Field Manual · FIELD MANUAL- TREATMENT GUIDELINES TABLE OF CONTENTS Continued on next page Table...

TREATMENT GUIDELINES

Field Manual

FIELD MANUAL- TREATMENT GUIDELINES TABLE OF CONTENTS

Continued on next page Table of Contents Page 1

Serving Mendocino, Napa and Sonoma Counties

Coastal Valleys EMS Agency

GENERAL PATIENT CARE – 7000

Use of Restraints.................................................................................................................................. July 2006……….7001 Physician and/or RN at the Scene ....................................................................................................... July 2006……….7002 Trauma Triage Decision Scheme......................................................................................................... July 2006……….7003 Treatment/Transport of Minors............................................................................................................. July 2006……….7004 Patient Refusal of Treatment or Transport ........................................................................................... July 2006……….7005 Determination of Death in the Prehospital Setting/ DNR and AHCD.................................................... July 2006……….7006 Patient Destination/Point of Entry......................................................................................................... July 2006……….7007 Trauma Center Bypass…………………………………………………………………………………………July 2006……….7008 Suspected Elder and Dependent Adult Abuse Reporting Guidelines ................................................... July 2006……….7009 Suspected Child Abuse Reporting Guidelines...................................................................................... July 2006……….7010 Unexpected Infant/Child Death ............................................................................................................ July 2006……….7011 Apparent Life Threatening Event – ALTE............................................................................................. July 2006……….7012 Interfacility Transfers ........................................................................................................................... July 2006……….7013

BLS TREATMENT GUIDELINES – 8000

BLS Routine Medical Care ................................................................................................................... July 2006……….8001 BLS Spinal Immobilization.................................................................................................................... July 2006……….8002 BLS Airway/Oxygen ............................................................................................................................. July 2006……….8003 Pulse Oximetry..................................................................................................................................... July 2006……….8004 Airway Obstruction ............................................................................................................................... July 2006……….8005 BLS Shortness of Breath/Chest Pain ................................................................................................... July 2006……….8006 Altered Mental Status........................................................................................................................... July 2006……….8007 Trauma Management........................................................................................................................... July 2006……….8008 Burns.................................................................................................................................................... July 2006……….8009 Environmental Emergencies ................................................................................................................ July 2006……….8010 Routine Obstetric Delivery.................................................................................................................... July 2006……….8011 Newborn Care ...................................................................................................................................... July 2006……….8012 Obstetric Emergencies......................................................................................................................... July 2006……….8013 Football Helmet Removal ..................................................................................................................... July 2006……….8014

ALS TREATMENT GUIDELINES – 9000

Routine Medical Care........................................................................................................................... July 2006……….9001 Airway Management ............................................................................................................................ July 2006……….9002 ALS Spinal Immobilization.................................................................................................................... July 2006……….9003 Severe Pain.......................................................................................................................................... July 2006……….9004 Sedation............................................................................................................................................... July 2006……….9005




CARDIAC EMERGENCIES– 9100

Ventricular Fibrillation/ Pulseless Ventricular Tachycardia ................................................................... July 2006……….9101 Wide Complex Ventricular Tachycardia ............................................................................................... July 2006……….9102 Narrow Complex Tachycardia, Atrial Fibrillation/Flutter........................................................................ July 2006……….9103 Narrow Complex Tachycardia .............................................................................................................. July 2006……….9104 Asystole/Pulseless Idioventricular Rhythm........................................................................................... July 2006……….9105 Pulseless Electrical Activity (EMD)....................................................................................................... July 2006……….9106 Brady Dysrhythmias ............................................................................................................................. July 2006……….9107 Suspected Acute Coronary Syndrome (ACS) ...................................................................................... July 2006……….9108 Cardiogenic Shock ............................................................................................................................... July 2006……….9109 Inappropriate Shock from Implanted Defibrillator ................................................................................. July 2006……….9110 Ventricular Ectopy ................................................................................................................................ July 2006……….9111

ENVIRONMENTAL EMERGENCIES– 9200

Mild Allergic Reaction........................................................................................................................... July 2006……….9201 Anaphylaxis.......................................................................................................................................... July 2006……….9202 Poisoning/Overdoses ........................................................................................................................... July 2006……….9203 Drowning/Near Drowning ..................................................................................................................... July 2006……….9204 Heat Illness .......................................................................................................................................... July 2006……….9205 Hypothermia......................................................................................................................................... July 2006……….9206 Snakebite ............................................................................................................................................. July 2006……….9207

NEUROLOGIC EMERGENCIES– 9300

Altered Level of Consciousness/Syncope ............................................................................................ July 2006……….9301 Seizures ............................................................................................................................................... July 2006……….9302 Acute Cerebrovascular Accidents (Stroke)........................................................................................... July 2006……….9303

OB-GYN EMERGENCIES– 9400

Vaginal Hemorrhage without Shock ..................................................................................................... July 2006……….9401 Vaginal Hemorrhage with Shock .......................................................................................................... July 2006……….9402 Severe Pre-Eclampsia/Eclampsia ........................................................................................................ July 2006……….9403 Imminent Delivery ................................................................................................................................ July 2006……….9404 APGAR Scoring ................................................................................................................................... July 2006……….9405

RESPIRATORY EMERGENCIES– 9500

Bronchospasm ..................................................................................................................................... July 2006……….9501 Acute Pulmonary Edema...................................................................................................................... July 2006……….9502

TRAUMA– 9600

Amputation........................................................................................................................................... July 2006……….9601 Burns.................................................................................................................................................... July 2006……….9602 Major Trauma....................................................................................................................................... July 2006……….9603 Head Injury........................................................................................................................................... July 2006……….9604 Crush Syndrome .................................................................................................................................. July 2006……….9605




PEDIATRIC– 9700

Pediatric Pulseless Arrest-Asystole/ Pulseless Electrical Activity......................................................... July 2006……….9701 Pediatric Pulseless Arrest-Ventricular Fibrillation/Pulseless Ventricular Tachycardia .......................... July 2006……….9702 Pediatric Brady Dysrhythmias .............................................................................................................. July 2006……….9703 Pediatric Tachycardia........................................................................................................................... July 2006……….9704 Neonatal Resuscitation ........................................................................................................................ July 2006……….9705 Pediatric Respiratory Distress-Croup, Stridor, Wheezing..................................................................... July 2006……….9706 Pediatric Respiratory Distress-Asthma, Bronchospasm....................................................................... July 2006……….9707 Pediatric Shock .................................................................................................................................... July 2006……….9708 Pediatric Allergic Reaction ................................................................................................................... July 2006……….9709 Pediatric Seizure .................................................................................................................................. July 2006……….9710 Pediatric Altered Level of Consciousness ............................................................................................ July 2006……….9711 Pediatric Toxic Exposures.................................................................................................................... July 2006……….9712 Pediatric Burns..................................................................................................................................... July 2006……….9713 Pediatric Severe Pain........................................................................................................................... July 2006……….9714

ALS PROCEDURES- 9800

Oral Endotracheal Intubation................................................................................................................ July 2006……….9801 Pediatric Endotracheal Intubation ........................................................................................................ July 2006……….9802 Endotracheal Tube Introducer (ETTI)................................................................................................... July 2006……….9803 Multi-lumen Airway (Combitube) Intubation.......................................................................................... July 2006……….9804 Nasotracheal Intubation ...................................................................................................................... July 2006……….9805 Continuous Positive Airway Pressure - CPAP...................................................................................... July 2006……….9806 Needle Cricothyrotomy for Complete Airway Obstruction ................................................................... July 2006……….9807 Needle Thoracostomy ......................................................................................................................... July 2006……….9808 EKG 12-lead......................................................................................................................................... July 2006……….9809 External Pacing Procedure................................................................................................................... July 2006……….9810 Accessing a Pre-Existing Vascular Access Device .............................................................................. July 2006……….9811 Intraosseous Infusion ........................................................................................................................... July 2006……….9812 Field Blood Alcohol Collections ............................................................................................................ July 2006……….9813

INTERFACILITY TRANSFER– 9900 Transport of Potassium Chloride (KCL) ............................................................................................... July 2006……….9901 Intravenous Infusions of Heparin & Nitroglycerin ................................................................................. July 2006……….9902 Monitoring Thoracostomy Tubes.......................................................................................................... July 2006……….9903



GENERAL PATIENT CARE

General Patient Care July 2006 Use of Restraints - 7001 Page 1 of 2



USE OF RESTRAINTS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Health and Safety Code, Division 2.5.; California Code of Regulations, Title 22, Division 9.; California Code of Regulations, Title 13. PURPOSE

To provide guidelines on the use of restraints in the field, or during transport, for patients who are violent, or potentially violent, or who may harm themselves or others.

PRINCIPLES The safety of the patient, community and responding personnel is of paramount concern. Restraints are to be used only in situations where the patient is violent and is exhibiting behavior that is dangerous to self or

others. Prehospital personnel must consider that aggressive or violent behavior may be a symptom of underlying medical conditions.

Base contact shall be strictly adhered to for those conditions that require it. The responsibility for patient health care management care rests with the highest medical authority on scene. Therefore,

prehospital personnel shall determine medical intervention and patient destination. Authority for scene management shall be vested in law enforcement.

The method of restraint used shall allow for adequate monitoring of vital signs and shall not restrict the ability to protect the patient’s airway nor compromise neurological or vascular status.

Restraints applied by law enforcement require the officer’s continued presence to remove or adjust the restraints for patient safety.

This policy is not intended to negate the need for law enforcement personnel to use appropriate restraint equipment that is approved by their respective agency to establish scene management control.

PROCEDURES The following procedures should guide prehospital personnel in the application of restraints and the monitoring of a restrained patient: Restraint equipment, applied by prehospital personnel, must be either padded leather restraints or soft restraints (i.e. posey,

Velcro or seatbelt type). Both methods must allow for quick release. The following forms of restraint shall NOT be used by prehospital personnel:

Hard plastic ties or any restraint device requiring a key to remove. Sandwiching patients between backboards, scoop-stretchers, or flat, as a restraint. Restraining a patient’s hands and feet behind the patient, i.e. hog-tying. Methods or other materials applied in a manner that could cause respiratory, vascular or neurological

compromise. Restraint equipment applied by law enforcement (handcuffs, plastic ties, or hobble restraints) must provide sufficient slack in

the restraint device to allow the patient to straighten the abdomen and chest and to take full tidal volume breaths.

General Patient Care July 2006 Use of Restraints - 7001 Page 2 of 2



Restraint devices applied by law enforcement require the officer’s continued presence to ensure patient and scene

management safety. The officer should, if possible, accompany the patient in the ambulance, or follow by driving in tandem with the ambulance on a predetermined route. A method to alert the officer of any problems that may develop during transport should be discussed prior to leaving the scene.

Patients shall not be transported in a prone position. Prehospital personnel must ensure that the patient’s position does not compromise the patient’s respiratory/circulatory systems, or does not preclude any necessary medical intervention to protect the patient’s airway should vomiting occur.

Restrained extremities should be evaluated for pulse quality, capillary refill, color, nerve and motor function every 15 minutes.

It is recognized that the evaluation of nerve and motor status requires patient cooperation, and thus may be difficult or impossible to monitor.

Restrained patients shall be transported to the most accessible basic emergency department facility within the guidelines of EMS Agency Ambulance Patient Destination Policy.

DOCUMENTATION Documentation on the EMS patient care report (PCR) shall include: The reasons restraints were needed. Which agency applied the restraints (i.e. EMS/law enforcement). Information and data regarding the monitoring of circulation to the restrained extremities. Information and data regarding the monitoring of respiratory status while restrained.

General Patient Care July 2006 Physician and/or R.N. at the Scene – 7002 Page 1 of 2



PHYSICIAN AND/OR R.N. AT THE SCENE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Health and Safety Code, Division 2.5.; California Code of Regulations, Title 22, Division 9.; California Code of Regulations, Title 13. POLICY

This policy outlines the steps to be followed when, at the scene of injury or illness, a bystander identifies himself or herself as a physician or a registered nurse (R.N.).

PROCEDURE FOR PHYSICIAN AT THE SCENE When a bystander at an emergency scene identifies himself/herself as a physician, the EMT-P will give the individual a "Note

to Physician on Involvement with EMT-Ps (Paramedic)." (See the example on the next page.) Thank the physician for his/her offer of assistance and remain courteous at all times. If the physician on the scene desires option 1

The Base Hospital will retain medical control if Base contact was established. The EMT-Ps will utilize the physician as an "assistant" in patient care activities.

If the physician on the scene desires option 2 or 3, the EMT-Ps will: Ask to see the physician's medical license, unless they know the physician. Immediately contact the Base and speak to the Base Hospital Physician. The EMT-Ps should instruct the physician on scene in radio/phone operation and have that physician speak directly with

the Base Hospital Physician. The Base Hospital Physician may: Request that the physician on scene function in an observer capacity only. (Option 1) Retain medical control but consider suggestions offered by the physician on the scene. (Option 2) Delegate medical control to the physician on the scene. (Option 3)

EMT-Ps will make ALS equipment and supplies available to the physician and offer assistance. Ensure that the physician accompanies the patient to the Receiving Hospital in the ambulance. Ensure that the physician signs for all instructions and medical care given on the EMS Response report. Keep the Base Hospital advised. Complete an ALS service provider incident report and forward a copy to the EMS agency within seventy-two (72) hours.

PROCEDURE FOR R.N. AT THE SCENE Identification

Recognition by paramedic; -OR- Valid California R.N. license; -OR-

An R.N. may perform BLS procedures at the discretion of the paramedics.

General Patient Care July 2006 Physician and/or R.N. at the Scene – 7002 Page 2 of 2



cma STATE OF CALIFORNIA California

Medical Association

NOTE TO PHYSICIAN ON INVOLVEMENT WITH EMT-Ps (PARAMEDIC)

A life support team [EMT-II or EMT-P (Paramedic) operates under standard policies and procedures developed by the local EMS agency and approved by their Medical Director under the Authority of Division 2.5 of the California Health and Safety Code. The drugs they carry and procedures they can do are restricted by law and local policy. If you want to assist, this can only be done through one of the alternatives listed on the back of this card. CMA, State EMS Authority, CCLHO, and BMQA have endorsed these alternatives. Assistance rendered in the endorsed fashion, without compensation, is covered by the protection of the "Good Samaritan Code" (see Business and Professions Code, Sections 2144, 2395-2398 and Health and Safety Code, Section 1799.104).

(over)

ENDORSED ALTERNATIVES FOR PHYSICIAN INVOLVEMENT After identifying yourself by name as a physician licensed in the State of California, and, if requested, showing proof of identity, you may choose to do one of the following: 1. Offer your assistance with another pair of eyes, hands, or suggestions, but let the life support team remain under base hospital control; or, 2. Request to talk to the base station physician and directly offer your medical advise and assistance; or, 3. Take total responsibility for the care given by the life support team and physically accompany the patient until the patient arrives at a hospital and the receiving physician assumes responsibility. In addition, you must sign for all instructions given in accordance with local policy and procedures. (Whenever possible, remain in contact with the base station physician).

Field Manual-Treatment Guidelines July 2006 Trauma Triage Decision - 7003 Page 1 of 1



Trauma Triage Decision Scheme

Step 1 - Major Physiologic Factors

1. GCS of thirteen (13) or less2. Systolic BP < 90 mm Hg

Adult Patients (age 15 and older) Pediatric Patients (age <15 yrs)1. GCS of thirteen (13) or less2. Systolic BP < 80 mm Hg - age 7-153. Systolic BP < 70 mm Hg - age < 7

Yes No

Transport to Closest AppropriateTraumaCenter

Assess Anatomic Factors

Step 2 - Major Anatomic Factors1. Penetrating injury to head, neck, chest, abdomen, pelvis, groin, or extremities proximal to elbow or knee2. Combination of trauma with burns of greater than or equal to 15%, or burns to face or airway3. Two or more proximal long-bone fractures4. Open or depressed skull fracture5. Flail chest6. Pelvic fracture7. Amputation proximal to wrist or ankle8. Traumatic paralysis9. Any patient < 5 yrs of age who has suffered major trauma but for whom it is not possible to fully determine

physiologic status

Yes No

Transport to Closest AppropriateTraumaCenter

Assess Mechanism of Injury Factors

Step 3 - Mechanism of Injury Factors1. Ejected from vehicle, e.g., auto, jet ski, or motorcycle traveling > 20 mph2. Death in the same passenger compartment3. Extrication time greater than 20 minutes4. Rollover without seatbelt5. Fall greater than 20 feet6. Auto-pedestrian or auto-bicycle with greater than 5 mph impact7. High speed motor vehicle collision and significant passenger space intrusion8. Significant blunt injury to head, neck, chest, abdomen, or pelvis without co-existing anatomic or physiologic

factor

Yes No

Transport to closest appropriate hospital

Age and Co-Morbid Factors1. Age less than 5 yrs & difficult to evaluate or age

greater than 55 yrs2. Cardiac or respiratory disease3. Insulin-dependant diabetic, cirrhosis or morbid

obesity4. Pregnancy5. Immunosuppressed patients6. Pt with bleeding disorder or on anticoagulants7. Inability to communicate; i.e. language,

psychological and/or substance impairment

Transport to Closest AppropriateTraumaCenter Transport to closest appropriate hospital

NoYes

Physiologic & Anatomic Factors1. Torso, abdomen, or pelvic complaint2. Persistent & unexplained respiratory difficulty,

tachycardia, or peripheral vaso-constriction

Assess Additional Factors

Step 4 - Additional Factors

General Patient Care July 2006 Treatment/Transport of Minors - 7004 Page 1 of 2



TREATMENT/TRANSPORT OF MINORS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Health and Safety Code, Division 2.5.; California Code of Regulations, Title 22, Division 9.; California Code of Regulations, Title 13; Family Code Section 6922 through 6929 & 7002; Business & Professions Code Section 2397.

PURPOSE

To describe the guidelines for treatment and/or transport of a patient under the age of eighteen. DEFINITIONS Minor: A person less than eighteen years of age who is not emancipated.

Emancipated Minor: A person less than eighteen years of age who: Is married or previously married Is on active duty in the military Is an emancipated minor (decreed by court, identification card by DMV)

Legal Representative: A person who is granted custody or conservatorship of another person by a court of law.

Emergency: Condition or situation in which an individual has a need for immediate medical attention or where the potential for need is perceived by EMS personnel or a public safety agency. PRINCIPLES Voluntary Consent: Treatment or transport of a minor child shall be with the verbal or written consent of the parents or legal representative. If the minor is legally able to consent, then treatment or transport shall be with the verbal or written consent of the minor.

Implied Consent: In the absence of a parent or legal representative, emergency treatment and/or transport of a minor may be initiated without consent. PROCEDURE Un-emancipated Minors Requiring Transport In the absence of a parent or legal representative, minors with an emergency condition shall be treated and transported to the

health facility most appropriate to the needs of the patients. Hospital or provider agency personnel shall make every effort to inform a parent or legal representative of where their child

has been transported. If prehospital care personnel believe a parent or other legal representative of a minor is making a decision that appears to be

endangering the health and welfare of the minor by refusing indicated immediate care or transport, law enforcement authorities should be involved.

General Patient Care July 2006 Treatment/Transport of Minors - 7004 Page 2 of 2



Un-emancipated Minors Not Requiring Transport A minor who is evaluated by EMS personnel who determine the minor’s condition does not require emergency treatment or transport, may be released to: Parent or legal representative A responsible adult at the scene Designated care giver Law enforcement

General Patient Care July 2006 Patient Refusal of Treatment or Transport - 7005 Page 1 of 3



PATIENT REFUSAL OF TREATMENT OR TRANSPORT

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY California Health and Safety Code, Division 2.5, Sections 1797.220, 1798, (a)(1); California Welfare and Institution Code, Sections 305, 625, 5150, and 5170; Title 22, California Code of Regulations, Section 100042(a). PURPOSE

To provide procedures for EMS personnel to follow when patients, parents, or legal representative refuse indicated medical treatment or ambulance transportations.

DEFINITIONS Adult: For purposes of this policy, a person at least eighteen years of age, or an emancipated minor. Minor: A person less than eighteen years of age who is not emancipated. Emancipated Minor: A person less than 18 years of age who:

Is married or previously married Is on active duty in the military Is an emancipated minor (decreed by court, identification card by DMV)

Competent: The patient is alert and oriented and has the capacity to understand the circumstances surrounding his/her illness or impairment, and the risks associated with refusing treatment or transport. Emergency: Condition or situation in which an individual has a need for immediate medical attention, or where the potential for need is perceived by EMS personnel or a public safety agency.

“Individual not requiring transport” or “release at scene”: An individual who, after a complete assessment by ALS personnel, does not appear to have a medical problem that requires immediate treatment and/or transportation by the medical system.

Refusing care against medical advice (AMA): A competent adult who is determined by EMS or base hospital personnel to have a medical problem which requires the immediate treatment and/or transport capabilities of the EMS system, and who has been advised of his/her condition and the known and unknown risks and/or possible complications of refusing medical care, and who still declines treatment or transport.

5150: Refers to a patient who is held against his/her will for evaluation under the authority of Welfare and Institutions Code, Section 5150, because the patient is a danger to him/herself, a danger to others, and/or gravely disabled, e.g., unable to care for self. This written order may be placed by a law enforcement officer, County mental health worker, or an emergency physician certified by the County to place an individual on a 5150 hold.




PRINCIPLES A competent adult or a competent emancipated minor has the right to determine the course of his/her own medical care and

shall be allowed to make decisions affecting his/her medical care, including the refusal of care. With the exceptions of minors who have clear legal capacity to refuse emergency treatment or transport (emancipated minors)

a patient less than 18 years old must have a parent or legal representative present to refuse evaluation, treatment, or transport.

An adult or emancipated minor may refuse medical evaluation, treatment, and/or ambulance/medical transportation, provided

that he/she is competent and has been advised of the risk and consequences, which may result in refusal of evaluation, treatment and/or transportation.

Refusal of evaluation, treatment and/or transportation should not be considered for patients who do not have the capacity to make competent decisions regarding their own care. A patient’s competence may be significantly impaired by mental illness, drug or alcohol intoxication, physical or mental impairment. Patients, who have attempted suicide, verbalized suicidal intent or when other factors lead EMS personnel to suspect suicidal intent, should not be regarded as competent.

PROCEDURE When a competent adult or emancipated minor refuses indicated emergency treatment or transportation, EMS personnel shall: Advise the patient of the risks and consequences which may result from refusal of treatment or transport. If the patient’s condition meets ALS treatment criteria, and a BLS unit is alone on scene, an ALS unit should be requested. Have the patient or his/her legal representative, as appropriate, sign the release (AMA) section of the RAS/AMA form. The

signature shall be witnessed, preferably by a family member. The patient should be advised to arrange for medical care immediately, if appropriate, or if he/she develops adverse symptoms at a later time. If the patient requests additional medical advice, the base hospital should be involved.

If the patient refuses to sign the AMA form, this fact should be documented on the form. If EMS personnel determine that a patient with an emergency condition is not competent to refuse evaluation, treatment or

transport, the following alternatives exist: Patient should be transported to an appropriate facility under implied consent. In this case, a 5150 hold is not necessary. If EMS personnel determine it is necessary to transport the patient against his/her will and the patient resists or the EMS

personnel believe the patient will resist, assistance from law enforcement should be requested in transporting the patient. The police may consider the placement of a 5150 hold on the patient, but this is not required for transport.

