resources if felt to be necessary

based on the information given by dispatch 4. Incident Commander/Scene personnel gets to the scene and does initial “size up” and makes

the radio report to TMC 5. Communications back up plan is to contact TMC directly by cell phone 6. TMC makes the decision, with the information available, whether to call other facilities • Practicing setting up ICS and our communication systems for the smaller multiple casualty incidents

will better prepare us for the “big one”

TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRIAGE



TRIAGE / The START Plan ~ Simple Triage And Rapid Treatment

Uses the same assessment techniques as RACE and CPR The first rescuers on the scene begin the triage process. Triage continues throughout the incident and each patient will be triaged several times throughout their journey through the incident. The goal is to separate the victims into four categories, with the more seriously injured, but salvageable patients, being treated and transported first. There are four levels of injury: Immediate (LEVEL I) (RED) Delayed (LEVEL II) (YELLOW) Walking Wounded (LEVEL III) (GREEN) Dead (OR Non-Salvageable) (LEVEL 0) (BLACK) The plan has four steps: STEP ONE: Walking Wounded should be directed away from the scene unless they are

incorporated to assist in triage Direct all patients who can walk to a specific area STEP TWO: Go to the nearest “down patient” and Check Respirations (may reposition head) Findings: (Estimate rate, don’t count it) No Respirations—Tag as Dead (LEVEL 0) Respirations below 10 / over 30—Tag Immediate (LEVEL I) Respirations below 30 - Go to Step Three STEP THREE: Check Perfusion Findings: No radial pulse (Patient is breathing)—Tag Immediate (LEVEL I) Radial Pulse – Go to Step Four (Apply direct pressure to major bleeding, Raise legs) STEP FOUR: Check Neuro Status Findings: (Patient has adequate perfusion and respirations) Unconscious - Tag Immediate (LEVEL I) Cannot follow simple directions - Tag Immediate (LEVEL I) Can follow simple directions - Tag Delayed (LEVEL II)

TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRIAGE


(Step Four Can Be Done at the Same Time You Are Checking Resp. and Pulse) REMEMBER, the first assessment that produces an IMMEDIATE category stops further triage assessment of the remaining areas. The patient is tagged IMMEDIATE (Level I) at that time and the rescuer moves to the next patient. Only correction of life-threatening problems, such as airway blockage or severe hemorrhaging would be corrected before moving on to the next patient. AT THIS TIME THE WALKING WOUNDED WOULD BE EVALUATED USING THE “START” METHOD.

Another similar method that may be easier to fall back on is the RPM Triage Respirations, Perfusion, Mentation

RESPIRATIONS YES NO Position Airway ≥ 30/min. ≤ 10/min. ≤ 30/min. YES NO IMMEDIATE IMMEDIATE DECEASED PERFUSION Radial Pulse Present Radial Pulse Absent Capillary Refill < 2 sec. > 2 sec. Mental Status Control Bleeding IMMEDIATE can’t follow can follow commands simple commands IMMEDIATE DELAYED

TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRANSPORT


Treatment Protocols: Trauma Treatment TRANSPORT DESTINATION (Revised 11/07)

B / I / P

HIGH RISK ADULT TRAUMA PATIENT*

Field Criteria

Transport Destination Significant Blunt Trauma with Physiologic Compromise as Evidenced by: • Systolic BP < 90 or • Pulse > 120 • Respiratory rate < 10 or > 29 or requiring endotracheal

intubation • Altered mental status (GCS < 10) with focal neurologic

deficit Penetrating Trauma to: • Thorax • Abdomen • Neck

• Transport to nearest facility. • Consider need for air transport. • Consider ALS rendezvous. • CONTACT MEDICAL CONTROL

High Risk Criteria (Without Physiologic Compromise): • Death of same car occupant • Extrication time > 20 minutes

Consult with medical control for appropriate destination as needed.

MODERATE RISK ADULT TRAUMA PATIENT

Field Criteria

Transport Destination

• Flail Chest • Spinal cord injury with neurologic deficit • Multi-system blunt injuries (> 2 systems injured) • Long bone fractures and/or Pelvic fractures In conjunction with multi-system injuries • Altered mental status (GCS < 10) with significant

trauma • Burn > 15% or involving face, airway • Amputation above wrist or ankle • Pedestrian hit @ > 20 MPH or thrown > 15 feet

• Transport to nearest facility. • Consider need for air transport. • Consider ALS rendezvous. • CONTACT MEDICAL CONTROL • Consider transfer to burn unit.

OTHER RISK FACTORS FOR INJURY

Risk Factors


• Falls > 20ft. • High energy transfer situations such as: · Auto crash with significant vehicle body damage,

motorcycle, ATV, bicycle accident

• Transport to nearest facility.

Co-morbid Factors-Moderate Trauma or Other Risk Factors Plus:


• Extremes of age (> 60) • Medical illness (COPD, CHF, renal failure,

anticoagulant therapy, etc.) • 2nd and 3rd trimester pregnancy


TFPD EMS PROTOCOLS TRAUMA TREATMENT: TRANSPORT


TRIAGE/TRANSPORT FOR PEDIATRIC (< 12 YEARS OLD*) TRAUMA PATIENTS (Revised 11/07)

HIGH RISK PEDIATRIC TRAUMA PATIENT

Field Criteria


Significant Blunt Trauma with Physiologic Compromise as Evidenced by: Tachycardia for age plus at least 2 signs of poor

perfusion: • Capillary refill > 2 seconds • Cool extremities • Decreased pulses • Altered mental status • Respiratory distress

OR • BP < lower limits for age • Altered mental status (GCS < 10) with significant

head trauma or focal neurologic deficit • Spinal cord injury with neurologic deficit

Penetrating Trauma to: • Thorax • Abdomen • Neck • Head

• Transport to nearest facility. • Consider need for air transport to a pediatric

trauma center. • Consider ALS rendezvous • CONTACT MEDICAL CONTROL

Burns • Second degree burns > 10% body surface area (TBSA) • Third degree burns > 5% (TBSA)

Initial assessment and stabilization at closest emergency department; transfer to specialized pediatric burn facility.

MODERATE RISK PEDIATRIC TRAUMA PATIENT

Field Criteria Transport Destination • Flail Chest • Multi-system blunt injuries (> 2 systems injured) • Long bone fractures and/or Pelvic fractures • In conjunction with multi-system injuries • Altered mental status (GCS < 10) with significant trauma • Burn > 15% or involving face, airway • Amputation above wrist or ankle • Pedestrian hit @ > 20 MPH or thrown > 15 feet

• Transport to nearest facility. • Consider need for air transport to a pediatric

trauma center. • Consider ALS rendezvous • CONTACT MEDICAL CONTROL

OTHER RISK FACTORS FOR INJURY

Field Criteria


• Falls > 20 feet • High energy transfer situations such as: · Auto crash with significant vehicle body damage · Motorcycle, ATV


*Individuals 13 to 18 years of age, transport will follow adult pre-hospital destination algorithms based on severity of illness

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: BITES & STINGS

January 1, 2008 IV - 1

Treatment Protocols: Environmental Injuries

BITES AND STINGS B/I/P

Specific Information Needed A. Type of animal or insect; time of exposure. B. Symptoms:

1. Local: Pain, stinging 2. Generalized: Dizziness, weakness, itching, trouble breathing, muscle cramps

C. History of previous exposures, allergic reactions

Specific Objective Findings A. Identification of spider, bee, marine animal if possible B. Local signs: Erythema, swelling, heat in area of bite C. Systemic signs: Hives, wheezing, respiratory distress, abnormal vital signs

Treatment A. Consider oxygen therapy B. Consider IV & fluid therapy C. I/P: Consider pain medication Snakes: See Snake Bites

Spiders: A. Cold compress for comfort B. Bring in spider, if captured and contained or if dead, for accurate identification C. Transport for observation if systemic signs and symptoms present

Bees and Wasps: A. Remove sting mechanism as soon as possible by any means necessary

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: BITES & STINGS


B. Observe patient for signs of systemic allergic reaction. Transport rapidly if needed.

Treat anaphylaxis per protocol C. Transport all patients with systemic symptoms or history of systemic symptoms from

prior bites Specific Precautions A. For all types of bites and stings, the goal of prehospital care is to prevent further

inoculation and to treat allergic reactions. B. Allergy kits consist of injectable Epinephrine and oral antihistamine, and are prescribed

for persons with known systemic allergic reactions. C. About 60% of patients who have experienced a generalized reaction to a bite or sting in

the past will have a similar or more severe reaction upon reinoculation. Thus, although it is not inevitable, this group of patients must be considered at high risk for anaphylaxis. In addition, a small group of patients will have anaphylaxis as a “first” reaction.

D. Time since envenomation is important. Anaphylaxis rarely develops more than 60

minutes after inoculation.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: DROWNING



DROWNING/NEAR-DROWNING

B/I/P

Specific Information Needed A. How long patient was submerged? B. Degree of contamination, water temperature? C. Diving accident? Water depth?

Specific Objective Findings A. Vital signs, including temperature B. Neurologic status: Monitor on a continuing basis C. Lung exam: Rales or signs of pulmonary edema, respiratory distress

Treatment A. Clear upper airway of vomitus or large debris B. Start CPR if needed C. Stabilize neck prior to removing patient from water if any suggestion of neck injury.

Remove patient from water on backboard when indicated D. Suction as needed E. Administer O2 F. If patient not awake and alert:

1. Assist ventilation using pocket mask or BVM 2. I/P: Intubate when indicated and apply positive pressure ventilation 3. Establish IV/IO access 4. Monitor cardiac rhythm during transport; treat dysrhythmias per protocol

G. Transport patient, even if normal by initial assessment

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: DROWNING


Specific Precautions A. Be prepared for vomiting. Patients should be secured on spineboard when indicated for

log-rolling to protect airway. B. ALL NEAR-DROWNINGS OR SUBMERSIONS SHOULD BE TRANSPORTED. Even if

patients initially appear fine, they can deteriorate. Monitor closely. Pulmonary edema often occurs due to aspiration, hypoxia, and other factors. It may not be evident for several hours after near-drowning.

C. Beware of neck injuries - they often go unrecognized. Collar and backboard can be

applied in the water. D. If patient is hypothermic, defibrillation may be unsuccessful until the patient is

rewarmed. Prolonged CPR may be needed. See Hypothermia Protocol. E. Under current ACLS standards, Heimlich maneuver is not indicated. F. If victim was submerged for more than one hour, and water temperature is > 70° do not

resuscitate if there are no signs of life.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HIGH ALTITUDE SICKNESS



HIGH ALTITUDE ILLNESS B/I/P

Specific Information Needed A. Presenting symptoms generally fall into two categories:

1. Cerebral symptoms:

a. Acute mountain sickness (AMS)—headache, sleeplessness, anorexia, nausea, fatigue.

b. High Altitude Cerebral Edema (HACE): ataxia, confusion, stupor, and coma.-

progression of cerebral symptoms in patients with AMS or HAPE. 2. Pulmonary symptoms:

a. High altitude pulmonary edema (HAPE)—Cough and weakness. B. Current and highest altitude, time at this altitude, rate of ascent. C. Medical problems, medications, previous experience at altitude.

Specific Objective Findings A. Vital signs. B. Neurological status: Confusion, lack of coordination, coma. C. Lungs: Respiratory rate, distress, rales, sputum (bloody or frothy).

Treatment A. Put patient at rest, position of comfort. B. Attain pulse oximetry prior to O2 administration C. Administer O2 to maintain SaO2 >92%.

1. If pulse oximetry is not available:

a. AMS- 2 - 4 lpm via NC

b. HAPE & HACE- 15 lpm via NRB D. Suction as needed. Assist ventilation if patient has cyanosis, confusion, and poor

respiratory effort.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HIGH ALTITUDE SICKNESS


E. For HAPE and HACE, establish venous access, if conditions permit. P: CONTACT BASE prior to administering Decadron for HACE. F. Monitor vitals during transport. Specific Precautions A. Recognition of the problem is the most critical part of treating high altitude illness. While

in the mountains, recognize symptoms which are out of proportion to those being experienced by the rest of the party: Dry cough, fatigue, ataxia, or trouble breathing (particularly at rest).

B. The mainstay of treatment is descent from altitude. Even a loss of 1,000-1,500 feet

makes enough difference in the O2 content of air that symptoms may be relieved or stop progressing. O2 administration can be life-saving as well as relieve symptoms and allow more time for orderly evacuation.

C. In addition to the more common pulmonary edema, cerebral edema may occur with

confusion. Treatment is the same. D. Acute mountain sickness, the mild form of illness during altitude adaptation, consists of

fatigue, headache, and poor sleeping, without CNS or respiratory findings. Treatment is rest. This increases the body’s time to acclimatize. Descend if symptoms progress, or ataxia present.

E. Patients at risk for high altitude illness for whatever reason may be taking Diamox.

Diamox may be useful in preventing some altitude illness because of direct effects on acid-base balance. Diuretics are not useful, however, in treating high altitude pulmonary edema, because the cause is excess capillary leakage of fluid, rather than increased venous pressure.

F. If transport is prolonged, consider giving Decadron (10 - 100 mg IV) for patients with

signs of HACE. G. Consider Albuterol nebulizer for any wheezing in HAPE.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPERTHERMIA



HYPERTHERMIA

B/I/P

Specific Information Needed A. Patient age, activity level B. Medications: Depressants, tranquilizers, alcohol, etc. C. Associated symptoms: Cramps, headache, orthostatic symptoms, nausea, weakness

Specific Objective Findings A. Vital signs: Temperature; usually 104 degrees Fahrenheit or greater (if thermometer

available) B. Mental status: Confusion, coma, seizures, psychosis C. Skin flushed and warm: With or without sweating D. Air temperature and humidity; patient dress

Treatment A. Ensure airway B. Remove patient from environment C. Remove clothing D. Administer O2 E. Spray or splash patient with water then fan to cool through evaporation, repeat when

patient dries F. Establish venous access:

1. TKO if vital signs stable 2. Fluid bolus if signs of hypovolemia

G. Treat seizures per protocol H. Monitor cardiac rhythm

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPERTHERMIA


I. Monitor vitals during transport Specific Precautions A. Heat stroke is a medical emergency. It is distinguished by altered level of

consciousness. Sweating may still be present, especially in exercise-induced heat stroke. The other persons at risk for heat stroke are the elderly and persons on medications that impair the body’s ability to regulate heat.

B. Differentiate heat stroke from heat exhaustion (hypovolemia of more gradual onset)

and heat cramps (abdominal or leg cramps). Be aware that heat exhaustion can progress to heat stroke.

C. DO NOT let cooling in the field delay your transport. Cool patient as possible while

en route. D. Do not use ice water or cold water to cool patients, as these may induce

vasoconstriction.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPOTHERMIA/FROSTBITE



HYPOTHERMIA AND FROSTBITE B/I/P

Specific Information Needed A. Length of exposure. B. Air temperature, water temperature, winds, patient wet? C. History and timing of changes in mental status. D. Drugs: Alcohol, tranquilizers, anticonvulsants, others. E. Medical problems: Diabetes, epilepsy, alcoholism, etc. F. With local injury: History of thawing/refreezing?

Specific Objective Findings A. Vital signs, mental status, shivering. (Prolonged observation for 1-2 min. may be

necessary to detect pulse, respirations.) Core temperature. B. Skin temperature (estimated); also note current temperature of environment. C. Evidence of local injury: blanching, blistering, erythema of extremities, ears, nose. D. Cardiac rhythm.

Treatment

A. Generalized:

1. CPR with intubation only if no electrical activity or V-Fib on the cardiac monitor. 2. Administer O2. Assist with bag-valve-mask as needed. Intubate only to protect airway or

in absence of organized cardiac electrical activity. Use warm, humidified O2. 3. Avoid unnecessary suctioning or airway manipulation. 4. Remove wet or constrictive clothes from patient. Wrap in blankets and protect from

wind exposure. Increase ambient temperature in ambulance. Move patient gently. 5. Establish venous access. Solution should be warmed. Do not start IV until patient is

moved to transport vehicle.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPOTHERMIA/FROSTBITE

January 1, 2008 IV - 10

6. Monitor cardiac rhythm for a minimum of 30 - 45 seconds. Attempt defibrillation if

without pulse or breaths, one shock only until core temperature is known. 7. I/P: IV meds (according to ACLS protocols) if core temperature > to 30|C (86|F), but at

longer than standard intervals. 8. 34°C-35°C or 93°F-95°F is considered mild hypothermia. 9. 30°C-34°C or 86°F-93°F is considered moderate hypothermia. 10. < 30°C or < 86°F is considered severe hypothermia. 11. Monitor vitals during transport.

B. Local (frostbite):

1. Remove wet or constricting clothing. Keep skin dry and protected from wind. 2. Do not allow the limb to thaw if there is a chance that limb may refreeze before

evacuation is complete, or if patient must walk to transportation. 3. Rewarm minor “frostnip” areas by placing in axilla or against trunk under clothing. 4. Dress injured areas lightly in clean cloth to protect from pressure, trauma or friction. Do

not rub. Do not break blisters. 5. Maintain core temperature by keeping patient warm with blankets, warm fluids, etc. 6. Transport with frostbitten areas supported and elevated if feasible. 7. For frostbite involving more than very tips of digits, force hydrate orally or start IV and

administer one liter of saline. 8. If transport is delayed give analgesics. Fentanyl recommended.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPOTHERMIA ALGORITHM

January 1, 2008 IV - 11


HYPOTHERMIA ALGORITHM B/I/P

REMOVE WET CLOTHING AND STOP HEAT LOSS

MOVE PATIENT GENTLY- DO NOT JOSTLE! Monitor core temperature and cardiac rhythm

If Pulse & Breathing If No Pulse or Breathing ` ` Mild Hypothermia: Start CPR (B) Passive rewarming Shock one (1) time at 120-200J Active external rewarming (I) Intubate, Ventilate with warm, humidified O2

(B)IV, warm normal saline

Moderate Hypothermia (B) Passive rewarming ` Consider use of heat packs (covered in towels) to truncal areas only If Core Temp > 30°C If Core Temp < 30°C ` (I) IV Meds & Shock Withhold IV Meds Severe Hypothermia for VT/VF as temp > (B) No more than 3 (B) Warm IV Fluids Shocks for VT/VF Warm, humid O2

Specific Precautions Hypothermia: A. Shivering does not occur below 90|F (32|C). Below this the patient may not even feel

cold, and occasionally will even undress and appear vasodilated. B. The heart is most likely to fibrillate below 85|-88|F (30|-31|C). Defibrillation should be

attempted once, but prolonged CPR may be necessary until the temperature is above this level.

C. ALS drugs should be used sparingly, since peripheral vasoconstriction may prevent

entry into central circulation until temperature is restored. At that time, a large bolus of unwanted drugs may be infused into the heart.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: HYPOTHERMIA ALGORITHM

January 1, 2008 IV - 12

D. Bradycardia is normal and should not be treated. E. Moderate to severe patients should not be permitted to move about or exert

themselves, as even minor physical activity can throw these patients into dysrhythmias. F. Severe patients should be ventilated with basic ventilation procedures first; head-tilt,

chin-lift and slow breaths. The use of adjuncts and intubation can cause dysrythmias. If required, the most experienced paramedic should perform these functions gently.

G. If patient has organized monitor rhythm, CPR is currently felt to be unnecessary. In

general, even very slow rates are probably sufficient for metabolic demands. CPR is indicated for asystole and ventricular fibrillation.

H. Patients who appear dead after prolonged exposure to cold air or water should not be

pronounced “dead” until they have been rewarmed. This does not apply to victims of snow burial, who die from suffocation. Full recovery from hypothermia with undetectable vital signs, severe bradycardia, and even periods of cardiac arrest has been reported.

I. Rewarming should be accomplished with careful monitoring in a hospital setting,

whenever possible. J. Consider other reasons for altered mental status. K. A helpful adjunct in hypothermia is a rectal thermometer.

Frostbite: A. Thawing is extremely painful and should be done under controlled conditions,

preferably in the hospital. Careful monitoring, pain medication, prolonged rewarming, and sterile handling are required.

B. It is clear that partial rewarming, or rewarming followed by refreezing, is far more

injurious to tissues than delay in rewarming or walking on a frozen extremity to reach help. Do not rewarm prematurely. Field rewarming should be doen only when evacuation is more than 2 hours away, refreezing is not possible, and facilities are available (tent or building).

C. Warming with heaters or stoves or rubbing with snow, dangerous and should not be

used.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: SNAKE BITES

January 1, 2008 IV - 13


SNAKE BITES B/I/P

Specific Information Needed A. Appearance of snake (i.e., Did snake have a rattle?) B. Time of bite. C. Prior first-aid by patient or friends. D. Symptoms: Local pain and swelling, peculiar or metallic taste sensations. Severe

envenomations may result in hypotension, coma, and bleeding.

Specific Objective Findings A. Bite wound: Location, configuration (1, 2, or 3 fang marks; entire jaw imprint, none). B. Signs of envenomation: Local edema and pain, ecchymosis, bleeding, hypotension.

Mark time and extent of erythema and edema with pen.

Treatment A. Remove patient and rescuers from area of snake, to avoid further injury. B. Remove rings or other bands that may become tight with local swelling. C. Immobilize bitten part in a neutral position. D. Transport promptly for definitive observation and treatment. E. Do not use ice or refrigerants. F. For all suspected envenomations, establish venous access in contralateral extremity

and administer O2. G. Treat patient for pain: Morphine or Fentanyl recommended. H. Monitor vital signs, cardiac rhythm, and swelling. I. Give IV fluids judiciously. If patient is normotensive, KVO IVF.

TFPD EMS PROTOCOLS ENVIRONMMENTAL INJURIES: SNAKE BITES

January 1, 2008 IV - 14

Specific Precautions A. If the snake is dead, bring it in for examination. Do not jeopardize fellow rescuers by

attempting to “round it up.” Be careful: A dead snake may still reflexively bite and envenomate. Do not pick up with hands, even if dead. Use a shovel or stick.

B. At least 25% of poisonous snake strikes do not result in envenomation. Conversely, the

initial appearance of the bite may not reflect the severity of envenomation. C. Fang marks are characteristic of pit viper bites, such as from the rattlesnake, water

moccasin, or copperhead, which are native to North America. Jaw prints (without fangs) are more characteristic of nonvenomous species.

D. Ice can cause serious tissue damage. Never use! E. Exotic poisonous snakes, such as those found in zoos or exotic pets, have different

signs and symptoms than those of pit vipers.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: GUIDELINES

January 1, 2008 V - 1

Treatment Protocols: Pediatric Treatment

GENERAL GUIDELINES FOR PEDIATRICS B/I/P

Pediatric patients have unique needs and problems that affect prehospital care as well as hospital care. These differences are all the more important because children make up a small percentage of total calls. Therefore, CONTACT BASE early for guidance when treating pediatric patients with complaints, including abnormalities of vital signs. In addition, the pediatric emergency is rarely preceded by any chronic disease. If intervention is swift and effective, the child will often be restored to full health. The following should be kept in mind during the care of children in the prehospital setting: A. Airways are smaller, softer, and easier to obstruct or collapse B. Respiratory reserves are small. A minor insult like improper position, vomiting, or airway

narrowing can be a major problem. C. Circulatory reserves are also small. The loss of as little as one unit of blood can produce

severe shock in an infant. Conversely, 500 mls of unnecessary fluid can create acute pulmonary edema.

D. Assessment of the pediatric patient is difficult, but can be done using knowledge of anatomy

and physiology specific to infants and children. A parent or guardian can often help make the child more comfortable during assessment and can provide information regarding both medical history and or aspects of the child’s behavior.

E. Listen to the parents’ assessment of the patient’s problem. They often can detect small

changes in their child’s condition and provide additional information such as “how many diaper changes” has the child had today and how many is normal for this patient.

F. The proper equipment is very important when dealing with the pediatric patient. A complete

selection of airway management equipment, IV catheters and drugs should be available. This equipment should be stored separately to minimize confusion.

G. When using these protocols, remember the age breakdown used INFANTS: birth to one year TODDLERS: one through five years SCHOOL AGE: six through fourteen years

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: GUIDELINES

January 1, 2008 V - 2

NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP AGE PULSE RESPIRATIONS BLOOD PRESSURE avg/min breaths/min systolic mmHg Newborn 125 40-60 60-80 6 mo 120 24-36 90± 30 1 yr 120 22-30 95± 30 3 yr 110 20-26 100± 25 5 yr 100 20-30 100± 15 8 yr 90 18-22 105± 15

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: RESUSCITATION

January 1, 2008 V - 3


INFANT AND CHILD RESUSCITATION B/I/P

Specific Information Needed A. Elapsed time since the child was last seen in good health B. History of any recent illness C. Past medical history Specific Physical Findings A. Airway: Obstruction, stridor, wheezing, drooling, cough B. Breathing: Respiratory rate, skin color, chest wall movement and symmetry, work of breathing

(grunting, nasal flaring, retractions) C. Circulation: Heart rate, pulse, capillary filling time, skin color, mottling, extremity skin

temperature D. Level of consciousness, mentation E. Associated injuries Treatment A. Airway/Breathing: 1. Manage airway 2. Administer O2 3. If apneic, ventilate with a BVM. Ventilation rate per AHA BLS Protocols a. I/P: Consider intubation B. Circulation: 1. Initiate CPR. NOTE: CPR may be indicated in the bradycardic infant. i.e. Do not wait until

asystolic to begin compressions. May begin at 40 to 50 bpm if infant has signs of circulatory collapse

2. Monitor cardiac rhythm 3. Establish a peripheral venous access


January 1, 2008 V - 4

4. I/P: If unable to establish a peripheral IV after 2 attempts, establish an intraosseous

infusion. If, on visual inspection, unable to see good peripheral, go straight to intraosseous infusion if warranted.

5. If any question of volume depletion, infuse a NS fluid bolus. CONTACT BASE if you feel

you need a second fluid bolus. Pediatric boluses are based on a 20cc/kg formula and should be administered in less than twenty minutes.

C. Medications: 1. B/I/P: Specific treatment should be focused on the etiology of the arrest HypoxemiaAcidosis Toxins/Drugs HypothermiaEmbolism Electrode Imbalance HypovolemiaCardiac Tamponade Trauma HypoglycemiaTension Pneumothorax Stabilizing the airway and supporting respiration is the mainstay of treatment 2. I/P: Dysrhythmias are treated as noted in dysrhythmia Algorithms. See Drug Protocols for

pediatric doses 3. Obtain IV or IO access 4. Consider intubation for additional drug route and definitive airway security D. Ventricular fibrillation or pulseless ventricular tachycardia:

1. Determine pulselessness and begin CPR 2. I/P: Defibrillate with 2 joules/kg 3. B/I/P: If no response to initial shock, resume CPR immediately for 2 min. 4. I/P: Defibrillate at 4 joules/kg 5. I/P: If no response, resume CPR immediately for 2 min. Epinephrine 0.01 mg/kg (or 1:10,000 at 0.1 ml/kg) IV/IO. Endotracheal tube 0.1 mg/kg (1:1000 0.1 ml/kg) every 3 to 5 min. Let drug circulate with CPR for 1 minute then, 6. I/P: Defibrillate again at 4 joules/kg 7. I/P: If no response, resume CPR immediately for 2 min. Amiodarone – 5 mg/kg IV/IO OR Lidocaine – 1 mg/kg IV/IO Consider Magnesium 25 – 50 mg/kg IV/IO Let drug circulate with CPR for 1 min. then,


January 1, 2008 V - 5

8. I/P: Defibrillate again at 4 joules/kg 9. I/P: Assess for hypovolemia, if present give NS fluid bolus, IV. E. P.E.A./Asystole

1. Determine Asystole or P.E.A. and begin CPR 2. Epinephrine IV/IO 0.01 mg/kg (1:10,000 0.1 ml/kg) every 3 to 5 min. OR

ET 0.1 mg/kg (1:1000 0.1 ml/kg) Specific Precautions A. Pediatric arrests are most likely to be primary respiratory events. The rescuer’s primary

attention must be directed to securing the airway and providing good ventilation before specific treatment of cardiac rhythm. Any cardiac rhythm can spontaneously convert to sinus rhythm in a well-ventilated child.

B. Pedi pads are suggested for use in infants (up to one year). Adult pads can be used beyond

that if they do not touch. As with all infant/child guidelines, common sense and each child’s size should be taken into account. AED mode on the Lifepak 12 can only be used in children eight years old or approximately eighty pounds.

C. Oxygen and Epinephrine are the mainstays of pediatric resuscitations. Atropine and Sodium

Bicarbonate are much less likely to be effective. D. Cardiopulmonary arrest in a trauma situation is treated with rapid transport and CPR en route. E. The most successful pediatric resuscitations occur before a full cardiopulmonary arrest. Assess

pediatric patients carefully and assist with airway, breathing, and circulatory problems before the arrest occurs, to improve the overall care to the pediatric patient.

F. The current American Heart Association recommendations for obstructed airway are for

abdominal thrusts over the age of one year. Infants less than one year old should be treated with back blows and chest thrusts. Early laryngoscopy should be used in an attempt to visualize and remove upper airway obstructions.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: PULSELESS ARREST

January 1, 2008 V - 6


PEDIATRIC PULSELESS ARREST B/I/P

INITIATE SUPPORTIVE MEASURES • Verify pulselessness • Begin CPR (15:2) • Administer O2 • Attach ECG

VF OR PULSELESS VT ASYSTOLE / P.E.A. Defibrillate 2J/Kg (manual) Continue CPR immediately AED > 1 yr. of age Secure airway when possible Ventilate with oxygen Continue CPR immediately Obtain IV or IO access Secure airway when possible Ventilate with oxygen Epinephrine IV/IO 0.01 mg/kg Obtain IV or IO access (1:10 0.1 ml/kg) every 3 – 5 min. OR ET administration 0.1 mg/kg If no change: (1:1 0.1 ml/kg) Defibrillate 4J/Kg Identify and treat causes* Continue CPR After ET tube placement give 8 – 10 breaths/min. during CPR Epinephrine IV/IO 0.01 mg/kg (1:10 0.1 ml/kg) every 3-5 min. OR ET administration 0.1 mg/kg (1:1 0.1 ml/kg) Identify and treat causes* If no change: Defibrillate 4J/Kg Continue CPR immediately Amiodarone 5 mg/kg IV/IO OR Lidocaine 1 mg/kg IV/IO Consider Magnesium 25-50 mg/kg IV/IO For Tosades – max. 2 gms. If no change: Defibrillate 4J/Kg Continue CPR immediately

*Hypoxemia - hypothermia – hypovolemia – hypoglycemia – acidosis – embolism – cardiac tamponade tension pneumothorax – toxins/drugs – electrolye imbalance - trauma

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SHOCK

January 1, 2008 V - 7


PEDIATRIC SHOCK B/I/P

Specific Information Needed A. History: Onset and progression of symptoms, frequency of vomiting, diarrhea, urine output,

recent trauma, possible drug ingestion, or trauma. B. Past medical history Specific Physical Findings A. General appearance, obvious trauma. Note living environment or other clues to possible

maltreatment or neglect. B. Vital signs C. Skin: Warmth, color, skin turgor, appearance of fontanels, capillary refill time (should be less

than 2 seconds). D. Mucous membranes: Level of hydration, presence of tears and saliva E. Neurologic: Mental status and level of consciousness F. Musculoskeletal: Evaluate for any evidence of trauma G. The signs of dehydration are: Capillary refill time longer than two seconds, cool skin, mucous

membranes dry, loss of skin turgor, sunken eyes and fontanels, shock, lethargy, & altered mental status.

Treatment A. Airway: Manage as indicated B. Breathing: Ventilations as indicated C. Administer O2 D. Circulation: 1. Establish peripheral venous access 2. Consider fluid bolus of NS, 20 ml/kg administered in less than twenty minutes. 3. Do not delay transport for IV attempts.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SHOCK

January 1, 2008 V - 8

4. I/P: The dehydrated patient is not a candidate for intraosseous infusion without base

approval. E. Determination of tachycardia or hypotension is based on age.

Blood Pressure

Age Pulse Systolic

0-1 >185 Or <40

2-3 >150 Or <80

4-8 >135 Or <80

9+ >120 Or <95

Specific Precautions A. Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but

they are nonspecific. B. Monitor carefully for signs of decreased tissue perfusion (shock). Specifically check for

capillary refill time of greater than 2 seconds, poor pulses, decreased mental status. Keep in mind that children can compensate up to the point that all compensatory mechanisms fail, at which point deterioration progresses rapidly.

C. Diagnosis of shock doesn’t depend on hypotension. Children with delayed capillary refill time

and tachycardia are in compensated shock.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: RESPIRATORY DISTRESS

January 1, 2008 V - 9


PEDIATRIC RESPIRATORY DISTRESS B/I/P

Specific Information Needed A. History: Sudden or gradual onset of symptoms, cough, fever, sore throat, hoarseness. Croup

will generally be more gradual, while epiglottitis will be more sudden (last 6-8 hours). Epiglottitis also progresses very rapidly.

