EMS System Protocols

Released September 2018

Revised December 2017

2017 NCCEP Treatment Protocol Index

Protocol Introduction PI (Black)

PI-1. Introduction

PI-2. Key to Protocol Utilization

Universal Protocols UP (Green 4)

UP-1. Universal Patient Care Protocol

UP-2. Triage

UP-3. Abdominal Pain / Vomiting and Diarrhea

UP-4. Altered Mental Status

UP-5. Back Pain

UP-6. Behavioral

UP-7. Dental

UP-8. Emergencies Involving Indwelling Central Lines

UP-9. Epistaxis

UP-10. Fever / Infection Control

UP-11. Pain Control

UP-12. Police Custody

UP-13. Seizure

UP-14 Suspected Stroke

UP-15. Suspected Sepsis

UP-16. Syncope

Airway Respiratory Section AR (Blue 7)

AR-1. Adult Airway

AR-2. Adult, Failed Airway

AR-3. Airway, Drug Assisted

AR-4. COPD / Asthma

AR-5. Pediatric Airway

AR-6. Pediatric Failed Airway

AR-7. Pediatric Respiratory Distress

AR-8 Post-intubation / BIAD Management

AR-9. Ventilator Emergencies

AR-10. Tracheostomy Tube Emergencies

Adult Cardiac Section AC (Blue 8)

AC-1. Adult Asystole / Pulseless Electrical Activity

AC-2. Bradycardia; Pulse Present

AC-3. Cardiac Arrest; Adult

AC-4. Chest Pain: Cardiac and STEMI

AC-5. CHF / Pulmonary Edema

AC-6. Adult Tachycardia Narrow Complex (≤ 0.11 sec)

AC-7. Adult Tachycardia Wide Complex (≥ 0.12 sec) AC-8. Ventricular Fibrillation Pulseless Ventricular Tachycardia

AC-9. Post Resuscitation

AC-10. Targeted Temperature Management with ROSC (Optional)

AC-11. Adult Team Focused CPR (Optional)

AC-12. Onscene Resuscitation / Termination of CPR (Optional)

Adult Medical Section AM (Blue 9)

AM-1. Allergic Reaction / Anaphylaxis

AM-2. Diabetic; Adult

AM-3. Dialysis / Renal Failure

AM-4. Hypertension

AM-5. Hypotension / Shock

AM-6. Stroke; Activase / t-PA Transfer (Optional)

Adult Obstetrical Section AO

AO-1. Childbirth / Labor

AO-2. Newly Born

AO-3. Obstetrical Emergency

Trauma and Burn Section TB (Red 2)

TB-1. Blast Injury / Incident

TB-2. Chemical and Electrical Burn

TB-3. Crush Syndrome Trauma

TB-4. Extremity Trauma

TB-5. Head Trauma

TB-6. Multiple Trauma

TB-7. Radiation Incident

TB-8. Spinal Motion Restriction

TB-9. Thermal Burn

TB-10. Traumatic Arrest (Optional)

Pediatric Cardiac Section PC (Purple Accent 3)

PC-1. Pediatric Asystole / PEA

PC-2. Pediatric Bradycardia

PC-3. Pediatric Pulmonary Edema / CHF

PC-4. Pediatric Pulseless Arrest

PC-5. Pediatric Tachycardia

PC-6. Pediatric Ventricular Fibrillation / Pulseless VT

PC-7. Pediatric Post Resuscitation

Pediatric Medical Section PM (Purple Accent Darker 50%)

PM-1. Pediatric Allergic Reaction

PM-2. Pediatric Diabetic

PM-3. Pediatric Hypotension / Shock

Toxin-Environmental Section TE (Orange 3)

TE-1. Bites and Envenomation

TE-2. Carbon Monoxide / Cyanide

TE-3. Drowning

TE-4. Hyperthermia

TE-5. Hypothermia / Frostbite

TE-6. Marine Envenomation / Injury

TE-7. Overdose / Toxic Ingestion

TE-8. WMD – Nerve Agent Protocol

Special Circumstances Section SC

SC-1. Ebola; Suspected

SC-2. Ebola; Suspected - EMS Unit Decontamination

SC-3. Ebola; Suspected - Safe Transportation of Human Remains

Special Operations Section SO

SO-1. Scene Rehabilitation: General (Optional)

SO-2. Scene Rehabilitation: Responder (Optional) Protocol Introduction

,

t s e

7 n

l g e

e

n e y e 1 r o

d o

n s r h i

o g e e v a i

0 c t o d

e r e r

n h s s n i f e i l

t n e i 2 v o e i e a g m a n

a

m i l

l t l r e i i t a 2

p w s s

s

a c s ; I

r o e t

e o t

a c f t l

, o m a s i o t

r r d p s ” e . v e e

h a n l e

o l n r o

. e t d t s

b e h

s

p e

d r e g v h r

t T e a l o o

e e t e y t n y

e h l l s e c

t s l t e t i l u t t i a t e l t c

e

n l o h r s z l l n s h o o b

. i g i n m a

e o p

p o s a o t c l l d d c g u a f b a t v o c a

s e P t i n d r e

t

n d x c o . l

i n h r n p a r h o u a n n o o

n e

t v i t t o C c e i e

t e t t e o y s

i

h o

e

r m u

a p v e a t r

t i o n l n ( m u s t p

b

c o n , t e i e r n i o

g d d y p n

r d a

a e r i o l l

a e s i t t o

a r i t e e s n e t t n u c o r 1 e t

g n h l r i c p h o n y c

e t s e e n h

p i e e p s i t

e n e m

p n e

n r r a t

p m i o c c h t

e i h e y r t t

r c d n t g v t a a s n n u o a

i

t o e i o t r r o e e h a e g n l

l s a

T d e e l e a n h t r o c i r

;

d i a i n k m n s e e p

e a m e e f a s

n l t e I o

h w a p t a p

r C m

d r r . l M x

a

h e e r e t p

t d o

l c c a r

i m t u m t p n d i

i y

s

t e u e

w t t

i e k a

h d b f e t l a l l e r s

e

i

a o c u l c n W E s a d n

a e w i d

n i o T o h

s n n e u e s v e p e

s f

g

i h a

f

n i n e e h i p h n d a l

. . s T

e n m v d w t o y s p

t a l n s o e e i i t

i e c e

g r i r

r i

s a n o d m

n

t I

n m

e u e

t

r v r g .

m t

e r n B a o g

e g p t a w d e o c o o . o r

. n f h h s

t n

r a t s o a t t l p s p e n I s

n e t n t t s

e c t e s s

r i i i t i a

o T a e f e n e l

i f e l t s l n o o r

. e e h f i n l t C

l a i l

o f l s

e p l p d i r i t t

e o i n t o a

e e t g r o b c i t . T b s y b v e l i e m r a r o a o i s l

a t h n

e - n

L

t e

r p n r a a n t a w

v a n

a e e . s a

s h p t e e r p a

e . r

h e e e d t a

e e i t

o p g

e t i e p t a s e l n t d v e c n

f s s

c i C o o

C v s h n p i l i d n e g p

l d t m m

t c C

a o s e o e o i e e n r

y n d g i t a

a

e l n l e N e

s a

m l y h i t a o t a

c g u c r c

t

c - e t e e f l b n n r a h t r i o

u g d , s o i r s a

a n

a r l i a p e d a t l e t d i l h d a n a e e

n e S n d t n f n i l l c h i o t

u c o a i d r r m S v i i

u n a S c a l - v

a

p d e l

t e c v i a o j i o

u s l p i c s

M r t .

i e d d

l t N i o a r : e e

w e m t M

u e n i e o y p l l s s c

g a

c

g r t o s n

i E e n

m o v i i f d

i a y a r f x o a y s e n p e f

a

o t n E f

2 n p a

i o l

c e

f r a e e i o e a

i h i h

o c

e l m t C h M a t

) h

n a

, n h h c s n f

s

o c

e

h t l i t r n y n T c e

t e s s a t a

s n l s t u 4 T e i m

c s

i t o o i S “ e i e r e h l r , h r

r n t

l r

t

(

b c i g l d

o t t t a a u t c .

a

p

t d n n d i d o p a e e

s r o e r o o h t d e i s r i a o e i M r d c i f i u f a e t t e o r d i

r r n n s r

s t i i d

p p o m p

v n w i v s . d i x

d i u e o P a E

l

b r r e

e m o e r a s a r e e a

e C t

o a i t d o e e i r w v e i

o N a s l b

f V o

a e o i a

r

d r

r v

f e l

s

o n t r

p . l

n c f t v C l h e i o l n r b

c o . . c

h

e d t p

c n p h v i

e y – e A r o a a o p

e a

n c

o d

o t t

i

e a e r e s n t i r d h h n o c c e o e d h t p t c c r i e p l i g c e t t i r n l n o s t i a d r

t

h n u

m c n i S d n a t n r t l

P

e

c T t o t h o n o

a w o u e

i

d h s e ) 1 n o

e e g i o e e t i t m a a e o t a f h

t r e t . a t

M c

t t

i a c z t f . o e m

n

3 w o

n c l u c h n i o f i c

o m g

i l b

e I c

i ( e m c l N s M i i a

n t o

r i E t y s l t

i e e e

r r r i

i H r . p O

C l a

l s t e

r t o l n e n f h

t g r e e

l d

f g p

, e b d n b n r t e p d P w s

l a s i i

r O O m o

g o e s u

o u

e o . o s e a o d n t t n t u a e t w e a

S e r

r o r e a i i f n r v l

r y

o

i

p z n i n s c t i

n r d m r n , n u d i t n e l m o ) i t c o

e a h i t S p e i o a o s j x r t d l i i M i l o t o a a d -

e t e e e i t h

u p b o i y a r i r d t u L r l h a l e e e C a t a d

t m o v r u r E c e c e e n g d m i r b

t

l t e p t r p o p o c

i

m

r t i e t a c m h e R o o i a l

a

p t p e r s o t a d e h o r t t h o p r o

s a h n i f r y h s p n e c t n

t i a d t o c A t i a o i n e r a

n d C

s c P a M t r

c e i

n l l n

s c i r t s , e o n

C

c o e i m r

h n

e

h a E e s n

r c

t D o o s i e o t e b a d / t s i I p y l w

r h I . t e o

h

a

o e e c s

l l t t

a h e a

c S n v e s P b a a n i e l p a N l s u e

t f

s r

i f c

t i n e c o s h

d a w t e f l L t e r s

d a o

s a t r i i a t o e l g e s e i s

e o s c d t e o

g s

m e i c

i e i

h d o e i v

i y n

R

s u d r h r d h a d n t t h

e n e g n h s

D n f e N i i e r t

d r s

w t

s d x s o m

l

e e N e o

e f i T A

e e n a

e o n o T l v h o l

r w e f r a d

i c e i r r d i c r

e o r n t o y n e ,

o v i d

r t g e r p

i e o E y

e d u

i . s e w o c a n

r c . e

b e i s r b b e a t t s a a s m y r

r

a P t t l M

a m ) )

P d e w i r

d i t w o t a

a v l

e o p e

r e l p

s

s a e

u n o e o 2 r

r

d d t s e l

d s o o n n u o o t l m S t ( l s e l e l v s

s e e p c o m u

h

i e r a o e c p

a l o

k p t

m m c e

t t u r o r t r

a a h o

g e

o t o c o z

M

p

o c h o t

l o 9 e m e e a o t i r r

f n o m a

r i c o u f r d d t l T i n t . l c m r l n s I

e r f s o t

i a i E

0 l

o i o

d h e

a h

p t o w t t p

e p

u t n o a n

e t

a e r . c m s t v a y t g c t

, t

0 a l . n i t s r d t r s i e l o u e

i q p a i i i t r e n

n e p e o a u n o s o p v

d r 2 e

n

e p o

i d m s r o r

e r r s v

p

e i p a t o o d e

i m p s o l n p i C m s y

t r h e d e h

e d m c a e s

p o m s o d s r t

c l p n

n e t i

n - r e a m t l

a t y

c D l r

i s d i n b c r o c

t

o , a h n o p s

e i e a m

g m r s e a g c c i

l t n o e i t t a p e f e r S

e

i c e r h e n a h p t n r p

r

e h a c o i t r a c e e n a n e l

i - v c y m - l o u t

n t s d p i r e t a a o c i l d n p s g i

o c i o A r h

i t e o a 2

d o e a e m l b h m i s

l o i s t t

l t m a t

p s r a r n v r o t y c . i w l t m p i c g 1

t a a u D s e o d i o h y u t t o

a a t m

i i m e i p l p r

a r o p i m d

a t p a a r l r l 0 x l

l c

p

e c s , r s s n i n r u a e p f h b u

e d p

s c i t e a 2 e a h s o h a m

o , P

m e i d s p e f i e n n s p e

i

r b t o u o h

M w y o

o

c c c

y s t r n

u

t g g l o h d

s n e

n u i i e o i o e d y

s t r r o l o

l i s

h m

d y n l i d s

g c q l s d a r e a s T n d h o l - h l i h n n d t

e

a d n a p l t i e

h e i l e e a o t n - n o i s i , t a

t p ( e

e i e a t

v c t a

a e c s w S m d

v p i u v v c i r s a e o

c a b p e i

e

n i s c t r i i c n e

t o d

e l t r n , e 2 i o a w M o c i o t l p s

v e n s e m o

d i h

e

r l u

r d e

o t g n e y s a a p r r o

n h d t a r i h o

o h o i

c

s r t e e s x s p

d a t e i p e f s e c a n e t r

d , e e

e o l

i s i o t

s

h g y s

d o f g

c o i f h n n d

h r o h n a i - p d d e t c m h e y m o d l

m t i a i t h

o e o l

m r r i a e t d

h

t

c a s b

e s o m T e t n l h

e y n

i c n

i

l

f s r

d r i g P o a p t t p e e m h e f d d l a a h i e

e

p e

e d a e y o r a r e o n

l e n c m p - x n H t c r s h t l i u e c a t s y s c

s c i

i i ( e n t p i h l c t o b e p i c 7 a f

o n e t

o a i

s t r b r f o

f c e -

o e n o i e

h x

c

i w a n h 0 o e o o s t y n m r ) s b s a o n n o n e p h

h a h

h t e l c

d e i t d o

d t e t w s u

0 t r e a b

w l e

i p c p

y e s a

g h l c T

o e o n t s p n e

e n i d n e r 2 i x m

l d u i e l i n o e y g r f

i r w c g o d t x e p m l a n e l d m e u i e n s e r o e a l p f r v h l i

b e n t r i e

p t v

o o s u e

a e c e e i v o l a e b

v i f p t

v t e e i l a n m i a d c a m

t e o e e o i i r r d t t t l d v d i t c e e e ) o e o o f d h r n e r n e o l m i u h h h v s a c e t u d r n l a o u r e n r e p p i 3 h r n n h e e p a p o F I s p a p o S m w t o i t e T ( p n o a P T d a p d E t u T s Protocol Introduction

