Standing Orders Emergency Medical Protocols

Critical Care Ground and Air Medical Division

Dr. Ronald Charles M.D.

Board Certified Emergency Physician Chief Medical Director of EMS

Dr. Joseph Varon M.D.

Certified Critical and Intensive Care Physician Clinical Professor of Medicine, UTHSC-Houston Clinical Professor of Medicine-UTMB Medical Director of Critical Care and Flight Services

Signature

Signature

Protocols Valid from October 01, 2011 through October 31, 2015

Table of Content
General Protocols GP01 GP02 GP03 GP04 GP05 GP06 GP07 GP08 GP09 GP10 GP11 GP12 GP13 GP14 GP15 GP16 GP17 GP18 GP18a GP19 GP20 GP21 GP22 GP23 GP23a GP24 GP25 GP26 GP27 GP28 AM01 AM02 AM03 AM04 AM05 AM06 AM07 AM08 AM09 AM10 AM11 AM12 AM13 AM14 AM15 AM16 AM17 Standard of Care Standing Orders General Therapies Patient Assessment Primary Survey Destination Determination Diagnostics/Procedures Rapid Transport Air Ambulance Use Consent for Treatment Authorization Levels Pain Management IV Fluid Selection Medical Scene Control and Responsibility Minimum Supply/Equipment List Minimum Drug Formulary Storage of Medications and Medical Devices Pharmacological Assisted Intubation Non Resuscitation Order TDSHS STOP Form/DNR Form Tissue Referral InService Dispositions HIPAA Compliancy and Standards Geographical Area and Personnel Status Disaster Plan Disaster Plan Flow Sheet Sedation of Confirmed Intubated Patient Facility Physician Orders Treating and Release of Patients Medical Control Consults Oxygen Calculation Worksheet Asystole Pulseless Electrical Activity Pulseless Ventricular Fibrillation Hypothermic Induces Cardiac Arrest Post Resuscitation Management Undifferentiated Tachycardia Unstable Ventricular Tachycardia Stable Ventricular Tachycardia Unstable Supraventricular Tachycardia Stable Supraventricular Tachycardia Bradycardia Ventricular Ectopy Acute Coronary Syndrome Cardiogenic Shock Hypertensive Crisis-Unstable Hypertensive Crisis-Stable Respiratory Distress-General Page 7 8 9-12 13-14 15 16-18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34-37 38 39-40 41 42 43 44 45 46 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Page 2 of 192

Adult Medical Protocols

Table of Content Continued

Adult Medical Protocols AM18 AM19 AM20 AM21 AM22 AM23 AM24 AM25 AM26 AM27 AM28 AM29 AM30 AM31 AM32 AM33 AM34 AM35 AM36 AM37 AM38 AM39 AM40 AM41 AM42 AM43 AM44 AT01 AT02 AT03 AT04 AT05 AT06 AT07 AT08 AT09 AT10 OB01 OB02 OB03 OB04 OB05 PM01 PM02 PM03 PM04 PM05 PM06 PM07 Pulmonary Edema Asthma Chronic Obstructive Pulmonary Disease Pneumonia Hyperventilation Syndrome Pneumonia Allergic Reactions Mild to Anaphylaxis Altered Mental Status-Unknown Etiology Seizures Cerebral Vascular Accident Overdose Poisoning Neurogenic Shock Hypoglycemia Hyperglycemia Dehydration Hypothermia Heat Related Emergencies Near Drowning Septic Shock Nausea/Vomiting Acute Appendicitis-Diagnosed Renal Calculi Acute Abdomen Etiology Unclear Gastrointestinal Hemorrhage Sedation / Chemical Restraint Excited Delirium Traumatic Cardiopulmonary Arrest Multi-System Trauma Head Injury Burns Muscle-Skeletal and Soft Tissue Injury Amputations Eye Injury Insect/Spider Bites Snake Bites Pulmonary Embolism Abdominal Pain Female Labor Childbirth and Delivery Vaginal Bleeding Spontaneous Abortion Asystole Pulseless Electrical Activity Pulseless Ventricular Fibrillation Hypothermic Induced Cardiac Arrest Post Resuscitation Management Undifferentiated Tachycardia Unstable Ventricular Tachycardia 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 91 92 94 95 96 97 98 99 100 101 102 103 105 106 107 108 109 111 112 113 114 115 116 117 Page 3 of 192

Adult Trauma Protocols

Obstetrics/Gynecology

Pediatric Medical Protocols

Table of Content Continued

Pediatric Medical Protocols PM08 PM09 PM10 PM11 PM12 PM13 PM14 PM15 PM16 PM17 PM18 PM19 PM20 PM21 PM22 PM23 PM24 PM25 PM26 PM27 PM28 PM29 PM30 PM31 PM32 PM33 PM34 PM35 PM36 PM37 PM38 PM39 PT01 PT02 PT03 PT04 PT05 PT06 PT07 PT08 PT09 PR01 PR02 PR03 PR04 PR05 PR06 Stable Ventricular Tachycardia Unstable Ventricular Tachycardia Stable Ventricular Tachycardia Bradycardia Ventricular Ectopy Hypoperfusion Cardiac Ischemia Cardiogenic Shock Respiratory Failure Respiratory Distress Pulmonary Edema Asthma Epiglottitis Croup Bronchiolitis/Pneumonia Airway Obstruction by Foreign Body Allergic Reactions Altered Mental Status Seizures/Status Epilepticus Seizures/Postictal State Overdose Poisoning Hypoglycemia Hyperglycemia/Diabetic Ketoacidosis Dehydration Hypothermia Heat Related Emergencies Heat Stroke Near Drowning Post Delivery Care Sepsis Acute Abdomen-Unknown Etiology Traumatic Cardiopulmonary Arrest Multi-System Trauma Head Injury Burns Muscular-Skeletal and Soft Tissue Injury Amputations Eye Injuries Insect/Spider Bites Snake Bites Electrocardiogram Esophageal Obturation Airways External Cardiac Pacing Defibrillation Zoll Cardiac Monitors Defibrillation Welsh Allen Monitors External/Internal Jugular Cannulation 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 151 152 153 154 155 156 157 158 159 161 162 163 164 165 166 Page 4 of 192

Pediatric Trauma Protocols

Procedures

Table of Content Continued

Procedures PR07 PR08 PR09 PR10 PR11 PR12 PR13 PR14 PR15 PR16 PR17 RF01 RF02 RF03 RF04 RF05 RF06 RF07 RF08 RF09 RF10 RF11 Injection Locks Intraosseous Cannulation EZ/IO Bone Drill and B.I.G. Intravenous Cannulation Nasogastric Tube Insertion Nasotracheal Intubation Nebulized Brochodilation Needle Chest Decompression Oral Tracheal Intubation Positive End Expiratory Pressure Surgical Airway Vagal Stimulation Burn Reference Trauma and Glascow Scoring Multi Lead ECG Guide to Drips Anatomical Positions Anatomical Reference to Movement Cardiac Muscle Reference Skull Bone Reference Eye Anatomy Reference Renal and Hepatic Reference Head and Neck Anatomy Reference 167 168 169 170 171 172 173 174 175 176 177 179 180 181 182 184 185 186 187 188 189 190

References

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Protocol Preface
These Protocols are to be utilized when the indicated conditions arise. They are not to be deviated from or changed in any way unless specified herein. The use and administration of oxygen in these protocols are not intended to be exact but to be a guideline. The adult protocols refer to patients over the age of 12. The pediatric protocols refer to patients 12 years of age and younger. It is the requirement of all ACUTE MEDICAL SERVICES, LLC employees and volunteers to be familiar with these protocols and all skills associated with these protocols. All Medics are to be knowledgeable with all drugs specified herein or used by ACUTE MEDICAL SERVICES, LLC, including but not limited to: indication, contraindication, anticipated effect, possible side effects and dosage. References for medications and drugs utilized can be confirmed by the use of Mosbys Critical Care Drug Reference as this is the reference of choice when cross references medications and administration of medications. Acute Medical Services medical director allows all medical certified staff to perform therapies under these protocols and may limit any certified personnel no matter what certification level the employee may hold to perform any therapies herein. If there is any doubt whether you may perform any therapy within these protocols the medical director should be notified for clarification. Emergency Medical Technician may apply the cardiac monitor but may not interpret any rhythm or treat patients based on any rhythm displayed on the cardiac monitor. EMT Basic technicians can perform ECG and 12 Lead for the receiving facilities. EMT Basic may draw blood and in some instance perform IV cannulations only to the upper extremities under direct supervision of an EMT Intermediate or Paramedic at the discretion of the Medical Director. EMTs may not administer any IV fluids and may only use Saline Locks. EMT must have the written approval from the medical director before performing such skills and the approval must be placed in the employees file for reference. Emergency Medical Technician-Intermediate may initiate intravenous access under these protocols and are limited to the use of Normal Saline or Lactated Ringer Solutions. The EMTIntermediate can initiate airway control on any patient that so requires through the use of all airway adjuncts excluding surgical airways. EMT Intermediates may use the mechanical ventilator for ventilation support and may use the IV pumps for administration of normal saline and LRS. Emergency Medical Technician Paramedics may practice to their level under the direction of ACUTE MEDICAL SERVICES, LLC Paramedic Incharge. While performing patient care all ACUTE MEDICAL SERVICES, LLC employees, Fire Services, and First Responders personnel shall comply with current Infection Control Policies and Procedures. This includes utilization of personal protective equipment for every patient in your care while employed with Acute Medical Services, LLC. Personal Protective Equipment shall include: Gloves Protective Eyewear Face shield (if indicated) Gown (if indicated)

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General Protocol

Standard of Care

GP 01

Clinical competence and high standards are vital functions in providing quality prehospital emergency medical care to the customers who rely on our services. The following treatment protocols represent a guideline for the minimum level of patient care that is to be provided. The Standard of Care Statement and the aforementioned treatment protocols represent only the minimal standards of care to be provided to patients in your care. Acute Medical Services, LLC and the Medical Director embrace as fundamental components of its standard of care and the following concepts: The emergent patient benefits from early medical interventions, especially the early and aggressive application of airway establishment and maintenance, early administration of oxygen, early protection of the cervical spine, early initiation of definitive therapies and rapid transfer to an institution of higher levels of care. Remember that oxygen therapy should never be withheld while initial patient evaluation takes place. The patient determines the emergency. As Paramedics and Nurses you are often called upon to assist with social or psychological problems and we must respond as professionally and thoroughly to these as we do for medical or surgical problems. The Facility providing patient care determines the emergency. As Paramedics and Nurses providing interfacility transfers and emergency inceptions to deliver patients to a higher level of care you may be requested to respond as rapidly as you would by a private caller. The customer determines the emergency. The customer may be a private physicians office or an emergency department at a local or rural hospital. We will treat these responses as any other emergency response when requested to do so. The Paramedics and Nurses role is to act as the eyes, ears, and hands of the physician in the remote and prehospital setting. To successfully do so requires that you educate yourself beyond first aid procedures and dedicate yourself to becoming an integral part of the total health care team. Paramedics, nurses, and healthcare providers acting under Acute Medical Services, LLC will maintain current continuing education as outlined throughout the course of the year. C.E. is mandated and participation is required. It is expected that you maintain and stay on the leading edge of healthcare to be the best practitioners possible. These protocols are intended to be used as guidelines to the paramedics and nurses treatment regimen. It is impossible to create protocols for every situation and every patient that may arise. The Paramedic and nurse must use his best judgment, along with his knowledge, clinical manuals, references, and the use of the medical director to ensure the best medical care be provided without further complicating the injury or illness. As stated as the basis of medical care, Do no harm. Any deviation from these protocols should be well documented and the medical director must be informed prior to such deviations. The Paramedic or nurse has no permission to perform any treatments or intervention in which he has not been trained to perform or therapies that would be considered outside the scope of the protocols and/or the standard of care in Emergency Medical Care.

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General Protocol

Standing Orders
Standing Orders:

GP 02

Standing orders are defined as those therapies, interventions, and procedures, which may be performed without or prior to a direct physician's order. Standing orders represent off-line medical control. They are superseded by any orders received by online Medical Control. The only physicians to dictate orders are ACUTE MEDICAL SERVICES, LLC Medical Director or his designee. At times when the Medical Director is unavailable it will be known which designee will be controlling medical issues in his absence. Paramedics and nurses will receive notice prior to medical direction being designated. Standing orders are allotted to perform all therapies, interventions, and procedures noted in these Protocols under "Treatment". In the event of communications failure, treatment is authorized on standing order to include those therapies, interventions, and procedures only under the Treatment " designation. The use of medical control consultation is to be undertaken prior to the event or during the situation in question. Informing Medical Control after the fact though interesting, is not acceptable as notification. Written Physician Orders: Interfacility transfer orders that are clear and precise and patients physicians orders can be carried out so there is no interruption of the continuity of care. Insure that you have a complete understanding of the orders that should be followed before departing the facility. If the patients condition worsens then you will revert back to Acute Medical Services protocols until the patients condition stabilizes. A copy of the written order should be photocopied and attached with the patient care report. It is imperative to cross reference treatment modalities with the references available to you. Phone Orders by treating Physician: You may find from time to time that it may be beneficial to contact the physician who initiated treatment on the patient you are transporting. These orders are considered on-line medical control and the orders should be followed if the patients condition warrants. The phone orders should be documented on the patient care report to include the date, time, and physicians name and license number dictating the order. No orders can be taken by third party communication.

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General Protocol

General Therapies

GP 03

The following procedures, therapies, and medications are authorized above and beyond those noted in the specific protocols for use at the Paramedics and Nurses discretion. 1. Oxygen Oxygen may be administered to any patient with demonstrated hypoxemia by pulse oximetry or with any clinical suspicion of hypoxia, chest pain, hemorrhage, or SOB. 2. IV Starts Unless specifically limited or prohibited by the particular protocol, advanced EMS personnel may initiate an IV on any patient at their discretion. EMT-I and/or EMT-P and/or RN personnel grouping may elevate care as per advanced protocol or direction. The attending Paramedic has discretion to determine whether IV therapy should be administered to patients in the field. EMT-Basics may initiate an IV if approved by the medical director and only with the direct supervision of the Paramedic or Registered Nurse. 3. Endotracheal Intubation/Esophageal Obturation/LMACombitube Advanced EMS personnel may secure the airway of any patient whom they believe is experiencing airway compromise, respiratory failure, or who requires positive pressure ventilation. The airway may be secured with endotracheal intubation (the preferred method) or an acceptable adjunct, so long as the patient does not have any contraindications to these procedures. In the event that RSI, Rapid Sequence Intubation is anticipated, pretreatment with a benzodiazepine may be administered. The attendant Paramedic has discretion regarding intubation administration to patients in the field. Specific indications for RSI are given in the RSI directive. 4. ET Medication Administration Medications may be given via the endotracheal tube IF: 1. IV access is delayed and intubation is accomplished AND 2. Auscultation reveals clear lung fields *Medications given via the ET tube are not picked up as well as IV meds, require higher doses and dilution, and are very susceptible to bronchial/alveolar infiltrates and alveolar wall disturbances. Medications that may be given via ET are: Naloxone, atropine, epinephrine, lidocaine The unit or bolus dose of any adult medication given via ETT is to be doubled from the standard IV dose 5. Dextrose Dextrose may be administered to any patient if the EMS personnel suspect hypoglycemia. In the hypoglycemic (or suspected hypoglycemic) patient with an intact gag reflex in whom an IV cannot be established, dextrose may be given orally. Oral dextrose may be administered as PO D50% or glucose paste. IV Dextrose may be given in a half-amp, ampule or greater than one ampule dosage depending on the patients response. For alterations of the dosing schedule MC should be consulted.

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6. Promethazine Promethazine may be given to a patient complaining of nausea and/or vomiting who has a stable BP and does not have any contraindications to the medication. A BP must be checked and documented immediately before Promethazine may be given either IM or IV. Dosage is 12.5 mg 25 mg for adults and 0.5 mg/kg up to 12.5 mg for pediatric patients. 7. Thiamine Thiamine may be administered to any adult patient in whom the paramedic has any reason to suspect malnutrition or alcohol abuse. Thiamine should be given as 50 mg IM and 50 mg IV. However, in the patient with inadequate muscle mass to receive IM injections, the entire 100-mg may be given IV. Conversely, if an IV cannot be established, the provider may administer the entire 100-mg IM. If no muscle mass and no IV, then thiamine should be withheld. 8. Nitroglycerin (Spray, Tablets, Paste, or Gel) Nitroglycerin may be administered to any patient with an elevated Blood pressure (Systolic at least 90 mmHg), Non Traumatic Chest Pain, and Shortness of Breath and at the discretion of the Paramedic or Nurse. 9. Cardiac Arrest Medications In addition to those therapies expressly listed in the protocol as standing orders, the following medications are available for use on standing order in any cardiac arrest situation where there is evidence that they are indicated: D50% 25-50 G Naloxone 2-8 mg, with decreased respiratory rate or respiratory depression *Refer to the dosage scale for age groups 10. Acetaminophen Acetaminophen may be administered to any febrile patient (without contraindications to the medication) as 15 mg/kg either PO or PR. EMT-Basic or Intermediate can give this medication at the discretion of the attending Paramedic or Nurse. 11. Sodium Bicarbonate Sodium Bicarbonate can be administered to any renal failure patient that is found to have any cardiac event leading to cardiac arrest.

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12. Ibuprophen Ibuprophen may be administered to any febrile patient (without contraindications to the medication) as 200mg1000mg for the adult patient. Use the table below to determine pediatric dosing. EMT-Basic or Intermediate can give this medication at the discretion of the attending Paramedic or Nurse. Weight 12 - 17 lbs 18 - 21 lbs 22 - 32 lbs 33 - 43 lbs 44 - 54 lbs 55 - 65 lbs 66 - 76 lbs 77 - 87 lbs 88 - 98 lbs Dose 50 mg 75 mg 100 mg 150 mg 200 mg 250 mg 300 mg 350 mg 400 mg Oral Drops (50 mg/1.25 ml) 1.25 ml 1.875 ml 2.5 ml 3.75 ml 5 ml Suspension (100 mg/5 ml) 1/2 tsp 3/4 tsp 1 tsp 1 1/2 tsp 2 tsp 2 1/2 tsp 3 tsp 3 1/2 tsp 4 tsp 2 3 4 5 6 7 8 1 1 1/2 2 2 1/2 3 3 1/2 4 2 2 1/2 3 3 1/2 4 Chewable Chewable Caplets 50 mg 100 mg 100 mg

13. Zofran Zofran (ONDANSETRON) may be given to a patient complaining of nausea and/or vomiting who has stable vital signs and does not have any contraindications to the medication. Vital signs must be checked and documented immediately before Zofran administration. Zofran is best used by administering IV as the results are much more rapid than other routes though can be administered IM. Dosage is 2 mg 8 mg for adults and 1mg to 4mg pediatric patients or 0.1-mg/kg dose for pediatric patients weighing 40 kg or less. 14. Foley Catherization Advanced providers may place a Foley catheter in any patient older than 12 years old who is incontinent and unable to use the toilet without assistance. This procedure should only be used in patients who are unable or unwilling to use other means of toiletry. This procedure may be useful in long distance transfers where the ability to use a toilet/urinal or the use of such would cause harm to a specific injury like unstable pelvis fracture.

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15. Sedation of the confirmed intubated patient From time to time the Paramedic or RN may come across a patient that has been intubated in a hospital setting that needs transport to definitive care. Some instances may be found where the patient that is intubated may be lightly sedated enough to achieve a calm state in a controlled environment like an ICU or Emergency Department. If the paramedic or RN attempts to move the patient to achieve patient transport and the patient sedation is such that is poses a risk of dislodging the ET tube or the patient appears to be conscious enough to have an understanding of the surrounding then the Paramedic or RN may administer additional sedatives to achieve a sedation that is appropriate to transport the patient without the patient being coherent enough to have a mental state that would generate fear or pain for the patient. Remember there is a fine line when it relates to humane and ethics. The paramedic or RN at their discretion may use additional sedatives to achieve a humane and ethical transport. If the patient is on a specific sedative you may attempt to increase the sedative being used. The following may be used to achieve sedation for a patient with a confirmed ET placement as long as there are no contraindications of the sedative: Valium Versed 5-10 mg IV q 15-30 mins 2-10 mg IV q 15-30 mins Consider Infusion (see Infusion Chart) Amidate Above the age of ten (10) years will vary between 0.2 and 0.6 mg/kg of body weight, and it must be individualized in each case. The usual dose for induction in these patients is 0.3 mg/kg, injected over a period of 30 to 60 seconds. 2mg IV q 30 mins Consider Infusion (see Infusion Chart) Propofol A slow rate of approximately 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg) should be used then a Maintenance Infusion 50 to 200 mcg/kg/min. Use with caution as Propofol may create Severe Hypotension If patient SBP falls below 100mmHg stop the infusion until such time the BP is above 100mmHg. Titration of this drug can be challenging. Start at the lowest dose and monitor how the patient reacts with the sedation and blood pressure responses. Increase slowly till you achieve the desired effect. The attempt is to achieve enough sedation to make the patient comfortable without a drastic change in patient blood pressure. Patients that are intubated must have pulse oximetry measurements, cardiac monitoring, and wave form CO2 capnography along with Vital Signs q 3-5 mins. ET Tubes should be secured with a Thomas ET Tube Tamer if possible. Patient may also need a cervical collar placed to insure and prevent tube displacement. The benefit from the use of wrist restraints may be indicated. Remember to insure the tube placement with auscultation of bilateral breath sounds, pulse oximetry, and end tidal CO2 capnography every 2-3 minutes to insure the tube has not been dislodged.

Ativan

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Patient Assessment Primary Survey

General Protocol

GP 04

Throughout these protocols, the acronym CABCs is used to indicate the primary survey of the emergent patient. Our primary survey consists of the evaluation and, if needed, management of the following components: Cervical spine Level of consciousness Airway Breathing Circulation The following is an outline for the assessment and management of these components. Cervical Spine If there is any possibility of a spinal injury, the provider must assume that one exists and approach the patient accordingly. Once permission to assess the patient is obtained, by actual or implied consent, the providers next step on any patient with the possibility of spinal injury is to manually obtain control of the c-spine. This manual c-spine stabilization must be maintained until: Further assessment indicates an absence of spinal injury. Only a physician with radiological support may rule out. The spine is adequately immobilized when adjuncts are applied which relieve the need for manual stabilization, or the patient refuses further treatment. In this case, the pt must sign an Against Medical Advice form. Level of Consciousness The level of consciousness should be briefly assessed next, to determine only the patients rating on the AVPU scale (alert, responsive to pain, responsive to voice, unresponsive). Further assessment of the level of consciousness is to be deferred until the secondary survey. This will also include judgment (a good place for a baby to play is: a highway, a playpen, a battlefield), memory (three numbers recalled after one minute). Airway The patients airway must next be evaluated for patency. If there is any indication of a compromise in the patients airway or threat that the patient is in impending failure, the provider should intervene to secure the airway. Indications of compromise may be as overt as apnea or a visible obstruction, or may be indicated by a less obvious sign such as airway noises (stridor, snoring, gurgling, etc.). The airway should be secured first with positioning, using a jaw-thrust if spinal injury cannot be ruled out or a head-tilt/chin-lift if spinal injury is not a concern. If material must be physically removed from the airway, this should be done next using abdominal or chest thrusts, possibly a finger sweep, and/or oral suctioning, or direct laryngoscopy and Magill forceps, as appropriate. If the patients level of consciousness is diminished (GLS<8), an airway adjunct should be placed next. Use an oral airway if the patient will tolerate it; otherwise use a nasal trumpet unless basal skull fracture is suspected. Manual positioning must be maintained concurrently with the use of such an adjunct. If possible, the airway should next be definitively secured with ET intubation (or esophageal obturation, CombiTube, KingTube or LMA). Even in the patient whose airway is initially patent, the provider must continuously re-assess and be prepared to intervene against any airway compromise.

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Breathing The next component to be assessed is the patients respiratory status. If the patient is not breathing spontaneously, ventilation with supplemental oxygen must be initiated immediately. If the patient is breathing spontaneously, the adequacy of the patients respiratory effort must be evaluated. One useful but not conclusive method is evaluation with pulse oximetry. If saturation is consistently below 86% then intubation must be considered. If the patients rate or tidal volume is inadequate, assisted ventilation with supplemental oxygen is to be provided immediately. The patients chest should also be rapidly assessed for open wounds, which would compromise respiration. If any open chest wound is found, it must be immediately occluded, initially with the providers gloved hand and then with an occlusive dressing. The bag-valve-mask device with oxygen at 10-15 1/min and a reservoir bag is the preferred method of providing ventilation. The demand-valve (oxygen-driven, manually triggered device) should not be used unless a properly functioning BVM is not available as the demand-valve offers, no sense of compliance or resistance to the operator and often results in excessive gastric distention. If possible, the airway should always be secured with ET intubation if positive pressure ventilation is to be instituted. As with the airway, the provider must continuously reassess the ventilatory status of even the most stable patient and be prepared to rapidly intervene if respiratory compromise develops. Circulation The patient shall next be assessed for adequate circulation and presence of major external hemorrhage. If the patient is awake or at least responsive to verbal or physical stimulus, the provider shall assume that circulation is adequate for the moment and move on. If the patient is unresponsive, the provider will assess for the presence and adequacy of a palpable carotid pulse. If the patient does not have a palpable carotid pulse, or has a pulse of less than 40/min in the adult (less than 50/Min in a child or less than 70/min in an infant), the provider must initiate CPR. A more accurate evaluation of the patients perfusion status will be done during the secondary survey. Next, the patient should be assessed for external bleeding. If major bleeding is found, it should be immediately controlled with direct pressure. In summary, the primary survey includes (in order): 1. 2. 3. 4. 5. 6. Obtain manual control of cervical spine. Quickly establish level of consciousness (AVPU). Evaluate airway. Establish patent airway if needed. Evaluate breathing. Initiate ventilation or ventilatory assistance if needed. Assess for open chest wounds. Occlude any found. Check for presence and adequacy of circulation. Initiate chest compressions if needed. Check for external bleeding. Control any significant bleeding found.

