Protocols Asesmen

DENVER PARAMEDIC DIVISION
PRE-HOSPITAL PROTOCOLS

REVISION DATE: 2/11
AIRWAY MANAGEMENT
GENERAL PRINCIPLES OF AIRWAY & VENTILATION

PROCEDURES:
OPENING THE AIRWAY
OBSTRUCTED AIRWAY
CLEARING AND SUCTIONING THE AIRWAY
ASSISTING VENTILATION
CAPNOGRAPHY
EMT-P: KING LTS-D
EMT-P: NASOTRACHEAL INTUBATION
EMT-P: OROTRACHEAL INTUBATION
EMT-P: SURGICAL CRICOTHYROTOMY
CARDIAC EMERGENCIES
MEDICAL CARDIAC ARREST ADULT (AGE > 12 YEARS)
BASIC LIFE SUPPORT/AUTOMATIC EXTERNAL DEFIBRILLATOR
VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA
ASYSTOLE
PULSELESS ELECTRICAL ACTIVITY (PEA)
GENERAL TREATMENT OF ARRHYTHMIAS
PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
BRADYCARDIA
TACHYCARDIA
CHEST PAIN
HYPERTENSION

PROCEDURES:
EMT-P: CARDIOVERSION
EMT-P: TRANSCUTANEOUS PACING
EMT-P: THREAPEUTIC INDUCED HYPOTHERMIA
PULMONARY/RESPIRATORY EMERGENCIES
RESPIRATORY DISTRESS
ASTHMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HYPERVENTILATION
PNEUMONIA
PNEUMOTHORAX
PULMONARY EDEMA
PULMONARY EMBOLISM

PROCEDURES:
EMT-P: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
EMT-P: TENSION PNEUMOTHORAX: NEEDLE DECOMPRESSION
MEDICAL EMERGENCIES
ABDOMINAL PAIN
ALCOHOL INTOXICATION
ALLERGIES/ANAPHYLAXIS
COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT
OBSTETRICS/GYNECOLOGICAL EMERGENCIES
POISONINGS & OVERDOSES
PSYCHIATRIC/BEHAVIORAL EMERGENCIES
SEIZURES
SHOCK
STROKE/CVA
SYNCOPE
VOMITING

PROCEDURES:
RESTRAINTS
ENVIRONMENTAL EMERGENCIES
BITES & STINGS
COLD EMERGENCIES
DROWNING/NEAR-DROWNING
HEAT EMERGENCIES
HIGH ALTITUDE ILLNESS
SNAKE BITES
TRAUMATIC EMERGENCIES
MULTIPLE TRAUMA OVERVIEW
MILE HIGH RETAC TRAUMA TRIAGE ALGORITHM GUIDELINE
ABDOMINAL TRAUMA
AMPUTATIONS
BURNS
CHEST INJURY
EXTREMITY INJURIES
FACE & NECK TRAUMA
HEAD TRAUMA
SPINAL TRAUMA
TRAUMA ARREST

PROCEDURES:
BANDAGING
SPLINTING: AXIAL
SPLINTING: EXTREMITY
TOURNIQUET
PEDIATRIC EMERGENCIES
GENERAL GUIDELINES FOR PEDIATRICS
APPARENT LIFE-THREATENING EVENT (ALTE)
INFANT AND CHILD RESUSCITATION
PEDIATRIC DEHYDRATION
PEDIATRIC RESPIRATORY DISTRESS
PEDIATRIC SEIZURES
POSSIBLE SUDDEN INFANT DEATH SYNDROME
PHARMACOLOGY/MEDICATION ADMINISTRATION
EMT-P: ADENOSINE (ADENOCARD)
ALBUTEROL SULFATE
EMT-P: AMIODARONE
ASPIRIN (ASA)
EMT-P: ATROPINE SULFATE
EMT-P: CALCIUM GLUCONATE
EMT-P: CYANOKIT
DEXTROSE
EMT-P: DIAZEPAM (VALIUM)
EMT-P: DIPHENHYDRAMINE (BENADRYL)
EMT-P: DOPAMINE (INTROPIN)
EMT-P: DROPERIDOL
EMT-P: EPINEPHRINE
EPINEPHRINE AUTO-INJECTOR
EMT-P: FENTANYL CITRATE
EMT-P: GLUCAGON
EMT-P: IPRATROPIUM BROMIDE (ATROVENT)
IV SOLUTIONS
EMT-P: MAGNESIUM SULFATE
DUODOTE NERVE AGENT ANTIDOTE KIT
METERED DOSE INHALER
EMT-P: METHYLPREDNISOLONE (SOLU-MEDROL)
EMT-P: MIDAZOLAM (VERSED)
EMT-P: MORPHINE SULFATE
NALOXONE (NARCAN)
NITROGLYCERIN
EMT-P: ONDANSETRON (ZOFRAN)
OXYGEN
EMT-P: PHENYLEPHRINE
EMT-P: RACEMIC EPINEPHRINE (VAPONEPHRINE)
EMT-P: SODIUM BICARBONATE
EMT-P: TOPICAL OPTHALMIC ANESTHETICS

PROCEDURES:
STANDARD DRUG ADMINISTRATION PROTOCOL
FIELD DRAWN BLOOD SAMPLES
EMT-P: INTRAOSSEOUS INFUSION
MEDICATION ADMINISTRATION (PARENTERAL)
EMT-P: VASCULAR ACCESS DEVICES
VENOUS ACCESS GENERAL PRINCIPLES
EMT-P: VENOUS ACCESS EXTERNAL JUGULAR
VENOUS ACCESS EXTREMITY
ASSESSMENTS
PATIENT ASSESSMENT ALGORITHM
SCENE SIZE-UP
INITIAL ASSESSMENT
FOCUSED ASSESSMENT MEDICAL
FOCUSED ASSESSMENT TRAUMA
RAPID ASSESSMENT MEDICAL-UNRESPONSIVE
RAPID ASSESSMENT TRAUMA
DETAILED ASSESSMENT
ONGOING ASSESSMENT
NEUROLOGIC ASSESSMENT
PEDIATRIC PATIENT ASSESSMENT
SPECIAL ASSESSMENT NOTES
OPERATIONS
EMT-P: ALS-TRAINED PROVIDER COORDINATION WITH PERSONNEL USING AEDs
COMMUNICATION
CONFIDENTIALITY
CONSENT
DESTINATIONS
DIVERTS
HAZARDOUS MATERIALS
INFECTIOUS AND COMMUNICABLE DISEASES
EMT-B: INTERHOSPITAL TRANSFERS
MASS CASUALTY INCIDENT MANAGEMENT
MCI EMS COMMAND AND OPERATIONS STRUCTURE
MCI START TRIAGE FLOWCHART
MCI COMMUNICATIONS BED COUNT LOG
MCI TRANSPORT LOG
MENTAL HEALTH HOLDS (MHH)
NON-TRANSPORT OF PATIENTS
NON-TRANSPORT/REFUSAL OF CARE ALGORITHM
NON-TRANSPORT/REFUSAL OF CARE REFUSAL FORM
PATIENT CARE REPORT REQUIREMENTS
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION NOTE TO PHYSICIANS
RESUSCITATION AND FIELD PRONOUNCMENT GUIDELINES
TRANSPORT OF THE HANDCUFFED PATIENT
APPENDIX
COMMONLY ACCEPTED ABBREVIATIONS FOR FIELD USE
EMT-B: PROTOCOLS REQUIRING BASE CONTACT
EMT-P: PROTOCOLS REQUIRING BASE CONTACT
REQUIRED RECORDS ON TREATMENT AND TRANSPORT OF PATIENTS
AIRWAY

PROCEDURES:
OPENING THE AIRWAY
OBSTRUCTED AIRWAY
CAPNOGRAPHY
EMT-P: KING LTS-D

Airway management is the most important skill set that a pre-hospital provider
can possess and is varied according to training and certification level.
Prolonged hypoxia will have devastating effects on the central nervous system
and other organ systems and will have a compounded effect in the setting of
concomitant hypotension.

Successful airway management in the vast majority of cases involves
observation and supplemental oxygen administration. In general, the least
invasive methods of airway management that will result in adequate
oxygenation and ventilation of the patient are indicated. However, aggressive
active airway compromise is prudent prior to the onset of hypoxia or
hypercapnea when airway compromise is anticipated, i.e., airway burns,
expanding neck mass or hematoma, allergic conditions.

Successful intubation usually implies successful airway management but the
inability to intubate a patient does not imply failure. Failure would be allowing
a patient to deteriorate because of an unrecognized malpositioned tube or not
using alternative strategies to ensure oxygenation and ventilation when
orotracheal intubation is unsuccessful. Unfortunately there will be those
patients in whom you cannot establish an airway or adequately ventilate.

Every provider should have a back up plan when intubation is unsuccessful. This
may involve simple airway maneuvers (suctioning, finger sweep, chin-lift or jaw
thrust), bag-valve mask ventilation or the use of alternative airway
interventions (King airway, bougie, cricothyroidotomy).

All patients require continuous monitoring of their airways to ensure airway
patency. Wherever the term "Monitor airway" is used throughout these
protocols, the following elements shall be utilized:
- Position of the patient's head
- Need for airway adjuncts
- Need for oropharyngeal suctioning
- EMT-P: Need for Advanced Life Support airway management techniques
- Use of pulse oximetry (SpO
2
)
- Use of secondary form of endotracheal tube placement confirmation in the
form of end-tidal capnography (ETCO
2
). Secondary confirmation devices are
not a substitute for primary confirmation techniques that rely upon direct
visualization and auscultation, but serve as an additional method of
documenting proper endotracheal tube placement.
DEFINITIONS
- Respiratory distress: Signs and symptoms may include increased respiratory
effort, peripheral cyanosis, tachypnea, accessory muscle use, anxiety and
adventitious lung sounds upon auscultation.
- Respiratory insufficiency/failure: Signs and symptoms include the above
with central cyanosis and insufficient air exchange, tiring, and inability to
speak in complete sentences.
- Pediatric respiratory distress: Characterized by increased respiratory effort
with peripheral cyanosis, i.e., anxiety, tachypnea, nasal flaring and
intercostal retractions.
- Respiratory failure in a child is characterized by ineffective respiratory
effort with central cyanosis, i.e., agitation or lethargy, severe dyspnea or
labored breathing, bobbing or grunting, and marked intercostal and
parasternal retractions. Note that bradycardia is an ominous sign that
indicates hypoxic cardiac arrest may be imminent.
OPENING THE AIRWAY
INDICATIONS
- Inadequate air exchange in the lungs due to jaw or facial fracture, causing
narrowing of air passage
- Lax jaw or tongue muscles causing airway narrowing in the unconscious
patient
- Noisy breathing or excessive respiratory effort that could be due to partial
obstruction
- In preparation for suctioning, assisted ventilation or other airway manage-
ment maneuvers
PRECAUTIONS
- For trauma victims, keep neck in midline and avoid flexion, extension,
traction or rotation.
- For medical patients, neck extension may be difficult in elderly persons
with extensive arthritis and little neck motion. Do not use force jaw thrust
or chin-lift without head tilt will be more successful.
- All airway maneuvers should be followed by an evaluation of their success;
if breathing is still labored, a different method or more time for recovery
may be needed.
- Children's airways have less supporting cartilage; overextension can kink the
airway and increase the obstruction. Watch chest movement to determine
the best head angle.
- Dentures should usually be left in place since they provide a framework for
the lips and cheeks and allow more effective mouth-to-mask or
bag-valve-mask ventilation.
TECHNIQUE
- Use BSI. To open the airway initially, choose method most suitable for
patient.
- Assess respirations.
- Begin BVM ventilation if the patient is not breathing.
- If partial or complete obstruction is present, follow obstructed airway
protocol.
- Assess oxygenation; use supplemental O
2
as needed.
- Consider positioning the patient on side if no c-spine precautions are
needed.
- Choose method to maintain airway patency during transport:
- Oropharyngeal airway:
- Choose size by measuring from mouth to ear margin.
- Depress tongue and insert gently with curve pointing upward. Avoid
snagging posterior tongue or palate.
- Insert to back of tongue, then turn to follow curve of airway.
- Move gently to be sure the tip is free in back of pharynx. In pediatric
patients, depress tongue and insert airway with curve down to avoid
injury to palate and pushing tongue posterior.
- Nasopharyngeal airway:
- Lubricate tube using viscous lidocaine.
- Insert in right or largest nostril, along floor of nose until flange is
seated at nostril. Keep curve in line with normal airway curve. If you
meet resistance, try the left side.
- Listen to breathing to be sure maneuver has resolved problem.
- EMT-P: Consider intubation to provide adequate airway.
- Resume ventilatory assistance and oxygenation as appropriate.
- Consider surgical cricothyrotomy only after conservative measures have
failed to intubate or ventilate adequately with a BVM. Cricothyrotomy is a
difficult and hazardous technique that is to be used only in extraordinary
circumstances.
COMPLICATIONS
- Cervical spinal cord injury from neck hyperextension in trauma victim with
cervical fracture
- Death due to inadequate ventilation or hypoxia
- Nasal or posterior pharyngeal bleeding due to trauma from tubes
- Increased airway obstruction from tongue following improper oropharyngeal
airway placement
- Aspiration of blood or vomitus from inadequate suctioning and continued
contamination of lungs from upper airway
SPECIAL CONSIDERATIONS
- Researchers have found that the head tilt-chin lift is successful at least as
often as the head tilt-neck lift, and that it may even be more reliable and
less fatiguing. Unfortunately, it cannot be simulated on manikins, but with
use it is easy to get comfortable with this excellent technique.
- During transport, medical patients can be placed in a stable position on
their sides for effective airway control. Use a flexed leg, arms, or pillows
for support.
- Nasopharyngeal airways are very useful for airway maintenance, and are
underused in most regions. The nasal insertion provides more stability, the
airway is better tolerated in partially awake patients, and it does not carry
the risk of blocking the airway further like the stiff oropharyngeal airway.

METHODS OF OPENING THE AIRWAY
HEAD TILT-CHIN LIFT:
Technique: From beside head, place one hand on forehead. Grasp lower edge of
chin with fingers of other hand and lift chin forward. Teeth may
come together.
Indications: Medical patient. May require less neck extension than head tilt.
Useful with dentures. May be used without head tilt in trauma
victims.
JAW THRUST:
Technique: Position yourself above patient. Place fingers of each hand under
angle of jaw, just below ears. Lift jaw, using forearms to maintain
head alignment.
Indications: Trauma victim or medical patient, where neck extension is not
possible. Another rescuer must do BVM ventilation, and this is a
fatiguing method. May be used with dentures in place.

Providers are reminded that aggressive treatment is indicated for better
outcomes.
OBSTRUCTED AIRWAY
INDICATIONS
- Complete or partial obstruction of the airway due to a foreign body
- Complete or partial obstruction due to airway swelling from anaphylaxis,
croup, or epiglottitis
- Patient with unknown illness or injury who cannot be ventilated after
applying appropriate methods to open the airway
PRECAUTIONS
- Perform chest thrusts only in visibly pregnant patients, obese patients, and
in infants.
- Patients with partial airway obstruction can be very uncomfortable and
vociferous. Abdominal or chest thrusts will not be effective and may cause
injury to the patient who is still breathing. Be ready to intervene promptly
if arrest occurs.
- Hypoxia from airway obstruction can cause seizures. Chest or abdominal
thrusts may not be effective until the patient becomes relaxed after the
seizure is over.
TECHNIQUE
- Complete airway obstruction:
- Open airway using head tilt-chin lift or jaw thrust.
- Attempt to ventilate using BVM ventilations.
- If unable to ventilate, reposition airway and reattempt ventilations.
- EMT-P: If airway remains obstructed, visualize with laryngoscope and
remove any obvious foreign body.
- If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts.
- Reposition the airway and reattempt to ventilate.
- Consider surgical cricothyrotomy if obstruction is unable to be removed
and it is impossible to ventilate adequately with the BVM.
- When obstruction is relieved:
- Keep patient on side, sweeping airway to remove debris.
- Administer high-flow oxygen via non-rebreather mask.
- Assess adequacy of ventilation, and support as needed.
- Suction aggressively.
- Restrain if combative per the Restraints protocol.
- Partial airway obstruction:
- Have patient assume most comfortable position.
- Administer high-flow oxygen by non-rebreather mask.
- Attempt suctioning of upper airway.
- If patient is unable to move air, confused, or otherwise deteriorating,
visualize airway, remove foreign body or perform abdominal thrusts as
noted above.
COMPLICATIONS
- Hypoxic brain damage and death from unrecognized or unrelieved
obstruction
- Trauma to ribs, lung, liver and spleen from chest or abdominal thrusts
(particularly when forces are not evenly distributed)
- Vomiting and aspiration after relief of obstruction
- Creation of complete obstruction after blind incorrect finger probing
- Tonsillar or pharyngeal laceration from overly vigorous finger sweep

INDICATIONS
- To remove foreign material that can be removed by a suction device
- To remove excess secretions or pulmonary edema fluid in upper airway or
lungs (with endotracheal tube in place)
- To remove meconium or amniotic fluid in mouth, nose and oropharynx of
newborn
TECHNIQUE
- Turn patient on side if possible, to facilitate clearance.
- Open airway and inspect for visible foreign material.
- Remove large or obvious foreign matter with gloved hands. Use
oropharyngeal airway (do not pry) to keep airway open. Sweep finger across
posterior pharynx and clear material out of mouth.
- Suction of oropharynx:
- Attach tonsil tip (or use open end for large amounts of debris).
- Ventilate and oxygenate the patient as needed prior to the procedure.
- Insert tip into oropharynx under direct vision and suction using a
sweeping motion.
- Continue intermittent suction interspersed with active oxygenation as
indicated. Use positive pressure ventilation if needed.
- EMT-P: Catheter suction of endotracheal tube:
- Ventilate patient prior to any suctioning attempts.
- Put on sterile gloves.
- When catheter tip has been gently advanced as far as possible, apply
suction and withdraw catheter slowly. NOTE: Suctioning should only be
done with a sterile catheter.
- Rinse catheter tip in sterile water or saline.
- Administer O
2
appropriately following suctioning.
- Suction of the newborn:
- Use neonatal suctioning device.
- As soon as infant's head has delivered, insert suction tip into the mouth
and back to oropharynx.
- Apply suction while slowly withdrawing catheter from the mouth.
- Insert catheter tip into each nostril and back to posterior pharynx.
- Apply suction while slowly withdrawing catheter from each nostril.
- As soon as infant has delivered, repeat process.
- EMT-P: Suction trachea under direct vision with laryngoscope if there is
evidence of meconium aspiration.
COMPLICATIONS
- Hypoxia due to excessive suctioning time without adequate ventilation
between attempts
- Persistent obstruction due to inadequate tubing size for removal of debris
- Lung injury from aspiration of stomach contents due to inadequate
suctioning
- Asphyxia due to recurrent obstruction if airway is not monitored after initial
suctioning
- Conversion of partial to complete obstruction by attempts at airway
clearance
- Trauma to the posterior pharynx from forced use of equipment
- Vomiting and aspiration from stimulation of gag reflex
- Induction of cardiorespiratory arrest from vagal stimulation
- Complications may be caused both by inadequate and overly vigorous
suctioning. Technique and choice of equipment are very important. Choose
equipment with enough power to suction large amounts rapidly to allow
time for ventilation.
- Proper airway clearance can make the difference between a patient who
survives and one who dies. Airway obstruction is one of the most common
treatable causes of pre-hospital death.

INDICATIONS
- Inadequate patient ventilation due to fatigue, coma, or other causes of
respiratory depression
- To apply positive pressure ventilation in patients with pulmonary edema and
severe fatigue
- To ventilate patients in respiratory arrest
PRECAUTIONS
- Two people are often required to obtain for ventilation one to ensure an
adequate mask fit and the other to ventilate.
- Assisted ventilation will not hurt a patient, and should be used whenever
the breathing pattern seems shallow, slow, or otherwise abnormal. Do not
be afraid to be aggressive about assisting ventilation, even in patients who
do not require or will not tolerate intubation.
- EMT-P: Early intubation may be of benefit for patients who continue to
bleed or vomit.
TECHNIQUE
- Open the airway. Check for respirations.
- Administer ventilations. If unsuccessful, use the Obstructed Airway
protocol.
- Check pulse. If absent for medical reasons, go to the Medical Cardiac Arrest
protocol. Otherwise refer to the Trauma Arrest protocol.
- Attach oxygen to the BVM.
- Position yourself above patient's head, continue to hold the airway position,
seat mask firmly on face, and begin assisted ventilation.
- Watch chest for rise and feel for air leak or resistance to air passage. Adjust
the mask fit as needed.
- If patient resumes spontaneous respirations, continue to administer
supplemental oxygen via the BVM. Intermittent assistance with ventilation
may still be needed.
- Continuous monitoring of pulse oximetry is required.
- Use capnography per protocol.
COMPLICATIONS
- Continued aspiration of blood, vomitus, and other upper airway debris
- Inadequate ventilations due to poor seal between patient's mouth and
ventilatory device
- Gastric distention, possibly causing vomiting
- Trauma to the upper airway from forcible use of airways
- Pneumothorax
CAPNOGRAPHY
INDICATIONS
- To help ensure proper initial placement of the endotracheal tube and assure
continuous airway patency. All intubated patients require continuous end-
tidal CO
2
monitoring.
- To detect displacement of the endotracheal tube
- To ensure effectiveness of cardiopulmonary resuscitation
- Symptomatic patients with bronchospasm or CHF should receive continuous
end-tidal CO
2
monitoring.
- Patients with evidence of hypoventilation regardless of reason should
receive continuous end-tidal CO
2
monitoring.
TECHNIQUE
- Lifepak 12:
- Intubated patient:
- Attach CO
2
sensor in-line between the endotracheal tube and the
BVM.
- Non-intubated patient:
- Place CO
2
sensor cannula on patient, replacing existing cannula if
applicable. CO
2
sensor cannula may be placed under NRB mask; leave
the cannula O
2
tubing disconnected and connect CO
2
tubing as
follows:
- Open the CO
2
tubing connector door and connect the Microstream CO
2

FilterLine tubing by turning the tubing clockwise.
- Verify that the ETCO
2
monitor display is on.
- Display CO
2
waveform on channel 2 or 3 (typically displayed on channel
3).
- Record the first ten seconds of waveform when placed.
- Evaluate the capnogram waveform and numerical value normal ETCO
2

is 35-45.
- If the numeric value falls to zero, consider loss of airway patency,
endotracheal tube obstruction, extubation, apnea or loss of cardiac
output.
- If a normal capnogram waveform falls flat, consider loss of airway
patency, endotracheal tube obstruction, extubation, apnea or loss of
cardiac output.
- If ETCO
2
waveform is flat consider that the endotracheal tube may
be in the wrong position (esophageal).
- If ETCO
2
numeric value is zero, there may be an absence of CO
2
in
the lungs due to lack of cardiac output.
- Record the last ten seconds of waveform prior to disconnecting monitor
from patient.
- If the capnogram shape appears abnormal, it may indicate an underlying
physiologic abnormality. A sharp or gradual upstroke in the waveform
resembling a shark fin is indicative of bronchospasm.
- ETCO
2
varies with cardiac output. If cardiac output increases after
resuscitation, ETCO
2
may provide information about the adequacy of
ventilation and circulation.

EMT-P: KING LTS-D
INDICATIONS
- To secure a patent airway and deliver ventilations as an alternative to
orotracheal intubation in patients over 35 inches tall
- To be used as an adjunct airway after two unsuccessful oral intubation
attempts
- Sizes 2 and 2.5 are to be used only in cardiac arrest
CONTRAINDICATIONS
- Patients with an intact gag reflex
- Patients with known esophageal disease (e.g., varices, history of Mallory-
Weiss tear)
- Any patient that has ingested a known caustic substance
- Patients who are less than 35 inches tall
TECHNIQUE
- Use BSI including gloves, mask and eye protection. Assemble the equipment
while continuing BVM ventilations.
- Choose correct tube size based on the patients height.
- 3 to 39 tall = size 2 (green)
- 3'5 to 43 tall = size 2.5 (orange)
- 4 to 5 tall = size 3 (yellow)
- 5 to 6 tall = size 4 (red)
- Check inflatable cuff for leaks.
- Apply water-soluble lubrication to posterior aspect of both distal and
proximal cuffs.
- Prepare and turn on suction.
- Perform head tilt-chin lift and introduce the King airway into either corner
of the mouth.
- Advance tip behind the base of the tongue while rotating the tube until the
base of the colored connector is aligned with the patients teeth or gums.
- Without excessive force, advance the tube until the base of the colored
connector is aligned
- Inflate cuff based on tube size.
- Size 2 = 25-35 ml
- Size 2.5 = 30-40 ml
- Size 3 = 45-60 ml
- Size 4 = 60-80 ml
- Attach BVM. While gently bagging, slowly withdraw the tube until
ventilation is easy to administer, i.e., a large tidal volume is achieved with
minimal airway pressure.
- Adjust cuff inflation if necessary to obtain an airway seal at peak
ventilation pressure.
- Assess for proper tube placement:
- Assess breath sounds.
- Assure chest rise and fall.
- Continue to re-assess that tube is properly placed and that patient
ventilation is easy and free-flowing with chest rise and adequate breath
sounds.
- Note proper placement and secure with tube tie.
- Utilize capnography to ensure proper placement.
- If at any time the provider is unsure of proper placement, deflate cuff,
remove, and use the BVM for ventilation.
COMPLICATIONS
- Hypoxia due to prolonged insertion attempt
- Unrecognized tracheal placement will result in an inability to successfully
ventilate the patient.
- Higher airway pressures may divert air into the stomach.
- Lubricate only the posterior aspect of the King airway to avoid blockage of
the ventilation ports or aspiration of lubricant.
- The King airway does not protect against aspiration, and its use in the
presence of a gag reflex may result in an airway emergency.
- Medications cannot be administered through this airway.
INDICATIONS
- Same function as orotracheal intubation in patients greater than 12 years of
age
- Used in the breathing patient requiring intubation
- Asthma or pulmonary edema with respiratory failure, where CPAP is
unsuccessful or contraindicated and intubation may need to be achieved in
a sitting position

PRECAUTIONS
- Head must be exactly in midline for successful intubation.
- Have suction ready. Vomiting can occur, as with any stimulation of the
airway.
- Often nares are asymmetrical and one side is much easier to intubate. Avoid
inducing bilateral nasal hemorrhage by forcing a nasotracheal tube on
multiple attempts.
- The use of nasotracheal intubation should be discouraged in patients with
significant nasal or craniofacial trauma.
- Blind nasotracheal intubation is a very gentle technique. In the field, the
secret of blind intubation is perfect positioning and patience.
- Only absolute contraindication is apnea.
- Should not be attempted in children less than 12 years of age.
TECHNIQUE
- Choose correct ET tube size (usually 7 mm tube in adult). Limitation is nasal
canal diameter.
- Position patient with head in midline, neutral position (cervical collar may
be in place, or assistant may provide cervical stabilization in trauma
patients).
- Administer phenylephrine nasal drops per protocol in both nostrils.
- Assist ventilations prior to procedure if spontaneous respirations are
inadequate.
- Lubricate ET tube with viscous lidocaine.
- With gentle steady pressure, advance the tube through the nose to the
posterior pharynx. Use right or largest nostril. Abandon procedure if
significant resistance is encountered.
- Keeping the curve of the tube exactly in midline, continue advancing
slowly.
- There will be a slight resistance just before entering trachea. Wait for an
inspiratory effort before final advance into trachea. Patient may also cough
or buck just before breath.
- Continue advancing until air is exchanging through the tube.
- Advance about 1 inch further, then inflate cuff.
- Ventilate and auscultate chest and abdomen for proper tube placement.
- Note proper tube position and tape securely.
COMPLICATIONS
- Same as orotracheal intubation. In addition:
- Further craniofacial injury particularly in patients presenting with facial
trauma
- Nasal bleeding caused by tube trauma
- Vomiting and aspiration in the patient with intact gag reflex

INDICATIONS
- In most cases orotracheal intubation provides definitive control of the
airway. Its purposes include:
- Actively ventilating the patient
- Delivering high concentrations of oxygen
- Suctioning secretions and maintaining airway patency
- Preventing aspiration of gastric contents, upper airway secretions, or
bleeding
- Preventing gastric distention due to assisted ventilation
- Administering positive pressure when extra fluid is present in alveoli
- Allowing more effective CPR
PRECAUTIONS
- Do not use intubation as the initial method of managing the airway in an
arrest. Oxygenation prior to intubation should be accomplished with a BVM
as needed.
- Appropriate intubation precautions should be taken in the trauma patient.
Nasotracheal intubation is preferred in the breathing patient. Oral
intubation with in-line cervical immobilization is the best alternative for a
trauma patient requiring definitive airway control.
- Never lever the laryngoscope against the teeth. The jaw should be lifted
with direct upward traction by the laryngoscope.
- Prepare suction beforehand. Vomiting is particularly common when the
esophagus is intubated.
- Intubation should take no more than 20 seconds to complete: do not lose
track of time. If visualization is difficult, stop and re-ventilate before trying
again.
- Orotracheal intubation can be accomplished in trauma victims if an
assistant maintains stabilization and keeps the neck in neutral position.
Careful visualization with the laryngoscope is needed, and McGill forceps
may be helpful in guiding the ET tube.
TECHNIQUE
- Use BSI including gloves, mask, and eye protection. Assemble the
equipment while continuing ventilation:
- Choose the correct endotracheal tube size (see table on next page). Use
the largest tube available.
- Introduce stylette and be sure it stops short of the tubes end.
- Assemble laryngoscope and check light.
- Connect and check suction.
- Position patient with neck flexed forward, head extended back. Back of
head should be level with or higher than back of shoulders.
- Give a minimum of 4 good ventilations before starting procedure.
- Have an assistant apply gentle cricothyroid pressure to prevent aspiration
and to assist in visualization of vocal cords.
- Gently insert laryngoscope to right of midline. Move it to midline, pushing
tongue to left and out of view.
- Lift straight up on blade (no levering) to expose the posterior pharynx.
- Identify epiglottis: the tip of curved blade should sit in vallecula (in front of
epiglottis); the straight blade should slip over epiglottis.
- With gentle further traction to straighten the airway, identify trachea from
the arytenoid cartilages and vocal cords.
- Insert tube from right side of the mouth, along blade into trachea under
direct vision.
- Advance tube so cuff is 1-1" beyond cords. Inflate cuff with 5-10 ml of air,
clamp if necessary to secure against leaks.
- Ventilate and watch for chest rise. Listen for breath sounds over stomach
(should not be heard), lungs and axillae.
- Document proper tube position and secure tube with appropriate methods.
- Re-auscultate over stomach and both sides of chest whenever patient is
moved.
- Tube placement should also be evaluated by other devices such as an end-
tidal CO
2
detector.
- Accurate documentation includes indications for intubation as well as
measures taken for tube verification.
COMPLICATIONS
- Esophageal intubation: particularly common when tube not visualized as it
passes through cords. The greatest danger is in not recognizing the error.
Auscultation over stomach during trial ventilations should reveal air gurgling
through gastric contents with esophageal placement. Also make sure
patient's color improves as it should when ventilating.
- Intubation of right mainstem bronchus: be sure to listen to chest bilaterally.
- Upper airway trauma due to excess force with laryngoscope or to traumatic
tube placement
- Vomiting and aspiration during traumatic intubation or intubation of patient
with intact gag reflex
- Hypoxia due to prolonged intubation attempt
- Cervical spine fracture in patients with arthritis and poor cervical mobility
- Cervical cord damage in trauma victims with unrecognized spine injury
- Ventricular arrhythmias or fibrillation in hypothermic patients from
stimulation of airway
- Induction of pneumothorax from traumatic insertion, forceful bagging, or
aggravation of underlying pneumothorax

ENDOTRACHEAL TUBE SIZE GUIDE
AGE ENDOTRACHEAL TUBE
Preemie
Newborn
6 mos.
18 mos.
3 yrs.
5 yrs.
8 yrs.
15 yrs.
Adult
2.5-3 uncuffed
3-3.5 uncuffed
3.5 uncuffed
4 uncuffed
4.5 uncuffed
5 uncuffed
6 cuffed
6.5-7 cuffed
7-9 cuffed

Note: The Broselow tape is the most accurate predictor of tube size in
pediatric patients.

- Surgical cricothyrotomy is a difficult and hazardous procedure that is to be
used in extraordinary circumstances as defined below. The reason for
performing this procedure must be documented and submitted for review to
the physician advisor or designee within 24 hours. Surgical cricothyrotomy is
to be performed only by paramedics trained in the procedure.
INDICATIONS
- When a life threatening condition exists and advanced airway management
is indicated, and you are unable to establish an airway or ventilate the
patient by any other means.
PRECAUTIONS
- Bleeding is possible, even with correct technique. Straying from the midline
is very dangerous and likely to cause hemorrhage from the carotid or
jugular vessels, or their branches.
TECHNIQUE
- Contact base.
- Using aseptic technique (Betadine/alcohol wipes), cleanse the area.
- Position the patient in a supine position, with in-line spinal immobilization
if indicated.
- Locate the anatomical landmarks of the neck and identify the cricothyroid
membrane.
- Use a scalpel to make a 1/4 vertical incision through the skin and fascia,
over the cricothyroid membrane.
- Make a horizontal incision through the cricothyroid membrane.
- Open the incision of the cricothyroid membrane by inserting the scalpel
handle. Rotate handle 90 to allow ET tube placement.
- Insert ET tube.
- Ventilate with BVM and 100% oxygen.
- Confirm tube placement is successful (chest rise and fall, breath sounds,
capnography). Observe for subcutaneous air, indicating tracheal injury or
improper placement.
- Secure tube with ties.
- Transport to appropriate facility.
CARDIAC EMERGENCIES
ASYSTOLE
BRADYCARDIA
TACHYCARDIA
CHEST PAIN
HYPERTENSION

PROCEDURES:
EMT-P: THERAPEUTIC INDUCED HYPOTHERMIA
SPECIFIC INFORMATION NEEDED
- Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR,
downtime before CPR and duration of CPR
- Past history: medications, medical history, suspicion of ingestion, trauma,
environmental factors (hypothermia, inhalation, asphyxiation)
SPECIFIC OBJECTIVE FINDINGS
- Unconscious, unresponsive
- Agonal or no respirations
- Absent pulses
- Signs of trauma, blood loss
- Skin temperature
GENERAL GUIDELINES: TREATMENT
- Check surroundings for safety to rescuers
- Treat according to BLS and ACLS algorithms
- Note that the initial steps for management of cardiac arrest depend on
whether arrest witnessed by EMS
- If patient not defibrillated within first 4 minutes of cardiac arrest,
attempted defibrillation must be preceded by 2 minutes of
uninterrupted CPR
- EMT-B: Call for ALS assistance if not already on scene or responding
GENERAL GUIDELINES: CHEST COMPRESSIONS
- 1 cycle of CPR = 30:2 chest compressions: breaths
- 5 cycles CPR = 2 minutes chest compressions
- Push hard and push fast (100/minute).
- Ensure full chest recoil.
- Rotate compressors every 2 minutes with rhythm checks.
- During CPR, any interruption in chest compressions deprives heart of
necessary blood flow and lessens chance of successful defibrillation.
- Continue CPR while defibrillator is charging, and resume CPR
immediately after all shocks. Do not check pulses except at end of CPR
cycle and if rhythm is organized at rhythm check.
GENERAL GUIDELINES: DEFIBRILLATION
- All shocks should be given as single maximum energy shocks
- EMT-P: Manual biphasic: device specific, if unsure, use 360J. Note that
Lifepak 12s are manual biphasic devices and the default is set to 360J.
- AED: device specific
GENERAL GUIDELINES: TIMING OF PLACEMENT OF ADVANCED AIRWAY
- EMT-P:
- Advanced airway may be placed at any time during resuscitation
provided it does not cause interruption in chest compressions.
- Once an advanced airway is in place, compressions are given
continuously and breaths given asynchronously at 8-10 per minute.
- Do not hyperventilate.
- Always confirm advanced airway placement by objective criteria: end-
tidal CO
2
in the form of continuous waveform capnography.
GENERAL GUIDELINES: PACING
- EMT-P:

- Pacing should not be undertaken if it follows unsuccessful defibrillation
of VT/VF as it will only interfere with CPR and is not effective.
GENERAL GUIDELINES: ICD/PACEMAKER PATIENTS
- If cardiac arrest patient has an implantable cardioverter defibrillator (ICD)
or pacemaker place Combi-Pads at least 1 inch from device. Biaxillary pad
placement may be used.
SPECIAL NOTES
- Consider reversible causes of cardiac arrest (Hs and Ts):
Hypovolemia IV fluid bolus
Hypoxia Ventilation
Hydrogen Ion (acidosis) Ventilation
Hyperkalemia EMT-P: Sodium bicarbonate, calcium
gluconate
Hypothermia See cold emergencies protocol
Toxins: e.g., opioid overdose Narcan 2 mg IV push
Tamponade (cardiac)
Tension pneumothorax EMT-P: Needle decompression
Thrombosis (coronary)
Trauma

- Survival from cardiac arrest is related to the time to BOTH BLS and ALS
treatment. Don't forget CPR in the rush for advanced equipment. A call for
back-up should be initiated promptly by any BLS unit. Likewise, standing
order administration of the first steps in treatment is recommended to
minimize time delays to ALS.
- Large peripheral veins (antecubital or EMT-P: external jugular) are
preferred IV sites in cardiac arrest. EMT-P: IO access should be considered if
peripheral access cannot be established after two attempts per protocol.
- Combi-Pads are preferred for initial rhythm check. Be sure machine is set to
record from whichever mode is in use.
- Be sure to recheck for pulselessness and unresponsiveness upon arrival,
even if CPR is in progress. This will avoid needless and dangerous treatment
of "collapsed" patients who are inaccurately diagnosed initially, or who have
spontaneous return of cardiac function after an arrhythmia or vasovagal
episode.
- After conversion to another rhythm, providers should switch to the
appropriate protocol for continued and ongoing treatment.
No movement or
response
Open airway &
check breathing
If not breathing, give 2
breaths that make chest rise
If still not responsive, check
pulse.
Is there a DEFINITE pulse?
Give cycles of CPR in 30:2 ratios until
AED/defibrillator arrives, ALS assumes care, or
patient starts to move. First 2 minutes compressions
given without pause for ventilations
AED/Defibrillator
arrives
Check rhythm
Shockable rhythm?
Resume CPR immediately
for 5 cycles
Check rhythm every 5
cycles, continue until ALS
providers take over or
patient starts to move
Give 1 shock
for 5 cycles
- Give 1 breath
every 5-6 seconds
- Recheck pulse
every 2 minutes
Definite
Pulse
No Pulse
Not Shockable Shockable

Cardiac arrest witnessed
by EMS?

BLS Algorithm
Oxygen via NRB
Attach monitor/defibrillator

200 uninterrupted chest
compressions (2 minutes)

Check rhythm
Shockable rhythm?

VF/VT

Asystole/PEA

Give 1 shock

5 cycles or 2 minutes CPR

Check rhythm
Shockable rhythm?

Give 1 shock
Give epinephrine 1 mg IV/IO
during CPR, before or after shock
when IV/IO available. Repeat
every 3-5 minutes

Check rhythm
Shockable rhythm?


Give 1 shock
Repeat epinephrine 1mg IV/IO
Give amiodarone 300mg IV/IO
Consider magnesium 2g IV/IO for
Torsades de pointes.
After 5 cycles CPR, go to box 3

Give epinephrine 1mg IV/IO.
Repeat every 3-5 minutes
Give atropine 1mg IV/IO for
asystole or slow PEA. Repeat
every 3-5 minutes up to 3 doses


Check rhythm
Shockable rhythm?

If asystole, go to box 4
If electrical activity,
check pulse, if no pulse,
go to box 4
If pulse present, begin
post resuscitation care

Go to box 2

Shockable

Not Shockable

Shockable

No

Shockable

No

No

1

2

4

3

Shockable

Yes

No
Search for and treat reversible
causes of cardiac arrest: 5 Hs
and 5 Ts

TREATMENT
- Refractory V-Fib or Pulseless V-Tach:
- Administer Amiodarone 300 mg IV push.
- Defibrillate at maximum joule setting.
- Consider magnesium sulfate 2 g IV push.
- Defibrillate at maximum joule setting.
- Consider transport options.
SPECIAL NOTES
- Torsade de pointes is a rare and special form of ventricular tachycardia.
Consider treating with magnesium sulfate per protocol.
- The initiation of IV or airway treatments should not delay defibrillation.
- After conversion from VF/VT, consider Amiodarone 150 mg IV infusion over
10 minutes.
- Pediatric defibrillation dosing:
- 2 joules/kg initial shock
- 4 joules/kg repeat shocks
ASYSTOLE
TREATMENT
- Begin Basic Life Support measures, including CPR.
- Establish airway.
- Establish IV access or EMT-P: IV/IO access per protocol.
- EMT-P: Begin cardiac monitoring. Confirm asystole in at least two leads.
- EMT-P: Administer epinephrine 1 mg (1 ml of a 1:10,000 solution) IV push. If
no change, repeat every 3-5 minutes.
- EMT-P: Administer sodium bicarbonate 1 mEq/kg IV push. This should be
considered only in prolonged cardiac arrest situations.
SPECIAL NOTES
- When asystole is diagnosed, check the integrity of the leads and electrode
patches and confirm this interpretation in at least two leads.
- In pediatric patients, after ABCs have been initiated, ventilate, consider an
IV fluid bolus of normal saline 20 ml/kg, reassess, EMT-P: consider
epinephrine.