d l u o h s

h o c t i

n

t h s o c i t w

t x l e

r h

r a l o o i y e g r c i a d B y l m h

c r u o t r i j h t y d t a s o o i l n g o t f a i e i r n r

u n n r R H C I M a p e m o

r m e o f s

m a o B e c

M s l i a C d

d n r N

e o e i r n t i h e t o d

d o n i l s d

s f o a e i a n i t

n o g t

r a n e o t i a r o n c s f

i s

c c

l e t i o

o s e s r i t i o n r d A b e n d

s t

i / f e n h r a

r

f x i l c i d o l s e l

e t a c i e

n n h o l D · i x c

s e o / T z o c l o i o w e n

t n

r l i c o o p s

i B h a i o t

d l l r a o t c s c c h n D t i i e l n

o

n o c

h e o t t e l i o r r d r d o o e t f t a g r t a i a r

r R T e d i o

a P t c t o

l n p

c

e n i e l l e

e i r a m n h

h U n n e e

z o a x d a a g t d s p i

o r g M

m o g

l o w n i o e c c

e n g i C r l

i i n a l i i i m n C l t

a i t t h b i y

l o a e

M

o o l o a d m d h C f

h d a t u c a

l o c t u n a o c c

2 e a e P L u n p i t t i

n

n l a

. c I

o r c

o / d l s i

t i i i

d c n i l n w M I M c m e t e f e c a o t

o r d d e d y n e v l o c o o s m s r i o g n a i i i P e S y y P

e d i e o r

o L p t , c e l o m s t h h l

a d c c g t m

m d i c

e M

a t o o t M y r e y D r

s n n n u n n c i t y

r o o

t i t i v n P o a t b t a t m r e o

e e p a

f

c o y

d e

a h e l o o c s l f p

r E r n g g D a n d

h o a r i m g p

a n I t a o r r r i c t e y p e . o t h p l t g p r m

l g s n d a

i

e e c k l o d l a o r h S r n o y S e r l 2 o e s

n t

P d

l l c e g N t a a m m l a o c e c S e o A i i C

a e a

o

l n t v

e e g D E E t

n i C g H w r a n d p d e c i

a p o t i a a l r

n o g r r e f l b n i D i p p o

v u p

o t

a U c l a

c S a y

m p P d

c d e

a o o a

t t u o s p d c m A

l i s I y o a s M n c t

r d i f s a y g p i e e i

a c

A e h M l S · e

m c l b

p K a a r a P B A s

c e o e

t e o g c r o L t n e

e r a

c i h i .

f h d i e

d c l c

g e a t e s a c s p i i t p m l

s d

n s

e n ) s t e e n i m o s

v

o ( m m e i s l r

e t t l e i

e o a t

f a t i a

c

e y t o a c n i s r t

o m x p t c s t o x r m o s i o n o o i p h t t t e o t L o a e E d

a t r f a s B

/ g e t x a

i c

i / n

a r p n l s

I i e y

k t h n c l o

m

r y i n l m t t c r t h a r p t e d o t a o n n a o n E g

r l n i s f h n f n u f m a a a L t I I o t t B n t s o H i E m r r I o r

t P u u o o n

o e a l M r c l y p p a p i r

m s r i u A i l m m o m o I I W r t S T D I C t a s e i

· P · · · · · H · · Bring all necessary equipment to patient Scene Demonstrate professionalism and courtesy Required VS: YES Safe Mass assembly consider WMD Blood pressure NO Palpated pulse rate Utilize appropriate PPE Respiratory rate Consider Airborne, Contact, or Droplet Isolation Pulse ox if available if indicated Call for help / additional If Indicated: resources Initial assessment Glucose Stage until scene safe BLS maneuvers 12 Lead ECG Initiate oxygen if indicated Temperature Adult Assessment Procedure Pain scale CO Monitoring Pediatric Assessment Procedure EtCO2 Monitoring Use Broselow-Luten tape

Trauma Medical Medical or Trauma Patient Patient

Evaluate MOI Mental Status Exam Universal Protocol Section Universal Protocol

Significant MOI No Significant MOI Unresponsive Responsive

Primary and Primary and Obtain Primary and secondary Chief Complaint Secondary Secondary trauma assessment assessment trauma Primary and Obtain history of assessment Secondary Focused assessment present illness from assessment on specific injury available sources / Focused assessment scene survey on specific complaint

Spinal Motion Restriction Procedure / Protocol TB 8 as indicated

Obtain VS

Obtain SAMPLE Repeat assessment while preparing for transport Exit to Age Appropriate Protocol(s) as indicated Continue on-going assessment Repeat initial VS Evaluate interventions / procedures Transfer Patient hand-off includes patient information, personal Patient does not property and summary of care and response to care fit specific protocol Notify Destination or Contact Medical Control

Revised UP 1 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Oct 2017 Universal Protocol Section Oct 2017 50 kg. Locally RevisedLocally 49 kg. as ongoing assessments ≤ 16 or weight ≥ or weight 16 ≥ ader to understand theader to understand ation) in cardiac arrest. aindications as well as as well aindications untoward s is 94 % regardless of delivery 15, weight ≤ mpleted disposition form. were not performed as well as performed were not hand off with all pain medications.with off hand scitation Tape, Age This should remain stable over time. Inability to Demonstrate a rational process to come to a decision. decision. a to come to process rational a Demonstrate UP 1 transport must have a co and why indicated procedures and indicated why patient to accept transport to medical facility. r at a minimum with patienta encounter. ation in a patient’s baseline mental mental patient’s baseline a in alteration any with trauma, etc. of stroke, assess signs and Sugar Patient should be able to display a factual understanding of the illness, the options er utilized. Oxygen is a pharmaceutical with indications, contr indications, with a pharmaceutical is Oxygen utilized. er eased mortality when given in overdose (hyperoxia / hyperventi when overdose given eased mortality in A reasonable target oxygen saturation in all treatment protocol treatment all in saturation oxygen reasonable target A e tachycardia in shock with e tachycardia in shock with low pulse rates. to normal if not noted on the specific protocol is vital signs, mental status with GCS, and Ability to communicate an understanding of the facts of the situation. They They situation. the of facts the of understanding an communicate to Ability y procedures were performed a very serious underlying process. underlying serious a very This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This and risks and benefits. benefits. and risks and Patient should be able to communicate a clear choice: : Manipulation of information in a rational manner: : : Relevant information is understood: : Appreciation of the situation: Should be able to describe the logic they are using to come to the decision, though you may not agree with decision. patient A pediatric is defined by fitting a Length-based Resu Encourage patient to allow an assessment, including vital signs. Documentation of the event is very important including a mental status assessment describing the patient’s capacity refuseto care. capacity: Assessing to Guide C communicate a choice or an inability to express the choice consistently demonstrates incapacity. R should be able to recognize the significance of the outcome potentially from their decision. M age until medications based weight have should tape coded color Length-Based the off Patients Special needs children may require continued use of Pediatric based protocols regardless of age and weight. of Work Appearance, encompasses which Triangle Assessment Pediatric the utilize should assessment Initial skin. to Circulation and Breathing The order of assessment may requirealteration dependent on the developmental state of the pediatric patient. Generally the child or infant should not be separated from the caregiver unless absolutely necessary during assessment and treatment. Patientrefusal is a high risk situation. Encourage A SAMPLE: Signs / Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness / injury Timing of transport should be based on patient's clinical condition and the transport policy. Never hesitate to contact medical control for patient who refuses transport. Blood Pressure is defined as a Systolic / Diastolic reading. palpatedA Systolic reading may be necessary at times. Pediatric Patient General Considerations: Patient Refusal Any patient contact which does not result in an EMS Vital signs should be obtained before, 10 minutes after, and at patient vitalsign acquisitions2 complete shouldoccu Pearls Recommended Exam: Minimal exam location of injury or complaint. Revised 01/01/2017 device. status. elderly. the in serious be very may adult typical the in moderate injury or Minor and utilization: administration Special note on oxygen patient ov and probably care Oxygen is ubiquitous in prehospital side effects. Recent research demonstrates incr a clear link with oxygen when indicated and not Utilize it because is available. Hip fractures and dislocations have high high Hip mortality. have and dislocations fractures Altered mental status is not always dementia. check Always Blood An adult is considered hypotensive when Systolic Blood Pressure is less than 90 mmHg. 90 less than Pressure is Blood Systolic when considered hypotensive is adult An Diabetic and women patients may have of atypical presentations such ascardiac problems related MI. General weakness can be symptom the of Beta blockers and other cardiac drugs may prevent a reflexiv Patient: Geriatric All patient care must be to level appropriate your of training and documented in the PCR. The PCR / EMR be should narrative a story ofconsidered the events circumstances, and care of the a and should patient allow re Scene Safety Evaluation: patient and public. hazards to rescuers, Identify potential START ofIdentify number indicated. protocol if patients and utilize position and surroundings. Observe patient General: complaint, the assessment, treatment,the wh interventions. and to treatment and response Adult Patient: Universal Protocol Section Oct 2017 Locally RevisedLocally IMMEDIATE Secondary Triage Evaluate Infants FIRST FIRST Infants Evaluate Repeating Triage Process Triage Repeating DELAYED IMMEDIATE IMMEDIATE IMMEDIATE YES YES Adult DECEASED UP 2 NO NO Adult Minor Pediatric NO Obeys Commands Obeys NO Appropriate to AVPU Appropriate Ped < 15 or > 45 Follow Adult or Ped Arm Adult > 30 / minute Reposition UpperAirway Cap Refill > 2 Sec (Adult) Results in Spontaneous Breathing No palpable Pulse (Pediatric) YES YES Pulse Pediatric Breathing IMMEDIATE 2 Rescue Breaths This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This YES NO NO Rate YES Status Mental Perfusion Breathing Respiratory Revised Able to Walk 01/01/2017 Ped > 15 or < 45 Ped > 15 Adult < 30 / minute Adult Universal Protocol Section Oct 2017 Locally RevisedLocally ensuring the best possible n be rememberedn be byRPM. iate heart rate may also be also rate may iate heart ts and nature of the incident, of the nature ts and hing over their head. r an individual patient to cer and triage officer if personnel available esignated area and assess third. third. esignated area and assess You may need to move patients to treatment areas. e same complaints consider HazMat, WMC or CO consider HazMat, complaints e same objective criteria which caobjective criteria which in temperature. Age-appropr in temperature. responders. Determine or ensure scene safety before dicate a purposeful movement and assesspurposefulsecond. them movement and dicate a LLOW TAGs. BLACK TAGs should remain in place. administerpatient. an antidote before movingto next UP 2 lling their shirt / clot lling their ave an obvious life threat,obvious first. assessave an incident where resources are limited: treatment process may proceedsimultaneously. Communicate the number of patien the number of Communicate G category, stop, place category,stop, RED TAG and moveG on to next patient. Attempt only to the incident to walk to a d d, give 2 rescuebreaths t number of patients. ed by many factors including sk including ed by many factors is utilized in NC. is utilized in This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This establish command and establish a medicalcommand and establishestablish offi a entering. If there are several patients with th patients with several entering. If there are poisoning. Once casualties are triaged focus on treatment can begin. outcome for the greates cannotFor those who walk, have them wave / in Those involved who are not moving or h Step 2: Individual assessments: hemorrhage Control major airway and if chil Open ProcedurePerform Needle Chest Decompression if indicated. if indicated injector antidotes Administer R: Respiratory P: Perfusion M: Mental Status / treatedRED TAGs are moved first followedYE by You may also indicate deceased patients by pu Step 1: Global sorting: Call out to those involved in 1. Conduct a scene size up. Assure well being of well Assure a scene size up. Conduct 1. Triage decisions mustrapidly be made withinformationto gather less time Emphasis shifts from ensuring the best possibleoutcome fo 2. Take Triage system kit. 3. Determine number of patients. As more help arrivesAs more/ the triage then When approaching a multiple casualty SMART triage tag system SMART Capillary refill can be alter correct airwaycorrectortreat uncontrolled problems, bleeding, If your patient falls into the RED TA Treatment: Assessthefirst patient thethree using you encounter used in triage decisions. Triage is a continual process and should recur in each section as resources allow.in each section as resourcesa continualTriage isshould recur and process Scene Size Up: . Revised 01/01/2017 Pearls Add info about secondary triage after initial treatment – SMART Triage System History Signs and Symptoms Differential Age Pain CNS (increased pressure, headache, stroke, Time of last meal Character of pain (constant, CNS lesions, trauma or hemorrhage, vestibular) Last bowel movement/emesis intermittent, sharp, dull, etc.) Myocardial infarction Improvement or worsening Distention Drugs (NSAID's, antibiotics, narcotics, with food or activity Constipation chemotherapy) Duration of problem Diarrhea GI or Renal disorders Other sick contacts Anorexia Diabetic ketoacidosis Past medical history Radiation OB-Gyn disease (ovarian cyst, PID, Pregnancy) Past surgical history Associated symptoms: Infections (pneumonia, influenza) Medications Fever, headache, blurred vision, Electrolyte abnormalities Menstrual history (pregnancy) weakness, malaise, myalgias, cough, Food or toxin induced Travel history headache, dysuria, mental status Medication or Substance abuse Bloody emesis / diarrhea changes, rash Psychological