If EMS personnel believe a parent or other legal representative of the patient is acting unreasonably in refusing indicated immediate care or transport, law enforcement authorities should be involved.

NOTE: At no time are field personnel to put themselves in danger by attempting to transport or treat a patient who refuses. At all

times, good judgment should be used and appropriate assistance obtained. RELEASE AT SCENE When ALS personnel have been called to an incident and have determined that an adult or emancipated minor does not

require treatment and/or transport, the patient may be released at scene. The patient should be advised to arrange for medical care if he/she develops adverse symptoms at a later time.

A patient released at scene should NOT sign an AMA form, as this implies that the patient is at significant risk by not utilizing the EMS system for treatment and/or transportation. ALS personnel shall document any advice given to the patient regarding follow-up treatment.




5150 Patients exhibiting signs of being a danger to themselves or others, or are gravely disabled, cannot be released at scene. EMS personnel should notify the proper authorities to request a 5150 determination and remain with the patient until authorities have made such a determination. DOCUMENTATION A PCR and a RAS/AMA form must be competed for each incident of patient refusal of emergency medical evaluation, care and/or transportation. EMS personnel shall ensure that documentation includes a patient history and assessment, details of the exam/evaluation that was performed, a description of the patient that clearly indicates his/her decision-making capacity, why the patient is refusing care, a statement that the patient understands the risks and consequences of refusing medical attention, and any alternatives presented to the patient.

General Patient Care July 2006 Determination of Death in the Prehospital Setting - 7006 Page 1 of 2



DETERMINATION OF DEATH IN THE PREHOSPITAL SETTING

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 CPR WILL NOT BE INITIATED OR MAY BE TERMINATED UNDER THE FOLLOWING CIRCUMSTANCES: UNWITNESSED ARREST Pulseless, apneic and “no shock” is indicated. WITNESSED ARREST Confirmed pulseless and apneic for ten or more minutes and “no shock” is indicated. A PULSELESS, APNEIC PATIENT WHO HAS MULTIPLE SIGNS OF PROLONGED LIFELESSNESS Rigor Mortis: Muscular stiffness following death, progressing from the upper to lower body, first detectable in the short

muscles. Determination of rigor mortis should include immobility of the jaw muscles and/or upper extremities. Lividity: Visible pooling of blood in dependant extremities or dependant areas of the body. Pupils: Fixed and dilated. Body Temperature: Loss of body warmth in a warm environment.

OBVIOUS DEATH Decapitation Incineration Destruction or separation of major organs (brain, heart, liver) Pulseless, apneic patient with injury not compatible with life Blunt traumatic arrest

DECLARED MCI'S Pulseless, apneic or agonal patient where triage principles and available resources preclude initiation of resuscitation

DO NOT RESUSCITATE ORDER Upon presentation of a valid Do Not Resuscitate Order or Durable Power of Attorney for Health Care, (DPAHC must request DNR or similar status): Do not initiate CPR. Terminate CPR if already in progress. If there is any doubt whether to start or withhold CPR, first responders should start CPR and await the arrival of an advanced

life support provider. Notify appropriate law enforcement agency and/or coroner. A completed Patient Care Report must be left at the scene or

faxed within 3 hours to the Coroner. Ensure scene security until released by law enforcement representative. Base Contact is NOT necessary.

Consideration: Strong family insistence on resuscitation may lead to base contact in cases where it otherwise may not be indicated.

General Patient Care July 2006 Determination of Death in the Prehospital Setting - 7006 Page 2 of 2



TERMINATION OF ADVANCED LIFE SUPPORT RESUSCITATION Resuscitation may be terminated under the following circumstances: Any case in which information becomes available that would have prevented initiation of resuscitation had that information

been available before resuscitation was initiated. Any patient who remains pulseless, apneic and asystolic after completing appropriate ACLS interventions per protocol. Any pulseless, apneic patient who’s presenting ECG deteriorates to asystole and is unresponsive to ACLS. Patients who remain pulseless and apneic but who remain in a cardiac rhythm other than asystole may have resuscitation

terminated with base physician approval only. Termination of Resuscitation During Transport If the patient is already enroute to the hospital, such a decision results in the immediate termination of "Code 3" transport. Transport shall continue to the closest receiving facility. All disposable ALS devices shall remain in place.

Termination of Resuscitation Prior to Transport If resuscitation is discontinued prior to transport, the Coroner shall be notified. The patient shall not be moved or searched. The area shall be secured until the arrival of the Coroner and/or the appropriate

law enforcement representative. All disposable ALS devices shall remain in place.

DOCUMENTATION A completed Patient Care Report must be left with the body or faxed within 3 hours to the coroner, including ECG strips showing date, time, patient name, paramedic ID#, and asystole in two leads PROCEDURE FOR AN ARREST IN A PUBLIC FORUM (Infineon, Petaluma and Sonoma County Fairgrounds, etc.) Victims of an arrest in a public forum shall be moved to a private working space or placed in the ambulance and fully assessed out of the view of bystanders in order to avoid a public spectacle. Exceptions include: Suspected crime scene Decapitation Incineration

Should determination of death be made during transport, an immediate termination of Code 3 transport shall occur. The patient will then be transported to the appropriate facility, either a hospital, or an authorized on-site medical facility. All other determination of death procedures shall apply.

General Patient Care July 2006 Patient Destination / Point of Entry - 7007 Page 1 of 4



PATIENT DESTINATION / POINT OF ENTRY

AUTHORITY Health and Safety Code Sections 1797.220, 1797.222 & 1798 California Code of Regulation, Title 22, Division 9, Sections 100144, 100304, 100107, 100128, 100175A2 PURPOSE Patients shall be transported to the nearest appropriate California licensed emergency receiving facility which is equipped, staffed, and prepared to receive emergency cases and administer emergency medical care appropriate to the needs of the patient as set forth herein. (Note: this does not preclude the transport of a patient to other facilities during the course of non-emergency inter-facility transfers or scheduled non-emergency transports at the request or direction of the patient’s private physician.) DEFINITION OF AN EMS RECEIVING HOSPITAL Title 22 (70411) requires that a Basic Emergency Service, Physician on Duty, be staffed and equipped at all times to provide prompt care for any patient presenting with urgent medical problems. Title 22 (70649) requires that a Standby Emergency Service, Physician on Call, be equipped and maintained at all times to receive patients with urgent medical problems and capable of providing physician service within a reasonable amount of time. DESTINATION DETERMINATION - GENERAL CONSIDERATIONS The destination for patients shall be based upon the clinical capabilities of the receiving hospital and the patient’s condition. Although the criteria listed below are the primary factors for determining the appropriate destination for patients, when the patient’s condition is unstable or life threatening, the patient should be transported to the closest appropriate hospital (based on its clinical capabilities). The following factors may also be considered in determining patient destination: Patient request Family request Patient's physician request or preference

DESTINATION FOR MAJOR TRAUMA PATIENTS Major trauma patients (i.e. those patients meeting trauma triage criteria) shall be transported as follows: Within 30 minutes transport time from a trauma center - patients shall be transported to the closest appropriate trauma

center. Between 30 - 60 minutes transport time from a trauma center - patients may be transported either to the closest hospital with

an emergency department or directly to the closest appropriate trauma center upon base hospital physician direction. Greater than 60 minutes transport time from a trauma center - patients shall be transported to the closest hospital with an

emergency department. Notwithstanding the above, patients with the following conditions shall be transported to the closest emergency department (including a standby ED):

Pulseless, apneic following trauma Unstable or unmanageable airway Rapidly deteriorating vital signs Base station physician order




APPROVED TRAUMA CENTERS The following factors shall be considered in determining the appropriate local trauma center for patient transports: Santa Rosa Memorial Hospital (Level II Trauma Center) - capable of receiving all types of trauma patients. Queen of the Valley Hospital (Level III Trauma Center) - Capable of receiving all trauma patients except those with neuro-

trauma (no patients with GCS < 13 or paralysis). DESTINATION FOR PEDIATRIC TRAUMA PATIENTS Pediatric patients (less than 15 years of age) with major trauma may be transported by EMS helicopter to an approved pediatric trauma center with the following exceptions: Greater than 30 minutes transport time unless otherwise authorized by base hospital. Pediatric patients meeting trauma triage criteria and originating from within the core areas of Santa Rosa and Napa will be

transported by ground ambulance to the closest appropriate Trauma Center. (Note: special consideration for safety and timeliness of transport should be exercised when utilizing an EMS Aircraft within other urban density areas located within the Coastal Valleys region.)

Notwithstanding the above, pediatric patients with the following conditions shall be transported to the closest appropriate emergency department: Pulseless, non-breathing following trauma Unstable or unmanageable airway Rapidly deteriorating vital signs Overall transport time to pediatric trauma center >30 minutes. (May be waived upon direct order of base station physician.) Base station physician order

DESTINATION FOR ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION PATIENTS Critical cardiac patients (i.e. those with ST segment elevation on prehospital 12 Lead ECG and with base physician concurrence) shall be transported as follows: Within 30 minutes transport time from a STEMI receiving center - patients shall be transported to the closest

appropriate STEMI receiving center.

Greater than 30 minutes transport time from a STEMI receiving center – patients shall be transported to the closest hospital with an emergency department.

APPROVED STEMI RECEIVING CENTERS STEMI receiving centers are those facilities that have met the requirements and are authorized according to the CVEMSA

STEMI Receiving Center policy. STANDBY EMERGENCY DEPARTMENTS Standby emergency departments are approved to receive ambulance patients with the following exceptions: Any patient meeting trauma triage criteria Massive bleeding from any source (including suspected internal bleeding) resulting in hypotension (systolic BP < 90) Patients with sustained altered level of consciousness (GCS < 13) Obstetric patients in active labor (imminent birth)

Patients meeting the above criteria should be transported either to a designated trauma center (if patient meets trauma triage) or the next closest hospital with a basic level ED.




Notwithstanding the above, patients with the following conditions shall be transported to the closest emergency department (including a standby ED): Pulseless, non-breathing following trauma Unstable or unmanageable airway Rapidly deteriorating vital signs Overall transport time to next closest acute care hospital with basic ED >30 minutes. (May be waived upon direct order of

base station physician.) Base station physician order

BURN PATIENT DESTINATION VIA EMS AIRCRAFT PURPOSE Patients with significant burns may be transported directly by EMS aircraft from the field to regional burn centers (with approved helipad) within the guidelines of the EMS Aircraft Policy. POLICY Patients with the following anatomical criteria are candidates for transport directly by air to the closest regional burn receiving facility: Full thickness burns greater than 5% burn surface area (BSA) Partial thickness burns greater than 10% BSA if under age 10 or over 50 Partial thickness over 20% - any age Partial or full thickness burns to the face, eyes, ears, hands, feet, perineum, genitalia, or major joints Significant electrical and caustic chemical agent burns Circumferential burns to an extremity or trunk Inhalation injury with evidence of significant burns Burns in high risk patients, including those with significant underlying medical conditions

Base contact should be made in cases where the burns are of uncertain depth or severity, or in any other case where the pre-hospital personnel require assistance deciding which is the most appropriate receiving facility.

EMS Air crews will be responsible for notifying the regional burn center with their ETA and field assessment. EXCEPTIONS Burn patients with traumatic injuries will be transported to the nearest appropriate trauma receiving facility. Patients with any of the following will be transported to the nearest receiving facility: Unmanageable airway Deteriorating vital signs Pulseless and apneic




REGIONAL BURN CENTERS (with approved helipad) Adult Patients - UC Davis Medical Center in Sacramento. Pediatric Patients - UC Davis Medical Center in Sacramento.

General Patient Care July 2006 Trauma Center Bypass - 7008 Page 1 of 3



TRAUMA CENTER BYPASS

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE The purpose of this policy is to mitigate Trauma Center Bypass occurrences by defining the criteria by which a Trauma Center may qualify for bypass and define the Trauma Centers responsibilities during an approved bypass occurrence. DEFINITIONS Disaster: Event(s) such that the hospitals internal disaster plans is initiated, and it is reported to the appropriate Department of Health Services official. Green: Normal operations. Able to receive all trauma patients that would normally be transported to the Trauma Center. Yellow: A Trauma Center on Yellow Bypass may still be considered the closest most appropriate Basic Emergency Department for patient destination. Patient acceptance will be considered on a case-by-case basis. Base hospital contact is required for patient destination decision. Red: Unable to accept Trauma Patients. Base hospital contact is required for patient destination decision. BYPASS ELIGIBILITY A Trauma Center may be considered eligible for bypass when any one of the following conditions exists. The physical plant is inoperable due to internal disaster i.e. fire, flood, structural damage, contamination, etc. such that the

physical plant is closed to emergency and walk-in traffic. The Trauma Center is inundated when any one of the following conditions are met:

1. The in-house trauma surgeon and back-up trauma surgeon(s) are encumbered in emergency resuscitation or operative procedures.

2. The anesthesia on-call and back-up anesthesia involved in emergency resuscitation or operative cases. 3. All O.R. crews involved in emergency resuscitation or operative cases.

Unusual circumstances other than the above may be approved for bypass on a case-by-case basis. This approval must be obtained from the on-call EMS duty officer (Sonoma County) . If it is after normal office hours, they may be contacted via the EMS dispatch center (707-568-5992). Napa County hospitals shall contact Napa Central Dispatch (707- 253-0911) who will notify the EMS Manager or Health Officer.

BYPASS INELIGIBILITY Except as noted in the Interfacility section below, the following conditions do not constitute acceptable grounds for Trauma Center bypass: There is a lack of clinical specialty back up, inpatient bed space or inpatient nursing staff. Trauma Bypass shall not be contingent upon ED saturation/diversion status or non-functioning CT scanner, except for

isolated traumatic head injuries. BYPASS PROCEDURE The on-call hospital administrator or designee must be notified and must approve the bypass status change prior to actual bypass of patients. The emergency department supervisor or designee shall make the bypass status change in the ReddiNet System. In the event of ReddiNet System outage, please refer to the Reddinet System Outage Notification Procedure section of this policy.




BYPASS PROCEDURE continued The bypass event shall last no longer than 2 hours for “Red Status”, at which time the Trauma Center status will be automatically updated to “Green”. Any ambulance transport initiated to the compromised Trauma Center prior to the status being changed shall continue to that facility and will not be redirected.

AMBULANCE DIRECTION Ambulance providers shall call their assigned base hospital for direction during any Trauma Center bypass event and consider the following: Transportation to the next closest Trauma Center by either ground or air. Ground ambulance providers should consider utilization of an EMS aircraft and/or transportation to an off-scene landing zone.

Patients may be transported to the nearest Emergency Department if timely access to an alternative Trauma Center is not possible. OFF BYPASS To re-establish normal ambulance traffic and acceptance of all trauma patients, the Trauma Center supervisor or designee shall update their status in the Reddinet System. In the event of Reddinet System outage, please refer to the Reddinet System Outage Notification Procedure section of this policy. REDDINET SYSTEM OUTAGE NOTIFICATION PROCEDURE In the event of ReddiNet System outage manual documentation will be required. Notification shall be documented in a written log, which shall indicate date and time the bypass was requested, specific qualifying reason for bypass, administrative approval, and time bypass ended. Copies of the bypass log must be submitted to the EMS agency on the first day of each month for the preceding month. Copies of the log may be requested by the EMS Agency at any time and must also be made available to state licensing agencies. Base hospitals must be notified immediately with all information from the bypass log, plus an estimate of time that the bypass event is expected to continue. Base Hospitals shall notify the other receiving hospitals that there is a Trauma Center bypass and an estimate of the time that the bypass event is expected to continue. Base Hospitals shall notify all EMS Dispatch Centers immediately with all information from the bypass log, plus an estimate of time that the bypass event is expected to continue. The EMS Dispatch Centers will then notify all ambulance providers and other appropriate dispatch centers of the bypass status of the affected Trauma Center. EMS AGENCY NOTIFICATION The EMS Dispatch Center will notify the on-call EMS duty officer with information provided by ReddiNet or the diversion log. The EMS Agency must be notified of the bypass event within two hours (weekdays); or the next working day (nights and weekends). The EMS Agency may at any time send EMS Agency staff to the facility on bypass to verify the reasons given for bypass.




BYPASS ADDENDUM Point of Entry Plan In circumstances of appropriate Trauma Center bypass, the EMS Agency, the base hospital, the requesting Trauma Center, and pre-hospital personnel shall not be considered in violation of the Coastal Valleys Region Point of Entry Plan. Bypass Prognosis Base hospitals and/or the EMS Agency may check with the Trauma Center at any time to determine the prognosis for continuance of bypass. Base Hospital Resource Availability Whenever a Trauma Center in the EMS system is on bypass, base hospitals shall keep an update of surrounding Trauma Center availability for their service area and applicable adjacent areas. The EMS Dispatch Center shall not be called regarding surrounding Trauma Centers status. INTERFACILITY TRAUMA TRANSFER – SPECIAL CONSIDERATIONS The trauma center shall not redirect interfacility trauma patients when: Patients are candidates for immediate surgical/operative intervention and when such services are available, and

the trauma center is not on “Bypass” regardless of bed availability. The trauma center may redirect interfacility trauma patient transfers when not on “Bypasss” in the following circumstances: Patients requiring surgical specialty care services when such services are not available, e.g., cardiothoracic.

In the event a sending facility is redirected by the Trauma Center, the sending facility shall contact the nearest Level I Trauma Center for consultation and direction. EMS AGENCY RIGHT TO DENY BYPASS The EMS Agency reserves the right to deny bypass approval based on overriding community need, impending EMS system need or determination that bypass criteria are unmet. If multiple Trauma Centers meet bypass criteria at the same time, Trauma Centers will be expected to treat patients to the best of their ability and there will be no EMS Agency approved bypass for any facility.

General Patient Care July 2006 Suspected Elder and Dependent Adult Abuse Reporting Guidelines - 7009 Page 1 of 3



SUSPECTED ELDER AND DEPENDENT ADULT ABUSE REPORTING GUIDELINES

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Welfare and Institutions Code Sections 1560 and the California Code of Regulations, Title 22, 100159 and 100075 PURPOSE To define suspected elder and dependent adult abuse and the required reporting procedures for prehospital care personnel. PRINCIPLES Elder adults (age 65 or over) and dependent adults (ages 18 to 64) with mental, developmental, or physical disabilities may be vulnerable to abuse or neglect. POLICY EMT-Is and EMT-Ps, as health care practitioners, are mandated reporters and have a legal obligation to report known or suspected elder or dependent adult abuse under the following circumstances: When the reporter has observed an incident that reasonably appears to be physical abuse When the reporter has observed a physical injury where the nature of the injury, its location on the body or the repetition of

the injury clearly indicates that physical abuse has occurred When an elder or a dependent adult tells the reporter that he or she has experienced behavior constituting physical abuse.

The law encourages mandated reporters to voluntarily report known or suspected instances of other types of abuse of an elder or of a dependent adult including neglect, mental abuse, financial abuse, isolation and abandonment. Reports made under this law are confidential. The identity of all persons making reports of elder or dependent abuse is also confidential. This information will be shared only between the investigating and licensing agencies, with the district attorney in a criminal prosecution resulting from the report, by court order, or when the reporter waives the right to remain anonymous. When two or more persons who are required to report are present and jointly have knowledge of a known or suspected instance of abuse of an elder or dependent adult, and when there is agreement among them, the telephone report may be made by a member of the team selected by mutual agreement and a single report may be made and signed by the selected member of the reporting team. Any member who has knowledge that the member designated to report has failed to do so shall hereafter make the report. Reporting is the individual responsibility of the mandated reporter. No supervisor or administrator may prohibit the filing of a required report.

Mandated reporters who report suspected cases of elder or dependent adult abuse in good faith, have absolute immunity, both civilly and criminally, for making a report of physical abuse of an elder or dependent adult. This includes taking of photographs of the victim and surroundings to submit with the report.

FAILURE TO MAKE A MANDATORY REPORT OF SUSPECTED PHYSICAL ABUSE OF AN ELDER OR DEPENDENT ADULT IS A MISDEMEANOR.




REPORTING PROCEDURES Reports of physical abuse are to be made immediately, or as soon as possible, by telephone. When reporting abuse that allegedly occurred in a long -term care facility or Adult Day Health Care Center, contact either the

local law enforcement agency or the Long-term Care Ombudsman Program: Napa Sonoma Mendocino 707-253-4625 707-565-5940 707-463-7900

When the abuse is alleged to have occurred anywhere else, contact either the local law enforcement agency or Adult Protective Services at:

Napa Sonoma Mendocino 707-253-4625 707-565-5940 707-463-7900

VERBAL REPORT Reports are to include the following information: The name, address, telephone number and occupation of the person making the report. The name, address, and age of the elder or dependent adult. Date, time, and place of the incident. Other details, including the reporter's observations and beliefs concerning the incident. Any statement relating to the incident made by the victim. The name(s) of any individual(s) believed to have knowledge of the incident. The name(s) of the individual(s) believed to be responsible for the incident and their connection to the victim.

WRITTEN REPORT The Report of Suspected Dependent Adult/Elder Abuse must be completed and submitted to the agency initially contacted within two (2) working days of the verbal report. VOLUNTARY REPORTS Reports of mental or financial abuse, neglect, isolation or abandonment of an elder or dependent adult by that person's caretaker may be made by verbal or written report. REPORT INSTRUCTIONS Complete a form for each incident and each victim of suspected elder physical abuse. Fill out the form as completely and clearly as possible using lay terminology. If any item of information is unknown, write 'unknown' beside the item.

Section A - Reporting Party: The person initiating the report must complete this section. It must include the reporting person's name, place of employment,

and employment phone number. For legal purposes, the date of the written report must be completed. The signature of the reporting party is required in this section.

Section B - Report Made To: Record the name of the person and agency to whom a verbal report was first made. This person will be receiving the written

reports. When the report was made to more than one agency, the contact person(s) for the additional agencies should be listed in the

comment section. The date and time of the verbal report must be recorded to provide legal proof of the verbal report.




Section C - Victim: Enter as much information as possible. If the birth date is unknown, enter the approximate age.

Section D - Incident Information: Record the date, time, and place of incident. Check the appropriate box indicating how the person filing the report became aware of the incident. If the incident occurred in an out-of-home-care setting, check the appropriate box. When more than one type of abuse is suspected, check all that apply.

Section E - Comments: Write objectively. Quote statements made by the victim or guardian. Document the incident as it was told by each person (use extra paper if necessary). Indicate circumstances that may have contributed to the abusive/neglectful situation (i.e. handicapped, bedridden, lack of

resources). Distribution Instruction Send the original report to the elder protective agency previously contacted by phone. Send a copy of the report to:

Mendocino County APS Sonoma County APS Napa County APS 126 North Orchard Avenue P O Box 1539 900 Combs St., Suite 257 Ukiah, CA 95482 Santa Rosa CA 95402 Napa CA 94559

The reporting party should retain one copy of the original.

