ICEMS Protocols 2014 Updated March 1, 2016 ICEMS 2014 Protocol Update Click Title to Link to Appropriate Protocol Click ICEMS Logo on any page to return to Link Page

ABDOMINAL PAIN CPR

ADULT AIRWAY CRUSH SYNDROME TRAUMA

ADULT ASYSTOLE/PEA DENTAL PROBLEMS

ADULT COPD/ASTHMA DIABETIC; ADULT

ADULT TACHYCARDIA NARROW COMLEX DIALYSIS/RENAL FAILURE

DROWNING/SUBMERSION INJURY ADULT TACHYCARDIA WIDE COMPLEX

ADULT THERMAL BURN EBOLA (SUSPECTED EBOLA)

EMERGENCIES INVOLVING INDWELLING ADULT, FAILED AIRWAY CENTRAL LINES

ALLERGIC REACTION/ANAPHYLAXIS EPISTAXIS

ALTERED MENTAL STATUS EXTREMITY TRAUMA

BACK PAIN FEVER/INFECTION CONTROL

BEHAVIORAL HEAD TRAUMA

BITES AND ENVENOMATIONS HYPERTENSION

BLAST INJURY/INCIDENT HYPERTHERMIA

BRADYCARDIA; PULSE PRESENT HYPOTESION/SHOCK

CARBON MONOXIDE/CYANIDE HYPOTHERMIA/FROSTBITE

CARDIAC ARREST; ADULT INDUCED HYPOTHERMIA

CHEMICAL AND ELECTRICAL BURN MARINE ENVENOMATIONS/INJURY

CHEST PAIN: CARDIAC AND STEMI MULTIPLE TRAUMA

CHF/PULMONARY EDEMA NEWLY BORN

CHILDBIRTH/LABOR OBSTETRICAL EMERGENCY ICEMS 2014 Protocol Update Click Title to Link to Appropriate Protocol Click ICEMS Logo on any page to return to Link Page

OVERDOSE/TOXIC INGESTION PEDIATRIC V-FIB, PULSELESS V-TACH

PAIN CONTROL: ADULT PEDIATRIC VOMITING/DIARRHEA

PEDIATRIC AIRWAY POLICE CUSTODY

PEDIATRIC ALLERGIC REACTION POST RESUSCITATION

PEDIATRIC ALTERED MENTAL STATUS RADIATION INCIDENT

RESPIRATORY DISTRESS WITH PEDIATRIC ASYSTOLE/PEA TRACHEOSTOMY TUBE

PEDIATRIC BRADYCARDIA RSI

PEDIATRIC DIABETIC SCENE REHAB: GENERAL

PEDIATRIC FAILED AIRWAY SCENE REHAB: RESPONDER

PEDIATRIC HEAD TRAUMA SEIZURE

PEDIATRIC HYPOTENSION/SHOCK SELECTIVE SPINAL IMMOBILIZATION

PEDIATRIC MULTIPLE TRAUMA SUSPECTED STROKE

PEDIATRIC OVERDOSE/TOXIC INGESTION SYNCOPE

PEDIATRIC PAIN CONTROL TRIAGE

PEDIATRIC POST RESUSCITATION UNIVERSAL PT. CARE

V-FIB PULSELESS VENTRICULAR PEDIATRIC PULMONARY EDEMA/CHF TACHYCARDIA

PEDIATRIC PULSELESS ARREST VENTILATOR EMERGENCIES

PEDIATRIC RESPIRATORY DISTRESS VOMITING AND DIARRHEA

PEDIATRIC SEIZURE WMD-NERVE AGENT PROTOCOL

PEDIATRIC TACHYCARDIA

PEDIATRIC THERMAL BURN Universal Patient Care

Bring all necessary equipment to patient Scene YES Demonstrate professionalism and courtesy Required VS: Safe Mass assembly consider WMD Blood pressure NO Palpated pulse rate Utilize appropriate PPE Respiratory rate Pulse ox if available Consider Airborne or Droplet Isolation Call for help / additional if indicated resources If Indicated: Stage until scene safe Initial assessment Glucose BLS maneuvers 12 Lead ECG Initiate oxygen if indicated Temperature Pain scale Adult Assessment Procedure CO Monitoring Pediatric Assessment Procedure Use Broselow-Luten tape Trauma Medical Patient Patient

Mental Status

Evaluate Mechanism of Injury (MOI) G Exam

Consider Spinal Immobilization e

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Unresponsive Responsive a

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Significant MOI No Significant MOI e c

Primary and Chief Complaint t i

secondary Obtain o assessment SAMPLE n

Primary and Primary and P

Secondary Secondary trauma r o

trauma assessment t assessment Primary and o

Obtain history of c Secondary Focused assessment present illness from o on specific injury assessment l available sources / s Obtain VS scene survey Focused assessment on specific complaint Obtain SAMPLE Obtain SAMPLE Obtain VS

Repeat assessment while preparing for transport

Exit to Continue on-going assessment Exit to Appropriate Protocol Repeat initial VS Appropriate Protocol Evaluate interventions / procedures

Transfer Patient hand-off includes patient information, personal property and summary of care and Patient does not Patient does not response to care fit specific fit specific protocol protocol Notify Destination or Contact Medical Control

Revised Protocol 1 10/3/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 General Section Protocols 2012 ell as ongoing ell ongoing as ion to skin. ion s w s der der to understand lat ment. tion tion in a patient’s g. Special needs needs Special g. l patient patient l contacts;if ed ed on patient all ith increased ith increased rea to refuse care. al 9 9 kgPatients less.or is 94 of94 is regardless % eat uir era ed. Oxygen ed. Oxygen a is ity k w k liz ols 49 kg. 49 an assessment, including including assessment,an ≤ low 15, weight 15, ≤ Luten tape, Age tape, Age Luten - 11 years of age. years 11 ≤ Protocol1 Luten Luten Tape, Resuscitation Age less15 and or /4 years weight or - This should remain stable over toa choice an to communicatestableor over time.Inability remain should Thisinability Demonstrate a rational to a torational a comeDemonstrate process Should decision. be able the to describe logic Universal Patient Care Patient should be Patient be should able to a factualdisplay understanding the of the illness, options and and risksbenefits. Ability to communicate an understanding an understanding to communicateAbility of the factsof the situation. should They be able to the recognize Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Luten Luten tape have should based weight age medications16 until greater than greater or weight or or equal to 50 k - SAMPLE: Signs / Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness illness / injury to leading Events oral intake;PMH; Medications; Last / Symptoms; Allergies; Signs SAMPLE: Timing of transport should be based on patient's clinical condition and the transport policy. policy. transport the clinical and condition patient's on based be should Timingtransport of transport. refuseswho patient forcontrol medical contact to Never hesitate times.at necessary may be Systolic reading A palpated / Diastolic a Systolic reading. as Pressure is defined Blood Any patientcompletedAny does not contact disposition in an EMStransport which result musta form. have fittingby patientpediatric definedA is on the Broselow patients defined by are Protocols Airway Pediatric Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mentalstatus withif notsigns, protocolvital noted Recommendedexam on Minimal Exam: the is specific complaint. or ofand location injury GCS, Revised 10/3/2012     Pearls     pharmaceutical with indications, contraindications as well as untoward as effects.untoward indications,demonstratesasa lin side well research Recent contraindications with clear pharmaceutical when given in overdose /in cardiac mortality(hyperoxia arrest. hyperventiation) oxygen when Utilize indicated and not because A available. is reasonable it target oxygen saturation all treatmentprotoc in device. delivery Manipulation of information in a a rational inmanner: information of Manipulation they using are to to the decision,come though you not decision.agree may with Special note oxygen on and utilization: Oxygen administration ubiquitous ispatient in prehospital and care probably uti over Appreciation situation:the of Appreciation ofsignificance decision.the outcometheir potentially from Patient should be able to communicate a a communicate clear be able to choice: shouldPatient the express demonstratesconsistentlyincapacity. choice is understood: informationRelevant Patient refusal is a high risk situation. Encourage Patient situation.a Encourage refusal ishigh risk Encourage patient to accept facility. to patient transport medical to al signs.Documentation of vital the including important the patient’sa describing event mental statusvery iscapac assessment of two setson of required isVS MINIMUM A for Criteria: FormRefusal Guide tocapacity:Please the utilize AssessingICEMS not thisispossible a detailed explanation needed. is Generally the infant Generally or should child not separated unless be and the absolutely during assessmenttrfromnecessary caregiver Refusal: Patient Initial assessment should utilize the Pediatric Assessment Triangle which encompasses Appearance, encompassesof Appearance, WorkTriangle Breathing which the and should AssessmentCircu assessmentInitialutilize Pediatric alteration require maydependent of order The assessment the on developmental state of the patient.pediatric Pediatric Pediatric Patient: patient Pediatric defined isby those the fitwhich on Broselow off the Broselow continued require mayuse children regardless based of of Pediatric age protocols and weight. Altered mental status is not always Blood mental dementia.Altered status checkSugar any Always not isalways of alt and signs stroke,trauma, etc. with assess baseline mentalstatus. adult or in serious the in typical the be elderly. moderate mayinjury Minor very General weakness can be the symptom of a very serious underlying weakness underlying can process.General be of serious a very the symptom Betapulse and torates.with low drugs blockerstachycardia normal a other prevent in mayshockcardiac reflexive Geriatric Patient: and dislocationsfractures have Hip mortality.high Adult Patient: Adult than An considered isadult Blood hypotensive 90 less when SystolicisPressure mmHg. patients Diabetic have presentations mayand such MI. of women atypical as cardiac related problems The PCR / EMR narrative should narrative events be a ofEMR /the and PCR considered The of story care the circumstances, patient and a allow should the the complaint,and performed the not indicated treatment,assessment,were why procedures why were a procedures performed and to assessmentstreatmentresponse and interventions. General: be patient must All appropriate of toof care training your level two sets of and req isVS documented MINIMUM Ain the PCR. not is ifa contacts;detailed thispossible explanation needed. is Scene Safety Evaluation:Scene Safety Identify potential patient hazards and to rescuers,public. Identify number of patientsindicated. ifand protocol START utilize Observe patient position and surroundings. Adult General Section Protocols 2012 90% YES Exit Exit to ≥ Protocol Effective? BVM / CPAP BVM if indicated Adult / PediatricAdult/ Supplemental oxygen Supplemental BVM Airway Consider CPAP Procedure Appropriate ProtocolAppropriate a Tracheostomy Tube Tube Tracheostomya Supplemental oxygen Supplemental Goal oxygen saturationoxygen Goal Respiratory DistressWithRespiratory I NO YES YES YES 5 minto 10mg up5 - NO NO YES if available if indicated Exit Exit to if indicated Oxygenation Consider SedationConsider Protocol2 Oral / NasotrachealOral Airway Patent?Airway Intubation ProcedureIntubation Support needed?Support Consider RSI ProtocolConsider Monitor / ReassessMonitor Consider AMS ProtocolAMS Consider Diazepam 4mg IV / IO IV 4mgDiazepam valve mask (BVM) mask valve If BIAD in placeIf or ETTBIAD - appropriate protocolappropriate Midazolam 2.5 mg IV/IO mg2.5 Midazolam Airway BIAD ProcedureAirway Supplemental Oxygen Supplemental Breathing / Oxygenation / Breathing Notify Notify Destination or Spinal Immobilization ProcedureImmobilizationSpinal open airway thrustlift/ jaw airway chin open airway oralor nasal Bag Contact Medical ControlContact Medical Repeat q 5 min up to 10 mg 10OR 5up min to q Repeat Basic Maneuvers First ManeuversBasic - - - Assess RespiratoryEffort,Rate, Assess Repeat 2 mg q 3 mg q 2Repeat Is Airway Adequate?/ Airway BreathingIs I P P B Adult Airway Adult NO NO P/I. - 90% Direct Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any ≥ YES management. Laryngoscopy Surgical ProcedureSurgical Airway Body ForeignAirway information for airway airway for information Airway CricothyrotomyAirway Obstruction ProcedureObstruction they contain very usefulvery containthey utilized together (even if (even togetherutilized Exit Exit to attempts. Protocol agency is not using RSI) asusingnotis agency Complete Obstruction?Complete Protocols 1, 2 and 3 should beshould 3and 1, 2 Protocols with continuedwith Revised attempts by mostby attempts 8/13/2012 Unable to VentilateUnable I intubation attempts . attemptsintubation Adult Failed Airway Airway AdultFailed P Anatomy inconsistentAnatomy or moreunsuccessfulor during or after one (1)one or afterduring experienced EMT experienced and Oxygenate Oxygenate and Three (3) unsuccessful (3)Three Adult General Section Protocols t al 2012 o teeth ubations tan aci N int ge 55; > A neck junction to junctionneck - 2 Rule (Mouth open(Mouth Rule 2 - Luten Tape. Luten - 3 90%, to is acceptable90%, it tiff or increased airway airway increasedortiff - S bstruction / Obese or late/ orObese bstruction O 35. - valuate 3 valuate E adiation treatment skinchanges;adiationtreatment R of 30 of 2 bese or latepregnancy;bese O 45. Avoid hyperventilation. Avoid 45. - istorted or disrupted airway; airway; disruptedoristorted D Procedure requires patient have spontaneous breathing. breathing.spontaneoushave patientrequires Procedure collar (in absence of trauma) to better maintain ETT ETT maintainto bettertrauma)of(in absence collar - bese or latepregnant;beseor O tiff or increased airway pressures (Asthma, COPD, Obese,COPD, (Asthma, pressuresairway ortiff increased S 12 or patients longer than thethan Broselowlonger or patients 12 tracheal intubation is unsuccessful.isintubation tracheal allampati (difficult to assess in the field);theinto assess (difficultallampati - M Protocol2 use oxygen, paperbag.aoxygen, not use – Difficult Airway Airway AssessmentDifficult Adult Airway Adult ematoma over lying neck; lyingover ematoma H bstruction / Obese or latepregnancy;orObesebstruction / 10 per minute to maintain a EtCO2 of 35EtCO2 maintainminuteato per 10 - O Orotracheal intubation is the preferred choice.preferredtheis intubation Orotracheal ask seal due to facial hair, anatomy, blood or secretions / trauma;or secretionsblood hair,anatomy,facial to due seal ask line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar frontcollaror BIADcervical theintubation use. During BVM BIAD or intubation, duringstabilizationcervical line - M spine immobilization for patients with suspected spinal injury. spinal suspectedwith for patientsimmobilization spine Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any - eck mobility.eck N ook externally for anatomical distortions (small mandible, short neck, largetongue);neck, short(small mandible, anatomicaldistortions forexternally ook urgery or distortion of airway; of airway; distortionurgery or Utilize inUtilize Difficult estricted mouth opening;estrictedmouth placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers.movesallpatient duringbe used tubeshould endotrachealof stabilization Manual placement. Gastric tube placement should be considered in all intubated patients if available or timeallows.or available patientsif allintubated in be considered shouldtubeplacementGastric c andconsidertubewell endotrachealthesecure importantisto It Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO ato maintainonlydone be should headtraumadeterioratingin Hyperventilation Do not assume hyperventilation is psychogenicis hyperventilationDo assumenot cases. someworsen view inThey may intubations. difficultassistwith tobe used BURP may maneuver andpressureCricoid It is strongly encouraged to complete an Airway Evaluation Form with any BIAD Intubation any procedure.Formor Evaluationwith anto Airway completestrongly encouragedIt is BIAD if useaoral shouldParamedicsand Intermediates C Maintain An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into thepastor inserted teeth tube bladeor endotracheal passinglaryngoscope the asis Attempt defined An Intubation nasalpassage.the berate 8 shouldVentilatory continue with basic airway measures instead of using a BIAD or Intubation.BIAD of a using instead measures withbasicairway continue and appropriate oxygenation receiving patientis the is whenairway aof protocol securethispurposes For the ventilation. Continuous capnography (EtCO2) is strongly recommended for the monitoring of all patients with a BIAD witha or BIAD patientsof theall monitoring recommended for is (EtCO2) capnography strongly Continuous tube. endotracheal of ≥ oximetry values BVMpulse withby continuousmaintainedbeing is airway effective If an This protocol is only Age ≥ withan in usefor only patientsisprotocol This Document of results. intubation. methodswithall mandatory (Color) or capnography is Capnometry Revised 8/13/2012 umor overlying neck.overlying umor              Pearls   trauma, basal skull fracture, head injury. Not a rapid procedure and exposes patient to risk ofto desaturation. riskpatient exposes andprocedure a rapid Notinjury. headfracture,skullbasal trauma, should be open or removed to facilitate translation of the mandible / mouth opening.mouth/ of mandiblethe totranslation facilitateor removed open beshould intubation: Nasotracheal f pressure,severe intracranial increased airways, or distorteddisrupted patients,anatomically combativein Contraindicated T Trauma: pressures (Asthma, COPD, Obese,Pregnant);COPD, (Asthma, pressures / SurgicalAirway: Cricothyrotomy Difficult S SHORT: pregnancy; BIAD: Difficult R RODS: Difficult Laryngoscopy: Laryngoscopy: Difficult LEMON: L chin 3fingers, patientaccommodate should tojunction neckmandible 3fingers, patient accommodate should fingers);patient2 accommodate should prominencethyroid (roll gauze and place between gums and cheeks to improve seal);to improve cheeksand gums between placeand (rollgauze Pregnant). Difficult BVM Ventilation: BVMDifficult MOANS: Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques. properBVM with or managed be temporized emergencies cannotairway prehospital Few information.additional3and forProtocols 2 torefer Please Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotrachealprehospital All transport.against fieldthe in intubation of endotrachealbenefitsandrisks weigh the Always impor most The besttheoption.be may transport rapidadequateis oxygenation / ventilation risk.If high consideredbe are laryngoscope).the (notMask Valve Bageffectivelytheis correctly toand usedifficult most devicetheand airway Adult General Section Protocols 2012 Call for additionalforCall management. Exit Exit to resources if availableif resources information for airway airway for information Continue BVM Continue they contain very usefulvery containthey utilized together (even if (even togetherutilized agency is not using RSI) asusingnotis agency YES Appropriate ProtocolAppropriate Protocols 1, 2 and 3 should beshould 3and 1, 2 Protocols Supplemental Oxygen Supplemental 90 % 90 90 % 90 45 ≥ ≥ – NO NO BVM BVM YES 10 breaths / minute/ breaths10 Distortion – EtCO2 35EtCO2 Failed Airway Failed BIAD Successful Significant FacialSignificant Adjunctive Airway Adjunctive Airway BIAD ProcedureAirway Trauma / Swelling / / SwellingTrauma Maintain SpO2 Maintain Maintains SpO2 Maintains Notify Notify Destination or Protocol3 Contact Medical ControlContact Medical Ventilate 8 Ventilate Continue Ventilation / Oxygenation / VentilationContinue B NO YES 90% during or during90% P/I. ≥ - Adult, Failed Airway Adult, Failed 90 % 90 ≥ equipment Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Oxygenation most experienced EMT experiencedmost Surgical ProcedureSurgical Continue Ventilation / VentilationContinue Three (3) unsuccessful attemptsby unsuccessful (3)Three Airway CricothyrotomyAirway Maintain SpO2 Maintain Anatomy inconsistent with continued attempts. continuedwith inconsistentAnatomy NO MORE THAN THREE (3) ATTEMPTS MORE (3)THREE THAN ATTEMPTS TOTAL NO Each attempt should include change in approach orapproach inchange includeshould Eachattempt Unable to Ventilate and Oxygenate Oxygenate andto VentilateUnable P P after one (1) or more unsuccessful intubation attempts. unsuccessfulintubation or more(1)one after Adult General Section Protocols % e e 90 tiv The The 2012 s. s can bes can ten thistenis he level of levelhe t t t Thi Of y. y. Protocol3 Adult, Failed Airway Adult, Failed AS AS EARLY aboutAS thePOSSIBLE patient's airway. failed difficult / line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar frontcollaror BIADcervical theintubation use. During BVM BIAD or intubation, duringstabilizationcervical line - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Medical Control Medical Change cricoid pressure. Cricoid pressure no longer routinely view. worsen may and recommended routinely cricoid longer Cricoid pressure. no pressure Change Right) patient's to Up, and [posterior], Back BURP (Push trachea maneuverApply positioning head Change Different laryngoscope blade / Video or other optical laryngoscopy devices laryngoscopy optical other or Video / blade laryngoscope Different Elastic GumBougie ETTDifferentsize Utilize inUtilize Notify  respiratory function. inadequate with an patients utilized all in oximetry be should pulse Continuous airways. advanced with patients or to all failure with respiratory patients all to applied be should EtCO2 Continuous    If intubation first an adjustmentand then consider: attempt make fails,   existing laryngeal or tracheal tumors, infections or abscess overlying the cricoidarea.theoverlying or abscess infectionstumors,trachealor laryngeal existing -     Pearls Relative contraindications include: contraindicationsRelative Pre / injury. landmarkdestructionor anatomicalHematoma Cricothyrotomy Airway Procedure: / SurgicalCricothyrotomy patients.usedyoungerisin ventilation jet transtracheal only. Percutaneousgreaterandage of years patients 12in Use your umbilicus which will place you at the optimal position.at place optimalwill the you which umbilicusyour Trauma: opening.mouth/ of mandiblethe totranslation facilitateor removed open beshould Use of cot in optimal patient / rescuer position: patient/ rescuerinof optimal cotUse nosea ispatients the raise untiloncot the patient Withtheintubation. facilitateto lowered andbe elevated cot canThe goal is to align the ear canal with the suprasternal notch in a straight line.a straightin notchsuprasternal thewith canal earthetois align goal position.the optimizewill or towels pillows placingblankets,by torsotheelevating patient pregnantor late obese theIn cot. theheadof raisingthe by facilitated Position of patient: Positionof intubations.difficultandforfailed many responsibleare rescuerand of patient thepositionimproper fieldthesettingIn doesoptimizenot manyrescuerthe times However must adapt.we and scenethe at presentconditions uncontrolledby dictated positionbestprobablytheare neck uponthe extended headsimplytheor sniffing The positionposition. rescuerand patient ventilation, difficult BIAD, difficult laryngoscopy and / or difficult cricothyrotomy. or difficultandcricothyrotomy. / difficultBIAD, laryngoscopy difficultventilation, difficultairwa potentialwith patientthe identifyhow into information for page2AdultAirway 1, Protocol to refer Please maneuvers. A patient near death or dying. deathnear A patient maneuvers. difficultBVM airway, difficult expectedwith to identify patientsis failedairway to avoid a importantway mostThe 2. Three (3) failed at intubation by the most experienced prehospital provider on scene even when adequate oxygen saturationoxygen adequateeven when on scene providerprehospital experiencedmost the by at failedintubation (3)Three 2. be maintained.greatercanor alternaattempttimeto insufficientand techniques BVM greaterwith % or90 saturation oxygen adequatemaintainUnable to3. Conditions which define a Failed Airway: a FailedAirway: whichdefine Conditions attempts.orintubation more failed2after or greater % 90 saturationoxygen maintainadequateto Failure 1. A failed airway occurs when a provider begins a course of airway management by endotracheal intubation and identifies thatidentifiesand endotrachealintubationby managementof course airway a beginsprovider a occurs when airway A failed notwill succeed.means thatby intubation

Adult General Section Protocols 2012 NO Appropriate Procedure as indicatedas Shock If indicated Cardiac ProtocolCardiac Instability? if indicated Hemodynamic Spinal ImmobilizationSpinal Monitor andReassessMonitor YES Pain Control ProtocolControlPain Muscle spasm / spasmstrainMuscle compression nerve with discHerniated Sciatica fractureSpine stoneKidney Pyelonephritis Aneurysm Pneumonia AbscessEpiduralSpinal CancerMetastatic AAA Differential            YES if indicated if indicated Cardiac Monitor Cardiac Mechanism Protocol5 Injury or TraumaticInjury IO Procedure 90 12 Lead ECG ProcedureLeadECG 12 Consider Cardiac EtiologyCardiacConsider ≥ Notify Notify Destination or 10 minutes P Contact Medical ControlContact Medical - YES P Back Pain Back B SBP Reassess VS Reassess 500 mL IV / IO IV / mL500 if indicated if indicated if indicated if indicated Pain (paraspinous, spinous(paraspinous,Pain process) Swelling of motion rangewith Pain weaknessExtremity numbnessExtremity extremity intoan pain Shooting dysfunction / bladderBowel Maximum 2 Liters 2Maximum every 5 every Normal SalineBolusNormal Airway Protocol(s)Airway Pain Control ProtocolControlPain       Signs and Symptoms and Signs  Repeat as needed to effect to effectneededas Repeat Multiple Trauma ProtocolMultiple Trauma IV Procedure Hypotension / Shock Protocol/ ShockHypotension NO I Shock Instability? Hemodynamic Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO Reassess Monitor andMonitor Protocol if indicated Pain ControlPain Improvement or worsening with with or worseningImprovement activity Traumatic mechanismTraumatic painof Location Fever Past surgical historyPastsurgical Medications injurypain/ ofOnset backinjuryPrevious Age historyPastmedical         History   Back Pain

** Documentation of pain scale is mandatory. ** Have a high suspicion of Abdominal Aortic Aneurysm (AAA) if the patient is > 50 years of age and presents with flank pain if no history of Kidney stones.

**First presentation of kidney stones in patient greater than 50 y/o is rare.

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Pearls  Patients with underlying spinal deformity should be immobilized in their functional position.  Abdominal aneurysms are a concern especially in patients over the age of 50 and / or with vascular or hypertensive disease.  Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area.  Patients with midline pain over the spinous processes should be spinally immobilized.  Any bowel or bladder incontinence is a significant finding which requires immediate medical evaluation  In patient with history of IV drug abuse a spinal epidural abscess should be considered. Protocol 5 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols 2012 3 minutes3 2 mg IV/IM2 - 65 - or ≥ 500 mL bolusmL500 5 mg IM5 Age Procedure as neededas if indicated IV Procedure Cardiac Monitor Cardiac Diabetic ProtocolDiabetic Maximum 2 Liters 2Maximum 1 L then 150 mL/hrL 150then 1 Monitor andReassessMonitor Normal SalineBolusNormal depressive) Preferably 2 large bore 2 largePreferably 2.5 mg IV / IN 2.5 mg IMmgIN 2.5 IV / mg2.5 - - Lorazepam .5Lorazepam May repeatMay IV / mgIN 2.5 Midazolam External Cooling Measures CoolingExternal 1 YES Repeat every every 2 Repeat Consider Restraint PhysicalRestraintConsider I P NO Altered Mental Status differential StatusMental Altered IntoxicationAlcohol abuse/ SubstanceToxin / overdoseeffectMedication syndromesWithdrawal Depression (manicBipolar Schizophrenia disordersAnxiety Differential          - NO if indicated Agitation If indicated hyperthermia Protocol6 behavioral changebehavioral Aggressive, Violent,Aggressive, Setting of Psychosisof Setting Threat to Self or othersto Selfor Threat Head TraumaProtocolHead Notify Notify Destination or aggression, hallucination,aggression, Contact Medical ControlContact Medical Excited Delirium Syndrome Delirium Excited Exit to ProtocolAppropriate Exit Blood Glucose Analysis ProcedureAnalysisGlucoseBlood Paranoia, disorientation, hyper disorientation,Paranoia, tachycardia, increased strength,increasedtachycardia, Altered Mental Status ProtocolStatus Mental Altered Behavioral Overdose/Toxic Ingestion ProtocolIngestion Overdose/Toxic Assume patient has Medical cause of causeMedicalpatienthas Assume Anxiety, agitation, confusion agitation,Anxiety, hallucinationschange,Affect Delusional thoughts, bizarre thoughts,Delusional behavior violentCombative homicidal/ suicidalof Expression thoughts  Signs and Symptoms and Signs     YES 2 mg IV/IMmg2 - 10 minutes10 - YES 1 mg IV/IN 2.5 mg2.5 mgIM IV/IN 1 2.5 mg IV/IMmg2.5 Maximum 5 mg Maximum and and Reassess – 2.5 mg IV/IN 5 mgIV/IN 5IM mg2.5 65 – if indicated IV Procedure ≥ Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Monitor Monitor 0.5 mg0.5 Age Haloperidol 5 mg IV/IM5 mg Haloperidol Safe Scene 65 May repeatMay Monitor per restraint procedurerestraint perMonitor ≥ May 5 inrepeat doseMay resources Midazolam 1 Midazolam Consider Restraint Physical ProcedurePhysicalRestraintConsider Injury to self or threats to othersthreatsselforto Injury tag alertMedic / overdoseabuseSubstance Diabetes Situational crisisSituational illness/medicationsPsychiatric Max. .5 ormg Lorazepam10 Max. Age Revised 11/24/2014 NO Stage until scene safesceneStageuntil I     History   Call for help / additionalhelp/ forCall P Adult General Section Protocols ning in us. tat 2012 threate he - n t n Diphenhydramine / / IO / mgIMPO 50IV Diphenhydramine Protocol6 Behavioral in pediatrics.in : : 1 mg/kg IV / IO / IM / PO IMPO IV / /IO / 1 mg/kg Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Condition causing involuntary muscle movements or spasms typically of the face, neck and upper extremities. May May presentextremities.upper andface,theneck typically of spasms movementsor musclecausing involuntary Condition likedrugs antipsychotic toreaction an adverse Typically motor movements. difficulttrunkwith neck and contorted with giveWhen recognized administration.with occur your mayand Haloperidol or adults Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances,speech hallucinations, anxiety, agitation, psychomotorof delirium, Combinationemergency: Medical lifePotentiallystrength.increased and pain, hyperthermiato insensitivity violentbehavior, / bizarre disorientation, cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may alsotrauma ormay head withdrawal Alcoholagents.or similar amphetaminesmethamphetamine, cocaine,crack cocaine, and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in malein seencommonly Most Tasers.and restraintsphysical including measures, controlphysical useof with associatedand asdrugssuch particularlystimulant abuse,chronicdrugacute or and/or illnessseriousmental historyof a with subjects contribute to the condition.theto contribute Excited Delirium Syndrome Delirium Excited Do not irritate the patient with a prolongedexam. a with patientthe Do irritate not abuse.childor violencedomestic associated of possibilitythe Do overlook not earlybicarbonatesodiumandfluidbolusa arrest, consider cardiac suffersdeliriumagitated of suspected ispatient If s or circulatoryrespiratory patientstheimpact could way athat suchis patient restrainedany transport or Do position not scene or immediately theirupon arrival. or immediately scene headhypoxia, abuse,substance overdose,behavior(hypoglycemia, for causesmedical/trauma possibleconsiderallsureto Be etc.)injury, enforcement in the ambulance.in enforcement withpresumedfor patientsa benzodiazepineof or psychosis patientswithhistory for or Ziprasidone HaldolConsider abuse.substance personnelby on ALS observed bemustrestraint continuously or chemicalphysical either whoreceive All patients Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Heart,Status,Skin, Lungs, MentalExam: Recommended priority. ismain the safety / respondersCrew by lawaccompaniedbeby must EMS transported and Lawor restrainedEnforcement handcuffedby patientwhois Any Extrapyramidal reactions Extrapyramidal Revised 8/13/2012       Pearls       Transport to DRMC to be considered if at all possible. If transported to another facility an explanation needs to be given i togiven beneeds explanation an facilityto anothertransported If possible. at ifall considered be DRMC to to Transport Guidelines.OperationICEMS This isper documentation. Pain Control: Adult

History Signs and Symptoms Differential  Age  Severity (pain scale)  Per the specific protocol  Location  Quality (sharp, dull, etc.)  Musculoskeletal  Duration  Radiation  Visceral (abdominal)  Severity (1 - 10)  Relation to movement, respiration  Cardiac  If child use Wong-Baker faces scale  Increased with palpation of area  Pleural / Respiratory  Past medical history  Neurogenic  Medications  Renal (colic)  Drug allergies

Enter from Protocol based on Specific Complaint

Assess Pain Severity Use combination of Pain Scale, Circumstances, MOI, Injury or Illness severity

Mild Moderate to Severe

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Consider IV Procedure Cardiac Monitor c

I t i Morphine 4 mg (0.1 mg/kg) IV / IM / IO o

Monitor and Reassess n

Repeat 2 mg every 10 minutes as needed. P

Maximum 10 mg r

Or o Fentanyl 50 - 100 mcg IN / IV / IM / IO t P o Repeat 50 mcg every 10 minutes as c

needed o l Maximum 200 mcg s

Monitor and Reassess Every 10 minutes following sedative Monitor and Reassess

Notify Destination or Contact Medical Control

Protocol 7 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2015 Pain Control: Adult

Documentation of pain scale is required.

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Pearls  Recommended Exam: Mental Status, Area of Pain, Neuro  Pain severity (0-10) is a vital sign to be recorded before and after PO, IV, IO or IM medication delivery and at patient hand off. Monitor BP closely as sedative and pain control agents may cause hypotension.  Both arms of the treatment may be used in concert. For patients in Moderate pain for instance, you may use the combination of an oral medication and parenteral if no contraindications are present.  Vital signs should be obtained before, 10 minutes after, and at patient hand off with all pain medications.  All patients who receive IM or IV medications must be observed 15 minutes for drug reaction in the event no transport occurs.  Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture deformities, headaches, or abdominal pain.  Ketorolac (Toradol) and Ibuprofen should not be used in patients with known renal disease or renal transplant, in patients who have known drug allergies to NSAID's (non-steroidal anti-inflammatory medications), with active bleeding, headaches, abdominal pain, stomach ulcers or in patients who may need surgical intervention such as open fractures or fracture deformities.  Do not administer Acetaminophen to patients with a history of liver disease.  Burn patients may required higher than usual opioid doses to effect adequate pain control Protocol 7 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols 2012 out - Extend Extend Extend Improve Improve Responder Exit Exit to Cannot WearCannot Rehabilitation Rehabilitation Time UntilVS Time Time UntilVS Time Protocol Protective Gear Protective Responder Scene RehabilitationScene YES YES COLD STRESS COLD YES Rehydration TechniquesRehydration Measures WarmingActive 32 oz Oral Fluid over 20 minutesFluid over Oraloz 32 Active MeasuresWarmingActive – Hot packs to axilla and / or groin and/ axilla or topacks Hot of fluid between SCBA changefluidbetweenof Dry responder, place in warm areawarm in responder,place Dry 110 HR 100.6 NO 12 NO Firefighters should consume 8 ouncesconsumeshould Firefighters Oral Rehydration may occur along with with alongmay occurRehydration Oral Temp ≥ ≥ YES 80 YES ≤ YES Mat Gear, Mat Turnout Suits, - Reports for ReassignmentReports Discharge Responder fromResponder Discharge 110 or HR General Rehabilitation SectionRehabilitationGeneral 100.6 NO NO NO NO Heat Temp ≥ ≥ Reassess VS Reassess Protocol8 InitialProcess Cold stressCold (Optional) Significant InjurySignificant General Rehabilitation SectionRehabilitationGeneral Respiratory Rate < 8 or > 40 or >< 8Rate Respiratory Diastolic BloodPressureDiastolic Reassess responder after 20 Minutes in20after responderReassess YES Cardiac Complaint: Signs / SymptomsSigns/ Complaint:Cardiac Other equipment as indicatedasequipment Other Respiratory Complaint: Serious Signs / SymptomsSigns/ Serious Complaint:Respiratory out - 3. Personnel assessed for signs / signssymptomsfor assessedPersonnel 3. 1. Personnel logged into General Rehabilitation SectionintoGeneralRehabilitation loggedPersonnel1. Temp) obtain(If HR > then110 / RecordedVS Assessed2. Haz PPE, Armor,Body Remove4. Scene Rehabilitation: General Scene 160 or160 ≥ 20 Minutes 20 – 100 may need100 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 10 ≥ HEAT STRESS HEAT Active Cooling Measures CoolingActive Rehydration TechniquesRehydration Active MeasuresCoolingActive 32 oz Oral Fluid over 20 minutesFluid over Oraloz 32 VITAL SIGN VITAL CAVEATS – of fluid between SCBA changefluidbetweenof 12 Firefighters should consume 8 ouncesconsumeshould Firefighters Oral Rehydration may occur along with with alongmay occurRehydration Oral Forearm immersion, cool shirts, coolshirts,coolimmersion, Forearm fansetc.mist oral or IV hydration.ororal Temperature: have increasedmay Firefighters rehabilitation.duringtemperature extended rehabilitation. However However thisrehabilitation. extended themprevent necessarilynot does to duty. fromreturning and is not typically pathologic.typicallynotisand BP Systolicwith Firefighters BP Diastolic be interpreted in context. in interpretedbe bloodelevated have Firefighters exertion todue physical pressure Blood Pressure:Blood scenes.Must on inaccuracytoProne appropriate treatmentappropriate should be treated usingtreatedbeshould protocol beyond needforbeyond protocol Injury / Illness / Complaint/ IllnessInjury Scene Rehabilitation: General (Optional)

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Pearls  This protocol is optional and given only as an example. Agencies may and are encouraged to develop their own.  Rehabilitation officer has full authority in deciding when responders may return to duty.  May be utilized with adult responders on fire, law enforcement, rescue, EMS and training scenes.  Responders taking anti-histamines, blood pressure medication, diuretics or stimulants are at increased risk for cold and heat stress.  Rehabilitation Section is an integral function within the Incident Management System.  Establish section such that it provides shelter, privacy and freedom from smoke or other hazards.