Consider Blood Glucose Analysis Procedure B 12 Lead ECG Procedure A IV Procedure P Cardiac Montior Age Appropriate Diabetic Protocol AM 2 / PM 2 if indicated Pain Control Protocol UP 11 if indicated Age Appropriate Cardiac IV / IO Procedure Protocol(s) Consider 2 Large Bore sites if indicated Normal Saline 500 mL Bolus Repeat as needed Serious Signs / Symptoms Titrate SBP ≥ 90 mmHg Hypotension, poor YES A Maximum 2 L perfusion, shock Peds: 20 mL/kg IV / IO Repeat as needed NO Titrate to Age Appropriate Normal Saline IV TKO SBP ≥ 70 + 2 x Age A Or Saline Lock Maximum 60 mL/kg Odansetron 4 mg Odansetron 4 mg IV / IO / ODT / IM IV / IO / ODT / IM P Peds: 0.2 mg/kg PO / ODT Peds: 0.2 mg/kg PO / ODT Peds Maximum 4 mg Peds Maximum 4 mg May repeat in 15 minutes P May repeat in 15 minutes Age Appropriate If no response Hypotension / Shock Promethazine Protocol AM 5 / PM 3 12.5 mg IV/ IO / IM if indicated May repeat x 1 as needed

Monitor and Reassess

Notify Destination or Contact Medical Control

Revised Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Oct 2017 Pearls Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age) mmHg and 11 years and older > 90 mmHg. Abdominal / back pain in women of childbearing age should be treated as pregnancy related until proven otherwise. The diagnosis of abdominal aneurysm should be considered with abdominal pain, with or without back and / or lower extremity pain or diminished pulses, especially in patients over 50 and / or patients with shock/ poor perfusion. Notify receiving facility early with suspected abdominal aneurysm. Consider cardiac etiology in patients > 50, diabetics and / or women especially with upper abdominal complaints. Repeat vital signs after each fluid bolus. Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal. Promethazine (Phenergan) may cause sedative effects in pediatric patients and ages ≥ 60 and the debilitated, etc.) When giving promethazine IV dilute with 10 mL of normal saline and administer slowly as it can also harm the veins. Document the mental status and vital signs prior to administration of Promethazine (Phenergan). Isolated vomiting (especially in children) may be caused by pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures). Vomiting and diarrhea are common symptoms, but can be the symptoms of uncommon and serious pathology such as stroke, carbon monoxide poisoning, acute MI, new onset diabetes, diabetic ketoacidosis (DKA), and organophosphate poisoning. Maintain a high index of suspicion.