General Patient Care July 2006 Suspected Child Abuse Reporting Guidelines - 7010 Page 1 of 3



SUSPECTED CHILD ABUSE REPORTING GUIDELINES

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Welfare and Institutions Code Sections 1560 and the California Code of Regulations, Title 22, 100159 and 100075 PURPOSE To provide guidelines for the identification of suspected child abuse and the procedure for reporting such suspicions by prehospital personnel. DEFINITIONS Agencies authorized to accept mandated reports: Police Department, Sheriff's Department, Child Protective Services (CPS). School District police and security departments are not included.

Child: Any person under the age of eighteen.

Mandated reporter: Any healthcare practitioner, childcare custodian, or employee of a child protective agency. This includes EMTs and paramedics.

Neglect: The negligent failure of a parent or caretaker to provide adequate food, clothing, shelter, medical/dental care, or supervision.

Physical abuse: A physical injury, including death, to a child that appears to have been inflicted by other than accidental means.

Sexual abuse: Sexual assault on or the exploitation of a minor. Sexual assault includes: rape, rape in concert (aiding or abetting or acting in concert with any person in the commission of a rape), incest, sodomy, oral copulation, penetration of genital or anal opening by a foreign object, and child molestation. It also includes lewd or lascivious conduct with a child under the age of fourteen years, which may apply to any lewd touching if done with the intention of arousing or gratifying the sexual desire of either the person involved or the child. Sexual exploitation includes conduct or activities related to pornography depicting minors and promoting prostitution by minors. PRINCIPLES The purpose of reporting suspected child abuse/neglect is to protect the child, prevent further abuse of the child and other children in the home, and begin treatment of the entire family. The infliction of injury, rather than the degree of that injury, is the determinant for intervention by the CPS and law enforcement. California Penal Code, Sections 11166 and 11168, requires that mandated reporters promptly report all suspected non-accidental injuries, sexual abuse, or neglect of children to local law enforcement and/or to the CPS. It is the job of law enforcement, CPS and the Courts to determine whether or not child abuse/neglect has, in fact, occurred. It is not necessary for the mandated reporter to determine child abuse, but only to suspect that it may have occurred. Children under the age of four, especially less than six months, are at highest risk.

Under current law, all healthcare professionals are mandated to report suspected child abuse/neglect that they have knowledge of or observe in their professional capacity. They are required to sign a statement acknowledging their understanding of this requirement. Any person who fails to report as required may be punished by six months in jail and/or a $1,000 fine.




When a mandated reporter has knowledge of or has observed child abuse or neglect, that individual is required to report to the local law enforcement and/or to the CPS immediately or as soon as practically possible by telephone and shall complete the suspected child abuse report form within 36 hours.

When two or more mandated reporters are present at scene and jointly have knowledge of a known or suspected instance of child abuse/neglect, the telephone report can be made by a selected member and a single written report may be made and signed by the selected member of the reporting team. Any member who has knowledge that the designated reporter failed to uphold their agreement, shall thereafter make the report. If the paramedics are not selected as the designated reporter, they shall document the name and agency of the appointed team member on the Patient Care Report to indicate that the reporting obligation has been met.

Those persons legally required to report suspected child abuse have immunity from criminal or civil liability for reporting as required. POLICY REPORTING PROCEDURES The primary purpose of the Department of Justice (DOJ) Suspected Child Abuse Report form SS 8572 is to make all agencies aware of possible abuse/neglect. This will lead to a thorough investigation and protection of the child. In order to facilitate this process in Coastal Valleys EMS Region, it is recommended that a prompt verbal report be made to both Child Protective Services (CPS) and local law enforcement. However, if the child is in imminent danger, local law enforcement should be notified immediately.

To make a verbal report to CPS, call the 24-hour Child Abuse Hotline.

Napa Sonoma Mendocino 707-253-4261 707-565-4604 707-463-7990 800-464-4216 800-870-7064

This should be done as soon as possible. It is recommended that the Child Abuse Report form be completed prior to making verbal notification. Prehospital care providers should be aware of their local law enforcement reporting procedures and telephone numbers for notification.

The suspected child abuse/neglect report is to be completed according to the instructions on the back of the form. The completed form shall be sent to local law enforcement and CPS within 36 hours.

Napa County CPS Sonoma County CPS Mendocino County CPS P O Box 815 PO Box 1539 126 North Orchard Ave Napa, CA 94559 Santa Rosa, CA 95402 Ukiah, CA 95482

The following should be documented on the EMS patient care report: 1. The name of the CPS social worker and/or name, department and badge number of the law enforcement officer. 2. Time of notification. 3. Disposition of child if not transported. REPORTING INSTRUCTIONS Complete DOJ Suspected Child Abuse Report form SS 8572 for all suspected cases of child abuse/neglect reported. The report shall be filled out as completely and clearly as possible using lay terminology.




Section A - Case Identification: To be completed by investigating agency authorized to receive the report.

Section B - Reporting Party: To be completed by the person who initiated the report. Include name, title, address, phone number (include area code), date

of report and signature. Section C - Report Sent To: Check the appropriate box that identifies the agency designated to receive the report. Enter the name and address of the agency to which the report is being sent. Enter the name and phone number of the official at the designated agency and the date and time that contact occurred. The date and time are extremely important as they provide legal proof of verbal report.

Section D - Involved Parties: Victim: Enter the name, address, physical data, present location and phone number where victim is located (attach additional

sheets if multiple victims). If the birth date is not known, enter the approximate age. Siblings: Enter the name and physical data of siblings living in the same household as the victim. It is important to indicate

when there are other children in the home even if no definitive information is available. Parents: Enter the names, physical data, addresses and phone numbers of father/stepfather and mother/stepmother. If

information is unavailable, document "information not available." Section E - Incident Information: Enter the date, time and place where the incident occurred or was observed and check the appropriate boxes. Check the type of abuse (there may be more than one type of abuse). Write objectively; carefully describe all injuries and evidence of sexual assault, if applicable. When obtaining information from the individual who is witness to the alleged abuse/neglect, attempt to use direct quotes when

describing the incident. If the parent, guardian or person accompanying the child changes his/her description of the occurrence, document both

versions (use extra paper if needed). If known, document prior incidents involving the victim. When documenting neglect situations, stress the endangerment of the child. Endangerment is a key factor in the timely

investigation of these cases. Indicate circumstances that may contribute to an abusive/neglectful situation (e.g. handicapped child or parent, substance

abuse, spousal abuse, lack of resources, etc.). DISTRIBUTION Retain the yellow copy of the suspected Child Abuse Report Form SS8572 for your records and submit top three copies (white, blue and green) to the applicable child protective agency.

Field Manual-Treatment Guidelines July 2006 Unexpected Infant – Child Death - 7011 Page 1 of 1



UNEXPECTED INFANT/CHILD DEATH ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE

To establish routine procedures to assist EMS personnel with calls involving the death of children in the pre-hospital setting. Goals of these procedures include minimizing the stress placed on parents and other family members, providing avenues for support to parents and families, and preventing scene contamination and disruption.

PROCEDURE

Determine whether to perform further resuscitation measures: If patient does not exhibit lividity or rigor, and there is no authorized DNR present, proceed with CPR and follow

applicable resuscitation treatment policies. If patient exhibits lividity and rigor, do not resuscitate or transport. If in the EMS personnel’s judgment, transport

will be beneficial due to scene conditions, transport may be initiated. Provide supportive measures for parents and siblings:

Do not express your assumptions or judgments regarding the cause of death. Explain the resuscitation process, transport decision, and further actions to be taken by hospital personnel or the

medical examiner. Use the child’s first name. Allow parent to see the child and say goodbye. Maintain a supportive, professional attitude no matter how the parents react. Whenever possible, be responsive to parental requests. Be sensitive to ethnic and religious needs or response and make allowances for them. Assist family with contacting grief support if available.

Obtain a patient history. Use a non-judgmental approach. Ask open ended questions as follows: When was your child well? What has changed or occurred since then? Has the child been sick? Who found the child? Where? Has the child been moved? What time was the child last seen breathing? Was the child taking any medications? What was done after the child was discovered? When did the child eat last?

DOCUMENTATION

Thoroughly document all findings obtained during history gathering, patient assessment, and scene examination.

Field Manual-Treatment Guidelines July 2006 Apparent Life Threatening Event - ALTE - 7012 Page 1 of 1



APPARENT LIFE THREATENING EVENT – ALTE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To increase awareness of the risks of Apparent Life-Threatening Events, and to encourage the transport of patients who have suffered symptoms of an ALTE.

DEFINITION An Apparent Life-Threatening Event (ALTE) is an episode that frightens a child’s caretaker. These events can involve any of the following:

Apnea Color change (cyanosis, pallor, erythema) Marked change in muscle tone (limpness) Choking or gagging

These events usually occur in infants less than 12 months old, but ALTE should be suspected in any child less than 2 years of age who displays these symptoms. Most patients will appear stable and may have a normal physical exam by the time field personnel arrive. Despite their appearance, some of these patients will be later diagnosed with conditions that may require further medical care. TREATMENT

Assume the history given is accurate. Obtain a description of the severity, nature, and duration of the event. Obtain a complete medical history. Check for:

Any known chronic illnesses Evidence of seizure activity Current or recent infections History of gastro-esophageal reflux (spitting, vomiting) Inappropriate mixture of formula History or evidence of recent trauma Medications (current and recent including over the counter drugs) Associated events (eating, crying, etc.)

Complete a comprehensive physical exam. Include evaluation of the child’s appearance, skin color, and interaction with the environment and parents. Check for any evidence of trauma.

Treat any identifiable injuries/illnesses. Transport.

If the parent or guardian refuses medical care and/or transportation, make base contact with the Base Hospital Physician prior to completing an AMA form and leaving the scene.

General Patient Care July 2006 Interfacility Transfers - 7013 Page 1 of 7



INTERFACILITY TRANSFERS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Health and Safety Code, Section 1798.172, Chapter 1240 (SB 12),California Code of Regulations, Title 22 , Chapter 1240 of the 1987-88 California Legislative Session, the Joint Commission on Accreditation of Hospital Standards, the OSHA Consent Manual. PURPOSE It is the intent of these guidelines to assure compliance with Health and Safety Code Section 1798.172, Chapter 1240 (SB 12) to assure that hospitals in meet the obligations of their license to provide emergency medical services and that patients requiring transfer to another facility for any reason will be transferred safely and without delay. Hospitals and transport providers shall adhere to any and all standards set forth here when implementing the interfacility transfer of patients. As defined in Chapter 1240, the State Department of Health Services shall be responsible for development of protocols and procedures for implementation as well as review and investigation of reported transfer violations. SCOPE This policy addresses the interfacility transfer of patients accompanied by prehospital care personnel. This policy applies to transfers originating at a facility in a designated EMSA region with destination within or out of the same region. The EMT-I's and Paramedics may perform any activity identified in their scope of practice, California Administrative Code, Title 22, Division 9, which has been approved by their local EMS Agency. DEFINITIONS Transferring Facility: The facility from which the patient is being transferred. Base Hospital: Approved base hospital directing the paramedic transfer call. Receiving Facility: The facility to which the patient is being transferred. BASIC RESPONSIBILITIES FOR TRANSFER A variety of reasons may exist for the transfer of a patient to another hospital or health facility including: needed services not available at the transferring facility; a shortage of needed beds at the transferring facility; patient request; patient repatriation; patient needing a lower level of care.

Hospitals licensed to provide emergency services must fulfill their obligation under the California Health and Safety Code to provide emergency treatment to all patients regardless of their ability to pay. Transfer made for reasons other than immediate medical necessity must be evaluated to assure that the patient can be safely transferred without medical hazard to the patient's health and without decreasing the patient's chances for or delaying a full recovery. In these cases, physicians and hospitals should take a generally conservative view, deciding in favor of patient safety. Patient transfers involve the following physician and hospital responsibilities: Each hospital is expected to process all transfers in accordance with Title 22 of the California Code of Regulations, Chapter

1240 of the 1987-88 California Legislative Session, the Joint Commission on Accreditation of Hospital Standards, the OSHA Consent Manual and those conditions specified by these transfer guidelines.




Each hospital shall have its own written transfer policy clearly establishing administrative and professional responsibilities.

Transfer agreements must also be negotiated and signed with hospitals that have specialized services not available at the transferring facility. In addition, hospitals seeking consent to transfer patients to county hospitals shall execute formal transfer agreements implementing these guidelines.

All hospitals with basic emergency room permits must maintain a roster of specialty physicians available for consultation at all times. Hospitals shall ensure that physician specialists or services are available for the treatment of emergency patients regardless of ability to pay. All hospitals in with stand-by emergency room permits must have transfer agreements with other hospitals that maintain a roster of specialty physicians available for consultation at all times. Notwithstanding the fact that the receiving facility or physicians at the receiving facility have consented to the patient transfer, the transferring physician and facility have responsibility for the patient until arrival at the receiving hospital. The transferring physician, in consultation with the receiving physician, decides what professional medical assistance should be provided for the patient during the transfer. The transferring physician has a responsibility to candidly and completely inform the receiving physician of the patient's condition so that the receiving physician can make suitable arrangements to receive the patient. A hospital shall not accept a patient in transfer when the appropriate level of care cannot be provided. TRANSFER STANDARDS Patient Safety Physicians considering patient transfer should exercise conservative judgment, always deciding in favor of patient safety. Emergency Care If the patient presents to an emergency room, the transferring physician or other appropriate medical personnel operating under a physician's direction, must examine and evaluate the patient to determine if the patient has an emergency medical condition or is in active labor and if so, perform emergency care and emergency services where appropriate facilities and qualified personnel are available. Emergency Medical Condition The term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the patient's health in serious jeopardy; serious impairment to bodily functions, or serious dysfunction of any body organ or part; potential for death.

Active Labor The term "active labor" means labor at a time at which: there is inadequate time to effect safe transfer to another hospital prior to delivery; or a transfer may pose a threat to the health and safety of the patient or unborn child.




Unavailability of Services Facilities and personnel for emergency care and emergency services shall be consistently available to patients regardless of ability to pay. If, however, a transferring physician is, for whatever reason, faced with the unavailability of needed emergency facilities and/or personnel, and therefore a greater risk exists to the patient if there is no transfer, then the transferring physician may initiate transfer and the receiving physician may accept the transfer.

Consent of Receiving Physician No transfer shall be made without the consent of the receiving physician and confirmation by the receiving hospital that the patient meets the hospital's admissions criteria relating to appropriate bed, personnel and equipment necessary to treat the patient. Medical Fitness of Patient For all other circumstances except those outlined above, the transferring physician must determine whether the patient is medically fit to transfer. This determination may include but should not be limited to: Establishing and assuring an adequate airway and adequate ventilation; Initiating control of hemorrhage; Stabilizing and splinting the spine or fractures; Establishing access routes for fluid administration as needed; Initiating fluid and/or blood replacement as needed; Determining that the patient's vital signs (including blood pressure, pulse, respirations as indicated) are sufficient to sustain

adequate perfusion. The vital signs should remain within these parameters for a reasonable period of time prior to transfer; Determining that the patient has a stable level of consciousness for a reasonable period of time prior to transfer; Providing that patient receives cardiac monitoring, if appropriate; and In the case of pregnant women, determining with reasonable certainty that delivery will not occur during the expected duration

of transfer and that neither the mother nor fetus show any signs of distress. Advisement of Patient The patient or the patient's legal representative must be advised, if possible, of the need for the transfer and the alternatives, if any, to the transfer as well as adequate information regarding the proposed transportation plans and the benefits and risks, if any, of the proposed transfer. Patient Needs Once the decision to transfer the patient has been reached, every effort should be made to affect the transfer as rapidly and safely as possible. The transferring physician must take into account the needs of the patient during transport and the ability of the transport personnel to care for the patient. Scope of Practice of Transport Personnel Transport personnel are not authorized and will not provide services beyond their scope of practice. Should services beyond scope be required, a person qualified in its performance shall accompany the patient during transport.




PREARRANGED TRANSFER AGREEMENTS Interfacility transfers shall be accomplished by prearranged transfer agreements between the transferring and receiving hospitals and transport shall be performed by an ALS ambulance, BLS ambulance, wheelchair / gurney car in accordance with the Interfacility Transfer Policy. The designated ALS transfer units shall be ALS equipped and staffed to the level required of ALS emergency response ambulances in Response and Transportation Section of The Coastal Valleys EMSA policy manual. If patient transport needs exceed the EMT-P scope of practice, then the transferring physician will order a critical care or emergency care level Registered Nurse and any other personnel, equipment or supplies necessary for patient care. This is true even when ambulances are staffed with EMT-P (paramedic) personnel. ADDITIONAL REQUIREMENTS FOR TRANSFER FOR NON-MEDICAL REASONS When patients are transferred for non-medical reasons such as an inability to pay; the transferring hospital must follow all of the above requirements. In particular, the transferring physician must ensure that emergency care and emergency services have been provided and shall determine that the transfer would not create a medical hazard to the patient and would not decrease that patient's chances for or delay the patient's full recovery. The transferring physician must verify these determinations on the patient transfer form. The transferring physician must still arrange for an accepting physician at the receiving facility. REPORTING REQUIREMENTS The receiving hospital personnel, physicians, emergency department personnel and prehospital care providers are required to report all apparent violations of these guidelines and regulations relating to patient transfers. The transferring hospital personnel are permitted to report all apparent violations of these guidelines and regulations relating to patient transfers. These reports shall be made to the State Department of Health Services on a form prescribed by the State Department, within 72 hours of the occurrence of the violation for the purpose of review and investigation. TRANSFER DETERMINATION Attending physician makes a determination that a interfacility transfer is needed and the level of transfer care required, as defined in "Guidelines for Determining Level of Transfer" (following). Receiving physician and facility agree to accept patient. Transferring facility requests appropriate level transfer unit from a EMS provider unless agreed between transferring and

receiving facility that receiving facility is to make arrangement. Transferring facility will advise EMS provider of the following:

Patient's name Diagnosis/level of acuity Destination Transfer date and time Unit transferring patient Level of transfer requested Sending doctor’s name Treatment received History, medication, allergies and orders Special equipment with patient Additional hospital personnel attending patient

If patient requires a ventilator, respirator, or in situations where additional airway management may be advantageous, a respiratory therapist or R.N. will accompany patient to assist in airway management.

The EMS provider agrees to accept the transfer based on reported information and advises ETA of transfer unit. The transfer unit notifies their operational area dispatch of destination per county protocol.




GUIDELINES FOR DETERMINING LEVEL OF TRANSFER

Determination of level of transfer required. (X = Minimum level of service required)

Wheelchair or Gurney

car

Basic Life Support (EMT)

Advanced

Life Support (paramedic)

RN

Physician

Vital signs stable

X

X

Oxygen by mask or cannula

X

Level of consciousness stable

X

IV fluids running (no additives)

X

Continuous respiratory assistance needed

X*

Peripheral IV medications running or anticipated (refer to following chart)

IV medications outside county protocols running or anticipated

X

Paramedic level interventions

X

Central IV line in use

X

PA line in use

X

Arterial line in place

X

Temporary pacemaker in place

X

ICP line in place

X

IABP in place

X

Chest tube

X

Neonatal transport

X

* Respiratory therapist or R.N.




Approved for Paramedic (ALS) Transfers 25% and 50% dextrose activated charcoal adenosine aerosolized or nebulized beta-2 specific bronchodilators amiodarone aspirin atrovent atropine sulfate calcium chloride diazepam diphenhydramine hydrochloride dopamine hydrochloride epinephrine furosemide glucagon midazolam lidocaine hydrochloride morphine sulfate naloxone hydrochloride nitroglycerin preparations, except intravenous unless permitted by EMS Agency Medical Director potassium <20mEq sodium bicarbonate syrup of ipecac

Approved for EMT (BLS) Transfer Monitor IV lines delivering intravenous glucose solutions or isotonic balanced salt solutions including Ringer’s lactate for

volume replacement. Monitor, maintain and adjust as necessary to maintain a preset rate of flow and/or turn off the flow of intravenous fluid. Transfer a patient, who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes,

gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines.

Approved for Wheelchair/Gurney Car Transfer Any patient who does not require monitoring or intervention by transport personnel. Any medical devices on the patient will

not be in use nor available to transporting personnel. Any transdermal medication applications must have been in use for 12 hours or more.

COMMUNICATION Transport personnel shall receive appropriate patient status report from transferring physician and/or RN. The paramedic shall receive the transferring orders from the transferring physician prior to leaving the sending hospital,

including a telephone number where the transferring physician can be reached during the patient transport. Copies of all pertinent medical records, lab reports, x-rays, and transfer forms accompany patient to receiving facility. Transport personnel shall receive patient report and confirm appropriate level of care for transfer. If transport personnel and

transferring physician are unable to agree, they will confer with the base hospital physician. All levels of transfer will have a patient care record completed by the transport personnel.




TRANSFER SUMMARY The records transferred with the patient shall include a "transfer summary" signed by the transferring physician which contains relevant transfer information. The form of the "transfer summary" shall, at a minimum, contain the patient's name, address, sex, race, age and medical condition; the name and address of the transferring doctor or emergency department personnel authorizing the transfer; the time and date the patient was first presented at the transferring hospital; the name of the physician at the receiving hospital consenting to the transfer and the time and date of the consent; the time and date of the transfer; the reason for the transfer; and the declaration of the signor that the signor is assured, within reasonable medical probability, that the benefits of the transfer outweigh any medical risk to the patient. Neither the transferring physician nor transferring hospital shall be required to duplicate in the "transfer summary" information contained in medical records transferred with the patient. In addition, the "transfer summary" shall include any other information pertinent to patient care as outlined in this policy. TRANSFER PROCEDURES FOR PATIENTS WITH DNR ORDERS Patients who are being transferred with Do Not Resuscitate orders shall also have orders to the effect of the destination of the patient in the case of death during transfer. Options for destination include the patient’s intended receiving facility (i.e. home, skilled nursing home, hospital), predetermined funeral home or the coroner’s office. It shall be the responsibility of the transferring facility and the provider of the transport to ensure that these arrangements have been made prior to the initiation of the transfer. EXCEPTIONS TO TRANSFER PROCEDURE If an ALS transfer unit is unavailable, the transferring physician may request a BLS unit staffed with at least one R.N. and appropriate equipment. QUALITY IMPROVEMENT ALS interfacility transfer calls will be reviewed as per the Quality Improvement policy of the CVEMSA policy manual.



BLS TREATMENT GUIDELINES

Field Manual-Treatment Guidelines July 2006 BLS Routine Medical Care -8001 Page 1 of 1



BLS ROUTINE MEDICAL CARE ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Scene Safety Assure scene safety prior to patient contact. ABC’s Assess Airway, Breathing and Circulation ( A B C )

ABC’s NOT OK Begin CPR in accordance with the standards established by the American Heart Association, including Early Defibrillation

(when available). Control significant external bleeding

ABC’s OK Administer oxygen per the Airway/Oxygen protocol Check vital signs – repeat every 5 minutes for emergent patients and every 15 minutes for non-emergent patients Obtain

Chief complaint History of current event Past medical history Medications Allergies

Perform secondary full patient exam Spinal Immobilization Perform manual spinal immobilization, if indicated, per the BLS Spinal Immobilization protocol.