Protocol 8 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols 2012 And Protocol Up to 2 L Up to of additional additionalof rehabilitation Important after 30 minutes30after No improvement General RehabilitationGeneral Use in conjunction with with conjunctioninUse Normal Saline IV Bolus SalineIV Normal evaluate in 10 minutes10in evaluate Systolic BP is 100 or greaterorBP is100 Systolic - Until Pulse Rate is 110 or110lessis Rate UntilPulse Rehydration is MostRehydration Mandatory RestPeriodMandatory Re I YES YES YES YES YES 100 160 100.6 ≥ ≥ ≥ Or NO NO NO NO NO Protocol9 Reports for Reports SPCO > 10 > % 10 SPCO InitialProcess fromGeneral Reassignment Systolic BP Systolic Diastolic BP Diastolic Temperature Discharge ResponderDischarge SectionRehabilitation 20 Minute RestPeriodMinute 20 Pulse oximetry <% 90oximetry Pulse Respirations < > 840 or Respirations Age Predicted Maximum Maximum PredictedAge Notify Notify Destination or Pulse Rate > 85 %> NFPA 85Rate Pulse Contact Medical ControlContact Medical Section 1. Personnel logged into Responder RehabilitationintoResponder loggedPersonnel 1. Signs OrthostaticVital/ RecordedandVS Assessed 2. available) (if andSPCO Pulseoximetry 3. / symptomssignsfor Personnelassessed 4. histamines, blood pressure medication, diuretics or stimulants are at increased risk for cold and coldfor risk increased at areor stimulants diureticsmedication, pressureblood histamines, - 132 160 155 152 148 140 136 170 165 Scene Rehabilitation: Responder (Optional) Rehabilitation: Responder Scene Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Section Continue: 65 35 40 45 50 60 25 30 55 Responders takinganti Responders stress.heat System. Management Incidentwithin the functionintegralanis Section Rehabilitation hazards.orsmoke otherfrom freedomand privacy shelter, itthat providessuch section Establish Rehabilitation officer has full authority in deciding when responders may to duty. returnmay whenrespondersdecidingauthority in full has officerRehabilitation Protocol. appropriateisRehabilitationfor General notwhen responder Utilized scenes.training andrescue, EMS lawonenforcement, fire,responderswithadult utilized May be This protocol is optional and given only as an example. Agencies may own.their to encourageddevelop are andmay Agenciesexample. an asoptionalgiven only and isprotocolThis ------Maximum Heart Heart Rate Maximum oral or IV hydration.ororal 51 from General Rehab fromGeneral 55 61 41 46 26 31 36 20 treatment techniquestreatment Heat and Cold StressColdandHeat appropriate treatmentappropriate NFPA Age % 85 Predicted Age NFPA       Pearls  should be treated usingtreatedbeshould protocol beyond needforbeyond protocol Injury / Illness / Complaint/ IllnessInjury Other equipment asequipment Other indicated Chemical Suits Chemical SCBA Gear Turnout Remove: PPE ArmorBody Adult Cardiac Section Protocols 2012 Follow Go to Protocol Return of Discontinue Circulation Resuscitation Spontaneous AT ANY TIME ANY AT Reversible CausesReversible Post ResuscitationPost Deceased SubjectsPolicyDeceased Hypovolemia Hypoxia (acidosis)ionHydrogen Hypothermia Hyperkalemia /Hypo Hypoglycemia pneumothoraxTension cardiacTamponade; Toxins pulmonaryThrombosis; (PE) coronary(MI) Thrombosis; Hypovolemia (Trauma, AAA, other)(Trauma, Hypovolemia tamponadeCardiac Hypothermia Beta(Tricyclic,Digitalis, overdose Drug channelblockers)Calciumblockers, infarction myocardialMassive Hypoxia pneumothoraxTension embolusPulmonary Acidosis Hyperkalemia NO YES Differential           → 100 / min) / 100 ≥ 10 seconds)10 ≤ IO Procedure P Or NO NO Protocol11 Cardiac Monitor Cardiac Resuscitation 2 inches) Push Fast ( Fastinches)Push 2 ≥ Shockable Rhythm Shockable Normal Saline Bolus 500 mL IV / IO IV / mL500 SalineBolusNormal Cardiac ArrestProtocolCardiac / for DeathNo Criteria Pulseless Apneic ECG onactivity No electrical on auscultationtonesNo heart Repeat every 5 minutestoevery 3 Repeat Notify Notify Destination or Vasopressin 40 units IV / IO IV units40Vasopressin Review DNR / MOSTDNR FormReview Contact Medical ControlContact Medical Criteria for DiscontinuationCriteria Search for Reversible Causes Causesfor ReversibleSearch Epinephrine (1:10,000) 1 mg IV / IO mg IV 1 (1:10,000) Epinephrine    Signs and Symptoms and Signs  Begin Continuous CPR CompressionsContinuousCPR Begin minutes2every CompressorsChange IV Procedure Consider Chest Decompression ProcedureDecompressionChestConsider Consider May replace first or second dose of epinephrinedosesecondfirstreplaceor May Push Hard ( Push (Limit changes / pulses checks/ pulseschanges(Limit I I P P YES YES Adult Asystole / Pulseless Electrical Activity Electrical Pulseless / Asystole Adult Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any life Tricyclic Digitalis blockersBeta blockersCalciumchannel Policy Follow Follow Protocol asystole Protocol Dialysis / Dialysis if indicated Rigor mortisRigor resuscitation Do beginnot RenalFailure   or LivingWill MOST, DNR, Suspected overdoseSuspected   Events leading to arrestleadingEvents renaldiseasestageEnd downtime Estimated hypothermiaSuspected Past medical historyPastmedical Medications Decomposition Dependent lividity Dependent Blunt force traumaBluntforce Deceased SubjectsDeceased Rhythm AppropriateRhythm Injury incompatible with with incompatibleInjury       History   Extended downtime with with downtime Extended Adult Asystole / Pulseless Electrical Activity

***Induced Hypothermia Therapy upon ROSC***

***Fill out the Cardiac Section of the PCR***

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Pearls  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and / or difficult IV access anticipated.  DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compressions to ventilations are 30:2. If advanced airway in place ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Breathing / Airway management after 2 rounds of compressions (2 minutes each round.)  Success is based on proper planning and execution. Procedures require space and patient access. Make room to work.  If no IV / IO, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV/IO is the preferred route when available.  Consider each possible cause listed in the differential: Survival is based on identifying and correcting the cause.  Potential association of PEA with hypoxia so placing definitive airway with oxygenation early may provide benefit.  PEA caused by sepsis or severe volume loss may benefit from higher volume of normal saline administration.  Return of spontaneous circulation after Asystole / PEA requires continued search for underlying cause of cardiac arrest.  Treatment of hypoxia and hypotension are important after resuscitation from Asystole / PEA.  Asystole is commonly an end-stage rhythm following prolonged VF or PEA with a poor prognosis.  Sodium bicarbonate no longer recommended. Consider in the dialysis / renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV / IO.  Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options.  Potential protocols used during resuscitation include Overdose / Toxic Ingestion, Diabetic and Dialysis / Renal Failure.

Protocol 11 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 ) ° , or 3 , ° , 2 , ° and / or / and Protocol Appropriate Airway Airway Appropriate Respiratory DistressRespiratory Acute myocardial infarctionmyocardialAcute Hypoxia failurePacemaker Hypothermia bradycardiaSinus Athletes StrokeICP) or (elevatedinjuryHead cordlesionSpinal syndromesinusSick (1 AV blocks Overdose Differential            YES AVB) rd IO Procedure or 3 or 5 minutes5 – nd P 20 mcg/kg/min IV / IO IV / mcg/kg/min20 NO Consider YES – Protocol12 Maximum 3 mg 3Maximum 10 mcg / min IV / IO IV / / mcgmin10 Cardiac Monitor Cardiac Symptomatic Maximum 2 LitersMaximum2 – If no clinical responseno clinicalIf Epinephrine Infusion Epinephrine Work of BreathingWorkof May as neededMay repeat Atropine 0.5 mg IV / mgIO 0.5 Atropine 1 Dyspnea / Increased/ Dyspnea Transcutaneous PacingTranscutaneous 12 Lead ECG ProcedureECG 12 Lead Repeat every every 3 Repeat especially with hypoxia with especially HR < 60/min with hypotension, acute hypotension,

Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set

For Dopamine to have a heart rate affect, higher doses may need to be applied. Doses of 2 mcg/kg/min - 5mcg/kg/min are considered to be "renal" doses however doses of 5mcg/kg/min - 10 mcg/kg/min are "cardiac" doses example: 100 kg pt x 7 mcg/min x .0375 = 26.25 gtts / min

______Epinephrine Infusion: Dose 1-10 mcg / min (must have medical control order) Mcg/min 4 mcg/ml concentration (60 gtt set) 1 ...... 15 gtt/min 2 ...... 30 gtt/min

3 ...... 45 gtt/min A

4 ...... 60 gtt/min d u

5 ...... 75 gtt/min l t

6 ...... 90 gtt/min C

7 ...... 105 gtt/min a r

8 ...... 120 gtt/min d i

9 ...... 135 gtt/min a c

10 ...... 150 gtt/min S

Dopamine 5 Mcg 10 Mcg 15 Mcg 20 Mcg e

1600Mcg c t

Lbs. Kg. gtts/min gtts/min gtts/min gtts/min 1 drip every i

o n

88 40 7.5 15 22.5 30 4 seconds = 10 mcg/min P

110 50 9.375 18.75 28.125 37.5 r o

132 60 11.25 22.5 33.75 45 t o

154 70 13.125 26.25 39.375 52.5 c

176 80 15 30 45 60 2 seconds = 10mcg/min o l 198 90 16.875 33.75 50.625 67.5 s 220 100 18.75 37.5 56.25 75 242 110 20.625 41.25 61.875 82.5 264 120 22.5 45 67.5 90 1.5 seconds = 10mcg/min 286 130 24.375 48.75 73.125 97.5 308 140 26.25 52.5 78.75 105 330 150 28.125 56.25 84.375 112.5 352 160 30 60 90 120 1 second = 10mcg/min 374 170 31.875 63.75 95.625 127.5 396 180 33.75 67.5 101.25 135 418 190 35.625 71.25 106.875 142.5 440 200 37.5 75 112.5 150

Pearls  Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro  Bradycardia causing symptoms is typically < 50/minute. Rhythm should be interpreted in the context of symptoms and pharmacological treatment given only when symptomatic, otherwise monitor and reassess.  Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount.  Atropine: Caution in setting of acute MI. The use of Atropine for PVCs in the presence of a MI may worsen heart damage. Should not delay Transcutaneous Pacing with poor perfusion. Ineffective in cardiac transplantation.  Utilize transcutaneous pacing early if no response to atropine. If time allows transport to specialty center as transcutaneous pacing is a temporizing measure and patient will likely require transvenous pacemaker.  Wide complex, bizarre appearance of complex with slow rhythm consider hyperkalemia.  Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.)  Hypoxemia is a common cause of bradycardia be sure to oxygenate the patient and support respiratory effort. Protocol 12 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS

Adult Cardiac Section Protocols 2012 Exit Exit to Protocol Appropriate Maximum 2 L 2Maximum 500 mL IV / IO IV / mL500 Repeat as neededas Repeat P Normal SalineBolusNormal Trauma vs. vs. Medical Trauma infarction vs. Myocardial Angina Pericarditis embolismPulmonary / COPD Asthma Pneumothorax aneurysmdissectionor Aortic hernia or Hiatal reflux GE spasmEsophageal painor injuryChest wall painPleural or(Cocaine) Overdose Methamphetamine NO I Differential             NO Notify Notify Destination or Contact Medical ControlContact Medical like - 10 Minutes10 ≤ STEMI STEMI YES YES if capableif Exit Exit to Edema Edema Protocol symptoms Lung Exam: Lung Reperfusion ChecklistReperfusion Transport based on: on: basedTransport / CHF Pulmonary Dyspnea / Atypical/ Dyspnea Adult CHF / Pulmonary Adult/ CHF If transporting to Non PCI toCenter transportingIf Suspect cardiac etiologycardiacSuspect Protocol14 Immediate Transmission of of ECG TransmissionImmediate EMS Triage and Destination Plan DestinationandTriageEMS Immediate Notification of FacilityNotificationImmediate Keep Scene Time to SceneTimeKeep B CP (pain, pressure, aching, vice pressure,aching,CP (pain, tightness) arm, epigastric,(substernal,Location shoulder) neck,jaw, of painRadiation Pale,diaphoresis of breathShortness dizzinessvomiting,Nausea, Onset of Time NO YES       Signs Symptoms and  NO eferred IO Procedure 100) Chest Pain: Cardiac and STEMI 100 R ≥ 75 mcgIV / 75IO ≥ Or Or - P needed. 4 mg (0.1 mg/kg) IV / IO mg/kg)IV (0.1/ 4 mg NO 325 mg PO mg325 YES – YES rovocation 2 ContiguousLeads)2 10) Or Or P Maximum 10 mg 10Maximum Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any - and (BP and SBP > 100 1 inch SBP > 100 2 inch SBP > 200 adiation / adiation Cardiac Monitor Cardiac New LBBB New SBP > 150 1.5 inch1.5 SBP > 150 ChestPain Nitroglycerin PasteNitroglycerin ≥ R Acute MI / MISTEMIAcute Systolic BP Systolic if prescribed to patientto if prescribed 12 Lead ECG ProcedureECG Lead12 Fentanyl 50Fentanyl with cardiacetiologywith Repeat every 5 minutes x x minutes3 every 5 Repeat Nitroglycerin SL / mg0.30.4 Nitroglycerin Repeat every 5 minutes as neededas minutesevery 5 Repeat Aspirin 81 mg x 4 (chewed)mg PO 81x Aspirin uality (crampy, constant, sharp,(crampy,ualityconstant, egion / egion everity (1 everity alliation / alliation (STEMI = 1 mm ST Segmentmm= (STEMI 1 ime (onset /duration / repetition)(onset/durationime Repeat 25 mcg every 10 minutesas 10every 25 mcgRepeat Signs / Symptoms consistent/ SymptomsSigns Repeat every 10 minutes as needed.as every minutes10Repeat Morphine 2 Morphine dull, etc.)dull, R S T Recent physical exertion exertion physicalRecent P Q Levitra / vardenafil, Cialis / tadalafil)Cialisvardenafil,/ Levitra Angina,history(MI, Pastmedical postmenopausal) Diabetes, Allergies Age / sildenafil,(ViagraMedications IV Procedure Nitroglycerin Sublingual/ mg0.30.4 Nitroglycerin Elevation Revised 11/24/2014 I I     History       P P B Adult Cardiac Section Protocols 2012 P.) - Protocol14 ICEMS utilizes the "STEMI RED &STEMI forcounty &STEMI GREEN" in"STEMI RED thepolicy utilizes ICEMS -- Lead ECG in the PCR as a Procedure along with the interpretation (EMT interpretation with the along a Procedure PCR as ECG in the Lead - Elevation Myocardial Infarction)Reperfusion should or positiveMyocardial Checklist beElevation - Chest Pain: Cardiac and STEMI Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any B may administer Nitroglycerin to patients already prescribed medication. May give from EMSsupply. give medication. prescribed May toadminister patients Nitroglycerin may already B - Document the time of the 12 the of timethe Document EMT administration. Control to Medical prior of may director medical Contact require Agency Monitor for hypotension after administration of nitroglycerin and narcotics (Morphine, Fentanyl, or Dilaudid). Fentanyl, (Morphine, narcoticsnitroglycerin and administration of after Monitor forhypotension guidelines. dosing per repeated be may Nitroglycerin opioids and complaints. generalized or only atypical pain, have often patients female geriatric and Diabetics, transportedDestination to based on theand STEMI appropriate EMSTriage facility Plan. MI.aVF) resultingIf from CHF Consider Right If STV4). / Cardiogenicinferior (II, III, shock or ECG (V3 Sided hypotension boluses.requiring normal saline noted cause or may Nitroglycerin opioidselevationand / medication. the of potency consider relief, nitroglycerin without taken has patient If Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil)in the past 24 or (sildenafil) Levitra used Viagra patientany Avoid Nitroglycerin who in has hypotension. hours (tadalafil)36 dueCialis hours to or in the potential past severe STEMI(ST Patients with Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Neuro Lung, Abdomen, Extremities, Neck, Heart, Back, RecommendedStatus,Skin, Mental Exam: for (STEMI)the indicators Acute performance Cardiac EMSCare theToolkitRed key are Items in Text Revised 11/24/2014          Pearls    **A new onset of RBBB maybe more specific for an MI and place more myocardial tissue at risk than a new onset LBBB onsetthana new risk attissue moremyocardialplaceandfor MI an morespecific onsetmaybeRBBB new of **A **Iredell memorial Hospital is the only in county facility that is currently participating. currentlyisparticipating.facility thatonlycounty the in isHospital memorial**Iredell or BypassProtocol facilityPCI closest theforPlan Destination STEMI Triage **Follow **Recommended to transfer to an appropriate facilityappropriateantoto transfer **Recommended capabilities. Adult Cardiac Section Protocols 2012 90 ≥ Protocol Dopamine if in placeif in if indicated Protocol(s) bradycardia hypotension AdultAirway if indicated Remove CPAP Remove 20 mcg/kg/min IV / IO IV mcg/kg/min20 Titrate to SBP Titrate – Airway Protocol(s)Airway Chest Pain and STEMI and ChestPain 2 Tachycardia followed by by followed Tachycardia CARDIOGENIC SHOCK CARDIOGENIC Hypertension followed by by followed Hypertension Myocardial infarction Myocardial failureheartCongestive Asthma Anaphylaxis Aspiration COPD effusionPleural Pneumonia embolusPulmonary tamponadePericardial Exposure Toxic I P Differential            NO IO Procedure P YES Afebrile (BP >100) ONLY IF ONLY Sublingual Furosemide 40IV mg Furosemide Elevated BP Elevated Cardiac Monitor Cardiac Airway PatentAirway if indicated SBP > 100 1 inch SBP > 100 Protocol15 Nitroglycerin PasteNitroglycerin SBP > 200 2 inchesSBP > 200 This space left blankspace leftThis intentionally Elevated Heart Rate Elevated inches1.5 SBP > 150 Airway Protocol(s)Airway Repeat every minutesevery 5 Repeat Airway CPAP ProcedureAirway Ventilations adequateVentilations 12 Lead ECG ProcedureLeadECG 12 Oxygenation adequateOxygenation MODERATE / MODERATE SEVERE Nitroglycerin / mg0.30.4 Nitroglycerin Known CHF / Daily Lasix CHF / DailyKnown Repeat every 5 minutes x x minutes3 every 5 Repeat Assess SymptomSeverity Assess if prescribed to patientand to if prescribed Notify Notify Destination or Nitroglycerin SL / mg0.30.4 Nitroglycerin Transport time > 30 minutes> 30time Transport Contact Medical ControlContact Medical Consider IV Procedure Respiratory distress,Respiratory rales bilateral orthopneaApprehension, distentionveinJugular frothy sputumPink, diaphoresisedema,Peripheral shockHypotension, Chestpain I I P P B       Signs and Symptoms and Signs  YES NO CHF / Pulmonary CHF / Pulmonary Edema past myocardialpast -- YES MILD Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Improving SBP > 100 1 inch SBP > 100 Nitroglycerin PasteNitroglycerin 2 inchesSBP > 200 SBP > 150 1.5 inches1.5 SBP > 150 Signs / SymptomsSigns Pulmonary EdemaPulmonary Normal Heart RateNormal consistent with CHF / with consistent Repeat every minutesevery 5 Repeat Elevated or Normal BP or NormalElevated Nitroglycerin SL / mg0.30.4 Nitroglycerin infarction Medications (digoxin, Lasix, Lasix, (digoxin, Medications / Levitra / sildenafil,Viagra tadalafil)/ Cialisvardenafil, historyCardiac Congestive heart failureheart Congestive historyPastmedical I   History   Adult Cardiac Section Protocols . 2012 1 second = = 10mcg/min 1 second 4 seconds = mcg/min= 10 4 seconds 2 seconds = = 10mcg/min 2 seconds 1 drip every 1 drip 1.5 seconds = seconds = 10mcg/min 1.5 135 142.5 150 gtts/min 127.5 30 45 60 75 90 105 120 Protocol15 95.625 95.625 101.25 106.875 112.5 gtts/min 61.875 82.5 61.875 67.5 97.5 73.125 78.75 112.5 84.375 90 22.5 37.5 28.125 33.75 52.5 39.375 45 67.5 50.625 56.25 63.75 63.75 67.5 71.25 75 gtts/min 45 52.5 60 15 18.75 22.5 30 37.5 CHF / Pulmonary CHF / Pulmonary Edema 28.125 56.25 28.125 30 31.875 33.75 35.625 37.5 15 33.75 16.875 18.75 41.25 20.625 22.5 48.75 24.375 26.25 gtts/min 7.5 9.375 11.25 26.25 13.125 5 Mcg 10 Mcg 15 Mcg 20 Mcg 20 Mcg 15 Mcg10 Mcg5 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any paste is used, do not continue to use Nitroglycerin use Nitroglycerin SL. to continue not do is used, paste - B may administer Nitroglycerin to patients already prescribed medication. May give from EMSsupplygive medication. prescribed May toadminister patients Nitroglycerin may already B - 150 160 170 180 190 200 80 90 100 110 120 130 140 Kg. 40 50 60 70 Agency medical director may require Contact of Medical Control. Medical of may director medical Contact require Agency Allow the patient to be in their position of comfort to maximize their breathing effort.maximizecomfortto breathing their of position in their be to patient Allow the Lead 12 the ECG using Lead 12 PCR. Document the in procedureCPAP the using application CPAP Document ECG procedure. EMT Contraindications to opioids include severe COPD and respiratory distress. Monitor the patient closely. patient Monitor the respiratory COPD and distress. severe include opioids to Contraindications pain, atypical have often patients female geriatric and Diabetics, patients. these myocardial all Consider infarction in complaints. generalized or only elevation noted Nitroglycerin and / or opioids may cause hypotension boluses. requiring normal saline noted cause or may Nitroglycerin opioidselevationand / Nitro If medication. the of potency consider relief, nitroglycerin without taken has patient If hours or Cialis (tadalafil) in the past 36 hours due to potential severe hypotension. hours (tadalafil)36 dueCialis hours to or in the potential past severe interventions.thestatus above with and respiratory BP, of monitor consciousness, Carefully the level MI.aVF) resultingIf from CHF Consider Right If STV4). / Cardiogenicinferior (II, III, shock or ECG (V3 Sided edema. Even though this historically has been a mainstay of treatment, EMS it is nomainstay longer routinely been a though has Even thishistorically edema. recommended. (vardenafil)in the past 24 or (sildenafil) Levitra used Viagra patientany Avoid Nitroglycerin who in has Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Neuro Lung, Abdomen, Extremities, Neck, Heart, Back, RecommendedStatus,Skin, Mental Exam: and care protocol compliance used to evaluate measures performance key Red are Items in Text NOTtothebeen shown outcomes ofimprovepatientspulmonary have EMS Furosemide and Opioids with               Pearls 440 352 374 396 418 286 308 330 220 242 264 132 154 176 198 88 110 Dopamine 1600Mcg Lbs. Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set agtt 60with X 0.0375=gtts/minkg Patientin Weight dose X Desired 1600forconcentration:Formula a Dopamine gtts/ min= 26.25 0.0375 x 7 mcg/minx ptkg 100 example: Adult Tachycardia Narrow Complex (≤ 0.11 sec) History Signs and Symptoms Differential  Medications  Heart Rate > 150  Heart disease (WPW, Valvular) (Aminophylline, Diet pills, Thyroid  Systolic BP < 90  Sick sinus syndrome supplements, Decongestants,  Dizziness, CP, SOB, AMS,  Myocardial infarction Digoxin) Diaphoresis  Electrolyte imbalance  Diet (caffeine, chocolate)  CHF  Exertion, Pain, Emotional stress  Drugs (nicotine, cocaine)  Potential presenting rhythm  Fever  Past medical history Atrial/Sinus tachycardia  Hypoxia  History of palpitations / heart racing Atrial fibrillation / flutter  Hypovolemia or Anemia  Syncope / near syncope Multifocal atrial tachycardia  Drug effect / Overdose (see HX) Ventricular Tachycardia  Hyperthyroidism  Pulmonary embolus Unstable / Serious Signs and Symptoms NO YES Cardioversion Procedure HR Typically > 150 Narrow / Regular: 50 -100 J Narrow / Irregular: 120 - 200 J B 12 Lead ECG Procedure May repeat if needed and I IV Procedure P IO Procedure P increase dose with subsequent P Cardiac Monitor shocks Consider Sedation pre-shock Midazolam 0 - 2.5 mg IV / IO Regular Rhythm Irregular Rhythm May repeat if needed

(SVT) (Atrial Fibrillation / Flutter) Maximum 5 mg A

P Attempt Vagal Maneuvers Consider Exit to d

Adenosine 6 mg IV / IO Appropriate u l Rapid push Protocol t P May repeat 12 mg IV / IO X 2 C

Rhythm Converts YES a

doses if needed r

May aid rhythm identification d

NO i

a c Adenosine 6 mg IV / IO Rapid push S P YES Rhythm Converts Single lead ECG able to e

May repeat 12 mg IV / IO X 2 c diagnose and treat arrhythmia doses if needed t

NO i o

12 Lead ECG not necessary to n

Diltiazem 20 mg IV / IO diagnose and treat, but preferred P ≥

Rhythm Converts r YES If age 60 give 10 mg then when patient is stable.

repeat 10 mg in 5 minutes o t

NO if SBP ≥ 100 o

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Diltiazem 20 mg IV / IO l If age ≥ 60 give 10 mg then s repeat 10 mg in 5 minutes P if SBP ≥ 100 If rate not controlled repeat bolus in 15 minutes This space left blank intentionally Diltiazem 25 mg IV / IO If age ≥ 60 give 15 mg then P repeat 10 mg in 5 minutes If rate not controlled repeat ≥ bolus in 15 minutes if SBP 100 Diltiazem 25 mg IV / IO Increase infusion to 10 mg / hr If age ≥ 60 give 15 mg then repeat 10 mg in 5 minutes Rhythm Converts / ≥ YES B 12 Lead ECG Procedure if SBP 100 Rate Controlled Increase infusion to 10 mg / hr NO Notify Destination or Contact Medical Control Protocol 16 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Tachycardia Narrow Complex (≤ 0.11 sec) Dilitiazem - 20 mg is average adult dose. Actual dose is 0.25 mg/kg of actual body weight. Repeat dose is 0.35 mg/kg

Consider Atrial Flutter if ventricular rate is around 150 bpm. Atrial Flutter waves are usually around 300 bpm (range is 240-340 bpm)

with the ventricular rate at about 1/2 the atrial rate (150 bpm)

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Pearls  Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE.  If at any point patient becomes unstable move to unstable arm in algorithm.  Symptomatic tachycardia usually occurs at rates of 120 -150and typically ≥150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF.  Serious Signs / Symptoms: Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute CHF.  Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.  If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g. Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available.  Typical sinus tachycardia is in the range of 100 to (200patient’s - age) beats per minute.  Regular Narrow-Complex Tachycardias: Vagal maneuvers and adenosine are preferred. Vagal maneuvers may convert up to 25 % of SVT. Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush. Agencies using both calcium channel blockers and beta blockers need choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia / hypotension.  Irregular Tachycardias: First line agents for rate control are calcium channel blockers or beta blockers. Agencies using both calcium channel blockers and beta blockers need choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia / hypotension. Adenosine may not be effective in identifiable atrial fibrillation / flutter, yet is not harmful and may help identify rhythm.  Synchronized Cardioversion: Recommended to treat UNSTABLE Atrial Fibrillation, Atrial Flutter and Monomorphic-Regular Tachycardia (VT.)  Monitor for hypotension after administration of Calcium Channel Blockers or Beta Blockers.  Monitor for respiratory depression and hypotension associated with Midazolam.  Continuous pulse oximetry is required for all SVT patients.  Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

Protocol 16 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Cardiac Section Protocols 2012 shock - 2.5 mg IV / IO mg2.5 IV - Exit Exit to Protocol Appropriate Appropriate Maximum 5 mgMaximum5 increase dose with with doseincrease subsequent shockssubsequent May neededrepeatif May Wide / Regular: 100 J 100/ WideRegular: Wide / Irregular: 200 J 200/ WideIrregular: Cardioversion ProcedureCardioversion diagnose and treat, but treat,and diagnose May andneededrepeat if May Single lead ECG ableto ECG leadSingle Consider Sedation pre SedationConsider Midazolam 0 Midazolam 12 Lead ECG not necessary to necessary notLeadECG 12 preferred when patient is stable.is patientwhen preferred Heart disease (WPW,Valvular)diseaseHeart syndromesinusSick infarction Myocardial imbalanceElectrolyte stressEmotional Pain,Exertion, Fever Hypoxia or AnemiaHypovolemia (seeHX) / Overdoseeffect Drug Hyperthyroidism embolusPulmonary diagnose and treat arrhythmia treatand diagnose P YES Sulfate Differential            2 gm IV / gmIO 2 IV Magnesium Over 2 minutesOver P Procedure Cardioversion YES Irregular Rhythm Irregular Follow Unstable Arm UnstableFollow Rhythm Converts Rhythm (Torsade de pointes)de(Torsade Polymorphic ComplexPolymorphic P NO Protocol17 Exit Exit to Atrial/Sinus tachycardiaAtrial/Sinus / flutterAtrialfibrillation atrialtachycardiaMultifocal TachycardiaVentricular Protocol Adult VF / AdultVF after rhythm conversionrhythmafter Pulseless VT VT Pulseless Notify Notify Destination or 12 Lead ECG ProcedureLeadECG 12 Heart Rate > 150RateHeart BP <90 Systolic AMS, CP, SOB, Dizziness, Diaphoresis CHF rhythm presentingPotential Contact Medical ControlContact Medical IO Procedure     Signs and Symptoms and Signs  excitation - Control B P Adult Adult Tachycardia (Pre Contact Medical Contact AtrialFibrillation) Irregular Rhythm Irregular Monomorphic ComplexMonomorphic Cardiac Monitor Cardiac Wide Complex (≥0.12 sec) (≥0.12 Complex Wide YES 12 Lead ECG ProcedureLeadECG 12 YES HR Typically > 150 Typically >HR IV Procedure NO Unstable / Serious Signs and SymptomsSignsandSerious / Unstable I B P if neededif 12 mg IV / mgIO 12 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO response Consider (VT (VT or Rapidpush D5W IV / IO D5W Amiodarone Amiodarone If no responseIf (Aminophylline, Diet pills, Thyroid Thyroid pills,Diet (Aminophylline, Decongestants,supplements, Digoxin) Over 10 minutes 10 Over NO Rhythm Converts Rhythm X dosesX 2 May repeat x 1norepeat ifx May Regular Rhythm Regular 150 mg in 100 mL of in 100mg150 Rhythm Converts Rhythm 1 mg/min (33mL / hr) mg/min(33mL/ 1 Adenosine 6 mg IV / IO IV 6/ mgAdenosine SVT aberrancy)SVT with May repeatMay Past medical historyPastmedical / racingheartpalpitations of History / syncopenear Syncope Diet (caffeine, chocolate)(caffeine,Diet cocaine)Drugs(nicotine, Medications 450 mg / 250 mL of D5W/ mL 250 mg450 Monomophic ComplexMonomophic Revised 8/13/2012 P P      History  Adult Tachycardia Wide Complex (≥0.12 sec)

The use of Adenosine is contraindicated in Atrial Fibrillation with wide complex. It is unlikely to convert the A-fib and may cause A d

ventricular fibrillation. u

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Aberrant conduction is the most common reason for a widened QRS duration in SVT, but it is still much less common that in V-Tach C a

Amiodarone Infusion: r d

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Dilute 2 gms (4 mL) of Magnesium Sulfate with 6 mL of NS = 2 gms Magnesium Sulfate in 10 mL Normal Saline P

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Pearls  Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE.  If at any point patient becomes unstable move to unstable arm in algorithm.  Symptomatic tachycardia usually occurs at rates of 120 – 150 and typically ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF.  Serious Signs / Symptoms: Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute congestive heart failure.  Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.  If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g., Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available.  Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.  Typical sinus tachycardia is in the range of 100 to (220 – patients age) beats per minute.  Regular Wide-Complex Tachycardias: Unstable condition: Immediate cardioversion or pre-cordial thump if defibrillator not available. Stable condition: Typically VT or SVT with aberrancy. Adenosine may be given if regular and monomorphic and if defibrillator available. Verapamil contraindicated in wide-complex tachycardias. Agencies using Amiodarone, Procainamide and Lidocaine need choose one agent primarily. Giving multiple anti-arrhythmics requires contact of medical control. Atrial arrhythmias with WPW should be treated with Amiodarone or Procainamide  Irregular Tachycardias: Wide-complex, irregular tachycardia: Do not administer calcium channel or beta blockers, adenosine as this may cause paradoxical increase in ventricular rate. This will usually require cardioversion. Contact medical control. PearlsPolymorphic / Irregular Tachycardia:  Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  This situation is usually unstable and immediate defibrillation is warranted. If patientWhen has associated history or with 12 Leadprolonged ECG QTreveals this isWolfe likely Parkinson Torsades Whitede pointes: (WPW), Give DO 2 NOT gm of administer Magnesium a Calcium Sulfate slow Channel Blocker (e.g., Diltiazem) or Beta Blockers.  IV / IO. AdenosineWithout may prolonged not be effective QT likely in identifiablerelated to ischemiaatrial flutter/fibrillation, and Magnesium yet mayis not not harmful. be helpful.  Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers.  Monitor for respiratory depression and hypotension associated with Midazolam.  ContinuousMonitor for respiratory pulse oximetry depression is required and hypotension for all SVT associated Patients. with Midazolam.  Continuous pulse oximetry is required for all SVT Patients.  Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.  FollowDocument manufacture's all rhythm changes recommendations with monitor concerningstrips and obtain defibrillation monitor strips/ cardioversion with each therapeuticenergy when intervention. specified.