B. History of potential foreign body aspiration C. Past medical history D. Current medications Specific Objective Findings A. Airway: Look for respiratory distress, listen for abnormal breathing sounds, feel for air

movement, crepitus, tracheal deviation (a late sign if detected if all) B. Breathing: Respiratory rate and effort, chest wall movement, use of accessory muscles,

retractions C. Audible respiratory noises: stridor, cough (croupy?), wheezing D. Respiratory sounds by auscultation of chest: Wheezing, rales, decreased (unilateral?), clear E. Mental status: Alert, agitated, confused. F. General appearance: Leaning forward or drooling (suggests epiglottitis), skin color and

temperature. Treatment A. As long as the child is adequately ventilating and mentating, avoid agitating the patient in any

way. Keep the patient in the position of comfort (probably on mom/dad’s lap). B. If the child is not ventilating adequately consider obstructed airway and treat accordingly.

Consider BVM assist. C. If the child cannot be ventilated with a BVM: 1. Manage airway. 2. I/P: If still unable to ventilate, visualize the airway with a laryngoscope. Remove any foreign

Object with Magill forceps.


January 1, 2008 V - 10

3. I/P: If nothing is seen, intubate the patient. D. I/P: Consider intubation only if unable to provide ventilatory support with a BVM. E. Assess and consider treatment for the following problems if respiratory distress is severe and

the patient does not respond to proper positioning and administration of O2, high flow. 1. Croup (viral, usually 6 mos-4 y/o) a. Allow patient to remain in position of comfort if alert.

b. Provide cool, humidified O2. Outside air temp on a cool night may be sufficient. c. P: Nebulized Racemic Epinephrine for severe obstructions.

2. Epiglottitis (bacterial, usually 3-7 y/o)

a. It is essential to allow the child position of comfort and to handle the child gently.

b. I/P: Do not attempt to visualize the airway if child is still ventilating adequately.

c. CONTACT BASE and prepare ventilation equipment.

d. Provide humidified O2 by mask or blow by if it can be done without agitating the child. 2. Asthma: a. I/P: Consider Albuterol Sulfate via nebulizer, through mask or BVM. b. I/P: Consider Epinephrine, SQ. CONTACT BASE. F. If diagnosis is unclear, transport patient with 100% O2, reassess frequently and be prepared to

manage the patient’s airway. Specific Precautions A. Children with croup, epiglottitis, or laryngeal edema usually have respiratory arrest due to

exhaustion. Most children may still be ventilated with a BVM. B. Do not attempt intubation if the airway can be managed by appropriate jaw and head

positioning and use of a BVM. If epiglottitis progresses to respiratory arrest, intubation should be expected to be difficult due to lack of visualization of the vocal cords from swollen supraglottic tissues Expect to use a smaller ET tube (one to two sizes than normal). Look for bubbles at the arytenoid folds. Chest compression during visualization may help produce bubbles. If unsuccessful, cricothyroidotomy may need to be considered.

C. Respiratory distress is a critical situation that can be made worse with prolonged scene times


January 1, 2008 V - 11

D. Intubation of the infant is most easily accomplished with an infant-sized straight laryngoscope

blade E. Any child with a witnessed or suspected apnea episode should be transported

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SEIZURES

January 1, 2008 V - 12


PEDIATRIC SEIZURES B/I/P

Specific Information Needed A. History: Onset, duration of seizure, number of seizures, description of seizure activity, vomiting

involved, fever, recent illness, possibility of ingestion or traumatic injury from seizure. B. Past history: Previous seizures, current medications and compliance, head trauma, chronic

illness. Specific Objective Findings A. Airway: Look for respiratory distress, listen for abnormal breathing sounds, feel for air

movement, tracheal deviation B. Breathing: Respiratory rate and effort, chest wall movement, use of accessory muscles,

retractions C. Circulation: Heart rate, pulse, capillary refill time, skin color, blood pressure D. Neurologic: Mental status, postictal period, incontinence E. Musculoskeletal: Note any associated injuries, crepitus, asymmetrical breathing F. Temperature: Cool patient if febrile by removing clothing, spray or splash cool water on skin

and fan vigorously, monitor rectal temperature every 15 minutes Treatment A. Airway: Manage as indicated; suction as needed B. Breathing: Administer 100% oxygen C. If child is in status seizure(30 minutes or longer): 1. Attempt peripheral venous access x 1 and measure blood glucose a. Administer dextrose 25% or 50% per medical direction if reading warrants.

b. I/P: If seizures do not stop, administer IV diazepam. 2. P: If unable to start peripheral IV, then administer Versed rectally or intramuscularly 3. P: IM glucagon can also be considered with medical control if hypoglycemic

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SEIZURES

January 1, 2008 V - 13

4. If seizures continue, CONTACT BASE D. If the child has stopped seizing and is postictal, transport while monitoring vital signs and

neurologic condition. Specific Precautions A. Febrile seizures occur in normal children between 5 months and 5 years. Such seizures are

usually short, lasting less than 5 minutes and usually do not require anti-seizure drug therapy. B. Do not force anything between the teeth. C. Consider hypoglycemia as a cause for nontraumatic seizure.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SUDDEN INFANT DEATH (SIDS)

January 1, 2008 V - 14


SUDDEN INFANT DEATH SYNDROME (SIDS) B/I/P

Specific Information Needed A. History: Position in which the child was found, condition and contents of the bed, last time the

child was seen well, seizure activity, possibility of ingestion. B. Associated symptoms: history of fever, respiratory symptoms, infection, vomiting, diarrhea. C. Past medical history: prematurity, development, nutrition, smokers in home Specific Physical Findings A. Airway B. Breathing: Respiratory effort, skin color C. Circulatory: Heart rate, pulses D. Neurologic: Level of consciousness, responsiveness, muscle activity and tone E. Any signs of trauma? F. Check for presence of froth or blood-tinged sputum at mouth or nose G. Temperature: rectal / core temperature Treatment A. Airway: Manage as indicated B. Breathing: Ventilate with 100% oxygen; suction as needed C. Circulatory: Support cardiac output as indicated by: 1. External chest compressions 2. Establish venous access 3. I/P: Pediatric ACLS as indicated 4. Monitor cardiac rhythm

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: SUDDEN INFANT DEATH (SIDS)

January 1, 2008 V - 15

D. Support the family. Because of the classic signs of SIDS, which include postmortem lividity and

the presence of frothy fluid in the mouth and nose, victims may appear to be abused. Avoid any question or comment that may imply suspicion of substandard care. If inappropriate care is suspected, the reporting of such should be made objectively to medical direction. Don’t be accusatory, but complete & detailed history is imperative including a list of all caregivers, food, medications (including homeopathic or herbal) and recent history of illness or trauma.

Special Considerations A. Initiate resuscitation based on field pronouncement protocol. B. Activate appropriate support for the family if the patient is pronounced dead in the field after

contacting base. Consider paging mental health on call. C. Contact Coroner or Deputy Coroner; consider paging/calling Mental Health on call and/or

Priest/Pastor.

TFPD EMS PROTOCOLS PEDIATRIC TREATMENT: CHOKING

January 1, 2008 V - 16


INFANT CHOKING B/I/P

Indications Complete or partial obstruction of the airway due to a foreign body Specific Precautions Hypoxia from airway obstruction can cause seizure. Chest or abdominal thrusts may not be effective until the patient become relaxed after seizure. Technique

A. Confirm obstruction: If infant can not make sounds, breathe, cry or is cyanotic.

B. Invert infant on forearm. Support head by cupping hand over face/jaw. DO NOT clench the neck.

C. Perform 5 back blows and 5 chest thrusts until object is dislodged or patient becomes

unconscious.

D. Repeat C until successful

E. If patient becomes unconscious start CPR (30:2)

F. Open airway, remove object if visible, ventilate x2

G. If unable: I/P: Consider using a laryngoscope and Magill forceps

H. Reposition head and chin, attempt to ventilate again.

I. Continue CPR Re-inspect Mouth Remove Object Ventilate CPR until successful

J. If patient resumes breathing, place in the recovery position

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ACTIVATED CHARCOAL

January 1, 2008 VI - 1

Drug Protocol

ACTIVATED CHARCOAL B/I/P

Pharmacology & Actions A. Binds many commonly ingested poisons and prevents their absorption Indications A. Suspected ingestion of a poisonous substance in the case of a long or delayed transport to the hospital Precautions A. Do not administer if patient ingested acid or alkali substance, has altered level of

consciousness, or cannot swallow. Administration A. Use suspension form; shake bottle vigorously to mix

1. B/I: CONTACT BASE prior to administration

2. Dosage is 1 gm/kg in children

3. Usual adult dose is 50 gm 4. P: Nasogastric administration: dilute charcoal 1:1 w/ normal saline and administer via piston

syringe into NG tube. Allow approx. 2 min. for absorption before suctioning NG tube. Side Effects & Special Notes A. Because the medication looks like mud, you may need to persuade the patient to drink it. Try to

cover the outside of the container and have the patient use a straw so fluid is not visible. Never force suspension into patient’s mouth. For kids, you can mix it w/ Coke, Dr. Pepper, etc., to make more palatable.

B. If patient vomits after taking charcoal, CONTACT BASE for order to repeat the dose. C. The major side effect is black stools.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ADENOSINE


Drug Protocol

ADENOSINE (ADENOCARD) I/P

Pharmacology & Actions A. Adenosine is an endogenous nucleoside with anti-arrhythmic activity. B. Because of short plasma half-life (less than 10 seconds with IV doses), the clinical effects of

Adenosine occur rapidly and are very brief. C. Produces a transient slowing of the sinus rate. D. Has a depressant effect on the AV node Indications A. For termination of episodes of acute supraventricular tachycardia involving the AV node. B. Wide complex tachycardia with pulse refractory to Lidocaine and Magnesium Sulfate Precautions A. Adverse effects include flushing, dyspnea, chest pain, anxiety, and occasional hemodynamic

disturbances, all of which are of short duration. Administration I: MUST CONTACT BASE for direct physician order. A. Direct rapid IV bolus over 1 – 2 seconds of 12 mg initially, followed immediately by 20 ml saline

flush. A second dose of 12 mg may be given after an interval of 1 – 2 minutes if the tachycardia persists. Total dose should not exceed 24 mg.

B. Pediatric dose: rapid IV 0.2 mg/kg initial dose, and second dose if the SVT persists. Side Effects & Special Notes A. Whenever possible establish the IV at the antecubital. The dose of adenosine has been

calculated for that IV location. B. Adenosine is safe in patients with Wolf-Parkinson-White Syndrome. C. Concomitant use of Dipyridamole (Persantine) enhances the effects of Adenosine. Smaller

doses may be required. D. Caffeine and Theophylline antagonize adenosine’s effects. Larger doses may be required. E. Warn patients to expect a brief sensation of chest discomfort. F. If patient is hemodynamically unstable, see appropriate tachycardia algorithm.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ALBUTEROL


Drug Protocol

ALBUTEROL SULFATE I/P

Pharmacology & Actions A. Has moderately selective B2 adrenergic stimulating properties resulting in potent

bronchodilation B. Relatively few cardiovascular effects compared with Metaproterenol HCL (Alupent) C. Rapid onset of action (under 5 minutes), and a duration of action between 2-6 hours Indications A. For relief of bronchospasm (asthma, anaphylaxis, COPD, and HAPE) Precautions A. Albuterol Sulfate has sympathomimetic effects. Discontinue immediately if patient develops

chest pain or dysrhythmias. B. Inhaled, Albuterol Sulfate can result in paradoxical bronchospasm, which can be life

threatening. If this occurs, the preparation should be discontinued immediately. Administration A. For nebulizer use only.

I: Must CONTACT BASE prior to administration.

1. For adults and children: Place 2.5 mg diluted in 3 ml of normal saline into an oxygen-powered nebulizer. Deliver as much of the mist as possible by nebulizer over 5-15 minutes.

2. P: For patients presenting with respiratory distress, initial treatment should be Albuterol

combined with Atrovent. CombiNebs are good for everyone. 3. Patients may be given Albuterol Sulfate by attaching nebulizer in-line, either BVM or ETT 4. I/P: CONTACT BASE if second treatment is required.

Side Effects & Special Notes A. Monitor blood pressure and heart rate closely and CONTACT BASE physician if any concerns

arise. B. If no history of airway disease or no response to therapy CONTACT BASE physician, as

presenting symptoms may instead be manifestations of severe allergic reaction.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ALBUTEROL


C. Medication such as MAO inhibitors and tricyclics may potentiate tachycardia and hypertension.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: AMIODARONE


Drug Protocol

AMIODARONE I/P

Pharmacology & Actions A. Amiodarone is a unique antidysrhythmic agent with multiple mechanisms of action. The drug

prolongs duration of the action potential and effective refractory period. Indications A. Initial treatment and prophylaxis of frequently recurring VF and hemodynamically unstable VT

in patients’ refractory to other therapy. Refractory PSVT in conjunction with electrical cardioversion

Contraindications A. Pulmonary congestion B. Cardiogenic shock C. Hypotension D. Sensitivity to Amiodarone E. Bradycardia Administration A. Adult:

Pulseless arrest: 300 mg IV push, consider repeating 150 mg in 3-5 min (max. cumulative dose 2 gm IV / 24 hrs.)

Wide-Complex Tachycardia: May be given as rapid infusion 150 mg IV over first 10 min., repeated every 10 min. as needed.

B. Pediatric:

Pulseless arrest: 5 mg/kg rapid IV bolus

Perfusing tachycardias: Loading dose 5 mg/kg IV over 20-60 min. Precautions Continuous ECG monitoring required, Pregnancy Safety: Category D. Slow infusion or discontinue if bradycardia or AV block occur. Maintain at room temperature and protect from excessive heat.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: AMMONIA INHALANTS


Drug Protocol

AMMONIA INHALANTS FR/B/I/P

Pharmacology & Actions 0.33 ml of 35% alcohol /15% ammonia over the counter inhaled agonist Indications A. Any unconscious patient with suspected ETOH overdose

B. Intended for use prior to sternal rub or other form of painful stimuli

Precautions

A. Avoid contact with patient’s skin

B. Avoid prolonged exposure to patient’s nose

Administration

A. Snap/crush packet between two fingers

B. Start administration of inhalant 6” away from patient’s nose and slowly move closer in a

sweeping back and forth motion stopping before physically contacting the patient’s nose.

C. As ammonia evaporates it might be necessary to move closer to patient’s nose

D. Provider should test strength frequently by holding packet up to his/her nose.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ASSISTING W/ NTG


Drug Protocol

ASPIRIN FR/B/I/P

Pharmacology & Actions A. Common over-the-counter analgesic and anti-inflammatory B. Anticoagulant Indications A. For anticoagulant actions in the setting of cardiac-type chest pain or other signs/symptoms

indicative of acute myocardial infarct (AMI). B. Not normally administered by prehospital personnel for pain or inflammation. Precautions A. Small potential for increasing existing nausea. B. If any water must be administered with tablet, it should be a very small amount to minimize

potential for nausea and vomiting. C. Some patients claim allergy to aspirin. Question patient carefully to determine true allergy or

“upset stomach” from aspirin administration. Discuss any concerns with the base physician prior to administration.

D. Do not give if patient has already taken aspirin today (check dose already taken; may be able to

supplement). E. Some patients with pre-existing stomach conditions such as ulcers, esophagitis, and others,

may have untoward effects from aspirin. Discuss with the base physician prior to administration. F. Aspirin is contraindicated in the presence of signs/symptoms of CVA or any internal bleeding. G. Aspirin is contraindicated in the presence of Coumadin and other anti-clotting agents - confirm

with Base Administration F/R/B: Direct on-line medical direction required. A. Optimal dose is two chewable baby aspirin (81 mg), chewed and swallowed. B. If chewable baby aspirin is not available, consider one adult aspirin (325 mg), given with a few

ounces of water. C. Administer prior to transport if patient is more than 10 minutes from ED. Side Effects & Special Notes A. If the patient has taken aspirin within the last 24 hours, an additional dose is not necessary, but

if any doubt, administer another aspirin.



B. Buffered aspirin may diminish potential nausea; enteric-coated aspirin will delay desired effects. Drug Protocol

ASSISTING WITH NITROGLYCERIN ADMINISTRATION B

Pharmacology & Actions A. Dilates coronary blood vessels and increased blood flow and oxygen supply to heart. Decreases

both preload and afterload. B. Dilates blood vessels: Lowers resistance for heart to pump against. Indications A. Patient having chest pain/angina with nitroglycerin on scene that is prescribed to the patient. Precautions A. Contraindications include:

1. Hypotension SBP < 100 mmHg (systolic blood pressure less than 100).

2. Head injury.

3. Infants/children.

4. Patient has already taken 3 tablets prior to your arrival. 5. Use of Viagra or other ED medications within 3 hours.

B. Do not get spray or melted tablet on your skin. It will have the same effect on you as it does on

the patient. C. If the patient has NTG patch on chest and you need to use defib, take patch off (it may catch on

fire).

D. IV access is strongly encouraged prior to NTG administration. Administration A. Ask patient if they have taken any NTG and effect on pain. B. B: CONTACT BASE for direct physician order regardless if NTG is the patient’s or from

Ambulance.

1. If prescribed to patient: Check expiration date and patient’s name on prescription.

2. Have patient lie down. Make sure SBP > 100 mmHg.

3. Have patient raise their tongue and place tablet under it. (Spray is given under tongue or



inside of cheek.)

4. Tell patient to keep mouth closed until dissolved and avoid swallowing tablet.

5. Retake BP w/in 2 min.. Reassess patient incl. effect on pain. Recheck BP every 2-3

minutes. Side Effects & Special Notes A. Side effects: hypotension, headache, burning under tongue, increase heart rate. B. NTG usually works in seconds, but it may be 5 minutes until full effect occurs.

1. If the initial dose does not work, a second dose should be given within 3-5 minutes if the BP is >100, if patient still has chest pain.

2. A third dose may be given 5 minutes after the second one.

3. If there is not relief after 3 doses, CONTACT BASE for further direction.

C. If NTG is older than 6 months, it may have lost its potency and effectiveness. (Should burn or

“fizz” under tongue or give patient headache if good, unless patient is very accustomed to NTG.) Note, however, NTG spray does have a longer shelf life.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ASSISTING W/ INHALER

January 1, 2008 VI - 10

Drug Protocol

ASSISTING WITH PRESCRIBED INHALER B

Pharmacology & Actions A. Beta-agonists: bronchodilator Indications A. Patients with breathing difficulty (asthma, COPD, anaphylaxis) with a prescribed inhaler on

scene. Precautions A. Assess airway, administer oxygen, and assist ventilation if necessary B. Confirm patient has prescribed B-agonist inhaler and that it has not expired C. The patient must be conscious and be able to cooperate with the use of the inhaler D. Ask patient if he/she has already taken any doses E. Make sure inhaler is at room temperature Administration A. Shake inhaler several times B. Remove oxygen mask/cannula from patient

1. Tell patient to exhale deeply

2. Tell patient to put mouthpiece in his/her mouth and make a seal with their lips (use spacer if avail.)

3. Tell patient to depress inhaler body as they inhale

4. Tell patient to hold their breath as long as they can comfortably do so

5. Reapply oxygen

6. May repeat a second time

Side Effects & Special Notes A. These drugs are very safe B. Side effects: increase heart rate, patient may feel shaky/nervous C. Reassess and monitor vital signs closely. If condition worsens, CONTACT BASE and perform

BLS as needed

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ASSISTING W/ INHALER

January 1, 2008 VI - 11

D. Document signs/symptoms and vital signs before and after administration

E. Transport inhaler with patient in the event repeat treatments are required

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ATROPINE

January 1, 2008 VI - 12

Drug Protocol

ATROPINE I/P

Pharmacology & Actions Atropine is a parasympathetic or cholinergic blocking agent. As such, it has the following effects: A. Increases heart rate (by blocking vagal influences) B. Increases conduction through A-V node C. Reduces motility and tone of GI tract D. Reduces action and tone of urinary bladder (may cause urinary retention) E. Dilates pupils Indications A. To counteract excessive vagal influences responsible for some bradysystolic and asystolic

arrests B. Indicated in PEA if the rate is slow C. To increase heart rate in hemodynamically significant bradycardia D. To improve conduction in some 2nd and 3rd degree heart block or in pacemaker failure E. As an antidote for some insecticide exposures (i.e., organophosphates) and nerve gases with

symptoms of excess cholinergic stimulation: salivation, constricted pupils, bradycardia, tearing, diaphoresis, vomiting, and diarrhea

Precautions A. Bradycardia in the setting of an acute MI is common and may be beneficial. Do not treat them

unless there are signs of poor perfusion (low blood pressure, mental confusion). If in doubt, consult the base physician.

B. People do well with chronic 2nd and 3rd degree block. Symptoms occur mainly with acute

change. Treat the patient, not the dysrhythmia. C. Pediatric bradycardia is most commonly secondary to hypoxia. Correct the ventilation first, and

only treat the rate directly if that fails. Epinephrine is almost always the first-line drug for bradycardia in pediatric patients.

Administration I: MUST CONTACT BASE prior to administration.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ATROPINE

January 1, 2008 VI - 13

A. Asystole:

1. Adult: 1.0 mg IV rapidly. Repeat every 3-5 min., not to exceed 0.04 mg/kg.

2. Pediatric: 0.02 mg/kg IV, minimum 0.1 mg. B. Symptomatic bradycardia:

1. Adult: 0.5-1.0 mg IV, repeated if needed at 3-5 minute intervals to a dose of 3 mg; not to exceed 0.04 mg/kg (stop at ventricular rate which provides adequate mentation, B/P - aim for HR = 60/minute).

2. Pediatric: 0.02 mg/kg IV, minimum 0.1 mg.

3. CONTACT BASE if bradycardia persists after 2 doses.

C. For symptomatic organophosphates / insecticide exposures: CONTACT BASE for dosage

(begin with 2 mg IV or IM and titrate until breath sounds are clear; total required dose may be massive).

Side Effects & Special Notes A. Remember that Atropine might dilate pupils in cardiac arrest situations if used in large doses.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: CALCIUM CHLORIDE

January 1, 2008 VI - 14

Drug Protocol

CALCIUM CHLORIDE P

Pharmacology & Actions A. Facilitates the actin myosin interaction in heart muscle

1. During electrical depolarization, calcium ions enter the myocardial cell and interact with

regulatory proteins adjacent to the actin and myosin contractile filaments. The function of the regulatory proteins is to inhibit the formation of cross-bridging between the contractile actin and myosin filaments, thus preventing myocardial contraction. When calcium interacts with these regulatory proteins the inhibition is terminated, cross bridges form, muscle tension is generated, and muscle shortening (contraction) ensues.

B. Increases myocardial force of contraction. C. May improve impulse conduction or impulse generation. Indications A. Calcium channel blocker intoxication

1. Hypotension and heart block due to calcium channel blockade can sometimes be reversed with the administration of intravenous calcium.

B. Acute hyperkalemia

1. While infusions of calcium do not alter plasma potassium, they counteract the adverse effects of potassium at the neuromuscular membrane. Calcium can be life-saving in severe hyperkalemia accompanied by cardiac arrhythmia. Calcium should never be used in the treatment of hyperkalemia with digitalis toxicity, as it will only worsen the condition.

Administration A. CONTACT BASE for direct physician order.

Adults: 500-1000 mg over 5-10 minutes. Peds: 20-25 mg/kg

B. Calcium should only be given IV Side Effects & Special Notes A. Digitalis toxicity – Calcium is contraindicated for patients taking Digoxin

B. Calcium Chloride can cause bradycardia, arrhythmia, syncope, nausea, vomiting, cardiac

arrest. C. Calcium Chloride precipitates easily. It is extremely important to flush the IV line between

administration of Calcium Chloride and any other drug, especially Sodium Bicarbonate.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: CALCIUM GLUCONATE

January 1, 2008 VI - 15

Drug Protocol

CALCIUM GLUCONATE P

Pharmacology & Actions A. Facilitates the actin myosin interaction in heart muscle

1. During electrical depolarization, calcium ions enter the myocardial cell and interact with

regulatory proteins adjacent to the actin and myosin contractile filaments. The function of the regulatory proteins is to inhibit the formation of cross-bridging between the contractile actin and myosin filaments, thus preventing myocardial contraction. When calcium interacts with these regulatory proteins the inhibition is terminated, cross bridges form, muscle tension is generated, and muscle shortening (contraction) ensues.

B. Increases myocardial force of contraction C. May improve impulse conduction or impulse generation Indications A. Calcium channel blocker intoxication

1. Hypotension and heart block due to calcium channel blockage can sometimes be reversed

with the administration of intravenous calcium.

2. Hypocalcaemia

B. Acute hyperkalemia

1. While infusions of calcium do not alter plasma potassium, they counteract the adverse effects of potassium at the neuromuscular membrane. Calcium can be life-saving in severe hyperkalemia accompanied by cardiac arrhythmia. Calcium should never be used in the treatment of hyperkalemia with digitalis toxicity, as it will only worsen the condition.

Administration A. CONTACT BASE for direct physician order.

Adults: 500-1000 mg over 5-10 minutes. Peds: 60 – 100 mg/kg

B. Calcium should only be given IV

TFPD EMS PROTOCOLS DRUG PROTOCOLS: CALCIUM GLUCONATE

January 1, 2008 VI - 16

Side Effects & Special Notes A. Digitalis toxicity – Calcium is contraindicated for patients taking digoxin B. Calcium Gluconate can cause bradycardia, arrhythmias, syncope, nausea, vomiting and cardiac arrest. C. Calcium Gluconate precipitates easily. It is extremely important to flush the IV line between

administration of Calcium Gluconate and any other drug, especially sodium bicarbonate.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DEXAMETHASONE

January 1, 2008 VI - 17

Drug Protocol

DEXAMETHASONE (DECADRON) P

Pharmacology & Actions A. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes,

fibroblasts, reversal of increased capillary permeability and lysosomal stabilization B. A glucocorticoid steroid and an anti-inflammatory it is used for allergies, cerebral edema, septic

shock Indications A. Reactive airway disease B. Cerebral edema (HACE) C. Anaphylactic reactions

D. Upper airway inflammation/edema Administration A. Airway / Anaphylaxis: adult 1-6 mg/kg IV OR 40 mg IV or IM q 2-6 hours B. Cerebral edema (HACE): adult 10 mg IV then 4-6 mg IM q 6 hours Side Effects & Special Notes A. Children < 2 y/o: Can cause growth suppression in large doses B. TB: Decreased ability to fight infection w/ high doses C. AIDS: Decreased ability to fight infection w/ high doses

D. Pregnancy: Hyperglycemia E. Diabetes Mellitus: Can cause hyperglycemia F. Seizure disorders: Can lower seizure threshold G. CHF: Large doses can exacerbate H. Glaucoma: Can cause increased intraocular pressure

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DEXTROSE 50%

January 1, 2008 VI - 18

Drug Protocol

DEXTROSE 50% B/I/P

Pharmacology and action Glucose is the body’s basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the blood stream, and glucagon, which mobilizes stored glucose into the blood stream. Indications A. Hypoglycemic states (i.e., insulin shock in the diabetic), patients with altered metal status. B. Consider in the unconscious patient with an unknown history. C. Consider in any patient with focal or partial neurologic deficit or altered state of consciousness

which may be due to hypoglycemia. D. Consider in the non-traumatic seizure patients who are postictal on your arrival. E. Consider in the patients in status epilepticus, not responsive to Valium. F. Consider with blood glucose test < 60 if clinically indicated. G. Consider in Poisons and Overdoses Protocol. H. Consider in extended cardiac arrest resuscitative efforts I. Consider in children less than 3 years of age with suspected sepsis, hypoperfusion or altered

mental status. Precautions A. Optional: Draw appropriate blood tubes for blood sugar determination prior to administering

dextrose. B. Extravasation of glucose can cause tissue necrosis. Ensure IV patency before and during

dextrose infusion.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DEXTROSE 50%

January 1, 2008 VI - 19

Administration B: CONTACT BASE prior to administration. A. Prior to administration of D50W, a blood glucose test should be performed with results of < 60,

if time allows. B. Adult dose: One 50 ml amp of D50W, IV into a secure vein (D50W is 25 gm dextrose per 50 ml) C. In patients 8 years and younger: 2-4 ml/kg of D25W (0.5-1.0 gm/kg).

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DIAZEPAM

January 1, 2008 VI - 20

Drug Protocol

DIAZEPAM (VALIUM) I/P

Pharmacology & Actions Diazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle relaxant through effects on the central nervous system. Indications A. Status seizures: In the field this will be any seizure which has lasted longer than 5 minutes or

two consecutive seizures without regaining consciousness. B. Sedation prior to cardioversion or external cardiac pacing. C. For the treatment of drug induced hyperadrenergic states manifested by tachycardia and

hypertension (i.e. cocaine, amphetamine overdose). D. For patients who are combative from head injury. E. Anxiety, ETOH withdrawals, and PCP OD. Precautions A. Since Diazepam can cause respiratory depression and/or hypotension, the patient should be

monitored closely. Very rarely, cardiac arrest can occur. B. Do not give unless the patient is actively seizing. C. Diazepam should be used with caution in any patient under the influence of alcohol. Administration I: CONTACT BASE for direct physician order for use other than status seizure. A. Adult dose: 1-10 mg slow IV push (seizure). Sedation 5-15 slow IVP or IM. B. Pediatric dose: 0.3 mg/kg slow IV, or 0.5 mg/kg rectally, up to a maximum of 10mg.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DIAZEPAM

January 1, 2008 VI - 21

Side Effects & Special Notes A. Common side effects include drowsiness, dizziness, fatigue, and ataxia. Paradoxical

excitement or stimulation can occur. B. Should not be mixed with other agents. C. If the patient is seizing on your arrival, status seizure can be assumed. D. When used to treat drug-induced hyperadrenergic states, larger doses of Diazepam may be required. E. Rectal administration in children should be through a TB/1 ml syringe with the needle

removed. Lubrication may be required before insertion of the syringe. Use 0.5 mg/kg for rectal use, maximum of 10 mg.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DIAZEPAM - RECTAL

January 1, 2008 VI - 22

Drug Protocol

RECTAL DIAZEPAM ADMINISTRATION I/P

General Information The rectal administration of diazepam is a rapid-acting method of treatment of status epilepticus. Although the onset of action of rectally administered Diazepam is slightly slower than that given per IV access, it should be considered to be an excellent alternative when IV access is unobtainable. Indications A. Status epilepticus in the pediatric patient in whom IV access is unsuccessful. Precautions A. There is a risk of respiratory depression following termination of seizure activity when

diazepam has been administered. Sa02 and airway should be closely monitored. B. Inadequate absorption may be due to improper medication placement in the anus or the

presence of fecal mass. C. The syringe should advance easily into the rectum with little or no resistance. Do not force the

syringe as trauma to the mucosa may occur. Dosage A. 2 to 5 years of age (via rectal catheter) 0.5 mg/kg to maximum dose of 10 mg. B. 6 to 11 years of age (via rectal catheter) 0.3 mg/kg to a maximum dose of 15 mg. Procedure A. Transfer appropriate dose of medication into a 1 ml TB syringe. Remove the needle from the

TB syringe. B. Lubricate the tip of the TB syringe with KY jelly. C. Insert the TB syringe approximately 4-5 cm into the rectum and dispense all medication rapidly. D. Manually hold the buttocks together for 1-2 minutes to prevent medication leakage.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DILTIAZEM

January 1, 2008 VI - 23

Drug Protocol

DILTIAZEM (CARDIZEM) P

Pharmacology and Action A. Inhibit calcium influx across the cell membrane during depolarization

B. Relaxes coronary vascular smooth muscles and dilates coronary arteries and slows SA/AV

node contraction time

C. Potent negative chronotropic effects

D. Minimal negative inotopic effects Indications A. Angina Pectoris

B. Hypertension

C. Atrial Fibrillation

D. Atrial Flutter

E. Paroxysmal Supraventricular Tachycardia

Precautions A. Congestive Heart Failure

B. Hypotension Contraindications A. Wolff-Parkinson-White Syndrome with Atrial Fibrillation.

B. Wide Complex Tachycardia (unless Supraventricular).

C. Sinus node or AV node dysfunction without a pacemaker.

D. Concurrent Intravenous or PO Beta Blocker use.

E. 2nd & 3rd degree heart blocks.

F. In cases of sever hypotension discontinue.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DILTIAZEM

January 1, 2008 VI - 24

Administration P: CONTACT BASE for direct physician order. A. 0.25 mg/kg slow IV push over 2 minutes.

B. 2nd dose 0.35 mg/kg slow IV push 15 minutes after 1st dose if indicated

C. CONTACT BASE: Infusion 5-15 mg/hour following direct injection

Side Effects & Special Notes A. Hypotension B. Decreased cardiac output C. Headache D. AV Blocks E. Bradycardia F. Prolonged QT G. Flushing

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DIPHENHYDRAMINE

January 1, 2008 VI - 25

Drug Protocol

DIPHENHYDRAMINE (BENADRYL) I/P

Pharmacology & Actions A. An antihistamine which blocks action of histamine released from cells during an allergic reaction B. Direct CNS effects, which may be stimulant or, more commonly, depressant, depending on

individual variation C. Anticholinergic, anti-Parkinsonian effect, which is used to treat acute dystonic reactions to

antipsychotic drugs (Haldol, Thorazine, Compazine, etc.). These reactions include: oculogyric crisis, acute torticollis, and facial grimacing

Indications A. The second-line drug in anaphylaxis and severe allergic reactions (after Epinephrine) B. To counteract acute dystonic reactions to antipsychotic drugs or Phenergan/Compazine Precautions A. May have additive effect with alcohol or depressants Administration I: CONTACT BASE for direct physician order. A. Adult: 50 mg slow IV push or deep IM B. Children up to age 8: 1-2 mg/kg slow IV (not to exceed 50 mg total). Side Effects & Special Notes A. Diphenhydramine is rarely necessary in the field. It is the first line drug for mild to moderate

allergic reactions and, therefore, may be useful for long transports. It may also be useful for acute dystonic reactions; but these, while emotionally and physically trying, are not life-threatening and do not require treatment in the field.