Ensure ALS response as appropriate

Field Manual-Treatment Guidelines July 2006 BLS Spinal Immobilization - 8002 Page 1 of 1



BLS SPINAL IMMOBILIZATION GUIDELINE ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Indications

Obvious head trauma Obvious spinal trauma Complaints of neck pain, spinal pain or numbness in the extremities Blunt or multi-system trauma Falls with possible head, neck or spine trauma Any decelerating mechanism of injury Penetrating injuries to the neck Unconscious patients with unknown injuries Impaired patient at risk for spinal injury

Manual immobilization with Cervical Collar

If indicated, apply manual immobilization and cervical collar Where a cervical collar is difficult or impossible to apply, manual immobilization alone may be used A cervical collar alone does NOT provide acceptable cervical spine immobilization

Maintain manual immobilization during and after patient movement until the patient has been fully immobilized on a

backboard.

Field Manual-Treatment Guidelines July 2006 Airway – Oxygen - 8003 Page 1 of 1



BLS AIRWAY/OXYGEN ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Assess respiratory rate Respirations <10/minute

Clear airway as necessary. This may include placing the patient on his/her side (left lateral position) and suctioning Consider inserting an airway adjunct Nasopharyngeal airway for patients with gag reflex Oropharyngeal airway for patients without gag reflex Assist ventilations as needed Consider inserting an airway adjunct

Respirations >10/minute Place on high-flow oxygen (12-15 liters/minute by non-rebreather mask) if ANY of the following:

Shortness of breath Major trauma Unconscious/altered mental status Chest pain Pregnancy with complications Major burns Respirations over 20 per minute and labored Smoke/toxic inhalations Blood pressure < 100 systolic in adults Stroke/TIA

Place on low-flow oxygen (2-6 liters/minute by nasal cannula) only if NONE of the above and ALL of the following criteria are met:

Skin pink/warm/dry Blood pressure >100 systolic in adults Pulse 60-100 bpm Respirations 12-20/minute and unlabored Alert & fully oriented

Field Manual-Treatment Guidelines July 2006 BLS Pulse Oximetry - 8004 Page 1 of 1



PULSE OXIMETRY ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To authorize provider agencies to use pulse oximetry in the prehospital setting. Pulse Oximetry Pulse oximetry is for reporting purposes only. Do not withhold oxygen therapy based on pulse oximetry reading.

Field Manual-Treatment Guidelines July 2006 Airway Obstruction - 8005 Page 1 of 1



AIRWAY OBSTRUCTION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Definition

Mechanical upper airway obstruction with history of food aspiration (especially if elderly), alcohol abuse, child playing with small objects

Conscious Patient - Able To Speak

Offer reassurance, do not intervene, encourage coughing Offer oxygen via cannula Frequent gentle suctioning as needed to control secretions

Conscious Patient - Unable To Speak or Cough

Confirm airway obstruction Adult / Child >1 Year Old

Administer continuous abdominal thrusts until the foreign body is expelled or the patient becomes unconscious (see treatment below).

Infants < 1 Year Old Administer 5 back blows and 5 chest thrusts repeatedly with child supported in a head down position until the foreign

body is expelled or the patient becomes unconscious (see treatment below). After obstruction is relieved, reassess airway, lung sounds, skin color and vital signs Oxygen as indicated

Unconscious Patient Adult, Child > 1 Year Old or Infants < 1 Year Old

Place patient in supine position Begin CPR; observe airway prior to each ventilation; if an object is seen remove object and reassess patient. Continue

CPR as indicated

Field Manual-Treatment Guidelines July 2006 BLS Shortness of Breath/Chest Pain - 8006 Page 1 of 1



BLS SHORTNESS OF BREATH/CHEST PAIN ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE

Position of comfort. (Never force a patient with shortness of breath to lie down.) If pregnant, do not place patient on back.

Administer high-flow oxygen (12-15 liters/minute by non-rebreather mask.) Prepare to assist ventilations with bag/valve/mask and 100% oxygen if needed.

Provide supportive care. Assist patients with the administration of physician-prescribed devices,and prescribed medications, including but not limited to:

Patient operated medication pumps Sublingual nitroglycerin Self-administered emergency medications, including epinephrine devices

Do not allow patient to exert him/herself.

Field Manual-Treatment Guidelines July 2006 BLS Altered Mental Status - 8007 Page 1 of 1



ALTERED MENTAL STATUS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Suspicion of Poisoning or Overdose

Maintain airway and left lateral “recovery” position. Attempt to determine cause.

Observed Seizure

If still seizing, protect from injury. During and after seizure, maintain airway and left lateral “recovery” position.

Trauma Mechanism

Maintain Spinal Immobilization precautions and airway. Known or Suspected Diabetic

If awake, able to hold head upright, and gag reflex present, assist the patient to self-administer glucose paste or solution. Patient MUST be able to swallow without difficulty.

If not awake, not able to swallow, unable to hold head upright, or no gag reflex, maintain airway and left lateral “recovery” position.

Unknown Cause and/or History

Maintain airway and left lateral “recovery” position.

Field Manual-Treatment Guidelines July 2006 Trauma Management - 8008 Page 1 of 1



TRAUMA MANAGEMENT ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE EXPEDITE TRANSPORT

Spinal Immobilization precautions as necessary. Remove or cut away the patient's clothing to expose injuries. Control significant external bleeding as follows (tourniquets should not be used):

Direct pressure Elevation - Use caution if suspect possible fracture Pressure points

Treat suspected shock. Shock should be suspected when there is a mechanism of injury or the skin is pale, cool and diaphoretic. Vital signs alone are not a reliable indicator of shock.

Elevate legs only if shock is suspected. Administer high-flow oxygen. Keep the patient warm.

Stabilize fractures in the position found or the patient's position of comfort. Pulses distal to the fracture should be checked within 2 minutes of completing the primary survey and at least

every 15 minutes thereafter. Distal pulses and capillary refill should also be checked before and after any movement of a suspected fracture.

Field Manual-Treatment Guidelines July 2006 Burns - 8009 Page 1 of 1



BURNS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Treatment

Extinguish burning or smoldering clothing. Flush chemical burns with copious amounts of water.

Airway Assess airway for burns. Airway burns should be suspected when the patient:

Is burned or exposed to smoke Has been exposed to toxic fumes Has burns to the face and/or the upper airway Has redness/blisters/soot in the mouth or nose, or singed nasal hair

Treatment Assess for other injuries and treat as indicated. Maintain airway and administer high-flow oxygen (see Airway/Oxygen guideline). Treat burns appropriately. Use saline-moistened sterile dressings to stop the burning process. Burns <10% total body surface may be kept wet with saline-moistened dressings (sterile preferred). Burns >10% total body surface area, wet dressings must be removed once the burning process has stopped.

The wet dressings should be replaced with clean dressings (sterile preferred). The patient should then be covered with a sterile burn sheet and blanket to prevent loss of body heat.

Field Manual-Treatment Guidelines July 2006 Environmental Emergencies – 8010 Page 1 of 1



ENVIRONMENTAL EMERGENCIES ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE HEAT

Protect patient from further exposure to heat. Move patient to cool environment. Remove heavy or constricting clothing. Apply moist dressing and fan patient.

COLD

Protect patient from further exposure to cold. Move patient to warm environment. Remove wet clothing. Do not actively re-warm patient or insert oral airway. Prevent unnecessary movement. Cover patient with a blanket.

BITES or STINGS

Remove stinger if still present. Administer 100% oxygen and ventilate as needed. Assess for signs and symptoms of shock and airway obstruction. Treat appropriately. If patient has Epi-Pen, you may assist patient in self-administration, if needed.

SMOKE INHALATION

Administer 100% oxygen and ventilate as needed. Examine nose and mouth for soot and other signs of airway burns.

HAZARDOUS MATERIALS

ASSURE PERSONNEL AND SCENE SAFETY FIRST. Do not approach patient. Isolate and deny access to hazard area. Initiate HAZ-MAT response. Establish safe treatment area uphill and upwind of the hazard area. Receive patient from rescue personnel after decontamination. DO NOT TRANSPORT A PATIENT PRIOR TO APPROPRIATE DECONTAMINATION.

Field Manual-Treatment Guidelines July 2006 Routine Obstetric Delivery - 8011 Page 1 of 1



ROUTINE OBSTETRIC DELIVERY ALWAYS USE UNIVERSAL PRECAUTIONS


Routine Medical Care for mother. Baby's Head Visible or Crowning

Assist delivery. Check for cord around baby’s neck and gently remove if present. Suction airway with bulb syringe as soon as possible, mouth before nose. Clamp cord X2 and cut between clamps (6-8 inches from the infant). Assess, dry, and wrap the baby. Massage fundus if infant is delivered and there is heavy vaginal bleeding. Deliver the placenta if presenting but do not force. See Newborn Care protocol.

Baby's Head Not Visible

Transport.

Field Manual-Treatment Guidelines July 2006 Newborn Care - 8012 Page 1 of 1



NEWBORN CARE ALWAYS USE UNIVERSAL PRECAUTIONS


Routine Medical Care for mother. Assess

Assess the baby. A normal newborn: Has a completely pink appearance Has a pulse >100 bpm Cries when stimulated Actively moves all extremities Has a good strong cry

A depressed newborn lacks one or more of the above characteristics. Normal Newborn

Dry the baby. Cover the head of the baby to maintain body heat. Allow mother to hold and breastfeed the baby if she wishes.

Depressed Newborn

Suction with bulb syringe, mouth before nose. Apply vigorous stimulation by rubbing the baby’s back or feet, do not “spank” the newborn. Provide 100% oxygen by pediatric mask, and assist ventilation as necessary. Check pulse rate:

Pulse >60 bpm: Expedite Transport. Pulse <60 bpm: Start CPR (if pulse <60 bpm, perfusion is inadequate. CPR is indicated even though the newborn

may have a pulse.). Reassess pulse every 30 seconds to see if newborn is improving.

Field Manual-Treatment Guidelines July 2006 Obstetric Emergencies - 8013 Page 1 of 1



OBSTETRIC EMERGENCIES ALWAYS USE UNIVERSAL PRECAUTIONS


Routine Medical Care for mother Cord Around Baby's Neck

Attempt to slip the cord over the baby's head. If unable, insert gloved finger between newborn’s neck and cord and rotate around neck in circular fashion in attempt to slide

cord over neck. As last resort, consider double clamping cord and cutting between clamps, expediting delivery ASAP. See Newborn Care protocol.

Prolapsed Cord or Breech Presentation

Administer 100% oxygen to the mother. Place mother supine with hips and legs elevated higher than the thorax. Lift any presenting part of baby off umbilical cord. In breech presentation, insert gloved finger to create airway space. Supply supplemental oxygen to baby. Advise mother not to push.

Other Obstetric Emergency (including abnormal vaginal bleeding, abdominal pain that is not labor-related, hypertension or seizures.)

Administer 100% oxygen to mother. Place mother in left lateral position. Elevate legs if signs or symptoms of shock. Do not lay flat on back. Advise no pushing. IF SEIZURE:

Maintain airway. Protect mother from injury. Position mother to enable blood return, i.e. left lateral position if possible.

Field Manual-Treatment Guidelines July 2006 Football Helmet Removal - 8014 Page 1 of 1



FOOTBALL HELMET REMOVAL ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION

A patient wearing a football helmet along with shoulder pads. TREATMENT

Helmets in conjunction with shoulder pads help immobilize the neck. If the helmet is removed, the head could fall back into extension due to the bulk of the shoulder pads.

If the airway is compromised, the face shield should be cut away from the helmet. If maneuvers to improve the airway cannot be performed with the helmet in place, the risks of helmet removal must be considered relative to the need for airway management.

If the helmet is ill fitting and the patient's C-spine cannot be immobilized with it in place, it should be removed carefully with manual immobilization of C-Spine and padding of the head may be required.

The helmet is radiolucent and can be x-rayed through.



ALS TREATMENT GUIDELINES

Field Manual-Treatment Guidelines July 2006 ALS Routine Medical Care - 9001 Page 1 of 1



ALS ROUTINE MEDICAL CARE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROCEDURE Routine Medical Care shall consist of the following:

BSI precautions BLS Treatment Guidelines ECG monitoring, as indicated Oxygen administration to maintain oxygen saturations > 96%, as indicated. IV access, as indicated, to include saline lock. Normal Saline may be substituted with Lactated Ringers. Glucose determination, as indicated Transport

ALS Treatment Guidelines July 2006 Airway Management - 9002 Page 1 of 2



AIRWAY MANAGEMENT ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221

If able to maintain an airway or ventilate and oxygenate the patient with BLS skills, continue and transport the patient. Effective use of the BVM often requires two people. BLS skills are often the airway procedures of choice for the pediatric and trauma patients if transport time is less

than 10 minutes. DO NOT DELAY TRANSPORT for advanced airway skills if you have an adequate BLS airway. If unable to adequately maintain the airway, reassess the patient’s airway problems and BLS skills application.

If two attempts to stabilize the airway with BLS skills are unsuccessful, attempt to intubate following:

Oral Endotracheal Intubation Guideline – Adult Guideline 9801, Pediatric Guideline 9802 Consider Endotracheal Tube Introducer (ETTI) Guideline.

Nasotracheal Intubation – Guideline 9805 as appropriate In restless/agitated patient consider Sedation when appropriate – Guideline 9005

Intubation may be attempted twice. If unsuccessful: re-attempt to manage the airway with BLS skills

If unsuccessful: Place a Multi-lumen airway (Combitube SA) Intubation. May attempt twice – Guideline 9804 If unsuccessful re-attempt to manage the airway with BLS skills.

If unable to establish airway due to complete airway obstruction perform Needle Cricothyrotomy – Guideline 9806

ALS Treatment Guidelines July 2006 Airway Management - 9002 Page 2 of 2



ADVANCED AIRWAY ATTEMPT REPORT

* THIS FORM MUST BE COMPLETED ON ALL ADVANCED AIRWAY ATTEMPTS (ET, NT & MULTI-LUMEN). ATTACH A COPY OF THE

PREHOSPITAL CARE REPORT (PCR) AND SUBMIT TO YOUR AGENCIES QI LIASON. Date: _______________ Agency: ______________________ Receiving facility:__________________________ Run number:___________Intubator:_______________________ Partner:__________________________________ Intubation Attempts: * The introduction of the tube past the patient’s teeth. Complete a line for each attempt Airway Attempted Circle each that apply Successful 1 ET CombiTube NT ETTI Cric. Pressure Sedation YES NO 2 ET CombiTube NT ETTI Cric. Pressure Sedation YES NO 3 ET CombiTube NT ETTI Cric. Pressure Sedation YES NO 4 ET CombiTube NT ETTI Cric. Pressure Sedation YES NO

If an advanced airway was not successfully placed, explain complications and how the airway was managed: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Method of Verification (check all that apply):

Breath sounds Chest movement End tidal CO2 Direct visualization Esophageal detector device (EDD) Tube condensation Epigastric auscultation

Placement confirmed after each time patient moved? YES NO Transfer Care to: Name of Paramedic/RN:_____________________________________Agency: _____________________________ Proper placement of advanced airway? YES NO Confirmed by:____________________________________ If No, Explain:__________________________________________________________________________________ Patient Expired? YES Field Determination or Hospital Pronouncement NO

ALS Treatment Guidelines July 2006 ALS Spinal Immobilization - 9003 Page 1 of 1



ALS SPINAL IMMOBILIZATION GUIDELINE ALWAYS USE UNIVERSAL PRECAUTIONS


To establish a guideline for determining the subset of trauma patients who can be safely triaged from the scene to the nearest appropriate receiving facility without full C-Spine immobilization.

OBJECTIVE

To avoid using full C-Spine precautions with patients whose C-Spine can be safely cleared in the field by using pre-established criteria thus avoiding patient discomfort and unnecessary resource utilization.

APPROPRIATE PATIENT TYPE

The only patient deemed appropriate for not applying C-Spine immobilization (or qualifying for removal) is a patient who has a mechanism of injury for C-Spine injury but successfully fits criteria for clearance.

TRAINING REQUIREMENTS

Each provider will have an in house training module for this protocol. CQI will occur with any patient transported with missed C-Spine injury with or without secondary injury.

CONTRAINDICATIONS

Any patient having sustained a mechanism of injury capable of injuring the cervical spine and with which there is a failure of any one of these criteria.

Any patient wherein the emergency service provider feels despite qualification by criteria the potential for C-Spine injury outweighs the patient advantage for clearance.

CRITERIA These are Physical Exam, Mechanism of Injury, and Level of Consciousness/Distracting Injuries questions. If you answer YES to any of the following questions, the patient MUST be immobilized. Does the patient present with neurological symptoms on physical assessment? Does the patient complain of point tenderness to palpation of the cervical or thoracic spine? Does the patient have obvious deformity noted upon palpation of the cervical/thoracic spine? Does the mechanism of injury suggest that the patient has a high probability of a cervical spine injury? Does the patient present with an altered level of consciousness? Does the patient appear to be under the influence of alcohol or drugs? Does the patient have a significant distracting injury? Does the patient have an abnormal range of motion of the neck? Is the patient 12 years of age or under?

If you answered NO to all questions, the patient may not require spinal immobilization in the field. The patient may also be immobilized any other time you feel the patient requires this procedure. SPECIAL CONSIDERATIONS Exercise caution when treating elderly or diabetic patients as they may present with minimal or no pain following a spinal injury.

Field Manual-Treatment Guidelines July 2006 Severe Pain - 9004 Page 1 of 1



SEVERE PAIN ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Severe pain in the presence of adequate vital signs and level of consciousness. Extrication, movement or transportation is required which will cause considerable pain to the patient AND there are no known

contraindications to administering analgesia. TREATMENT Establish IV access NS TKO. Morphine Sulfate:

2-5 mg IV, q 5 minutes until pain is relieved, maintain SBP > 90 mmHg. 5-10 mg IM, if IV not accessible, may repeat in 30 minutes.

Monitor patient and vital signs carefully, ensure patent airway.

CONTRAINDICATIONS ABSOLUTE Sensitivity to the medication to be administered. RELATIVE

Nausea/vomiting Depressed mentation ‡ Hypotension ‡ Suspected drug/alcohol intoxication ‡ Head injury * Multiple systems trauma * Concomitant sedation chemical administration ‡

*These relative contraindications may be the proximate cause for the condition that requires proposed pain control. The best judgment of the paramedic is necessary to evaluate the need for pain control. ‡These relative contraindications may still need proposed pain control at reduced dose typically ½ the normal dose. The best judgment of the paramedic is necessary to evaluate the need for pain control.

ALS Treatment Guidelines July 2006 Sedation - 9005 Page 1 of 4



SEDATION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 GENERAL INDICATIONS

Anxiety communicated by patient not relieved with other calming measures.

Combative behavior that endangers patient or caregivers (This is considered to be chemical restraint, careful documentation is required when using sedation for this purpose)

Sedation prior to ALS treatment such as cardioversion etc.

Trismus

CONTRAINDICATIONS ABSOLUTE

Sensitivity to the medication to be administered. RELATIVE

Nausea/vomiting Depressed mentation ‡ Hypotension ‡ Suspected drug/alcohol intoxication ‡ Head injury * Multiple systems trauma * Concomitant narcotic administration ‡

*These MAY be the proximate cause for the condition that requires proposed sedation. The best judgment of the paramedic is necessary to evaluate the need for sedation ‡These relative contraindications may still need proposed pain control at reduced dose typically ½ the normal dose. The best judgment of the paramedic is necessary to evaluate the need for pain control.

APPROVED AGENTS FOR SEDATION

Diphenhydramine (Benadryl) Midazolam (Versed)

Patients receiving Midazolam frequently experience hypotension. Consider a one-time 250cc bolus of IV saline prior to Midazolam administration.




PROCEDURE

Give supplemental oxygen. Institute continuous oximetry. Institute continuous cardiac monitoring. Establish IV NS TKO. Be prepared to provide airway/ventilation management. Ensure that receiving personnel are aware that patient has been sedated.

MILD SEDATION INDICATIONS

Profound anxiety Behavioral Motion sickness

DIPHENHYDRAMINE ADULT 50 mg IM or 25 mg IV PEDIATRIC 1 mg/Kg IM to a maximum of 50 mg 0.5 mg/Kg IV to a maximum of 25 mg MODERATE SEDATION INDICATIONS Anticipated cardioversion (in the conscious patient). Anticipated cardiac pacing (in the conscious patient). Anticipated movement of fractures/dislocations. Behavioral. (NOTE- Midazolam is not intended for use in motion sickness). MIDAZOLAM ADULT INITIAL 2 mg SLOW IV push loading dose Titration to desired degree of sedation can be accomplished with repeated 1-2 mg doses every 3 minutes, to a MAX. of 0.1 mg/Kg, maintain SBP > 90 mmHg

(Patients with concomitant narcotic administration should receive a max of 0.05 mg/Kg). May be administered IM 0.1 mg/kg if unable to establish IV access and may repeat every 30 min

PEDIATRIC <40Kg INITIAL 0.5 –1 mg SLOW IV push loading dose

Titration to desired degree of sedation can be accomplished with repeated doses every 3 minutes, to MAXIMUM of 0.05 mg/Kg, maintain SBP > 60 mmHg. (Patients with concomitant narcotic administration should receive a max of 0.05 mg/Kg). May be administered IM 0.1 mg/kg if unable to establish IV access and may repeat every 30 min

PROFOUND SEDATION INDICATIONS Airway management - physiological state that interferes with essential airway management.




MIDAZOLAM ADULT INITIAL 2 mg SLOW IV push loading dose Titration to desired degree of sedation can be accomplished with repeated 1-2 mg doses every 3 minutes, to a MAX. of 0.1 mg/Kg, maintain SBP > 90 mmHg.

(Patients with concomitant narcotic administration should receive a max of 0.05 mg/Kg). May be administered IM 0.1 mg/kg if unable to establish IV access and may repeat every 30 min.

PEDIATRIC <40Kg INITIAL 0.5 –1 mg SLOW IV push loading dose

Titration to desired degree of sedation can be accomplished with repeated doses every 3 minutes, to MAXIMUM of 0.1 mg/Kg, maintain SBP > 60 mmHg.

(Patients with concomitant narcotic administration should receive a max of 0.05 mg/Kg). May be administered IM 0.1 mg/kg if unable to establish IV access and may repeat every 30 min.

SPECIAL CONSIDERATIONS Patients requiring prolonged sedation for airway management (such as long transport times) may receive sedation maintenance doses of 1 mg IV every 15 minutes, maintaining a SBP > 90 mmHg. Airway management in the sedated patient does not necessarily mandate intubation, assess the patient’s ability to protect his own airway.

Pediatric patients being considered for intubation after sedation should be pre-medicated with Atropine, 0.02 mg/Kg IV, to a maximum of 0.5 mg. Patients over 65 years of age should receive Midazolam max dose of 0.05 mg/Kg IV/IM.