Revised Protocol 17 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 Consider 2g IV / 2gIO Exit Exit to Protocol if indicated over 2 minutes 2over Dialysis / RenalDialysis Defibrillate 200 J200 Defibrillate Failure ProtocolFailure Magnesium Sulfate Sulfate Magnesium Tosades de pointsde Tosades PostResuscitation Low MagnesiumStatesLow (Malnourished / alcoholic)/ (Malnourished P Suspected Digitalis Toxicity DigitalisSuspected Asystole Failure/ DeviceArtifact Cardiac / Medicine Endocrine Drugs Pulmonary ) - YES ) Differential       100 / min) / 100 100 / min) / 100 ≥ 10 seconds10 ≥ 10 seconds10 ≤ ≤ IO Procedure 150 mg IV / mgIO 150 Or P if no responsenoif AND AND / OR Defibrillate 200 J 200 Defibrillate Defibrillate 300 J 300 Defibrillate J 360 Defibrillate 2 inches) Push Fast ( Fastinches)Push 2 2 inches) Push Fast ( Fastinches)Push 2 If Rhythm If RefractoryRhythm Airway Protocol(s)Airway Protocol18 ≥ during compressions.during ≥ Repeat every 5 minutestoevery 3 Repeat Lidocaine 1.5 mg/kg IV / IO mg/kg1.5Lidocaine Amiodarone 300 mg IV / mgIO 300 Amiodarone Notify Notify Destination or May repeatat May Vasopressin 40 units IV / IO IV units40Vasopressin Contact Medical ControlContact Medical to defibrillate with device charged.withto defibrillate Epinephrine (1:10,000) 1 mg IV / IO mg IV 1 (1:10,000) Epinephrine Repeat pattern during resuscitation.duringpatternRepeat Return of Spontaneous CirculationSpontaneousofReturn High Quality, Continuous CompressionsContinuousQuality,High May repeat ½ initial dose in no in response doseinitialrepeat½ May Begin Continuous CPR CompressionsContinuousCPR Begin minutes2every CompressorsChange IV Procedure Begin Continuous CPR CompressionsContinuousCPR Begin minutes2every CompressorsChange arrhythmics VasopressinEpinephrine/ / arrhythmics Unresponsive, apneic, pulselessapneic,Unresponsive, ventricularorfibrillation Ventricular EKG on tachycardia May replace first or second dose of epinephrinedosesecondfirstreplaceor May Limit changes / pulses checks/ pulseschangesLimit Continue CPR and give Agency Anti Agency specificgive andCPR Continue Push Hard ( Push ( Continue CPR up to point where you are ready ready arewhereto you point up CPR Continue Limit changes / pulses checks/ pulseschanges Limit Push Hard ( Push ( Ventricular Fibrillation Ventricular  Signs Symptoms and  I P P P NO Pulseless Ventricular Tachycardia Ventricular Pulseless Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Consider Defibrillate 200 J 200 Defibrillate Go to Protocol Discontinuation Return of Intentionally left blankleftIntentionally Intentionally left blankleftIntentionally Circulation Spontaneous Cardiac ArrestProtocolCardiac Medications to arrestleadingEvents Dialysis/ Renalfailure form or MOST DNR Estimated down timedown Estimated HistoryPastMedical of Resuscitation PolicyResuscitationof AT ANY TIME ANY AT Post ResuscitationPost     History   P P P Ventricular Fibrillation Pulseless Ventricular Tachycardia

***Induced Hypothermia Therapy upon ROSC***

***Fill out the Cardiac Section of the PCR***

Consider going straight to Debrillation at 360J for unwitnessed arrest in VF/Pulseless VT

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Pearls  Recommended Exam: Mental Status  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and difficult IV anticipated.  DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compressions to ventilations are 30:2. If advanced airway in place ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Breathing / Airway management after second shock and / or 2 rounds of compressions (2 minutes each round.)  Avoid Procainamide in CHF or prolonged QT.  Effective CPR and prompt defibrillation are the keys to successful resuscitation.  If no IV / IO, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available.  Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.  Do not stop CPR to check for placement of ET tube or to give medications.  If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5 defibrillation sequences have been completed.  Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions.  Sodium bicarbonate no longer recommended. Consider in the dialysis / renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV / IO.  Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. Protocol 18 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 Utilized Protocol if available This space left blankspace leftThis intentionally Refer to AppropriatetoRefer Chest Pain and ChestPain Arrhythmia Protocol(s)Arrhythmia STEMI ProtocolSTEMI Destination Plan Destination Continue AntiarrhythmicContinue Induced HypothermiaInduced STEMI Triage andEMS STEMI P Continue to address specificaddressto Continue thewith originalassociateddifferentials dysrhythmia P Differential  NO YES YES IO Procedure 12 / minute12 45 mmHg 45 – – 94 % 94 if indicatedif ≥ P 75 mcg IV / IO bolusIV mcg/ 75 NO NO NO And / Or / Or And NO YES – As neededAs STEMI / STEMI ROSC with with ROSC Cardiac Monitor Monitor Cardiac Hypotension Suspicion of MI of Suspicion Maximum 200 mcg 200Maximum Systolic BP < 90Systolic Protocol19 Versed 2.5 mg IV / IO IV / mg2.5 Versed Follows CommandsFollows 12 Lead ECG ProcedureLeadECG 12 Antiarrhythmic given Antiarrhythmic Notify Notify Destination or Consider Sedation / Paralysis SedationConsider Symptomatic BradycardiaSymptomatic Monitor Vital Signs / ReassessSigns/ VitalMonitor Return of pulseofReturn Contact Medical ControlContact Medical Maintain SpO2 Maintain airway Advanced 35 ideallyETCO2 8 Rate Respiratory Device ThresholdImpedanceRemove HYPERVENTILATE NOT DO May neededminutesif 5repeat in May Repeat Primary AssessmentPrimary Repeat Fentanyl 50Fentanyl May repeat 25 mcg every every minutes10mcgrepeat 25 May Use only with definitive airway placeairway in with onlydefinitive Use This Time This Signs/Symptoms  Optimize VentilationOxygenation andOptimize       YES P IV Procedure March 2016 March NO YES I P B B Post Post Resuscitation 90 ≥ Dopamine after ROSC after Maximum 2 L 2Maximum follow Rhythm follow Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Protocol 20 mcg/kg/min IV / IO IV mcg/kg/min20 Titrate to SBP Titrate Bradycardia; if lungs remain clearremainlungs if Appropriate ProtocolAppropriate Pulse PresentPulse If ArrhythmiaPersistsIf May repeatneededasMay – and usually self limitingselfusuallyand Arrhythmias are commonareArrhythmias 2 NOT Utilized in Iredell County At County in Iredell Utilized NOT Respiratory arrestRespiratory arrestCardiac Normal Saline Bolus 500 mL IV / mLIO 500 SalineBolusNormal Revised 11/24/2014 I History   P Adult Cardiac Section Protocols 2012 1 second = = 10mcg/min 1 second 4 seconds = mcg/min= 10 4 seconds 2 seconds = = 10mcg/min 2 seconds 1 drip every 1 drip 1.5 seconds = seconds = 10mcg/min 1.5 resuscitation care. resuscitation - arrest patient including hypothermia therapy, therapy, hypothermia including patient arrest - 135 142.5 150 gtts/min 127.5 30 45 60 75 90 105 120 90. Ensure adequate fluid resuscitation is ongoing. is resuscitation fluid adequate Ensure 90. resuscitation but will usually normalize. While goal is goal normalize.While usually butresuscitation will - ≥ Protocol19 95.625 95.625 101.25 106.875 112.5 gtts/min 61.875 82.5 61.875 67.5 97.5 73.125 78.75 112.5 84.375 90 22.5 37.5 28.125 33.75 52.5 39.375 45 67.5 50.625 56.25 This Time This March 2016 March Post Post Resuscitation 63.75 63.75 67.5 71.25 75 gtts/min 45 52.5 60 15 18.75 22.5 30 37.5 resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and and pneumothorax, hypovolemia, hyperventilation, include hypotension resuscitation - resuscitation patients fluctuates rapidly and continuously, and they monitoring. close require they and continuously, rapidly and fluctuates patients resuscitation - resuscitation management may best be planned in consultation with with control. medical consultation in planned bestmay be management resuscitation - 28.125 56.25 28.125 30 31.875 33.75 35.625 37.5 15 33.75 16.875 18.75 41.25 20.625 22.5 48.75 24.375 26.25 gtts/min 7.5 9.375 11.25 26.25 13.125 5 Mcg 10 Mcg 15 Mcg 20 Mcg 20 Mcg 15 Mcg 10 5 Mcg Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 45 mmhyperventilation. Hg avoid45 – 150 160 170 180 190 200 80 90 100 110 120 130 140 Kg. 40 50 60 70 NOT Utilized in Iredell County At At County Iredell in Utilized NOT Titrate Dopamine or other vasopressors to maintain SAP maintainto SAP vasopressors other or Dopamine Titrate Appropriate post Appropriate post of causes Common drugs. ALS to reaction medication Consider transport to facility capable of managing the post of managing capable transport toConsider facility service. care catherterization and intensive cardiac will resuscitation assistance. ventilatory post require immediately Most patients post of condition The resuscitation phase and must be avoided at all costs. and must be avoided phaseresuscitation post immediately be elevatedmay Initial tidal End CO2 35 Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Heart, Abdomen, Neuro Lungs, Skin, Extremities, Recommended Status,Neck, Mental Exam: during post arrest of cardiac potentialcause for Continue to search the post arrest in of hypotension of cardiac significantand cause recurrence a Hyperventilation is Revised 11/24/14         Pearls  440 352 374 396 418 286 308 330 220 242 264 132 154 176 198 88 110 Dopamine 1600Mcg Lbs. Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set agtt 60with X 0.0375=gtts/minkg Patientin Weight dose X Desired 1600forconcentration:Formula a Dopamine / min 26.25 gtts .0375 = x 7 mcg/min x ptkg 100 example: Adult Cardiac Section Protocols 2012 Post Exit Exit to Cooling Protocol intentionally Continue Resuscitation This space left blankspace leftThis arrest cooling arrest Consider Consider - Intra P This space left blankspace leftThis intentionally (Begin coolASAP) fluids(Begin F (33.3 C) F (33.3 92 ≥ Continue to address specific differentialsspecificaddressto Continue arrhythmia thewith associated NO NO Differential  90 ≥ 34C) – 75 mcg IV / IO bolusIV mcg/ 75 20 mcg/kg/min IV / IO IV / mcg/kg/min20 And / Or / Or And YES YES – – Maximum 2 L 2Maximum 93.2 F (34C) 93.2 and groin areas groinand 30 mL/kg IV / IO mL/kgIV 30 with mmHg> 20with EtCO2 Temperature Titrate to SBP Titrate Maximum 200 mcg 200Maximum ≥ Shivering noted Shivering Protocol20 Reassess RectalReassess Versed 2.5 mg IV / IO IV / mg2.5 Versed Circulation ROSC Circulation Versed 2.5 mg IV / IO IV / mg2.5 Versed ( Range 32( Range Continued Shivering Continued Target: 91.4 F (33C) 91.4F Target: Cold Normal Saline Bolus BolusNormal ColdSaline Return of SpontaneousofReturn Initial rectal temperaturerectalInitial Notify Notify Destination or (Range 89.6 F to F) 93.389.6F (Range place Contact Medical ControlContact Medical May neededminutesif 5repeat in May Perform Neurological AssessmentNeurologicalPerform Fentanyl 50Fentanyl This Time This Expose and apply ice packs to axilla axilla topacks ice andapplyExpose cardiac arrest cardiac Criteria for Induced Hypothermiafor InducedCriteria - Dopamine 2 Dopamine Advanced Airway inBIAD) Airway (includesAdvanced March 2016 March Cardiac arrestCardiac CirculationSpontaneousofReturn post May repeat 25 mcg every 10 minutes as neededas every minutes10 mcgrepeat 25 May I B P P YES  Signs and Symptoms and Signs  P NO NO 91.4 F C) (33 91.4 ≤ Induced Hypothermia (Optional) Hypothermia Induced Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Exit Exit to Protocol as indicatedas traumatic cardiac arrests cardiactraumatic NOT Utilized in Iredell County At County Iredell in Utilized NOT - Airway Protocol(s)Airway transport. PostResuscitation minutes temperature increases Reassess measures Age 18 or greater18Age asphyxiation are permissible inare permissible asphyxiation protocol.)this are rhythmspresentingAll thisinprotocol permissible Non / hangingand (drownings assessment notassessment Stop coolingStop change in rectalinchange Agencies utilizingAgencies Continue PostContinue temperature duringtemperature are unlikely to seea to unlikely are Untiltemperature warranted with thesewith warranted Resuscitation Care Resuscitation Continued temperatureContinued   History  cerebral cooling devicescoolingcerebral temperature every 10every temperature devices. Document initialDocumentdevices. Adult Cardiac Section Protocols 2012 arrest and arrest patient - 1 second = = 10mcg/min 1 second 4 seconds = mcg/min= 10 4 seconds 2 seconds = = 10mcg/min 2 seconds 1 drip every 1 drip 1.5 seconds = seconds = 10mcg/min 1.5 127.5 135 142.5 150 gtts/min 30 45 60 75 90 105 120 resuscitation but will usually normalize. While goal is goal normalize.While usually butresuscitation will - Protocol20 95.625 95.625 101.25 106.875 112.5 gtts/min 61.875 82.5 61.875 67.5 97.5 73.125 78.75 112.5 84.375 90 22.5 37.5 28.125 33.75 52.5 39.375 45 67.5 50.625 56.25 This Time This March 2016 March : 63.75 63.75 67.5 71.25 75 gtts/min 45 52.5 60 15 18.75 22.5 30 37.5 Induced Hypothermia (Optional) Hypothermia Induced 26.25 56.25 28.125 30 31.875 33.75 35.625 37.5 13.125 26.25 13.125 15 33.75 16.875 18.75 41.25 20.625 22.5 48.75 24.375 gtts/min 7.5 9.375 11.25 5 Mcg 10 Mcg 15 Mcg 20 Mcg 20 Mcg 15 Mcg 10 5 Mcg Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 45 mmhyperventilation. Hg avoid45 Temperature greater than 93 degrees (34 C).(34 thandegrees 93 Temperaturegreater (includingcommands.with BIAD) noAdvanced airway purposeful toin place verbal response Return ofcirculation not spontaneous to related blunt / penetratinghemorrhage. trauma or – 140 150 160 170 180 190 200 70 80 90 100 110 120 130 Kg. 40 50 60 NOT Utilized in Iredell County At At County Iredell in Utilized NOT Monitor advance airway frequently, especially after any patient. of any movement especially after airway frequently, Monitor advance continuation of induced hypothermia therapy. medicalorder from control. on initiated may be only cooling obtained, in airway place advanced no If cooling. may during place remainin Undergarments modesty. patient Maintain resuscitation phase and must be avoided at all costs. and must be avoided phaseresuscitation post immediately be elevatedmay Initial tidal End CO2 35 Utilization oftransportthe thisprotocol of capable post managing mandates to facility Do not delay Do nottransport to delay initiate induced hypothermia. the post arrest in of hypotension of cardiac significantand cause recurrence a Hyperventilation is Criteria Criteria for Induced Hypothermia  Pearls        418 440 352 374 396 264 286 308 330 198 220 242 132 154 176 Lbs. 88 110 Dopamine 1600Mcg Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set agtt 60with X 0.0375=gtts/minkg Patientin Weight dose X Desired 1600forconcentration:Formula a Dopamine / min26.25 gtts .0375 = x 7 mcg/min x ptkg 100 example: Adult Cardiac Section Protocols 2012 with Go to Protocol Return of Circulation Spontaneous AT ANY TIME ANY AT Utilize this ProtocolUtilizethis Post ResuscitationPost B - Cardiac Arrest Protocol Arrest Cardiac ALS EMT (Hierarchy) Establish IV / IO IV / Establish Establish IV / IO IV / Establish EMS ALS PersonnelEMS ) First Arriving ResponderFirstArriving Establish TeamLeaderEstablish Continuous Cardiac Monitoring CardiacContinuous Fire Department or Squad Officeror SquadDepartmentFire Administer Appropriate Medications AppropriateAdminister Medications AppropriateAdminister Initiate Defibrillation Manual ProcedureManual DefibrillationInitiate Continue Cardiac Arrest Protocol Arrest CardiacContinue Establish Airway with BIAD if not in place innot BIAD if with Airway Establish Establish Airway with BIAD if not in place innot BIAD if with Airway Establish Initiate Defibrillation Automated ProcedureAutomatedDefibrillationInitiate 100 / min) / 100 ≥ 10 seconds10 I P ≤ NO Procedure if available BIAD Place Protocol21 BLS or ALS (Optional) 2 inches) Push Fast ( Fastinches)Push 2 ≥ Assume Compressions or CompressionsAssume Call for additional resourcesadditionalforCall DO NOT CompressionsInterrupt NOT DO Third Arriving Arriving ThirdResponder Review DNR / / MOST DNR FormReview Initiate Compressions Only Only CPR CompressionsInitiate Ventilate at 6 to 8 breaths per minuteperbreathsto at 86 Ventilate This Time This First Arriving / ALS ResponderArriving FirstBLS Initiate Defibrillation Automated / Manual / Manual AutomatedDefibrillationInitiate Second Arriving BLS / ALS ALS ResponderBLS / SecondArriving Team Focused CPR Focused Team Initiate Defibrillation Automated ProcedureAutomatedDefibrillationInitiate Begin Continuous CPR CompressionsContinuousCPR Begin minutes2every CompressorsChange March 2016 March Criteria for Death / No Resuscitationfor Death Criteria Limit changes / pulses checks/ pulseschanges Limit Push Hard ( Push ( B - BLS quality compressionsquality EMT - YES (Hierarchy) compressions TeamLeader ALS PersonnelALS Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Incident CommanderIncident Rotate withCompressorRotate First Arriving ResponderFirstArriving Establish TeamLeaderEstablish Responsible for patient care for patientResponsible Manages Scene / BystandersSceneManages Team Leader until ALS arrival ALS LeaderuntilTeam life Take direction from Team LeaderdirectionfromTake Take direction from Team LeaderdirectionfromTake Policy Fire Department or Squad Officeror SquadDepartmentFire Follow Ensures highEnsures asystole NOT Utilized in Iredell County At County in Iredell Utilized NOT Ensures frequent compressor changecompressorfrequentEnsures Continue Cardiac Arrest Protocol Arrest CardiacContinue Rigor mortisRigor To prevent Fatigue and effect highqualityeffectand Fatigue prevent To resuscitation Do beginnot Fire Department / First Responder Officer/ FirstResponderDepartment Fire Decomposition Fourth / Subsequent Arriving RespondersArriving / SubsequentFourth Responsible for briefing / counseling family/ counselingfor briefingResponsible Dependent lividity Dependent Blunt force traumaBluntforce Deceased SubjectsDeceased Responsible for briefing family prior to ALS arrivalfamilytoprior for briefingResponsible Injury incompatible with with incompatibleInjury Extended downtime with with downtime Extended Adult Cardiac Section Protocols 2012 use King LTD LTD useKing MUST Protocol21 (Optional) This Time This Team Focused CPR Focused Team March 2016 March 10 breaths per minute.breathsper10 – P) - patient carepatient Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any ALL NOT Utilized in Iredell County At County in Iredell Utilized NOT Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. work. roomto Make access. patientand require space Procedures execution. and properplanningon based isSuccess Do not interrupt compressions to place endotracheal tube. Consider BIAD first tointerruptions. limitBIAD firsttube.Consider endotrachealplace tocompressions Do interruptnot when indicated. Consider early anticipated.difficult IV andavailable if IO placementearly Considerindicated. when If 30:2. advancedare to ventilationsETT)(BIAD, compressionsairway advancedHYPERVENTILATE: If NOT no DO 8 ventilate in placeairway This protocol is optional and given only as an example. Agencies may own.their to encourageddevelop are andmay Agenciesexample. an asoptionalgiven only and isprotocolThis defibrillationearly and limitedinterruptions compressionswith continuousand directedatquality should highbe Efforts Performs tasks as assigned by Primary Caregiver (Team Leader) and within Scope of Practice of credentialofPractice of within Scopeand Leader) (Team Caregiver Primaryby assignedastasksPerforms Establishes Airway (if not in place) May make (1) attempt at Endotracheal Intubation time thentime Intubation Endotrachealat attemptmake (1)May innot place)(if Airway Establishes VentilationsProvide of level by credential) (permittedMedicationsAdminister Briefing / Counseling Family / CounselingBriefing tolevel credential duecannot Secondarycaregiver that otherprocedures Performs Team LeaderTeam Oversees Monitoring CardiacContinuous VascularAccessEstablishes ------   Pearls   Additional Caregiver(s): Caregiver(s): Additional Secondary Caregiver Secondary EMS Personnel Roles: PersonnelRoles: EMS (EMTCaregiver Primary Adult Medical Section Protocols NO 2012 90 ≥ IO Procedure P NO Exit Exit to Etiology Protocol Maximum 2 L 2Maximum Improving Cardiac Monitor Cardiac Vomitingor if indicated Titrate SBP Titrate Nausea and / andNausea Repeat as neededas Repeat Signs / SymptomsSigns Suggesting CardiacSuggesting Hypotension / ShockHypotension Normal Saline Bolus 500 mL500 SalineBolusNormal Adult Pain ControlProtocolAdult Pain IV Procedure Pneumonia or Pulmonaryembolusor Pneumonia CHF) (hepatitis,Liver Gastritisdisease/ ulcerPeptic Gallbladder infarction Myocardial Pancreatitis stoneKidney aneurysmAbdominal Appendicitis disorder/ ProstateBladder Ovarian pregnancy,Ectopic(PID, Pelvic cyst) enlargementSpleen Diverticulitis obstructionBowel (infectious)Gastroenteritis TorsionTesticularand Ovarian I YES P Differential                 YES YES IV / IO / IMIV shock Protocol23 Appropriate as indicatedas Odansetron 4 mg 4Odansetron Cardiac ProtocolCardiac May minutes15repeatin May Pain (location / / migration)(locationPain Tenderness Nausea Vomiting Diarrhea Dysuria Constipation / dischargebleedingVaginal Pregnancy Notify Notify Destination or Serious Signs / SymptomsSignsSerious Contact Medical ControlContact Medical Hypotension, poor perfusion,poor Hypotension,        Signs Symptoms and   symptoms: Associated source) to (Helpfullocalize malaise,weakness,headache, Fever, mentalheadache,cough, myalgias, rashchanges,status P Abdominal Abdominal Pain NO YES 10) Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any - NO Etiology IV Procedure or Vomitingor if indicated Nausea and / andNausea Signs / SymptomsSigns Suggesting CardiacSuggesting Age history / surgicalPastmedical Menstrual history(pregnancy)Menstrual Time (duration / repetition)(durationTime Fever mealeatenLast / emesis movementbowel Last dull, etc.)dull, / Referred/ RadiationRegion (1 Severity Medications Onset / ProvocationPalliation sharp,(crampy,constant,Quality Adult Pain ControlProtocolAdult Pain I History              Adult Medical Section Protocols Age ≥ Age emetics - Protocol23 This space left blank intentionallyblankleft This space Abdominal Abdominal Pain Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Consider cardiac etiology in patients > 50, diabetics and / or women especially complaints. abdominal especially with upper women/ or and diabetics > 50, in patients cardiac etiology Consider The use of metoclopramide (Reglan) may worsen diarrhea and should be avoided in patients with with symptom.this patients in avoided be should (Reglan) and worsen may diarrhea metoclopramideof useThe (e.g., effectssedative likely experience to forpatients (Phenergan) promethazine of lower the dose Choose slowly. administernormal and mL saline ofwith 10 dilute IV giving promethazine etc.) Whendebilitated, 60, Antacids should be avoided in patients with with renal disease. in patients avoided be should Antacids / 50 and over in patients especially pain with abdominal considered be aneurysm should abdominal of diagnosis The perfusion. with poor shock/ or patients bolus. fluid each signs after vital Repeat Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lung, Abdomen, Lung, Neuro Heart, HEENT,Recommended Status,Skin, Abdomen, Extremities, Neck, Mental Exam: Back, anti of administration prior to signs vital and status mental the Document otherwise. proven until related as pregnancy treated be should age childbearing women of in pain Abdominal         Pearls 

Adult Medical Section Protocols 2012 where circumstanceswhere Head traumaHead seizure,infection)tumor, (stroke, CNS Cardiac (MI, CHF) (MI, Cardiac Hypothermia andother)(CNS Infection / hypo) (hyper Thyroid traumatic)(septic,metabolic,Shock / hypoglycemia)(hyperDiabetes Toxicological or IngestionToxicological / AlkalosisAcidosis exposure Environmental (Hypoxia) Pulmonary abnormalityElectrolyte disorderPsychiatric Exit Exit to Exit Exit to Exit to Exit to Exit to Exit to Protocol Protocol Protocol suggest a mechanism of injury.of a mechanismsuggest Differential               as indicatedas as indicatedas indicatedas CVA / Seizure Diabetic ProtocolDiabetic Toxic / Overdose Utilize Spinal Immobilization Protocol ProtocolImmobilizationSpinalUtilize Exposure Protocol Exposure Hypo / Hyperthermia /Hypo Hypotension / Shock Hypotension Appropriate Cardiac ProtocolCardiacAppropriate Protocol25 YES YES YES YES YES YES Notify Notify Destination or Contact Medical ControlContact Medical skin) fruity skin; dry (warm, Hyperglycemia signsrespirations;Kussmaul breath; dehydration)of Irritability Decreased mental status or lethargyorstatus mentalDecreased statusmentalbaselinein Change behaviorBizarre diaphoretic(cool,Hypoglycemia      Signs and Symptoms and Signs  250 Altered Mental Status ≥ IO Procedure 69 or 69 P ≤ NO NO NO NO NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any if indicated 12 Lead ECG ProcedureLeadECG 12 Airway Protocol(s)Airway Arrhythmia / STEMI Arrhythmia Signs of Seizure CVA Or Signs Signs of / Toxicology OD Signs Blood GlucoseBlood Signs of Hypo / Hyperthermiaof Hypo Signs Blood Glucose Analysis ProcedureAnalysisGlucoseBlood Signs of shock / Poor perfusion/ Poorof shockSigns IV Procedure Changes in feeding or sleepor feedingin Changes habits Medications traumaof History conditionin Change Drugs, drug paraphernalia paraphernaliaDrugs,drug useor illicitdrugofReport ingestiontoxic historyPastmedical Known diabetic, medic alertmedic diabetic, Known tag I        History  B Adult Medical Section Protocols 2012 Mat exposure and protect personal safety. personal Mat protect and exposure - Protocol25 This space left blank intentionallyblankThisleft space Altered Mental Status Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. restraint the per protection personnel's and/or forpatient's Restraints ifConsider necessary Glucagon have may and hypoglycemia develop frequently Alcoholics picture. clinical the confusealcohol let Do not injuries. unrecognized Pay attentioncareful for signs ofexam bruisingPay to or other the injury. head or Haz toxin environmental an of sign presenting AMS as of aware Be or Dextrose after glucose blood Recheck exists. if doubt hyperglycemia than hypoglycemia assumeto safer is It Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Neuro. Recommended Lungs,Status,HEENT,Abdomen, Heart, Mental Exam: Extremities, Skin, Back,      Pearls  Adult Medical Section Protocols 2012 YES 5 mg 5 – Protocol(s) AdultAirway Allergic ReactionAllergic NO YES Anaphylaxis ProtocolAnaphylaxis 125 mg IV / IO IV / mg125 Improving Improving STRIDOR Methylprednisolone Methylprednisolone Repeat as needed x x needed3 as Repeat Epinephrine NebulizerEpinephrine 1 mg (1:1000) / 2 mL of NS mL / mg2 (1:1000)1 Albuterol Nebulizer 2.5 NebulizerAlbuterol Asthma Anaphylaxis Aspiration (Emphysema,Bronchitis)COPD effusionPleural Pneumonia embolusPulmonary Pneumothorax or(MI CHF) Cardiac tamponadePericardial Hyperventilation etc.)monoxide, (Carbontoxin Inhaled NO YES I P B NO Differential             IO Procedure P 5 mg 5 – 0.5 mg IM mg0.5 Cardiac Monitor Cardiac Exam Lung Protocol26 – Airway PatentAirway 2.5 if indicated 12 Lead ECG ProcedureLeadECG 12 0.3 Over 10 minutes 10 Over Ipratropium 0.5 mgIpratropium0.5 Ventilations adequateVentilations as indicatedas Oxygenation adequateOxygenation - Epinephrine 1:1000 Epinephrine Albuterol NebulizerAlbuterol Repeat as needed x x needed3 as Repeat Shortness of breathShortness lipbreathingPursed speakabilityto Decreased andrate respiratory Increased effort rhonchiWheezing, accessorymusclesof Use coughFever, Tachycardia +/ IV Procedure Airway CPAP ProcedureAirway Allergic Reaction Anaphylaxis ReactionAllergic Adult Airway Protocol(s)AdultAirway Notify Notify Destination or Magnesium Sulfate 2 g IV / 2IO Sulfate g Magnesium I        Signs Symptoms and  P Contact Medical ControlContact Medical B I P NO 5 mg 5 Adult COPD / Asthma Adult COPD / – chronicbronchitis, -- YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Improving 125 mg IV / IO IV / mg125 or Asthmaor WHEEZING Methylprednisolone Methylprednisolone Repeat as needed x x needed3 as Repeat Signs / SymptomsSigns consistent with COPD COPD with consistent Albuterol Nebulizer 2.5 NebulizerAlbuterol Medications (theophylline, steroids,(theophylline, Medications inhalers) inhalationsmokeexposure, Toxic Home treatment (oxygen, (oxygen, nebulizer)Hometreatment Asthma; COPD COPD Asthma; heartfailure congestiveemphysema, Revised 12/13/2012    History  P B Adult Medical Section Protocols 2012 Agency Agency Agonist dose. Agonist - 0.25 mg of 1:1000.) mg of 1:1000.) 0.25 – Blockers / Digoxin / or Blockers - half the dose of half (0.15 the dose epinephrine - Protocol26 respiratory sign. arrestrespiratory - 150 give one give 150 Adult COPD / Asthma Adult COPD / 50 years of age, have a history of cardiac disease, take Beta take disease, ofa history cardiac of age, have years 50 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any s who have heart rates ≥ ≥ rates heart haves who B may administer Albuterol andadminister from EMS may supply. administerprescribed Albuterol may if patient already B - 10 min10 medical director may require Contact of Medical Control prior to administration. to prior Control Medical of Contact may require director medical ETCO2 should be used when Respiratory Distress is significant and does not respond to initial Beta initial to respond not does Respiratory Distresswhen and significant is used be ETCO2should pre a is distress respiratory in chest silent A EMT Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG at somelead point a 12 patients should receive These ischemia. cardiac precipitate Epinephrine may butNOT administration thisshould in theirdelay care, of epinephrine. continuously. be monitored should oximetry Pulse patient' Recommended Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Lungs,Heart, Abdomen, Neuro Recommended Status,HEENT,Extremities, Neck, Mental Exam: Skin, and care protocol compliance to evaluateused measures performance key are Red Text in Items ≥ are Patients who 50 ml x / min = gtts 50 x mlgtts 5010 Revised 12/13/2012       Pearls  Magnesium Sulfate Infusion: Dose 2 g over 10 min 10 g over 2Infusion: DoseSulfate Magnesium gttsset10 NS using ml 50in gms SulfateMag 2 Adult Medical Section Protocols 2012 NO . 2 mg IMmg 2 69 mg / dl and/ mgdl69 – ≤ NO YES symptomatic Overload 250 mg / dlmg 250 500 mL IV / IO IV / mL500 CHF / CHF Fluid Hypotension ≥ Blood SugarBlood No venous accessNo venous no evidence of evidenceno Dehydration with with Dehydration Normal SalineBolusNormal May repeatneededasMay Glucagon 1Glucagon Then infuse 150 mL / hr mL / infuse150Then Repeat in 15 minutes if neededif inminutes 15Repeat Blood GlucoseBlood I Alcohol / drug usedrug / Alcohol ingestionToxic injuryheadTrauma; Seizure CVA statusmentalbaselineAltered YES I Differential       Exit Exit to Protocol Procedure Exit Exit to IO Procedure 249 mg / dl mg249 Hypotension / Shock Hypotension – Blood SugarBlood P Protocol27 70 if condition changesif condition Blood Glucose AnalysisGlucoseBlood Appropriate ProtocolAppropriate Procedure Notify Notify Destination or if indicated Contact Medical ControlContact Medical Cardiac Monitor Cardiac Blood Glucose AnalysisGlucoseBlood 12 Lead ECG ProcedureLeadECG 12 Altered mental statusmentalAltered / irritableCombative Diaphoresis Seizures painAbdominal / vomitingNausea Weakness Dehydration breathing/ Deeprapid IV Procedure Diabetic; Adult Diabetic;         Signs and Symptoms and Signs  YES I P B 25 gm IV / gmIO 25 arm - NO YES 69 mg / dl mg 69 Improving Consider Oral Oral Consider Repeat D50 per D50Repeat ≤ Every minutes5 Every Symptomatic Blood SugarBlood If no improvementIf Glucose SolutionGlucose D50 12.5 gm IV / 12.5gmIO D50 70 mg / dl or greater/ dlmg or 70 Until Blood UntilGlucose Awake and alert / andalertAwake appropriate treatmentappropriate Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any D50 12.5D50 I I Protocol if indicated Recent blood glucosecheckbloodRecent mealLast Past medical historyPastmedical Medications NO Revised 11/19/2012   History   Altered Mental StatusMental Altered Adult Medical Section Protocols 2012 : Protocol27 Diabetic; Adult Diabetic; Patient’s who meet criteria to refuse care should be instructed to contact their physician physician their contact to instructed be should care criteria refuseto meetwho Patient’s : Patient’s who meet criteria to refuse care should be instructed to contact their physician immediately physician their contact to instructed be should care criteria refuseto meetwho Patient’s Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any immediately and consume a meal.a consume and immediately even hypoglycemia riskrecurrent at of patient the places insulin acting exist. Longer now insulin formsMany of Medical forControl so Contact action prolonged have insulins Not all established. is glucose normalblood a after advice. a meal.consume and Patient’s taking oral diabetic medications should be strongly encouraged to allow transportation to a medicalto transportation allow to encouraged strongly be should medications oral diabetic taking Patient’s monitoring close require and forhours delayed can be that hypoglycemia riskrecurrentare at of facility. They Medical Contact so action prolonged have oral all Not agents is established. glucose normalblood after even advice. Control for Insulin Agents Oral Agents: Oral Contact medical control for advice. medical for control Contact glucometers.forall recommendationmanufacturers per maintained be should checkscontrol Quality after treatment ofrefusingPatient’s transport hypoglycemia to facility medical Patients with prolonged hypoglycemia my not respond to glucagon. glucagon. to respond hypoglycemia my not with prolonged Patients airway. their swallow or protect to able not are that patients to glucose oral administer not Do rectally. administered % can be 50 Dextrose glucagon, to response no and IV with circumstancesextremeno In Recommended exam: Mental Status, Skin, Respirations and effort,Mental Recommended Respirations and Status,Skin, Neuro. exam: Revised 11/19/2012   Pearls       Chronic alcoholics may not respond to Glucagon secondary to low storeslow toglycogensecondary to Glucagon mayrespond notalcoholics Chronic Adult Medical Section Protocols 2012 Exit Exit to Diabetic Protocol Exit Exit to Protocol Appropriate YES NO IO Procedure 250 Congestive heart failureheartCongestive Pericarditis emergencyDiabetic Sepsis tamponadeCardiac P ≥ 0.12 sec 0.12 as this will cause clotting of the shunttheclottingof cause will thisas NO NO NO Or Or ≥ YES Differential      dressingbulkyavoidbut dressingApply 4 hours4 Serious Dressing must not compress fistula / shunt/ fistulacompressnot mustDressing 69 Blood Sugar Blood ≤ Apply site pressureto bleedingfirmtipApply finger QRS QRS Cardiac Monitor Cardiac Peaked T WaveT Peaked Signs / symptomsSigns Hemodialysis in pastinHemodialysis 12 Lead ECG ProcedureLeadECG 12 IV Procedure Blood Glucose Analysis ProcedureAnalysisGlucoseBlood I P B YES YES Protocol28 Exit Exit to Protocol Notify Notify Destination or Contact Medical ControlContact Medical NO YES CHF / Pulmonary Edema / CHF Pulmonary Hypotension Bleeding Fever imbalanceElectrolyte vomiting/ andor Nausea StatusMental Altered Seizure Arrhythmia Maximum 1Maximum Liter        Signs and Symptoms and Signs  YES 50 mEq IV / mEqIO 50 Pressure < 90 < Pressure Systolic BloodSystolic Over 23 minutes toOver If lungs remain clearremainlungsIf Sodium BicarbonateSodium Dialysis Dialysis Renal / Failure Normal Saline Bolus 250 mL250 SalineBolusNormal (Or Calcium Gluconate 2 gm) CalciumGluconate(Or Calcium Chloride 1 gm IV 1/ Chloride gmIO Calcium Repeat as neededas Repeat I P NO NO YES CHF / CHF Arrest Exit Exit to Cardiac Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Bleeding 50 mEq IV / mEqIO 50 Shunt / FistulaShunt/ Sodium BicarbonateSodium Pulmonary EdemaPulmonary Appropriate protocolAppropriate (Or Calcium Gluconate 2 gm) CalciumGluconate(Or Calcium Chloride 1 gm IV 1/ Chloride gmIO Calcium Catheter access notedaccessCatheter notedShuntaccess Hyperkalemia Peritoneal or HemodialysisPeritoneal Anemia    History   P Adult Medical Section Protocols 2012 or t f t dead patient only with no other available access. IO if IO access. withonly dead patientno other available - Protocol28 Dialysis Dialysis Renal / Failure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Do not take Blood Pressure or start IV in extremity which has a shunt / fistulain place. which has Do in extremity not IV start or Blood take Pressure of shuntin the near Access dead or indicated Recommended exam: MentalNeurological. Lungs.RecommendedHeart. status. exam: Renal dialysis patients have numerous medical problems typically. are prevalent. cardiac disease and Hypertension problemsmedicaltypically. numerous have patients Renal dialysis Use ofUse tourniquet Contact fistula withbleedingControl. of requires Medicaluncontrolled dialysis consider Hyperkalemia Always patients. in dialysis failure all or renal lines. in separate give mixed.Ideally be not should Calcium / Gluconate Chloride and Bicarbonate Sodium available. Pearls        The use of sodium bicarbonate is an adjunct therapy for hyperkalemia. It is not to be used first and/or as the only treatmenonlyand/orthe asused first be Itto not is hyperkalemia.fortherapy adjunctan is bicarbonate sodium useofThe primarily.be used shouldChlorideCalcium or CalciumGluconate hyperkalemia. Adult Medical Section Protocols 2012 eed Exit Exit to Exit to Exit to Exit to Protocol Protocol Protocol(s) Protocol(s) Appropriate Appropriate Cushing’s Response with with ResponseCushing’s andBradycardia Hypertension eclampsia / Eclampsiaeclampsia Chest Pain / STEMI ChestPain - Obstetrical EmergencyObstetrical Hypertensive encephalopathyHypertensive Injury CNS Primary Infarction Myocardial / DissectionAneurysm Aortic Pre Differential      hospital setting in most cases. mostinsetting hospital - YES YES YES YES NO NO NO NO IV Procedure Pregnancy ChestPain Cardiac Monitor Cardiac CVA / AMS Dyspnea / CHF / Dyspnea 12 Lead ECG ProcedureLeadECG 12 Obtain and DocumentBP andObtain Measurement in Both ArmsBothin Measurement Notify or Notify Destination Contact Medical ControlContact Medical Protocol29 Systolic BP 220 or greaterorBP 220 Systolic greaterorBP 120 Diastolic I Headache ChestPain Dyspnea StatusMental Altered Seizure P B One of theseOne of   theseone ofat leastAND      Signs and Symptoms and Signs Hypertension YES treated based on specific protocols and consultation with Medical Control. Medical with consultationandprotocols specificon based treated Or Or NO Exit Exit to Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any minutes apartminutes Appropriate Protocol(s)Appropriate Systolic BP 220 or greaterorBP 220 Systolic Diastolic BP 120 or greaterorBP 120 Diastolic damage such as MI, CVA or renal failure. This is very difficult to determine in the pre thein determine tovery isdifficult Thisrenal failure. CVA or MI, as such damage Pain and Anxiety are addressed are Anxiety andPain Ensure appropriate size blood pressure cuff utilized for body habitus.for cuffutilizedblood pressuresize appropriate Ensure Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro Abdomen, Back,Extremities,Heart,Lung,Neck, Status,Skin, MentalExam: Recommended Erectile Dysfunction medicationsDysfunctionErectile Pregnancy Failure; Cardiac ProblemsCardiacFailure; Hypertensionfor Medications Hypertensivewith Compliance Medications Documented HypertensionDocumented CVA; Renal Diabetes;diseases:Related Elevated blood pressure is based on two ofsigns. vitalthreesetstwo toon basedis blood pressure Elevated systems. orCNS renaltocardiac, the dysfunction organend through typicallyisrevealed hypertension Symptomatic degrees.30at theirheadelevatedwith transported beshould hypertensionwith patientssymptomaticAll BP taken on 2 occasions at least 5 leastat 2 occasionson BP taken only supportive care. Specific complaints such as chest pain, dyspnea, pulmonary edema or altered mental status should be shouldstatusmentalor alterededema pulmonarypain,dyspnea,chestas such Specific complaints care.supportive only Hypertension is not uncommon especially in an emergency setting. Hypertension is usually transient and in response to stressto responseintransientand usuallyis Hypertensionsetting.anin emergency especiallyuncommonnotis Hypertension and / or pain. A hypertensive emergency is based on blood pressure along with symptoms which suggest an organsufferingisan which suggest symptomswith along pressureblood on basedis emergency A hypertensive or pain. / and Aggressive treatment of hypertension can result in harm. Most patients, even with significant elevation in blood pressure,n bloodinelevation significanteven with patients, Most in result harm. hypertensioncan of treatmentAggressive Pearls  History          