Revised Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Oct 2017 Universal Protocol Section Oct 2017 Oct Locally Revised Exit to Exit to Exit to Exit to Exit to Exit to Protocol TE 7 Protocol Age Appopriate Age Age Appropriate Head trauma Head CNS (stroke, tumor, seizure, infection) CHF) Cardiac (MI, Hypothermia Infection (CNS and other) Thyroid (hyper / hypo) Shock (septic, metabolic, traumatic) Diabeteshypoglycemia) (hyper / or Ingestion Toxicological / Alkalosis Acidosis Environmental exposure Pulmonary (Hypoxia) abnormality Electrolyte Psychiatric disorder Fever Protocol UP 10 Seizure Protocol UP 13 Head Injury Protocol TB 5 Hypothermia Protocol TE 5 Overdose / Toxic Exposure Hyperthermia Protocol TE 4 Differential Multiple Trauma ProtocolTB 6 Appropriate Cardiac Protocol(s) Suspected Stroke Protocol UP 14 Protocol Stroke Suspected Suspected Sepsis Protocol UP 15 Protocol Sepsis Suspected Hypotension / Shock Protocol AM 5 / PM 3 UP 4 YES YES YES YES YES YES Notify Destination or Contact Medical Control Contact Medical Change in baseline mental status mental baseline in Change Bizarre behavior diaphoretic (cool, Hypoglycemia skin) Hyperglycemia (warm, dry skin; fruity breath; Kussmaul respirations; signs of dehydration) Irritability Decreased mental status or lethargy status mental Decreased Signs and Symptoms Signs This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO NO NO NO NO IV / IO Procedure if indicated if indicated Fever / Sepsis 12 Lead ECG Procedure Traumatic Injury Age Appropriate Age Protocol(s) AM 2 / PM 2 Arrhythmia / STEMI / CP Signs of CVA Or Seizure Signs of OD / Toxicology Age AppropriateDiabetic Signs of Hypo Hyperthermia / Hypo of Signs Blood GlucoseAnalysis Procedure Signs of shock / Poor perfusion Poor / shock of Signs Changes in feeding or sleep habits Medications History of trauma condition in Change Drugs, drug paraphernalia or use drug illicit of Report toxic ingestion history medical Past Known diabetic, medic alert alert medic diabetic, Known tag Revised Airway Protocol(s) AR 1, 2, 3, 5, 6 01/01/2017 History A B Universal Protocol Section Oct 2017 Oct Locally Revised ack, Extremities, Neuro. on of a patientsunderlyingon of disease. Heart, Lungs, Abdomen, B nd the circumstances should be undertaken. mia if doubt exists. Recheck glucose blood after xin or Haz-Mat exposure - protect personal safety. UP 4 eat challengeeat a differential. in forming mmunicated to the receiving facility. /or personnel's protectionrestraint per the procedure. ion warrants. for signs for signs of bruising or other injury. ondition precipitates a deteriorati the most significant challenges. on if the situat This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This DO NOT assume AMS is the result solely of an underlying psychiatric etiology. trauma c Often an underlying or medial immobilizati spinal Only utilize The behavioralhealth patient maypresent gr a Patients ingesting substancesgreatpose can a challenge. the sole reasonsareor alcoholrecreationalDO NOT assume for AMS. drug use and / may lead to hypoglycemia.alcoholMisuse of underlyingMore serious medical and trauma the cause. conditions may be with increasedmay worsenThe patient with AMS agitation when immobilized. The patient with AMS poses one of A careful assessment of the patient, the scene a Assume the patient has a lifeuntil proven otherwise. threateningtheir AMS cause of Pay careful attention to the head exam Information found at the scene must be co Dextrose or Glucagon Dextrose Consider Restraints if necessaryfor patient'sand It is safer to assume hypoglycemia than hyperglyce Spinal Motion Restriction / Trauma: Behavioral health: Substance misuse: Recommended Exam: Mental Status, HEENT, Skin, to an environmental of sign a AMS may present as General: Revised 01/01/2017 Pearls Universal Protocol Section October 2017 Locally Revised Muscle spasm / strain Herniated disc with nerve compression Sciatica fracture Spine stone Kidney Pyelonephritis Aneurysm Pneumonia Spinal Epidural Abscess Cancer Metastatic AAA Differential 90 ≥ 70 + 2 x Age ≥ If indicated 2 L Maximum2 L Normal Saline if indicated if indicated if indicated if indicated UP 5 Bolus 500 mL IV SBP Titrate to SBP Age Appropriate Age Appropriate Maximum 60 mL/kg Monitor andReassess Titrate age appropriate Peds: 20 mL/kg IV / IO Hypotension / Shock Spinal MotionRestriction Procedure / Protocol TB 8 Protocol(s) AM 5 / PM 3 Notify Destination or Pain Control Protocol UP 11 Multiple Trauma Protocol TB 6 Protocol Trauma Multiple Contact Medical Control Medical Contact Airway Protocol(s) AR 1, 2, 3, 5, 6 A Swelling Pain with range of motion Extremity weakness numbness Extremity Shooting pain into an extremity Bowel / bladder dysfunction Pain (paraspinous, spinous spinous (paraspinous, Pain process) Signs and Symptoms Signs and YES YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO Shock if indicated if indicated Cardiac Monitor Mechanism if indicated Age Appropriate Injury or Traumatic Cardiac Protocol(s) 12 Lead ECG Procedure Procedure ECG Lead 12 Consider Cardiac Etiology Cardiac Consider Improvementor worsening with activity Traumatic mechanism pain of Location Fever Past surgical history surgical Past Medications Onset of pain / injury Previous backinjury Age history medical Past Hemodynamic Instability Hemodynamic Revised 01/01/2017 History P B Universal Protocol Section October 2017 Locally Revised pain with diminished Most often it is a benign process but o, Lower extremity o, perfusion especially in patients over 50 and/or patients50patients over with especially in in and / or lower extremity dicine and effects more than 90 % of adults at some nal or back pain in women of childbearing age. nal or back pain in childbearing of women deformity should be maintained in their functional position. ves of spinal cord are being compressedves of (Symptoms UP 5 ected abdominal aneurysm. etics and / or women especially with upper abdominal ents on chronic steroidsents on chronic prednisone. like nary retention, or bowel incontinence) us, Heart, Lungs, Abdomen, Neur Abdomen, Heart, Lungs, us, so common in the pediatric population. common in so bowel dysfunction. (Urinebowel dysfunction. retention and bowel incontinence) eurysm with abdominal pain pain eurysm with abdominal facility early with susp This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Initial Pain Control is Morphine 2-4 mg up to 10mg then move to Hydromorphone if needed 1-2mg Severe or progressive neurological deficit in the lower extremity. Motor weakness of thigh muscles or foot drop Saddle anesthesia Recent onset of bladder and Fever / chills. IV Drug user (consider spinal epidural abscess) Recent bacterial infection like pneumonia. Immune suppressionpatisuch as HIV or Meningitis. Age > 50 or < 18 Neurologicalweakness, deficituri (leg IV Drug use Fever History of cancer, either current or remote Night time pain in pediatric patients in some circumstances can be life or limb threatening. in some circumstances can Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area. Spinal motion inrestriction patients with underlying spinal Back pain associated with infection: pain associated with Back Cauda equinasyndrome is wherethe terminal ner Cauda include):. point in their life. Back pain is al Consider cardiac etiology in patients > 50, diab patients > in etiology Consider cardiac serious process signal more maywhich associated with back Red Flags pain: Consider pregnancy or ectopic pregnancy with abdomi with pregnancy ectopic or Consider pregnancy an Consider abdominal aortic Back pain is one of the most common complaints in me Recommended Exam: Mental Stat RecommendedMental Exam: complaints. shock/ poor perfusion. Patients have abdominal pa may receivingpulses, . Notify Revised 01/01/2017 Pearls Kidney Stones: Universal Protocol Section Bolus 65 ≥ 500 mL 5 mg IM Age 2.5 mg IM mg 2.5 Procedure as needed as needed See Pearls if indicated 150 –150 / hr mL 200 Maximum 2 L Maximum IV / IO / IM / IN IM / / IO IV / Cardiac Monitor IV / IO Procedure IV Maximum 60 mL/kg Ketamine 400IM mg 1 –/ IN IO IV / mg 2.5 Peds: 0.1 – Peds: mg/kg 0.2 Preferably 2 large bore Then Normal Saline 1 L Bolus 1 L Saline Normal Repeat every 2-3 minutes May repeat External Cooling Measures Consider Restraint Physical toxication Peds: 20 –Peds: 20 IO IV / 60 mL/kg Midazolam 2.5 mg IV / IO / IN IO / 2.5 mg IV Midazolam Monitor per restraint procedure P P A Altered Mental Status differential Alcohol In abuse / Substance Toxin Medication effect / overdose Withdrawal syndromes Depression Bipolar (manic-depressive) Schizophrenia Anxiety disorders Differential 12 65 65 Stage until scene safe scene until Stage ≥ ≥ ≥ IM the NC OEMS Protocol Change Policy and be approved by OEMS be approved and Policy Change Protocol NC OEMS the 5 mg IM Consider Age Age Age 2.5 mg IM mg 2.5 2.5 mg IM mg 2.5 as needed Calladditional for help / resources if indicated UP 6 IV / IO / IM / IN IM / / IO IV / IV / IO Procedure IV Maximum 10 mg Haloperidol 2 - 2 Haloperidol mg 5 1 –/ IN IO IV / mg 2.5 Peds: 0.1 – Peds: mg/kg 0.2 Repeat every 2-3 minutes Monitor and Reassess Restraint Physical Procedure Notify Destination or Notify Destination May repeat every 5 as needed 5 every repeat May Midazolam 2.5 mg IV / IO / IN IO / 2.5 mg IV Midazolam Monitor per restraint procedure Contact Medical Control Medical Contact YES P A Anxiety, agitation, confusion agitation, Anxiety, Affect change, hallucinations Delusional thoughts, bizarre behavior Combative violent Expression of suicidal / homicidal thoughts YES Signs and Signs and Symptoms NCOEMS Ketamine Pilot Project Ketamine NCOEMS entation, hyper- NO NO if available if indicated Abuse Agitation if indicated if indicated if if indicated if If available Destination Mental Health and Any local EMS System changes to this document must follow must follow document this to changes System EMS local Any CIT Paramedic Only Substance Use Protocol Use Substance Aggressive, Violent, Setting of Psychosis Evaluation and Screening and Evaluation Protocol AM 3 / PMProtocol 2 AM 3 / Threat to Self / others / to Self Threat Triage and Alternative Age Appropriate Diabetic Head Trauma Protocol5 TB P Mental Health / Substance Mental Health / Excited Delirium Syndrome Delirium Excited Blood GlucoseAnalysis Procedure Multiple Trauma Protocol TB 6 TB Protocol Trauma Multiple Paranoia, disori increased strength, hyperthermia AlteredMentalStatus Protocol UP 4 Injury to self or threats to others Medictag alert Substanceoverdose abuse / Diabetes Situational crisis illness/medications Psychiatric aggression, hallucination, tachycardia, Overdose / Toxic Ingestion Protocol TE 7 Overdose / Toxic Ingestion Protocol TE Revised 01/01/2017 History Universal Protocol Section ening in in tus. en in male Most commonly se eech disturbances, antipsychotic drugs like hallucinations, sp Diphenhydramine 50 mg IV / IO / IM / PO IM / / IO IV / 50 mg Diphenhydramine theneck face, and upperextremities. May present reaction to an adverse physical restraints and Tasers. physical milar agents. Alcoholwithdrawal or head trauma may also ting, respiratory depression,laryngospasms.or agitation, anxiety, psychosis or a benzodiazepine for patients with presumed with presumed for patients a benzodiazepine or psychosis the NC OEMS Protocol Change Policy and be approved by OEMS be approved and Policy Change Protocol NC OEMS the imuli such assounds,lighting, or activity. raint must be continuously observed by ALS personnel on on by ALS personnel observed must be continuously raint UP 6 12 years old. Safety and efficacy is not established in younger in younger established is not efficacy and Safety old. years 12 ≥ nger fit on a Pediatric Length-based Resuscitation Tape. Resuscitation Length-based Pediatric a on fit nger movements. Typically movements. nts or spasms typically of nts or spasms in pediatrics. NCOEMS Ketamine Pilot Project Ketamine NCOEMS ination of delirium, psychomotor delirium, ination of unk with difficult motor unk with difficult motor ent in pediatric patients patients pediatric in ent ted to: Patients who no lo ted to: gional Specialist. Specialist. gional the patient withpatientthe a prolonged exam. 1 mg/kg IV / IO / IM / PO / / IM IO IV / 1 mg/kg Laryngospasm respondsto BVM. Ketaminecan cause apneageriatric in thepopulation. Ketamine may cause hypotension, hypertension, vomi Treatmentincludes benzodiazepines asMidazolam, such Lorazepam, or Diazepam. May require repeat dosing. Treatmentalso includes decreasing ambient st Any local EMS System changes to this document must follow must follow document this to changes System EMS local Any subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as such drugs stimulant particularly abuse, drug chronic or acute and/or illness mental serious of history a with subjects cocaine, crack cocaine, methamphetamine, amphetamines or si condition. to the contribute Ketamine: Condition causing involuntary muscle moveme disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially life-threat Potentially strength. increased and hyperthermia pain, to insensitivity behavior, / bizarre violent disorientation, and associated with usephysical of control measures, including monitoring. EtCO2 continuous requires administration Ketamine Ketamine Dissociation syndrome: contorted neck and tr with Agencies participating in the NCOEMS Ketamine Project must complete both Ketamine Evaluation Forms and and Forms Evaluation Ketamine both complete must Project Ketamine NCOEMS the in participating Agencies submit to the Re Medical emergency: Comb limi Behavior for Use Haloperidolandoccurmay with your administration. When recognized give adults or Excited Delirium Syndrome: Delirium Excited Do not overlook the possibility of associated domestic violence, child, or geriatric abuse. or geriatric child, violence, domestic of associated possibility the not overlook Do Do not position or transport any restrained patient is such a way that could impact the patients respiratory or circulatory sta ages. patients whoAll receive either physicalchemical or rest arrival. their upon immediately or scene Be sureconsider to all possible medical/trauma causes for behavior (hypoglycemia, overdose,substance abuse, hypoxia,head injury, etc.) Do not irritate If patient is suspected of EDS suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early bicarbonate and sodium bolus a fluid consider arrest, cardiac of EDS suffers suspected is If patient Extrapyramidal reactions: substance abuse. Haldol is acceptable treatm Consider Haldol or Ziprasidone for patients with history of history with for patients Ziprasidone or Haldol Consider Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Lungs, Heart, Skin, Status, Mental Exam: Recommended priority. the main safety is / responders Crew Any patientwho is handcuffed restrained or by Law Enforcement andtransported EMS must by be accompanied by law ambulance. the in enforcement Mayadd page 3 to protocol for specificfor local mental health and/ or substance misuse resources ordestinations. Revised 01/01/2017 Pearls Universal Protocol Section October /2017 Locally Reviewed tapping or touch (or sensitivitytapping to Decay Infection Fracture Avulsion Abscess Facial cellulitis (wisdom) tooth Impacted syndrome TMJ Myocardial infarction Differential tooth avulsions. Reimplantation possible is within 4 Cardiac Monitor Age Appropriate teeth to exert pressure exert to teeth Cardiac Protocol(s) 12 Lead ECG Procedure Pain Protocol UP 11 Protocol Pain Monitor and Reassess Do not rub or scrub tooth UP 7 Place tooth in Milk / Normal Notify Destination or Notify Destination May rinse gross contamination Saline / CommercialPreparation place into socket with patient closing Control Bleeding with Direct Pressure Contact Medical Control Contact Medical Fashion gauze into a small square and al cavity can represent a cellulitis or abscess.oral cavitycellulitis can represent a P B sociated with a tooth which is tender to Pain Fever Swelling Tooth missing or fractured Bleeding Signs and Symptoms Signs and YES YES YES YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO NO NO Exit to Bleeding Protocol(s) Significant Pain Dental Avulsion Age Appropriate Appropriate Age Dental or Jaw Pain Suspicious for Cardiac for Suspicious cold or hot). Occasionally cardiacjaw. to the chest pain can radiate teeth should be as All pain associated with Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs, Neuro Significant soft tissueface or or the swelling to Scene and transport times shouldcompletebe minimized in hoursthe tooth if is properlycared for. Whole vs. partial tooth injury tooth partial vs. Whole Medications Onset of pain / injury Trauma with "knocked out" tooth Location of tooth Age history medical Past Revised 01/01/2017 Pearls History Universal Protocol Section October 2017 Locally Reviewed Fever Hemorrhage Reactions from home nutrient or medication Respiratory distress Shock Differential indwelling catheter. caregiver if it is appropriate to stop or change infusion. Clamp catheter Clamp Continue infusion Continue as indicated Age Appropriate Exit to Stop infusionif ongoing Stop infusionif ongoing Stop infusionif ongoing UP 8 Do not exceedDo 20 mL/kg Protocol(s) Notify Destination or Notify Destination Age Appropriate Contact Medical Control Contact Medical / manipulating an May use hemostat wrapped in gauze Clamp catheter proximal to disruption Apply direct pressure around catheter Apply direct pressure around catheter r and utilizeproperly. if functioning Airway Protocol(s) AR 1, 2, 3, 5, 6 5, 3, 2, AR 1, Protocol(s) Airway Place on left side in head down position stopped for any reason monitor for hypoglycemia. A A A A they have specific knowledge and skills. Complete catheter dislodgement Damaged catheter Bleeding at catheter site Internal bleeding Blood clot embolus Air Erythema, warmth or drainage about catheter site indicating infection External catheter dislodgement Emergencies Involving Involving Emergencies Indwelling Central Lines Central Indwelling Signs and SymptomsSigns and YES YES YES YES YES YES er open if occlusion evident. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This site NO NO NO NO NO NO Chest Pain Ongoing infusion Tunneled Catheter (Broviac / Hickman) Implanted catheter Hickman) / (Mediport PICC (peripherally inserted central catheter partially dislodged partially Circulation Problem Circulation Damage to catheter Suspect Air Embolus Tachypnea, Dyspnea, Dyspnea, Tachypnea, Catheter completely or Hemorrhage atcatheter Hyperalimentation infusionsIf nutrition): (IV Cardiac arrest: May access central cathete to force cathet attempt Do not stop.Ask family or to detrimentalSome infusions may be Always talk to family / caregivers as strict sterile techniqueUse when accessing Revised Complete or partial disruption Occlusion of line Complete or partial dislodge Central Venous Catheter Type 01/01/2017 Pearls History Universal Protocol Section October 2017 Locally Reviewed and ticlopidine(Ticlid) can Trauma Infection(viralSinusitis) URI or Allergic rhinitis ulcers) (polyps, Lesions Hypertension Differential to Nostril th Direct Pressure lequis), heparin, enoxaparin (Lovenox),dabigatran 1 month –month 1 1 year – 1 year < 70 mmHg, 10 years < 70 + pirin/dipyridamole (Aggrenox), If indicated UP 9 Direct Pressure IV / IO Procedure Head Tilt Forward PositionComfort of Age Appropriate Monitor and Reassess if available / indicated Suction Active Bleeding Have Patient Blow Nose AppropriateTrauma Hypotension / Shock Protocol AM 5 / PM 3 Topical Hemostatic Agent Followed by Direct Pressure Notify Destination or Contact Medical Control Contact Medical over the counter headache relief powders. Protocol(s) TB 5 / TB 6 / TB / TB 6 / 8 TB 5 Protocol(s) Oxymetazoline 2 Sprays 2 Oxymetazoline Compress Nostrils wi Compress Nostrils Pain Nausea Vomiting Bleeding from nasal passage A B us, HEENT, Heart, Lungs, Neuro Heart, Lungs, us, HEENT, Signs and Symptoms Signs and YES YES e amount of blood lossamount withepistaxis.e This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO Head Tilt Forward Position of Comfort of Position Active Bleeding Monitor and Reassess System Trauma Significant or Multi- contribute to bleeding. Anticoagulants(EApixaban include warfarin (Coumadin), asagentslike aspirin, clopidogrel (Plavix), Anti-platelet It is very difficult to quantify th alsobe occurringBleedingmay posteriorly. Evaluate forposterior bloodloss by examining the posterior pharnyx. (Pradaxa), rivaroxaban (Xarelto), and many Recommended Exam: Mental Stat RecommendedMental Exam: Age specific hypotension: 0 – < 60 mmHg, 28days Duration of bleeding of Duration Quantity of bleeding Medications (HTN, anticoagulants, aspirin, NSAIDs) Previous episodes of epistaxis Trauma Age history medical Past ( 2 x age)mmHg, 11 years and greater < 90 mmHg. Leave Gauze in place if present Revised 01/01/2017 Pearls History Universal Protocol Section who with found found October 2017 Locally Revised tients in the back of t contact, and strict Exit to Exit to Protocol(s) as indicated Protocol 15 UP Age Appropriate Appropriate Age Suspected Sepsis Arthritis Vasculitis ions. This level of precaution is FLUID Infections / Sepsis Cancer / Tumors / Lymphomas Medication or drug reaction Connective tissue disease Hyperthyroidism Heat Stroke Meningitis Differential oves after every patien YES ADMINISTRATION??? oviders who accompany pa NO Sepsis of a gown, change of gl And / Or surgical mask for pr Indications of UP 10 rborne precautions plus contact precaut rborne precautions (if age > 6 months) > age (if Ibuprofen 10 mg / kg PO Acetaminophen 15 mg / kg PO Adult Ibuprofen 400 – 600 mg PO Flushed Sweaty Chills/Rigors myalgias, cough,chest pain, headache, dysuria, abdominal pain, mental status changes, rash Warm YES Adult Acetaminophen 325 – 1000 mg PO Associated Symptoms (Helpful to localize source) Signs and Symptoms Signs and B 15 years. years. 15 ≤ ≥ Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro if available If indicated include standard PPE plus ai IV / IO Procedure IV (38° C) include standard PPE plus utilizationplusinclude standard PPE 100.4° F include standard PPE plus a standard This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Temperature Temperature Temperature Measurement Procedure Measurement Temperature Contact, Droplet, and Airborne Precautions NO Exit to give aspirin to a child, age Protocol(s) as indicated as B A Age Appropriate have renal disease or renal transplant. Agency Medical Director may require contact of medical control prior to EMT / EMR administering any medication. Allergies to NSAIDs (non-steroidal anti-inflammatory medications) are a contraindication to Ibuprofen. Do not give to patients NSAIDs should not be used in the setting of environmental heat emergencies. Do not Rehydration with fluids increases the patient’s ability to sweat and improves heat loss. All patients should have drug allergies documented prior to administering pain medications. All-hazards precautions All-hazards precautions Airborne precautions Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. Patients with a history of liver failure should not receive acetaminophen. Droplet precautions Recommended Exam: Mental the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient a potentially infectious rash should be treated with droplet precautions. hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected. Environmental exposure Last acetaminophen or ibuprofen Severity of fever history medical Past Medications Immunocompromised (transplant, HIV, diabetes,cancer) Age Duration of fever utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is to be highly contagious (e.g. SARS). Revised 01/01/2017 Pearls History NCOEMS Ketamine Pilot Project 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

Ibuprofen 10 mg/kg PO IV / IO Procedure Universal Protocol Section (400 – 600 mg typical adult) Ketorolac 30 mg IV / IO Maximum 800 mg A 60 mg IM Or Maximum 60 mg Acetaminophen 15 mg/kg B Peds: 0.5 mg/kg IV / IO / IM (325 – 1000 mg typical adult) Maximum 30 mg Maximum 1000 mg Cardiac Monitor Or Aspirin 324 to 650 mg PO Nitrous Oxide 50:50 Mix (≥ 16 only) if available Consider IV Procedure A if indicated Fentanyl 50 – 75 mcg IV / IO Repeat 25 mcg every 20 minutes Maximum 200 mcg Peds: 1 mcg/kg IV / IO / IM / IN May repeat 0.5 mg/kg every 5 minutes Maximum 2 mcg/kg P Or Morphine 4 mg IV / IO / IM Repeat 2 mg every 5 minutes as needed Peds: 0.1 mg/kg IV / IO / IM May repeat every 5 minutes Maximum 10 mg Ketamine 0.2 mg/kg IV / IO Maximum 20 mg Mix in 50 - 250 mL NS and Infuse over 10 minutes May repeat in 30 minutes as needed

Monitor and Reassess Every 10 minutes following sedative

Notify Destination or Contact Medical Control

Revised UP 11 01/01/2017 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NCOEMS Ketamine Pilot Project Universal Protocol Section Universal

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. Pediatrics: For children use Wong-Baker faces scale or the FLACC score (see Assessment Pain Procedure) Use Numeric (> 9 yrs), Wong-Baker faces (4-16yrs) or FLACC scale (0-7 yrs) as needed to assess pain 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 titrate adequate pain control. Consider agency-specific anti-emetic(s) for nausea and/or vomiting. Ketamine: Agencies participating in the NCOEMS Ketamine Project must complete both Ketamine Evaluation Forms and submit to the Regional Specialist. Use for pain limited to: Patients who no longer fit on a Pediatric Length-based Resuscitation Tape to ≤ 65 years of age. Must administer by IV / IO infusion over 10 minutes. Recommended volumes are 50 – 250 mL. Ketamine Dissociation syndrome: With rapid push or rapid infusion side effects such as hallucinations or agitation could occur. Doses ≥ 0.2 mg/kg may also cause similar symptoms. Symptoms may occur even with slow infusion. Treatment includes benzodiazepines such as Midazolam, Lorazepam, or Diazepam. May require repeat dosing. Treatment also includes decreasing ambient stimuli such as sounds, lighting, or activity. Ketamine can cause apnea in the geriatric population. While uncommon, Ketamine may cause hypotension. Revised UP 11 01/01/2017 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Universal Protocol Section October 2017 Locally Revised Agitated Delirium Secondary to Psychiatric Illness Agitated Delirium Secondary to Abuse Substance Traumatic Injury Closed HeadInjury Exacerbation Asthma Cardiac Dysrhythmia as indicated Exit to if indicated Differential Removal Procedure Utilize Protocol(s) AR 4, 7 4, AR Protocol(s) Protocol(s) Wound Care-Taser Probe Probe Care-Taser Wound Wound Care Procedure(s) as indicated Age Appropriate Behavioral Protocol UP 6 Irrigatecopiously face and eyes Remove contaminatedclothing Age Appropriate Respiratory Distress YES YES YES YES UP 12 Notify Destination or Contact Medical Control Contact Medical Palpitations Shortness of breath Wheezing Altered Mental Status Intoxication/Substance Abuse External signs of trauma Signs and Symptoms Signs and NO NO Use of Use of Chemical Spray Spray Chemical Medical Illness? This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Excited Delerium Syndrome Conducted Electrical Weapon Evidence of Traumatic Injury or Injury Traumatic of Evidence Cardiac History Asthma of History History Psychiatric Traumatic Injury Drug Abuse Revised 01/01/2017 History Patient’s should not be hand cuffed to the stretcher.