INITIATE SUPPORTIVE MEASURES:
- ABCs
- CPR
- Orotracheal intubation
- Establish venous access

CONSIDER POSSIBLE CAUSES: TREATMENT:
Hypovolemia IV fluid bolus (20 ml/kg normal saline)
Tension pneumothorax EMT-P: Needle decompression per protocol
Hypoxia Ensure airway patency
Acidosis Ventilation
Cardiac tamponade IV fluid bolus (20 ml/kg normal saline)
Hypothermia See Cold Emergencies protocol
Pulmonary embolism
Myocardial infarction
Drug overdose If opioids suspected, Narcan
Hyperkalemia EMT-P: Sodium bicarbonate, calcium gluconate

EPINEPHRINE (1:10,000)
1 mg IV/IO push,
repeat every 3 5
minutes
Pediatric doses: First dose: 0.01 mg/kg IV/IO (0.1 ml/kg
of 1:10,000 solution); Subsequent doses: 0.01 mg/kg,
IV/IO (0.1 ml/kg of 1:10,000 solution

ATROPINE for BRADYCARDIA
1 mg IV/IO push, repeat every 3-5
minutes, not to exceed 3 mg
Pediatric dose: refer to
Broselow tape

INITIATE TRANSPORT
SPECIAL NOTES
- Standing orders should expedite care - not prolong scene time. Rapid
transport is still the goal.
- In pediatric patients, ventilate, consider fluid bolus, reassess, EMT-P:
consider epinephrine.
- Present symptoms: sudden or gradual onset, palpitations
- Associated symptoms: chest pain, dizziness or fainting, trouble breathing,
abdominal pain, fever
- Prior history: arrhythmias, cardiac disease, exercise level, pacemaker
- Current medications, particularly cardiac
- Vital signs
- Signs of poor cardiac output:
- Altered level of consciousness
- "Shocky" appearance: cool/clammy skin, pallor
- Systolic blood pressure < 90 mmHg
- Signs of cardiac failure (increased back-up pressure):
- Neck vein distention
- Lung congestion, rales
- Peripheral edema is sign of chronic failure, not acute.
- Signs of hypoxia: marked respiratory distress, cyanosis, tachycardia
TREATMENT
- Administer O
2
, position of comfort.
- Establish venous access.
- Evaluate the patient. Is the patient perfusing adequately or are there signs
of inadequate perfusion?
- EMT-P: Apply cardiac monitor and evaluate arrhythmia.
- Is there a pulse corresponding to monitor rhythm?
- Rate: tachycardia, bradycardia, normal?
- Are the ventricular complexes wide or narrow?
- What is the relation between atrial activity (P waves) and ventricular
activity?
- Is the arrhythmia potentially dangerous to the patient?
- EMT-P: Document the arrhythmia by rhythm strip and 12 lead EKG.
- EMT-P: Treat if needed according to pulse rate, perfusion status, and risk of
deterioration or as directed by base physician.
- EMT-P: Document results of treatment (or lack thereof) by checking pulse
and recording change on paper tape.
- Transport patient. Monitor condition en route.
SPECIFIC PRECAUTIONS
- Treat the patient, not the arrhythmia! If the patient is perfusing
adequately, he does not need emergency treatment. This is true of
bradyarrhythmias as well as tachyarrhythmias. What is normal for one
person may be fatal for another.
- Documentation of arrhythmias is extremely important. Field treatment of
an arrhythmia may be life saving, but long-term treatment requires knowing
what the problem was.
- Correct arrhythmia diagnosis based only on monitor strip recordings is
difficult and often not possible. Treatment must be based on observable
parameters: rate, patient condition and distance from the hospital.
- Dangerous rhythms are those that do not necessarily cause poor perfusion,
but are likely to deteriorate. They require recognition and treatment to
prevent degeneration to mechanically significant arrhythmias. Some of
these dangerous rhythms include ventricular tachycardia and Mobitz type II
second-degree AV block.
- Cardiac arrest and life-threatening arrhythmias can be treated in the field,
and show the benefits of "stabilization before transfer" in pre-hospital care.
The patient is better off when the duration of arrest or poor perfusion is
minimized.
- Drug dosages vary in the pediatric and elderly populations.
- The treatment of PVCs is rarely, if ever, indicated in the pre-hospital
setting.
- EMT-P: Patients with PVCs and active chest pain should have pain treated
aggressively with oxygen, aspirin, nitroglycerin, and pain medications.
- EMT-P: Prophylactic use of Amiodarone is contraindicated.

BRADYCARDIA
Patients who are asymptomatic with normal blood pressure do not need
treatment of bradycardia in the field; they require transport. EMT-B: Consider
ALS if patient needs monitoring or advanced measures.

Bradycardia
HR < 60 and inadequate for
clinical condition

Maintain airway
Assist breathing as needed
Give oxygen
EMT-P: Monitor EKG and
identify rhythm
Start IV

Signs or symptoms of poor perfusion caused by bradycardia?
(altered mental status, chest pain, hypotension, signs of shock)

Adequate Perfusion Poor Perfusion

Monitor and
transport

EMT-P:
Prepare for transcutaneous pacing
Pace immediately for high-grade
block (type II second-degree AV block
or third-degree AV block)
Give atropine 0.5-1 mg IV
Reminders:
may repeat to total dose 3 mg
If pulseless arrest develops, go
to pulseless arrest algorithm
If ineffective, begin pacing
If pacing ineffective, contact base
Search for possible
contributing factors: 5Hs and
5 Ts
Consider epinephrine 2-10 mcg/min
or dopamine 2-10 mcg/kg/min if
pacing ineffective

TACHYCARDIA
EMT-B: Consider ALS if patient needs monitoring or advanced measures. Box 2
and on are for EMT-P only.

Tachycardia with a pulse

Support ABCs
Give oxygen

Is patient stable?
(unstable signs include altered
mental status, chest pain,
hypotension, signs of shock)
Rate-related symptoms
uncommon with HR < 150

EMT-P: Perform
immediate
synchronized
cardioversion with
device-specific
energy
recommendations

Start IV
EMT-P: 12-lead
EKG: identify
rhythm
Measure QRS
duration
Stable

2
1

Unstable

Narrow QRS (< 0.12 msec)
Is rhythm regular?

Wide QRS (> 0.12 msec)
Is rhythm regular?

Attempt Valsalva
maneuver
Give adenosine 6mg
IVP. If no conversion,
give 12 mg IVP. May
repeat 12 mg dose
once

Atrial fibrillation,
atrial flutter or MAT
Do not give
adenosine
Monitor and
transport
If becomes unstable,
go to box 2

Regular Irregular
Narrow
Wide

Irregular Regular
See box 3
V-Tach (>80 %) or
SVT with
aberrancy
3
Contact base for
consult
Give amiodarone
150mg over 10
minutes
Do NOT give
adenosine

If becomes
unstable, go to
box 2

Does rhythm
convert?

Converts
Does Not Convert
Probably reentrant
SVT
Contact base for
consult
Monitor and
transport
Monitor and transport
If unstable, go to box 2
If recurrent
arrhythmia, go to
box 1

CHEST PAIN
- Symptoms: Patient of either gender, more than 20 years old, with any of
the following chief complaints:
- Suspected Acute Coronary Syndrome
- Chest pressure, tightness, heaviness
- Radiation of pain to neck, jaw, shoulders, back, and/or one or both arms
- Indigestion or heartburn, nausea and/or vomiting, belching
- Persistent shortness of breath
- Weakness, dizziness, lightheadedness
- Syncope or altered mental status with or without pain
- Cocaine use
- Respiratory
- Acute onset of shortness of breath
- Wheezing
- Vital signs
- General appearance: color, apprehension, diaphoresis
- Signs of heart failure: neck vein distention, peripheral edema, respiratory
distress
- Lung exam by auscultation: rales, wheezes or decreased sounds
- Chest wall tenderness, abdominal tenderness
TREATMENT
- Reassure and place patient at rest, position of comfort.
- Administer O
2
.
- EMT-P: Place patient on cardiac monitor (or obtain immediate 12 lead EKG
for suspected ACS).
- If patients history and physical exam suggest a potential cardiac origin to
the chest pain:
- EMT-B: Call for ALS.
- Administer aspirin chewable tables if patient is able to swallow.
- EMT-P: Administer nitroglycerin SL if systolic BP > 100 mmHg. Repeat
every 5 min up to 3 doses until pain relieved or systolic BP < 100 mmHg.
- EMT-P: For extended patient contact (e.g., DIA) with systolic BP > 100
mmHg, consider administration of 1 nitroglycerin paste applied to chest
wall after initiation of nitro therapy. Remove nitro-paste if patients
systolic BP drops below 100 mmHg.
- EMT-P: If pain persists after third nitroglycerin, administer morphine
sulfate for patients with no alteration of mental status and systolic BP >
100 mmHg.
- EMT-P: Consider base contact for additional nitroglycerin and or
morphine sulfate if pain persists.
- Consider NS fluid challenge or EMT-P: vasopressor if hypotensive.
- EMT-P: Consider advance notification and activation of a CARDIAC ALERT
along with direct transport to a facility capable of emergent primary
coronary intervention (PCI) when the patient meets all of the following
criteria:
- Active chest pain classic for acute coronary syndrome (ACS)
- Age 35-85
- ECG showing ST elevation > (greater than or equal to) 1 millimeter in
at least 2 anatomically contiguous leads
- No LBBB, paced rhythm, or other wide complex rhythm
- Symptoms < 12 hour total duration
- Second paramedic, if available, concurs with diagnosis
- Remember that there are many causes for chest pain. Consider pericarditis,
aortic dissection, aortic aneurysm, pulmonary embolus, pneumothorax, and
pneumonia as potential causes.
- Beware of IV fluid overload in the potential cardiac patient.
- Patients taking medications for erectile dysfunction such as Viagra
(sildenafil) or Levitra (vardenafil) should not be given nitroglycerin within
24 hours, and Cialis (tadalafil) within 48 hours of use, and then only with
caution and consideration of risk and benefits. Consider base contact for
physician consultation.
- The elderly and patients with volume depletion are at risk for developing
hypotension following nitroglycerin administration.

HYPERTENSION
- History of hypertension
- New symptoms: dizziness, nausea, confusion, visual impairment,
paresthesia, weakness
- Drug use, especially sympathomimetics
- Current medications and compliance
- Other symptoms: chest pain, dyspnea, abdominal/back pain, severe
headache
- Evidence of encephalopathy: confusion, seizures, coma, vomiting
- Presence of associated findings: pulmonary edema, neurologic signs, neck
stiffness, unequal peripheral pulses
TREATMENT
- Administer O
2
.
- Place the patient in a position of comfort.
- Recheck BP, with special attention to diastolic pressure, correct cuff size
and placement.
- Treat chest pain, pulmonary edema, seizure activity as per usual protocols.
- If diastolic remains above 130 on repeated readings and patient has
symptoms of encephalopathy, chest pain, or pulmonary edema without
presence of CVA or head injury, EMT-P: contact base to consider:
- Nitroglycerin
- Morphine sulfate
- EMT-P: Monitor cardiac rhythm.
- Monitor vital signs and mental status during transport.
- Secondary hypertension (high BP in response to stress or pain) is commonly
seen in the field. It does not require field treatment, and may not even
mean the patient has chronic hypertension requiring ongoing treatment.
- Hypertensive encephalopathy is rare, but can be treated with nitroglycerin
or morphine. Hypertension is more common in association with other
problems (pulmonary edema, seizures, chest pain, coma or altered mental
status). It should be managed by treating the primary problem.
- Diastolic pressures and mean arterial pressures are much more important in
determining danger of severe hypertension than are systolic pressures.
These are poorly measured in the field. The diagnosis of malignant
hypertension is not based on numerical levels but rather on microscopic
changes in blood vessels and damage to organs, which place this disease
beyond the scope of pre-hospital care.
- Dont forget that false elevation of BP can result from a cuff that is too
small for the patient. The cuff should cover 1/3 to 1/2 of the upper arm,
and the bladder should completely encircle the arm.
- Hypertension is seen in severe head injury and intracranial bleeding and is
thought to be a protective response that increases perfusion to the brain.
Treatment should be directed at the intracranial process, not the blood
pressure.
- Nitroglycerin is not to be given for hypertension alone.


Tachycardia:
For patients who are conscious, but with altered mental status and signs of
poor perfusion and a systolic B/P below 90 mmHg.

If ventricular rate is > 150 BPM prepare for IMMEDIATE CARDIOVERSION. May
give brief trial of medications based on specific arrhythmia algorithms.
Immediate cardioversion is generally not needed for rates < 150 BPM.

Check:
Ensure adequate oxygenation
Suction device
IV line
Intubation equipment

Pre-medicate with midazolam whenever possible

Synchronized cardioversion
Adult
(Biphasic)
Adult
(Monophasic)
Ped. sync
cardioversion
Pediatric
defib
VT 100 j 100 j 0.5 j/kg 2 j/kg
PSVT 150 j 200 j 1 j/kg 4 j/kg
Atrial fibrillation 200 j 300 j 1.5 j/kg 4 j/kg
Atrial flutter 2 j/kg
PRECAUTIONS
- Precautions for defibrillation apply. Protect rescuers!
- A patient who is talking to you is probably perfusing adequately.
- If the defibrillator does not discharge on "synch" with tachycardia, turn off
"synch" button and re-fire. The waves may not have enough amplitude to
trigger the "synch" mechanism.
- If sinus rhythm is achieved, even transiently, with cardioversion, subsequent
cardioversion at a higher energy setting will be of no additional value.
Leave the setting the same; consider correction of hypoxia, acidosis, etc. to
hold the conversion.
- If the patient is pulseless, begin CPR and treat as cardiac arrest, even if the
electrical rhythm appears organized.
- People with chronic atrial fibrillation are very difficult to convert, and their
atrial fibrillation is not usually the cause of their decompensation. If you get
a history of "irregular heartbeat," look elsewhere for the problem.
- Sinus tachycardia rarely exceeds 150 BPM in adults (220 BPM in children < 8
years old), and does not require cardioversion. Treat the underlying cause.
- Do not be overly concerned about the arrhythmias that normally occur in
the few minutes following successful cardioversion. These usually respond
to time and adequate oxygenation, and should only be treated if they
persist.
- Biphasic monitors require different energy doses.

INDICATIONS
- Use cardiac pacing only when there is insufficient cardiac rate to maintain
adequate perfusion, and rate is unaffected by atropine and adequate
oxygen and ventilation.
- Symptomatic bradyarrhythmias (includes AV block)
PRECAUTIONS
- Capture can be difficult in some patients.
- Patient may experience discomfort; consider midazolam.
- Use the same precautions as with defibrillation.
- Patients in atrial fibrillation may require higher energy settings for capture
than others.
TECHNIQUE
- Apply Combi-Pads as per manufacturer specifications: (-) left anterior, (+)
left posterior.
- Turn pacer unit on.
- Select pacing rate at 80 beats per minute (BPM).
- If the patient is awake, consider the use of sedation.
- Start pacing unit.
- Confirm that pacer senses intrinsic cardiac activity by adjusting EKG size. If
not, pacer may discharge on an existing complex.
- Set initial current to 40 mAmps.
- Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps
(usually captures around 100 mAmps).
- If there is capture, check for pulses.
- If there are no pulses with capture, consider a fluid challenge or dopamine.
- If no capture occurs with maximum output, discontinue pacing and resume
ACLS.
COMPLICATIONS
- Ventricular fibrillation and ventricular tachycardia are rare complications,
but follow appropriate protocols if either occurs.
- Pacing is rarely indicated in patients under the age of 12 years.
- Muscle tremors may complicate evaluation of pulses.
- Pacing may cause diaphragmatic stimulation.
- CPR is safe during pacing. A mild shock may be felt if direct active
electrode contact is made.
EMT-P: THERAPEUTIC INDUCED HYPOTHERMIA
BACKGROUND
- Mild hypothermic induction (32-34) applied to cardiac arrest patients, who
have a return of spontaneous circulation (ROSC), may protect against
ischemic neuronal injury
INDICATIONS
- ROSC after non-traumatic cardiac arrest without return of purposeful
neurologic signs in the adult patient.
CONTRAINDICATIONS
- Pregnancy
- Age < 16 years
- Cardiac arrest of suspected hypothermic origin
- Cardiac arrest of traumatic origin
PROCEDURE
- Expose patient as much as possible to facilitate placement of icepacks.
- Apply cold packs to groin over femoral arteries, axillae, and bilateral
aspects of the neck.
- Consider administration of 5 mg IV or IM Midazolam to prevent shivering.
- Consider Dopamine if BP < 90 mmHg systolic.
- If patient loses pulses during TIH, discontinue procedure and resuscitate
according to appropriate arrest algorithm.
- If patient regains purposeful neurological signs, discontinue TIH
immediately.

PULMONARY/RESPIRATORY EMERGENCIES
ASTHMA
HYPERVENTILATION
PNEUMONIA
PNEUMOTHORAX
PULMONARY EDEMA
PULMONARY EMBOLISM

PROCEDURES:
- History: acute change or injury, slow deterioration
- Past history: chronic lung or heart problems or known diagnosis,
medications, home oxygen, past allergic reactions, recent surgery, tobacco
abuse
- Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia
- Vital signs
- Oxygenation: level of consciousness, cyanosis
- Respiratory effort: accessory muscle use, forward position, pursed lips
- Neurologic signs: slurred speech, impaired consciousness, evidence of
drug/alcohol ingestion
- Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest
wall movements, inspiratory stridor
- Signs of congestive failure: neck vein distention in upright position, rales,
peripheral edema
- Breath sounds: clear, decreased, rales, wheezing, or rhonchi
- Hives, upper airway edema
- Evidence of trauma: crepitation of neck or chest, bruising, steering wheel
damage, penetrating wounds
TREATMENT
- Put patient in position of comfort, usually upright.
- EMT-B: Consider ALS for advanced measures.
- Identify and treat upper airway obstruction if present (e.g., suctioning,
NPA/OPA, EMT-P: orotracheal intubation).
- Administer high flow oxygen.
- Prepare to assist ventilations if patient fatigues or develops altered
mentation, or if respiratory arrest occurs.
- If diagnosis unclear, place patient in position of comfort, and administer O
2
,
transport.
- Assess and consider treatment for other problems if respiratory distress is
severe and patient does not respond to proper positioning and
administration of oxygen.
- Don't over-diagnose "psychogenic" in the field. Your patient could have a
pulmonary embolus or other serious problem; give him/her the benefit of
the doubt. Treatment with oxygen will not harm the hyperventilator and
it will keep you from underestimating the problem.
- Wheezing in older persons may be due to pulmonary edema ("cardiac
asthma"). Pulmonary embolus is an uncommon cause of wheezing.
ASTHMA
- Vital signs
- Breath sounds: clear, decreased, wheezing, or rhonchi
TREATMENT
- Use appropriate airway adjuncts as indicated.
- EMT-B: If the patient is wheezing and has a metered dose inhaler (MDI),
initiate MDI protocol. EMT-Bs must contact base.
- EMT-P: Monitor cardiac rhythm. Perform 12 lead EKG.
- Administer albuterol sulfate. EMT-B: Contact base prior to administration.
EMT-P: Consider adding Atrovent.
- EMT-P: Consider epinephrine, 0.3 mg IM (0.3 ml of 1:1,000 solution).
- EMT-P: Consider Solu-Medrol, 125 mg IV.
- EMT-P: Consider CPAP as needed per protocol.
- EMT-P: Contact base for magnesium sulfate, 2 g IV over 2 minutes
- Utilize pulse oximetry and capnography as indicated.

- Vital signs
- Breaths sounds: clear, decreased, rales, wheezing, or rhonchi
TREATMENT
- EMT-B: If the patient is wheezing and has a metered dose inhaler (MDI),
- EMT-P: Monitor cardiac rhythm. Perform 12 lead EKG.
- Administer albuterol sulfate. EMT-B: Contact base prior to administration.
EMT-P: Consider adding Atrovent.
- EMT-P: Consider epinephrine, 0.3 mg IM (0.3 ml of 1:1,000 solution).
- EMT-P: Consider Solu-Medrol, 125 mg IV.
- EMT-P: Contact base for magnesium sulfate, 2 g IV over 2 minutes
- Some COPD patients rely on a hypoxic drive for ventilatory support. Never
withhold oxygen for fear of decreasing this hypoxic drive.
HYPERVENTILATION
- History: anxiety provoking episode, acute change or injury
- Past history: panic attack, anxiety attack, chronic lung or heart problems or
known diagnosis, medications, home oxygen, past allergic reactions, recent
surgery, tobacco use
- Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia,
carpal pedal spasm, cerebrovascular constriction resulting in headache,
dizziness or euphoria
- Vital signs
- Neurologic signs: slurred speech, impaired consciousness, evidence of
drug/alcohol ingestion
- Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest
wall movements, inspiratory stridor
- Signs of congestive failure: neck vein distention in upright position, rales,
peripheral edema
- Breath sounds: clear, decreased, rales, wheezing, or rhonchi.
- Hives, upper airway edema
- Evidence of trauma: crepitation of neck or chest, bruising, steering wheel
damage, penetrating wounds
TREATMENT
- Identify and treat upper airway obstruction if present.
- Assess and consider treatment for the following problems:
- Coaching of breathing pattern and ventilations
- Calming of anxiety and stress inducing factors
- With suspicion that the symptoms are indicative of other illness, disorder
or overdose, patient should be transported.
- Dont over-diagnose psychogenic in the field. Your patient could have a
pulmonary embolus or other serious problem; give him/her the benefit of
the doubt. Treatment with oxygen will not harm the hyperventilator, and
it will keep you from underestimating the problem.
PNEUMONIA
- History: acute change or injury, slow deterioration, general malaise
- Past history: chronic lung or heart problems or known diagnosis,
medications, home oxygen, past allergic reactions, recent surgery, tobacco
use
- Associated symptoms: chest pain, productive cough, fever, sputum
production
TREATMENT
- Place patient in position of comfort, usually upright.
- Assist ventilation if necessary.
- Assess and consider treatment if respiratory distress is severe and patient
does not respond to proper positioning and administration of oxygen.
- EMT-P: Administer albuterol sulfate.
- Consider pulse oximetry and capnography.
- Pneumonia can be caused by bacterial, viral, or fungal infection; these
diseases may spread by droplets or contact with infected persons. Utilize
appropriate Body Substance Isolation (BSI) precautions.
- If diagnosis is unclear, place patient in position of comfort, administer O
2

and transport.
PNEUMOTHORAX
- History: acute change or injury, slow deterioration
- Past history: chronic lung or heart problems, medications, home oxygen,
past allergic reactions, recent surgery, tobacco use
- Associated symptoms: chest pain
- Vital signs
- Respiratory effort: accessory muscle use, shortness of breath, tachypnea,
decreased breath sounds on affected side
- Neurologic signs: impaired consciousness, evidence of drug/alcohol
ingestion
- Signs of upper airway obstruction: exaggerated chest wall movements
- Assess for evidence of trauma: crepitation of neck or chest, bruising,
steering wheel damage, penetrating wounds
- Other signs and symptoms: sudden onset of chest pain, diaphoresis, pallor,
subcutaneous emphysema.
TREATMENT
- Identify and treat upper airway obstruction if present
- Assess and consider treatment for severe cases: airway, ventilatory and
circulatory support. EMT-B: Consider ALS for advanced measures.
- EMT-P: If a tension pneumothorax develops, follow Tension Pneumothorax
protocol.
- May occur in apparently healthy persons; often men between 20 and 40
years of age, which are tall and thin.
- May occur in patients with COPD, patients with AIDS and pneumonia, history
of Marfans Syndrome, drug abusers.
PULMONARY EDEMA
- Vital signs
- Signs of congestive failure: Neck vein distention in the upright position,
rales, peripheral edema
TREATMENT
- Place patient in position of comfort, usually upright.
- Sit patient up with legs dependent if possible.
- Assist ventilations with BVM if necessary.
- Monitor cardiac rhythm. Perform 12-lead EKG.
- EMT-P: Consider:
- Nitroglycerin 0.4 mg SL
- Morphine sulfate, initial dose up to 4 mg, then 2 mg increments up to a
total dose of 10 mg.
- If diagnosis is unclear, place patient in position of comfort, administer O
2
,
and transport.
- Wheezing in older persons may be due to pulmonary edema (cardiac
asthma). Pulmonary embolus is an uncommon cause of wheezing.
PULMONARY EMBOLISM
- History: diabetes, chronic lung disease, congestive heart failure (CHF)
- Past history: sedentary life style, surgery or recent fractures, pregnancy,
oral contraceptives, atrial fibrillation
- Associated symptoms: anxiety, dyspnea, chest pain, tachycardia, JVD
- Vital signs
- Oxygenation: level of consciousness, anxiety
- Respiratory effort: dyspnea, tachypnea, shortness of breath
- Neurologic signs: impaired consciousness, syncope
- Objective findings: distended neck veins, chest splinting, hypotension,
tachycardia
TREATMENT
- Because pre-hospital care is primarily supportive and diagnosis difficult;
understanding the contributing factors is paramount.
- A pulmonary embolism should be considered with any person who has an
unexplained cardiorespiratory problem.

INDICATIONS
- For consideration in moderate to severe respiratory distress secondary to
asthma/reactive airway disease, COPD, CHF, or acute cardiogenic
pulmonary edema who present with any of the following:
- Pulse oximetry < 88% not improving with standard therapy.
- ETCO
2
> 50mmHg
- Accessory muscle use/retractions
- Respiratory rate > 25
- Wheezes, rales, rhonchi
- Signs of fatigue
CONTRAINDICATIONS
- Pneumothorax
- Respiratory arrest
- Agonal respirations
- Children less than 12 years of age
- Unconscious
- Penetrating chest trauma
- Persistent nausea/vomiting
- Facial abnormalities/trauma
- Stroke obtundation
- Has active upper GI bleeding or history of recent gastric surgery
PROCEDURE
- Treat the patients underlying condition according to appropriate protocol.
- Ensure full monitoring in place (EKG, SpO
2
, ETCO
2
)
- Assess breath sounds; ensure no signs or symptoms of pneumothorax.
- Confirm adequate BP (>90 mmHg).
- Have patient in upright position.
- Carefully explain procedure to patient.
- Gently hold the delivery device to the patients mouth and nose.
- Attach the straps loosely at first, gradually tightening as the patient
tolerates. Proceed with tightening the straps until air leaks are eliminated.
- Repeat and record vital signs every 5 minutes.

CONSIDERATIONS AND SPECIAL NOTES
- Success is highly dependent upon patient tolerance, and EMT-Ps ability to
coach. Instruct patient to breathe in through nose and exhale through
mouth as long as possible.
- Deterioration while on CPAP should lead to consideration of mechanical
ventilation/intubation:
- Deterioration of mental status
- Increase of ETCO
2

- Decline of SpO
2

- Progressive fatigue
- Monitor closely for development of pneumothorax and or hypotension.
- Patients should be closely monitored with SpO
2
, EKG, BP, ETCO
2
.
- Monitor patients closely for vomiting and or gastric distention.
- Inline nebulization may be utilized with CPAP in place.
- Chemical and physical restraints should never be used to facilitate this
procedure.

INDICATIONS
- The following signs are significant. Signs of pneumothorax as well as signs of
tension must be present before treatment is undertaken:
- Simple Pneumothorax:
- Respiratory distress mild to severe
- Chest pain
- Decreased or absent breath sounds on affected side to auscultation
of chest
- Subcutaneous crepitation
- Signs of tension:
- Progressive respiratory distress (severe)
- Tympanitic percussion note on affected side
- Hyperexpanded chest on affected side
- Tracheal shift away from affected side
- Distended neck veins
- Shock low BP
- If patient is intubated, increasing difficulty in bagging
PRECAUTIONS
- Treatment of tension pneumothorax is not difficult, although complications
of the procedure can be severe. Diagnosis is not always easy but must be
accurate. Note that simple pneumothorax has a characteristic set of signs
and tension pneumothorax has additional findings.
- Tension pneumothorax is a rare condition, and can occur both
spontaneously and with trauma. It may also occur as a complication of CPR.
When present, it may be the cause of, or rapidly lead to death and must be
treated promptly.
- Simple pneumothorax is relatively common, is not immediately life
threatening, and should not be treated in the field.
- While rare in all settings, a tension pneumothorax is more likely to be
encountered in victims of penetrating trauma.
TECHNIQUE
- Standing order: For peri-arrest or patients in arrest from penetrating
trauma.
- All other indications: contact base.
- Expose entire chest. Clean chest vigorously with alcohol, Betadine, or soap.
- Insert an angiocath (14 gauge or larger in adult; 18 gauge in children) with
syringe attached, in the 4th or 5th intercostal space, midaxillary line
(horizontal nipple line in children). Alternatively, the angiocath may be
inserted in the 2nd and 3rd intercostal space, midclavicular line.
- Insert the needle over the superior surface of the rib and then slide above
it.
- If air is under tension, barrel will pull easily and pop out the back.
Remove syringe, advance catheter and remove needle.
- Place the Asherman Chest Seal over the hub of the catheter to provide a
one-way flow of air from the thoracostomy.
COMPLICATIONS
- Complications include:
- Creation of pneumothorax if none existed previously
- Laceration of lung
- Laceration of blood vessels: this complication is reduced when the
needle is inserted directly above the rib (intercostal vessels run in grove
under each rib)
- Pain at the insertion site
- Infection
- Tension pneumothorax can be precipitated by occlusion of an open chest
wound with a dressing. If, after dressing an open chest wound, the patient
deteriorates, remove the dressing. The use of a one-way valve such as the
Asherman Chest Seal may prevent these complications.

MEDICAL EMERGENCIES
ABDOMINAL PAIN
SEIZURES
SHOCK
STROKE/CVA
SYNCOPE
VOMITING

PROCEDURES:
RESTRAINTS

ABDOMINAL PAIN
- Pain: nature (cramping or constant), duration, location, radiation to the
back, groin, chest or shoulder
- Associated symptoms: nausea, vomiting (bright red blood or coffee ground
emesis), diarrhea, constipation, black or tarry stools, urinary difficulties,
abnormal menstruation, fever
- Past history: previous trauma, abnormal ingestions, medications, known
diseases, chance of pregnancy, surgery
- Vital signs
- General appearance: restless, quiet, sweaty, pale
- Abdomen: tenderness, guarding, distention, rigidity, pulsatile mass
- Emesis, stool or urine: description of and amount
- Check for equality of pulses
TREATMENT
- Position of comfort
- NPO
- If BP < 90 mmHg systolic and signs of hypovolemic shock:
- Administer O
2
.
- Establish venous access with 2 large bore lines, NS fluid bolus
- EMT-B: Contact base and consider transport to a trauma center based
on destination protocol. EMT-P: No base contact is needed.
- Establish venous access even if vital signs are normal.
- EMT-P: Cardiac monitor and 12 lead EKG for upper abdominal pain
- Consider pain medication for hemodynamically stable patients with
transport times > 10 minutes.
- EMT-P: Fentanyl citrate per protocol
- EMT-P: For patients that have severe nausea or are vomiting, consider an
anti-emetic such as droperidol or Zofran.
- Monitor vitals during transport.
- The most important diagnoses to consider are those associated with
catastrophic internal bleeding: ruptured aneurysm, liver, spleen, ectopic
pregnancy, etc. Since the bleeding is not readily apparent you must think of
the volume depletion and monitor patient closely to recognize shock. If a
patient presents in shock, EMT-B: contact base and consider transport to a
trauma center where appropriate surgical consultation is readily available.
EMT-P: No base contact is needed.
- Elderly patients may have significant hypovolemic shock with systolic blood
pressures about 90 mmHg. With signs of hypovolemia, treat with fluids.
- Upper abdomen and lower chest pain may reflect thoracic pathology such as
myocardial infarction, etc. Massive fluid resuscitation may be
contraindicated.
- Level of consciousness
- Vital signs and complete history including patient medications. Understand
this may be difficult to ascertain in some situations.
- Perform a complete patient exam, including signs of traumatic injury. Other
findings to look specifically for include, but are not limited to: ataxia,
slurred speech, slow motor responses. (Note: Some or all of these signs may
or may not be present, and their absence does not preclude significant
intoxication.)
- General appearance: color, apprehension, sweating
CRITERIA MANDATING ED TRANSPORT INSTEAD OF DENVER CARES
- Patients with any of the following should be considered for transport to an
emergency department for evaluation
- Incapacitating intoxication:
- Inability to maintain airway.
- Inability to stand from a seated position, and walk independently.
- Intoxication with associated illness or injury: If the patient exhibits
evidence of intoxication in conjunction with any of the signs and symptoms
stated below, he or she must be transported to an emergency department
for evaluation:
- Abnormal vital signs
- Physical complaints including, but not limited to: headache, vomiting,
chest pain or shortness of breath that might indicate an acute illness or
injury
- Seizure or hypoglycemia associated with the intoxicated episode
- A history of associated acute trauma, including falls from standing,
assault, or other significant mechanisms of injury
- Physical exam findings consistent with recent head injury, including, but
not limited to: facial bruising, abrasion, tenderness or deformity
- A thorough patient assessment is essential in every case as many medical
and psychiatric conditions can mimic intoxication.
- If objective findings indicate a potential for hypoglycemia, determine blood
glucose level.
- In general, if a patient lacks decision-making capacity for reasons of
intoxication with alcohol or other substances, and there is reasonable
concern about the possibility of an acute illness or injury, then the patient
should be transported to an emergency department for evaluation,
including against the patients will if necessary.
- Clinical judgment about who does or does not have decision-making
capacity may be difficult and consultation with the base physician is
prudent if there is any question.
- Treat medical and traumatic emergencies such as hypoglycemia, seizures or
combativeness according to protocol.
- Not every intoxicated patient requires transport to an emergency
department. Every effort should be made to determine the capacity of a
patient to care for his or herself if transport is not immediately indicated.
- Minors that are intoxicated should be transported for evaluation.
- Parents may wish to take their children home to sleep it off. The
intoxicated minor is at risk for adverse outcome and often benefits from
evaluation of both medical and psychosocial concerns.
- The parent or guardian must speak with the base physician if he or she is
refusing transport of the minor.
- Document thoroughly all patient contacts, including objective signs of
intoxication, presence or absence of signs of acute illness or injury, base
station contact, offers made to transport, and precautions given. If
possible, attempt to document the following:
- What, when and how much was ingested, over what time span
- Was a combination of alcohol and drugs ingested?
- History: medications, allergies, medical conditions/illnesses
- History of abuse chronic ingestion or if an acute episode, why?
- Associated trauma
- Patient belongings that can complete clinical picture
- History: current sequence of events, exposure to allergens (bee stings,
drugs, nuts, and seafood are most common), prior allergic reactions
- Current symptoms: itching, wheezing, respiratory distress, nausea, rash,
anxiety, swelling
- Medications, past medical history
- Vital signs, level of consciousness
- Respirations: wheezing, upper airway noise, effort
- Mouth: tongue and airway swelling
- Skin: hives, swelling, flushing
TREATMENT
- Ensure a patent airway. EMT-B: Consider ALS as early orotracheal intubation
may be advisable before swelling becomes severe. Suction as needed.
Prepare to assist ventilations.
- Position of comfort: upright if respiratory stress predominates, supine if
shock is prominent
- Administer O
2
as indicated.
- Remove injection mechanism if still present (stinger, needle, etc.). Do not
squeeze the venom sac; scrape with a straight edge.
- If signs of severe generalized reaction are present, establish venous access.
- EMT-P: Administer Benadryl 50 mg IV or IM as indicated.
- EMT-P: For objective findings of respiratory distress such as stridor,
wheezing, hypoxia, tachypnea or angioedema, epinephrine 0.3-0.5 mg of
1:1,000 IM is indicated.
- EMT-P: Contact base for additional epinephrine orders.
- EMT-P: Consider Solu-Medrol 125 mg IV.
- For signs of shock (BP < 90 mmHg systolic) or altered mental status:
- NS fluid bolus 20 ml/kg
- EMT-P: Administer epinephrine 0.3-0.5 mg 1:1,000 IM followed by IV
infusion of 1 mg (1:1,000) in 250 ml NS. Run at 2-4 ml/min.
- Transport rapidly if patient is unstable, EMT-B: contact base prior to
transport.
- Allergic reactions can take multiple forms. Early consult with the base
physician is encouraged.
- Anxiety, tremor, palpitations, tachycardia, and headache are not
uncommon with the administration of epinephrine. These may be
particularly severe with IV administration. In children, epinephrine may
induce vomiting.
- Angina, MI or arrhythmias may be precipitated.
- Use caution in the administration of epinephrine in cardiac patients or the
elderly.
- Two forms of epinephrine are carried as part of paramedic equipment. The
standard ampules of aqueous epinephrine contain a 1:1,000 dilution
appropriate for IM injection. IV epinephrine should be given in a 1:10,000
dilution and is only for cardiac arrest. Be sure you are giving the proper
dilution to your patient.
- Before treating anaphylaxis, be sure your patient has objective signs as well
as subjective symptoms and history. Hyperventilators will occasionally think
they are having an allergic reaction. Epinephrine will just aggravate their
anxiety.
- Lethal edema may be localized to the tongue, uvula, or other parts of the
upper airway. Examine closely and be prepared for early intubation before
swelling precludes this intervention.
- Present history: duration of illness, onset and progression of present state
illness, preceding symptoms such as headaches, seizures, confusion,
trauma, etc.
- Past history: previous medical or psychiatric problems
- Medications: use, misuse or abuse
- Surroundings: check for pill bottles, syringes, etc. and bring to the hospital
with the patient. Note odor in the house.
- Safety to rescuer: check for gases or other toxins
- Vital signs
- Level of consciousness and neurological status
- Signs of trauma
- Breath odor
- Needle tracks
- Medical alert tag
TREATMENT
- Administer O
2
.
- Establish venous access and NS fluid bolus as indicated.
- Draw appropriate blood tubes and test for blood glucose level.
- Administer dextrose 50% 25 g IV push if blood glucose reading < 60 and if
clinically indicated.
- EMT-P: If venous access is unsuccessful and unable to administer
dextrose, administer Glucagon 1 mg IM.
- Administer Narcan if clinically indicated.
- Transport in lateral recumbent position. If trauma is suspected, transport
supine with cervical collar and backboard, logroll as necessary.
- Monitor vitals during transport.
- Be particularly attentive to airway. Difficulty with secretions, vomiting and
inadequate tidal volume is common.
- Hypoglycemia may present as focal neurologic deficit or coma (stroke-like
picture).
- Coma in the diabetic may be due to hypoglycemia or hyperglycemia
(diabetic ketoacidosis). Dextrose IV push should be given to all unconscious
diabetics as well as patients with coma of unknown origin unless a blood
glucose reading in the high range is obtained. The treatment may be life-
saving in the hypoglycemic patient and will do no harm in the normal or
hyperglycemic patient. Do not give oral sugar to an unconscious patient.
- Stroke patients may be alert but unable to respond (aphasic). Communicate
with the patient and explain what you are doing. Avoid inappropriate
comments.
- Narcan is useful in any potential narcotic overdose, but be certain the
airway and the patient are controlled before giving Narcan to a known drug
addict. The acute withdrawal precipitated in an addict may result in violent
combativeness.
- Symptoms: pain, cramping, passage of clots or tissue, dizziness, weakness.
If pregnant, inquire about swelling of the face and extremities, urge to
push, contractions (regularity and timing), ruptured membranes, fever.
- Obtain menstrual history: last normal menstrual period, duration of period,
amount of flow, birth control method
- If pregnant, inquire about due date, prior problems with pregnancy,
gravida/para
- Past and present history of hypertension (preeclampsia/eclampsia)
- Past history: bleeding problems, pregnancies, medications, allergies
- Vital signs and orthostatic changes
- Evidence of blood loss, clots or tissue fragments
- Signs of hypovolemic shock, altered mental status, hypotension,
tachycardia, diaphoresis, pallor, fever
- If pregnant, observe for contractions and relaxation of uterus. Where
privacy is possible, examine perineum by observation only for:
- Vaginal bleeding or fluid (note color)
- Crowning (check during a contraction)
- Abnormal presentation (i.e., foot, arm, face, or cord)
TREATMENT
- If patient has moderate to heavy vaginal bleeding:
- Administer O
2
.
- If hypotensive, give NS fluid bolus and consider a second line.
- If hypotensive and pregnant, position onto the left side.
- If the patient is delivering:
- Use a clean or sterile technique.
- Administer O
2
.
- Guide and control but do not retard or hurry the delivery.
- Suction the mouth (not throat), then nose with a bulb syringe.
- Protect the infant from a fall or temperature loss. Wipe off amniotic
fluid and wrap in a clean or sterile blanket, check vital signs and provide
CPR as indicated.
- Clamp the umbilical cord in two places approximately 8-10 from the
infant.
- Cut the cord between the clamps.
- Record an APGAR score with vital signs at one and five minutes.
- Establish venous access in the mother and monitor vital signs.
- Transport. Do not wait for or attempt delivery of the placenta. If the
placenta delivers spontaneously, bring to the hospital.
- If the patient is bleeding in the postpartum period (within 24 hours of
delivery):
- Massage uterus and have mother nurse infant to aid in uterine
contractions.
- Administer O
2
.
- If the patient is in the final weeks of pregnancy and there is crowning or
other indication of imminent delivery, deliver or transport. Be prepared to
stop the ambulance if delivery occurs en route.
- Transport immediately any pregnant patient with an abnormal presenting
part or vaginal bleeding.
- Amount of vaginal bleeding is difficult to estimate. Try to get an estimate
of saturated pads in a 6 hour time frame.
- A patient in shock from vaginal bleeding should be treated like any other
patient with hypovolemic shock.
- Always consider pregnancy as a cause of vaginal bleeding. The history may
contain inaccuracies, denial, or wishful thinking.
- If the patient is pregnant ask if she feels as though she is delivering. Most
mothers who have delivered before will know.
- The primary enemy of newborns is hypothermia, which can occur within
minutes due to increased evaporative heat loss resulting from the infants
large body surface area and the presence of amniotic fluid.
- EMT-P: Consider early tracheal suctioning after delivery of the infant with
evidence of meconium.
APGAR SCORE:
Sign 0 1 2
Muscle tone
(Activity)
Limp Some flexion Active, good flexion
Pulse Absent <100/min =100/min
Reflex irritability*
(Grimace)
No response Some grimace or
avoidance
Cough, cry or sneeze
Color
(Appearance)
Blue, pale Pink body, blue
hands/feet
Pink
Respirations Absent Slow, irregular,
ineffective
Crying, rhythmic,
effective
*Nasal or oral suction catheter stimulus
- What, when, and how much was ingested? Bring the poison, the container,
description of emesis, all medications and everything questionable in the
area with the patient to the ED.
- Reason for exposure: think of child neglect, depression, etc.
- Symptoms: respiratory distress, sleepiness, nausea, agitation, or decreased
level of consciousness
- Past history: medications, diseases, psychiatric
- Action taken by bystanders: induced emesis? Antidote given?
- Vital signs
- Airway: patency and adequacy of ventilation
- Level of consciousness and neurologic status: check frequently.
- Breath odor, increased salivation, oral burns
- Skin: diaphoresis, cyanosis
- Systemic signs: vomitus, arrhythmias, lung sounds
TREATMENT
- Assess and support ABCs
- Administer O
2
.
- Support patient on side and protect airway.
- Test for blood glucose. Administer dextrose 50% 25 g IV push if blood
glucose reading < 60 and if clinically indicated.
- Administer Narcan in patients with significantly decreased respiratory effort
and observe patient for improved ventilations.
- EMT-P: Monitor cardiac rhythm
- EMT-P: May need to administer sodium bicarbonate per protocol if widened
QRS or ventricular arrhythmias are on monitor after excessive tricyclic
antidepressant(s) are ingested.
- EMT-P: May need to administer Valium per protocol in suspected stimulant
use/abuse (cocaine, methamphetamine, Ecstasy, etc.).
- EMT-P: May need to administer calcium gluconate per protocol for calcium
channel blocker overdose.
- Monitor vital signs frequently during transport.
- There are few specific antidotes. Product labels and home kits can be
misleading and dangerous.
- Do not neutralize acids with alkalis. Do not neutralize alkalis with acids.
These treatments cause heat-releasing chemical reactions that can
further injure tissue.
- Inhalation poisoning is particularly dangerous to rescuers. Recognize an
environment with ongoing contamination and extricate rapidly.
- EMT-P: Organophosphate pesticide exposure may require massive doses of
atropine. Contact base for direction.
- For personal exposure to nerve agents refer to the DuoDote protocol.