B. May see CNS stimulation in children. C. Side effects include dry mouth, dilated pupils, flushing, and drowsiness. D. Diphenhydramine should be used with caution in patients with asthma/COPD, glaucoma, and

bladder obstruction, as all of these conditions can be exacerbated by its administration.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DOPAMINE

January 1, 2008 VI - 26

Drug Protocol

DOPAMINE (INTROPIN) P

Pharmacology & Actions A. Dopamine is a chemical precursor of Epinephrine. It occurs naturally in humans. B. Dopamine has the following dose related effects:

1. 1-2 mcg/kg/min: Dilates renal and mesenteric blood vessels (no effect on heart rate or blood pressure).

2. 2-10 mcg/kg/min: Beta effects on heart usually increase cardiac output without increasing

heart rate or blood pressure.

3. 10-20 mcg/kg/min: Alpha peripheral effects cause peripheral vasoconstriction and increased blood pressure.

4. 20-40 mcg/kg/min: Alpha effects reverse dilatation of renal and mesenteric vessels with

resultant decreased flow. Indications A. Cardiogenic shock. B. Septic or neurogenic shock when unresponsive to other measures. Precautions A. Dopamine is contraindicated in hypovolemic shock. Pressor agents worsen tissue hypoxia

in the presence of hypovolemia from diuretics and poor intake; careful differentiation is necessary. Invasive monitoring is often the only way to differentiate forms of shock in the elderly, and treatment with Dopamine is therefore indicated in the field only in severely unstable patients with evidence of increased venous pressure.

B. Dopamine is best administered by an infusion pump to accurately regulate rate. This is another

reason it is hazardous for field use. Monitor closely. C. Dopamine may induce tachydysrhythmias. If the heart rate exceeds 140, the infusion should be

stopped. D. At low doses, decreased blood pressure may occur due to peripheral vasodilatation. Increasing

infusion rate will correct this. E. Should not be added to Sodium Bicarbonate or other alkaline solutions, since Dopamine will be

inactivated at higher pH. F. Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure to

make Emergency Department personnel aware if there has been any extravasation of

TFPD EMS PROTOCOLS DRUG PROTOCOLS: DOPAMINE

January 1, 2008 VI - 27

Dopamine-containing solutions, so that proper treatment can be instituted. G. Can cause hypertensive crisis in susceptible individuals. H. Certain antidepressants potentiate the effects of this drug. Check for medications and

CONTACT BASE if other medications are being used. Administration A. CONTACT BASE for direct physician order.

B. Dosage to be determined by Medical Control

C. Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/ml.

D. Ideally Dopamine should be administered w/ central line venous access. If possible use an EJ

or at least a large bore antecubital. Never administer into a hand or foot IV.

Intravenous Drip Rates for Dopamine Concentration: 1600 mcg/ml.

DOSE Weight (kg)

5

10

15

20

(mcg/kg/min)

50

10

20

30

40

microdrips/min

60

10

25

35

45

70

15

25

40

50

80

15

30

45

60

90

15

35

50

70

100

20

35

55

75

110

20

40

60

85

DISCLAIMER: These methods of calculation are NOT EXACT and are meant to expedite treatment

2 AM RULE DOWN & DIRTY Patient weight in lbs. = 180 lbs. Patient weight in lbs. = 180 lbs Drop last number = 18 Divide by 10 = 18 Subtract 2 = 16 gtts/min Subtract 2 = 16 gtts/min

TFPD EMS PROTOCOLS DRUG PROTOCOLS: EPINEPHRINE

January 1, 2008 VI - 28

Drug Protocol

EPINEPHRINE I/P

Pharmacology & Actions A. Catecholamine with alpha and beta effects B. Cardiovascular:

1. Increased heart rate

2. Increased blood pressure

3. Arterial vasoconstriction

4. Increased myocardial contractile force

5. Increased myocardial oxygen consumption

6. Increased myocardial automaticity and irritability C. Pulmonary:

1. Potent bronchodilator Indications A. Medical cardiac arrest, including:

1. Ventricular fibrillation

2. Asystole

3. Pulseless electrical activity (PEA)

B. Bradycardia:

1. Adults with BP < 90 with signs of poor perfusion, if refractory to atropine

2. Pediatrics with signs of poor perfusion C. Asthma D. Moderate to severe allergic reactions E. Anaphylaxis or severe angioedema Precautions


January 1, 2008 VI - 29

A. Do not add to solutions containing bicarbonate. B. Increase in myocardial oxygen consumption can precipitate angina or MI in patients with

coronary artery disease. C. Use with caution in patients with hypertension, hyperthyroidism, peripheral vascular disease, or

cerebrovascular disease. D. Asthma is not the only cause of wheezing. Epinephrine is contraindicated in pulmonary edema. E. Anaphylaxis is a systemic allergic reaction with cardiovascular collapse. Angioedema involves

swelling of mucous membranes; potential exists for airway compromise. Mild or moderate allergic reactions with urticaria or wheezing may progress to anaphylaxis or severe angioedema. Monitor patient carefully and treat according to patient status.

F. Epinephrine comes in two strengths. Use of the wrong formulation will result in a ten-fold

difference in dosage. Be sure you use the right one. G. Anxiety, tremor, palpitations, vomiting, and headache are common side effects. Administration I: CONTACT BASE prior to administration. A. Adult

1. Cardiac arrest: 1.0 mg (10 ml of 1:10,000 solution) IV every 3 to 5 minutes.

2. Bradycardia (CONTACT BASE for direct physician order): 0.1 mg (1 ml of 1:10,000 solution) IV.

3. Mild or moderate allergic reactions (CONTACT BASE for direct physician order): 0.3 mg

(0.3 ml of 1:1,000 solution) SQ.

4. Anaphylaxis (CONTACT BASE for direct physician order): 0.1 mg (1 ml of 1:10,000 solution) IV, over 5 minutes if time allows. Reassess. Repeat.

5. Asthma (CONTACT BASE for direct physician order): 0.3 mg (0.3 ml of 1:1,000 solution)

SQ.

6. The EMT-B may assist in administering an Epi-pen in the setting of allergic reaction/anaphylaxis after receiving direct order from base physician.

B. Pediatric

1. Cardiac arrest

a. First dose: 0.01 mg/kg IV or I/O (0.1 ml/kg of 1:10,000 solution).

b. Subsequent doses: 0.1 mg/kg, IV or I/O (0.1 ml/kg of 1:1,000 solution).


January 1, 2008 VI - 30

c. Pediatric endotracheal dose is 0.1 mg/kg of 1:1,000.

2. Bradycardia (CONTACT BASE for direct physician order): 0.01 mg/kg (0.1 ml/kg of

1:10,000) IV/IO.

3. Mild or moderate allergic reactions (CONTACT BASE for direct physician order): 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) SQ.

4. Anaphylaxis (CONTACT BASE for direct physician order): 0.01 mg/kg (0.01 ml/kg of

1:1,000 solution) IV/IO.

5. Asthma (CONTACT BASE for direct physician order): 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) SQ.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: EPINEPHRINE AUTO INJECTOR

January 1, 2008 VI - 31

Drug Protocol

EPINEPHRINE AUTO INJECTOR B/I/P

Pharmacology & Actions A. Rapid acting catecholamine B. Pulmonary: bronchodilator C. Cardiovascular: vasoconstriction causing increase in blood pressure Indications A. Severe allergic reactions B. Anaphylaxis Precautions A. Whether an auto injector is patient prescribed or from the ambulance, check to ensure that the

pen has not expired or discolored. Administration B/I: Direct orders required. A. Assist patient if they are able to self-inject, otherwise administer

1. Remove safety cap and wipe patient’s thigh with alcohol

2. Place tip against lateral part of patient’s thigh midway between waist and knee

3. Push injector firmly against thigh until it activates (5-10 seconds)

4. Hold injection in place until medication is injected

5. Remove injector and dispose in biohazard container

6. Adult system delivers 0.3 mg Epi; infant/child system delivers 0.15 mg Epi

7. Closely monitor vital signs and reassess patient. BLS as indicated Side Effects & Special Notes A. Side effects: tachycardia, pallor, dizziness, chest pain, headache, nausea/vomiting, anxiety,

palpitations B. If patient’s condition becomes worse, CONTACT BASE control before giving another injection

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ETOMIDATE

January 1, 2008 VI - 32

Drug Protocol

ETOMIDATE P

Pharmacology & Actions A. Etomidate is a hypnotic sedative without analgesic activity or hypotension. B. Produces deep sedation within 45 seconds with approximate 5 minute duration of action. C. Produces a modest decrease of intracranial pressure and suppresses adrenal gland function. Indications A. Sedation to facilitate endotracheal intubation in the patient with unconsciousness, Glasgow

Coma Scale of 8 or less, or trismus

Precautions A. Do not use in patients under 10 years of age

B. Should be used cautiously in pregnancy

C. Must be prepared to assist with ventilation prior to administration

D. Do not administer to a patient who you do not think you can intubate

Administration A. Contact Medical Control for orders

B. 0.3 mg/kg slow IV push. (30-60 seconds)

Side Effects & Special Notes A. A common side effect is transient venous pain during administration, especially in smaller

distal veins.

B. Transient skeletal muscle movement is common after sedation.

C. Transient hyperventilation, hypoventilation and apnea are possible.

D. Too rapid administration or overdose may result in hypotension.

E. Etomidate is supplied in single dose pre-filled syringes, 40 mg/20ml.

F. Fentanyl decreases Etomidate elimination.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: FENTANYL

January 1, 2008 VI - 33

Drug Protocol

FENTANYL (SUBLIMAZE) I/P

Pharmacology & Actions

Fentanyl is a potent opioid analgesic that is a prominent member of the narcotic analgesic class of drugs designed to relieve pain. Fentanyl has a rapid onset of action and a relatively short duration of action. Indications I: CONTACT BASE for direct physician order. A. Relief of pain from musculo-skeletal injury B. Rarely, for relief of other pain or anxiety (i.e. acute abdomen), dosage to be determined by

Medical Control. Precautions A. Any patient receiving analgesics (i.e. Fentanyl, Morphine) will be placed on O2 to ensure high

saturation

B. Fast IV push of high doses can result in “frozen chest”. May require paralysis and intubation to overcome (i.e. push slow and in small increments)

Contraindications A. Hypersensitivity to Fentanyl (caution if pt hypersensitive to other opioids) B. Severe respiratory depression or respiratory disease. C. Severe CNS depression

D. Pregnant women (confirmed or suspected)

E. Children under the age of 1 y/o.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: FENTANYL

January 1, 2008 VI - 34

Administration/Dosing A. Child (for anesthesia or sedation)

1. Dose: 1-2 mcg/kg/dose (maximum 50 mcg) IV, IM or IN a. May repeat IV Fentanyl (same dose) q 2 minutes to achieve desired effect.

B. Adult 1. Dose: 50 to 100 mcg IV, IN or IM, in 50 mcg increments.

a. May repeat Fentanyl (same dose) q 2 minutes to achieve desired effect, not to exceed 200 mcg

b. DIRECT ORDER required to exceed total of 200 mcg. First choice for administration is slow IV push over one-two minutes — avoid “bolus” injection. Onset of analgesia following a usual dose of 50-100 mcg is less than 2 minutes and persists for 1 to 2 hours.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: GLUCAGON

January 1, 2008 VI - 35

Drug Protocol

GLUCAGON I/P

Pharmacology & Actions A. Glucagon is a natural hormone comprising 29 amino acids in a single polypeptide chain. It is

produced by the alpha-islet cells of the pancreas, and is chemically unrelated to insulin.

B. Converts liver glycogen to glucose.

C. Stimulates glucagon receptors in cardiac cells (in larger doses), increasing heart rate, and myocardial force of contraction and conduction velocity.

D. Reverses hypoglycemia:

1. Glucagon administered IM will raise blood sugar concentration within 4–8 minutes, and has a duration of action of 1-2 hours

Indications I: CONTACT BASE for direct physician order A. Symptomatic hypoglycemia when IV access is delayed.

1. Patients at risk for hypoglycemia accompanied by difficult IV access include those with Diabetes mellitus, drug or alcohol abuse, chronic renal failure, congestive heart failure, and those who are debilitated.

2. If IV access is accomplished after the administration of IM glucagon, and a positive clinical

response has not yet been observed, the patient should be given 50 ml D50. B. Beta blocker overdoses, to be determined by Medical Control.

1. Glucagon reverses bradycardia, hypotension, and myocardial depression associated with this overdose.

C. Anaphylactic shock unresponsive to epinephrine, especially in patients taking beta blockers. Administration A. Hypoglycemia – no IV access:

1. Adult: 1 mg IM, may repeat if necessary in 7 – 10 minutes

2. Peds: 0.5 mg IM, may repeat if necessary in 7 – 10 minutes B. Beta blocker overdose:

1. 3 – 10 mg IV, may be followed by an IV drip of 2 –5 mg/hr in D5W

TFPD EMS PROTOCOLS DRUG PROTOCOLS: GLUCAGON

January 1, 2008 VI - 36

2. Multiple doses may be necessary to titrate antagonist effects.

C. Anaphylactic shock: 1. CONTACT BASE.

. Side Effects & Special Notes

A. Nausea and Vomiting

1. Adverse reactions are uncommon and mild when they do appear. Nausea and vomiting occur in an occasional patient, and are secondary to Glucagon’s ability to decrease GI motility.

B. It is of vital importance to reverse hypoglycemia as rapidly as possible. Low blood sugar is

particularly damaging to brain cells and prolonged or repeated hypoglycemic episodes may result in permanent brain damage. IV Dextrose is the therapeutic modality of choice for hypoglycemia, but if IV access cannot be rapidly obtained, IM Glucagon is an excellent alternative.

C. Optimally, in the non-diabetic patient, blood sugar should be measured rapidly before the

administration of Dextrose or Glucagon, as inducing hyperglycemia in patients with ischemic cerebral insults (e.g. stroke, intracranial hemorrhage) or head trauma may increase neuronal damage.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: HALDOL

January 1, 2008 VI - 37

Drug Protocol

HALDOL (HALOPERIDOL LACTATE) I/P

Pharmacology & Actions Haldol is an antipsychotic/neuroleptic drug with properties similar to those of the phenothiazines. The drug is thought to block dopamine (type 2) receptors in the brain, altering mood and behavior. In emergency care, Haldol usually is administered IM, but may also be given IV. The onset IM is 30-60 minutes; duration is 12-24 hours. Indications I: CONTACT BASE for direct physician order. A. Acute psychotic episodes. B. Emergency sedation of severely agitated or delirious patients. Precautions A. Haldol is contraindicated in patients with CNS depression, coma, hypersensitivity, pregnancy,

severe liver or cardiac disease. Administration A. Adult: 2-5 mg IM every 4-8 hr or 2-5 mg IVP every 15-30 minutes. CONTACT BASE for larger doses. B Pediatric: 0.5 mg IM Side Effects & Special Notes A. Dose related extrapyramidal reactions include pseudoparkinsonism, dystonias and akathisia.

May cause hypotension, nausea, vomiting, allergic reactions, blurred vision. B. Other CNS depressants may potentiate effects. May inhibit vasoconstrictor effects of Epinephrine

TFPD EMS PROTOCOLS DRUG PROTOCOLS: HEPARIN

January 1, 2008 VI - 38

Drug Protocol

HEPARIN P

Pharmacology & Actions A. Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory

effects of antithrombin Indications A. Acute myocardial infarction, acute coronary syndrome (ACS), pulmonary embolism, deep vein

thrombosis (DVT), disseminated intervascular coagulation (DIC) Precautions and contraindications A. Active bleeding, known or suspected intracranial hemorrhage (CVA), chronic renal failure,

recent surgery or other significant risk for bleeding such as thrombocytopenia or hemophilia.

B. Patients who have already received Lovenox (1.5 mg/kg wait 24 hours. 1 mg/kg or less wait 12 hours).

C. Peptic ulcer disease, hepatic disease, sever hypertension

D. Consider stopping infusion if patient develops signs of bleeding such as petechiae or bruising, hematemesis, bleeding from gums, epistaxis, sudden tachycardia

Administration A. Mix 25,000 U into 250 ml NS. For suspected cardiac patients: Initial bolus is 50-100 units/kg

IVP followed by an infusion of 7-15 units/kg/hr.

B. Drips will be established at the Telluride Medical Center and maintained by the Paramedic through transport.

C. Suggest a heparin drip on all post-thrombolytic patients.

D. Suggest running all heparin drips at 12 U/kg/hr when indicated. Side Effects & Special Notes A. Bleeding, allergy, thrombocytopenia, itching

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ATROVENT

January 1, 2008 VI - 39

Drug Protocol

IPRATROPIUM BROMIDE (ATROVENT) I/P

Pharmacology & Actions A. Anticholinergic interfering with uptake of acetylcholine to bronchial smooth muscle B. Few cardiovascular effects C. Rapid onset of action (under 5 minutes) and a half-life of two hours Indications A. For relief of severe bronchospasm associated with asthma, emphysema, bronchitis Precautions A. Discontinue immediately if patient develops chest pain or arrhythmias B. Atrovent is contraindicated for patients with allergies to soy products or peanuts C. Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, bladder-neck

obstruction or pregnant/nursing women D. Significant pain and blurring of vision may occur if medication flows from nebulizer into patient’s

eyes Administration A. For nebulized administration only B. Ipratropium Bromide comes in premixed unit-dose vials containing 0.5mg of Ipratropium

Bromide in 2.5 ml of Sodium Chloride C. For patients presenting with respiratory distress, initial treatment should be Albuterol combined

with Atrovent. CombiNebs are good for everyone, especially children. D. For adults: Twist top off unit-dose container and pour into medicine chamber of an oxygen-

powered nebulizer. Deliver as much of the mist as possible by nebulizer over 5-15 minutes. Talk the patient through taking controlled deep breaths to maximize treatment.

1. For children, 5 to 12 years of age: Place ½ of the premixed diluent in the nebulizer chamber.

Dilute with NS to 3-5 ml. Administer as in procedure C.1 above.

2. CONTACT BASE if a second treatment is required. Side Effects & Special Notes A. Monitor blood pressure and heart rate closely and CONTACT BASE physician if any concerns

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ATROVENT

January 1, 2008 VI - 40

arise. B. If there is no history of airway disease and/or no response to therapy, CONTACT BASE

physician

immediately, as presenting symptoms may instead be manifestations of severe allergic reaction. C. Medication such as MAO inhibitors and tricyclics may potentiate tachycardia and hypertension. D. CAREFULLY document pre-and post-administration assessment as the patient will have

significant changes by the time he/she is seen in the Emergency Department.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: IV SOLUTIONS

January 1, 2008 VI - 41

Drug Protocol

IV SOLUTIONS B/I/P

Pharmacology & Actions Initiation of all IVs in the field in these protocols utilizes normal saline (NS). The standard IV drip rate will be TKO unless a fluid bolus or fluid challenge is required. TKO FLUID RATE Indications A. Prophylactic IV B. Drug administration Administration A. TKO = 5-10 drops/min or buffalo cap FLUID BOLUS Indications A. Hemorrhagic shock, volume depletion (dehydration, burns, severe vomiting) B. Shock caused by increased vascular space (neurogenic shock) Precautions A. In hemorrhagic shock, volume expansion with blood is the treatment of choice. Crystalloid

solutions (NS) will temporarily expand intravascular volume and “buy time,” but do not increase oxygen-carrying capacity, and are insufficient in severe shock. Because of this, rapid transport is still necessary to treat severely hypovolemic patients who need blood and possibly surgical intervention.

B. Volume overload is a constant danger, particularly in cardiac patients. Keep a close eye on your

IV rate during transport. Mysterious excess fluid boluses are all too common. Administration A. 20 ml/kg NS through large bore cannula, as rapidly as possible. CONTACT BASE if more than

one fluid bolus is indicated.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: FLUID CHALLENGE

January 1, 2008 VI - 42

Drug Protocol

FLUID CHALLENGE Indications A. History of chest pain suggests a cardiac origin and the patient is hypotensive. B. The history and physical findings indicate the possibility of hypovolemia and a cautious

approach to expanding intravascular volume is indicated, such as history of cardiac disease. Administration A. 250-500 ml rapidly through a large bore cannula or pressure bag, then reassess the patient. Side Effects & Special Notes A. Flow rate through a 14g cannula is twice the rate through an 18g cannula, and volume

administration in trauma patients can be accomplished more rapidly. If the patient has poor veins, a smaller bore is better than no IV at all, in some instances.

B. IVs in an unstable trauma patient should be placed en route, and may be left to the hospital

setting for short transports. Do not delay transport in critical patients for IV attempts. C. If you are unable to start in two attempts, another qualified attendant may try, or you may leave

the IV for the hospital. D. If IV access is required but volume expansion is not, consider starting a buff cap. E. 1 ml/min = 60 microdrops/min = 10 regular drops/min

TFPD EMS PROTOCOLS DRUG PROTOCOLS: LIDOCAINE

January 1, 2008 VI - 43

Drug Protocol

LIDOCAINE I/P

Pharmacology & Actions A. Cardiovascular

1. Increased ventricular fibrillation threshold

2. Decreased conduction rate (at toxic levels)

3. Decreased myocontractility (at toxic levels) B. CNS

1. Stimulation

2. Decreased cough reflex Indications A. Following successful defibrillation B. Recurrent or refractory ventricular fibrillation C. Ventricular or wide complex tachycardia with pulses D. Significant PVCs in the setting of myocardial infarction:

1. PVCs greater than 6/minute

2. R on T

3. Multifocal PVCs

4. 2 or more PVCs in a row E. Prior to intubation in setting of coma following head trauma (suspected increased intracranial pressure) Precautions A. High grade A-V block is a relative contraindication B. Diazepam should be available to treat convulsions if they occur C. Do not treat ventricular escape beats or accelerated idioventricular rhythm with Lidocaine D. Lidocaine is metabolized in the liver; elderly patients and those with liver disease or poor liver

TFPD EMS PROTOCOLS DRUG PROTOCOLS: LIDOCAINE

January 1, 2008 VI - 44

perfusion secondary to shock or congestive heart failure are more likely to experience side

E. effects. F. Side effects include drowsiness, confusion, convulsion, hypotension, bradycardia, and

tachycardia. G. Head trauma requires careful airway management. If endotracheal intubation is appropriate,

pretreatment with Lidocaine may help avoid further increase in intracranial pressure, if time permits.

Administration A. Cardiac

1. V. Fib., pulseless V. Tach: 1.5 mg/kg, repeat in 3-5 minutes at 1.5 mg/kg.

2. V. Tach with pulse: 1.5 mg/kg slow IVP, repeat if indicated in 3-5 minutes at 0.75 mg /kg slow IVP.

3. Post-arrest, 1.5 mg/kg, slow IVP.

4. Significant ventricular ectopy: 1.0 mg/kg, slow IV, repeat if indicated at 0.5 mg /kg.

5. Maximum IVP is 3.0 mg/kg.

6. Follow IVP with a Lidocaine drip as time allows. Administer 2-4 mg/min of a 4 mcg/ml mix.

B. Head trauma: If patient is to be intubated, consider 1.5 mg/kg IV bolus 3-5 minutes prior to

intubating. C. To counter laryngospasm, squirt 2 to 3 ml of Lidocaine directly on cords. Side Effects & Special Notes A. Resist the urge to treat every PVC. Lidocaine is a toxic drug. PVCs outside the setting of acute

MI should not be treated. Hypoxia can generate PVCs, and Lidocaine will not help; treat the cause.

B. Best available evidence currently indicates that prophylactic Lidocaine (in the setting of MI

without PVCs) may actually increase mortality. C. For patients over the age of 70, or with liver/hepatic dysfunction, administer one half the

indicated dosing.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: MAGNESIUM SULFATE

January 1, 2008 VI - 45

Drug Protocol

MAGNESIUM SULFATE P

Pharmacology & Actions A. Cardiac: Stabilizes potassium pump, correcting repolarization. Shortens the Q-T interval in the

presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance. B. Respiratory: Acts as a bronchodilator in acute bronchospasm due to asthma or other

bronchospastic diseases. For best results, it should be used after normal field inhalation therapy has been attempted.

C. Obstetrics: Controls seizures by blocking neuromuscular transmission. Also lowers blood

pressure and decreases cerebral vasospasm. Indications A. Cardiac: Ventricular arrhythmias, particularly Torsades de Pointes, refractory to Lidocaine. B. Respiratory: used when 3 nebulized treatments of Albuterol have failed to relieve acute

bronchospasm. C. Obstetrics: Pregnancy > 20 weeks with signs and symptoms of pre-eclampsia (PIH), defined as:

1. Blood pressure > 180 mm systolic or > 120 mm diastolic with altered mental status, or

2. Seizures Precautions A. AV block B. Decrease in respiratory or cardiac function Administration A. CONTACT BASE for direct physician order. B. In cardiac or respiratory emergencies previously discussed, 2 g IV over 1 minute. C. In PIH pre-eclampsia/eclampsia patients, mix 4g in 50 ml of NS and run over 15-30 minutes

(micro at 2 gtts/sec).

1. With microdrip 2 gtts/sec. Side Effects & Special Notes A. Principle side effect is respiratory depression. Ventilatory assistance may be needed. B. Not for pediatric use.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: METHYLPREDNISOLONE

January 1, 2008 VI - 46

Drug Protocol

METHYLPREDNISOLONE (SOLU-MEDROL) I/P

Pharmacology & Actions A. Solu-Medrol is classified as a steroid, a glucocorticoid, and an anti-inflammatory. Its mechanism

of action is not completely understood, although it is thought to stabilize cellular and intracellular membranes. Stabilizing the membranes of lysosomes would theoretically block the release of many destructive lysosomal enzymes such as hydrolases and proteases, while stabilizing mast cell membranes would inhibit the release of many vasoactive amines such as histamine, serotonin, and bradykinin. Together these chemicals are not only destructive in their own right, but are powerful initiators of the inflammatory response.

B. Reduces the inflammatory response C. Diminishes the allergic response Indications A. Reactive airway disease

1. In severe exacerbation of emphysema, chronic bronchitis or asthma, steroids may be life-

saving but usually take 2 to 6 hours to work. 2. Solu-Medrol decreases the inflammatory and/or the allergic response, resulting in

decreased bronchospasm, bronchial secretions, and mucosal edema. B. Anaphylactic reactions

1. Steroids diminish the anaphylactic response, probably because of their stabilizing effects on mast cells.

C. Reduction of elevated intracranial pressure (ICP) & HACE

1. Effectiveness in reducing cerebral edema and ICP depends on the etiology of the disturbance. Metabolic causes of cerebral edema (eg: brain tumor) respond much better than structural causes (eg: head trauma).

Administration I: CONTACT BASE for direct physician order. A. Reactive airway disease and anaphylaxis:

1. 40 – 125 mg IV 2. Peds: 2 –4 mg/kg IV

TFPD EMS PROTOCOLS DRUG PROTOCOLS: METHYLPREDNISOLONE

January 1, 2008 VI - 47

Side Effects & Special Notes A. Hypotension – very rare; usually seen in very large doses. B. Note: Steroids are definitely advantageous in severe exacerbations of reactive airway disease,

and should be used early in these conditions.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: MIDAZOLAM

January 1, 2008 VI - 48

Drug Protocol

MIDAZOLAM (VERSED) P

Pharmacology & Actions: A. Stimulates benzodiazepine receptors in the CNS, potentiating the action of the inhibitory

neurotransmitter gamma-aminobutyric acid (GABA).

B. Actions include sedation, amnesia, anxiolysis (decreased anxiety), and anti-convulsant activity. C. Compared to Valium, Versed is 3-4 times more potent, has a faster onset and recovery, and

causes less pain and irritation to the veins when injected. Indications: A. Sedation for:

1. Rapid Sequence Intubation (RSI) 2. Combative head injuries

3. Pre-cardioversion

4. Seizures

5. Severe anxiety

Administration A. To facilitate orotracheal intubation as part of RSI:

1. Adult: 0.1-0.2 mg/kg IV, a reasonable starting dose is 5-10 mg IV administered over 20-30 seconds.

2. Peds: 0.05-0.1 mg/kg IV and may be repeated B. Seizures:

1. Adults: 2.5 mg IV. May repeat in five minutes. 2. Adults without an IV: may give 5 mg IM, IN or 2.5 mg rectal. 3. Peds without an IV: may be given 0.1-0.15 mg/kg IM, IN or 1.5-2.5 mg rectal.

Side Effects & Special Notes A. CNS/Respiratory depression and hypotension are the most common significant side effects.

B. Side effects are more likely in patients who have received narcotics or other respiratory

depressants. Respiratory depression must be treated aggressively with positive pressure ventilation.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: MIDAZOLAM

January 1, 2008 VI - 49

C. Hypotension secondary to Versed is usually transient and responds to fluids and/or raising the

legs.

D. All patients that receive Versed MUST be on a cardiac monitor & pulse ox.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: MORPHINE SULFATE

January 1, 2008 VI - 50

Drug Protocol

MORPHINE SULFATE I/P

Pharmacology & Actions A. Analgesia B. Pupil constriction C. Respiration: Decreased rate and tidal volume D. Peripheral vasodilatation E. Reflex cardiac effect (from vasodilatation):

1. Decreased myocardial oxygen consumption

2. Decreased left ventricular end-diastolic pressure

3. Decreased cardiac work F. Effect: Maximum within 7 minutes IV or 15 minutes IM. Indications I: CONTACT BASE for direct physician order. A. Presumed cardiac chest pain unresponsive to Nitroglycerin B. Extremity injury when severe pain is present: To be given only in the absence of any evidence

of head, chest or abdominal injuries C. Severe burns D. Cardiogenic pulmonary edema Precautions A. Hypotension is a relative contraindication to use. Remember that some people will be

hypotensive in response to pain itself. Smaller doses are less likely to cause or aggravate hypotension.

B. Head or abdominal injuries are also relative contraindications to morphine use, since the

analgesic effect removes the clinical signs that need to be watched. C. Do not use in persons with respiratory difficulties (except pulmonary edema), because their

respiratory drive may become depressed. D. Do not use in the presence of major blood loss. The body’s compensatory mechanisms will be

TFPD EMS PROTOCOLS DRUG PROTOCOLS: MORPHINE SULFATE

January 1, 2008 VI - 51

suppressed by the use of morphine and the hypotensive effect will become very prominent. E. May cause vomiting; administer slowly F. Any patient receiving analgesics (ie. Fentanyl, Morphine) will be placed on O2 to ensure high

oxygen saturation Administration A. P: Standing orders for up to 10 mg for pain management B. P: Adult dose: 2 mg initially; repeat every 3-5 minutes if needed up to 10 mg. The goal is

decreased anxiety and patient comfort; patient need not be completely pain-free. CONTACT BASE for additional dosage. I: DIRECT ORDER: Adult dose: 2 mg initially; repeat every 3-5 minutes if needed up to 10 mg. The goal is decreased anxiety and patient comfort; patient need not be completely pain-free. CONTACT BASE for additional dosage

C. Pediatric dose: 0.1 mg-0.2 mg/kg IV slowly. Side Effects & Special Notes A. The major side effects and complications from morphine result from vasodilatation. This causes

no problems if the patient is supine and not volume depleted. It may cause problems if the patient is upright, hypovolemic, or has decreased cardiac output (after MI).

B. Morphine can cause respiratory depression. Be prepared to ventilate if the patient stops

breathing. This can be reversed with Narcan.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: NALOXONE

January 1, 2008 VI - 52

Drug Protocol

NALOXONE (NARCAN) B/I/P

Pharmacology & Actions A. Naloxone is a narcotic antagonist which completely binds to narcotic sites, but which exhibits

almost no pharmacological activity of its own. Duration of action: 1-4 hours. Indications A. Reversal of narcotic effects, particularly respiratory depression, due to narcotic drugs either

ingested, injected, or administered in the course of treatment. Narcotic drugs include morphine, meperidine (Demerol), heroin, hydromorphone (Dilaudid), oxycodone (Percodan, Percocet, Oxycontin), codeine, propoxyphene (Darvon), pentazocine (Talwin).

B. Diagnostically in coma or altered mental status of unknown etiology, to rule out (or reverse)

narcotic cardiorespiratory depression. C. Seizure of unknown etiology, to rule out narcotic overdose (particularly propoxyphene). Precautions A. In patients physically dependent on narcotics, frank and occasionally violent withdrawal

symptoms may be precipitated. Be prepared to restrain the patient. Titrate the dose (1-2 ml at a time) to reverse cardiac and respiratory depression, but to keep the patient groggy.

B. May need large doses (8-12 mg) to reverse propoxyphene (Darvon) overdose. Administration A. Adult or pediatric: 2 mg (2 ml) IV. With a likely opiod overdose consider titrating at 0.4 mg until

patient exhibits desired results. B. If no response is observed, this dose may be repeated after 5 min if narcotic overdose strongly

suspected.

C. May be given IN or IM at 2x the IV dose.

D. B: CONTACT BASE May administer up to 2 mg IN/IV Side Effects & Special Notes A. The duration of some narcotics is longer than Naloxone and the patient must be monitored

closely. Repeated doses of Naloxone may be required. Patients who have received this drug must be transported to the hospital because coma may reoccur when Naloxone wears off.