Adult Medical Section Protocols 2012 1222 - 2 mg 2 OD – 2 mg IN 2 Exit Exit to 222 Protocol – Cyanide / Cyanide - Appropriate if indicated Control If Needed If CarbonMonoxide 800 - 1 oxygenation Carolinas Carolinas Poison IV / IO / IM / IO / IMIN IV / if indicated CONSCIOUSNESS Naloxone 0.4 Naloxone Naloxone 1 Naloxone adequate ventilation andventilation adequate if indicated NOT GIVEN TO RESTORE RESTORE TO GIVEN NOT Naloxone is titrated to effecttitratedis Naloxone Tricyclic antidepressants (TCAs) Tricyclicantidepressants (Tylenol) Acetaminophen Aspirin Depressants Stimulants Anticholinergic medicationsCardiac agentsCleaningAlcohols,Solvents, (organophosphates)Insecticides Appropriate Airway Protocol(s)Airway Appropriate I B Hypotension/ Shock ProtocolShockHypotension/ Differential          if availableif Exit Exit to WMD / WMD Protocol Antidote Kit Antidote Nerve Agent Nerve if indicated Nerve AgentNerve Organophosphate NO YES NO IO Procedure OD QRS QRS YES P 0.12 sec 0.12 Protocol31 Tricyclic ≥ Normal SalineNormal 50 mEq IV mEq/ IO 50 100 mEq in 1 L in 1mEq100 NO NO 200 mL/hr IV / IO IV / mL/hr200 YES Antidepressant Notify Notify Destination or Cardiac Monitor Cardiac Sodium BicarbonateSodium Sodium BicarbonateSodium Mental status changes statusMental / hypertensionHypotension rate respiratoryDecreased dysrhythmiasTachycardia, Seizures S.L.U.D.G.E. D.U.M.B.B.E.L.S Contact Medical ControlContact Medical P Potential Cause Potential Systolic BP < 90Systolic 12 Lead ECG ECG ProcedureLead12       Signs and Symptoms and Signs  Altered Mental StatusMental Altered Adequate Respirations / RespirationsAdequate Oxygenation / Ventilation / Oxygenation Serious Signs / SymptomsSignsSerious IV Procedure I P B OD Calcium 20 20 – YES Channel BlockerChannel YES Overdose / Toxic Ingestion Overdose Toxic / Consider if neededif May repeatMay if no responsenoif Over 3 minutesOver Dopamine 2 Dopamine Mcg/kg/min IV / IO Mcg/kg/min Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Glucagon 2 mg IV / mgIO 2Glucagon Cardiac External PacingExternal Cardiac May repeat in 15 minutes minutes15repeatin May (Or CalciumGluconate)(Or Procedure Safe Procedure for Severe CasesSevere forProcedure Scene Calcium Chloride 1 gm IV 1/ Chloride gmIO Calcium as indicatedas OD Diabetic / AMS AMS / Diabetic resources Blood Glucose AnalysisGlucoseBlood Behavioral ProtocolsBehavioral I Substance ingested, route, quantityroute,ingested, Substance of ingestionTime criminal)accidental,(suicidal,Reason Ingestion or suspected ingestion of a of ingestionsuspectedor Ingestion substancetoxic potentially Past medical history, medicationshistory,Pastmedical Available medications in home homein medications Available P P Beta BlockerBeta Revised 11/24/2014 NO Stage until scene safesceneStageuntil  History    Call for help / additionalhelp/ forCall   Adult Medical Section Protocols 2012 ia specific pupilsspecific - Agency medical director may requiredirectormedicalAgency 7 minutes.7 - Protocol31 No patient with a QRS duration of 100 milliseconds or less suffering a a sufferingor lessmilliseconds100of a duration QRS with patient No - 3 minutes and the peak effect should be5 at shouldpeaktheeffectand minutes 3 contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self administration or selfadministrationforautoinjector anin pralidoximeofmg 600and Atropine 2contain mgof - depressant overdose depressant - dysrhythmias and mental status changesstatusmentaland dysrhythmias initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failureliverirreversible causestreated,and If detected not or nausea/vomiting.normalinitially increased HR, increased temperature, dilated pupils, mental status changesstatusmentalpupils,dilated temperature, HR, increasedincreased Overdose / Toxic Ingestion Overdose Toxic / Blocker Overdose Overdose Blocker decreased HR, decreased BP, decreased temperature, decreased respirations, non respirations,decreasedtemperature,decreased BP, decreasedHR, decreased - increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpointpupilsdiarrhea,vomiting,nausea, secretions, increasedHR, decreasedor increased rapid progression from alert mental status tostatusmental death.fromalertprogression rapid increased HR, increased BP, increased temperature, dilated pupils, seizures pupils,dilatedtemperature, BP, increased increasedHR, increased , liver failure, and or cerebral edema among other things can take place later. later.cantakeplace otherthings among edemacerebral or and failure, , liver Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any nausea, coughing, vomiting, and mental status changesstatusmentaland vomiting, coughing,nausea, 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma;or statusmentaldecreased hypotension,dysrhythmias, seizures, toxicity: of major areas 4 : Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renaloccurlater.may statusmental alteredand Tachypneavomiting.and pain abdominalconsistof : Early signs B may administer naloxone by IN route only. May administer from EMS supply. fromsupply. EMSadminister routeby only. May naloxoneIN administermay B - example: 100 kg pt x 7 mcg/min x min gtts/ = x 26.25 x mcg/min.0375pt kg7 100 example: Depressants: Stimulants: Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying othercarrying is not still patient Makesureattempts. in suicide especially ingestion,on patientof rely history Do not weapons.any or has medications to ED. emesiscontents, Bring bottles, Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro Lungs,Abdomen, Extremities, Heart,HEENT, Status,Skin, MentalExam: Recommended Solvents: Solvents: Insecticides: Anticholinergic: Anticholinergic: Medications:Cardiac S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis distress,GI Defecation,Urination, Lacrimation, Salivation, S.L.U.D.G.E: Salivation.Lacrimation,Bronchorrhea,Emesis,Bradycardia, Miosis, Urination, Diarrhea, D.U.M.B.B.E.L.S: Nerve Agent kitsAntidote Agent Nerve of Destruction. forMass Weaponspreparednessdomestictheof part as available bekits These may care. patient Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure.Restrainttheper personnel's protection and/orpatient'sfornecessary if restraints Consider Acetaminophen: Acetaminophen: Tricyclic: Tricyclic: Consider contacting the North Carolina Poison Control Center for guidance.Center for North CarolinaControlPoison thecontacting Consider EMT administration.toprior Medical Control of Contact Aspirin dysfunction Revised 11/24/2014 Deep slurred S wave LeadI aVLandinwave S slurredDeep 3 mm ingreaterthan aVR R wave ms0.7 greaterinthan aVRS ratio R to QRS greater than 100 msthan100 greater QRS Pearls                   - - - - If no effect seen, call medical control for further instruction. forcontrol furthermedical call noseen, effectIf Glucagonofside effectais known well Vomiting **Glucagon in Beat in **Glucagon 1 observedinbe effect shouldAn seizure or ventricular arrhythmia. Patients with a QRS greater than 160 milliseconds has a 50% chance of ventricular arrythm ventricularofchance50% hasa milliseconds than160 a greater QRS with Patientsor ventriculararrhythmia.seizure TCA overdosecardiotoxicityin suggest that signs **EKG **Sodium Bicarb infusion runs 33gtts/min with a 10gtt set** a 10gttwith 33gtts/min runsBicarbinfusion **Sodium TricyclicAnti in**QRS Duration **Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set agtt 60with X 0.0375=gtts/minkg inWeight X PatientDesired dose 1600concentration: a forFormula **Dopamine Adult Medical Section Protocols 2012 IO Procedure 2 mg IV/10mg 2 - / IO mg IV 2.5 - P or or if indicated as indicatedas Protect patientProtect YES Cardiac Monitor Monitor Cardiac If no IV/IO accessno IV/IO If Airway Protocol(s)Airway 10 mg Per RectumPermg 10 If no IV / noIO access IVIf Second Dose 2 mg 2 SecondDose 5 mg IM IM mg2 mgIN 5or every 3 to 5 minutes 35 toevery Diazepam 4 mg IV/IO4 Diazepam EpilepticusStatus Lorazepam 1 Lorazepam Maximum 10mg for each 10mgMaximum compliance - YES Midazolam 0.5 Midazolam Loosen any constrictive clothingconstrictive any Loosen Spinal Immobilization ProcedureImmobilizationSpinal IV Procedure May of medicationstherepeat any May Blood Glucose Analysis ProcedureAnalysisGlucoseBlood CNS (Head) trauma (Head)CNS Tumor failureor RenalHepatic, Metabolic, Hypoxia Mg) (Na, Ca, abnormalityElectrolyte Drugs,Medications, Non / Fever Infection withdrawal Alcohol Eclampsia Stroke Hyperthermia Hypoglycemia I P Differential             NO Or Activity Protocol Consider if indicated if indicated Active Seizure Active Protocol32 Postictal State Postictal Diabetic ProtocolDiabetic Seizure Altered Mental StatusMental Altered Notify Notify Destination or Monitor andReassessMonitor Contact Medical ControlContact Medical Decreased mental statusmentalDecreased Sleepiness Incontinence activity seizureObserved traumaof Evidence Unconscious      Signs and Symptoms and Signs  NO NO YES if indicated if indicated if indicated IV Procedure 3 minutes3 Protect patientProtect Cardiac Monitor Monitor Cardiac Awake, AlertAwake, – Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Monitor andReassessMonitor 2 g IV / IO g IV / 2 Normal Mental StatusMental Normal Loosen any constrictive clothingconstrictive any Loosen Spinal Immobilization ProcedureImmobilizationSpinal Over Over 2 May repeat dose x 1 x repeatdoseMay Magnesium Sulfate Magnesium Blood Glucose Analysis ProcedureAnalysisGlucoseBlood I Document number of numberseizures Document or abruptabuse use,Alcohol cessation Fever History of diabetesof History pregnancyof History onsetof seizureTime Previous seizurehistory Previous informationalerttagMedical medicationsSeizure traumaof History activity Reported / witnessed seizure/ witnessed Reported P Active Seizure in Known or Known inSeizure Active          History   P Suspected Pregnancy > 20 Weeks> 20 PregnancySuspected Seizure

Magnesium Sulfate must be given in 20% or less concentrations intravenously.

Dilute 2 gms (4 mL) of Magnesium Sulfate with 6 mL of NS = 2 gms Magnesium Sulfate in 10 mL Normal Saline

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Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro  Items in Red Text are key performance measures used to evaluate protocol compliance and care  Midazolam 5 – 10 mg IM is effective in termination of seizures. Do not delay IM administration with difficult IV or IO access. IM Preferred over IO.  Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport.  Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma.  Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness  Be prepared for airway problems and continued seizures.  Assess possibility of occult trauma and substance abuse.  Be prepared to assist ventilations especially if diazepam or midazolam is used.  For any seizure in a pregnant patient, follow the OB Emergencies Protocol.  Diazepam (Valium) is not effective when administered IM. Give IV or Rectally. Midazolam is well absorbed when administered IM. Protocol 32 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols 2012 10 Minutes10 ≤ STROKE STROKE Hypertension Transport based on: on: basedTransport if indicated Concerning Treatmentof Concerning Contact Receiving FacilityReceivingContact Thrombotic or Embolic (~85%)or EmbolicThrombotic (~15%)Hemorrhagic Diabetic ProtocolDiabetic See Altered Mental Status Mental AlteredSee attack) (TransientischemicTIA Seizure ParalysisTodd’s Hypoglycemia Stroke Tumor Trauma Failure/ RenalDialysis EMS Triage and Destination Plan DestinationandTriageEMS Immediate Notification of FacilityNotificationImmediate Keep Scene Time to SceneTimeKeep Differential          YES YES 120 220 ≥ ≥ NO IV Procedure Protocol33 Procedure < 5 Hours < 5 SBP DBP Cardiac Monitor Cardiac after 3 readings3after 12 Lead ECG ProcedureLeadECG 12 Last Seen Normal is isNormal Seen Last This space left blank intentionallyblankleftspace This at least 5 minutes apart5 minutesleastat Blood Glucose AnalysisGlucoseBlood Notify Notify Destination or Time of Onset Time Or of Time Altered mental statusmentalAltered Paralysis / Weakness losssensoryotheror Blindness Dysarthria/ Aphasia Syncope / Dizziness Vertigo Vomiting Headache Seizures changepatternRespiratory / hypotensionHypertension Contact Medical ControlContact Medical I P B           Signs and Symptoms and Signs  Suspected Stroke YES P Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO Exit Exit to Stroke PREHOSPITAL STROKE SCREEN STROKE Appropriate ProtocolAppropriate Signs and Symptoms Symptoms andSigns History of traumaof History Associated diseases: diabetes,diseases:Associated CAD hypertension, Atrialfibrillation thinners)(bloodMedications Previous CVA, TIA's Previous surgery/ cardiacvascularPrevious Consistent with Acute withAcute Consistent Prehospital Stroke Screen StrokePrehospital consistent withStroke consistent Revised 8/13/2012     History   Suspected Stroke

**Please fill out the Stroke Specialty Section of the PCR

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Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro  Items in Red Text are key performance measures used in the EMS Acute Stroke Care Toolkit.  Acute Stroke care is evolving rapidly. Time of onset / last seen normal may be changed at any time depending on the capabilities and resources of your hospital based on Stroke: EMS Triage and Destination Plan.  Time of Onset or Last Seen Normal: One of the most important items the pre-hospital provider can obtain, of which all treatment decisions are based. Be very precise in gathering data to establish the time of onset and report as an actual time (i.e. 13:47 NOT “about 45 minutes ago.”) Without this information patient may not be able to receive thrombolytics at facility. Wake up stroke: Time starts when patient last awake.  The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 5 HOURS , scene times should be limited to ≤ 10 minutes, early notification / activation of receiving facility should be performed and transport times should be minimized.  Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time when the patient went to sleep or last time known to be symptom free.)  The differential listed on the Altered Mental Status Protocol should also be considered.  Be alert for airway problems (swallowing difficulty, vomiting/aspiration).  Hypoglycemia can present as a localized neurologic deficit, especially in the elderly.  Document the Stroke Screen results in the PCR.  Agencies may use validated pre-hospital stroke screen of choice.

Revised Protocol 33 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols 2012 Protocol Appropriate if indicated if indicated if indicated if indicated Cardiac / ArrhythmiaCardiac Multiple Trauma ProtocolTrauma Multiple Altered Mental StatusProtocol AlteredMental Hypotension / Shock Protocol/ ShockHypotension Spinal Immobilization ProtocolImmobilizationSpinal Vasovagal hypotensionOrthostatic syncopeCardiac syncope/ DefecationMicturition Psychiatric Stroke Hypoglycemia Seizure Protocol)(seeShockShock (Alcohol)Toxicological (hypertension)effectMedication PE AAA Differential              YES YES YES NO NO NO Status IV Procedure Cardiac Monitor Cardiac if indicated Suspected or Suspected Hypotension / Hypotension Altered Mental Mental Altered Poor PerfusionPoor Evident TraumaEvident Protocol34 Airway Protocol(s)Airway 12 Lead ECG ProcedureLeadECG 12 Notify Notify Destination or Syncope Contact Medical ControlContact Medical Blood Glucose Analysis ProcedureAnalysisGlucoseBlood Loss of consciousness with recoverywith consciousnessof Loss dizziness Lightheadedness, rapidpulse orslow Palpitations, irregularityPulse pressurebloodDecreased I P B     Signs and Symptoms and Signs  if indicated Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Diabetic ProtocolDiabetic Medications Females: LMP, bleedingvaginalLMP, Females: vomiting,nausea,loss:Fluid diarrhea historyPastmedical Cardiac history, stroke, seizure history,stroke,Cardiac ectopic)loss (GI, bloodOccult History       Syncope

Additional History Questions: 1) Type of epispode? 2) Was the a complete loss of consciousness? 3) Was there spontaneous recovery? 4) Are there other associated symtpoms? 5) Was there a sudden onset? (Cardiac causes are usually rapid onset) 6) Position? (Orthostatic Hypotension) 7) Are there any provocative factors? 8) Gestational Syncope? 9) What was the duration of the syncope? 10) Were there any signs witnessed? 11) Is the age of the patient a factor? 12) Are there any pre-existing medical conditions? 13) Any significant family history? 14) Is there recent injury? 15) Medication or recreational drugs use?

16) Try to discern from seizure. Seizure can mimic up to 15% of syncopal episodes.

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Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Assess for signs and symptoms of trauma if associated or questionable fall with syncope.  Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.  These patients should be transported.  More than 25% of geriatric syncope is cardiac dysrhythmia based.

Protocol 34 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols 2012 90 ≥ IO Procedure P NO Procedure Exit Exit to Etiology Protocol IV Procedure Improving Maximum 2 L 2Maximum Titrate SBP Titrate Repeat as neededas Repeat Abdominal Pain Abdominal Signs / SymptomsSigns Nausea / VomitingNausea Blood Glucose AnalysisGlucoseBlood Suggesting CardiacSuggesting Hypotension / ShockHypotension Consider 2 Large Bore sitesLargeBore 2Consider Normal Saline Bolus 500 mL500 SalineBolusNormal IV Procedure I YES CNS (increased pressure, headache, stroke,headache, pressure, (increasedCNS vestibular)or hemorrhage,trauma lesions,CNS infarction Myocardial narcotics, Drugs(NSAID's, antibiotics, chemotherapy) Renaldisorders orGI ketoacidosisDiabetic PID) cyst,(ovarian diseaseGynecologic influenza)(pneumonia,Infections abnormalitiesElectrolyte inducedtoxin Foodor abuseor SubstanceMedication Pregnancy Psychological YES YES Differential             IV / IO / ODT / IO / ODT IV Protocol Appropriate if indicated if indicated as indicatedas Odansetron 4 mg 4Odansetron perfusion, shockperfusion, Protocol35 Diabetic ProtocolDiabetic Adult Pain ControlAdult Pain Hypotension, poor Hypotension, Cardiac Protocol(s)Cardiac Notify Notify Destination or May minutes15repeatin May Contact Medical ControlContact Medical Serious Signs / SymptomsSignsSerious P YES Pain pain(constant,of Character etc.)sharp,dull, intermittent, Distention Constipation Diarrhea Anorexia Radiation NO YES       symptoms: Associated source) to (Helpfullocalize vision,blurred headache, Fever, cough,myalgias, malaise,weakness, Signs Symptoms and  headache, dysuria, mental statusmentaldysuria, headache, rash changes, Vomiting and Diarrhea Vomiting Or Or NO Procedure SalineLock Etiology IV Procedure Improving Then 150 mL / hr mL150 Then Abdominal PainAbdominal Signs / SymptomsSigns Nausea / VomitingNausea Normal Saline IV TKO TKO SalineIV Normal Blood Glucose AnalysisGlucoseBlood Suggesting CardiacSuggesting Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Normal Saline Bolus 500 mL500 SalineBolusNormal I I Medications history(pregnancy)Menstrual historyTravel / diarrheaemesisBloody Other sick contactssickOther historyPastmedical historyPastsurgical Last bowel movement/emesisbowel Last or worseningImprovement activity foodor with problemof Duration Age mealof lastTime Revised 8/13/2012           History   Vomiting and Diarrhea

Normal Saline Infusion is 25gtts/min with a 10 gtt set

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Pearls  Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro  The use of metoclopramide (Reglan) may worsen diarrhea and should be avoided in patients with this symptom.  Choose the lower dose of promethazine (Phenergan) for patients likely to experience sedative effects (e.g., Age ≥ 60, debilitated, etc.) When giving promethazine IV dilute with 10 mL of normal saline and administer slowly.  Document the mental status and vital signs prior to administration of Promethazine (Phenergan).  Isolated vomiting in pediatrics may be caused by pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures).

Revised Protocol 35 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Obstetrical Section Protocols 2012 Go to Go Crowning Delivery Protocol Newly Born Newly Expedite transport Expedite Multiple gestationMultiple Protocol Priority symptoms: Priority <36 weeks gestationweeks<36 Obstetrical Emergency as indicatedas Abnormal presentationAbnormal Severe vaginal bleeding Severe vaginal Buttock Foot Hand Abnormal presentationAbnormal cord Prolapsed previa Placenta placentaAbruptio YES Differential     pushing Support imminent Transport Do Not PullDo Not to refrainfromto Unless delivery Unless Presenting Parts Presenting Breech Birth Breech Encourage Mother Mother Encourage NO Crowning IV Protocol Inspect PerineumInspect Protocol37 Spasmodic painSpasmodic bleedingor dischargeVaginal pushorto urge Crowning Meconium (No digital vaginalexam) (No digital Childbirth ProcedureChildbirth >36 Weeks Gestation Weeks>36 Notify Notify Destination or Hypertension / HypotensionHypertension    Signs Symptoms and  Abnormal Vaginal Bleeding / BleedingVaginalAbnormal Contact Medical ControlContact Medical Over cordOver I HipsElevated Knees to ChestKnees Saline DressingSaline vagina to relievetovagina pressure on cordpressure Insert fingers intofingersInsert Prolapsed Cord Prolapsed Shoulder Dystocia Shoulder Childbirth Childbirth / Labor Left lateral positionlateralLeft duration Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any of contractionsof No Crowning Monitor andReassessMonitor fromface Document frequency andfrequency Document part of infant.ofpart Medications Status/ Para Gravida RiskHighpregnancy Rupture of membranesRupture bleeding vaginalany of/ amount Time fetalactivityof Sensation historydeliveryand Pastmedical Due dateDue / how startedoftencontractions Time Lateral PositionLateral Unable to Deliver to Unable Transport in Knee toKnee inTransport Place 2along fingersPlace Chest Position or LeftChestPosition supporting presentingsupporting Create air passage by by passageairCreate        History   side nose and push away pushaway nose andside Childbirth / Labor

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Pearls  Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro  Document all times (delivery, contraction frequency, and length).  If maternal seizures occur, refer to the Obstetrical Emergencies Protocol.  After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control post- partum bleeding.  Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.  Record APGAR at 1 minute and 5 minutes after birth. Protocol 37 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Obstetrical Section Protocols 2012 94 % 94 ≥ Maintain warmth Maintain NO Supplemental Oxygen Supplemental Monitor andReassessMonitor Maintain SpO2 Maintain needed Secretions drive Respiratory May repeat x 1 repeatx May Labored breathing / breathingLabored Persistent CyanosisPersistent 10 mL / kg IV / / kgIO mL 10 0.01 mg /kg IV / IO IV / /kg 0.01mg Monitor andReassessMonitor Airway failureAirway Infection effectmedication Maternal Hypovolemia Hypoglycemia heartdisease Congenital Hypothermia Normal SalineBolus Normal Epinephrine 1:10,000 Epinephrine Clear airway if necessaryairway Clear Every 3 to 5 minutes as 35 minutes toEvery Provide warmth / Dry Dry infant /warmth Provide YES Differential        I NO YES NO YES IO Procedure Protocol38 P YES YES YES NO Pulse Oximetry Pulse Cardiac Monitor Cardiac BVM VentilationsBVM BVM VentilationsBVM Heart Rate < 60RateHeart < 60RateHeart Newly Newly Born ChestCompressions Respiratory distressRespiratory mottlingorcyanosis Peripheral (normal) (abnormal)cyanosisCentral of levelresponsiveness Altered Bradycardia Heart Rate < 100RateHeart Heart Rate < 100RateHeart Term GestationTerm Warm, Dry andStimulateWarm,Dry Clear airway if necessaryairway Clear Good Muscle Tone Muscle Good Breathing or Crying or Breathing down algorithm to intubationto algorithmdown Notify Notify Destination or     Signs Symptoms and  Agonal breathing or ApneabreathingAgonal Pediatric Airway Protocol(s)Airway Pediatric IV Procedure If repeating cycle takecorrectivecyclerepeating If ContactControl Medical action: Change in position or BVM or BVM positionin Changeaction: Technique. If no improvement moveimprovement no If Technique. I P B NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Suctioning substance abuse substance smoking epinephrine. Care of Caremother hypovolemia, may undergo:may vigorous newborns vigorous recommended - DirectEndotracheal Maternal riskfactors Maternal Meconium Delivery difficulties diseaseCongenital (maternal)Medications Due date and gestational age gestationaldateandDue (twins etc.)gestationMultiple Suction only when when only Suction Appropriate ProtocolAppropriate ventilations / BVM, BVM, / ventilations Airway Airway Suctioning or if BVM ifneeded.is BVM or Meconium present:Meconium hypoglycemia (< 40.) hypoglycemia Clear amniotic fluid: amnioticClear compressions and / andor compressions pneumothorax and / or / and pneumothorax newborn is no longeris nonewborn Non Most newborns requiring newborns Most I      History   If not responding considerrespondingnot If obstruction is present and / andpresentis obstruction Routine suctioning of thesuctioningRoutine resuscitation will respond to respondwill resuscitation Adult Obstetrical Section Protocols 2012 , 95%. – 70% – supportive care only). supportive - 65 %, 2 minutes = = 2 minutes65 %, 65 - 85 % and 10 minutes = = 85 minutes 10 % and 85 – Protocol38 80 %, 5 minutes = 80 80 = minutes %, 5 80 – This space left blank intentionallyblankleftspace This Newly Newly Born Following 60 = 1 minuteat Following birth 75 %, 4 minutes = 75 75 = minutes %, 4 75 – Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 3 minutes = = 70 minutes3 Expected pulse oximetry readings: oximetry pulseExpected Most important vital signs in the newly born are respirations / respiratory effort respiratory / and rate. respirations heart Mostborn are in the newly importantsigns vital umbilical the pulse. of palpation followed pulse precordial the of auscultation by assessed bestHeart rate body. the of side right the to applied be oximetry Pulse should Document 1 and 5 minute Apgars in in PCR Apgars 5 minute and 1 Document Maternal sedation or narcotics will NO LONGER (Naloxone recommendedwill or narcoticsinfant sedate Maternal sedation in infant. hypoglycemia Consider Normal4 mlml with Saline) D50 of(1 of = diluted D10 D50 CPR in infants is 120 compressions/minute with a 3:1 compression to ventilation ratio. ventilation compressionto with a 3:1 compressions/minuteis 120 CPR infants in warm infant keepto important extremely It is Recommended Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Neuro Abdomen, Chest, HEENT, Heart, Extremities, Recommended Status,Skin, Neck, Mental Exam: need no resuscitation. will/ breathingTermgestation,good andtone strong with cry muscle generally        Pearls      Adult Obstetric Section Protocols 2012 Exit Exit to YES Protocol Childbirth IO Procedure 90 ≥ P YES NO NO YES YES SBP Labor Shock Activity Seizure Improving Maximum 2 L 2Maximum 500 mL IV / IO IV / mL500 Pregnancy / Pregnancy Hypotension / Hypotension Missed PeriodMissed eclampsia / Eclampsiaeclampsia Poor Perfusion / PerfusionPoor - Normal SalineBolusNormal Known or Suspected or Known Repeat as needed to effect to effectneededas Repeat Placenta previa Placenta abruptioPlacenta abortion Spontaneous Pre YES Left lateral recumbant positionrecumbantlateralLeft IV Procedure YES    Differential  I I NO NO NO Exit Exit to Shock Protocol Exit Exit to Hypotension / Hypotension Protocol Abdominal Pain Abdominal Or Exit Exit to Protocol39 Notify Notify Destination or Appropriate ProtocolAppropriate Contact Medical ControlContact Medical Abdominal Pain ProtocolPainAbdominal Vaginal bleedingVaginal painAbdominal Seizures Hypertension headacheSevere changesVisual face andof hands Edema Exit Exit to Vaginal Bleeding / Abdominal Pain/ AbdominalBleedingVaginal Diabetic Protocol       Signs Symptoms and  NO NO Obstetrical Emergency 5 mg IV / mgIO 5 every 35 toevery - 3 minutes Or Or – 2 mg Procedure as neededas YES YES YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any IV Procedure Cardiac Monitor Cardiac Maximum 10 mg 10Maximum Maximum 10 mg 10Maximum minutes as neededas minutes Pregnancy / Pregnancy If no IV / noIO access IVIf If no IV / noIO access IVIf Over 2 Over Hypertension Midazolam 5 mg IM5 mg Midazolam May repeat dose x 1 x repeatdoseMay Missed PeriodMissed Seizure ActivitySeizure Blood Glucose AnalysisGlucoseBlood Repeat Midazolam 2.5 mg IV / mgIO 2.5 Midazolam Known or Suspected or Known Diazepam 2.5Diazepam Diazepam 10 mg Per Rectummg 10 Diazepam Magnesium Sulfate 2 g IV / 2IO Sulfate g Magnesium May minutesto 5 3repeat every May Left lateral recumbant positionrecumbantlateralLeft Prenatal carePrenatal / birthspregnanciesPrior / Para Gravida Past medical historyPastmedical meds Hypertension P P Revised I 12/13/2012    History   NO NO Obstetrical Emergency

Magnesium Sulfate must be given in 20% or less concentrations intravenously.

Dilute 2 gms (4 mL) of Magnesium Sulfate with 6 mL of NS = 2 gms Magnesium Sulfate in 10 mL Normal Saline

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Pearls  Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro  Severe headache, vision changes, or RUQ pain may indicate preeclampsia.  In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure.  Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome.  Ask patient to quantify bleeding - number of pads used per hour.  Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation. Greater than 20 weeks generally require 4 to 6 hours of fetal monitoring. DO NOT suggest the patient needs an ultrasound.  Magnesium may cause hypotension and decreased respiratory drive. Use with caution.  Midazolam 5 – 10 mg IM is effective in termination of seizures. Do not delay IM administration with difficult IV or IO access.

Revised Protocol 39 12/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Trauma and Burn Section Protocols 2012 Don’t include in Don’tinclude Degree Burn Degree rd /3 painful ( painful nd - compromise CriticialBurn Degree) blisteringDegree) nd Degree) painless/charred or leatherypainless/charred Degree) transport to a Burn Center)a totransport Burns with definitive airway airway definitiveBurnswith Burns with Multiple Trauma MultipleBurns with rd (When reasonably accessible,(Whenreasonably Degree) red Degree) >15% >15% 2 TBSA if indicatedif st Electrical injuryElectrical – IV Procedure to appropriate destination usingdestinationappropriateto Normal SalineNormal if indicated if indicated as indicatedas (More info below)info(More Trauma and Burn: Traumaand Cyanide Exposure Cyanide Carbon Monoxide / CarbonMonoxide for up to the first 8 hours.tofirstup thefor TBSA) Thickness(2 Partial (3 FullThickness skin injuryThermal Chemical injury Radiation injuryBlast Superficial (1 Superficial IO Procedure Adult Pain ControlPainProtocol Adult Adult Airway Protocol(s)AdultAirway Dry Clean Sheet or Dressings CleanSheetor Dry 0.25 mL / kg ( x % hr % TBSA) / ( x/ kg0.25mL Lactated Ringers if Ringersavailable Lactated       Differential  Adult Multiple Trauma ProtocolTrauma AdultMultiple EMS Triage and Destination Plan DestinationandTriageEMS Consider 2 IV sites if greater than 15TBSA %greater thanifIV sites 2Consider Remove Rings, Bracelets / Constricting Items ConstrictingBracelets/ Rings,Remove Degree Burn Degree Rapid TransportRapid rd /3 nd I I P Protocol40 Serious Burn Serious transport to a Burn Center)a totransport (When reasonably accessible,(Whenreasonably 15% TBSA 2 TBSA 15% Hypotension or GCS 13 or 13 Lessor GCS Hypotension - intubation for airway airway stabilizationfor intubation Carbon 5 Cyanide Protocol Burns, pain,swellingBurns, Dizziness consciousnessof Loss Hypotension/shock compromise/Airway becould distress by indicated hoarseness/wheezing Monoxide / Monoxide Suspected inhalation injury or requiringor injuryinhalation Suspected Assess Burn / Concomitant Injury Severity InjuryConcomitant Burn / Assess  Signs and Symptoms andSigns     Notify Notify Destination or Contact Medical ControlContact Medical Adult Adult Thermal Burn Degree Burn Degree rd /3 nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any if available Normal SalineNormal Minor Burn Minor if indicated if indicated if indicated as indicatedas IV Procedure Constricting ItemsConstricting Lactated Ringers Lactated Normotensive (More info below)info(More Cyanide Exposure Cyanide GCS 14 or Greater 14GCS Carbon Monoxide / CarbonMonoxide for up to the first 8 hours.tofirstup thefor 1. Lactated Ringers preferred over Normal Saline. Use if available, if not change over once available. onceover not changeavailable,if Use if Saline.preferredRingers Normal over Lactated1. 2. Formula example; an 80 kg (196 lbs.) patient with 50% hour. of per 1000fluidcc willTBSA needwith50% kgpatient lbs.)80(196 an Formulaexample;2. Remove Rings, Bracelets / Bracelets/ Rings,Remove Adult Pain ControlPainProtocol Adult Transport Facility of Choiceof FacilityTransport Adult Airway Protocol(s)AdultAirway Dry Clean Sheet or Dressings CleanSheetor Dry 0.25 mL / kg ( x % hr % TBSA) / ( x/ kg0.25mL Adult MultipleProtocol Trauma Adult Medications traumaOther Consciousnessof Loss status Tetanus/Immunization Inhalation injuryInhalation of InjuryTime historyandPastmedical Type of exposure (heat, gas, (heat, of exposure Type chemical) < 5% 2 TBSA < 5% No inhalation injury, Notinjury, Intubated, No inhalation I History        Adult Trauma and Burn Section Protocols tical 2012 cri st th and and 6 th 5 th ) ) thickness burns. rd degree degree burn from those of st ) ) or full (3 referring referring to a burn that destroys referring to a burn that destroys referring to a burn that destroys nd th th th 4 the dermis and involves muscle tissue. 5 dermis, penetrates muscle tissue, and involves tissue around the bone. 6 dermis, destroys muscle tissue, and penetrates or destroys bone tissue.   Seldom do you Seldom do you find a complete isolated body part that is injured as described the in of Rule Nines. More it be likely, portions will of one area, portions of another, and an approximation be needed. will For the purpose of determining the extent of serious injury, differentiate the area with minimal or 1 Other burn classifications general in include:  partial partial (2 For For the purpose of determining Body Total Surface Area (TBSA) of burn, include only Partial and ThicknessFull burns. Report the observation of other superficial (1 degree) burns but do not include those burns in your TBSAestimate. Some texts refer will to 4 degree burns. There is significant debate regarding the actual value of identifying a burn injury beyond that of the superficial, partial and thickness full burn at least at the of level emergent and primary care. For our work, are all included Full in Thickness burns. Rule ofRule Nines       degree burns, or burns, degree rd Protocol40 1 % 1 or 3 nd never apply ice or cool the burn, must maintain normal body temperature.body normalmustmaintaincoolburn, theiceorapply never - Adult Adult Thermal Burn size of the patient’s palmaspatient’sthe of size Estimate spotty areas of burn by using the usingby burnareasspottyof Estimate Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 15% total body (TBSA) 2 surfaceareabody total 15% degree burns > 5% TBSA for any or group,agefor any TBSA burns5% > degree - rd suspicion of abuse or neglect, or abuseor neglect,of suspicion or injury, inhalation or burns,chemical or feethands,perineum,of burnsface, circumferential burns of or extremities,burns circumferential injuries,or or lightning electrical > 5 3 Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling.tissueto softsecondary compromisepotentialvascularto due dangerous are to extremitiesburns Circumferential hypothermiatoare prone patientsBurn injuries.burnand childrenwith ofabuse possibilitychildthe Evaluate patient.burna injectionstoIM pain administerNever Burn patients are trauma patients, evaluate for multisystem trauma.for multisystemevaluatepatients,are trauma patientsBurn process!)burningthe (Stopinjury.the longernocontactingisburnthe hascaused whatever Assure injuries.inhalationsignificantexperiencespatient the when requiredis Early intubation Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or excessiveisCenter Burn to if distanceonly utilizedbeshould facility aCenter. Local Burntotransport direct Require field.thein available notare management airway assuch interventions Critical or SeriousBurns: Critical Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro andBack, Lungs,Abdomen, Extremities, Neck,Heart,HEENT, Mental Exam: Status,Recommended System. TriageStartto / theJumpStartnotseverity apply Indo burn YellowRed andGreen,   Pearls          Adult Trauma and Burn Section Protocols 2012 94 % 94 ≥ 16 Breaths16 – 35 mmHg35 45 mmHg45 – – YES 35 Maintain EtCO2 Maintain if indicated Supplemental oxygen Supplemental Monitor andReassessMonitor Maintain SpO2 Maintain Airway Protocol(s)Airway Brain HerniationBrain / PosturingPupils EtCO2 30EtCO2 per minutes to maintainminutesper B Hyperventilate 14 Hyperventilate Unilateral or Bilateral Dilation of or BilateralDilationUnilateral Skull fractureSkull Contusion,(Concussion,injuryBrain or Laceration)Hemorrhage hematomaEpidural hematomaSubdural hemorrhageSubarachnoid injurySpinal Abuse Cough Able to Able Differential        NO YES 45 mmHg45 – if available RSI Protocol 35 Maintain EtCO2 Maintain Airway Protocol(s)Airway IO Procedure B 8 ≤ Protocol41 P Notify Notify Destination or GCS GCS Contact Medical ControlContact Medical if indicated if indicated if indicated if indicated Record GCS Record Pain, swelling, bleedingPain,swelling, statusmentalAltered Unconscious / failuredistressRespiratory Vomiting injurymechanismof traumaticMajor Seizure Seizure ProtocolSeizure Assess MentalStatus Assess    Signs and Symptoms andSigns     Head Head Trauma Spinal Immobilization ProtocolImmobilizationSpinal Altered Mental Status Protocol StatusMental Altered Adult Multiple Trauma ProtocolTrauma AdultMultiple Blood Glucose Analysis ProcedureAnalysisGlucoseBlood IV Procedure I NO trauma - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 45 mmHg45 10 Breaths10 – – DO NOT NOT DO Monitor andReassessMonitor Evidence for multifor Evidence Loss of consciousnessof Loss Bleeding historyPastmedical Medications Time of injuryTime vs. penetrating)(bluntMechanism HYPERVENTILATE EtCO2 35EtCO2 per minute to maintaintominute per      History   Ventilate 8 Ventilate