Rocky Mountain Poison and Drug Center/Nationwide Poison Control Access:
1-800-222-1222
Hazardous materials exposure - CHEMTREC: 1-800-424-9300
- Obtain history of current event, inquire about recent crisis, toxic exposure,
drugs, alcohol, emotional trauma, suicidal or homicidal ideation
- Obtain past history; inquire about previous psychiatric and medical
problems, medications.
- Evaluate vital signs.
- Note medic alert tags, odor to breath.
- Determine ability to relate to reality.
- Note hallucinations and behavior.
TREATMENT
- Attempt to establish rapport.
- Assure patent airway.
- Restrain if necessary per the Restraints protocol.
- Monitor vital signs.
- If altered mental status or unstable vital signs:
- Administer O
2
.
- Test for blood glucose. Administer dextrose 50% 25 g IV push if blood
glucose reading < 60 and if clinically indicated.
- Administer Narcan in patients with significantly decreased respiratory
effort and observe patient for improved ventilations.
- EMT-P: Consider Versed for agitation or stimulant use/abuse per
protocol.
- Psychiatric patients often have an organic basis for mental disturbances.
Beware of hypoglycemia, hypoxia, head injury, intoxication, or toxic
ingestion.
- If emergency treatment is unnecessary, do as little as possible except to
reassure while transporting. Try not to violate the patient's personal space.
- If the situation appears threatening, consider a show of force involving
police before attempting to restrain.
- Beware of weapons. These patients can become very violent.
- EMT-Bs and EMT-Ps may initiate a Mental Health Hold only with base
contact.

SEIZURES
- Seizure history: onset, time interval, previous seizures, type of seizure
- Medical history: head trauma, diabetes, headaches, drug/alcohol use,
medications, compliance with anticonvulsants, pregnancy
- Vital signs
- Description of seizure activity
- Level of consciousness
- Head and mouth trauma
- Incontinence
- Air temperature, patient temperature
- Skin color and moisture
TREATMENT
- Airway: ensure patency nasopharyngeal airways are useful. Dont force
anything between the teeth.
- Administer O
2
.
- Suction as needed.
- Protect patient from injury.
- Check pulse immediately after seizure stops.
- Keep patient in lateral recumbent position.
- Test for blood glucose. Administer dextrose 50% if blood glucose reading <
60 and if clinically indicated.
- Administer Narcan in patients with significantly decreased respiratory effort
and observe patient for improved ventilations.
- EMT-P: Administer Valium 1-10 mg slow IV push per for status seizures.
- EMT-P: If venous access is unsuccessful after two attempts, administer
Versed 2-5 mg IM or IN per protocol.
- Keep in lateral recumbent position for transport.
- Monitor vital signs.
- Move hazardous materials away from the patient. Restrain the patient only
if needed to prevent injury. Protect the patients head.
- Trauma to the tongue is unlikely to cause serious problems, however trauma
to the teeth may. Attempts to force an airway into the patients mouth can
completely obstruct the airway.
- Seizures can be due to a lack of glucose or oxygen to the brain as well as to
the irritable focus we associate with epilepsy. Hypoxia from transient
arrhythmias or cardiac arrest (particularly in younger patients) may cause
seizures and should be treated promptly. Dont forget to always check for a
pulse once a seizure terminates.
- Hypoxic seizures can also result when the tongue obstructs the airway in the
supine position or when overly helpful bystanders prop the patient up or
improperly elevate the head.
- Alcohol-related seizures are common but cannot be differentiated from
other types of seizures in the field. Assessment in the intoxicated patient
should still include consideration of hypoglycemia and all other potential
causes. Field management is the same as other seizures.
- Seizures may be due to arrhythmias or stroke. It is important to look for and
recognize arrhythmias in the field since they may be the cause of the
seizure.
- Medical personnel are often called to assist epileptics who seize in public. If
the patient clears completely, is taking his/her medications, has his/her
own physician and is experiencing his/her usual frequency of seizures,
transport may be unnecessary. Consult your base physician.
- Valium has a tendency to decrease respiratory effort; therefore be prepared
to assist ventilations.
- Seizures in pregnant patients (or even those who are postpartum) may be
the presenting sign of eclampsia or toxemia of pregnancy. EMT-P: Seizures
in those patients will respond better to magnesium sulfate.
SHOCK
- Onset: gradual or sudden; precipitating cause or event
- Associated symptoms: itching, peripheral or facial edema, thirst, weakness,
respiratory distress, abdominal or chest pain, dizziness on standing
- History: allergies, medications, blood in vomitus or stools, significant
medical diseases, history of recent trauma, last menstrual period, vaginal
bleeding, fever
- Vital signs: pulse > 120 (occasionally < 50); BP < 90 mmHg systolic
- Mental status: apathy, confusion, restlessness, combativeness
- Skin: flushed, pale, sweaty, cool or warm, hives, or other rash
- Signs of trauma
- Signs of cardiogenic shock: jugular venous distention in upright position,
rales, peripheral edema
- In children under 8 years old, 2 or more of the following signs: tachycardic
for age, diminished capillary refill, thready pulses, cool extremities, poor
color, altered mental status, diminished respiratory effort
TREATMENT
- Administer O
2
.
- Cover patient to avoid excess heat loss. Do not over-bundle.
- Assess for cardiogenic cause:
- If pulse is > 150 treat tachyarrhythmia according to protocol.
- If pulse is < 60 treat bradyarrhythmia according to protocol.
- If distended neck veins, chest pain, or other evidence of cardiac cause:
- Position of comfort
- Be prepared to assist ventilations or initiate CPR.
- Evaluate for possible tension pneumothorax
- EMT-P: Consider dopamine.
- Transport rapidly for definitive diagnosis and treatment.
- If no evidence of cardiogenic cause, institute general treatment measures:
- Place patient supine, elevate legs 10-12 inches. If respiratory distress
results, leave patient in position of comfort.
- Administer IV fluid bolus of normal saline.
- Assess and treat for specific cause, such as anaphylaxis, if this can be
determined.
- Monitor vital signs, cardiac rhythm, and level of consciousness during
transport.
- Shock in a cardiac patient may be caused by hypovolemia; however, contact
should be made with base prior to administering fluid boluses.
- Mixed forms of shock are treated as hypovolemia, but the other factors
contributing to the low perfusion should be considered. Neurogenic shock is
caused by relative hypovolemia as blood vessels lose tone, either from
spinal cord trauma, drug overdose, or sepsis. Cardiac depressant factors can
also be involved. Anaphylaxis is a mixed form of shock with hypovolemic,
neurogenic, and cardiac depressant components. Epinephrine is used in
addition to fluid load.
- Cardiogenic shock from various causes is difficult to treat even in a hospital
setting. Rapid transport is recommended.

STROKE/CVA
- Altered level of consciousness
- Impaired speech
- Unilateral weakness/hemiparesis
- Facial asymmetry/facial droop
- Headache
- Poor coordination or balance
- Vision changes
- Seizure activity
- Previous CVA/TIA
- Chest pain
- Last time without symptoms
- Vital signs and complete history including patient medications
- General appearance: color, apprehension, sweating
- Cincinnati Pre-hospital Stroke Scale (CPSS)
- Face facial droop present
- Arm upper extremity arm drift present (arms extended, palms up)
- Speech inability to speak a simple sentence
- Time time of onset of symptoms / last time without symptoms
- Complete neurologic exam
- Determine blood glucose level
- EMT-P: Monitor cardiac rhythm. Perform 12-lead EKG.
TREATMENT
- Reassure and place patient with head slightly elevated (< 30)
- Administer O
2
.
- NPO
- Transport to appropriate facility
- Contact receiving facility early with symptoms and objective findings
- Establish venous access (proximal 18 gauge or larger is preferred)
- Administer dextrose 50% 25 g IV push if blood glucose reading < 60 and if
clinically indicated.
- Treatment of hypertension in the setting of CVA/TIA is not indicated in the
pre-hospital setting.
SYNCOPE
- History of the event: onset, duration, seizure activity, precipitating factors.
Was the patient sitting, standing, or supine? Pregnant?
- Past history: medications, diseases, prior syncope
- Associated symptoms: dizziness, SOB, nausea, chest or abdominal/back
pain, headache, palpitations
- Vital signs
- Neurological status: level of consciousness, residual neurological deficit
- Signs of trauma to the head or mouth or incontinence
- Neck stiffness
TREATMENT
- Place patient in position of comfort. Do not sit patient up prematurely;
supine or lateral positioning if not completely alert.
- Administer O
2
.
- Monitor vital signs and level of consciousness closely for changes or
recurrence.
- Establish venous access and administer NS if indicated.
- Consider hypoglycemia. If signs of hypoglycemia are present (clinical
indications and blood glucose < 60):
- Administer dextrose 50% 25 g IV push.
- If vital signs unstable or age > 40 years:
- Administer O
2
.
- Keep patient supine, elevate legs 10-12 inches.
- EMT-P: Monitor cardiac rhythm. Consider 12-lead EKG.
- Syncope is by definition a transient state of unconsciousness from which the
patient has recovered. If the patient is still unconscious, treat as coma. If
the patient is confused, treat according to the Coma/Altered Mental
Status/Neurologic Deficit protocol.
- Most syncope is vasovagal, with dizziness progressing to syncope over
several minutes. Recumbent position should be sufficient to restore vital
signs and level of consciousness to normal.
- Syncope that occurs without warning or while in a recumbent position is
potentially serious and often caused by an arrhythmia.
- Patients with syncope, even though apparently normal, should be
transported. In middle-aged or elderly patients, syncope can be due to a
number of potentially serious problems. The most important of these to
monitor and recognize are arrhythmias, occult GI bleeding, seizure, or
ruptured abdominal aortic aneurysm.
- Any elderly patient with syncope and back pain should be considered to
have a ruptured abdominal aortic aneurysm until proven otherwise.
- In children 1-4 years of age breath-holding spells associated with
heightened emotional states can cause syncopal-like events. Children may
be pallid or cyanotic and seizures can occur. No specific treatment is
indicated for these events. Consult base for questions.

VOMITING
- Frequency, duration of vomiting
- Color of vomitus: presence of blood or bile
- Associated symptoms: abdominal pain, weakness, confusion
- Medication ingestion
- Past medical history: diabetes, cardiac disease, abdominal problems,
alcoholism
- Abdomen: tenderness, guarding, rigidity, distention
- Signs of dehydration: poor skin turgor, dry mucous membranes, confusion
TREATMENT
- Position patient: left lateral recumbent if vomiting; otherwise, supine.
- Administer O
2
.
- NPO
- If BP < 90 mmHg systolic and signs of hypovolemic shock or for signs of poor
perfusion in pediatric patients:
- Elevate legs 10-12 inches.
- Administer NS bolus of 20 ml/kg.
- EMT-P: For patients who are nauseated or vomiting consider Zofran or
droperidol administration.
- Vomiting may be a symptom of a more serious problem. The most serious
causes are GI bleed or other intra-abdominal catastrophe. A rare cardiac
patient may also present with vomiting as the predominant symptom.
- Consider drug overdose; a patient who does not call the ambulance for
medication ingestion may call later when GI symptoms become severe.
- The vast majority of persons with vomiting have become sick over days, not
minutes. Treat appropriately.
- Dehydration may be particularly severe in children with simple vomiting. IVs
may be very difficult to start, particularly with infants.

RESTRAINTS
INDICATIONS
- Use of physical restraint on patients is permissible if the patient poses a
danger to himself or to others. Only reasonable force is allowable, i.e., the
minimum amount of force necessary to control the patient and prevent
harm to the patient or others. Try alternative methods first (e.g., verbal
de-escalation should be used first if the situation allows). EMT-P: Consider
chemical sedation in patients that require transport and are behaving in a
manner that poses a threat to their own wellbeing or others.
- Restraints are to be applied to patients who meet the following criteria:
- A patient who is significantly impaired (e.g., intoxication, medical
illness, injury, psychiatric condition, etc.) and lacks decision-making
capacity regarding their own care.
- A patient who exhibits violent, combative or uncooperative behavior
which does not respond to verbal de-escalation.
- A patient who is suicidal and considered to be a risk for behavior
dangerous to themselves or the health care providers.
- A patient who is on a mental health hold or a police hold.
PRECAUTIONS
- Restraints shall be used only when necessary to prevent a patient from
seriously injuring themselves or others (including the ambulance crew), and
only if safe transportation and treatment of the patient cannot be done
without restraints. They may not be used as punishment, or for the
convenience of the crew.
- Any attempt to restrain a patient involves risk to the patient and the pre-
hospital provider. Efforts to restrain a patient should only be done with
adequate assistance present.
- Be sure to evaluate the patient adequately to determine the medical
condition, mental status and decisional capacity of the patient. The hostile,
angry, unwilling patient with decision-making capacity may refuse
treatment.
- Be sure that restraints are in good condition (will not break and will not
injure the patient).
- Do not use hobble restraints and do not restrain patient in the prone
position.
- Ensure that patient has been searched for weapons.
TECHNIQUE
- Determine that the patient's medical or mental condition warrants
ambulance transport to the hospital and that the patient lacks decision-
making capacity, or there is basis for police custody or a mental health hold
to be instituted.
- Treat the patient with respect. Attempts to verbally calm the patient
should be done prior to the use of restraints. To the extent possible, explain
what is being done and why.
- Have all equipment and personnel ready (restraints, suction, a means to
promptly remove restraints, and adequate number of personnel).
- Use assistance such that, if possible, one rescuer handles each limb and one
manages the head or supervises the application of restraints.
- Consider the patient's strength and range of motion in the need for and
method of applying restraints.
- Apply restraints to the extent necessary to allow treatment of, and prevent
injury to, the patient. Do not use restraints to punish the patient.
- After application of restraints, check all limbs for circulation. During the
time that a patient is in restraints, an assessment of the patient's condition
including assessment of the patients airway, circulation and vital signs shall
be made at least every fifteen minutes, but more frequently if conditions
warrant.
- During transport and pending the arrival at the hospital, the patient shall be
kept under constant supervision, observing for any significant change in the
patients condition.
- The run report shall include:
- Description of the facts justifying use of restraints
- Efforts to de-escalate prior to the use of restraints
- The type of restraints
- A description of the steps taken to assure that the patient's needs,
comfort and safety were properly cared for
- The condition of the patient during restraint, including reevaluations
during transport
- The condition of the patient on arrival at the hospital.
- Removal of restraints should be done with sufficient manpower and caution
for protection of the patient and healthcare providers.
- Utilize police assistance if necessary and if possible.
- Handcuffs or other hard restraints are not to be applied by pre-hospital
providers. If police apply handcuffs, the officer should be requested to stay
with the patient and ride in the ambulance during transport.
- EMT-P: The use of chemical restraints is limited to the use of droperidol for
agitation felt to be related to alcohol intoxication or psychiatric
disturbances. For agitation felt to be related to cocaine, PCP or
methamphetamine use, Versed is indicated.
COMPLICATIONS
- Aspiration can occur, particularly if the patient is supine. It is the
responsibility of the attendant to continually monitor the patient's airway.
- Nerve injury can result from hard restraints, be aware of restraints that are
too tight especially at the wrist.
- Do not overlook the medical causes for combativeness, such as hypoxia,
hypoglycemia, stroke, hyperthermia, hypothermia, or drug ingestion.
- Contraindications, precautions, and special considerations regarding the use
of chemical restraints are found in the droperidol protocol.
ENVIRONMENTAL EMERGENCIES
BITES & STINGS
COLD EMERGENCIES
HEAT EMERGENCIES
SNAKE BITES
BITES & STINGS
- Type of animal or insect
- Time of exposure
- Symptoms:
- Local: pain, stinging
- Generalized: dizziness, weakness, itching, trouble breathing, muscle
cramps
- History of previous exposures, allergic reactions
- Identification of spider, bee, marine animal if possible
- Local signs: erythema, swelling, heat in area of bite
- Systemic signs: hives, wheezing, respiratory distress, abnormal vital signs
TREATMENT
- SNAKES: See Snake Bites.
- SPIDERS:
- Ice for comfort
- Bring in spider, if captured and contained or if dead, for accurate
identification, if possible.
- Transport for observation if systemic signs and symptoms present.
- BEES AND WASPS:
- Remove sting mechanism. Do not squeeze venom sac if this remains on
stinger, rather, scrape with straight edge.
- Observe patient for signs of systemic allergic reaction. Treat per the
Allergies/Anaphylaxis protocol and transport rapidly if needed
- Transport all patients with systemic symptoms or history of systemic
symptoms from prior bites.
- For all types of bites and stings, the goal of pre-hospital care is to prevent
further inoculation and to treat allergic reactions.
- Allergy kits consist of injectable epinephrine and oral antihistamine, and
are prescribed for persons with known systemic allergic reactions. EMT-B:
Contact base before assisting the patient with their own medication.
- About 60% of patients who have experienced a generalized reaction to a
bite or sting in the past will have a similar or more severe reaction upon re-
inoculation. Thus, although it is not inevitable, this group of patients must
be considered at high risk for anaphylaxis. In addition, a small group of
patients will have anaphylaxis as a "first" reaction.
- Time since envenomation is important. Anaphylaxis rarely develops more
than 60 minutes after inoculation.

COLD EMERGENCIES
- Length of exposure
- Air temperature, water temperature, winds, is patient wet?
- History and timing of changes in mental status
- Drugs: alcohol, tranquilizers, anticonvulsants, others
- Medical problems: diabetes, epilepsy, alcoholism, etc.
- With local injury: history of thawing/refreezing?
- Vital signs, mental status, shivering. Prolonged observation for 1-2 min. may
be necessary to detect pulse, respirations.
- Skin temperature (estimated); also note current temperature of
environment
- Evidence of local injury: blanching, blistering, erythema of extremities,
ears, nose
- Cardiac rhythm
TREATMENT
- Generalized:
- CPR, if no pulse
- Administer O
2
. Assist with bag-valve-mask as needed.
- Use appropriate airway adjunct only to protect airway or in absence of
organized cardiac electrical activity.
- Avoid unnecessary suctioning or airway manipulation.
- Remove wet or constrictive clothes from patient. Wrap in blankets and
protect from wind exposure. Increase ambient temperature in
ambulance.
- Attempt defibrillation, if appropriate, up to 3 shocks.
- Establish venous access. Solution should be warmed if possible. Do not
start IV until patient is moved to transport vehicle.
- EMT-P: No more than one round of ACLS drugs should be administered to
a hypothermic patient in the pre-hospital setting.
- Local (frostbite):
- Remove wet or constricting clothing. Keep skin dry and protected from
wind.
- Do not allow the limb to thaw if there is a chance that limb may
refreeze before evacuation is complete, or if patient must walk to
transportation.
- Re-warm minor "frostnip" areas by placing in axilla or against trunk under
clothing.
- Dress injured areas lightly in clean cloth to protect from pressure,
trauma or friction. Do not rub. Do not break blisters.
- Maintain core temperature by keeping patient warm with blankets,
warm fluids, etc.
- Transport with frostbitten areas supported and elevated if feasible.
- Hypothermia:
- Shivering does not occur below 90F. Below this the patient may not
even feel cold, and occasionally will even undress and appear
vasodilated.
- The heart is most likely to fibrillate below 85-88F. Defibrillation should
be attempted with no more than 3 shocks. Prolonged CPR may be
necessary until the temperature is above this level.
- ALS drugs should be used sparingly, since peripheral vasoconstriction
may prevent entry into central circulation until temperature is restored.
At that time, a large bolus of unwanted drugs may be infused into the
heart.
- Bradycardias are normal and should not be treated.
- If patient has organized monitor rhythm, CPR is currently felt to be
unnecessary. In general, even very slow rates are probably sufficient for
metabolic demands. CPR is indicated for asystole and ventricular
fibrillation.
- Patients who appear dead after prolonged exposure to cold air or water
should not be pronounced "dead" until they have been re-warmed. Full
recovery from hypothermia with undetectable vital signs, severe
bradycardia, and even periods of cardiac arrest has been reported.
- Re-warming should be accomplished with careful monitoring in a hospital
setting, whenever possible.
- Consider other reasons for altered mental status.
- Frostbite:
- Thawing is extremely painful and should be done under controlled
conditions, preferably in the hospital. Careful monitoring, pain
medication, prolonged re-warming, and sterile handling are required.
- It is clear that re-warming followed by refreezing is far more injurious to
tissues than delay in re-warming or walking on a frozen extremity to
reach help. Do not re-warm prematurely. Indications for field re-
warming are almost nonexistent.
- Warming with heaters or stoves, rubbing with snow, drinking alcohol and
other methods of stimulating the circulation are dangerous and should
not be used.

- How long patient was submerged?
- Degree of contamination, water temperature
- Diving accident? Water depth?
- Vital signs
- Neurologic status: monitor on a continuing basis.
- Lung exam: rales or signs of pulmonary edema, respiratory distress
TREATMENT
- Clear upper airway of vomitus or large debris.
- Start CPR if needed.
- Stabilize neck prior to removing patient from water if any suggestion of
neck injury.
- Suction as needed.
- Administer O
2
.
- If patient not awake and alert:
- Establish venous access
- EMT-P: Intubate when indicated and apply positive pressure ventilation.
- EMT-P: Monitor cardiac rhythm during transport; treat arrhythmias per
protocol.
- Transport patient, even if normal by initial assessment.
- Be prepared for vomiting. Patients should be secured on a backboard when
indicated for log-rolling to protect the neck and manage the airway.
- All near-drownings should be transported. Even if patients initially appear
fine, they can deteriorate. Monitor closely. Pulmonary edema often occurs
due to aspiration, hypoxia, and other factors. It may not be evident for
several hours after near-drowning.
- Beware of neck injuries - they often go unrecognized. Collar and backboard
straps can be applied in the water.
- If patient is hypothermic, defibrillation and pharmacologic therapy may be
unsuccessful until the patient is re-warmed. Prolonged CPR may be needed.
- Under current ACLS standards, Heimlich maneuver is not indicated.
HEAT EMERGENCIES
- Patient age, activity level
- Medications: depressants, tranquilizers, alcohol, etc.
- Associated symptoms: cramps, headache, orthostatic symptoms, nausea,
weakness
- Vital signs: temperature - usually 104F or greater (if thermometer
available)
- Mental status: confusion, coma, seizures, psychosis
- Skin flushed and warm to hot with or without sweating
- Air temperature and humidity, patient dress
TREATMENT
- Remove clothing.
- Administer O
2
.
- Cool with water-soaked sheets.
- Establish venous access:
- TKO if vital signs stable
- IV fluid bolus of 20 ml/kg if signs of hypovolemia.
- EMT-P: Treat seizures with Valium 1-10 mg slow IV push.
- EMT-P: If unable to obtain venous access after two attempts administer
Versed 2-5 mg IM.
- Heat stroke is a medical emergency. It is distinguished by altered level of
consciousness. Sweating may still be present, especially in exercise-induced
heat stroke. The other persons at risk for heat stroke are the elderly and
persons on medications which impair the body's ability to regulate heat.
- Differentiate heat stroke from heat exhaustion (hypovolemia of more
gradual onset) and heat cramps (abdominal or leg cramps). Be aware that
heat exhaustion can progress to heat stroke.
- Do not let cooling in the field delay your transport. Cool patient as possible
while en route.
- Do not use ice water or cold water to cool patients as these may induce
vasoconstriction.
- Presenting symptoms generally fall into three categories:
- Acute mountain sickness (AMS) - headache, sleeplessness, anorexia,
nausea, fatigue.
- High-altitude pulmonary edema (HAPE) - breathlessness, cough,
headache, trouble breathing, confusion, fatigue, nausea
- High-altitude Cerebral Edema (HACE) ataxia, headache, confusion,
stroke like picture with focal deficits, seizure and coma
- Current and highest altitude, time at this altitude, duration of ascent
- Medical problems, medications, previous experience at altitude
- Vital signs
- Mental status: confusion, lack of coordination, coma
- Lungs: respiratory rate, distress, rales, sputum (bloody or frothy)
TREATMENT
- Put patient at rest in position of comfort.
- Administer O
2
.
- Suction as needed. Assist ventilations if patient has cyanosis, confusion, and
poor respiratory effort.
- Establish venous access if conditions permit.
- Recognition of the problem is the most critical part of treating high altitude
illness. While in the mountains, recognize symptoms which are out of
proportion to those being experienced by the rest of the party: fatigue, or
trouble breathing (particularly at rest).
- The mainstay of treatment is descent from altitude. Even a loss of 1,000 -
1,500 feet makes enough difference in the oxygen content of air that
symptoms may be relieved or stop progressing. Oxygen administration can
also relieve symptoms and may allow more time for orderly evacuation.
- In addition to the more common pulmonary edema, cerebral edema may
occur, with confusion and a stroke-like picture with focal deficits.
Treatment is the same.
- Acute mountain sickness, the mild form of illness during altitude
adaptation, consists of fatigue, headache, and poor sleeping, without
severe CNS or respiratory symptoms. Treatment is rest. This increases the
body's time to acclimatize.
- Commercial airlines pressurize cabins to a level equivalent to about 5,000 -
8,000 feet.
- Patients at risk for high altitude illness for whatever reason may be taking
Diamox (acetazolamide). Diamox may be useful in preventing some altitude
illness because of direct effects on acid-base balance. Diuretics are not
useful, however, in treating high altitude pulmonary edema, because the
cause is excess capillary leakage of fluid rather than increased venous
pressure.
SNAKE BITES
- Appearance of snake (e.g., rattle, color, banding)
- Time of bite
- Prior first-aid by patient or friends
- Symptoms: local pain and swelling, peculiar or metallic taste sensations.
Severe envenomations may result in hypotension, coma, and bleeding.
- Bite wound: location, configuration (e.g., 1, 2, or 3 fang marks, entire jaw
imprint)
- Snake identification: look for elliptical pupils, thermal pit and rattle
- Signs of envenomation: spreading numbness and tingling from the site, local
edema and pain, ecchymosis, bleeding, hypotension. Mark time and extent
of erythema and edema with pen.
TREATMENT
- Remove patient and rescuers from area of snake to avoid further injury.
- Remove rings or other bands which may become tight with local swelling.
- Immobilize bitten part at heart level.
- Minimize venom absorption by keeping bite area still and patient quiet.
- Transport promptly for definitive observation and treatment.
- Do not use ice or refrigerants.
- For all suspected envenomations establish venous access and administer O
2
.
- Monitor vital signs, swelling, and EMT-P: cardiac rhythm.
- The prairie rattlesnake is native to the Denver metro region. If the snake is
dead, bring it in for examination. Do not jeopardize fellow rescuers by
attempting to "round it up." Be careful: a dead snake may still reflexively
bite and envenomate. Do not pick up with hands, even if dead. Use a shovel
or stick.
- At least 25% of poisonous snake strikes do not result in envenomation.
Conversely, the initial appearance of the bite may not reflect the severity
of envenomation.
- Fang marks are characteristic of pit viper bites, such as from the
rattlesnake, water moccasin, or copperhead, which are native to North
America. Jaw prints (without fangs) are more characteristic of non-
venomous species.
- Ice can cause serious tissue damage. Never use!
- Exotic poisonous snakes, such as those found in zoos, have different signs
and symptoms than those of pit vipers.
TRAUMATIC EMERGENCIES
ABDOMINAL TRAUMA
AMPUTATIONS
BURNS
CHEST INJURY
EXTREMITY INJURIES
FACE & NECK TRAUMA
HEAD TRAUMA
SPINAL TRAUMA
TRAUMA ARREST

PROCEDURES:
BANDAGING
SPLINTING: AXIAL
TOURNIQUET
- Mechanism of injury:
- Cause, precipitating factors, weapons used
- Trajectories and forces involved
- For vehicular trauma:
- Specific description of mechanism such as auto vs. pole, rollover,
broadside, high speed
- Condition of vehicle including windshield, steering wheel, compartment
intrusion, condition of dashboard/firewall/pedals, type and use of
seatbelts, supplemental restraint system (i.e., airbag) deployment
- Helmet use: motorcycle, bicycle, skiing, snowboarding, skateboarding,
rollerblading
- Patient complaints
- Initial position and level of consciousness of patient.
- Patient movement, treatment since injury
- Other factors such as drugs, alcohol, medications, diseases, pregnancy
- Scene evaluation:
- Note potential hazard to rescuers and patient.
- Identify number of patients; organize triage operations if appropriate
- Observe position of patient, surroundings, probable mechanism, and
vehicle condition.
- Patient evaluation: see treatment below
TREATMENT
- Initial assessment in multiple trauma is performed at the same time as
treatment.
- Airway with spinal precautions and immobilization
- Administer O
2
.
- Circulation, with control of major bleeding
- Transport decision
- If patient unstable, transport immediately. Treat en route.
- If patient stable, assess for potentially life-threatening injuries and treat
accordingly.
- Monitor vital signs, neurologic status and EMT-P: cardiac rhythm en route.
- EMT-P: Pain management. Administer fentanyl citrate 100 mcg slow IV for
suspicion of pain and:
- No contraindication to fentanyl citrate
- Age 18 or greater
- GCS 13 or greater
- Systolic BP > 90 mmHg
- No signs of imminent deterioration of patients condition
- Assessment and management of trauma in the field has changed
considerably in the past 5 years. There are patients who cannot tolerate a
full assessment before life saving intervention is needed. Likewise,
splinting, bandaging, and, often, the focused history and physical
examination are procedures that may need to be bypassed in the critical
patient. Time and the treatment available in a trauma center are critical
elements in resuscitation. Therefore, with severely injured patients, it is
most appropriate to rapidly transport (load and go) the patient rather
than using extended stabilization or the old "grab and run," with no trauma
stabilization or care rendered.
- Critical injuries involve:
- Difficulty with respiration
- Difficulty with circulation (hypoperfusion, AKA shock)
- Decreased level of consciousness
- Any trauma patient with one or more of these above conditions is a "load
and go," with treatment occurring en route.
- Even in the noncritical patient with significant injury, "stabilization in the
field" does not occur. With major injuries, the very most you can do is to
buy time. If the initial bolus of fluids results in improved vitals, do not
become complacent. This patient frequently needs blood and an operating
room to truly "stabilize" the traumatic process. Rapid transport is still the
highest priority.
- Serial vital signs and observations of respiratory, circulatory and neurologic
status prior to arrival are critical.
- The trauma patient is the greatest risk to the rescuer for exposure to bodily
fluids. Use all appropriate body substance isolation precautions.


Step 1 Respiratory
1. Unable to adequately ventilate
YES

- Transport to appropriate
facility.
NO +

Step 2 Physiology
Children (AGE 0-12)
Or < 5 FT IN HEIGHT
Adult
1. Intubation or
2. Respiratory Distress or
3. Capillary Refill > 2 sec or BP
abnormal for age (<70+2x
age) or
4. Glasgow Motor Score < 5
1. Intubation or
2. Systolic BP < 90 mmHg or
3. Respiratory rate < 10 or >
29 with distress or
4. Glasgow Motor Score < 5

YES

- Transport to a Level I or II
trauma center.
- Transport children 5 years
of age or younger to The
Childrens Hospital when
time and conditions allow.
- Children 6-18 years of age
can be taken to Level I, II
or TCH.
NO +
Step 3 Anatomy (any one of the below)
1. Penetrating injuries head, neck, torso, pelvis
2. Flail chest
3. Bilateral femur fractures
4. Unstable pelvis or suspected significant pelvic fracture
5. Paralysis or evidence of spinal cord injury
6. Amputation above the wrist or ankle
7. Significant burns
8. Unreactive or unequal pupils

YES

- Transport to a Level I or II
trauma center.
- Transport children 5 years
of age or younger to The
Childrens Hospital when
time and conditions allow.
- Children 6-18 years of age
can be taken to Level I, II
or TCH.
NO +
Step 4 Mechanism (any one of the below)
1. Ejection from motor vehicle/conveyance
2. Falls > 15 feet (adults); 2xs height of child
3. Pedestrian, motorcyclist or pedal cyclist thrown > 15 feet or run over
4. Significant crush injury
5. High energy dissipation
6. Extrication > 20 min with an injury
7. Unrestrained occupant in vehicle rollover
8. Death of same car occupant
9. Significant assault
10. Exposure to blast or explosion
11. Intrusion of vehicle of > 12 in occupant compartment
12. Suspected non-accidental trauma

YES

NO +
Step 5 Co-morbidity Considerations (any one of the below)
1. Extremes of ages: < 5 and > 55 years of age
2. Extreme heat or cold
3. Medical illness (such as COPD, CHF, renal failure, diabetes, etc.)
4. Presence of intoxicants
5. Pregnancy
6. EMT clinical suspicion of occult injury

YES

- Transport to closest
appropriate level trauma
facility as time and
conditions allow.

- Transport to a Level I-IV
trauma center.

NO +
Transport to closest appropriate hospital
- Transport to any acute
care facility.

Revised May 3, 2005, adopted by the MHRETAC on May 19, 2005
NOTES
- Use of this algorithm in multiple casualty events will be determined in the
future.
- This algorithm applies to both air and ground scene transports.
- The Childrens Hospital, a Level I trauma center, is an appropriate
destination for ages 0-18.
- DISCRETION OF PRE-HOSPITAL PERSONNEL BASED ON ABOVE FACTORS MAY
DETERMINE TRANSPORT.
- The MHRETAC recognizes that the identification of specific injuries on scene
may be limited.
ABDOMINAL TRAUMA
- Patient complaints
- For penetrating trauma: weapon, trajectory
- For auto: condition of steering wheel, dash, vehicle; speed, patient
trajectory; seatbelts in use, airbag deployment
- Past history: medical problems, medications, pregnancy, drugs, alcohol
- Observe: distention, bruising, entrance/exit wounds
- Palpate: areas of tenderness, guarding; pelvis stability to lateral and
suprapubic compression
TREATMENT
- Stabilize life threatening airway and circulatory problems first.
- Administer O
2
.
- Observe carefully for signs of blood loss. If signs of shock:
- Rapid transport. Contact base.
- Consider second IV using large bore catheter.
- Administer fluid bolus of normal saline if clinically indicated, further
fluids as directed.
- For penetrating injuries: cover wounds and eviscerations with moist saline
gauze to prevent further contamination and drying. Do not attempt to
replace.
- Monitor vital signs during transport.
- The extent of abdominal injury is difficult to assess in the field. Be very
suspicious; with significant blunt trauma, injuries to multiple organs are the
rule.
- Patients with spinal cord injury, altered sensorium due to drugs or alcohol,
head injury or significant distracting injuries (e.g., long bone fractures) may
not complain of tenderness and may lack guarding in the face of significant
intra abdominal injury.
- Seatbelts, steering wheels, and other blunt objects may cause occult intra-
abdominal injury that is not apparent until several hours after the trauma.
You must consider forces involved to properly assess and treat a trauma
victim.
- In children, significant intra-abdominal injury, which may lead to shock,
may be present without any external signs of injury, such as abrasions or
hematomas.
- The pregnant patient deserves special attention during transport. Transport
the patient on her left side or angle backboard to prevent Supine
Hypotension Syndrome from uterine compression of the inferior vena cava.
AMPUTATIONS
- History: time and mechanism of amputation; care for severed part prior to
rescuer arrival
- Past history: medications, bleeding disorders, medical problems
- Vital signs
- Other injuries
- Blood loss at scene
- Structural attachments in partial amputations if identifiable
TREATMENT
- Manage airway and breathing
- Resuscitate and treat other more urgent injuries.
- Control hemorrhage with direct pressure, elevation.
- If hypotension or signs of shock:
- Normal saline fluid bolus
- Patient: gently cover stump with sterile dressing. Saturate with sterile
saline. Cover with dry dressing. Elevate.
- Severed part: wrap in sterile gauze, preserving all amputated material.
Moisten with sterile saline. Place in watertight container (specimen cup,
plastic bag, etc.). Place container in cooler with ice (do not freeze).
- Contact base for optimal transport destination.
- Partial amputations should be dressed and splinted in alignment with
extremity to ensure optimum blood flow. Avoid torsion in handling and
splinting.
- Do not use dry ice to preserve severed part.
- Control all bleeding by direct pressure only to preserve tissues. The most
profuse bleeding may occur in partial amputations, where cut vessel ends
cannot retract to stop bleeding. Avoid tourniquet if at all possible. Never
clamp bleeding vessels.
- Many factors enter into the decision to attempt replantation (age, location,
condition of tissues, other options). A decision regarding treatment cannot
be made until the patient and part have been examined by a physician and
may not be made at the primary care hospital. Try to help the family and
patient understand this, and don't falsely elevate hopes.
BURNS
- History of injury: time elapsed since burn. Was patient in a closed space
with steam or smoke? Electrical contact? Loss of consciousness?
Accompanying explosion, toxic fumes, other possible trauma?
- Past history: prior cardiac or pulmonary disease, medications?
- Vital signs
- Extent of burns: description or diagram of areas involved
- Depth of burns:
- Superficial - erythema only
- Partial or full thickness - blistered or charred areas
- Estimate size of burn. Use Rule of Nines or area of one patient palm = 1%
burn.
- Evidence of carbon monoxide poisoning or other toxic inhalation: altered
mental status, headache, vomiting, seizure, coma
- Evidence of inhalation burns: respiratory distress, cough, hoarseness, singed
nasal or facial hair, soot, erythema of mouth, carbonaceous sputum
- Entrance and exit wounds for electrical burns
- Associated trauma
TREATMENT
- Thermal burns:
- Remove clothing which is smoldering or which is non-adherent to the
patient.
- Administer O
2
if indications from history or physical of respiratory burns,
toxic inhalation, or significant flame or smoke exposure.
- Assess and treat for associated trauma (blast or fall).
- Consider cervical spine injury.
- Remove rings, bracelets, and other constricting items.
- If burn is moderate-to-severe (over 15% of body surface area), cover
wounds with dry clean dressings to avoid hypothermia. Preheat
ambulance to maximum temperature to prevent hypothermia during
transport.
- Use cool, wet dressings in smaller burns (less than 15%) for patient
comfort.
- Establish venous access in non-burned extremity when possible.
- EMT-P: Consider morphine sulfate 2-10 mg, IV bolus for pain relief.
- Transport, monitoring vital signs.
- Observe for airway distress
- EMT-P: Be prepared to intubate.
- NOTE: For patients older than 12 years of age with isolated second
degree or third degree burns greater than 20% body surface area,
consider direct transport to the University Hospital Emergency
Department. For patients 12 years of age and younger with isolated
second degree or third degree burns greater than 20% body surface area,
consider direct transport to the Children's Hospital Emergency
Department.
- Patients in immediate need of airway management should be
transported to the nearest Emergency Department.
- Inhalation injury:
- Administer O
2
via NRB during transport.
- EMT-P: Be prepared to intubate or assist if respirations inadequate.
- EMT-P: Consider Cyanokit per protocol.
- Chemical burns:
- Protect rescuer from contamination. Wear appropriate gloves and
clothing.
- Remove all clothing and any solid chemical that might provide
continuing contamination.
- Assess and treat for associated injuries.
- Decontaminate patient using running water for 15 min. prior to transport
if patient stable.
- Check eyes for exposure and rinse with free-flowing water for 15 min.
- Evaluate for systemic symptoms that might be caused by chemical
contamination. Contact base for possible treatment.
- Remove rings, bracelets, constricting bands.
- Wrap burned area in clean, dry cloths for transport. Keep patient as
warm as possible after decontamination.
- Electrical injury:
- Protect rescuers from continued live electric wires.
- Separate victim from electrical source when area safe for rescuers.
- Initiate CPR as needed, EMT-P: monitor cardiac rhythm and treat
arrhythmias per protocols.
- Prolonged respiratory support may be needed.
- Immobilize cervical spine when appropriate, assess for other injuries.
- Leave blisters intact when possible.
- Suspect airway burns in any facial burns or burns received in closed places.
Edema may become severe, but not be immediately apparent. Avoid
unnecessary trauma to the airway. Humidified oxygen is preferred if
available.
- Assume carbon monoxide poisoning in all closed space burns. Treatment is
100% O
2
continued for several hours. In addition, other toxic products of
combustion are more commonly encountered than realized.
- Contact base for special instructions if other toxic inhalations are
suspected. Consider suicide attempt as cause of burn, and child abuse in
pediatric burns.
- Lightning injuries can cause ventricular asystole and prolonged respiratory
arrest. Prompt, continuous respiratory assistance (sometimes for hours to
days) can result in full recovery.
- Field decontamination of chemical exposures has been shown to
significantly reduce extent of burn. Gross decontamination should occur
prior to transport. Notify hospital immediately to mobilize internal
resources.
- EMS personnel should not participate in decontamination unless trained and
equipped to do so.
- In patients with severe burns, their ability to prevent heat loss is
significantly compromised. The time of transport may be enough to cause
hypothermia. Keep the ambulance as warm as possible during transport
despite discomfort to EMS personnel.
- Isolated carbon monoxide poisoning should be taken to the closest facility.
Multiple trauma patients with suspected carbon monoxide poisoning should
be taken to the appropriate trauma center.
CHEST INJURY
- Patient complaints: chest pain type (pleuritic, positional, location sharp,
dull, etc.), respiratory distress, neck pain, other areas of injury
- Mechanism: amount of force involved (particularly deceleration), speed of
impact, seatbelt use/type, airbag
- Penetrating trauma: size of object, caliber of bullet, trajectory, distance
from patient
- Past medical history: medications, prior medical problems
- Observe: wounds, air leaks, chest wall movement, neck veins
- Palpate: tenderness, crepitation, tracheal position, tenderness on sternal
compression, pulse pressure
- Auscultate: breath sounds, heart sounds (quality)
- Surroundings: vehicle, steering wheel condition, dashboard
TREATMENT
- Clear and open airway. Immobilize cervical spine if indicated.
- Administer O
2
.
- Assist breathing if patient is apneic or respirations are depressed.
- If penetrating injury present, transport rapidly with further stabilization en
route.
- For open chest wound with air leak, use Vaseline type gauze or occlusive
dressing taped on three sides only, to allow air to escape but not enter the
chest.
- Observe chest for paradoxical movements.
- Obtain baseline vital signs, neurologic assessment.
- If the patient is in shock transport rapidly to a trauma center. Contact
base.
- If neck veins flat and patient in shock, transport rapidly and treat
hypovolemia en route:
- Fluid bolus: normal saline
- If patient in shock with neck veins distended, also transport rapidly, and
consider:
- Tension pneumothorax if respiratory status markedly deteriorating with
clinical findings of pneumothorax:
- Release occlusive dressings on open chest wounds.
- EMT-P: Needle decompression per protocol contact base.
- Pericardial tamponade, if suggested by clinical findings (distant heart
sounds, narrow pulse pressure):
- Fluid bolus: normal saline
- Cardiac contusion with typical ischemic chest pain or severe chest wall
contusion:
- If patient stable without signs or symptoms of shock:
- Complete focused assessment.
- If significant injury suspected:
- EMT-P: Monitor cardiac rhythm en route.
- Immobilize impaled objects in place with dressings to prevent movement.
Large objects may require manual stabilization during transport.
- Monitor and record vital signs, and level of consciousness every five minutes
with significant injury.
- Chest trauma is treated with difficulty in the field and prolonged treatment
before transport is not indicated if significant injury is suspected. If patient
is critical, transport rapidly and avoid treatment of non-emergent problems
at the scene. Penetrating injury particularly should receive immediate
transport with minimal intervention in the field.
- Consider medical causes of respiratory distress such as asthma, pulmonary
edema or COPD that have either caused trauma or been aggravated by it.
- Chest injuries sufficient to cause respiratory distress are commonly
associated with significant blood loss. Consider hypovolemia.
- Myocardial contusion can occur, particularly with sudden deceleration
injury, as from a steering wheel. Pain is similar to myocardial infarct pain.
EMT-P: Monitor the patient and treat arrhythmias as in a medical patient,
but think first of hypoxia and hypovolemia as potential causes of
arrhythmias.
- Check the back for injuries, especially the patient in shock, where a cause
is not evident (check the back, axillary region and base of neck).
- Significant intrathoracic injuries can exist without external signs of injury.
EXTREMITY INJURIES
- Mechanism of injury: direction of forces, if known
- Areas of pain, swelling or limited movement
- Treatment prior to arrival: realignment of open or closed fracture, or
dislocations, movement of patient
- Past medical history: medications, medical illnesses
- Vital signs
- Observe: localized swelling, discoloration, angulation, lacerations, exposed
bone fragments, loss of function, guarding
- Palpate: tenderness, crepitation, instability, quality of distal pulses,
sensation
- Note estimated blood loss at scene.
TREATMENT
- Treat airway, breathing, and circulation as first priorities.
- Immobilize cervical spine when appropriate.
- Examine for additional injuries to head, face, chest, and abdomen; treat
those problems with higher priority first.
- If patient is unstable, transport rapidly, treating life threatening problems
en route. Splint patient to minimize fracture movement by securing to
backboard.
- If patient stable, or isolated extremity injury exists:
- Check and record distal pulses and sensation prior to immobilization of
injured extremity.
- Apply sterile dressing to open fractures. Note carefully wounds that
appear to communicate with bone.
- Splint areas of tenderness or deformity: apply gentle traction throughout
treatment and try to immobilize the joint above and below the injury in
the splint.
- Realign angulated fractures by applying gentle axial traction if
indicated:
- To restore circulation distally
- To immobilize adequately, e.g., realign femur fracture
- Check and record distal pulses and sensation after reduction and
splinting.
- Elevate simple extremity injuries. Apply ice pack if time and extent of
injuries allow.
- Monitor circulation (pulse and skin temperature), sensation, and motor
function distal to site of injury during transport.
- Consider fentanyl citrate 1-2 mcg/kg slow IV or morphine sulfate 2-10
mg IV push for pain control.
SPECIAL PRECAUTIONS
- Patients with multiple injuries have a limited capacity to recognize areas
which have been injured. A patient with a femur fracture may be unable to
recognize that he has other areas of pain. Be particularly aware of missing
injuries proximal to the obvious ones (e.g., a hip dislocation with a femur
fracture, or a humerus fracture with a forearm fracture).
- Do not use ice or cold packs directly on skin or under air splints. Pad with
towels or leave cooling for hospital setting.
- Do not attempt to realign angulated fractures in the field unless circulation
is compromised. Splint in the position of comfort.
- Injuries around joints may become more painful and circulation may be lost
with attempted realignment. If this occurs, stabilize the limb in the position
of most comfort with the best distal circulation.
FACE AND NECK TRAUMA
- Mechanism of injury: impact to steering wheel, windshield, or other
objects; clothesline type injury to face or neck; blunt object to head, face,
or neck
- Management before arrival by bystanders, first responders
- Patient complaints: areas of pain; trouble with vision, hearing; neck pain;
dental occlusion, tooth loss; short of breath
- Past medical history: medications, medical illnesses
- Vital signs
- Airway: jaw or tongue instability, loose teeth, vomitus or blood in airway,
other evidence of impairment or obstruction
- Neck: tenderness, crepitation, hoarseness, bruising, swelling, stridor
- Blood or drainage from ears, nose
- Level of consciousness, evidence of head trauma
- Injury to eye: lid laceration, blood anterior to pupil, abnormal pupil,
abnormal globe position
TREATMENT
- Control airway with cervical spine immobilization if indicated:
- Open airway using jaw thrust, keeping neck in alignment with in-line
cervical immobilization.
- Use finger sweep to remove oral foreign bodies.
- Suction blood and other debris.
- Stabilize tongue and mandible with chin lift. Manual traction of the
tongue may be necessary to keep posterior pharynx open as needed.
- Note evidence of laryngeal injury and transport immediately if signs
present.
- EMT-B: If bleeding is severe, attempt to manage with suctioning, oral
airway, and bag-valve-mask. Consider ALS for advanced measures
- EMT-P: Intubate if bleeding is severe or airway cannot be maintained.
When midface fractures are suspected, nasotracheal intubation is
contraindicated. If intubation cannot be performed due to severe facial
injury, attempt to manage with suctioning and the King airway or bag-
valve-mask.
- Support breathing as needed.
- If necessary, consider surgical cricothyrotomy
- Administer O
2
.
- Control hemorrhage, check pulse and circulation.
- Establish venous access:
- TKO if stable
- Normal saline fluid bolus for signs of hypovolemia
- Cover injured eyes with protective shield or cup; avoid pressure or direct
contact to eye.
- Do not attempt to stop free drainage from ears, nose. Cover lightly with
dressing to avoid contamination.
- Bring avulsed teeth with you. Keep moist in saline-soaked gauze.
- Monitor airway closely during transport for development of obstruction or
respiratory distress. Suction and treat as needed.
- Fracture of the larynx should be suspected in patients with respiratory
distress, abnormal voice, and history of direct blow to neck from steering
wheel, rope, fence wire, etc. Both intubation and surgical cricothyrotomy
may be unsuccessful in the patient with a fractured larynx, and attempts
may result in increased injury. Transport rapidly for definitive treatment if
you suspect this potentially lethal injury. Do not attempt intubation or
surgical cricothyrotomy unless the patient is in severe respiratory distress.
Bag-valve-mask ventilation is preferred.
- Airway obstruction is the primary cause of death in persons sustaining head
and face trauma. Meticulous attention to suctioning and basic airway
maneuvers may be the most important treatment rendered.
- Remember that the apex of the lung extends into the lower neck and may
be injured in penetrating injuries of the lower neck, resulting in
pneumothorax or hemothorax.
- Do not be concerned with contact lens removal in the field.
- EMT-P: No nasotracheal intubation under age 12.