B. With an endotracheal tube in place and assisted ventilation, narcotic overdose patients may be

safely managed without Naloxone. Think twice before totally reversing coma; airway may be lost, or (worse) the patient may become violent and may refuse transport.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: NITROGLYCERIN

January 1, 2008 VI - 53

Drug Protocol

NITROGLYCERIN (NTG) B/I/P

Pharmacology & Actions A. Cardiovascular effects include:

1. Reduced venous tone; causes blood-pooling in peripheral veins, decreasing venous return to the heart

2. Decreased peripheral resistance

3. Dilatation of coronary arteries (if not already at maximum) and relief of coronary artery

spasm B. Generalized smooth muscle relaxation Indications A. Angina B. Chest, arm, or neck pain caused by coronary ischemia C. Control of hypertension in angina, acute MI, or hypertensive encephalopathy D. Cardiogenic pulmonary edema: To increase venous pooling, lowering cardiac preload and

afterload E. P: Hemodynamically stable patient needing transport from one hospital to another on a

nitroglycerin infusion (i.e., unstable angina, now pain free on a nitro drip, who needs to be transported to a hospital with a cardiac catheterization laboratory).

Precautions A. Generalized vasodilatation may cause profound hypotension and reflex tachycardia B. NTG tablets lose potency easily; should be stored in dark glass container with tight lid and not

exposed to heat C. Use with caution in hypotensive patients D. Patients using Viagra, Cialis or Levitra should be given special consideration due to a potentially

dangerous blood pressure drop when given Nitrates Administration

A. 0.4 mg. (1/150) tablet sublingually, or one metered spray; may repeat every 5 minutes as needed for effect.


January 1, 2008 VI - 54

CONTACT BASE for direct physician order for administration beyond 3 doses. (Includes patient-administered Nitroglycerin within last 15 minutes) During longer transports, CONTACT BASE to consider “maintenance” of NTG by SL route.

B. Blood pressure to be checked prior to each dose.

C. EMT-Basic may assist with administration of patient’s Nitro with physician order only.

D. CONTACT BASE for direct physician order for patients with BP less than 100 mmHg or with signs of poor peripheral perfusion, pulmonary edema or hypertension.

E. P: Continue Nitroglycerin drip at the rate begun at the transferring hospital, under direct physician order.

F. In cases when pain is not relieved with current drip rate, Paramedic may increase drip rate

by 5-10 ug/min q 5 minutes until pain is relieved with physicians order.

G. Maximum dose is 200 ug/min

AMOUNT TO INFUSE 25 mg in

250ml Dose Ordered

(ug/min) Ugtts/minute (or

ml/hr)

10 ug 6 ugtts/min 20 ug 12 ugtts/min 30 ug 18 ugtts/min 40 ug 24 ugtts/min 50 ug 30 ugtts/min 60 ug 36 ugtts/min

70 ug 42 ugtts/min 80 ug 48 ugtts/min 90 ug 54 ugtts/min

100 ug 60 ugtts/min 110 ug 66 ugtts/min 120 ug 72 ugtts/min 130 ug 78 ugtts/min 140 ug 84 ugtts/min 150 ug 90 ugtts/min 160 ug 96 ugtts/min

Side Effects & Special Notes A. Common side effects include throbbing headache, flushing, dizziness, and burning under the


January 1, 2008 VI - 55

tongue. These side effects may be used to check potency. B. Nitroglycerin may be given prior to starting IV but is not advised. Nitroglycerin may cause

marked orthostatic hypotension. Strongly consider starting IV prior to administration. C. Note: Therapeutic effect is enhanced, but adverse effects are increased when patient is

upright. D. Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in

relieving chest pain caused by esophageal spasm. E. May be effective even in patients using paste, discs, or oral long-acting nitrate preparations.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: OXYGEN

January 1, 2008 VI - 56

Drug Protocol

OXYGEN FR/B/I/P

Pharmacology & Actions A. Oxygen added to the inspired air raises the amount of oxygen in the blood, and therefore, the

amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Breathing, in most people, is regulated by small changes in the acid/base balance and CO2 levels. It takes relatively large decreases in oxygen concentration to stimulate respiration. Since oxygen binds with hemoglobin, it increases oxygen saturation (SaO2 of the blood); it does not dissolve appreciably in blood at atmospheric pressures. Therefore, oxygen flow beyond when SaO2 approaches 100% is unnecessary.

Indications A. Suspected hypoxemia or respiratory distress from any cause B. Acute chest or abdominal pain C. Hypotensive states from any cause D. Major trauma E. All acutely ill patients F. Any suspected carbon monoxide poisoning G. Pregnant females in the setting of trauma H. Any patient who has been given ANY analgesic Precautions A. If the patient is not breathing adequately on his own, the treatment of choice is ventilation, not

just oxygen. B. A small percentage of patients with chronic lung disease breathe because they are hypoxic.

Administration of oxygen will inhibit their respiratory drive. Do not withhold oxygen because of this possibility. Be prepared to assist ventilations if needed.

C. When pulse oximeter is available, titrate Sa02 to 90% or greater. D. In the COPD patient, if there is no improvement or symptoms deteriorate despite oxygen

administration, initiate assisted ventilations with bag-valve mask and consider intubation. Administration A. Dosage: Whatever is necessary to maintain SaO2 > 90% for most conditions, to 100% for CO

poisoning, hypovolemic shock, cardiac or cerebral ischemia.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: OXYGEN

January 1, 2008 VI - 57

Side Effects & Special Notes A. Restlessness may be an important sign of hypoxia. B. On the other hand, some people become more agitated when a nasal cannula is applied,

particularly when it is not needed. Acquiesce to your patient if it is reasonable. C. Nasal prongs work equally well on nose and mouth breathers, except babies. D. Non-humidified oxygen is drying and irritating to mucous membranes. E. Oxygen toxicity is not a hazard of short term use. F. In patients with a history of COPD. Provide supplemental Oxygen. MAINTENANCE OF RATE AND VOLUME OF VENTILATION IS AS IMPORTANT (POSSIBLY MORE IMPORTANT) THAN SUPPLEMENTAL OXYGEN. G. If high flow oxygen is inadequate, assist ventilations with a BV

TFPD EMS PROTOCOLS DRUG PROTOCOLS: PROMETHAZINE

January 1, 2008 VI - 58

Drug Protocol

PROMETHAZINE (PHENERGAN) I/P

Pharmacology & Actions A. Antiemetic action thought to be due to depression of CTZ in the medulla B. Affects the central, autonomic, and peripheral nervous systems C. Exerts antiserotonin, anticholinergic, antimotion sickness, sedative and amnesic actions D. Potentiates respiratory depressant effects of narcotics and other CNS depressants E. Potentiates sedative effects of narcotics and other CNS depressants F. Potentiates hypotensive effects of narcotics and other CNS depressants G. Readily absorbed, primarily metabolized in the liver and excreted in the urine H. Relaxes smooth muscle

I. Lowers seizure threshold Indications I: CONTACT BASE for direct physician order A. Treatment of acute nausea, vomiting, and motion sickness Precautions/Contraindications A. Use with caution in patients with asthma, cardiovascular disease, hepatic disease, and

respiratory impaired patients, especially pediatric patients, acute or chronic. B. Contraindicated in patients with bone marrow depression, hypersensitivity to phenothiazines,

jaundice, lactation, pregnancy and Reye’s syndrome. C. Never inject into an artery. D. Side effects may include cardiorespiratory symptoms, CNS stimulation, coma, convulsions,

confusion, drowsiness, restlessness, sedation, transient mild hypertension or hypotension, anorexia, blurred vision, dry mouth, photosensitivity and urinary retention

E. Use caution when using in head injured patients since the drug does lower seizure threshold Dosage and Administration A. For nausea, the adult dosage is 12.5-25 mg IV, pediatric dose is 0.25-0.5 mg/kg. B. For motion sickness, the adult dosage is 25 mg IV, pediatric dose 0.25-0.5 mg/kg.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: PHENYLEPHRINE

January 1, 2008 VI - 59

Drug Protocol

PHENYLEPHRINE (INTRANASAL) NEO-SYNEPHRINE

I/P Pharmacology & Actions A. Used as topical nasal drops, Phenylephrine exhibits primarily alpha-adrenergic stimulation.

This stimulation can produce moderate to marked vasoconstriction and nasal decongestion. Indications A. Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa. Precautions A. Avoid administration into the eyes, due to dilation of the pupil. Administration A. Place two drops or administer two sprays of 1% solution in the nostril prior to attempting

nasotracheal intubation.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: PITOCIN

January 1, 2008 VI - 60

Drug Protocol

PITOCIN (OXYTOCIN) P

Pharmacology & Actions A. A hormonal agent that stimulates uterine muscle contraction Indications A. Control of postpartum hemorrhage Precautions/Contraindications A. Be sure the baby (or all babies, in the case of multiple births) and the placenta have been

completely delivered before administration of this drug. B. Contraindicated in patients with hypersensitivity to Pitocin Administration A. 10-20 units in 1000 ml NS IV infusion pump, as per Medical Direction B. For inter-facility transfer only. Drip must be initiated at TMC. EMS continuation and monitoring

only without upward titration of the drug Side Effects & Special Notes A. Pitocin causes very painful contractions B. Other side effects include nausea, vomiting, hypotension and arrhythmias C. Cardiac monitoring must be in place for patient on Pitocin drip. D. Drug has a very short half life, so toxic effects often resolve spontaneously within a few minutes.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: RACEMIC EPINEPHRINE

January 1, 2008 VI - 61

Drug Protocol

RACEMIC EPINEPHRINE (VAPONEPHRINE) I/P

Pharmacology & Actions Racemic epinephrine is an epinephrine preparation in a 1:1,000 dilution for oral inhalation only. Effects are those of epinephrine. Inhalation causes local effects on the upper airway as well as systemic effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and beta effects on bronchial smooth muscle may relieve bronchospasm. Indications I: CONTACT BASE for direct physician order. A. Life threatening airway obstruction suspected secondary to croup or epiglottitis Precautions A. O2 Mask and noise may be frightening to small children, try using the pedi-bear. Agitation will

aggravate symptoms of respiratory obstruction. Try to enlist the support of parents and child for administration.

B. Try to differentiate croup from epiglottitis by history. Cough is usually present in croup. Do not use a tongue blade to examine the back of the throat. The diagnosis is frequently difficult in the field, but a critical patient deserves a trial of Racemic Epinephrine during transport. Although used as a specific therapy for croup, it may also buy some time in patients with epiglottitis.

C. In a less than critical patient, saline alone via nebulizer may bring symptomatic relief from croup.

D. Racemic Epinephrine is heat and light sensitive. It should be stored in a dark and cool place. Discoloration is an indication for discarding it.

E. Tachycardia and agitation are the most common side effects. Other side effects of parenteral Epinephrine may also be seen. (Since these are also the hallmarks of hypoxia, watch the patient very closely!)

F. Nebulizer treatment may cause blanching of the skin in the mask area due to local Epinephrine absorption. Reassure parents.

G. Clinical improvement in croup can be dramatic after administration of Racemic Epinephrine, and presentation in the ED may be markedly altered. Rebound worsening of airway obstruction can occur however, in 1-4 hours. For this reason, many physicians admit any patient whom they treat with Racemic Epinephrine. Field administration should be limited to critical patients during transport so as to avoid unnecessary delays.

H. If respiratory arrest occurs, it is usually due to patient fatigue or laryngeal spasm. Complete obstruction is not usually present. Ventilate the patient, administer O2, and transport rapidly. If

TFPD EMS PROTOCOLS DRUG PROTOCOLS: RACEMIC EPINEPHRINE

January 1, 2008 VI - 62

you can ventilate and oxygenate the patient adequately with BVM or mouth – mask, intubation is best left to a controlled setting.

Administration A. 0.5 ml Racemic Epinephrine (acceptable dose for all ages) + 2 ml saline, via nebulizer driven

by O2 (6-8 l/minute) to create a fine mist.

< 20 kg. = 0.25 ml = 20-40 kg. = 0.50 ml Mix with 2 to 3 ml of NS or sterile water > 40 kg. = 0.75 ml for nebulization

TFPD EMS PROTOCOLS DRUG PROTOCOLS: SODIUM BICARBONATE

January 1, 2008 VI - 63

Drug Protocol

SODIUM BICARBONATE I/P

Pharmacology & Actions A. Sodium Bicarbonate is an alkaline solution that neutralizes acids found in the body. Acids are

increased when body tissues become hypoxic due to cardiac or respiratory arrest. Indications A. Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures B. Consider in patients with prolonged cardiac arrest C. Aspirin overdose D. Crush injury E. Other indicated poisonings per Medical Control Precautions A. Addition of too much Sodium Bicarbonate may result in alkalosis. Alkalosis is very difficult to

reverse and can cause as many problems in resuscitation as acidosis. B. Should not be given with catecholamines or calcium. Administration A. CONTACT BASE for direct physician order. B. Solutions:

1. Adult: 8.4% = 1.0 mEq/ml.

2. Neonatal: 4.2% = 0.5 mEq/ml. (Either prepackaged or adult solution diluted 1:1 with sterile NS or water.)

C. For cardiac arrest:

1. Adult: 1 mEq/kg (1 ml/kg).

2. Pediatric: 1 mEq/kg (1 ml/kg).

3. Neonatal: 1 mEq/kg (2 of 4.8% strength ml/kg). D. For tricyclic overdose (Adult): 1 mEq/kg (1 ml/kg), call base if considering a second dose.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: SODIUM BICARBONATE

January 1, 2008 VI - 64

Side Effects & Special Notes

A. Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a paradoxical intracellular acidosis.

B. Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This increases

intravascular volume, which increases the work load of the heart.

C. Hyperosmolality of the blood can occur, resulting in cerebral impairment.

D. Sodium Bicarbonate's lack of proven efficacy and its numerous adverse effects have lead to the reconsideration of its role in cardiac resuscitation. Effective ventilation and circulation of blood during CPR are the most effective treatments for acidemia associated with cardiac arrest.

E. Administration of sodium bicarbonate has not been proven to facilitate ventricular

defibrillation or to increase survival in cardiac arrest. Metabolic acidosis lowers the threshold for the induction of ventricular fibrillation, but has no effect on defibrillation threshold.

F. The inhibition effect of metabolic acidosis on the actions of catecholamines has not been

demonstrated at the pH levels encountered during cardiac arrest.

G. Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field treatment is rarely indicated.

H. Sodium Bicarbonate may be considered for the dialysis patient in cardiac arrest due to

suspected hyperkalemia.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: SUCCINYLCHOLINE

January 1, 2008 VI - 65

Drug Protocol

SUCCINYLCHOLINE (ANECTINE) P

Pharmacology & Actions A. Succinylcholine is an ultra-short acting, depolarizing type, skeletal muscle relaxant. B. Succinylcholine stimulates the nicotinic receptors on the motor end-plate of skeletal muscle

cells (including the diaphragm), as does acetylcholine, and stimulates the muscle to contract. While acetylcholine is rapidly broken down by the enzyme acetylcholinesterase (less than a millisecond) which allows the muscle cells to recover, succinylcholine is somewhat resistant to acetylcholinesterase, and therefore is not broken down as quickly. This causes the muscle to undergo rapid repetitive depolarization (sometimes grossly visible as muscle fasciculations) without the opportunity to recover. The motor end-plate fatigues and becomes resistant to further depolarization, which results in flaccid paralysis, including respiratory arrest.

C. The onset of paralysis is rapid (30-60 seconds, peaking at about 2 minutes) and lasts

approximately 4-8 minutes. Paralysis appears in the following muscles consecutively: elevators of the eyelids, jaw muscles, limb muscles, abdominal muscles, muscles of the glottis, the intercostals then the diaphragm and all other skeletal muscles. Recovery of normal muscle tone is in reverse order.

D. Succinylcholine has no effect on pain or consciousness. Therefore, unconsciousness should

ALWAYS be induced before succinylcholine is administered. Indications A. To facilitate endotracheal intubation

1. Succinylcholine eliminates potential problems complicating intubation, such as trismus,

coughing, gagging, bucking, and flailing Contraindications A. Hyperkalemia

1. Renal failure patients

B. Massive sub-acute burns <72°

C. Abdominal sepsis

D. Upper/Lower motor neuron disease

1. CVA non-acute

2. Para/Quadriplegia non-acute

3. ALS/MS

TFPD EMS PROTOCOLS DRUG PROTOCOLS: SUCCINYLCHOLINE

January 1, 2008 VI - 66

E. Familial pseudocholinesteras deficit

F. Open globe

G. Major crush injury Administration A. 1.5 mg/kg IV – patient must be sedated. 2.0 mg/kg IV in peds B. If adequate relaxation not present 5 minutes after administration, or if paralysis wears off

earlier than required, additional incremental doses (usually 25-50% of the initial dose) may be administered to adults. Before giving additional dose, ensure that the IV line is functioning and not infiltrated. A second dose is contraindicated in children.

C. Treat bradycardia occurring during intubation with Atropine 0.5 mg IV push (peds 0.02 mg/kg

minimum 0.1 mg) and by temporarily halting intubation attempts and hyperventilating the patient with a BVM. Repeat doses of Succinylcholine are more likely to cause bradycardia than the initial dose.

D. Pre-treat all pediatric patients with Atropine prior to Succinylcholine administration. Side Effects & Special Notes

A. Death – As succinylcholine causes total skeletal muscle paralysis, including apnea, death may

ensue if airway control and ventilation cannot be established. In the event that the patient cannot be intubated after the administration of succinylcholine, bag mask ventilation should be attempted. If bag mask ventilation is inadequate, LMA should be considered.

B. Aspiration – reduce the risk of aspiration by applying cricoid pressure (Sellick Manuever.) Other side effects include: prolonged apnea, malignant hyperthermia, myoglobinemia, and myoglobinuria, in increased intraocular pressure. In the emergency situation where succinylcholine is required for airway control, the above side effects are not a priority.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: TERBUTALINE

January 1, 2008 VI - 67

Drug Protocol

TERBUTALINE P

Pharmacology & Actions A. Relaxes bronchial smooth muscle by direct action on B2 adrenergic receptors through

accumulation of cAMP at B-adrenergic receptor sites; bronchodilation, diuresis, CNS, cardiac stimulation occur; relaxes uterine smooth muscle.

Indications A. Premature labor with DIRECT PHYSICIAN ORDER Contraindications A. Hypersensativity to sympathomimetics, NAG, tachydysrhythmias. Precautions A. Pregnancy, cardiac disorders, hyperthyroidism, diabetes mellitus, lactation, elderly,

hypertension. Administration A. 0.25 mg SQ

TFPD EMS PROTOCOLS DRUG PROTOCOLS: TETRACAINE

January 1, 2008 VI - 68

Drug Protocol

TOPICAL OPHTHALMIC ANESTHETICS (TETRACAINE) P

Pharmacology & Actions A. Topical, local ophthalmic anesthetics have a rapid (20-30 second) onset of action with a 15-30

minute duration. Indications I: CONTACT BASE for direct physician order. A. Used to provide topical ophthalmic anesthesia during transport of patients with actual or

potential serious eye injuries that present with a “foreign body sensation.” Precautions A. Use of topical ophthalmic anesthetics is contraindicated in patients with global laceration/rupture

injuries. B. Do not apply until patient consents to transport to an emergency department for definitive

therapy since application may totally relieve pain and, therefore, instigate an inappropriate refusal.

C. Contraindicated in patients with any known allergy to local anesthetics. D. Topical ophthalmic anesthetics should never be given to a patient for self-administration. E. The patient may further damage the eye secondary to anesthesia of the cornea. F. Occasional burning/stinging can occur when initially applied, although this is usually transient. G. Only use fresh, unopened bottle for each patient. If discolored, do not use (discard immediately

as this implies contamination). H. Do not touch the tip of the bottle on anything as this will contaminate the medication. Administration A. Only the following agents are approved: Proparacaine or Tetracaine. B. Place 2 drops in the affected eye(s); one application only in the prehospital setting. C. Indications for repeat administration (i.e., delayed transport, loss of therapeutic effect, etc.) shall

be determined via consultation with base physician. Any repeat application requires base physician approval.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: TETRACAINE

January 1, 2008 VI - 69

Side Effects & Special Notes A. Do not administer until patient consents to transport to an emergency department for definitive

therapy. B. Each bottle is for single patient use only.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: VASOPRESSIN

January 1, 2008 VI - 70

Drug Protocol

VASOPRESSIN I/P

General Information A. The administration of this medication is only for the patient in cardiac arrest after initial

attempts at defibrillation are unsuccessful. Actions A. An antidiuretic hormone, vasopressin is a naturally secreted hormone of the pituitary,

regulating water conservation in the body. In the setting of cardiac arrest, this medication is used for the potent peripheral vasoconstriction achieved. Half-life of this effect of the medication is 10 to 20 minutes.

Indications A. Adult patient in cardiac arrest secondary to pulseless VT or VF, refractory to initial 200J shock. B. Adult patient in PEA or asystole. C. May be useful for hemodynamic support in vasodilatory shock (e.g., septic shock), by direct

physician order only. Precautions A. To be administered one time only. This medication causes peripheral vasoconstriction.

Extravasation will cause tissue necrosis. Dosage A. 40 units, rapid IV push (supplied in two 20 unit, 1cc vials). May be given IV / IO Procedure A. Draw the contents of two vials of Vasopressin into a 3 or 5 ml syringe. Administer rapid IV

push, through a pinched-off IV line, followed by a short saline bolus. Do not mix in-line with other medications.

Special Note A. The half-life is 10 to 20 minutes. When following the algorithm, step-by-step, drug-shock-drug-

shock, about 10+ minutes is when the first administration of Vasopressin is due. This is the same time that base should be contacted to consider treatment of special circumstances or termination of resuscitation.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: VECURONIUM

January 1, 2008 VI - 71

Drug Protocol

VECURONIUM (NORCURON) P

Pharmacology & Actions A. Vecuronium is a short to intermediate acting, non-depolarizing type, skeletal muscle

relaxant. B. Vecuronium blocks acetylcholine from binding to receptors on the motor end-plate of

skeletal muscle cells, thus inhibiting depolarization, resulting in flaccid paralysis, including apnea, secondary to diaphragmatic paralysis.

C. By inhibiting depolarization, Vecuronium blocks fasciculations secondary to Succinylcholine. D. Maximum neuromuscular blockage occurs in 3 – 5 minutes. Indications A. To facilitate endotracheal intubation.

1. Administered prior to succinylcholine to block fasciculations. 2. Administered after intubation to maintain paralysis.

Administration A. 0.01 mg/kg prior to administration of succinylcholine to block fasciculations. B. 0.04- 0.06 mg/kg post-intubation as needed to maintain paralysis. C. Children (1-10 years) may require slightly higher doses and slightly more frequent

supplementation. Side Effects & Special Notes A. Less than 1% tachycardia, bradycardia, circulatory collapse, hypersensitivity reaction. B. Increases effect with ketamine, magnesium sulfate, verapamil, and furosemide. C. Use with caution in patients with hepatic impairment, neuromuscular disease, and the

elderly. Ventilation must be supported during neuromuscular blockade.

TFPD EMS PROTOCOLS DRUG PROTOCOLS: ZOFRAN

January 1, 2008 VI - 72

Drug Protocol

ZOFRAN (ONDANSETRON) I/P

Pharmacology & Actions Zofran is a serotonin antagonist. It blocks the serotonin receptors in the chemoreceptor trigger zone (CTZ), the stomach and the small intenstines. It is very effective in the treatment of nausea and vomiting associated with chemotherapy and is increasingly used for patients with any kind of nausea and vomiting. Unlike Dopamine antagonists, it does not cause extrapyramidal effects like dystonia and ataxia and does not lower the seizure threshold. Indications A. Nausea / vomiting Precautions/Contraindications A. DO NOT use in patients with known allergy to Zofran Administration A. 4 mg slow IV B. 4 mg tablets SQ C. Single dose of 4 mg is generally sufficient. May repeat once (e.g. for extended transport time)

after consulting with MD.

Side Effects & Special Notes A. Most common side effects are headache and diarrhea; usually in cancer patients on high doses B. Zofran is safe to use, even in children over 2 y/o (2-4 mg.) For children under 2 y/o consult with

MD. C. Safe to use in pregnant women D. Drug of choice for nausea/vomiting associated with head injury and seizure disorder

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: GENERAL PRINCIPLES

January 1, 2008 VII - 1

Procedure Protocol

AIRWAY MANAGEMENT GENERAL PRINCIPLES

B/I/P Stepwise procedures for obtaining control of the airway in medical situations have been well accepted and standardized by AHA protocol as well as practical clinical experience. We encourage more widespread use of nasopharyngeal airways in lightly comatose patients who still require some support for a lax tongue. But when is active control of the airway needed? In many instances, the maximally invasive form of airway management is chosen because of incorrect judgments about “impending” respiratory arrest. Especially with head injuries, this is hard to predict, and an irregular breathing pattern may represent chaotic breathing rather than impending arrest. On the other hand, despite the obvious risks of active airway management, the risks of inadequate oxygenation are even greater. Both under-treatment and over-treatment may be costly to the patient, but it is better to err on the side of aggressive airway management to achieve adequate oxygenation. The unsolved problem of emergency airway management is what to do with the patient who requires active airway management and in whom there exists great potential for (or actual presence of) a cervical spine injury. Clearly no one wishes to save a life at the expense of producing a quadriplegic. Nevertheless, if the patient is in full trauma arrest, to what avail is it to save the spinal cord function, if the patient is vegetated or dies because of prolonged attempts to perform difficult operative procedures with inadequate experience. Currently, the best method to control the airway is to intubate orally with an assistant maintaining stabilization (digital intubation, also with stabilization, is an alternative.) In a non-arrested patient, nasotracheal intubation is an alternative if there is no midface trauma. Technical competence requires good training, adequate practice, and compulsive attention to detail to ensure safe and effective performance of any procedure. In certain settings, the LMA may provide a good alternative to enodtrachael intubation. Needle cricothyrotomy remains the only effective alternative for a small number of patients who have injuries that preclude routine airway procedures. The following protocols are recommended as a guide for approaching difficult medical and trauma airway problems. They assume that the responder is skilled in the various procedures, and will need to be modified according to training level. Advanced procedures should only be attempted if simpler ones fail and if the technician is qualified. Individual cases may require modification of these protocols. Medical Respiratory Arrest A. Open airway using head tilt-chin lift or head tilt-neck lift. B. Apply pocket mask or BVM with supplemental oxygen to ventilate. C. Insert nasopharyngeal airway or oropharyngeal airway if patency is difficult to maintain.



D. Suction as needed. E. I/P: Perform orotracheal intubation prior to transport if arrest continues. Medical Hypoventilation A. Open the airway using most efficient method. B. Insert nasopharyngeal airway. C. Suction as needed. D. Apply supplemental O2 by nasal cannula or mask as needed. E. Assist respirations by BVM as needed. F. P: Perform nasotracheal or orotracheal intubation if prolonged support is needed, or if

airway requires continued protection from aspiration. Traumatic Respiratory Arrest A. Open airway using jaw thrust maneuver, protecting neck. B. Clear the airway with suction as needed. C. Have assistant stabilize head and neck. D. Draw tongue and mandible forward if needed in patients with facial injuries. E. Use pocket mask or BVM for initial control of ventilation. F. I/P: Perform orotracheal intubation with in-line immobilization of neck. Pressure over

larynx (cricoid pressure or sellick’s) may make intubation easier. G. B/I//P: If placement of an ET tube proves unattainable, reoxygenate the patient and

place an LMA. H. P: If intubation and LMA placement cannot be performed due to severe facial injury,

and patient cannot be ventilated with mask, perform a needle cricothyrotomy. Cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances.

Trauma with Hypoventilation A. Open airway using jaw thrust maneuver, protecting neck.



B. Clear the airway with suction as needed. C. Have assistant provide continuous stabilization to head and neck. D. Use hand to draw tongue and mandible forward if needed with facial injuries. E. Administer high flow O2; support with BVM ventilations. F. Attempt nasotracheal intubation to secure airway, if needed, and if no significant midface

trauma G. If patient deteriorates, and cannot be supported by less invasive means: 1. I/P: Attempt orotracheal intubation with neck stabilized. 2. B/I//P: If placement of an ET tube proves unattainable, reoxygenate the patient and

place an LMA. 3. P: If intubation and LMA placement cannot be performed due to severe facial

injury, and patient cannot be ventilated with mask, perform a needle cricothyrotomy. Cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: OPENING AIRWAY


Procedure Protocol

AIRWAY MANAGEMENT OPENING THE AIRWAY

B/I/P Indications A. Inadequate air exchange in the lungs due to jaw or facial fracture, causing narrowing of

air passage. B. Lax jaw or tongue muscles causing airway narrowing in the unconscious patient. C. Noisy breathing or excessive respiratory effort that could be due to partial obstruction. D. In preparation for suctioning, assisted ventilation or other airway management

maneuvers. Precautions A. For trauma victims, keep neck in midline and avoid flexion, extension, traction or

rotation. B. For medical patients, neck extension may be difficult in elderly persons with extensive

arthritis and little neck motion. Do not use force; jaw thrust or chin lift without head tilt will be more successful.

C. All airway maneuvers should be followed by an evaluation of their success; if breathing

is still labored, a different method or more time for recovery may be needed. D. Children’s airways have less supporting cartilage; overextension can kink the airway and

increase the obstruction. Watch chest movement to determine the best head angle. E. Dentures should usually be left in place since, they provide a framework for the lips and

cheeks and allow more effective mouth-to-mask or bag-valve-mask ventilation. Technique A. Put on gloves. To open the airway initially, choose method most suitable for patient. B. Assess ventilations. C. Begin BVM ventilation if patient is not breathing. D. Relieve partial or complete obstruction, if present. E. Assess oxygenation; use supplemental O2 as needed. F. Choose method to maintain airway patency during transport:



1. Position patient (if medical problem) left lateral recumbent to lower possibility of aspiration of vomitus for unconscious patient.

2. Oropharyngeal airway: a. Choose size by measuring from mouth to ear margin. b. Depress tongue with tongue blade, OR insert gently with curve pointing

UPWARD. Avoid snagging posterior tongue or palate. c. Insert to back of tongue, then turn to follow curve of airway. Move gently to be

sure the tip is free in back of pharynx. d. In pediatric patients, depress tongue and insert airway with curve down to avoid

injury to palate and pushing tongue posterior. 3. Nasopharyngeal airway: a. Lubricate tube. b. Insert into largest nare along floor of nose until flange is seated at nostril. Keep

curve in line with normal airway curve. If you meet resistance, try the left side. G. Listen to breathing to be sure maneuver has resolved problem. H. Resume ventilatory assistance and oxygenation as appropriate. I. I/P: Consider intubation to provide adequate airway. J. B/I//P: If ET tube placement prove unattainable, consider placement of an LMA. K. P: Consider needle cricothyrotomy only if unable to intubate or place an LMA.

Cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances.

Complications A. Cervical spinal cord injury from neck hyperextension in trauma victim with cervical

fracture. B. Death due to inadequate ventilation or hypoxia. C. Nasal or posterior pharyngeal bleeding due to trauma from tubes. D. Increased airway obstruction from tongue following improper oropharyngeal airway

placement. E. Aspiration of blood or vomitus from inadequate suctioning and continued contamination

of lungs from upper airway.



Side Effects & Special Notes A. During transport, medical patients can be placed in a stable position on their sides for

effective airway control. Use a flexed leg, arms, or pillows for support. B. Nasopharyngeal airways are very useful for airway maintenance, and are underused in

most regions. The nasal insertion provides more stability, the airway is better tolerated in partially awake patients, and it does not carry the risk of blocking the airway further like the stiff oropharyngeal airway.

METHODS OF OPENING THE AIRWAY HEAD TILT-CHIN LIFT: Technique: From beside head, place one hand on forehead. Grasp lower

edge of chin with fingers of other hand and lift chin forward. Teeth may come together.

Indications: Medical patient. May require less neck extension than head tilt.

Useful with dentures. May be used without head tilt in trauma victims.

JAW THRUST: Technique: Position yourself above patient. Place forefingers of each

hand under angle of jaw, just below ears with thumbs on cheekbones. Lift jaw, using forearms to maintain head alignment.

Indications: Trauma victim or medical patient, where neck extension is not

possible. BVM ventilation must be done by another rescuer, and this is a fatiguing method. May be used with dentures in place.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: OBSTRUCTED AIRWAY


Procedure Protocol

AIRWAY MANAGEMENT OBSTRUCTED AIRWAY

B/I/P Indications A. Complete or partial obstruction of the airway due to a foreign body. B. Complete or partial obstruction due to airway swelling from anaphylaxis, croup, or

epiglottitis. C. Patient with unknown illness or injury who cannot be ventilated after procedures of

previous protocol: Opening the Airway. Precautions A. Perform chest thrusts only in visibly pregnant patients and in infants. B. Patients with partial airway obstruction can be very uncomfortable. Abdominal or chest

thrusts will not be effective and may be injurious to the patient who is still ventilating. Resist the temptation to attempt relief of obstruction if it is not complete, but be ready to intervene promptly if arrest occurs.

C. Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts may

not be effective until the patient becomes relaxed after the seizure is over. Technique COMPLETE AIRWAY OBSTRUCTION: A. Perform Heimlich maneuver and repeat until successful or patient becomes

unconscious. B. Open airway using head tilt-chin lift or jaw thrust. C. Attempt to ventilate using mouth-to-mask or BVM ventilations. D. If unable to ventilate, reposition airway and reattempt ventilations. E. If airway remains obstructed, perform CPR (30:2) F. Reposition the airway, inspect mouth and remove objects if seen. If unsuccessful

perform CPR. G. I/P: If unable to ventilate visualize with laryngoscope and remove any obvious foreign

body using magil forceps. H. Reposition the airway and reattempt to ventilate.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: OBSTRUCTED AIRWAY


I. P: Consider cricothyrotomy if obstruction above the cords unrelieved. Cricothyrotomy

is a difficult and hazardous technique that is to be used only in extraordinary circumstances.

J. When obstruction relieved: 1. Keep patient on side, sweeping airway to remove debris. 2. Apply O2, high flow; reservoir mask. 3. Assess adequacy of ventilation, and support as needed. 4. Suction as needed. 5. Restrain if combative. PARTIAL AIRWAY OBSTRUCTION: A. Have patient assume most comfortable position. B. Apply O2, high flow by non-rebreather mask. C. Attempt suctioning of upper airway. D. If patient unable to move air, confused, or otherwise deteriorating, visualize airway,

remove foreign body or perform abdominal thrusts as noted above. Complications A. Hypoxic brain damage and death from unrecognized or unrelieved obstruction. B. Trauma to ribs, lung, liver and spleen from chest or abdominal thrusts (particularly when

forces are not evenly distributed). C. Vomiting and aspiration after relief of obstruction. D. Creation of complete obstruction after incorrect finger probing. E. Tonsillar or pharyngeal laceration from over-vigorous finger sweep.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: CLEARING & SUCTIONING


Procedure Protocol

AIRWAY MANAGEMENT CLEARING AND SUCTIONING THE AIRWAY

B/I/P Indications A. To remove foreign material that can be removed by a suction device. B. To remove excess secretions or pulmonary edema fluid in upper airway or lungs (with

endotracheal tube in place). C. To remove meconium or amniotic fluid in mouth, nose and oropharynx of newborn. Technique A. Use gloves, mask, eye protection as needed for safety of personnel. B. Turn patient on side if possible, to facilitate clearance. C. Open airway and inspect for visible foreign material. D. Remove large or obvious foreign matter with gloved hands. Use oropharyngeal airway

(do not pry) to keep airway open. Sweep finger across posterior pharynx and clear material out of mouth.

E. Attach suction machine and test motor. Set suction between 80 and 120 mm Hg. Higher suction is needed for tracheobronchial suctioning. F. Suction of oropharynx: 1. Attach tonsil tip (or use open end for large amounts of debris). 2. Ventilate and oxygenate the patient as needed prior to the procedure. 3. Insert tip into oropharynx under direct vision, with sweeping motion. 4. Continue intermittent suction interspersed with active oxygenation by mask BVM.

Do not suction more than 5 seconds before re-oxygenation. Use positive pressure ventilation if needed.

5. If suction becomes clogged, dilute by suctioning water from a glass to clean tubing.

If suction clogs repeatedly, use connecting tubing alone, or manually remove large debris.

6. If clog cannot be removed switch to portable motor suction and /or manual suction. G. Catheter suction of endotracheal tube: 1. Attach suction catheter to tubing of suction device (leaving suction end in sterile



container). 2. Use of Pulsoximeter and end tidal CO2 should provide proper indication for

ventilation method. 3. Detach BVM from endotracheal tube and insert sterile tip of suction catheter

without suction. 4. When catheter tip has been gently advanced as far as possible, apply suction and

withdraw catheter slowly. Do not suction longer than 5 seconds. 5. Clean catheter tip by suctioning sterile water or saline. 6. Oxygenate patient before each suction attempt. H. Suction of the newborn: 1. Use neonatal suctioning device. 2. Suction the newborn’s mouth prior to suctioning the nose when delivery is complete. NOTE: Be prepared to suction infants born with meconium staining

immediately upon delivery of the head. Again, suction the mouth first. Be sure to monitor heart rates during suction attempts.

3. Apply suction while slowly withdrawing catheter from the mouth or use bulb

syringe. 4. Insert catheter tip into each nostril and back to posterior pharynx or use bulb

syringe, only after suctioning the mouth FIRST. 5. Apply suction while slowly withdrawing catheter from each nostril. Complications A. Hypoxia due to excessive suctioning time without adequate ventilation between

attempts. B. Persistent obstruction due to inadequate tubing size for removal of debris. C. Lung injury from aspiration of stomach contents due to inadequate suctioning. D. Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning. E. Conversion of partial to complete obstruction by attempts at airway clearance. F. Trauma to the posterior pharynx from forced use of equipment. G. Vomiting and aspiration from stimulation of gag reflex. H. Induction of cardiorespiratory arrest from vagal stimulation.



Side Effects & Special Notes A. Complications may be caused both by inadequate and overly vigorous suctioning.

Technique and choice of equipment are very important. Choose equipment with enough power to suction large amounts rapidly to allow time for ventilation.

B. Proper airway clearance can make the difference between a patient who survives and

one who dies. Airway obstruction is one of the most common treatable causes of pre-hospital death.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: ASSISTING VENTILATION


Procedure Protocol

AIRWAY MANAGEMENT ASSISTING VENTILATION

B/I/P Indications A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory

depression. B. To apply positive pressure breathing in patients with pulmonary edema and severe

fatigue. C. To ventilate patients in respiratory arrest. Precautions A. Two people are often required to obtain an adequate mask fit and also ventilate. B. Assisted ventilation will not hurt a patient, and should be used whenever the breathing

pattern seems shallow, slow, or otherwise abnormal. Do not be afraid to be aggressive about assisting ventilation, even in patients who do not require or will not tolerate intubation.

Technique A. Use gloves, mask, eye protection as needed for safety of personnel. B. Open the airway. Check for ventilation. C. If patient is not breathing, perform 2 full breaths using BVM or pocket mask and check

pulse. Begin CPR as needed. D. If pulse is present, but patient is not breathing, continue assisted ventilation until

adjuncts are available. E. Attach O2 to BVM. F. Position yourself above patient's head, insert oral or nasal airway, continue to hold

airway position, seat mask firmly on face, and begin assisted ventilation. G. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust head tilt

and mask fit as needed. Tidal volume can be estimated using the 10cc/kg rule. H. Always use end tidal CO2 coupled with Pulsoximeter when ventilating patients. I. If patient resumes spontaneous respirations, continue to administer supplemental

oxygen. Intermittent assistance with ventilation may still be needed.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: ASSISTING VENTILATION


Complications A. Continued aspiration of blood, vomitus, and other upper airway debris. B. Inadequate ventilations due to poor seal between patient's mouth and ventilatory device. C. Gastric distention, possibly causing vomiting. D. Trauma to the upper airway from forcible use of airways. E. Pneumothorax.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: OROTRACHEAL INTUBATION


Procedure Protocol

ADVANCED AIRWAY MANAGEMENT OROTRACHEAL INTUBATION

I/P Indications In most cases orotracheal intubation provides definitive control of the airway. Its purposes include: A. Actively ventilating the patient. B. Delivering high concentrations of oxygen. C. Suctioning secretions and maintaining airway patency. D. Preventing aspiration of gastric contents, upper airway secretions, or bleeding. E. Preventing gastric distention due to assisted ventilation. F. Administering positive pressure when extra fluid is present in alveoli. G. Administering drugs during resuscitation for absorption through the lungs. H. Allowing more effective CPR. Precautions A. Do not use intubation as the initial method of managing the airway in an arrest.

Oxygenation prior to intubation should be accomplished with pocket mask or BVM as needed.

B. Appropriate intubation precautions should be taken in the trauma patient. Nasotracheal

intubation is an alternative in the breathing patient. Oral intubation with in-line cervical immobilization is the best alternative for a trauma patient requiring definitive airway control.

C. Never lever the laryngoscope against the teeth. The jaw should be lifted with direct

upward traction by the laryngoscope. D. Prepare suction beforehand. Vomiting is particularly common when the esophagus is

intubated. E. Intubation should take no more than 15-20 sec to complete. If visualization is difficult,

stop and reventilate before trying again. Be mindful of your Pulsoximeter, if readings that were previously adequate drop below 85% again reventilate.

F. Orotracheal intubation can be accomplished in trauma victims if an assistant maintains

stabilization and keeps the neck in neutral position. Careful visualization with the laryngoscope is needed, and McGill forceps may be helpful in guiding the ET tube.



G. Increased intracranial pressure frequently accompanies intubation attempts. Administer Lidocaine IV/IO before intubation attempts on patients with significant head injury. Do not delay intubation, however, for IV efforts in a patient.

H. Reflex Bradycardia can be common with intubation of pediatric patients < 2 yo, therefore

Atropine 0.02 mg/Kg IV/IO should be given prophylactically Technique A. Put on gloves, mask, eye protection. Assemble the equipment while continuing

ventilation: 1. Choose tube size (see Table). Use as large a tube as possible. 2. Introduce the stylet and be sure it stops 1/2” short of the tube’s end. 3. Assemble laryngoscope and check light. 4. Connect and check suction. B. Position patient: Neck flexed forward, head extended back. Back of head should be level

with or higher than back of shoulders. C. Give a minimum of 4 good ventilations before starting procedure. D. Have an assistant apply gentle cricothyroid pressure (Sellick’s Maneuver) to prevent

aspiration and to assist in visualization of vocal cords. E. Insert laryngoscope to right of midline. Move it to midline, pushing tongue to left and out

of view. F. Lift straight up on blade (no levering) to expose posterior pharynx. G. Identify epiglottis: Tip of curved blade should sit in vallecula (in front of epiglottis),

straight blade should slip over epiglottis. H. With gentle further traction to straighten the airway, identify trachea from arytenoid

cartilages and vocal cords. I. Insert tube from right side of mouth, along blade into trachea under direct vision. J. Advance tube so cuff is 1-1.5” beyond cords. Inflate cuff with 5-10 ml of air, clamp if

necessary to secure against leaks. Positioning the ET tube so that the 19-21 cm mark (females) or 21-24 cm mark (males) is at the teeth will help to avoid endobronchial intubation.

K. Ventilate and watch for chest rise. Listen for breath sounds over stomach (should not be

heard) and lungs and axillae, recognize adequate ETCO2 reading and wave form. L. Note proper tube position and secure tube with tube securing device.



M. Consider use of full CTLS immobilization to prevent tube dislodgement when moved. N. Re-auscultate over stomach and both sides of chest whenever patient is moved. O. Tube placement should also be evaluated by end tidal CO2 detector whenever available. Complications A. Esophageal intubation: Particularly common when tube not visualized as it passes

through cords. The greatest danger is in not recognizing the error. Auscultation over stomach during trial ventilations should reveal air gurgling through gastric contents with esophageal placement. Also make sure patient’s color improves as it should when ventilating.

B. Intubation of right mainstem bronchus: Be sure to listen to chest bilaterally. C. Upper airway trauma due to excess force with laryngoscope or to traumatic tube

placement. D. Vomiting and aspiration during traumatic intubation or intubation of patient with intact

gag reflex. E. Hypoxia due to prolonged intubation attempt. F. Cervical spine fracture in patients with arthritis and poor cervical mobility. G. Cervical cord damage in trauma victims with unrecognized spine injury. H. Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of airway. I. Induction of pneumothorax, either from traumatic insertion, forceful bagging, or

aggravation of underlying pneumothorax.

OROTRACHEAL TUBE SIZE

AGE ENDOTRACHEAL TUBE (uncuffed)

Preemie 2.5-3.0 Newborn 3.0-3.5 6 mos. 3.5 18 mos. 4.0 3 yrs. 4.5 5 yrs. 5.0 8 yrs. 6.0 Cuffed 10-15 yrs. 6.5-7.0 Cuffed Adult 7.0-9.0 Cuffed

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: NASOTRACHEAL INTUBATION


Procedure Protocol

ADVANCED AIRWAY MANAGEMENT NASOTRACHEAL INTUBATION

P Indications A. Same function as orotracheal intubation. B. Used in the breathing patient requiring intubation. C. Asthma or pulmonary edema with respiratory failure, where intubation may need to be

achieved in a sitting position. Precautions A. Head must be exactly in midline for successful intubation. B. Have suction ready. Vomiting can occur, as with any stimulation of the airway. C. Often nares are asymmetrical and one side is much easier to intubate. Avoid inducing

bilateral nasal hemorrhage by forcing a nasotracheal tube on multiple attempts. D. Use with caution in patients with significant nasal or craniofacial trauma. E. Blind nasotracheal intubation is a very “elegant” technique. In the field, the secret of

blind intubation is perfect positioning and gentle patience. F. Only absolute contraindication is apnea. G. Should not be attempted in children under 8 years of age. Technique A. Choose correct ET tube size (usually 7 mm tube in adult). Limitation is nasal canal

diameter. B. Position patient with head in midline, neutral position (cervical collar may be in place, or

assistant may provide cervical stabilization in trauma patients). C. Administer neosynephrine nasal drops in both nostrils. D. Assist ventilations prior to procedure if spontaneous respirations are inadequate. E. Lubricate ET tube with xylocaine jelly or other water-soluble lubricant. F. With gentle steady pressure, advance the tube through the nose to the posterior

pharynx. Use right nostril if possible. Abandon procedure if significant resistance is encountered.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: NASOTRACHEAL INTUBATION


G. Keeping the curve of the tube exactly in midline, continue advancing slowly. H. There will be a slight resistance just before entering trachea. Wait for an inspiratory

effort before final advance into trachea. Patient may also cough or buck just before breath.

I. Continue advancing until air is exchanging through the tube. If using a BAMB a whistle

sound will be heard on exhalation, verifying tracheal placement. J. Advance about 1 inch further, then inflate cuff. K. Ventilate and auscultate chest and abdomen for proper tube placement. Use of ETCO2

will also confirm gas exchange in the lungs. L. Note proper tube position and secure. Complications Same as orotracheal intubation. In addition: A. Further craniofacial injury particularly in patients presenting with facial trauma. B. Nasal bleeding caused by tube trauma. C. Vomiting and aspiration in the patient with intact gag reflex.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: LARYNGEAL MASK AIRWAY


Procedure Protocol

LARYNGEAL MASK AIRWAY (LMA) INSERTION B/I/P

Introduction The laryngeal mask airway is an airway device composed of a cuffed mask at the end of a tube. The LMA is introduced into the oropharynx and advanced until resistance is felt. This positions the cuffed mask around the epiglottis and the glottis which are sealed when the mask is inflated. The LMA provides a more secure airway than a face mask. It allows insertion from most positions while the head and neck are in neutral position. The LMA can be used as a back-up airway device when endotracheal intubation cannot be achieved. The intubating LMA is an advanced laryngeal mask airway designed to facilitate tracheal intubation with an endotracheal tube.

Indications A. Inability to intubate patient who is in need of airway protection.

B. Difficulty with intubation when rapid control of the airway is essential, especially during rapid sequence induction (RSI).

C. May be particularly useful for patients with facial or cervical spine abnormalities.

Precautions A. Avoid contact with sharp or pointed objects at all times. This includes broken teeth or

dental work that may tear the cuffed mask. B. A bite block should be used with the LMA and kept in place until the device is removed.

C. The LMA is not considered a definitive airway but instead an adjunct for those patients in whom orotracheal intubation is not successful.

Technique A. Initiate airway control with primary methods: CPR, mouth-to-mask, or bag valve-mask

with oxygen.

B. Select the appropriate size LMA.

C. Examine the surface of the LMA for damage, including cuts, tears, or scratches. Examine the 15 mm connector to assure it fits tightly into the airway tube. Do not twist the connector as this may break the seal.

D. Carefully insert a syringe into the valve port and fully deflate the cuff so that the cuff walls are tightly flattened against each other. Examine the cuff walls to determine whether they remain tightly flattened.

E. Over inflate the cuff with air from provided syringe and look for signs of leaks.

F. Prior to insertion, deflate the cuff tightly so that it forms a “spoon” shape. This may be accomplished by pressing the aperture side down onto a flat surface or by using your fingers.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: LARYNGEAL MASK AIRWAY


G. Lubricate the posterior surface of the LMA with water-soluble lubricant just before insertion.

H. Insure oxygenation. Suction upper airway if needed.

I. In trauma patients, have assistant maintain neutral alignment of head and neck, avoiding hyperextension. In medical patients, simply position head in neutral or sniffing position to ease insertion.

J. Hold the airway tube like a pen with the mask facing forward and the black line oriented anteriorly toward the upper lip.

K. Carefully position the mask tip so it is flat against the hard palate just inside the mouth behind the upper incisors. Continue to slide the mask backwards following the natural curvature of the hard palate and the posterior pharyngeal wall until a resistance is met.

L. Inflate the cuff just enough to obtain a seal. Do not inflate the cuff more than the volumes indicated.

M. Before securing the LMA, insert a bite block.

Complications A. Aspiration is still possible due to regurgitation or vomiting.

B. May cause minor soft-tissue abrasions, gagging, coughing, or bronchospasm.

Special Notes A. LMAs other than the Fastrach may require digital manipulation in the oral cavity to assure

proper positioning.

B. A bite block can be fabricated from three or four 4x4 gauze pads tightly rolled and taped into a cylindrical pad. Do not use a standard oropharyngeal airway as a bite block.

C. LMAs are not tolerated in the patient with intact gag reflex. The device may need to be removed if the patient begins to wake.

D. The handle on the LMA- Fastrach may be used to facilitate a mask seal only after it is properly positioned with the cuff inflated.

LMA Size Selection

LMA Size Patient Size

1 upto5kg

2 10-20kg

3 30-50kg

4 50-70kg

5 70-100kg

6 over 100kg

Maximum Inflation Volumes

LMA Size Air Volume

1 4m1

2 lOmi

3 2Oml

4 3Oml

5 40m1

6 50m1

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: NEEDLE CRICOTHYROTOMY


Procedure Protocol

ADVANCED AIRWAY MANAGEMENT NEEDLE CRICOTHYROTOMY

P Introduction Needle cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances as defined below. The reason for performing needle cricothyrotomy must be documented and submitted for review to the agency physician advisor or his designee within 24 hours. Needle cricothyrotomy is to be performed only by those trained in the procedure. Indications A. Inability to establish airway by any other means. B. Acute upper airway obstruction that cannot be relieved by obstructed airway maneuvers. C. Upper airway trauma with inability to ventilate the patient with severe respiratory

insufficiency. Precautions A. Bleeding is always common, even with correct technique. It should stop once the airway

is successfully intubated. Straying from the midline is very dangerous and likely to cause major hemorrhage by injury to the carotid or jugular vessels.

B. Remember that the distance to the carina is very short. Care must be taken not to allow

the tube to slip into the right mainstem bronchus if using an endotracheal tube for passage through the cricothyroid space.

Technique A. Have suction supplies available and ready.

B. Using aseptic technique, cleanse the area.

C. Position the patient in a supine position, with in-line spinal immobilization if indicated.

D. Assure stable positioning of the neck region and hyperextend the neck. Secure the

larynx laterally between the thumb and forefinger. Find the cricothyroid ligament (in the midline between the thyroid cartilage and the cricoid cartilage). This is the puncture site.

E. If using the Rusch kit, firmly hold the device and puncture the cricothyroid ligament at a 90 degree angle.

F. After pucturing the cricothyroid ligament, check the entry of the needle into the trachea

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: NEEDLE CRICOTHYROTOMY


by aspirating air through the syringe. If air is present, the needle is within the trachea. Change the angle to 60 degrees and advance the device forward into the trachea to the level of the stopper.

G. Remove the stopper. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until the flange rests on the neck. Carefully remove the needle and the syringe. Confirm placement with chest rise and fall and end tidal CO2 capnoghraphy.

H. Secure catheter by best method available.

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: SURGICAL CRICOTHYROTOMY


Procedure Protocol

ADVANCED AIRWAY MANAGEMENT SURGICAL CRICOTHYROTOMY

P

Procedure allowed for only those agencies that have obtained the necessary waiver from the State of Colorado Board of Medical Examiners

Introduction Surgical cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances as defined below. The reason for performing surgical cricothyrotomy must be documented and submitted for review to the agency physician advisor or his designee within 24 hours. Surgical cricothyrotomy is to be performed only by those trained in the procedure. Indications A. Inability to establish airway by any other means. B. Acute upper airway obstruction that cannot be relieved by obstructed airway maneuvers. C. Upper airway trauma with inability to ventilate the patient with severe respiratory

insufficiency. Precautions A. Bleeding is always common, even with correct technique. It should stop once the airway

is successfully intubated. Straying from the midline is very dangerous and likely to cause major hemorrhage by injury to the carotid or jugular vessels.

B. Remember that the distance to the carina is very short. Care must be taken not to allow

the tube to slip into the right mainstem bronchus if using an endotracheal tube for passage through the cricothyroid space.

C. Surgical cricothyrotomy is contraindicated in children 8 years of age and younger

because of small cricothyroid space. Technique A. Have suction supplies available and ready. B. Locate the cricothyroid membrane utilizing landmarks C. Prep the area with antiseptic swab D. Make a 1” vertical incision thru the skin and subcutaneous tissue. E. Using blunt dissection technique expose the cricothyroid membrane this may be a

TFPD EMS PROTOCOLS AIRWAY MANAGEMENT: SURGICAL CRICOTHYROTOMY


bloody procedure F. Make a horizontal stabbing incision approx. 1” through this membrane

G. Using a gloved finger to maintain surgical opening insert a cuffed #6 endotracheal tube

into the trachea H. Inflate the endotracheal cuff with 5-10cc of air and ventilate I. If opening is difficult to maintain consider use of introducer (buggie) into tracheal opening

and then slide endotracheal tube over introducer J. Confirm placement with chest rise and fall and end tidal CO2 capnography K. Secure the tube

TFPD EMS PROTOCOLS PROCEDURES: VENTILATOR AIRWAY OPERATIONS


Procedure Protocol

VENTILATOR AIRWAY OPERATIONS P

Indications Management of ventilation of a patient during a prolong or interfacility transport of an intubated patient Technique A. Transport ventilator should be used only on direct verbal or written orders of medical

control or the primary care physician B. Transporting personnel should review the operation of the ventilator prior to the event C. All ventilator setting including respiratory rate mode of ventilation and tidal volumes

should be recorded prior to initiating transport D. Once in the transporting unit confirm adequate oxygen delivery to the ventilator E. Assess breath sounds to assess for possible tube dislodgment, confirm end tidal CO2

after transfer F. Frequently assess the patient’s respiratory status noting any decrease in oxygen

saturation or changes in tidal volume. G. If any significant change in patient condition including vital signs or oxygen saturation or

there is a concern of ventilator performance / alarms remove the ventilator from the endotracheal tube and use a bag valve device with 100% oxygen.

H. Note any changes in vent setting or patient condition on patient care report

TFPD EMS PROTOCOLS PROCEDURES: RAPID SEQUENCE INDUCTION INTUBATION


Procedure Protocol

RAPID SEQUENCE INDUCTION INTUBATION P

Adult/Pediatric Introduction Rapid Sequence Intubation is a technique that involves virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent for the purpose of endotracheal intubation. RSI provides optimal intubation conditions while minimizing the risk of aspiration of gastric contents. RSI is to be performed only by those trained in the procedure and with authorized medical direction. Indications A. To facilitate positive pressure ventilation.

B. The inability to maintain a patent airway due to secretions or neurologic failure.

C. Unconsciousness, intractable seizure or Trismus.

D. Glasgow Coma Scale of 8 or less.

E. Facial and/or neck burns associated with inhalation injuries and accompanied by stridor,

carbonaceous sputum or air hunger.

F. All other attempts at intubation have been tried and were unsuccessful

Precautions A. Remember that paralyzed patients lose all ability to regulate, or generate heat (keep

them warm!). B. In MVA’s, or in situations where you have major orthopedic injuries as well as airway

management problems, you should consider the use of Morphine Sulfate or Fentanyl. Remember that Succinylcholine and Vecuronium are paralytics, not pain medications.

C. Obtain Hx regarding allergies. Do not administer if a family Hx of Malignant

Hyperthermia is noted. D. Relative contraindications include concern that intubation or mask ventilation would be

unsuccessful; significant facial or laryngeal edema, trauma or distortion; or a spontaneously breathing patient who requires upper airway muscle tone and positioning (eg. Upper airway obstruction, epiglottitis).



Technique A. Preparation

1. Assess the patient for difficulty of intubation

2. Prepare all drugs and equipment

3. Ensure one or more patent IV lines. B. Preoxygenation

1. Preoxygenate the patient with 100% oxygen for 5 minutes C. Pretreatment

1. Increased ICP? If no, move on; if yes, consider Lidocaine ; 1-1.5 mg/kg up to 100 mg.

2. Bradycardia? If no, move on, if yes, consider Atropine in pediatric patients, 0.02

mg/kg, min dose to max 0.5 mg/kg. D. Paralysis (with sedation)

1. Administer Midazolam (Versed) 0.1 mg/kg IV or 1-2.5 mg increments , pediatric dose is 0.1 mg/kg to produce unconsciousness, and Etomidate 0.3mg/kg IV, immediately followed by Succinylcholine , 1-1.5mg/kgIV, pediatric dose is 2mg/kg.

2. Perform Sellick’s Maneuver as the patient loses consciousness to prevent

regurgitation.

3. Within 45 seconds of administration of Succinylcholine, the patient will be relaxed enough for intubation.

E. Placement

1. Perform orotracheal intubation under direct visualization and confirm placement (chest rise and fall, breath sounds, end tidal CO2).

F. Postintubation Management

1. Secure tube in place.

2. Initiate ventilation.

3. Monitor the patient continuously.

4. Continue with Midazolam 0.1 mg/kg IV or 1–2.5 mg increments q 30-60 min.



5. Maintain paralysis with Vecuronium (Norcuron) 0.01 – 0.05 mg/kg. IV q 30-60 min.

TFPD EMS PROTOCOLS PROCEDURES: BANDAGING


Procedure Protocol

BANDAGING B/I/P

Indications A. To stop external bleeding by application of direct and continuous pressure to wound site. B. To protect patient from contamination to lacerations, abrasions, burns. Precautions A. Use gloves. B. Although external skin wounds may be dramatic, they are rarely a high management

priority in the trauma victim. C. Do not use circumferential dressings around neck. Continued swelling may block airway. Equipment A. 1,000 ml normal saline for irrigation B. Dressings: 1. 4x4 inch sterile gauze material 2. Large absorbent sterile dressing material (Universal dressing) C. Bandages: 1. Self-adherent gauze materials (rolled) 2. Clean cloth or triangular bandages 3. Tape Technique A. Control hemorrhage with direct pressure, using sterile dressing. B. Assess patient fully and treat all injuries by priority once assessment is complete. C. Remove gross dirt and contamination from wound: Clothing (if easily removable), dirt,

gasoline, acids, or alkalis. Use copious irrigating saline or tap water for chemical contamination.

D. Evaluate wound for depth, presence of fracture in wound, foreign body, or evidence of

injury to deep structures. Note distal motor, sensory, and circulatory function prior to

TFPD EMS PROTOCOLS PROCEDURES: BANDAGING


applying dressings. E. Apply sterile dressing to wound surface. Touch outer side of dressing only. F. Wrap dressing with clean gauze or cloth bandages applied just tightly enough to hold

dressing securely (if no splint applied). G. Assess wound for evidence of continued bleeding. H. Check distal pulses, color, capillary refill, and sensation after bandage applied. I. Continue to apply direct hand pressure over dressing, or use air splint if bleeding not

controlled with bandage alone. Complications A. Loss of distal circulation from bandage applied too tightly around extremity; for this

reason, do not use elastic bandages or apply bandages too tightly. B. Airway obstruction due to tight neck bandages. C. Restriction of breathing from circumferential chest wound splinting. D. Continued bleeding no longer visible under dressings. (This is particularly common with

scalp wounds that continue to lose large amounts of unnoticed blood.) E. Inadequate hemostasis: some wounds require continuous direct manual pressure to

stop bleeding.

TFPD EMS PROTOCOLS PROCEDURES: CARDIOVERSION ALGORITHM


Procedure Protocol

CARDIOVERSION ALGORITHM (Patient is not in cardiac arrest)

P CONTACT BASE PHYSICIAN UNLESS TIME DELAY COMPROMISES PATIENT CARE Tachycardia With serious signs (list) and symptoms, hypotension, altered LOC, related to the tachycardia If ventricular rate is > 150 beats/min., prepare for IMMEDIATE CARDIOVERSION. May give brief trial of medications based on specific dysrhythmia algorithms. Immediate cardioversion is generally not needed for rates < 150 beats/min.

Check

• Ensure adequate oxygenation • Suction device

• IV line • Intubation equipment

Premedicate with diazepam/MS whenever possible (5-10 mg) or Midazolam (3-5 mg)

Synchronized cardioversion Rhythm Adult dose Pediatric dose (Successive shocks if (Successive shocks if no change in rhythm) no change in rhythm) VT 75j, 120j, 150j, 200j 0.5 j/kg, 1.0 j/kg, 1.5 j/kg, 2.0

j/kg PSVT 30j, 50j, 75j, 120j 0.5 j/kg, 1.5 j/kg, 2.0 j/kg Atrial fibrillation 30j, 50j, 75j, 120j 0.5 j/kg, 1.0 j/kg, 1.5 j/kg, 2.0 j/kg Atrial flutter 30j, 50j, 75j, 120j 0.5 j/kg, 1.0 j/kg, 1.5 j/kg, 2.0 j/kg Precautions A. Precautions for defibrillation apply. Protect rescuers! B. A patient who is talking to you is probably perfusing adequately. C. The “synch” button needs to be reselected after each attempt. D. If sinus rhythm is achieved, even transiently, with cardioversion, subsequent

cardioversion at a higher energy setting will be of no additional value. Leave the setting the same; consider correction of hypoxia, acidosis, etc. to hold the conversion.

E. If the patient is pulseless, begin CPR and treat as cardiac arrest, even if the electrical

rhythm appears organized.

TFPD EMS PROTOCOLS PROCEDURES: CARDIOVERSION ALGORITHM


F. Cardioversion is rarely indicated in children. G. People with chronic atrial fibrillation are very difficult to convert, and their atrial fibrillation

is not usually the cause of their decompensation. If you get a history of “irregular heartbeat,” look elsewhere for the problem.

H. Sinus tachycardia rarely exceeds 150 beats/min. in adults (220 beats/min. in children < 8

years old), and does not require cardioversion. Treat the underlying cause. I. IV diazepam may be used in conscious patients prior to cardioversion, but field

cardioversion is not usually indicated. Contact base. J. Do not be overly concerned about the dysrhythmias that normally occur in the few

minutes following successful cardioversion. These usually respond to time and adequate oxygenation, and should only be treated if they persist.

Technique A. Turn on defibrillator and select “synch” mode. B. Ensure that R waves are coinciding with the markers. C. Place electrodes as you would for defibrillation. Monitoring electrodes should already be

in place. D. Set energy level as dictated by protocol. E. Clear the patient. F. Depress the shock button and hold it there until the machine synchronizes and delivers

a shock. G. If synchronization fails, follow treatment algorithm. If a repeat attempt is required, you

will have to reselect the “synch” mode.

TFPD EMS PROTOCOLS PROCEDURES: DENTAL PROBLEMS


Procedure Protocol

DENTAL PROBLEMS FR/B/I/P

Indications Any type of tooth loss, chipped tooth or tooth avulsion Treatment A. Assess ABC’s B. Control bleeding with pressure (be careful not to occlude airway w/ too much gauze) C. Pain control protocol as needed D. Place tooth in milk or NS or in patient’s own mouth if no airway compromise (re-

implantation is possible within 4 hours if tooth is properly cared for) E. Contraindication: decayed tooth, infected tooth, abscessed, facial cellulites, impacted

tooth (wisdom), myocardial infarction.

TFPD EMS PROTOCOLS PROCEDURES: TRANSCUTANEOUS CARDIAC PACING


Procedure Protocol

TRANSCUTANEOUS CARDIAC PACING I/P

(Procedure does not appear in 2005-2006 AHA guidelines) Indications Use cardiac pacing only when there is insufficient cardiac rate to maintain adequate perfusion, and rate is unaffected by atropine and adequate oxygen and ventilation. A. Symptomatic bradyarrhythmias. B. Heart blocks with reduced cardiac output that are unresponsive to atropine (or are likely

to be). C. Patients who convert from a viable rhythm into asystole. Precautions A. Capture can be difficult in some patients. B. Patient may experience discomfort; consider Diazepam or Midazolam. C. Use the same precautions as with defibrillation. D. Patients in atrial fibrillation may require higher energy settings for capture than others. E. Proper electrode placement is important! The negative electrode (or anterior) should be

placed to the left of the sternum as close as possible to maximum cardiac impulse, while the positive electrode (or posterior) should be placed directly behind the anterior, to the left of the thoracic spinal column.

Technique A. Contact base for patient with symptomatic bradycardia. B. Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left posterior.

Consider analgesic or anti-anxiety agent. Remember: the Lifepak 12 cannot read rhythms in “pace” mode. Monitoring electrodes are necessary as well.

C. Turn pacer unit on. D. Select pacing rate at 80 beats per minute (BPM). E. Set initial current to 40 milliamps. Increase until capture is obtained. F. If there is capture, check for pulses (mechanical capture). G. Observe patient and ECG, obtaining rhythm strips as appropriate.