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Destination Determination

General Protocol

GP 05

This protocol shall serve as the basis for the decision by both Paramedic or RN and Medical Director as to the transport destinations of patients. This protocol is a standing order. The patient shall always be transported to a facility in which appropriate definitive therapy can be administered; we should avoid facilities which are medically inappropriate We should try and limit transport to the closest appropriate facility unless the paramedic or nurse deems it necessary for the patient's well-being to be transported to a facility outside our service area. In some instances the family or patient may desire transport to a facility outside our distance boundary or one of their choice when the patient can receive the same or better level of care at a hospital in our general service area. In these instances the EMS Director must be notified for approval for transport to other hospitals outside the normal hospitals we generally deliver to. ACUTE MEDICAL SERVICES, LLC must transport any unstable patient that meets the Application listed below and may not transfer care to any other service unless the service is responding as mutual aid. 1. 2. 3. 4. 5. Systolic BP of less than 90mm/Hg Respiratory compromise or difficulty breathing including Hyperpnea or Bradypnea Chest Pain of any etiology including trauma Altered Mental Status of unknown etiology Any Trauma related emergencies

If the patient is deemed to be medically unstable, that patient must be transported to the closest appropriate hospital emergency department. If that facility is on divert and cannot accept the patient, the Paramedic will make arrangements to have the patient diverted to the next closest hospital emergency department. If the patient or patient representative does not specify a facility, the patient shall be transported to a facility within the operational boundaries of the transporting service, if appropriate. Should the patient or the patient's representative request a facility which is in conflict with this protocol or which the attending Paramedic or Nurse feels is inappropriate for the patient's medical problem, The Paramedic or Nurse should decide conservatively based on the patients status. A separate incident report should be filed with the patient chart. The following represent patient types for which a specific facility or set of facilities is designated as the appropriate transport destination. Paramedics and Nurses MUST transport patients meeting these type definitions to the nearest facility, unless ordered otherwise by on-line Medical Control. CPRs: All CPR patients (from any etiology) will go to the closest appropriate Emergency Department. NO EXCEPTIONS [unless pronounced deceased with agreement of Medical Control.] Amputations: All amputation patients will go to the closest appropriate facility. Hospital Utilization: All Patients needing advanced trauma care or immediate surgical intervention will be transported to either hospital below: Ben Taub General Hermann Hospital

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General Protocol

Diagnostics/Procedures GP 06
Diagnostic tools and procedures are defined as vital signs, blood glucose determination, temperature, ECG evaluation, pulse oximetry, urinalysis, blood chemistry, complete blood count, strep screens, doppler, snelling eye chart, any other component not mentioned here that will help differentiate a diagnosis in patients illness/injury. Vital Signs Complete vital signs are defined as respiratory rate, pulse or heart rate (indicate which), capillary refill, temperature, and blood pressure (auscultated if possible with both systolic and diastolic). Capillary refill (CR) may be used as an adjunct to blood pressure in assessing/describing the perfusion status of any patient. A systolic BP alone (palpated BP) is acceptable ONLY: As an additional vital sign in the non-urgent patient in whom an auscultated BP has already been obtained and was within normal limits. In the critical trauma patient in who serial palpated BP's are being obtained. In the patient in whom an auscultated BP ABSOLUTELY cannot be obtained. An initial complete set of vital signs is to be obtained within 5 mins. of patient contact. Patients refusing treatment/transport must have one complete set of v/s taken and charted, if the patient allows. If the vitals are out of normal limits, at least a second set should be obtained a minimum of 5 minutes after the first. All subsequent repeat v/s should be at least 5 mins. apart. "Stable" patients with non-life or limb-threatening problems should have vitals repeated every 15 mins. Urgent or critical patients must have vitals taken every 5 to 10 mins. Respiratory rate, blood pressure, and pulse rate are to be obtained on all patients assessed The accuracy of an obtained blood pressure is influenced by many factors, one of, which is the size of the cuff used. It is important that the size of the cuff be correct for the patient. A cuff too small for the arm will yield a falsely elevated blood pressure while one too large will result in a falsely low reading in patients blood pressure. The cuff should easily go around the patient's upper arm, but the air bladder should not overlap itself. The cuff itself should be 2/3 the length of the patient's upper arm. It is imperative to note the difference between a heart rate and a pulse rate. The term "heart rate" refers most correctly to the rate of electrical depolarization (usually ventricular) noted on the ECG monitor. "Pulse rate" refers to the palpable rate of perfusion noted at a pulse point. While in most patients these are identical values, this is not always the case. When reporting the rate on the ECG monitor, use the term "heart rate". When reporting the rate derived by feeling the radial, brachial, or carotid pulse, use the term "pulse rate". When using the ECG monitor or an apical pulse to observe the patient's heart rate, one must be absolutely certain that this rate correlates with the palpable pulse rate. For a critical patient, for whom time is a factor, the Paramedic may use palpable pulses to estimate and document blood pressure. The acceptable values are as follows: Palpable radial pulse: systolic pressure of at least 80 mm Hg Palpable axillary or brachial pulse: systolic pressure of at least 70 mm Hg Palpable femoral pulse: systolic pressure of at least 60 mm Hg Palpable carotid pulse: systolic pressure of at least 50 mm Hg Page 17 of 192

Remember that the pulse, not the BP, is the most sensitive and earliest indicator of volume and metabolic status. In all patients suspected of hypovolemia then orthostatic blood pressure monitoring must be performed. Remember that a positive change in pulse, even without BP change, is still positive. Blood Glucose Blood Glucose may be performed on any patient. Blood glucose must be assessed on all patients with altered mental status. Those patients with altered mental status which appears to be secondary to trauma should also have their blood glucose assessed IF such assessment will not delay definitive interventions, such as airway management, cervical spine immobilization, bleeding control, transport, or IV access. Blood glucose must be assessed on all patients with a history of Diabetes Mellitus or glucose problems, or altered mental status, regardless of complaints or findings or any other patient at the discretion of the Paramedic. Blood glucose must be assessed on all patients who experience a seizure prior to Paramedic care or while in the care of the Paramedic. Blood glucose values are reported or documented in terms of milligrams per deciliter (mg/dl). After administering D25 % or D50 %, the blood glucose value will remain falsely elevated for quite some time as the cells attempt to uptake the glucose. Therefore, repeat D-sticks may not be useful in determining accurate BG levels. The patient's clinical status should be used to determine whether or not to administer additional dextrose. If a repeat Blood Glucose Analysis is used, wait at least 10 minutes after dextrose administration before obtaining one. Temperature Temperature must be assessed on all seizure patients, all patients suspected of being septic, and all patients whose complaints or findings indicate possible fever. Temperature also must be obtained on all patients suspected of either hypothermia or heat stroke, and all near drowning patients who present in cardiopulmonary arrest. Temperature will be taken orally in patients who are capable of holding the thermometer correctly. Temperature will be taken rectally in all other patients. Neither rectal nor oral temperature represents true "core" temperature. Therefore, neither of these may be used to truly determine hypothermia. For our purposes, a rectal temperature may be used to determine temperature in hyperthermic states (heat stroke, febrile seizures, or sepsis), and should be used to guide cooling along with the patient's clinical response. A rectal temperature is to be used in Hypothermic patients. Axillary temperatures are absolutely not acceptable. When reporting or documenting a temperature value, indicate the source (oral, rectal). ECG Monitoring ECG should be assessed and monitored on ALL patients on whom ALS intervention involving medication administration is given intravenously. ECG may be assessed on any patient. ECG must be assessed on ALL patients complaining of chest pain (or other possible myocardial ischemia pain), shortness of breath, syncope or dizziness, or nausea/vomiting, or who display tachycardia, hypotension, or altered mental status. ECG must also be assessed on all patients who have suffered a convulsion or syncopal episode. ECG must be assessed within 5 mins of patient contact. Stable patients presenting in rhythms thought to be either SVT or VT MUST have a multi-lead (12 Lead) ECG obtained and recorded. See the "ECG" procedure and the "Multi-Lead ECG Interpretation" reference.

Page 18 of 192

Pulse Oximetry Pulse oximetry, if available, should be used in part to evaluate the oxygen saturation status of all patients in whom hypoxia or ischemia is suspected. Remember, 02 therapy must not be withheld to establish baseline saturation in cases of suspected chest pain, N/V or other possible cardiac presentations. Pulse oximetry may be used to titrate oxygen delivery, and will permit the Paramedic to utilize delivery devices or flow rates other than those dictated in the protocols. Pulse oximetry readings are accurate only if: The probe is able to "see" the arterial blood flow, The patient is reasonably well perfused peripherally. This means that the probe must be firmly attached to a clean finger or toe. Nail polish may occlude the probe's light beam, so unpolished nails are preferred. Additionally, hypotensive, CO Poisonings, hypo-perfused, or peripherally vasoconstricted patients are generally not good candidates for pulse oximetry. Be sure the pulse oximeter's heart rate matches the patient's palpable pulse rate, that the waveform is peaked sharply or the light is green, and that the light is flashing in concert with the patient's pulse before accepting the SaO2 value. Pulse oximeter values are reported as % SaO2 (saturation of oxygen). Pulse oximetry readings below normal may indicate either a problem with oxygenation or perfusion. Doppler Doppler, if available, should be used to evaluate the fetal heart rate of all pregnant patients. It may also be used to determine the presence of a peripheral pulse or to obtain a systolic BP in patients when such cannot be heard or felt otherwise. CO2 Monitoring/Capnography CO2 Monitoring/Capnography should be used to evaluate the CO2/Oxygen exchange in all patients that are intubated. Disposable End-Tidal CO2 detection devises are also useful diagnostic tool, but not a substitute for continuing capnography, that will be used on any patient that ACUTE MEDICAL SERVICES, LLC intubates and results will be clearly documented on patient care report. In cases where capnography is available, continuous ETCO2 must be monitored on intubated patients and the results must be recorded.

Page 19 of 192

General Protocol

Rapid Transport

GP 07

Occasionally, The Paramedic or Nurse will encounter a patient whose injury can only be treated definitively with surgery. When confronted with such a patient, the attending Paramedic or Nurse shall institute the basic interventions noted here and begin the process of transport to an appropriate facility following ACUTE MEDICAL SERVICES, LLC Emergency Evacuation Procedures. Remember: If there is a chance that this is the case with the patient, err on the side of conservative management while loading and perform all advanced interventions while enroute to definitive care. Always transport as rapidly as possible. ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INTIATING EMERGENCY EVACUATION PROCEDURE. Spinal immobilization BLS airway and ventilation procedures Intubation IF it can be accomplished rapidly Surgical airway if necessary Occlusion of open chest wounds Vital signs (may use peripheral pulses to estimate--see "Diagnostic Tools and Procedures" reference) Freeing patient from entrapment. All other interventions are to be done once RAPID TRANSPORT is initiated. The following represent patients for whom rapid transport is required: Adult Trauma as described by BTLS/ATLS Guidelines Head Injury or CVA with evidence of increasing ICP Suspected aortic aneurysm Suspected ectopic pregnancy, abruptio placenta, or uterine rupture (vaginal bleeding in pregnant patients greater than or equal to 20 weeks gestation) All abdominal pain patients with unstable vital signs (Tachycardia with normotension, hypotension) Obstetrical emergencies resulting in possible fetal distress, such as limb presentation, breech delivery, or prolapsed cord GI bleeding with unstable vital signs (Tachycardia with normotension or hypotension) Any other patient requiring urgent surgical intervention GCS/Revised Trauma Score These scores will be reported with the appropriate letter in front of the score: GSC Example: E-2 (Eye Opening) M-5 (Motor) V-3 (Verbal) ---------------------------Total GCS=10 ATS Example: R-3 (Respiratory) S-3 (Systolic BP) G-3 (Glasgow Score) -----------------------------Total ATS=9

*Note* Transport requires the incharge paramedic or nurse to be in the patient care compartment (if possible) overseeing or administering patient care.

Page 20 of 192

General Protocol

Air Ambulance Use

GP 08

This protocol provides guidelines and authorization for the use of helicopter ambulance to transport a patient directly from a scene. By standing order, The Paramedic or Nurse is authorized to utilize helicopter ambulances to evacuate patients at his/her discretion. The following are guidelines for their use; however, these do not represent absolute rules. The Incharge Paramedic or Nurse is personally responsible for selecting the mode of transport most beneficial for the patient. All helicopter utilizations will be reviewed by the Medical Director. Things to consider when utilizing an air-ambulance: Time of Day, Location from Major Street/Highway, Weather Conditions, Flight ETA Remember to consider flight team loading, takeoff, landing, passing off patient and care report, reloading patient, helicopter restarting, flight time to hospital, landing, etc. The primary indication for the use of a helicopter ambulance is when the helicopter can deliver the patient to definitive care (i.e., surgery) faster than any other transportation available. This usually means: A critically ill or injured patient requiring care not available from local facilities in which extrication, basic procedures, and transport time will exceed the total call-received to arrival at the hospital time for the helicopter. A multi-patient scene including urgent or critical patients where the time for other transportation to arrive and provide transport would exceed the total time for the helicopter. Many trauma victims would be better served by transporting them directly to a Level 1 or Level 2 Trauma Center. Situations like: Trauma victims with no spontaneous eye openings Penetrating cranial injuries Penetrating thoracic injury between the mid-clavicular lines Gunshot wounds to the abdomen or thorax. Blunt trauma to the chest with an unstable chest wall Penetrating wounds to the neck All patients that have suffered burns of second degree or better that are greater than 15% of BSA over face, hands and genitalia. Other patients may need to be transported to the trauma center. Field personnel may use helicopter evacuation on the following trauma victims: Surviving victims of vehicular accidents in which fatalities occurred. Pedestrians struck by fast-moving vehicles. Patients requiring extrication which takes longer than 30 minutes. Patients who were ejected from the vehicle. If a helicopter evacuation is required, the incharge paramedic or nurse will contact Harris County EMS Dispatch Center and give location or GPS Coordinates of where the air ambulance is being requested Any patient transported by helicopter will receive, if time allows on scene, complete documentation by the crew. Any patient that the in-charge medic feels should be flown, but does not meet the above requirements, can utilize the air ambulance. However, the in-charge medic or nurse should file an incident report with the EMS Director and Medical Director for review.

Page 21 of 192

General Protocol

Consent for Treatment GP 09

Following are guidelines to be utilized in the decision process to determine whether to transport or allow the patient to refuse treatment. Definitions: Informed Consent-when a patient has been told (in a way that the patient will understand) by the attending medical team of their suspected medical condition, the type of treatment that will be rendered and the consequences and possible risk of that treatment or the refusal thereof and the patient agrees to the treatment or refusal. Implied Consent-when the treatment is performed on a patient who is unable to give consent due to the inability to comprehend or hear the informed consent requirements or on a minor when a guardian cannot be contacted, but for whom implied consent is held reasonable, i.e. matters of life and death. Refusal-when a patient refuses either transport or treatment after being informed of their suspected medical condition, the type of treatment that will be rendered and the consequences and possible risk of that treatment. Mental Competence-a patient who is oriented of person, place and time, exhibits sound judgment and memory, and who understands their medical condition and can comprehend the treatment description and the consequences of the treatment or refusal thereof. Policy: Treatment / Transport All paramedics and nurses must have consent before treating / transporting a patient. Consent may be either implied or informed. Any mentally competent adult may refuse treatment / transport. Any mentally competent guardian may either give consent for, or refuse treatment / transport for a patient they are responsible for. A police officer may order treatment or transportation of any prisoner in their custody. A patient may be transported against their will if the medic has a court order for the patient to receive treatment or the patient is in custody of a law enforcement officer. Mentally Incompetent Patients Patients who are considered mentally incompetent by either the courts or by the definition of this policy may be treated with implied consent. If the patient still refused to be treated / transported, Law Enforcement should be notified to help safely restrain the patient. If law enforcement refuses to restrain patient for transport the Operations Manager and Medical Director should be notified. Refusals Any competent adult has the right to refuse treatment, even if that lack of treatment may result in his or her death. Any patient refusing treatment / transport shall be informed of the possible consequences of that refusal and shall sign a refusal form. Individuals other than employees should witness this form if possible. Any medic who does not feel comfortable with a patient refusing treatment / transport because the medic feels that the refusal may result in death, should contact the Medical Director and Operations Manager. Special Situations The Paramedic may be faced with several special situations in which the patient does not fit any of the above policies. While it is impossible to discuss every situation, in most cases the paramedic or nurse will have to rely on their training, experience and judgment to determine if the patient meets Application for refusal. If at any time the medic or nurse is in doubt as to either treating or transporting a patient, a supervisor must be consulted. If the supervisor has reasonable doubt, Medical Control must be consulted. If at all possible always elect to treat/transport rather than leave the patient.

Page 22 of 192

General Protocol

Authorization Level

GP 10

The following represents those patient care activities, which are authorized to be performed by personnel as stated in the "Protocols" protocol. All BLS activities are authorized on standing order, to be used as needed. Authorization for ALS activities is indicated in the protocol or procedure document for each intervention. The incharge paramedic or registered nurse determines who practices using these guidelines and has the authority to delegate beyond the guidelines if needed. Emergency Medical Technician
Oxygen administration Oral Airways Nasal Airways Bag Valve Mask Oral Suctioning AHA approved CPR Vital Signs Bandaging Splinting Traction Splinting Cervical Spinal Restriction Patient Assessment Manual Airway Maintenance Manual Ventilatory Support Airway Obstruction Relief Control External Hemorrhage Automated External Defibrillator Automatic CPR Devices Blood Glucose Reagents Esophageal Obturation King Tube ASA administration *NTG Spray/Tablets Nebulization of Albuterol *Nebulization of Atrovent *Blood Draw *IV Catheter Insertion for SL Restraint Devices Kendrick Extrication Device

EMT Intermediate
All EMT Skills IV Accesses IV Fluid Administration Administration of NS Administration of LRS Administration of D50 Administration of D25 Administration of Thiamin Administration of Naloxone Oral tracheal Intubation Nasal tracheal intubation Intraosseous Cannulation Combi Tube Insertion Operation of Mechanical Vent CPAP/BiPAP Operation

Paramedic/Registered Nurse
All EMT-I Skills Nebulized bronchodilators Obtaining ECGs Interpretation of ECGs Defibrillation Cardioversion External Cardiac Pacing Vagal Maneuvers Administration of IV Medications Administration of IM Medications Administration of SQ Medications Administration of PO Medications Administration of PR Medications Administration of SL Medications Chest Decompression External Jugular Cannulation Nasogastric Tube Insertion Nasogastric Lavage Oralgastric Tube Insertion Oralgastric Lavage Surgical Airway Pharmacological Assisted Intubation Administration of Rx Medications Foley Catheter Insertion

Items indicated by an astrics * should have the approval of the Medical Director or under direct supervision of the incharge paramedic or nurse

NOTE: The In-Charge or Attending Paramedic or Nurse is responsible for the care, selection of treatment, and selecting the mode of transportation that is most beneficial for the patient. Thus, the final determination is that of the attending Paramedic unless superseded by the Medical Director of Acute Medical Services, LLC.

Page 23 of 192

General Protocol

Pain Management

GP 11

With todays technology, advanced medical care, and improved medications there is no reason any patient meeting this application should be withheld from receiving pain management in the field. Application: Patient must have no neurological deficits from the injury. Patient must have vital signs within normal limits. Systolic BP must be Minimum of 100 mm/Hg Patient cannot have multi system trauma. Patient must have +Pulse Motor Sensory + Range Of Motion in extremities Patient not Allergic to Pain Medications Patient must weigh minimal of 35kg. A Complete Neurological Exam must be completed prior to administering any Pain Medications and results of the exam fully documented on the patient report. Pain:

Any fracture of a long bone that meets the above Application Pain associated from End Stage Cancer of known Etiology Amputations/Crushing Injuries of the extremities Stabbing/GSW/Penetration injuries to the extremities (Excluding Torso) Pelvic Fractures meeting the above Application Renal Calculi Burns that are greater than 20% BSA of the First or Second Degree Chronic Back Pain Acute Back Pain Acute Appendicitis Known History of Cholecystitis Known History of Diverticulitis

If BP is > 90 systolic, then consider: Treatment: 12.5 - 25 mg Phenergan IVP or 4 - 8mg Zofran and any one of the following if not contraindicated or allergic Analgesic Morphine Hydromorphone Fentanyl Demoral Toradol Adult Dosage 2-10mg IVP with a max dose of 12mg. 0.25 to 2 mg IVP may repeat q 30 to a max of 4mg 25-100 mcg IVP, with a max of 200 mcg 0.5 to 1.0 mg/kg IVP q 4-6 hrs 15-30 mg IV q 4-6 hrs Child Dosage .05 - .25 mg/kg IVP q 30 min

2-3 mcg/kg IVP 0.5 -1.0 mg/kg IVP q 4-6 hrs

Page 24 of 192

General Protocol

IV Fluid Selection

GP 12

Purpose: This protocol shall guide Paramedics and Nurse in making the most appropriate choice in IV Fluid therapy. Some flexibility is permitted specifically pertaining to Lactated Ringers and Normal Saline. These fluids are considered interchangeable throughout these protocols, except where explicit protocols prohibit such changes. If the Paramedic or Nurse has any doubt which fluid is appropriate Normal Saline should be used at the appropriate rate for the patients condition. D5W Cardiac Ischemia Cardiac Dysrhythmias Hypoglycemia 0.9% Normal Saline All CPRs V-Tach and SVT Cardiogenic Shock Allergic Reactions Altered Mental Status Hypothermia Heat Related Emergency Overdoses Poisoning Airway Obstructions Sepsis Surgical OB/GYN emergencies Asthma COPD Seizures Hyperglycemia Near Drowning CVA Hypertensive Crisis Head Injuries Lactated Ringers Renal Failure Acidosis Burns Hypovolemia Hyperthermia Heat Exhaustion Heat Cramps Hespan/Dextran Hypovolemia

Page 25 of 192

Medical Scene Control General Protocol GP 13 Responsibility

Occasionally, the Paramedic will encounter a scene in which other medical personnel may be present. Whether it be co-workers, medical care providers from other services and or facilities; the Incharge Medic or Nurse initiated to a scene by Harris County EMS Dispatch is responsible for their patients care, mode of transport, and medical scene control that is most beneficial for the patient. If the scene or call is a multi-unit response, the Incharge Medics or Nurse responsible is those who are assigned to a Texas Department of Health Licensed MICU Unit (Ambulance). The only persons who may dictate or give orders for a patients care counteracting the Incharge Medics or Nurses judgment/decision are: 1. 2. 3. 4. 5. 6. 7. Harris County EMS Medical Director Medical Directors Designees (Listed Below) Quality Assurance Officer/Medical Control Officer EMS Director Clinical Director/Manager Supervisors Field Training Officers

Note: This protocol only pertains to patient care issues and mode of transport and in no way carries over to operational issues.

Page 26 of 192

Minimum Supply/Equipment List for Ambulances

4X4 Non sterile Loaf 4X4 Sterile Package AA Batteries Alcohol Preps BAAM Whistle Bacteriostatic NaCl Flush
Band Aids Large/Small Box

General Protocol

GP 14
2 10 6 2 2 1/1 4 6 6 1 1 4 1 2 2 5 5 1 1 3 1 1 1 2 1 1 1

Blood Tubes Blue Blood Tubes Purple Blood Tubes Red BP Cuff Adult child infant BP Cuff Adult large/thigh Pedi Wheel/Broslow Tape Bulbs large/small Burn Sheets Butterflies 19g/21g BVM Adult BVM Child BVM Infant C Batteries Capnography Adaptor C-Collar Infant C-Collar Pedi C-Collar Neckless C-Collar Short C-Collar Regular C-Collar Tall Chest Decompression Kit CO2 Detector Adult/Pedi Cold Packs Combi-Dressing Combi-Tube Large/Small Combo Pads Adult/Pedi Cricothyrotomy Kit Fire Extinguisher D5W 250 ml
Disposable Pulse Ox Sensor Adult/Pedi

Duct Tape ET Tube 2.0 ET Tube 2.5 ET Tube 3.0 ET Tube 3.5 ET Tube 4.0 ET Tube 4.5 ET Tube 5.0 ET Tube 5.5 ET Tube 6.0 ET Tube 6.5 ET Tube 7.0 ET Tube 7.5 ET Tube 8.0 ET Tube 8.5 ET Tube 9.0

2 40 2 10 1 10 10 5 5 5 1/1/1 1/1 1 1/1 2 5/5 2 1 1 2 2 4 4 4 4 4 4 1 2/2 4 6 1/1 2/2 1 1 4 2/2 1 2 2 2 2 2 2 2 2 2 2 3 3 2 2 2

ECG Batteries ECG Electrodes Adult/pedi ECG Paper Emergency Rain Blanket Emesis Bags Endotrol Tube 6.0 Endotrol Tube 7.0 Endotrol Tube 8.0 Face Shields Gloves Small Gloves Medium Gloves Large Gloves X-Large Glucometer Glucometer Lancets Glucometer Test Strips Headbeds Hot Packs Humidifier Hydrogen Peroxide Intraosseous Needle Isolation Kit Isolation Mask X-Small Isolation Mask Small Isolation Mask Medium Isolation Mask Large IV Cath 14g L/S IV Cath 16g L/S IV Cath 18g IV Cath 20g IV Cath 22g IV Cath 24g IV Tubing Blood-Y IV Tubing Buretrol IV Tubing Dial-A-Flow IV Tubing Extension Sets IV Tubing Maxi Drip IV Tubing Mini Drip KED Kerlex/Rolled Gauze Laryngoscope Handle L/S Long Spine Board MacIntosh-1 MacIntosh -2 MacIntosh-3 MacIntosh-4 Magill Forceps Adult/Pedi Main O2 /Regulator Mask-Adult NRB Mask-Infant Mask-Pedi NRB MAST Trousers

2
5pk/3pk

2 2 5 2 2 2 4 2 2 2 2 1 10 10 4 2 1 1 2 2 2 2 2 2 6 6 6 6 6 6 2 2 2 6 6 6 1 6 1/1 2 1 1 1 1 1/1 1/1 6 4 4 1

Miller-0 Miller-1 Miller-2 Miller-3 Miller-4 Multi Trauma Dressings NG Tube 8 French NG Tube 14 French NG Tube 18 French NaCl Infusion 100 cc NaCl/LRS Infusion 250 cc NaCl/LRS Infusion 1000 cc NaCl/LRS Irrigation 500 cc Nail Polish Removal Pads Nasal Cannula Pedi/Adult Nebulizers Pedi/Adult Needles 18g/25g Nasopharyngeal Airways O2 Wrench L/S OB Kit Occlusive Dressing Oropharyngeal Airways Padded Arm Splints Pedi Restraint System Pen Light Pillow Portable O2 tanks/regulator Portable Suction Pulse Oximeter w/sensor S/L Razors (disposable) Ring Cutter w/extra blade Sharps Container S/L Sheets Silver Rescue Blanket Soft Restraints Splints, Cardboard S/L Sterile H2O Stethoscope Stretcher fixed/portable
Suction, Main/Canisters(Disp)

Suction Caths-Yankauer Suction Caths 6f/10f/14f/18f Suction Tubing Supply Tubing (oxygen) Surgilube Syringe 1cc/3cc./10cc Syringe 20cc/60cc Tape, Cloth 1/2 Tape, Transpore
Thermometer w/probe covers

1 1 1 1 1 2 2 2 2 2 4 4 2 10 3 3 10/10 2 sets 1/1 2 5 2 sets 2 1 1 1 4/2 1 1/1/1 2 1/1 1/1 5 2 2pr 2/2 4 2 1/1 1/2 4 2/2/2/2 4 2 6
8/8/6

Trauma Shears Triage Tags Triangular Bandages Tube Securing Device Pedi Tube Securing Device Adult Urinal/Bedpan Vacutainer Barrels Vacutainer Leur Adaptors Vacutainer Needles V-Vac portable suction
V-Vac replacement cartridge

Webbing ECG Monitor Pulse ox sensor adult Pulse ox sensor pedi Bags-Garbage Bags-Red Biohazard Cleaner-Tubercularcidal Emergency Response Guide Emergency Triangles Fire Extingushers Flashlight Keymap No Smoking Signs Protocol Book Provider License TDH Designation

Tourniquets/Veniguards Traction Splint adult/pedi

2/2 2/2 2 1/20 6/6 1/1

Dr. Ronald Charles, M.D. Board Certified Emergency Physician

10/1/2011 Effective Date

10/31/2015 Expiration Date

Page 27 of 192

Drug Formulary Minimal Inventory

Medication Generic
Acetaminophen Acetylsalicylic Acid Activated Charcoal Adenosine Adrenaline Chloride Amiodarone Atropine Sulfate Ketamine Calcium Chloride D25 D50 D5W Diazepam Diphenhydramine Dopamine Hydrochloride Esomeprazole Etomidate Furosemide Glucagon Hydralazine Hydromorphone Ibuprophen Ipratropium Bromide Labetalol HCL Lidocaine HCL Maalox Magnesium Sulfate Methyleprednisolone Metoprolol Tartrate Morphine HCL Naloxone HCL Nitroglycerin Norpinephrine Oral Glucose Oxytocin Procainamide HCL Promethazine HCL Propofol Salbutamol Sulfate Sodium Bicarbonate Succinylcholine HCL Terbutaline Sulfate Thiamine Vecuronium Versed Haldol

General Protocol

GP 15
Min.Total Mg
3000mg 810 mg 30ml 30mg 30mg 300mg 8mg 500mg 1000mg 30 gr 25gr 500ml 15mg 100mg 400mg 80mg 30mg 120mg 1mg 40mg 4mg 2000mg 1.5mg 100mg 300mg 60ml 2gr 2gr 10mg 30mg 4mg 8mg 4mg 30gr 10 units 1000mg 75mg 100mg 15mg 200 Meq 200mg 2mg 200mg 10mg 15mg 10mg

Trade Name
Tylenol Aspirin Activated Charcoal Adenocard Epinephrine Amiodarone Atropine Ketamine Calcium Chloride Dextrose Dextrose D5W Valium Benadryl Intropin Nexium IV Amidate Lasix Glucagon Apresoline Dilautid Motrin Atrovent Trandate Lidocaine Maaolox Suspension Mag sulfate Solu-Medrol Lopressor or Toprol Morphine Narcan Nitroglycerin Levophed Oral Glucose Pitocin Pronestyl Phenergan Diprivan Albuterol Sodium Bicarbonate Anectine Brethine Vitamin B1 Norcuron Midazolam Haloperidol

Preferred Supplied/Packaged
325 mg Capsules/500 mg Tablets and Elixir 81mg chewable Tab 30ml or 60ml 6mg/2ml pre-filled syringes or 6mg vial or 12mg vial 1:1000 1 ml ampule /1:10000 10ml Prefilled & MDV 50mg/ml 0.1mg/ml @ 1 mg/10ml prefilled syringe 500mg/10ml 100mg/ml 15 gr /5ml 25 Grams/50ml 250ml and 500 ml bags 5 mg inj. 25mg/ml injectable 40mg/ml Must be Diluted 40mg Vial 20 mg ampules 40mg/5ml injectable 1mg powdered injectable 20mg/ml 2mg/ml 200mg/capsule or tablet and Elixir/Solution/Liquid 0.5mg/2.5ml 5mg/ml injectable 100mg/5ml 2% inj & 2%Viscous 30 ml Unit Dose 500mg/ml prefilled injectable or 1gr/2ml 125mg/ml 1 gram powered injectable 1mg/ml injectable (5mg and 10mg vials) 1mg/ml prefilled jets or 10mg/ml ampules 0.4mg/ml & 1mg/ml 0.4mg/metered spray or 0.4mg/tablets or Paste 1mg/ml 15 Gr 10 units/ml 100mg/ml 25mg/ml ampules 10mg/ml 2.5 mg premix bullets/0.5% Solution 4.2% and 8.4% prefilled injectable 20mg/ml 10ml Vials 1mg/ml ampules 100mg/ml vial 10mg ampules 1mg/ml 5mg/2ml 5mg/ml

Dr. Ronald Charles, M.D. Board Certified Emergency Physician

Effective Date: Expiration Date:

10/1/2011 10/31/2015

From time to time the drugs on the above list may be supplied in concentrations or amounts other than those indicated. Regardless of the particular manner in which drugs are supplied, equivalent total amounts must be present, and it is the paramedics and nurses responsibility to be certain that correct dosages are administered to patients. Unless specified otherwise, generics and brand name products are considered interchangeable. Some instances there may be a national shortage or back log of some medications as we have seen in the past. For reasons beyond the control of Acute Medical Services to fulfill the required medications because of the unavailability inform the medical director of such shortages so temporary adjustment may be made to these Protocols.