HEAD TRAUMA
- History: mechanism of injury, estimate of force involved; helmet use.
- History since injury: loss of consciousness (duration), change in level of
consciousness, memory loss for events before and after trauma, movement
(spontaneous or moved by bystanders), seizure activity
- Past history: medications (esp. insulin), medical problems, seizure history,
alcohol or drug use
- Vital signs (note respiratory pattern and rate)
- GCS
- External evidence of trauma: contusions, abrasions, lacerations, drainage
from nose, ears
TREATMENT
- Assess airway and breathing; treat life threatening conditions. Use assistant
to provide in-line cervical immobilization when indicated, while managing
respiratory difficulty.
- Administer O
2
.
- Control hemorrhage. Stop scalp bleeding with direct pressure. Continued
pressure may be needed.
- Transport rapidly if patient has multiple injuries, or unstable neurologic,
respiratory or circulatory status.
- Obtain initial vital signs, neurologic assessment.
- If unconscious:
- Assist ventilations.
- EMT-B: Consider airway adjuncts. EMT-P: Consider intubation.
- Ventilate at 10 breaths per minute for adults (15 breaths for children, 20
breaths for infants).
- If signs of cerebral herniation are present, hyperventilate at 20 BPM for
adults (30 BPM for children, 35 BPM for infants).
- Contact base.
- Immobilize cervical, thoracic and lumbosacral spine when indicated.
- If signs of hypovolemic shock are present, initiate treatment en route:
- Fluid bolus of normal saline.
- Look carefully for possible sources of bleeding (abdomen, pelvis, chest).
- Contact base.
- If patient stable:

- Complete detailed assessment.
- Splint fractures and dress wounds if time permits.
- Monitor and record airway, vital signs, and level of consciousness
repeatedly at scene and during transport. Status changes are important.
- When head injury patients deteriorate, check first for airway, oxygenation
and blood pressure. These are the most common causes of "neurologic"
deterioration. If the patient has tachycardia or hypotension, evaluate for
hypovolemia from associated injuries.
- Secondary brain injury and adverse outcomes can occur in brain-injured
patients who exhibit hypotension and/or hypoxia. Early aggressive
treatment of hypotension and administration of high flow oxygen may
prevent further injury.
- The most important information you provide for the base physician is level
of consciousness and its changes. Is the patient stable, deteriorating or
improving?
- Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent
cause of death in head injury.
- Hypoventilation aggravates cerebral edema.
- EMT-P: If patient is combative from head injury, consider sedation. Contact
base for orders if indicated. The cervical spine immobilization can be more
appropriately managed with a relaxed patient.
- Scalp lacerations can cause profuse bleeding, and are difficult to define and
control in the field. If direct local pressure is insufficient to control the
bleeding, evacuate any large clots from flaps and large lacerations with
sterile gauze, and use direct hand pressure to provide hemostasis. If the
underlying skull is unstable, pressure should be applied to the periphery of
the laceration over intact bone.
- Routine prophylactic hyperventilation should be avoided. It has been shown
to be detrimental to cerebral blood flow and patient outcome.
Hyperventilation in the field for head trauma is indicated only when signs of
cerebral herniation such as extensor posturing or pupillary abnormalities
(asymmetric or bilaterally fixed and dilated pupils) are present after
correcting hypotension and/or hypoxemia.
SPINAL TRAUMA
- Mechanism of injury and forces involved: be suspicious with falls,
decelerations, diving accidents and motor vehicle accidents.
- Past medical problems and medications
- Vital signs, including neurological assessment
- Level of sensory and motor deficit, presence of any evidence of neurological
function below level of injury
- Physical exam, with careful attention to organs or limbs which may not have
sensation
TREATMENT
- Assess airway and breathing; treat life threatening difficulties. Use
controlled ventilation for high cervical cord injury associated with
abdominal breathing. Use assistant to provide in-line cervical
immobilization while managing ABCs.
- Administer O
2
.
- Control hemorrhage.
- Immobilize cervical, thoracic and lumbosacral spine as indicated.
- Obtain and record vital signs and neurologic assessment before and after
immobilization.
- Establish venous access. If signs of hypovolemia: fluid bolus of Normal
Saline, contact base.
- Monitor airway, vitals, and neurologic status frequently at scene and during
transport.
- Be prepared to turn entire board on side if patient vomits (patient must be
secured to spine board or scoop stretcher).
- Neurogenic shock is likely with significant spinal cord injury. If present,
elevate legs 10-12 inches. Ensure adequate respirations.
- If hypotension is unresponsive to simple measures, it is likely due to other
injuries. Neurological deficits make other injuries hard to evaluate. Cord
injury above the level of T-8 makes the abdominal examination unreliable.
- Spinal immobilization in patients with penetrating trauma should be
accomplished only when neurological deficit or impaled foreign body is
present.
- It is important from a clinical and medical legal perspective to record
neurological assessment before and after spinal immobilization.
TRAUMA ARREST
- Time of arrest
- Mechanism: blunt vs. penetrating
- Signs of irreversible death (decapitation, dependent lividity, etc.)
- Vital signs
- Evidence of massive external blood loss
- Evidence of massive blunt head, thorax or abdominal trauma
TREATMENT
- Blunt trauma arrest:
- Initiate basic life support
- Use appropriate airway adjuncts as indicated. Administer O
2
.
- If no vital signs or other signs of life present after above treatments,
consider field pronouncement.
- If pulse returns with above treatment, treat per protocol and transport
rapidly to a Level I or II trauma center.
- Penetrating trauma arrest:
- Initiate basic life support
- Use appropriate airway adjuncts as indicated. Administer O
2
.
- Begin rapid transport. Contact base.
- Establish venous access; administer IV fluid bolus of normal saline.
- If cardiac activity returns with above treatment, treat arrhythmias per
protocols.
- Consider field pronouncement (See Resuscitation and Field
Pronouncement guidelines) for the following:
- Signs of irreversible death
- ALS has been unavailable for at least 20 minutes from the time EMS
personnel initiate on-scene assessment and there is no return of vital
signs or signs of life
- Victims of blunt trauma arrest without vital signs at the scene after
initiation of ALS have a mortality rate of 100%.
- Trauma arrests secondary to penetrating truncal injuries can be
resuscitated and saved. There is a higher rate of survival in victims of low
velocity penetrating injuries versus victims of high velocity injuries.
BANDAGING
INDICATIONS
- To stop external bleeding by application of direct and continuous pressure
to wound site
- To protect patient from contamination to lacerations, abrasions, burns
PRECAUTIONS
- Although external skin wounds may be dramatic, they are rarely a high
management priority in the trauma victim.
- Do not use circumferential dressings around neck. Continued swelling may
block airway.
TECHNIQUE
- Use BSI.
- Control hemorrhage with direct pressure, using sterile dressing.
- Assess patient fully and treat all injuries by priority once assessment is
complete.
- Remove gross dirt and contamination from wound: clothing (if easily
removable), dirt, gasoline, acids, or alkalis. Use copious irrigating saline or
tap water for chemical contamination.
- Evaluate wound for depth, presence of fracture in wound, foreign body, or
evidence of injury to deep structures. Note distal motor, sensory, and
circulatory function prior to applying dressings.
- Apply sterile dressing to wound surface. Touch outer side of dressing only.
- Wrap dressing with clean gauze or cloth bandages applied just tightly
enough to hold dressing securely (if no splint applied).
- Assess wound for evidence of continued bleeding.
- Check distal pulses, color, capillary refill, and sensation after bandage
applied.
- Continue to apply direct hand pressure over dressing, or use air splint if
bleeding not controlled with bandage alone.
- For deep or gaping muscle wounds in which bleeding cannot be controlled
with direct pressure, pack the wound with sterile gauze than reapply a
sterile dressing with pressure.
COMPLICATIONS
- Loss of distal circulation from bandage applied too tightly around extremity;
for this reason, do not use elastic bandages or apply bandages too tightly.
- Airway obstruction due to tight neck bandages
- Restriction of breathing from circumferential chest wound splinting
- Continued bleeding no longer visible under dressings. This is particularly
common with scalp wounds that continue to lose large amounts of
unnoticed blood.
- Inadequate hemostasis: some wounds require continuous direct manual
pressure to stop bleeding.
SPLINTING: AXIAL
INDICATIONS
- Pain, swelling, or deformity of spine which may be due to fracture,
dislocation, or ligamentous instability.
- Neurologic deficit that might be due to spine injury.
- Prevention of neurologic deficit or further deficit in patients with suspected
spine injury or instability.
- In all trauma victims who are unconscious or with impaired consciousness
due to head injury or drug ingestion, to protect against damage or further
damage in patients where injury to the spine cannot be ruled out by
accurate exam or history.
PRECAUTIONS
- All patients with significant head trauma should be immobilized because of
the potential for unrecognized coexistent neck trauma.
- Perform and document complete neurologic exam prior to moving the
patient. Reassess and document finding after splinting is completed and
after each set of vital signs (i.e., every 5 minutes for a critical patient and
every 15 minutes for a non-emergent patient).
TECHNIQUE
- Cervical splinting:
- Perform cervical splinting immediately following initial assessment (if
indicated). If necessary, use assistant to maintain cervical stabilization
while completing initial assessment.
- Use two people to apply splint if at all possible.
- Do not use excessive force to straighten. Gently restore normal
alignment.
- Advise patient of procedure and purpose before and during application.
- Immobilize the cervical spine with a semi-rigid collar of appropriate size
for age.
- Pad behind head in adults to maintain an anatomically neutral position.
- Use long/short spine board or orthopedic scoop to support patient as
situation dictates.
- Use tape and/or straps to secure patient effectively and allow turning as
a unit for airway control.
- Continue to monitor airway and effectiveness of immobilization.
- Board with an appropriate size collar is preferred to KED in pediatric
patients.
- Spinal immobilization:
- Splint cervical spine concurrent with the initial assessment. Document
neurologic findings.
- Complete detailed assessment and splint fractures prior to movement of
patient when possible.
- Document neurologic findings.
- In a sitting patient, use short board or Kendrick Extrication Device (KED)
may be beneficial for extrication:
- Slide short board or KED behind patient.
- Apply thigh straps snugly as close to groin as possible.
- Apply shoulder or chest straps.
- Use padding as needed to keep neck (in cervical collar) in a neutral
position.
- For pediatrics, use padding as needed to prevent misalignment.
- Secure head to board.
- Use long backboard for supine patients.
- For sitting patients, after short board or KED is applied:
- Logroll or lift patient as a unit to board. Apply continuous cervical
stabilization during movement. One person should protect neck in
collar. Do not use force to straighten spine.
- Release leg straps if short board or KED was used.
- Use padding as needed behind knees to support a neutral axis under
small of back, neck and knees.
- Use towel rolls or commercially available cervical immobilization
device and tape to secure neck immobilization.
- Apply straps or tape to secure chest, thighs, and lower legs to allow
turning as a unit in case of vomiting or airway difficulty.
- Reassess patient status, particularly airway and neurologic findings
frequently.
COMPLICATIONS
- Vomiting is common in head/spine-injured patients. Your splinting must be
good enough to allow turning of the patient for airway protection but must
not impede breathing efforts.
- It is easy to miss injuries below the level of a neurological deficit. Look
carefully for abdominal and chest injuries, pelvic fractures, and extremity
injuries without symptoms. With loss of sensation below T-8, there will be
no guarding, rebound pain, or tenderness to alert you to internal abdominal
injuries.
- Pelvis fractures are difficult to diagnose in the field. Suspected pelvis injury
can be immobilized by use of the long board during spine immobilization
with a circumferential pelvic wrap.
- Patients with helmets and shoulder pads (football, lacrosse, hockey):
- When immobilization is indicated for football players with shoulder pads
and helmets, it should be accomplished with the helmet and pads in
place.
- The only indications for removal of a football helmet during
immobilization are:
- Airway management cannot be accomplished without removal.
- Bleeding cannot be controlled without removal.
- The helmet does not provide adequate control of the head.
- If the helmet is removed, the provider(s) should ensure adequate
padding is in place behind the head to allow for neutral alignment.
- If the patient is immobilized with helmet and pads in place, the
facemask/shield must be removed prior to transport.
- Lacrosse and hockey shoulder pads may not provide enough padding to
prevent hyperflexion. The helmet may need to be removed and head
padded or padding may be placed under the shoulders to accomplish
neutral alignment.
- EMS responders should utilize the tools and expertise that the athletic
trainers at the scene can provide.
- A flat lift with the backboard introduced from the patients feet is
preferred to a standard roll when the patient has shoulder pads.
- It is recommended that EMS practice these procedures and become
familiar with athletic training staff tools and policies frequently.
- As always, neurologic exam must be done and documented reflecting
status before and after the procedure.
- Patient with motorcycle, ATV, racing helmets:
- Patients with these types of helmets should usually have them removed
early in the assessment to allow immediate access to the airway, face
and posterior skull.
- Two providers are required to perform this procedure. One to control
the head and maintain in-line stabilization and one to manipulate and
remove the helmet.
- As always, neurologic exam must be done and documented reflecting
status before and after the procedure.
- Axial immobilization should be initiated any time it is indicated. However,
the procedure is not without complications. Research indicates that axial
immobilization may cause back pain, muscle spasm, pressure sores,
claustrophobia or restricted breathing efforts. As such, routine prophylactic
axial immobilization may not be indicated in a patient who meets all the
following criteria:
- Is conscious, awake, and oriented to person, place and time (Glasgow
Coma Score = 15) and has no pre-existing mental impairment which
might hinder cognitive function (i.e., psychological disorder or mental
retardation) and does not complain of neck pain.
- No language barrier exists which might hinder the assessment process.
- Did not experience a loss of consciousness (either documented or
suspected).
- The mechanism of injury does not warrant activation of a trauma team.
- Upon physical exam, there is no evidence of tenderness, deformity, or
spasm in the neck, back or paraspinal region.
- There is no evidence of peripheral sensory or motor deficit or
impairment (i.e., paresthesia, peripheral tingling, or decreased motor
function following incident).
- There are no complaints or evidence of visual disturbances such as
diplopia or blurred vision.
- There is no evidence of an unstable or staggered gait.
- There is no evidence that suggests the use of prescribed CNS
depressants, analgesics, ETOH, or other mind-altering substances.
- The patient has no pre-existing neck, back or neurologic injury.
- There are no distracting injuries present which might mask an underlying
neurologic or spinal injury.
- Once a patient has been immobilized by a first responder, the patient
may not have a cervical collar or other immobilization device removed
by subsequent responders. Patient must be transported to a healthcare
facility. Contact base if questions and/or clearance is desired.
INDICATIONS
- Pain, tenderness, swelling, or deformity in extremity which may be due to
fracture or dislocation
- In an unstable extremity injury: to reduce pain; limit bleeding at the site of
injury; and prevent further injury to soft tissues, blood vessels or nerves
PRECAUTIONS
- Critically injured trauma victims should not be delayed in transport by
lengthy evaluation of possible non-critical extremity injuries. Prevention of
further damage may be accomplished by securing the patient to a
backboard when other injuries demand prompt hospital treatment.
- The patient with altered level of consciousness from head injury or
drug/alcohol influences should be carefully examined and conservatively
treated, because his ability to recognize pain and injury is impaired.
- Make sure the obvious injury is also the only one. It is particularly easy to
miss fractures proximal to the most visible one.
- In a stable patient where no environmental hazard exists, splinting should
be done prior to moving the patient.
TECHNIQUE
- Extremity splinting:
- Check pulse and sensation distally prior to movement or splinting.
- Remove bracelets, watches, or other constricting bands prior to splint
application.
- Identify and dress open wounds. Note wounds that contain exposed bone
or are near fracture sites and may communicate with a fracture.
- To minimize pain and soft tissue damage, avoid sudden or unnecessary
movement of fracture site.
- Choose splint to immobilize joint above and below injury. Pad rigid
splints to prevent pressure injury to extremity.
- Apply gentle continuous traction to extremity and support to fracture
site during splinting operation.
- Reduce angulated fractures (if no pulses), including open fractures, with
gentle axial traction as needed to immobilize properly.
- Check distal pulses and sensation after reduction splinting. Realign
gently if adequate circulation and sensation is lost.
- Traction splinting (for suspected femur fractures):
- Use two persons for splint application procedure.
- Remove sock and shoe and check for distal pulse and sensation (unless
you cannot protect exposed foot from weather; then just ask patient
about sensation and observe movement).
- Identify and dress open wounds, and note exposed bone or wounds
overlying fractures and potential communicating wounds.
- Measure splint length prior to application.
- Apply gentle axial traction with support to calf and fracture site,
reducing angulation of open fractures as necessary for secure
tractioning.
- Position ischial pad under buttocks, up against bony prominence (ischial
tuberosity). Empty pockets if necessary for patient comfort and
appropriate splinting.
- Secure groin strap carefully.
- Maintain continuous traction and support to fracture site throughout
procedure.
- Adjust support straps to appropriate positions under leg.
- Apply ankle hitch and tighten traction until patient experiences
improved comfort. (Movement at the fracture site will cause some pain,
but if traction continues to cause increased pain, do not proceed. Splint
and support leg in position of most comfort.)
- Secure support straps after traction properly adjusted.
- Re-check distal pulses and sensation.
COMPLICATIONS
- Circulatory compromise from excessive constriction of limb
- Continued bleeding not visible under splint
- Pressure damage to skin and nerves from inadequate padding
- Delayed treatment of life-threatening injuries due to prolonged splinting
procedures
- Traction splints should only be used if the leg can be straightened easily and
patient is comfortable with the traction device on. Particularly with injuries
about the hip and knee, forced application of traction device can cause
increased pain and damage. If this occurs, do not use traction device, but
support in position of most comfort and best neurovascular status.
- When in doubt and the patient is stable, splint. Do not be deceived by
absence of deformity or disability. Fractured limbs often retain some ability
to function.
- Splinting body parts together can be a very effective way of immobilizing:
arm-to-trunk or leg-to-leg. Padding will increase comfort. This method can
be very useful in children when traction devices and pre-made splints do
not fit.
- EMT-P: Administration of analgesics prior to splinting may be needed.
TOURNIQUET
INDICATIONS
- A tourniquet should be used to control potentially fatal hemorrhagic wounds
only after other means of stopping blood loss have failed.
PRECAUTIONS
- Use BSI.
- A tourniquet applied incorrectly can increase blood loss and lead to death.
- Applying a tourniquet can cause nerve and tissue damage whether applied
correctly or not. Proper patient selection is of utmost importance.
- Damage is unlikely if the tourniquet is removed within an hour. Low risk to
tissue is acceptable over death secondary to hypovolemic shock.
- A commercially made tourniquet is the only acceptable tourniquet to be
used; improvised tourniquets are not as effective and may cause more
harm.
TECHNIQUE
- Attempt to control hemorrhage using direct pressure, elevation and indirect
pressure on pressure points prior to considering the application of a
tourniquet.
- If unable to control hemorrhage using above means, apply a tourniquet
using the steps below:
- Cut away any clothing so that the tourniquet will be clearly visible. The
tourniquet should NEVER be obscured by clothing or bandages.
- Apply tourniquet proximal to the wound and not across any joints.
- Tighten tourniquet until bleeding stops.
- Applying tourniquet loosely will only increase blood loss by inhibiting
venous return.
- Mark the time and date of application on the patients skin next to the
tourniquet. Use a permanent marker.
- Keep tourniquet on throughout hospital transport a correctly applied
tourniquet should only be removed by the receiving hospital.
- Transport should be initiated as soon as possible following placement of
tourniquet.
PEDIATRIC EMERGENCIES
PEDIATRIC SEIZURES
POSSIBLE SUDDEN INFANT DEATH SYNDROME
Pediatric patients, for the purpose of the protocols, defined as age < 12 years,
have unique anatomy, physiology, and developmental needs that affect pre-
hospital care as well as hospital care. Because children make up a small
percentage of total calls and few pediatric calls are critically ill or injured, it is
important to stay attuned to these differences to provide good care.
Therefore, contact base early for guidance when treating pediatric patients
with significant complaints, including abnormalities of vital signs. Pediatric
emergencies are usually not preceded by chronic disease. If recognition of
compromise occurs early, and intervention is swift and effective, the child will
often be restored to full health.

The following should be kept in mind during the care of children in the pre-
hospital setting:
- Airways are smaller, softer, and easier to obstruct or collapse.
- Respiratory reserves are small. A minor insult like improper position,
vomiting, or airway narrowing can result in major deficits in ventilation and
oxygenation.
- Circulatory reserves are also small. The loss of as little as one unit of blood
can produce severe shock in an infant. You can be confident that good
hands-on circulation assessment will accurately determine fluid needs.
- Assessment of the pediatric patient can be accurately done using your
knowledge of the anatomy and physiology specific to infants and children.
- Listen to the parents' assessment of the patient's problem. They often can
detect small changes in their child's condition. This is particularly true if the
patient has chronic disease.
- The proper equipment is very important when dealing with the pediatric
patient. A complete selection of pediatric airway management equipment,
IV catheters, cervical collars, and drugs has been mandated by the state.
This equipment is stored separately to minimize confusion.
- When following these protocols, the age groups used are:
- Infants: birth to one year
- Toddlers: one through five years
- School age: six through fourteen years

NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP
AGE
PULSE
average/minute
RESPIRATIONS
breaths/minute
BLOOD PRESSURE
systolic in mmHg
Premature 140 40-60 40-60
Newborn 125 40-60 60-80
6 mo 140 25-40 65-105
1 yr 135 20-30 70-110
3 yr 110 20-30 80-110
5 yr 100 20-30 80-110
8 yr 90 12-25 90-115
12 yr 85 12-18 100-130
GENERAL PRINCIPLES
An Apparent Life-Threatening Event (ALTE) is any episode that is frightening to
the observer and usually involves one or more of the following symptoms:
- Apnea (central or obstructive)
- Altered mentation
- Color change
- Marked change or loss in muscle tone
- Choking or gagging

ALTEs (or near-miss SIDS as previously termed) usually occur in infants under
12 months old, however, any child less than 2 years of age who exhibits any of
the above symptoms should considered to have had an ALTE.
- History of any of the symptoms listed above.
- Determine the severity, nature and duration of the episode.
- Was the child awake or sleeping at the time of the episode?
- What resuscitative measures were taken?
- Obtain a complete medical history to include:
- Known chronic diseases
- Evidence of seizure activity
- Current or recent infections
- Recent trauma
- Medication history
- Known GERD or feeding difficulties
- Unusual sleeping or feeding patterns
TREATMENT
- Perform a comprehensive physical assessment that includes:
- General appearance
- Skin color
- Extent of interaction with the environment
- Evidence of current or past trauma
- Note: Physical exam may be normal.
- Treat any identifiable causes as indicated.
- Transport.
- If a parent/guardian refuses medical care and/or transport, this is
considered to be a high-risk refusal and base contact is required.
- Consider possible NAT (non-accidental trauma, child abuse) and pass on any
concerns to receiving facility personnel. In most cases, the infant or child
will have a normal physical exam when assessed by pre-hospital personnel.
The parent/caregivers perception that something is or was wrong must be
taken seriously.
- Approximately 40-50% of ALTE cases can be attributed to an identifiable
cause such as child abuse, SIDS, swallowing dysfunction, infection,
bronchiolitis, seizures, CNS anomalies, chronic respiratory disease, upper
airway obstruction, metabolic disorders or anemia. The remaining cases
have no known etiology.

- Time since the child was last in good health
- History of any recent illness or injury
- Past medical history
- General appearance: LOC, muscle tone, color
- Airway: obstruction, stridor, drooling, cough
- Breathing: respiratory rate, skin color (cyanosis late sign), chest wall
symmetry and depth of movement, work of breathing (grunting, nasal
flaring, retractions), wheezing
- Circulation: heart rate, peripheral pulses, capillary filling time, skin color,
extremity skin temperature
- Level of consciousness, pupil size and reaction to light
- Physical assessment
TREATMENT
- Airway/Breathing:
- Manage airway. Effective airway management is by far the most critical
aspect of treatment. BVM ventilation may be as good as and in some
cases superior to orotracheal intubation in pediatrics.
- Administer O
2
via blow-by, non-rebreather mask, or BVM ventilation.
- If apneic, ventilate with a BVM, intubate as indicated, ventilation rate
per AHA BLS protocols. Ensure adequate chest rise and fall (tidal
volume), and air entry.
- Circulation:
- Initiate CPR if indicated.
- In the event that the patient is in V-Fib/V-Tach the defibrillation
dosing should be 2 j/kg initially and 4 j/kg for all subsequent doses.
- Establish peripheral venous access.
- EMT-P: If unable to establish a peripheral IV after 2 attempts, establish
an intraosseous infusion. If unable to see good peripheral vein, go
straight to IO infusion.
- If any signs of poor perfusion, infuse a 20 ml/kg of normal saline fluid
bolus. Contact base if you feel perfusion is compromised on
reassessment.
- Medications:
- Stabilizing the airway and supporting respiration are the mainstays of
treatment. Specific treatment should be focused on the etiology of the
arrest.
- Arrhythmias are treated as noted in their respective arrhythmia
algorithms.
- Hypoglycemia is common in younger children. If the child has altered
mental status, either administer dextrose (1-8 years should receive 2
ml/kg of a 25% solution IV; <1 year should receive 2-4 ml/kg of 10%
solution) or rule out hypoglycemia with a blood sugar check.
Hypoglycemia in pediatrics is commonly defined as a blood sugar <40.
- Respiratory distress is a critical situation that can be made worse with
prolonged scene times.
- Any child with a suspected apnea episode should be transported.
- The most successful pediatric resuscitations occur before a full
cardiopulmonary arrest. Assess pediatric patients carefully and assist with
airway, breathing, and circulatory problems before the arrest occurs, to
improve the outcome in pediatric patients.
- Pediatric arrests are most likely to be primary respiratory events. The
rescuer's primary attention must be directed to securing the airway and
providing good ventilation before specific treatment of cardiac rhythm. Any
cardiac rhythm can spontaneously convert to sinus rhythm in a well-
ventilated child.
- Oxygen and epinephrine are the mainstays of pediatric resuscitations.
Atropine and sodium bicarbonate are not first line drugs in pediatrics.
- Cardiopulmonary arrest from trauma is treated with airway management,
rapid transport, CPR and fluid administration en route.
- Recommendations for obstructed airway are abdominal thrusts over the age
of one year. Infants less than one year old should be treated with back
blows and chest thrusts. Early laryngoscopy should be used in an attempt to
visualize and remove upper airway obstructions.
- If a child 1 year of age or older is in cardiac arrest, an AED may be used,
preferably one with pediatric capabilities.
- Use of a length-based emergency tape (LBET) such as the Broselow tape is
highly accurate and allows for rapid drug and fluid doses and correct
equipment size and use. LBET use should be routine for any pediatric
emergency.
- History: onset and progression of symptoms, frequency of vomiting and
diarrhea, urine output, oral intake, recent trauma, possible drug ingestion
- General appearance: LOC, muscle tone, color
- ABCs and vital signs
- Skin: warmth of distal extremities, color, skin turgor, capillary fill time
(should be less than 2 seconds), pulses
- Mucous membranes: wetness of mouth, presence of tears
- Musculoskeletal: evaluate for trauma
- The signs of dehydration are:
- Early: tachycardic and tachypneic for age, decreased LOC, capillary
filling time longer than two seconds, cool skin, mucous membranes dry,
sunken eyes and fontanelle
- Late: loss of skin turgor, diminished pulses, and shock
TREATMENT
- Administer O
2
.
- Breathing: ventilation as indicated
- Circulation:
- Establish pulse rate and capillary refill time.
- Establish peripheral venous access.
- Consider fluid bolus of normal saline 20 ml/kg.
- Do not delay transport for IV attempts.
- Assessment of dehydration is primarily by physical exam. Vital signs may be
abnormal, but they are nonspecific.
- Determination of tachycardia or hypotension is based on age.
- Monitor carefully for signs of decreased tissue perfusion (shock). Early
(compensated) shock is present if capillary fill time is greater than 2
seconds, and there are poor pulses, muscle tone and color, and/or are
normotensive. Decompensated shock is present if systolic BP is less than
normal for age, patient has a decreased mental status and/or weak or
absent central pulses.
- History: sudden or gradual onset of symptoms, cough, fever, sore throat,
hoarseness
- History of potential foreign body aspiration or trauma
- Current medication use
- Airway: look for respiratory distress during inspiration, listen for abnormal
breathing sounds such as stridor, cough (croup-like?), and wheezing, feel for
air movement, crepitation, and tracheal deviation (late finding).
- Breathing: respiratory rate and effort, chest wall movement/adequacy of
tidal volume, color, use of accessory muscles, retractions, nasal flaring,
head bobbing, or grunting
- Respiratory sounds by auscultation of chest: wheezing, rales, decreased
(unilateral?), prolonged inspiratory (croup) or expiratory (wheezing) phases
- Mental status: AVPU
- General appearance: leaning forward or drooling (suggests upper airway
obstruction), skin color and temperature, muscle tone
TREATMENT
- Administer high-flow O
2
by blow-by or non-rebreather mask.
- As long as the child is adequately ventilating and has adequate mentation,
avoid agitating the patient. Keep the patient in his position of comfort.
- EMT-B: If the child is wheezing and has a metered dose inhaler (MDI),
- If the child is not ventilating adequately, assist with a BVM.
- In the rare case that the child cannot be ventilated with a BVM device:
- Reposition airway. Consider oral airway if patient unconscious.
- EMT-P: If still unable to ventilate, visualize the airway with a
laryngoscope. Remove any foreign object with Magill forceps.
- EMT-P: If nothing is seen, orally intubate the patient.
- EMT-P: Consider intubation only if unable to provide ventilatory support
with a BVM and oral airway.
- Assess and consider treatment for the following problems if respiratory
distress is severe and the patient does not respond to proper positioning and
administration of high flow oxygen.
- Croup or epiglottitis:
- Allow patient to remain in position of comfort if alert.
- EMT-P: Consider administering racemic epinephrine 0.5 ml + 2 ml
saline via nebulizer if croup is likely and there is respiratory distress.
- Asthma:
- EMT-P: Administer albuterol sulfate, 2.5 mg by nebulizer. Consider
adding Atrovent 0.5 mg for patients over 2 years of age.
- EMT-P: Use continuous nebulization of albuterol sulfate for
respiratory distress.
- EMT-P: Consider epinephrine 0.01 mg/kg (0.01 ml/kg of a 1:1000
solution) IM.
- EMT-P: Consider Solu-Medrol 2 mg/kg IV.
- If diagnosis is unclear, transport patient with 100% O
2
, reassess frequently
and be prepared to manage the patient's airway.
- Children with croup, epiglottitis, or laryngeal edema usually have
respiratory arrest due to exhaustion. Most children can still be ventilated
with a BVM.
- Children with severe asthma may not exhibit wheezing. The patients will
have prolonged expiratory phases and may appear listless, agitated, or
unresponsive.
- Respiratory distress is a critical situation that can be made worse with
prolonged scene times.
- Cyanosis is a late sign in pediatric hypoxia. Provide 100% O
2
for any child in
distress.
- Consider the differential assessment for each finding:
- Stridor: foreign body, croup, epiglottitis or other bacterial upper airway
infection, larynx trauma, etc
- Wheezing: foreign body, asthma, bronchiolitis, hydrocarbon exposure,
etc.
- Respiratory distress: pneumothorax, foreign body, pneumonia, shock,
CHF, etc.
- Any child with a witnessed or suspected apnea episode should be
transported.
- EMT-P: Intubation of the infant is most easily accomplished with an infant-
sized straight laryngoscope blade.
- EMT-P: Do not intubate unless you can visualize the ETT going through the
cords. If you are unable to intubate the trachea quickly, withdraw, re-
oxygenate with BVM, and try again. No harm will result to the child if you
keep the patient well oxygenated and don't traumatize the airway with
intubation attempts. Transporting while using BVM only is acceptable and
may be preferable in many circumstances.
PEDIATRIC SEIZURES
- History: preceding activity level, onset and duration of seizure, description
of seizure activity, fever, color change, recent illness, head trauma,
possibility of ingestion, cardiac symptoms
- Past history: previous seizures, current medications, chronic illness
- Airway: look for respiratory distress, listen for abnormal breathing sounds,
feel for air movement, crepitus.
- Breathing: respiratory rate and effort, chest wall movement (adequacy of
tidal volume), use of accessory muscles, retractions
- Circulation: heart rate, pulse, capillary filling time, skin color, blood
pressure
- Neurologic: mental status, muscle tone, focal findings, postictal period,
incontinence. Note improvement or deterioration in mental status with
time.
- Musculoskeletal: note any associated injuries.
TREATMENT
- Airway: Maintain patent airway by BLS maneuvers. Suction as needed.
Administer high concentration O
2
.
- Breathing: Assist ventilation as needed (rarely necessary).
- If child is in status epilepticus:
- EMT-B: Contact base. Attempt peripheral venous access x1. EMT-P: If
successful, administer Valium 0.3 mg/kg, slow IV.
- If unable to start peripheral IV:
- EMT-P: For ages under 8, administer Valium, 0.5 mg/kg rectally, not
to exceed 10 mg.
- EMT-P: For ages 8 and above, administer Versed 0.1 mg/kg IM or IN,
not to exceed 10 mg.
- Determine blood glucose level and draw appropriate blood tubes if
possible.
- If hypoglycemic, give dextrose (1-8 years should receive 2 ml/kg of a 25%
solution IV; <1 year should receive 2-4 ml/kg of 10% solution) or rule out
hypoglycemia with a blood sugar check. Hypoglycemia in pediatrics is
commonly defined as a blood sugar <40. If seizures continue, contact
base.
- If the child has stopped seizing and is postictal, transport while continuing
to monitor vital signs and neurological condition. Continue to provide
supplemental O
2
.
- If child is febrile initiate passive cooling measures.
- Febrile seizures occur in normal children between 6 months and 6 years.
Such seizures are usually short, lasting less than 5 minutes, generalized, and
usually do not require anti-seizure drug therapy.
- Do not force anything between the teeth.
- Consider hypoglycemia as a cause for non-traumatic seizure.
- Breath-holding spells in toddlers can resemble seizures, but are not a true
seizure.
- Most airways of seizing children can be managed with BLS measures.
Intubation is only necessary if there is prolonged apnea from Valium or from
the seizure activity itself.
POSSIBLE SUDDEN INFANT DEATH SYNDROME (SIDS)
- History: position in which the child was found, condition of the bed, last
time the child was seen well, seizure activity, trauma, possibility of
ingestion
- Associated symptoms: history of fever, respiratory symptoms, infection,
vomiting, diarrhea, other signs of infections
- Past medical history: prematurity, chronic illness
- ABCs
- Neurologic: level of consciousness, responsiveness, muscle activity and tone
- Skin: signs of trauma
- Dependent lividity or early rigor mortis
- Body temperature
TREATMENT
- Initiate or continue resuscitation based on field pronouncement protocol.
EMT-B: If resuscitation is to be performed, consider ALS for advanced
measures.
- Ventilate with 100% O
2
; suction as needed.
- Support cardiac output as indicated by:
- CPR
- EMT-P: Pediatric ALS as indicated
- Contact base for field pronouncement if appropriate.
- Support the parents and siblings.
- Activate appropriate support for the family if the patient is pronounced
dead in the field. Police, County Social Services, and the SIDS support line
should be contacted.
- Automatic External Defibrillator (AED) should be used in patients >1 year
old.
- Avoid premature assessments.
- The cause of SIDS is unknown. Cases occur between one month and one year
of age. All cases are mandatory coroner cases.
- Consider possible NAT (non-accidental trauma, child abuse) and pass on any
concerns to receiving facility personnel.
- For family support and community education, family members may welcome
the following contact information:
The Colorado SIDS Program, Inc., 425 S. Cherry St., Suite 890, Denver, CO
80246
Local #: 303-320-7771
Toll-free #: 1-888-285-7437
Website: http://www.coloradosids.org
PHARMACOLOGY/MEDICATION ADMINISTRATION
ALBUTEROL SULFATE
EMT-P: AMIODARONE
ASPIRIN (ASA)
EMT-P: CYANOKIT
DEXTROSE
EMT-P: DROPERIDOL
EMT-P: EPINEPHRINE
EMT-P: GLUCAGON
IV SOLUTIONS
DUODOTE NERVE AGENT ANTIDOTE KIT
NALOXONE (NARCAN)
NITROGLYCERIN
OXYGEN