TFPD EMS PROTOCOLS PROCEDURES: TRANSCUTANEOUS CARDIAC PACING


H. Continue monitoring of the patient. Complications A. V-fib and V-tach are rare complications, but follow appropriate protocols if either occur. B. Pacing is rarely indicated in patients under the age of 12 years. C. Muscle tremors may complicate evaluation of pulses. D. Pacing may cause diaphragmatic stimulation. E. CPR is safe during pacing. A mild shock may be felt if direct active electrode contact is

made.

TFPD EMS PROTOCOLS PROCEDURES: DEFIBRILLATION


Procedure Protocol

DEFIBRILLATION I/P

Indications A. Ventricular fibrillation by monitor. B. Wide complex tachycardia in pulseless patient. Precautions A. Do not treat the monitor strip alone. Treat the patient! A patient who is talking is not in

ventricular fibrillation, whatever the monitor shows. CHECK MONITOR LEADS. Artifact can commonly simulate ventricular fibrillation.

B. Dry the chest wall if wet. Do not drip saline or electrode jelly across the chest. This

results in bridging, which conducts the current through the skin rather than through the heart.

C. Nitroglycerin paste, which is commonly used by cardiac patients, is flammable, and may

ignite if not wiped completely from the chest prior to paddle contact. Other transdermal patches should be removed.

D. Defibrillation should be accompanied by visible muscle contraction by patient. If this

does not occur, the paddles did not discharge; recheck equipment. E. Unsuccessful defibrillation is often due to hypoxia or acidosis. Careful attention to airway

management and proper CPR is important. F. Protect rescuers–“Clear” the area! Technique A. Determine unresponsiveness and pulselessness. B. Open airway, check for breathing, and initiate CPR. C. Maintain CPR with 1 or 2 rescuers. D. Second or third person should get monitor-defibrillator and turn it on. E. For pediatric patients up to about one year, use pedi pads. Place pads as indicated. F. Stop CPR and evaluate rhythm (5-10 second maximum). If ventricular fibrillation is

present, continue with protocol. Otherwise see Cardiac Arrest Protocol. G. If arrest is witnessed and defibrillator is available: shock at 200j ASAP.

TFPD EMS PROTOCOLS PROCEDURES: DEFIBRILLATION


H. If arrest in not witnessed; perform at least 2 minutes of CPR before defibrillation attempt. I. Check synchronizer switch “off.” J. Set joules and press shock. 1. Adult: 120 joules delivered energy. 2. Child: 2 joules/kg or 1 joule/pound. (See Infant and Child Resuscitation protocol for

the remainder of pediatric defibrillation protocol.) K. Check rhythm. If lethal rhythm is still present, continue CPR for 2 minutes.

L. Shock immediately at 200 joules.

M. Check rhythm. If lethal rhythm is still present, continue CPR for 2 minutes.

N. Shock immediately at 200 joules O. If organized rhythm appears, check pulse. P. If no pulse, resume CPR and continue with Cardiac Arrest Protocol. Complications A. Rescuer defibrillation may occur if you forget to clear the area or lean against metal

stretcher or patient during the procedure. Side Effects & Special Notes A. Defibrillation is not the only step in treating fibrillation due to traumatic hypovolemia.

CPR and fluid resuscitation should be started first. B. Defibrillation may not be successful in ventricular fibrillation due to hypothermia until the

core temperature is above 88°F. Attempt to defibrillate, but prolonged CPR during rewarming may be necessary before conversion is possible.

C. Knowledge of your defibrillator is important! Make sure your machine is maintained

regularly.

TFPD EMS PROTOCOLS PROCEDURES: AUTOMATIC EXTERNAL MANUAL DEFIBRILLATION


Procedure Protocol

USE OF AUTOMATIC EXTERNAL MANUAL DEFIBRILLATION

B/I/P Indications Ventricular Fibrillation Ventricular Tachycardia Precautions Confirm patient is pulseless and apneic Dry the chest, shave if necessary before pad placement. Check patient for nitroglycerin patches or paste. Technique A. Provide CPR until AED arrives. B. Minimize interruption in CPR (eg. to analyze rhythm, deliver shocks). Keep interruption

as short as possible. C. Turn power on (some AED’s automatically turn on)

D. Attach to patient

1. Select correct size pad per child vs. adult specifications

2. Open package and exposed adhesive surface

3. Attach pads to patient (upper right sternal border and cardiac apex)

4. Attach cables to AED if needed

E. Place in analyze mode if needed

1. Announce to bystanders/ team members “Analyzing Rhythm, Stand Clear”

2. Press analyze (some AED’s omit this control)

F. Press shock button

1. Announce “Shock is indicated, I am going to shock on 3 stand clear”

2. Verify no one is touching patient

TFPD EMS PROTOCOLS PROCEDURES: AUTOMATIC EXTERNAL MANUAL DEFIBRILLATION


3. Press shock button G. Repeat CPR and step 3 and 4 until VF/VT is no longer present. H. The rescuer should deliver one shock and then immediately resume CPR beginning with

chest compressions. I. After 5 cycles (about two minutes) of CPR, the AED should then analyze the rhythm and

deliver another single shock if indicated. The cycle is then repeated. J. The single rescuer with an AED should verify unresponsiveness,

1. open the airway

2. give two respirations

3. check the pulse

K. If a full cardiac arrest is confirmed, the rescuer should attach the AED and proceed with

the algorithm. L. If “no shock indicated” appears, check pulse, repeat 1 minute of CPR, and then

reanalyze. After three “no shock indicated” messages are received, repeat analyze period every 1-2 minutes.

M. Pulse check is not required after shocks, 1, 2, 4, and 5 unless the “no shock indicated”

message appears. N. If ventricular fibrillation recurs after transiently converting (rather than persists without

ever converting), restart the treatment algorithm from the top.

TFPD EMS PROTOCOLS PROCEDURES: VENOUS ACCESS TECHNIQUE


Procedure Protocol

VENOUS ACCESS TECHNIQUE B(IV)/I/P

GENERAL PRINCIPLES Indications A. Administer fluids for volume expansion. B. Administer drugs. Precautions A. Do not start IVs distal to a fracture site or through skin damage with more than erythema

or superficial abrasion. B. Due to the uncontrolled environment in which prehospital IVs are started, take extra care

to use sterile technique. C. Due to the high complication rate associated with prehospital IV therapy, use good

judgment when deciding which patients should receive an IV. Technique A. Connect tubing to IV solution bag. B. Fill drip chamber one-half full by squeezing. C. Prepare tape or catheter adhesive dressing to secure catheter. D. Wear exam gloves E. For pediatric patients consider applying an arm board or splint prior to venipuncture. F. Scrub insertion site with alcohol or iodine pads. G. Don't palpate, unless necessary, after prep. H. Perform venipuncture or enter bone marrow as described in the specific techniques

described in this protocol. I. After the catheter is in place, remove the surgical or stylet and connect tubing. J. Open full to check flow and placement, then slow to TKO rate unless otherwise indicated

or ordered.

TFPD EMS PROTOCOLS PROCEDURES: VENOUS ACCESS TECHNIQUE


K. Secure tubing with tape, making sure of at least one 180-degree turn in the tubing when taping to be sure any traction on the tubing is not transmitted to the cannula itself.

L. Anchor with arm board or splint as needed to minimize chance of losing line with

movement. Consider coban wrap in combative patient. M. Recheck to be sure IV rate is as desired. Complications A. Febrile reactions due to contaminated fluids become evident in about 30 min after

starting the IV. Patient will develop fever, chills, nausea, vomiting, headache, backache, or general malaise. If observed, stop and remove IV immediately. Save the solution so it may be cultured.

B. Local: Hematoma formation, infection, thrombosis, phlebitis. Note: the incidence of

phlebitis is particularly high in the leg. Avoid use of lower extremity if possible. C. Systemic: Sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from

solution in IV. Side Effects & Special Notes A. Antecubital veins are useful access sites for patients in shock, but if possible, avoid

areas near joints (or splint well!). B. The point between the junction of two veins is more stable and often easier to use. C. Start distally, and if successive attempts are necessary, you will be able to make more

proximal attempts on the same vein without extravasating IV fluid. D. Venipuncture itself is seldom morbid; however, the excess fluids inadvertently run in

when nobody is watching can be fatal! E. The most difficult problem with IV insertion is knowing when to try and when to stop

trying. Valuable time is often wasted attempting IVs when a critical patient requires blood. IV solutions may “buy time,” but they frequently loose time instead. If the patient is CRITICAL, IV MAY BE STARTED AT SCENE, BUT UNNECESSARY DELAY FOR REPEATED ATTEMPTS IS NOT APPROPRIATE AND IV SHOULD BE DONE IN ROUTE.

F. For the purpose of this protocol, peripheral IV will be defined as an extremity vein.

TFPD EMS PROTOCOLS PROCEDURES: BUFF CAP


Procedure Protocol

BUFF CAP (OR EXTENSION SET) B(IV)/I/P

Indications A. Prophylactic IV access. B. Drug administration. Precautions A. Consider the patient, and whether a running IV or a buff cap is needed. B. For any buff cap established in the prehospital setting, the attendant is responsible for

showing the buff cap to the receiving nurse. Technique A. Assemble the necessary equipment. B. Proceed with the technique for extremity IVs. C. Remove the needle from the catheter and insert the extension set. D. Flush the extension set with 2-5 ml of sodium chloride. Contraindications A. Any catheter placed in the external jugular vein. B. Any patient who is in need of fluid or is hypotensive. C. The cardiac arrest patient.

TFPD EMS PROTOCOLS PROCEDURES: EXTERNAL JUGULAR VEIN


Procedure Protocol

EXTERNAL JUGULAR VEIN (I/P)

Indications Inability to secure extremity IV access. Technique A. Position the patient: Supine, head down (this may not be necessary or desirable if

congestive heart failure or respiratory distress present). Turn patient’s head opposite side of procedure.

B. Align the cannula in the direction of the vein, with the point aimed toward the ipsilateral

shoulder (on the same side). C. “Tourniquet” the vein lightly with one finger above the clavicle and apply traction to the

skin above the angle of the jaw. D. Make puncture midway between the angle of the jaw and the midclavicular line,

“tourniqueting” the vein lightly with one finger above the clavicle. E. Puncture the skin with the bevel of the needle upward; enter the vein either from the side

or from above. F. Note blood return and advance the catheter over the needle and remove tourniqueting

finger. EXTREMITY Technique A. Apply tourniquet proximal to proposed site to venous return only. B. Hold vein in place by applying gentle traction on vein distal to point of entry. C. Puncture the skin (with the bevel of the needle upward) about 0.5 to 1 cm from the vein

and enter the vein either from the side or from above. D. Note blood return and advance the catheter over the needle and remove tourniquet. E. Connect tubing, continue as above.

TFPD EMS PROTOCOLS PROCEDURES: INJECTIONS (SUBCUTANEOUS/INTRAMUSCULAR)


Procedure Protocol

INJECTIONS – SUBCUTANEOUS/INTRAMUSCULAR I/P

Indications When medication administration is necessary and the medication must be given SQ or IM route or as an alternative route in selected medications Precautions Know what medication routes are available to each medication you may intend to administer. Technique

A. Confirm medication order and or perform according to protocols.

B. Prepare equipment and medication, expelling air from syringe.

C. Explain procedure to patient and reconfirm patient allergies.

D. The most common site for subcutaneous injections is the arm. Injection volume should not exceed 1cc.

E. The possible injections sites for intramuscular injections include the arm, the buttock

and the thigh. Injection volume should not exceed 1cc in the arm or 2cc in the thigh or buttock.

F. The thigh should be used for pediatric patents, and injection volumes should not

exceed 1cc.

G. Expose the selected area and cleanse the site with alcohol.

H. Insert the needle into the skin with a smooth steady motion: 1. Subcutaneous: 45° angle with skin pinched 2. Intramuscular: 90° angle with skin flattened

I. Aspirate for blood to ensure there is no venous access.

J. Inject the medication.

K. Withdrawal the needle quickly and dispose of properly.

L. Apply pressure to site.

M. Monitor patient for desired therapeutic effect as well as possible side effects.

N. Document medication, dose, route and time on the PCR.

TFPD EMS PROTOCOLS PROCEDURES: INJECTIONS (INTRAOSSEOUS)


Procedure Protocol

INTRAOSSEOUS PLACEMENT & INFUSION I/P

Indications Clinical states that require immediate IV access, (i.e., cardiac arrest, shock, widespread burns, massive trauma, infants/children/adults) when common venous cannulation is not successful within 3-5 minutes of first attempt. Intraosseous infusion is only indicated when all of the following criteria are met: A. There is confirmed existence of shock, cardiac arrest, or unresponsive with

unstable/unacceptable vital signs. B. Two peripheral IV attempts have been unsuccessful. Equipment A. Equipment needed for manual IO:

1. 1-Jamshidi disposable intraosseous needle 2. 1-3-way valve

3. 1- extension set

4. Buretrol set

5. Betadine wipes

6. 10cc syringe

B. BIG (bone injection gun)

1. Usage per manufacturer guidelines Procedure A. Gather and set up equipment before the skin is penetrated. B. Place leg in a semi-externally rotated position. C. Select site.

1. FIRST AND SECOND CHOICES are the tibias. THIRD AND FOURTH CHOICES are the femur: proximal to the patella approximately two finger breadths. Iliac sites are available, but access is difficult.



2. Avoid using a leg that has been badly traumatized, burned, or obviously infected.

D. Palpate the tibial tuberosity and locate site 1-3cm (2 finger-breadths) below and medially

to the tibial tuberosity on the anteromedial flat surface. E. Using aseptic technique, prep area well with Betadine swabs and blot dry with sterile 4x4

gauze pad. F. Manual Needle Insertion.

1. Hold leg with non-dominant hand. 2. Grasp needle with dominant hand (with stylet in place), holding at 90 degree angle to

the bone or slightly caudally (toward the toes) to avoid the epiphysial plate. 3. Using a firm twisting motion, pass the needle through the skin and cortex of the bone

until an obvious “pop” or give is felt. A child of less than 4 years will require a penetration depth of 2-4cm.

4. Withdraw stylet. 5. Attach 10cc syringe filled with saline and aspirate just enough bone marrow to confirm

placement. Aspirate no more than 1cc of marrow. In some circumstances, one may only get enough marrow to fill the hub of the syringe or none at all. Infuse saline by syringe to ensure placement and to clear clots.

6. Connect extension set and three way prior to buretrol set. Open wide to assure

patency, adjust to prescribed rate. In the event that the intraosseous (I/O) will not run freely, consider the following options:

a. Using 10cc syringe and 18g needle attempt to flush I/O via IV tubing medport. Ability to flush easily denotes correct placement of I/O. Reattempt to run I/O by gravity. In event that the I/O will not run by gravity, in the presence of patency, consider repeat boluses, consider pressure bag (or BP Cuff). b. If the I/O does not flush freely on initial attempt consider improper placement.

Remove I/O and reattempt in other leg.

7. Adjust flange of Jamshidi needle by screwing it down until the hub is flush with the skin. The needle will feel firmly fixed by the bone.

8. Dress site with splint ,2x2 ,and IV tape. 9. Use bulky dressing and tape to protect Jamshidi as situation dictates.

G. BIG (Bone Injection Gun) Needle Insertion

1. Place appropriate end of gun at 90° to tibia tuberosity. Be very sure of needle



placement prior to placement.

2. Remove safety from gun.

3. Maintain pressure against tibia while squeezing double trigger into the palm.

4. Once gun has gone off and needle is in place, use safety to stabilize needle at its base, then tape down.

5. Follow procedure #4 through #9 above.

6. Remove needle when satisfactory alternative vascular access is available. Local pressure should be applied to the site once the needle has been removed.

Complications Although rare, the following are potential complications: A. IMMEDIATE

1. Compartment syndrome with improper placement.

2. Subperiosteal infusion with improper placement.

3. Slow infusion secondary to clotting of marrow in the needle.

4. Bone fracture.

B. DELAYED

1. Sepsis. 2. Fat embolism. 3. Osteomyelitis (0.5% incidence) occurs in septic patients, use of intraosseous lines

beyond 24 hours, and infusion of hypertonic solutions (i.e., Sodium Bicarbonate). 4. Needle broken off in the bone (one reported case; needle left in bone without

subsequent complications). 5. Growth plate and marrow damage from intraosseous infusions are possible, but

largely unstudied.

TFPD EMS PROTOCOLS PROCEDURES: FIELD DRAWN


Procedure Protocol

FIELD DRAWN BLOOD SAMPLES B/I/P

Indications A. Any medical patient receiving an IV in the field. B. Diabetic patients prior to receiving IV dextrose in the field; BGL should also be done. C. Patients that may have been exposed to carbon monoxide. D. Cardiac patients. Precautions A. Proper identification of the patient and of the specimens is mandatory. Mislabeling may

result in the death of the patient. B. Improper technique in obtaining the specimen will result in inaccurate or invalid

test results. This wastes critical time and defeats the purpose of drawing specimens in the field.

Technique A. After initiating an IV and removing the needle, attach the Vacutainer holder to the hub of

the IV catheter. (This is accomplished using the Luer adaptor attached to the Vacutainer holder.)

B. Fill all the desired blood tubes in appropriate order per system requirements. Red, green, blue, and purple. C. Tubes containing anticoagulant should be inverted gently back and forth at least 10

times to insure adequate mixing of blood with the substance in the tube. Do not shake the tube, as this could cause hemolysis, which could interfere with test results.

D. The tubes should be placed in a small biohazard bag. The bag should be labeled with

the patient’s name, date, and time. E. The blood tubes should be given to a nurse attending to the patient. Side Effects & Special Notes A. Any discrepancy in identification must be reported immediately to the receiving facility. B. The blue top tube must be filled to the line on the label.

TFPD EMS PROTOCOLS PROCEDURES: MEDICATION ADMINISTRATION


Procedure Protocol

MEDICATION ADMINISTRATION (PARENTERAL) I/P

Indications Illness or injury that requires medication to improve or maintain the patient’s condition. Precautions A. Wear gloves. B. Certain medications can be administered via one route only, others via several. If you

are uncertain about the drug you are giving—check with base. C. Make certain that the medication you want to give is the one in your hand. Always

double check medication ,dose, and expiration before administration. D. IM and SQ routes are unpredictable: Medications are absorbed erratically via these

routes and may not be absorbed at all if the patient is seriously ill and severely vasoconstricted. The IV route should be used almost exclusively in the field.

Technique A. Use syringe just large enough to hold appropriate quantity of medication (or use prefilled

syringe). B. Attach large gauge needle to syringe. C. Break ampule or cleanse multi-dose vial with alcohol (the latter is less desirable for field

use). D. Using sterile technique, draw medication into syringe. E. Change needles to small gauge for IM or SQ. Intranasal Technique A. Prepare medication for administration in a 1, 3 or 5cc syringe

B. Check medication in hand: confirm medication, dose, amount and expiration date.

C. Screw on atomizer cone to end of syringe

D. As needed, have patient clear any mucus from nostrils (ie blow their nose) for better

efficacy of medications

E. Position patient (ie. laying supine in sniffing position)

F. Insert atomizer cone into one nare and depress plunger for ½ the amount of medication



desired

G. Repeat above for other nare. H. Advise patient not to swallow though it’s not harmful if they accidentally do. For best

results, IN medications should be allowed to remain in contact with the cribiform plate for rapid blood-brain exchange.

I. Record medications - time, dose and amount. Intraosseous Technique A. Prepare medication to be administered. B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Inject into port on intraosseous line, or D. Remove needle from syringe and inject directly into intraosseous needle. E. Record medication given, dose, amount, and time. Intravenous Injection Technique A. Use needle appropriate for viscosity of fluid injected. Glucose requires larger gauge

needle; for most other medications, smaller is appropriate. B. Cleanse IV tubing injection site with alcohol. C. Check medication in hand. Confirm medication, dose, amount, and expiration date. D. Eject air from syringe. E. Insert needle into injection site. F. Pinch IV tubing closed between bag and needle. G. Inject at a rate appropriate for medication. H. Withdraw needle and release tubing to restore flow. I. Record medication given, dose, amount, and time. J. Give 20 cc saline fluid after giving any drugs.

Intramuscular Injection Technique A. Use needle appropriate for viscosity of fluid and insertion into tissue.

B. Clean injection site.



C. Check medications in hand. Confirm medication, dose, amount and expiration date. D. Draw up medications and void air from syringe. E. Quickly insert needle at a 90° angle to skin. F. Amounts over 1 ml can be uncomfortable at injection site. If injecting ≥ 2 ml, inject slowly

while withdrawing needle approximately ¼ inch until medication is gone. G. Record medication, dose, amount and time. Nebulization Technique A. Use hand-held nebulizer with mouthpiece (or mask for patient unable to hold

mouthpiece). B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Draw up dose of medication in syringe or dropper; inject into nebulizer. D. Attach to O2 tubing and set at 6-8 L/min (sufficient to produce good vaporization). E. Administer for approximately 5 minutes, until solution is gone from chamber. F. Record medication given, dose, amount, and time. Subcutaneous Injection Technique A. Use 25 g needle, 5/8” length for most subcutaneous injections. B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Select injection site (usually just distal and posterior to deltoid). D. Cleanse site. E. Eject air from syringe. F. Pinch skin. Insert needle at 45° angle with bevel up. G. Aspirate, and if there is no blood return, inject medication. H. Remove needle and put pressure over injection site with sterile swab. I. Record medication given, dose, amount, and time. Complications



A. Local extravasation during IV medication injection, particularly with dopamine or dextrose, may cause tissue necrosis. Watch carefully and be ready to stop injection immediately.

B. Allergic and anaphylactic reactions occur more rapidly with IV injections, but may occur

with medication administered by any route. C. Too rapid IV injection can cause untoward side effects (except for adenosine); for

example, diazepam can cause apnea, and epinephrine can cause asystole or severe hypertension.

D. IM or SQ injection causes uncertain medication levels over time. Later treatment may be

jeopardized because of slow release and late effects of medication given hours before. Side Effects & Special Notes A. Several medications are carried in different concentrations in an emergency medical kit.

Be sure you are using the correct concentration! B. Endotracheal medication administration provides onset of drug effect almost as rapidly

as with IV.

TFPD EMS PROTOCOLS PROCEDURES: NASOGASTRIC/OROGASTRIC TUBE PLACEMENT


Procedure Protocols

NASOGASTRIC/OROGASTRIC TUBE PLACEMENT P

Indications A. Provides for direct suction of gastric contents and decompression of the stomach in the

setting of bowel obstruction, pancreatitis or similar illnesses. This will provide symptomatic relief for the patient and decrease the frequency of vomiting and the chance for aspiration.

B. Decompress air from the stomach after intubation decreasing likelihood of vomiting and

increasing ventilator capacity. C. Provide a route of administration of oral medications (particularly activated charcoal) to

an obtunded patient. Precautions A. Placement of an NG or OG tube in the conscious patient may induce vomiting. B. Use of NG tubes is contraindicated in the patient with significant facial trauma as

inadvertent intracranial placement may occur. C. Inadvertent tracheal placement may cause pulmonary damage and may rupture the cuff

of an endotracheal tube. D. Administration of medication in an improeperly placed NG/OG tube may result in

aspiration pneumonia. E. Forceful placement may cause severe epistaxis. Technique A. Assess the need for the procedure. For a non-intubated patient contact medical control

for direct physician order. B. If possible sit the patient in an upright position. For the comatose patient flexion of the

neck facilitates passage of the tube into the esophagus. C. Select an appropriate size tube. For adults a 14F or 16F size tube is generally

appropriate for NG tube placement and a 16F or 18F for oral placement.

TFPD EMS PROTOCOLS PROCEDURES: PNEUMATIC ANTI-SHOCK GARMENT


Procedure Protocol

PNEUMATIC ANTI-SHOCK GARMENT (PASG) PROTOCOL

B/I/P Indications: The use of Pneumatic Anti-Shock Garment (PASG) has been studied and debated widely over the last few years. Differing opinions and unanswered question remain. The following list is based on recent information from the National Association of EMS Physicians following their review of all available literature. Any questions arising about appropriateness of PASG use should be discussed with medical control prior to application. CLASS I USUALLY INDICATED, USEFUL AND EFFECTIVE Hypotension due to ruptured AAA Confirmed pelvic fracture for stabilization and minimizing blood loss CLASS IIa ACCEPTABLE, UNCERTAIN EFFICACY, WEIGHT OF EVIDENCE FAVORS

USEFULNESS AND EFFICACY Hypotension due to suspected pelvic fracture Anaphylactic shock (unresponsive to standard therapy) Otherwise uncontrollable lower extremity hemorrhage Severe traumatic hypotension (palpable pulse, blood pressure unobtainable) CLASS IIb ACCEPTABLE, UNCERTAIN EFFICACY, MAY BE HELPFUL, PROBABLY

NOT HARMFUL History of CHF meeting other indication for use of PASG Elderly patient meeting other indications for use of PASG Penetrating abdominal trauma Paroxysmal supraventricular tachycardia Gynecologic hemorrhage otherwise uncontrollable Hypothermia-induced hypotension Pelvic fracture without hypotension Ruptured ectopic pregnancy] Septic shock Spinal shock Urologic hemorrhage otherwise uncontrolled Assist intravenous cannulation CLASS III INAPPROPRIATE OPTION, NOT INDICATED, MAY BE HARMFUL Adjunct to CPR Diaphragmatic rupture Penetrating thoracic injury Pulmonary edema As splint of lower extremities Abdominal evisceration Acute myocardial infarct Cardiac tamponade Cardiogenic shock Gravid uterus (pregnancy)



Precautions: A. Pulmonary edema, cardiogenic shock, ruptured diaphragm, and hemorrhage within the

chest cavity, are all considered absolute contraindications. B. Do not inflate abdominal compartment only. C. Do not deflate in field unless acute or exacerbated pulmonary edema. D. Consider base contact prior to inflation. E. Pressure in PASG changes with altitude, even a few hundred feet “matter.” Also, a rise

in temperature will cause a rise in pressure within the MAST pants. Technique: A. Utilize/place PASG in initial “packaging” of patient, do not increase scene time. Place

MAST pants with upper edge below patient’s bottom rib. B. Place PASG over bare skin, no clothing under garment. C. Perform brief physical exam of area to be covered by PASG, including distal PSM

(assess circulation, sensation, movement). D. Obtain baseline vitals and assess breath sounds. E. Secure the Velcro in all compartments and check tubing. The stopcocks to the legs

should be opened, while the stopcock to the abdominal compartment should be closed. Inflate the legs first, until the Velcro crackles.

F. If systolic BP remains below 90 mmHg, inflate the abdominal compartment. G. Record time of inflation. H. Recheck and record vital signs and PSM at 5 minute intervals. I. Monitor inflation pressure of PASG. Complications: A. Pulmonary edema, especially in the geriatric patients B. Respiratory compromise from abdominal section infringement on abdomen and

diaphragm C. Inability to examine area covered by PASG D. Vomiting, urination, or defecation due to pressure of abdominal section



E. Acidosis and circulatory compromise from long term inflation F. Inflation of PASG may cause/increase hemorrhage above the level of the suit and/or

increase intracranial bleeding/pressure. Special Note: Unless time delay compromises patient care, discuss the inflation of PASG with base station Physician prior to inflation.

TFPD EMS PROTOCOLS PROCEDURES: PHYSICAL RESTRAINTS


Procedure Protocol

PHYSICAL RESTRAINTS B/I/P

Indications A. Use of physical restraint on patients is permissible if the patient poses a danger to

himself or to others. Only reasonable force is allowable (i.e., the minimum amount of force necessary to control the patient and prevent harm to the patient or others). Contact base for physician direction if there is uncertainty as to whether or not the use of restraints is warranted to transport the unwilling or uncooperative patient.

B. RESTRAINTS ARE TO BE APPLIED TO PATIENTS ONLY IN LIMITED

CIRCUMSTANCES: 1. A patient whose medical or mental condition warrants immediate ambulance

transport and who is exhibiting behavior that the prehospital provider feels may or will endanger the patient or others.

2. The prehospital provider reasonably believes the patient’s life or health is in danger

and that delay in treatment and transport would further endanger the patient’s life or health, and there is no reasonable opportunity to obtain the necessary consent to provide treatment or obtain informed refusal.

3. The patient is being transported under the direction of a mental health hold or police

custody. Precautions A. Restraints shall be used only when necessary to prevent a patient from seriously injuring

himself or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done without restraints. They may not be used as punishment, or for the convenience of the crew.

B. Any attempt to restrain a patient involves risk to the patient and the prehospital provider.

Efforts to restrain a patient should only be done with adequate assistance present. C. Be sure to evaluate the patient adequately to determine the medical condition, mental

status and decisional capacity of the patient. The hostile, angry, unwilling patient with decision-making capacity may refuse treatment.

D. TYPE OF RESTRAINT: When possible, use a manufactured soft restraint designed for

this use. If another type is used be sure that it is applied in such a manor as not to create a tourniquet affect.

Technique



A. Determine that the patient's medical or mental condition warrants ambulance transport

to the hospital and that the patient lacks decision-making capacity, or there is basis for police custody or a mental health hold to be instituted.

B. Treat the patient with respect. Efforts to verbally calm the patient may avoid the need for

restraints. To the extent possible, explain what is being done and why. C. Have all equipment and personnel ready (restraints, suction, a means to promptly

remove restraints, and adequate number of personnel). D. Use assistance such that, if possible, one rescuer handles each limb and one manages

the head or supervises the application of restraints. E. Consider the patient’s strength and range of motion in the need for and method of

applying restraints. F. Apply restraints to the extent necessary to subdue the patient. Do not use restraints to

punish the patient. G. After application of restraints, check all limbs for circulation. During the time that a

patient is in restraints, an assessment of the patient’s condition and vital signs shall be made at least every five minutes, but more frequently if conditions warrant.

H. During transport and pending the arrival at the hospital, the patient shall be kept under

constant supervision. I. The run report shall include: description of the facts justifying use of restraints; the type

of restraints; a description of the steps taken to assure that the patient's needs, comfort and safety were properly cared for; the condition of the patient during restraint, including reevaluations during transport; and the condition of the patient on arrival at the hospital.

J. Removal of restraints should be done with sufficient manpower and caution for

protection of the patient and healthcare providers. K. Utilize police assistance if necessary and if possible. L. Handcuffs or other “hard restraints” are not to be applied by prehospital providers. If

police apply handcuffs, the officer should be requested to stay with the patient and ride in the ambulance during transport.

Complications A. Aspiration can occur, particularly if the patient is supine. It is the responsibility of the



attendant to continually monitor the patient’s airway. B. Nerve injury can result from hard restraints. C. Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia,

stroke, hyperthermia, hypothermia, or drug ingestion.

TFPD EMS PROTOCOLS PROCEDURES: CHEMICAL RESTRAINTS


Procedure Protocol

CHEMICAL RESTRAINTS I/P

Indications A. Use of chemical restraint on patients is permissible if the patient poses a danger to

himself or to others. Contact base for physician direction if there is uncertainty as to whether or not the use of chemical restraints is warranted to transport the unwilling or uncooperative patient

B. CHEMICAL RESTRAINTS ARE TO BE ADMINISTERED TO PATIENTS ONLY IN

LIMITED CIRCUMSTANCES: 1. A patient whose medical or mental condition warrants immediate ambulance

transport and who is exhibiting behavior that the prehospital provider feels may or will endanger the patient or others.

2. The prehospital provider reasonably believes the patient’s life or health is in danger

and that delay in treatment and transport would further endanger the patient’s life or health, and there is no reasonable opportunity to obtain the necessary consent to provide treatment or obtain informed refusal.

3. The patient is being transported under the direction of a mental health hold or police

custody. Precautions A. Chemical restraints shall be used only when necessary to prevent a patient from

seriously injuring himself or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done without restraints. They may not be used as punishment, or for the convenience of the crew.

B. Any attempt to restrain a patient involves risk to the patient and the prehospital provider.

Efforts to chemically restrain can provide a safer environment for providers and law enforcement.

C. Be sure to evaluate the patient adequately to determine the medical condition, mental

status and decisional capacity of the patient. The hostile, angry, unwilling patient with decision-making capacity may refuse treatment.

D. I: Appropriate sedating medications: WITH MEDICAL CONTROL

Haldol: 5 – 10mg. IV or IM Diazepam: 5 – 15mg. IV or IM P: Appropriate sedating medications: Versed: 0.1mg/kg or up to 5mg IV or IM

TFPD EMS PROTOCOLS PROCEDURES: CHEMICAL RESTRAINTS


Technique A. Determine that the patient's medical or mental condition warrants ambulance transport to

the hospital and that the patient lacks decision-making capacity, or there is basis for police custody or a mental health hold to be instituted.

B. Treat the patient with respect. Efforts to verbally calm the patient may avoid the need for

chemical restraints. To the extent possible, explain what is being done and why. C. Have all equipment and personnel ready (medication, suction, a means to promptly

reverse medication, and adequate number of personnel). D. Administer medication to the extent necessary to subdue the patient. E. During transport and pending the arrival at the hospital, the patient shall be kept under

constant supervision. An assessment of the patient’s condition and vital signs shall be made at least every five minutes, but more frequently if conditions warrant.

F. The run report shall include: description of the facts justifying use of chemical restraints. G. Utilize police assistance if necessary and if possible. H. Handcuffs or other “hard restraints” are not to be applied by prehospital providers. If

police apply handcuffs, the officer should be requested to stay with the patient and ride in the ambulance during transport.