Page 28 of 192

Storage of Medications General Protocol and Medical Devices GP 16

Acute Medical Services, LLC maintains compliancy with the strict FDA and United States Pharmacopia recommended storage of Drugs and Medical Devices by: Overstock of medication and medical devices are maintained at the administrative offices at Acute Medical Services, LLC. Such facility is climate controlled and secured by a locking device. Controlled substances are secured by at least two locking devices. Medical devices such as (but not limited to): 1. ECG Machines 2. Pulse Oximeters 3. Blood Glucometers 4. Stretchers Are maintained according to manufactures specifications with such records kept on file. All Mobile Intensive Care Units are climate controlled through shore lines, even when not in use. Reserve units have no drugs or medical devices stored on them when not in service.

Page 29 of 192

Pharmacological Assisted Intubation

General Protocol

GP 17

The utilization of PAI should never be attempted in any patient that cannot be intubated. Anatomical abnormalities including traumatized airway, the absence of materials necessary, a lack of adequate experience, and patients with intact breathing mechanisms are just a few of the definite contraindications to PAI. Simply put, if there is a question that the airway can be obtained and protected, do not perform PAI. Supervising paramedics that have a proven capability in airway management may only perform PAI. Indications for PAI include: Glasgow Coma Score <8 Burn patients with evidence of respiratory injury or compromise Masseter spasm with deoxygenation Chest trauma with compromise Risk of massive aspiration Severe head trauma Equipment Checklist: BMV Oxygen source Laryngoscope blade of appropriate size including backup Suction with Yankauer handle Appropriately sized endotracheal tube, with the next size above and below available Ten cc syringe Lubricated Stylet Airway Adjunct for failed intubation (Combitube, LMA, COPA, King LT) Cricothyrotomy kit Medications should be drawn and labeled in syringes before utilization. Equipment MUST be in place, tested and prepared for use before PAI is initiated. Procedure: CABC Pre-oxygenation 100% oxygen ventilation with a sealed system ( minimum of 60 seconds or 20 ventilations) Pulse Oximetry Monitoring Cricoid pressure must be applied Lidocaine 1-1.5 mg/kg IVP (half the dose for patients >70 years of age) Pretreatment with 5 mg IV Diazepam or 5-10 mg Versed may be administered prior to initiation of sequence Administration of induction agents (etomidate, and succinylcholine if needed) Etomidate 0.3mg/kg IVP (if SBP <100mmHg, then Etomidate 0.2mg/kg IVP) Succinylcholine 1-1.5mg/kg IVP Direct laryngoscopy and endotracheal intubation Maintenance of patient comfort and paralysis may be achieved by the following once a definitive airway is established and secured: Rocuronium 0.6-1.2mg/kg IV or Vecuronium 0.1mg/kg IV Remember to keep patient oxygenated even with multiple attempts of laryngoscopy and endotracheal intubation. Secondary adjuncts may be used for failed endotracheal intubation: LMA, KingTube, CombiTubes, and BVMs, Cricothrothmy for failed airway.

Page 30 of 192

Non Resuscitation Order

General Protocol

GP 18

It is the policy of Acute Medical Services, LLC to follow Do Not Resuscitate guidelines in accordance to the guidelines set forth by the Texas Department of Health. A valid Do Not Resuscitate directive must be executed by one of the following mechanisms: Current (within one month) written, original (not a photocopy) DNR order signed by the patients physician. A valid State of Texas Out Of Hospital DNR order. (Please see following page). These patients might be identified by other means as well such as a bracelet or necklace containing the DNR logo. This device is a reminder to ask for the original form. The Texas Department of Health standardized DNR form specifically lists designated treatments that shall be withheld. Those treatments include: Cardiopulmonary Resuscitation Advanced Airway Management Artificial Ventilation Defibrillation Transcutaneous Cardiac pacing Should a dispute arise regarding an OOH-DNR, the Medical Control Officer must be notified immediately. It is the duty of the Medical Control Officer to notify the Director of EMS Services, and the Medical Director to resolve any conflicts regarding DNR patients. It is acceptable under certain circumstances for Acute Medical Services, LLC EMS personnel to elect to withhold resuscitative measures from an apneic/pulseless patient or discontinue resuscitative attempts initiated by non-medical personnel. These circumstances include: Decapitation Rigor Mortis Decomposition Dependent Lividity Visible trauma to the head or trunk with injuries clearly incompatible with life. Instances which mass casualties START Triage are initiated.

Page 31 of 192

TDSHS STOP Form DNR Form

General Protocol

GP 18a

Page 32 of 192

General Protocol

Tissue Referral

GP 19

Purpose: To have a phone referral system between LifeGift (or other regional tissue donation center) and Acute Medical Services, LLC for potential tissue donors. Statistics show that the earlier a referral is made, the higher the recovery rate. When deaths occur in the field, EMS agencies have proven to be one of the most reliable referral sources and actually facilitate the process by providing valuable clinical information about the decedent. Disqualification for donation will be determined by the LifeGift coordinator, and not the EMS crew on scene. Indications: Obvious trauma with injuries incompatible with life Extended down time with evidence of rigor mortis or dependent lividity. Any death not transported regardless of down time, age or disease. Procedure: LifeGift will determine suitability of the donor and will approach the family for donor consent. Contact LifeGift (from scene if at all possible) @ 800-633-6562. Inform call taker that you would like to report a death. Be prepared to provide vital patient information including: Location of deceased Next of Kin or contact person with phone number (when possible) Name, age, sex, and race of deceased. Cause of death (mechanism of injury) Brief medical history if available

1. 2. 3. 4. 5.

The following information must be provided for follow up on referral 1. EMS Agency and Unit number 2. Name of referring medic 3. Agency telephone number (281-448-0200) LifeGift will provide follow-up information directly to the crew regardless of outcome. This will be done either by phone or letter within thirty business days.

Page 33 of 192

General Protocol

Inservice Dispositions

GP 20

In order to accurately calculate transport statistics on a monthly basis, only the following dispositions should be utilized before returning to service following a no transport: Disregard- This should be used when you never reach the scene and have been disregarded by another unit, law enforcement, or dispatch. Refusal AMA- This should be used when you have a patient that refuses to go to the hospital. Parental Refusal AMA- This should be used when the parent or guardian refuses transport to the hospital of a minor. Referral-This should be used when you release the patient to another service or entity. If you release the patient to law enforcement with injuries, a patient refusal must be obtained. Gone on Arrival- This should be used when you reach the scene and no patient is found or the patient has left the scene. False Alarm- This can only be used when an alarm company has been notified and the alarm company disregards EMS. No other reason is this disposition to be used. Mutual Aid Handled- In most instances dispatch will utilize this disposition. This will be used if you pass the patient off to another EMS agency. DOS- Dead on scene. Cancelled Incident- This will only be used by Acute Medical Services Communications personnel. Pt by Air Ambulance- This will be used when you have a patient transported by an air ambulance. Remember that there are three services providing air ambulance transportation, so it is important to use generic terminology as not to discriminate. In the event that a patient or family member decides to seek medical treatment on their own or POV, a patient refusal must be obtained. This will reduce any liability on the part of the individual crew and Acute Medical Services, LLC. Acute Medical Services, LLC does not recognize any type of public service disposition. If a caller requests an ambulance and does not request transportation to a healthcare facility, then a patient refusal must be obtained.

Page 34 of 192

General Protocol

HIPAA Compliancy

GP 21

Acute Medical Services, LLC and its employees must make every attempt to conform to all policies and regulations mandated by Federal and State governments regarding patient confidentiality issues. The following policies must be adhered to: Privacy Officer Acute Medical Services, LLC will maintain a designated Privacy Officer to oversee all confidentiality issues and to serve as a contact point for patients and their families to voice concerns, complaints, to access records, or to request amendments to be made to their patient records. This individual will have authority to gain ready access to all patient records. All requests for patient information/records should be referred to the Privacy Officer. The Privacy Officer will be responsible for monitoring employee and company compliance with all State and Federal Privacy Standards. Should a complaint or accusation arise against an employee or the company regarding privacy issues, the Privacy Officer will investigate the situation and follow company procedures regarding appropriate disciplinary action if the investigation supports the complaint. The Privacy Officer will provide initial and ongoing training regarding privacy issues to all personnel who have direct or indirect access to PHI. The Privacy Officer will also be responsible for ensuring that all personnel have signed a Confidentiality Statement and have attended appropriate training sessions. Confidentiality Statement All personnel, riders, students, first responders, office managers, billing personnel or agency, administrators, board members, or any other individual who may have direct or inadvertent access to patient records will be required to sign a Confidentiality Statement that will remain in effect permanently. Should the person no longer be employed by Acute Medical Services, LLC or have no further access to patient records in the future, they must still maintain the necessary confidentiality of any PHI with which they may have had contact or knowledge during their employment, rotations, contact period, etc. Patient Consent Form Signatures All adult mentally competent patients must sign consent to use or disclose PHI on all patient contacts transports and no transports. All transported patients must sign a billing authorization/financial responsibility form. The patients legal guardian or adult parent (if a minor) should sign for the patient. Other next of kin may be able to sign if the patient can reasonably be expected not to be able to sign the form at a later date, if mailed to the patient. If there is just cause why the patient or other authorized person cannot sign the form at the time of service, the reason must be documented on the consent form including a notation of when the follow-up consent letter was mailed and the crew members signature. The follow-up letter should be mailed and the activity documented in the Follow-Up Consent Log. Reasonable efforts must be documented showing that attempts to gain the patients signature were made. It is the crews responsibility to ensure that proper consents are obtained from every patient at the time of service or appropriate follow-up is completed. Patient Care Record Security All patient charts and associated paperwork are to be treated as highly confidential and security must be maintained at all times to ensure that PHI is not inadvertently shared with those who do NOT have the right to know. Verbal and written information being received from or given to other healthcare providers that is necessary to maintain the continuity of care if NOT to be withheld. While this information remains confidential, it must be shared under patient care circumstances to provide adequate assessment and treatment.

Page 35 of 192

Acute Medical Services, LLC personnel should make every effort to minimize information that can be heard or read by those who do NOT have a right to know. This includes bystanders, law enforcement officers, and even some family members. Because the decision on who has the right to know is so difficult to prove, Acute Medical Services, LLC personnel should not share information with anyone unless it is necessary to continue care for the patient. If in doubt, tactfully decline the information until proper lines of authority have been established. Without exception, any information classified as PHI will not be shared in verbal, written, electronic or any other format unless it is required by the following criteria: As necessary for continuity of patient care, and treatment As necessary for payment or collection services Case reviews Education Obtaining legal and accounting services Business planning Resolving complaints Employee discipline Fundraising and marketing activities, including contacting the patients to tell them about services we can offer to them Medical research Databases which involve PHI, but do not identify individual information Reminders of patient appointments for scheduled transports or care As indicated and mandated by state and federal requirements As legally required by law, either local, state or federal such as: To law enforcement officials when necessary to identify someone who has committed a crime To law enforcement officials when there is an immediate need for the information to prevent or solve a crime To public health authorities to report births, deaths, or a disease that we are required to report To people why may have been exposed to a communicable disease by the patient To report child abuse, elder abuse, or domestic violence as required by law To the FDA and other agencies to report an adverse event from the use of a drug or medical device To government agencies who have a right to the information for conducting investigations, audits, inspections, disciplinary proceedings or other administrative or judicial actions in order to determine our compliance with the law In response to subpoenas, search warrants, and other legal requests or directives which require us to produce and disclose your PHI To government military, defense, investigative, security and other agencies who have a right to your PHI or order to protect citizens, officials of the United States or a foreign country and to investigate or prevent terrorist activities To public health officials of the US or foreign countries to avert a serious threat to the safety and health of the people As required by workers compensation laws. When working on PCRs/Medical Charts prior to submitting them for Quality Improvement and billing, the employee must take extra care to ensure that no patient information or records are left out in the open where they can inadvertently be seen by those who have no right to know. Once the PCR/Medical Chart is complete, it should be placed in the locked container/area provided. Appropriate personnel responsible for handling the PCR/Medical Chart for billing, Quality Improvement, or record keeping purposes will continue to ensure the security of these records by keeping them in locked rooms/locked cabinets or drawers when not physically in use.

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Release of Records/Amendments/Restrictions The patient or the patients legal representative has the right to require us to restrict our use and disclosure of PHI with certain exceptions, but we dont have to agree if any of the following exceptions apply: Exceptions We are not required to agree with the request for restriction if: The information requested might be used in a civil or criminal suite, proceeding, or other administrative action The information requested would reveal the source of confidential information provided by others The information requested could cause or produce a threat to any persons physical safety or life. If we DO agree to the request for restrictions, we must honor them and must tell all others to whom we would normally disclose the patients PHI about the restrictions and require them to honor them when we are required by law to disclose your information or when the PHI is needed for the patients treatment in an emergency. A patient or his/her legal guardian may also request a restriction for release of certain PHI by using the proper form supplied by the Privacy Officer. Such requests will also be evaluated and approval or denial will be postmarked within 60 days of the original request. If a patient or patients legal representative believes the PHI is not correct, he/she can ask us to amend it using the appropriate form. If we agree, we must do so within 60 days from the date of the original request. However, we can refuse the request if: The records were not created by us We dont have access to the records or we cant get access to them We believe our records are correct Amendment would result in our being unable to obtain payment for services rendered to the patient The patient or patients legal representative may request an accounting for our use and disclosures of the patients PHI for a 6 year period prior to the request unless that time period involves records before April 14, 2003. We are not legally required to account for use and disclosures prior to April 14, 2002. We also do not have to account to the patient for disclosures made in connection with treatment, for payment, health care operations or disclosures that we were required by law to make. A patient has the right to one free accounting in any 12 month period; for additional accountings we may charge a reasonable fee. All requests for PHI or any PCR/Medical Chart information will be made through the Privacy Officer. All requests will be carefully reviewed prior to the approval or denial of such requests. Requests other than routine disclosures, state or federally mandated information releases, or other releases mandated by law will not require any other type of consent by the patient or the patients legal guardian. Any other record release or request for amendments to PHI shall be utilizing the proper forms as provided by the Privacy Officer. Approvals or denials for release of records or amendments to records will be post-marked within 30 business days if held by us or 60 business days if held by another agency of the original written request. An approvals or denials for release of information, amendments to patient care records, or restrictions on PCRs/Medical Charts will be based on accepted interpretation of the HIPAA rule. Training All Acute Medical Services, LLC personnel will be provided with initial training and updates on HIPAA rules and policies. Such training is considered to be mandatory. This training may be live or through other media presentations as indicated. Personnel must ensure that they have completed and signed the roster for each training session provided.

Page 37 of 192

Complaint Procedure All complaints or potential violations of these policies should be forwarded to the Privacy Officer. If the complaint or suspected violation is found to be valid and justified, following a thorough investigation by the Privacy Officer, then the following actions will be taken: The Privacy Officer will follow the company-designated chain of command for notification of the violation, including the names of specific employees and circumstances surrounding the event Company disciplinary policies and procedures will be followed with the nature and severity of the infraction considered to determine appropriate action The Privacy Officer will review the event to determine need for individual or company training or policy revisions as indicated. If the incident involves a filed complaint with the Secretary of the Department of Health and Human Services, all requested documentation, policies and information regarding the related incident or any other requested HIPAA related documentation or information will be provided by the Privacy Officer to the investigating agency. All employees will make every attempt to comply with the investigating agencys requests, and any questions or concerns should be directed to the Privacy Officer.

Page 38 of 192

Geographical Area Personnel Status

General Protocol

GP 22

Geographical Area These Protocols are in effect within the service area covered by ACUTE MEDICAL SERVICES, LLC, any area covered by mutual-aid agreements or understandings and when on transfers. Personnel operating within ACUTE MEDICAL SERVICES, LLC or on ACUTE MEDICAL SERVICES, LLC units will utilize these protocols anytime contact is made with a patient or injured person. Medics and nurses may practice under these protocols while on duty with ACUTE MEDICAL SERVICES, LLC in any geographical area within the State of Texas and may continue practicing if the patients destination leads you to another state or country. Medics and nurses may practice under these protocols for air ambulance operations if the medic or nurse departs from Texas or the final destination for the patient is Texas. Medics and nurses will as well be covered under these protocols if an emergency arises and the intended destination is bypassed in order to seek immediate definitive medical care in another state or country. Medics and nurses may practice under these protocols while on duty with ACUTE MEDICAL SERVICES, LLC on other services unit or ambulance. Duty Status ACUTE MEDICAL SERVICES, LLC employees, Fire Services, and First Responders personnel shall utilize these protocols under my medical direction only when acting in their official capacity when representing ACUTE MEDICAL SERVICES, LLC. Non-EMS certified or licensed medical personnel not associated with ACUTE MEDICAL SERVICES, LLC Non-EMS certified or licensed medical personnel may not operate under these protocols without the written authorization of the medical director or an ACUTE MEDICAL SERVICES, LLC Incharge on scene.

Page 39 of 192

General Protocol

Disaster Plan

GP 23

A Disaster or Mass Casualty Incident is defined as any accident or emergency situation that overwhelms local response capabilities. The determining factor is not the magnitude of the incident per say, but the number of casualties versus the amount of available resources on hand. It is the responsibility of Acute Medical Services, LLC personnel to set up an organized Incident Command System in order to do the greatest good for the greatest number of victims. An Incident Command System is an organized management program designed to quickly and effectively integrate and manage all emergency response resources when faced with a Mass casualty incident. INCIDENT COMMAND / MEDICAL COMMAND Incident Command- Individual responsible for the management of all incident operations at the incident site. Medical Command- This is typically the role of the first arriving In-Charge Paramedic until relinquished to the higher ranking EMS Supervisor. The focus of Medical Command shall include (but not limited to): Rapid Scene Size Up Request necessary Resources Create strategy plan Delegate Duties to various staff, and organizations Set up various Sectors and Sector Officers for direct communications. Medical Command shall retain his role until: The incident is complete He is relieved by a higher ranking or more appropriate person Physically cannot complete the incident Medical Command will be in constant communications following: Incident Command Triage Officer Extrication Officer Treatment Officer Transportation Officer Communication Officer TRIAGE Triage- The theory behind the triage system is to recognize the most critically ill or injured for prompt treatment. Acute Medical Services, LLC utilizes the START Triage System. START is an acronym for Simple Triage and Rapid Treatment. (Please refer to flow chart on the following page) The Triage Officer is directly responsible for categorizing the severity of injuries. He shall report directly to Incident Command. The focus of the Triage Officer shall include (but not be limited to): Estimate number of victims and inform Medical Command. Inform the Extrication Officer to determine resources needed. In a systematic formation, account for all victims and categorize accordingly. Triage tags are provided for this purpose. Patients shall be identified as Immediate, Delayed, Minor, or Dead. Maintain accurate count of patients with their initial status to cross check upon conclusion of incident. Patients shall immediately be extricated to the treatment sector following triage. Report all progress and complications to Medical Command. After ensuring that all victims are triaged and extricated, the Triage Officer shall report to the treatment sector.

Page 40 of 192

General Protocol

Disaster Plan

GP 23

EXTRICATION It is the duty of the Extrication Officer to ensure that all victims are removed from the mass casualty site and extricated to the treatment sector. The Extrication Officer shall report to Medical Command. The focus of the Extrication Officer shall include (but not limited to): Communication with Triage Officer and Medical Command to determine resources needed to extricate patients and get them delivered to the Treatment Sector. Provide site safety for personnel and patients. Supervise all Extrication Sector activities. Delegate duties to arriving personnel and allocate equipment. Remove patients from incident site safely and in an acceptable order. Patients shall be moved directly to treatment sector unless there is a contamination issue. Report progress and complications to Incident Command. Decides suitable location for temporary Morgue. When all patients have been extricated, report to Incident Command for reassignment. TREATMENT The treatment sector is where the treatment phase begins for the patient. Patients will be treated according to severity of illness or injury. It is the duty of the Treatment Officer to ensure that all patients are being treated appropriately to all treatment guidelines. The Treatment Officer shall report to Medical Command. The focus of the Treatment Officer shall include (but not limited to): Communication with Medical Command for additional resources (medical personnel and medical supplies). Provide site safety for personnel and patients. Locates suitable location and reports location to Medical Command. Decides need for additional Treatment Sectors (Immediate, Delayed). Supervise all Treatment Sector activities. Provide continuous triage of all patients even after arrival. Report progress and complications to Medical Command. Reports to Medical Command when all patients have been delivered to Transportation Sector for reassignment. TRANSPORTATION / COMMUNICATION The transportation sector is where actual transportation of patients begins. Patients will be transported according to severity of illness or injury. It is the duty of the Transportation Officer to ensure that all patients are being transported appropriate to guidelines. The Transportation Officer shall report to Medical Command. The focus of the Transportation shall include (but not limited to): Communication with Medical Command to determine resources to provide transportation of all patients to an appropriate facility. (Air ambulances, buses, etc.) Supervise all Transportation Sector Activities. Provide site safety for personnel and patients. Locates suitable site for Transportation Sector, and reports location to Medical Command. Delegate organization and operation of helicopter landing zone to Fire Department Personnel. Determine capabilities of regional hospitals. Assign a Communication Officer to handle transportation information to Harris County Emergency Communications. Coordinate patient allocation and safe departure. Maintain an accurate MCI log of all patients with destinations, units, major injuries to be cross checked with initial triage information.

Page 41 of 192

Disaster Plan Flow Sheet

General Protocol

GP 23a

Page 42 of 192

Sedation of Confirmed General Protocol GP 24 Intubated Patient

From time to time the Paramedic or RN may come across a patient that has been intubated in a hospital setting that needs transport to definitive care. Some instances may be found where the patient that is intubated may be lightly sedated enough to achieve a calm state in a controlled environment like an ICU or Emergency Department. If the paramedic or RN attempts to move the patient to achieve patient transport and the patient sedation is such that is poses a risk of dislodging the ET tube or the patient appears to be conscious enough to have an understanding of the surrounding then the Paramedic or RN may administer additional sedatives to achieve a sedation that is appropriate to transport the patient without the patient being coherent enough to have a mental state that would generate fear or pain for the patient. Remember there is a fine line when it relates to humane and ethics. The paramedic or RN at their discretion may use additional sedatives to achieve a humane and ethical transport. If the patient is on a specific sedative you may attempt to increase the sedative being used. The following may be used to achieve sedation for a patient with a confirmed ET placement as long as there are no contraindications of the sedative: Valium Versed 5-10 mg IV q 15-30 mins 2-2.5 mg IV q 15-30 mins Consider Infusion (see Infusion Chart) Above the age of ten (10) years will vary between 0.2 and 0.6 mg/kg of body weight, and it must be individualized in each case. The usual dose for induction in these patients is 0.3 mg/kg, injected over a period of 30 to 60 seconds. 2mg IV q 30 mins Consider Infusion (see Infusion Chart) A slow rate of approximately 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg) should be used then a Maintenance Infusion 50 to 200 mcg/kg/min. Use with caution as Propofol may create Severe Hypotension If patient SBP falls below 100mmHg stop the infusion until such time the BP is above 100mmHg. Titration of this drug can be challenging. Start at the lowest dose and monitor how the patient reacts with the sedation and blood pressure responses. Increase slowly till you achieve the desired effect. The attempt is to achieve enough sedation to make the patient comfortable without a drastic change in patient blood pressure. Rocuronium 0.6-1.2 mg/kg IV Vecuronium 0.1 mg/kg IV

Etomidate

Ativan

Propofol

Patients that are intubated must have pulse oximetry measurements, cardiac monitoring, and wave form CO2 capnography along with Vital Signs q 3-5 mins. ET Tubes should be secured with a Thomas ET Tube Tamer if possible. Patient may also need a cervical collar placed to insure and prevent tube displacement. The benefit from the use of wrist restraints may be indicated. Remember to insure the tube placement with auscultation of bilateral breath sounds, pulse oximetry, and end tidal CO2 capnography every 2-3 minutes to insure the tube has not been dislodged.