PROCEDURES:
DESCRIPTION
- Adenosine is primarily formed from the breakdown product of adenosine
triphosphate (ATP). Both compounds are found in every cell of the human
body and have a wide range of metabolic roles.
- Adenosine slows tachycardias associated with the AV node via modulation of
the autonomic nervous system without causing negative inotropic effects. It
acts directly on sinus pacemaker cells and vagal nerve terminals to decrease
chronotropic and dromotropic activity.
- Adenosine is the drug of choice for paroxysmal supraventricular tachycardia
(PSVT).
ONSET AND DURATION
- Onset: almost immediate
- Duration: 10 seconds
INDICATIONS
- Conversion of PSVT to sinus rhythm
CONTRAINDICATIONS
- Second- or third-degree AV block
- Sick sinus syndrome
- Hypersensitivity to adenosine
ADVERSE REACTIONS
- Facial flushing
- Lightheadedness
- Paresthesia
- Headache
- Diaphoresis
- Palpitations
- Chest pain
- Hypotension
- Nausea
- Metallic taste
- Shortness of breath
DRUG INTERACTIONS
Methylxanthines (for example, caffeine and theophylline) antagonize the action
of adenosine. Dipyridamole potentiates the effect of adenosine; reduction of
adenosine dose may be required. Carbamazepine may potentiate the AV-nodal
blocking effect of adenosine.
DOSAGE AND ADMINISTRATION
- Adult:
- 12 mg IV rapid push followed by a 20 ml NS flush.
- Contact base for a second dose of 12 mg IV rapid push after an interval
of 1-2 minutes if the tachycardia persists.
- Total dose should not exceed 24 mg.
- Pediatric:
- 0.1 mg/kg, IV rapid push followed by 20 ml NS flush.
- If SVT persists, a second dose may be given using 0.2 mg/kg IV rapid
push, followed by 20 ml NS flush.
PROTOCOL
Tachycardia
- May produce bronchoconstriction in patients with asthma or
bronchopulmonary disease.
- At the time of conversion asystole or new rhythms may result. These
generally last a few seconds without intervention.
- Warn patients to expect a brief sensation of chest discomfort.
- Adenosine is not effective in atrial flutter or fibrillation.
- Concomitant use of dipyridamole (Persantine) enhances the effects of
adenosine. Smaller doses may be required.
- Caffeine and theophylline antagonize adenosine's effects. Larger doses may
be required.
- A 12-lead EKG should be performed and documented.
ALBUTEROL SULFATE
DESCRIPTION
- Albuterol is a sympathomimetic that is selective for beta-2 adrenergic
receptors. It relaxes smooth muscles of the bronchial tree and peripheral
vasculature by stimulating adrenergic receptors of the sympathetic nervous
system.
ONSET AND DURATION
- Onset: 5-15 minutes after inhalation
- Duration: 3-4 hours after inhalation
INDICATIONS
- Relief of bronchospasm in patients with reversible obstructive airway
disease
- Prevention of exercise-induced bronchospasm
CONTRAINDICATIONS
- Prior hypersensitivity reaction to albuterol
- Cardiac arrhythmias associated with tachycardia
- Tachycardia caused by digitalis intoxication
ADVERSE REACTIONS
- Tachycardia
- Restlessness
- Anxiety
- Headache
- Dizziness
- Nausea
- Palpitations
- Hypertension
- Arrhythmias
DRUG INTERACTIONS
- Sympathomimetics may exacerbate adverse cardiovascular effects.
Antidepressants may potentiate the effects on the vasculature. Beta
blockers may antagonize albuterol. Albuterol may potentiate diuretic-
induced hypokalemia.
- EMT-B: Contact base for orders.
- Adult:
- Place 2.5 mg/3 ml albuterol into a nebulizer; run at a flow rate (6-8
lpm) that will deliver the solution over 5 to 15 minutes. May be repeated
twice (total of 3 doses).
- Pediatric:
- Place 2.5 mg/3 ml albuterol into a nebulizer; run at a flow rate (6-8
lpm) that will deliver the solution over 5 to 15 minutes. May be repeated
twice (total of 3 doses).
PROTOCOL
Asthma
Chronic Obstructive Pulmonary Disease
Pneumonia
Pediatric Respiratory Distress
- May precipitate angina pectoris and arrhythmias.
- Should be used with caution in patients with diabetes mellitus,
hyperthyroidism, prostatic hypertrophy, or seizure disorder.
EMT-P: AMIODARONE
DESCRIPTION
- Amiodarone has multiple effects showing Class I, II, III and IV actions with a
quick onset. The dominant effect is prolongation of the action potential
duration and the refractory period.
INDICATIONS
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Wide complex tachycardia refractory to cardioversion
CONTRAINDICATIONS
- Wolff-Parkinson-White Syndrome (relative contraindication)
- Pulmonary congestion
- Cardiogenic shock
PRECAUTIONS
- Wide complex irregular tachycardia
- Sympathomimetic toxidromes, i.e., cocaine or amphetamine overdose
- NOT to be used to treat ventricular escape beats or accelerated
idioventricular rhythms
ADVERSE REACTIONS
- Severe hypotension
- Profound bradycardia
- Adult:
- Cardiac arrest:
- 300 mg IV/IO push, repeat once 150 mg IV/IO push in 3-5 minutes.
- After successful defibrillation, 150 mg IV/IO infusion over 10 minutes.
- Contact base for further doses. Maximum cumulative dose is 2 g
IV/24 hrs.
- Wide complex tachycardia:
- Contact base. 150 mg IV infusion over 10 minutes.
- Pediatric:
- Cardiac arrest:
- 5 mg/kg IV/IO over 3-5 minutes.
- Contact base for additional doses.
PROTOCOL
Ventricular Fibrillation/Pulseless Ventricular Tachycardia
Tachycardia
- A 12-lead EKG should be performed and documented.
- In the setting of cardiac arrest or peri-arrest, Amiodarone may be
administered by an EMT-B under the direct supervision of an EMT-P.
ASPIRIN (ASA)
DESCRIPTION
- In low doses, aspirin inhibits blood clotting, specifically the formation of
thromboxane A2, a platelet aggregating, vasoconstricting prostaglandin.
- Platelet aggregation has been implicated in the pathogenesis of
atherosclerosis contributing to the acute episodes of transient ischemic
attacks, unstable angina, and acute myocardial infarction. This has been
linked to anginal episodes. Unstable angina is precipitated by a sudden fall
in coronary blood flow.
- Aspirin has been shown to be beneficial in decreasing sudden cardiac death
and myocardial infarction in patients with unstable angina. It has also been
shown to be of added benefit in maintaining vessel patency after
thrombolytic therapy.
INDICATIONS
- Patients with chest pain that may be related to cardiac origin.
CONTRAINDICATIONS
- Patients with an active gastrointestinal bleed
- Patients with an allergy to aspirin
- Aspirin should be given to conscious patients who can voluntary chew and
swallow. Dose is four (4) 81 mg tablets.
PROTOCOL
Premature Ventricular Contractions (PVCs)
Chest Pain
- Aspirin should not be given for analgesia, e.g., head or body aches.
- Patients on Coumadin may be given aspirin.
DESCRIPTION
- Atropine is a parasympathetic or cholinergic blocking agent. As such, it has
the following effects:
- Increases heart rate (by blocking vagal influences)
- Increases conduction through AV node
- Reduces motility and tone of GI tract
- Reduces action and tone of urinary bladder (may cause urinary
retention)
- Dilates pupils
- Note: This drug blocks cholinergic (vagal) influences already present. If
there is little cholinergic stimulation present, effects will be minimal.
INDICATIONS
- Idioventricular cardiac arrests
- Hemodynamically unstable bradycardias
- To improve conduction in 2nd and 3rd degree heart block or in pacemaker
failure
- Organophosphate pesticide or nerve agent poisoning
PRECAUTIONS
- Should not be used without base contact for stable bradycardias
- Closed angle glaucoma
ADVERSE REACTIONS
- Headache
- Dry mouth
- Nausea
- Dizziness
- Tachycardia
- Palpitations
- Adult:
- Cardiac arrest:
- 1 mg IV/IO rapid push. Repeat every 3-5 minutes, not to exceed 3
mg.
- Hemodynamically unstable bradycardia:
- 0.5-1 mg IV/IO rapid push. Repeat if needed at 3-5 minute intervals
to a total of 3 mg. Stop at a ventricular rate which provides adequate
mentation and BP.
- Pediatric:
- Cardiac arrest:
- Refer to Broselow tape
- Hemodynamically unstable bradycardia:
- 0.02 mg/kg, IV/IO push. Minimum dose is 0.1 mg.
PROTOCOL
Bradycardia
Poisonings & Overdoses
Infant and Child Resuscitation
- Atropine causes pupillary dilation, even in cardiac arrest settings.
- In the setting of cardiac arrest or peri-arrest, atropine may be administered
by an EMT-B under the direct supervision of an EMT-P.
DESCRIPTION
- Calcium moderates nerve and muscle performance and facilitates normal
cardiac function. It is necessary for cardiac and vascular muscle
contractility.
- Calcium may aid in antagonizing cardiac toxicity caused by hyperkalemia.
INDICATIONS
- Cardiac arrest with history including any of the following:
- Patient with known hyperkalemia
- Renal failure
- Dialysis patient with suspected hyperkalemia
- Calcium channel blocker overdose
- Calcium channel blocker overdose confirmed by history or witnesses.
CONTRAINDICATIONS
- Known hypercalcemia
PRECAUTIONS
- Extravasation of calcium may cause tissue necrosis. Ensure IV patency prior
to infusion. When possible, infuse through an 18 gauge or larger IV.
- Can cause hypotension
- Adverse reactions may be increased by rapid administration.
- Should be used with caution in patients with digitalis toxicity
- Adult:
- Cardiac arrest:
- 1-3 g slow IV push over 2-3 minutes.
- Calcium channel blocker overdose:
- Contact base. 1-3 g slow IV push, may repeat every 10-20 minutes for
total 3-4 doses.
- Pediatric:
- Calcium channel blocker overdose:
- Contact base. 30-100 mg/kg (0.3-1.0 ml/kg), not to exceed 1 g slow
IV push, may repeat every 10-20 min for total 3-4 doses.
PROTOCOL
Medical Cardiac Arrest - Adult
Pulseless Electrical Activity (PEA)
- A 20 ml flush of normal saline should be given prior to administration of
calcium gluconate when other IV medications have been given.
- In the setting of cardiac arrest or peri-arrest, calcium gluconate may be

EMT-P: CYANOKIT
DESCRIPTION
- Hydrogen cyanide gas, which when inhaled can be fatal, is emitted in
smoldering and burning synthetics or plastics, most often common
household goods, or foam, asphalt and construction material.
- Cyanokit, the antidote to Hydrogen cyanide, contains hydroxocobalamin, a
precursor to vitamin B-12, which binds to cyanide and neutralizes it so the
poison is no longer toxic. The chemical is then eliminated through urination.
INDICATIONS
- Suspected moderate or severe exposure to Carbon Monoxide (CO), Cyanide
(CN), or a combination of both.
CONTRAINDICATIONS
- Hypersensitivity to vitamin B-12
- Moderate Exposure
- Exposure is considered to be a moderate level when:
- The patient has soot in the nose/mouth/oropharynx and
- The patient has altered mentation.
- Hypotension may or may not be present.
- Administer 100% O
2
, ventilate via BVM, ET intubation or CPAP as
indicated.
- Collect blood sample via purple top tube before starting IV.
- Initiate IV with NS @ TKO.
- Monitor EKG and pulse oximetry. Note that pulse oximetry
monitors may give false readings in patients exposed to CO and/or
CN.
- If hypotensive, consider fluid challenge and administer Cyanokit
on scene or en route:
- Adult:
- 5 g IV push over 15 minutes
- Pediatric:
- 70 mg/kg IV push
- Severe Exposure
- Exposure is considered to be severe when:
- The patient has soot in the nose/mouth/oropharynx and
- Is in a coma/respiratory or cardiac arrest and
- Is hypotensive
- Administer 100% O
2
, ventilate via BVM, ET intubation or CPAP as
indicated.
- Collect blood sample via purple top tube before starting IV.
- Initiate IV with NS @ TKO.
- Administer Cyanokit:
- Adult:
- 5 g IV push over 15 minutes, monitor for clinical
response/need for second 5g dose.
- Pediatric:
- 70 mg/kg IV push, monitor for clinical response/need for
second 70 mg/kg dose.
- Consider fluid challenge.
- Monitor EKG and pulse oximetry. Note that pulse oximetry
monitors may give false readings in patients exposed to CO and/or
CN.

Special Considerations
- Hydroxocobalamin can be the cause of multiple side effects, many of these
side effects increase dramatically with administration of the second 2.5 g
dose. The side effects, in order of frequency (and percentage of patients
that will experience them after the administration of the second 2.5 g
dose), are: chromaturia (100%), profound erythema (100%), rash (44%),
increase in B/P (44%), injection site reaction (39%), headache (33%).
- Cyanokit is provided with its own IV administration set. This administration
set is designed to run wide open and deliver each 2.5 g portion of the total
dose over 7.5 minutes.

PROTOCOL
Burns
DEXTROSE
DESCRIPTION
- Glucose is the body's basic fuel and is required for cellular metabolism. A
sudden drop in blood sugar level will result in disturbances of normal
metabolism, manifested clinically as a decrease in mental status, sweating
and tachycardia. Further decreases in blood sugar may result in coma,
seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin,
which stimulates storage of excess glucose from the blood stream, and
glucagon, which mobilizes stored glucose into the blood stream.
INDICATIONS
- Hypoglycemic states (i.e., insulin shock in the diabetic)
- The unconscious patient with an unknown history. Any patient with focal or
partial neurologic deficit or altered state of consciousness, which may be
due to hypoglycemia.
- Non-traumatic seizure patients who show no improvement in postictal state
- Patients in status epilepticus not responsive to Valium
- For adults, blood glucose test < 60 if clinically indicated; for pediatric
patients, blood glucose test < 40 if clinically indicated
- Poisons and Overdoses protocol
- In children with alcohol exposure, suspected sepsis, hypoperfusion or
altered mental status
PRECAUTIONS
- Patients presenting with signs of CVA, unless presenting with a significantly
low blood glucose
- Adult:
- 25 g (50 ml of a 50% solution) IV push
- Pediatric:
- 1-8 years: 2-4 ml/kg of a 25% solution IV push
- < 1 year: 2-4 ml/kg of a 10% solution IV push
- Note: Oral glucose can be used for conscious patients able to swallow.
PROTOCOL
Coma/Altered Mental Status/Neurologic Deficit
Psychiatric/Behavioral Emergencies
Seizures
Syncope
Pediatric Seizures
- Draw blood sample before administration if possible.
- Use glucometer before administration.
- Extravasation may cause tissue necrosis; use a large vein and aspirate
occasionally to ensure route patency.
- Dextrose should be diluted 1:1 with normal saline (to create D25W) for
patient 8 years and younger.
- In the setting of cardiac arrest or peri-arrest, dextrose may be administered
by an EMT-B under the direct supervision of an EMT-P.
DESCRIPTION
- Diazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle
relaxant through effects on the central nervous system.
INDICATIONS
- Status epilepticus
- Drug-induced hyperadrenergic states manifested by tachycardia and
hypertension (i.e., cocaine, amphetamine overdose)
- Combative patients from head injury or from suspected stimulant abuse
(i.e., cocaine, PCP, ecstasy, amphetamines)
- Severe musculoskeletal back spasms
- Sedation for cardioversion or transcutaneous pacing (TCP)
PRECAUTIONS
- Patients under the influence of alcohol
ADVERSE REACTIONS
- Drowsiness
- Dizziness
- Respiratory depression
- Fatigue
- Ataxia
- Paradoxical excitement or stimulation may occur
- Adult:
- 1-10 mg, slow IV push. Base contact is required for all situations except
status epilepticus.
- Pediatric:
- 0.3 mg/kg slow IV push over 2 minutes OR 0.5 mg/kg rectally up to a
maximum of 10 mg
PROTOCOL
Tachycardia
Seizures
Heat Emergencies
Head Trauma
Pediatric Seizures
- Since diazepam can cause respiratory depression and/or hypotension, the
patient should be monitored closely (vital signs, EKG, pulse oximetry).
Cardiac arrest can occur, although it is very rare.
- Patients receiving diazepam should be placed on oxygen.
- Do not give unless the patient is actively seizing.
DESCRIPTION
- Diphenhydramine blocks action of histamine released from cells during an
allergic reaction. Direct CNS effects, which may be stimulant or, more
commonly, depressant, depending on individual variation.
- Also has anticholinergic, anti-parkinsonian effects, which is used to treat
acute dystonic reactions to antipsychotic drugs (Haldol, Thorazine,
Compazine, etc.) These reactions include oculogyric crisis, acute torticollis,
and facial grimacing.
INDICATIONS
- Moderate allergic reactions
- Second line for anaphylaxis and severe allergic reactions
- Control extrapyramidal effects
PRECAUTIONS
- Lower respiratory diseases such as asthma or COPD
- Narrow-angle glaucoma
- Bladder obstruction
ADVERSE REACTIONS
- Dose-related drowsiness
- Dilated pupils
- Dry mouth and throat
- Flushing
- May potentiate with alcohol usage
DRUG INTERACTIONS
- CNS depressants and alcohol may have additive effects. MAO inhibitors may
prolong and intensify anticholinergic effects of antihistamines.
- Adult:
- 50 mg, IV bolus, or IM if vascular access has not been obtained
- Pediatric (< or = 8 y/o):
- 1-2 mg/kg slow IV push or IM (not to exceed 50 mg)
PROTOCOL
Allergies/Anaphylaxis
DESCRIPTION
- Dopamine is chemically related to epinephrine and norepinephrine. It acts
primarily on alpha-1 and beta-1 adrenergic receptors, increasing systemic
vascular resistance and exerting a positive inotropic effect on the heart. In
addition, the actions of this drug on dopaminergic receptors dilate renal
and splanchnic vasculature, maintaining blood flow. Dopamine is commonly
used to treat hypotension associated with cardiogenic shock.
INDICATIONS
- Symptomatic hypotension from causes other than hypovolemia
CONTRAINDICATIONS
- Patients with hypovolemia
ADVERSE REACTIONS
- Dose-related tachyarrhythmias
- Hypertension
- Increased myocardial oxygen demand
- Contact base for orders.
- Mix 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of
1600 mcg/ml.
PROTOCOL
Shock
- Dopamine is better administered using an infusion pump to ensure accurate
dosing.
- May become ineffective if added to solutions containing alkaloids.
- At low doses, decreased blood pressure may occur due to peripheral
vasodilatation. Increasing infusion rate will correct this.
- Tissue extravasation at the IV site can cause skin sloughing due to
vasoconstriction. Be sure to make Emergency Department personnel aware
if there has been any extravasation of dopamine-containing solutions, so
that proper treatment can be instituted.
- Can cause hypertensive crisis in susceptible individuals
- Certain antidepressants potentiate the effects of this drug. Check for
medications and contact base if other medications are being used.
INTRAVENOUS DOPAMINE DRIP RATES

Concentration: 1600 mcg/cc
Dose
Weight 5 10 15 20 (mcg/kg/min)
50 10 20 30 40 microdrops/min
60 10 25 35 45
70 15 25 40 50
80 15 30 45 60
90 15 35 50 70
100 20 35 55 75
110 20 40 60 85

EMT-P: DROPERIDOL
DESCRIPTION
- Droperidol is a butyrophenone derivative closely related to haloperidol.
Droperidol produces a dopaminergic blockage, a mild alpha-adrenergic
blockage, and causes peripheral vasodilation. Its major actions are
sedation, tranquilization, and a potent anti-emetic effect.
ONSET AND DURATION
- Onset: 3-10 minutes after IM or IV administration with peak effect in 30
minutes
- Duration: 2-4 hours
INDICATIONS
- The primary indication is to act as a chemical restraint in patients that
require transport and are behaving in a manner that poses a threat to their
own well-being or others.
- The secondary indication is for intractable vomiting with transport time
greater than 10 minutes.
- Combative head injured patients
CONTRAINDICATIONS
- Any patient:
- with a suspected acute myocardial infarction
- with a systolic blood pressure under 100 mm/Hg, or the absence of a
radial pulse
- under the age of 8
- exhibiting signs of sedation or respiratory depression
- with known kidney or liver dysfunction
- with known Parkinsons Disease
PRECAUTIONS
- Due to the vasodilation effect, droperidol can cause a transient hypotension
that is usually self-limiting and can be treated effectively with position and
fluids. Droperidol has also been known to cause tachycardia which usually
does not require pharmacologic intervention.
- Some patients may experience unpleasant sensations manifested as
restlessness, hyperactivity, or anxiety following droperidol administration.
- Extra-pyramidal reactions have been noted hours to days after treatment,
usually presenting as spasm of the muscles of the tongue, face, neck, and
back.
- Rare instances of neuroleptic malignant syndrome (very high fever,
muscular rigidity) have been known to occur after the use of droperidol.
- Adverse reactions have been known to be enhanced by rapid administration.
DRUG INTERACTIONS
- Droperidol will block the effectiveness of dopamine and causes a
paradoxical hypotension in the presence of epinephrine.
- Chemical restraint
- Adult:
- 2.5 mg slow IV push or IM administration
- After 10 minutes if desired effect has not been achieved, contact
base to consider a second dose.
- Antiemetic
- Contact base for orders
- Adult:
- 1.25 mg slow IV push or IM
- Pediatric (8-14 y/o):
- 0.05 mg/kg slow IV push or IM
PROTOCOL
Vomiting
Restraints
- Although extra-pyramidal reactions have an incidence less than 1 % and
usually present after the pre-hospital phase, be prepared to administer 50
mg diphenhydramine IV push or IM.
- Hypotension and tachycardia secondary to droperidol are usually self-
limiting and hypotension is correctable through recumbent positioning and
fluid administration. Be aware of other causes of these conditions,
especially in relation to a patient that is the victim of trauma.
- The action of droperidol potentiates the effect of sedative/tranquilizer type
medications and is relatively contraindicated in the known presence of
these types of indications. In this setting, be prepared for respiratory
depression, apnea, muscular rigidity to droperidol, and a reduced dose
should be used. Consult with base to determine the appropriate dose.
- IV fluids are the preferred treatment for nausea and vomiting in all children
below the age of 14.
- Due to droperidols potential effect on QT interval prolongation, all patients
receiving droperidol will be placed on the cardiac monitor. Though it is
understood that obtaining an ECG tracing on the combative or agitated
patient may be difficult, every effort should be made to do so.
EMT-P: EPINEPHRINE
DESCRIPTION
- Epinephrine stimulates alpha, beta-1, and beta-2 adrenergic receptors in
dose-related fashion.
- The cardiovascular effects include increased heart rate and blood pressure,
arterial vasoconstriction and increased myocardial contractile force, oxygen
consumption, automaticity and irritability.
- Epinephrine also serves as a potent bronchodilator.
INDICATIONS
- Bronchial asthma
- Acute allergic reaction
- Bradycardia
- Cardiac arrest
- Airway obstruction secondary to croup or epiglottitis
ADVERSE REACTIONS
- Headache
- Nausea
- Vomiting
- Anxiety
- Tremors
- Palpitations
- May precipitate angina
DRUG INTERACTIONS
- May be deactivated by alkaline solutions (e.g., sodium bicarbonate, Lasix).
- Adult:
- Cardiac arrest:
- 1 mg (10 ml of 1:10,000 solution) IV/IO push. Repeat every 3-5
minutes.
- Bradycardia:
- 1 mg (1:1,000) in 250 ml NS. Begin at 2 mcg/min. Titrate to BP of 90
mmHg systolic.
- Moderate or severe allergic reactions:
- 0.3-0.5 mg (0.3-0.5 ml of 1:1,000 solution) IM (in the thigh if
possible)
- Anaphylaxis:
- 0.3-0.5 mg (1:1,000) IM (in the thigh if possible) followed by 1 mg
(1:1,000) in 250 ml NS. Run at 2-4 ml/min.
- Asthma:
- 0.3-0.5 mg (0.3-0.5 ml of 1:1,000 solution) IM (in the thigh if
possible)
- Pediatric:
- Cardiac arrest:
- 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO push. Repeat every
3-5 minutes.
- Bradycardia:
- 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV
- Moderate or severe allergic reactions:
- 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM
- Anaphylaxis:
- Asthma:
- Life-threatening airway obstruction suspected secondary to croup or
epiglottitis:
- In the absence of racemic epinephrine, plain L-epinephrine can be
used. The dose is 5 mg (5 ml of 1:1,000 solution of L-epinephrine,
undiluted, nebulized). In smaller infants, weighing <10 kg, the
recommended dose is 0.5 ml/kg of 1:1,000 L-epinephrine.

PROTOCOL
Asystole
Bradycardia
Asthma
- Syncope has occurred after epinephrine administration to asthmatic
children.
- May increase myocardial oxygen demand.
- In the setting of cardiac arrest or peri-arrest, epinephrine may be
DESCRIPTION
- Epinephrine stimulates alpha, beta-1, and beta-2 adrenergic receptors in
dose-related fashion.
- The cardiovascular effects include increased heart rate and blood pressure,
arterial vasoconstriction and increased myocardial contractile force, oxygen
consumption, automaticity and irritability.
- Epinephrine also serves as a potent bronchodilator.
INDICATIONS
- The patient has a history consistent with allergic reaction and exhibits any
one of the following:
- Respiratory distress/airway compromise with tongue swelling or stridor.
- Signs and symptoms of hypoperfusion (shock)
- Patient has his/her own physician prescribed Epinephrine Auto-Injector.
PRECAUTIONS
- Increased myocardial oxygen consumption can precipitate angina or
myocardial infarction in patients with coronary artery disease.
- Use with caution in patients with hypertension or known coronary artery
disease.
ADVERSE REACTIONS
- Headache
- Nausea
- Vomiting
- Anxiety
- Tremors
- Palpitations
- May precipitate angina
- Adult:
- One Epinephrine Auto-Injector (0.3 mg)
- Pediatric:
- One pediatric Epinephrine Auto-Injector (0.15 mg)
- Follow the standard drug administration protocol.
- Administer a single dose of Epinephrine Auto-Injector.
- In a patient with hypoperfusion, early venous access should be anticipated.
- Dispose of Auto-Injector in a biohazard container.
- Reassess patients vital signs and condition 1-2 minutes after
administration.
- Only a single auto-injector should be utilized. Should the patients condition
persist or worsen, contact base for additional orders.
DESCRIPTION
- Used as an analgesic and sedative. Does not cause histamine release.
ONSET AND DURATION
- Onset: Within 5 minutes, with a peak effect within 30 minutes
- Duration: 90 minutes
INDICATIONS
- Pain management of extremity injuries; to be given only in the absence of
any evidence of head, chest or abdominal injuries.
- Management of pain secondary to selected medical problems (abdominal
pain, back pain, kidney stones).
- Burns
CONTRAINDICATIONS
- Hypersensitivity to opiates
- Hypotension
ADVERSE REACTIONS
- Can cause significant respiratory depression and hypotension especially
when used in combination with other sedatives such as alcohol or
benzodiazepines.
- Can increase intracranial pressure.
- Chest wall rigidity has been reported with rapid administration.
- Pediatric patients may develop apnea without manifesting significant
mental status changes.
- Adult:
- 2-4 mcg/kg IN or slow IV push with a max dose of 4 mcg/kg or 300 mcg
not to exceed 100 mcg every 2-5 minutes.
- Contact base for any single dose > 100 mcg or cumulative doses > 300
mcg.
- Pediatric:
- 1-2 mcg/kg IN or slow IV push
PROTOCOL
Multiple Trauma Overview
Abdominal Pain
Extremity Injuries

Special Considerations
For minor orthopedic injury that may warrant pain management but does not
require IV access, intranasal administration of Fentanyl, using the same IV/IM
dose, is acceptable.
EMT-P: GLUCAGON
DESCRIPTION
- Increases blood sugar concentration by converting liver glycogen to glucose.
- Glucagon also causes relaxation of smooth muscle of the stomach,
duodenum, small bowel, and colon.
ONSET AND DURATION
- Onset: Within 1 minute
- Duration: 3-6 minutes
INDICATIONS
- Altered level of consciousness where hypoglycemia is suspected and IV
access is unavailable.
- May be used for beta-locker/calcium channel blocker overdose.
CONTRAINDICATIONS
- Hypersensitivity to Glucagon
- Use with caution in patients with a history of cardiovascular disease, renal
disease, pheochromocytoma or insulinoma.
ADVERSE REACTIONS
- Tachycardia
- Headache
- Nausea and vomiting
DOSAGE AND ADMINISTRATIONS
- Adult:
- Hypoglycemia:
- 1 mg IM
- Beta blocker/Calcium channel blocker overdose:
- 2 mg IV push
- Pediatric (> 8 y/o):
- Hypoglycemia:
- 0.1 mg/kg IM. Maximum dose 1 mg.
- Beta blocker/Calcium channel blocker overdose:
- 0.1 mg/kg IV. Maximum dose 1 mg.
PROTOCOL
Seizures
Syncope
DESCRIPTION
- Used as a bronchodilator that dries respiratory tract secretions.
ONSET AND DURATION
- Onset: 5-15 minutes after inhalation
- Duration: 6-8 hours after inhalation
INDICATIONS
- Bronchospasm related to asthma, chronic bronchitis, or emphysema
CONTRAINDICATIONS
- Hypersensitivity reaction to Atrovent
PRECAUTIONS
- Should not be used as the primary agent for treatment of bronchospasm.
- Use with caution in patients with coronary artery disease.
- Vital signs and EKG must be monitored.
ADVERSE REACTIONS
- Palpitations
- Dizziness
- Anxiety
- Tremors
- Headache
- Nervousness
- Dry mouth
- Adult and pediatric (> 2 y/o):
- Mild/Moderate bronchospasm:
- Ipratropium may be used in combination with albuterol as described
below if patient is unresponsive to initial albuterol nebulization
treatment.
- Severe bronchospasm:
- Place one premixed vial of Atrovent (0.5 mg/2.5 ml) along with
albuterol in a nebulizer and administer via oxygen-powered nebulizer
to create a fine mist. If patient requires further treatment,
continuous nebulization of plain albuterol should be utilized (see
albuterol protocol).
PROTOCOL
Asthma
- Can cause paradoxical bronchospasm. Discontinue treatment if this occurs.
IV SOLUTIONS
DESCRIPTION
- Initiation of all IVs in the field in these protocols utilizes normal saline (NS).
- The standard IV drip rate will be TKO unless a fluid bolus or fluid challenge
is required.
- Flow rate through a 14 gauge IV catheter is twice the rate through an 18
gauge IV catheter volume administration in trauma patients can be
accomplished more rapidly. If the patient has poor veins, a smaller bore is
better than no IV at all in some instances.
- IVs in an unstable trauma patient should be placed en route, and may be
left to the hospital setting for short transports. Do not delay transport in
critical patients for IV attempts.
- If you are unable to start in two attempts, another qualified attendant may
try, or you may leave the IVs for the hospital.
- 1 ml/min = 60 microdrops/min = 15 regular drops/min.
TKO FLUID RATE
INDICATIONS
- Prophylactic IV
- Drug administration
- TKO = 5-10 drops/min. or saline lock
FLUID REPLACEMENT/BOLUS
INDICATIONS
- Hemorrhagic shock, volume depletion (dehydration, burns, severe vomiting)
- Shock caused by increased vascular space (neurogenic shock)
PRECAUTIONS
- In hemorrhagic shock, volume expansion with blood is the treatment of
choice. Normal saline will temporarily expand intravascular volume and buy
time, but does decrease oxygen-carrying capacity, and is insufficient in
severe shock. Because of this, rapid transport is still necessary to treat
severely hypovolemic patients who need blood and possibly surgical inter-
vention.
- Volume overload is a constant danger, particularly in cardiac patients. Keep
a close eye on your IV rate during transport. For this reason, a fluid
challenge (see below) is more appropriate in cardiac patients.
- 20 ml/kg NS through a large bore cannula, as rapidly as possible. Contact
base if more than one fluid bolus is indicated.
FLUID CHALLENGE
INDICATIONS
- Hypotension felt to be secondary to cardiac cause (i.e., acute MI,
pericardial tamponade, cardiogenic shock)
- 250-500 ml rapidly through a large bore cannula, then re-assess the patient.
DESCRIPTION
- Magnesium sulfate reduces striated muscle contractions and blocks
peripheral neuromuscular transmission by reducing acetylcholine release at
the myoneural junction.
- In cardiac patients, it stabilizes the potassium pump, correcting
repolarization. It also shortens the Q-T interval in the presence of
ventricular arrhythmias due to drug toxicity or electrolyte imbalance.
- In respiratory patients, it may act as a bronchodilator in acute
bronchospasm due to asthma or other bronchospastic diseases. For best
results, it should be used after normal field inhalation therapy has been
attempted.
- For obstetric cases, it controls seizures by blocking neuromuscular
transmission. Also lowers blood pressure and decreases cerebral vasospasm
INDICATIONS
- Cardiac:
- Refractory VF and pulseless VT (after amiodarone)
- Cardiac arrest from suspected torsade de pointes
- Wide complex tachycardia with pulse and without poor perfusion
- Respiratory:
- Acute bronchospasm unresponsive to continuously nebulized albuterol
and Atrovent, and epinephrine.
- Obstetrics: Pregnancy > 20 weeks with signs and symptoms of pre-
eclampsia, defined as:
- Blood pressure > 180 mmHg systolic or > 120 mmHg diastolic with altered
mental status or
- Seizures (eclampsia)
PRECAUTIONS
- Heart block
- Decrease in respiratory or cardiac functions
- Use with caution in patients on digitalis
ADVERSE REACTIONS
- Reduced heart rate
- Circulatory collapse
- Cardiac arrest refractory VF and pulseless VT or torsade de pointes:
- 2 g IV push
- Wide complex tachycardia with pulse and without poor perfusion or acute
bronchospasm:
- 2 g IV over 2 minutes
- Pre-eclampsia/eclampsia patients:
- Mix 6 g in 50 ml of NS and run over 15-30 minutes
PROTOCOL
Asthma
Seizures
- Principal side effect is respiratory depression.
- NOT to be used in pediatric patients
- In the setting of cardiac arrest or peri-arrest, magnesium sulfate may be

DuoDote
TM
NERVE AGENT ANTIDOTE KIT
DESCRIPTION
- Nerve agents can enter the body by inhalation, ingestion, and through skin.
These agents are absorbed rapidly and can produce injury or death within
minutes. The DuoDote
TM
Nerve Agent Antidote Kit consists of one auto-
injector for self and/or buddy administration. One injector contains 2.1mg
atropine and 600mg pralidoxime chloride (2-PAM).

INDICATIONS
- Suspected nerve agent exposure accompanied with signs and symptoms of
nerve agent poisoning
- Injection sites:
- Outer thigh mid-lateral thigh (preferred site)
- Buttocks upper lateral quadrant of buttock (gluteal) in thin individuals
- Place the auto-injector in the dominant hand. Firmly grasp the center of
the auto-injector with the green tip (needle end) pointing down.

- With the other hand, pull off the gray safety release. The DuoDote
TM
auto-
injector is now ready to be administered.

- The injection site is the mid-outer thigh. The DouDote
TM
auto-injector can
inject through clothing. However, make sure pockets at the injection site
are empty.

- Swing and firmly push the green tip at a 90 degree angle against the mid-
outer thigh. Continue to firmly push until you feel the auto injector trigger.

- No more than three (3) sets of antidote should be administered.

- Presence of tachycardia is not a reliable indicator of effective treatment
due to potential nicotinic effects of nerve agent exposure. The end point of
treatment is clear, dry lung sounds.
- Attempt to decontaminate skin and clothing between injections.