MIDAZOLAM DOSE CHART

WEIGHT BASED CHART

MAXIMUM DOSE

MIDAZOLAM Weight Dose

KG LB 0.1 mg / kg 5 11 0.5 mg

10 22 1 mg 13 28 1.3 mg 15 33 1.5 mg 17 37 1.7 mg 20 44 2 mg 22 48 2.2 mg 25 55 2.5 mg 28 61 2.8 mg 30 66 3 mg 35 77 3.5 mg 40 88 4 mg 45 99 4.5 mg 50 110 5 mg 55 121 5.5 mg 60 132 6 mg 65 143 6.5 mg 70 154 7 mg 75 165 7.5 mg 80 176 8 mg 85 187 8.5 mg 90 198 9 mg 95 209 9.5 mg

>100 >220 10 mg



CARDIAC EMERGENCIES

ALS Treatment Guidelines July 2006 Ventricular Fibrillation / Pulseless Ventricular Tachycardia - 9101 Page 1 of 2



VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 TREATMENT If witnessed arrest monitored/witnessed by paramedic, perform precordial thump. If unwitnessed arrest, confirm pulselessness and begin CPR while preparing equipment. Defibrillate 1 x @ 360 w/s monophasic (or biphasic equivalent); resume CPR immediately, administer CPR for 5 cycles / 2

minutes. During 2 minutes of CPR,

Provide appropriate airway management Establish IV / IO NS TKO

After 2 minutes of CPR perform rhythm / pulse check. If V-fib persists, Defibrillate 1 x @ 360 w/s monophasic (or biphasic equivalent). Administer Epinephrine 1 mg (1:10,000) IV / IO; resume CPR 5 cycles / 2 minutes.

Repeat every 3-5 minutes. The preferred method of administration of Epinephrine is IV / IO, if unable to establish IV / IO,

Administer Epinephrine 2.0 mg (1:1000) diluted in 10 cc's NS ETT.

Perform Rhythm / pulse check; If V-fib persists, Defibrillate 1 x @ 360 w/s monophasic (or biphasic equivalent) Administer Amiodarone 300 mg IV / IO (flush tubing with 20cc's NS); resume CPR immediately, administer CPR for 5 cycles /

2 minutes. May repeat Amiodarone 150 mg IVP / IO (flush tubing with 20 cc’s NS) in 5 minutes for persistent V-fib.

Perform Rhythm / pulse check; If V-fib persists, Defibrillate 1 x @ 360 w/s monophasic (or biphasic equivalent), resume CPR immediately, after 5 cycles / 2 minutes.

If rhythm converts after Amiodarone bolus

Transport time < 20 minutes –Infuse 150 mg Amiodarone IV /IO over ten minutes (Add 150 mg to 100 cc of Normal Saline and infuse total contents over 10 minutes).

Transport time > 20 minutes – Amiodarone infusion IV / IO (Add 900 mg of Amiodarone to 500 cc of Normal Saline. With a dial-a-flow adjust the infusion rate to 30 cc/hour).

ALS Treatment Guidelines January 2006 Ventricular Fibrillation / Pulseless Ventricular Tachycardia - 9101 Page 2 of 2



SPECIAL CONSIDERATIONS Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should

not interrupt the CPR cycles. Begin immediate transport if unable to establish IV / IO or ETT, continue treatment while transporting. Consider and treat possible contributing factors.

Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo/Hyperkalemia

If Hyperkalemia is suspected in renal dialysis patients. Administer 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IV / IO

Hypoglycemia Hypothermia Toxins (overdoses) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary Trauma

Consideration may be given by base physician to field pronouncement. If transport is indicated, consider Code 2.

ALS Treatment Guidelines July 2006 Wide Complex Tachycardia - 9102 Page 1 of 2



WIDE COMPLEX TACHYCARDIA ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Regular, wide ventricular complexes greater than 150 beats/minutes. TREATMENT If decreased perfusion but responsive Consider 12 Lead ECG if available. Transport time < 20 minutes –Infuse 150 mg Amiodarone IV /IO (Add 150 mg to 100 ml of Normal Saline and infuse total

contents over 10 minutes). Transport time > 20 minutes – Amiodarone infusion IV / IO (Add 900 mg of Amiodarone to 500 cc of Normal Saline. With a

dial-a-flow adjust the infusion rate to 30 cc/hour). If decreased responsiveness Consider sedation per Sedation Policy. Synchronized cardioversion at 100 w/s (or biphasic equivalent); check pulse and rhythm. If no response: repeat synchronized cardioversion at 200 w/s (or biphasic equivalent); check pulse & rhythm. If no response: repeat synchronized cardioversion at 300 w/s (or biphasic equivalent); check pulse & rhythm. If no response: repeat synchronized cardioversion at 360 w/s (or biphasic equivalent); check pulse & rhythm. If rhythm converts with cardioversion attempts, rebolus

Transport time < 20 minutes –Infuse 150 mg Amiodarone IV /IO over ten minutes (Add 150 mg to 100 cc of Normal Saline and infuse total contents over 10 minutes). or

Transport time > 20 minutes – Amiodarone infusion IV / IO (Add 900 mg of Amiodarone to 500 cc of Normal Saline. With a dial-a-flow adjust the infusion rate to 30 cc/hour).

If rhythm does not convert with cardioversion or Pulses not present Refer to Ventricular Fibrillation Protocol.

SPECIAL CONSIDERATIONS Begin immediate transport if unable to establish IV / IO, continue treatment while transporting Consider and treat possible contributing factors

Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo/Hyperkalemia Hypoglycemia Hypothermia Toxins (overdoses) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary Trauma

Cardiac Emergencies July 2006 Narrow Complex Tachycardia Atrial Fibrillation/Flutter - 9103 Page 1 of 1



NARROW COMPLEX TACHYCARDIA ATRIAL FIBRILLATION/FLUTTER

ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Atrial Fibrillation - Appearance of irregularly irregular rhythm with variations in both R wave to R wave interval and amplitude.

If QRS width > 0.12, go to Wide Complex protocol. Atrial Flutter – Appearance of classic saw tooth pattern rhythm with ventricular response rates rarely >150 to 180. If QRS

width > 0.12, go to Wide Complex protocol. TREATMENT If decreased perfusion and responsive Consider sedation per Sedation Policy Synchronized cardioversion @ 100 w/s (or biphasic equivalent); check pulse/rhythm If no response: synchronized cardioversion @ 200 w/s (or biphasic equivalent); check pulse/rhythm If no response: synchronized cardioversion @ 300 w/s (or biphasic equivalent); check pulse rhythm If no response: synchronized cardioversion @ 360 w/s (or biphasic equivalent); check pulse rhythm If no response, administer Amiodarone 150 mg in 100 cc NS over 10 minutes IV / IO.

Cardiac Emergencies July 2006 Narrow Complex Tachycardia- 9104 Page 1 of 2



NARROW COMPLEX TACHYCARDIA ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION QRS < 0.12 sec documented rhythm in two leads. (If > 0.12 sec, go to Wide Complex protocol). Compatible history (vague, nonspecific). P waves absent / abnormal. HR is not variable and is >150 bpm. History of abrupt rate changes.

TREATMENT If decreased perfusion but responsive

Obtain 12 Lead ECG if available. Consider valsalva maneuver. Establish IV NS TKO.

A proximal vein is the preferred IV site. Adenosine 6 mg RAPID IVP followed by 10 cc saline flush . If no response after 2 minutes: Adenosine 12 mg rapid IVP followed by 10 cc saline flush. If no response after 2 minutes: Adenosine 12 mg rapid IVP followed by 10 cc saline flush. Elevate the extremity during each rapid bolus.

If decreased perfusion and responsiveness or if above therapy is not working Consider sedation per Sedation Policy. Synchronized cardioversion @ 100 w/s (or biphasic equivalent); check pulse/rhythm. If no response: synchronized cardioversion @ 200 w/s (or biphasic equivalent); check pulse/rhythm. If no response: synchronized cardioversion @ 300 w/s (or biphasic equivalent); check pulse rhythm. If no response: synchronized cardioversion @ 360 w/s (or biphasic equivalent); check pulse rhythm.

Cardiac Emergencies July 2006 Narrow Complex Tachycardia- 9104 Page 2 of 2



SPECIAL CONSIDERATIONS Begin immediate transport if unable to establish IV / IO, continue treatment while transporting Consider and treat possible contributing factors.


Cardiac Emergencies July 2006 Asystole/ Pulseless Idioventricular Rhythm - 9105 Page 1 of 2



ASYSTOLE / PULSELESS IDIOVENTRICULAR RHYTHM ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 CONSIDERATIONS If arrest was unwitnessed and asystole has been confirmed, criteria for field determination of death may have been met. If asystole is witnessed by paramedic or determined to be of short duration, and external cardiac pacer is readily available,

consider pacing protocol for witnessed asystole and refer to pacing protocol. WITNESSED ARREST Confirm pulselessness and rhythm. If rhythm is unclear and possibly ventricular fibrillation, refer to ventricular fibrillation

protocol.

TREATMENT Maintain adequate airway. Establish IV / IO NS 10 cc/kg then TKO. Administer Epinephrine 1 mg (1:10,000) IV / IO; resume CPR 5 cycles / 2 minutes, perform rhythm / pulse check

Repeat every 3-5 minutes. The preferred method of administration of Epinephrine is IV / IO, if unable to establish IV / IO,

Administer Epinephrine 2 mg (1:1000) ETT dilute in 10 cc's NS Repeat every 3-5 minutes

Administer Atropine 1 mg IV / IO; resume CPR 5 cycles / 2 minutes, perform rhythm / pulse check Repeat every 3-5 minutes to a total of 3 mg The preferred method of administration of Atropine is IV / IO, if unable to establish IV / IO

Administer Atropine 2 mg ETT, 2.0 mg Repeat every 3-5 minutes to a total of 3 mg

SPECIAL CONSIDERATIONS Place a high importance on BLS skills If able to maintain an adequate BLS airway you may consider deferring the placement of an advanced airway for several

minutes into the arrest. AVOID HYPERVENTILATION. Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should not

interrupt the CPR cycles. Begin immediate transport if unable to establish IV / IO or ETT, continue treatment while transporting. Consider and treat possible contributing factors:


If Hyperkalemia is suspected in renal dialysis patients. Administer 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IV / IO

Hypoglycemia Hypothermia Toxins (overdoses)

Cardiac Emergencies July 2006 Asystole/ Pulseless Idioventricular Rhythm - 9105 Page 2 of 2



Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary Trauma


Cardiac Emergencies July 2006 Pulseless Electrical Activity (EMD) - 9106 Page 1 of 1



PULSELESS ELECTRICAL ACTIVITY (ELECTROMECHANICAL DISSOCIATION)


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 TREATMENT Provide appropriate airway management. Establish IV / IO NS 10 cc/kg then TKO. Administer Epinephrine 1 mg (1:10,000) IV/IO.

Repeat every 3-5 minutes. The preferred method of administration of Epinephrine is IV / IO, if unable to establish IV / IO.

Administer Epinephrine (1:1,000) 2 mg ETT, diluted in 10 cc's NS. Repeat every 3-5 minutes.

For heart rate < 50 If external cardiac pacer is readily available, consider pacing, and refer to pacing protocol. Consider Atropine1 mg IV / IO .

Repeat every 3-5 minutes to a total of 3 mg. The preferred method of administration of Atropine is IV / IO, if unable to establish IV / IO.

Administer Atropine may be given via ETT, 2.0 mg. Repeat every 3-5 minutes to a total of 3 mg.

SPECIAL CONSIDERATIONS Place a high importance on BLS skills. If able to maintain an adequate BLS airway you may consider deferring the placement of an advanced airway for several

minutes into the arrest. AVOID HYPERVENTILATION. Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should not

interrupt the CPR cycles. Begin immediate transport if unable to establish IV / IO or ETT, continue treatment while transporting. Consider and treat possible contributing factors:


If Hyperkalemia is suspected in renal dialysis patients. Administer 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IV / IO.

Hypoglycemia Hypothermia Toxins (overdoses) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary Trauma


Cardiac Emergencies July 2006 Bradydysrhythmias - 9107 Page 1 of 1



BRADYDYSRHYTHMIAS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Heart rate < 50 bpm with decreasing perfusion and responsiveness. TREATMENT Obtain 12-lead ECG if available. If external cardiac pacer is readily available, consider cardiac pacing and refer to pacing protocol. IV NS TKO.

Consider fluid challenge if hypotensive and lungs clear, NS 10cc/kg. Recheck vital signs every 250cc. Atropine 0.5 mg IV / IO Repeat q 5 min. to a total of 3 mg. If inadequate response, IV / IO infusion of Dopamine 400 mg/250 cc premix. Start at 10 ug/kg/min. Titrate to SBP 90.

DOPAMINE

400 mgm in 250 cc D5W 60 drops/min = 60 ml/hr Weight (kg)

gtts/min to = 10 ug/kg/min

Weight (kg)


35-45

15 gtts/min

85-90

35 gtts/min

45-55

20 gtts/min

95-105

40 gtts/min

60-70

25 gtts/min

110 & up

45 gtts/min

75-80

30 gtts/min

SPECIAL CONSIDERATIONS Begin immediate transport if unable to establish IV / IO, continue treatment while transporting. Consider and treat possible contributing factors:

Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo/Hyperkalemia Hypoglycemia Hypothermia

Toxins (overdoses) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary Trauma

Cardiac Emergencies July 2006 Suspected Acute Coronary Syndrome (ACS)- 9108 Page 1 of 1



SUSPECTED ACUTE CORONARY SYNDROME (ACS)


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 TREATMENT If systolic blood pressure above 100, administer nitroglycerin 0.4 mg SL - may repeat every five (5) minutes if signs/symptoms

persists and systolic blood pressure remains above 100. Administer four (4) 81 mg aspirin PO as one time dose. Obtain 12 Lead ECG if available. If systolic blood pressure remains above 100, administer Morphine Sulfate 2-5 mg IV - may repeat in 2 mg doses as needed

for pain control if systolic blood pressure remains above 100. If acute ST Elevation Myocardial infarction (STEMI) detected on 12 Lead ECG. Direct transport to the closest authorized STEMI Receiving Center (see Patient Destination / Point of Entry policy). For

questionable interpretations consider base hospital consultation with transmission of the 12 lead EKG when capable. Contact receiving facility ASAP. Consider establishing a second IV Normal Saline TKO during transport.

SPECIAL CONSIDERATIONS If systolic blood pressure less than 100, administer a 250 cc fluid bolus If systolic blood pressure less than 90, refer to Cardiogenic Shock protocol For transport times of over 1 hour, apply ½ inch of 2% Nitroglycerin paste - may apply an additional 1/2 inch as needed if

signs/symptoms persist and systolic blood pressure remains above 100 Nitroglycerin should NOT be administered to patients of either gender who have taken Viagra/Levitra within 24 hours or Cialis

within 72 hours. Aspirin should NOT be administered to patients with allergy to aspirin Aspirin should NOT be administered to patients with active GI bleed

Cardiac Emergencies July 2006 Cardiogenic Shock- 9109 Page 1 of 1



CARDIOGENIC SHOCK ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Systolic blood pressure less than 90. Shock-like appearance suggestive of cardiac origin; MAY have chest pain typical of myocardial ischemia. Clear lung sounds. If rales present - see Pulmonary Edema protocol. TREATMENT Obtain 12 Lead ECG if available. Treat significant arrhythmias. Establish IV NS, give 10 cc/kg fluid challenge. Recheck vital signs every 250cc. May give up to 2 liters fluid.

Reminder: Lungs must remain clear. If lungs remain clear and after fluid challenge, if systolic blood pressure remains less than 90 then: IV / IO infusion of Dopamine 400 mg/250 cc D5W.

Begin at 10 ug/kg/min. Monitor blood pressure every five (5) minutes. Aim for systolic blood pressure 90 or above.

Consider placing multifunction defib/pacer pads.

DOPAMINE

400 mgm in 250 cc D5W 60 drops/min = 60 ml/hr

Weight (kg)


Weight (kg)


35-45

15 gtts/min

85-90

35 gtts/min

45-55

20 gtts/min

95-105

40 gtts/min

60-70

25 gtts/min

110 & up

45 gtts/min

75-80

30 gtts/min

Cardiac Emergencies July 2006 Inappropriate Shock from Implanted Defibrillator- 9110 Page 1 of 1



INAPPROPRIATE SHOCK FROM IMPLANTED DEFIBRILLATOR


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Defibrillator shocks observed by paramedic in the absence of Ventricular Tachycardia or Ventricular Fibrillation. TREATMENT Apply magnet directly over center of defibrillator (If any question of location, ask patient). Tape magnet in place. If another shock is delivered, magnet may have moved; re-center over defibrillator, and tape in place. The defibrillator device is now non-functional; however the pacer may still function.

Cardiac Emergencies July 2006 Ventricular Ectopy- 9111 Page 1 of 1



VENTRICULAR ECTOPY ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION The presence of continuous chest pain with couplets, or non-sustained runs of ventricular tachycardia. TREATMENT Obtain 12 Lead ECG if available. Establish IV NS TKO. Transport time < 20 minutes –Infuse 150 mg Amiodarone IV /IO over ten minutes (Add 150 mg to 100 cc of Normal Saline

and infuse total contents over 10 minutes). Transport time > 20 minutes – Amiodarone infusion IV / IO (Add 900 mg of Amiodarone to 500 cc of Normal Saline. With a

dial-a-flow adjust the infusion rate to 30 cc/hour). SPECIAL CONSIDERATIONS Begin immediate transport if unable to establish IV / IO, continue treatment while transporting. Consider and treat possible contributing factors.




ENVIRONMENTAL

EMERGENCIES

Environmental Emergencies July 2006 Allergic Reaction- 9201 Page 1 of 1



ALLERGIC REACTION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 MILD DEFINITION: Urticaria (itchy, raised welts only) TREATMENT: Benadryl 50mg IM

MODERATE TO SEVERE DEFINITION: Urticaria with one or more of the following: Swelling of mucus membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps. TREATMENT: For Bronchospasm

Adminster Albuterol 5 mg in 6 ml NS via nebulizer May repeat Abluterol as needed Consider adding Atrovent 0.5 mg in 3 ml NS to second and subsequent nebulizers

Epinephrine 1:1000, 0.01mg/kg SQ. Maximum dose 0.5 mg. (Use with caution over 35 years of age, and in patients with coronary artery disease.)

IV NS TKO or saline lock Benadryl 1mg/kg IV or IM to a maximum of 50 mg

Environmental Emergencies July 2006 Anaphylaxis- 9202 Page 1 of 1



ANAPHYLAXIS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Urticaria and signs of shock. May have any or all of the following: Swelling of mucus membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps. TREATMENT

Epinephrine (1:1,000) 0.01mg/kg SQ to a max of 0.5 mg SQ. Benadryl 1 mg/kg IM to a max of 50mg Large bore IV NS fluid challenge, 10cc/kg, recheck vitals every 250cc

If unresponsive and no palpable BP:

Epinephrine (1:10,000) 0.01mg/kg to a maximum of 0.5 mg IV. Large bore IV / IO NS fluid challenge, 10cc/kg, recheck vitals every 250cc If blood pressure improves Benadryl 1 mg/kg IM to a max of 50mg

If hypotension persists after two fluid challenges

IV / IO infusion of Dopamine 400 mg/250cc NS (or premix); 10 ug/kg/minute, monitor BP q 3-5 min.

DOPAMINE

400 mgm in 250 cc D5W 60 drops/min = 60 ml/hr

Weight (kg)


Weight (kg)


35-45

15 gtts/min

85-90

35 gtts/min

45-55

20 gtts/min

95-105

40 gtts/min

60-70

25 gtts/min

110 & up

45 gtts/min

75-80

30 gtts/min

Environmental Emergencies July 2006 Poisoning/ Overdose- 9203 Page 1 of 2



POISONING/OVERDOSE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION - Ingestion and/or exposures to one or more toxic substances, including alcohol. TREATMENT

I.V. NS TKO if indicated. Early transport and receiving hospital notification

Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine, furniture polish, etc.)

Do not induce vomiting - transport immediately. Caustic Substances (acids/alkalies)

Do not induce vomiting. Consider dilution with no more than 1-2 glasses of water or milk; if no respiratory compromise or change in mental status.

Insecticides (organophosphates, carbonates)

Skin exposure: decontaminate patient as soon as possible (remove clothes, wash skin). Avoid contamination of prehospital personnel. Atropine 2.0 mg I.V. slowly. If no tachycardia or pupil dilation, repeat once 2.0 mg I.V. until signs of atropinization

appear (dilated pupils, mild tachycardia). To be used only for bronchospasm and copious bronchial secretions. Atropine does not reverse muscle weakness that leads to respiratory failure.

Atropine has its own toxicity and repeat doses above 4.0 mg should be given by PHYSICIAN ORDER ONLY. Cyclic Antidepressants

IV NS TKO, start immediately Anticipate rapid deterioration of condition In the presence of life-threatening dysrhythmias, (hemodynamically significant supraventricular rhythms, ventricular

dysrhythmias) Hyperventilate if assisting ventilations or if intubated Sodium bicarbonate 1 mEq/kg IVP

For seizures, see SEIZURE protocol For signs of shock see CARDIOGENIC SHOCK protocol

Paramedic Academy


Environmental Emergencies July 2006 Poisoning/ Overdose- 9203 Page 2 of 2

Phenothiazine Reactions IV NS TKO Benadryl 1 mg/kg IV to a maximum of 50 mg. If unable to establish IV access administer IM.

Other Non-Caustic Drugs: Patient Awake and Alert

Consider activated charcoal orally -- 1 gm/kg PO, not to exceed 50 gms if within the first 60 minutes of ingestion. Consider contacting Poison Control

Environmental Emergencies July 2006 Drowing/ Near Drowing- 9204 Page 1 of 1



DROWNING/NEAR DROWNING ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DROWNING DEFINITION Loss of consciousness in water, now in full cardiopulmonary arrest. TREATMENT Treat as CARDIOPULMONARY ARREST, using specific dysrhythmia treatment guideline, with consideration for hypothermia and spinal precautions. NEAR DROWNING DEFINITION Loss of consciousness in water, not in full cardiopulmonary arrest. TREATMENT

Anticipate vomiting; take precautions against aspiration, be prepared for suctioning. Remove wet clothing; keep patient warm and dry If dyspnea non responsive to suctioning and oxygen, consider CPAP.

Environmental Emergencies July 2006 Heat Illness- 9205 Page 1 of 1



HEAT ILLNESS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 HEAT CRAMPS/HEAT EXHAUSTION DEFINITION Cramping of the most worked muscles following replacement of exertion induced fluid losses (sweating) with water; exhaustion, fatigue, flu-like symptoms, normal/slightly elevated body temperature, normal mental status with clear lung sounds. TREATMENT

Move patient to cool environment – passive cooling measures If lungs clear, consider IV fluid challenge of 10 cc/kg NS. Recheck every 250 cc's.

HEAT STROKE DEFINITION Triad of exposure to heat stress, altered level of consciousness and elevated body temperature (usually 104o F or 40o C); often associated with absence of sweating, tachycardia and hypotension. TREATMENT

Move to cool environment and begin cooling measures: Remove clothing and splash/sponge/mist with water Place cool packs on neck, axilla, and inguinal areas Promote cooling by fanning

IV NS 10cc/kg, repeat vitals every 250 ccs. If seizures/ALOC present - see SEIZURE/ALOC GUIDELINE.