Page 43 of 192

Facility Physician Orders

General Protocol

GP 25

This protocol is designed to preserve the treatment regimen that is currently in place for patients we are called to transport to definitive care. We should always follow the orders of the attending physician who has knowledge or who has been caring for the patient. We will only go outside the orders if the patients condition worsens or the patients condition changes while in our care. Though the patient may require treatment beyond the orders of the physician like emetics or pain control the paramedic or nurse will find the protocol that most closely matches the diagnosis of the patient at time of patient transfer. For physician orders that are outside the scope of these protocols, the paramedic or nurse should obtain a photocopy of the orders if possible and attach the physician orders to the patient care chart. If a photocopy of the orders is not obtainable, document the ordering physicians name and patient medical chart number in your patient care report. Remember you may only carry out orders that you are trained to perform and or comfortable with. In any instance where the paramedic or nurse feels uncomfortable with the orders of a physician then the paramedic or nurse should revert back to the standing orders/protocols and contact medical control immediately. The paramedic or nurse may only carry out orders of a medical doctor or doctor of osteopathy. Orders cannot be carried out from Physicians Assistance, Nurse Practitioners, Registered Nurses not affiliated with Acute Medical Services LLC. In some rare instances you may have a patient that requires transport without physicians orders; you are then to revert to the protocol most appropriate for the patients condition.

Page 44 of 192

Treating and Release of Patients

General Protocol

GP 26

Some instances you may find that the paramedic or nurse has begun to treat a patient and the patient then wants to refuse transport. In these instances the paramedic or nurse should attempt to talk the patient into being transported to seek medical treatment from a licensed physician. In the event that the patient in persistent in not being transported to definitive care medical control must be notified before departing the patients care. For those patients that are being discharged to a lower level of care that may need some treatment that is scheduled and the transport is being performed during the scheduled treatment then the paramedic or nurse may deem in necessary to continue the treatment on the normal and routing schedule so the patient does not miss a scheduled treatment or therapy. Examples of this would be for patients that require breathing treatment ever 4-6 hours. For patient that are being returned back to a nursing care home or residence that treatment may need to be rendered, medical control should be consulted prior to the initiation of treatment.

Page 45 of 192

Medical Control Consultations

General Protocol

GP 27

Medical Control consultations should be made any time there is a question about the treatment modality of a patient. Because the majority of the patients we transport are patients that are critically ill, and some instances where the standing protocol or standing orders do not fit the patients condition medical control is available for consult 24/7. I have in place a medical control system and a group of physicians that are ready to assist you in the event that assistance is needed. The medical control physicians may change from time to time and the most current schedule will be located in these protocols after the table of content and labeled Medical Control Schedule. When calling on medical control the patient report to the physician should be clear and precise. The outline below will assist you in insuring medical control has a clear understanding of the patients history, medical condition, treatment being rendered, and possible diagnosis of the patient. We should follow this format anytime we are relaying patient information to medical control or a receiving facility. Outline of Patient Care Consultation Give your name and unit number Inform Medical Control you have a patient consult Give the following information in this order: o Patient being transferred from where and what department o Patient being transferred to where and what department o Patient age, race, sex o Patient being transferred for o Patients vital signs, GCS, ATS o Patients complaint o Patients past medical history o Patients current prescribed medications o Patients Allergies o Patients Diagnosis from receiving facility o Treatment that receiving facility has performed and or initiated o Patients general appearance o Treatment that you are continuing or have initiated Advise medical control of your needs and or problem o Let medical control know the treatment you want to perform or initiate

Document your medical control consultation on the patient care report and include the physician name and time consulted and the treatment ordered. Document the outcome of the treatment ordered.

Page 46 of 192

General Protocol

Oxygen Calculation
OXYGEN CYLINDER ENDURANCE CALCULATION FORMULA

GP 28

duration of flow in minutes = (gauge pressure - safe residual pressure) x constant flow rate in liters per minute safe residual pressure: 200 Constants: D cylinder E cylinder M cylinder H cylinder Example: To calculate the duration flow in minutes for a full M cylinder being used at 15 LPM: duration of flow in minutes = (3000 - 200) x 1.56 = 291.2 minutes = 4 hours 50 minutes 15LPM Example: In order to figure out whether an ambulance's oxygen cylinder has the minimum O2 required for a trip, use the formula above. Minimum required gauge pressure = duration of trip in minutes x LPM + 200 constant for the size of cylinder Minnedosa to Winnipeg = 2.5 hours = 150 minutes cylinder in use: M cylinder constant is 1.56 oxygen flow rate for the patient = 15 LPM minimum required gauge pressure = 150 min x 15 LPM + 200 = 1642 PSI 1.56 0.16 0.28 1.56 3.14

Page 47 of 192

Adult Medical Protocols

Protocol
AM01 AM02 AM03 AM04 AM05 AM06 AM07 AM08 AM09 AM10 AM11 AM12 AM13 AM14 AM15 AM16 AM17 AM18 AM19 AM20 AM21 AM22 AM23 AM24 AM25 AM26 AM27 AM28 AM29 AM30 AM31 AM32 AM33 AM34 AM35 AM36 AM37 AM38 AM39 AM40 AM41 AM42

Description
Asystole Pulseless Electrical Activity Pulseless Ventricular Fibrillation Hypothermic Induces Cardiac Arrest Post Resuscitation Management Undifferentiated Tachycardia Unstable Ventricular Tachycardia Stable Ventricular Tachycardia Unstable Supraventricular Tachycardia Stable Supraventricular Tachycardia Bradycardia Ventricular Ectopy Acute Coronary Syndrome Cardiogenic Shock Hypertensive Crisis-Unstable Hypertensive Crisis-Stable Respiratory Distress-General Pulmonary Edema Asthma Chronic Obstructive Pulmonary Disease Pneumonia Hyperventilation Syndrome Pneumonia Allergic Reactions Mild to Anaphylaxis Altered Mental Status-Unknown Etiology Seizures Cerebral Vascular Accident Overdose Poisoning Neurogenic Shock Hypoglycemia Hyperglycemia Dehydration Hypothermia Heat Related Emergencies Near Drowning Septic Shock Nausea/Vomiting Acute Appendicitis-Diagnosed Renal Calculi Acute Abdomen Etiology Unclear Gastrointestinal Hemorrhage

Page
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 Page 48 of 192

Adult Medical Protocol

Asystole-Adult
Application: Pulseless/apneic in two or more leads

AM01

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Conscider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 25-50 gm IVP Consider Naloxone if question of opiate overdose Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose administration ECG (consider Transcutaneous Pacing) Epinephrine 1:10,000 1mg IVP or 1:1000 2 mg ET Repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET ACLS Guidelines External Cardiac Pacing Atropine 1.0mg IVP or 2.0mg ET Repeat every 3-5 minutes up to 0.04mg/kg Additional Atropine at 1.0mg IVP or 2.0mg ET may be administered if a clinically beneficial response is obtained even is maximum recommended dosage is exceeded. Nasogastric or Oralgastric Tube Insertion Sodium bicarbonate 1mEq/kg IVP if metabolic acidosis is likely Consider Calcium Chloride 0.5 1.0 Gram IVP

EMT Intermediate

Basic EMT

Paramedic or RN

Page 49 of 192

Pulseless Electrical Activity Adult

Application:

Adult Medical Protocol

AM02

Pulseless/apneic in conjunction with any ECG rhythm other than Ventricular Fibrillation, Ventricular Tachycardia, or Asystole

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Conscider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 25-50 gm IVP Consider Naloxone 1-2 mg IVP if question of opiate overdose Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG (consider Transcutaneous Pacing) If due to a surgical problem or injury initiate Rapid Transport Procedure If Tension Pneumothorax chest decompression Epinephrine 1:10,000 1mg IVP or 1:1000 2 mg ET Repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET ACLS Guidelines External Cardiac Pacing If Bradycardia rhythm Atropine 1.0mg IVP or 2.0mg ET Repeat every 3-5 minutes up to 0.04mg/kg Additional Atropine at 1.0mg IVP or 2.0mg ET may be administered if a clinically beneficial response is obtained even is maximum recommended dosage is exceeded. If evidence of hypovolemia Bolus Infusion of 500ml NS or 500ml LRS Nasogastric or Oralgastric Tube Insertion Sodium bicarbonate 1mEq/kg IVP if metabolic acidosis is likely If evidence of hemorrhage induced hypovolemia consider Hespan 250ml-750ml IV infusion at no more than 20ml/kg/hr. Use only after a minimum of 1:2 ratio (blood loss) fluid bolus of NS or LRS has been administered. Use caution in Renal Insufficient patients. Do not mix or administer any other medications is same IV administration set.

Paramedic or RN

EMT Intermediate

Basic EMT

Page 50 of 192

Pulseless Ventricular Fibrillation

Adult Medical Protocol

Adult
Application:

AM03

Pulseless/apneic or pulseless with agonal respirations and Ventricular Fibrillation of Ventricular Tachycardia on the ECG

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Conscider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 25-50 gm IVP Consider Naloxone 1-2 mg IVP if question of opiate overdose Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG Defibrillation at the following until conversion BiPhasic Defibrillation: 120 J then 150 J then 200 J Monophasic Defibrillation: 200 J then 300 J then 360 J Epinephrine 1:10,000 1mg IVP or 1:1000 2 mg ET or Vasopressin 40 units in place of 1st and 2nd dose of epinephrine. If using epinephrine, repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET or ACLS Guidelines Check rhythm, resume CPR, Shock if indicated Amiodarone 300mg Bolus IVP or Lidocaine 1.0-1.5 mg/kg IVP Check rhythm, resume CPR, Shock if indicated 2nd Dose Amiodarone 150mg Bolus IVP or Lidocaine 1.0-1.5 mg/kg IVP Check rhythm, resume CPR, Shock if indicated Nasogastric or Oralgastric Tube Insertion Anti-rhythmic Infusion: If Amiodarone was administered then 1mg/min Amiodarone Infusion If Lidocaine was administered them 2-4 mg/min Lidocaine Infusion Consider: Sodium bicarbonate 1mEq/kg IVP if Hyperkalemia or tricyclic toxicity Consider: Magnesium 1-2 grams if hypomagnesemia or Torsades de points

Paramedic or RN

EMT Intermediate

Basic EMT

Page 51 of 192

Hypothermic Induced Cardiac Arrest

Adult Medical Protocol

Adult
Application: Pulseless/apneic or pulseless with environmental evidence of hypothermia

AM04

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 25-50 gm IVP Consider Naloxone 1-2 mg IVP if question of opiate overdose Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG If V-Fib or V-Tach Defibrillation at the following until conversion BiPhasic Defibrillation: 120 J then 150 J then 200 J Monophasic Defibrillation: 200 J then 300 J then 360 J Epinephrine 1:10,000 1mg IVP or 1:1000 2 mg ET or Vasopressin 40 units in place of 1st and 2nd dose of epinephrine. If using epinephrine, repeat every 3-5 minutes as 1.0 mg IVP or 2.0mg ET ACLS Guidelines Do Not Attempt defibrillation again if temperature is below 85 degrees F. Temperature is 85 degrees or greater appropriate Protocol for Dysthythmia Check rhythm, resume CPR, Shock if indicated NS 500ml Bolus or LR 500ml Bolus if evidence of hypovolemia Check rhythm, resume CPR, Shock if indicated Nasogastric or Oralgastric Tube Insertion Resuscitation may not be terminated until the patient is normothermic

Paramedic or RN

EMT Intermediate

Basic EMT

Page 52 of 192

Post Resuscitation Management

Adult Medical Protocol

Adult
Application:

AM05

Patient with spontaneous circulation or respiratory efforts after treatment of a non-perfusing rhythm Basic EMT

CABC's O2 by Bag Valve Mask or King Tube Blood Glucose Check Vital Signs

EMT Intermediate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 25-50 gm IVP Consider Naloxone 1-2 mg IVP if question of opiate overdose Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG If V-Fib or V-Tach Defibrillation converted from defibrillation and patient is not bradycardic If Amiodarone was administered prior to then 150mg slow IVP over 8-10 minutes and infusion of 1mg/min If Lidocaine was administered prior to then 0.5-1.0 mg/kg IVP then infusion of 2-4 mg/min Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg If Hypotensive 500ml of NS Consider Induced Hypothermia-Use chilled bolus of NS Cooling blanket, Artic Sun, or Ice Pacs to carotid, inguinal, and axilla If Hypotensive after flood bolus Dopamine Infusion 2-20 mcg/kg/min Start infusion at 2mcg/kg/min and continue to increase until systolic is > 90 mmHg Norepinephrine Infusion 0.5 1.0 mcg/min titrate to a max of 30mcg.min for severe refractory hypotension Bradycardia after resuscitation: Refer to Bradycardia Protocol Nasogastric or Oralgastric Tube Insertion Patients intubated that are attempting to dislodge or fighting the ET tube Consider the following for sedatives: Versed IVP or Versed Infusion Benzodiazepine IVP Etomidate IVP or Infusion Propofol Infusion

Paramedic or RN

Page 53 of 192

Undifferentiated Tachycardia

Adult Medical Protocol

Adult
Application:

AM06

A wide complex Tachycardia with a QRS > 0.12 seconds with a rate heart rate > 150 bpm with uncertain origin with symptoms of impaired perfusion, diaphoresis, chest pain, or shortness of breath without hypotension, altered mental status, or pulmonary edema. Patients with hypotension, hypotension, altered mental status, or pulmonary edema should be managed using either the Unstable SVT or VT Protocol Note: If uncertain, consider the rhythm as undifferentiated. Do not treat specific arrhythmias unless certain Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG Adenosine 6mg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg If ectopy still not resolved Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg If patient becomes unstable Prepare for Cardioversion and use Unstable V-Tach or SVT Protocol

Page 54 of 192

Unstable Ventricular Tachycardia

Adult Medical Protocol

Adult
Application:

AM07

Ventricular Tachycardia on ECG with Systolic BP < 90mm Hg or Pulmonary Edema or Significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Consider Intubation if hypoxemia present

Paramedic or RN

ECG Prepare for Synchronized Cardioversion Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Monophasic Cardioversion use 100j then 200j then 300j then 360j Biphasic Cardioversion use 100j then 120j then 150j then 200j Anti-arrhythmic Medication: Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min Alternate with synchronized cardioversion at highest level of energy noted above Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg

Page 55 of 192

Stable Ventricular Tachycardia

Adult Medical Protocol

Adult
Application:

AM08

Ventricular Tachycardia on ECG with Systolic BP > 90mm Hg without Pulmonary Edema or Significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Consider Intubation if hypoxemia present

ECG Anti-arrhythmic Medication: Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg Prepare for Synchronized Cardioversion if patient becomes unstable Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Monophasic Cardioversion use 100j then 200j then 300j then 360j Biphasic Cardioversion use 100j then 120j then 150j then 200j

Paramedic or RN

Page 56 of 192

Unstable Supraventricular Tachycardia

Adult Medical Protocol

Adult
Application:

AM09

SVT on ECG at rates >150 bpm with systolic BP <90 mmHg and one or more of the following: Severe dyspnea or Pulmonary Edema or significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Consider Intubation if hypoxemia present

Paramedic or RN

ECG Prepare for Synchronized Cardioversion Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion If known PSVT or Atrial Flutter, may start with synchronized cardioversion at 50 j otherwise: Synchronized Cardioversion in energy sequence below until conversion of rhythm Monophasic Cardioversion use 100j then 200j then 300j then 360j Biphasic Cardioversion use 100j then 120j then 150j then 200j Adenosine 6mg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg

Page 57 of 192

Stable Supraventricular Tachycardia

Adult Medical Protocol

Adult
Application:

AM10

SVT on ECG with a rate >150 bpm with systolic BP of > 90 mmHg without severe dyspnea, pulmonary edema, or significant altered mental status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG Vagal Maneuvers Adenosine 6mg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 12mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg If ectopy still not resolved Prepare for Synchronized Cardioversion for unstable patient Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Monophasic Cardioversion use 100j then 200j then 300j then 360j Biphasic Cardioversion use 100j then 120j then 150j then 200j

Page 58 of 192

Bradycardia Adult
Application:

Adult Medical Protocol

AM11

Any underlying cardiac rhythm with a ventricular rate of <60 bpm with and one or more of the following: Systolic BP<90 mmHg or PVCs at >6 complexes per minute or Pulmonary Edema or Dyspnea or Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG Atropine 0.5mg IVP May repeat every 3-5 minutes up to a total dose of 0.04mg/kg Refractory Bradycardia External Cardiac Pacing Use the following for sedatation and pain management of the paced patient Valium 2.0mg IVP every 2-5 minutes or Midazolam 1.0mg IVP for sedation prior to cardioversion Morphine Sulfate 2-4 mg IVP or 1mg Dilaudid IVP for pain management prior to cardioversion For Bradycardia or cardiogenic hypotension refractory to atropine and or pacing Dopamine 5-20 mcg/kg/min IV Infusion Norepinephrine Infusion 0.5 1.0 mcg/min IV and titrate to a max of 30 mcg/min

Page 59 of 192

Ventricular Ectopy Adult

Application:

Adult Medical Protocol

AM12

Premature ventricular complexes occurring whether unifocal or multifocal in origin with 12 or more complexes occurring per minute for more than 3-5 minutes and in the setting of Acute Coronary Syndrome and in the absence of Bradycardia Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG and if time permits diagnostic 12 Ld recording Anti-arrhythmic Medication: Amiodarone 150mg slow IVP over 8-10 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 1-2 grams IVP Procainamide 20-30 mg/min IVP with a maximum dose of 17mg/kg

Page 60 of 192

Acute Coronary Syndrome Adult

Application:

Adult Medical Protocol

AM13

Non Traumatic pain of visceral quality from the neck to the pelvis inlet in cause for suspicion and chest/back/shoulder/neck/jaw or other discomfort may be indicative of myocardial ischemia and associated symptoms indicating myocardial ischemia or Acute Coronary Syndrome or Angina to include shortness of breath, nausea, vomiting, diaphoresis with a systolic BP of 90 mmHg or greater or 30% of baseline systolic. Basic EMT CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check If BG <80mg/dL administer Oral Glucose if patient has an intact gag reflex Vital Signs Assistance with self-administration of NTG if patient has a script 0.4mg tablet dissolved under tongue if systolic BP is >100 mmHg may repeat another dose after 10 minutes if systolic BP is >90mmHg ASA 324 mg PO chewable If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Preferred D5W but NS can be used Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG with diagnostic 12 Ld recording and include a Right Sided evaluation If Positive Right Sided MI Flood Bolus of 250ml may repeat if symptoms improve NTG spray or tablet 0.4mg SL May repeat every 3-5 minutes with a maximum of 3 doses/30 Minutes or if relief is found after 1-2 doses then NTG Paste 1 applied to chest wall if systolic BP is >90mmHg Antiemetic Therapy: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.5-25 mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP Pain Management Therapy: They are listed in preferred order if not contraindicated Morphine Sulfate 2.0 mg every 5 minutes to a maximum of 10mg every hour Hydromorphone 0.5mg to 1mg every 30 minutes to a maximum of 2mg every hour Fentanyle 50 100 mcg slow IVP may repeat as 50 mcg every 30 minutes to a maximum of 150 mcg per hour Consider NTG Infusion 5 mcg/min by infusion pump increasing 5mcg/min every 5 minutes if Systolic BP >90 mmHg to desired effect to a maximum of 20 mcg/min Consider Metoprolol IVP 5mg every 2 minutes for 3 doses (give each dose over a 2 minutes) Do not use if patient is in cardiogenic shock, Acute Coronary Syndrome with a rate less than 45 beats/minute or systolic BP <100 mmHg, or heart blocks. Page 61 of 192

EMT Intermediate Paramedic or RN

Cardiogenic Shock Adult

Application:

Adult Medical Protocol

AM14

Hypotension with a systolic BP <90mmHg and is symptomatic for MI or Acute Coronary Syndrome which may include myocardial ischemia, ECG changes, or pulmonary edema with an altered mentation or GCS <8 without evidence of hypovolemia, dehydration, sepsis, or other non-cardiogenic source of hypotension without bradycardia

EMT Intermediate

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

IV access Preferred D5W but NS can be used Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes

Paramedic or RN

ECG with diagnostic 12 Ld recording and include a Right Sided evaluation If Positive Right Sided MI Consider fluid bolus of 20ml/kg Epinephrine 1mg IVP may repeat every 3-5 minutes if systolic BP >70mmHg Dopamine Infusion 2.0 20 mcg/kg/min start at 2.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until systolic BP >90 mmHg Refractory to above treatment: Norepinephrine Infusion 0.5 1.0 mcg/min titrate to a max of 30 mcg/min

Page 62 of 192

Hypertensive Crisis-Unstable

Adult Medical Protocol

Adult
Application:

AM15

Systolic BP > 200mmHg and or Diastolic BP of >110mmHg and clinical evidence of end-organ dysfuction, including one or more of the following: Altered Mentation, CVA like symptoms, Chest Pain or Acute Coronary Syndrome, Shortness of Breath, Headache, Nausea or Vomiting, and/or Diaphoresis

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Assistance with self-administration of NTG if patient has a script 0.4mg tablet dissolved under tongue if systolic BP is >100 mmHg may repeat another dose after 10 minutes if systolic BP is >90mmHg ASA 324 mg PO chewable If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Preferred D5W but NS can be used Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG with diagnostic 12 Ld recording and include a Right Sided evaluation If Positive Right Sided MI caution with use of Nitrates NTG spray or tablet 0.4mg SL May repeat every 3-5 minutes with a maximum of 3 doses/30 Minutes or if relief is found after 12 doses then NTG Paste 1 applied to chest wall if systolic BP is >90mmHg Antiemetic Therapy: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.525 mg IVP If refractory to Nitrates consider one of the following treatment modalities: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Metoprolol Tartrate 5mg Slow IVP every 5-10 minutes to a total maximum of 15mg Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

EMT Intermediate

Paramedic or RN

Page 63 of 192

Hypertensive Crisis-Stable

Adult Medical Protocol

Adult
Application:

AM16

Systolic BP > 200mmHg and or Diastolic BP of >110mmHg without clinical evidence of endorgan dysfunction

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Assistance with self-administration of NTG if patient has a script 0.4mg tablet dissolved under tongue if systolic BP is >100 mmHg may repeat another dose after 10 minutes if systolic BP is >90mmHg If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose ECG with diagnostic 12 Ld recording and include a Right Sided evaluation If Positive Right Sided MI caution with use of Nitrates Antiemetic Therapy if indicated: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.525 mg IVP Consider one of the following: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Metoprolol Tartrate 5mg Slow IVP every 5-10 minutes to a total maximum of 15mg Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

EMT Intermediate

Paramedic or RN

Page 64 of 192

Respiratory Distress-General

Adult Medical Protocol

Adult
Application: Dyspnea without a clear etiology

AM17

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Albuterol 2.5mg by Nebulization or assistance in self-administration of patient own inhalers If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

Basic EMT

IV access Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Albuterol 2.5mg by Nebulization every 10 minutes to a total of 3 doses

Paramedic or RN

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Terbutaline 0.25mg SQ if tidal volume inadequate for inhalation therapy or refractory to Albuterol Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses Consider Combi Vent after the initial dose of Atrovent Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

Page 65 of 192

Pulmonary Edema

Adult Medical Protocol

Adult
Application:

AM18

Shortness of Breath with evidence of pulmonary edema and cardiac history with systolic BP greater than 100mmHg

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

Basic EMT

IV access Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP

Paramedic or RN

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation NTG spray or tablet 0.4mg SL May repeat every 3-5 minutes with a maximum of 3 doses/30 Minutes or if relief is found after 12 doses then NTG Paste 1 applied to chest wall if systolic BP is >90mmHg Antiemetic Therapy: Zofran 2-8 mg IVP or Promethazine 12.5-25mg IVP diluted in 10 ml NS or Diphenhydramine 12.525 mg IVP Consider Morphine Sulfate 2-4mg IVP every 5 minutes to a total dose of 10mg Consider Furosemide 1.0mg/kg IVP Consider CPAP Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

Page 66 of 192

Asthma Adult
Application:

Adult Medical Protocol

AM19

Dyspnea with evidence of bronchospasm with or without wheezing or silent breath sounds

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Albuterol 2.5mg by Nebulization or assistance in self-administration of patient own inhalers If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

Basic EMT

IV access with NS at 250-500 ml per hour Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Albuterol 2.5mg by Nebulization every 10 minutes to a total of 3 doses

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Terbutaline 0.25mg SQ if tidal volume inadequate for inhalation therapy or refractory to Albuterol Consider Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses Solu-Medrol or Solu-Cortef 250 mg to 500 mg IVP over 2 minutes Asthma refractory to above treatment regimens: Consider Mag Sufate 1-2 grams IV Infusion over 15 minutes Consider Atropine by Nebulization 0.5mg in 3ml NS Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

Paramedic or RN

Page 67 of 192

COPD Adult
Application:

Adult Medical Protocol

AM20

Exacerbation of chronic bronchitis or emphysema with shortness of breath or dyspnea or a history of COPD

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Albuterol 2.5mg by Nebulization or assistance in self-administration of patient own inhalers If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

Basic EMT

IV access with NS at 250-500 ml per hour Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Albuterol 2.5mg by Nebulization every 10 minutes to a total of 3 doses

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Terbutaline 0.25mg SQ if tidal volume inadequate for inhalation therapy or refractory to Albuterol Consider Atrovent 500ug/3.0 ml by Nebulization may repeat every 10 minutes for a total of 3 doses Solu-Medrol or Solu-Cortef 250 mg to 500 mg IVP over 2 minutes Consider CPAP with peep Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

Paramedic or RN

Page 68 of 192

Pneumonia Adult
Application:

Adult Medical Protocol

AM21

Pneumonia cannot be diagnosed in the field without confirmation of imaging however it may be supported or suggested with the following: a history of mucopurulent sputum production, fever, dyspnea, abnormal CBC findings, and a positive sputum culture. Use this protocol for dyspnea with one or more of the following: Fever, Productive and Purulent Cough, Chest wall or Pleuritic Pain

Basic EMT

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Albuterol 2.5mg by Nebulization or assistance in self-administration of patient own inhalers If Febrile Acetaminophen 15mg/kg PO or Ibuprophen 200mg 600mg PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

IV access with NS at 150-300 ml per hour Blood Draw Red or Green Top Lavender Top If available Blood Culture Tubes If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Albuterol 2.5mg by Nebulization every 10 minutes to a total of 3 doses

Paramedic or RN

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Terbutaline 0.25mg SQ if tidal volume inadequate for inhalation therapy or refractory to Albuterol Consider CPAP with peep Consider Atrovent 500ug/3.0ml Saline, may be beneficial if patient has underlying COPD or emphysema. May repeat dosage if proven to be effective after initial dose up to 3 doses Consider Intubation using Pharmacological Assisted Intubation Protocol if patient pO2 <80% Other considerations: Bag Valve Mask

Page 69 of 192

Hyperventilation Syndrome Adult

Application:

Adult Medical Protocol

AM22

An increased rate and depth of respirations without evidence of hypoxemia with one or more of the following: Facial and peripheral tingling and/or extremity cramping or carpopedal spasms without adequate oxygenation SaO2 greater than 98%

Basic EMT

CABC's Pulse Oximetry without Oxygen if possible O2 by NRB preferred if patient will tolerate or Nasal Cannula Verbal coaching on breathing Blood Glucose Check Vital Signs Psychological and Emotional Support If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

IV access Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Consider sedative or sedative like pharmacology 25mg Diphenhydramine IVP 12.5 mg Promethazine IVP 2mg Diazapam IVP Continue psychological and emotional support

Page 70 of 192

Foreign Body Airway Obstruction

Adult Medical Protocol

Adult
Application:

AM23

Partial of complete airway obstruction secondary to a foreign body aspiration with evidence of one or more of the following: asymmetric and paroxysmal chest movement, decreased LOC, cyanosis, obvious inadequate air exchange

CABC's Abdominal Chest Thrust per AHA guidelines Reassess the airway and if not clear repeat abdominal thrust per AHA guideline, if clear then O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs

Basic EMT

EMT Intermediate

Direct Laryngoscopy and attempt to visualize the object and remove with Magill forceps If available Video/Camera Laryngoscopy maybe beneficial Intubate as needed IV Access Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

If all interventions have failed and the patient airway is a complete obstructions Surgical Airway See Cricothyrotomy Procedure

Page 71 of 192

Allergic Reaction-Mild to Moderate Anaphylaxis with Hypotension

Adult Medical Protocol

Adult
Application:

AM24

Mild allergic reaction that involves contact dermatitis and or uticaria and dermal itching without evidence of dyspnea, hypotension, wheezing, or complaint of airway fullness or Moderate allergic reaction that also includes localized or generalized peripheral edema, shortness of breath without hypotension

Basic EMT

CABC's O2 Blood Glucose Check Vital Signs If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.3ml SQ

EMT Intermediate

IV Access Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose If severe Anaphylaxis with airway restriction Epi 1:10,000 0.5mg IVP or Epi 1:1,000 0.3ml SQ

Paramedic or RN

ECG Diphenhydramine 25mg IVP or Diphenhydramine 25mg IM Solumedrol 125 250mg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.3ml SQ may repeat one time after 5 minutes Terbutaline 0.25mg SQ if refractory to Epinephrine ECG Epinephrine 1:10,000 0.5 mg IVP or 0.5mg SL Injection Diphenhydramine 25mg IVP or Diphenhydramine 25mg IM Solumedrol 125 250mg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Terbutaline 0.25mg SQ if refractory to Epinephrine Consider Intubation Consider Pharmacologically Assisted Intubation

Anaphylaxis with Hypotension

Page 72 of 192

Altered Mental Status Etiology Unknown Adult

Application:

Adult Medical Protocol

AM25

Unresponsive or disoriented patient without a clear mechanism for altered mental status

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs AED application If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

Basic EMT

IV access with NS or LRS Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose Naloxone 1-2mg IVP every 5 minutes to a total dose of 10mg Consider Intubation if GCS <8 or patient unable to protect their own airway

Paramedic or RN

ECG consider diagnostic 12 Ld recording and include a Right Sided evaluation Refer to a more specific protocol

Page 73 of 192

Seizures/Status Epilepticus Adult

Application:

Adult Medical Protocol

AM26

Witnessed, reported, or suspected seizures prior to arrival or active seizure activity with normothermia

EMT Intermediate

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

IV access with NS Blood Draw If BG < 80mg/dL administer D50% 25-50 gm IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

Paramedic or RN

ECG Consider one of the following: (Airway control measures should be available) Diazepam 2.0-10.0 mg IVP or 4-20 mg per rectum if IV unobtainable Versed 2mg IV may repeat once Ativan 0.05-0.1 mg/kg IVP For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg IVP (if available) Mag Sulfate 4 Grams IV Infusion over 20 minutes then 1-4 grams per hour IV Infusion

Page 74 of 192

Cerebral Vascular Accidents Transient Ischemic Attaches Adult

Application:

Adult Medical Protocol

AM27

Altered mental status or slurred speech without probable etiology or unilateral weakness, paralysis, facial drooping, dysphagia, aphagia, or other neurological deficit. Patient has a history of CVA or TIA.