DESCRIPTION
- Medication names:
- Generic: albuterol. isoetharine, metaproternol
- Trade: Proventil, Ventolin, Bronchosol, Alupent, Metaprel
- These medications are all bronchodilators.
ONSET AND DURATION
- Onset: Rapid
INDICATIONS
- Wheezing due to bronchial asthma, COPD or bronchospasm related to an
allergic reaction.
- Patient has chief complaint of shortness of breath and has a history of
bronchial asthma or COPD.
- Patient has a physician-prescribed bronchial inhaler. Note: The
bronchodilator must be prescribed for this patient. If in doubt, contact
base. No over-the-counter medications should be administered.
PRECAUTIONS
- If the patient is not breathing adequately on his/her own, the treatment of
choice is ventilation.
- The patient in need of a metered dose inhaler for wheezing should also be
on supplemental O
2
.
ADVERSE REACTIONS
- Common adverse reactions include hypertension, chest pain, increased
heart rate, nervousness, tremors, nausea, vomiting, and sore throat.
- Follow the steps in the Standard Drug Administration Protocol.
- Administer supplemental O
2
.
- Confirm prescription identification.
- Ascertain how many times the patient has used the inhaler.
- Shake the inhaler vigorously.
- Have the patient place the actuator two finger breadths away from his/her
mouth. If the patient has a spacer, use it. The patient should begin to
inhale as deeply as he/she can. Depress the canister shortly after inhalation
has begun. Have the patient hold his or her breath as long as comfortably
possible, and then exhale. This should be repeated to accomplish the two
puffs.
- In the event of a prolonged transport and the patient is not getting better,
contact base for additional orders.
PROTOCOL
Asthma

DESCRIPTION
- Solu-Medrol is a synthetic steroid that suppresses acute and chronic
inflammation and may alter the immune response. In addition, it
potentiates vascular smooth muscle relaxation by beta-adrenergic agonists
and may alter airway hyperactivity. An additional newer use is for reduction
of posttraumatic spinal cord edema.
INDICATIONS
- Anaphylaxis
- Severe asthma
- COPD
CONTRAINDICATIONS
- Hypersensitivity reaction to Solu-Medrol
ADVERSE REACTIONS
- Gastrointestinal bleeding
- Hypertension
- Adult:
- 125 mg, slow IV push over 2 minutes
- Pediatric:
- 2 mg/kg, slow IV push over 2 minutes
PROTOCOL
Asthma
- Must be reconstituted and used immediately.
- Be aware that the effect of Solu-Medrol is generally delayed for several
hours. Although it is worthwhile to administer Solu-Medrol early in the
treatment of a patient with severe respiratory distress or anaphylaxis you
may not see any effect from the drug for several hours. Do not expect to
see any immediate response.
- Solu-Medrol is not considered a first line drug. Be sure to attend to the
patients primary treatment priorities (i.e., airway, ventilation, beta-
agonist neublization) first. If primary treatment priorities have been
completed and there is time while in route to the hospital, then Solu-Medrol
can be administered. Do not delay transport to administer this drug.
DESCRIPTION
- Versed is a water-soluble benzodiazepine that may be administered for
sedation to relieve apprehension or impair memory.
- Versed is also used as an anticonvulsant.
INDICATIONS
- Sedation for cardioversion or transcutaneous pacing (TCP)
- Status epilepticus in adults as an IM or IN benzodiazepine when two IV
attempts have been unsuccessful. If an IV is obtained, then Valium should
be used.
- Chemical sedation in the combative patient due to suspected
sympathomimetic (e.g., meth, cocaine, PCP) overdose.
- Chemical sedation for an intubated patient.
- To mitigate possible shivering in response to Therapeutic Induced
Hypothermia
CONTRAINDICATIONS
- Hypersensitivity reaction to benzodiazepines
- Acute narrow angle glaucoma
ADVERSE REACTIONS
- Significant hypotension
- Significant respiratory depression
- Apnea
- Amnesia
DRUG INTERACTIONS
- Sedative effect of Versed may be heightened by associated use of
barbiturates, alcohol, CNS depressants, or narcotics.
- Adult:
- Cardioversion and TCP:
- 2 mg IV/IO, may repeat if necessary.
- Status epilepticus:
- > 8 y/o: 2-5 mg IV/IM or IN, titrate to effect.
- Combative sympathomimetic overdose:
- 5 mg IM or IN
- Sedation for an intubated patient:
- 2 mg IV
- Therapeutic Induced Hypothermia:
- 5 mg IV or IM
- Pediatric:
- Cardioversion and TCP:
- 0.1 mg/kg IV/IM/IO
- Maximum dose 10 mg
- Status Epilepticus
- 0.1 mg/kg IV/IM/IN

PROTOCOL
Bradycardia
Tachycardia
Seizures
Restraints
Heat Emergencies
Pediatric Seizures
- Provide continuous monitoring of respiratory and cardiac function.
- Have resuscitation equipment and medication readily at hand.
- Consider lower doses for elderly patients.
- Though IV or IM (if IV access is unavailable) are the preferred routes of
administration, if unable to utilize either route IN administration is
acceptable.
DESCRIPTION
- Morphine sulfate is a natural opium alkaloid that increases peripheral
venous capacitance and decreases venous return. It promotes analgesia,
euphoria, and respiratory and physical depression. Morphine sulfate is a
schedule II drug.
ONSET AND DURATION
- Onset: Immediate
INDICATIONS
- Chest pain of a likely cardiac origin
- Severe burns
- Cardiogenic pulmonary edema
- Pain management of extremity injuries, to be given only in the absence of
head, chest or abdominal injuries
CONTRAINDICATIONS
- Hypersensitivity reaction to morphine
- Hypovolemia
- Hypotension (relative)
- Head injury or undiagnosed abdominal pain
ADVERSE REACTIONS
- Hypotension
- Nausea and/or vomiting
- Vasodilation (tachycardia or bradycardia)
- IV only
- Adult:
- 2-10 mg slow IV push. Initial dose up to 4 mg, then 2 mg increments up
to a total of 10 mg, then contact base. The goal is decreased anxiety
and patient comfort; patient need not be completely pain-free.
- Pediatric:
- 0.1-0.2 mg/kg slow IV push.
PROTOCOL
Chest Pain
Hypertension
Pulmonary Edema
Burns
Extremity Injuries
- Vital signs, including pulse oximetry and EKG should be monitored regularly.
- Narcan and resuscitation equipment should be readily available.
- Patients with isolated extremity injuries can receive morphine in
conjunction with fentanyl.
NALOXONE (NARCAN)
DESCRIPTION
- Narcan is a narcotic antagonist which completely binds to narcotic sites, but
which exhibits almost no pharmacological activity of its own.
ONSET AND DURATION
- Onset: Within 5 minutes
INDICATIONS
- For reversal of CNS and respiratory depression induced by narcotics:
- Codeine
- Fentanyl citrate (Sublimaze)
- Heroin
- Morphine sulfate
- Hydromorphone (Dilaudid)
- Methadone
- Meperidine (Demerol)
- Oxycodone (Percodan)
- Paregoric
- Propoxyphene (Darvon)
- Coma/altered mental status of unknown origin
- Seizure of unknown etiology (rule out narcotic overdose, specifically
propoxyphene)
PRECAUTIONS
- Hypersensitivity reaction to Narcan
- Use with caution in narcotic-dependent patients who may experience
violent withdrawals. Do not hesitate to restrain these patients.
ADVERSE REACTIONS
- Tachycardia
- Hypertension
- Arrhythmias
- Diaphoresis
- Adult (> or = 8 y/o):
- Titrate up to 2 mg IV, IM or IN if IV not available
- If no response is observed, this dose may be repeated after 5 min. if
narcotic overdose strongly suspected.
- Pediatric (< 8 y/o):
- 1 mg IV
- If no response is observed, this dose may be repeated after 5 min. if
narcotic overdose strongly suspected.
PROTOCOL
Medical Cardiac Arrest
Seizures
- This drug is remarkably safe and free from adverse reactions. Do not
hesitate to use it if indicated.
- While Narcan is used diagnostically in coma or altered mental status with
cardiorespiratory depression, the drug is not to be used on patients who do
not exhibit the above indications. For example, a patient who is alert and
oriented with slow verbal response does not need Narcan.
- The duration of some narcotics is longer than Narcan and the patient must
be monitored closely. Repeated doses of Narcan may be required. Patients
who have received this drug must be transported to the hospital because
coma may reoccur when Narcan wears off.
- With an endotracheal tube in place and assisted ventilation, narcotic
overdose patients may be safely managed without Narcan. Think twice
before totally reversing coma airway may be lost, or (worse) the patient
may become violent and may refuse transport.
NITROGLYCERIN
DESCRIPTION
- It was originally believed that nitrates and nitrites dilated coronary blood
vessels, thereby increasing blood flow to the heart. It is now believed that
atherosclerosis limits coronary dilation and that the benefits of nitrates and
nitrites result from dilation of arterioles and veins in the periphery. The
resulting reduction in preload and to a lesser extent in afterload decreases
the workload of the heart and lowers myocardial oxygen demand.
- Nitroglycerin is very lipid soluble and is thought to enter the body from the
Gl tract through the lymphatics rather than the portal blood.
ONSET AND DURATION
- Onset: 1-3 minutes
- Nitro paste:
- Varies greatly (15-60 minutes for onset with peak effect in 30-120
minutes) and is largely affected by application site and amount of drug
in contact with the skin.
INDICATIONS
- Angina
- Chest, arm, or neck pain caused by coronary ischemia
- Patients with 12-lead evidence of acute MI, with or without chest pain
- Control of hypertension in angina, acute MI, or hypertensive encephalopathy
without evidence of CVA
- Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac
preload and afterload
PRECAUTIONS
- Hypersensitivity reaction to nitroglycerin
- Use with caution in patients with EKG evidence of right ventricular
infarction
- Hypotension
- Patients taking medications for erectile dysfunction such as Viagra
(sildenafil) or Levitra (vardenafil) should not be given nitroglycerin within
24 hours, and Cialis (tadalafil) within 48 hours of use, and then only with
caution and consideration of risk and benefits. Consider base contact for
physician consultation
ADVERSE REACTIONS
- Transient headache
- Postural syncope
- Hypotension
- Flushing
- Dizziness
- Burning under the tongue
- EMT-P:
- 0.4 mg (1/150) tablet sublingually, or one metered spray; may repeat
every 5 minutes as needed for effect. Contact base for direct physician
order for administration beyond 3 paramedic administered doses.
- For extended patient contact (e.g., DIA) with systolic BP > 100 mmHg,
consider administration of 1 nitroglycerin paste applied to chest wall
after initiation of nitro therapy. Remove nitro paste if patients systolic
BP drops below 100 mmHg.
- Blood pressure to be checked prior to each dose.
- Contact base for direct physician order for patients with systolic BP less
than 100 mmHg or with signs of poor peripheral perfusion or
hypotension.
- EMT-B: Follow the below instructions to assist patient with their own
nitroglycerin and call for ALS.
- Ascertain how many nitro tablets or sprays were taken by the patient
prior to your arrival.
- Follow the steps in the Standard Drug Administration Protocol.
- The dosage of nitroglycerin should be one tablet or spray sublingually
every 3-5 minutes if the chest pain/discomfort persists and systolic
blood pressure remains > 100 mmHg. Not to exceed three tablets or
sprays including any doses prior to your arrival.
- Contact base for an order to administer.
- Administer one tablet or spray under the patients tongue.
- Reassess the vital signs and the patients condition (chest
pain/discomfort) after 1-2 minutes.
- If the patient is continuing to have chest pain after three nitroglycerin
tablets or sprays, contact base physician again. The physician may want
to authorize additional nitroglycerin depending on the situation.
PROTOCOL
Premature Ventricular Contractions (PVCs)
Chest Pain
Hypertension
Pulmonary Edema
- Susceptibility to hypotension in older adults increases.
- Nitroglycerin loses potency when exposed to light or heat.
- Because nitroglycerin causes generalized smooth muscle relaxation, it may
be effective in relieving chest pain caused by esophageal spasm.
DESCRIPTION
- Ondansetron is a selective 5-HT3 receptor antagonist. Mechanism of action
has not been fully characterized. It is not certain whether ondansetrons
anti-emetic action is mediated centrally, peripherally, or in both sites.
INDICATIONS
- Severe nausea
- Vomiting
CONTRAINDICATIONS
- Patients with a known hypersensitivity to odansetron.
PRECAUTIONS
- Ondansetron is listed as a category B with regard to use in pregnancy.
- Adult:
- 4 mg slow IV push or IM over 2 to 5 minutes
- Pediatric < 40 kg:
- 0.1 mg/kg slow IV push or IM to a maximum of 4 mg
- For pregnant patients and individuals under the age of 18, base contact is
required.
PROTOCOL
Abdominal Pain
Vomiting
OXYGEN
DESCRIPTION
- Oxygen added to the inspired air raises the amount of oxygen in the blood,
and therefore, the amount delivered to the tissue. Tissue hypoxia causes
cell damage and death. Breathing, in most people, is regulated by small
changes in the acid-base balance and CO
2
levels. It takes relatively large
decreases in oxygen concentration to stimulate respiration.
INDICATIONS
- Suspected hypoxemia or respiratory distress from any cause
- Acute chest or abdominal pain
- Hypotensive states from any cause
- Trauma
- All acutely ill patients
- Any suspected carbon monoxide poisoning
- Pregnant females
PRECAUTIONS
- If the patient is not breathing adequately, the treatment of choice is
ventilation not just oxygen.
- A small percentage of patients with chronic lung disease breathe because
they are hypoxic. Administration of oxygen will inhibit their respiratory
drive. Do not withhold oxygen because of this possibility. Be prepared to
assist ventilations if needed.
- When pulse oximeter is available, titrate SaO
2
to 90% or greater.
- In the COPD patient: increase oxygen in increments of 2 liters/minute every
2-3 minutes until improvement is noted (color improvement or increase in
mental status).
Dosage Indications
Low Flow 1-2 liters/min Minor medical/trauma
Moderate Flow 3-9 liters/min Moderate medical/trauma
High Flow 10-15 liters/min Severe medical/trauma
- Restlessness may be an important sign of hypoxia.
- On the other hand, some people become more agitated when a nasal
cannula is applied, particularly when it is not needed. Acquiesce to your
patient if it is reasonable.
- Nasal prongs work equally well on nose and mouth breathers, except babies.
- Non-humidified oxygen is drying and irritating to mucous membranes.
- Oxygen toxicity is not a hazard of short-term use.
- Do not use permanently mounted humidifiers. If the patient warrants
humidified oxygen, use a single patient use device.
- During long transports for high altitude illness, reduce oxygen flow from
high to low to conserve oxygen.

OXYGEN FLOW RATE
METHOD FLOW RATE OXYGEN INSPIRED AIR
(approximate)
Room Air 21%
Nasal Cannula

1 L/min
2 L/min
6 L/min
24%
28%
44%
Simple Face Mask 8 - 10 L/min 40-60%
Non-Rebreather Mask 10 L/min 90%
Mouth to Mask 10 L/min
15 L/min
80%
50%
Bag-valve-mask (BVM) Room Air
12 L/min
21%
40%
Bag-valve-mask with reservoir 10-15 L/min 90-100%
O
2
-powered breathing device Hand-regulated 100%

NOTE:
Most hypoxic patients will feel more comfortable with an increase of inspired
oxygen from 21% to 24%.
DESCRIPTION
- Used for topical nasal administration, phenylephrine primarily exhibits
alpha adrenergic stimulation. This stimulation can produce moderate to
marked vasoconstriction and subsequent nasal decongestion.
INDICATIONS
- Prior to nasotracheal intubation to induce vasoconstriction of the nasal
mucosa
PRECAUTIONS
- Avoid administration into the eyes, as it will cause dilation of the pupils
- Instill two drops of 1% solution in the nostril prior to attempting
nasotracheal intubation
PROTOCOL
EMT-P: Nasotracheal Intubation
DESCRIPTION
- Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for
use by oral inhalation only. Effects are those of epinephrine. Inhalation
causes local effects on the upper airway as well as systemic effects from
absorption. Vasoconstriction may reduce swelling in the upper airway, and
beta effects on bronchial smooth muscle may relieve bronchospasm.
ONSET AND DURATION
- Onset: 1-5 minutes
INDICATIONS
- Life threatening airway obstruction suspected secondary to croup or
epiglottitis
ADVERSE REACTIONS
- Tachycardia
- Anxiety
- Palpitations
- Do not delay transport to begin administration
- 0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml
saline, via nebulizer at 6-8 LPM to create a fine mist
- If racemic epinephrine is not available plain L-epinephrine may be used:
- Place 5 mg (5.0 ml of a 1:1,000 solution) in a nebulizer at 6-8 LPM to
create a fine mist
- For infants <10 kg, the recommended dose is 0.5 mg/kg (0.5 ml/kg of
1:1,000 solution) of L-epinephrine.
PROTOCOL
- Always try to utilize the parents help as the mask may frighten children.
- Racemic epinephrine is heat and light sensitive. It should be stored in a
dark, cool place. Discoloration is an indication for discarding it.
- Do not confuse the adverse reactions with respiratory failure or imminent
respiratory arrest.
- If respiratory arrest occurs, it is usually due to patient fatigue or laryngeal
spasm. Complete obstruction is not usually present. Ventilate the patient,
administer oxygen, and transport rapidly. If you can, ventilate and
oxygenate the patient adequately with a BVM. Intubation is best left to a
specialist in a controlled setting.
- Try to differentiate croup from epiglottitis by history. Cough is usually
present in croup. Do not use a tongue blade to examine the back of the
throat. The diagnosis is frequently difficult in the field, but a critical
patient deserves a trial of racemic epinephrine during transport. Although
used as specific therapy for croup, it may also buy some time in patients
with epiglottitis.
DESCRIPTION
- Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in
the body. Acids are increased when body tissues become hypoxic due to
cardiac or respiratory arrest.
INDICATIONS
- Tricyclic overdose with arrhythmias, widened QRS complex, hypotension,
seizures
- Consider for patients in prolonged cardiac arrest.
- Consider for dialysis patients in cardiac arrest (presumed secondary to
hyperkalemia).
CONTRAINDICATIONS
- Metabolic and respiratory alkalosis
- Hypocalcemia
- Hypokalemia
ADVERSE REACTIONS
- Metabolic alkalosis
- Hyperosmolarity may occur, causing cerebral impairment
DRUG INTERACTIONS
- May precipitate in calcium solutions.
- Alkalinization of urine may increase half-lives of certain drugs.
- Vasopressors may be deactivated.
- Contact base for direct physician order for tricyclic overdose.
- Solutions:
- Adult/Pediatric: 8.4% = 1.0 mEq/ml
- Neonatal: 4.2% = 0.5 mEq/ml
- (Either prepackaged or adult solution diluted 1:1 with sterile NS)
- Adult:
- 1 mEq/kg (1 ml/kg)
- Pediatric:
- Neonatal:
PROTOCOL
Medical Cardiac Arrest
Asystole
- Sodium bicarbonate administration increases CO
2
which rapidly enters cells,
causing a paradoxical intracellular acidosis.
- Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This
increases intravascular volume, which increases the workload of the heart.
Sodium bicarbonate's lack of proven efficacy and its numerous adverse
effects have lead to the reconsideration of its role in cardiac resuscitation.
Effective ventilation and circulation of blood during CPR are the most
effective treatments for acidemia associated with cardiac arrest
- Administration of sodium bicarbonate has not been proven to facilitate
ventricular defibrillation or to increase survival in cardiac arrest. Metabolic
acidosis lowers the threshold for the induction of ventricular fibrillation,
but has no effect on defibrillation threshold.
- The inhibition effect of metabolic acidosis on the actions of catecholamines
has not been demonstrated at the pH levels encountered during cardiac
arrest.
- Metabolic acidosis from medical causes (e.g., diabetes) develops slowly,
and field treatment is rarely indicated.
- Sodium bicarbonate may be considered for the dialysis patient in cardiac
arrest due to suspected hyperkalemia.
- In the setting of cardiac arrest or peri-arrest, sodium bicarbonate may be
DESCRIPTION
- Used for topical administration as a pain reliever for eye irritation. Only
proparacaine and tetracaine are approved for use.
ONSET AND DURATION
- Onset: 20-30 seconds
INDICATIONS
- Used to provide topical ophthalmic anesthesia during transport of patients
with actual or potential serious eye injuries that present with a "foreign
body sensation".
CONTRAINDICATIONS
- Known allergy to local anesthetics
- Global lacerations or rupture
- Discoloration of medication
ADVERSE REACTIONS
- Occasional burning/stinging can occur when initially applied, although this
is usually transient
- Instill two drops into affected eye.
- Repeat only with base contact.
- Do not apply until patient consents to transport to an emergency
department for definitive therapy since application may totally relieve pain
and, therefore, instigate an inappropriate refusal.
- Topical ophthalmic anesthetics should never be given to a patient for self-
administration.
- The patient may further damage the eye secondary to anesthesia of the
cornea.
- Only use a fresh, unopened bottle for each patient.
- Do not touch the tip of the bottle on anything as this will contaminate the
medication.
- The following protocol should be followed with the administration of any
pre-hospital medication.
- Perform initial patient assessment.
- Administer supplemental oxygen.
- Obtain vital signs.
- Assess the need for medication.
- Ensure medication to be delivered is prescribed to the patient.
- Contact base if required per protocol for an order to administer
medication.
- Administer the medication.
- Reassess the vital signs and patient condition after 1-2 minutes.
- If the patients condition persists or worsens, contact base for additional
guidance.
- Complete your patient care record with full documentation of the
patients symptoms, the patient assessment, the patient vital signs, the
time and the amount of the drug given, and the effect the medication
had on the patients condition.
- The above steps should be performed while initiating patient
transportation. The administration of field medication should not delay
patient transportation.
- EMT-B: All patients receiving patient assisted drug administration should be
transported to the hospital.
INDICATIONS
- Patients receiving an IV in the field and who, in the judgment of the field
providers, will need blood tests in the emergency department
- Patients receiving IV dextrose in the field
- Patients that may have been exposed to carbon monoxide
PRECAUTIONS
- Use BSI.
- Proper identification of the patient and the specimen(s) is mandatory.
- Improper technique in obtaining the specimen will result in inaccurate or
invalid test results. This wastes critical time and defeats the purpose of
drawing specimens in the field.
TECHNIQUE
- After initiating an IV and removing the needle, attach the Vacutainer holder
to the hub of the IV catheter (this is accomplished using the Luer adaptor
attached to the Vacutainer holder).
- Fill all the desired blood tubes in appropriate order per system
requirements.
- Tubes containing anticoagulant should be inverted gently back and forth at
least ten times to insure adequate mixing of blood with the substance in the
tube. Do not shake the tube as this could cause hemolysis, which could
interfere with test results.
- Any discrepancy in identification must be reported immediately to the
emergency department charge nurse.
- Pediatrics receiving an IV should have at least a speckled red tube and
lavender top tube drawn. The red top may be filled only halfway and the
lavender only 1/4 of the way to do the needed tests. If available, red and
lavender pediatric tubes may be used.
- The blue top tube must be filled exactly, according to the vacuum.
- Blood samples should be drawn prior to the administration of IV fluid, in
order to provide a better and less dilute sample for potential donor
patients.
INDICATIONS
- Peripheral IV cannot be established in 2 attempts and the patient exhibits
one or more of the following:
- Cardiac arrest (medical or trauma)
- Peri-arrest (see definition under Special Considerations)
CONTRAINDICATIONS
- Consider alternate site if any of the following exist:
- Fracture of the bone selected for IO infusion.
- Excessive tissue at insertion site with the absence of anatomical
landmarks.
- Previous significant orthopedic procedures to include IO insertion within
24 hours or prosthesis.
- Infection at the site selected for insertion.
EQUIPMENT REQUIRED
- EZ-IO Driver
- EZ-IO Adult or Pediatric Needle Set
- Adult patients are categorized as > 40 kg, pediatric patients are
categorized as 3-39 kg.
- Alcohol Swab
- EZ-Connect or blood pump
- Pressure bag
- 10 ml syringe
- Normal Saline
TECHNIQUE
- Locate appropriate insertion site
- Tibial plateau one finger breadth below the tuberosity on the
anteromedial surface
- Prepare insertion site using aseptic technique
- Prepare the EZ-IO driver and appropriate needle set
- Stabilize site and insert appropriate needle set
- Remove EZ-IO driver from needle set while stabilizing catheter hub
- Remove stylet from catheter, place stylet in sharps container
- Confirm placement
- Connect primed EZ-Connect or blood pump
- Syringe bolus or blood pump flush the EZ-IO catheter with normal saline.
- Utilize pressure via pressure bag for continuous infusion.
- Dress site, secure tubing and apply wristband to patient.
- Monitor EZ-IO site for occlusion
- If the initial IO attempt is unsuccessful, attempt again at another site. Do
not use the same extremity more than once.
- If a rapid syringe bolus or blood pump flush of saline is not performed prior
to infusion the IO will not likely flow.
- Insertion of the EZ-IO in conscious patients does not require local
anesthesia. IO infusion in conscious patients has been noted to cause severe
discomfort.
- For purposes of this protocol, peri-arrest is defined as: A condition in which
the patient presents with a reasonable expectation of suffering cardiac
arrest in the absence of immediate intervention, while in the care of the
pre-hospital provider.
INDICATIONS
- Illness or injury which requires medication to improve or maintain the
patient's condition
PRECAUTIONS
- Use BSI.
- Certain medications can be administered via one route only, others via
several. If you are uncertain about the drug you are giving, check with
base.
- Make certain that the medication you want to give is the one in your hand.
Always double check medication and dose before administration.
- The IM route is unpredictable; medications are absorbed erratically via this
route and may not be absorbed at all if the patient is seriously ill and
severely vasoconstricted. The IV route should be used almost exclusively in
the field. If an IV cannot be started, the IO route is the best alternative.
EMT-P: MEDICATION DRAW TECHNIQUE
- Use syringe just large enough to hold appropriate quantity of medication (or
use pre-filled syringe).
- Attach large gauge needle to syringe.
- Break ampule or cleanse vial with alcohol.
- Using sterile technique, draw medication into syringe.
EMT-P: INTRAMUSCULAR ADMINISTRATION
- Prepare medication to be administered.
- Check medication in hand. Confirm medication, dose, amount, and
expiration date.
- Prep area of skin with alcohol or Betadine wipes.
- Inject 22 gauge needle, 1.5 length into desired muscular site (deltoid,
gluteus, or vastus lateralis) at a 90 angle. Aspirate to ensure needle is not
in blood vessel.
- Inject medication slowly into muscular site.
- Withdraw needle and observe for any bleeding or swelling. Apply sterile
dressing to injection site.
- Record medication given, dose, amount, and time.
INTRAVENOUS INJECTION ADMINISTRATION
- Use needle appropriate for viscosity of fluid injected. Glucose requires
larger gauge needle; for most other medications, smaller is appropriate.
- Wipe IV tubing injection site with alcohol.
expiration date.
- Eject air from syringe.
- Insert needle into injection site.
- Pinch IV tubing closed between bag and needle.
- Inject at a rate appropriate for medication.
- Withdraw needle and release tubing to restore flow.
- Give 20 ml NS flush after giving any drugs.
MUCOSAL ATOMIZER DEVICE
- Draw up medication to be administered.
- Expel air from syringe.
- Attach the IN directly to syringe.
- Briskly compress plunger.
NEBULIZATION ADMINISTRATION
- Use hand-held nebulizer with mouthpiece (or mask for patient unable to
hold mouth piece).
expiration date.
- Draw up dose of medication in syringe or dropper; inject into nebulizer.
- Attach to O
2
tubing and set at 6-8 LPM (sufficient to produce good
vaporization).
- Administer for approximately 5 minutes, until solution is gone from
chamber.
EMT-P: RECTAL ADMINISTRATION
- Use a tuberculin syringe (without needle) lubricated with a water-soluble,
lubricating jelly.
- Check medication in hand. Confirm medication, dose, and expiration date.
- Insert needleless syringe into rectum completely to end of syringe (4-5cm).
- Inject the medication and withdraw the syringe. No flushing is necessary.
COMPLICATIONS
- Local extravasation during IV medication injection, particularly with
dopamine or dextrose, may cause tissue necrosis. Watch carefully and be
ready to stop injection immediately.
- Allergic and anaphylactic reactions occur more rapidly with IV injections,
but may occur with medication administered by any route.
- Too rapid IV injection can cause untoward adverse reactions (except for
adenosine); for example, Valium can cause apnea, and epinephrine can
cause asystole or severe hypertension.
- IM injections cause uncertain medication levels over time. Later treatment
may be jeopardized because of slow release and late effects of medication
given hours before.
- Several medications are carried in different concentrations in an emergency
medical kit. Be sure you are using the correct concentration!
INDICATIONS
- Peri- or post-arrest after two unsuccessful peripheral IV attempts
- Otherwise same indications as venous access technique
PRECAUTIONS
- Discontinue any intermittent or continuous infusion pumps.
- Assure placement and patency of the Vascular Access Device (VAD) prior to
infusing any fluids or medications.
- Due to uncontrolled environment in which pre-hospital IVs are started, take
extra care to use sterile technique.
- For graft and fistula access:
- Due to possible high pressures exerted against IV catheters with a return
in pulse, a chevron must be placed in addition to typical IV securement
techniques.
- For tunneled catheter access:
- Place patient in either supine or reverse trendelenburg position and have
them hold their breath to prevent air embolism when
connecting/disconnecting from ports.
- Be sure to withdraw heparin from the port that is to be used.
- Complications for this procedure are the same as complications related to
venous access.
GRAFT AND FISTULA ACCESS TECHNIQUE
- Base contact is required.
- Clean area of graft/fistula with betadine and with aseptic technique.
- Graft (artificial/implanted):
- Do not use a tourniquet.
- Grasp both sides of a graft to prevent it from rolling.
- Use a 14 or 16 gauge needle with the bevel up.
- Insert needle at a 45 angle, wait for a flash and advance catheter.
- Connect to IV tubing and fluid
- Secure with at least one piece of tape over the catheter and chevron.
- Fistula (native vasculature):
- Can use a tourniquet for < 1 minute
- Hold traction on the vein.
- Use a 14 or 16 gauge needle with the bevel up. If using fistula for the
first time or the fistula is immature, use a smaller gauge needle.
- Insert needle at a 25-30 angle, wait for a flash and advance
catheter.
- Connect to IV tubing and fluid
- Secure with at least one piece of tape over the catheter and chevron.
- Assess for a thrill or bruit whenever possible to help determine if it is
functional access (also will be on the arterial side).
- Dont advance a needle into a dip or shallow region of the access it is a
bad site for access.
- Vascular access might be on an arterial side. This will require a pressure bag
or pump to keep blood from backing up with the return of cardiac activity.
- If this happens, a blood pressure cuff can be used. Inflate cuff to point
where blood no longer backs up.
- There is no need to remove access.
- If patient has both a fistula and/or graft as well as a tunneled catheter, use
tunneled catheter as this is probably the only functioning access.
- If access attempt is unsuccessful, leave line in place and tape it securely
down.
- If the catheter is pulled, apply direct constant pressure for at least 10
minutes.
- No more than 2 attempts at each site.
- Reassess site often as needles can frequently work their way out of the
access point.
SURGICALLY IMPLANTED CATHETERS TECHNIQUE
- Assemble IV bag, tubing, tape, and two 5 ml syringes
- Use aseptic technique (use sterile gloves and apply betadine on both ports).
- Unclamp port that you will be using.
- Withdraw 5 ml from port that is to be used, to remove heparin/TPA.
- Clamp port that fluid has been withdrawn from.
- Connect IV tubing to ports.
- Unclamp ports.
- Secure in similar fashion to peripheral IV.
- Leave the port unclamped if using and if connecting to syringe/tubing.
IMPLANTED PORTS TECHNIQUE
- Identify the location and type of VAD (e.g., implanted port).
- Utilize knowledgeable family members, significant others or home visiting
nurse if available.
- Discontinue and/or disconnect any pumps or medications.
- Carefully palpate the location of the implanted port.
- If multiple ports, identify the port to be used.
- Using sterile technique, prep the site with alcohol and/or povidone-iodine
pad. Wipe from the center outward three times in a circular motion.
- Using a sterile gloved hand, press the skin firmly around the edges of the
port.
- Using a syringe filled with solution, insert the needle perpendicular to the
skin.
- Aspirate slowly for blood return and then flush the port prior to infusion.
When aspirating blood from a VAD, use a syringe that is 10 ml or less to
avoid complications.
- Secure the IV tubing.
- Reassess the infusion site.
- Reassess the patient.
COMPLICATIONS
- Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is
suspected, do not utilize the lumen.
- Catheters are durable but may leak or can be torn. Extravasation of fluids
or medications occurs and may cause burning and tissue damage. Clamp the
catheter and do not use.
- Air embolism may occur if the VAD is not clamped in between infusions.
Avoid this by properly clamping the catheter and preventing air from
entering the system.
- If heparin/TPA was not removed prior to accessing the surgically implanted
catheter, the hospital needs to be notified of this event.
INDICATIONS
- Administer fluids for volume expansion
- Administer drugs
PRECAUTIONS
- Do not start IVs distal to a fracture site or through skin damage with more
than erythema or superficial abrasion.
- Due to the uncontrolled environment in which pre-hospital IVs are started,
take extra care to use sterile technique.
- Due to the high complication rate associated with pre-hospital IV therapy,
use good judgment when deciding which patients should receive an IV.
TECHNIQUE
- Connect tubing to IV solution bag.
- Fill drip chamber one-half full by squeezing.
- Tear sufficient tape to anchor IV in place.
- Use BSI.
- For pediatric patients consider applying an arm board or splint prior to
venipuncture.
- Scrub insertion site with alcohol or iodine pads.
- Don't palpate, unless necessary, after prep.
- Perform venipuncture as described in the specific techniques described in
this protocol.
- After the catheter is in place, remove the needle or stylette, draw bloods
when possible and connect tubing.
- Open full to check flow and placement and then slow to TKO rate unless
otherwise indicated or ordered.
- Secure tubing with tape, making sure of at least one 180 turn in the tubing
when taping to be sure any traction on the tubing is not transmitted to the
cannula itself.
- Anchor with arm board or splint as needed to minimize chance of losing line
with movement.
- Re-check to be sure IV rate is as desired.
COMPLICATIONS
- Pyrogenic reactions due to contaminated fluids become evident in about 30
min after starting the IV. Patient will develop fever, chills, nausea,
vomiting, headache, backache, or general malaise. If observed, stop and
remove IV immediately. Save the solution so it may be cultured.
- Local: hematoma formation, infection, thrombosis, phlebitis. Note: the
incidence of phlebitis is particularly high in the leg. Avoid use of lower
extremity if possible.
- Systemic: sepsis, pulmonary embolus, catheter fragment embolus, fiber
embolus from solution in IV
- Antecubital veins are useful access sites for patients in shock, but if
possible, avoid areas near joints (or splint well!).
- The point between the junction of two veins is more stable and often easier
to use.
- Start distally, and if successive attempts are necessary, you will be able to
make more proximal attempts on the same vein without extravasating IV
fluid.
- Venipuncture has little morbidity; however, the excess fluids inadvertently
run in when nobody is watching can be fatal!
- The most difficult problem with IV insertion is in knowing when to try and
when to stop trying. Valuable time is often wasted attempting IVs when a
critical patient requires blood. IV solutions may buy time, but they
frequently lose time instead. In critical patients do not delay transport
while attempting IV insertion at the scene. IVs may be placed en route.
- Blood pumps are only necessary on those patients that will be receiving
blood products due to hemorrhage secondary to medical or traumatic
etiology upon arrival at the Emergency Department.
- Cardiac Alerts, hypotensive patients not requiring blood products or
patients who are candidates for Adenosine administration do not require a
blood pump. Use of a macro drip administration set is sufficient.

INDICATIONS
- Inability to secure extremity IV access
TECHNIQUE
- Position the patient: supine, head down (this may not be necessary or
desirable if congestive heart failure or respiratory distress present). Turn
patient's head opposite side of procedure.
- Align the cannula in the direction of the vein, with the point aimed toward
the ipsilateral shoulder (on the same side).
- Tourniquet the vein lightly with one finger above the clavicle and apply
traction to the skin above the angle of the jaw.
- Make puncture midway between the angle of the jaw and the midclavicular
line.
- Puncture the skin with the bevel of the needle upward; enter the vein
either from the side or from above.
- Note blood return and advance the catheter over the needle and remove
tourniquet.
TECHNIQUE
- Apply tourniquet proximal to proposed site to venous return only.
- Hold vein in place by applying gentle traction on vein distal to point of
entry.
- Puncture the skin (with the bevel of the needle upward) about 0.5 to 1 cm
from the vein and enter the vein either from the side or from above.
- Note blood return and advance the catheter over the needle and remove
tourniquet.
ASSESSMENTS
SCENE SIZE-UP
INITIAL ASSESSMENT
FOCUSED ASSESSMENT MEDICAL
DETAILED ASSESSMENT
ONGOING ASSESSMENT

Scene Size Up
Safe Scene Unsafe
Scene
Control Scene
Move Patient
Correct Hazard
Initial Assessment
TRAUMA PATIENT MEDICAL PATIENT
Focused History
and Physical Exam
Focused History
and Physical Exam
Evaluate
Mechanism of
Injury
Responsive Unresponsive
SAMPLE History Rapid Medical
Assessment
Significant MOI No Significant MOI
Focused Medical
Assessment Based
on Patient
Complaint
Rapid Trauma
Assessment
Focused Trauma
Assessment for
Specific Injury
Baseline Vital Signs
SAMPLE History
Transport
SAMPLE History
Transport
SAMPLE History
Detailed Physical
Exam Transport
Components of
Detailed Physical
Exam
Transport
Detailed Physical
Exam
Components of
Detailed Physical
Exam
Ongoing Assessment
Communication
Documentation
SCENE SIZE-UP

- Recognize environmental hazards to rescuers, and secure area for treat-
ment. Implement body substance isolation (BSI).
- Make sure you and your partner are safe. Also make sure the patient and
bystanders are safe. Move the patients and bystanders to safe area if
needed.
- Recognize hazard for patient, and protect from further injury.
- Identify number of patients. Initiate a triage system if appropriate per the
Mass Casualty Incident Management protocol.
- Observe position of patient, mechanism of injury, surroundings.
- Identify self.
- Initiate communications if hospital resources require mobilization call for
backup if needed.
INITIAL ASSESSMENT

- Form a general impression of the patient (sick/not sick; hurt/not hurt).
- Determine the chief complaint/apparent life threats.
- Assess mental status:
- A Alert
- V Responsive to verbal stimulus
- P Responsive to painful stimulus
- U Unresponsive
- Briefly note body position and extremity movement.
- Airway:
- Observe the mouth and upper airway for air movement.
- Open airway if needed: use head tilt-chin lift in medical patients, chin
lift (without head tilt) or jaw thrust in trauma victims.
- Protect cervical spine from movement in appropriate trauma victims.
Use assistant to provide continuous manual stabilization.
- Look for evidence of upper airway problems such as vomitus, bleeding,
or facial trauma.
- Clear upper airway of mechanical obstruction with finger sweep or
suction as needed.
- Breathing:
- Expose chest and observe chest wall movement.
- Note respiratory rate (qualitative), noise, and effort.
- Auscultate breath sounds.
- Treat respiratory arrest with:
- BVM for initial ventilatory control
- Check pulse and begin CPR if no pulse.
- EMT-P: Intubate after initial ventilations if necessary.
- Assess for partial or complete obstruction. Treat according to the
Obstructed Airway protocol.
- If respiratory rate < 12/min or breathing appears inadequate:
- Assist respirations with BVM; administer supplemental O
2
.
- EMT-P: Consider nasotracheal or orotracheal intubation to secure airway
if necessary.
- Transport rapidly.
- Observe skin color and mentation for signs of hypoxia.
- Administer O
2
for signs of hypoxia.
- Look for life-threatening respiratory problems and briefly stabilize.
- Open or sucking chest wound: seal
- Large flail segment: stabilize
- Tension pneumothorax: transport rapidly and EMT-P: decompress chest
per Needle Decompression protocol.
- Circulation:
- Pulse
- Palpate for a pulse. The presence of a radial pulse implies BP > 80
mmHg systolic; carotid or femoral pulse presence implies BP > 60-70
mmHg systolic. If the patient is pulseless and apneic, begin CPR.
- Note pulse quality (strong, weak) and general rate (slow, fast,
moderate).
- Pediatric patients: check capillary refill time in fingertips. 2 seconds
is normal.
- Major bleeding
- Control hemorrhage by direct pressure with clean dressing to wound.
If needed, use elevation and pressure points. Use a tourniquet ONLY
in an extreme situation.
- Identify priority patients
- If evidence of medical shock or severe hypovolemia, obtain baseline vital
signs immediately and begin treatment according to medical and trauma
protocols.
SPECIAL NOTES
- Initial assessment may take 30 seconds or less in a medical patient or victim
of minor trauma. In the severely traumatized patient, however, assessment
and treatment of life-threatening injuries evaluated in the initial
assessment may require rapid intervention, with further assessment and
treatment en route to the hospital.
- In the patient that is awake, your initial greeting to the patient may
complete the initial assessment. This may make it clear that the ABCs are
stable and emergency intervention is not required before completing the
assessment.
- The neck should be immobilized and secured during airway assessment or
immediately following the initial assessment if indicated.
- Vital signs should be obtained during the focused and detailed assessment.
If immediate intervention for profound shock or hypoventilation is required,
this may need to be initiated before numerical vital signs are taken.
FOCUSED ASSESSMENT - MEDICAL

- A focused medical assessment is done on all conscious medical patients. In
patients that are awake, this may consist only of identifying yourself and
noting the patients responsiveness and general appearance.
- The formal detailed assessment may not need to be done on patients with a
specific complaint, such as chest pain. Assessment must be no less
thorough, but it may be limited to the body systems that are pertinent to
the presenting problem.
- Based on the information obtained from the initial assessment, perform
either a rapid or focused medical assessment followed by a detailed exam.
FOCUSED RESPONSIVE PATIENT
- Chief complaint
- Assess history of present illness:
- O Onset (When did it begin?)
- P Provocation (What brings it on or makes it better or worse?)
- Q Quality (On a scale of 1-10 can you rate the pain?)
- R Radiation (Does the pain go anywhere? Where is the pain?)
- S Severity (Compare the pain to before is it worse/better/the same?)
- T Time (How long does the pain last?)
- Obtain SAMPLE information:
- S Signs and symptoms
- A Allergies
- M Medications
- P Pertinent medical history
- L Last oral intake, last menstrual period
- E Events leading to illness
- Obtain baseline vital signs: blood pressure, pulse, respirations, skin
temperature, and color.
- Based on the exam findings, initiate proper interventions.
- Transport as soon as possible.
- Perform detailed physical exam.
- Perform ongoing assessments.

- The focused assessment is performed on the specific injury site.
- As you inspect and palpate the specific injury, look and feel for the
following examples of injuries or signs of injury:
- D Deformities
- C Contusions/Crepitation
- A Abrasions
- P Punctures/Penetrations/Paradoxical movement
- B Burns
- T Tenderness
- L Lacerations
- S Swelling
- Assess baseline vital signs: blood pressure, pulse, respirations, skin
- S Signs and symptoms, chief complaint
- A Allergies
- M Medications

- Perform a rapid assessment of the specific area of complaint.
- Position the patient to protect the airway.
- Assess the head.
- Assess the neck.
- Assess the chest.
- Assess the abdomen.
- Assess the pelvis.
- Assess the extremities.
- Assess the posterior body.
- Obtain baseline vital signs: blood pressure, pulse, respirations, skin
- A Allergies
- M Medications

- Perform a rapid trauma assessment on patients with significant mechanism
of injury (MOI) to determine life-threatening injuries. The rapid trauma
assessment should be performed on responsive and unresponsive patients
alike. An integral part of this assessment is evaluation using the simple
mnemonic DCAP-BTLS. In the responsive patient, symptoms should be
sought before and during the trauma assessment.
- Continue spinal immobilization
- Reconsider transport decision
- Assess mental status:
- A Alert
- V Responsive to verbal stimulus
- P Responsive to painful stimulus
- U Unresponsive
- As you inspect and palpate, look and feel for the following examples of
injuries or signs of injury:
- D Deformities
- C Contusions/Crepitation
- A Abrasions
- P Punctures/Penetrations/Paradoxical movement
- B Burns
- T Tenderness
- L Lacerations
- S Swelling
- Assess the head; inspect and palpate for injuries or signs of injury
(DCAP-BTLS).
- Assess the neck; inspect and palpate for injuries or signs of injury (DCAP-
BTLS).
- Assess the chest; inspect and palpate for injuries or signs of injury
(DCAP-BTLS).
- Assess the abdomen; inspect and palpate for injuries or signs of injury
(DCAP-BTLS).
- Assess the pelvis; inspect and palpate for injuries or signs of injury
(DCAP-BTLS).
- Assess the extremities; inspect and palpate for injuries or signs of injury
(DCAP-BTLS).
- Roll the patient with spinal precautions and assess posterior body;
inspect and palpate for injuries or signs of injury (DCAP-BTLS).
- Assess baseline vital signs: blood pressure, pulse, respirations, skin
- A Allergies
- M Medications

DETAILED ASSESSMENT

- Detailed assessment is the systematic assessment of the entire patient. It
should be performed after:
- Initial assessment
- Stabilization and initial treatment of life-threatening airway, breathing,
or circulatory difficulties
- Cervical immobilization as needed
- The purpose of the detailed assessment is to uncover problems which are
not life-threatening, but which could be injurious or could become life-
threatening to the patient.
- Initial vital signs
- Head and face:
- Observe for deformities, asymmetry, bleeding.
- Palpate for deformities, tenderness, and crepitation.
- Reassess airway for potential obstruction: dentures, bleeding, loose
or avulsed teeth, vomitus, abnormal tooth position from mandible
fracture, and absent gag reflex.
- Eyes: pupils (equal or unequal, responsiveness to light), foreign
bodies, contact lenses
- Nose: deformity, bleeding discharge
- Ears: bleeding, discharge, bruising behind ears
- Neck:
- Reassess for deformity or tenderness if the patient is not already
immobilized.
- Observe for wounds, neck vein distention, use of neck muscles for
respiration, altered voice, and medical alert tags.
- Palpate for crepitation, tracheal shift.
- Chest:
- Observe for wounds, chest wall movement, and accessory muscle
use.
- Palpate for tenderness, wounds, fractures, crepitation, and unequal
rise of chest.
- Have patient take a deep breath and observe for pain, symmetry, or
air leak from wounds.
- Auscultate chest for rales, wheezes, ronchi, or decreased breath
sounds.
- Abdomen:
- Observe for wounds, bruising, and distention.
- Palpate all four quadrants for tenderness and rigidity.
- Consider orthostatic vital signs for volume status.
- Pelvis:
- Palpate and compress lateral pelvic rims for tenderness or instability.
- Shoulders/upper extremities:
- Observe for angulation, protruding bone ends, and symmetry.
- Palpate for tenderness and crepitation.
- Note distal pulses, color, and medical alert tags.
- Check sensation.
- Test for weakness by having the patient squeeze your hands if no
obvious fracture is present.
- If there is no obvious fracture, gently move arms to check overall
function.
- Lower extremities:
- Observe for angulation, protruding bone ends, and symmetry.
- Palpate for tenderness and crepitation.
- Note distal pulses and color.
- Check sensation.
- Test for weakness by having the patient push and pull feet against
your hands if no obvious fracture is present.
- If there is no obvious fracture, gently move legs to check overall
function.
- Back:
- Immobilize if there is any suspicion of back injury. To the extent that
immobilization allows, palpate for wounds, fractures, and
tenderness.
- Re-check motor and sensory function as appropriate.
ONGOING ASSESSMENT

- Repeat and record the initial assessment for a stable patient every 15
minutes. For an unstable patient, repeat and record the initial assessment
every 5 minutes.
- Reassess mental status.
- Maintain an open airway.
- Monitor breathing for rate and quality.
- Reassess pulse for rate and quality.
- Monitor skin color and temperature.
- Reassess and record vital signs.
- Repeat the focused assessment regarding patient complaints or injuries.
- Check interventions:
- Assure adequacy of oxygen delivery/artificial ventilation
- Assure management of bleeding.
- Assure adequacy of other interventions.