Environmental Emergencies July 2006 Hypothermia- 9206 Page 1 of 1



HYPOTHERMIA ALWAYS USE UNIVERSAL PRECAUTIONS


MODERATE HYPOTHERMIA DEFINITION Conscious and shivering, lethargic, skin pale and cold. TREATMENT Early receiving hospital notification. Ensure patent airway. Move to sheltered area minimizing physical exertion or movement, remove wet clothing and cover with warm, dry sheet or

blankets. If lungs clear, consider fluid challenge of 10 cc/kg NS. Recheck every 250 cc's.

SEVERE HYPOTHERMIA DEFINITION Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations. TREATMENT

Early receiving hospital notification. Handle gently, ensure patent airway. Prepare to support ventilations using appropriate airway adjuncts. If spontaneous respirations are present, intubate only if

necessary to prevent aspiration or if ventilations are inadequate (4-6/min may be adequate). Ventilate using warm, humidified oxygen if available. Avoid hyperventilating the patient.

Observe for organized rhythm and pulses for one minute. If organized rhythm present, move quickly but gently to warm environment (ambulance). If in asystole, begin chest compressions If in ventricular fibrillation, defibrillate once; perform chest compressions Withhold medication administration until patient has been re-warmed.

If lungs clear, consider fluid challenge of 10 cc/kg NS. Recheck every vital signs every 250 cc's.

Environmental Emergencies July 2006 Snakebite- 9207 Page 1 of 1



SNAKEBITE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION When a person knows they have been bitten by a poisonous or unidentified snake OR is bitten by an unknown source with physical evidence of rattlesnake bite (one or more puncture wound) and has symptoms of envenomation such as local pain, swelling or numbness. Identify causative agent or provide description of snake.

TREATMENT

Expedite transport. Early receiving hospital notification. Immobilize extremity at or below heart level. Consider pain management.

DO NOT

Apply ice to site. Make incisions over bite. Delay transport to initiate I.V. Use restrictive bands.



NEUROLOGIC EMERGENCIES

Neurologic Emergencies July 2006 Altered Level of Consciousness/ Syncope- 9301 Page 1 of 1



ALTERED LEVEL OF CONSCIOUSNESS/SYNCOPE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Glasgow Coma Scale less than 15, etiology unclear (consider AEIOU TIPS). Consider indications for spinal immobilization precautions. Consider diabetes-related complications.

TREATMENT If symptoms of shock, IV NS.

10 cc/kg, check vital signs every 250cc

Blood glucose determination. If BS < 80 mg/dl or unmeasurable: Administer Dextrose 50% 25 gm IV Administer Glucagon 1 mg IM or SQ if unable to establish IV access

If narcotic overdose suspected, Narcan IV, SQ, IM, IN, or SL titrated to effect (max. 2.0 mg).

Treat rhythm disturbances, if any, as appropriate.

Consider 12-lead EKG

Neurologic Emergencies July 2006 Seizures- 9302 Page 1 of 1



SEIZURES ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Two generalized seizures without regaining consciousness or paramedic-observed activity for two minutes. TREATMENT Protect from injury, cooling measures if febrile. Maintain open airway and assist ventilations as needed.

IV NS TKO.

Blood glucose determination.

If BS < 80 mg/dl or unmeasurable: AdministerDextrose 50% 25 gm IV Administer Glucagon 1 mg IM or SQ if unable to establish IV access

If narcotic overdose suspected, Narcan IV, SQ, IN or SL titrated to effect (max. 2.0 mg). Midazolam (Versed) 2 mg slow IV or 0.2 mg/kg IM; may be repeated if necessary in increments q 5 min. (total maximum

dose not to exceed 10 mg). Base Contact if seizures continue after total midazolam dosing.

Neurologic Emergencies July 2006 Acute Cerebrovascular Accident (Stroke)- 9303 Page 1 of 1



ACUTE CEREBROVASCULAR ACCIDENT ALWAYS USE UNIVERSAL PRECAUTIONS (STROKE)

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Sudden onset of weakness, paralysis, confusion, speech disturbances, may be associated with headache.

TREATMENT Maintain an open airway and administer oxygen to maintain oxygen saturations > 96%, assist respiratory effort if needed. Perform a Prehospital Stroke Assessment.

Assess Facial Droop Assess Arm Drift Assess Speech

Establish an accurate time of onset of symptoms. IV NS TKO Blood glucose determination.

If BS < 80 mg/dl or unmeasurable: AdministerDextrose 50% 25 gm IV Administer Glucagon 1 mg IM or SQ if unable to establish IV access

Obtain 12 Lead EKG if available.

Contact receiving facility ASAP.

Consider establishing a second IV Normal Saline TKO during transport.

If symptom onset is less than 3 hours consider code 3 transport.



OB-GYN EMERGENCIES

OB-GYN Emergencies July 2006 Vaginal Hemorrhage without Shock- 9401 Page 1 of 1



VAGINAL HEMORRHAGE WITHOUT SHOCK ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Abnormal (non-menstrual) vaginal bleeding, between menses, during pregnancy, post-partum or post-operative; any bleeding in third trimester. TREATMENT – NON-PREGNANT PATIENT

IV NS TKO. If post-partum and placenta has delivered.

Fundal massage and put infant to breast if appropriate. TREATMENT – PREGNANT PATIENT

Left lateral position. If any bleeding in third trimester, 2 large bore IV NS TKO.

OB-GYN Emergencies July 2006 Vaginal Hemorrhage with Shock- 9402 Page 1 of 1



VAGINAL HEMORRHAGE WITH SHOCK ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Profuse vaginal bleeding, signs of shock. TREATMENT – NON-PREGNANT PATIENT Place in trendelenburg position. Rapid transport. Large bore IV NS fluid challenge, 10 cc/kg. Recheck vital signs every 250 cc's. Consider second Large bore IV NS. If post-partum and placenta delivered.

Fundal massage and put infant to breast if appropriate.

TREATMENT – PREGNANT PATIENT Code 3 transport. Position in left lateral position if concern for spinal injury is not present. If concern is present, keep in spinal precaution and

rotate back board 30 degrees to the left or manually attempt movement of uterus towards left side with gentle traction. Large bore IV NS fluid challenge, 10 cc/kg. Recheck vital signs every 250 cc's. Consider second Large bore IV NS. If any bleeding in third trimester, insert second IV.

OB-GYN Emergencies July 2006 Severe Pre-Eclampsia/ Eclampsia- 9403 Page 1 of 1



SEVERE PRE-ECLAMPSIA/ECLAMPSIA ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Third trimester pregnancy with hypertension (BP systolic > 160, diastolic > 110), mental status changes, visual disturbances, peripheral edema (pre-eclampsia), seizures and/or coma (eclampsia). TREATMENT Position on left side. IV NS TKO started enroute. If patient manifests seizure activity

Midazolam (Versed) 2 mg slow IV or 0.2 mg/kg IM; may be repeated if necessary in increments q 5 min. (total maximum dose not to exceed 10 mg).

Contact base hospital. PHYSICIAN ORDER ONLY: NTG 0.4 mg SL, may repeat in 10 minutes. Hold if diastolic BP less than 110.

OB-GYN Emergencies July 2006 Imminent Delivery- 9404 Page 1 of 2



IMMINENT DELIVERY ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Regular contractions, bloody show, low back pain, feels like bearing down, crowning. REMINDERS - Determine gestational age, number of births, number of babies. TREATMENT IV NS TKO as time allows. As head is delivered, gently suction baby's mouth and nose keeping the head dependent. If cord is around neck and can't be

slipped over the head, double clamp and cut between clamps. Allow delivery, dry baby and keep warm, placing baby on mother's abdomen or breast. Allow cord to stop pulsating, then clamp and cut 6-8 inches from baby. Assess baby for heart rate, respirations, and color, APGAR if possible at 1 and 5 minutes (see NEONATAL

RESUSCITATION). Allow delivery of placenta – save and bring to the hospital with mother and child. If infant is premature (<36 weeks gestation), prepare for neonatal resuscitation and early transport.

COMPLICATIONS BREECH PRESENTATION DEFINITION - Presentation of buttocks or both feet TREATMENT High flow oxygen. Begin rapid transport with early base contact. Allow delivery to proceed passively until baby's waist appears. Rotate baby to face down position (do not pull). If head does not deliver in 3 minutes, insert gloved hand into vagina to create an air passage for infant. As mother bears down, sweep the head out of the vagina. IV NS TKO if can be accomplish without delaying transport.

LIMB PRESENTATION DEFINITION - Presentation of single extremity TREATMENT High flow oxygen. Begin rapid transport with early base contact. Position mother on gurney with hips elevated and left lateral. IV NS TKO if can be accomplish without delaying transport.

OB-GYN Emergencies July 2006 Imminent Delivery- 9404 Page 2 of 2

Paramedic Academy

Coastal Valleys EMS Agency PROLAPSED CORD TREATMENT High flow oxygen therapy. Begin rapid transport with early base contact. Insert gloved hand into vagina and gently push presenting part off cord, ensure cord pulsations return. Do not attempt to re-

position cord. Cover cord with saline soaked gauze. Position mother on gurney with hips elevated and left lateral. IV NS TKO if can be accomplished without delaying transport.

OB-GYN Emergencies July 2006 Apgar Scoring - 9405 Page 1 of 1



APGAR SCORING ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 REMINDER Check APGAR score at 1 minute, 5 minutes and every 5 minutes thereafter. Apgar 7-10

Suction with bulb syringe. Keep dry and warm (skin to skin with mother and blanket).

Apgar 4-6

Suction with bulb syringe. Ventilate 40-60 breaths/min with 100% oxygen. Monitor (begin cardiac compressions if heart rate not increasing after 15-30 seconds of assisted ventilations). Keep warm and dry.

Apgar 0-3

Suction with bulb syringe. Support ventilation 40-60 breath/min with 100% oxygen, bag and mask, intubate if bagging inadequate. Monitor; if heart rate < 80/min and not increasing with assisted ventilation after 15-30 seconds, begin cardiac

compression. Keep warm and dry.

APGAR SCORING CHART

0 1 2

Appearance

Pulse

Grimace Activity

Respiratory Effort

Blue-pale

0

No response Flaccid Absent

Body pink Limbs blue

<100 Grimace

Some flexion Slow, irregular

Pink all over

>100

Cough, cry, sneeze Active movement Strongly crying



RESPIRATORY EMERGENCIES

Respiratory Emergencies July 2006 Bronchospasm- 9501 Page 1 of 1



BRONCHOSPASM ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Acute onset of respiratory difficulty, including toxic inhalation, asthma, COPD and other etiologies that may induce bronchospasm. MILD TO MODERATE

Administer Albuterol 5mg in 6 cc NS and Atrovent 0.5mg in 3 cc NS. Repeat Albuterol 5mg in 6 cc NS as needed, do not repeat Atrovent.

SEVERE

Assist ventilations with 100% oxygen and inline nebulization with: Albuterol 5mg in 6 cc NS. Atrovent 0.5mg in 3 cc NS.

Continue Albuterol 2.5mg in 3cc NS nebulizer/bag-valve-mask. Consider CPAP. Epinephrine 1:1000, 0.01mg/kg SQ. Maximum dose 0.5 mg. (Use with caution in patients over 35 years of age and in

patients with coronary artery disease.). Early receiving hospital notification.

If respiratory arrest appears imminent:

Consider 0.5 mg of epinephrine (1:10,000) IV. Intubation of the severe asthmatic is extremely difficult and all other measures should be exhausted first.

Respiratory Emergencies July 2006 Acute Pulmonary Edema- 9502 Page 1 of 1



ACUTE PULMONARY EDEMA ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Acute onset of respiratory difficulty with systolic blood pressure over 120. May have history of cardiac disease, rales, occasional wheezes.

TREATMENT

Nitroglycerin 0.4 mg SL, may repeat every 5 minutes if systolic blood pressure remains greater than 100. For transport times of over 1 hour:

Apply ½ inch of 2% Nitroglycerin paste - may apply an additional ½ inch if signs/symptoms persist and systolic blood pressure remains above 100.

Administer Lasix 40mg IV. If patient takes Lasix regularly, give 80 mg Lasix IV. In moderate to severe respiratory distress, consider CPAP. Consider Morphine Sulfate 2-5 mg IVP.



TRAUMA

Trauma July 2006 Amputation- 9601 Page 1 of 1



AMPUTATION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Isolated extremity amputation. TREATMENT

Elevate and, if indicated, splint the injured extremity. Control bleeding.

Apply a pressure dressing. If unable to control bleeding with pressure in:

Upper extremity: apply a blood pressure cuff and inflate to 20 mm/Hg above systolic pressure. Lower extremity: apply a blood pressure cuff and inflate to a pressure, which controls bleeding.

IV NS TKO If SBP < 90, fluid challenge, 10cc/kg. Recheck vital signs every 250 cc's.

For pain management, in absence of hypotension and no narcotic allergies, Morphine Sulfate per Severe Pain protocol Consider sedation per sedation protocol for anxiety. Once all bleeding is controlled and this patient is a possible reimplantation candidate, administer aspirin 162 mg po.

CARE OF THE AMPUTATED PART When load and transport time is MORE than 20 minutes Place the amputated part in a plastic container. Do not add ice or saline to the container in which the part has been placed.

Place that container in a second plastic wrap in which has been placed iced saline or water. When load and transport time is LESS than 20 minutes

Place the amputated part in a sterile saline moistened gauze wrap.

Trauma July 2006 Burns- 9602 Page 1 of 1



BURNS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 ALS TREATMENT

BLS Burn Guideline. Consider early advanced airway if airway burn involved. Administer oxygen to maintain oxygen saturations above 96%. IV NS 10 cc/kg. Recheck vital signs every 250 cc's. May repeat bolus if transport time is over 30 minutes. For pain management, in absence of hypotension, significant other trauma, altered level of consciousness and narcotic

allergy, Morphine Sulfate per Severe Pain protocol .

Trauma July 2006 Major Trauma- 9603 Page 1 of 1



MAJOR TRAUMA ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 NOTE It must be recognized that rapid transport to appropriate definitive care is of the utmost importance; therefore, the estimated time of arrival to the trauma receiving facility must be taken into account in the field management of major trauma patients. TREATMENT

Begin immediate transport. Establish 1-2 large bore I.V. of normal saline. Administer Normal saline bolus (10 cc/kg).

After each 250 cc bolus, recheck vital signs. If altered LOC, consider medical etiology and follow hypoglycemia and/or narcotic OD protocol. Early trauma center notification.

Trauma July 2006 Head Injury- 9604 Page 1 of 1



HEAD INJURY ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Head injury, known or suspected, with persistent altered level of consciousness. TREATMENT IV NS at TKO. Blood Glucose determination.

BS < 80 mg/dl or unable to measure: Dextrose 50% 25 gm IV. If unable to establish an IV AND

BS < 80 or unable to measure: Glucagon 1mg IM or SQ. If clear evidence of narcotic overdose is present and the patient has decreased respirations, 0.8 mg Narcan IV, ETT, SQ, SL,

IN or IV may be administered. Moderate or severe decreased LOC (GCS 9 or less) Ventilate patient at the normal age based respiratory rate. Consider endotracheal intubation. If patient combative, extremely agitated, or clenched (trismus), see Sedation Guideline. If patient is seizing, see Seizure Guideline.

Trauma July 2006 Crush Syndrome- 9605 Page 1 of 1



CRUSH SYNDROME ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Crush syndrome can develop when an individual is entrapped with extensive tissue involvement. Entrapment should be broadly interpreted to mean that movement and circulation have been compromised and some type of extrication assistance is necessary. Patients with extended extremity or torso entrapment (usually > 2hours) TREATMENT Check for: Pain Paresthesia Paralysis Pallor Pulselessness

Not all need to be present, but they are good indicators that crush syndrome is likely. PRIOR TO EXTRICATION – if possible Establish two (2) large bore IV’s of NS and flow at 500ml/hr total. If hypotension is present, increase flow. Consider patients with co-morbid factors (age, history of renal or cardiac disease,

Presence of hypothermia, and/or alcohol or drug use). Consider prophylactic Sodium Bicarbonate 50 mEq in the IV bag, infuse at drip rate. Check lung sounds and anticipate broncho-constriction due to histamine release. Administer Albuterol 5mg in 6cc NS. Monitor Cardiac rhythm. Administer CaCl if life-threatening changes occur. CaCl dose is 2-4mg/kg of 10% solution via slow IV push.

NOTE DO NOT run Sodium Bicarbonate and CaCl concurrently. Either flush line well or use a separate line.



PEDIATRIC EMERGENCIES

Pediatric Emergencies July 2006 Pediatric Cardiac Arrest Asystole/ Pulseless Electrical Activity- 9701 Page 1 of 1



PEDIATRIC PULSELESS ARREST ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 TREATMENT

Confirm pulselessness. Begin CPR. Evaluate rhythm. If rhythm is unclear and possibly ventricular fibrillation, refer to pediatric ventricular fibrillation protocol. Provide appropriate airway management. Establish IV or IO NS at TKO.

Consider fluid bolus 20 cc/kg. Epinephrine (1:10,000) – 0.01mg/kg (0.1 ml/kg) IV/IO, Administer CPR 5 cycles / 2 minutes (15:2), perform rhythm / pulse

check. Max of 1 mg per dose; Repeat every 3-5 minutes, max cumulative dose 15 mg. The preferred method of administration is IV / IO, if unable to establish IV / IO.

Epinephrine (1:1,000) 0.1 mg/kg (0.1 ml /kg) may be given via ETT. SPECIAL CONSIDERATIONS Use length based color-coded resuscitation tape whenever possible. Place a high importance on good BLS skills. If able to maintain an adequate BLS airway you may consider deferring the placement of an advanced airway for several

minutes into the arrest. AVOID HYPERVENTILATION. Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should

not interrupt the CPR cycles. If unable to establish IV/IO and unable to intubate, begin transport. Continue efforts to establish IV/IO/ETT while transporting. Consider Atropine 0.02 mg/kg IV /IO if PEA is suspected to be due to increased vagal tone or primary AV block.

Minimal dose 0.1 mg (<5 Kg) Maximum total dose 1 mg

Consider and treat possible contributing factors. Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo/Hyperkalemia Hypoglycemia Hypothermia Toxins (overdoses) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary / pulmonary) Trauma

Consideration may be given by base physician for field pronouncement. If transport indicated, consider Code 2.

Pediatric Emergencies July 2006 Pediatric Cardiac Arrest Ventricular Fibrillation/Pulseless Ventricular Tachycardia 9702 Page 1 of 1



PEDIATRIC PULSELESS ARREST VENTRICULAR FIBRILLATION /

PULSELESS VENTRICULAR TACHYCARDIA ALWAYS USE UNIVERSAL PRECAUTIONS


Confirm pulselessness. Begin CPR while preparing equipment . Evaluate Rhythm . Defibrillate 2 J/kg monophasic (or biphasic equivalent). Resume CPR immediately. Administer CPR 5 cycles / 2 minutes

(15:2)

Provide appropriate airway management Establish IV / IO NS at TKO

▪ Consider fluid bolus 20 ml / kg Perform rhythm / pulse check; for persistent V-Fib Defibrillate 4 J/kg monophasic (or biphasic equivalent). Resume CPR

immediately. Administer Epinephrine (1:10,000) – 0.01mg/kg (0.1 ml/kg) IV/IO, resume CPR 5 cycles / 2 minutes (15:2)

▪ Repeat every 3-5 minutes ▪ Do not exceed 1 mg in a single dose

▪ The preferred method of administration is IV / IO, if unable to establish IV / IO, ▪ Epinephrine (1:1,000) 0.1 mg/kg (0.1 ml /kg) may be given via ETT

Perform rhythm / pulse check; for persistent V-fib Defibrillate 4 J/kg Amiodarone 5mg/kg IV/IO. Administer CPR 5 cycles / 2 minutes (15:2), Perform rhythm / pulse check; for persistent V-fib Defibrillate 4 J/kg monophasic (or biphasic equivalent); Administer CPR 5

cycles / 2 minutes (15:2), perform rhythm / pulse check

SPECIAL CONSIDERATIONS Use length based color-coded resuscitation tape whenever possible Place a high importance on good BLS skills If able to maintain an adequate BLS airway you may consider deferring the placement of an advanced airway for several

minutes into the arrest. AVOID HYPERVENTILATION. Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should

not interrupt the CPR cycles If < 10 kg, use pediatric pads/paddles for cardioversion if available; if unavailable, use adult pads/paddles in A-P position If available defibrillator will not dial down to appropriate level, use lowest possible setting

Pediatric Emergencies July 2006 Pediatric BradyDysrhythmias- 9703 Page 1 of 1



PEDIATRIC BRADYDYSRHYTHMIAS ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 TREATMENT Assure adequate oxygenation and ventilation, bradycardia in children is usually due to hypoxia and secondarily hypothermia. If signs of decreased perfusion and HR < 60/min start CPR; (consider CPR if HR < 80/min in infant). Check blood glucose. Check temperature and warm if hypothermic.

NORMAL PERFUSION IV NS TKO.

DECREASED PERFUSION OR RESPIRATORY DISTRESS Consider immediate external cardiac pacing, using pediatric pacing patches at 100 BPM. Establish IV / IO NS @TKO.

Consider fluid bolus 20 cc/kg. Epinephrine (1:10,000) – 0.01mg/kg (0.1 ml/kg) IV/IO, Administer CPR 5 cycles / 2 minutes (15:2), perform rhythm / pulse check.

Max of 1 mg per dose; Repeat every 3-5 minutes, max cumulative dose 15 mg. The preferred method of administration is IV / IO, if unable to establish IV / IO.

Epinephrine (1:1,000) 0.1 mg/kg (0.1 ml /kg) may be given via ETT . Consider Atropine 0.02 mg/kg IV /IO if bradycardia is suspected to be due to increased vagal tone or primary AV block.

Minimal dose 0.1 mg (<5 Kg) Maximum total dose 1 mg

SPECIAL CONSIDERATIONS Use length based color-coded resuscitation tape whenever possible. If external cardiac pacing is utilized use caution in dialing up energy. The smaller the child, the lower the amount of energy

(milliamps) required to obtain capture. Start at 5 milliamps in children with incremental increases of 5 milliamps until obtaining capture.

Pediatric July 2006 Pediatric Tachycardia- 9704 Page 1 of 2



PEDIATRIC TACHYCARDIA ALWAYS USE UNIVERSAL PRECAUTIONS


Provide appropriate airway management. Establish IV or IO NS at TKO.

Consider fluid bolus 20 cc/kg. Evaluate Rhythm.

Probable Sinus Tachycardia

Consistent compatible history. P waves present / normal. Variable RR; constant PR QRS < 0.08 sec Infants HR < 220; Children HR < 180 Search for and treat cause.

Probable Supraventricular Tachycardia

Vague, nonspecific compatible history. P waves absent / abnormal HR not variable. QRS < 0.08 sec History of abrupt rate changes. Infants HR > 220; Children HR > 180 If decreased perfusion, but responsive

Consider vagal maneuvers. Adenosine 0.1 mg/kg rapid IV/IO to max of 6 mg.

May repeat in 3 min at 0.2 mg/kg IV/IO to max of 12 mg. If perfusion and responsiveness decreasing or above therapy unsuccessful Synchronized cardioversion 0.5 ws/kg monophasic (or biphasic equivalent). If no response, repeat 1 ws/kg monophasic (or

biphasic equivalent); if no response, 2 ws/kg monophasic (or biphasic equivalent), repeat 4 ws/kg monophasic (or biphasic equivalent) if needed.