Patients should not be restrained in the prone position. Section Universal Protocol

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. All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. 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 with decision-making capacity in police custody retain the right to participate in decision making regarding their care and may request care or refuse 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. Haldol is acceptable treatment in pediatric patients ≥ 12 years old. Safety and efficacy is not established in younger ages. 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 suspected of EDS 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. Patients exposed to chemical spray, with or without history of respiratory disease, may develop respiratory complaints up to 20 minutes post exposure.

Revised UP 12 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director October 2017 Universal Protocol Section CNS (Head) trauma Tumor Metabolic, Hepatic, or Renal failure Hypoxia Electrolyte abnormality (Na, Mg) Ca, Medications, Drugs, Non-compliance Infection / Fever Alcohol withdrawal Eclampsia Stroke Hyperthermia Hypoglycemia Differential needed needed **OR** mg dose) controlled. if indicated IV / IO / IM / IN as indicated Age Appropriate Maxiumum 10 mg 5 mg IM or 2 mg IN 2 mg or IM mg 5 Monitor and Reassess Peds: 0.1 – mg/kg 0.2 UP 13 Childbirth Protocol AO 3 Notify Destination or Notify Destination Lorazepam 2 – 2 Lorazepam IV/IM mg 4 Contact Medical Control Contact Medical Midazolam 2 –Midazolam IO / IV mg 2.5 May repeat every 5 to 10 minutes repeatMayto 10 every 5 Airway Protocol(s) AR 1, 2, 3, 5, 6 6 5, 3, 2, AR 1, Protocol(s) Airway May repeat every 3 to 5 minutes as minutes repeatMayto 5 every 3 May repeat every 3 to 5 minutes as repeatMayto 5 every 3 (Maximum of 3 doses) if seizures(Maximum of not Peds: –0.05 Peds: (max 2 IV/IM mg/kg 0.1 Obstetrical Emergency Protocol AO 1 P Sleepiness Incontinence activity seizure Observed trauma of Evidence Unconscious Decreased mental status mental Decreased Signs and Symptoms Signs and YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO if indicated if indicated Protect patient Cardiac Monitor if indicated if indicated IV / IO Procedure IV Protocol UP 4 Altered Mental Status Active Seizure Activity Behavioral Protocol UP 6 Protocol Behavioral Loosen any constrictive clothing Document number of seizures Alcohol use, abuse or abrupt cessation Fever History of diabetes History of pregnancy Time of seizure onset Previous seizure history Medical alert tag information Seizure medications History of trauma Reported / witnessed seizure seizure / witnessed Reported activity Revised Blood GlucoseAnalysis Procedure 01/01/2017 History P A Universal Protocol Section Protocol Universal

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 Adult: 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. Pediatrics: Midazolam 0.2 mg/kg (Maximum 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 affect only a part of the body and are not usually associated with a loss of consciousness, but can propagate to generalized seizures with loss of consciousness. Be prepared for airway problems and continued seizures. Assess possibility of occult trauma and substance abuse. In an infant, a seizure may be the only evidence of a closed head injury. 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. UP 13 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Universal Protocol Section October 2017 Locally ReviewedLocally 10 Minutes ≤ Hypertension STROKE STROKE Concerning Treatment of Contact Receiving Facility Facility Receiving Contact Transport based on: Thrombotic or Embolic (~85%) Hemorrhagic (~15%) See Altered MentalStatus TIA (Transient ischemic attack) Seizure Todd’s Paralysis Hypoglycemia Stroke Tumor Trauma Dialysis / Renal Failure EMS Triage and Destination Plan Immediate Notification of Facility Keep Scene Time to Time Scene Keep Differential YES YES 120 220 UP 14 ≥ ≥ NO Procedure Procedure Procedure if applicable SBP DBP Cardiac Monitor < 12 Hours if indicated if indicated if indicated if indicated IV / IO Procedure PreferablySites 2 Protocol UP 4 after 3 readingsafter 3 Age Appropriate Reperfusion Checklist Time of Onset Or Cardiac Protocol(s) Blood Glucose Analysis Analysis Glucose Blood 12 Lead ECG Procedure Altered Mental Status Venous Access Blood Draw at least 5 minutes apart Weakness / Paralysis Weakness Blindness orother sensory loss Dysarthria / Aphasia Syncope Dizziness / Vertigo Vomiting Headache Seizures Respiratory pattern change hypotension / Hypertension Altered mental status Seizure Protocol UP 13 Notify Destination or Time Last Seen Normal Seen Last Time Head Trauma Protocol TB 5 Contact Medical Control Contact Medical Multiple Trauma Protocol TB 6 Signs and Symptoms Signs and P B A YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO Exit to Stroke Protocol(s) Appropriate as indicated Prehospital Stroke Screen Congenital heart defects heart Congenital Maternal infection / hypertension History of trauma Sickle Cell Disease Immune disorders Associated diseases: diabetes, hypertension, CAD Atrial fibrillation Medications (blood thinners) Previous CVA, TIA'sPrevious CVA, surgery / vascular cardiac Previous Consistent with Acute Revised 01/01/2017 History Universal Protocol Section Protocol Universal

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 or symptom free. You are often in the best position to determine the actual Time of Onset while you have family, friends or caretakers available. Often these sources of information may arrive well after you have delivered the patient to the hospital. Delays in decisions due to lack of information may prevent an eligible patient from receiving thrombolytics. The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 12 , scene times should be limited to ≤ 10 minutes, early notification / activation of receiving facility should be performed and transport times should be minimized. If possible place 2 IV sites. Blood Draw: Many systems utilize EMS venous blood samples. Follow your local policy and procedures. 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. Pediatrics: Strokes do occur in children, they are slightly more common in ages < 2, in boys, and in African-Americans. Newborn and infant symptoms consist of seizures, extreme sleepiness, and using only one side of the body. Children and teenagers symptoms may consist of severe headaches, vomiting, sleepiness, dizziness, and/or loss of balance or coordination.

Revised UP 14 Locally Reviewed 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director October 2017 History Signs and Symptoms Differential Duration and severity of fever Warm Infections: UTI, Pneumonia, skin/ Past medical history Flushed wound Medications / Recent antibiotics Sweaty Cancer / Tumors / Lymphomas Immunocompromised (transplant, Chills / Rigors Medication or drug reaction HIV, diabetes, cancer) Delayed cap refill Connective tissue disease: Arthritis, Indwelling medical device Mental status changes Vasculitis Last acetaminophen or ibuprofen Associated Symptoms Hyperthyroidism Recent Hospital / healthcare facility (Helpful to localize source) Heat Stroke Bedridden or immobile myalgias, cough, chest pain, Meningitis Elderly and very young – at risk headache, dysuria, abdominal pain, Hypoglycemia/hypothermia Prosthetic device / indwelling device rash MI / CVA

Consider: Contact, Droplet, and Airborne Precautions Temperature Measurement Procedure if available Fever / Infection Control Protocol UP 10 if needed Altered Mental Status Protocol UP 4 if needed B 12 Lead ECG Procedure IV / IO Procedure A If indicated P Cardiac Monitor

Exit to SEPSIS ALERT Sepsis Screen Age Appropriate NO YES Notify Receiving Facility Positive Section Protocol Universal Condition Appropriate Immediately Protocol(s) Venous Access Blood Draw if applicable Adult SIRS Criteria Normal Saline 500 mL Bolus Temperature Repeat as needed ≥ 100.4° F (38° C) Titrate SPB ≥ 90 mmHg Or MAP > 65 mmHg MAP ≤ 96.8° F (36° C) A Maximum 2 L AND (Mean Arterial Pressure) Any 1 of the following: HR > 90 Peds: 20 mL/kg IV / IO SBP + 2(DBP) RR > 20 Repeat to titrate EtCO < 25 mmHg Age Appropriate 3 SBP ≥ 70 + 2 x Age Monitor usually calculates this Adult qSOFA Criteria Maximum 60 mL/kg value on screen SBP ≤ 100 mmHG RR ≥ 22 AMS or new mental status change

Pediatrics SIRS Criteria This Space Left Blank P Temperature Intentionally Same as adult

AND Heart Rate Age Appropriate 1 month – 1 year > 180 2 – 5 years > 140 Hypotension / Shock 6 – 12 years > 130 Protocol AM 5 / PM 3 13 – 18 years > 120

Notify Destination or Contact Medical Control

Revised UP 15 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director October 2017 Abdominal pain is not a typical presentation of sepsis, but some patients do have nausea and vomiting.

Septic shock is the result of a massive systemic inflammatory response to infection by gram-negative or gram-positive aerobes, Section Universal Protocol anaerobes, fungi, or viruses. Gram-negative organisms appear to be the primary cause of sepsis, especially hospitalized patients. More patients are remaining at home and have medical devices inserted, making the patients prone to infection. Many of these patients have compromised immune systems, putting them at even greater risk for sepsis.

The basis of septic shock and systemic inflammatory response syndrome (SIRS) is a complex process of inflammatory response and multisystem organ failure. Two or more of the following criteria must be met for a diagnosis of SIRS: - Temp. >100F (38C) or <97F (36C) - Pulse rate > 90 beats/min - Resp. rate >20 bpm or PaCO2 <32 mmHg - WBC >12,000/mm3, <4,000/mm3, or >10% band neutrophilia

The Robson Prehospital Severe Sepsis Screening tool has a 75% success rate in identifying sepsis. It is key that prehospital providers relay the potential for sepsis to hospital personnel. - Temp. >100.9F (38.3C) or <96.8F (36.0C) - Pulse rate > 90 bpm - Resp. rate > 20 bpm - Acutely altered mental status - FSBS > 119 mg/dL – unless diabetic If these findings are present in a patient with a history that is suggestive of infection, sepsis should be considered. Pearls Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Recommended Exam Pediatrics: In childhood, physical assessment reveals important clues for sepsis. Look for mental status abnormalities such as anxiety, restlessness, agitation, irritability, confusion, or lethargy. Cardiovascular findings to look for include cool extremities, capillary refill >3 seconds, or mottled skin. Sepsis is a life threatening condition where the body’s immune response to infection injures its own tissues and organs. Severe sepsis is a suspected infection and 2 or more SIRS criteria (or qSOFA) with organ dysfunction such as AMS or hypotension. Septic shock is severe sepsis and poor perfusion unimproved after fluid bolus. Agencies administering antibiotics should inquire about drug allergies specific to antibiotics or family of antibiotics. Following each fluid bolus, assess for pulmonary edema. Consider administration of agency specific vasopressor. Supplemental oxygen should be given and titrated to oxygenation saturation ≥ 94%. EKG should be obtained with suspected sepsis, but should not delay care in order to obtain. Abnormally low temperatures increase mortality and found often in geriatric patients. Quantitative waveform capnography can be a reliable surrogate for lactate monitoring in detecting metabolic distress in sepsis patients. EtCO2 < 25 mm Hg are associated with serum lactate levels > 4 mmol/L. Patients with a history of liver failure should not receive acetaminophen. Droplet precautions: Include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions. Airborne precautions: Include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected. All-hazards precautions: Include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is found to be highly contagious (e.g. SARS). Allergies to NSAIDs (non-steroidal anti-inflammatory medications) are a contraindication to Ibuprofen. Agency Medical Director may require contact of medical control prior to EMT / MR administering any medication. Sepsis Screen: Agencies may use Adult / Pediatric Systemic Inflammatory Response Syndrome (SIRS) criteria or quickSOFA (qSOFA) criteria. Robson Prehospital Severe Sepsis Screening Tool Receiving facility should be involved in determining Sepsis Screen utilized by EMS.