Management of patients with head injury or neurologic illness depends on
careful assessment of neurologic function. Changes are particularly important.
The first observations of neurologic status in the field provide the basis for
monitoring sequential changes. Therefore, it is important that the first
responder accurately observes and records neurologic assessment using
measures that will be followed throughout the patients hospital course.

- Vital signs: observe particularly for adequacy of ventilations depth,
frequency, and regularity of respirations.
- Level of consciousness:

Glasgow Coma
Score
Eye opening: Spontaneously
To speech
To pain
None
4
3
2
1
Best verbal response: Oriented
Disoriented sentences
Inappropriate words
Garbled sounds
None
5
4
3
2
1
Best motor response: Obeys commands
Localizes pain
Withdrawal to pain
Abnormal flexion
Abnormal extension
None
6
5
4
3
2
1
Score = Sum of scores in 3 categories (15 points possible)

- Eyes: direction of gaze, extraocular movement, size and reactivity of pupils
- Movement: observe whether all four extremities move equally well.
- Sensation (if the patient is awake): observe for absent or abnormal
sensation at different levels if cord injury is suspected.
SPECIAL NOTES
- The Glasgow Coma Scale (GCS) used above has gained acceptance as one
method of scoring and monitoring patients with head injury. It is readily
learned, has little observer-to-observer availability, and accurately reflects
cerebral function. Always record specific responses rather than just the
score (sum of observations). In areas where numerical assignment of scores
is not a formal procedure, the observations of the GCS still provide an
excellent basis for field neurologic assessment. Note also that the other
parameters listed must be observed to assess fully the neurologically
impaired patient.
- Use your written report to follow and document changes in neurologic
findings.
- At a minimum, gross motor function must be documented before and after
moving a patient with suspected spinal injury.
- Sensory deficit levels should be marked gently on the patients skin with a
pen to help identify any changes.
- Note what stimulus is being used when recording responses. Applied noxious
stimuli must be adequate to the task but not excessive. Initial mild stimuli
can include a light pinch, dull pinprick, or light sternal rub. If these are
unsuccessful at eliciting a pain response, pressure with a dull object to the
base of the nail bed, a stronger pinch (particularly in the axilla), or sternal
rub will be necessary to demonstrate the patients best motor response.
- When responses are not symmetrical, use the motor response of the best
side for scoring GCS and note asymmetry as part of the neurologic
examination.
- Use of restraints or intubation of the patient will make some observations
less accurate. Be sure to note in report if circumstances do not permit a full
verbal, motor or sensory evaluation.
- Remember that a patient who is totally without response will have a score
of 3, not 0.
- In small children, the GCS may be difficult or impossible to evaluate. Use an
age-appropriate neurological assessment for small children. Children who
are alert and appropriate should focus their eyes and follow our actions,
respond to parents or caregivers, and use language and behavior
appropriate to their age level. In addition, they should have normal muscle
tone and a normal cry. Several observers should attempt to elicit a best
verbal response to avoid over or underestimation of level of consciousness.

Children can be examined easily from head to toe, but lack of understanding by
the patient, poor cooperation, and fright often limit the ability to assess
completely in the field. Children often cannot verbalize what is bothering
them, so it is important to do a systematic survey that covers areas that the
patient may not be able to tell you about. Any observations about spontaneous
movements of the patient and areas that the child protects are very important.
In the patient with a medical problem, the more limited set of observations
listed below should pick up potentially serious problems.
- General:
- Level of alertness, eye contact, attention to surroundings
- Muscle tone: normal, increased, or weak and flaccid
- Responsiveness to parents, caregivers: Is the patient playful or irritable?
- Head:
- Signs of trauma
- Fontanelle, if open: abnormal depression or bulging
- Face:
- Pupils: size, symmetry, reaction to light
- Hydration: brightness of eyes: Is child making tears? Is the mouth moist?
- Neck:
- Note stiffness.
- Chest:
- Note presence of stridor, retractions (depressions between ribs on
inspiration) or increased respiratory effort.
- Auscultate the chest:
- Breath sounds: symmetrical, rales, wheezing?
- Heart: rate, rhythm
- Abdomen: distention, rigidity, bruising, tenderness
- Extremities:
- Brachial pulse
- Signs of trauma
- Muscle tone, symmetry of movement
- Skin temperature and color, capillary refill
- Areas of tenderness, guarding or limited movement
- Neurologic exam


- Do not let the gathering of information distract from management of life-
threatening problems.
- Appropriate questioning can provide valuable information while establishing
authority, competence, and rapport with the patient. Questions should be
objective and should not lead the patient.
- Two types of information are used to assess medical or trauma conditions.
Subjective information is related by the patient in taking a history and
describes symptoms. The physical exam provides signs or objective
information that may or may not correlate with the patients symptoms.
- In medical situations, history is commonly obtained before or during the
physical assessment. In trauma cases, it may be simultaneous or following
the detailed assessment. An assessment is often used for gathering
information from family or bystanders.
- In trauma cases, carefully examine all areas where the patient complains of
pain, but realize that the patients capacity to feel pain is usually limited to
one or two areas even if more areas are injured! That is why a systematic
survey is important even in a patient that is awake.
- Use bystanders to confirm information obtained from the patient and to
provide facts when the patient cannot. History from the scene is invaluable.
- Over-the-counter medications including aspirin, homeopathic remedies, and
herbal supplements are frequently overlooked by the patient and the
rescuer but may be relevant to emergent problems. Birth control pills are
also frequently overlooked so be sure to ask.
- Confidentiality is mandatory. Patients are in need and vulnerable; they
deserve respect, kindness, and discretion.
- Complete, legible documentation is critical to convey the information
above.
- Be systematic. If you jump from one obvious injury to another, the subtle
injury that is most dangerous to the patient is easily missed.
- If the patient has any significant airway or circulatory deterioration, these
problems must be addressed immediately. Otherwise, complete the
assessment before you begin to address the problems that have been
identified.
- Obtain and record two or more sets of vital signs and neurological
observations. A patient cannot be called stable without at least two sets of
vital signs and neurological observations. Serial vital signs are an important
parameter of the patients physiologic status. Vital signs should be repeated
frequently at least every 15 minutes in stable patients and at least every 5
minutes in unstable patients.

OPERATIONS
EMT-P: ALS-TRAINED PROVIDER COORDINATION WITH PERSONNEL USING AEDs
COMMUNICATION
CONFIDENTIALITY
CONSENT
DESTINATIONS
DIVERTS
HAZARDOUS MATERIALS
MCI TRANSPORT LOG
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION NOTE TO PHYSICIANS
RESUSCITATION AND FIELD PRONOUNCMENT GUIDELINES
EMT-P: ALS-TRAINED PROVIDER COORDINATION WITH PERSONNEL
USING AEDs
GENERAL PRINCIPLES
- With the increasing availability of AEDs, ALS-trained emergency personnel
will interact frequently with both trained and untrained AED providers. The
following are guidelines for this interface between ALS personnel and
personnel using AEDs:
- ALS-trained and authorized providers always have authority over the
scene.
- On arrival, ALS-trained providers should ask for a quick report from the
automated defibrillation providers and, if the providers are trained in
the use of AEDs; direct them to proceed with their protocols. This is
particularly applicable when ALS-trained providers are unfamiliar with
the operation of the AED. In the event that the AED provider is an
untrained citizen, attach a conventional defibrillator, as most citizen
access AEDs will not have a rhythm display monitor.
- ALS-trained providers should use the AED for additional shocks and
rhythm monitoring. They can direct the trained providers to operate the
AED. To save time, avoid disorganization, and allow a coordinated
transfer of care, ALS providers should not remove the AED and attach a
separate conventional defibrillator unless the AED in use lacks a rhythm
display screen. Some AEDs have the capacity for manual override by ALS-
trained providers, should that be necessary. The method and ease of
manual override will vary among models.
- ALS-trained providers should consider the shocks delivered by the AED
operators as part of their ALS protocols. For example, if the patient
remains in V-fib after defibrillation by the AED, then ALS personnel
should enter the ALS V-fib treatment sequence at the point at which the
defibrillation has been delivered. Consequently, ALS providers should
move immediately to perform orotracheal intubation, establish IV line
access, and administer epinephrine.
COMMUNICATION
PURPOSE
- The purpose of contacting the receiving hospital is to provide enough data
to allow the Emergency Department staff to decide what preparations they
will need to make for the patient. In addition, a base physician may direct
appropriate treatment to be administered en route.
PROCEDURE
- Radio contact should only include essential, relevant information.
Remember, the Emergency Department staff may be busy and radio time is
valuable.
- First, always identify agency, unit, person, and the reason for contact such
as treatment orders/requests, notification, and/or consultation.
- Only a physician may provide authorization to a paramedic to perform a
procedure or administer a medication pursuant to these protocols. The
paramedic should be clear and concise in requesting that a physician be
available for consultation or orders.
NOTIFICATION TO RECEIVING FACILITY
- Report the following, to the extent pertinent, to the receiving facility:
- Transport status or code
- Chief complaint
- Age and gender of patient
- General status and course of events, stable, improving, deteriorating
- Past medical history, only if pertinent
- State of consciousness
- Vital signs
- Pertinent localized findings
- Treatment in progress
- Estimated time of arrival
REQUESTS FOR TREATMENT ORDERS
- Request to talk to a physician to obtain an order.
- Identify yourself to the physician and state the order you are requesting.
- Provide pertinent information that is the basis of the request, such as:
- En route (emergent or non-emergent, estimated time to destination
hospital) or on scene
- Chief complaint
- Course of events, stable, improving, deteriorating
- Past medical history, only if pertinent
- General status
- State of consciousness
- Vital signs
- Pertinent localized findings
- Treatment in progress
- Order requested, stating dosage and route to be given
- All patient allergies
- In the event a request is for a field pronouncement, the report should
include information about the responses to resuscitation efforts,
mechanism, and duration of resuscitation efforts. If the pronouncement is
made, state the time.
- Communication with a physician at the base is appropriate if you are not
sure whether or not a treatment, procedure or destination is appropriate
for a patient. Base contact should be considered as a consultation, not just
as a source of authorization for medications and procedures.
- Requests for orders should be made to a hospital's recorded line whenever
possible.
CONFIDENTIALITY
PURPOSE
- The patient-physician relationship, the patient-registered nurse
relationship, and the patient-EMT relationship are recognized as privileged.
This means that the physician, nurse, or EMT may not testify as to
confidential communications unless:
- The patient consents or
- The disclosure is allowable by law (such as Medical Board or Nursing
Board proceedings, or civil litigation in which the patient's medical
condition is an issue).
- The patient's medical information should be kept confidential by the
pre-hospital provider, and regarded as private information in medical
care. The patient likely has an expectation of privacy and trusts that
personal, medical information will not be disclosed by medical personnel
to any person not directly involved in the patient's medical treatment.
EXCEPTIONS
- The patient is not entitled to confidentiality of information that does not
pertain to the medical treatment, medical condition, or is unnecessary for
diagnosis or treatment.
- The patient is not entitled to confidentiality for disclosures made publicly.
- The patient is not entitled to confidentiality with regard to evidence of a
crime.
ADDITIONAL CONSIDERATIONS
- Any disclosure of medical information should not be made or allowed unless
necessary for the treatment, evaluation or diagnosis of the patient.
- Any disclosures made by any person, medical personnel, the patient, or law
enforcement should be treated as limited disclosures and not authorizing
further disclosures to any other person.
- Any discussions of pre-hospital care by and between the receiving hospital,
the crew members in attendance, or at in-services or audits are done
strictly for educational purposes. Further disclosures are not authorized.
- Radio communications should not include disclosure of patient names.

CONSENT
ADULTS
GENERAL PRINCIPLES
- An adult in the State of Colorado is 18 years of age or older.
- Every adult is presumed capable of making medical treatment decisions.
This includes the right to make bad decisions that the pre-hospital
provider believes are not in the best interests of the patient.
- A person is deemed to have decision-making capacity if he/she has the
ability to provide informed consent, i.e., the patient:
- Understands the nature of the illness/injury or risk of injury/illness;
- Understands the possible consequences of delaying treatment/refusing
transport; and
- Given the risks and options, the patient voluntarily refuses or accepts
treatment/transport.
- A call to 9-1-1 itself does not prevent a patient from refusing treatment. A
patient may refuse medical treatment (IVs, O
2
, medications), but you
should try to inform the patient of the need for therapies, offer again, and
treat to the extent possible.
- The odor of alcohol on a patients breath does not, by itself, prevent a
patient from refusing treatment.
- Implied consent: An unconscious adult is presumed to consent to treatment
for life-threatening injuries/illnesses.
- Involuntary consent: In rare circumstances, consent may be authorized by a
person other than the patient (such as a court order [guardianship], from a
peace officer for prisoners in custody or detention, and persons under a
mental health hold or commitment who are a danger to themselves or
others or are gravely disabled).
PROCEDURE
- Consent may be inferred by the patient's actions or by express statements.
If you are not sure that you have consent, clarify with the patient or
contact base. This may include consent for treatment decisions or
transport/destination decisions.
- Determining whether or not a patient has decision-making capacity to
consent or refuse medical treatment in the pre-hospital setting can be very
difficult. Every effort should be made to determine if the patient has
decision-making capacity.
- For patients who do not have decision-making capacity, contact base.
- If the patient lacks decision-making capacity and the patient's life or health
is in danger, and there is no reasonable ability to obtain the patient's
consent, proceed with transport and treatment of life-threatening
injuries/illnesses. If you are not sure how to proceed, contact base.
- For patients who refuse medical treatment, refer to the Non-Transport of
Patients protocol.
- If you are unsure whether or not a situation of involuntary consent applies,
contact base.
MINORS
GENERAL PRINCIPLES
- A parent, including a parent who is a minor, may consent to medical or
emergency treatment of his/her child. There are exceptions:
- Neither the child nor the parent may refuse medical treatment on
religious grounds if the child is in imminent danger as a result of not
receiving medical treatment, or when the child is in a life-threatening
situation, or when the condition will result in serious handicap or
disability.
- The consent of a parent is not necessary to authorize hospital or
emergency health care when an EMT in good faith relies on a minor's
consent, if the minor is at least 15 years of age and emancipated or
married.
- Minors may seek treatment for abortion, drug addiction, and venereal
disease without consent of parents. Minors > 15 years may seek
treatment for mental health.
- When in doubt, your actions should be guided by what is in the minor's best
interests and base contact.
PROCEDURE
- A parent or legal guardian may provide consent to or refuse treatment in a
non-life-threatening situation.
- When the parent is not present to consent or refuse:
- If a minor has an injury or illness, but not a life-threatening medical
emergency, you should attempt to contact the parent(s) or legal
guardian. If this cannot be done promptly, transport.
- If the child does not need transport, they can be left at the scene in the
custody of a responsible adult (e.g., teacher, social worker,
grandparent). It should only be in very rare circumstances that a child of
any age is left at the scene if the parent is not also present.
- If the minor has a life-threatening injury or illness, transport and treat
per protocols. If the parent objects to treatment, contact base
immediately and treat to the extent allowable, and notify police to
respond and assist.
DESTINATIONS
PURPOSE
- To provide a set of guidelines to help ensure proper disposition of the
various patients encountered in the field.
GENERAL PRINCIPLES
- Critical patients with a special medical need should be taken to the nearest
facility that can best provide for that need.
- Critical patients without a special need (e.g., cardiopulmonary arrest)
should be taken to the closest emergency department.
- All other patients should have their request accommodated, consistent with
the ability of that system to meet that request.
PARTICIPATING HOSPITALS
- Patient transport requests to the following hospitals will be honored unless
excepted by this protocol:
- Denver Health
- Anschutz Inpatient Pavilion (Fitzsimons)
- Lutheran Medical Center
- Medical Center of Aurora
- Porter Memorial Hospital
- Presbyterian/St. Lukes Hospital
- Rose Medical Center
- St. Anthony Central Hospital
- St. Josephs Hospital
- Swedish Medical Center
- Swedish SW
- Transports to Swedish SW must originate from the area south of
Hampden and west of Sheridan.
- The Childrens Hospital
- Transports to destinations outside of the above facilities may be honored at
the discretion of the Chief Paramedic or his/her designee, or:
- The transport is by the Critical Care Transport service
- The transport is by a BLS unit, with approval of the EMS Captain on duty,
an Assistant Chief, or the Chief Paramedic
- The transport is by a private ambulance service provider
- The transport is a BLS transfer to or from the Denver/Metro area
PATIENT REQUESTS
- Legitimate patient transport destination requests will be honored, unless
excepted by this protocol. Legitimate requests include requests by:
- Legally competent individuals over the age of 18 whose decision making
capacity is not impaired by the use of drugs or alcohol, or by their
medical condition
- Healthcare providers, guardians, or medical powers of attorney, on
behalf of incompetent patients
- Patients who do not require specialty centers for their presenting
problem or complaint
- Patients who do not meet above criteria will be transported to the most
appropriate participating 911 receiving hospital. Determination of the most
appropriate facility will be made considering:
- Distance
- Transport time
- Traffic
- Need for specialty center
- Hospital diverts or advisories
SPECIALTY CENTERS
The following list of clinical conditions and facilities best able to care for those
clinical conditions is described.
- Burns
- Patients older than 12 years of age with second degree or third degree
burns greater than 20% body surface area should be transported directly
to the University Hospital emergency department. Patients 12 years of
age and younger with second degree or third degree burns greater than
20% body surface area should be transported directly to The Children's
Hospital emergency department.
- Special considerations: Complications of airway compromise or
cardiovascular instability require transport to the nearest appropriate
emergency department. Burns associated with multi-system trauma
should be transported according to the Mile High RETAC Trauma Triage
Algorithm Guideline.
- Cardiac Alert
- Patients meeting the cardiac alert criteria noted in the Chest Pain
protocol need to be transported to the closest hospital enrolled in a
cardiac alert program.
- Obstetric/Gynecologic
- For patients in uncomplicated labor:
- Delivery not imminent:
- If the patient has a private obstetrician or gynecologist, then
follow the patient's request for destination, when possible.
- If the patient has no private physician, then follow the patient's
request for destination (if expressed), or transport to the closest
hospital.
- Imminent delivery:
- If the patient has a private obstetrician/care giver, then follow the
patient's request for destination, provided the requested facility is no
greater than five minutes beyond the closest hospital. If the
requested facility does not meet these time constraints and the
patient still requests the facility, consult with the base physician.
- If the patient has no private physician, then transport to the closest
participating hospital.
- Denver Health OB transports:
- Patients with gestation of 20 weeks or greater with none of the
following complications will be taken to OB Screening:
- MVA
- Trauma
- Assault physical and/or sexual
- < 20 weeks gestation
- Need for immediate, non-OB related medical assistance
- These patients need to be transported directly to the Emergency
Department.
- Ambulance crews will notify the OB Screening Room at (303) 602-
9137 and provide a report which should include patient name,
patient age, gravida/para, gestational age, vital signs, chief
complaint(s) and any other problems or medical conditions.
- Ambulances will park in the turnaround for Pavilion C under the
canopy, which is found off of 7th Avenue and Delaware Street, and
take the patient through the main doors of Pavilion C to the OB
Screening area.
- OB Screening Room staff will make access for crews to the OB
Screening area, and direct them to an exam room. In rare cases,
crews may be directed to transport the patient up to Labor and
Delivery based on patient condition.
- OB Screening will assume care of all patients delivered to the
Screening Room by ambulance, unless they are in extremis, and
warrant transport directly to L&D.
- Conditions which may warrant direct transport to L&D by ambulance
crews via the dedicated elevator in OB Screening Room may include,
but not limited to the following situations (these situations will be
rare):
- Presenting fetal limb
- Prolapsed umbilical cord
- Hemorrhage
- Psychiatric patients (also refer to the Mental Health Holds (MHH) protocol)
- Patients placed on a Mental Health Hold (MHH) by the Denver Police
Department shall be taken to the closest 911 participating hospital.
- Patients placed on an MHH by Mental Health Corporation of Denver
personnel shall be transported to DHMC.
- Patients with psychiatric problems not on an MHH shall be taken to the
closest hospital or per legitimate requests as defined in Patient Requests
above.
- Patients with psychiatric problems who have an acute medical or
traumatic concern shall be treated according to the appropriate medical
or trauma protocol.
- An MHH may be placed by a state-certified EMT by direction of the
Denver Health base physician.
- Trauma
- All transports of major trauma patients will be to Denver Health,
regardless of Denver Healths divert status, unless otherwise directed by
the attending ED physician, or the patients condition and location
indicate transport to another Level I trauma center.
- When Denver Health is on ED divert, base contact will be made, and the
attending physician will determine transport destination for major
trauma patients.
- Victims of major trauma aged five and under will be transported to The
Childrens Hospital.
- Traumatic arrests and imminent traumatic arrests will be transported to
the closest participating Level I trauma center.
- Transport of patients who need limb preservation will be to Denver
Health.
SYSTEM STATUS
- When the demands on the system create coverage gaps and the potential
for prolonged responses, the EMS Captain(s) on duty may implement Status
Red transport destination. The decision to implement Status Red
transport destination may be suggested by the Paramedic Dispatch
Supervisors (PDS), dispatchers or field personnel, but the on-duty EMS
Captain(s) will make the final decision to implement Status Red transport
destination. Status Red transport destination:
- Will require transport to the most appropriate participating facility as
defined by Patient requests: Appropriate facility determination (above).
- Will remain in place until the Captain(s) return the system to Status
Green.
- Will require dispatchers to notify field crews of changes in status by
radio and pager, and require acknowledgement from each field
ambulance by radio.
- Will require the status change to be noted in the EMESIS computer, along
with the initials of the Captain who implements Status Red.
- Will not alter the destinations of ambulances in the process of
transporting when the system status changed.
- Will require EMS Captain approval for deviation from this transport
protocol.

WEATHER
- During times of inclement weather, street crews may be faced with
prolonged response and transport times. These conditions may also create
potentially hazardous driving conditions, road closures, and other adverse
conditions.
- When these conditions exist, the on-duty EMS Captain(s) may implement the
Weather Destination Policy. The dispatcher on the board will poll street
crews in various areas of the city to ascertain road and weather conditions.
This may be after suggestions from the street crews, or at the discretion of
the EMS Captain(s) on duty. The EMS Captain(s) will then decide whether or
not to implement the Weather Destination Policy.
- When the decision has been made to implement the policy, dispatch shall
notify the Attending Physician in the DH Emergency Department, as well as
all of the private ambulance agencies who run OLFAs in the City. When
implemented, Weather Destination:
- Will require transport of major trauma patients to the closest (by time)
Level I or Level II trauma center.
- Will require transport to the most appropriate participating facility as
defined by Specialty centers above, for all other patients.
- Will remain in place until the EMS Captain(s) take(s) the system off of
Weather Destination.
- Will require dispatchers to notify field crews of the change to Weather
Destination by radio and pager, and require acknowledgement from
each field ambulance by radio.
- Will require the status change to be noted in the EMESIS computer, along
with the initials of the Captain who implemented it.
- Will not alter the destinations of ambulances in the process of
transporting when the system status changed.
- May be implemented when only a portion of the city is experiencing
adverse weather conditions. Additionally, it may be applied only in an
affected geographical area.
- Will require EMS Captain approval for deviation from this transport
protocol.
DIVERTS
(modified with permission from a document created by Art Kanowitz, Pridemark Paramedic Services)
PURPOSE
- To provide a standard approach to ambulance diversion that is practical for
field use.
- To facilitate unobstructed access to hospital emergency departments for
ambulance patients
- To allow for optimal destination policies in keeping with general EMS
principles and Colorado State Trauma System Rules and Regulations.
GENERAL PRINCIPLES
- EMSystem, an internet-based tracking system, is used to manage diverts in
the Denver Metro region
- The State Trauma Triage Algorithms should be followed.
- The only time an ambulance can be diverted from a hospital is when that
hospital is posted on EMSystem as being on official divert (RED) status. As of
April 15, 2009, Emergency Department divert is the only category
recognized in the Denver Metro region.
- Overriding factors:
- The following are appropriate reasons for a paramedic to override ED
divert and, therefore, deliver a patient to an emergency department
that is on ED divert:
- Cardiopulmonary arrest
- Imminent cardiopulmonary arrest
- Unmanageable airway emergencies
- Unstable Level I trauma patients for Level I and Level II trauma
centers
- Pre-hospital personnel should honor advisory categories, when possible,
considering patients condition, travel time, and weather. Patients with
specific problems that fall under an advisory category should be transported
to a hospital not on that specific advisory when feasible.
- There are several categories that are considered advisory (yellow) alert
categories. These categories are informational only and should alert field
personnel that a hospital listed as being on an advisory alert may not be
able to optimally care for a patient that falls under that advisory category.
- The following are advisory (yellow) categories:
- ICU (Intensive Care Unit)
- OB (Obstetrics)
- Psych (Psychiatric)
- Trauma (Trauma Services)
- Operating Room (OR)
- Zone saturation is when all hospitals in that zone are on ED Divert.
- A Zone Master is a hospital contact that is responsible for determining
hospital destinations when the zone is saturated.
- When an ambulance is transporting a patient that the paramedic feels
cannot go outside the zone due to patient acuity or other concerns, the
paramedic should contact the Zone Master and request a destination
assignment.
- In general, patients contacted within a zone should be transported to an
appropriate facility within the zone. Patients may be transported out of the
primary zone at the paramedics discretion, if it is in the patients best
interest or if the transport to an appropriate facility is shorter.
FACILITY ZONES
ZONE HOSPITALS ZONE MASTER ZM PHONE NUMBER
Zone 1
NORTH/
NORTHWEST
St. Anthonys
Central
Lutheran
St. Anthonys Central 303-595-6135
Zone 2
SOUTH
Swedish
Porter
Swedish 303-788-6911
Zone 3
EAST
Rose
Aurora
University
Aurora and University*
alternate every quarter:
1
st
and 3
rd
quarter Aurora
2
nd
and 4
th
quarter
University
(*Zone Master date rollover occurs at
midnight on the first day of each
quarter.)
303-695-2946
Aurora

720-848-5120
University
Zone 4
MIDTOWN
Denver Health
St. Josephs
Presbyterian-St.
Lukes
Denver Health 303-436-8100

HAZARDOUS MATERIALS
INDICATIONS
- Responding to reported and/or known hazardous materials incident
- Vapor clouds, fire, smoke, leaking substances, frost lines on cylinders, sick
personnel, dead or distressed animals and noxious odors are present on or
near scene.
PRECAUTIONS
- Senses are one of the best ways to detect chemicals, particularly the sense
of smell. If you smell something you are too close.
- A safe approach to the scene is the first element of any EMS response.
Unless you arrive safely at the site, you will not be able to perform your
duties.
- Observe the site from a distance using binoculars, if possible, before you
get too close. Look for danger signs such as vapor clouds, fire and smoke,
placards, shape of vehicle or container, leaking substances, frost lines on
cylinders, injured personnel, and dead or distressed animals. These are key
clues to warn you not to get too close. Remember that you want to be part
of the solution, not part of the problem.
- If the fire department is already on the scene, report in to the incident
commander. If you are first on the scene and a hazardous material is
suspected, request a hazardous materials team response. Keep yourself and
your unit at a safe distance. This usually requires your unit to leave the
scene, leaving patients and bystanders in a hazardous situation. Your safety
comes first. Seek a location uphill and upwind from the incident.
- EMS personnel should not be participating in patient decontamination unless
trained and equipped to do so in a safe manner.
PROCEDURE
- Your safety is the highest priority. EMS operations should be established in
the cold zone. You should report to the incident commander.
- Position your vehicle to make a hasty retreat. This may require you to leave
the scene to seek safety.
- The hazardous materials team should perform the initial assessment,
treatment, and decontamination. Decontaminated patients should then be
brought to the EMS unit.
- Once the situation has been assessed, notify the receiving hospital of the
following information:
- Location of the incident
- Name of chemicals/products involved
- Number of injured and contaminated
- Extent of the injuries/contamination
- Extent that the patients will be decontaminated in the field
- Your estimated time of arrival
- Other pertinent information that is available
- Patient treatment is usually based on signs and symptoms. Specific patient
treatment should be based on information obtained from base.
PURPOSE
- Field personnel occasionally come into contact with infectious and
communicable diseases. It is important that a protocol is followed so that
the appropriate persons are notified. Not all diseases require immediate
treatment; however, early awareness will assist those involved to take any
necessary precautions and actions.
PRECAUTIONS
- Contamination by infectious and communicable diseases may be minor or
serious. Field personnel should take precautions to avoid unnecessary
exposure. When dealing with a suspected contagious patient, attempt to
avoid direct contact with the patient's blood, sputum, emesis, urine, feces,
or respiratory and lesion secretions. The provider should wear disposable
latex or vinyl gloves and any other appropriate BSI. Routine practice of good
hand washing and equipment cleaning may help decrease the incidence of
contamination.
PROCEDURE
- The following guidelines are for infections exposure and injury on the job:
- Employees exposed to bloodborne pathogens shall call the Ouch line
(303-436-6824) and be directed to the most appropriate clinic (e.g., ED,
AUCC, OHSC). Employees will be examined in the Occupational Health
and Safety Clinic (OHSC) for their initial medical contact, except when
the first contact is in the Emergency Department (ED) or Adult Urgent
Care Clinic (AUCC). All subsequent treatment and evaluation will be
through OHSC, with consultation from Infectious Disease staff when
indicated.
- Employees injured on the job, or who have a job-related illness, shall
call the Ouch line (303-436-6824) and be directed to the most
appropriate clinic (e.g., ED, AUCC, OHSC). Employees will be examined
in the OHSC for their initial medical contact, except when the first
contact is in the Emergency Department (ED) or Adult Urgent Care Clinic
(AUCC). All subsequent treatment and evaluation will be case managed
by the OHSC, or as otherwise designated.
- The OHSC will be open from 7:00 a.m. to 5:00 p.m., Monday through
Friday, except for holidays observed by Denver Health.
- Injured employees may be treated in the OHSC or referred to other DH
staff or a private physician at the discretion of the clinic. However, the
clinic will maintain contact with referred employees at appropriate
intervals in order to monitor the quality of medical care and to minimize
lost time from work.
- The OHSC will be responsible for maintaining all correspondence and for
completing all necessary forms for its patients.
PURPOSE
- Interhospital patient transfers are commonly initiated when definitive
diagnosis or therapeutic needs of a patient are beyond the capacity of the
transferring hospital. In these cases the patient may be unstable, and
medical treatment must be continued and possibly even initiated en route.
Likewise, patients being transferred for diagnostic or therapeutic purposes
may be stable but on continuous pharmacological or ventilatory therapy. It
is imperative that such therapies be continued or interruptions in care
planned to minimize risk to the patient. These guidelines encourage orderly
transfer of patients with appropriate continuity of care.
PROCEDURE
- All patients should be stabilized, if possible, before transfer.
- The attending EMT should receive a summary of the patients condition,
current treatment, possible complications and other pertinent medical
information.
- Treatment orders should be given to the attending EMT. These orders should
be either in writing or by direct verbal order from the doctor who is
initiating the transfer.
- Any unstable or potentially unstable patients must have at least one IV in
place. Orders for IV fluid and rate should be provided.
- Transfer papers (summary, lab work, x-rays, etc.) should be given to the
attending EMT rather than family or friends.
- The attending EMT should confirm that the receiving hospital and physician
have been notified prior to initiation of transfer.
- The personnel used to transfer a patient should be appropriate to the
treatment needed or anticipated during transfer. EMTs who are not IV
approved should not attend patients who have or may require IV therapy.
Paramedics should be utilized if any advanced resuscitation or treatment is
anticipated. In specialized fields not ordinarily handled by paramedics (e.g.,
high risk obstetrics) an appropriately trained person should accompany the
patient.
- The equipment used to transfer a patient should be appropriate to the
treatment being provided. For example, IV medications being delivered by
an IV pump should be either maintained on an IV pump during the transfer,
discontinued, or the IV tubing should be appropriate for manual control.
- In order to maintain these standards, it may be appropriate for the
receiving hospital to send an ambulance with more specifically trained
personnel to transfer the patient. This is particularly true in the case of
newborns, but has also been shown to be effective in the treatment of
other critically ill or injured patients.
PURPOSE
- To utilize a framework for consistent management of mass casualty
incidents. This expandable protocol will be used on all EMS incidents with
multiple patients to provide for efficient and consistent management. The
principles outlined below will be implemented to ensure that EMS Incident
Command is initiated on all mass casualty incidents (MCI henceforth).
DEFINITION
- An MCI is an incident which generates more patients than available
resources can handle using routine procedures. This MCI management
guideline, should be utilized when:
- Three or more patients from one incident, triage category yellow or red,
are going to be transported by ambulance to the same receiving hospital.
Three or more patients being transported from the same incident to Denver
Health, regardless of triage category, requires base contact.
- Four or more patients from one incident, triage category yellow or red, are
going to be transported by ambulance to multiple receiving hospitals.
PROCEDURE
- First Responding Ambulance: The first ambulance to arrive on any mass
casualty scene will be referred to as EMS Operations.
- EMS Operations will be responsible for initial Incident Command System
roles. As an incident grows in size, the EMS Operations ambulance will be
expected to delegate the following positions as necessary:
- Triage: Responsible for implementing START triage and routing patients
to appropriate treatment area.
- Treatment: Responsible for establishing treatment sectors and providing
on scene stabilization and treatment.
- Transport: Responsible for coordinating patient transport with
Treatment and Staging officers. Also responsible for maintaining patient
transport log. Consider utilizing BLS personnel for this position.
- Staging: Responsible for staging area, maintaining appropriate level of
available EMS resources, and assigning units as required by Transport
officer. Consider utilizing BLS personnel for this position.
- Communications: Responsible for all hospital contacts including Denver
Health base contact, hospital notifications, and maintaining current bed
count system wide. Consider utilizing BLS personnel for this position.
- Priorities for EMS Operations:
- Early identification and request of required resources
- Early utilization of the Mass Casualty Incident Operations radio channel
(MCI Ops)
- Early contact of Denver Health base attending physician
- Provide clear and concise ingress/egress information to additional
responding ambulances
- Implementation of START Triage
- Provide destinations for all transport ambulances
- Radio procedure for EMS Operations:
- Once on the MCI Ops channel, the first arriving ambulance will be
identified as EMS Operations.
- Dispatch will be notified once the location has been named. The incident
name plus the "Operations" identifier will be used for the duration of the
incident. Example: "Main Street Operations."
- When additional Incident Command roles are delegated, dispatch should
be notified and appropriate radio designations should be assigned.
Example: "Main Street Triage."
- First Arriving Command Staff: The first arriving member of the Command
Staff (EMS Captain, Assistant Chief or Chief Paramedic) will assume the role
of EMS Incident Command.
- Priorities and responsibilities for EMS Incident Command:
- Join other public safety agencies at a Command Post or establish
Command Post if it has not been done and begin face to face
communication with public safety partners.
- Notify dispatch that EMS Incident Command has been assumed and that
the radio designation will be the incident name plus Command.
Example: Main Street Command.
- Ensure that EMS Operations has fulfilled initial responsibilities and
developed an appropriate action plan for management of the incident.
- Determine what level (see below) MCI has occurred and instruct dispatch
to make appropriate administrative notifications
- Mobilize required resources through dispatch, Denver Health, and the
Office of Emergency Management (OEM).
- Ensure that all patients are accounted for and that patients being
transported are dispersed among 911 receiving hospitals and specialty
centers appropriately.
MASS CASUALTY INCIDENT TRIAGE DESIGNATIONS
- First priority (Red): Immediate
- Second priority (Yellow): Delayed
- Third priority (Green): Minor
- Fourth priority (Black): Deceased
MASS CASUALTY INCIDENT BASE CONTACT
- Denver Health Base should be contacted when:
- Three or more patients from one incident are going to be transported by
ambulance to the same receiving hospital.
- Four or more patients from one incident are going to be transported by
ambulance to multiple receiving hospitals.
- Initial contact to base:
- Should be made through Paramedic Dispatch
- Should be early and include a brief summary of the incident and
estimated patient count
- The intention of this preliminary notification is to initiate the process of
obtaining bed counts for patient transport.
- Secondary base contact should be direct via phone or radio, should build
upon initial contact, and should include the following information:
- Paramedic name/unit number
- Incident location (nearest main intersection/neighborhood)
- Type of incident
- Number of patients by triage designation categories
- Confer with base physician on hospital destination based on triage
designation and availability of beds/resources
- While making base contact, incidents should not be referred to by Level I,
II, or III. MCI levels are designed to be used for administrative, command,
and review purposes only.
MASS CASUALTY INCIDENT LEVELS
- Level 1 (Small Incident): Three to ten patients requiring transport or four
ambulance response
- Level 2 (Medium Incident): Eleven to twenty five patients requiring
transport or five to ten ambulance response
- Level 3 (Large Incident): Twenty five to one hundred patients requiring
transport or more than ten ambulance response
- Disaster: An incident that clearly overwhelms all available EMS and
Emergency Department resources within the Metro Denver Area.
- The delegation and separation of responsibilities between EMS Operations
and EMS Command is designed to prevent loss of information that may occur
if all aspects of Operations and Command are reassigned as higher ranking
members of the Command Staff respond to an incident.
- Unified Command: As the size of an incident grows, or looks to be prolonged
in duration, it may be appropriate to establish a Unified Command with
other public safety partners. Unified Command will have responsibilities
that include: planning ongoing operations at the incident, maintenance of
normal street operations, relaying information to decision makers in OEM,
mobilization of resources beyond routine procedures and others.

EMS Incident Command
EMS Operations

Triage Communications Treatment Transport Staging
Patients that can initially ambulate with or without assistance are GREEN tags.
Constant reassessment is necessary and there should be no hesitation in up-
triaging when necessary.


Time Hospital Red Yellow Green
DHMC
St. Anthonys
Central

Swedish
Aurora
Childrens
Lutheran
St. Josephs
P/SL
Rose
UH/Fitz
Porter

MCI TRANSPORT LOG

Last Name First
Name
Sex Age Tag Number
R/Y/G
Ambulance
Number
Destination

INDICATIONS
- Any person who appears to be:
- Mentally ill and
- An imminent danger to others or to him/herself or
- Gravely disabled
PROCEDURE
- Restrain if necessary per the Restraints protocol.
- Call receiving facility for the physician to place MHH.
- Transport to the Emergency Department.
- Provide appropriate documentation of events so 72-hour MHH can be filled
out by the physician at the receiving facility.
GENERAL PRINCIPLES
- The EMT-B or EMT-P may initiate an MHH only with the permission and
online contact with the receiving physician.
- The law allows only physicians, trained nurses, and peace officers to place
MHH.
- EMT-Bs and EMT-Ps may act as the field representative of the physician
when the above protocol is followed.
GENERAL PRINCIPLES
- A patient who has decision-making capacity may refuse treatment,
examination or transport. See Legal Issues in Consent protocol.
- A person has decision-making capacity sufficient to refuse
treatment/transport if he/she:
- Understands the nature of the illness/injury or risk of injury/illness and
- Understands the possible consequences of refusing treatment/refusing
transport and
- Given the risks and options, the patient voluntarily refuses
treatment/transport.
- The pre-hospital provider is responsible for deciding if the patient's refusal
is informed and voluntary. The pre-hospital provider should consider the
nature of the incident, potential mechanism, obvious actions of the patient,
as well as the verbal statements of the patient. The pre-hospital provider is
responsible for a reasonable assessment of the patient to determine if there
is an injury/illness or reason for transport or treatment. Only then is a
patient's refusal an informed refusal (see the Consent protocol). Do not
attempt to diagnose, do assess carefully.
- Remember: it is your assessment and advice to the patient and proper
documentation of it that are most important in the non-transport.
PROCEDURE FOR NON-TRANSPORTS
(see the Non-Transport/Refusal of Care algorithm)
- The Denver Health Paramedic Division Refusal Form will be used for all
refusal of care situations. All patient refusing treatment or transport will be
requested to sign the form.
- For the patient who has only an isolated soft tissue injury and has decision-
making capacity, treatment and transport should be offered. If the patient
refuses, then warn the patient of the risks of non-transport and delay in
treatment. Base contact should be made in high risk situations as defined
by:
- Any language barrier
- Under 18
- Pulse > 100
- SBP < 90 mmHg
- Any evidence of ETOH or other intoxicants
- Trauma in pregnancy 20 weeks or greater
- Any patient considered to be high risk by the EMT-B or EMT-P
- Patients with medical conditions/injuries that may recur or deteriorate, or
may render the patient unable to seek medical care, should be carefully
evaluated and warned to not delay in obtaining medical treatment. High-
risk areas in EMS are head injury, chest pain, abdominal pain, flu-like
symptoms, alcohol-related illnesses, or injuries.
- For the patient refusing transport/treatment:
- Assess patient to the extent possible. Look for objective causes of
injuries/illnesses that may impair decision-making. Evaluate
mechanism/history, scene and potential for unseen injuries/illnesses. Do
not diagnose.
- Inform patient of findings, possible injuries or illnesses that warrant
treatment and transport, and of the risks of non-transport, delaying
treatment, and non-physician examination.
- If the patient still refuses treatment/transport, then determine the
patient's ability to understand the immediate medical situation and need
for treatment. Questions asked might include:
- If the patient still refuses transport, refer to the Denver Health
Paramedic Division Refusal Form. Contact base for all high risk refusal
situations.
- The base physician may:
- Agree or determine that the patient's decision-making capacity is
impaired and instruct transport of the patient.
- The patient may be transported under the basis of a medical
emergency (i.e., patient is incapacitated and unable to consent).
- The patient may be transported under the basis of a mental
health emergency. Police should be requested to place the
patient under a Mental Health Hold. Appropriate paperwork, such
as the Mental Health Hold, must accompany the patient. (Also see
the Mental Health Holds (MHH) protocol)
- Agree or determine that the patient has decision-making capacity, in
which case:
- The patient may refuse treatment and transport but must be
advised of the risks of non-transport (informed refusal).
- The pre-hospital provider must warn the patient that non-
transport is against medical advice (AMA).
- The patient should be urged to seek medical attention and
transport.
- For the patient who refuses treatment and transport (against medical
advice), providing the patient with clear instructions and warnings is
imperative.
- Minors: Base is to be contacted any time a minor under the age of 18 is not
transported via ambulance regardless of mechanism or complaint.
- The following must be documented for every patient examined, offered and
refused treatment/transport (in addition to Paramedic Division guidelines):
- All assessment findings
- Description of mechanism or scene factors (damage, environment, etc.)
- Description of mental status and decision-making capacity
- Vital signs, unless the patient refused
- Patient's response to warning about risks of non-transport/non-
treatment
- Base physician's advice
- Patient's condition at termination of patient contact, such as
ambulatory, with family
- Obtaining a patient's signature on a run report or release form is encouraged
because signing may be evidence of the patient's decisional capacity and
physical stability. However, do not have a patient sign a release or waiver
that you do not understand, and do not expect that a signature relieves you
of responsibility for a reasonable assessment or treatment of the patient.
- The role of base contact is to assist in determining or verifying the patient's
ability or inability to make medical treatment decisions and assist when
transport should be done. It is imperative that an accurate, concise report
be given for the physician to give good advice.
- Have all AMA forms co-signed by a witness when possible. The witness
should not be an employee of the responding agency.