Consider Midazolam 0.1 mg/kg IV / IO / IM before cardioversion if child is responsive.

Probable Ventricular Tachycardia Vague, nonspecific compatible history P waves absent / abnormal HR not variable QRS > 0.08 sec History of abrupt rate changes Infants HR > 220; Children HR > 180 If decreased perfusion, but responsive, PHYSICIAN ORDER ONLY

Infuse 5 mg/kg Amiodarone in 50 ml NS over 20 to 60 minutes (If using 100ml bags, withdraw 50ml prior to adding Amiodarone)

ALS Treatment Guidelines July 2006 Pediatric Tachycardia- 9704 Page 2 of 2



If decreased responsiveness Synchronized cardioversion 0.5 ws/kg monophasic (or biphasic equivalent). If no response, repeat 1 ws/kg monophasic (or

biphasic equivalent); if no response, 2 ws/kg monophasic (or biphasic equivalent), repeat 4 ws/kg monophasic (or biphasic equivalent) if needed. Consider Midazolam 0.1 mg/kg IV / IO / IM before cardioversion if child is responsive. If cardioversion successful

Infuse 5 mg/kg Amiodarone in 50 ml NS over 20 to 60 minutes. If transport time greater than 20 mins., contact base for rebolus guidelines.

If cardioversion not successful Refer to Pediatric Pulseless Arrest, Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol.

CONSIDERATIONS

Use length based color-coded resuscitation tape whenever possible. Establishment of IV / IO, airway and medication administration should occur during 5 cycles / 2 minutes of CPR and should

not interrupt the CPR cycles. If < 10 kg, use pediatric pads/paddles for cardioversion if available; if unavailable, use adult pads/paddles in A-P position. If available defibrillator will not dial down to appropriate level, use lowest possible setting. Pulse oximeter if available.

Pediatric Emergencies July 2006 Newborn Resuscitation- 9705 Page 1 of 2



NEWBORN RESUSCITATION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE It is the intent of the policy to provide optimal care to all newborn patients transported by the ALS provider. PROTOCOL A majority of newborns respond to simple measures. This algorithm reflects relative frequencies of resuscitative efforts for a newborn that does not have meconium-stained amniotic fluid.

Pediatric Emergencies July 2006 Newborn Resuscitation- 9705 Page 2 of 2



TERM NEWBORN VITAL SIGNS Heart Rate (awake): 100 to 180 bpm Respiratory Rate: 30 to 60 breaths / min Systolic Blood Pressure: 55 to 90 mm Hg Diastolic Blood Pressure: 26 to 55 mm Hg

INITIAL CARDIOPULMONARY RESUSCITATION Ventilation rate 40-60 / min when performed without compression. Compression rate: 120 events / min (90 compressions interspersed with 30 ventilations). Compression-ventilation ratio: 3:1 (pause compressions for ventilation).

MEDICATIONS USED FOR RESUSCITATION OF THE NEWBORN

Medications Dose / Route Concentration Precautions Epinephrine 0.01 - 0.03 mg / kg IV

0.1 mg / kg ETT 1:10,000 Give rapidly

Repeat every 3-5 min ETT Route (class Indeterminate) Higher IV doses not recommended

Volume Expansion (NS) 10 ml / kg IV Indicated for shock Give over 5-10 min Reassess after each bolus

Dextrose 0.2 g / kg or 2 ml / kg IV 10% Solution (0.1 g/ml)

Check bedside glucose To make 10 % dextrose add 50 ml D50 to 200 ml NS

Naloxone (Class Indeterminate)

0.1 mg / kg IV or IM 0.4 mg / ml Establish adequate ventilation first Not recommended for initial resusucitation Give rapidly Repeat ever 2-3 min PRN Caution in opiod-addicted mothers (may precipitate seizures)

Sodium Bicarbonate 1-2 mEq / kg IV 4.2% Solution (0.5 mEq /ml)

Establish adequate ventilation first Only for prolonged resuscitation Give slow IV Push over 2 minutes

ENDOTRACHEAL TUBE SIZE AND DEPTH

Weight (g) Gestational Age (Wk)

Laryngoscope Blade

ETT Size * / Suction Cath Size

Depth of Insertion from upper lip ** (cm)

Below 1000 g < 28 wks 0 2.5 / 5 F 6.5 – 7 cm 1000 - 2000 g 28 – 34 wks 0 3.0 / 6 F 7 – 8 cm 2000 – 3000 g 34 – 38 wks 0 – 1 3.5 / 8 F 8 – 9 cm

> 3000 g > 38 wks 1 3.5 – 4.0 / 8 F > 9 cm * Use uncuffed ETT **Do not cut ETT SPECIAL CONSIDERATIONS Use length based color-coded resuscitation tape whenever possible. If unable to establish IV and unable to intubate, begin transport. Continue efforts to establish IV/IO/ETT while

transporting. No clinical data regarding IO route of administration of medications or volume expansion.

Pediatric Emergencies July 2006 Pediatric Respiratory Distress Croup, Stridor, Wheezing- 9706 Page 1 of 1



PEDIATRIC RESPIRATORY DISTRESS STRIDOR / CROUP


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PROBABLE UPPER AIRWAY OBSTRUCTION

Administer high flow oxygen, allow parent to administer if appropriate. If patient deteriorates, or becomes completely obstructed, attempt positive pressure ventilation via bag-mask.

▪ endotracheal intubation should be performed ONLY if bag-mask ventilation is inadequate. Consider nebulized epinephrine, 5ml 1:1,000 by inhalation.

OTHER, NON-OBSTRUCTIVE CAUSES OF RESPIRATORY DISTRESS

Consider IV access. Consider Narcan 0.1 mg/kg IV / IM / IO / ET / IN for respiratory depression

SPECIAL CONSIDERATIONS

Transport in a position of comfort. The goal is to not make the patient worse, avoid procedures that will cause the patient to become upset. (i.e. If the

patient will not tolerate a mask, try blow by, etc.). Allow the caregivers to assist where they can to keep the patient calm.

Pediatric Emergencies July 2006 Pediatric Respiratory Distress Asthma, Bronchospasm- 9707 Page 1 of 1



PEDIATRIC RESPIRATORY DISTRESS BRONCHOSPASM


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 Mild Distress

Administer Albuterol 2.5mg in 3 cc NS via nebulizer. May repeat Albuterol 2.5mg in 3 cc NS via nebulizer.

Moderate to Severe Distress

If patient has spontaneous respirations with adequate tidal volume: Continuous Albuterol 2.5mg in 3 cc NS via nebulizer. Add Atrovent 0.5 mg in 3 cc NS ( > 8 years), 0.25 mg in 1.5 cc (< 8 years) to 2nd and subsequent nebulizer treatments.

If patient is apneic or has inadequate tidal volume: Assist ventilations with 100 % oxygen . Epinephrine 1:1000, 0.01mg/kg SQ. Maximum dose 0.5 mg. < 1 year 1:10,000 – 5 cc (0.5 mg) IV / IO. Provide appropriate airway management.

Albuterol 2.5mg in 3 cc NS/ET tube or nebulizer/bag-value-mask, not to exceed 20 mg per hour nebulization. If further deterioration, consider epinephrine 0.01 mg/kg (1:10,000) (0.1 ml/kg) IV / IO or 0.1 mg/kg (1: 1000) (0.1 ml/kg)

ETT .

Pediatric Emergencies July 2006 Pediatric Shock- 9708 Page 1 of 1



PEDIATRIC SHOCK ALWAYS USE UNIVERSAL PRECAUTIONS


Fluid bolus 20 cc/kg NS IV/IO prn to maintain perfusion status. Administer boluses with 60 ml syringe over 5-10 minutes. Note children may require several boluses, reassess after each bolus.

If Shock state is not due to Hypovolemia consider: Dopamine infusion: if hypotension persists despite NS fluid administration. PHYSICIAN ORDER ONLY

Use rule of sixes to calculate dopamine infusion Weight in Kg x 6 mg = mg of dopamine to be added to a total of 100 ml of NS 1 ml/hr = 1 mcg/kg/min

For example 10 Kg patient • 10 Kg x 6 mg = 60 mg • Dopamine on hand is 400 mg in 5 ml (80 mg / ml) • 60 mg / 80 mg = 0.75 ml to be added to a total of 100 ml of NS • Start infusion at 10 ml /hr for 10 mcg/kg/min

Pt. Weight Dopamine mg

Dopamine mls to be added (40mg/ml)

3.0 kg 18 mg 0.45 ml 5.0 kg 30 mg 0.75 ml 7.5 kg 45 mg 1.125 ml 10.0 kg 60 mg 1.5 ml 12.5 kg 75 mg 1.875 ml 15.0 kg 90 mg 2.25 ml 17.5 kg 105 mg 2.625 ml 20.0 kg 120 mg 3.0 ml 25.0 kg 150 mg 3.75 ml 30.0 kg 180 mg 4.5 ml 35.0 kg 210 mg 5.25 ml 40.0 kg 240 mg 6.0 ml 45.0 kg 270 mg 6.75 ml 50.0 kg 300 mg 7.5 ml 55.0 kg 330 mg 8.25 ml 60.0 kg 360 mg 9.0 ml 65.0 kg 390 mg 9.75 ml

Add appropriate amount (mg of dopamine) to a total of 100 mls of Normal Saline Concentration: 10ml/hr = 10µg/kg/min

Pediatric Emergencies July 2006 Pediatric Allergic Reaction- 9709 Page 1 of 1



PEDIATRIC ALLERGIC REACTION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 MILD DEFINITION: Urticaria (Itchy, raised welts)

TREATMENT: Benadryl 1 mg/kg IM to max of 50 mg

MODERATE or SEVERE DEFINITION: Urticaria, and at least one of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps.

TREATMENT Epinephrine 1:1000, 0.01 mg/kg SQ, max of 0.5 mg Benadryl 1 mg/kg IM to max of 50 mg Albuterol 2.5mg in 3 cc NS via nebulizer 20 mg/hr May repeat Albuterol 2.5mg in 3 cc NS. Consider adding Atrovent 0.5 mg in 3 cc NS ( > 8 years), 0.25 mg in 1.5 cc (< 8 years).

ANAPHYLAXIS DEFINITION: Urticaria with signs of shock.

TREATMENT Epinephrine 1:1000, 0.01 mg/kg, SQ/SL, max of 0.5 mg If dysrhythmias,are present treat per specific protocol. Establish IV / IO

Administer fluid challenge, 20 cc/kg NS may repeat as needed. If unresponsive and no palpable BP

Epinephrine 1:10,000, 0.01 mg/kg IV/IO, max 0.5 mg Benadryl 1 mg/kg IV/IO max of 50 mg Consider CPR.

Pediatric Emergencies July 2006 Pediatric Seizure- 9710 Page 1 of 1



PEDIATRIC SEIZURE ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 Definition Two generalized seizures without regaining consciousness or EMT-P observed seizure activity for two (2) minutes. Treatment

Protect from injury, do not restrain, cooling measures if febrile. Establish IV or IO. Evaluate blood glucose.

If < 60 (40 if neonate) or unmeasurable and > 2 years, administer Dextrose 50% 1 cc/kg IV / IO. < 2 years, administer Dextrose 25% 2 cc/kg IV / IO. Neonate, administer Dextrose 10% 3 cc/kg IV / IO. If no vascular access, administer Glucagon 1 mg IM.

For continued seizure activity Midazolam 0.1 mg/kg IV or IM may repeat every 5 minutes X 2.

Pediatric Emergencies July 2006 Pediatric Altered Level of Consciousness - 9711 Page 1 of 1



PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS ALWAYS USE UNIVERSAL PRECAUTIONS


Provide appropriate airway management. Establish IV or IO.

Evaluate blood glucose .

If < 60 (40 if neonate) or unmeasurable and

> 2 years, administer Dextrose 50% 1 cc/kg IV / IO. < 2 years, administer Dextrose 25% 2 cc/kg IV / IO. Neonate, administer Dextrose 10% 3 cc/kg IV / IO. If no vascular access, administer Glucagon 1 mg IM.

If mental status and respiratory effort are depressed Narcan 0.1 mg/kg IM / IV / IO / ET / IN. May repeat every 5 minutes if strong suspicion of opiate overdose or if response is

noted

Pediatric Emergencies July 2006 Pediatric Toxic Exposures- 9712 Page 1 of 1



PEDIATRIC TOXIC EXPOSURES ALWAYS USE UNIVERSAL PRECAUTIONS


Provide appropriate airway management. Establish IV or IO . Bring identifying substance containers to hospital when possible/appropriate.

Hydrocarbons or petroleum distillates

Do not induce vomiting. Transport immediately.

Caustics/Corrosives

Do not induce vomiting. Consider dilution with no more than 1-2 glasses of water or milk if NO respiratory compromise or change in mental status.

Insecticides

Decontaminate patient. Atropine 0.05 mg/kg IV/IO slowly every 5-10 min to max of 4 mg or signs of atropinization(dilated pupils, mild

tachycardia). If seizures occur, administer Midazolam 0.1 mg/kg IV or IM. Contact base.

Cyclic Antidepressants

Anticipate rapid deterioration of condition. Activated charcoal, 1 gm/kg PO, max of 50 gms. At first signs of deterioration, hyperventilate and give Sodium bicarbonate 1 mEq/kg IVP. If seizures occur, administer Midazolam 0.1 mg/kg IV or IM.

Phenothiazine Reactions

Benadryl 1 mg/kg IM or slow IV to max 50 mg. Other Non-Caustic Drugs, awake and alert

Activated charcoal 1 gm/kg PO, max of 50 gms . SPECIAL CONSIDERATION

If suspected opiate overdose in non-neonate, administer Narcan, 0.1 mg/kg IV / IO / IM / IN prior to advanced airway.

Pediatric Emergencies July 2006 Pediatric Burns- 9713 Page 1 of 1



PEDIATRIC BURNS ALWAYS USE UNIVERSAL PRECAUTIONS


Provide appropriate airway management. High flow oxygen if inhalation injury suspected. Stop burning process; remove jewelry and clothing from affected areas.

If dry chemical, brush off, then flush with copious water. If liquid, flush with copious water. If eye involvement, flush continuously with NS during transport.

Once burning process has been stopped, pat wound dry, and apply clean dry wound dressing and/or sheet to involved area. Shock position if appropriate.

Thermal Injury/Chemical Burns

IV or IO as indicated. Fluid challenge 20 ml/kg NS may repeat as necessary. Morphine 0.05 mg/kg IV or IM may repeat as needed.

Electrical Burns

Cardiac monitor. IV or IO as indicated. Fluid challenge 20 ml/kg NS may repeat as necessary. Treat dysrhythmia by appropriate protocol. Consider Morphine 0.05 mg/kg IV may repeat as needed.

SPECIAL CONSIDERATIONS

Do not apply cool dressings or allow environmental exposure due to risk of hypothermia. Pulse oximeter if available, if smoke inhalation, reading may be artificially high. Early receiving hospital notification. Consider direct transport to U.C. Davis Med Center

Pediatric Emergencies July 2006 Pediatric Severe Pain- 9714 Page 1 of 1



PEDIATRIC SEVERE PAIN ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION Severe pain (usually musculoskeletal) in the presence of adequate vital signs and level of consciousness. Patient does not fit any other treatment protocol, i.e., major trauma, burns, etc. Extrication, movement or transport is required which will cause considerable pain to the patient AND there are no known

contraindications to administering analgesia. TREATMENT

Establish IV access (IV NS or NS lock as appropriate). Morphine Sulfate IV or IM 0.05 mg/kg may repeat as needed. Monitor patient and vital signs carefully, insure patent airway.

RELATIVE CONTRAINDICATIONS Deteriorating LOC Hypotension



ALS PROCEDURES

ALS Procedures July 2006 Adult Oral Endotracheal Intubation - 9801 Page 1 of 2



ADULT ORAL ENDOTRACHEAL INTUBATION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 INDICATIONS

Unconscious, apneic, or near apneic, patients without a gag reflex.

RELATIVE CONTRAINDICATIONS Suspected opiate overdose Profound hypoglycemia

PROCEDURE

Place patient in correct position. Hyperoxygenate patient with BVM ventilations with adequate tidal volume and rate for 1-3 mins with 100% oxygen, avoid

hyperventilation . Apply cricoid pressure as needed to prevent passive regurgitation. Instruct partner to place patient on cardiac and pulse oximeter monitors. Select a proper ETT. Insert stylet. Select proper sized blade and visualize landmarks (Epiglottis, posterior notch, vocal cords).

Suction as needed. Insert ETT 2-3 cm past the cords under direct visualization.

Attempts should be limited to a fall in HR or Pulse Ox. or 30 seconds per attempt. Hyperoxygenate between attempts.

Remove stylet, inflate cuff and bag ventilate. Confirm position with at least three of the following methods (one method needs to be mechanical):

Direct endotracheal visualization Esophageal intubation detector Absence of epigastric sounds Presence of bilateral breath sounds Equal chest rise Misting or fogging in the ETT CO2 detection device

Secure the tube. (Consider cervical collar to prevent extubation). Reassessment tube placement after each patient movement (may be done with CO2 detection device). If any doubt about proper placement, use direct visualization to confirm.

ALS Treatment Guidelines July 2006 Adult Oral Endotracheal Intubation Policy- 9801 Page 2 of 2



Special Considerations:

The goal is to always ventilate the patient. Do not sacrifice good ventilation with repeated attempts at intubation. Make 2 attempts at intubation and move to next procedure as defined in Airway Management Protocol . Do not delay transport with repeated unsuccessful intubation attempts.

Cardiac Arrest Endotracheal intubation should be performed prior to I.V. insertion but should not precede defibrillation in cardiac

arrest victims in ventricular fibrillation or tachycardia.

ALS Procedures July 2006 Pediatric Endotracheal Intubation Policy- 9802 Page 1 of 2



PEDIATRIC ENDOTRACHEAL INTUBATION ALWAYS USE UNIVERSAL PRECAUTIONS


All unconscious and apneic or near apneic patients without a gag reflex when BLS airway management is not effective. Patients in whom controlled ventilations is mandatory such as those in cardiac arrest, respiratory arrest, profound shock

with respiratory failure, severe head injury with coma. Airway protection. Bypass airway obstruction.

CONTRAINDICATIONS

Adequate spontaneous respirations are present. Patient is awake with intact gag reflex.

TREATMENT PROTOCOL

Child must be in supine position. Apply general cervical immobilization and minimize neck movement in patients with head and/or neck trauma. In an infant under 12 months, the larger head may require shoulder towel roll to maintain a neutral spine position. Do not overflex the neck as this can occlude the airway. The larynx is more anterior and cephalad than in the adult. The tracheal orifice is small and may be easily obstructed by

incorrect positioning. PROCEDURE

Place patient in correct position. Hyperoxygenate with bag valve mask ventilation with 100% oxygen for 1-3 minutes. Apply cricoid pressure. Prevent passive regurgitation. Instruct partner to place patient on cardiac and pulse oximeter monitors. Select a properly sized ETT per length based resuscitation tape. Insert stylet properly. Ensure suctioning equipment is available. Select proper sized blade and visualize the larynx. Insert ETT 2-3 cm past the cords under direct visualization.

Attempts should be limited to a fall in HR or Pulse Ox. or 30 seconds per attempt. Hyperoxygenate between attempts.

Remove stylet and bag ventilate.

ALS Procedures July 2006 Pediatric Endotracheal Intubation Policy- 9802 Page 2 of 2



Confirm position with at least three of the following methods: Direct endotracheal visualization Esophageal intubation detector Absence of epigastric sounds Presence of bilateral breath sounds Equal chest rise Misting or fogging in the ETT CO2 detection device Stabilize head in neutral position with a cervical collar and secure the tube. Reassessment of proper tube placement shall be performed after each patient movement (this can be done with a

CO2 device). If there is any doubt as to proper placement of the ET tube, visualize the pharynx with laryngoscope and confirm

position. If still in doubt, remove the ET tube and suction the airway if needed. Hyperoxygenate the patient for at least 1 minute before next attempt at intubation.

Special Considerations:

The goal is to always ventilate the patient. Do not sacrifice good ventilation with repeated attempts at intubation. Make 2 attempts at intubation and move to next procedure as defined in Airway Management Protocol. Do not delay transport with repeated unsuccessful intubation attempts.

Cardiac Arrest Endotracheal intubation should be performed prior to I.V. insertion but should not precede defibrillation in cardiac

arrest victims in ventricular fibrillation or tachycardia.

ALS Procedures July 2006 Endotracheal Tube Introducer (ETTI) - 9803 Page 1 of 1



ENDOTRACHEAL TUBE INTRODUCER (ETTI) ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 ENDOTRACHEAL TUBE INTRODUCER (ETTI) In almost all cases, Endotracheal Tube Introducer (ETTI) should be attempted before proceeding to needle cricothyrotomy. INDICATIONS

Patients with Grade III and IV laryngeal views. Patients with airway edema regardless of laryngeal view. Anatomic conditions that preclude either adequate visualization for intubation by conventional means.

CONTRAINDICATIONS

Do not use on endotracheal tubes smaller than 6.0. PROCEDURE

Perform laryngoscopy as per oral tracheal intubation procedure, and obtain the best possible laryngeal view. Holding the ETTI in your right hand and the angled tip pointing upward, gently advance the ETTI anteriorly (under the

epiglottis or over the posterior notch) to the glotic opening (cords). Gently advance the device until resistance is encountered at the carina.

Because this device can potentially cause pharyngeal/tracheal perforation, NEVER FORCE the ETTI. If no resistance is encountered and the entire length of the ETTI is inserted, the device is in the esophagus.

The ETTI is correctly placed when you see the device going through the cords, when you feel the washboard effect of the tip on the trachea, and/or when you meet resistance while advancing the ETTI (ETTI is at the carina).

Once positioned, withdraw the ETTI until the 37 cm black line mark is aligned with the lip and advance the lubricated ETT over the ETTI and into the trachea. This indicates that the tip is well beyond the cords and the proximal end has enough length to slide the ETT over.

If resistance is encountered – caused by the ETT catching on the arytenoids or aryepiglottic folds – withdraw the ETT slightly, rotate 90 degrees and reattempt. If this is unsuccessful, use a smaller tube.

Once ETT is in position, while holding the tube, remove the ETTI through the ETT. Because this is a blind intubation, ETCO2 must be present to confirm tracheal placement.

ALS Procedures July 2006 Multi-Lumen Airway (Combitube- SA) Intubation- 9804 Page 1 of 2



MULTI-LUMEN AIRWAY (COMBITUBE- SA) INTUBATION ALWAYS USE UNIVERSAL PRECAUTIONS


MLA (size Small Adult) intubation may be performed only on those patients who meet ALL of the following criteria: Are unconscious and without purposeful movement. Do not have a gag reflex. Unable to perform endotracheal intubation. Apneic or have a respiratory rate of <6. Appear to be at least 4. 5 feet tall.

CONTRAINDICATIONS

MLAs must NOT be placed on patients who meet any one of the following criteria: Have a positive gag reflex. Have known esophageal injury, surgery, or disease (e.g., tumor, varices). Have a foreign body airway obstruction (FBAO). Have a history of laryngectomy with stoma. Are known narcotic overdoses, with ALS less than 10 minutes away. Any circumstance where airway edema is suspected or could develop. Ingestion of a caustic substance. Allergic / anaphylactic reaction.