Revised UP 15 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director October 2017 Universal Protocol Section October 2017 Locally ReviewedLocally 90 mmHg Vasovagal Orthostatic hypotension Cardiac syncope Micturition / Defecation syncope Psychiatric Stroke Hypoglycemia Seizure Shock (see Shock Protocol) Toxicological (Alcohol) Medication effect(hypertension) PE AAA ≥ 70 + 2 x Age + 2 70 Differential ≥ Exit to Maximum 2 L Protocol(s) IV / IO Procedure Repeat as needed Repeat as needed SBP Maximum 60 mL/kg 60 Maximum Age Appropriate Peds: 20 mL/kg IV / IO Titrate SPB Titrate to Age Appropriate Condition Appropriate Appropriate Condition Consider 2 Large Bore sites Normal Saline 500 mL Bolus A UP 16 YES gularity Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irre Decreased blood pressure Loss of consciousness with recovery with consciousness of Loss Signs and Symptoms Signs and NO Protocol(s) Cardiac Monitor if indicated if indicated if indicated if indicated if indicated IV / IO Procedure Protocol UP 4 Protocol Age Appropriate Age Appropriate perfusion, shock Hypotension, poor 12 LeadProcedure ECG Hypotension / Shock Protocol AM 5 / PM 3 Altered MentalStatus Notify Destination or Age Appropriate Cardiac This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Spinal Motion Restriction Restriction Motion Spinal Procedure/ Protocol TB 8 Serious Signs / Symptoms Contact Medical Control Medical Contact Blood Glucose Analysis Procedure Multiple Trauma Protocol TB 6 Airway Protocol(s) AR 1, 2, 3, 5, 6 I P B Medications Females: LMP, vaginal bleeding vaginal LMP, Females: Fluid loss: nausea, vomiting, diarrhea history medical Past Cardiac history,stroke, seizure Occult blood loss (GI, ectopic) Revised 01/01/2017 History Universal Protocol Section Protocol Universal

Pearls Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro Syncope is both loss of consciousness and loss of postural tone. Symptoms preceding the event are important in determining etiology. Syncope often is due to a benign process but can be an indication of serious underlying disease in both the adult and pediatric patient. Often patients with syncope are found normal on EMS evaluation. In general patients experiencing syncope require cardiac monitoring and emergency department evaluation. Differential should remain wide and include: Cardiac arrhythmia Neurological problem Choking Pulmonary embolism Hemorrhage Stroke Respiratory Hypo or Hyperglycemia GI Hemorrhage Seizure Sepsis High-risk patients: Age ≥ 60 Syncope with exertion History of CHF Syncope with chest pain Abnormal ECG Syncope with dyspnea Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age) mmHg and 11 years and older > 90 mmHg. Abdominal / back pain in women of childbearing age should be treated as pregnancy related until proven otherwise. The diagnosis of abdominal aneurysm should be considered with abdominal pain, with or without back and / or lower extremity pain or diminished pulses, especially in patients over 50 and / or patients with shock/ poor perfusion. Notify receiving facility early with suspected abdominal aneurysm. Consider cardiac etiology in patients > 50, diabetics and / or women especially with upper abdominal complaints. Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal. Syncope with no preceding symptoms or event may be associated with arrhythmia. 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. Patients who experience syncope associated with headache, neck pain, chest pain, abdominal pain, back pain, dyspnea, or dyspnea on exertion need prompt medical evaluation. More than 25% of geriatric syncope is cardiac dysrhythmia based. Revised UP 16 Locally Reviewed 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director October 2017 Adult Cardiac Protocol Section 12/01/2017 Locally Revised life Policy Follow asystole Rigor mortis resuscitation Do notbegin Decomposition Dependent lividity Blunt force trauma Deceased Subjects Reversible Causes Injury incompatible with Extended downtime with Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypothermia / Hyperkalemia Hypo Tension pneumothorax Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) YES See Reversible Causes below Causes See Reversible Differential 10 seconds) ≤ 2 inches) ≥ on if no Advanced Airway AC 1 AC NO if available if available IV / IO Procedure MaximumL 2 Monitor EtCO2 Cardiac Monitor AED Procedure as indicated as indicated (sooner if fatigued) Protocol(s)12 AC May repeatneeded as Push Hard ( Push Hard Repeat every 3 to 5 minutes Push Fast (100 - 120 / min) Notify Destination or Notify Destination Searchfor Reversible Causes Apneic No electrical on activity ECG auscultation on tones heart No Pulseless Review DNR / MOST Form Review DNR / MOST Contact Medical Contact Control Cardiac Arrest AC Protocol 3 This area intentionallyThis area left blank Available for Agency Medications Epinephrine (1:10,000) 1 mg IV / IO Ventilate 1 breath every 6 seconds Ventilate 1 breath every Normal Saline Bolus 500 mL IV / IO Signs and Symptoms Signs and Begin Continuous CPR Compressions Change Compressors every 2 minutes 2 every Change Compressors Adult Rhythm Appropriate Protocol(s) Appropriate Rhythm Adult Consider Chest Decompression Procedure Decompression Chest Consider Criteria for Death / No Resuscitation (Limit changes / pulse checks 30:2 Compression:Ventilati On Scene Resuscitation / Termination of Resuscitation I P P A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Adult Asystole / Pulseless Electrical Activity Electrical Pulseless / Asystole Adult Go to Return of Circulation Spontaneous Protocol AC 9 Protocol See Reversible Causes below Will DNR, MOST, or Living SAMPLE Estimated downtime Revised 01/01/2017 AT ANY TIME Post Resuscitation History Adult Asystole / Pulseless Electrical Activity Adult Cardiac Protocol Section

Pearls Team Focused Approach / Pit-Crew Approach recommended; assigning responders to predetermined tasks. Refer to optional protocol or development of local agency protocol. Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT), compression to ventilation ratio is 30:2. If advanced airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions. Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. Passive oxygenation optional in agencies practicing Team Focused Approach / Pit-Crew Approach. Reassess and document BIAD and / or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation. Defibrillation: Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. End Tidal CO2 (EtCO2) If EtCO2 is < 10 mmHg, improve chest compressions. If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC) Special Considerations Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport preferably to obstetrical center if available and proximate. Place mother supine and perform Manual Left Uterine Displacement moving uterus to the patient’s left side. IV/IO access preferably above diaphragm. Defibrillation is safe at all energy levels. Renal Dialysis / Renal Failure - Refer to Dialysis / Renal Failure protocol caveats when faced with dialysis / renal failure patient experiencing cardiac arrest. Opioid Overdose - Naloxone 2 mg IM / IV / IO / IN. EMT may administer Naloxone via IN route only. May give from EMS supply. Drowning / Suffocation / Asphyxiation / Hanging / Lightening Strike – Hypoxic associated cardiac arrest and prompt attention to airway and ventilation is priority followed by high-quality and continuous chest compressions and early defibrillation. Transcutaneous Pacing: Pacing is NOT effective in cardiac arrest and pacing in cardiac arrest does NOT increase chance of survival Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options.

Revised AC 1 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Adult Cardiac Protocol Section 11/08/2017 Locally Revised Fentanyl 75-150mcg IV / IO / IM / IN / / IO / IM IV Maximum 10 mg 10 Maximum Consider Sedation Consider Maximum 500mcg Reversible Causes Consider Pain Control Pain Consider Midazolam 2 – 2 Midazolam mg 2.5 Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypothermia / Hyperkalemia Hypo Tension pneumothorax Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) P Acute myocardial infarction Hypoxia / Hypothermia Pacemaker failure Sinus bradycardia Head injury (elevated ICP) or Stroke Spinallesion cord Sick sinus syndrome AV blocks (1°, 2°, or 3°) Overdose Differential AVB) rd or 3 or nd 90 mmHg 90 mmHg ≥ ≥ Or AC 2 AC YES MaximumL 2 Cardiac Monitor Maximum 3 mg if indicated if indicated if indicated IV / IO Procedure Protocol AC 4 Protocol Protocol AR 4 Protocol If No Improvement (Unless Acute CHF) 12 Lead ECG Procedure Lead 12 Atropine 0.5 mg IV / IO 500 mL – 2 L NS IV / IO Respiratory Distress Distress Respiratory Titrate to SBP Titrate to SBP Typically HR < 50 / min Typically HR < 50 / Normal Saline Fluid Bolus Normal Notify Destination or Notify Destination secondary to bradycardia Searchfor Reversible Causes Chest pain distress Respiratory Hypotension or Shock Altered mental status Syncope HR < 60/minHR < with hypotension, acute altered mental status, chest pain, acute CHF, seizures, syncope, or bradycardia to secondary shock May repeat– every3 minutes 5 Contact Medical Contact Control Airway Protocol(s) AR 1, 2, 3 This area intentionallyThis area left blank (Consider earlier in 2 Transcutaneous Pacing Procedure Epinephrine 1 - 10 mcg/min IV / IO Chest Pain: Cardiac and STEMI Dopamine 2 – 20 mcg/kg/min IV / IO Signs and Symptoms Signs and Acute CHF, Seizures, Syncope, or Shock Heart Rate < 60 / min and Symptomatic: Hypotension, Acute AMS, Ischemic Chest Pain, P P B A A NO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Exit to Clonidine Digoxin Beta-Blockers Calciumchannel blockers Protocol(s) Appropriate Appropriate Pacemaker Past medical history medical Past Medications Revised 06/08/2017 History Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount. Rhythm should be interpreted in the context of symptoms and pharmacological treatment given only when symptomatic, otherwise monitor and reassess. Consider hyperkalemia with wide complex, bizarre appearance of QRS complex, and bradycardia. Hypoxemia is a common cause of bradycardia. Ensure oxygenation and support respiratory effort. Atropine Do NOT delay Transcutaneous Pacing to administer Atropine in bradycardia with poor perfusion. Caution in setting of acute MI. Elevated heart rate can worsen ischemia. Ineffective and potentially harmful in cardiac transplantation. May cause paradoxical bradycardia. Transcutaneous Pacing Procedure (TCP) Utilize TCP early if no response to atropine. If time allows transport to specialty center because transcutaneous pacing is a temporizing measure. Transvenous / permanent pacemaker will probably be needed. Immediate TCP with high-degree AV block (2d or 3d degree) with no IV / IO access. Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.)