EMT Intermediate

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

IV access with NS Blood Draw If BG < 80mg/dL administer half of the usual dose of D50% 12.5-25 gram IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose

ECG Consider one of the following for nausea: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If hypertensive: ECG with diagnostic 12 Lead recording and include a Right Sided evaluation If Positive Right Sided MI caution with use of Nitrates NTG spray or tablet 0.4mg SL May repeat every 3-5 minutes with a maximum of 3 doses/30 Minutes or if relief is found after 12 doses then NTG Paste 1 applied to chest wall if systolic BP is >90mmHg If refractory to Nitrates consider one of the following treatment modalities: Labetalol 5mg slow IVP every 15-20 minutes to a maximum of 20mg total Hydralazine 10-20 mg slow IVP preferred to start at 10mg with 5mg increment every 5-10 minutes till desired effect is achieved

Paramedic or RN

Page 75 of 192

Overdose Adult
Application:

Adult Medical Protocol

AM28

Known or suspected ingestion, injection of pharmacoactive substance, whether intentional or accidental.

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Poison Control Consultation If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP Consider 100mg Thiamine IVP if question of alcoholism, prior to glucose If respiratory compromised: Intubation Naloxone 0.4 2mg IV may repeat every 2-5 minutes to a maximum dose of 10mg ECG If dystonic reaction: Diphenhydramine 25-50mg IVP or IM If TCA overdose with significant CNS and Cardiovascular symptoms : Sodium Bicarbonate 1.0 mEq/kg IVP may repeat every 2-5 minutes if patient responds to initial dose Activated Charcoal 25-50 Grams PO if oral overdose and patient airway reflexes intact Maybe administered through a NG or OG tube if patient has no airway reflex intact after confirmed Oral Tracheal Intubation

Basic EMT

EMT Intermediate

Paramedic or RN

Page 76 of 192

Poisoning Adult
Application:

Adult Medical Protocol

AM29

Known or suspected ingestion, injection of pharmacoactive substance, whether intentional or accidental.

If Inhalation poisoning, remove from environment and contact local fire department CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Decontamination of patient-Contact local fire department Blood Glucose Check Vital Signs Poison Control Consultation If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation Naloxone 0.4 2mg IV may repeat every 2-5 minutes to a maximum dose of 10mg if suspected opiate related poisoning ECG If organophosphate poisoning and or symptoms parasympathetic response SLUDGE Atropine 2.0mg IVP repeat every 5 minutes as needed If metabolic acidosis likely Sodium Bicarbonate 1.0 mEq/kg IVP NG or OG intubation and lavage if indicated If dystonic reaction: Diphenhydramine 25-50mg IVP or IM If TCA overdose with significant CNS and Cardiovascular symptoms : Sodium Bicarbonate 1.0 mEq/kg IVP may repeat every 2-5 minutes if patient responds to initial dose Consider Activated Charcoal 25-50 Grams PO if oral overdose and patient airway reflexes intact Maybe administered through a NG or OG tube if patient has no airway reflex intact after confirmed Oral Tracheal Intubation

Basic EMT

EMT Intermediate

Paramedic or RN

Page 77 of 192

Neurogenic Shock Adult

Application:

Adult Medical Protocol

AM30

Shock that is hemodynamically instable without an etiology, this type of shock is extremely difficult to diagnose in the field. A thorough examination is pertinent in determining and ruling our other sources of instable hemodynamics.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat dysthymias per protocol SoluMedrol 10-30 mg/kg IV Infusion over 15-30 minutes Fluid Bolus 20-40 ml/kg IV to a max of 3 L Consider Vasopressors: Epinephrine Infusion 0.1 1.0 mcg/kg/min to maintain systolic BP of 90 mmHg Dopamine Infusion 2.0 20.0 mcg/kg/min Levophed Infusion 0.5 mcg -30 mcg per minute Vasopressin Infusion 0.01-0.04 units per minute

Quick Infusion Chart

Epinephrine Infusion
Mix 1mg/250ml NS which yields 4mcg per ml 15ml/hr=1mcg/min 30ml/hr=2mcg/min 45ml/hr=3mcg/min 60ml/hr=4mcg/min 75ml/hr=5mcg/min 120ml/hr=8mcg/min 150ml/hr=10mcg/min

Dopamine Infusion
DOUBLE STRENGTH Mix 200 mg/250ml NS which yields 800mcg per ml

Levophed Infusion
Mix 4ml/250ml D5W which yields 16 mcg per ml 3.8ml/hr=1 mcg/min 7.5ml/hr=2 mcg/min 18.8ml/hr=5 mcg/min 37.5ml/hr=10 mcg/min 56.3ml/hr=15 mcg/min 75.0ml/hr=20 mcg/min 112.5ml/hr=30mcg/min

Vasopressin
Mix 20 units/100ml NS which yields 0.2 units per ml 3ml/hr=0.01 units/min 6ml/hr=0.02 units/min 9ml/hr=0.03 units/min 12ml/hr=0.04 units/min

See Dopamine Infusion Chart

Page 78 of 192

Hypoglycemia Adult
Application:

Adult Medical Protocol

AM31

Blood Glucose Analysis of less than 80mg/dL with altered mental status or other sign/symptoms of hypoglycemia, including tremors, weakness, nausea, and intense hunger

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Blood Glucose <80 mg/dL and airway intact and able to swallow 15g-30g oral glucose If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or D5W Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP may repeat once in 10-15 minutes if symptoms not resolved Repeat BG analysis every 15 minutes after administration of D50% If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Consider if available Glucagon 1mg if IV access is unobtainable

Page 79 of 192

Hyperglycemia Adult
Application:

Adult Medical Protocol

AM32

Blood Glucose Analysis of greater than 180mg/dL with one of the following: Altered mental status, tachypnea, abdominal pain, hypotension, and tachycardia

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS Blood Draw If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Fluid Bolus of 20-40 ml/kg to a maximum of 3 Liters If available and Blood Sugar is greater than 300mg/dL Insulin Humulin R 0.1 units/kg IVP then infusion of 0.05 units/kg/hr 100 units/100ml NS yields 1 unit/ml Fluid Bolus 20-40 ml/kg IV to a max of 3 L

Page 80 of 192

Dehydration Adult
Application:

Adult Medical Protocol

AM33

Hypovolemia either compensated or uncompensated or other signs and symptoms of dehydration, including any one of the following: Poor skin turgor, decrease in urine output, dry mucous membranes, orthostatic hypotension, dry cracked membranes and with evidence of a dehydration mechanism which may include vomiting, diarrhea, fever, diminished oral intake, and or sweating.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs to include orthostatics If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LR 20ml/kg bolus with 10ml/kg every 15 minutes up to a maximum of 3 liters Blood Draw If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Fluid Bolus of 20-40 ml/kg to a maximum of 3 Liters Consider one of the following for nausea: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 81 of 192

Hypothermia Adult
Application:

Adult Medical Protocol

AM34

Temperature of 90 degrees or less and altered mental status or uncoordinated physical activity without shivering

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula If respiratory compromised BVM for rates less than 12/min or over 30/min Vital signs and Tympanic or Rectal Temperature Vital Signs BG analysis Remove from environment, remove wet clothing, wrap patient in dry/warm blankets If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS 250-500ml/hour with warm fluid Blood Draw If BG <80 mg/dL then D50% 25-50 grams IVP Consider: Thiamine 50mg IVP if alcohol abuse suspected If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Consider: Sodium Bicarbonate 1mEq/kg IVP if metabolic acidosis is suspected Treat cardiac dysrhythmia as per specific protocol

Page 82 of 192

Heat Related Emergencies Adult

Application:

Adult Medical Protocol

AM35

Environmental evidence of extreme hot conditions that would have dehydration effects and cramping of the extremities or weakness, vertigo, nausea, profuse sweating, tachycardia, or syncope with an elevated core temperature by 1-2 degrees or patient is dry and core temperature is 105 degrees with altered mental status or seizures present

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula If respiratory compromised BVM for rates less than 12/min or over 30/min Vital signs and Tympanic or Rectal Temperature Vital Signs BG analysis Remove from environment, provide external cooling Commercial electrolyte substitute 250-500ml slow PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS 250-500ml bolus then 125ml/hour infusion Blood Draw If BG <80 mg/dL then D50% 25-50 grams IVP Consider: Thiamine 50mg IVP if alcohol abuse suspected If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG If nauseated consider: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient shivering Diazepam 2-10 mg IVP Supportive Care Continue to cool the patients until the temperature returns to a normal range

Page 83 of 192

Near Drowning Adult

Application: Water submersion without cardiopulmonary arrest and without hypothermia

Adult Medical Protocol

AM36

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula If respiratory compromised BVM for rates less than 12/min or over 30/min Vital signs and Tympanic or Rectal Temperature Vital Signs BG analysis Oral/Nasal Airway if patient unconscious AED If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS Blood Draw If BG <80 mg/dL then D50% 25-50 grams IVP Consider: Thiamine 50mg IVP if alcohol abuse suspected If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG NG or OG Tube Insertion Supportive Care Treat dysrhythmias as per specific protocol

Page 84 of 192

Septic Shock Adult

Application:

Adult Medical Protocol

AM37

Shock that is hemodynamically unstable with evidence of infectious process, one of the following maybe indicative for septicemia: Fever, recent would infection, recent surgery, decubitus ulcerations or dermal breakdown, recent URI or UTI, urinary catheter placement, PEG placement, rash, elevated WBC, and petechial

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febril Tylenol 500-1000 mg PO or 400-800mg Ibuprophen PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS Fluid challenge of 20ml/kg max of 3 L Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat dysthymias per protocol Consider Vasopressors: Epinephrine Infusion 0.1 1.0 mcg/kg/min to maintain systolic BP of 90 mmHg Dopamine Infusion 2.0 20.0 mcg/kg/min Levophed Infusion 0.5 mcg -30 mcg per minute Vasopressin Infusion 0.01-0.04 units per minute

Quick Infusion Chart

Epinephrine Infusion
Mix 1mg/250ml NS which yields 4mcg per ml 15ml/hr=1mcg/min 30ml/hr=2mcg/min 45ml/hr=3mcg/min 60ml/hr=4mcg/min 75ml/hr=5mcg/min 120ml/hr=8mcg/min 150ml/hr=10mcg/min

Dopamine Infusion
DOUBLE STRENGTH Mix 200 mg/250ml NS which yields 800mcg per ml

Levophed Infusion
Mix 4ml/250ml D5W which yields 16 mcg per ml 3.8ml/hr=1 mcg/min 7.5ml/hr=2 mcg/min 18.8ml/hr=5 mcg/min 37.5ml/hr=10 mcg/min 56.3ml/hr=15 mcg/min 75.0ml/hr=20 mcg/min 112.5ml/hr=30mcg/min

Vasopressin
Mix 20 units/100ml NS which yields 0.2 units per ml 3ml/hr=0.01 units/min 6ml/hr=0.02 units/min 9ml/hr=0.03 units/min 12ml/hr=0.04 units/min

See Dopamine Infusion Chart

Page 85 of 192

Nausea/Vomiting/Gastritis Adult
Application:

Adult Medical Protocol

AM38

Acute Nausea/Vomiting without evidence of internal hemorrhage and physical exam reveals no palpable pulsating masses and no clinical evidence of diaphoresis with normal vital signs and afebrile without guarding on abdominal exam.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS 100-250 ml/hr Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat dysthymias per protocol Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP

Page 86 of 192

Acute Appendicitis Diagnosed

Adult Medical Protocol

Adult
Application:

AM39

Acute Nausea/Vomiting without evidence of internal hemorrhage and physical exam reveals no palpable pulsating masses and no clinical evidence of diaphoresis with normal vital signs.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febrile and the patient is not nauseated Tylenol 500-1000mg PO or Ibuprophen 400-800mg PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS 100-250 ml/hr Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP Consider one of the following for Pain Management: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg Consider in conjunction with pain management anti-inflammatory Ketorolac 15-30mg IVP, or 60mg IM

Page 87 of 192

Renal Calculi

Adult Medical Protocol

Adult
Application:

AM40

Sudden onset of back or flank pain without association of trauma with excruciating and intermittent pain in the kidney area radiating to flank or groin area with nausea, vomiting, chills, fever, polyuria, or hematuria

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febrile and the patient is not nauseated Tylenol 500-1000mg PO or Ibuprophen 400-800mg PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS 100-250 ml/hr Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetics: *Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP Consider one of the following for Pain Management: *medication of choice if no contraindications Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg *Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg *Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg Consider in conjunction with pain management anti-inflammatory *Ketorolac 15-30mg IVP, or 60mg IM

Page 88 of 192

Acute Abdomen Etiology Unclear

Adult Medical Protocol

Adult
Application:

AM41

Non Traumatic abdominal pain without a clear etiology except female patients of childbearing age.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with NS or LRS 100-250 ml/hr Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP

Page 89 of 192

Gastrointestinal Hemmorhage

Adult Medical Protocol

Adult
Application:

AM42

Abdominal pain with guarding, rebound, distention, with or without bowel sounds with evidence of occult blood in stool or vomiting of blood

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Move to a more specific protocol Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP If patient complaining of heartburn or indigestion symptoms consider Esomeprazole 20-40mg IVP

Page 90 of 192

Sedation / Chemical Restraint

Application: Sedation or chemical restraint of patients

Adult Medical Protocol

AM43

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

ECG

Mild Sedation (i.e. Anxiety) Versed 1-2 mg IV/IN, or Ativan 0.5-2mg IV/IM
Paramedic or RN

Moderate Sedation (Cardioversion, painful procedures, potential harm to self or others) Versed 2-5 mg IV/IN

Chemical Restraint (Potential harm to self or others) IV (Must be administered in separate syringes) Haldol 5mg Versed 2-5 mg and/or Ativan 2mg IM (Must be administered in separate syringes) Haldon 5-10 mg Versed 5mg and/or Ativan 2mg

Page 91 of 192

Excited Delirium
Application: Sedation of combative or violent patients Symptoms: Agitation Aggressive, Threatening, or Combative behavior Amazing feats of strength Pressured, loud, incoherent speech Sweating (or loss of sweating late) Dilated pupils/less reactive to light Rapid breathing Stripping of clothes

Adult Medical Protocol

AM44

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs, include temperature If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG, SaO2, ETCO2

Options Ketamine 1-2 mg/kg IV over 1 minute or 4-5 mg/kg IM Versed 2-5 mg IV/IN and/or Ativan 2mg IV/IM Zofran 4-8 mg IV

Special Considerations May have clinically significant cardiac effect, Use cautiously in patients with significant cardiac history Dose section is elderly patients should be cautious, usually starting at the low end of the dosing range Patient with hepatic or renal insufficiency should receive a half dose Page 92 of 192

Adult Trauma/Surgical Protocols

Protocol
AT01 AT02 AT03 AT04 AT05 AT06 AT07 AT08 AT09 AT10

Description
Traumatic Cardiopulmonary Arrest Multi-System Trauma Head Injury Burns Muscle-Skeletal and Soft Tissue Injury Amputations Eye Injury Insect/Spider Bites Snake Bites Pulmonary Embolism

Page
91 92 93 94 95 96 97 98 99 100

Page 93 of 192

Traumatic Cardiopulmonary Arrest

Adult Trauma Protocol

Adult
Application:

AT01

Pulseless/apneic with underlying multi-system trauma or other surgical problem usually caused by hypoxemia secondary to hypovolemia

Basic EMT

CABCs CPR AED Occlude open chest wounds Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway BVM, KingTube Intubate IV access x 2 Large Bore Consider: Bone Injection Gun, EZ IO If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw

EMT Intermediate

Paramedic or RN

If Incompatible with Life Decision to resuscitate If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol If Tension Pneumothorax Chest Decompression

Page 94 of 192

Multi-System Trauma

Adult Trauma Protocol

Adult
Application:

AT02

Injury to the chest, abdomen, pelvis, or extremities with evidence of significant possible injury or multiple soft tissue or musculoskeletal injuries with evidence of compensated or uncompensated shock

Basic EMT

CABCs Transport Immediately AED Occlude open chest wounds Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw

EMT Intermediate

Paramedic or RN

If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension If Tension Pneumothorax Chest Decompression If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

Page 95 of 192

Head Injury

Adult Trauma Protocol

Adult
Application:

AT03

Injury to the head with altered mental status or loss of consciousness substantial mechanism of injury isolated or in the presence of other injuries with the exception of patients meeting the Multi-System Trauma criteria

Basic EMT

CABCs Transport as soon as practical Oxygen of NRB Vital Signs AED Treat underlying injuries If <10% BSA Cool burns with sterile saline, dress burns, remove loose clothing and jewelry Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube Intubate IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw

EMT Intermediate

Paramedic or RN

If Indicated Surgical Airway ECG Treat any dysthymias per protocol If seizures consider one of the following Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available Solumedrol 30mg/kg IVPB over 10 minutes Evidence of ICP Consider Intubation using the PAI Protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension If Tension Pneumothorax Chest Decompression If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

Page 96 of 192

Burns

Adult Trauma Protocol

Adult
Application:

AT04

Tissue injury form direct contact with heat source or chemical reaction, inhalation, or electrical/lightening contact

Basic EMT

CABCs Transport as soon as practical Oxygen of NRB Vital Signs AED Treat underlying injuries If <10% BSA Cool burns with sterile saline, dress burns, remove loose clothing and jewelry Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw Initiate the Parkland Burn Formula for fluid resuscitation (Burn Area) (Patient Weight in Kg) = ml/hour to administer 4

EMT Intermediate

Paramedic or RN

If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension and inhalation and respiratory burns Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

Page 97 of 192

Muscle-Skeletal/Soft Tissue Injury

Adult Trauma Protocol

Adult
Application:

AT05

Isolated muscular-skeletal/soft tissue injury in the absence of significant head, chest, abdominal, or multi-systems injury with mechanism of injury capable of resulting in a muscular-skeletal injury with pain on palpation or movement and with ecchymosis, swelling, or deformity to the area

Basic EMT

CABCs Control hemorrhage Oxygen of NRB Vital Signs AED Treat underlying injuries Splinting/Immobilize/Chemical Cold Packs Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Move to a more specific protocol If traction, reduction, or realignment of limb pain management must be achieved to be successful Treat pain as per pain management protocol with one of the following and considerations of potential hypotension Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 98 of 192

Amputations

Adult Trauma Protocol

Adult
Application:

AT06

Any part of the body, pathologically or surgically separated from the rest of the body

Basic EMT

CABCs Control hemorrhage Oxygen of NRB Vital Signs AED Treat underlying injuries Splinting/Immobilize/Chemical Cold Packs Secondary Survey Cervical Spinal Restriction if indicated Transport amputated part Amputation should be wrapped in a moist dressing of saline and placed in a plastic back and kept cool with a cold pack or ice. Amputation should not be placed directly on ice or cold pack and should not be submersed in water Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Move to a more specific protocol Treat pain as per pain management protocol with one of the following and considerations of potential hypotension Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 99 of 192

Eye Injuries

Adult Trauma Protocol

Adult
Application:

AT07

Injury to the globe, open or closed, including: Corneal abrasion, foreign body in the eye, chemical burn, lacerated or avulsed globe, ARC burn of the globe

Basic EMT

CABCs Vital Signs If Chemical Burn: Flush continuously with Normal Saline If Open Injury to the Globe: Patch both eyes If Corneal Abrasion, ARC Burn, or Foreign Body: Patch the affected eye

EMT Intermediate

IV access Blood Draw

Paramedic or RN

ECG Treat any dysthymias per protocol Treat pain as per pain management protocol with one of the following and considerations of potential hypotension Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg Consider Antiemetics: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 100 of 192

Insect/Spider Bites

Adult Trauma Protocol

Adult
Application:

AT08

Known or suspected envenomation by a hymenoptera, Brown Recluse spider, or Black Widow spider

Basic EMT

CABCs Oxygen Vital Signs Remove jewelry if bite is on the hand

EMT Intermediate

IV access Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Paramedic or RN

ECG Treat any dysthymias per protocol If allergic reaction: Follow appropriate allergic reaction protocol Benadryl 25mg IM or IV If Seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available Solu-Medrol 125mg SIVP Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 101 of 192

Snake Bites

Adult Trauma Protocol

Adult
Application:

AT09

Known or suspected envenomation by snake with fang marks, swelling, and pain at the site

CABCs Oxygen Vital Signs Remove jewelry if bite is on the hand Wash would with copious amount of soap and water Keep patient supine and treat symptoms Immobilize the limb and keep at the level of the heart

Basic EMT

EMT Intermediate

IV access Blood Draw

Paramedic or RN

ECG Treat any dysthymias per protocol If allergic reaction: Follow appropriate allergic reaction protocol Benadryl 25mg IM or IV If Seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available Solu-Medrol 125mg SIVP Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Consider Pain Management Protocol: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

Page 102 of 192

Pulmonary Embolism

Adult Trauma Protocol

Adult
Application:

AT10

Sudden onset of shortness of breath with mechanism of pulmonary embolism including one of the following: Recent surgery, history of Atrial Fibrillation or CHF, bed confinement, history of thrombophlebitis or DVT, pregnant females, and female patients that are smokers and on oral contraceptive

Basic EMT

CABCs Oxygen by NRB Consider BVM if indicated Vital Signs

EMT Intermediate

IV access Blood Draw

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Move to a more specific protocol

Page 103 of 192

OB/GYN Protocols
Protocol
OB01 OB02 OB03 OB04 OB05 Abdominal Pain Female Labor Childbirth and Delivery Vaginal Bleeding Spontaneous Abortion

Description

Page
102 103 104 105 106

Page 104 of 192

Abdominal Pain-Female

Adult OB Protocol

Adult
Application:

OB01

Any female patient of child-bearing potential complaining of abdominal pain without evidence of labor or trauma

Basic EMT

CABCs Oxygen Vital Signs Blood Glucose Check

EMT Intermediate

IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

Paramedic or RN

ECG Treat any dysthymias per protocol Fetal Heart Tones if suspected pregnancy of > 1st Trimester (Doppler if Available) Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Move to a more specific protocol Consider the following: Incomplete Abortion, PID, Ectopic Pregnancy, Abruptio Placenta, Placenta Previa, Uterine Rupture, Non-Obstetric etiologies, Appendicitis, Renal Calculi Consider Pain Management Protocol: Morphine 2mg IVP may repeat in 2mg increment every 10 minutes to a total dose of 12mg Hydromorphone 0.25mg to 1.0mg IVP may repeat every 30 minutes to a total of 4mg Fentanyl 25mcg to 100 mcg IVP may repeat every 30 minutes to a total of 200 mcg Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours to a total dose of 2.0mg

Page 105 of 192

Labor

Adult OB Protocol

Adult
Application:

OB02

Patient with intra uterine pregnancy of greater than 20 weeks with back or abdominal cramping or pains, which occur periodically

CABCs Oxygen Vital Signs Blood Glucose Check Perineal Exam

Basic EMT

EMT Intermediate

IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

Paramedic or RN

ECG Treat any dysthymias per protocol Fetal Heart Tones if suspected pregnancy of > 1st Trimester (Doppler if Available) Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Move to a more specific protocol Premature Labor of Gestational Age of 18-37 weeks Consider: Terbutaline 0.25 mg SQ when contractions are less than 10 minutes apart Fentanyl 0.5 to 1 mcg/kg may repeat every 60 mins

Page 106 of 192

Childbirth/Delivery

Adult OB Protocol

Adult
Application:

OB03

Patient with intra uterine pregnancy of greater than 20 weeks with back or abdominal cramping or pains, which occur periodically

CABCs Oxygen Vital Signs Blood Glucose Check Perineal Exam

Basic EMT

EMT Intermediate

IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

Paramedic or RN

ECG Treat any dysthymias per protocol Fetal Heart Tones Deliver Infant Post-Delivery Care Clamp and cut umbilical cord Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Deliver placenta If continued postpartum bleeding Consider: Uterine Massage Encourage breast feeding Oxytocin Infusion 20 units in 1 liter of Normal Saline-Infuse at 200ml/hour

Page 107 of 192

Vaginal Bleeding

Adult OB Protocol

Adult
Application:

OB04

Vaginal bleeding that is non-menstrual without labor, history of trauma, or evidence of spontaneous or elective abortion (tissue, ect.)