Head Trauma

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Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro  GCS is a key performance measure used in the EMS Acute Trauma Care Toolkit.  If GCS < 12 consider air / rapid transport  In areas with short transport times, RSI/Drug-Assisted Intubation is not recommended for patients who are spontaneously breathing and who have oxygen saturations of ≥ 90% with supplemental oxygen including BIAD / BVM.  Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response).  Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated.  An important item to monitor and document is a change in the level of consciousness by serial examination.  Consider Restraints if necessary for patient’s and /or personnel’s protection per the Restraint Procedure .  Limit IV fluids unless patient is hypotensive.  Concussions are traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. Protocol 41 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Trauma and Burn Section Protocols 2012 90 ≥ Needle - 10 minutes10 ≤ to appropriateto Tension pneumothoraxTension chestFlail tamponadePericardial wound chestOpen Hemothorax Procedure if indicated Abnormal if indicated Maximum 2 Liters 2Maximum abdominal bleedingabdominal destination usingdestination Monitor andReassessMonitor - Trauma and Burn: Traumaand Head Injury ProtocolInjuryHead Repeat to effect SBP to effectRepeat ChestDecompression Chest: Intra Femurfracture/ Pelvis injury/ Cordfracture Spine Trauma)(seeHeadinjuryHead / Dislocation fractureExtremity obstruction)(Airway HEENT Hypothermia Provide Early Notification Early Provide Splint Suspected FracturesSuspectedSplint BindingPelvicConsider HemorrhageExternal Control Rapid TransportRapid Normal Saline Bolus 500 mL IV mL/ 500IO SalineBolus Normal Limit SceneTimeLimit EMS Triage and Destination Plan DestinationandTriageEMS Differential (Life threatening) Differential         I P IO Procedure P GCS Shock Protocol Symptoms Cardiac Monitor Cardiac Hypotension / Hypotension if indicated VS / Perfusion/ VS / ABC and LOC ABC and Protocol42 Airway Protocol(s)Airway Notify Notify Destination or Contact Medical ControlContact Medical Pain,swelling bleedinglesions,Deformity, Altered mental status or statusmentalAltered unconscious or shockHypotension Arrest Assessment of Serious Signs/ Seriousof Assessment IV Procedure Spinal Immobilization ProcedureImmobilizationSpinal  Signs Symptoms and     I P Multiple Trauma to appropriateto Normal Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any destination usingdestination Monitor andReassessMonitor Trauma and Burn: Traumaand Transport Splint Suspected FracturesSuspectedSplint BindingPelvicConsider HemorrhageExternal Control Repeat Assessment Adult ProcedureAssessmentAdult Repeat EMS Triage and Destination Plan DestinationandTriageEMS Past medical historyPastmedical Medications Location in structure or vehicleorstructure in Location deador injuredOthers MVC detailsofand Speed equipment/ protectiveRestraints Time and mechanism of injurymechanismandTime vehicleorstructure to Damage     History    

Multiple Trauma

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Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro  Items in Red Text are key performance measures used in the EMS Acute Trauma Care Toolkit  Transport Destination is chosen based on the EMS System Trauma Plan with EMS pre-arrival notification.  Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid transport of the unstable trauma patient to the appropriate facility is the goal.  Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained ≥ 90%  Geriatric patients should be evaluated with a high index of suspicion. Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning.  Mechanism is the most reliable indicator of serious injury.  In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood.  Do not overlook the possibility of associated domestic violence or abuse. Protocol 42 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Airway

Assess Respiratory Rate, Effort, Supplemental oxygen Oxygenation Goal oxygen saturation Is Airway / Breathing Adequate? YES ≥ 94% NO

Basic Maneuvers First Exit to -open airway chin lift / jaw thrust Appropriate Protocol -nasal or oral airway -Bag-valve mask (BVM) Spinal Immobilization Procedure if indicated Consider AMS Protocol

Airway Foreign Body NO Airway Patent Obstruction Procedure I Direct Laryngoscopy

YES P e

Supplemental oxygen d i

Complete Obstruction Breathing / Oxygenation BVM a NO YES

Unable to Clear Support needed Maintain Oxygen t r

Saturation ≥ 90 % i c

NO G

YES e Monitor /Reassess n Tension e Supplemental Oxygen r

Airway Cricothyrotomy if indicated Pneumothorax a l

P Needle Procedure S

See Pearls Section YES e

Exit to c t

Appropriate Protocol NO i o

Chest n

P Decompression P

Procedure r

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BVM / Oxygen l Unable to Ventilate NO s and Oxygenate ≥ 90% Effective during or after one (1) or more unsuccessful Airway Blind Insertion B YES intubation attempts . Device Procedure Oral-Tracheal Anatomy inconsistent I Intubation Procedure with continued Supplemental oxygen attempts. BVM Maintain Oxygen Consider Sedation ≥ Three (3) unsuccessful Saturation 90 % If BIAD or ETT in place attempts by most experienced EMT-P/I. Midazolam 0.1 – 0.2 mg/kg IV / IO P May repeat in 5 minutes if Exit to needed. Use only with definitive Pediatric Failed airway in place Airway Protocol Notify Destination or Contact Medical Control

Revised Protocol 44 2/22/2013 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Pediatric General Section Protocols 2012 90%, to is acceptable90%, it 35. - of 30 of 2 11 years age. years of 11 collar (even in absence of trauma) to better maintain ETT maintainETT trauma)bettertoof (evenabsence in collar - . 11 years of age or any the bewithincan measured patientor any whichage years of 11 Protocol44 tracheal intubation is unsuccessful.isintubation tracheal - : This space left blank intentionallyblankleftspace This Pediatric Airway Pediatric last resort procedure in pediatric patients ≤ pediatricpatientsprocedurein resort last pediatric is defined as less than ≤ lessthanas is definedpediatric Luten tape. Luten Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any - Indicated as a lifesaving / a lifesavingas Indicated safetyanduseto it’sevidencesupportlittle Very procedurerare.this the of usemakenowavailable airway devices of pediatric alternativevariety A program,maintaintraininga procedure, establish a writtendevelop procedure mustthis whoutilizeAgencies Office. RegionalEMSDirector / Stateto planthe Medicaland trainingsubmitprocedureand equipment It is important to secure the endotracheal tube well and consider c andconsidertubewell endotrachealthesecure importantisto It / transfers.movesallpatient duringbe used tubeshould endotrachealof stabilization Manual placement. NeedleProcedureAirway Cricothyrotomy Paramedics should consider using a BIAD if oralusingBIAD if aconsider shouldParamedics cases. someworsen view inThey may intubations. difficultassistwith tobe used BURP may maneuver andpressureCricoid patients.allintubatedin be considered shouldtubeplacementGastric It is strongly encouraged to complete an Airway Evaluation Form with any BIAD Intubation any procedure.Formor Evaluationwith anto Airway completestrongly encouragedIt is a gagreflex. maintain patientswho in intubation Do attemptnot Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult normalAdult therate Adolescents and for School Age, for 20 for Toddlers,25be for Neonates,rate 30 should Ventilatory hyperventilation. 45 andavoid and35 between EtCO2 aminute. Maintainperof 12 pCO maintainabeonly to done should traumaheadin deteriorating Hyperventilation ventilation. or inserted teethinto the past or endotrachealtube laryngoscope bladethe passingdefinedasattemptis An intubation nasalpassage.the If an effective airway is being maintained by BVM with continuous pulse oximetry of ≥ oximetry values BVMpulse withby continuousmaintainedbeing is airway effective If an or Intubation.BIAD of ausing instead measures withbasicairway continue and appropriate oxygenation receiving patientisthe is whenairway aof protocol securethispurposes For the Capnometry (color) or capnography is mandatory results. Documentof allintubation. methods mandatory withisor capnography (color) Capnometry isthis though notuse tube BIAD endotracheal recommendedor with is(EtCO2) capnography strongly Continuous recommended).is other by means(2)twopopulation neonatal(verificationin the impossible prove may andvalidated Broselow For this protocol,For this Revised 2/22/2013               Pearls  Pediatric General Section Protocols 2012 90 % 90 90 % 90 ≥ ≥ Exit Exit to Continue BVM Continue Supplemental oxygen Supplemental BVM Oxygen Maintain Saturation oxygen Supplemental BVM Oxygen Maintain Saturation Call for additionalforCall Appropriate ProtocolAppropriate resources if availableif resources Supplemental Oxygen Supplemental YES YES YES 90 % 90 ≥ NO NO BVM BVM Adequate Successful Failed Aiway Failed Significant FacialSignificant Adjunctive Airway Adjunctive Maintains Oxygen Oxygen Maintains Airway ProcedureBIAD Airway Saturation Notify Notify Destination or Airway BIAD ProcedureAirway Oxygenation / Ventilation / Oxygenation Contact Medical ControlContact Medical Place Oral and / or Nasal Airway or NasalOral and/ Place Trauma / Swelling / Distortion/ / SwellingTrauma Protocol45 B YES NO 90% during90% ≥ P/I. - Pediatric Failed Airway Pediatric Failed 90 % 90 attempts . attempts ≥ or equipmentor Procedure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any experienced EMT experienced See Pearls SectionPearlsSee Supplemental oxygen Supplemental BVM Oxygen Maintain Saturation Airway NeedleCricothyrotomyAirway Three (3) unsuccessful attempts by mostattemptsby unsuccessful (3)Three P Revised 2/22/2013 Anatomy inconsistent with continued attempts. continuedwith inconsistentAnatomy or after one (1) or more unsuccessful intubationmoreunsuccessful(1)one orafter or Each attempt should include change in approachinchange includeshould Eachattempt Unable to Ventilate and Oxygenate Oxygenate andto VentilateUnable NO MORE THAN THREE (3) ATTEMPTS MORE (3)THREE THAN ATTEMPTS TOTAL NO

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Pearls  For this protocol, pediatric is defined as less than ≤ 11 years of age or any patient which can be measured within the Broselow-Luten tape.  Capnometry (color) or capnography is mandatory with all methods of intubation. Document results.  Continuous capnography (EtCO2) is strongly recommended with BIAD or endotracheal tube use though this is not validated and may prove impossible in the neonatal population (verification by two (2) other means is recommended).  If an effective airway is being maintained by BVM with continuous pulse oximetry values of ≥ 90%, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation.  For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation.  An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage.  Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 12 per minute. Maintain a EtCO2 between 35 and 45 and avoid hyperventilation.

 Hyperventilation in deteriorating head trauma should only be done to maintain a pCO2 of 30-35.  It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure.  If first intubation attempt fails, make an adjustment and then try again: Different laryngoscope blade; Gum Elastic Bougie; Different ETT size; Change cricoid pressure; Apply BURP; Change head positioning  Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful.  Cricoid pressure and BURP maneuver may be used to assist with difficult intubations. They may worsen view in some cases.  Gastric tube placement should be considered in all intubated patients.  It is important to secure the endotracheal tube well and consider c-collar (even in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers.  Airway Cricothyrotomy Needle Procedure: Indicated as a lifesaving / last resort procedure in pediatric patients ≤ 11 years of age. Very little evidence to support it’s use and safety. A variety of alternative pediatric airway devices now available make the use of this procedure rare. Agencies who utilize this procedure must develop a written procedure, establish a training program, maintain equipment and submit procedure and training plan to the State Medical Director / Regional EMS Office.

Revised Protocol 45 2/22/2013 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS

Pediatric Cardiac Section Protocols 2012 ) Go to Protocol Return of Circulation Spontaneous Reversible CausesReversible AT ANY TIME ANY AT Post ResuscitationPost Thrombosis; coronary Thrombosis; (MI) Hypovolemia Hypoxia (acidosis)ionHydrogen Hypothermia Hyperkalemia /Hypo Hypoglycemia pneumothoraxTension cardiacTamponade; Toxins pulmonaryThrombosis; (PE) Maximum 10 mg 10 Maximum NO ) Respiratory failureRespiratory bodyForeign Hyperkalemia epiglotitis)(croup,Infection (dehydration)Hypovolemia heartdisease Congenital Trauma pneumothoraxTension Hypothermia or medicationToxin Hypoglycemia Acidosis via via ETT( → Differential             10 seconds10 ≤ IO Procedure Needle Procedure Needle 100 / min) / 100 - ≥ 5 minutes5 – Maximum 60 mL/kgMaximum P NO 20 mcg/kg/min IV / IO IV / mcg/kg/min20 Consider – Cardiac Monitor Cardiac as indicatedas Resuscitation Shockable Rhythm Shockable Epinephrine1:10,000 Protocol48 (0.1 mL / kg of 1:10,000)/ ofmLkg (0.1 Repeat every every 3 Repeat Criteria for Death / for DeathNo Criteria Notify Notify Destination or 0.01 mg/kg IV/IO1mg) (max 0.01mg/kg Pediatric Diabetic ProtocolDiabeticPediatric Review DNR / MOSTDNR FormReview Contact Medical ControlContact Medical Blood Glucose Analysis ProcedureAnalysisGlucoseBlood Children) Push Fast ( FastPushChildren) Search for Reversible Causes Causesfor ReversibleSearch Dopamine 2 Dopamine Normal Saline Bolus 10 mL/kg IV / IO mL/kgIV / 10SalineBolus Normal Begin Continuous CPR CompressionsContinuousCPR Begin Change Compressors every minutes2every CompressorsChange IV Procedure Push Hard (1.5 inches Infant / 2 inchesin/ 2Infant Hard inches(1.5Push May repeatneededasMay Limit changes / pulses checks/ pulseschangesLimit Unresponsive ArrestCardiac rigorofor lividitySigns ( Consider Chest DecompressionChestConsider I I I I   Signs and Symptoms and Signs  P P YES Epinephrine 1:1000 0.1 mg/kg mL/kg) (0.1 0.1 Epinephrine 1:1000 YES Pediatric Asystole Asystole / PEA Pediatric Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any OD ArrestProtocol Follow Protocol Protocol Policy Follow Consider Pediatric PulselessPediatric Do beginnot Resuscitation If no IV / IO access may usemay / IO accessIV no If In most cases pediatric airways can be managed by basic interventions. by managed be pediatric airways can casesmostIn In order to be successful in pediatric arrests, a cause must be identified and corrected. and identified must be a cause arrests, pediatric in successfulbe to order In is critical. airway early Unlikeintervention arrest. adults cardiac ofcommon is causeRespiratory arrest a Beta Blocker OD BlockerBeta syndrome, pattern of injuriesof patternsyndrome, SIDS Airway obstructionAirway Hypothermia baby shakenabuse;Suspected Past medical historyPastmedical Medications terminalillnessof Existence Events leading to arrestleadingEvents downtime Estimated Pediatic Toxicology Toxicology Pediatic Rhythm AppropriateRhythm Deceased SubjectsDeceased Calcium Channel BlockerCalciumChannel     Pearls        History   Pediatric Cardiac Section Protocols e 2012 5 minutes5 – Or as indicatedas Consider 20 mL / kg IV / / kgIO mL 20 Pediatric AMS AMS ProtocolPediatric 0.01 mg / kg IV / IO IV / / kg0.01mg Epinephrine 1:1000 Epinephrine Normal SalineBolusNormal Repeat as needed x x needed3 as Repeat Epinephrine 1:10,000 Epinephrine Maximum 0.1 to 1 mg to 0.1Maximum Pediatric Airway Protocol(s)Airway Pediatric Foreign bodyForeign Secretions epiglotitis)(croup,Infection Repeat in 5 minutes x x 1 inminutes 5Repeat Cardiac Pacing ProcedurePacingCardiac Repeat every every 3 Repeat Atropine 0.02 mg / kg IV / IO IV / / 0.02mgkg Atropine Respiratory failureRespiratory (dehydration)Hypovolemia heartdisease Congenital Trauma pneumothoraxTension Hypothermia or medicationToxin Hypoglycemia Acidosis 0.1 mg / kg via ETT (Max 1 mg) ETT via (Max/ kg mg 0.1 I Differential          P NO YES IO Procedure P NO NO YES Shock Adequate Continued Cardiac Monitor Cardiac Protocol49 Airway PatentAirway Heart Rate < 60RateHeart Poor Perfusion / PerfusionPoor Identify underlying causeunderlyingIdentify Poor Perfusion / Shock/ PerfusionPoor Notify Notify Destination or Oxygenation / Ventilation / Oxygenation Decreased heart rateheart Decreased cyanosisor refillcapillaryDelayed coolskin Mottled, or arrestHypotension of levelconsciousness Altered Contact Medical ControlContact Medical IV Procedure Blood Glucose Analysis ProcedureAnalysisGlucoseBlood I     Signs Symptoms and  P YES Pediatric Bradycardia - Luten Tape for drug dosages if applicable.dosagesfor drugTape Luten - Exit Exit to Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any AMS AMS 1 year of age ofyear 1 ArrestProtocol Pediatric CardiacPediatric Protocol Bradycardia Toxicology Follow Pediatric Follow Suspected Beta ChannelBlocker Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro Extremities,Lungs,Abdomen, Back, Heart, Skin,Status,HEENT, MentalExam: Recommended Medication (maternal or infant)or(maternal Medication Respiratory distress or arrestdistressRespiratory Apnea exposure ortoxic poisonPossible diseaseCongenital Past medical historyPastmedical exposure body Foreign Minimum Atropine dose is 0.1 mg IV. mg0.1is dose AtropineMinimum Most maternal medications pass through breast milk toinfant.milk thebreast through pass medicationsmaternal Most bradycardia.producemay effects narcoticanddehydrationsevere Hypoglycemia, th per patientsfor pediatricappropriatepads useofthe require pacing transcutaneousexternal patientsrequiring Pediatric guidelines.manufacturers Use BroselowUse ≤ Infant airway problems.todue arearrests of pediatric majorityThe Causing Hypotension / HypotensionCausing Poor Perfusion / Shock/ PerfusionPoor Blocker or Calcium or Calcium Blocker Pearls       History          Pediatric Cardiac Section Protocols 2012 Pediatric Protocol(s) Pediatric Airway Pediatric Allergic ReactionAllergic Anaphylaxis ProtocolAnaphylaxis ° Congestive heart failureheartCongestive Asthma Anaphylaxis Aspiration effusionPleural Pneumonia embolusPulmonary tamponadePericardial Exposure Toxic ) ° Differential          40 NO - YES - position (25 position - if indicated IO Procedure P NO YES Cardiac Monitor Cardiac Anaphylaxis Airway PatentAirway if available Protocol50 Allergic ReactionAllergic Pulse Oximetry / Oximetry EtCO2 Pulse 12 Lead ECG ProcedureLeadECG 12 Ventilations adequateVentilations Oxygenation adequateOxygenation Notify Notify Destination or if indicated IV Procedure Contact Medical ControlContact Medical I P B Infant: Respiratory distress, poordistress, RespiratoryInfant: gain,+/ lethargy,weight feeding, cyanosis distress,RespiratoryChild/Adolescent: apprehension,rales,bilateral distentionvein jugularorthopnea, sputum,peripheralfrothy pink,(rare), painchestdiaphoresis,edema, shockHypotension, Pulmonary edema may vary depending on the underlying cause and may may andunderlying dependingthecausevary on edema may Pulmonary : Transport to a Pediatric Specialty CenterPediatricSpecialtya toTransport   Signs/Symptoms  NO Position child with head of bed inbed upof with childheadPosition Flexing hips with support under knees so that they are bent 90 benttheythat areso knees under supporthipswith Flexing 20 mcg/kg IV / IO. Titrate to age specific systolic pressure.bloodsystolic to specificTitrateageIV / IO. mcg/kg20 Pediatric Pulmonary Edema / CHF – Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 6 months: Ventricular septal defects (VSD), Atrioseptal defects(ASD). (VSD), Atrioseptaldefectsseptal months:Ventricular 6 known CHF known – History / Signs / / SignsHistory Any age: Myocarditis, Pericarditis, SVT, blocks.SVT, Pericarditis,heart age:Myocarditis,Any Fentanyl: mcg.50dose IO. MaxsingleIV / 1 mcg/kg Fentanyl: Control. Medicalof determinedconsultationDose after Nitroglycerin: / IO. 1 mg/kgIV Lasix < 1 month: Tetralogy of Fallot, Transposition of the great arteries, Coarctation of aorta.theCoarctation greatarteries,the of Transpositionof Fallot,Tetralogy month:< 1 2 5mg/dosedose IO. Maxsinglemg/kgIV / 0.1 MorphineSulfate: Dopamine 2 Dopamine with crackles / rales / / cracklesraleswith Symptoms consistentSymptoms with respiratory distress respiratorywith Treatment of Congestive Heart Failure / Heartof FailureCongestiveTreatment include the following with consultation by Control: by consultationMedicalthewith following include Contact Medical Control early cardiacpatient.pediatricof carethein early the Control MedicalContact history. precisemedicalpastdefect,aobtain heart congenital ahave withCHF Mostchildren age varies by diseaseheart Congenital Recommended exam: Mental status, Respiratory, NeuroCardiac,Skin, status, Respiratory, Mentalexam: Recommended Congestive heart failureheart Congestive historyPastmedical Congenital Heart DiseaseHeart Congenital LungDiseaseChronic wheezing secondary to pulmonary etiology (discuss with with Control)Medical etiology(discusspulmonaryto secondary wheezing Do not assume all wheezing is pulmonary, especially in a cardiac child: avoid albuterol unless strong history of recurrenthistoryof unlessstrong albuterol avoidchild: a cardiacin especiallypulmonary,is allwheezing Do assume not     Pearls    History    Pediatric Cardiac Section Protocols 2012 YES Follow VF / VT VF / Pediatric Protocols Exit Exit to Exit Exit to Protocol Pediatric Airway Pediatric Pediatric Tachycardia Pediatric Adult Cardiac Arrest AdultCardiac Newly ProtocolBornNewly Shockable Rhythm Shockable Foreign body, Secretions, Infection InfectionSecretions,body, Foreign epiglotitis)(croup, ) YES YES YES Respiratory failureRespiratory (dehydration)Hypovolemia heartdisease Congenital Trauma cardiactamponade,pneumothorax, Tension embolismpulmonary Hypothermia or medicationToxin K) (Glucose,abnormalities Electrolyte Acidosis NO Differential          Follow Pediatric Protocols Asystole / PEA Asystole Pediatric Airway Pediatric 10 seconds10 ≤ 100 / min) / 100 ≥ 31 days olddays31 ≤ NO NO NO Protocol51 16 years oldyears16 if available ALS AvailableALS ≥ Unresponsive arrestCardiac Defibrillation AutomatedDefibrillation Newly / BornNewly Review DNR / MOSTDNR FormReview YES Children) Push Fast ( FastPushChildren)  Signs Symptoms and  Protocol(s) Begin Continuous CPR CompressionsContinuousCPR Begin Change Compressors every minutes2every CompressorsChange Pediatric Airway Airway Pediatric Push Hard (1.5 inches Infant / 2 inchesin/ 2Infant Hard inches(1.5Push Criteria for Death / for DeathNo Resuscitation Criteria Limit changes / pulses checks/ pulseschangesLimit ( Continue CPR Continue Minutes / Cycles2 5 Repeat and reassessand Repeat Defibrillation AutomatedDefibrillation NO YES Pediatric Pulseless Arrest Pediatric Pulseless Shockable Rhythm Shockable Notify Notify Destination or Contact Medical ControlContact Medical Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Protocol(s) NO Policy Follow Go to Pediatric Airway Airway Pediatric Protocol Return Return of resuscitation Do beginnot Circulation Medications bodyforeignof Possibility Hypothermia Time of arrestTime historyMedical Spontaneous Repeat and reassessand Repeat Continue CPR Continue Minutes / Cycles2 5 AT ANY TIME ANY AT Deceased SubjectsDeceased Revised Post ResuscitationPost 12/13/2012    History   Pediatric Cardiac Section Protocols 2012 posterior diameter of chest, in infants 1.5 inches and posterior inches of1.5 diameter chest, in infants - Protocol51 1/3 anterior 1/3 10 breaths per minutebreaths per withcontinuous, 10 uninterrupted compressions. – This space left blank intentionallyblankleftspace This Compress ≥ Crew Approach. Refer to optional protocol or development of local agency protocol. agency local of development or protocol optional to Refer Crew Approach. - Pediatric Pulseless Arrest Pediatric Pulseless Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any in children 2 inches. Consider early IO placement if available and / or difficult IV access anticipated. anddifficult / or access IV available placement if IO Considerinches. early in children 2 DO NOTIf(BIAD, 30:2. HYPERVENTILATE: ETT)to airway ventilationsare If nocompressions advanced In order to be successful in pediatric arrests, a cause must be identified and corrected. and identified mustbe cause a arrests, pediatric in successful be to order In care. care. BiphasicMonophasic and waveformdefibrillators same energy levels the should use and increase2 joules/ kgto 4 shocks. subsequent kgon joules / Success is based on proper planning and execution. Procedures require space and patient access. Make room to room Make access. patient and require space Procedures execution. and proper planning on is based Success tasks.predetermined to responders assigning Approach Focusedwork. Team Consider Pit / Approach Focused Team of transfer at and move,every after EtCO2 frequently, and placementtube endotracheal documentand Reassess Do not interrupt compressions to place endotracheal tube. Consider BIAD Do notConsider interruptendotracheal tube. BIAD compressions to tofirst place limit interruptions. quickly with BVM or accomplished be Thisshould arrests. in pediatric intervention Airway importantmoreis a / Airway Interventions. oxygenation and proper ventilation on dependent survival is often Patient device. supraglottic advanced airway in place ventilate 8 in place ventilate airway advanced RecommendedStatus Mental Exam: Efforts continuous at highbe directed limitedshould quality and interruptions with compressions and early defibrillationindicated. when Revised 12/13/2012           Pearls Pediatric Cardiac Section Protocols 2012 YES shock - 1 J/kg1 arrhythmia 0.2 mg/kg0.2 - Cardiac arrest: arrest:Cardiac Over 2 minutesOver – Over 10 minutes 10 Over 12 Lead ECG notLeadECG 12 40 mg / kg IV / / kgIO mg 40 2 J/kg. diagnose and treatand diagnose Magnesium Sulfate Magnesium Torsades de pointesde Torsades when patient is stable.is patientwhen necessary to diagnosenecessary and treat, but preferredbut treat, and Single lead ECG ableto ECG leadSingle IV / IO IV Exit Exit to NO P shocks Maximum 5 mg 5Maximum May neededrepeatif May Appropriate ProtocolAppropriate SVT / VT: VT: 0.5SVT / Heart disease (Congenital)diseaseHeart Hyperthermia /Hypo or AnemiaHypovolemia imbalanceElectrolyte stress / PainEmotional/ Anxiety / Sepsis/ InfectionFever Hypoxia Hypoglycemia HX) / Drugs(see/ Toxin Medication embolusPulmonary Trauma PneumothoraxTension Cardioversion ProcedureCardioversion May andneededrepeat if May Midazolam 0.1 Midazolam Consider Sedation pre SedationConsider 0.2 mg/kg IN Maximum 2Maximum mg mg/kgIN 0.2 increase dose with with subsequentdoseincrease Differential             Probable Sinus TachycardiaSinusProbable P Consider Adenosine Amiodarone Amiodarone If no responseIf 5 mg/kg IV / IO mg/kgIV / 5 Maximum 6 mg 6Maximum Minutes 20 Over 0.1 mg / kg IV / IO IV / / kg mg 0.1 Maximum 150 mg 150Maximum P P YES Infant > 220/bpmInfant Rhythm Converts Converts Rhythm Protocol52 12 Lead ECG ProcedureLeadECG 12 Notify Notify Destination or Contact Medical ControlContact Medical YES Heart Rate: Child > 180/bpmChild >Rate: Heart Pale or CyanosisorPale Diaphoresis Tachypnea Vomiting Hypotension of LevelConsciousness Altered CongestionPulmonary Syncope Signs and Symptoms and Signs          B May repeatMay Adenosine Adenosine Amiodarone Amiodarone If no responseIf 5 mg/kg IV / IO mg/kgIV / 5 Maximum 6 mg 6Maximum Over 20 Minutes 20 Over Maximum 12 mg 12Maximum Vagal Maneuvers Vagal 0.1 mg / kg IV / IO IV / / kg mg 0.1 Maximum 150 mg 150Maximum 0.2 mg / kg IV / / kgIO mg 0.2 Probable SVT SVT Probable IO Procedure Pediatric Tachycardia P P P NO 0.09 seconds0.09 ≥ HR Typically > 180 Child180 Typically > HR HR Typically > 220 Infant220 Typically > HR Cardiac Monitor Cardiac 12 Lead ECG ProcedureLeadECG 12 QRS QRS Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Unstable / Serious Signs and SymptomsSignsandSerious / Unstable IV Procedure Decongestants, Digoxin) Decongestants, (Aminophylline, Diet pills,Diet (Aminophylline, supplements,Thyroid Exit Exit to Go to Protocol I P B Pulseless Appropriate Tachycardia Congenital Heart DiseaseHeart Congenital DistressRespiratory Syncopeor Near Syncope Drugs (nicotine, cocaine)Drugs(nicotine, Past medical historyPastmedical IngestionToxic or Medications Probable SinusProbable Identify and Treat Treat and Identify Underlying CauseUnderlying Arrest Arrest Protocol AT ANY TIME ANY AT NO Revised Pediatric Pulseless Pulseless Pediatric 12/13/2012     History   Pediatric Cardiac Section Protocols R - 2012 . : Luten Luten color if available. Purple - 0.09 seconds.) P waves absent or abnormal. R or abnormal. absent waves P seconds.) 0.09 ≤ the patient’s age in in years age patient’s the – R waves. Infants usually < 220 beats / minute. Children usually usually Children / minute. beats usually < 220 R waves. Infants - Have child blow out “birthday candles” or through an obstructed an or through candles” “birthday out blow Have child ): Protocol52 ): This space left blank intentionallyblankleftspace This 0.09 seconds 0.09 ≤ 0.09 seconds 0.09 : ≥ Pediatric Tachycardia : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Rate is typically 150 to 250 beats / minute. / beats 250 to typically is Rate 150 drugs. cardiac many hypokalemia, hypomagnesaemia, QTsyndrome, long with Associated VT. to May quickly deteriorate balloon. into a glove Blowing a holding. Breath airway. the occlude to not careful facethe of half upper over ice water the of a bag May put straw. Infants: minute. Fibrillation / Flutter Atrial with aberrancy. SVT with have VT Most children / minute. > normalto 200 Ratesvary from may children. Uncommon VT: in near cardiomyopathy. QTsyndrome / / long surgery / cardiac disease heart underlying Sudden collapse with rapid, weak pulse withrapid, weakSudden collapse R Variable present. waves P tachycardia: Sinus / minute. beats < 180 narrow children will with QRS ( SVT a > % of90 have SVT: / beats Children > 180 usually / minute. > beats 220 usually Infants onset. Usually abrupt variable. not waves Respiratory / failure. distress Respiratory poor Signs ofor perfusion / shock withwithouthypotension. AMS Generally, 220 is rate maximumthe Generally, sinus tachycardia Pediatric paddles should be used in children < 10 kg or Broselow kgor < children 10 in used be should paddles Pediatric if Diazepam or Midazolam is used. associated hypotension and depression Monitor forrespiratory available. if oximetry SVTall for Patients is required pulse Continuous intervention. therapeutic strips monitorwith each obtain with monitorstrips and rhythm changes all Document Separating the child from the caregiver may worsen the child's clinical clinical child's condition. caregiver worsen may child the from the the Separating Vagal ManeuversVagal Torsades de Pointes / Polymorphic (multiplePointes / Polymorphic shaped) Tachycardia de Torsades Wide Complex Tachycardia ( Wide Complex Tachycardia Narrow Complex Tachycardia ( ComplexNarrow Tachycardia Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Neuro Lung, Abdomen, Extremities, Neck, Heart, Back, RecommendedStatus,Skin, Mental Exam: and Symptoms Signs Serious Revised 12/13/2012        Pearls      Pediatric Cardiac Section Protocols 2012 May repeat May Maximum 2 g 2Maximum every 5 minutesevery 40 mg/kg IV / IO mg/kgIV 40 Magnesium Sulfate Magnesium Tosades de pointsde Tosades P ) ) - Respiratory failure / Airway / obstructionAirway failureRespiratory hypokalemia /Hyper Hypovolemia Hypothermia Hypoglycemia Acidosis pneumothoraxTension Tamponade or medicationToxin Embolism/ PulmonaryCoronary Thrombosis: heartdisease Congenital Differential            10 seconds10 10 seconds10 ≤ ≤ 100 / min) / 100 IO Procedure 100 / min)/ 100 ≥ ≥ P compressions. Repeat 0.5 mg/kg0.5Repeat Maximum 100 mg 100Maximum If Rhythm If RefractoryRhythm Repeat every minutesevery 5 Repeat Defibrillate 4 Joules/kgDefibrillate Maximum dose 300 mg300 doseMaximum mg150 doseMaximum Defibrillate 4 Joules/kgDefibrillate Maximum 3 mg/kgtotal 3 Maximum Lidocaine 1 mg/kg IV / IO mg/kgIV / 1 Lidocaine Protocol53 Maximum 1 mg eachdosemg 1Maximum Repeat every 5 minutestoevery 3 Repeat Notify Notify Destination or Amiodarone 5 mg/kg IV / IO 5 mg/kgAmiodarone Pediatric Airway Protocol(s)Airway Pediatric Maximum total dose 15 mg/kg15dosetotal Maximum Contact Medical ControlContact Medical Children) Push Fast ( FastPushChildren) arrhythmics Epinephrineduring/ arrhythmics Push Hard. Push( Hard.Fast Push to defibrillate with device charged.withto defibrillate Repeat pattern during resuscitation.duringpatternRepeat High Quality, Continuous CompressionsContinuousQuality,High Begin Continuous CPR CompressionsContinuousCPR Begin Begin Continuous CPR CompressionsContinuousCPR Begin Change Compressors every minutes2every CompressorsChange Change Compressors every minutes2every CompressorsChange IV Procedure Push Hard (1.5 inches Infant / 2 inchesin/ Infant2 Hard inches(1.5Push Epinephrine (1:10,000 ) 0.01 mg/kg IV / IO mg/kgIV / ) 0.01(1:10,000 Epinephrine Limit changes / pulses checks/ pulseschangesLimit Limit changes / pulses checks/ pulseschangesLimit Continue CPR and give Agency Anti Agency specificgive andCPR Continue ( ( Continue CPR up to point where you are ready ready arewhereto you point up CPR Continue Unresponsive Cardiac ArrestCardiac I P P P  Signs and Symptoms and Signs  Pediatric Ventricular Fibrillation Ventricular Pediatric Pulseless Ventricular Tachycardia Ventricular Pulseless Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 10 Joules/kg10 Go to ArrestProtocol Protocol Maximum Return of May repeatMay Pediatric PulselessPediatric Circulation Maximum 2 g 2Maximum Defibrillation 2 Joules/kgDefibrillation every 5 minutesevery Spontaneous 40 mg/kg IV / IO mg/kgIV 40 Airway obstructionAirway Hypothermia Past medical historyPastmedical Medications terminalillnessof Existence Events leading to arrestleadingEvents downtime Estimated Persistent VF / VT Persistent AT ANY TIME ANY AT Magnesium Sulfate Magnesium Post Resuscitation Resuscitation Post may increase energy inincreaseenergy may Revised P After second defibrillationsecondAfter increments of 2 Joules/kgof 2 increments 12/13/2012      History   not to exceed exceed tonot Pediatric Ventricular Fibrillation

Pulseless Ventricular Tachycardia

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Pearls  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Compress ≥ 1/3 anterior-posterior diameter of chest, in infants 1.5 inches and in children 2 inches. Consider early IO placement if available and / or difficult IV access anticipated.  DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compressions to ventilations are 30:2. If advanced airway in place ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Airway is a more important intervention in pediatric arrests. This should be accomplished quickly with BVM or supraglottic device. Patient survival is often dependent on proper ventilation and oxygenation / Airway Interventions  In order to be successful in pediatric arrests, a cause must be identified and corrected.  Respiratory arrest is a common cause of cardiac arrest. Unlike adults early ventilation intervention is critical.  In most cases pediatric airways can be managed by basic interventions.  Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.  Monophasic and Biphasic waveform defibrillators should use the same energy levels 2 joules / kg and increase to 4 joules / kg on subsequent shocks.  In order to be successful in pediatric arrests, a cause must be identified and corrected.