EQUIPMENT

Multi-Lumen Airway 100 + cc syringe for inflation of pharyngeal cuff 20 cc syringe for inflation of distal cuff Water soluble lubricant Stethoscope Portable suction device

ALS Procedures July 2006 Multi-Lumen Airway (Combitube- SA) Intubation- 9804 Page 2 of 2



INSERTION PROCEDURE

Inflate each cuff and check for leaks, apply emesis diverter to tube # 2. Apply water-soluble lubricant to distal end of tube. Hyperoxygenate patient. Place patient’s head in a neutral position. Grab lower jaw and lift upward. Insert tube; advance until teeth / gums are between black rings on tube. Alternately you can omit steps 5 & 6 and use a Laryngoscope and visualize placement of the MLA into the esophagus. Inflate pharyngeal cuff (Port # 1 blue pilot balloon) with 85 cc of air (do not hold tube during inflation). Inflate distal cuff (Port # 2 white pilot balloon) with 15 cc of air. Ventilate through TUBE # 1. Assess ventilation:

Rise and fall of the chest. Bilateral lung sounds. Confirm placement with CO2 detector

Gastric auscultation. If CHEST RISE is present and GASTRIC SOUNDS are absent:

Secure tube. Verify placement. Continue ventilation.

If NO CHEST RISE and GASTRIC SOUNDS are present:

Remove the emesis diverter and ventilate on TUBE # 2. Assess ventilation as above.

IF UNABLE TO CONFIRM PLACEMENT VIA EITHER TUBE:

Deflate both cuffs. Pull the MLA back approximately 2 cm. Reinflate cuffs and recheck tube placement. If you are unable to confirm placement via either tube discontinue the MLA and return to a BLS airway.

SPECIAL INFORMATION

The MLA will enter the esophagus 85% of the time, so ventilation with tube # 1 is ordinary. If ventilation is through tube # 2 then the tube is in the trachea and tube # 2 may be used for medication administration

and suctioning just as if it were an ordinary ET tube. Removal of the MLA should be accomplished with the patient on their side and suction immediately available. If resistance is met when advancing the tube, the attempt should be discontinued. MLAs should not be forced. If resistance is met on intubation attempts, the tube should be removed and BVM continued.

ALS Procedures July 2006 Nasotracheal Intubation - 9805 Page 1 of 2



NASOTRACHEAL INTUBATION ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 INDICATIONS Respiratory failure with a decreasing level of consciousness, or in deep coma. Respiratory failure with trismus (clenched teeth). Trauma patients without significant midfacial trauma or midface instability.

CONTRAINDICATIONS Absolute Apneic patients. Patients with suspected epiglottitis. Trauma patients with midfacial instability. Pediatric patients < 40 kilograms or < 8 years of age

Relative Basilar skull fracture Nasal foreign bodies or large nasal polyps Recent nasal surgery or a history of frequent episodes of epistaxis Bleeding disorders or those on anticoagulation therapy Upper neck hematomas or infections

EQUIPMENT

Correct size ETT 7.0-7.5 for average size adult female and 7.5-8.0 for average size male) Lidocaine jelly Syringe Suction Topical vasoconstrictor

1% Lidocaine with epinephrine or, 5 ml or 2 sprays of oxymetazoline hydrochloride, 0.05% (Afrin7) or, 2 sprays of phenylephrine hydrochloride, 0.25% (Neo-Synephrine7)]

BAAM Device or equivalent placement indicator Cetacaine or Hurracaine topical spray anesthetic

ALS Procedures July 2006 Nasotracheal Intubation - 9805 Page 2 of 2



PROCEDURE

Visually inspect each nares for foreign bodies or large polyps. Digitally inspect and dilate the selected nare with a gloved and lubricated fifth finger. Place NPA lubricated with lidocaine jelly into selected nare, leave in place while you prepare ET tube and BVM. Spray cetacaine spray into patients oropharynx. Remove NPA and instill nasal vasoconstrictor into nare that has been selected. Place the BAAM device on the universal adapter of the ET tube. Try to advance the tube through the larynx during inspiration. Continue advancement of the tube watching for condensation in the tube, and listening for the ‘whistle’ of the BAAM

device to help guide you. The BAAM device will make a shrill ‘whistling’ sound as the patient breathes, making it easier to time placement with

inspiration. Once placed properly, the ‘whistling’ sound will be heard continuously. REMOVE the BAAM device from the universal adapter. Inflate the cuff and confirm tube placement. Ventilate the patient, watch for chest movement; auscultate the chest and

the epigastrium. VENTILATIONS

Attach the end tidal CO2 detector and ventilate the patient 6 times while checking for proper color change. COLOR OF CO2 DETECTOR

If the CO2 detector is in the C range (yellow), secure the tube. If the CO2 detector is in the B range, the location of the tube is uncertain. Deliver 6 additional breaths. If the color remains in the B range (and the patient does not have low pulmonary perfusion), remove the tube and

reintubate the patient. If the color is in the A range (purple) and the patient does not have a low pulmonary perfusion, remove the tube and

reintubate the patient.

ALS Procedures July 2006 Continuous Positive Airway Pressure – CPAP- 9806 Page 1 of 2



CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE: To improve ventilation and oxygenation, and avoid intubation, in patients with congestive heart failure (CHF) with acute pulmonary edema, or near drowning. CPAP is an optional skill. INDICATIONS: Patients age 8 or older in severe respiratory distress and: 1. History of CHF with pulmonary edema

a) On medications such as digoxin, or lasix b) Pedal edema c) Severe and/or sudden onset SOB

2. Near drowning

1) Orthopnea 2) Anxious 3) Diaphoresis 4) Rales or coarse wheezes 5) Hypertension

CONTRAINDICATIONS – Bag-valve-mask ventilation or endotracheal intubation should be considered for any patient who exhibits one or more of

the following contraindications. Absolute Contraindications (DO NOT USE):

Age < 8 Respiratory or cardiac arrest Agonal respirations Severely depressed level of consciousness Systolic blood pressure < 90 Signs and symptoms of pneumothorax Inability to maintain airway patency Major trauma, especially head injury with increased ICP or significant chest trauma Facial anomalies or trauma (e.g., burns, fractures) Vomiting

Relative Contraindications (USE CAUTIOUSLY):

History of Asthma/COPD History of Pulmonary Fibrosis Decreased LOC Claustrophobia or unable to tolerate mask (after first 1-2 minutes trial)

ALS Procedures July 2006 Continuous Positive Airway Pressure – CPAP- 9806 Page 2 of 2



COMPLICATIONS:

Hypotension Pneumothorax Corneal Drying

GOALS OF CPAP:

Elimination of dyspnea Decreased respiratory rate Decreased heart rate Increased Sp02 Stabilized blood pressure

Bag-valve-mask ventilation or endotracheal intubation should be considered if the patient fails to show improvement based on the above goals.

ALS Treatment Guidelines July 2006 Needle Cricothyrotomy for Complete Airway Obstruction- 9807 Page 1 of 1



NEEDLE CRICOTHYROTOMY FOR COMPLETE AIRWAY OBSTRUCTION


AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 INDICATION Life threatening upper airway obstruction where all other BLS and ALS maneuvers and techniques have failed. Equipment:

#10 gauge angiocath Adaptor for ETT – BVM or Jet Insufflation Device (optional)

NEEDLE CRICOTHYROTOMY PROCEDURE

Locate the cricothyroid membrane and prep area. Extend the neck to bring the membrane anterior. Insert #10 gauge angiocath through membrane at 50 degree angle to the feet. May consider using second angiocath, in the same puncture site, for expired air outlet. Aspirate air during the insertion to confirm placement in the trachea. Once air has been aspirated, advance the catheter towards the feet while withdrawing the needle. Attach the adaptor to the end of the angiocath. Hyperventilate as rapidly as possible using the BVM. At the discretion of provider agency and assuring availability of equipment, a jet insufflation device may be used at a

ratio of one (1) sec of inflation to five (5) sec of exhalation. If the airway pressure progressively increases with each insufflation, then briefly disconnect to allow for exhalation or

insert second catheter for exhalation port. If subcutaneous emphysema occurs, stop insufflation and attempt second catheter placement.

QI

Each cricothyrotomy device use will be audited.

ALS Treatment Guidelines July 2006 Needle Thoracostomy- 9808 Page 1 of 1



NEEDLE THORACOSTOMY ALWAYS USE UNIVERSAL PRECAUTIONS


DEFINITION TENSION PNEUMOTHORAX: Air leak into pleural space through a hole in lung, acting as a one-way valve. Assessment confirmed by some of the following:

Decreased breath sound, uni- or bilaterally Tracheal shift away from affected side Extreme dyspnea Neck vein distension Agitation Possible cyanosis Hypotension Hyperresonance to percussion

EQUIPMENT

#10 gauge angiocath or other appropriate over the catheter needle 12 cc syringe Connecting tubing Heimlich valve or similar one-way valve device

LOCATION

The second intercostal space in the midclavicular line on the affected side. PROCEDURE Introduce either angiocath or other appropriate over the catheter needle (attached to 12 cc syringe) just above the rib margin during expiration.

Continue until lack of resistance or "pop" as needle enters pleural space. Once air returns under pressure or is aspirated with ease

Remove plunger. Listen for air escaping.

Once air has ceased escaping Remove syringe barrel from needle. Advance the catheter.

Secure catheter with needle guard or tape. Attach connecting tubing. Attach one-way valve device or Heimlich valve with BLUE end toward patient.

ALS Treatment Guidelines July 2006 EKG – 12 Lead- 9809 Page 1 of 2



EKG - 12 LEAD ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 INTRODUCTION

• 12-lead electrocardiograms (EKGs) are used with a variety of patients. Our goal is to incorporate the 12-lead EKG into our hospitals’ decision making about the ST-elevation MI (STEMI) patient. The transmission or reporting of the ST-elevation MI should decrease “door-to-intervention” times in our communities’ hospitals.

• 12-lead EKGs can and should be used with a number of patient care policies. Treatment under these policies should proceed in conjunction with the application of the 12-lead EKG.

INDICATIONS Any patient with known or suspected Acute Coronary Syndrome (ACS). – examples:

• substernal pain • discomfort or tightness radiating to the jaw, left shoulder or arm • nausea • diaphoresis • dyspnea • anxiety • syncope/dizziness • other “suspicious symptoms” • Known treatment for ACS

EKG CRITERIA FOR STEMI Convex, “tombstone,” or flat ST segment elevation in two or more contiguous leads. PROCEDURE Attach EKG leads to the patient (limb leads to the upper arms, ankles and six chest leads) and perform EKG.

• V1: right 4th intercostal space • V2: left 4th intercostal space • V3: halfway between V2 and V4 • V4: left 5th intercostal space, mid-clavicular line • V5: horizontal to V4, anterior axillary line • V6: horizontal to V5, mid-axillary line • V4R: right 5th intercostal space, mid-clavicular line (use in all

suspected inferior MIs at physician request)

ALS Treatment Guidelines July 2006 EKG – 12 Lead- 9809 Page 2 of 2



If the EKG indicates an ST elevation MI, transport to an approved Cardiac Receiving Center according to the point of Entry policy. Provide early notification so the receiving facility may initiate internal STEMI activation protocol. Transmit the EKG (if capable) to the receiving facility. INCLUDE THE FOLLOWING INFORMATION IN YOUR REPORT:

• Age and sex • Interpretation of the 12-lead EKG (leads, amount of ST elevation in millimeters, “confidence” in your 12-lead assessment) • Location of reciprocal changes (if applicable) • Symptoms (including presence or absence of chest pain) • Presence of new left bundle branch block. Presence of imposters (early repolarization left bundle branch block, left

ventricular hypertrophy, pericarditis or paced rhythms) • Significant vital signs and physical findings • Attach a copy of the EKG to the hospital copy and the file copy of the PCR • Serial 12-lead EKGs, enroute, are encouraged

ALS Treatment Guidelines July 2006 External Pacing- 9810 Page 1 of 2



EXTERNAL PACING ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 DEFINITION The following procedure is to be followed when the appropriate protocol dictates. TREATMENT Lay patient flat if they will tolerate. Place patient on 3 lead EKG monitor. Place pre-gelled adhesive pads on chest wall in anterior / posterior position or sternal / apex position according to manufacturer

recommendations. Confirm ECG.

RATE Start at a rate 80. Confirm Pacing spikes on ECG screen.

CONSCIOUS PATIENT Slowly adjust output control until capture is seen on ECG screen. Confirm pulses with paced beats.

UNCONSCIOUS PATIENTS Begin pacing at full output.

CAPTURE Turn output down until capture is lost, then back up slightly to determine lowest threshold response. Check blood pressure. If blood pressure is low and patient shows signs of decreased perfusion, increase rate. DO NOT EXCEED 100 BPM.

SPECIAL CONSIDERATIONS Any movement of patient may increase capture threshold response. Output may have to be adjusted up slightly to compensate.

Monitor pulse, blood pressure and level of consciousness closely.

ALS Treatment Guidelines July 2006 External Pacing- 9810 Page 2 of 2



Pediatric Pacing

Use pediatric patches. Set Rate to 100 BPM. Start at 5 milliamps and increase by 5 milliamps until capture is obtained.

The smaller the child the lower the required energy for capture.

Discomfort associated with pacing: Administer Morphine per severe pain protocol for analgesia. Consider Midazolam per sedation protocol.

ALS Treatment Guidelines July 2006 Accessing Pre-Existing Vascular Access Device- 9811 Page 1 of 2



ACCESSING A PRE-EXISTING VASCULAR ACCESS DEVICE

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To provide vascular access for patients in extremis due to circulatory shock or cardiopulmonary arrest with no other vascular access available. POLICY Paramedics may access pre-existing vascular access devices under appropriate circumstances. They may encounter various types of catheters. A pre-existing vascular access device is an indwelling catheter/device placed into one of the central veins to provide vascular access for those patients requiring long term intravenous therapy or hemodialysis. The types of catheters used are: Indwelling silastic catheter/device exiting externally: (Broviac, Hickman and others); silicone catheter inserted into SCV or the

right atrium usually via the cephalic vein; enter the skin through an incision in the right anterior chest; line is kept heparinized and protected by an injectable cap.

Hemodialysis shunt: a tube that diverts blood flow from an artery to a vein. Internal subcutaneous infusion ports/fistulas: any access that is subcutaneous requiring entry through the skin. Not

recommended for use in the prehospital setting. INDICATIONS Only in the absence of any other observable vascular access, when the patient has:

Cardiopulmonary arrest Extremis due to circulatory shock

COMPLICATIONS Infection Due to the location of the catheter, strict adherence to aseptic technique is crucial when handling a PVAD:

Use sterile gloves; Prep injectable port and surrounding skin with alcohol swab prior to attaching I.V. tubing; Use new supplies if equipment becomes contaminated; Recover port with sterile dressing and securely tape.

Air Embolism The PVAD provides a direct line into the central circulation; introduction of air into these devices can be hazardous.

ALS Treatment Guidelines July 2006 Accessing Pre-Existing Vascular Access Device- 9811 Page 2 of 2



APPROVED INFUSIONS

Intravenous solutions All medications except diazepam (Valium) as it interacts with silicone causing crystallization of the medications

and deterioration of the silicone. FLUSH

Follow all medications with 5 ml of saline to avoid clots. PRECAUTIONS

Do not remove injection cap from catheter. Do not allow I.V. fluids to run dry. Always expel air from preload/syringe prior to administration. Do not inject medications of fluids if resistance is met when establishing patency. Should damage occur to the external catheter, clamp immediately between the skin exit site and the damaged area to

prevent air embolism or blood loss. Use padded hemostats.

Do not use a syringe smaller than 10 ml to prevent catheter damage from excess infusion pressure. Do not manipulate or remove an indwelling catheter under any circumstances.

ALS Treatment Guidelines July 2006 Intraosseus Infusion- 9812 Page 1 of 2



INTRAOSSEOUS INFUSION POLICY ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To provide a mechanism to treat critically ill patients when a peripheral I.V. cannot be established. *All approved ALS IV drugs may be administered IO DEFINITION "Intraosseous infusion" refers to the placement of an intraosseous or intramedullary needle into an approved marrow space for the purpose of fluid or drug administration. (e.g. Peds and Adults – proximal or distal tibia, distal femur; Additional Options for adults – Humerus). INDICATIONS

Any patient in extremis / cardiac arrest when IV attempts have been unsuccessful in 90 seconds or 3 attempts. CONTRA-INDICATIONS ABSOLUTE

Recent (less than six weeks) fracture of involved bone. Sites below the waist when there has been vascular disruption of extremity or pelvis.

RELATIVE Infection, burn or cellulitis overlying the site Congenital deformities of the bone Metabolic bone disease

EQUIPMENT

Intraosseous infusion needle/device (e.g. Bone Injection Gun or B.I.G.; EZ IO, etc.) Betadine swabs or solution on gauze Sterile gauze pads 10 or 12cc syringe filled with 5cc saline IV solution, flooded tubing and 3-way stopcock Normal saline or lactated ringer solution only Supplies to secure infusion

ALS Treatment Guidelines July 2006 Intraosseus Infusion- 9812 Page 2 of 2



PROCEDURE ** No more than 2 attempts, each attempt should be limited to 90 seconds. Sterile technique must be followed at all times.

Position appropriately and stabilized leg Identify infusion site

Primary Adult: 1-2 cm medially and 1 cm proximally to the tibial tuberosity Peds: 1-2 cm medially and 1-2 cm distally to the tibial tuberosity

Alternate Distal tibia, anteromedial flat bony surface, 1-3 cm above

medial malleolus Distal femur, 2-3 cm above external condyles, midline Additional infusion site options for adults (if using B.I.G. or EZ IO): Humerus

Swab with antiseptic/antimicrobial solution (Betadine). Air or sterile gauze dry surface. Insert IO Needle (If using B.I.G. or EZ IO – use according to manufacturer’s directions).

Insert needle through skin at 90 degree angle. Penetrate to periosteal surface (bone contact). Rotate and apply firm pressure on needle. Stop when "pop" felt. Remove obturator.

Confirm Placement Attach 10-12cc syringe with 5 cc of saline to needle. Aspirate to confirm position. Flush with 5 cc saline. If needle flushes without resistance, proceed. If resistance is met, remove needle, apply pressure to site.

Disconnect syringe. Attach pre-flooded IV tubing. Stabilize needle with gauze pads, secure with tape and immobilize. Fluid Administration may require hand or pressure pump.

ALS Treatment Guidelines July 2006 Field Blood Collection For Non-Medical Purpose- 9813 Page 1 of 1



FIELD BLOOD COLLECTIONS FOR NON-MEDICAL PURPOSES

ALWAYS USE UNIVERSAL PRECAUTIONS AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To establish guidelines for blood collections for non-medical purposes at the request of law enforcement personnel. POLICY EMT-P’s are empowered by law to obtain blood samples by request of appropriate law enforcement agency. If the patient is in the care of the paramedic the blood collection must not interfere with medical care. PROCEDURE

A law enforcement representative must requests the blood sample be collected and must be present to witness. There must be the appropriate collection equipment immediately available. The paramedic will obtain the collection sample only if the following conditions are met: The paramedic provider agency has a written agreement with the local law enforcement agency to provide blood

collection services; The paramedic is capable of obtaining the collection sample; If the individual that the blood sample is being drawn from is a patient, treatment may not be delayed, compromised, or

interfered with as a result of the blood collection; The paramedic ensures appropriate chain of custody of the blood sample.

It will be the provider agency’s right to determine if their personnel shall participate in this policy.



INTERFACILITY TRANSPORTS

ALS Procedures July 2006 Transport of Potassium Chloride Policy- 9901 Page 1 of 1



TRANSPORT OF POTASSIUM CHLORIDE (KCL) ALWAYS USE UNIVERSAL PRECAUTIONS


Monitoring an I.V. solution containing KCL for the treatment of potassium deficiency. POLICY

A paramedic may transport a patient who has a pre-existing I.V. solution containing KCL< 20mEq. PROCEDURE Prehospital care providers are not allowed to start or add KCL to the I.V. solution. Infusions containing KCL that have been established may be monitored only. Monitor ECG rhythm to detect dysrhythmias

USUAL DOSE

Usual dose is 10-20 mEq added to 1 liter of I.V. solution and administered at a mechanically controlled rate not to exceed 10 mEq/hour (restrictions in scope of practice limits dose to 20 mEq/L).

INFILTRATION

Monitor I.V. site as infiltration may cause necrosis. If patient complains of burning or irritation at the insertion site, the I.V. should be checked for patency and the infusion rate slowed.

FLUID BOLUS

If fluid bolus or I.V. medications are needed, the KCL infusion shall be discontinued and a new I.V. solution without KCL and administration device shall be used as replacement.

ADVERSE EFFECTS Observe for:

Cardiovascular: dysrhythmias, cardiac arrest Respiratory: depression/arrest Gastrointestinal: nausea/vomiting, diarrhea, abdominal pain Neurological: paresthesia of extremities, muscular paralysis, confusion. Other: hyperkalemia, venous thrombosis

ALS Procedures July 2006 Monitoring Thoracostomy Tubes- 9903 Page 1 of 1



MONITORING THORACOSTOMY TUBES ALWAYS USE UNIVERSAL PRECAUTIONS

AUTHORITY Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221 PURPOSE To monitor thoracostomy tubes previously established. EQUIPMENT

Firm plastic thoracostomy tube Negative pressure drainage receptacle attached to the thoracostomy tube to form a closed drainage system. Rubber-tipped clamp

PRECAUTIONS

Keep drainage receptacle below level of chest to prevent drained fluid from re-entering pleural space. Keep drainage tubing in view. Do not permit dependent loops of kinks to form, as this will increase pleural pressure, formation of clots or interference

with the flow of drainage. Keep dressing at insertion site secure to prevent air entering the pleural space. Maintain aseptic technique. Do not disconnect drainage system or puncture tubing. Tape all connections securely to prevent violation of sterility and loss of negative drainage pressure. Avoid pulling on thoracostomy tube to prevent accidental dislodging of the tube.

COMPLICATIONS

Complications require immediate intervention. Contact the base hospital to report the problem, the intervention taken and to request further assistance.

TUBE DISLODGEMENT OR WITHDRAWAL

If accidental withdrawal of tube occurs, place occlusive dressing over insertion site. If the tube becomes dislodged or a malfunction with air leak occurs in the system, clamp the tube close to the chest wall

and observe for signs and symptoms of tension pneumothorax. DRAINED FLUID RE-ENTERS PLEURAL SPACE

If drained fluid re-enters the pleural space place receptacle below level of chest to facilitate gravity drainage. HEMORRHAGE THROUGH TUBE

If hemorrhage occurs through chest tube, observe for signs and symptoms of shock and treat according to protocol. RECEPTACLE FILLS IN TRANSIT

If drainage receptacle fills in transit Keep in position Do not remove or elevate

Field Manual · FIELD MANUAL- TREATMENT GUIDELINES TABLE OF CONTENTS Continued on next page Table...

Documents

Transcript of Field Manual · FIELD MANUAL- TREATMENT GUIDELINES TABLE OF CONTENTS Continued on next page Table...