CABCs Oxygen Vital Signs Blood Glucose Check Perineal Exam

Basic EMT

EMT Intermediate

IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 108 of 192

Spontaneous Abortion

Adult OB Protocol

Adult
Application: Vaginal bleeding that is non-menstrual

OB05

CABCs Oxygen Vital Signs Blood Glucose Check Perineal Exam Place pad at vaginal opening Collect all passed tissue, if possible

Basic EMT

EMT Intermediate

IV access If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw If BG < 80mg/dL administer of D50% 25-50 gram IVP If respiratory compromised: Supportive Airway Management or Intubation

Paramedic or RN

ECG Treat any dysthymias per protocol Fetal Heart Tones Deliver Infant Post-Delivery Care Clamp and cut umbilical cord Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Deliver placenta If continued copious vaginal bleeding: Oxytocin Infusion 20 units in 1 liter of Normal Saline-Infuse at 200ml/hour Evacuate visible clots and tissue from vagina (save all)

Page 109 of 192

Pediatrics Medical Protocols

Protocol
PM01 PM02 PM03 PM04 PM05 PM06 PM07 PM08 PM09 PM10 PM11 PM12 PM13 PM14 PM15 PM16 PM17 PM18 PM19 PM20 PM21 PM22 PM23 PM24 PM25 PM26 PM27 PM28 PM29 PM30 PM31 PM32 PM33 PM34 PM35 PM36 PM37 PM38 PM39

Description
Asystole Pulseless Electrical Activity Pulseless Ventricular Fibrillation Hypothermic Induced Cardiac Arrest Post Resuscitation Management Undifferentiated Tachycardia Unstable Ventricular Tachycardia Stable Ventricular Tachycardia Unstable Ventricular Tachycardia Stable Ventricular Tachycardia Bradycardia Ventricular Ectopy Hypoperfusion Cardiac Ischemia Cardiogenic Shock Respiratory Failure Respiratory Distress Pulmonary Edema Asthma Epiglottitis Croup Bronchiolitis/Pneumonia Airway Obstruction by Foreign Body Allergic Reactions Altered Mental Status Seizures/Status Epilepticus Seizures/Postictal State Overdose Poisoning Hypoglycemia Hyperglycemia/Diabetic Ketoacidosis Dehydration Hypothermia Heat Related Emergencies Heat Stroke Near Drowning Post Delivery Care Sepsis Acute Abdomen-Unknown Etiology

Page
108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146

Page 110 of 192

Asystole Pediatric
Application: Pulseless/apneic in two or more leads

Pediatric Medical Protocol

PM01

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

EMT Intermediate

Basic EMT

Paramedic or RN

ECG (consider Transcutaneous Pacing) Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET Repeat every 3-5 minutes ACLS Guidelines Atropine 0.02 mg/kg IV/IO/ET Minimum single dose of 0.1 mg Maximum single dose of 0.5 mg Maximum total dose of 0.04 mg/kg Sodium bicarbonate 1mEq/kg IV/IO if metabolic acidosis is likely

Page 111 of 192

Pulseless Electrical Activity

Pediatric Medical Protocol

Pediatric
Application:

PM02

Pulseless/apneic in conjunction with any ECG rhythm other than Ventricular Fibrillation, Ventricular Tachycardia, or Asystole

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

EMT Intermediate

Basic EMT

Paramedic or RN

ECG (consider Transcutaneous Pacing) If due to a surgical problem or injury initiate Rapid Transport Procedure If Tension Pneumothorax chest decompression Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET Repeat every 3-5 minutes ACLS Guidelines If Bradycardia, Atropine 0.02 mg/kg IV/IO/ET Minimum single dose of 0.1 mg Maximum single dose of 0.5 mg Maximum total dose of 0.04 mg/kg If evidence of hypovolemia Bolus Infusion of NS 20 ml/kg IV Nasogastric or Oralgastric Tube Insertion Sodium bicarbonate 1mEq/kg IV/IO if metabolic acidosis is likely

Page 112 of 192

Pulseless Ventricular Fibrillation

Pediatric Medical Protocol

Pediatric
Application:

PM03

Pulseless/apneic or pulseless with agonal respirations and Ventricular Fibrillation of Ventricular Tachycardia on the ECG

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

EMT Intermediate

Basic EMT

Paramedic or RN

ECG Defibrillation at the following until conversion Defib 2 j/kg Defib 4 j/kg Defib 4 j/kg Epinephrine 0.1 mg/kg 1:1,000 IV/IO/ET Pediatric Neonate 0.1 mg/kg 1:10,000 IV/IO/ET Defib 4 j/kg Repeat Epinephrine every 3-5 mins followed by defib 4 j/kg each time ACLS Guidelines Check rhythm, resume CPR, Shock if indicated Lidocaine 1.5 mg/kg IV / 3.0 mg ET, Repeat in 5 min as 1.5 mg/kg IV / 3.0 mg ET, defib 4 j/kg after each administration Check rhythm, resume CPR, Shock if indicated Consider: Sodium bicarbonate 1mEq/kg IVP if Hyperkalemia or tricyclic toxicity

Page 113 of 192

Hypothermic Induced Cardiac Arrest

Pediatric Medical Protocol

Pediatric
Application: Pulseless/apneic or pulseless with environmental evidence of hypothermia

PM04

CABC's CPR American Heart Association Guidelines O2 by Bag Valve Mask or King Tube Automated External Defibrillator Blood Glucose Check Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

EMT Intermediate

Basic EMT

Paramedic or RN

ECG ECG If V-Fib Defib 2 j/kg Defib 4 j/kg Defib 4 j/kg ACLS Guidelines Measure Temperature Do Not Attempt defibrillation again if temperature is below 85 degrees F. IF Temperature is 85 degrees or greater appropriate Protocol for Dysthythmia Check rhythm, resume CPR, Shock if indicated Nasogastric or Oral gastric Tube Insertion

Page 114 of 192

Post Resuscitation Management

Pediatric Medical Protocol

Pediatric
Application:

PM05

Patient with spontaneous circulation or respiratory efforts after treatment of a non-perfusing rhythm Basic EMT

CABC's O2 by Bag Valve Mask or King Tube Blood Glucose Check Vital Signs

EMT Intermediate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

Paramedic or RN

ECG If V-Fib or V-Tach Defibrillation converted from defibrillation and patient is not bradycardic Lidocaine 1.0 mg/kg IV/IO (if patient did not previously receive Lidocaine) Lidocaine drip 20-50 mcg/kg/min ACLS Guidelines Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 25-50 mg/kg IV/IO Consider Induced Hypothermia-Use chilled bolus of NS Cooling blanket, Artic Sun, or Ice Pacs to carotid, inguinal, and axilla If Hypotensive after flood bolus Dopamine Infusion 2-20 mcg/kg/min Start infusion at 2mcg/kg/min and continue to increase until systolic is > 90 mmHg Norepinephrine Infusion 0.5 1.0 mcg/min titrate to a max of 30mcg/min for severe refractory hypotension Bradycardia after resuscitation: Refer to Bradycardia Protocol Nasogastric or Oral gastric Tube Insertion Patients intubated that are attempting to dislodge or fighting the ET tube Consider the following for sedatives: Versed IVP or Versed Infusion Benzodiazepine IVP Etomidate IVP or Infusion

Page 115 of 192

Undifferentiated Tachycardia

Pediatric Medical Protocol

Pedi
Application:

PM06

A wide complex Tachycardia with a QRS > 0.12 seconds with a rate heart rate > 190 bpm with uncertain origin with symptoms of impaired perfusion, diaphoresis, chest pain, or shortness of breath without hypotension, altered mental status, or pulmonary edema. Patients with hypotension, hypotension, altered mental status, or pulmonary edema should be managed using either the Unstable SVT or VT Protocol Note: If uncertain, consider the rhythm as undifferentiated. Do not treat specific arrhythmias unless certain Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

Paramedic or RN

ECG Adenosine 0.1 mg/kg IVP followed by a rapid push If ectopy not resolved Adenosine 0.2 mg/kg IVP followed by a rapid push If ectopy still not resolved Adenosine 0.2 mg/kg IVP followed by a rapid push If ectopy still not resolved Amiodarone 5 mg/kg bolus or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min Persistent ventricular ectopy consider one of the following: Magnesium Sulfate 25-50 mg/kg IV/IO If patient becomes unstable Prepare for Cardioversion and use Unstable V-Tach or SVT Protocol Diazepam 0.2-0.3 mg/kg IV for cardioversion if awake, not hypotensive, not respiratory failure

Page 116 of 192

Unstable Ventricular Tachycardia

Pediatric Medical Protocol

Pedi
Application:

PM07

Ventricular Tachycardia on ECG with Hypotension or Pulmonary Edema or Significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

Intubation Secure Tube with Thomas Tube Tamer or equivalent Consider cervical collar for stabilization of the head and to prevent dislodging of the ET tube IV access If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Naloxone if question of opiate overdose

Paramedic or RN

ECG Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion (if patients mental status requires sedation for cardioversion) Prepare for Synchronized Cardioversion Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min If Lidocaine was chosen and persistent ventricular ectopy consider the following: Do Not Use Amiodarone and Procainamide Together Procainamide 15 mg/kg IVPB over 30-60 minutes Additional synchronized cardioversion at 2.0 j/kg Repeat Lidocaine 0.5 mg/kg every 5 mins; alternate with repeat synchronized cardioversion at 2.0 j/kg

Page 117 of 192

Stable Ventricular Tachycardia

Pediatric Medical Protocol

Pediatric
Application:

PM08

Ventricular Tachycardia on ECG with Hypotention without Pulmonary Edema or Significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present

ECG Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min If Lidocaine was chosen and persistent ventricular ectopy consider the following: Do Not Use Amiodarone and Procainamide Together Procainamide 15 mg/kg IVPB over 30-60 minutes Prepare for Synchronized Cardioversion if patient becomes unstable Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg

Paramedic or RN

Page 118 of 192

Unstable Supraventricular Tachycardia

Pediatric Medical Protocol

Pediatric
Application:

PM09

SVT on ECG at rates >190 bpm with profound hypotension and one or more of the following: Severe dyspnea or Pulmonary Edema or significant Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present

ECG Prepare for Synchronized Cardioversion Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg Adenosine 0.1mg/kg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg Consider: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min If Lidocaine was chosen and persistent ventricular ectopy consider the following: Do Not Use Amiodarone and Procainamide Together Procainamide 15 mg/kg IVPB over 30-60 minutes

Paramedic or RN

Page 119 of 192

Stable Supraventricular Tachycardia

Pediatric Medical Protocol

Pediatric
Application:

PM10

SVT on ECG with a rate >190 bpm with evidence of hemodynamic compromise without profound hypotension without severe dyspnea, pulmonary edema, or significant altered mental status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present

Paramedic or RN

ECG Vagal maneuvers Prepare for Synchronized Cardioversion Adenosine 0.1mg/kg IVP followed by a rapid push of 10ml NS If ectopy not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS If ectopy still not resolved Adenosine 0.2mg IVP followed by a rapid push of 10ml NS Maximum Adenosine dosage is 30mg Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to cardioversion Synchronized Cardioversion in energy sequence below until conversion of rhythm Synchronized Cardioversion 0.5 j/kg Synchronized Cardioversion 1.0 j/kg Synchronized Cardioversion 2.0 j/kg If patient becomes unstable move to Protocol PM09

Page 120 of 192

Bradycardia Pediatric
Application:

Pediatric Medical Protocol

PM11

Any underlying cardiac rhythm with a ventricular rate of <60 bpm in a child or <80 bpm in an infant with and one or more of the following: Hypotension or Pulmonary Edema or Dyspnea or Altered Mental Status Basic EMT

CABC's O2 Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present

ECG Epinephrine 0.1mg/kg 1:1000 IV/IO/ET (pediatric) Epinephrine 0.1mg/kg 1:10000 IV/IO/ET (neonate) May repeat every 3-5 minutes Refractor Bradycardia to Epinephrine Atropine 0.02mg/kg IV/IO/ET Minimum single dose 0.1mg Maximum single dose 0.5mg Maximum total dose 0.04mg/kg May repeat every 3-5 minutes Refractory Bradycardia External Cardiac Pacing Consider Diazepam 0.2-0.3 mg/kg IV or Midazolam 0.05-0.2 mg/kg IVP for sedation prior to TCP Epinephrine Infusion 0.1-1.0 mcg/kg/min if refractory to Epinephrine, Atropine, and Pacing For Bradycardia or cardiogenic hypotension refractory to atropine and or pacing Dopamine 2-20 mcg/kg/min IV Infusion

Paramedic or RN

Page 121 of 192

Ventricular Ectopy Pediatric

Application:

Pediatric Medical Protocol

PM12

Premature ventricular complexes occurring whether unifocal or multifocal in origin with 12 or more complexes occurring per minute for more than 3-5 minutes and in the setting of Acute Coronary Syndrome and in the absence of Bradycardia Basic EMT

CABC's O2-High Flow Blood Glucose Check Vital Signs

EMT Intermediate

IV access should be large bore and minimal of 2 cannulations If BG < 80mg/dL administer D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present

ECG and if time permits diagnostic 12 Ld recording Oxygenate Consider one of the following Anti-arrhythmic Medication: Amiodarone 5mg/kg slow IVP over 20-60 minutes or Lidocaine 1.0 mg/kg repeat every 5 minutes as 0.5mg/kg up to 3.0 mg/kg total Ectopy Resolved then: If Amiodarone was administered start Amiodarone Infusion at 1mg/min If Lidocaine was administered Lidocaine Infusion at 2-4 mg/min If Lidocaine was chosen and persistent ventricular ectopy consider the following: Do Not Use Amiodarone and Procainamide Together Procainamide 15 mg/kg IVPB over 30-60 minutes

Paramedic or RN

Page 122 of 192

Shock Pediatric
Application:

Pediatric Medical Protocol

PM13

Significant hypoperfusion such as diminished pulses, prolonged capillary refill, cool, pale, mottled skin

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

Basic EMT

EMT Intermediate

IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present Consider the use of Mechanical Ventilator if intubated Naloxone 0.1mg/kg IV for persistent altered mental status or respiratory depression

Paramedic or RN

ECG Move to a more specific diagnosis and protocol

Page 123 of 192

Cardiac Ischemia Pediatric

Application:

Pediatric Medical Protocol

PM14

Patient with check, back, shoulder, neck, jaw, or other discomfort indicative of myocardial ischemia associated with symptoms indicating myocardial ischemia as in shortness of breath, nausea, or diaphoresis

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

EMT Intermediate

IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP

Paramedic or RN

ECG Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg NTG 0.4mg SL for patients over >40kg Morphine Sulfate 0.1 -0.2mg/kg IV in increments of 0.05mg/kg every 5 minutes with a maximum single dose of 2.0mg Move to more specific Protocol

Page 124 of 192

Cardiogenic Shock Pediatric

Application:

Pediatric Medical Protocol

PM15

Significant hypoperfusion with evidence of myocardial ischemia without evidence of hypovolemia, dehydration, sepsis, or other non-cardiogenic source of hypotension without bradycardia

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

Basic EMT

EMT Intermediate

IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP

Paramedic or RN

ECG Consider fluid bolus of 20ml/kg over 5-10 minutes Refractory to Fluid Dopamine Infusion 5 10 mcg/kg/min start at 5.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until perfusion is present Consider if refractory to Dopamine Epinephrine 0.1-1.0 mcg/kg/min IV Infusion

Page 125 of 192

Respiratory Failure Pediatric

Application:

Pediatric Medical Protocol

PM16

Dyspnea with tachypnea, bradypnea, or accessory muscle use and cyanosis or agitation or obtundation

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider CPAP with PEEP Consider Intubation if hypoxemia present Consider the use of Mechanical Ventilator if intubated Naloxone 0.1mg/kg IV for persistent altered mental status or respiratory depression

Basic EMT

EMT Intermediate

Paramedic or RN

ECG Considers if evidence of pneumothorax Chest Decompression Move to a more specific diagnosis and protocol Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator Consider Nebulization of Epinephine 1:1000 0.5ml + 2.5ml NS Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg

Page 126 of 192

Respiratory Distress Pediatric

Application: Dyspnea with unclear etiology

Pediatric Medical Protocol

PM17

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider Intubation if hypoxemia present Consider CPAP with PEEP Consider the use of Mechanical Ventilator if intubated Naloxone 0.1mg/kg IV for persistent altered mental status or respiratory depression Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator ECG Considers if evidence of pneumothorax Chest Decompression Move to a more specific diagnosis and protocol May repeat if continued evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator Atrovent 2.5 mg by nebulization mask or inline by ventilator If evidence of bronchial constriction consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes Consider Combi Treatment by mixing the Albuterol and Atrovent in one Nebulization Treatment Consider Nebulization of Epinephine 1:1000 0.5ml + 2.5ml NS Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg

Basic EMT

EMT Intermediate

Paramedic or RN

Page 127 of 192

Pulmonary Edema Pediatric

Application:

Pediatric Medical Protocol

PM18

Dyspnea with shortness of breath and auscultated finding of pulmonary edema to include rales, wheezes, or silent breath sounds

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider CPAP with PEEP Consider Intubation if hypoxemia present Consider the use of Mechanical Ventilator if intubated Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator ECG NTG 0.4 mg SL for children over 40kg Furosemide 0.5-1.0 mg/kg IV Maximum single dose of 40mg Morphine Sulfate 0.1mg/kg every 5 minutes to a maximum dose of 0.2mg/kg IV If respiratory rate not depressed in increments of 0.05mg/kg (Maximum single dose of 2mg) May repeat if continued evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator Atrovent 2.5 mg by nebulization mask or inline by ventilator If evidence of bronchial constriction consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes Consider Combi Treatment by mixing the Albuterol and Atrovent in one Nebulization Treatment Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg

Basic EMT

EMT Intermediate

Paramedic or RN

Page 128 of 192

Asthma Pediatric
Application:

Pediatric Medical Protocol

PM19

Shortness of breath and auscultated finding of bronchospasm, wheezing, and or silence with a history of asthma or reactive airway disease

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator May repeat every 10 to 15 minutes Consider Atrovent 2.5 mg by nebulization mask or inline by ventilator May repeat every 10-15 minutes Consider Combi Treatment by mixing Albuterol and Atrovent in one nebulization treatment Consider Intubation if hypoxemia present Consider the use of Mechanical Ventilator if intubated

Basic EMT

EMT Intermediate

Paramedic or RN

ECG Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes Consider Combi Treatment by mixing the Albuterol and Atrovent in one Nebulization Treatment Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg If refractory to Albuterol and Atrovent consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS Status Asthmaticus Mag Sulphate 25mg/kg to a maximum of 2 Gram IV Infusion over 30 minutes

Page 129 of 192

Epiglottitis Pediatric
Application:

Pediatric Medical Protocol

PM20

Dyspnea with evidence of upper airway obstruction which may include inspiratory stridor, drooling, or hoarseness and any one or more of the following: Fever, recent history of Respiratory infection, dysphagia or severe sore throat

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula preferred to be humidified Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG Consider Solu-Medrol 2.0 mg/kg IV Infusion over 10 minutes Consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS If patient condition deteriorates Prepare for Emergency Airway Procedures

Basic EMT

EMT Intermediate

Paramedic or RN

Page 130 of 192

Croup Pediatric
Application:

Pediatric Medical Protocol

PM21

Dyspnea with evidence of upper airway obstruction which may include inspiratory stridor, with recent history of Respiratory infection

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula preferred to be humidified Blood Glucose Check Vital Signs Maintain normothermia If Febril give anti-pyretic and dose to patient weight Tylenol or Ibuprophen If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG If doubt as to whether the patient is suffering from Croup or Epiglottitis treat for Epiglottitis Pediatric Medical Protocol 20 If patient condition deteriorates Prepare for Emergency Airway Procedures

EMT Intermediate

Paramedic or RN

Page 131 of 192

Bronchiolitis/Pneumonia Pediatric
Application:

Pediatric Medical Protocol

PM22

Dyspnea without evidence of upper airway obstruction with evidence of lower airway involvement such as wheezing crackles, forced inhalation, or abnormal chest imaging with evidence of infiltrates or pulmonary effusion or pneumonia accompanied by mucopurulent sputum, fever, and dyspnea

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If Febril give anti-pyretic and dose to patient weight Tylenol or Ibuprophen If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Consider if evidence of bronchial restriction Albuterol 2.5mg by nebulization mask or inline by ventilator May repeat every 10 to 15 minutes Consider Atrovent 2.5 mg by nebulization mask or inline by ventilator May repeat every 10-15 minutes Consider Combi Treatment by mixing Albuterol and Atrovent in one nebulization treatment Consider Intubation if hypoxemia present Consider the use of Mechanical Ventilator if intubated

EMT Intermediate

Paramedic or RN

ECG Consider if evidence of inadequate inhalation for therapy Epinephrine 0.01mg/kg SQ of 1:1000 or Terbutaline 0.25mg SQ for patients over 35kg If refractory to Albuterol and Atrovent consider Nebulization of Epinephrine 1:1000 0.5ml into 2.5ml NS

Page 132 of 192

Airway Obstruction by Foreign Body

Pediatric Medical Protocol

Pediatric
Application:

PM23

Partial of complete airway obstruction secondary to foreign body aspiration with decreased level of consciousness or cyanosis or obvious inadequate air exchange

CABC's Abdominal Thrusts Vital Signs Reassess Airway Continue Abdominal Thrusts until ventilations can be obtained BVM to attempt ventilation Direct Laryngoscopy Attempt to visualize object and remove with Magill forceps Intubate when able IV access Buretrol Consider the use of Mechanical Ventilator if intubated

EMT Intermediate

Basic EMT

Paramedic or RN

If all attempts have failed prepare Emergency Airway Procedures

Page 133 of 192

Allergic Reaction-Mild to Moderate Anaphylaxis with Hypotension

Adult Medical Protocol

Pediatric
Application:

PM24

Mild allergic reaction that involves contact dermatitis and or uticaria and dermal itching without evidence of dyspnea, hypotension, wheezing, or complaint of airway fullness or Moderate allergic reaction that also includes localized or generalized peripheral edema, shortness of breath without hypotension

Basic EMT

CABC's O2 Blood Glucose Check Vital Signs If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.1mg/kg SQ If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization

EMT Intermediate

IV Access Blood Draw If severe Anaphylaxis with airway restriction Epi 1:1,000 0.1mg/kg SQ

Paramedic or RN

ECG Diphenhydramine 1.0mg/kg IVP or Diphenhydramine 1.0mg/kg IM Solumedrol 2-3mg/kg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes Terbutaline 0.25mg SQ if refractory to Epinephrine patients over 35kg ECG Epinephrine 1:10,000 0.5 mg IVP or 0.5mg SL Injection Diphenhydramine 25mg IVP or Diphenhydramine 25mg IM Solumedrol 125 250mg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization Terbutaline 0.25mg SQ if refractory to Epinephrine patients over 35kg Consider Intubation Consider Pharmacologically Assisted Intubation
Page 134 of 192

Anaphylaxis with Hypotension

Altered Mental Status Pediatric

Application: Unresponsive or disoriented without a clear etiology for altered mental status

Pediatric Medical Protocol

PM25

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula preferred to be humidified Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose ECG Move to a more specific protocol when appropriate

Basic EMT

EMT Intermediate

Paramedic or RN

Page 135 of 192

Seizures/Status Epilepticus Pediatric

Application: Actively seizing patient

Pediatric Medical Protocol

PM26

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febrile administer antipyretic if able to control airway Tylenol or Ibuprophen with dosing for patients weight If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose ECG Consider one of the following: (Airway control measures should be available) Diazepam 0.2-0.3 mg/kg IVP or 0.4-0.6 mg/kg per rectum if IV unobtainable Midazolam 0.05-0.2 mg/kg IVP Ativan 0.05-0.1 mg/kg IVP For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg/kg IVP administer at a rate of 100mg per minute (if available)

EMT Intermediate

Paramedic or RN

Page 136 of 192

Seizures/Postictal State Pediatric

Application:

Pediatric Medical Protocol

PM27

Witnessed seizing patient with evidence of altered mental status, confusion, or obtundation

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febrile administer antipyretic if able to control airway Tylenol or Ibuprophen with dosing for patients weight If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose ECG Nasal Gastric or Oral Gastric Tube if prolonged BVM ventilations If Seizures reappear: Consider one of the following: (Airway control measures should be available) Diazepam 0.2-0.3 mg/kg IVP or 0.4-0.6 mg/kg per rectum if IV unobtainable Midazolam 0.05-0.2 mg/kg IVP Ativan 0.05-0.1 mg/kg IVP For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg/kg IVP administer at a rate of 100mg per minute (if available)

EMT Intermediate

Paramedic or RN

Page 137 of 192

Overdose Pediatric
Application:

Pediatric Medical Protocol

PM28

Known or suspected ingestion of a pharmaco-active substance, whether intentional or accidental

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Transport as soon as practical If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose ECG Consult with Poison Control for antidotes, suggested treatments, and possible symptoms Nasal Gastric or Oral Gastric Tube with lavage of sterile water Activated Charcoal 1gr/kg PO or through Gastric Tube after confirmation of placement If TCA overdose with significant CNS or Cardiovascular compromise Sodium Bicarbonate 1.0 mEq/kg IV over 5-10 minutes Treat symptoms as they arise by changing to corresponding protocol

Basic EMT

EMT Intermediate

Paramedic or RN

Page 138 of 192

Poisoning Pediatric
Application:

Pediatric Medical Protocol

PM29

Known or suspected ingestion, inhalation, or absorption of a potential harmful nonpharmaceutical substance, whether intentional or accidental

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Inhalation move from area NOW Blood Glucose Check Vital Signs Transport as soon as practical If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. Consult with Poison Control for antidotes, suggested treatments, and possible symptoms IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP Naloxone 0.1mg/kg IVP to a maximum single dose of 2.0mg May repeat every 10-15 minutes if patient responds to initial dose ECG Nasal Gastric or Oral Gastric Tube with lavage of sterile water if ingestion Activated Charcoal 1gr/kg PO or through Gastric Tube after confirmation of placement If evidence of metabolic acidosis Sodium Bicarbonate 1.0 mEq/kg IV over 5-10 minutes If evidence of organophosphate poisoning with parasympathetic response Atropine 0.02mg/kg IVP repeat ever 3-5 minutes as needed Treat symptoms as they arise by changing to corresponding protocol

EMT Intermediate

Basic EMT

Paramedic or RN

Page 139 of 192

Hypoglycemia Pediatric
Application:

Pediatric Medical Protocol

PM30

Blood Glucose analysis of less than 80mg/dL or less than 40mg/dL in newborn infants with altered mental status or signs and symptoms of hypoglycemia which may include tremors, weakness, nausea, and intense hunger

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If BG <80 mg/dL (40mg/dL in infants < 1 month old) Oral Glucose 5-15 Grams PO if patient can protect their own airway with intact gag reflex If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG If no IV access initiated Glucagon 0.5mg IM if less than 20kg or 1.0mg IM if patient is more than 20kg Initiate D5W IV infusion at a rate of 3-10ml/kg/hr

EMT Intermediate

Paramedic or RN

Page 140 of 192

Hyperglycemia/DKA Pediatric
Application:

Pediatric Medical Protocol

PM31

Blood Glucose analysis greater than 180mg/dL and one or more of the following: Altered mental status, abdominal pain, nausea, weakness, tachypnea, hypotension, tachycardia with or without evidence of metabolic acidosis

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If BG >180 mg/dL use this protocol If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol 5-10ml/kg/hr of NS Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes

Basic EMT

EMT Intermediate

Paramedic or RN

ECG Sodium Bicarbonate 1.0 mEq/kg IV if profound acidosis present

Page 141 of 192

Dehydration Pediatric
Application:

Pediatric Medical Protocol

PM32

Compensated or uncompensated hypovolemia or other signs and symptoms of dehydration including any one of the following: Poor skin turgor, little to no urine output, dry mucous membranes, depressed fontanels, absence of tearing with evidence of the following: vomiting or diarrhea, fever, diminished oral intake

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If febrile administer antipyretic Tylenol or Ibuprophen dosage to patient weight If BG <80 mg/dL (40mg/dL in infants < 1 month old) Oral Glucose 5-15 Grams PO if patient can protect their own airway with intact gag reflex If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol IV fluid challenge of NS or LRS at 20ml/kg may repeat every 10-15 minutes if still symptomatic Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG

EMT Intermediate

Paramedic or RN

Page 142 of 192

Hypothermia Pediatric
Application:

Pediatric Medical Protocol

PM33

Temperature of 90 degrees of less and altered mental status or uncoordinated physical activity

Basic EMT

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs IF respiration less than 14/min use BVM to assist at a rate of 20/30 breaths per minute External Warming If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Warmed IV fluid of NS or LRS at 10ml/kg Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG Sodium Biacarbonate 1mEq/kg IV is metabolic acidosis likely Other medications and treatments based on temperature and cardiac dysthymias

EMT Intermediate

Paramedic or RN

Page 143 of 192

Heat Cramps/Heat Exhaustion

Pediatric Medical Protocol

Pediatric
Application:

PM34

Environmental evidence of hyperthermia and cramps in extremities without heat exhaustion signs or symptoms or profuse sweating, tachycardia, and normal temperature or 1-2 degree elevation in normal temperature

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If BG <80 mg/dL (40mg/dL in infants < 1 month old) Oral Glucose 5-15gr PO if not nauseated External cooling If not nauseated and available Commercial electrolyte solution 250ml to 500ml slow PO If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg

Basic EMT

EMT Intermediate

Paramedic or RN

Page 144 of 192

Heat Stroke

Pediatric Medical Protocol

Pediatric
Application: Temperature of at least 105 degrees and altered mental status or seizures

PM35

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs External cooling If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol IV fluid of NS or LRS at 20ml/kg IV Bolus Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP ECG Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg If active seizures or shivering: Diazepam 0.2 -0.3 mg/kg IV may repeat every 5 minutes to 1mg/kg

Basic EMT

EMT Intermediate

Paramedic or RN

Page 145 of 192

Near Drowning

Pediatric Medical Protocol

Pediatric
Application:

PM36

Water submersion without cardiopulmonary arrest and without evidence of hypothermia

CABC's Remove from water O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs External warming if required, remove wet clothing If respiratory compromised BVM If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access Buretrol IV fluid of NS Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP If respiratory compromised Intubate ECG Treat dysrhythmias as per specific protocol If unconscious NG Tube Insertion

Basic EMT

EMT Intermediate

Paramedic or RN

Page 146 of 192

Post Delivery Care

Pediatric Medical Protocol

Pediatric
Application: Care and resuscitation of the newborn infant

PM37

CABC's Dry, warm, position, suction, stimulate APGAR assessment and scoring O2 by NRB preferred if patient will tolerate or Nasal Cannula If respiratory compromised BVM Vital Signs If Heart Rate less than 60: Chest compressions If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. If indicated IV access Buretrol IV fluid of NS If indicated Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP If respiratory compromised Intubate ECG Treat dysrhythmias as per specific protocol If HR <60, Epinephrine 0.1mg/kg :10000 IV/IO/ET every 3-5 minutes If persistent obtundation, Naloxone 0.1mg/kg IV/IO/ET repeat every 2-3 minutes if initial dose has a positive response to a maximum of single dose of 2.0mg For persistent Bradycardia, Atropine 0.02 mg/kg IV with minimum single dose of 0.1mg and maximum single dose of 0.5mg to a total dose of 0.04mg/kg Repeat Dextrose if continued evidence of hypoglycemia If evidence of metabolic acidosis Sodium Bicarbonate, 1mEq/kg of 4.2% solution IV

Basic EMT

EMT Intermediate

Paramedic or RN

Page 147 of 192

Sepsis Pediatric
Application: Significant hypoperfusion with evidence of systemic infection and fever

Pediatric Medical Protocol

PM38

CABC's O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs Maintain normothermia If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility.