Complications A. Aspiration can occur, particularly if the patient is supine. It is the responsibility of the

attendant to continually monitor the patient’s airway. B. Nerve injury can result from hard restraints. C. Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia,

stroke, hyperthermia, hypothermia, or drug ingestion.

TFPD EMS PROTOCOLS PROCEDURES: SPLINTING - AXIAL


Procedure Protocol

SPLINTING: AXIAL (BACKBOARDING) B/I/P

Indications A. Pain, swelling, or deformity of spine that may be due to fracture, dislocation, or

ligamentous instability. B. Neurologic deficit that might be due to spine injury. C. Prevention of neurologic deficit or further deficit in patients with suspected spine injury or

instability. D. In all trauma victims who are unconscious or with impaired consciousness due to head

injury or drug ingestion, to protect against damage or further damage in patients where injury to the spine cannot be ruled out by accurate exam or history.

Precautions A. All patients with significant head trauma should be immobilized because of the potential

for unrecognized coexistent neck trauma. B. If at all possible, perform and document complete neurological exam prior to movement.

Reassess and document after your splinting is complete. Cervical Splinting Technique A. Perform cervical splinting during or following initial assessment if indicated. Use

assistant to maintain cervical stabilization while completing assessment. B. Use two persons to apply splint if at all possible. C. Do not use force to straighten. Gently restore normal alignment. D. Advise patient of procedure and purpose before and during application. E. Immobilize the cervical spine with a semi-rigid collar of appropriate size for age. F. Pad behind head in adults to maintain an anatomically neutral position, generally 1 to 1.5

inches. G. Use long/short spine board or orthopedic scoop to support patient as situation dictates. H. Use tape, straps, or both to secure patient effectively and allow turning as a unit for

airway control. I. Continue to monitor airway and effectiveness of immobilization. Spine Immobilization Technique

TFPD EMS PROTOCOLS PROCEDURES: SPLINTING - AXIAL


A. Splint cervical spine following initial assessment. B. Complete focus physical and history and splint fractures prior to movement of patient

when possible. C. Document neurological findings. D. Use long back board for spine patients. 1. Logroll or lift patient as a unit to board. Apply continuous cervical stabilization during

movement. One person should protect neck in collar. Do not use force to straighten spine.

2. Place a towel 1” to 1 ½ ” under head for proper horizontal alignment. 3. Use padding as needed behind knees to support a neutral axis under small of back,

neck and knees. 4. Apply straps to secure chest, thighs, and lower legs and to allow turning as a unit in

case of vomiting or airway difficulty. 5. Use C-spine bags or towel rolls and tape to secure neck immobilization. E. Reassess patient status, particularly airway and neurologic findings. F. Monitor airway and neck immobilization. Complications A. Vomiting is common in head/spine injured patients. Splinting must be secure enough to

allow turning of the patient for airway protection. B. It is easy to miss injuries below the level of a neurological deficit. Look carefully for

abdominal and chest injuries, pelvis fractures, and extremity injuries without symptoms. With loss of sensation below T-8, there will be no guarding, rebound pain, or tenderness to clue you to internal abdominal injuries.

Side Effects & Special Notes Pelvis fractures are difficult to diagnose in the field. Suspected pelvis injury can be immobilized by use of the long board during spine immobilization or a large vacu-splint. MAST pants may also be considered.

TFPD EMS PROTOCOLS PROCEDURES: SPLINTING - EXTREMITY


Procedure Protocol

SPLINTING: EXTREMITY B/I/P

Indications A. Pain, swelling, or deformity in extremity that may be due to fracture or dislocation. B. In an unstable extremity injury: To reduce pain; limit bleeding at the site of injury; and

prevent further injury to soft tissues, blood vessels or nerves. Precautions A. Critically injured trauma victims should not be delayed in transport by lengthy evaluation

of possible noncritical extremity injuries. Prevention of further damage may be accomplished by securing the patient to a spine board when other injuries demand prompt hospital treatment.

B. The patient with altered level of consciousness from head injury or drug/alcohol

influences should be carefully examined and conservatively treated, because his ability to recognize pain and injury is impaired.

C. Make sure the obvious injury is also the only one. It is particularly easy to miss fractures

proximal to the most visible one. D. In a stable patient where no environmental hazard exists, splinting should be done prior

to moving the patient. Extremity Splinting Technique A. Check pulse and sensation distally prior to movement or splinting. B. Remove bracelets, watches, or other constricting bands prior to splint application. C. Identify and dress open wounds. Note wounds that contain exposed bone or lie near

fracture sites and may communicate with a fracture. D. To minimize pain and soft tissue damage, avoid sudden or unnecessary movement of

fracture site. E. Choose splint to immobilize joint above and below injury. Pad rigid splints to prevent

pressure injury to extremity. F. Apply gentle continuous stabilization to extremity and support to fracture site during

splinting operation. G. Reduce angulated fractures (if no pulses), including open fractures, with gentle axial

traction as needed to immobilize properly. H. Check distal pulses and sensation after reduction splinting. Remanipulate gently if



adequate circulation and sensation is lost. Traction Splinting Technique (for suspected femur fractures): A. Use two persons for splint application procedure. B. Remove sock and shoe and check for distal pulse and sensation (unless you cannot

protect exposed foot from weather; then just ask patient about sensation and observe movement).

C. Identify and dress open wounds, and note exposed bone or wounds overlying fractures

and potential communicating wounds. D. One EMT should hold manual traction. E. Measure splint length prior to application. Sager splint should be measured from the

groin to 4 inches below the heel, medially. F. Secure thigh strap. G. Wrap ankle harness above malleoli and secure it under heel. H. Maintain continuous traction and support to fracture site throughout procedure. I. Release lock and extend splint to achieve desired traction. Sagers typically provide relief

at 10% of patient body weight (not to exceed 15 pounds). J. Secure remaining straps. K. Secure injured leg to the other. L. Continue to recheck distal pulses and sensation. Complications A. Circulatory compromise from excessive constriction of limb. B. Continued bleeding not visible under splint. C. Pressure damage to skin and nerves from inadequate padding. D. Delayed treatment of life-threatening injuries due to prolonged splinting procedures. Side Effects & Special Notes



A. Traction splints should only be used if the leg can be straightened easily and patient is

comfortable with the traction device on. Particularly with injuries about the hip and knee, forced application of traction device can cause increased pain and damage. If this occurs, do not use traction device, but support in position of most comfort and best neurovascular status.

B. When in doubt and the patient is stable, splint. Do not be deceived by absence of

deformity or disability. Fractured limbs often retain some ability to function. C. Splinting body parts together can be a very effective way of immobilizing: arm-to-trunk or

leg-to-leg. Padding will increase comfort. This method can be very useful in children when traction devices and pre-made splints do not fit.

TFPD EMS PROTOCOLS PROCEDURES: SPLINTING – PELVIC FRACTURES


Procedure Protocol

SPLINTING: PELVIC FRACTURES B/I/P

Indications A. Pain, swelling, or deformity in pelvic girdle that may be due to fracture or dislocation. B. In an unstable pelvic injury: To reduce pain; limit bleeding at the site of injury; and

prevent further injury to soft tissues, blood vessels or nerves. Precautions A. Critically injured trauma victims should not be delayed in transport by lengthy evaluation

of possible noncritical pelvic injuries. B. The patient with altered level of consciousness from head injury or drug/alcohol

influences should be carefully examined and conservatively treated, because his ability to recognize pain and injury is impaired.

C. Make sure the obvious injury is also the only one. It is particularly easy to miss fractures

proximal to the most visible one. D. In a stable patient where no environmental hazard exists, splinting should be done prior

to moving the patient. Pelvic Splinting Technique A. Check pulse and sensation distally prior to movement or splinting. B. Identify and dress open wounds. Note wounds that contain exposed bone or lie near

fracture sites and may communicate with a fracture. C. To minimize pain and soft tissue damage, avoid sudden or unnecessary movement of

fracture site. D. Choose appropriate pelvic splint to immobilize injury.

1. SAM Sling: use as per manufacturers guidelines. 2. Sheet Wrap Technique 3. Long sleeve shirt wrap technique 4. Pneumatic Anti-Shock Garment

E. Apply gentle continuous stabilization and support to pelvis during splinting operation to

minimize bleeding and pain w/ movement. F. Check distal pulses and sensation after reduction splinting. Remanipulate gently if

adequate circulation and sensation is lost.

TFPD EMS PROTOCOLS PROCEDURES: SPLINTING – PELVIC FRACTURES


Complications A. Circulatory compromise from excessive constriction to limb. B. Possible continued bleeding into pelvic cavity. C. Pressure damage to skin and nerves from inadequate padding. D. Delayed treatment of life-threatening injuries due to prolonged splinting procedures. Side Effects & Special Notes A. When in doubt and the patient is stable, splint. Do not be deceived by absence of

deformity or disability.

TFPD EMS PROTOCOLS PROCEDURES: TENSION PNEUMOTHORAX


Procedure Protocol

TENSION PNEUMOTHORAX DECOMPRESSION I/P

Indications A. Tension pneumothorax is rare, but when present may rapidly lead to death and must be

treated promptly. B. Nontension pneumothorax (also known as closed or simple)is relatively common, is not

immediately life threatening, and should not be treated in the field. C. Treatment is not difficult, although complications of the procedure can be severe, but

diagnosis must be accurate and is not always easy. D. The following signs are significant. Signs of pneumothorax as well as signs of tension

must be present before treatment is undertaken: 1. Simple Pneumothorax: a. Respiratory distress—mild to severe. b. Chest pain. c. Decreased or absent breath sounds on affected side to auscultation of chest. d. Subcutaneous crepitation, and 2. Signs of Tension: a. Progressive respiratory distress (severe). b. “Drumlike” percussion note on affected side. c. Hyperexpanded chest on affected side. d. Tracheal shift away from affected side (an unreliable sign). e. Distended neck veins. f. Shock–low BP or narrowing pulse pressures – circulatory collaspe g. If patient is intubated, increasing difficulty in bagging. Precautions A. Accurate diagnosis is paramount. Note that simple pneumothorax has one set of signs

and tension pneumothorax has an additional set of signs.

TFPD EMS PROTOCOLS PROCEDURES: TENSION PNEUMOTHORAX


B. This is a rare condition, but can occur both with trauma and spontaneously. It can also occur as a complication of CPR.

Technique A. Contact base. B. Decompress using the following techniques: 1. Needle: a. Expose entire chest. Clean chest vigorously with alcohol, Betadine or soap. b. Locate the 3rd rib, mid-clavicular line on the affected side. Insert an angiocath

with a 10cc syringe attached (14g or larger in adult;18g in children). Strike the 3rd rib and slide the angiocath over the rib into the 2nd intercostal pleural space.An alternative site (if hemo/pneumo is suspected) is the fifth intercostal space, just over the sixth rib, in the midaxillary line.

c. If air is under tension, barrel will pull easily and “pop’’ out the back. Remove

syringe, advance catheter and remove needle. Complications Complications include: A. Creation of pneumothorax if none existed previously. B. Laceration of lung. C. Laceration of blood vessels: Slide above rib (intercostal vessels run in grove under each

rib). D. Severe pain: If you’re doing this in the field, patient should be sick enough not to require

anesthesia, but he’ll let you know when you go through pleura. Don't let that deter you - move briskly on.

E. Infection: Clean rapidly but vigorously. Use sterile gloves, if possible. Side Effects & Special Notes A. Sudden onset of chest pain and shortness of breath in a normal individual may also be

caused by a pneumothorax (particularly in patients with COPD or asthma). These can also progress to a “tension” state.

B. Tension pneumothorax can be precipitated by occlusion of an open chest wound with a

dressing. If, after dressing an open chest wound, the patient deteriorates, remove dressing.

TFPD EMS PROTOCOLS PROCEDURES: URINARY CATHERIZATION


Procedure Protocol

URINARY CATHETERIZATION (Foley) P

Indications: A. Only under direct medical control supervision.

B. Monitoring a patients fluid status and or response to therapy during transport

C. Collection of urine for laboratory analysis

D. Preparation for air transport of an unconscious patient Precautions: A. This procedure is contraindicated if trauma is suspected to the genitourinary region Procedures: A. Explain the procedure to the patient if conscious: maximize patient privacy.

B. Have a second crew member present if performing procedure on a member of the

opposite sex.

C. If there is any concern of traumatic injury to the genitourinary region DO NOT perform procedure.

D. Using a sterile technique open the catheter kit.

E. Test the balloon at the catheter tip.

F. Connect the catheter to the urinary collection system.

G. Don sterile gloves from the kit.

H. Use one hand to come in contact with the patient and the other to use items from the kit. Recall that once your hand comes in contact with the patient it is no longer sterile and CANNOT be use to obtain items from the kit

I. Using the Betadine swabs from the kit thoroughly cleanse the area around the uretha.

1. For males, this will require contracting the foreskin if uncircumcised and cleansing the glands for all males.

2. For females, this will require retracting of the labia majora. And cleasing the area around the urethra.

J. Once the patient has been cleansed place sterile sheets.

K. Lubricate the distal tip of the sterile catheter

TFPD EMS PROTOCOLS PROCEDURES: URINARY CATHERIZATION


L. While retracting the skin (foreskin / labia) visualize the urethral opening. Gently guide the catheter through the external opening of the urethra. Advance the catheter slowly until there is a return of urine. Do not force the catheter through any resistance it may meet. If resistance is encountered, withdrawal the catheter slightly and gently redirect the catheter.

M. Once the urine is returned, gently inflate the balloon and tape catheter to leg, secure the

urine collection device. N. Replace the foreskin of uncircumcised males.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: AED – SCENE COORDINATION

January 1, 2008 VIII - 1

Operational Guidelines

AUTOMATED EXTERNAL DEFIBRILLATOR (AED): COORDINATION OF ALS-TRAINED PROVIDERS

WITH AED AGENCY AT A SCENE General Principles With the increasing availability of AEDs, ALS-trained emergency personnel will interact more often with BLS agencies using an AED. The following are guidelines for the interface between an ALS-trained provider and an agency approved for and using an AED in a resuscitation situation: A. The agency responding to the emergency call and the medic-in-charge are operating under

the medical direction of a Colorado Physician, and as such, are responsible and accountable for the care of that patient. ALS-trained personnel outside of that agency may offer to assist with the resuscitation. The medic-in-charge is responsible to accept or reject the offer and to determine where assistance is needed. NOTE: The ALS-trained Good Samaritan may assist with patient care without “taking charge” of the situation or the patient.

B. The Good Samaritan should consider the following: 1. The medic-in-charge is skilled at defibrillation through the AED and should continue. 2. The Good Samaritan’s skills at assessment, airway management, or IV/meds may be

needed. 3. The Good Samaritan’s skills may be needed in dealing with family and bystanders or in

communications with the base hospital. 4. If the medic-in-charge gives charge of the patient to the Good Samaritan, the Good

Samaritan then gives up the Good Samaritan designation, is responsible for and accountable for patient care, and must accompany the patient to the hospital.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: CONFIDENTIALITY



CONFIDENTIALITY General Principles A. Colorado law does not recognize the relationship of EMT to patient as privileged. The patient-

physician relationship and the patient-registered nurse relationship are recognized as privileged. This means that the physician or nurse may not testify as to confidential communications unless:

1. The patient consents; or 2. The disclosure is allowable by law (such as Medical Board or Nursing Board proceedings,

or civil litigation in which the patient’s medical condition is in issue). B. Nonetheless, the patient’s medical information should be kept confidential by the prehospital

provider as private information in medical care. The patient likely has a reasonable expectation of privacy and trust that personal, medical information will not be disclosed by medical personnel to any person not directly involved in the patient’s medical treatment.

Exceptions A. The patient is not entitled to confidentiality of information that does not pertain to the medical

treatment, medical condition, or is unnecessary for diagnosis or treatment. B. The patient is not entitled to confidentiality for disclosures made publicly. C. The patient is not entitled to confidentiality with regard to evidence of a crime. Additional Considerations A. Any disclosure of medical information should not be made or allowed unless necessary for the

treatment, evaluation or diagnosis of the patient. B. Any disclosures made by any person, medical personnel, the patient, or law enforcement

should be treated as limited disclosures and not authorizing further disclosures to any other person.

C. Any discussions of prehospital care by and between the receiving hospital, the crew members

in attendance, or at in services or audits are done strictly for educational purposes. Further disclosures are not authorized.

D. Radio communications should not include disclosure of patient names.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: CONSENT



CONSENT General Principles: Adults A. An adult in the State of Colorado is 18 years of age or older. B. Every adult is presumed capable of making medical treatment decisions. This includes the

right to make “bad” decisions which the prehospital provider believes are not in the best interests of the patient.

C. A person is deemed to have decision-making capacity if he/she has the ability to provide

informed consent, i.e., the patient: 1. Understands the nature of the illness/injury or risk of injury/illness; 2. Understands the possible consequences of delaying treatment/refusing transport; and 3. Given the risks and options, the patient voluntarily refuses or accepts treatment/transport. D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse

medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible.

E. Implied Consent: An unconscious adult is presumed to consent to treatment for life-

threatening injuries/illnesses. F. Involuntary Consent: In rare circumstances, consent may be authorized by a person other

than the patient (such as a court order [guardianship], from a peace officer for prisoners in custody or detention, and persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled).

Procedure: Adults A. Consent may be inferred by the patient’s actions or by express statements. If you are not sure

that you have consent, clarify with the patient or contact base. This may include consent for treatment decisions or transport/destination decisions.

B. Determining whether or not a patient has decision-making capacity to consent or refuse

medical treatment in the prehospital setting can be very difficult. Efforts should include establishing that the patient:

1. Understands the nature of the illness/injury or risk of injury/illness; 2. Understands the possible consequences of refusing treatment/refusing transport; and 3. Given the risks and options, the patient voluntarily refuses treatment/transport.



C. For patients who do not have decision-making capacity, contact base. D. If the patient lacks decision-making capacity and the patient’s life or health is in danger, and

there is no reasonable ability to obtain the patient’s consent, proceed with transport and treatment of life-threatening injuries/illnesses. If you are not sure how to proceed, contact base.

E. For patients who refuse medical treatment, see Non-Transport of Patients protocol. F. If you are unsure whether or not a situation of involuntary consent applies, contact base. General Principles: Minors A. A parent, including a parent who is a minor, may consent to medical or emergency treatment

of his/her child. There are exceptions: 1. Neither the child nor the parent may refuse medical treatment on religious grounds if the

child is in imminent danger as a result of the lack of medical treatment, or when the child is in a life-threatening situation, or when the condition will result in serious handicap or disability.

2. The consent of a parent is not necessary to authorize hospital or emergency health care

when an EMT-P in good faith relies on a minor’s consent, if the minor is 15-17 years of age and emancipated or married.

3. Minors may seek treatment for abortion, drug addiction, and venereal disease without

consent of parents. B. When in doubt, your actions should be guided by what is in the minor’s best interests and

base contact. Procedure: Minors A. A parent or legal guardian may provide consent to or refuse treatment in a nonlife-threatening

situation. B. When the parent is not present to consent or refuse: 1. If a minor has an injury or illness, but not a life-threatening medical emergency, you may

attempt to contact the parent(s) or legal guardian. If this can not be done promptly, transport.

2. If there is some reason to believe the child does not need transport and can be left at the

scene in the custody of a responsible adult, (i.e., teacher, social worker, grandparent), contact base. Report on condition of patient and scene situation. It should only be in very rare circumstances that a child of any age be left at the scene if the parent is not also present.



3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the

parent objects to treatment, contact base immediately and treat to the extent allowable, and notify police to respond and assist.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: CPR DIRECTIVE



CPR DIRECTIVE PROTOCOL B/I/P

General Principles A. This protocol is for the prehospital management of the statutory “CPR Directive,” which refers

to a specifically identifiable, numbered form that is printed on security paper. The form must be signed by the patient or the patient’s authorized agent. The patient must be 18 years of age or older, and have decision-making capacity. The form must also be signed by the patient’s attending physician (sample form attached).

B. In addition to the written CPR Directive form, the patient or authorized agent may obtain a

CPR Directive necklace or bracelet to be worn by the patient. This bracelet or necklace will have imprinted on it the identical number as the form.

C. CPR shall be withheld in the event: 1. The original “CPR Directive” form, necklace, or bracelet is readily accessible (i.e., on or

immediately present); and 2. The patient is in cardiac or pulmonary arrest or malfunction (i.e., agonal, non-perfusing

rate or rhythm). D. A CPR directive may be implemented for a minor only after a physician issues a “Do Not

Resuscitate” order and the parents of the minor (if married and living together), custodial parent, or legal guardian execute(s) a CPR Directive for the minor.

Procedure Upon finding a patient with a CPR Directive (form, bracelet, or necklace): A. Perform initial patient assessment and determine if patient is in cardiac arrest. B. The EMT-P or EMT-I (if present) should also verify with a cardiac monitor, in at least two

leads, that the patient is in cardiac arrest. C. Verify that the CPR Directive form is the original (it should be light blue color below the title

portion of document) and is unaltered (not defaced or altered physically in some way), or is the Colorado CPR directive bracelet or necklace.

D. Verify that the information on the form or, if present, on the back of necklace or bracelet,

reasonably appears to be appropriate for the patient (look at race, sex, date of birth, eye and hair color). If possible, try to verify identity of patient by an additional source (e.g., family member identification, driver’s license, or other readily available source).

E. If the CPR Directive has been verified, then CPR shall be withheld. If CPR has been started, it

shall be stopped.



F. If there is any question or uncertainty, or verification cannot be accomplished for any reason,

then initiate full resuscitation measures, and contact the base for guidance. Be sure to inform the base of the CPR Directive form, bracelet, or necklace, and the condition and history of the patient.

G. Complete documentation, including attaching a copy of monitor strips on each copy of the run

report (EMT-P or EMT-I), in addition to information noted in section L below. H. Provide appropriate emotional support to family if possible. I. If the death occurs outside of a health care facility, then the coroner is to be immediately

contacted. J. The following resuscitation measures are to be withdrawn or withheld from a person who has

a valid CPR Directive: 1. CPR 2. Endotracheal intubation or other advanced airway management. 3. Artificial ventilation. 4. Defibrillation. 5. Cardiac resuscitation measures. K. The following interventions may be administered or provided: 1. Assist in maintenance of airway (non-advanced airway management). 2. Suctioning. 3. Oxygen. 4. Pain medication (per protocol for EMT-P). 5. Control bleeding. L. The following information must be documented by the prehospital provider on the run report

(in addition to management of call or treatment rendered prior to cardiac arrest): 1. Patient's status (e.g. condition found, medical history obtained). 2. Type of “CPR Directive” found (document, bracelet or necklace). 3. CPR Directive number.



4. Name of attending physician, if known. 5. Any variance in protocol that warranted initiating resuscitation despite the presence or

presentation of the CPR Directive. 6. ECG status in at least two leads (EMT-P and EMT-I). Additional Considerations A. The patient may revoke the CPR Directive at any time by oral expression of revocation or by

destruction of the CPR Directive form, bracelet or necklace. If the CPR Directive was executed by a guardian, agent or proxy decision-maker, then the CPR Directive may be revoked by the guardian, agent or proxy decision-maker.

B. CPR is to be initiated if the original CPR Directive form, necklace or bracelet is not readily

available, (i.e., physically present with or being worn by the patient). Note that the bracelet or necklace may not be obtained without the form being executed; however, removal of the bracelet or necklace may be construed as revocation. Therefore, if the bracelet or necklace is readily accessible but not on the patient, any question as to whether or not the Directive has been revoked should result in resuscitation until the situation is clarified. Consult with base if you have questions about terminating CPR and transport.

C. In the absence of the existence of a CPR Directive, a person’s consent to CPR shall be

presumed. However, this statutorily authorized form is only one manner for a patient to document resuscitation preferences. Other "Do Not Resuscitate" forms and advance directives may be honored but base contact is required (see Field Pronouncements protocol).

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: RESUSCITATION



RESUSCITATION AND FIELD PRONOUNCEMENT GUIDELINES

Purpose To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting. General Principles A. Agency policy determines base contact requirement for patients for whom resuscitative

efforts are being withheld. B. All patients found pulseless and apneic are to be resuscitated, except patients found in any of

the following conditions: 1. Decapitation; or 2. Decomposition; or 3. Third degree burns over more than 90% of the total body surface area; or 4. Dependent lividity or rigor mortis; or 5. A valid CPR directive present with the patient (see CPR Directive protocol); or 6. Signs of massive blunt trauma or head trauma. Special Considerations in Resuscitation Decisions: All cases described below require contact with a base physician to approve termination of treatment. A. Blunt Trauma: Resuscitative efforts may be withheld or terminated in patients found apneic

and pulseless with: 1. Blunt trauma to the head, neck or torso; and 2. No spontaneous pulse or respirations following appropriate medical interventions, which

include, for example: ensuring a patent airway or chest decompression. (The majority of injuries sustained by these patients are not compatible with life. “Appropriate” interventions will vary and should be dictated by guidance from the base.)

B. Penetrating Trauma: 1. Research data shows that a significant number of victims of penetrating trauma to the

neck or torso, who are found without signs of life, may be successfully resuscitated.



Therefore, resuscitation and rapid transport to a trauma facility should be initiated on all

patients found in full arrest secondary to penetrating trauma. Exceptions may exist in the following circumstance:

a. Patients found pulseless and apneic with penetrating trauma if the provision of ALS

(EMT-Intermediate or EMT-Paramedic or emergency department) has been unavailable for at least 20 minutes from the time EMS personnel initiate on-scene assessment. (Some of the injuries sustained by these patients may be compatible with life. “Appropriate” interventions will vary and should be dictated by guidance from the base physician.)

b. However, if there is any doubt about duration of the arrest, then resuscitation

and rapid transport should be initiated. C. Medical Patients (i.e., no evidence of trauma and presumed medical arrest) should receive

resuscitative treatment until there is: 1. No return of spontaneous pulse or respirations during 30 minutes of CPR (after successful

intubation and medications) and no reversible causes have been identified; or 2. Continuous asystole for at least 10 minutes in the adult patient, and 30 minutes in a

pediatric patient (after successful intubation and medications), and no reversible causes have been identified.

3. However, the following patients found pulseless and apneic warrant resuscitation efforts

beyond 30 minutes and should be transported: a. Hypothermic; or b. Drowning with submersion less than 60 minutes (with hypothermia); or c. Pregnant and estimated to be 20 weeks or later in gestation. Advance Medical Directives A. There are several types of advance medical directives (documents in which a patient identifies

the treatment to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions).

1. Do not resuscitate (DNR) orders are generally intended to be written by a physician for a

patient whose medical condition is such that commencement of resuscitation efforts would be futile.

2. A Colorado living will (“Declaration as to Medical or Surgical Treatment”) requires a patient

to have a terminal condition, as certified in the patient's hospital chart by two physicians. For the document to become operative, the patient must be unresponsive because of a terminal condition for a period of seven days.



3. Other types of advance directives may be a “Durable Medical Power of Attorney,” or

“Health Care Proxy” (the CPR Directive is covered separately; see CPR Directive Protocol). Each of these documents can be very complex and require careful review and verification of validity and application to the patient’s existing circumstances. Therefore, the consensus is that resuscitation should be initiated until the document can be reviewed by a physician or the patient’s situation can be discussed with the base physician by field personnel.

B. Resuscitation may be withheld from or terminated for a patient who has a valid, written do not

resuscitate order or other advance medical directive (see also CPR Directive protocol) only if: 1. The document is clear, unequivocally to the prehospital provider that CPR, intubation and

defibrillation are refused by the patient or by the patient's attending physician who has signed the document; and

2. Base physician has approved of withholding or ceasing resuscitative efforts; and 3. There is no apparent indication of suicidal gesture or intent by the patient. 4. If there is disagreement at the scene about what should be done, the base should be

contacted immediately for guidance. 5. Prehospital providers presented with equivocal DNR orders or advance medical directives

should proceed with resuscitation and establish base contact for guidance on treatment and transport.

a. If the directive document is long and detailed, then it is probably more reasonable for

resuscitation to be initiated and the patient to be transported so that the base physician can review the document and possibly contact the patient's attending physician.

b. The duration of the resuscitation should be guided by the same factors of any medical

cardiac arrest (see section II.C. above). C. Verbal DNR “orders” are not to be accepted by the prehospital provider. In the event family or

an attending physician directs resuscitation be ceased, the prehospital provider should immediately contact base. The prehospital provider should accept verbal orders to cease resuscitation only from the base physician.

D. There may be times in which the prehospital provider feels compelled to perform or continue

resuscitation, such as a hostile scene environment, family members adamant that “everything be done,” or other highly emotional or volatile situations. In such circumstances, the prehospital provider should attempt to confer with the base for direction and if this is not possible, the prehospital provider must use his or her best judgment in deciding what is reasonable and appropriate, including transport, based on the clinical and environmental conditions, and establish base contact as soon as possible.



Additional Considerations: A. Mass casualty incidents are not covered by these guidelines. B. These guidelines apply to both adult and pediatric patients. C. If the situation appears to be a potential crime scene, EMS providers should disturb the scene

as little as possible. D. ALS personnel should document asystole for 10 seconds in at least two leads prior to

withholding or terminating resuscitative efforts. However, base physicians and prehospital providers must use discretion when considering the need for a rhythm strip (i.e., monitor strips are not necessary in patients found decapitated, decomposed or with dependent lividity or rigor mortis).

E. Mechanism for disposition of bodies by means other than EMS providers and vehicles should

be prospectively established in each county or locale. F. In all cases of unattended deaths occurring outside of a medical facility, the coroner should be

contacted immediately. G. Patients with valid DNR orders or advance medical directives should receive medical

treatment and supportive or comfort care prior to cardiac arrest (see also CPR Directive protocol).

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: HAZARDOUS MATERIALS



HAZARDOUS MATERIALS PROTOCOL Indications A. Responding to reported and/or known hazardous materials incident. B. Vapor clouds, fire and smoke, leaking substances, frost lines on cylinders, sick personnel,

dead or distressed animals and noxious odors are present on or near scene. Precautions A. Senses are one of the best ways to detect chemicals, particularly the sense of smell. If you

smell something you are too close. B. A safe approach to the scene is the first element of any EMS response to a hazardous

materials emergency. Unless you arrive safely at the site, you will not be able to perform your duties.

C. Observe the site from a distance using binoculars, if possible, before you get too close. Look

for danger signs such as vapor clouds, fire and smoke, placards, shape of vehicle or container, leaking substances, frost lines on cylinders, injured personnel, and dead or distressed animals. These are key clues to warn you not to get too close. Remember, you want to be part of the solution, not part of the problem.

D. If the fire department is already on the scene, report in to the incident commander. If you are

first on the scene and a hazardous material is suspected, request a hazardous materials team response. Keep yourself and your unit at a safe distance. This usually requires your unit to leave the scene, leaving patients and bystanders in a hazardous situation. Your safety comes first. Seek a location uphill and upwind from the incident.

E. EMS personnel should not be participating in patient decontamination unless trained and

equipped to do so. Procedure A. Your safety is the highest priority. EMS operations should be established in the cold zone.

You should report to the incident commander. B. Position your vehicle to make a hasty retreat. This may require you to leave the scene to seek

safety. C. Initial assessment, treatment, and decontamination should be performed by the hazardous

materials team. Decontaminated patients will be brought to the EMS unit.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: HAZARDOUS MATERIALS


D. Once the situation has been assessed, notify the receiving facility of the following information: 1. Location of the incident. 2. Name of chemicals/products involved. 3. Number of injured and contaminated. 4. Extent of the injuries/contamination. 5. Extent that the patients will be decontaminated in the field. 6. Your estimated time of arrival. 7. Other pertinent information that is available. E. Patient treatment is usually based on signs and symptoms. Specific patient treatment should

be based on information obtained from base. F. Base will coordinate patient care information with command/ hazmat team.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: BLOOD/BODY FLUID EXPOSURE



BLOOD AND/OR BODY FLUIDS EXPOSURE FR/B/I/P

The following are recommendations for blood and/or body fluids exposures. Exposures may occur by a contaminated needle stick, laceration by a contaminated instrument, body fluids on open wounds or abraded skin, or a splash to mucous membrane (eyes or mouth). These guidelines will assist with getting the quickest treatment for exposures. Personnel should review and familiarize themselves with local exposure policies and Worker’s Compensation Insurance coverage. Agency Infection Control Officers will have pertinent information. The goal is to get the exposed health care provider the proper treatment within the two-hour window recommended by the Center for Disease Control (CDC). Recommendations A. Exposed personnel should take immediate first aid measures to wash or irrigate the exposed

area. B. If a significant exposure has occurred, the crew should notify the Emergency Department (ED)

destination of the exposure as soon as possible to allow the staff adequate time to prepare testing equipment prior to arrival.

C. The crew should draw a minimum of two red-top blood tubes from the source patient. One of

the tubes should be marked “source blood.” This procedure allows for regular lab testing without requiring another blood tube to be drawn.

D. Take the blood tube to the Telluride Medical Center. E. Applicable nurse personnel will flag the chart to monitor the length of time the patient has

been in the system and to document the time of exposure and test start time. F. The crew member should wait for the results of all tests. Further assessment will include

tetanus and Hepatitis B vaccine status. Immunizations will be started according to TMC guidelines.

G. If test results are positive, the ED physician will consult with the patient and prophylaxis

treatment will be implemented in accordance with CDC guidelines. Treatment should be started within the one-hour window.