Revised AC 2 06/08/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Adult Cardiac Protocol Section Locally Revised 11/1/2017 life Policy YES Follow Airway Airway asystole VF / VT Rigor mortis resuscitation Do notbegin Tachycardia as indicated Decomposition Protocol AC 8 Protocol Protocol AC 6, 7 Dependent lividity Blunt force trauma Deceased Subjects Protocol(s) AR 1, 2, 3 Injury incompatible with Extended downtime with YES Cardiac Monitor Shockable Rhythm Shockable YES NO 10 seconds) Airway P ≤ as indicated Protocol AC 1 Asystole / PEA Protocol(s) AR 1, 2, 3 2, AR 1, Protocol(s) 2 inches) ≥ on if no Advanced Airway AC 3 AC NO if available Monitor EtCO2 as indicated (sooner if fatigued) (sooner if ALS Available Protocol AC 12 Push Hard ( Push Hard Push Fast (100 - 120 / min) Termination on Scene on Termination Notify Destination or Review DNR / MOST Form / MOST Review DNR Contact Medical Control Contact Medical Ventilate 1 breath every 6 seconds every 1 breath Ventilate Begin Continuous CPR Compressions Change Compressors every 2 minutes 2 every Change Compressors Criteria for DeathNo / Resuscitation YES NO (Limit changes / pulse checks checks pulse / changes (Limit AED Procedure 30:2 Compression:Ventilati 2 Minutes Airway This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This if available Continue CPR AED Procedure AED Procedure Shockable Rhythm Shockable Repeat and reassess Protocol(s) AR 1, 2, 3 2, AR 1, Protocol(s) NO Go to Return of Circulation Revised Spontaneous Protocol AC 9 01/01/2017 AT ANYTIME Post Resuscitation Adult Cardiac Protocol Section . nosis and identifying possiblenosis and identifying ventilation ratio is 30:2. If – Hypoxic associated cardiac arrest de. IV/IO accesspreferablyde. IV/IO above ocol caveats whenocol caveatswith dialysis / faced ociated cardiac arrest. If suspected, AD first to limit interruptions. acement and EtCO2 frequently, after every move, and ease in importance.easenotNaloxone associated is with us compressions with limited interruptions and early and interruptionsus compressions with limited iority followed by high-quality and continuousiority chest ailable and proximate. Place mother supine and performandPlace mother supineailable and proximate. quality chest compressions and early defibrillation developing a differential diag developing a differential AC 3 AC der Return of Spontaneous Circulation (ROSC) airway (BIAD, ETT) compression to airway (BIAD, ng uterus to the patient’s left sithe patient’s left ng uterus to - Refer to Dialysis / Renal Failure prot 10 breaths per minute with continuous, uninterrupted compressions.per minute withuninterrupted 10 breaths continuous, encies practicing Team FocusedApproach Approach.Team / Pit-Crewencies practicing evelopment of local agency protocol. - Naloxone cannotopioid-ass in be recommended -Controlto Medical and mother per appropriateimmediate notification Treat protocol with This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This en indicated. indicated. en Follow manufacture's recommendations concerning defibrillation / cardioversionenergy when Pacing is NOT effectivecardiacarrestpacingandin cardiac arrest in NOT increase does of chance survival Maternal Arrest rapid transport preferably to obstetrical center if av If EtCO2 is < 10mmHg,< improveIf EtCO2 is chest compressions. If EtCO2 spikes,consi typically > 40 mmHg, Manual Left Uterinemovi Displacement improved outcomes in cardiac arrest. Strike / Lightning Hanging / / Asphyxiation Suffocation / Drowning attention to airway, oxygenation, and ventilation incr and prompt attention to airway and ventilation is pr compressions and early defibrillation. diaphragm. Defibrillationlevels.all energysafe is at Renal Dialysis / Renal Failure renalfailure patient experiencing cardiacarrest. Overdose Opioid Success is basedon properplanningandexecution. Procedures requirespace and patient access. Make room to work. valuableMedicalDiscussion tool be a Control can with in Transcutaneous Pacing: advanced airway in place, ventilate advanced airway in place, ventilate at transfer care. of Considerations Special treatment options. Defibrillation: specified. CO2 (EtCO2) Tidal End Reassesstube pl BIAD and / or endotracheal and document high- secondarydrug delivery is to and IV / IO access place endotracheal place to tube. ConsiderDo not BI interrupt compressions optionaloxygenation in ag Passive Efforts should be directed at high quality and continuo DO NOT HYPERVENTILATE: no advanced If ended; assign responders to predetermined tasks.Team Focused predetermined Approach / Pit-Crew Approachended; assign responders to recomm to optional protocol or d Refer defibrillation wh defibrillation Revised 01/01/2017 Pearls Adult Cardiac Protocol Section 11/01/2017 Locally Revised TraumaMedical vs. Angina vs. Myocardial infarction Pericarditis Pulmonary embolism Asthma / COPD Pneumothorax or aneurysm dissection Aortic hernia or Hiatal GE reflux Esophageal spasm Chest wallinjury or pain Pleural pain Overdose: Cocaine or Methamphetamine Differential 10 Minutes ≤ Plavix Heparin STEMI Thrombolytic if capable Reperfusion Checklist Transport based on: Agency Specific Medications AC 4 AC If transporting to Non PCI Center Immediate Transmission of ECG EMS Triage and Destination Plan Immediate Notification of Facility Keep Scene Time to P B More likely to have dyspnea, N/V, weakness, back or jaw pain Notify Destination or CP (pain, pressure, aching, vice-like tightness) Location (substernal, epigastric, arm, jaw, neck, shoulder) Radiation of pain diaphoresis Pale, breath of Shortness Nausea, vomiting, dizziness Time of Onset Women: Contact Medical Control Contact Medical YES Signs and Symptoms Signs and eferred This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 100) R ≥ Or needed NO 325 mg PO 2 Contiguous Leads) Or Provocation and (BP adiation / Cardiac Monitor if indicated if indicated Maximum 10 mg ≥ Protocol AC 5 Protocol Protocol AM 5 AM Protocol R Maximum 200 mcg Nitroglycerin Paste Acute MI / STEMI if prescribed to patient Hypotension / Shock Shock / Hypotension 12 Lead ProcedureECG Morphine 2 – 4 mg IV / IO Repeat every 5 minutes x 3 x 5 minutes every Repeat IV / IO / Blood Draw Procedure CHF / Pulmonary Edema Edema Pulmonary / CHF Fentanyl 50 – 75 mcg IV / IO Nitroglycerin 0.3 / 0.4 mg SL mg / 0.4 0.3 Nitroglycerin Aspirin 81 mg x 4 PO (chewed) uality (crampy, constant, sharp, egion / (STEMI = 1 mm ST Segment ime (onset /duration / repetition) Repeat every minutes 5 as needed Repeat every 5 minutes as needed Repeat 25 mcg every 20 minutes as as minutes 20 every mcg 25 Repeat dull, etc.) R Severity (1-10) T Recent physical exertion Palliation / Q Past medical history (MI, Angina, Angina, (MI, history medical Past Diabetes, post menopausal) Allergies Age Medications (Viagra / sildenafil, Levitra / vardenafil, Cialis / tadalafil) Revised Nitroglycerin 0.3 / 0.4 mg Sublingual mg 0.4 / 0.3 Nitroglycerin Elevation Elevation 01/01/2017 History P P A A B Adult Cardiac Protocol Section d n show nting with with nting 11/01/2017 Locally Revised normal saline boluses. prior MI, PCI/CABG, CVA/TIA, May give from EMS supply. potential severe hypotension. ck, Extremities, Neuro (Morphine, Fentanyl, or Dilaudid). or only generalized complaints. y of the medication. ); atherosclerotic disease; d to the appropriate facility based on STEMI EMS III, aVF), consider Right Sided ECG (V3 or V4). If ST ST If V4). (V3 or ECG Sided Right consider aVF), III, CI centers use the right radial vein forvein intervention.CI the right radial centers use s for the EMS Acute Cardiac (STEMI) Care Toolkit (STEMI) the EMS Acute Cardiac s for in the past 36 hours due to past in the cause hypotension requiring Lung, Heart, Abdomen, Ba Heart, Abdomen, Lung, AC 4 AC bolus of 250 – 500 mL as pre-cath hydration. ofControl Medicaladministration. prior to physician during encode to activate the cath-lab. the activate to encode during physician relief, consider potenc ration of nitroglycerinration and narcotics ients often have atypical pain, ients ing Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra Viagra (sildenafil) or used has who patient ing Nitroglycerin in any cardial Infarction) This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Triage and Destination Plan. or peripheral arterial disease family history (parent or sibling with CVD before age 65 - points: 2 ST depression / elevation not due to LBBB, LVH, or digoxin Positive Reperfusion Checklist should be transporteChecklistPositive should be Reperfusion Consider placing 2 IV sites in the left arm: Many PT Many left arm: sites in the Consider placing 2 IV precaution. as a patient pads on defibrillator Consider placing Lactatedor Ringers Saline Consider Normal - 1-2x normal limit = +1 - 2x > normal limit = +2 - = 0 factors risk known No - risk factors 1-2 = +1 - > 3 risk factors or history of atherosclerotic disease = +2 - < normal limit = 0 - Slightly Suspicious = 0 - = +1 suspicious Moderately - Highly suspicious = +2 0 = -Normal - Non-specific repolarization disturbance = +1 - Significant ST depression = +2 0 = 45 -< - 45-64+1 = +2 = ->65 Agency medical director may requiremedical director mayAgency Contact Diabetic, geriatric and female pat ProcedureaasDocumentinterpretation along with the in the PCR 12-Lead (Paramedic). ECG time of the the already prescribed medication. patients may administer Nitroglycerin to EMT If patient has taken nitroglycerin without Monitor for hypotension after administ If CHF / Cardiogenic shock resulting from inferior MI (II, MI inferior from resulting shock Cardiogenic / CHF If STEMI (ST-Elevation Myo (ST-Elevation STEMI Items in Red Text are the key performanceindicator are the key Text Items in Red caution whenUse administer Recommended Exam: Mental Status, Skin, Neck, (vardenafil) in the past 24 hours or Cialis (tadalafil) mayor opioids / elevation noted Nitroglycerin and Revised 01/01/2017 Pearls Notify the receiving facility of the STEMI – Speak with Obtain serial 12 leads after medication administration to follow the potential evolution/changes with the ECG. Scores 0-3: 0.9-1.7% risk of adverse cardiac event. event. cardiac adverse of risk 12-16.6% 4-6: Scores – event cardiac adverse of risk 50-65% 7: > Scores measures. invasive early for candidates be may high/low risk for the patient that can be relayed to the receiving facility. This can be used in patients > 21 years old prese When encountering Non-ST change chest pain that is potentially Acute Coronary Syndrome (ACS) related you should consider the HEART Score for risk stratification. While troponin may not be immediately available in the field, the other score portions ca - T – Initial Troponin: Use local assays and corresponding cutoffs arrhythmias and hypertensive episodes is usually benzodiazepine administration, which tempers the effects of cocaine on the Control. Medical contact question, any If administered. be may 1-2mg Ativan system. cardiovascular and system nervous central - R – Risk Factors: HTN, hypercholesterolemia, DM, obesity (BMI >30), smoking (current or cessation less than 3 months), positive symptoms suggestive of ACS. Do not use if new ST-segment elevation > 1mm or other new ECG changes, hypotension, life expectancy less than 1 year, or non-cardiac medical/surgical/psychiatric illness determined. –History -H - E – ECG – 1 point: No ST depression but LBBB, LVH, repolarization changes (ex. Digoxin); –Age -A Patients who areabusing cocaine will show signs of agitation and have dilated pupils. First-line treatment for cocaine-induce Adult Cardiac Protocol Section 11/01/2017 Locally RevisedLocally if in place bradycardia if indicated hypotension Protocol AM 5 Protocol Remove CPAP Remove CPAP Tachycardia followed by CARDIOGENIC SHOCK CARDIOGENIC Hypertension followedby Adult Hypotension / Shock Myocardial infarction Congestive heart failure Asthma Anaphylaxis Aspiration COPD Pleural effusion Pneumonia Pulmonary embolus Pericardial tamponade Exposure Toxic B Differential Afebrile ONLY IF AC 5 AC Furosemide 40 mg IV (BP >100) Airway Sublingual ACE-Inhibitor IV / IO Procedure Elevated BP Elevated Cardiac Monitor if indicated as indicated Nitroglycerin Paste Nitroglycerin Protocol AC 4 Protocol Repeat every 5 minutes Elevated Heart Rate Known CHF / Daily Lasix Known CHF Airway CPAP Procedure Airway 12 Lead ECG Procedure ECG 12 Lead Transport time > 30 minutes 30 > time Transport Protocol(s) AR 1, 2, 3 1, 2, Protocol(s) AR MODERATE / SEVERE Nitroglycerin 0.3 / 0.4 mg Notify Destination or Repeat every 5 minutes x x 3 5 minutes every Repeat Chest Pain and STEMI Nitroglycerin 0.3 / 0.4 mg SL mg 0.4 / 0.3 Nitroglycerin Assess Symptom Severity if prescribed to patient and Consider Contact Medical Control Contact Medical Apprehension, orthopnea Apprehension, distention vein Jugular sputum frothy Pink, Peripheral edema, diaphoresis Hypotension, shock Chest pain Respiratory distress, Respiratory rales bilateral P A B P B A Signs and Symptoms Signs and NO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This YES MILD Improving Nitroglycerin Paste Normal Heart Rate Repeat every 5 minutes Elevated or Normal BP Nitroglycerin 0.3 / 0.4 mg SL mg / 0.4 0.3 Nitroglycerin Medications (digoxin, Lasix, Viagra / sildenafil, Levitra / vardenafil, Cialis / tadalafil) myocardial --past history Cardiac infarction Congestiveheart failure history medical Past Revised 01/01/2017 History A Adult Cardiac Protocol Section . 11/01/2017 Locally RevisedLocally (sildenafil) or Levitra alert enough, normal saline boluses. help the help the get into patient potential severe hypotension. May give from EMS supply ck, Extremities, Neuro onitor the patient closely.onitor If the patient is tcomes patients EMS of with pulmonary pressure is above 100 mm/Hg, pressure is above y of the medication. tientwho has used Viagra III, aVF), consider Right Sided ECG (V3 or V4). If ST ST If V4). (V3 or ECG Sided Right consider aVF), III, ics, geriatricics,have atypicaloften and female patients pain, mize their breathing effort. in the PCR. Document 12 Lead ECG usingDocumentthe PCR.the 12 Lead 12 Lead ECG in instay of EMS treatment, it is no longer routinely respiratoryM distress. nd respiratory status thewith above interventions. in the past 36 hours due to past in the cause hypotension requiring Lung, Heart, Abdomen, Ba Heart, Abdomen, Lung, used to evaluate protocol compliance and care used AC 5 AC eady prescribed medication. relief, consider potenc y ventilation will will be necessary. y ventilation CHF who also feel volume overloaded may be given furosemide to furosemide given may be overloaded volume feel who also CHF ntilation, if the systolic blood r position of comfort to maxi s have NOT been shown to improve the ou pressure ventilation simultaneously; systemic blood pressure can drop d pressure > 100 mm/Hg), > 100 mm/Hg), d pressure (systolic bloo adequate This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This edema. Even though this historically has been a ma been a has this historically though Even edema. recommended. or only generalized complaints. ECG procedure. Agency medical director may require Contact of Medical Control.ofrequiremedical director may MedicalAgency Contact DocumentapplicationCPAP CPAP procedure using the alr patients may administer Nitroglycerin to EMT Consider myocardialpatients. Diabet these infarction in all Allow the patient to be in thei If patient has taken nitroglycerin without Contraindicationsto opioids include severeand COPD Use CAUTION when administering Nitroglycerin in any pa a CarefullymonitorBP, the level of consciousness, (II, MI inferior from resulting shock Cardiogenic / CHF If Furosemide and Opioid Recommended Exam: Mental Status, Skin, Neck, are key performance measuresText Items in Red (vardenafil) in the past 24 hours or Cialis (tadalafil) mayor opioids / elevation noted Nitroglycerin and Revised 01/01/2017 Pearls Along with positive pressure ve a comfortable position. Many times this can be done with the patient sitting with legs dependent. with legs sitting patient the with done can be this times Many position. a comfortable for possible patient the evaluate so you should desired, are 90% above saturations Oxygen status, mental with altered along failure respiratory signs of are If there assistance. ventilatory invasive pulmonar intubation and decreasing ways: (1) in two therapeutic can be (NIPPV) ventilation pressure positive noninvasive exchange. gas improving (2) and edema, pulmonary reducing thereby preload, and return venous to acts Nitroglycerin edema. pulmonary of treatment primary as the emerged has nitroglycerin employing when be exercised must Caution vasodilation. peripheral through preload decrease nitroglycerin and positive quickly. Patients with subacute initiate diuresis. Furosemide should also be used with caution because many patients with can be of patients this group in Diuresis pneumonia. to have found later are exam on “crackles” the overloaded; not total-body-fluid are CHF do have who those of many In addition, detrimental. many because patients in these detrimental be can Diuresis correctly. distributed just is not fluid with. begin to function renal have poor Management of heart failure is geared toward improving gas exchange and cardiac output. output. If the cardiac and exchange gas improving toward is geared failure of heart Management actual is blood pressure Narrow Complex (≤ 0.11 sec) REGULAR RHYTHM

Unstable / Serious Signs and Symptoms HR Typically > 150 Cardioversion Procedure Hypotension, Acute AMS, Ischemic Chest Pain, YES Acute CHF, Seizures, Syncope, or Shock secondary to tachycardia Narrow and Regular: 50 – 100J

NO Narrow and Irregular: 120 – 200J

B 12 Lead ECG Procedure P May repeat and increase dose with A IV / IO Procedure subsequent cardioversion attempts Cardiac Monitor Consider Sedation Prior to Attempt Vagal Maneuvers Procedure Cardioversion

Adenosine 6 mg IV / IO Midazolam 2 – 2.5 mg IV / IO Rapid push with flush May repeat as needed May repeat 12 mg IV / IO Maximum 10 mg May repeat 12 mg IV / IO Adult Cardiac Protocol Section Protocol Cardiac Adult Exit to Amiodarone 150 mg in Appropriate Protocol(s) 100 mL of D5W IV / IO if rhythm converts Infuse over 10 minutes May repeat if wide complex tachycardia recurs

Amiodarone 450 mg in 250 mL of D5W P 1 mg/min (33 mL/hr)

Or Diltiazem 0.25 mg/kg IV / IO Single lead ECG able to Over 2 – 3 minutes diagnose and treat arrhythmia Maximum 25 mg 12 Lead ECG not necessary to diagnose If No Improvement and treat, but preferred when patient is Diltiazem 5 – 15 mg/hr IV / IO stable.