Basic EMT

EMT Intermediate

IV access Buretrol NS at 20ml/kg (10ml/kg in the neonate) may repeat every 5-10 minutes if symtomatic Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff and Cardiac Enzymes If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP

Paramedic or RN

ECG Consider fluid bolus of 20ml/kg over 5-10 minutes Refractory to Fluid Epinephrine 0.1-1.0 mcg/kg/min IV Infusion Consider if refractory to Epinephrine Infusion Dopamine Infusion 5 10 mcg/kg/min start at 5.0 mcg/kg/min with increment of 2.0 mcg/kg/min every 5 minutes until perfusion is present

Page 148 of 192

Acute Abdomen Etiology Unclear

Pediatric Medical Protocol

Pediatric
Application:

PM39

Non Traumatic abdominal pain without a clear etiology except female patients of childbearing age.

Basic EMT

CABCs O2 by NRB preferred if patient will tolerate or Nasal Cannula Blood Glucose Check Vital Signs If available- Recording of 12 Ld ECG to give to receiving facility EMT Basic and Intermediate may perform a 12 Ld ECG but may not interpret or treat any patient from the ECG. The recording is only to be used for the receiving facility. IV access with TKO rate unless evidence of Hypovolemia Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff If BG <80 mg/dL (40mg/dL in infants < 1 month old) D50% 1-2ml/kg slow IVP, or D25% 2-4 ml/kg slow IVP If respiratory compromised: Supportive Airway Management or Intubation

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg Move to a more specific Protocol

Page 149 of 192

Pediatrics Trauma Protocols

Protocol
PT01 PT02 PT03 PT04 PT05 PT06 PT07 PT08 PT09

Description
Traumatic Cardiopulmonary Arrest Multi-System Trauma Head Injury Burns Muscular-Skeletal and Soft Tissue Injury Amputations Eye Injuries Insect/Spider Bites Snake Bites

Page
148 149 150 151 152 153 154 155 156

Page 150 of 192

Traumatic Cardiopulmonary Arrest

Pediatric Trauma Protocol

Pediatric
Application:

PT01

Pulseless/apneic with underlying multi-system trauma or other surgical problem usually caused by hypoxemia secondary to hypovolemia

Basic EMT

CABCs CPR AED Occlude open chest wounds Primary Scene Assessment and Primary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway BVM Intubate IV access x 2 Large Bore Consider: Bone Injection Gun, EZ IO If hypovolemic NS or LR 20-30ml/kg bolus Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff Nasogastric or Oral Gastric Tube placement

EMT Intermediate

Paramedic or RN

If Incompatible with Life Decision to resuscitate If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol If Tension Pneumothorax Chest Decompression

Page 151 of 192

Multi-System Trauma

Pediatric Trauma Protocol

Pediatric
Application:

PT02

Injury to the chest, abdomen, pelvis, or extremities with evidence of significant possible injury or multiple soft tissue or musculoskeletal injuries with evidence of compensated or uncompensated shock

Basic EMT

CABCs Transport Immediately AED Occlude open chest wounds Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

EMT Intermediate

Paramedic or RN

If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension If Tension Pneumothorax Chest Decompression If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

Page 152 of 192

Head Injury

Pediatric Trauma Protocol

Pediatric
Application:

PT03

Injury to the head with altered mental status or loss of consciousness substantial mechanism of injury isolated or in the presence of other injuries with the exception of patients meeting the Multi-System Trauma criteria

CABCs Transport as soon as practical Oxygen of NRB Vital Signs AED Treat underlying injuries Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM Intubate IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff If Indicated Surgical Airway ECG Treat any dysthymias per protocol Consider one of the following: (Airway control measures should be available) Diazepam 0.2-0.3 mg/kg IVP or 0.4-0.6 mg/kg per rectum if IV unobtainable Midazolam 0.05-0.2 mg/kg IVP Ativan 0.05-0.1 mg/kg IVP For seizures refractory to Benzodiazepines consider: Phenytoin 15-20mg/kg IVP administer at a rate of 100mg per minute (if available) Evidence of ICP Consider Intubation using the PAI Protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension If Tension Pneumothorax Chest Decompression If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

Basic EMT

EMT Intermediate

Paramedic or RN

Page 153 of 192

Burns

Pediatric Trauma Protocol

Pediatric
Application:

PT04

Tissue injury form direct contact with heat source or chemical reaction, inhalation, or electrical/lightening contact

Basic EMT

CABCs Transport as soon as practical Oxygen of NRB Vital Signs AED Treat underlying injuries If <10% BSA Cool burns with sterile saline, dress burns, remove loose clothing and jewelry Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM or KingTube

Rule of Nines for determining BSA

EMT Intermediate

Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw Initiate the Parkland Burn Formula for fluid resuscitation (Burn Area) (Patient Weight in Kg) = ml/hour to administer 4 If Indicated Surgical Airway ECG Treat any dysthymias per protocol Move to a more specific protocol Treat pain as per pain management protocol with considerations of hypotension and inhalation and respiratory burns Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours

Paramedic or RN

Page 154 of 192

Muscular-Skeletal and Soft Tissue Injury

Pediatric Trauma Protocol

Pediatric
Application:

PT05

Isolated muscular-skeletal or soft tissue injury in the absence of significant head, chest, abdominal, or multi-systems injury or mechanism of injury capable of resulting in a muscularskeletal injury and pain on palpation or movement with ecchymosis, swelling, or deformity to area in question

CABCs Oxygen delivery Control hemorrhage Oxygen delivery Vital signs Splint and immobilize Secondary Survey Cervical Spinal Restriction Oral Airway or Nasal Airway if indicated Consider BVM Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Basic EMT

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Treat pain as per pain management protocol with considerations of hypotension Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg Consider Fracture reduction if distal circulation compromised If Tension Pneumothorax Chest Decompression If Hypotensive and evidence of exsanguination consider after Fluid Bolus: Hespan 20ml/kg/hr (1.2G/kg/hr)

Page 155 of 192

Amputations

Pediatric Trauma Protocol

Pediatric
Application:

PT06

Any part of the body, pathologically or surgically separated from the rest of the body

Basic EMT

CABCs Control hemorrhage Oxygen of NRB Vital Signs AED Treat underlying injuries Splinting/Immobilize/Chemical Cold Packs Secondary Survey Cervical Spinal Restriction if indicated Transport amputated part Amputation should be wrapped in a moist dressing of saline and placed in a plastic back and kept cool with a cold pack or ice. Amputation should not be placed directly on ice or cold pack and should not be submersed in water Intubate if indicated IV access x 2 Large Bore If hypovolemic NS or LR 20-30ml/kg bolus to maintain systolic of 90mm/Hg Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

EMT Intermediate

Paramedic or RN

ECG Treat any dysthymias per protocol Treat pain as per pain management protocol with considerations of hypotension Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg

Page 156 of 192

Eye Injuries

Pediatric Trauma Protocol

Pediatric
Application:

PT07

Injury to the globe, open or closed, including: Corneal abrasion, foreign body in the eye, chemical burn, lacerated or avulsed globe, ARC burn of the globe

Basic EMT

CABCs Vital Signs If Chemical Burn: Flush continuously with Normal Saline If Open Injury to the Globe: Patch both eyes If Corneal Abrasion, ARC Burn, or Foreign Body: Patch the affected eye

EMT Intermediate

IV access Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Paramedic or RN

ECG Treat any dysthymias per protocol Treat pain as per pain management protocol with considerations of hypotension Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours Consider Antiemetic: Promethazine 0.5mg/kg IVP max dose of 12.5mg Zofran 0.1-0.15mg/kg IVP max dose of 4mg

Page 157 of 192

Insect/Spider Bites

Pediatric Trauma Protocol

Pediatric
Application:

PT08

Known or suspected envenomation by a hymenoptera, Brown Recluse spider, or Black Widow spider

Basic EMT

CABC's O2 Blood Glucose Check Vital Signs Remove jewelry if on the hand or feet If severe Anaphylaxis with airway restriction EpiPen 1:1,000 0.1mg/kg SQ If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization

EMT Intermediate

IV access Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Paramedic or RN

ECG Treat any dysthymias per protocol ECG Diphenhydramine 1.0mg/kg IVP or Diphenhydramine 1.0mg/kg IM Solumedrol 2-3mg/kg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes If seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP

Page 158 of 192

Snake Bites

Pediatric Trauma Protocol

Pediatric
Application:

PT09

Known or suspected envenomation by snake with fang marks, swelling, and pain at the site

CABCs Oxygen Vital Signs Remove jewelry if bite is on the hand Wash would with copious amount of soap and water Keep patient supine and treat symptoms Immobilize the limb and keep at the level of the heart

Basic EMT

EMT Intermediate

IV access Blood Draw-Label appropriately and insure you have the accurate draw time recorded Red or Green Top-Chemistry Blue Top- PT/PTT and Sed Rates Lavender Top- CBC with Diff

Paramedic or RN

ECG Treat any dysthymias per protocol Diphenhydramine 1.0mg/kg IVP or Diphenhydramine 1.0mg/kg IM Solumedrol 2-3mg/kg IVP over 30 seconds If wheezing/shortness of breath consider Albuterol 2.5mg via Nebulization Epinephrine 1:1000 0.5ml mixed in 2.5ml NS via Nebulization Consider if allergic reaction is moderate to severe without hypotension: Epinephrine 1:1000 0.1mg/mg SQ may repeat one time after 5 minutes If seizures consider one of the following: Diazepam 2-10 mg SIVP Ativan 1-2 mg SIVP Versed 5-10 mg SIVP Phenytoin 1 gram over 20 minutes if available Consider Antiemetic: Promethazine 12.5 25mg IVP Zofran 4-8mg IVP Treat pain as per pain management protocol with considerations of hypotension Morphine 0.05-0.25 mg/kg IVP may repeat in 30 minutes Fentanyl 2.0mcg to 3.0mcg/kg IVP may repeat every 30 minutes Demoral 0.5 to 1.0 mg/kg IVP may repeat every 4-6 hours

Page 159 of 192

Procedures
Protocol
PR01 PR02 PR03 PR04 PR05 PR06 PR07 PR08 PR09 PR10 PR11 PR12 PR13 PR14 PR15 PR16 PR17

Description
Electrocardiogram Esophageal Obturation Airways External Cardiac Pacing Defibrillation Zoll Cardiac Monitors Defibrillation Welsh Allen Monitors External/Internal Jugular Cannulation Injection Locks Intraosseous Cannulation EZ/IO Bone Drill and B.I.G. Intravenous Cannulation Nasogastric Tube Insertion Nasotracheal Intubation Nebulized Brochodilation Needle Chest Decompression Oral Tracheal Intubation Positive End Expiratory Pressure Surgical Airway Vagal Stimulation

Page
158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174

Page 160 of 192

Electrocardiogram
Criteria:

Procedural Protocol

PR01

Any patient in whom other ALS interventions are perform, Any patient who complains of: possible myocardial ischemia symptoms (chest pain, etc.) shortness of breath syncope or dizziness nausea or vomiting Any patient who displays: Tachycardia Hypotension Altered mental status Convulsion or syncope, including prior to EMS arrival Multilead ECG MUST be obtained on stable patients (as defined in the VT and SVT protocols) in rhythms thought to be VT or SVT. It should also be obtained on all patients presenting with signs or symptoms of myocardial ischemia or those with any other cardiac dysrhythmia. 12 lead ECG MUST (if available) be obtained on patients with signs or symptoms suspicious of cardiac ischemia or infarct. "Stable" cardiac ischemia patients are defined as patients in whom the 12 lead ECG will not result in a delay (that might adversely affect the patient's outcome) in the provision of other urgent or definitive therapies. Any other patient at the paramedic's discretion Contraindications: None Treatment: Obtaining and interpreting ECG include Multilead and 12 lead if available. Equipment: ECG monitor Patient cables (electrodes) Monitoring electrode patches Procedure: FOR STANDARD ECG MONITORING 1. Turn on monitor and attach patient cables to monitor as per manufacturer's instructions. 2. Apply electrode patches to patient. If at all possible, apply to clean, dry skin. Electrode patches are to be placed as follows: a. Right arm in the mid-humerus area, either anteriorly or laterally (or distal right clavicle area). b. Left arm in the mid-humerus area, either anteriorly or laterally (or distal left clavicle area). c. Left leg, anywhere between the hip and the lower calf, laterally (or left chest, midaxillary, below the 12th rib). 3. Attach the patient cables to the electrode patches. 4. Select the desired lead (I, II, or III). 5. Record a strip of the ECG of at least 12 seconds duration. Record any changes in rhythm or any significant chances in rate. Record "pre" and "post" ECG strips before and after any intervention that will affect the cardiac rhythm or rate (meds, electrical therapy, etc.). 6. If using a machine with a memory function, be sure to record or otherwise store the summary or memory of the patient contact prior to disabling the function. FOR MULTILEAD ECG 1. Prepare the monitor and cables as above. 2. Place 5 electrode patches on patient: a-c as above d. on the right sternal border in the 4th intercostal space e. on the left mid-axillary line on the 6th rib. 1. Attach the patient cables to the right arm (RA), left arm (LA), and left leg (LL) patches as usual. 4. 5. 6. 7. Evaluate and record the ECG in Leads I, II, and III as above. Move the "LL" cable wire to the anterior chest patch. Position the monitor lead selector to "Lead III". This is now modified chest lead 1 (MCL1). Evaluate and record the ECG in MCL1. Move the "LL" cable wire to the mid-axillary patch. Leave the monitor on "Lead III". This is now modified chest lead 6 (MCL6). Evaluate and record the ECG in MCL6. 8. To return to Leads 1, 11, or 111, move the "LL" cable wire back to the LL patch. 9. The ECG may be monitored continuously in any of the 5 leads as the paramedic chooses. 10. If using a machine with a memory function, be sure to record or otherwise store the summary or memory of the patient contact prior to disabling the function.

Page 161 of 192

Esophageal Obturation Protocol PR02 Airway

Criteria: Unconscious, adult in whom endotracheal intubation cannot be immediately obtained. Contraindications: Age less than 16 years. Height less than 5' or greater than 6'7". Esophageal disease or injury Cirrhosis of the liver or alcoholism Ingestion of caustic substance Treatment: Intubation and obturation of the esophagus with an EOA or EGTA Equipment: Procedure: 1. 2. 3. 4. 5. 6. 7.

Procedural

Esophageal airway (EOA or EGTA). 35 ml syringe. BVM, complete. Water soluble lubricant. Suction equipment. Stethoscope. Oxygen.

Provide or maintain airway and oxygenation with basic methods. Prepare and assemble equipment. Hyperventilate/pre-oxygenate patient for 30 seconds. Remove mask and oral airway. Ensure that patient's head is in a neutral position. Open the patient's mouth by grasping tongue and lower jaw and lifting upward. Insert the tube into the oropharynx and advance the tube gently until the mask seats against the patient's face. If resistance is encountered, withdraw slightly, emphasize the jaw lift, and advance again. 8. Seal the mask against the patient's face and attach BVM. 9. Auscultate for breath sounds while ventilating patient with the BVM. Listen over the epigastrium first, then over all four quadrants of the anterior chest. If air is heard in the epigastrium and/or not heard in the lungs, remove the airway and reattempt intubation after 30 seconds to a minute of pre-oxygenation. 10. Once placement is confirmed, inflate bulb with syringe. 11. Reassess placement after inflating bulb, and frequently thereafter.

Page 162 of 192

External Cardiac Pacing

Procedural Protocol

PR03

Criteria: Bradycardic, asystolic and agonal dysrhythmias that do not respond to drug therapy, and that result in insufficient perfusion as evidenced by the symptoms of shock, hypotension or decreased level of consciousness. Treatment: Initiation of external pacing Equipment: Cardiac monitor/defibrillator with pacing capability ECG monitoring supplies and equipment Pacing pads, 1 set Pacing lead wires, 1 set Small scissors or razor Procedure:
1. Apply anterior adhesive electrode on left side of sternum. If possible place pads on clean dry skin. If necessary, shave or trim hair. 2. Place posterior electrode just below left scapula. NOTE: Anterior/Anterior placement of electrodes may be used if the anterior/posterior is not feasible. 3. Attach the lead wires to the electrodes as prescribed by the manufacturer. 4. Turn pacer on. DO NOT start current flow yet. 5. Set pacer rate at 80 bpm. 6. Start pacer current. 7. Increase milliamp setting by 20's until a capture is obtained or up to the maximum energy available from the device. NOTE: Electrical capture is usually evident by a wide QRS and tall, broad T-waves. In some patients it may be less obvious, noted only by a change in QRS morphology. Mechanical capture may be evident by a palpable pulse, rise in blood pressure, improved level of consciousness, and improved skin color/temperature. 8. Once electrical capture is obtained begin decreasing Ma by 5's until capture is lost. 9. Then increase Ma by 5's until electrical capture is regained. This will be the electrical or stimulation threshold (the minimum level of electrical energy needed to consistently depolarize the heart muscle). 10. Check for a pulse to determine the presence of mechanical capture. 11. If there is electrical capture but not mechanical capture, increase the rate only, up to a maximum of 120. DO NOT increase the energy (if electrical capture is achieved). 12. If no response is obtained from maximum pacing output at a rate from 80 - 120, interrupt pacing and continue with the appropriate cardiac protocol. Intermittently check for possible capture using maximum pacer setting. 13. If mechanical capture is obtained, interrupt pacing every 2-3 minutes to check for return of spontaneous pulse for 5-10 seconds. 14. Documentation: a) Date and time pacing initiated b) Baseline and pacing rhythm strips c) Current required obtaining capture d) Pacing rate e) Evaluation of patients response to pacing, in terms of electrical and/or mechanical response if applicable f) Date and time pacing terminated.

Page 163 of 192

Defibrillation Zoll Monitors

Criteria: Pulseless/apneic patient V-fib or V-Tach on ECG Contraindications: Dysrhythmias other than VF or VT Treatment: External defibrillation in VF and pulseless VT Equipment: ECG monitor/defibrillator Defibrillation pads or gel ECG electrodes ECG monitor leads

Procedural Protocol

PR04

Procedure: 1. IF patient is unconscious, immediately determine airway, breathing, and circulatory status using "CABC" procedure. 2. IF patient is pulseless, immediately determine ECG rhythm. Initiate CPR if there is any delay in determining rhythm. 3. IF ECG reveals VF or VT, ready paddles for use with conductive medium. 4. Charge defibrillator to 120 j. 5. Place paddles against chest in correct positions. Use 20 pounds of pressure. 6. Stop CPR. Clear all other responders from patient contact. 7. Visually re-confirm rhythm as VF or VT 8. IF still VF or VT, defibrillate at 150 j. 9. Leave paddles against chest in correct positions. 10. Charge device to 200 j. 11. Visually reconfirm rhythm as VF or VT. 12. Clear all other responders from patient contact. 13. IF still VF or VT, defibrillate at 200 j. 14. Leave paddles against chest in correct positions. 15. Charge device to 200 j. 16. Clear all other responders from patient contact. 17. Visually re-confirm rhythm as VF or VT. 18. IF still VF or VT, defibrillate at 200 j. 19. Check pulse. 20. IF still pulseless, continue CPR. 21. Continue ALS therapies as directed in "Ventricular Fibrillation" Protocol. 22. If patient's rhythm should change at any point, move to the appropriate ALS protocol. 23. If patient should develop a spontaneous pulse, move to the "Post Resuscitation Management" Protocol.

Page 164 of 192

Defibrillation Welsh Allen Monitors

Criteria: Pulseless/apneic patient V-fib or V-Tach on ECG Contraindications: Dysrhythmias other than VF or VT Treatment: External defibrillation in VF and pulseless VT Equipment: ECG monitor/defibrillator Defibrillation pads or gel ECG electrodes ECG monitor leads

Procedural Protocol

PR05

Procedure: 1. IF patient is unconscious, immediately determine airway, breathing, and circulatory status using "CABC" procedure. 2. IF patient is pulseless, immediately determine ECG rhythm. Initiate CPR if there is any delay in determining rhythm. 3. IF ECG reveals VF or VT, ready paddles for use with conductive medium. 4. Charge defibrillator to 120 j. 6. Place paddles against chest in correct positions. Use 20 pounds of pressure. 6. Stop CPR. Clear all other responders from patient contact. 7. Visually re-confirm rhythm as VF or VT 8. IF still VF or VT, defibrillate at 150 j. 10. Leave paddles against chest in correct positions. 11. Charge device to 200 j. 11. Visually reconfirm rhythm as VF or VT. 12. Clear all other responders from patient contact. 13. IF still VF or VT, defibrillate at 200 j. 14. Leave paddles against chest in correct positions. 15. Charge device to 200 j. 16. Clear all other responders from patient contact. 17. Visually re-confirm rhythm as VF or VT. 18. IF still VF or VT, defibrillate at 200 j. 19. Check pulse. 20. IF still pulseless, continue CPR. 21. Continue ALS therapies as directed in "Ventricular Fibrillation" Protocol. 22. If patient's rhythm should change at any point, move to the appropriate ALS protocol. 23. If patient should develop a spontaneous pulse, move to the "Post Resuscitation Management" Protocol.

Page 165 of 192

External/Internal Jugular Cannulation

Procedural Protocol

PR06

Criteria: As initial, primary venous access or secondary access in any critical patient unconscious or otherwise at risks for imminent death or in any urgent patient in whom access cannot be obtained in 3 attempts at other peripheral sites. A Paramedic or Intermediate may only do EJ cannulation under the direct supervision and authorization of the Paramedic attendant. Contraindications: This procedure is contraindicated in anti-coagulated patients or Carotid Atherosclerotic patients. NOTE: DO NOT compromise c-spine while establishing EJ or IJ IV cannulation. Treatment: Establishment of external jugular IV Equipment: IV catheter (over-the-needle type) of appropriate gauge Alcohol /Iodine preps 4x4's Band-Aid and tape or commercial securing device ("Venigaurd", "Opsite", etc.) IV fluid of desired type Volume administration set (60 gtt/ml or 10-12 gtts/ml) as indicated Extension set. 10 cc syringe IF DRAWING BLOOD: 10 cc syringe Blood Collection Tubes Syringe needle, 18 ga. Procedure: 1. Select and prepare equipment. Attach 10 cc syringe to hub of catheter/needle to assist in identification of placement in patients with low or no cardiac output. 2. Select IV fluid. Check for expiration date and visually examine for contamination. 3. Connect administration set and extension set. 4. Clear air from IV tubing. Don appropriate personal protective (infection control) items 5. Identify external jugular vein. 6. Prepare site with alcohol or povidone/iodine. 7. Stabilize vein at site with distal (or cephalad) pressure. 8. Direct needlepoint caudally (toward chest). Pierce skin just lateral to vein. 9. Advance needle/catheter until needle enters lumen of vein (recognized by change in resistance and return of blood into catheter hub). In-patients with low or no cardiac output, it might be necessary to aspirate for blood with the syringe to confirm entry into the lumen. 10. Once the needle has entered the lumen, advance the catheter/needle assembly very slightly farther into the lumen. This ensures that the catheter has entered the vessel. 11. Stop advancing the needle. Advance the catheter off the needle and into the vein. 12. Withdraw needle from catheter. If needed, gentle pressure may be applied proximal to catheter to stop bleeding from catheter. 13. IF drawing blood, gently draw required volume. Avoid hemolysis. 14. Attach IV tubing, to catheter hub. 15. IF blood drawn, attach needle to syringe and insert into clot tube. Allow tube to draw blood from syringe. DO NOT push blood into tube. 16. Open IV to wide open briefly, and check for good flow and lack of extravasation. 17. If IV patent, secure catheter/tubing with tape/Band-Aid or commercial device. 18. Set IV flow to desired rate. 19. Properly dispose of contaminated equipment/supplies.

Page 166 of 192

Injection Locks

Procedural Protocol

PR07

Criteria: Injection locks may be used to secure venous access in any patient in whom: 1. The EMS personnel do not anticipate the immediate need for administering IV medications or IV fluid to in the pre-hospital setting. 2. The EMS crew has already secured a patent IV line for medications or fluid and simply desires a second IV site for "backup". 3. The patient will be receiving, Adenocard. In this situation, the EMS personnel must also establish a second IV, with large bore catheter, of NS. Contraindications: None Treatment: Establishment of IV access with an injection lock. Placement of secondary access with an injection lock. Equipment: Angiocaths of the appropriate gauge Alcohol preps. Injection lock (catheter cap). 3 cc syringe Sterile normal saline, 2 cc. Tape and Band-Aid or commercial securing device ("Venigaurd", "Opsite", etc.) Procedure: 1. Assemble and prepare equipment. Don appropriate personal protective (infection control) items. 2. Select, prepare for, and establish IV with angiocath in usual manner. 3. Once stylet is removed, attach injection lock to IV catheter. 4. Flush lock and catheter with 1-2 cc of normal saline. 5. If patent, secure IV catheter in usual manner.