Revised Protocol 53 12/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Cardiac Section 2012 Years Days 28 – < 60 mmHg< 60 mmHg< 70 0 Age Based Age Years and olderandYears 1 to 101 Hypotension Utilized 1 MonthYearto 11 11 < 70 + ( 2 x mmHg( 2age) x + < 70 mmHg( 2age) x + < 90 Arrhythmia ProtocolArrhythmia Continue AntiarrhythmicContinue Refer to Appropriate PediatricAppropriatetoRefer Pediatic Diabetic Protocol Protocol Pediatric Tachycardia Continue to address specific differentialsspecificaddressto Continue dysrhythmiaoriginal thewith associated P Differential  NO YES YES IO Procedure 10 45 mmHg 45 – – 94 % 94 P ≥ 250 ≥ 0.2 mg/kg IV / IO mg/kgIV 0.2/ 5 minutes as neededas5 minutes - – NO NO NO NO NO NO And / Or / Or And As neededAs Cardiac Monitor Cardiac 69 or 69 Age basedAge ROSC After ROSC Bradycardia Protocol54 Tachycardia Hypotension Symptomatic Symptomatic of pulse of ≤ Antiarrhythmic Blood GlucoseBlood 12 Lead ECG ProcedureLeadECG 12 Defibrillation and Defibrillation Monitor Vital Signs / ReassessSigns/ VitalMonitor Maximum dose 2 mcg/kg 2 mcg/kgdoseMaximum Maintain SpO2 Maintain indicatedairway if Advanced 35 ideallyETCO2 8 Rate Respiratory Device ThresholdImpedenceRemove Notify Notify Destination or Consider Sedation / Paralysis SedationConsider Repeat Primary AssessmentPrimary Repeat Versed 0.1Versed Return Contact Medical ControlContact Medical Fentanyl / IO bolus IV 1 mcg/kgFentanyl May 3repeat inMay Optimize VentilationOxygenation andOptimize      HYPERVENTILATE NOT DO Use only with definitive airway placeairway in with onlydefinitive Use May minutes 10mcg/kgevery repeat1 May IV Procedure Signs/Symptoms  P YES YES YES I P B B Pediatric Post Resuscitation Post Pediatric Pediatic Protocol 60 mL/kg60 Bradycardia arrest Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Dopamine Dopamine 10 mL/kg IV / IO mL/kgIV 10 20 mcg/kg/min IV / IO IV mcg/kg/min20 if lungs remain clearremainlungsif Normal Saline Bolus SalineBolusNormal Infuse over 10 minutes 10over Infuse – May repeatto May after ROSC after 2 follow Rhythm follow Amiodarone 5 mg/kg IV / IO 5 mg/kgAmiodarone Titrate to SBP age appropriateageto SBP Titrate Respiratory arrestCardiac Appropriate ProtocolAppropriate If ArrhythmiaPersistsIf and usually self limitingselfusuallyand Arrhythmias are commonareArrhythmias I History   P P Pediatric Post Resuscitation

**Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set

example: 100 kg pt x 7 mcg/min x .0375 = 26.25 gtts / min

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Pearls  Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro  Hyperventilation is a significant cause of hypotension / recurrence of cardiac arrest in post resuscitation phase and must be avoided.  Appropriate post-resuscitation management may best be planned in consultation with medical control. Protocol 54 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS

Pediatric Medical Section Protocols 2012 Exit Exit to Protocol infection, metabolic, traumatic)metabolic,infection, - Pediatric DiabeticPediatric Hypoxia infection)seizure,stroke, (trauma, CNS / hypo) (hyper Thyroid (septicShock / hypoglycemia)(hyperDiabetes Toxicological / AlkalosisAcidosis exposure Environmental abnormatilitiesElectrolyte disorderPsychiatric Exit Exit to Exit to Exit to Exit to Protocol Protocol Protocol Pediatric as indicatedas Differential           YES Hypo / Hyperthremia /Hypo Appropriate PediatricAppropriate Overdose / Toxic IngestionToxic / Overdose Cardiac / Arrhythmia Protocol/ ArrhythmiaCardiac Pediatric Hypotension / ShockHypotensionPediatric Mat exposure and protect personalsafety. protectexposureMat and - 250 ≥ 69 or 69 Protocol57 ≤ Blood GlucoseBlood YES Notify Notify Destination or Contact Medical ControlContact Medical YES YES YES Decrease in mentationinDecrease mentationbaselinein Change sugarBloodinDecrease skin Cool,diaphoretic Bloodsugarin Increase fruityskin, breath,Warm, dry, of respirations,signskussmaul dehydration       Signs and Symptoms and Signs IO Procedure Pediatric Altered Mental Status Mental Altered Pediatric P NO NO NO related Signs of Signs Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Toxicology if indicated if indicated Signs of OD Signs Signs of shockSigns perfusionPoor Cardiac Monitor Cardiac Hypo / Hyperthermia /Hypo 12 Lead ECG ProcedureLeadECG 12 Pediatric Airway Protocol(s)Airway Pediatric Spinal Immobilization ProtocolImmobilizationSpinal Blood Glucose Analysis ProcedureAnalysisGlucoseBlood IV Procedure Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro Extremities,Lungs,Abdomen, Back, Heart, Skin,Status,HEENT, MentalExam: Recommended Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure.restrainttheper protection and/orpersonnel'spatient'sfornecessary if RestraintsConsider Be aware of AMS as presenting sign of an environmental toxin or Haz or toxin ofenvironmental ansign ofpresentingas aware AMS Be orDextrose Glucagonafter glucosebloodexists. Recheck doubt if thanhyperglycemia assumehypoglycemiasaferisto It etiology.potentialaas preparations Over andCounter the drugs drugs, illicit prescription alcohol,Consider Pay otherof injury. bruisingor examheadfor signsto the carefulattention Pay Potential ingestionPotential Trauma Lethargy sleeping/ feedinginChanges Diabetes Recent illnessRecent Irritability Past medical historyPastmedical Medications I Pearls              History   P B Pediatric Diabetic

History Signs and Symptoms Differential  Past medical history  Altered mental status  Alcohol / drug use  Medications  Combative / irritable  Toxic ingestion  Recent blood glucose check  Diaphoresis  Trauma; head injury  Last meal  Seizures  Seizure  Abdominal pain  CVA  Nausea / vomiting  Altered baseline mental status.  Weakness  Dehydration  Deep / rapid breathing

≤ Blood Glucose Analysis Blood glucose 69 mg / dl Pediatric Procedure Symptomatic with Altered Mental Status NO IV / IO Access: Protocol I IV Procedure P IO Procedure Awake, alert and able to tolerate oral if indicated agent: Give oral glucose solution Cardiac Monitor I P If unable to tolerate oral: if indicated Glucagon 0.1 mg/kg IM (Maximum 1 mg) Repeat every 15 minutes as needed to keep Blood glucose > 60 mg / dl.

Blood Sugar Blood Sugar Blood Sugar P

≤ 69 mg / dl 70 – 249 mg / dl ≥ 250 mg / dl e

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Oral Glucose Solution Protocol l If age appropriate Normal Saline Bolus S

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Repeat Dextrose per appropriate treatment arm

Every 5 minutes Until Blood Glucose 70 mg / dl or greater

Notify Destination or Contact Medical Control Protocol 58 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Pediatric Medical Section Protocols 2012 Protocol58 This space left blank intentionallyblankleftspace This Pediatric Diabetic : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Adult caregiver must be present with pediatric patient. Blood sugar must be 100 or greater and patient has has patient and or greater 100 be must sugar Blood patient. pediatric with present be mustcaregiver Adult and diabetes of history known have must Patient scene. on with responders foodof availability and eat to ability control. medical contact Otherwise agents. oral diabetic any takingbe not Quality control checks should be maintained per manufacturers recommendation for all glucometers.forall recommendationmanufacturers per maintained be should checkscontrol Quality Patient Refusal dilute with 25 mLdilute25 of NS. with rectally. administered can be % 50 Dextrose glucagon to response no and IV with circumstancesextremeno In advice. medical for control Contact Patients with prolonged hypoglycemia my not respond to glucagon. glucagon. to respond hypoglycemia my not with prolonged Patients airway. swallow their or protect to able are not that patients to glucose oral administer Do not mL of and D50 mL mLremoving25 ofby and of diluteD25 D50 NS. removing with10 by Make40 D10 Make Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Neuro Recommended Lungs,Status,HEENT, Heart, Abdomen, Mental Exam: Extremities, Skin, Back,       Pearls  Pediatric Medical Section Protocols 2012 70 + (2 x Age)x + (270 YES Exit Exit to ≥ Procedure if indicted if indicated Trauma Protocol Pediatric Obstructive Normal SalineNormal Repeat to effect to effectRepeat Age appropriateAge Pediatric Needle ProcedureNeedle Multiple Trauma Multiple if indicated Maximum 60 mL/kg60Maximum SBP ChestDecompression Spinal ImmobilizationSpinal Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus Diabetic ProtocolDiabetic I P Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic NO NO Shock Trauma Infection Dehydration heartdisease Congenital or Toxin Medication Differential       Or 70 + (2 x Age)x + (270 YES Trauma Exit Exit to ≥ Procedure if indicted Protocol Anaphylaxis Normal SalineNormal Repeat to effect to effectRepeat Age appropriateAge Distributive Maximum 60 mL/kg60Maximum SBP Spinal ImmobilizationSpinal Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus IO Procedure Appropriate PediatricAppropriate I P Cardiac Monitor Cardiac if indicated Protocol59 Type of ShockType History, Exam andExam History, tarry stools tarry - Circumstances SuggestCircumstances Notify Notify Destination or Pediatric Airway Protocol(s)Airway Pediatric Restlessness, confusion, weaknessconfusion, Restlessness, Dizziness Tachycardia (Latesign) Hypotension skinclammyPale,cool, refillcapillaryDelayed Dark ProcedureAnalysisGlucoseBlood Contact Medical ControlContact Medical IV Procedure I       Signs and Symptoms and Signs  P 10 mL/kg IV / IO mL/kg IV /10 - as indicatedas Cardiogenic 5 Maximum 10 mL/kg10Maximum Normal SalineBolusNormal Arrhythmia ProtocolArrhythmia Appropriate PediatricAppropriate I NO Pediatric Hypotension / Shock / Hypotension Pediatric Age x Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any 70 + (2 x Age)x + (270 YES Procedure Exit Exit to ≥ Procedures if indicated Trauma Hypotension Wound Care Wound Protocol as indicatedas Pediatric Normal SalineNormal Repeat to effect to effectRepeat Age Specific VS SpecificAge Age appropriateAge Hypovolemic SBP < 70 + 270 +SBP < Control HemorrhageControl Multiple Trauma Multiple Maximum 60 mL/kg60Maximum Vomiting Diarrhea Fever Infection Blood lossBlood lossFluid Spinal ImmobilizationSpinal SBP Poor perfusion / ShockperfusionPoor Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus Revised I 11/19/2012     History  

Hypotension / Shock

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Pearls  Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Lowest blood pressure by age: < 31 days: > 60 mmHg. 31 days to 1 year: > 70 mmHg. Greater than 1 year: 70 + 2 x age in years.  Consider all possible causes of shock and treat per appropriate protocol. Majority of decompensation in pediatrics is airway related.  Decreasing heart rate and hypotension occur late in children and are signs of imminent cardiac arrest.  Shock may be present with a normal blood pressure initially.  Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation.  Consider all possible causes of shock and treat per appropriate protocol.  Hypovolemic Shock; Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding.  Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical / septum / valve / toxins.  Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins  Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneumothorax. Signs may include hypotension with distended neck veins, tachycardia, unilateral decreased breath sounds or muffled heart sounds.  Acute Adrenal Insufficiency: State where body cannot produce enough steroids (glucocorticoids / mineralocorticoids.) May have primary adrenal disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting, dehydration and / or abdominal pain. If suspected EMT-P should give Methylprednisolone 2 mg/kg IV / IO or Dexamethasone 0.3 mg/kg (Maximum 10 mg) IV / IO. Use agency-specific steroid.

Revised Protocol 59 11/19/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Medical Section Protocols 2012 1222 - OD 222 - Exit Exit to Carbon Control Cyanide / Cyanide If Needed If Monoxide / Monoxide 800 - Cyanide ProtocolCyanide CarbonMonoxide 1 Carolinas Carolinas Poison oxygenation IN / IMETT IN / / Maximum 2 mg 2Maximum as indicatedas CONCIOUSNESS Shock ProtocolShock Airway Protocol(s)Airway Naloxone 0.1 mg/kgIN 0.1 Naloxone adequate ventilation andventilation adequate Appropriate PediatricAppropriate Pediatric Hypotension / HypotensionPediatric NOT GIVEN TO RESTORE RESTORE TO GIVEN NOT Naloxone is titrated to effecttitratedis Naloxone Naloxone 0.1 mg/kg IV / IO / mg/kgIV / 0.1 Naloxone I B if availableif Exit Exit to Antidote Kit Antidote Nerve Agent Nerve Tricyclicantidepressants Acetaminophen Depressants Stimulants Anticholinergic medicationsCardiac agentsCleaningAlcohols,Solvents, (organophosphates)Insecticides WMD / Nerve WMD Severity ArmsSeverity AgentProtocol Follow SymptomFollow Organophosphate Differential         NO YES ; NO 0.09 rination 0.5 in 10in ≥ I Upset; U G mEq Sodium seconds QRS QRS YES Repeat IO Procedure 0.09 sec 0.09 Tricyclic Bicarbonate Maximum 50Maximum mEq/kg remains minutes if QRS minutes ≥ NO 1 mEq/kg IV / IO mEq/kgIV / 1 P Potential Cause Potential Protocol60 acrimation, Antidepressant OD Antidepressant P L uscle Twitching uscle YES Notify Notify Destination or M Serious Signs / SymptomsSignsSerious Contact Medical ControlContact Medical Hypotension Age SpecificAge CardiacMonitor 12 Lead ECG ECG ProcedureLead12 efecation / Diarrhea,efecation alivation, mesis, Altered Mental StatusMental Altered Mental status changes statusMental / hypertensionHypotension rate respiratoryDecreased dysrhythmiasTachycardia, Seizures S control,of lossincreased, / cramping,painAbdominal D E Adequate Respirations / RespirationsAdequate Oxygenation / Ventilation / Oxygenation IV Procedure      Signs and Symptoms and Signs  I P B OD YES Over 10 minutes 10 Over 60 mg/kg IV / IO mg/kgIV 60 Calcium Gluconate Calcium YES Pediatric Overdose / Toxic Ingestion / Toxic Overdose Pediatric P Calcium Channel BlockerCalciumChannel Dopamine Dopamine If not improvementnot If 20 mcg/kg/min IV / IO IV mcg/kg/min20 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any – Cardiac External PacingExternal Cardiac 2 Procedure for Severe CasesSevere forProcedure Safe Scene Blood GlucoseBlood Appropriate 2 mg 2 as indicatedas IV / IO IV / resources OD Analysis ProcedureAnalysis P Glucagon Glucagon mg/kg 0.1 Maximum medications, past psychiatricpastmedications, history criminal) homein medicationsAvailable history,Pastmedical Substance ingested, route,ingested, Substance quantity importantisof Ingestion Time accidental,(suicidal,Reason Ingestion or suspected ingestionsuspectedor Ingestion substancetoxic potentiallyof Behavioral Protocol(s)Behavioral Beta BlockerBeta Revised Pediatric Diabetic / AMS / / DiabeticAMS Pediatric 2/22/2013 NO Stage until scene safesceneStageuntil I Call for help / additionalhelp/ forCall      History  Pediatric Medical Section Protocols re 2012 specific pupilsspecific - 10 years andx age)mmHg + > (27010 years - Contact Medical Control for orders Control MedicalContact 7 minutes.7 - 1 year 1mmHg, > year 70 1 - Call Medical Control for orders Control MedicalCall blocker overdoses. overdoses.blocker - Protocol60 No patient with a QRS duration of 100 milliseconds or less suffering a seizu asuffering lessor of milliseconds 100QRS aduration with No patient - 28 days 1mmHg, month60 days > 28 – 3 minutes and the peak effect should be5 at shouldpeaktheeffectand minutes 3 - contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self administration or selfadministrationforautoinjector anin pralidoximeofmg 600and Atropine 2contain mgof Pediatric Overdose / Toxic Ingestion / Toxic Overdose Pediatric dysrhythmias and mental status changesstatusmentaland dysrhythmias initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failureliverirreversible causestreated,and If detected not or nausea/vomiting.normalinitially increased HR, increased temperature, dilated pupils, mental status changesstatusmentalpupils,dilated temperature, HR, increasedincreased decreased HR, decreased BP, decreased temperature, decreased respirations, non respirations,decreasedtemperature,decreased BP, decreasedHR, decreased increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpointpupilsdiarrhea,vomiting,nausea, secretions, increasedHR, decreasedor increased Blocker Overdose Overdose Blocker - increased HR, increased BP, increased temperature, dilated pupils, seizures pupils,dilatedtemperature, BP, increased increasedHR, increased Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any nausea, coughing, vomiting, and mental status changesstatusmentaland vomiting, coughing,nausea, 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapidprogressioncoma;or statusmental decreased hypotension,dysrhythmias, seizures, toxicity: of major areas 4 : Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renaloccurlater.may statusmental alteredand Tachypneavomiting.and pain abdominalconsistof : Early signs example: 100 kg pt x 7 mcg/min x min gtts/ = x 26.25 x mcg/min.0375pt kg7 100 example: Insecticides: Stimulants: Anticholinergic: Medications:Cardiac Solvents: Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying othercarrying is not still patient Makesureattempts. in suicide especially ingestion,on patientof rely history Do not to ED. emesisbottles,contents, weapons.Bring any or has medications Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro Lungs,Abdomen, Extremities, Heart,HEENT, Status,Skin, MentalExam: Recommended patient care. These kits may be available as part of the domestic preparedness for Weapons of Destruction. forMass Weaponspreparednessdomestictheof part as available bekits These may care. patient Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure.Restrainttheper personnel's protection and/orpatient'sfornecessary if restraints Consider kitsAntidote Agent Nerve 11 years mmHg.> 90older years and 11 Tricyclic: death.tostatus mentalfromalert Acetaminophen: Age specific blood pressure0blood specific Age Consider contacting the North Carolina Poison Control Center for guidance.forCenter Carolina ControlNorththePoison contactingConsider Aspirin later.takeplace can thingsother among edemacerebral orand failure, liver dysfunction, Depressants: Revised R wave in aVR greater than 3 mm ingreaterthan aVR R wave ms0.7 greaterinthan aVRS ratio R to QRS greater than 100 msthan100 greater QRS LeadI aVLandinwave S slurredDeep 2/22/2013 Pearls                - - - - **Dopamine Formula for a 1600 concentration: Desired dose X Patient Weight in kg X 0.0375=gtts/min with a 60 gtt set agtt 60with X 0.0375=gtts/minkg inWeight doseX Patient Desired 1600 forconcentration: a Formula**Dopamine ______Calcium Chloride and Calcium Gluconate can be used for beta forbe usedcanCalciumGluconate and CalciumChloride overdoses.channelblockercalcium usedforbe canGlucagon If no effect seen, call medical control for further instruction. forcontrol furthermedical call noseen, effectIf Glucagonofside effectais known well Vomiting Glucagon in Beat inGlucagon 1 observedinbe effect shouldAn EKG signs that suggest cardiotoxicity in TCA overdosein TCA cardiotoxicitysuggest that signsEKG QRS Duration in Tricyclic Antidepressant overdoseAntidepressant in Tricyclic DurationQRS arrythmiaof ventricularchance50%hasa milliseconds 160than a greater QRS Patientswith arrythmia. ventricularor Pediatric Medical Section Protocols NO 2012 5 mg - prednisolone - Nebulizer YES Pediatric 1.25 Protocol(s) Pediatric STRIDOR May repeat x 1 repeatx May Worsening 2 mg/kg IV / IO mg/kgIV / 2 0.01 mg / kg IM / kg0.01mg Over 20 minutes 20 Over 40 mg/kg IV / IO mg/kgIV 40 Pediatric Airway Pediatric 1 mg in 2 mL NS 2mg mL in 1 as indicatedas Allergic ReactionAllergic Maximum 0.3 mg0.3Maximum Maximum 125 mg 125Maximum Magnesium Sulfate Magnesium Epinephrine 1:1000 Epinephrine Albuterol NebulizerAlbuterol 1:1000 Epinephrine Methyl Anaphylaxis ProtocolAnaphylaxis Airway Protocol(s)Airway I I P P B Asthma / Reactive Airway DiseaseAirway / ReactiveAsthma Aspiration bodyForeign airway infectionlower or Upper heartdisease Congenital CHF / ingestion / Toxic OD Anaphylaxis Trauma NO YES YES Differential         - 5 mg 2.5 mg2.5 - x 3 x - Lung Exam Lung 0.5 mg0.5 Methyl Ipratropium Albuterol Albuterol Albuterol Nebulizer Nebulizer 1.25 - Signs / SymptomsSigns 1.25 prednisolone prednisolone Worsening 2 mg/kg IV / IO mg/kgIV / 2 +/ Repeat as neededas Repeat Maximum 125 mg 125Maximum YES I P B Anaphylaxis Airway PatentAirway Protocol61 Allergic ReactionAllergic YES NO Ventilations adequateVentilations Oxygenation adequateOxygenation NO Notify Notify Destination or Contact Medical ControlContact Medical Wheezing / Stridor / Crackles / Rales/ Crackles/ / StridorWheezing / Grunting/ RetractionsFlaringNasal Rate Heart Increased AMS Anxiety Distractability/ Attentiveness Cyanosis feedingPoor Sputum/ Frothy JVD Hypotension NO 2.5 mg2.5 x 3 x -      Signs and Symptoms andSigns      NO 1:1000 0.5 mg0.5 Ipratropium Nebulizer YES Albuterol Albuterol Nebulizer 12 months12 - Epinephrine 1.25 ≥ Protocol(s) Worsening +/ as indicatedas 1 mg2NS mL 1in Repeat as neededas Repeat WHEEZING Pediatric Airway Airway Pediatric Age I I if indicated IO Procedure YES Pediatric Respiratory Respiratory Distress Pediatric P NO - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Cardiac Monitor Cardiac 2.5 mg2.5 2.5 mg2.5 x 3 x - - 12 Lead ECG ProcedureLeadECG 12 History / Signs / / SignsHistory 0.5 mg0.5 Methyl NO Ipratropium Albuterol Albuterol Albuterol Albuterol Nebulizer Nebulizer if indicated - Symptoms consistentSymptoms Episode IV Procedure 1.25 1.25 prednisolone prednisolone with respiratory distress respiratorywith stridor or wheezing with Protocol(s) 2 mg/kg IV / IO mg/kgIV / 2 +/ Congenital heartdisease Congenital History of traumaof History chokingof / possibilityHistory / OD Ingestion Past Medical HistoryPastMedical Medications / IllnessFever ContactsSick Time of onsetTime bodyforeignof Possibility as indicatedas Repeat as neededas Repeat Maximum 125 mg 125Maximum FirstWheezing Pediatric Airway Airway Pediatric I P B Revised 2/22/2013 I         History   P B Pediatric Medical Section Protocols sition. po 2012 antssitup to agonists. t w t - 5 mg. 5 – Agency medicalAgency 15 years years 2.515 ≥ no drooling is noted.isdroolingno agonist treatment. agonist - 14 years mg; years 2.514 – 2.5 mg; 6 mg; 2.5 – 92 % agonisttreatment.beta% first 92after Protocol61 6 years years 1.256 – This space left blank intentionallyblankleftspace This you may use Albuterol for the first treatment then use the patient’s supply for repeatsupplyfor patient’sthe thenuseforfirst thetreatment useAlbuterol mayyou . 1 year 1 of 1.25mg; year age1 Pediatric Respiratory Respiratory Distress Pediatric ≤ Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any B may administer Albuterol if patient already prescribed and may administer from EMS supply. fromsupply. EMSadministermay and prescribed if Albuterol patientalready administermay B - Epiglottitis typically affects children > 2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patienstridor, possiblerapidonset, fever, with It bacterial,isof yearsage. > 2 childrentypicallyaffects Epiglottitis nebulizers orsupply agency’snebulizers to keep airway open, drooling is common. Airway manipulation may worsen the condition.worsen the may Airway manipulationcommon.isdrooling open, keepairway to (Xopenex) levalbuterolpatientsusingIn Do not force a child into a position, allow them to assume position of comfort. They will protect their airway by their by body their airway protect will They comfort.of assumepositionto themallow a position, ainto childDo force not Recommended Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro Extremities,Lungs,Abdomen, Heart,Neck, Skin, Status,HEENT, MentalExam: Recommended Croup typically affects children < 2 years of age. It is viral, possible fever, gradual onset,gradualfever, possibleviral, is age. It of2 yearschildren< affects typicallyCroup The most important component of respiratory distress is airway control.airway isdistressof respiratoryimportantcomponent mostThe betatorespond notwhich may in wheezing which resultsaffectinginfantstypically viral infectionais Bronchiolitis betainitialto respondingnotand 18 months< patientif nebulizer EpinephrineConsider director may require Contact of Medical Control prior to administration.Controltoprior ContactMedical ofrequire may director dosing: Albuterol ≤ remainswhenoximetry Pulse access IV Consider Items in Red Text are key performance measures used to evaluate protocol compliance and care.and complianceprotocolevaluate to usedmeasures performancekey Redare Text Itemsin distress.patientinwithrespiratory the monitored continuously shouldbe oximetry Pulse EMT Revised 2/22/2013  Pearls            Pediatric Medical Section Protocols e 2012 IO Procedure 0.1 mg/kg IV/10 mg/kg 0.1 P or or - or YES if indicated 0.3 mg/kgIV/IO 0.3 or 0.2 mg IN mgor 0.2 - Protect patientProtect Cardiac Monitor Monitor Cardiac 0.2 mg/kg IV/IM/ IO mg/kg IV/IM/ 0.2 as indicatedas - 0.1 every 3 to 5 minutes 35 toevery Status EpilepticusStatus Diazepam (Max 4mg) (MaxDiazepam Midazolam (Max2mg) Midazolam 0.1 Pregnancy > 20 Weeks> 20 Pregnancy 0.5 mg/kg (Max 10mg)Rectal mg/kg(Max0.5 Loosen any constrictive clothingconstrictive any Loosen Pediatric Airway Protocol(s)Airway Pediatric Spinal Immobilization ProcedureImmobilizationSpinal IV Procedure Lorazepam .05Lorazepam May of medicationstherepeat any May Blood Glucose Analysis ProcedureAnalysisGlucoseBlood Active Seizure in Known or SuspectedKnown inSeizure Active Exit to Obstetrical Emergency Protocol EmergencyObstetricalExit to I Febrile seizureFebrile Infection traumaHead or Toxin Medication failure RespiratoryorHypoxia Hypoglycemia / acidosisabnormalityMetabolic Tumor P NO Differential         YES Or Activity Pediatric Pediatric Consider Reassess if indicatedif if indicated Monitor andMonitor Active Seizure Active Protocol62 Postictal State Postictal Altered Mental Mental Altered Status ProtocolStatus Diabetic ProtocolDiabetic NO Fever; hot, dry skindry hot,Fever; activitySeizure Incontinence traumaTongue Rash rigidityNuchal statusmentalAltered NO       Signs and Symptoms and Signs  Pediatric Seizure Notify Notify Destination or Contact Medical ControlContact Medical YES if indicated Protect patientProtect if indicated if indicated Awake, AlertAwake, IV Procedure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Cardiac Monitor Monitor Cardiac Montior andReassessMontior Normal Mental StatusMental Normal Loosen any constrictive clothingconstrictive any Loosen Spinal Immobilization ProcedureImmobilizationSpinal Blood Glucose Analysis ProcedureAnalysisGlucoseBlood I Assess possibility of occult trauma and substance abuse, overdose or ingestion / toxins and fever. / andtoxins ingestion or overdoseabuse,substance trauma andof possibilityoccult Assess Be prepared to assist ventilations especially if a benzodiazepine is used. Avoiding hypoxemia is extremely important. isextremely hypoxemia Avoidingused.is a benzodiazepineif especiallyventilationsto assistpreparedBe injury. closedheadof a onlythe evidencemay be a seizureinfant, an In ais tru Thisor recovery. of consciousnessperiodwithout a seizures moresuccessivetwo asordefinedis epilepticus Status transport.and control,treatment,rapidairway requiringemergency Midazolam 0.2 mg/kg (Maximum 10 mg) IM is effective in termination of seizures. Do not delay withIMnot administration delay of Do seizures. terminationisinIM effective mg) 10mg/kg(Maximum0.2 Midazolam IO. over PreferredIM access.or IO difficultIV seizure.the thanstopping glucoseimportantasisblood verifying and ABCs the Addressing Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro Extremities, Heart,HEENT, Lungs, MentalExam: Status, Recommended careand complianceprotocolevaluate to usedmeasures performancekey Redare Text Itemsin activity Single/multipleDuration, AbnormalityCongenital Prior history of seizureshistoryof Prior complianceMedication headtraumaRecent seizureunilateral body vs Whole Fever contactsSick P      Pearls          History   Pediatric Medical Section Protocols 2012 IO Procedure P 70 + 2 x Agex + 270 NO Pediatric ≥ 10 years > 70 + + (2 70 x > years 10 Exit Exit to if indicated Protocol Pediatric - Improving Normal SalineNormal Repeat to effect to effectRepeat Age appropriateAge Diabetic ProtocolDiabetic 0.15 mg/kg IV / IO 0.15mg/kg SBP Maximum 60 mL/kg60Maximum Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus Hypotension / ShockHypotension Ondansetron 0.2 mg/kg ODT mg/kgODT 0.2 Ondansetron IV Procedure I P YES CNS (Increased pressure, headache, tumor,headache, pressure, (IncreasedCNS trauma or hemorrhage)trauma Drugs Appendicitis Gastroenteritis Renaldisorders orGI KetoacidosisDiabetic influenza)(pneumonia,Infections abnormalitiesElectrolyte YES Differential         1 year > 70 mmHg, > 1 70 year 1 - Procedure Notify Notify Destination or Contact Medical ControlContact Medical Protocol Pediatric if indicated perfusion, shockperfusion, Protocol63 Pain ControlPain Hypotension, poor Hypotension, Blood Glucose AnalysisGlucoseBlood Serious Signs / SymptomsSignsSerious Pain Distension Constipation Diarrhea Anorexia Fever Cough, Dysuria 28 days > 60 mmHg,month > 1 60 days 28 –        Signs and Symptoms and Signs  NO YES Pediatric Vomiting / Diarrhea / PediatricVomiting NO NO if indicated 10 mL/kgIV 10 IV Procedure Ondansetron Ondansetron Improving Maximum 4 mg 4Maximum Abdominal PainAbdominal 0.2 mg/kg PO / ODT ODT / mg/kgPO 0.2 Normal SalineBolusNormal Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any I P Age blood 0 pressure specific Age mmHg. and > older 90 years age) mmHg and 11 increases as dehydration becomes more severe, very unlikely to be significantly dehydrated is dehydrated if rate heart to be significantly unlikely very more severe, dehydration becomes as increases to normal. close increased CSF pressures) all often present with with vomiting. present CSF all pressures) oftenincreased Beware of vomiting only in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or tumors,CNS (bleeding, processes and bowel obstruction, Pyloric in stenosis,children. only vomiting ofBeware Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia tachycardia rate, heart increased signs of dehydration, Rate:Heart almost of always the clinical One first Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Neuro Lungs,Heart, HEENT,Abdomen, Recommended Extremities, Status,Skin, Neck, Back, Mental Exam: Travel historyTravel diarrheaEmesisor Bloody Past Medical HistoryPastMedical History PastSurgical Medications Last bowel movement / emesis movementbowel Last with or worseningImprovement activityfoodor contactssickOther Age mealof lastTime    Pearls          History   Pediatric Trauma and Burn Section Protocols 2012 Protocol Pediatric Protocol Pediatric Pediatric as indicatedas AMS / DiabeticAMS Multiple Trauma Multiple Seizure ProtocolSeizure Skull fractureSkull Contusion,(Concussion,injuryBrain Hemorrhage) hematomaEpidural hematomaSubdural hemorrhageSubarachnoid injurySpinal Abuse YES YES Differential        if indicated IO Procedure P NO NO YES YES Trauma if indicated Hypotension Oxygenation Isolated Head Isolated Seizure ActivitySeizure Protocol65 (SBP < 70 + 2 x Age)270 x +(SBP < Adequate Ventilation / VentilationAdequate Poor Perfusion / Shock/ PerfusionPoor Notify Notify Destination or Obtain and Recordand GCS Obtain Contact Medical ControlContact Medical Blood Glucose Analysis ProcedureAnalysisGlucoseBlood 35 mmHg.35 if indicated Spinal Immobilization ProcedureImmobilizationSpinal Pain, swelling, bleedingPain,swelling, statusmentalAltered Unconscious / failuredistressRespiratory Vomiting mechanismof traumaticMajor injury Seizure IV Procedure -    Signs and Symptoms and Signs     I NO NO Pediatric Head Trauma trauma - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Protocol Pediatric Pediatric Airway ProtocolAirway Multiple Trauma Multiple Fluid resuscitation should be titrated to maintain at least a systolic BP of > 70 + 2 x years.inagethe x + > 270BP ofsystolic aat leastmaintain to titratedbeshould resuscitation Fluid An important item to monitor and document is a change in the level of consciousness by serial examination. serialby consciousnessof level thea isin change document and to monitorimportantitem An or vomiting, LOC, confusion, includingof numbersymptomsof a any involving brain injuriestraumatic are Concussions any or15 minuteswithin normalreturntonot which does abnormalitystatus mentalor confusion prolonged Any headache. ASAP. aby physicianevaluatedbeshould of lossconsciousness documented Hypotension usually indicates injury or shock unrelated to the head injury and should be treatedaggressively.be shouldandheadinjurythe to or shockinjuryunrelated usuallyindicates Hypotension Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, NeuroBack, Lungs,Abdomen, Extremities, Heart,Status,HEENT, MentalExam: Recommended Evidence for multifor Evidence Loss of consciousnessof Loss Bleeding historyPastmedical Medications Time of injuryTime vs. penetrating)(bluntMechanism decreasing GCS). If hyperventilation is needed (35 / minute for infants <1 year and 25 / minute for children >1 year) >1 year) minutefor childrenandyear / 25 <1 / minutefor infants(35 neededhyperventilation is If GCS). decreasing 30between maintained shouldbeEtCO2 Response).(Cushing'sbradycardiaand hypertensioncause (ICP) maypressure intracranial Increased GCS is a key carecomplianceand protocolto usedevaluate measureperformancekey isGCS a anticipated. shouldbe9GCS and intubation transport < ifrapid air / consider < If 12GCS bradycardia, posturing, / decerebratedecorticatepupil, (blown of only evidenceherniation the patientif Hyperventilate Pearls       History           Pediatric Trauma and Burn Section Protocols . 2012 Needle 90% - ≥ 10 minutes10 ≤ to appropriateto 70 + 2 x Agex + 270 ≥ Procedure Abnormal if indicated Tension pneumothoraxTension Hemothoraxchest,Flail tamponadePericardial wound chestOpen Normal SalineNormal if indicated SBP Maximum 60 mL/kg60Maximum destination usingdestination Monitor andReassessMonitor Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus Consider Pelvic BindingPelvicConsider Trauma and Burn: Traumaand Splint Suspected FracturesSuspectedSplint Control External HemorrhageExternal Control ChestDecompression abdominal bleedingabdominal Repeat to effect Age appropriateAgeto effect Repeat - Provide Early Notification Early Provide 10 years > 70 + (2 x 11andage)mmHg(2 x + > 70years 10 Pediatric Head InjuryHead Protocol Pediatric - Rapid TransportRapid Limit SceneTimeLimit EMS Triage and Destination Plan DestinationandTriageEMS Chest: Intra cordinjuryfracture,Femur / Spine/ Pelvis Trauma)(seeHeadinjuryHead / Dislocation fractureExtremity obstruction)(Airway HEENT Hypothermia I P Differential        IO Procedure 1 year > 70 mmHg, 1 >year mmHg, 701 - P Pediatric GCS as indicatedas Hypotension / Hypotension Shock ProtocolShock Perfusion/ Assess VS / Assess Cardiac Monitor Cardiac Protocol66 if indicated Pediatric Airway Protocol(s)Airway Pediatric IV Procedure Spinal Immobilization ProcedureImmobilizationSpinal Pain,swelling bleedinglesions,Deformity, Altered mental status or statusmentalAltered unconscious or shockHypotension Arrest  Signs and Symptoms and Signs     I P 28 days > 60 mmHg, 1 monthmmHg,> 60days 28 – Notify Notify Destination or Contact Medical ControlContact Medical Pediatric Multiple Trauma to appropriateto Procedure Normal Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any destination usingdestination Monitor andReassessMonitor Consider Pelvic BindingPelvicConsider Trauma and Burn: Traumaand Splint Suspected FracturesSuspectedSplint Control External HemorrhageExternal Control Repeat Assessment Pediatric AssessmentPediatricRepeat Transport Do not overlook the possibility of child abuse.childof possibilitythe Do overlooknot years and older > 90 mmHg.> 90 olderandyears pneumothorax. tensionof torsoevidenceandtoinjuryand of signs shockwith DecompressionChest Consider Activation.Trauma declaringwhen GuidelinesTraumaRegional See tourniqueta applicationofthe necessitatemaypressure directwith controlled extremity rapidlyfromannot bleeding Severe transport of the unstable trauma patient to the appropriate facility isgoal. thefacility the appropriatepatient to trauma unstable of transport the maintained becan if pulse oximetry airway the methodof managing isacceptable anvalve maskBag 0pressure bloodspecificAge Items in Red Text are key ToolkitEMS TraumaCare the Acute inused measures performancekey Redare Text Itemsin Rapid whenpossible.route performeden shouldbe Thesebefor procedures. delayed shouldnot Scenetimes Location in structure or vehicleorstructure in Location deador injuredOthers MVC detailsofand Speed / protectiveRestraints Time and mechanism of injurymechanismandTime vehicleorstructure to Damage equipment historyPastmedical Medications EMS Triage and Destination Plan DestinationandTriageEMS       Pearls       History     Pediatric Trauma and Burn Protocols ) 2012 Degree Burn Degree rd /3 Don’t Don’t include in TBSA nd compromise CriticialBurn painful painful ( - Degree) Degree) blistering transport to a Burn Center)a totransport Burns with definitive airway airway definitiveBurnswith Burns with Multiple Trauma MultipleBurns with nd Degree) Degree) painless/charred or leathery skin (When reasonably accessible,(Whenreasonably rd >15% >15% 2 TBSA if indicatedif Degree) Degree) red st Electrical – NO IV Procedure Normal SalineNormal if indicated if indicated to appropriate destination usingdestinationappropriateto as indicatedas (More info below)info(More Trauma and Burn: Traumaand Cyanide Exposure Cyanide Superficial Superficial (1 Partial Thickness (2 ThicknessFull (3 Thermal Chemical Carbon Monoxide / CarbonMonoxide for up to the first 8 hours.tofirstup thefor IO Procedure Dry Clean Sheet or Dressings CleanSheetor Dry 0.25 mL / kg ( x % hr % TBSA) / ( x/ kg0.25mL Lactated Ringers if Ringersavailable Lactated Pediatric Pain ControlPainProtocol Pediatric Pediatric Airway Protocol(s)Airway Pediatric Differential      EMS Triage and Destination Plan DestinationandTriageEMS Pediatric Multiple Trauma ProtocolMultiple Trauma Pediatric Consider 2 IV sites if greater than 15TBSA %greater thanifIV sites 2Consider Remove Rings, Bracelets / Constricting Items ConstrictingBracelets/ Rings,Remove Degree Burn Degree rd Rapid TransportRapid YES /3 nd I P Protocol67 Serious Burn Serious Notify Notify Destination or Contact Medical ControlContact Medical transport to a Burn Center)a totransport Carbon Cyanide Protocol (When reasonably accessible,(Whenreasonably 15% TBSA 2 TBSA 15% Monoxide / Monoxide Hypotension or GCS 13 or 13 Lessor GCS Hypotension - intubation for airway airway stabilizationfor intubation 5 Burns, Burns, pain, swelling Dizziness Loss of consciousness Hypotension/shock Airway compromise/distress could be indicated by hoarseness/wheezing Suspected inhalation injury or requiringor injuryinhalation Suspected Assess Burn / Concomitant Injury Severity InjuryConcomitant Burn / Assess     Signs and and Symptoms Signs  YES Pediatric Thermal Burn Degree Burn Degree rd /3 NO nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any if available if indicated IV Procedure Normal SalineNormal Minor Burn Minor if indicated if indicated as indicatedas Constricting ItemsConstricting Lactated Ringers Lactated Normotensive (More info below)info(More 1. Lactated Ringers preferred over Normal Saline. Use if available, if not change over once available. onceover not changeavailable,if Use if Saline.preferredRingers Normal over Lactated1. 2. Formula example: an 80 kg (196 lbs.) patient with 50% hour. of per 1000fluidcc willTBSA needwith50% kgpatient lbs.)80(196 an Formulaexample:2. Cyanide Exposure Cyanide GCS 14 or Greater 14GCS Carbon Monoxide / CarbonMonoxide for up to the first 8 hours.tofirstup thefor Remove Rings, Bracelets / Bracelets/ Rings,Remove Transport Facility of Choiceof FacilityTransport Dry Clean Sheet or Dressings CleanSheetor Dry 0.25 mL / kg ( x % hr % TBSA) / ( x/ kg0.25mL Pediatric Pain ControlPainProtocol Pediatric Pediatric Airway Protocol(s)Airway Pediatric Past medical history Past medical history and Medications Other trauma Loss of Consciousness Tetanus/Immunization status Type Type of exposure (heat, gas, chemical) Inhalation injury Time of Injury Pediatric Multiple Trauma ProtocolMultiple Pediatric < 5% 2 TBSA < 5% No inhalation injury, Notinjury, Intubated, No inhalation I     History    Pediatric Thermal Burn

Rule of Nines

 Seldom do you find a complete isolated body part that is injured as described in the Rule of Nines.  More likely, it will be portions of one area, portions of another, and an approximation will be needed.  For the purpose of determining the extent of serious injury, differentiate the area with minimal or 1st degree P nd rd e

burn from those of partial (2 ) or full (3 ) thickness d i

burns. a

 For the purpose of determining Total Body Surface t r

Area (TBSA) of burn, include only Partial and Full i c Thickness burns. Report the observation of other st T

superficial (1 degree) burns but do not include those r burns in your TBSA estimate. a  th th th u

Some texts will refer to 4 5 and 6 degree burns. m

There is significant debate regarding the actual value a

of identifying a burn injury beyond that of the a

superficial, partial and full thickness burn at least at n

the level of emergent and primary care. For our work, d

all are included in Full Thickness burns. B

 Other burn classifications in general include: u

 th r

4 referring to a burn that destroys the dermis n

and involves muscle tissue. P  th 5 referring to a burn that destroys dermis, r

penetrates muscle tissue, and involves tissue o t around the bone. o  th c

6 referring to a burn that destroys dermis, o

destroys muscle tissue, and penetrates or l s destroys bone tissue.