H. The patient will be provided with written instructions upon discharge that will include basic

exposure safety counseling and instructions for follow-up with Occupational Health or the individual PCP. Currently, only HIV statuses have been addressed; follow-up is required to address Hepatitis B and C.

I. Refer to local agency’s exposure policy for follow-up treatment guidelines.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: BLOOD/BODY FLUID EXPOSURE


J. The patient should expect counseling from either the agency’s or facility’s Occupational Health

Officer. Counseling will include follow-up testing, safety precautions, and immunization review.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: INFECTIOUS/COMMUNICABLE DISEASES



INFECTIOUS/COMMUNICABLE DISEASE PROTOCOL

Field personnel occasionally come into contact with communicable diseases. It is important that a protocol is followed so that the appropriate persons are notified. Not all diseases require immediate treatment, however, early awareness will assist those involved in taking any necessary precautions. Contamination by infectious diseases may be minor or serious. Field personnel should take precautions to avoid unnecessary exposure. When dealing with a suspected contagious patient, attempt to avoid direct contact with the patient’s blood, sputum, emesis, urine, or feces. The provider should wear disposable latex or vinyl gloves as an added precaution. Routine practice of good hand washing and equipment cleaning may help decrease the incidence of contamination. The following guidelines have been provided for reference. Follow your individual agency infectious disease exposure policy and procedure. A. Persons with significant exposure shall report the incident to the Designated Infection Control

Officer of his/her agency. B. Agency policy, developed in conjunction with the Physician Advisor, will dictate procedure with

regard to screening, follow-up testing, prophylaxis and/or treatment. C. Exposed Pre-Hospital Care Personnel may be counseled and treated according to the

following guidelines:

Infection/Disease Means of Exposure Follow-up After Exposure

AIDS Intimate contact with infected person. Contact with blood/body fluids of infected person. Needle sticks. Presence in room without contact does not constitute exposure.

Patient may be known HIV positive. Testing patient for antibodies to the HIV virus requires consent. Post mortem samples may be submitted but may not be acceptable to the testing lab. Turn around on testing is 7-10 days.

Current CDC and OSHA recommendations suggest personnel with exposure to body fluids be tested within the week of exposure, and 6 weeks, 3 months and 6 months following exposure. Testing requires consent. Results are confidential. No prophylactic treatment is known or recommended for positive HIV AB. OSHA recommends that AZT prophylaxis be considered.




HEPATITIS B Needle stick, contact with blood/body fluids of infected person.

Patient should be tested for presence of Australian Antigen (HAA) (also known as Hepatitis B Surface Antigen). If positive, those exposed should receive Hepatitis B Immuno Globulin (HBIG) as soon as possible post exposure and definitely within seven days. Exposure to known Hepatitis B carriers require the same treatment. Post-mortem blood sample may be submitted but may not be acceptable to the lab.

CDC and OSHA expect all field personnel to have Hepatitis B vaccination. If an individual is not vaccinated, CDC and OSHA recommend that the Hepatitis B vaccine be initiated with HBIG treatment.

HEPATITIS A Contact with blood, emesis or feces of infected person.

Exposed personnel may receive injection of Gamma Globulin if diagnosis is confirmed. Confirmation based on clinical and laboratory analysis.

Policy the same as Hepatitis B.

HEPATITIS C (NON A, NON B)

CDC and OSHA recommend consideration of Hepatitis C screening and ISG administration.

NOTE: Documented exposure to patient suspected of having hepatitis and not available for blood testing may warrant administration of both Gamma Globulin and HBIG if patient is a member of a high risk group. Incident should be discussed with the Designated Infection Control Officer and your physician advisor.

TUBERCULOSIS TB

Contact with the infected person.

Decision to treat based on skin testing of individual. Intermediate PPD administered currently and 3 months later. Any positive test suggests need for therapy. Follow up including medication (INH) and care is provided free through the Denver TB Clinic.

HERPES ZOSTER (Shingles)

Same as Chickenpox.

CHICKENPOX (Varicella)

Contact with respiratory and/or lesion secretions.

Susceptible persons are considered to be contagious during the incubation period, the 10th-21st day after exposure. If disease acquired, they are considered to be contagious until all lesions are crusted. A titer may be obtained to determine immune status.




MEASLES (Ruebeola or Rubella)

Direct or droplet contact with respiratory secretions.

Susceptible persons are considered to be contagious during the incubation period, the 5th-21st day after exposure. If disease acquired, they are considered to be contagious until 7 days after rash appears. A titer may be obtained to determine immune status. Immunization is recommended.

MUMPS Direct or droplet contact with respiratory secretions.

Susceptible persons are considered to be contagious during the incubation period, the 12th-21st day after exposure. If disease acquired, they are considered contagious for 9 days following onset of symptoms. A titer may be obtained to determine immune status. Immunization is recommended.

VIRAL MENINGITIS

Contact of feces. No specific recommendation.

BACTERIAL MENINGITIS

Direct or droplet contact respiratory secretions.

Individual cases need to be assessed. Recommendation will be made based on hospital review, and communicated to the physician advisor and the Designated Infection Control Officer of the agency.

STREPTOCOCCAL DISEASE

Direct or droplet contact with secretions.

If exposed individual develops a sore throat, culture should be done. If disease acquired, they are considered contagious until adequate therapy has been received (24 hours) or until a Strep infection has been ruled out.

SYPHILIS Contact with blood or lesion secretions

Treatment is based on laboratory testing and presentation of symptoms. Prophylactic treatment may be considered. Testing should be done soon after exposure and repeated in 3 months.

GONORRHEA Contact with infective discharge.

No prophylactic treatment is recommended unless S/S present.

HERPES Direct contact with exudative lesions. (Mucous membrane contact.)

No prophylactic treatment is recommended.




SCABIES Transfer of parasites is by direct skin to skin contact and to a limited extent from undergarments or bedclothes of infected person.

Treatment based on presentation of symptoms after consult with ED physician.

NOTES:

All personnel must report incidents to the Designated Infection Control Officer of their agency. All personnel should be advised to consult with their private physician as well.

All health care personnel should always practice good hygiene before, during and after delivering patient care. Each patient contact should be considered to be a potential source of infection.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: MEDICAL DIRECTION



PHYSICIAN AT THE SCENE MEDICAL DIRECTION

Purpose To provide guidelines for prehospital personnel who encounter a physician at the scene of an emergency. General Principles A. The prehospital agency and its EMTs, if dispatched to the incident through normal operations,

have a duty to respond, assess, treat, and transport if indicated. B. A physician who voluntarily offers or renders medical assistance at an emergency scene is

generally considered a “good Samaritan.” However, once a physician initiates treatment, he/she may feel a physician-patient relationship has been established. In such a case, the physician must then either maintain control of the patient’s care and travel with the patient, or make a formal transfer of care to the EMT and his/her acting medical director (EDP).

C. If a physician is already providing care when the prehospital agency arrives, then the

physician has already established a physician-patient relationship. Thereafter, a formal report and transfer of care is required from the on-scene physician if he/she chooses to transfer the patient’s care rather than accompany the patient to the hospital.

D. If any confrontation develops, patient care suffers. Every situation is different and must be

handled with the best care of the patient as the guiding principle. E. Any problems should be referred to the base Physician by telephone (prefer) or radio.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: TRANSPORT



TRANSPORT OF PATIENT Policy All individual served by TFPD will be evaluated, cared for, and provided with ambulance transportation if indicated, in the most timely and appropriate manner for each individual situation. Purpose A. To provide rapid emergency transportation when needed B. To provide appropriate medical stabilization and treatment at the scene when necessary C. To provide for the protection of patients, EMS personnel, and citizens from undue risk when

possible. D. To provide for effective use of emergency resources. Procedure A. All patients will be transported to the closest available acute care facility, unless specifically

ordered elsewhere by Medical Control due to medical necessity. Transports to other facilities will not be provided for based on patient or physician preference.

B. All trauma patients with mechanisms or history for multiple systems trauma will be transported

as soon as possible. Scene time should be 10 minutes or less C. Medical patients will be transported in the moist efficient manner possible considering medical

condition. Advanced Life Support therapy should be provided at the scene if it would positively impact patient care. Justification for scene times greater than 20 minutes should be documented

D. Initial response vehicles should not be used for transport. Unless needed for access over

rough terrain. Patient refusals that meet TFPD guidelines can be considered for courtesy transport in the initial response vehicle. (ie. QRV). Arrangements for transfer to an appropriated ground or air ambulance must be made as soon as practical.

E. The decision to transport patients with lights and sirens to a facility is that of the highest care

provider present. And should only be done in times of true emergency where patients will benefit from care beyond the scope of EMS providers. (ie. multi-systems trauma , surgery)

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: TRANSPORT - AIR



AIR TRANSPORTATION Policy Air transportation may be utilized when ever patient care can be improved by decreasing transport time to a facility or by giving advanced care not available by this department, but available from air medical service. Purpose

A. Improve patient care in prehospital setting

B. Allow for expedient transport to a higher level of definitive care (ie. Level I or Level II Trauma Center)

Procedure

A. The paramedic on duty or the physician on call request air transport. Both should be made aware of such a decision so as to not duplicate request.

B. If potential need for air transport is anticipated, either from scene or from the receiving facility, the air service mat be placed on stand by or requested to launch to the closest medical facility for rendezvous

C. Patient transport via ground ambulance will not be delayed to wait for air transportation. If a

patient is packaged and ready for transport and air service is not on the ground or within reasonable distance transport towards to closet appropriate facility or coordinated rendezvous point will be initiated by ground ambulance.

D. Air transportation may be considered if any of the following criteria apply:

1. High priority patient with greater than 45 minute transport time

2. Multiple casualty incident with red/yellow tag patients

E. If scene conditions or patient condition improves after activation of air transport and it has been determined unnecessary contact medical control to cancel the request.

F. In the event field personnel are unable to contact medical control or the paramedic on call,

air medical transportation may be requested through dispatch by EMT B/I.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: TRANSPORT – NONTRANSPORT



NON-TRANSPORT OF PATIENTS General Principles A. A patient who has decision-making capacity may refuse treatment, examination or transport.

See Legal Issues in Consent protocol. B. A person probably has decision-making capacity sufficient to refuse treatment/transport if

he/she: 1. Understands the nature of the illness/injury or risk of injury/illness; 2. Understands the possible consequences of refusing treatment/refusing transport; and 3. Given the risks and options, the patient voluntarily refuses treatment/transport. C. The prehospital provider is responsible for deciding if the patient’s refusal is informed and

voluntary. The prehospital provider should consider the nature of the incident, potential mechanism, obvious actions of the patient, as well as the verbal statements of the patient. The prehospital provider is responsible for a reasonable assessment of the patient to determine if there is an injury/illness or reason for transport or treatment. Only then is a patient’s refusal an informed refusal (see Legal Issues in Consent protocol). Do not attempt to diagnose, do assess carefully.

D. Remember: It is your assessment and advice to the patient that are most important in the non-

transport, not how well you write a report after the fact or what document the patient signs. E. Paramedic-initiated refusals pose significant risk if assessments are inadequate or incorrect.

Failure to transport a patient who requests transport requires base contact and appropriate documentation.

F. Paramedic may advise and even medicate patient before transferring care to a lesser provider

of the same service. As long as there are no potential complications of Paramedic interventions and all parties are comfortable with such a transfer.

Procedure for Non-Transports (see Algorithm pg. VIII-25) A. If a patient has no injury, no complaint of illness or injury, and this is consistent with the

history/mechanism, base contact is still required. B. For the patient who has only an isolated soft tissue injury and has decision-making capacity,

treatment and transport should be offered. If the patient refuses, then warn the patient of the risks of non-transport and delay in treatment.

C. In all other situation of patient refusal of transport or non-transport, base contact is required.



D. Patients with medical conditions/injuries that may recur or deteriorate, or may render the patient unable to seek medical care, should be carefully evaluated and warned to not delay in obtaining medical treatment. High risk areas in EMS are head injury, chest pain, abdominal pain, “flu” like symptoms, alcohol related illnesses or injuries.

E. For the patient refusing transport/treatment: 1. Assess patient to the extent possible. Look for objective causes of injuries/illnesses that

may impair decision-making. Evaluate mechanism/history, scene and potential for unseen injuries/illnesses. Do not diagnose.

2. Inform patient of findings, possible injuries or illnesses that warrant treatment and

transport, and of the risks of non-transport, delaying treatment, and non-physician examination.

3. If the patient still refuses treatment/transport, then determine the patient’s ability to

understand the immediate medical situation and need for treatment. Questions asked might include:

a. Why don’t you want to go to the hospital? b. What other means of transport do you have? c. What will you do if you get sick again? d. What are the risks I just explained to you about delaying treatment? 4. If the patient still refuses transport, contact base. 5. The base physician may: a. Agree or determine that the patient’s decision-making capacity is impaired and instruct

transport of the patient. 1. The patient may be transported under the basis of a medical emergency (i.e.,

patient is incapacitated and unable to consent). 2. The patient may be transported under the basis of a mental health emergency.

Police should be requested to place the patient under a Mental Health Hold. b. Agree or determine that the patient has decision-making capacity, in which case: 1. The patient may refuse treatment and transport but must be advised of the risks of

non-transport (informed refusal). 2. The prehospital provider must warn the patient that non-transport is against

medical advice (AMA).



3. The patient should be urged to seek medical attention and transport. 6. For the patient who refuses treatment and transport (against medical advice), providing

the patient with clear instructions and warnings is imperative (use of an Information Sheet is recommended).

F. Minors. The base is to be contacted under the same circumstances as an adult, any time a

minor is not left in the custody of the parents. G. The following must be documented for every patient examined, offered and refused

treatment/transport (in addition to EMS Division guidelines): 1. All assessment findings. 2. Description of mechanism or scene factors (damage, environment, etc.). 3. Description of mental status and decision-making capacity. 4. Vital signs, unless the patient refused. 5. Patient’s response to warning about risks of non-transport/non-treatment. 6. Base physician’s advice. 7. Patient’s condition at termination of patient contact (i.e., ambulatory, with family). H. The “AMA” (refusal) patient should be provided with an Information Sheet (see sample).

Obtaining a patient's signature on a run report or release form is encouraged because signing may be evidence of the patient’s decisional capacity and physical stability. However, do not have a patient sign a release or waiver that you do not understand, and do not expect that a signature relieves you of responsibility for a reasonable assessment or treatment of the patient.

I. The role of base contact is to assist in determining or verifying the patient’s ability or inability

to make medical treatment decisions and assist when transport should be done. It is imperative that an accurate, concise report be given for the physician to give good advice.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: REFUSAL ALGORITHM



ALGORITHM NON-TRANSPORT/REFUSAL OF CARE

(See Non-Transport of Patients Protocol) Determine mental status and extent and history of injury, mechanism, or illness. ⇓ ⇓ ⇓ Pt. alert, oriented and has Injury or illness or has altered mental decision-making capacity (DMC) status or impaired decision-making

capacity (DMC) ⇓ ⇓ ⇓ No apparent injury/illness Limited injury Pt. refuses consent or offer No complaints, no consistent with of treatment and transport significant hx. hx and mechanism ⇓ ⇓ Pt doesn't want tx/transport; Offer treatment and Advise Pt. appropriately. transport Contact base Document appropriately. Contact base ⇓ Pt. still refuses Contact base ⇓ ⇓ Consider consult with base Base physician determines Base physician determines Pt. does not have DMC. Pt. does have DMC (Treatment/transport may be

authorized under Mental Health Hold or implied consent if a medical emergency exists.)

⇓ ⇓ Warn Pt. of risks of Transport; request MHH non-transport/non-treatment or use police if against medical advice necessary for assistance. and document appropriately. NOTE: CAREFUL DOCUMENTATION ON TRIP REPORT OF MEDICAL ASSESSMENT AND

REASONS FOR REFUSAL ARE MANDATORY

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: RADIO REPORT



RADIO REPORT PROCEDURE The purpose of contacting the receiving facility is to provide enough data to allow the Emergency Department staff to decide what preparations they will need to make for the patient. In addition, a base physician may direct appropriate treatment to be administered en route. Procedure for Notification to Receiving Facility Report the following, to the extent pertinent, to the receiving facility: A. Transport status or code. B. Chief complaint. C. General status and course of events, stable, improving, deteriorating. D. Past medical history, only if pertinent. E. Level of consciousness. F. Vital signs. G. Pertinent localized findings. H. Treatment in progress. I. Estimated time of arrival. Procedure for Requests for Treatment Orders Only a physician may provide authorization to a paramedic to perform a procedure or administer a medication pursuant to these protocols. The EMT should be clear and concise in requesting that a physician be available for consultation or orders. ED nurses may relay information and orders to/from the ED Physician if time constraints require. A. Request to talk to a physician to obtain an order. B. Identify yourself to the physician and state the order you are requesting. C. Provide pertinent information that is the basis of the request, such as: 1. En route (emergent or non-emergent, estimated time to destination hospital) or on scene. 2. Chief complaint.

TFPD EMS PROTOCOLS OPERATIONAL GUIDELINES: RADIO REPORT


3. Course of events, stable, improving, deteriorating. 4. Past medical history, only if pertinent. 5. General status. 6. Level of consciousness. 7. Vital signs. 8. Pertinent localized findings. 9. Treatment in progress. 10. Order requested, stating dosage and route to be given. D. In the event a request is for a field pronouncement, the report should include information

about the responses to resuscitation efforts, mechanism, and duration of resuscitation efforts. If the pronouncement is made, state the time.

E. Communication with a physician at the base is appropriate if you are not sure whether or not

a treatment, procedure or destination is appropriate for a patient. Base contact should be considered as a consultation, not just as a source of authorization for medications and procedures.

F. Requests for orders should be made to dispatch on the radio so there is a recorded line

whenever possible.

TFPD EMS PROTOCOLS POLICY PROCEDURE: REGISTRATION/RECORD KEEPING

January 1, 2008 IX - 1

Policy and Procedures

REGISTRATION AND RECORD KEEPING POLICY State of Colorado EMS Rules require that Physician Advisors track and register all prehospital care providers (i.e., certified First Responders, EMT-B, EMT-I, EMT-P) working under their advisorship with the State. The attached form is for the purpose of registering those persons with the Physician Advisor and Telluride Fire Protection District and then secondarily with the State. It is also required, either by the State, the Physician Advisor, or both, that:

• All active First Responders and EMTs maintain current BLS-C training (or equivalent healthcare provider CPR certification), documented through possession of a current card, no longer than 12 months since issue (for those with a 2-year card, a 12-month skills check-off is required);

• All active First Responders and EMTs maintain current FR/EMT training documented by

possession of a current certification card;

• All active EMT-Is are recommended to keep current ACLS certification or required at a minimum to perform annual ACLS skills check-off, documented in CE records;

• All active EMT-Ps are required to maintain current ACLS certification, documented by possession

of a current AHA ACLS card. PROCEDURE This form is to be submitted by a responsible person from the Telluride Fire District, to Dr. Dianna Koelliker on a biannual basis, to document that the above-noted requirements are being met. Further, the agency will keep in its files proof of the same. The paper form may be submitted, or identical data in electronic format may be submitted. These files are open to and will be inspected by the Physician Advisor (or his/her designee) at any time he/she is in the agency for training, case review, or other business. After initial submission, duplicates of the submission form may be dated and re-signed indicating no change in any of the information listed. Failure of the agency to keep current and accurate files will be grounds for termination of Physician Advisor support to the agency and its medics. EFFECTIVE DATE: JANUARY 1, 2008 Approved by Dr. Dianna Koelliker January 1, 2008




Telluride Fire District EMS Rescuer’s Agreement with the Physician Advisor

Rescuer Agency EMS Certification Level Physician Advisor I, the Rescuer, do hereby agree to adhere to the Physician Advisor’s principles of prehospital emergency care listed below: A. Rescuers must abide by the policies of their agency/department concerning planned

maintenance/inspection of vehicles, equipment, medicines, and supplies. The minimum required is daily for full-time/paid agencies, no more than weekly for volunteer agencies and immediately following each call.

B. All emergency calls must be triaged or transferred to the most qualified Rescuer or agency with the

quickest predictable response time to insure appropriate care for the stated emergency. C. The number of vehicles responding lights and siren to a call must be kept to the minimum required by

the call without compromising patient care. D. Any vehicle responding to a call or transporting to a hospital operating lights and sirens must report

same to the local dispatch center. This report must be immediate and include the location/destination and nature of the call. When entering another jurisdiction operating lights and siren, the appropriate dispatch center must be immediately notified as above.

E. When arriving at the scene of an emergency call, scene/Rescuer safety and multiple victim triage must

precede individual patient care. F. All emergency patients MUST BE placed under the direct care of the Physician Advisor/Emergency

Room Physician as soon as is safely possible. Until then , the most qualified Rescuer (first on scene if otherwise equally qualified) MUST assume control of and responsibility for patient care. Radio contact with and transport to the emergency department must not be unduly delayed.

G. The Physician Advisor extends his/her medical licensure to cover procedure, protocols, and standing

orders. These are distributed in the format of the Telluride Fire District EMS Manual (a.k.a. Protocol Manual), of which this agreement is a part. All portions of the manual are to be followed as written. Failure to comply may make the Rescuer subject to criminal and civil prosecution and penalties as well as loss of Physician Advisor.

H. Written documentation, in duplicate, of patient care (trip report) must be completed for all patient

contacts. The original is to be kept by the originating agency with copy to the receiving facility at the time of patient transfer.



I. Any incidents of the following are to be reported, by trip report or Q/A report, to the Telluride Fire

District EMS Administrator. 1. Protocol use/misuse. 2. Instructive cases for educational purposes. 3. Any incident of medico-legal significance (equipment malfunction, therapeutic complications,

incorrect treatment, lack of cooperation amongst responding agencies, patient/family complaints, etc.).

J. The EMS Administrator is to serve as liaison between the Rescuers and the Physician Advisor to insure compliance with the EMS Manual requirements and insure quality assurance/quality improvement activities are carried out. K. The Physician Advisor MUST BE welcome to inspect any EMS vehicle, equipment, supplies, and/or personnel files during normal reasonable hours. The Physician Advisor and/or EMS administrator must be welcome to ride with any Rescuer at any reasonable time. The Physician Advisor agrees to assume medico-legal responsibility for prehospital care provided by the Rescuer if the above principles are followed. IT IS CLEARLY UNDERSTOOD THAT FAILURE TO COMPLY WITH ANY OF THE ABOVE-LISTED ITEMS OR ITEMS IN THE EMS MANUAL WILL IMMEDIATELY CANCEL THIS AGREEMENT AND DISSOLVE ANY MEDICAL OR LEGAL RELATIONSHIP BETWEEN THE RESCUER AND THE PHYSICIAN ADVISOR. This agreement is valid until revoked by the Rescuer or the Physician Advisor. Revocation may be accomplished immediately on written notification of the other party to the agreement.

I have read, understand and will comply with this agreement and those requirements listed in the current Telluride Fire District EMS Manual.

Rescuer Date Physician Advisor (approval) EMS Administrator (approval)

TFPD EMS PROTOCOLS POLICY PROCEDURE: TRIP/DATA REPORTS



TRIP AND DATA REPORTS Policy In order to comply with State rules and local requirements and as a tool in the QA/QI process, EMS personnel providing prehospital care in the Telluride Fire District EMS System will complete and file a trip report and a data report for all patient contacts. Procedure Trip Report Any First Responder, EMT-B, EMT-I, EMT-P, or RN being the responsible medic and providing patient care under the advisorship of the Physician Advisor for Telluride Fire District EMS will complete and file a trip report for each patient contact. This includes any patient assessed—even if not transported. The original of the trip report will be returned to the agency for its use in billing, record maintenance, etc. The copy will be left at the facility to which the patient is transported for that patient’s medical record. A. The report will be completed on a form provided by the Telluride Fire District . B. The copy of the trip report will be placed on the patient’s hospital clipboard or placed in the hands of

the nurse/tech caring for that patient. C. Other pertinent information (DNRs, rhythms strips, patient medication lists, other patient records,

thromb sheet, etc.) will be placed with the patient copy of the trip report. D. If the medic completing the report requires an additional copy of the report, both TMC and MMH

EDs have photocopy machines available for making copies. E. A signature indicating the receiving facility’s receipt of the patient shall be obtained on the original

copy of the trip report. F. If medics from two or more agencies participate in patient care of a critical or unstable patient

during transport to a facility, trip reports must be completed and filed as above by the responsible medics from each agency.

G. The completed report must be signed by the medic completing the report. If this signing medic is a

subordinate, the report must also be signed by the responsible medic indicating approval of the report and responsibility for the patient care.

H. The narrative portion of the trip report will be completed using the SOAP format. 1. S = subjective information gained from dispatch, patient, bystanders, family law enforcement,

etc. 2. O = objective information obtained from assessment of the patient, examination of the scene,

etc.

TFPD EMS PROTOCOLS POLICY PROCEDURE: TRIP/DATA REPORTS


3. A = assessment: the problem, condition or complaint for which the patient is being treated or

transported. Note that this does not have to be a “diagnosis.” Beware of Medicare requirements.

4. P = plan: a chronological listing of the care given the patient, including results of specific

treatment modalities.

TFPD EMS PROTOCOLS POLICY PROCEDURE: MEDICAL ABBREVIATIONS


APPROVED MEDICAL ABBREVIATIONS

A&O X 3/AAOX3 -alert and oriented to person, place and time A&OX4/AAOX4 -alert and oriented to person, place, time, and event A-FIB -atrial fibrillation AAA -abdominal aortic aneurysm ABC -airway, breathing, circulation ABD -abdomen (abdominal) ACLS -advanced cardiac life support ALS -advanced life support AMA -against medical advise AMS -altered mental status AMT -amount APPROX -approximately ASA -aspirin ASSOC -associated BG -blood glucose BILAT -bilateral BLS -basic life support BP -blood pressure BS -breath sounds BVM -bag-valve-mask C-SECTION -caesarean section C-SPINE -cervical spine CTLS -cervical, thoracic, lumbar, sacral (spinal column) C/O -complian(s)(ing) of CA -cancer CABG -coronary artery bypass graft CAD -coronary artery disease CATH -catheter CC -chief complaint CHF -congestive heart failure

CNS -central nervous system COPD -chronic obstructive pulmonary disease CP -chest pain CPR -cardiopulmonary resuscitation CSF -cerebral spinal fluid CT -cat scan CVA -cerebral vascular accident (stroke) D5W -5% dextrose in water DIB -difficulty in breathing DKA -diabetic ketoacidosis DNR -do not resuscitate DOA -dead on arrival DT -delirium tremens Dx -diagnosis ECG -electrocardiogram EEG -electroencephelogram ET -endotracheal ETOH -ethanol (alcohol) ETT -endotracheal tube EXT -external/extension F -female FB -foreign body Fx -fracture G(g) -gram GI -gastrointestinal GSW -gun shot wound Gtt(s) -drops GU -gastrourinary GYN -gynecology (gynecological) H/A -headache HEENT -head, eyes, ears, nose, throat HR -heart rate HTN -hypertension Hx -history ICP -intracranial pressure ICU -intensive care unit IM -intramuscular

IV -intravenous JVD -jugular venous distension Kg (kg) -kilogram KVO -keep vein open L-Spine -lumbar spine L&D -labor and delivery LAT -lateral Lb (lb) -pound LLQ -left lower quadrant LMP -last menstrual period LOC -level of consciousness / loss of consciousness LR -lactated ringers LUQ -left upper quadrant M -male MAST -military antishock trousers (MAST Pants) Mcg(mcg) -microgram Mg(mg) -milligram(s) MI -myocardial infarction Min -minimum/minute Ml(ml) -milliliter(s) MOE -movement of extremities MS -mental status MSO4 -morphine sulfate MVA -motor vehicle accident N/V -nausea and vomiting N/V/D -nausea, vomiting, diarrhea NC -nasal cannula NEB -nebulizer NKDA -no known drug allergies NRB -non-rebreather mask NS -normal saline NSR -normal sinus rhythm OB/GYN -obstetrics/gynecology PALP -palpation

TFPD EMS PROTOCOLS POLICY PROCEDURE: MEDICAL ABBREVIATIONS


PAC -premature atrial contraction PE -pulmonary embolus PEARL -pupils equal and reactive to light PMHx -past medical history PO -orally PRN -as needed PT -patient PVC -premature ventricular contraction RLQ -right lower quadrant RUQ -right upper quadrant Rx -prescription SOB -shortness of breath SQ -subcutaneous ST -sinus tachycardia SVT -supraventricular tachycardia Sz -seizure T-Spine -thoracic spine TIA -transient ischemic attack TKO -to keep open Tx -treatment Txfr -transfer Txmt -treatment Txpt -transport U/A -upon arrival VF -ventricular fibrillation VS -vital signs VT -ventricular tachycardia WAP -wandering atrial pacemaker WNL -within normal limits W/ -with W/O -without Y/O(YOA) -years old ♂ -male ♀ -female + -positive - -negative ? -questionable � -approximately > -greater than < -less than

= -equal ↑ -upper (increased) ↓ -lower (decrease) → -to ∆ -change L -left R -right 1° -primary 2° -secondary

TFPD EMS PROTOCOLS POLICY PROCEDURE: QUALITY ASSURANCE/IMPROVEMENT



QUALITY ASSURANCE/QUALITY IMPROVEMENT PLAN

QA-QI PLAN COMPONENTS

TRIP REPORT (patient care record) REVIEW The Telluride Fire District will review trip reports, on a monthly basis. One person, designated by the agency, will review reports for the following: A. Review 100% of trip reports for SENTINEL EVENTS and submit those reports to QA/QI committee. Sentinel Events Include (review/change regularly): 1. Death/arrest in field after EMS arrival, or in ED. 2. Lights-and-siren transports. 3. Request for review from Physician, ER Staff, EMS Agency, or attending medic. 4. Use of medication or advanced procedure. 5. Protocol violation. 6. Multiple patient incidents. 7. “Bad” calls. B. Review 100% of reports for minimal requirements (specifications from QA/QI Committee,

review/change periodically, plus intra-agency requirements) submit a monthly summary report to Dr. Koelliker.

Summary Report includes: 1. Total number of calls for the month. 2. Total number of ALS calls for the month. 3. Number of trip reports subjected to “critical review.” 4. Comments on statistics or trends. C. Perform Critical Review of 1/3 of reports, monthly (format from QA/QI Committee, review/change

periodically). 1. Keep written records. 2. Forward reports meeting/exceeding “Critical Review” criteria to Committee.

TFPD EMS PROTOCOLS POLICY PROCEDURE: TRIP REPORT REVIEWS



PROBLEMS IDENTIFIED IN TRIP REPORT REVIEWS Errors, omissions, and other discrepancies in trip reports will be categorized as follows with the indicated actions possible: Categories Level I: Serious breech of protocol or negative impact on patient.

Level II: Serious breech of protocol, little or no impact on patient, obvious inadequate decision-making and/or treatment.

Level III: Minor protocol deviation or other error/omission with potential for problem or harm. Level IV: Minor protocol deviation or other error/omission. Actions A. Level I and Level II 1. Review by Committee and Physician Advisor. a. No action necessary i. Documentation b. System failure identified ii. Review, revise, develop protocol/policy iii. Evaluate system trends iv. Modify, add training/continuing education v. Documentation c. Individual error/failure identified

2. To Physician Advisor for review/action a. Meet with individual, discuss, no action b. Remediation c. Probation d. Protocol suspension/withdrawal e. Communicate with individual’s supervisor f. Documentation

3. Periodic specifications for review will be changed to verify success of changes or indicate additional changes.

B. Level III and Level IV 1. Review/handle intra-agency 2. Repeat offenses reported to Committee and Physician Advisor for evaluation/action as a Level II

TFPD EMS PROTOCOLS POLICY PROCEDURE: QA QI REPORT

January 1, 2008 IX - 10


TELLURIDE FIRE DISTRICT EMS MONTHLY QA/QI REPORT

Month/Yr Number of EMS Calls Number of Trip Reports Reviewed Number of Patients Transported Number of A.L.S. (Oxy, IV, Monitor) Calls Number of No-transport Calls Comments: Prepared by Date Agency Month/Yr

TFPD EMS PROTOCOLS POLICY PROCEDURE: CONTINUING EDUCATION

January 1, 2008 IX - 11


EMS Continuing Education Program

The Telluride Fire District offers monthly training for your continuing education hours. These trainings are mandatory both for recertification every three years, and for the district’s in-house requirements. Vital information regarding on-going issues as well as new equipment and or policies is covered at these

meetings. Meetings are typically held the first and third Thursdays of each month. In addition to regular trainings , the district has made providing special trainings with the best instructors we can find a priority.

We hope that you are able to take advantage of these opportunities.

Completion Requirements Colorado Recertification at FR, EMT-B, EMT-I, or EMT-P levels requires 1) completion of required CE hours and topics; 2) possession of current professional rescuer’s CPR card at time of completion; 3) successful completion of state-approved practical exam (*); and 4) sending completed application to the State EMS Office (†), including a copy of current CPR/ACLS cards, current driving record check (original only), and successful completion (with a passing score) of State written examination. Minimum CE hour requirements are: a total 36 hours minimum 1/3 medical minimum 1/3 trauma 1/3 elective *As of this date, Colorado accepts national registry certification, and Colorado retesting is not necessary. National registry requires recertification every two years. † Paramedics must have a current ACLS card, PALS card, PHTLS card.

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