Determine mental status and extent
and history of injury, mechanism, or
illness.

1
Mental Health Hold: see Destinations protocol if transporting a psychiatric patient.
2
Alcohol Treatment Hold
Pt. alert, oriented, and has
decision-making capacity
(DMC).
Limited injury consistent with
mechanism
Offer treatment and transport
Injury or illness or has altered
mental status or impaired
decision-making capacity
(DMC).
Pt. refuses consent or offer of
treatment and transport.
Contact base
Pt. still refuses. Have pt. sign
refusal form. Refer to policy
regarding base contact for
non-transport of patients.
Base physician
determines pt. does have
DMC.
Warn pt. of risks of AMA
non-transport/non-
treatment and document
appropriately.
Base physician
determines pt. does not
have DMC.
(Treatment/transport
may be authorized under
MHH
1
, ATH
2
or implied
consent if medical
emergency exists).
Transport, request MHH
or use police if necessary
for assistance.
Trip#___________
ACKNOWLEDGMENT OF INFORMATION
I have been offered an evaluation, medical care and /or transportation to a medical facility;
however, I am refusing the offered services. I have been advised and understand the risks and
consequences of refusing care/transport, including the fact that a delay in treatment and/or
transport by means other than an ambulance could be hazardous to my health, and under
certain circumstances, include disability and/or death.
RELEASE OF LIABILITY
By signing this form, I am releasing Denver Health Medical Center, Denver Health Paramedic
Division, of any liability or medical claims resulting from my decision to refuse the medical
care/transport offered.
NOTICE OF PRIVACY PRACTICES
I acknowledge receipt of Denver Health Paramedic Division Notice of Privacy Practices.

I have read and understand the Acknowledgment of information, Release of Liability, and
Notice of Privacy Practices.

Signature: _________________________________________ Refused to Sign
Patients Name: _____________________________________________
Date: __________________

Relationship (If not the patient): Parent Legal Guardian

This form has been given to you because you have refused treatment and/or transport by the Denver
Health Paramedic Division employee before you. Your health and safety are our primary concern, so
even though you have decided not to accept our advice, please remember the following:

1. The evaluation and/or treatment provided to you by Denver Health Paramedic Division is
not a substitute for medical evaluation and treatment by a doctor. We advise you to get
medical evaluation and treatment.
2. Your condition may be more serious than you realize. Without treatment, you condition or
problem could become worse. If you are planning to get medical treatment, a decision to
refuse treatment or transport by the Paramedic Division my result in a delay which could
make your condition or problem worse.
3. Medical Evaluation and/or treatment may be obtained by calling your doctor, if you have
one, or by going to any hospital Emergency Department in this area, all of which are staffed
24-hours a day by Emergency Physicians. You may be seen at these Emergency Departments
without an appointment.
4. If you change your mind or your condition becomes worse; call 9-1-1, go to an emergency
department in your area or call your primary care provider
5. Dont Wait! When medical treatment is needed, it is usually better to get it right away.
6. If the box at the left has been checked, it means that your problem or condition has
been discussed with an Emergency Physician at Denver Health Emergency Department by
radio or telephone.

FORM COMPLETED BY: _____________________________________________ BADGE #: ______
Witness:__________________________ Name:_____________________________
Signature Please Print

Original to DHPD Administration Copy to Patient
GENERAL PRINCIPLES
- The pre-hospital report is an integral component of patient care, quality
improvement and professional responsibility.
- The pre-hospital report must be legible.
- Vital information should also be immediately communicated to the
Emergency Department (ED) staff for efficient and safe transfer of care.
- A legible copy of the pre-hospital report should be given to the ED staff at
the time of transport to the ED. If this is not possible, the report or a
facsimile copy must be received in the ED within 24 hours from the time of
transport.
PROCEDURE
- All pre-hospital run reports must include the information noted in the EMS
Division policy statement.
- Additional considerations and information to be included to the extent
pertinent.
- The physical examination should include assessment findings:
- Head, Ears, Eyes, Nose and Throat (HEENT), including mentation, skin
color and condition, and trauma
- Neck
- Chest
- Abdomen
- Pelvis
- Back
- Extremities
- Neurologic status
- Cardiovascular status
- Respiratory status
- Treatment rendered should be detailed, including:
- The reason or assessment findings that were the basis of the
treatment, procedure or medication
- The effects (including lack of effect)
- Treatment rendered prior to your arrival or by others
- Medication administration should include time(s) and dose(s).
- Facility contact information:
- Name of physician and facility
- Orders requested or denied
- Time of contact
- Additional documentation should be included, where pertinent to
particular protocols. For example:
- Resuscitations in the field should document time and effects of all
procedures and medications, and time of pronouncement or
termination of resuscitation.
- Refusals of transport should include documentation of mental status,
decision-making capacity, warnings given and condition of patient at
termination of contact.
- Copies of EKG tracings should be affixed to copies of run reports left
with the hospital.
- The mechanism of injury in trauma should be descriptive, not
general.
- The pre-hospital provider who authors the report must include his/her
name and signature on the report.
PURPOSE
- To provide guidelines for pre-hospital personnel who encounter a physician
at the scene of an emergency
GENERAL PRINCIPLES
- The pre-hospital provider has a duty to respond to an emergency, initiate
treatment, and conduct an assessment of the patient to the extent possible.
- A physician who voluntarily offers or renders medical assistance at an
emergency scene is generally considered a Good Samaritan. However,
once a physician initiates treatment, he/she may feel a physician-patient
relationship has been established.
- Good patient care should be the focus of any interaction between pre-
hospital care providers and the physician.
PROCEDURE
- See Physician at the Scene/Medical Direction Algorithm
SPECIAL NOTES
- Every situation may be different, based on the physician, the scene, and the
condition of the patient.
- Contact base when any questions arise.

EMS arrives on scene,
attempts patient care

Document patient care on run report.
Document difficulties or problems on an Incident Report.
Physician on scene reports on
patient, relinquishes patient care.
Physician does not relinquish
patient and continues care
inconsistent with protocols.
Physician complies
Continue patient care per
protocol.
Contact base physician and
follow base physicians
directions.
Physician wants to help or is
involved with patient care and will
not relinquish patient care.
Pre-hospital provider identifies
self and level of training.
Physician wishes to just help
out.
Physician requests or
performs care inappropriate
or inconsistent with
protocols.
Pre-hospital care provider
shares Physician at the
Scene/Medical Direction
note with physician. Advise
physician of your
responsibility to patient.
Physician on scene
Provide care per protocol.
Provide general instructions
and utilize physician
assistance.
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION: NOTE TO PHYSICIANS

THANK YOU FOR OFFERING YOUR ASSISTANCE.

The pre-hospital personnel at the scene of this emergency operate under
standard policies, procedures, and protocols developed by their physician
advisor. The drugs carried and procedures allowed are restricted by law and
written protocols.

After identifying yourself by name as a physician licensed in the State of
Colorado and providing identification, you may be asked to assist in one of the
following manners:

- Offer your assistance or suggestions, but the pre-hospital care providers will
remain under the medical control of their base physician or
- With the assistance of the pre-hospital care providers, talk directly to the
base physician and offer to direct patient care and accompany the patient
to the receiving hospital. Pre-hospital care providers are required to obtain
an order directly from the base physician for this to occur.

THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY.

Physician Advisor Agency
RESUSCITATION AND FIELD PRONOUNCEMENT GUIDELINES
PURPOSE
- To provide guidelines for resuscitation and field pronouncement of patients
in cardiac arrest in the pre-hospital setting
GENERAL PRINCIPLES
- Agency policy determines base contact requirements for patients for whom
resuscitative efforts are being withheld.
- All patients found pulseless and apneic are to be resuscitated, except
patients found in any of the following conditions:
- Decapitation or
- Decomposition or
- Third degree burns over more than 90% of the total body surface area or
- Dependent lividity or
- Rigor mortis or
- A valid CPR directive present with the patient or
- Evidence of massive blunt head, chest, or abdominal trauma
SPECIAL CONSIDERATIONS IN RESUSCITATION DECISIONS
- It is expected that all patients will undergo a thorough physical examination
to determine death.
- Base contact is not required in the following conditions:
- 18 years of age or older and
- Pulseless and apneic and
- Decapitation or
- Decomposition or
- Obvious dependent lividity or
- Obvious rigor mortis
- When it is determined that the patient meets the criteria listed above, the
time of death determination and Medical Directors name is appropriate for
purposes of documentation. If there is any question, or if the patient does
not meet the criteria above, base contact should be made.

- All cases described below require contact with a base physician to approve
termination of treatment.
- Blunt trauma:
- Resuscitative efforts may be withheld or terminated in patients found
apneic and pulseless with:
- Blunt trauma to the head, neck or torso and
- No spontaneous pulse or respirations following appropriate
medical interventions, which include, for example: ensuring a
patent airway or chest decompression. (The majority of injuries
sustained by these patients are not compatible with life.
Appropriate interventions will vary and should be dictated by
guidance from the base physician.)
- Penetrating trauma:
- Research data shows that a significant number of victims of
penetrating trauma to the neck or torso, who are found without signs
of life, may be successfully resuscitated. Therefore, resuscitation and
rapid transport to a trauma facility should be initiated on all patients
found in full arrest secondary to penetrating trauma. Exceptions may
exist in the following circumstance:
- Patients found pulseless and apneic with penetrating trauma if
the provision of ALS has been unavailable for at least 10 minutes
from the time EMS personnel initiate on-scene assessment. (Some
of the injuries sustained by these patients may be compatible
with life. Appropriate interventions will vary and should be
dictated by guidance from the base physician.)
- However, if there is any doubt about duration of the arrest, then
resuscitation and rapid transport should be initiated.
- Medical patients (i.e., no evidence of trauma and presumed medical
arrest) should receive resuscitative treatment until there is:
- No return of spontaneous pulse or respirations during 15 minutes of
CPR (after successful intubation and medications) and no reversible
causes have been identified or
- Continuous asystole for at least 10 minutes in the adult patient, and
30 minutes in a pediatric patient (after successful intubation and
medications), and no reversible causes have been identified
- The following patients found pulseless and apneic warrant
resuscitation efforts beyond 30 minutes and should be transported:
- Hypothermic or
- Drowning with submersion less than 60 minutes (with
hypothermia) or
- Pregnant and estimated to be 20 weeks or later in gestation
- After pronouncement, do not alter condition in any way or remove
equipment (e.g., lines, tubes), as the patient is now a potential coroners
case.
ADVANCE MEDICAL DIRECTIVES
GENERAL PRINCIPLES
- There are several types of advance medical directives (documents in which
a patient identifies the treatment to be withheld in the event the patient is
unable to communicate or participate in medical treatment decisions).
- Do not resuscitate (DNR) orders are generally intended to be written by
a physician for a patient whose medical condition is such that
commencement of resuscitation efforts would be futile.
- A Colorado living will (Declaration as to Medical or Surgical
Treatment) requires a patient to have a terminal condition, as certified
in the patient's hospital chart by two physicians. For the document to
become operative, the patient must be unresponsive because of a
terminal condition for a period of seven days. In most cases, these do
not impact pre-hospital care, but become effective in the in hospital
setting.
- Durable Medical Power of Attorney or Health Care Proxy are
documents that can be very complex and require careful review and
verification of validity, and application to the patient's existing
circumstances. Therefore, the consensus is that resuscitation should be
initiated until a physician can review the document or field personnel
can discuss the patients situation with the base physician.
- The Colorado CPR Directive is a specific situation under Colorado law
that provides for CPR to be withheld or withdrawn (see CPR Directive
protocol below).
- Resuscitation may be withheld from or terminated for a patient who has a
valid, written do not resuscitate order or other advanced medical directive
only if:
- The documentation is clear, unequivocally to the pre-hospital provider
that CPR, intubation and defibrillation are refused by the patient or by
the patient's attending physician who has signed the document, and
- Base physician has approved of withholding or ceasing resuscitative
efforts, and
- There is no apparent indication of suicidal gesture or intent by the
patient.
- If there is disagreement at the scene about what should be done, the
base should be contacted immediately for guidance.
- Pre-hospital providers presented with equivocal DNR orders or advance
medical directives should proceed with resuscitation and establish base
contact for guidance on treatment and transport.
- If the directive document is long and detailed, then it is probably
more reasonable for resuscitation to be initiated and the patient to
be transported so that the base physician can review the document
and possibly contact the patient's attending physician.
- The duration of the resuscitation should be guided by the same
factors of any medical cardiac arrest (see the Medical Cardiac Arrest
protocol).
- Verbal DNR orders are not to be accepted by the pre-hospital provider. In
the event family or an attending physician directs resuscitation be ceased,
the pre-hospital provider should immediately contact base. The pre-hospital
provider should accept verbal orders to cease resuscitation only from the
base physician.
- There may be times in which the pre-hospital provider feels compelled to
perform or continue resuscitation, such as hostile scene environment,
family members adamant that everything be done, or other highly
emotional or volatile situations. In such circumstances, the pre-hospital
provider should attempt to confer with base for direction. If this is not
possible, the pre-hospital provider must use his or her best judgment in
deciding what is reasonable and appropriate, including transport, based on
the clinical and environmental conditions, and establishes base contact as
soon as possible. Documentation of these events must be explicit.
- These guidelines apply to both adult and pediatric patients.
- If the situation appears to be a potential crime scene, EMS providers should
disturb the scene as little as possible.
- ALS personnel should document asystole for 10 seconds in at least two leads
prior to withholding or terminating resuscitative efforts. However, base
physicians and pre-hospital providers must use discretion when considering
the need for a rhythm strip (i.e., monitor strips are not necessary in
patients found decapitated, decomposed or with dependent lividity or rigor
mortis).
- In all cases of unattended deaths occurring outside of a medical facility, the
coroner should be contacted immediately.
CPR DIRECTIVE
GENERAL PRINCIPLES
- This protocol is for the pre-hospital management of the statutory CPR
Directive, which refers to a specifically identifiable, numbered form that is
printed on security paper. The patient or the patients authorized agent
must sign the form. The patients attending physician must also sign the
form.
- In addition to the written CPR Directive form, the patient or authorized
agent may obtain a CPR Directive necklace or bracelet to be worn by the
patient. This bracelet or necklace will have imprinted on it the same
number as the form.
- CPR shall be withheld or terminated if the original CPR Directive form is
readily accessible with an original signature, or if the necklace or bracelet
is worn by the patient.
- A CPR Directive may be implemented for a minor only after a physician
issues a Do Not Resuscitate order and the parents of the minor (if married
and living together), custodial parent, or legal guardian execute(s) a CPR
Directive for the minor.
- A CPR Directive does not only apply to patients in full cardiac arrest, but
should also be honored by withholding resuscitation in patients who are
seriously ill or near arrest.
PROCEDURE
- Upon finding a patient with a CPR Directive (form, bracelet, or necklace):
- Perform initial patient assessment.
- Verify that the CPR Directive form is one of the original copies (it should
be light blue color below the title portion of document) and is unaltered
(not defaced or altered physically in some way).
- Verify that the information on the form or, if present, on the back of
necklace or bracelet, appears to be appropriate for the patient (look at
race, sex, date of birth, eye and hair color). If possible, try to verify
identity of patient by an additional source (i.e., family member, driver's
license or other readily available sources).
- Upon verification of the CPR Directive, withhold CPR. If CPR has been
started, it should be stopped.
- If there is any question of the validity of the document or the identity of
the patient, initiate full resuscitation measures and contact the base for
guidance. Be sure to inform the base of the CPR Directive form, bracelet, or
necklace, and the condition and history of the patient.
- Provide appropriate emotional support to family if possible.
- If the death occurs outside of a health care facility or if tissue donation has
been declared, then the coroner is to be immediately contacted. If the
declarant has indicated on the CPR Directives form a desire to donate any
tissues, appropriate authorities should be notified.
- The following resuscitation measures are to be withdrawn or withheld from
a person who has a valid CPR Directive:
- CPR and chest compressions
- Endotracheal intubation or other advanced airway management
- Artificial ventilation
- Defibrillation
- Cardiac resuscitation measures and medications.
- The following interventions may be administered or provided:
- Assist in maintenance of airway (non-advanced airway management,
such as positioning)
- Suctioning
- Oxygen
- EMT-P: Pain medication
- Control bleeding
- In addition to the standard documentation, the following information should
be documented when possible by the pre-hospital provider on the run
report:
- Patient's status (e.g., condition found, medical history obtained)
- Type of CPR Directive found (document, bracelet or necklace)
- CPR Directive number
- Name of attending physician, if known
- Special circumstances which justify initiating resuscitation if this was
done despite the presence of the CPR Directive
- Monitor strips in at least two leads
- The patient may revoke the CPR Directive at any time by oral expression of
revocation or by destruction of the CPR Directive form, bracelet or
necklace. If a guardian, agent or proxy decision-maker executed the CPR
Directive, then the guardian, agent or proxy decision-maker may revoke the
CPR Directive.
- CPR is to be initiated if the original CPR Directive form, necklace or
bracelet is not readily available, (i.e., being worn by or physically present
with the patient). The bracelet or necklace is only available to the patient
after the form has been properly executed. Removal of the bracelet or
necklace may be construed as revocation. Therefore, if the bracelet or
necklace is readily accessible but not on the patient, any question as to
whether or not the Directive has been revoked should result in resuscitation
until the situation is clarified. Consult with base if you have questions about
terminating CPR and transport. If not in full arrest, patients with CPR
Directives may still be transported to provide comfort measures.
- In the absence of the existence of a CPR Directive, a person's consent to
CPR shall be presumed. The statutorily authorized CPR Directive is only one
manner for a patient to document resuscitation preferences. Other Do Not
Resuscitate forms and advance directives may be honored but base contact
is required.
- Under Colorado Law, refraining from performing CPR when there is a CPR
Directive does not constitute assisting a suicide, and caregivers who honor a
CPR Directive by withholding CPR are protected from legal liability.
INDICATIONS
- The patient is being transported under police custody and has already been
placed in handcuffs by a police officer.
PRECAUTIONS
- Any attempt to restrain a patient involves risks to the patient and the pre-
hospital provider. Efforts to restrain a patient should only be done with
adequate assistance present.
- At no time should the patient be placed in a prone position for a prolonged
time at the scene or during transport to the hospital.
- Ensure that patient has been searched for weapons.
TECHNIQUE
- For the patient who does not require spinal immobilization or transport in a
supine position:
- Maintain restraint via the handcuffs.
- Escort the patient to the bench seat inside the ambulance.
- Secure the patient in a sitting position with the seat belt.
- Treatment and transport should be done with the patient remaining in
the handcuffs.
- Request that the officer stay with the patient and ride in the ambulance
during transport. Ultimately, we are not responsible for the hold on this
patient.
- For the patient who requires transport with spinal immobilization or in a
supine position and is found in standing or sitting position:
- Ensure that you have adequate assistance available to maintain restraint
of the patient.
- Secure the patient's cervical spine with a cervical collar if indicated.
- Assign one individual to support the patient's head.
- Bring the stretcher, with backboard or scoop if indicated, to the patient.
- Have the patient sit down on the stretcher and secure each arm with
Kerlix before having the officer remove the handcuffs.
- Lie the patient down on the stretcher in a supine position.
- Secure one arm of the patient to the scoop or backboard with the
handcuffs. If further restraint is required, use Kerlix or Velcro cuffs to
restrain other extremities.
- For the patient who requires transport with spinal immobilization or in a
supine position and is found in a prone position:
- Ensure that you have adequate assistance available to maintain restraint
of the patient.
- Secure the patient's cervical spine with a cervical collar if indicated.
- Assign one individual to support the patient's head.
- Secure each arm and both legs with Kerlix prior to having the officer
remove the handcuffs.
- Roll the patient onto a backboard or scoop.
- Place the stretcher next to the patient and lift the patient onto the
stretcher.
- Secure one arm of the patient to the scoop or backboard with handcuffs.
If further restraint is required, use Kerlix or Velcro cuffs to restrain
other extremities.
- EMT-P: If the patient remains combative after physical restraints, consider
the use of chemical restraint.
APPENDIX
REQUIRED RECORDS ON TREATMENT AND TRANSPORT OF PATIENTS

a before
AAA abdominal aortic aneurysm
AAO x awake, alert, and oriented
times ____
abd abdomen
AB abortion
ABC airway, breathing, circulation
ACLS Advanced Cardiac Life Support
adm admission
ALS Advanced Life Support
am morning
AMA against medical advice
AMS altered mental status
amp(s) ampule(s)
ant anterior
asa aspirin
ASCVD arteriosclerotic cardiovascular
disease
ASHD arteriosclerotic heart disease
asys asystole
ATLS Advanced Trauma Life Support
A&P anterior and posterior
a&p auscultation and percussion
~ approximately
@ at
BBB Bundle Branch Block
BCLS Basic Cardiac Life Support
BLS Basic Life Support
bil bilateral
BM bowel movement
BP blood pressure
BS breath sounds
BVM bag, valve, mask
c with
C Centigrade
Ca cancer
Ca
++
calcium
CABG coronary artery bypass graft(s)
CAD coronary artery disease
cath catheter, catheterization
CBC complete blood count
cc cubic centimeter
CC chief complaint
CCU coronary care unit
CHF congestive heart failure
CHI closed head injury
circ circulation
cm centimeter
CMS circulation, movement,
sensation
CNS central nervous system
CO carbon monoxide
c/o complaining of/complaint of
CO
2
carbon dioxide
change

COPD chronic obstructive pulmonary
disease
COR-O cardiopulmonary arrest

C-spine cervical spine
C-section cesarean section
CSF cerebrospinal fluid
CSM carotid sinus massage
CVA cerebral vascular accident
CVP central venous pressure
CPR cardiopulmonary resuscitation
d/c discharge/discontinue
D&C dilatation and curettage
detox detoxification
D
5
W dextrose 5% in water
D
50
W dextrose 50% in water
DOA dead on arrival
DOB date of birth
DOE dyspnea on exertion
DOS dead on-scene
Dr. doctor
drsg/dsg dressing
DT delirium tremens
Dx diagnosis
+ decrease
ea each
ED emergency department
ECG/EKG electrocardiogram
EENT eye, ear, nose, throat
EMS emergency medical services
ENT ear, nose, throat
EOA esophageal obturator airway
EOM extraocular movement
et and
ET endotracheal
ETT endotracheal tube
ETA estimated time of arrival
etc and so forth
ETOH alcohol (ethyl)
exam examination
= equal
F Fahrenheit
FB foreign body
FD fire department
fl fluid
Fx fracture
female
1
o
first degree/primary
GB gallbladder
GC gonorrhea or gonococcus
GCS Glasgow coma scale
GI gastrointestinal
g gram
GPA gravida, para, abort
gr grain
GSW gunshot wound
gtt(s) drop(s)
GU genitourinary
GYN gynecology
going to/leading to
> greater than
h/hr hour
HA headache
HACE high-altitude cerebral edema
HAPE high-altitude pulmonary
edema
HAZMAT hazardous materials (incident)
HB heart block
HBV hepatitis B virus
Hct hematocrit
HEENT head, eyes, ears, nose, throat
Hg mercury
Hgb hemoglobin
HIV human immunodeficiency virus
H & P history and physical
HR heart rate
ht height
Hx history
hypo- low
H
2
O water
ICS intercostal space
ICU intensive care unit
I & D incision and drainage
IM intramuscular
inf inferior
int internal
IV intravenous
| increase
J Joule(s)
JVD jugular venous distention
K
+
potassium
KVO/ TKO keep vein open / to keep open
L/l liter
L left
lac laceration
lat lateral
LBBB left bundle branch block
lb pound
lg large
LLL left lower lobe
LLQ left lower quadrant
LMP last menstrual period
LOC loss of consciousness
L-spine lumbar spine
LUL left upper lobe
LUQ left upper quadrant
< less than
/\ lying
MAE moves all extremities
mcg microgram
MCL midclavicular line, modified
chest lead
med(s) medication(s)
mEq milliequivalent
Mg magnesium
mg/mgm milligram
MI myocardial infarction
misc miscellaneous
ml milliliter
mm millimeter
MOE x movement of extremities
times _____
MVA motor vehicle accident
male
N/A not applicable
NaCl/NS normal saline
NaHCO
3
sodium bicarbonate
NC nasal cannula
neg negative
NKA no known allergies
noc/noct night
NPO nothing by mouth
NSR normal sinus rhythm
NTG nitroglycerin
N/V/D nausea and vomiting and
diarrhea
C none
O
2
oxygen
OB obstetrics
occ occasional
O.D. right eye (oculus dexter)
OD overdose
OJ orange juice
ophth ophthalmology

OPP organophosphate poisoning
OR operating room
Ortho orthopedics
O.S. left eye (oculus sinister)
O.U. both eyes (oculus uterque)
oz ounce
p after
PAC premature atrial contraction
PASG pneumatic antishock garment
PAT paroxysmal atrial tachycardia
path pathology
PD police department
PE physical
examination/pulmonary
edema/pulmonary embolus
peds pediatrics
per by or through
PERL pupils equal and react to light
PERLA pupils equal and react to light
and accommodation
PID pelvic inflammatory disease
PND paroxysmal nocturnal dyspnea
po by mouth
pos//+ positive
post posterior
POV privately owned vehicle
PSVT paroxysmal supraventricular
tachycardia
psych psychiatric
pt patient
PTA prior to arrival
PVC premature ventricular
contractions
+ psychiatric
q every
right
RBBB right bundle branch block
RBC red blood cell
resp respirations
RHD rheumatic heart disease/right
hand dominant
RLQ right lower quadrant
R/O rule out
ROM range of motion
ROS review of systems
RUQ right upper quadrant
Rx take, treatment
s without
SAB spontaneous abortion
SC/sub q subcutaneous
SL sublingual
SOB shortness of breath
sol solution
sm small
stat at once
sup superior
Sx sign/symptom
surg surgery
SVT supraventricular tachycardia
synch synchronous
2
o
second degree/secondary

sitting

_

standing

TAB therapeutic abortion
TB tuberculosis
tbsp tablespoon
temp temperature C
TIA transient ischemic attack
tid three times a day
TKO to keep open
TLC tender loving care, total lung
capacity
TM tympanic membranes
tol tolerated
tsp teaspoon
Tx treatment
therefore
3
o
third degree, tertiary
U/A upon arrival
uncons unconscious
unk unknown
URI upper respiratory infection
uro urology
UTI urinary tract infection
= not equal/unequal
vag vaginal
VD venereal disease
VF ventricular fibrillation
via by way of
vol volume
V/S vital signs
VT ventricular tachycardia
WAP wandering atrial pacemaker
WBC white blood cell
wc wheelchair
WNL within normal limits
WPW Wolff-Parkinson-White
Syndrome
wt weight
x times
y/o year(s) old
yr year(s)

MEDICATION PROTOCOLS STANDING ORDERS AND BASE CONTACT REQUIREMENTS
Drug Standing Orders Base Contact
Albuterol Sulfate Adult: 6 mg, 2
nd
dose 12 mg rapid IV, Ped:
0.1 mg/kg, 2
nd
dose: 0.2 mg/kg
Aspirin (ASA) Four 81 mg chewable tables p.o. (324 mg total)
Dextrose Adult: 25 g (D50), Ped: 2-4 ml/kg: 1-8 yr (D25), <1 yr (D10),
2
nd
dose

Epinephrine Auto-
Injector
Adult: One Epinephrine Auto-Injector (0.3
mg)
Ped: One Epinephrine Auto-Injector (0.15
mg)
IV Solutions Adult: Bolus: 1 at 20 ml/kg, challenge: up to 2 of 250 ml NS,
Ped: Up to 2 at 20 ml/kg
Contact base if additional fluid may be
needed.
Metered Dose Inhaler
Administration of pt.s prescription
Naloxone (Narcan)
Adult (> 8 y/o): 2 mg (2 ml) IV, IM or IN if IV not available
Ped (< 8 y/o): 1 mg IV

Nitroglycerin Adult: CP cardiac origin, pt.s
prescription: One 0.4 mg tab or SL spray q
5 min up to 3x
Oxygen All indications
PATIENT TRANSPORT
Standing Orders Base Contact
1. Patients must be at least 3 years old.
2. Vital signs must be within normal limits, which is defined as the
following:
a. Systolic blood pressure > 90 mmHg
b. Pulse 50-120 BPM
c. Respiratory rate 10-30
3. Patients cannot be experiencing altered mental status unless it is felt
to be related to acute alcohol use.
4. Any medical complaints that do not involve chest pain, shortness of
breath or is from a dialysis patient.
All patients outside of standing
order criteria

REFUSALS
REFUSAL: All patients not considered to be
high risk refusals. These patients need to have
their refusal of treatment and transport
documented with the Denver Health
Paramedic Division Refusal Form.
Adult: High risk refusals needing both a signed refusal
form and base contact are:
- Patients with any language barrier
- Under 18
- Pulse > 100
- SBP < 90 mmHg
- Any patient considered to be high risk by the
paramedic
Minor: Uninjured or not ill but unable to contact
parent or legal guardian, OR ill or injured without
guardian or parent to support patient refusal of
treatment, OR with life-threatening illness or injury
but parent or legal guardian refusing treatment of
minor.
DESTINATION POLICY FOR PATIENTS WITH SPECIAL NEEDS
Condition Guideline (Review
Protocol)
Base Contact
Burns Isolated 2/3 burns > 20%
and >12y/o Anschutz
Inpatient Pavilion
(Fitzsimons)
Isolated 2/3 burns > 20%
and <12y/o The
Childrens Hospital

Multi-system trauma Per state destination
guidelines

Pediatrics Normal transport
destination, except if
significant burns or long
standing hx treatment @
The Children's Hospital
Early base contact recommended for
significant complaints.
Psychiatric Pt is under Denver MHH
DHMC
MHH by other agency
appropriate affiliated
hospital
Not on MHH closest
appropriate hospital

OB/GYN Delivery not imminent
pt preference
Delivery imminent & no
more than 5 min
transport pt
preference
DHMC OB Screening > 20
wks and if no complications
(review protocol)
If acute or imminent delivery and pt
wants transport to hospital over 5 min
away, or if facility w/o 24 hr in-house
OB capability

MEDICATION PROTOCOLS STANDING ORDERS AND BASE CONTACT REQUIREMENTS
Drug Standing Orders Base Contact
Adenosine Adult: 12 mg, 2
nd
dose 12 mg rapid IV, Ped: 0.1 mg/kg, 2
nd

dose: 0.2 mg/kg
Contact base for 2
nd
dose 12 mg rapid IV
Albuterol Sulfate Mild bronchospasm: 2.5 mg/3 ml NS (adult and ped) via
nebulizer, moderate/severe: continuous nebulizer
Concern regarding pt, no response or
poor response to tx
Amiodarone Cardiac arrest: Adult: 300 mg IV P, may repeat 150 mg IV
bolus (x1) in 3-5 min.
Following successful defib: Adult: 150 mg IV over 10 min.
Sustained WCT with a pulse, unstable
WCT after unsuccessful cardioversion:
Adult: 150 mg IV over 10 min.
Aspirin (ASA) Four 81 mg chewable tables p.o. (324 mg total)
Atropine Sulfate PEA: Adult: 1 mg q 3-5 min x2, max 3 mg or 0.04 mg/kg
Ped: 0.02 mg/kg (min. 0.1 mg)
Bradycardia w/poor perfusion: Adult: 0.5-1.0 mg, max 3 mg
or 0.04 mg/kg Ped: 0.02 mg/kg (min. 0.1 mg)
For bradycardia, after 2 doses, if signs of
poor perfusion or pt. remains
bradycardic. For symptomatic OPP.
Calcium Gluconate Cardiac arrest: Adult: 1-3 g slow IV P over 2-3 minutes Use other than cardiac arrest
Cyanokit Adult: 5g IVP, Ped: 70 mg/lg IVP
Dextrose Adult: 25 g (D50), Ped: 2-4 ml/kg: 1-8 yr (D25), <1 yr (D10) 2
nd
dose
Diazepam (Valium) Status seizures: Adult: 1-10 mg IV, Ped: 0.3 mg/kg IV or 0.5
mg/kg rectally, up to 10 mg
Use other than status seizures
Diphenhydramine
Hydrochloride (Benadryl)
Adult: 50 mg slow IV P or IM, Ped: < 8 y/o: 1-2 mg/kg, up to
50 mg slow IVP

Dopamine All indications and doses
Droperidol Chemical restraint: Adult: 2.5 mg slow IVP or IM Chemical restraint: Adult: Second dose
Anti-emetic: Adult: 1.25 mg slow IVP or
IM, Ped: 0.05 mg/kg slow IVP or IM
Epinephrine Cardiac arrest: Adult: 1 mg (1:10,000) every 3-5 min IVP,
Ped: 0.01 mg/kg (1:10,000) IV/IO every 3-5 min.
Allergic reactions: Adult: 0.3-0.5 mg 1:1,000 IM, Ped: 0.01
mg/kg 1:1,000 IM
Anaphylaxis: Adult: 0.3-0.5 mg 1:1,000 IM, followed by 1 mg
(1:1,000) in 250 ml NS infused at 2-4 ml/min, Ped: 0.01
mg/kg IM 1:1,000
Asthma: Adult: 0.3-0.5 mg 1:1,000 IM, Ped: 0.01 mg/kg
1:1,000 IM Croup/Epiglottitis: Ped: 5 mg of 1:1,000 (5 ml)
neb undiluted; if < 10 kg: 0.5 mg/kg 1:1,000 nebulized
Bradycardia: Adult: 1 mg (1:1,000) in 250
ml NS infused at 2 mcg/min, Ped: 0.01
mg/kg (1:10,000) IVP

Fentanyl Citrate Pain from isolated extremity injury, burns, or appropriate
medical problem. Adult: 2-4 mcg/kg slow IVP up to 300 mcg,
Ped: 1-2 mcg/kg slow IVP
Code 10 trauma return with c/o pain or suspicion of pain, >
18 y/o, GCS > 13, SBP > 90 mmHg, no evidence of imminent
deterioration: 100 mcg IV
Any single dose >100 mcg, cumulative
doses > 300 mcg
Glucagon Hypoglycemia without IV access: Adult: 1.0 mg IM Beta blocker/Ca
++
Channel blocker OD:
Adult: 2 mg IV push, Ped: 0.1 mg/kg IV
(max. dose 1 mg)
Ipratropium (Atrovent) Adult: 0.5 mg in 2.5 ml NS via nebulizer. Ped over 2 y/o: 0.5
mg in 2.5 ml NS via nebulizer, 1x only

IV Solutions Adult: Bolus: 1 at 20 ml/kg, challenge: up to 2 of 250 ml NS,
Ped: Up to 2 at 20 ml/kg
Contact base if additional fluid may be
needed.
Magnesium Sulfate Cardiac arrest refractory VF and pulseless VT or torsade de
pointes: Adult: 2 g slow IV P
WCT w/pulse & without poor perfusion or
acute bronchospasm: Adult: 2 g slow IV
push
Preeclampsia/eclampsia: 6 g in 50 ml NS
over 15-30 minutes
Methylprednisolone (Solu-
Medrol)
Anaphylaxis, severe asthma or COPD: Adult: 125 mg IV, Ped:
2 mg/kg IV

Midazolam (Versed)
Cardioversion and TCP: Adult: 2 mg IV, may repeat x1 if
necessary,
Ped: 0.1 mg/kg IV/IM/IO (max 10 mg)
Status epilepticus: Adult (> 8 y/o): 2-5 mg IV/IM, titrate to
effect
Combative symptomatic sympathomimetic overdose: Adult:
5 mg IM
Sedation for an intubated patient: Adult: 2 mg IV

Morphine Sulfate Adult: 2-10 mg IV. Initial dose up to 4 mg, then 2 mg
increments up to a total of 10 mg, all indications, Ped: 0.1-
0.2 mg/kg IV slowly
Adult: After initial 10 mg, all indications.

Naloxone (Narcan) Adult: 2 mg, may repeat x1 p 5 min, Ped < 8 y/o: 1 mg.
Pt. must be transported if med is used.

Nitroglycerin Adult: CP cardiac origin or pulmonary edema: One 0.4 mg
tab or SL spray q 5 min up to 3x
More than 3 doses; if SBP is <100 mmHg
prior to administration; if poor perfusion
or hypertension (crisis)
Ondansetron (Zofran) Adult: Severe nausea and vomiting: 4 mg slow IVP or IM over
2-5 min.
Ped (< 40 kg): 0.1 mg/kg slow IVP or IM over 2-5 min, max 4
mg
Pregnant or patients < 18 y/o
Oxygen All indications
Phenylephrine 1% 2 drops prior to nasal intubation
Racemic Epinephrine
(Vaponephrine)
For life-threatening airway obstruction from croup or
epiglottitis. neb only, 0.5 ml in 2 ml NS, all ages

Sodium Bicarbonate Prolonged cardiac arrest or dialysis patient in cardiac arrest
(presumed hyperkalemia): Adult and Ped: 1 mEq/kg,
Neonate: dilute 1:1 with NS
Tricyclic overdose with objective
findings: Adult and Ped: 1 mEq/kg,
Neonate: dilute 1:1 with NS
Topical Ophthalmic
Anesthetic
2 drops in affected eye once during transport For additional dose
ADVANCED PROCEDURES
Procedure Standing Orders Base Contact
Airway management Oral or nasal
intubation, King LTS-D,
CPAP
Surgical cricothyrotomy
Cardioversion Symptomatic
tachycardias start @
100 j, then 150 j, 200 j
Atrial dysrhythmias -
start at 50 j

Defibrillation All indications
Restraint and chemical
sedation
Droperidol 2.5 mg slow
IVP or IM
Midazolam (Versed) 5
mg IM
When uncertain as to whether or not the
use of restraints is warranted to
transport the unwilling or uncooperative
patient.
Tension Pneumothorax
Decompression
Penetrating trauma
arrest
All other indications
Transcutaneous Pacing All indications
REFUSALS
REFUSAL: All patients not considered to be
high risk refusals. These patients need to
have their refusal of treatment and transport
documented with the Denver Health
Paramedic Division Refusal Form.
Adult: High risk refusals needing both a signed refusal
form and base contact are:
- Patients with any language barrier
- Under 18
- Pulse > 100
- SBP < 90 mmHg
- Any patient considered to be high risk by the
paramedic

Minor: Uninjured or not ill but unable to contact parent
or legal guardian, OR ill or injured without guardian or
parent to support patient refusal of treatment, OR with
life-threatening illness or injury but parent or legal
guardian refusing treatment of minor.
DESTINATION POLICY FOR PATIENTS WITH SPECIAL NEEDS
Condition Guideline (Review
Protocol)
Base Contact
Cardiac Alert All hospitals except
cardiac alerts. DHMC
accepts between the
hours of 0800-1600, M-F

Burns Isolated 2/3 burns >
20% and >12y/o
University
Isolated 2/3 burns >
20% and <12y/o The
Childrens Hospital

Multi-system trauma Per state destination
guidelines

Pediatrics Normal transport
destination, except if
significant burns or long
standing hx treatment
@ The Children's
Hospital
Early base contact recommended for
significant complaints.
Psychiatric Pt is under Denver MHH
DHMC
MHH by other agency
appropriate affiliated
hospital
Not on MHH closest
appropriate hospital

OB/GYN Delivery not imminent
pt preference
Delivery imminent & no
more than 5 min
transport pt
preference
DHMC OB Screening >
20 wks and if no
complications (review
protocol)
If acute or imminent delivery and pt
wants transport to hospital over 5 min
away, or if facility w/o 24 hr in-house
OB capability

REQUIRED RECORDS ON TREATMENT AND TRANSPORTATION OF
PATIENTS

Policy Statement of the Colorado Dept. of Health EMS Division:

Section 9.2 of the EMS Rules specifies that each ambulance service shall
maintain records of the treatment and transportation of all patients cared for.
Such records shall include all information determined by the Department of
Health to be essential for the maintenance of adequate minimum records on a
patient's condition and medical care provided. In addition, these records shall
be preserved by the ambulance service for a period of three (3) years.

In compliance with Section 9.2, the Emergency Medical Services Division of the
Department of Health has established the foregoing policy that specifies the
essential information to be recorded and preserved for each patient cared for
by an ambulance service.

The Emergency Medical Services Division of the Colorado Department of Health
hereby determines that the following information shall be recorded and
preserved by each pre-hospital care EMS service in the state on each patient
cared for:

- Patient name, if known, as complete as possible and ideally including full
first and last name.
- Patient residential address, if known, as complete as possible (to allow
medical or public health follow up, if needed).
- Patient sex (both for purposes of identification and to facilitate diagnosis
and treatment).
- Patient age, as accurate as possible (both for purposes of identification and
to facilitate diagnosis and treatment).
- Patient location at time of response and apparent cause of the injury or
nature of illness (to assist in subsequent diagnosis and treatment).
- Patient condition at time of response, including a preliminary assessment of
the patient based on vital signs, apparent symptoms, and known medical
history.
- Patient vital signs at time emergency medical care is begun, to include
respiratory rate, pulse rate, blood pressure, level of consciousness, and
pupil size and reaction to light. Subsequent vital signs shall be recorded at
least every 15 minutes when either treatment or transport time exceed 15
minutes.
- Known patient history related to the apparent illness or injury, including
allergies and medications. If it is determined that the patient is on
medication of any kind, the prescribing physician should be identified, if
possible, so he/she may be contacted for confirmation, consultation, or
actual care of the patient.
- Treatment rendered to the patient at the scene and during transport, in
sufficient detail to permit the receiving facility (i.e., hospital, clinic, etc.),
physician advisor, and any other reviewing physician or nurse to determine
the nature and extent of treatment rendered.
- Patient's apparent condition upon delivery to the receiving facility, and any
pertinent comments regarding changes in the patient's condition during
transport (to assist the receiving physician in diagnosis and treatment).
- Identity and location of the receiving facility and signature or other
indication of the physician or nurse receiving the patient and assuming
responsibility for the care of the patient.
- Full name and level of training and certification or licensure of each
member of the EMS crew caring for the patient.
- Times of dispatch and departure to the emergency scene, time of arrival at
the scene, time of departure from the scene, and time of arrival at the
receiving facility.
- Indication of whether emergency lights and siren were used en route to the
scene and/or during transport.

In all cases, a copy of the patient care report should be delivered to the
receiving facility along with the patient.

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DENVER PARAMEDIC DIVISION

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