Estimate spotty areas of burn by using the size of the patient’s palm as 1 %

Pearls  Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro  Green, Yellow and Red In burn severity do not apply to the Start / JumpStart Triage System. Critical or Serious Burns:  > 5-15% total body surface area (TBSA) 2nd or 3rd degree burns, or  3rd degree burns > 5% TBSA for any age group, or  circumferential burns of extremities, or  electrical or lightning injuries, or  suspicion of abuse or neglect, or  inhalation injury, or  chemical burns, or  burns of face, hands, perineum, or feet, or  any burn requiring hospitalization.  Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or critical interventions such as airway management are not available in the field.  Burn patients are trauma patients, evaluate for multisystem trauma.  Assure whatever has caused the burn is no longer contacting the injury. (Stop the burning process!)  Early intubation is required when the patient experiences significant inhalation injuries.  Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling.  Burn patients are prone to hypothermia - never apply ice or cool the burn, must maintain normal body temperature.  Evaluate the possibility of child abuse with children and burn injuries.  Never administer IM pain injections to a burn patient. Protocol 67 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric General Section Protocols 2012 IMMEDIATE Secondary Triage Secondary Evaluate Evaluate Infants FIRST DECEASED Repeating Repeating Process Triage DELAYED IMMEDIATE IMMEDIATE IMMEDIATE YES NO YES Adult NO NO Triage Protocol69 NO Adult Minor Pediatric Breathing Results inResults Spontaneous Obeys CommandsObeys Appropriate to AVPU Appropriate Ped < 15 or or > < 45 Ped 15 Position Upper Airway Upper Position Adult Adult > / minute30 Cap Refill > 2 Sec (Adult) Cap Refill> 2 Sec No palpable Pulse (Pediatric) No palpable Pulse YES YES Pulse Pediatric Breathing NO YES IMMEDIATE 5 Rescue BreathsRescue5 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO Rate YES Status Mental Perfusion Breathing Respiratory Able to WalktoAble Ped > 15 or or < > 45 Ped 15 Adult Adult < / minute30 Adult / Pediatric General Section Protocols 2012 appropriate heart rate may may be also rate heart appropriate - Triage Protocol69 This space left blank intentionallyblankleftspace This Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any used in decisions. in triage used First evaluate all children who did not walk under their on power where possible and safety allows. safety and possible where power their on walk under not did children all who First evaluate Age skintemperature. including factors many by Capillary altered be refill can Pearls   Adult / Pediatric General Section Protocols th too hot). 2012 or Exit Exit to Exit to Appropriate Cardiac ProtocolCardiacAppropriate ProtocolTrauma Appropriate Decay Infection Fracture Avulsion Abscess cellulitisFacial tooth(wisdom) Impacted TMJ syndrome infarction Myocardial Differential          See belowSee if indicated Monitor and Reassess Monitor and pressure Notify Notify Destination or Pressure Appropriate Pain ProtocolPain Appropriate Contact Medical ControlContact Medical Cardiac Monitor Cardiac contamination Normal Saline Normal/ Saline May May rinse gross Protocol70 Place tooth in in Milk / tooth Place 12 Lead ECG ProcedureLeadECG 12 Treat Dental Avulsion: DentalTreat CommercialPreparation and placed into socket with intosocketwith placedand Do not rub or scrub tooth or scrub rub Do not Control Bleeding with Directwith Bleeding Control patient closing teeth to exert to exert teethclosing patient Control Bleeding with DirectPressurewith Bleeding Control Small gauze rolled intoa squarerolled gauze Small Bleeding Pain Fever Swelling or fracturedmissingTooth P B     Signs and Symptoms and Signs  YES Dental Problems YES YES YES YES - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO NO NO NO NO Exit Exit to Bleeding Transport Dental AvulsionDental System TraumaSystem Dental or Jaw Painor Jaw Dental Significant or Multi or Significant Appropriate ProtocolAppropriate Suspicious for CardiacSuspicious Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs,Neuro Neck,Chest,Status,HEENT, MentalExam: Recommended Whole vs. partial tooth injurytooth vs. partialWhole Medications injurypain/ ofOnset out"tooth "knockedwith Trauma toothof Location Age historyPastmedical All pain associated with teeth should be associated with a tooth which is tender to tapping or touch (or sensitivity to cold(orto sensitivity touch or tappingtenderis to toothwhich a associatedwith beshould teethwith painassociatedAll Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is possible within 4 hours if thehoursifwithin 4 possibleis Reimplantation toothavulsions.completein minimized beshould times transportand Scene for. caredproperlyis jaw. theto pain canradiatechest cardiac Occasionally Significant soft tissue swelling to the face or oral cavity can represent a cellulitis or abscess.a cellulitiscanrepresentor oralcavity toface the swellingtissue softSignificant Pearls     History         Adult / Pediatric General Section Protocols 2012 Exit Exit to Exit Exit to Appropriate 10 years + years x( 70 2 < 10 YES – Hypotension ProtocolHypotension If indicated IV Procedure Head Tilt Tilt Forward Head Position of ComfortPosition Appropriate Trauma ProtocolTrauma Appropriate Bleeding ControlledBleeding I Trauma orURI Sinusitis)(viral Infection rhinitisAllergic ulcers)(polyps,Lesions Hypertension YES Differential      Compress Nostrils with DirectPressurewith Nostrils Compress NO 1 year < 70 mmHg, 1 year mmHg, < 1 year 70 1 year – NO IV Procedure DirectPressure Protocol71 Suction Active BleedingActiveSuction Have Patient Blow NoseBlow PatientHave Hypotensive SBP < 90 Hypotensive Followed by Direct Pressure Directby Followed Notify Notify Destination or Age specific hypotensionspecificAge This space left blank intentionallyblankleftspace This Epistaxis Contact Medical ControlContact Medical Oxymetazoline 2 Sprays to Sprays Nostril 2 Oxymetazoline Bleeding from nasal passagefromnasal Bleeding Pain Nausea Vomiting I    Signs and Symptoms and Signs  B YES 28 days < mmHg,month60 days 1 28 YES YES – - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO NO Head Tilt Tilt Forward Head Position of ComfortPosition platelet agents like aspirin, clopidogrel (Plavix), aspirin/dipyridamole (Aggrenox), and ticlopidine (Ticlid) ticlopidine canand (Plavix), like(Aggrenox), clopidogrel aspirin, aspirin/dipyridamole agents platelet - Active BleedingActive Active BleedingActive System Trauma System Significant or Multi or Significant Into posterior pharynx posteriorInto contribute to bleeding. to contribute (Xarelto), and many over the counter headache relief powders. relief headache counter the over many (Xarelto), and Anti Anticoagulants include warfarin (Coumadin), heparin, enoxaparin (Lovenox), dabigatran (Pradaxa), rivaroxaban (Pradaxa), rivaroxaban dabigatran (Lovenox), enoxaparin warfarin (Coumadin),heparin, include Anticoagulants Age specific hypotension: 0 hypotension: specificAge mmHg. < greater 90 and years age)mmHg,11 loss with epistaxis. blood of amount the quantify difficult very It is to pharnyx. posterior the examining loss by blood forposterior Evaluate posteriorly. occurring be also may Bleeding RecommendedStatus,HEENT, Mental Lungs, Exam: Heart, Neuro artery knowncoronary or diastolic than 110 of greater blooda pressure whohave Afrin Avoid in patients disease. Duration of bleedingof Duration bleedingof Quantity Medications (HTN, (HTN, anticoagulants,Medications NSAIDs) aspirin, of epistaxisepisodesPrevious Trauma Age historyPastmedical Leave Gauze in place if presentif place inGauze Leave       Pearls   History       Adult / Pediatric General Section Protocols , ith ound t w t s f s 2012 800 mg PO PO mg800 - And / Or / Or And Exit Exit to Arthritis Vasculitis (if age > 6 months)> age6(if Infections / Sepsis/ Infections / / LymphomasTumors Cancer Medication orreaction drug Medication diseasetissueConnective   Hyperthyroidism StrokeHeat Meningitis Appropriate ProtocolAppropriate Ibuprofen 10 mg/kg PO PO mg/kgIbuprofen10 Differential        Acetaminophen 15 mg/kg PO mg/kgPO 15 Acetaminophen Adult: Ibuprofen400Adult: Adult: mg PO Acetaminophen1000Adult: YES B medication.any administering/ MR - drug resistant organisms (e.g. MRSA), or scabies,MRSA), (e.g. resistantorganisms drug - B IO Procedure If indicated P (38 C) (38 if available Protocol72 Temperature Greater than 100.4 F than100.4Greater Warm Flushed Sweaty Chills/Rigors pain,chestcough, myalgias, pain,abdominal dysuria,headache, mental status changes, rashchanges,statusmental    Symptoms Associated source) to (Helpfullocalize  Signs and Symptoms and Signs  Temperature Measurement ProcedureMeasurementTemperature inflammatory medications) are a contraindication to Ibuprofen.to a contraindicationare medications) inflammatory - Contact, Droplet, and Airborne PrecautionsAirborneand Droplet, Contact, IV Procedure If indicated NO I B include standard PPE plus airborne precautions plus contact precautions. This level of precaution isof levelprecaution This contactprecautions.plus precautions airbornePPE plusstandard include steroidal anti steroidal - include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strictand contact, patient every glovesafterof change gown, a utilizationof PPE plusincludestandard Fever / Infection Control include standard PPE plus a standard surgical mask for providers who accompany patients in the back of backthepatientsin accompany who formask providerssurgical a standardPPE plusstandard include Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any give aspirin to a child.to agive aspirin Exit Exit to hazardsprecautions - Agency Medical Director may require contact of medical control prior to EMT topriorcontrol medicalcontactof may requireDirectorMedical Agency NSAIDs should not be used in the setting of environmental heat emergencies.heatenvironmental ofsetting usedtheinbenot should NSAIDs Do not All patients should have drug allergies documented prior to administering pain medications.painadministeringtoprior documented allergiesdrughave should patients All (nonto NSAIDs Allergies utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent i agentcausative thewhen or unknownis infection theof etiology thewhen outbreak an of phasesinitial the duringutilized SARS). (e.g. contagioushighlybe to loss.heat improvessweat and abilityto patients theincreased fluidswith Rehydration Airborne precautionsAirborne multiwhen utilizedisprecaution Thisof level precautions. washing hand suspected. contactareby spreadotherillnesses or (shingles),zoster All Droplet precautionsDroplet influenzawhen utilizedbeshould precaution of level This patient. the foror mask NRB O2 mask aand surgical ambulancethe A patienare suspected.particledropletsvia largespread otherillnessesand pharyngitis, mumps,streptococcal meningitis, precautions. dropletwith treated berashshould infectiouspotentially a Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Extremities,Back, Lungs,Abdomen, Neck,Heart, HEENT, Status,Skin, MentalExam: Recommended in temperature. with rapidelevationa and ofseizures afebrile historywith in childrenmore likelyare seizures Febrile receiveacetaminophen.not shouldliver failurehistoryof a with Patients HIV, diabetes, cancer)HIV, diabetes, exposure Environmental ibuprofenor acetaminophenLast Severity of fever ofSeverity historyPastmedical Medications (transplant,Immunocompromised Age fever of Duration Appropriate ProtocolAppropriate             Pearls       History   Adult / Pediatric General Section Protocols 2012 YES NO Taser Probe Taser - Or Or Exit Exit to YES Dyspnea if indicated as indicatedas if indicated Chest pain / Chestpain Palpitations / Palpitations Cardiac HistoryCardiac RemovalProcedure Behavioral ProtocolBehavioral Restraint ProcedureRestraint Appropriate ProtocolAppropriate Taser entry pointTaser Significant Injury / InjurySignificant Wound Care Wound Wound Care Procedure(s)Wound Multiple Trauma ProtocolTrauma Multiple Agitated Delirium Secondary to SecondaryDeliriumAgitated IllnessPsychiatric to SecondaryDeliriumAgitated AbuseSubstance InjuryTraumatic InjuryHeadClosed ExacerbationAsthma DysrhythmiaCardiac TASER Differential       YES NO NO NO NO NO Protocol73 Medical Illness?Medical NO Notify Notify Destination or Excited Delerium Syndrome DeleriumExcited Contact Medical ControlContact Medical Use of Pepper Spray or Taser? Pepper orSpray of Use External signs of traumaof signs External Palpitations of breathShortness Wheezing StatusMental Altered Abuse Intoxication/Substance Evidence of Traumatic Injury orTraumatic Injuryof Evidence      Signs and Symptoms and Signs  Police CustodyPolice YES History Asthma / COPD Minutes Wheezing? Dyspnea orDyspnea Observe 20 Observe YES NO YES PEPPER SPRAY PEPPER Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Exit Exit to Protocol(s) Appropriate clothing YES Remove Exit Exit to Wheezing Dyspnea / Dyspnea contaminated Protocol(s) Appropriate Cardiac HistoryCardiac Asthmaof History HistoryPsychiatric Traumatic InjuryTraumatic AbuseDrug Irrigate face / eyes face Irrigate Revised Respiratory DistressRespiratory 11/7/2012    History  

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Pearls  Patient does not have to be in police custody or under arrest to utilize this protocol.  Local EMS agencies should formulate a policy with local law enforcement agencies concerning patients requiring EMS and Law Enforcement simultaneously. Agencies should work together to formulate a disposition in the best interest of the patient.  Patients restrained by law enforcement devices must be transported accompanied by a law enforcement officer in the patient compartment who is capable of removing the devices. However when rescuers have utilized restraints in accordance with Restraint Procedure, the law enforcement agent may follow behind the ambulance during transport.  The responsibility for patient care rests with the highest authorized medical provider on scene per North Carolina law.  If an asthmatic patient is exposed to pepper spray and released to law enforcement, all parties should be advised to immediately contact EMS if wheezing/difficulty breathing occurs.  All patients in police custody retain the right to participate in decision making regarding their care and may request care of EMS.  If extremity / chemical / law enforcement restraints are applied, follow Restraint Procedure.  Consider Haldol or Ziprasidone for patients with history of psychosis or a benzodiazepine for patients with presumed substance abuse.  All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival.  Excited Delirium Syndrome: Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially life- threatening and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also contribute to the condition.  If patient is suspected of excited delirium suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early  Do not position or transport any restrained patient is such a way that could impact the patients respiratory or circulatory status.

Revised Protocol 73 11/7/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult / Pediatric General Section Protocols 2012 Fever Hemorrhage or medicationnutrienthomefrom Reactions distressRespiratory Shock Differential      position Clamp catheterClamp Continue infusionContinue Exit Exit to Stop infusion if ongoingif infusionStop ongoingif infusionStop Stop infusion if ongoingif infusionStop Notify Notify Destination or Do not exceed 20 mL / mLkg20 Do exceed not Contact Medical ControlContact Medical Protocol74 Place on left side in head down down sideleftheadinon Place Appropriate protocol(s)Appropriate May use hemostat wrapped in gauzewrapped usehemostatMay Clamp catheter proximal to disruptionproximalcatheter Clamp Apply direct pressure around catheteraroundpressuredirect Apply catheteraroundpressuredirect Apply I I I I External catheter dislodgement catheterExternal dislodgementcatheterComplete catheterDamaged siteat catheterBleeding bleedingInternal clot Blood embolusAir orwarmth drainageErythema, indicatingsitecatheterabout infection Emergencies Involving Involving Emergencies Indwelling Central LinesCentral Indwelling        Signs and Symptoms and Signs  YES YES YES YES YES YES site NO NO NO NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any ChestPain Ongoing infusionOngoing central cathetercentral catheterImplanted / Hickman) (Mediport Tunneled Catheter Tunneled Hickman)/ (Broviac insertedPICC (peripherally partially dislodgedpartially Circulation ProblemCirculation Damage to catheterto Damage Airway, Breathing or Airway, Breathing Suspect Air EmbolusAirSuspect Tachypnea, Dyspnea, Tachypnea, Catheter completely or completelyCatheter Hemorrhage at catheterHemorrhage Hyperalimentation infusions (IV nutrition): If stopped for any monitorforhypoglycemia. reason forany stopped If nutrition): (IV infusions Hyperalimentation Do not attempt to force catheter open if occlusion evident. occlusion if open force catheter to attempt Do not infusion. or change stop to Askfamily or caregiver appropriate is ifstop. it detrimental to be may Someinfusions properly. utilize functioning if and catheter central arrest:Cardiac Access Always talk to family / caregivers as they have specific knowledge and skills. knowledge specific havethey as caregivers / to family talk Always indwelling catheter. an / manipulating accessingwhen Use strict sterile technique a PICC is located. line where side same the on cuffor BP a tourniquet place Do not Complete or partial disruptionpartialorComplete Occlusion of lineof Occlusion dislodgepartialorComplete Central Venous CatheterType Venous Central        Pearls      History  Adult / Pediatric General Section Protocols 2012 NO to insertto quipment failure.quipment E Or stoma Exit Exit to YES Caregiver Protocol(s) Continued Tracheostomy Tube Tracheostomy Respiratory DistressRespiratory Appropriate PediatricAppropriate Allow Allow Respiratory DistressRespiratory Place Appropriately sizedAppropriately Place Place Trachesotomy Tube / Tube TrachesotomyPlace Appropriately sized ETT ETT sizedinto Appropriately endotracheal tube into stomatubeinto endotracheal neumothorax and neumothorax Allergic reactionAllergic Asthma Aspiration Septicemia bodyForeign Infection heartdisease Congenital or toxin Medication Trauma 3 mL of NS before suctioning.mLof NS before3 P I I – Differential          YES oxygenate before and between attempts.betweenand before oxygenate - Protocol75 Notify Notify Destination or NO Contact Medical Control Contact Medical bstructed tracheostomy tube / ETT, tube/ ETT, tracheostomy bstructed Assist Ventilations via VentilationsAssist Remove Speaking Valve SpeakingRemove O Remove InnerCannulaRemove Tracheostomy Tube / ETT Tube Tracheostomy Suction Tracheostomy Tube TracheostomySuction Remove Decannulation plug DecannulationRemove Remove ObturatorRemove Trachesotomy Suction Tracheostomy Tube TracheostomySuction Tube availableTube Nasal flaringNasal (with or retractions Chestwall sounds)breathabnormalwithout coughtoAttempts notedcoming secretionsCopious tubetheof out bothsideson breathsounds Faint significantdespitechestof effortrespiratory AMS Cyanosis Respiratory Distress Respiratory I I I B       Signs and Symptoms and Signs  With a Tracheostomy Tube a Tracheostomy With NO NO YES YES NO traumatic brain or brain traumatic - Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO NO isplaced tracheostomy tube / ETT, tube/ ETT, tracheostomy isplaced YES YES YES in placein Removed Continued Tube in place inTube InnerCannula Trachesotomy (Double lumen)(Double Speaking Valve Speaking Monitor andReassessMonitor Decannulation plug Decannulation Obturator Removed Obturator Respiratory DistressRespiratory DOPE: D DOPE: Suction depth: Ask family / caregiver. No more than 3 to 6 cm typically. Instill 2 cmtypically. Instill6than3 to No more/ caregiver. Askfamily depth:Suction preandattempt seconds10each morethan Do suction not be changed.tubeshouldtracheostomy tothen pass,unable catheter.If force NOT suction DO available.if monitoring andEtCO2 oximetry pulseremoval.Continual cuffbefore tube tracheal deflate Always Always talk to family / caregivers as they skills. and knowledge specifichave they as/ caregivers to talk family Always properly.functioningand if availableequipmentpatients Use down. roundingand tubediameter tracheostomy innerthe size doubling by suctioncatheterEstimate Suction Tracheostomy Tube TracheostomySuction pulmonary dysplasia, musculardysplasia,pulmonary dystrophy) Trauma (postTrauma injury) cordspinal or (bronchialconditionMedical abnormalities) complicationsSurgical phrenictodamage (accidental nerve) Birth defect (tracheal atresia,(trachealdefect Birth craniofacialtracheomalacia, I         Pearls    History  Adult / Pediatric General Section Protocols 2012 Exit Exit to Take patient’s ventilatorpatient’s Take quipment failure.quipment YES E Appropriate protocol(s)Appropriate neumothorax and neumothorax Disruption of oxygen sourceof oxygen Disruption tubetracheostomyor obstructedDislodged circuitventilatordisrupted or Detached arrestCardiac / demand requirementoxygen Increased failureVentilator P Differential       NO Other problemsOther . Notify Notify Destination or Problem with Circulation / Circulationwith Problem Contact Medical ControlContact Medical and maintain current settingscurrentmaintainand Transport on patients ventilatorpatientson Transport P with a with Protocol Protocol76 Correctcause Tracheostomy Tube Tracheostomy Respiratory DistressRespiratory Emergencies Emergencies bstructed tracheostomy tube / ETT, tube/ ETT, tracheostomy bstructed O Transport requiring maintenancerequiringTransport ventilatora mechanicalof at failure or equipmentPower residence Involving Ventilators Involving NO YES  Signs and Symptoms and Signs  YES YES YES YES Low Power: Internal battery depleted.battery Internal Power: Low circuit.airway or/ obstructedPluggedPressure:High Low Pressure / Apnea: Loose or disconnected circuit, leak in circuit or around tracheostomy site. aroundtracheostomycircuitor in circuit,leak or disconnected Loose / PressureApnea: Low 45 mmHg45 traumatic brain or brain traumatic – - 94 % 94 Or NO NO NO NO NO YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any ≥ isplaced tracheostomy tube / ETT, tube/ ETT, tracheostomy isplaced Tube / ETT /Tube Tube / ETT ETT /Tube Cause correctedCause Problem with Airway, Airway, with Problem Remove patient fromventilatorpatientRemove EtCO2 35EtCO2 Oxygenation saturationOxygenation and manually ventilate with BVM with ventilatemanuallyand (Ask Caregiver: What isWhat (AskCaregiver: Dislodged TracheostomyDislodged Detached Oxygen SourceOxygen Detached Obstructed TracheostomyObstructed Detached Ventilator CircuitVentilatorDetached Ventilation or Oxygengation or Ventilation to hospital even if not functioning properly.functioningnoteven if hospitalto alarms:Typical Continuous pulse oximetry and end tidal CO2 monitoring must be utilized during assessment and transport.andassessment duringbe utilizedmust monitoring CO2 tidal andendoximetry pulse Continuous D DOPE: BVM. usingventilatemanuallyand fromventilator patientRemove problem:toventilator correctUnable Always talk to family / caregivers as they skills. and knowledge specifichave they as/ caregivers to talk family Always properlyfunctioningandavailable if equipment use patient’sAlways muscular dystrophy) muscular spinal cord injury) cordspinal conditionMedical dysplasia,(bronchopulmonary abnormalities) (damagecomplicationsSurgical nerve) phrenicto (postTrauma Birth defect (tracheal atresia,(trachealdefect Birth craniofacialtracheomalacia, baseline saturation for patient)for saturationbaseline     Pearls      History  Adult / Pediatric Environmental Section Protocols 2012 NO Officer contact Control Document 1222 with with Animal Contact and and Contact Animal bites: - 222 - Protocol Protocol YES If Needed If Appropriate Anaphylaxis 800 Dog / Cat Dog Transport - Human Bite Human if indicated Immobilize InjuryImmobilize 1 Allergic Reaction / ReactionAllergic Trauma Protocol(s)Trauma Hypotension / Shock Hypotension Carolinas Control Carolinas Poison Extremity Trauma Protocol Trauma Extremity Animal biteAnimal bite Human bite(poisonous)Snake bite(poisonous)Spider tick)ant,(bee,wasp, / bitestingInsect Infection riskInfection riskRabies riskTetanus YES YES Differential         if indicated IO Procedure P if able Notify Notify Destination or NO NO Pain Contact Medical ControlContact Medical Allergy / Allergy Snake Bite Snake clothing / bandsclothing Anaphylaxis Immobilize InjuryImmobilize Hypotension Redness and Time andRedness Remove alljewelry Remove Serious Injury / Injury Serious DO NOT apply apply ICE NOT DO Protocol78 from affected extremity fromaffected Moderate / Severe Moderate Elevate wound location wound Elevate Remove any constrictingany Remove Mark Margin of/ Margin Swelling Mark Identification of Animalof Identification if indicated General Wound Care ProcedureWoundCare General IV Procedure Rash, skin break, wound break,Rash,skin rednessswelling,tissue Pain,soft bitewound thefromoozing Blood infectionof Evidence wheezing of breath,Shortness hives,itching reaction,Allergic Hypotension or shockHypotension I      Signs and Symptoms and Signs   YES YES 2 mg IV / mgIO 2 Bites and Envenomations – 0.2 mg/kg IV / IO mg/kg0.2 – PED: PED: if able Spider Bite Spider bands / jewelry bands Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Safe Muscle SpasmMuscle Apply IcePacksApply Maximum 5 mg 5Maximum Immobilize InjuryImmobilize Bee / Wasp Sting/ WaspBee Scene Midazolam 5IM mgMidazolam Over minutesto 3Over 2 Over minutesto 3Over 2 Elevate wound location wound Elevate Midazolam 1 to 2 mg IN 2 mg1 to Midazolam Midazolam 0.2 mg/kgIN 0.2 Midazolam resources Midazolam 0.5 Midazolam Appropriate Pain ProtocolPain Remove any constricting clothing / clothing constrictingany Remove Midazolam 0.1Midazolam NO with patient for identificationfor patient with / stingof sizebite location, Time, Type of bite / sting of biteType photo/ bring creatureor Description Tetanus and Rabiesriskand Tetanus patientImmunocompromised Previous reaction to bite/ stingtoreaction Previous vs. WildDomestic Stage until scene safesceneStageuntil Call for help / additionalhelp/ forCall Revised 8/22/2012  History       P Adult / Pediatric Environmental Section Protocols 2012 venom lack."venom - . TOXIN). - 84 - 800 - kill a fellow, red on black kill on red a fellow, - of snake bites are “dry” are “dry” bites bites snakeof Protocol78 This space left blank intentionallyblankleftspace This Bites and Envenomations Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially the at necrosis tissue initially but noted is reaction Little painless. to minimally are painful bites spider Recluse Brown back).on shape with (brown spider fiddle days few next the over develops bite the ofsite wound. streaksproximalto fever, red drainage, swelling, redness, infection: ofEvidence If no pain or swelling, envenomation is unlikely. % 25 About is unlikely. swelling, or envenomation pain no If pain abdominal severe and muscularpain few hours,over a minimally but be to painful, Widow tend Black bites spider belly). hourglass on with black(spider is red develop may Amount of envenomation is variable, generally worse with larger snakes and early spring. in early and worse with snakeslarger is variable, generally envenomation of Amount Recommended Exam: Mental Status, Skin, Extremities (Location of injury), and a complete Neck, Lung, Heart, (Location a complete Extremities Neck, Recommended ofStatus,Skin, and Mental Exam: injury), Consider contacting the North Carolina Poison Control Center for guidance (1 guidance for Control Center Poison North Carolina the contacting Consider Immunocompromised patients are at an increased risk for infection: diabetes, chemotherapy, transplant patients. transplant chemotherapy, diabetes, riskincreased forinfection: an are at Immunocompromisedpatients Poisonous snakes in this area are generally of the pit viper family: rattlesnake and copperhead. and rattlesnakepit family: viper the of generally area are this in snakes Poisonous yellow on very toxic. "Red but rare: Very little pain are bites Coral snake Human bites have higher infection rates than animal bites due to normalmouthbacteria. to due bites animal than rates infection higher have Humanbites riskRabies exposure.have all of and infected more are muchCarnivore bites likely becometo multicoda). (Pasteurella bacteria specific a to due rapidly infection to progress may bites Cat Abdomen, Back, and Neuro exam if systemic effects are notedare effects ifAbdomen, systemic and Neuro exam Back, Revised 8/22/2012      Pearls         Adult / Pediatric Environmental Section Protocols 2012 ingestant or exposures or ingestant - Diabetic relatedDiabetic Infection MI Anaphylaxis problemdialysis/ Renalfailure / injurytraumaHead Co Differential        if available Maximum 5 gm 5Maximum Oxygen Protocol Continue Care Continue Appropriate Appropriate Appropriate if indicated if indicated Continue High Flow Flow HighContinue Monitor andReassesMonitor Diabetic ProtocolDiabetic Trauma Protocol(s)Trauma Hydroxocobalamin 70 mg/kg IV / IO mg/kgIV 70 Hydroxocobalamin Hypotension / Shock Hypotension Protocol79 P Notify Notify Destination or Contact Medical ControlContact Medical AMS illnesslikefluweakness, Malaise, Dyspnea crampingN/V; Symptoms;GI Dizziness Seizures Syncope skinReddened Chestpain YES YES YES         Signs and Symptoms andSigns  IO Procedure Age x P NO NO NO Carbon Carbon Monoxide Cyanide / SBP <90 Cardiac Monitor Cardiac Adequate if indicated Continue Care Continue of Cyanide of as indicatedas High SuspicionHigh Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Age Specific VS SpecificAge High Flow Oxygen Flow High Monitor andReassesMonitor 12 Lead ECG ProcedureLeadECG 12 SBP < 70 + 270 +SBP < Poor Perfusion / Shock/ PerfusionPoor Continue High Flow Oxygen Flow HighContinue Oxygenation VentilationOxygenation IV Procedure Blood Glucose Analysis ProcedureAnalysisGlucoseBlood ProtocolImmobilizationSpinal Immediately Remove fromExposure Remove Immediately Appropriate Airway Protocol(s)Airway Appropriate I Continue high flow oxygen regardless of pulse ox readings. ox pulse of regardless flow oxygen high Continue Scene safety is priority. is safety Scene combustion of any product with CO Cyanide Consider and CO poisoning. exclude not CONormal level does environmental elderly. the children and lower COwith levels Symptoms pregnancy, in present Recommended exam: Neuro, Skin, Heart, Lungs, Abdomen, Neuro, Lungs,Recommended Heart, Abdomen, exam:Skin, Extremities accidental HistoryPastMedical of / exposure DurationTime Eating large quantity of fruitpitsof largequantityEating exposure Industrial Trauma criminal, Suicide,Reason: Smoke inhalationSmoke cyanideof Ingestion P B     Pearls        History    Adult / Pediatric Environmental Section Protocols 2012 Consider NO Pulse if indicated Exit Exit to Arrhythmia Protocol(s) Arrest and / or / Arrestand Unresponsive Hypothermia ProtocolHypothermia Age AppropriateAge Cardiac / PulselessCardiac immersion syndrome immersion - Barotrauma sicknessDecompression existing medical problemmedicalexisting - YES Trauma Pre (diving)injuryPressure Post Differential       be rescuers. be - IO Procedure P NO if indicated Protocol80 as indicatedas Wheezing Dyspnea / Dyspnea Cardiac Monitor Cardiac Age AppropriateAge as indicatedas Dry / WarmPatientDry Notify Notify Destination or Age AppropriateAge Remove wet clothingwet Remove Airway Protocol(s)Airway Contact Medical Control Contact Medical Mental Status Exam StatusMental Awake but withAMS Awake Altered Mental Status Protocol StatusMental Altered IV Procedure Spinal Immobilization ProcedureImmobilizationSpinal Unresponsive changes statusMental signsvitalorabsent Decreased Vomiting Rales,Wheezing, Coughing, Rhonci,Stridor Apnea I P YES      Signs and Symptoms and Signs  Age resuscitate all. These patients have an increased chance of survival. survival. of anchance increasedpatients have Theseall. resuscitate Distress -- Protocol(s) Respiratory Appropriate YES - Drowning / Submersion Injury Submersion / Drowning Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any NO symptoms if indicated if indicated IV Procedure to 6 hours for 6 hoursto asymptomatic Wheezing Dyspnea / Dyspnea development of development Cardiac Monitor Cardiac drowning victimsdrowning Dry / WarmPatientDry Asymptomatic nearAsymptomatic Encourage transportEncourage Remove wet clothingwet Remove With pressure injuries (decompression / barotrauma), consider transport to or availability of a hyperbaric chamber.a hyperbaricof availabilityto or transport consider/ barotrauma),injuries(decompression Withpressure With cold water no time limittime waterno cold With injuriesspinalpossiblesuspicionfor of high index aHave injuries.submersionand drowning associatedwith often isHypothermia severalhours.next theover for worseningpotential todue evaluation for transportedbe should victimsAll Recommended Exam: Trauma Survey, NeuroSkin,Extremities, Back,Abdomen, Pelvis,Chest, Neck, Head, TraumaExam: Survey, Recommended amongwouldof deathleadingiscause asafety. Drowning sceneEnsure areasof danger.fromremove victims rescuersand to certified trainedAllowappropriately possibility of hypothermiaof possibility contaminationwater Degreeof Possible history of trauma ie: traumahistoryof Possible boarddiving immersionof Duration or water of Temperature Submersion in water regardlesswater in Submersion depthof should be observed 4 observedbeshould and evaluation even if evaluationand Awake and Alert and Awake Monitor andReassessMonitor Monitor andReassessMonitor I         Pearls     History  P

Adult / Pediatric Environmental Section Protocols 2012 NO Pulse Exit Exit to Cardiac / Cardiac Protocols See PearlsSee Unresponsive and Arrhythmiaand Age AppropriateAge ArrestPulseless if indicated YES Age AppropriateAge Diabetic ProtocolDiabetic Stroke injuryHead cordinjurySpinal Age Sepsis exposure Environmental Hypoglycemia dysfunctionCNS Distress Protocol(s) Respiratory Appropriate Differential     YES Systemic Hypothermia Systemic IO Procedure P 70 + 2 x Agex + 270 Procedure ≥ Protocol82 Maximum 2 L 2Maximum Dry / WarmPatientDry 500 mL IV / IO IV / mL500 Cardiac Monitor Cardiac Remove wet clothingwet Remove as indicatedas as indicatedas indicatedas Blood Glucose AnalysisGlucoseBlood SBP Maximum 60 mL/kg60Maximum Age AppropriateAge Age AppropriateAge AppropriateAge Normal SalineBolusNormal Monitor andReassessMonitor Airway Protocol(s)Airway Passive warming measureswarming Passive Altered mental status / comastatusmentalAltered Cold,clammy Shivering sensory painor Extremity abnormality Bradycardia or shockHypotension Hypothermia / FrostBite / Hypothermia 12 Lead ECG ProcedureLeadECG 12 Respiratory DistressRespiratory Active warming measureswarmingActive Repeat to effect SBP > 90 SBP >to effectRepeat Hypotension/ Shock or ShockHypotension/ Notify Notify Destination or Multiple Trauma ProtocolTrauma Multiple PED: Bolus 20 mL/kg IV / IO mL/kgIV / 20Bolus PED: Awake with / without AMS with/ withoutAwake      Signs Symptoms and  Repeat to effect Age appropriateAgeto effect Repeat Contact Medical ControlContact Medical IV Procedure Altered Mental Status Protocol StatusMental Altered I I P B Hypothermia / FrostbiteHypothermia Hypothermia Hypothermia Frostbite / Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Procedure if available Hypothermia General WoundCare General Monitor andReassessMonitor and / or Frostbite/ and DO NOT refreezingallow NOT DO DO NOT to warm Rub NOT SkinDO Localized Cold Injury Localized Signs / Symptoms of of / SymptomsSigns Temperature MeasurementTemperature Length of exposure / Wetness / Wind/ Wetness/ exposure of Length chill but may occur in normal temperaturesoccurnormalinmay but Medicationshistory/ Pastmedical barbituatesuse: Alcohol,Drug Sepsis/ Infections Age, very young and oldand young very Age, temperaturesto decreased Exposure Revised 10/30/2012     History   B

Hypothermia / Frostbite

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Pearls  Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro  NO PATIENT IS DEAD UNTIL WARM AND DEAD (Body temperature ≥ 93.2 degrees F, 32 degrees C.)  Hypothermia categories: Mild 90 – 95 degrees F ( 32 – 35 degrees C) Moderate 82 – 90 degrees F ( 28 – 32 degrees C) Severe < 82 degrees F ( < 28 degrees C)  Mechanisms of hypothermia: Radiation: Heat loss to surrounding objects via infrared energy ( 60 % of most heat loss.) Convection: Direct transfer of heat to the surrounding air. Conduction: Direct transfer of heat to direct contact with cooler objects (important in submersion.) Evaporation: Vaporization of water from sweat or other body water losses.  Contributing factors of hypothermia: Extremes of age, malnutrition, alcohol or other drug use.  If the temperature is unable to be measured, treat the patient based on the suspected temperature.  CPR: Severe hypothermia may cause cardiac instability and rough handling of the patient theoretically can cause ventricular fibrillation. This has not been demonstrated or confirmed by current evidence. Intubation and CPR techniques should not be with-held due to this concern. Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. Below 86 degrees F (30 degrees C) antiarrythmics may not work and if given should be given at reduced intervals. Contact medical control for direction. Epinephrine / Vasopressin can be administered. Below 86 degress F (30 degrees) pacing should not be done Consider withholding CPR if patient has organized rhythm or has other signs of life. Contact Medical Control. If the patient is below 86 degrees F (30 degree C) then defibrillate 1 time if defibrillation is required. Deferring further attempts until more warming occurs is controversial. Contact medical control for direction. Hypothermia may produce severe bradycardia so take at least 45 second to palpate a pulse.  Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin.