Page 167 of 192

Intraosseous Cannulation EZ IO Bone Drill & B.I.G

Procedural Protocol

PR08

Criteria: CRITICALLY ill or injured child in whom IV access cannot be established in two attempts OR within 90 seconds. General: Any medications or fluids that can be administered using IV infusion can be infused with an adult IO. IO medication dosages and fluid boluses are the same as those used in IV infusion, as both procedures route directly into the patient's bloodstream. Indications: A. Inability to obtain peripheral access in an adult patient that requires access in an emergency manner. B. Its use should be considered after two IV attempts have failed or if no peripheral IV sites are found and exhibits one or more of the following: a) An altered mental status (GCS of 8 or less) b) Respiratory compromise (SaO 80% after appropriate oxygen therapy) c) Hemodynamic instability (systolic BP <90) C. The IO is not intended nor should it be considered for prophylactic use. Contraindications: A. Fracture of the tibia or femur consider alternate tibia. B. Previous orthopedic procedure at insertion site. C. Infection at injection site. D. Inability to locate landmarks (significant edema, obesity) E. Pre-existing medical condition (tumor near site or peripheral vascular disease) F. Excessive fatty tissue at the insertion site, obesity. Paramedic or Intermediate Use: A. The EZ-IO or the B.I.G. (Bone Injection Gun) is the two adult IO devices approved by the for use. C. Pain, in alert patients, consider 20 to 50 mg of 2% Lidocaine IO, prior to saline infusion. Procedure: A. Wear appropriate PPE. B. Determine EZ-IO/B.I.G. indications. C. Rule out contraindications and locate insertion site. D. Cleanse insertion site and prepare EZ-IO/B.I.G. driver and needle set. E. Stabilize leg and insert EZ-IO/B.I.G. needle. F. Remove stylet and confirm placement. G. Flush or bolus the catheter with 5 ml of normal saline. H. Connect IV tubing and begin infusion. I. Apply dressing and monitor the site and the patient condition.

Page 168 of 192

Intravenous Cannulation

Procedural Protocol

PR09

Criteria: Any patient requiring IV access for medication or fluid administration, either immediate or anticipated. As directed by specific protocol. IV cannulation can be made on any patient upon the discretion of the Paramedic including but not limited to EJ, AC cannulations. Blood should be collected when: Patient is going to receive dextrose Patient is going to receive Phenytoin Any other situation, at the EMS personnel's discretion Contraindications: Only as noted in specific protocols. Treatment: Establishment of peripheral IV (see specific procedure for external jugular IV) Administration of IV fluid as indicated in specific protocols. Collection of blood into clot tubes for laboratory analysis. Equipment: IV catheter (over-the-needle type) of desired gauge Alcohol or povidine/iodine preps 4x4's Band-Aid and tape or commercial securing device ("Venigaurd", "Opsite", etc.) IV fluid bag of desired type Minidrip or volume administration set (60 gtt/ml or 10-12 gtts/ml) as indicated Extension set, if indicated Tourniquet (BP cuff may be used instead). IF DRAWING BLOOD: 10 cc syringe Blood Collection tubes Syringe needle, 18 ga. Procedure: 1. Select and prepare equipment. Don appropriate personal protective (infection control) items. 2. Select IV fluid. Check for expiration date and visually examine for contamination. 3. Connect administration set and extension set. 4. Clear air from IV tubing. 5. Apply constricting band. Confirm distal pulse after application. If using BP cuff, inflate cuff to 80% of patient's systolic pressure. 6. Select site below constricting band. 7. Clean area with alcohol or povidone/iodine prep. 8. Inspect catheter/needle assembly for defects. 9. Stabilize vein at site. 10. Pierce skin with needle/catheter, keeping bevel up. 11. Enter lumen of vein with needle, as evidenced by blood return into catheter hub. 12. Very slightly advance assembly to ensure that catheter tip has entered lumen. 13. Stabilize needle and advance catheter into vessel lumen. 14. Withdraw needle from catheter. If needed, gentle pressure may be applied proximal to catheter to stop bleeding from catheter. 15. IF drawing blood, attach syringe to catheter hub and gently draw required volume. Avoid hemolysis. 16. Attach IV tubing to catheter hub. Remove constricting band. 17. IF blood drawn, attach needle to syringe and insert into clot tube. Allow tube to draw blood from syringe. DO NOT push blood into tube. 18. Open IV to wide open briefly, and check for good flow and lack of extravasation. 19. If IV patent, secure catheter/tubing with tape/bandaid or commercial device. 20. Set IV flow to desired rate. 21. Properly dispose of contaminated equipment/supplies.

Page 169 of 192

Nasogastric Tube Insertion

Procedural Protocol

PR10

Criteria: Cardio-pulmonary arrest with gastric distention Gastric distention secondary to near drowning Respiratory arrest/distress with assisted ventilations AND gastric distention. Poisoning and/or overdose requiring immediate gastric emptying WITH secure and patent airway. The Paramedic attendant can only perform Nasogastric Tube Insertion Contraindications: Altered mental status WITHOUT secured airway Treatment: NG intubation in CPR, respiratory arrest/distress Equipment: Nasogastric tube(s) of correct size 60 cc syringe, catheter-tip type Disposable cup Disposable straw Water soluble lubricant Sterile water 1/2 or 1 inch tape Suction equipment and supplies Stethoscope Oxygen Procedure: 1. Assemble, prepare equipment. Don appropriate personal protective (infection control) items. 2. Inspect nares. If unconscious, place a nasal trumpet (airway) in most dilated nare. 3. Measure, using NG tube, the distance from the nare, across oropharynx, and down to navel. 4. With tip at navel, mark distance to nare on NG tube. 5. Remove nasal airway, if placed. Place tip of lubricated NG tube into most dilated nare. 6. Advance tube into posterior pharynx. If patient is conscious, have him/her swallow while advancing tube through pharynx and into esophagus. Advance tube with each swallow. (Have patient use straw to drink and swallow water). 7. If patient is unconscious, position patient's head in a neutral or flexed position while advancing tube through pharynx and into esophagus. 8. If patient develops stridor or dyspnea, STOP. Remove tube, oxygenate patient, and attempt NG placement again. 9. Once tube is advanced to distance mark, stop and manually stabilize tube. 10. Attach syringe aspirate for gastric contents. 11. After aspirating, auscultate over epigastrium while re-injecting aspirate. 12. Tube placement is confirmed by auscultating air or aspirate entering stomach. The presence of gastric contents on aspiration helps confirm placement, but its absence does not necessarily indicate improper placement. 13. Once placement is confirmed, secure tube with tape. 14. Attach to suction. Turn suction off every 3 - 5 mins. 15. If lavage is to be used, draw up sterile saline in the syringe and inject it into the NG tube. Attach tube to suction for 3 - 5 mins or until all saline is recovered. Repeat this cycle as needed.

Page 170 of 192

Nasotracheal Intubation

Procedural Protocol

PR11

Criteria: Any patient requiring tracheal intubation (as in "Orotracheal Intubation" procedure) who cannot be intubated orally or has an intact Gag Reflex. Contraindications: Infants USE WITH CAUTION IN: Basilar skull fracture. Severe maxillo-facial trauma. Nasal fracture or deviated septum. Young children. Treatment: Nasotracheal intubation Equipment: Endotracheal tube(s) of appropriate size Bag-valve-mask, complete 10 cc syringe Water-soluble lubricant Tape or commercial tube securing device Nasal airway of the appropriate size Nasal intubation "whistle" tip. Stethoscope Suction equipment and supplies Oxygen Procedure: 1. Manually establish or secure airway. Pre-oxygenate and hyperventilate patient. 2. Assemble and prepare equipment. Lubricate ET tube, attach "whistle" tip. 3. While oxygenating, inspect nares. 4. Place nasal airway (lubricated) in most dilated or least obstructed nare. The airway will further dilate nare. 5. Position patient's head as appropriate (neutral if cervical spine precautions indicated, It sniffing" position otherwise). 6. Remove mask and nasal airway. 7. Place tip of ET tube into nare. 8. Advance tube through nare, keeping bevel to the floor of the nasal passage. Use a gentle twisting motion to help advance the tube. If resistance is met, retreat a short distance and advance again using gentle twisting. If persistent resistance is met, withdraw tube, re-oxygenate, and try other nare. 9. Advance tube through pharynx and toward glottis. Listen for air movement at tip. 10. As glottis is approached, air noise at tip should become more sharply defined. 11. At either inhalation or exhalation, advance tube into glottis. Adapter hub should seat near or against nare. 12. Listen for air at tip. If not present, withdraw and reattempt. If present, remove whistle tip. 13. Attach BVM. Confirm placement by auscultating epigastrium and lung fields with ventilation. If placement confirmed, inflate cuff. 14. Reposition tube or re-intubate patient as needed. Each attempt must be preceded by 30-60 seconds of oxygenation. 15. Secure tube. 16. RECONFIRM tube placement often, especially after moving patient or manipulating ET tube. Page 171 of 192

Nebulized Brochodilation

Procedural Protocol

PR12

Criteria: Dyspnea WITH evidence of bronchospasm (wheezes, silence), due to asthma or COPD. WITH adequate mental status and respiratory effort to inspire mist. Can be performed by the EMT-Basic and Intermediate under the Direct Supervision and approval of the attending Paramedic Contraindications: CHF/Pulmonary Edema. Severely obtunded or unconscious patient. Treatment: Nebulized administration of approved medications. Equipment: Medication for nebulization 3 cc syringes, 2 (if medication not premixed) Sterile normal saline, 2 cc (if medication not premixed) Oxygen-driven nebulizer Oxygen Procedure: 1. Assemble, prepare equipment and medication. Don appropriate personal protective (infection control) items. 2. Explain procedure to patient. 3. If possible, encourage the patient to exhale as much as possible. 4. Place, or have the patient place, the mouthpiece in the patient's mouth OR direct the medication at patient's nose/mouth. 5. Have the patient inhale to his/her maximum volume. 6. If possible, have the patient hold his/her breath for 1 - 2 seconds, then slowly exhale. 7. Repeat the process until all the mist is gone. 8. DISCONTINUE therapy if: a) The patient's heart rate increases by 20 beats/min or more from baseline b) Cardiac dysrhythmias appear (or worsen, if already present) 9. In some cases, the patient will be too dyspneic to follow these directions. This is not a contraindication to this procedure. Nebulized bronchodilation will generally still be effective as long as the patient is able to inspire the mist. Modify the procedure as needed to administer the medication to the anxious or extremely dyspneic patient.

Page 172 of 192

Needle Chest Decompression

Criteria: Signs/symptoms of a tension pneumothorax Contraindications: None Can only be performed by attending Paramedic Treatment: Needle chest decompression for traumatic tension pneumothorax. Equipment: Chest decompression kit, which includes: 10 or 12, 14, and 16 ga over-the-needle catheters (2 ea) One-way valve (X 2) Povidone-iodine prep Number 10 scalpel 10 cc syringe Stethoscope ECG monitoring supplies and equipment Oxygen Appropriate ventilation equipment

Procedural Protocol

PR13

Procedure: 1. Ensure that patient is being ventilated. It is important that patient also have a patent IV in place and be on the ECG monitor. 2. Assemble, prepare equipment. Don appropriate personal protective (infection control) items. 3. Locate second intercostal space at mid-clavicular line on affected side of chest. Alternatively, the third space at mid-axillary line may be used. 4. Prepare area with povidone-iodine. 5. Attach the syringe to the over-the-needle catheter. 6. At the selected location, make a small stab incision with the scalpel. Incise only through the dermis, superior to and longitudinally with the rib. 7. Insert the over-the-needle catheter assembly through the incision and into the chest, directing it just over third rib (mid-clavicular) or fourth rib (mid-axillary). Direct the assembly slightly caudally. (I prefer the mid-axillary approach.) 8. Once the pleural space is entered (recognized by a change in resistance and/or air entry into the syringe), advance catheter into space until the hub is flush with the skin. 9. Remove needle and syringe while manually stabilizing catheter. 10. Attach the one way valve to the hub of the catheter. 11. Secure the assembly to the chest wall with tape. 12. Auscultate chest for improvement in breath sounds. 13. Contact Medical Control and advise them of procedure and results. 14. Monitor catheter and valve to insure continued correct functioning, and patient for need for additional decompression.

Page 173 of 192

Oral Tracheal Intubation

Criteria: An patient requiring mechanical ventilation, PEEP, or airway protection. As directed in the specific protocols Contraindications: None Treatment: Orotracheal intubation. Equipment: Endotracheal tube(s) of appropriate size Stylet for ET tubes Laryngoscope handle and batteries Laryngoscope blades of the appropriate sizes and desired type Bag-valve-mask, complete 10 cc syringe Water-soluble lubricant Tape or commercial tube securing device Oral airway of the appropriate size Stethoscope Suction equipment and supplies Oxygen

Procedural Protocol

PR14

Procedure: 1. Manually establish or secure airway. Pre-oxygenate and hyperventilate patient. 2. Assemble and prepare equipment. 3. Position patient's head as appropriate (neutral if cervical spine precautions indicated, "sniffing" position otherwise). 4. Remove mask and oral air-way. 5. Insert laryngoscope blade, moving tongue to the left and lifting epiglottis. DO NOT apply pressure to teeth. 6. Visualize glottis and vocal cords. 7. Pass ET tube through pharynx and into glottis. Directly visualize passage of tube through cords. 8. Advance tube until cuff is just past cords. STOP advancing. 9. Manually stabilize/secure tube 10. Attach BVM to tube adapter and ventilate patient. 11. Confirm placement by auscultating over epigastrium FIRST, then bilaterally over anterior chest (use lateral chest in pedi patients). 12. Reposition tube or re-intubate patient as needed. Each attempt must be preceded by 30-60 seconds of oxygenation. 13. Once tube is confirmed to be in place, inflate cuff. 14. REASSESS tube placement. If still in correct position, place oral air-way as a bite block and secure tube with tape or use a commercial device. 15. RECONFIRM tube placement often, especially after moving patient or manipulating ET tube.

Page 174 of 192

Positive End Expiratory Pressure

Procedural Protocol

PR15

Criteria: Any patient with evidence of moderate to severe atelectasis, aspiration, or alveolar infiltrate, especially: * Pulmonary edema * Near drowning * Smoke or fume inhalation with severe respiratory distress Contraindications: None Treatment: Provision of PEEP. Equipment: PEEP valve, BVM, complete Intubation equipment ECG monitoring equipment and supplies Oxygen Procedure: 1. ENDOTRACHEALLY INTUBATE PATIENT. 2. Attach PEEP valve to end adapter of BVM. 3. Attach BVM to ET tube in usual manner. 4. Ventilate patient as usual. 5. Observe ECG rhythm and vital signs closely. PEEP may cause dysrhythmias and/or changes in vitals. Discontinue or decrease PEEP if significant adverse responses occur.

Page 175 of 192

Surgical Airway

Procedural Protocol

PR16

Criteria: CRITICAL patient in whom a patent airway cannot be maintained or established by oro-pharyngeal or naso-pharyngeal airway, BVM, or oro- or naso-tracheal intubation, due to maxillo-facial trauma, inflammation or swelling of the airway, or other mechanism resulting in a life-threatening airway compromise. Can only be done by a Paramedic. Must be the last resort in managing a patients airway Contraindications: An airway obtainable by no other means. Treatment: Establishment of a surgical airway in the patient with complete obstruction. Equipment: Surgical Airway Kit, which includes: Povidone-iodine prep. One-quarter inch wide umbilical tape ties. Cricothyroidotomy device, adult and pediatric Number 10 scalpel. Suction equipment and supplies. BVM complete. Stethoscope Oxygen Procedure: Prepare, assemble equipment. If at all possible, hyperventilate patient. Prepare the anterior neck with povidone-iodine. Locate the cricothyroid membrane. Place finger on thyroid cartilage ("Adam's apple")and move finger down into soft depression between thyroid cartilage and cricoid cartilage (next firm "bump"). 5. Leave finger on membrane. 6. Stabilize tissue by applying finger pressure bilaterally to membrane with hand that is marking site. 7. Place the tip of the scalpel on the skin in the center of the membrane. 8. Make a horizontal incision (approx. 2-4 cm across) through the epidermis and adipose tissue over the membrane, exposing the membrane. 9. Stabilize the cricoid cartilage with thumb and forefinger, while identifying (if possible) and exposing the cricoid membrane. 10. Once the cricoid membrane is exposed and identified make a horizontal incision (approx 2-4 cm across the membrane). 11. Insert hemastats into the incision and spread incision open and introduce a 5.0 cuffed ET Tube caudally and medially through the incision. Inflate the cuff. 12. Confirm proper placement by the ease of ventilating of air into the ET tube with BVM. 13. Remove syringe. 14. Ventilate and confirm placement with auscultation and observation of chest wall movement. 15. Secure airway with umbilical tape. 16. Apply dressing (if bleeding) to site. 17. Contact Medical Control and advise physician of procedure and results. 1. 2. 3. 4.

Page 176 of 192

Vagal Stimulation
Criteria: STABLE SVT as defined in the specific protocols. Contraindications: For Carotid Sinus Massage * Unequal carotid pulses. * Bruit to either carotid artery. * History of CVA. * History of carotid or neck surgery. * Patient age greater than 50 years. For Valsalva's Maneuver None Treatment: Applications of vagal maneuvers for stable SVT. Equipment: ECG monitor and monitoring supplies. Equipment and supplies for IV.

Procedural Protocol

PR17

Procedure: FOR VALSALVA MANEUVER: 1. Ensure that patient in on continuous ECG monitoring, is receiving O2, and has a patent IV in place. 2. Reconfirm that patient is still in SVT and that patient's clinical status is appropriate for vagal maneuvers. 3. Briefly explain the overall procedure to the patient. 4. Have the patient take a deep breath. 5. Have the patient "bear down" against a closed glottis, as if trying to "clear" or "pop" his or her ears. Have the patient perform this for as long as he or she can. 6. If no conversion, have the patient take another deep breath and repeat the procedure, up to three attempts total. 7. If still no conversion and not contraindicated, move to carotid sinus massage. FOR CAR0TID SINUS MASSAGE 1. Place the patient supine or semi-Fowler's with neck extended. 2. Separately palpate each carotid artery for pulse quality, and auscultate each for bruits. 3. Ensure that patient in on continuous ECG monitoring, is receiving O2, and has a patent IV in place. 4. Tilt the patient's head to one side. 5. Place the index and middle fingers over the carotid artery just below the angle of the jaw, as high on the artery as possible. 6. Press the artery firmly back against the vertebral column and massage the artery. 7. Massage the artery until the first indication of conversion or heart block, but no longer than 20 seconds. 8. If no conversion after the first attempt, repeat the procedure once.

Page 177 of 192

References and Guides

Protocol
RF01 RF02 RF03 RF04 RF05 RF06 RF07 RF08 RF09 RF10 RF11

Description
Burn Reference Trauma and Glascow Scoring Multi Lead ECG Guide to Drips Anatomical Positions Anatomical Reference to Movement Cardiac Muscle Reference Skull Bone Reference Eye Anatomy Reference Renal and Hepatic Reference Head and Neck Anatomy Reference

Page
176 177 178 179 181 182 183 184 185 186 187

Page 178 of 192

Burn References
Rule of Nines

Reference Protocol

RF01

Parkland Burn Formula: (IV fluids for first 8 hours) (% Burn Area) X (Pt. Wt. in Kg) ______________________________________ = cc/hr 4

Page 179 of 192

Trauma and Glascow Come Score

Adult Glasgow Coma Score Eye Opening Spontaneous To Voice To Pain None Verbal Response Oriented Confused Inappropriate Words Incomprehensible Words No Response Motor Response Obeys Commands Localizes Pain Withdraws from Pain Flexes from Pain Extension on Pain No Response Glasgow Total Score
The Sum of Eye+Verbal+Motor = 3-15

Reference Protocol

RF02
4 3 2 1 4 3 2 1 4 3 2 1

4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Adult Revised Trauma Score Respiratory Rate/Min 14-36/Minute 11-14/Minute >36/Minute <10/Minute Systolic BP >90 70-89 50-70 <50 Neurological (Glasgow) Score is 14-15 Score is 11-13 Score is 8-10 Score is <8

ATS Total Score

Sum of Respiratory+BP+Neurological = 3-12

Mild Injury is 13 through 15 points Moderate Injury is 9 to 12 points Severe Injuries 3 through 8 points

Report GCS as 3 numbers:

Example: E2+V3+M5 = GCS of 10

Report ATS as 3 Numbers:

Example: R2+BP3+N4 = ATS of 9

Eye opening tests indicate the function of the brain's activating centers. The patient's eyes may open spontaneously, only on verbal request, or only with painful stimulation. Best verbal response indicates the condition of the central nervous system within the cerebral cortex. The patient may be able to speak normally and be oriented to time and place, or he or she may be disoriented and use inappropriate words. At the other end of the scale, the patient may only make incomprehensible sounds or no sound at all. Best motor response tests examine a patient's ability to move arms and legs. Responses may vary from the ability to move about on command to the ability to move only in response to pain. Each element of the Glasgow Coma Scale is rated using "1" as the lowest possible score in each category. Physicians classify brain injuries as mild, moderate, or severe, using these scores.

Page 180 of 192

Multi-Lead ECG Interpretation

Reference Protocol

RF03

For our purposes, "multilead ECG" is considered to be the use of 5 or more ECG leads. It is required on all stable patients who are thought to be in SVT or VT. Additionally, it should be used routinely on all patients who display signs or symptoms of myocardial ischemia or those with an unclear or potentially significant dysrhythimia. Since ECG leads are actually electrical "angles of vision", utilizing more than one lead to evaluate the ECG provides the paramedic with a more complete picture of the electrophysiology of the patient's heart. To use just one lead to evaluate the ECG is akin to trying to view a whole room through the peephole on the door. Routinely using multiple leads will allow the paramedic to: * More accurately evaluate and interpret unclear or unusual rhythms. * Rapidly and accurately differentiate a wide complex SVT from VT. * Consistently identify crucial ECG changes, such as ST elevation (which often does not appear in Lead II). The first step to proper ECG interpretation is good lead placement. The location of the lead attachment points on the patient significantly affects the accuracy of the ECG image. Leads placed too closely to one another distort the ECG we see, especially the QRS morphology and the relative positions of the ST and T wave. For diagnostic quality ECG'S, the electrode patches should be placed as follows: 1. One on each arm, in the mid humerus area. The patches should be even with the heart, either on the lateral or anterior aspects of the biceps. 2. One on the left leg, as far away from the arm leads as practical. A good place is on the lower, lateral calf. To run leads I, II, and III, simply attach the lead wires to the arm and leg patches as usual. The only real disadvantage to this placement of the patches is that it increases patient movement artifact considerably. When running a diagnostic ECG, you will need to have the patient hold as still as possible to minimize the artifact. If you do not need a diagnostic quality ECG and are merely monitoring the patient for general evaluation or gross changes (e.g. tachycardia vs. bradycardia, NSR vs. VT), you will get a more clear "picture" with the patches placed near the right and left shoulders and on the lower left torso. You must realize, however, that in this "standard" placement, you will not be able to evaluate ST and T changes accurately. The multilead ECG consists of Leads I, II, 111, MCL1 (modified chest lead 1), and MCL6 (modified chest lead 6). MCL1 and MCL6 are rough equivalents of VI and V6 on a 12 lead ECG. If running a multilead ECG, run at least a six (6) second strip each in leads I, II, and III using patches in the diagnostic positions. Then run six (6) second strips in leads MCL1 and MCL6 as described in the "Electrocardiogram" procedure in this protocol. If patient movement artifact is a problem, you may now move your electrode patches in to the more standard placement.

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Guide to Drips Amiodarone Infusion

3 Phase Dosing over First 24 Hours
Infusion Mix Rapid Loading Phase Slow Loading Phase Maintenance Infusion Phase 150mg in 100ml D5W 900mg in 500ml D5W 900mg in 500ml D5W Concentration 1.5mg/ml 1.8mg/ml 1.8mg/ml Dose (mg/min) 15 1 0.5 Rate (ml/hr) 600 33.3 16.6

Reference Protocol

RF04

Goal 1000mg over 24 hrs 150mg over 10 mins 360mg over 6hrs 520mg over 18 hrs

Anectine Infusion
Preparation 1 gram into 250ml NS yields a concentration of 4mg/ml Dose Range 2.5-4.0 mg/min
g/min gtts/min 1 15 1.5 22.5 2.0 30 2.5 37.5 3.0 45 3.5 52.5 4.0 60

Dopamine Infusion ggts/minute (60 ggt set) or ml/hr:

Preparation Dose Range
Patient kg 2g/kg/min 5g/kg/min 10g/kg/min 15g/kg/min 20g/kg/min

400mg in 250ml D5W yields a concentration of 1600 ug/ml 2-20 ug/kg/min

2.5 * * 1 1.4 2 5 * 1 2 3 4 10 * 2 4 6 8 20 1.5 4 8 11 15 30 2 6 11 17 23 40 3 8 15 23 30 50 4 9 19 28 38 60 5 11 23 34 45 70 5 13 26 39 53 80 6 15 30 45 60 90 7 17 34 51 68 100 8 19 38 56 75 105 9 20 40 59 79 110 10 21 42 65 83

Lidocaine Infusion
Preparation Dose Range
g/min gtts/min 1 15

1 Gram in 250ml NS yields 4mg/ml 2-4 mg/min

2 30 3 45 4 60

Procainamide Infusion
Preparation Dose Range
g/min gtts/min 1 15

1 Gram in 250ml NS yields 4mg/ml 1-6 mg/min

2 30 3 45 4 60 5 75 6 90

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Must use In-Line Filter

Mannitol Infusion
Preparation Dose Range
Patient kg 1.0 g/kg 1.5 g/kg 2.0 g/kg

25%/50ml (250mg/ml) in 250ml NS yields 1Gr/ml Adult: 1.5-2.0 Gr/kg of 25% solution over 30-60 minutes Children: 1.0-2.0 Gr/kg over 30-60 minutes
Milileters to Administer over 30-60 minutes 2.5 2.5 3.75 5 5 5 7.5 10 10 10 15 20 20 20 30 40 30 30 45 60 40 40 60 80 50 50 75 100 60 60 90 120 70 70 105 140 80 80 120 160 90 90 135 180 100 100 150 200 105 105 157 210 110 110 165 220

Bretylium Dose: 5-10 mg/kg over 10 minutes for V-Tach and 5mg/kg Bolus for V-Fib Maintenance Drip: 2mg/minute Mix: 500mg Bretylium in 250-ml D5W yields 2mg/ml Drip 1 ggt/second=2mg/minute

Drug Administration Formulas

D (desired dose) x V (vehicle) H (dose on hand) = Amount to Give

Infusion Rate (mL/h)

Weight (kg) x Dose (ug/kg/min) x 60 min/h Concentration (ug/mL)

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Anatomical Reference

Reference Protocol

RF05

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Anatomical Reference Movements

Reference Protocol

RF06

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Cardiac Muscle

Reference Protocol

RF07

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Skull Bone Reference

Reference Protocol

RF08

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Eye Anatomy Reference

Reference Protocol

RF09

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Renal and Hepatic Anatomy Reference

Reference Protocol

RF10

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Neck and Head Anatomy Reference

Reference Protocol

RF11

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Medication Reference/Guide
Protocol
RX01 RX02 RX03 RX04 RX05 RX06 RX07 RX08 RX09 RX10 RX11

Description

Page

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Acetaminophen

Reference Medications

RX01

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