Revised Protocol 82 10/30/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Environmental Section Protocols 2012 1222 - 222 - If Needed If if indicated if indicated if indicated Immobilize injuryImmobilize 800 - Allergy ProtocolAllergy Large OrganismLarge Age AppropriateAge AppropriateAge Age AppropriateAge 1 Pain Control ProtocolControlPain Multiple Trauma ProtocolTrauma Multiple Extremity Trauma Protocol Trauma Extremity Carolinas Poison Control Poison Carolinas Jellyfish stingJellyfish UrchinstingSea barbStingray stingCoral itchSwimmers stingShellCone bite Fish FishstingLion YES Differential         if indicated IO Procedure P 114 Degrees114 NO NO – if available 1 gm IV / gmIO IV1 Lion FishLion StingRay (or Gluconate) (or Gluconate) muscle spasmsmuscle if indicated Immobilize injuryImmobilize Hypotension Sea CreatureSea Calcium Chloride Calcium 110 Serious Injury / Injury Serious Identification of Identification Urchin / StarfishUrchin Age AppropriateAge Protocol83 Immerse inWater Hot Immerse Remove Barb or SpineBarbRemove Peds: 20 mg/kg IV / IO mg/kgIV 20Peds: If large Barb in thorax or thorax inlargeBarb If abdomen stabilize objectstabilizeabdomen Allergy / Anaphylaxis Allergy Over 3 minutes for severefor 3 minutesOver Pain Control ProtocolControlPain Moderate / Severe Pain/ Severe Moderate Notify Notify Destination or if indicated General Wound Care ProcedureWoundCare General Contact Medical ControlContact Medical IV Procedure P I Intense localized pain localizedIntense secretionsoralIncreased / vomitingNausea crampingAbdominal / anaphylaxis reactionAllergic     Signs and Symptoms and Signs  YES YES Marine Envenomations / Injury / Envenomations Marine War - O Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any - DO NOT NOT DO If available 1 gm IV / gmIO IV1 Protocol Pain ProtocolPain Jelly FishJelly Anemone (or Gluconate)(or clean seawater clean muscle spasmsmuscle Man Age AppropriateAge if indicated Immobilize injuryImmobilize Lift away tentaclesaway Lift Calcium Chloride Calcium Do Not brush or rub brushDo Not Apply Vinegar RinseVinegarApply Otherwise wash with with wash Otherwise Age AppropriateAge Age AppropriateAge use fresh water or icewater usefresh Peds: 20 mg/kg IV / IO mg/kgIV 20Peds: Trauma Protocol(s)Trauma Hypotension / ShockHypotension Pain Control ProtocolControlPain Over 3 minutes for severefor 3 minutesOver Previous reaction to marinetoreaction Previous organism Immunocompromised pet Household Type of bite / sting of biteType organismof Identification P    History  

Marine Envenomations / Injury

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Pearls  Ensure your safety: Avoid the organism or fragments of the organism as they may impart further sting / injury.  Patients can suffer cardiovascular collapse from both the venom and / or anaphylaxis even in seemingly minor envenomations.  Sea creature stings and bites impart moderate to severe pain.  Arrest the envenomation by inactivation of the venom as appropriate.  Ensure good wound care, immobilization and pain control. Protocol 83 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Environmental Section Protocols 2012 IO Procedure P 25 mg/kg IV / / IMIO mg/kg 25 0.05 mg/kg IV / / IMIO 0.05mg/kg if availableif IV / IM / IMIO IV / Arrest – – Over 30 minutes 30 Over 3 Doses RapidlyDoses3 Nerve Agent Kit IM Agent Nerve until symptomsresolveuntil Major Symptoms: Major Repeat every minutesevery 5 Repeat Sarin, Soman, etc.)Sarin,Soman, exposure Organophosphate (pesticide) (e.g.,Mustard exposure Vesicant etc.)Gas, (e.g.,Exposure Irritant Respiratory Ammonia,Sulfide,Hydrogen etc.)Chlorine, Nerve agent exposure (e.g., VX, (e.g.,VX, exposure agentNerve Atropine 6 mg IV / IM / IMIO 6IV / mgAtropine Pralidoxime (2 PAM) mg PAM) 1800(2 Pralidoxime Peds: 15Peds: administer or administer to a patientto a or administer administer -    Differential  IV Procedure Peds: 0.02Peds: Altered Mental Status,Seizures, Mental Altered Respiratory Distress, Respiratory Distress,Respiratory Respiratory , narcotics, vesicants, etc.)vesicants,, narcotics, I P B selfmay carry, - PAM) and 2 mg of 2 and mgAtropine. PAM) - IO Procedure 25 mg/kg mg/kg25 0.05 mg/kg 0.05mg/kg P – – as indicated.as Protocol84 Symptom Severity Symptom if availableif IV / IM / IMIO IV / IV / IM / IMIO IV / Notify Notify Destination or Over 30 minutes 30 Over uscle Twitching uscle 2 Doses RapidlyDoses2 Obtain history of history exposureObtain Contact Medical ControlContact Medical I Upset; Abdominal pain/ crampingAbdominal I Upset; rination; increased, loss of losscontrol increased, rination; / Diarrheaefecation mesis alivation acrimation symptoms resolve symptoms 600 mg IV / IMIO IV // mg600 Nerve Agent Kit IM Agent Nerve S L U D G E M ActivitySeizure ArrestRespiratory Peds: 15Peds: Pralidoxime (2 PAM) PAM) (2 Pralidoxime Minor Symptoms: Minor Observe for specific toxidromesspecific for Observe Peds: 0.02Peds: Atropine 2 mg IV / IM / IMIO 2IV / mgAtropine Repeat every 5 minutes until minutesevery 5 Repeat Initiate triage and/or decontaminationand/ortriage Initiate         Signs and Symptoms and Signs  IV Procedure Nerve Agent Agent Protocol Nerve I P Respiratory Distress+ SLUDGEM Respiratory - YES contains 600 mg of Pralidoxime (2 of Pralidoximemg600 contains it K WMD PPE Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Appropriate Scene Safe Scene symptoms Nerve Agent Nerve Appropriate Arm Appropriate resources Go toGo Every 15 minutes for 15 minutesEvery Asymptomatic Initiate Treatment per TreatmentInitiate Monitor andReassessMonitor atropine / pralidoxime by protocol. Agency medical director may require Contact of Medical Control prior toprior administration. Controlof MedicalContact require may director protocol.medical Agencyby pralidoxime/ atropine The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves.salivationbeuntil given should atropineso secretions excessiveis addressesatropine thethat symptom main The / EMT RespondersMedicaland officerssafetypublic personnel,EMS for patients greater than 90 poundskg).(>4090than greater for patients Each routeacceptable.any isby Activity: Any benzodiazepineSeizure In the face of a bona fide attack, begin with 1 Nerve Agent Kit for patients less than 7 years Kits Agent 2age, Nerve than years of patients7 Agent lessNerve Kit for beginwith1 aattack,thefide bona faceof In andage over. years of 15Kits for Agent 3 patientsof Nerve andage,8 toyears from 14 Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Gastrointestinal, NeuroLungs,Gastrointestinal, Heart,HEENT, Status,Skin, MentalExam: Recommended equipment. personalprotective of use and protocols for decontamination localHAZMAT Follow Potential exposure to unknownexposure to Potential substance/hazard Exposure to chemical, biologic,to chemical, Exposure orhazard nuclearradiologic, For patients with major symptoms, there is no limit for atropine dosing.limitatropinenoisfor symptoms, there major patientswith For agent(e.g.another to fromexposure notensure tothey patients Carefullyevaluate If Triage/MCI issues exhaust supply of Nerve Agent Kits, use pediatric atropines (if available). Use the 0.5 mg0.5 if dosethe Use (if available).pediatric useatropines Nerve Kits, supply Agent of exhaustissuesIf Triage/MCI mg dose402 and kg), to poundsto (18 9040 between patientweighsif dose 1 mgkg),pounds (18 40 lessthan patient is Seizure ActivitySeizure Seizure ProtocolSeizure Revised NO Stage until scene safesceneStageuntil 11/19/2012  Pearls    History         Call for help / additionalhelp/ forCall Adult / Pediatric Trauma and Burn Section Protocols Don’t 2012 94 % 94 painful ( painful - Degree) blisteringDegree) nd Degree) painless/charredDegree) Protocol(s) Maintain Oxygen Oxygen Maintain Protocol as indicatedas Saturation ≥ Saturation rd Protocol Degree) red Degree) Thermal Burn / BurnThermal Age AppropriateAge st Adult / Pediatric Airway PediatricAirway Adult/ Trauma ProtocolTrauma CrushSyndrome Electrical injuryElectrical Radiation IncidentRadiation – Chemical and Electrical Burn Electricaland Chemical g Trauma. g Superficial (1 Superficial TBSA) in include Thickness(2 Partial (3 FullThickness leatheryskinor injuryThermal Chemical injury Radiation injuryBlast YES YES Differential        YES YES if indicated IO Procedure P if indicated Exposure Exposure Cardiac Monitor Cardiac if indicated if indicated Protocol86 CrushInjury as indicatedas to appropriate destination usingdestinationappropriateto Blast LungInjuryBlast Electrical Burn or Burn Electrical Radiation Burn or Radiation Trauma and Burn: Traumaand Thermal / Chemical/ / Thermal Notify Notify Destination or Contact Medical ControlContact Medical Adult / Pediatric Airway Protocol(s)PediatricAirway Adult/ EMS Triage and Destination Plan DestinationandTriageEMS if indicated Burns, pain,swellingBurns, Dizziness consciousnessof Loss Hypotension/shock could compromise/distress Airway hoarseness/by indicatedbe / Hypotension wheezing Adult / Pediatric Pain Control ProtocolControlPediatricPainAdult/ IV Procedure Adult / Pediatric Multiple Trauma ProtocolTrauma PediatricMultiple Adult/ Signs and Symptoms and Signs      Rapid TransportRapid I P Blast Injury Blast Injury Incident/ Open / Closed.Open Intervening protective barrier. Other environmental hazards, Other environmentalbarrier.protectiveIntervening Incendiary / Explosive Incendiary Agent / Amount. Industrial Explosion. Terrorist Incident. Improvised Explosive Device.Explosive ImprovisedIncident.TerroristExplosion. IndustrialAgent/ Amount. Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Blunt Trauma / Crush Injury / Compartment Syndrome / Traumatic Brain Injury / Concussion / Tympanic Membrane Tympanic / ConcussionInjury / TraumaticBrainSyndrome/ CompartmentCrushInjury / / BluntTrauma Scene Safety / Quantify Enroute / AssessmentTreatmentandLoad Go withPatients Triage/ and / Quantify SceneSafety Accidental / Accidental (See Pearls)(See Rupture / Abdominal hemorrhage or Evisceration, Blast Lung Injury and PenetratinandLungInjury Blast or Evisceration, hemorrhage/ AbdominalRupture Triage ProtocolTriage Type of exposure (heat, gas, (heat, of exposure Type Other traumaOther Consciousnessof Loss status Tetanus/Immunization Inhalation injuryInhalation of InjuryTime history/ Pastmedical Medications chemical) Intentional Explosions Intentional Revised 10/30/2012 History        Nature of Device: of Device: Nature of Delivery: Method of Environment: Nature Distance from Device: from Device: Distance for: Evaluate Blast Injury / Incident

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Pearls e  d

Types of Blast Injury: i a

Primary Blast Injury: From pressure wave. t r

Secondary Blast Injury: Impaled objects. Debris which becomes missiles / shrapnel. i Tertiary Blast Injury: Patient falling or being thrown / pinned by debris. c Most Common Cause of Death: Secondary Blast Injuries. T  r Triage of Blast Injury patients: a Blast Injury Patients with Burn Injuries Must be Triaged using the Thermal / Chemical / Electrical Burn Destination u Guidelines for Critical / Serious / Minor Trauma and Burns m  Care of Blast Injury Patients: a

Blast Injury Patients with Burn Injuries Must be cared for using the Thermal / Chemical / Electrical Burn Protocols. a n

Use Lactated Ringers (if available) for all Critical or Serious Burns. d

 Blast Lung Injury: B

Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur (rarely) in patients without external u

thoracic trauma. More likely in enclosed space or in close proximity to explosion. r n Symptoms: Dyspnea, hemoptysis cough, chest pain, wheezing and hemodynamic instability.

Signs: Apnea, tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. S e

Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. c

Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid t i

hyperventilation. o n Air transport may worsen lung injury as well and close observation is mandated. Tension pneumothorax may occur

requiring chest decompression. Be judicious with fluids as volume overload may worsen lung injury. P r

 Accident Explosions: o t

Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials.· o

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Consider structural collapse / Environmental hazards / Fire.· l Conditions that led to the initial explosion may be returning and lead to a second explosion. s Patients who can, typically will attempt to move as far away from the explosive source as they safely can.  Intentional Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials. Greatest concern is potential threat for a secondary device. Evaluate surroundings for suspicious items; unattended back packs or packages, or unattended vehicles. If patient is unconscious or there is(are) fatality(fatalities) and you are evaluating patient(s) for signs of life: Before moving note if there are wires coming from the patient(s), or it appears the patient(s) is(are) lying on a package/pack, or bulky item, do not move the patient(s), quickly back away and immediately notify a law enforcement officer. If no indications the patient is connected to a triggering mechanism for a secondary device, expeditiously remove the patient(s) from the scene and begin transport to the hospital. Protect the airway and cervical spine, however, beyond the primary survey, care and a more detailed assessment should be deferred until the patient is in the ambulance. If there are signs the patient was carrying the source of the blast, notify law enforcement immediately and most likely, a law enforcement officer will accompany your patient to the hospital. Consider the threat of structural collapse, contaminated particles and / or fire hazards.

Revised Protocol 86 10/30/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Chemical and Electrical Burn

History Signs and Symptoms Differential  Type of exposure (heat, gas,  Burns, pain, swelling  Superficial (1st Degree) red - painful (Don’t chemical)  Dizziness include in TBSA)  Inhalation injury  Loss of consciousness  Partial Thickness (2nd Degree) blistering  Time of Injury  Hypotension/shock  Full Thickness (3rd Degree) painless/charred  Past medical history /  Airway compromise/distress could or leathery skin Medications be indicated by hoarseness/  Thermal injury  Other trauma wheezing / Hypotension  Chemical – Electrical injury  Loss of Consciousness  Radiation injury  Tetanus/Immunization status  Blast injury

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Pearls  Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro  Green, Yellow and Red In burn severity do not apply to the Start / JumpStart Triage System.  Refer to Rule of Nines: Remember the extent of the obvious external burn from an electrical source, does not always reflect more extensive internal damage not seen.  Chemical Burns: Refer to Decontamination Procedure. Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids.  Electrical Burns: DO NOT contact patient until you are certain the source of the electrical shock is disconnected. Attempt to locate contact points (generally there will be two or more.) A point where the patient contacted the source and a point(s) where the patient is grounded. Sites will generally be full thickness. Do not refer to as entry and exit sites or wounds. Cardiac Monitor: Anticipate ventricular or atrial irregularity including VT, VF, atrial fibrillation and / or heart blocks. Attempt to identify then nature of the electrical source (AC / DC,) the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Protocol 87 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Trauma and Burn Section Protocols 2012 YES 1 L IV / IO L IV / 1 VF / VT VF / 50 mEq IV / mEqIO 50 Exit Exit to Over 3 minutesOver Asystole / PEA Asystole Hypotension / Hypotension Normal Saline Bolus SalineBolusNormal Sodium Bicarbonate BicarbonateSodium as indicatedas Calcium Chloride (or Chloride Calcium Peds: 20 mL/kg IV / IO mL/kgIV 20Peds: Peds: 20 mg/kg IV / IO mg/kgIV 20Peds: Peds: 1 mEq/kg IV / IO mEq/kgIV / 1 Peds: Gluconate) 1 gm IV 1/ gmIO Gluconate) Entrapped > 1 hour> Entrapped Arrhythmia Protocol(s)Arrhythmia I P Age Appropriate CardiacAppropriate Age Arrest / Pulseless Arrest/ Pulseless Arrest/ Entrapment without crush syndrome without crushEntrapment crush without significantEntrapment statusmentalAltered YES Differential    every every 10 IO Procedure 3 minutes 2 mg IV / mgIO 2 – – 75 mcg IV mcg/ IO 75 2 mg 2 P Or Or - 2 mg IN 2 0.2 mg/kg IV / IO mg/kg0.2 NO – - as needed neededas as neededas 1 0.2 mg/kgIN 0.2 50 mEq IV / mEqIO 50 Maximum 5 mg 5Maximum Maximum 2 mg 2Maximum Maximum 5 mg 5Maximum Maximum 10 mg 10Maximum as indicatedas minutes as needed.as minutes Maximum 200 mcg 200Maximum Cardiac Monitor Cardiac Age AppropriateAge Abnormal ECG / ECG Abnormal Protocol88 Sodium Bicarbonate BicarbonateSodium Normal SalineBolusNormal Morphine 4 mg IV 4 /IO mg Morphine Monitor andReassessMonitor Airway Protocol(s)Airway Peds: 0.1 mg/kg IV / IO mg/kg 0.1Peds: Peds: 1 mEq/kg IV / IO mEq/kgIV / 1 Peds: maintenance fluid rate fluid maintenance Monitor for fluid overloadfluid forMonitor Slowly over 2 Slowly 1 L then 500 mL/hr IV / mL/hrIO L 500then 1 Repeat every every Repeat Fentanyl 50Fentanyl Notify Notify Destination or 12 Lead ECG ProcedureLeadECG 12 Peds: 0.1Peds: Midazolam 0.5 Midazolam Hemodynamically unstableHemodynamically Peds: 20 mL/kg IV / IO then 3/ xIO then mL/kgIV 20Peds: Contact Medical ControlContact Medical IV Procedure Immediately Prior to ExtricationImmediately Repeat 25 mcg every minutes10every mcg 25 Repeat I I P P P B Hypotension Hypothermia findingsECG Abnormal Pain Anxiety     Signs and Symptoms and Signs  YES YES Crush Syndrome Crush Syndrome Trauma Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any YES 0.12 seconds0.12 Safe 0.46 seconds0.46 Scene ≥ 50 mEq IV / mEqIO 50 Over 3 minutesOver ≥ Loss of P wave of Loss Consider resources Peaked T WavesT Peaked Protocol(s) Sodium Bicarbonate BicarbonateSodium Calcium Chloride (or Chloride Calcium QT QT Peds: 20 mg/kg IV / IO mg/kgIV 20Peds: Peds: 1 mEq/kg IV / IO mEq/kgIV / 1 Peds: as indicatedas Gluconate) 1 gm IV 1/ gmIO Gluconate) QRS QRS Trauma ProtocolTrauma Extremity / body crushed / body Extremity trenchcollapse, Building accident,industrialcollapse, equipmentheavy underpinned Entrapped and crushed undercrushed andEntrapped minutes> 30 loadheavy NO Stage until scene safesceneStageuntil Call for help / additionalhelp/ forCall Revised Age Appropriate Multiple AppropriateAge 8/13/2012 Hypothermia / Hyperthermia/ Hypothermia   History  P

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Pearls  Recommended exam: Mental Status, Musculoskeletal, Neuro  Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call for appropriate resources.  Avoid Ringers Lactate IV Solution due to potassium and potential worsening hyperkalemia  Hyperkalemia from crush syndrome can produce ECG changes described in protocol, but may also be a bizarre, wide complex rhythm. Wide complex rhythms should also be treated using the VF/Pulseless VT Protocol.  Patients may become hypothermic even in warm environments.  Pediatric IV Fluid maintenance rate: 4 mL per first 10 kg of weight + 2 mL per second 10 kg of weight + 1 mL for every additional kg in weight.

Revised Protocol 88 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012

Adult / Pediatric Trauma and Burn Section Protocols Don’t 2012 painful ( painful - Degree Burn Degree rd Degree) blisteringDegree) Arrest/ /3 nd Degree) painless/charredDegree) Protocol(s) nd as indicatedas rd Age AppropriateAge Critical Burn Critical Degree) red Degree) compromise st Electrical injuryElectrical Cardiac Arrest/ PulselessCardiac Age Appropriate ArrhythmiaAppropriate Age – transport to a Burn Center)a totransport Burns with definitive airway airway definitiveBurnswith Burns with Multiple Trauma MultipleBurns with (When reasonably accessible,(Whenreasonably >15% >15% 2 TBSA Superficial (1 Superficial TBSA) in include Thickness(2 Partial (3 FullThickness leatheryskinor injuryThermal Chemical injury Radiation injuryBlast Differential        if indicated Information may be available from those on site who who have siteon fromthose availablemay be Information Degree Burn Degree rd /3 Exit Exit to nd Serious Burn Serious Protocol91 Age AppropriateAge Eye InvolvementEye Thermal Burn ProtocolBurnThermal Cardiac Monitor Monitor Cardiac Radiation Burn / Exposure Burn / Radiation transport to a Burn Center)a totransport (When reasonably accessible,(Whenreasonably 15% TBSA 2 TBSA 15% Hypotension or GCS 13 or 13 Lessor GCS Hypotension - intubation for airway airway stabilizationfor intubation 5 Burns, pain,swellingBurns, Dizziness consciousnessof Loss Hypotension/shock could compromise/distress Airway hoarseness/by indicatedbe / Hypotension wheezing Suspected inhalation injury or requiringor injuryinhalation Suspected Assess Burn / Concomitant Injury Severity InjuryConcomitantBurn / Assess Signs and Symptoms and Signs      P Flush Contact Area with Normal Saline for 15 Normalfor minutes with SalineArea Contact Flush Radiation Incident Degree Burn Degree rd Most all injuries immediately seen will be a result of collateral injury, such as heat from the blast, trauma fromtrauma blast,heatfromtheas such injury, collateral ofa be result will seen immediately Most allinjuries /3 nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS be Policy approved and the Change OEMS Protocol NCfollow document must this to changes SystemEMS local Any Scene Safety / Quantify Enroute / AssessmentTreatmentand Load Go withPatients Triage / and/ Quantify SceneSafety Minor Burn Minor Normotensive Determine exposure (generally measured in Grays/Gy). Grays/Gy). in measured(generallyexposure Determine Determine exposure type; external irradiation, external contamination with radioactive material, internal contaminationinternalmaterial, radioactivewith contamination external irradiation,external type; exposure Determine GCS 14 or Greater 14GCS May repeatneededasMay Irrigate Involved Eye(s) with Eye(s) with Involved Irrigate Type of exposure (heat, gas, (heat, of exposure Type Other traumaOther Consciousnessof Loss status Tetanus/Immunization Inhalation injuryInhalation of InjuryTime history/ Pastmedical Medications chemical) Normal Saline for 15 minutesSaline15for Normal < 5% 2 TBSA < 5% No inhalation injury, Notinjury, Intubated, No inhalation Collateral Injury: Injury: Collateral monitoring equipment, do not delay transport to acquire thisinformation.to acquire dotransportdelay not equipment, monitoring with radioactive material.· radioactivewith Quantify: concussion, treat collateral injury based on typical care for the type of displayed.·injurytype the careforon typicalbased injurycollateral treatconcussion, Qualify: History       

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decontaminated patient is not a good outcome. Refer to the Decontamination Procedure for more information. n

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burn being presented as well as a radiation exposure. Where the burn is from a radiation source, it indicates the patient has o c

been exposed to a significant source, (> 250 rem). o

 Patients experiencing radiation poisoning are not contagious. Cross contamination is only a threat with external and internal l s contamination.  Typical ionizing radiation sources in the civilian setting include soil density probes used with roadway builders and medical uses such as x-ray sources as well as radiation therapy. Sources used in the production of nuclear energy and spent fuel are rarely exposure threats as is military sources used in weaponry. Nevertheless, these sources are generally highly radioactive and in the unlikely event they are the source, consequences could be significant and the patient’s outcome could be grave.  The three primary methods of protection from radiation sources: Limiting time of exposure Distance from Shielding from the source  Dirty bombs ingredients generally include previously used radioactive material and combined with a conventional explosive device to spread and distribute the contaminated material.  Refer to Decontamination Procedure / WMD / Nerve Agent Protocol for dirty contamination events.  If there is a time lag between the time of exposure and the encounter with EMS, key clinical symptom evaluation includes: Nausea/ Vomiting, hypothermia/hyperthermia, diarrhea, neurological/cognitive deficits, headache and hypotension.  This event may require an activation of the National Radiation Injury Treatment Network, RITN. UNC Hospitals, Wake Forest- Baptist and Duke are the NC hospitals, with burns managed at UNC and Wake Forest. Protocol 91 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Page 1 of 2 Suspected Ebola

Immediate Concern: Evolving Protocol: Travelers from an area with an Ebola outbreak can arrive in This protocol should be considered an evolving protocol that can North Carolina prior to exhibiting symptoms and become ill change as out break locations change. All EMS personnel should here. carefully monitor this protocol for updates.

A Suspected Ebola Patient Defined •1) Within the past 21 Days before the onset of symptoms, residence in, or travel within, an area where Ebola transmission is active West Africa (Sierra Leone, Guinea, or Liberia) AND •2) Presents with a Fever, headache, Joint & Muscle aches, Weakness, Fatigue, Vomiting & Diarrhea, Stomach pain, Lack of appetite, or Bleeding.

EMD DISPATCH CENTER STAFF

•Use Emerging Infectious Disease [EID] Surveillance Tool With The Following Chief Complaints• **TYPICAL FLU-LIKE SYMPTOMS** and/or **UNEXPECTED BLEEDING** •THE EMERGING INFECTIOUS DISEASE TOOL SHOULD BE USED WITH THE FOLLOWING PROTOCOLS•

•EMD Protocol 26 Sick Person •EMD Protocol 6 Breathing Problem •EMD Protocol 18 Headache •EMD Protocol 10 Chest Pain •EMD Protocol 21 Hemorrhage (Medical) Ask the Following Questions 1)“In the past 21 days have you been to Africa?” •If Yes, 2)“Do you have a fever?”

If “yes” answer to the above questions, First Responders should NOT be dispatched. Dispatch EMS unit and alert the EMS supervisor on duty. Confidentially, notify both that there is a potential Ebola case. •DO NOT RELY SOLELY ON EMD PERSONNEL TO DIAGNOSE AN EBOLA PATIENT DUE TO DISPATCH TIME CONSTRAINTS •EMS PERSONNEL MUST OBTAIN A TRAVEL HISTORY AND CHECK CLINICAL SIGNS AND SYMPTOMS ONCE ON SCENE.

EMS Personnel Required Personal Protective Equipment (PPE) must be donned prior to entry (please see next page for PPE requirement and Donning and Doffing guidelines)

No Routine Aerosol Generating Procedures No Routine Intravenous (IV) Lines •Pre-hospital providers should avoid aerosol generating •Unless absolutely medically necessary do not initiate IV’s procedures unless absolutely medically necessary. ‘ on suspected Ebola patients in the pre -hospital •These include; CPAP, BiPAP, nebulizer treatments, environment. intubation and suctioning. •If an IV is necessary, it must be performed under •If these airway procedures are absolutely medically controlled conditions (e.g. briefly stop vehicle) to lessen necessary, control conditions (e.g. briefly stop vehicle). the chance exposure from a contaminated needle. Links CDC Ebola info Link NC Department of Health Link CDC PPE Standards Link

Pearls -Incubation period 2-21 days -A patient is only infectious when symptomatic -Personnel should only use PPE if they have been well trained in its use and know how to put it on on take it off safely and properly. -Once ill, a person can spread virus to others through direct contact with body fluids: blood, urine, sweat, semen, feces, tears. -Limit the use of needles and other sharps as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers. Safety devices must be employed immediately after use. -Personnel caring for possible Ebola cases should contact their local health department or the state Communicable Disease Branch (919-733-3419; available 24/7) -Always have a monitor for the doffing procedure to insure there is no provider self contamination during doffing -There should be a standardized procedure for donning and doffing that is monitored by a safety officer -There should be no exposed skin once full PPE has been put on

Protocol 100 Suspected Ebola Precautions Current as of: Orignialy created by Wilkes County EMS and reviewed by NCOEMS and Division of Public Health 10/23/2014 Page 2 of 2 Protocol Suspected Ebola EMS Contact of Suspected Ebola Patient

•REMEMBER, PARTICULAR ATTENTION MUST BE PAID TO PROTECTING MUCOUS MEMBRANES OF THE EYES, NOSE, & MOUTH FROM SPLASHES OF INFECTIOUS MATERIAL OR SELF INOCULATION FROM SOILED PPE / GLOVES. THERE SHOULD BE NO EXPOSED SKIN •1) Don personal protective equipment (PPE) BEFORE you enter the patient area. Recommended PPE PAPR: A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposable) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR.

N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield. If N95 respirators are used instead of PAPRs, careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.

Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Coveralls with or without integrated socks are acceptable.

Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.

Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers. Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker.

Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.

Single-use (disposable), fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea. An apron provides additional protection against exposure of the front of the body to body fluids or excrement. If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure

•2) Obtain a Travel History and Clinical Signs and Symptoms. •3) If there are no Ebola risk factors, proceed to the appropriate EMS treatment protocols based on clinical status •4) If Travel history and Clinical signs and symptoms is positive and Ebola is suspected, a surgical mask (Non- N-95) should be placed on the patient, (Use Non-Rebreathing Mask if oxygen is clinically indicated). •4) If the patient is being transported via stretcher then a disposable sheet can be placed over them. Doffing PPE: OUTSIDE OF PPE IS CONTAMINATED! DO NOT TOUCH 1) PPE must be carefully removed without contaminating one’s eyes , mucous membranes, or clothing with potentially infectious materials. Use great care while doffing your PPE so as not to contaminate yourself (e.g. Do not remove your N-95 facemask or eye protection BEFORE you remove your gown). There should be a trained and dedicated monitor to observe donning and doffing of PPE. It is very easy for personnel to contaminate themselves when doffing. A dedicated monitor should observe doffing to insure it is done correctly. Follow CDC guidance on doffing. PPE should not be worn unless personnel have been well trained in its use. 2)PPE must be double bagged and placed into a regulated medical waste container and disposed of in an appropriate location. 3)Appropriate PPE must be worn while decontaminating / disinfecting EMS equipment or unit. 3)Re-useable PPE should be cleaned and disinfected according to the manufacturer's reprocessing instructions. 1)Hand Hygiene should be performed by washing with soap and water with hand friction for a minimum of 20 seconds. 2)Alcohol-based hand rubs may be used if soap and water are not available. 3)EVEN IF AN ALCOHOL-BASED HAND RUB IS USED, WASH HANDS WITH SOAP AND WATER AS SOON AS FEASIBLE. THE USE OF GLOVES IS NOT A SUBSTITUTE FOR HAND WASHING WITH SOAP & WATER For any provider exposure or contamination contact occupational health. Alert the Receiving Medical Facility •1) As soon as feasible, confidentially notify the receiving medical facility that you are transporting a potential Ebola patient. Patient Disposition •2) DO NOT TAKE THE PATIENT INTO THE MEDICAL FACILITY UNTIL YOU ARE INSTRUCTED TO DO SO. •3) MEDICAL FACILITY PERSONNEL WILL DIRECT YOU TO THE PROPER ROOM THROUGH A SAFE ENTRANCE. •Diligent Decontamination / disinfection along with safe handling of potentially contaminated materials (Objects such as contaminated EMS Equipment-supplies, sharps) is paramount, as blood, sweat, urine, saliva, feces, vomit, and semen represent potentially infectious materials. EMS Personnel Exposure-Immediate Actions

•If EMS personnel are exposured to blood , bodily fluids, secretions, or excretions from a patient with suspected or confirmed Ebola should immediately: •1) Stop working and wash the affected skin surfaces with soap and water. •2) Mucous membranes (e.g., conjunctiva) should be irrigated with a large amount of water or eyewash solution;

Protocol 100 Suspected Ebola Orignialy created by Wilkes Current as of: County EMS and reviewed by NCOEMS and Division of Public Health 10/23/2014 Protocol Suspected Ebola EMS Unit Decontamination

Decontamination / Disinfection Guidelines: The following are general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with suspected or confirmed Ebola: Required Personal Protective Equipment (PPE) for Decontamination

When performing Decontamination EMS Personnel MUST wear appropriate PPE: -Follow current CDC guidelines for PPE. -There should be no exposed skin. -Refer to Protocol 100 Suspected Ebola page 2 for PPE guidelines

Recommendations for Personal Protective Equipment (PPE) for Decontamination

•1) EMS personnel performing decontamination / disinfection should wear recommended PPE (described above)

•2) Face protection (N-95 respirator with goggles or face shield) should be worn since tasks such as liquid waste disposal can generate splashes. •3) Patient-care surfaces (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces) are likely to become contaminated and should be decontaminated and disinfected. •4) A blood spill or spill of other body fluid or substance (e.g., feces or vomit) should be managed through removal of bulk spill matter, cleaning the site, and then disinfecting the site. For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient. An EPA-registered hospital disinfectant with label claims fornon -enveloped viruses to disinfect environmental surfaces should be used according tolabel instructions. If the label states that it's effective against common nonenveloped viruses like norovirus, rotavirus, adenovirus, or poliovirus then it should be effective on Ebola.

(Alternatively, a 1:10 dilution of household bleach (final working concentration of 500 parts per million or 0. 5% hypochlorite solution) that is prepared fresh daily (i.e., within 12 hours) can be used to treat the spill before covering with absorbent material and wiping up. The spill should soak in the bleach solution for 15 minutes. After the bulk waste is wiped up, the surface should be disinfected as described in the section above).

•5) Contaminated reusable patient care equipment should be placed inred biohazard bags (double-bagged) and labeled for decontamination and disinfection. Place bags in leak proof spill proof containers. •6) Reusable equipment should be cleaned and disinfected according to manufacturer's instructions by appropriately trained personnel wearing correct PPE. •7) Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. •8) To reduce exposure, all potentially contaminated textiles (cloth products) should be discarded. This includes non-fluid-impermeable pillows or mattresses. They should be considered regulated medical waste and placed in biohazard red bags. They must be double-bagged prior to being placed into regulated medical waste containers. •9) Use caution when removing PPE as to avoid contaminating the wearer. A buddy system should be used to insure that doffing is done safely. Use the established CDC guidelines. •10) Hand hygiene should be performed immediately following the removal of PPE. Soap and water should be used when available. If not available then use an alcohol based hand rub and soap and water as soon as possible

Ebola Information: For a complete review of Ebola EMS Vehicle Disinfection go to: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety- answering-points-management-patients-known-suspected-united-states.html

Protocol 101 Ebola Unit DecontaminationOriginally Created By Current as of: reviewed by NCOEMS and Division of Public Health Wilkes County EMS 10/23/2014 Protocol Ebola (Safe Transportation of Human Remains)

These recommendations are designed to offer guidance on the safe transportation and handling of human remains that may contain the Ebola Virus. •Only personnel trained in handling infected human remains , and wearing full PPE, should touch, or move any Ebola- infected remains. •Handling human remains should be kept to a minimum . Putting on(Donning) PPE Removal of (Doffing) PPE

PPE should be in place BEFORE contact with the body Remove PPE following appropriate guidelines.

-Refer to protocol 100 Suspected Ebola page 2 for PPE •1) Use caution when removing PPE as to avoid guidelines contaminating the wearer. A buddy system -There should be no exposed skin and checklist should be used to insure that -Refer to CDC guidelines for doffing and donning doffing is done safely.

•2) Hand hygiene (washing your hands thoroughly with soap and water or an alcohol based hand rub) should be performed immediately following the removal of PPE.Soap and water is preferred. If hands visibly soiled must use soap and water

Preparation of the Body

•1) At the site of death, the body should be wrapped in a plastic shroud. Wrapping of the body should be done in a way that prevents contamination of the outside of the shroud. •2) Change your coveralls or gloves if they become heavily contaminated with blood or body fluids. •3) Leave any intravenous lines or endotracheal tubes that may be present in place. •4) Avoid washing or cleaning the body. •5) After wrapping, the body should be immediately placed in a leak-proof plastic bag not less than 150μm thick and zippered closed The bagged body should then be placed in another leak-proof plastic bag not less than 150 μm thick and zippered closed before being transported to the morgue.

Surface Decontamination

•1) Prior to transport to the morgue, perform surface decontamination of the corpse-containing body bags by removing visible soil on outer bag surfaces with EPA-registered disinfectantsthat can kill non-enveloped viruses. •2) Follow the product’s label instructions. Once the visible soil has been removed, reapply the disinfectant to theentire bag surface and allow to dry. •3) Following the removal of the body, thesurrounding area where the body was removed fromshould be cleaned and disinfected. •4) Reusable equipment should be cleaned and disinfectedwith agents as described in protocol 101. Transportation of Ebola Infected Remains

•1) Individuals driving or riding in a vehicle carrying human remains: PPE is not required for individuals driving or riding in a vehicle carrying human remains, provided that drivers or riders will not be handling the remains of a suspected or confirmed case of Ebola, and the remains are safely contained and the body bag is disinfected as described above.

Ebola Information: For a complete review of Handling Remains of Ebola Infected Patients go to: http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html Pearls of Wisdom • In patients who die of Ebola virus infection, virus can be detected throughout the body. • Ebola virus can be transmitted in postmortem care settings by laceration and puncture with contaminated instruments used during postmortem care, through direct handling of human remains without appropriate personal protective equipment, and through splashes of blood or other body fluids (e.g. urine, saliva, feces) to unprotected mucosa (e.g., eyes, nose, or mouth) which occur during postmortem care. • Only personnel trained in handling infected human remains, and wearing PPE, should touch,move, or any Ebola-infected remains. • Handling of humanremains,which may accour during postmortem care should be kept to a minimum.

Protocol 102 Ebola (Safe Transportation of Remains) Current as of: Originally Created By Wilkes County EMS Reviewed by NCOEMS and Division of Public Health 10/23/2014