If No Improvement in 15 minutes Diltiazem 0.35 mg/kg IV / IO Maximum 25 mg

RHYTHM CONVERTS YES B 12 Lead ECG Procedure Monitor and Reassess NO

Monitor and Reassess

Notify Destination or Contact Medical Control

Locally Revised AC 6 Revised 06/08/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/08/2017 Adult Cardiac Protocol Section Locally Revised 11/08/2017 Exit to stable. Cardioversion Maximum 10 mg 10 Maximum May repeat as needed if rhythm converts Cardioversion Procedure Appropriate Protocol(s) Consider Sedation Prior to Midazolam 2 – 2.5 mg IV / IO Single lead ECG able to Narrow and Regular: 50 – 100J Narrow and Irregular: 120 – 200J May repeat and increase dose with attempts cardioversion subsequent diagnose and treat arrhythmia and treat, but preferred when patient is MonitorReassess and 12 Lead ECG not necessary to diagnose P 12 Lead ECG Procedure Lead 12 B YES YES AC 6 AC 0.11 sec) IRREGULAR RHYTHM IRREGULAR sec) 0.11 ≤ Notify Destination or Contact Medical Control NO NO IV / IO Procedure Cardiac Monitor Maximum 25 mg Maximum 25 mg If No Improvement Over 2 – 3 minutes HR Typically > 150 Typically HR Monitor andReassess RHYTHM CONVERTS RHYTHM Diltiazem 0.35 mg/kg IV / IO Diltiazem 0.25 mg/kg IV / IO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This secondary to to tachycardia secondary 12 Lead ECG Procedure Lead 12 Diltiazem 5 – 15 mg/hr IV / IO If No Improvement in 15 minutes Attempt Vagal Maneuvers Procedure Maneuvers Vagal Attempt Unstable / Serious Signs and Symptoms Serious Signs and Symptoms Unstable / Acute Seizures, CHF, Syncope, or Shock Hypotension, Acute AMS, Ischemic Chest Pain, Pain, Chest Ischemic AMS, Acute Hypotension, B Narrow Complex ( Complex Narrow A P Revised 06/08/2017 If treating with Diltiazem/Cardiazem for irregular rhythm and the patient is concious and borderline hypotension, consider treatment with calcium chloride prior to administration of Diltiazem / Cardiazem. Adult Cardiac Protocol Section Protocol Cardiac Adult

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 and SYMPTOMATIC. Rhythm should be interpreted in the context of symptoms. Unstable condition Condition which acutely impairs vital organ function and cardiac arrest may be imminent. If at any point patient becomes unstable move to unstable arm in algorithm. Symptomatic condition Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. Symptomatic tachycardia usually occurs at rates ≥ 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 (200 - patient’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 should 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 should 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. Amiodarone may be given in CHF, risk of rhythm conversion in patients with arrhythmia > 48 hours. 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. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

Locally Revised AC 6 Revised 06/08/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/08/2017 Adult Cardiac Protocol Section 11/01/2017 Locally Revised Locally stable. (Not Synchronized) Cardioversion Maximum 10 mg 10 Maximum May repeat as needed Cardioversion Procedure Wide and Regular: 100J and Regular: Wide Consider Sedation Prior to Midazolam 2 – 2.5 mg IV / IO Wide and Irregular: 200 – 360J Single lead ECG able to May repeat and increase dose with attempts cardioversion subsequent diagnose and treat arrhythmia MonitorReassess and and treat, but preferred when patient is P 12 Lead ECG Procedure Lead 12 12 Lead ECG not necessary to diagnose B YES YES AC 7 AC 0.12 sec) REGULAR RHYTHM REGULAR 0.12 sec) ≥ Notify Destination or Contact Medical Control Or Adult Tachycardia Adult NO YES NO patient is stable in 250 mL of D5W IV / IO Procedure Cardiac Monitor Rapid push with flush HR Typically > 150 Typically HR Amiodarone 450 mg Amiodarone 150 mg Infuse over 10 minutes 10 over Infuse Adenosine 6 mg IV / IO in 100 mL of D5W IV / IO May repeat 12 mg IV / repeat IO May 12 mg IV / repeat IO May 1 mg/min (33 mL/hr) IV / IO Lidocaine 1 mg / kg IV / IO. Monitor and Reassess secondary to to tachycardia secondary RHYTHM CONVERTS REGULAR RHYTHM and REGULAR This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 12 Lead ECG Procedure Lead 12 Monomorphic QRS Complex QRS Monomorphic first bolus, repeat 1 mg / boluskg Wide Complex ( Wide Unstable / Serious Signs and Symptoms If infusion is initiated > 15 minutes from Acute Seizures, CHF, Syncope, or Shock May repeat if wide complex tachycardia recurs tachycardia complex if wide repeat May Consider consultation with medical control if Hypotension, Acute AMS, Ischemic Chest Pain, Pain, Chest Ischemic AMS, Acute Hypotension, P P B A P NO Revised 01/01/2017 Adult Tachycardia Wide Complex (≥0.12 sec) IRREGULAR RHYTHM

Unstable / Serious Signs and Symptoms Cardioversion Procedure HR Typically > 150 Wide and Regular: 100J Hypotension, Acute AMS, Ischemic Chest Pain, YES Acute CHF, Seizures, Syncope, or Shock Wide and Irregular: 200 – 360J secondary to tachycardia (Not Synchronized)

NO May repeat and increase dose with P subsequent cardioversion attempts B 12 Lead ECG Procedure Consider Sedation Prior to A IV / IO Procedure Cardioversion P Cardiac Monitor Midazolam 2 – 2.5 mg IV / IO May repeat as needed Maximum 10 mg

IRREGULAR RHYTHM and IRREGULAR RHYTHM and MONOMORPHIC QRS Complex POLYMORPHIC QRS Complex Adult Cardiac Protocol Section Protocol Cardiac Adult

Airway Protocol(s) AR 1, 2, 3 as indicated Amiodarone 150 mg in 100 mL of D5W IV / IO Pulseless VF / VT Infuse over 10 minutes Protocol AC 8 Cardiac Arrest May repeat if wide complex tachycardia Protocol AC 3 recurs as indicated

Amiodarone 450 mg P in 250 mL of D5W 1 mg/min (33 mL/hr) IV / IO Single lead ECG able to diagnose and treat arrhythmia Or Lidocaine 1 mg / kg IV / IO. 12 Lead ECG not necessary to diagnose If infusion is initiated > 15 minutes from and treat, but preferred when patient is stable. first bolus, repeat 1 mg / kg bolus

Consider consultation with medical control P if patient is stable

RHYTHM CONVERTS YES B 12 Lead ECG Procedure

NO Monitor and Reassess

Monitor and Reassess

Notify Destination or Contact Medical Control

Revised AC 7 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/01/2017 Adult Tachycardia Wide Complex (≥0.12 sec) Adult Cardiac Section

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 and SYMPTOMATIC. Rhythm should be interpreted in the context of symptoms Unstable condition Condition which acutely impairs vital organ function and cardiac arrest may be imminent. If at any point patient becomes unstable move to unstable arm in algorithm. Symptomatic condition Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. Symptomatic tachycardia usually occurs at rates ≥ 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 defibrillation if pulseless and begin CPR. 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: Pearls Wide-complex, irregular tachycardia: Do not administer calcium channel, beta blockers, or adenosine as this Recommendedmay cause paradoxical Exam: Mental increase Status, in Skin, ventricular Neck, Lung, rate. He Thisart, willAbdomen, usually Back, require Extremities, cardioversion. Neuro Contact medical If patientcontrol. has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium PolymorphicChannel Blocker / Irregular (e.g., Diltiazem) Tachycardia: or Beta Blockers. AdenosineThis situation may not isbe usually effective unstable in identifiable and immediate atrial flutter/fibrillation, defibrillation isyet warranted. is not harmful. MonitorWhen for associated hypotension with after prolonged administration QT this of Calcium is likely TorsadeChannels Blocker de pointes: or Beta Give Blockers 2 gm of. Magnesium Sulfate slow MonitorIV / forIO. respiratory depression and hypotension associated with Midazolam. ContinuousWithout pulse prolonged oximetry QT is likelyrequired related for all to SVT ischemia Patients. and Magnesium may not be helpful. Document all all rhythm rhythm changes changes with with monitor monitor strips strips and and obtain obtain monitor monitor strips strips with eachwith therapeuticeach therapeutic intervention. intervention.

Revised AC 7 Locally Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/01/2017 Adult Cardiac Protocol Section Reversible Causes Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypothermia Hyperkalemia / Hypo Tension pneumothorax Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) 10 seconds) 10 seconds) ) ) ≤ ≤ fibrillations Attempts Refractory Refractory if available AC 8 AC IV / IO Procedure Maximum 3 mg/kg sooner if fatigued if (sooner sooner if fatigued if (sooner If Rhythm Refractory Rhythm If May repeat if refractory May repeat if refractory 2 inches) Push Fast (100 - 120 / min) 2 inches) Push Fast (100 - 120 / min) Magnesium 2 gm IV / IO Check AED / ECG Check AED / ECG Monitor ≥ ≥ Repeat every 3 to 5 minutes Amiodarone 300 mg IV / IO Amiodarone 150 mg IV / IO Lidocaine 0.75 mg/kg IV / IO Search for Reversible Causes arrhythmics and Epinephrine Notify Destination or Continue CPR Compressions continue chest compressions chest continue defibrillate with device charged. Contact Medical Control Contact Medical At the end of each 2 minute cycle Cardiac Arrest Protocol AC 3 Cardiac Arrest Epinephrine (1:10,000) 1 mg IV / IO Repeat pattern during resuscitation. Begin Continuous Compressions CPR Change Compressors every 2 minutes Change Compressors every 2 minutes Consider Lidocaine 1.0 – 1.5 mg/kg IV / IO Refractory after 5 De Limit changes / pulse checks checks pulse / changes (Limit Limit changes / pulse checks checks pulse / changes (Limit ContinueAgency CPR and give specificAnti- Consider Dual Sequential Defibrillation Procedure Defibrillation Sequential Dual Consider Continue CPR up to point where you are ready to Push Hard ( Push Hard ( If shockable rhythm, deliver shock and immediately Ventricular Fibrillation Ventricular P A Pulseless Ventricular Tachycardia Ventricular Pulseless This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Go to Return of Circulation Spontaneous Spontaneous Protocol AC 9 AT ANY TIME ANY AT Post Resuscitation Revised 06/08/2017 Ventricular Fibrillation Pulseless Ventricular Tachycardia Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls Recommended Exam: Mental Status, neuro, heart, and lung Team Focused Approach / Pit-Crew Approach recommended; assigning responders to predetermined tasks. Refer to optional protocol or development of local agency protocol. 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) compression to ventilation ratio is 30:2. If advanced airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions. Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. Passive oxygenation optional in agencies practicing Team Focused Approach / Pit-Crew Approach. Reassess and document BIAD and / or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation. Defibrillation: Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. End Tidal CO2 (EtCO2) If EtCO2 is < 10 mmHg, improve chest compressions. If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC) Avoid Procainamide in CHF or prolonged QT. Magnesium Sulfate is not routinely recommended during cardiac arrest, but may help with Torsades de points, Low Magnesium States (Malnourished / alcoholic), and Suspected Digitalis Toxicity If no IV / IO, with drugs that can be given down ET tube, double dose and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available. Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions.

Revised AC 8 06/08/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Adult Cardiac Protocol Section If Arrhythmia Persists follow Rhythm Appropriate Protocol Arrhythmias are common and usually self limiting after ROSC after limiting self usually 94 % 94 ≥ AC 9 AC Airway Cardiac Monitor if available if indicated IV / IO Procedure as indicated as indicated as indicated Protocol AC 4 Protocol AR 8 Protocol AM 5 Protocol AC 10 12 LeadECG Procedure Hypotension / Shock Protocol(s) AC 2, 6, 7 Chest Pain and STEMI and STEMI Chest Pain Appropriate Arrhythmia Protocol(s) AR 1, 3,2, 4 Notify Destination or Monitor Vital Signs / Reassess Contact Medical Control Contact Medical DO NOT HYPERVENTILATE Maintain SpO2 SpO2 Maintain – 35 ideally ETCO2 Hg mm 45 Respiratoryminute Rate/ 10 Device Threshold Impedance Remove Repeat Primary Assessment Post Intubation BIAD Management Targeted Temperature Management Return of CirculationSpontaneous Optimize Ventilation and Oxygenation P B A B This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Reversible Causes Revised 01/01/2017 Tension pneumothorax Tension Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypothermia Hypo / Hyperkalemia Adult Cardiac Protocol Section

gan icity. ic to 12 94%. ≥ ll usually normalize. While goal ll usually normalize. Extremities, Neuro ent including hypothermia therapy, therapy, hypothermia ent including ously, and they require close monitoring. ce of cardiac arrest in the post tion to maintain SBP of90 – mmHg or Mean 100 re ventilatory assistance. re ventilatory AC 9 AC , Lungs, Heart, Abdomen, , Lungs, ty with evidence of STEMI on 12 Lead ECG. l costs. Titrate FiO2 of to maintain SpO2 diac arrest during post-resuscitationdiac care. ive care service,careive and neurology services. mmended in the prehospital setting. setting. the prehospital in mmended le of managing le the post-arrest pati of managing causeof hypotension and recurren ion patients fluctuates rapidly and continu post resuscitation will requi This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Maintain core temperature between 32 -core temperature between 32 Maintain 36°C. Infusion of cold saline is NOT reco Transport to a primary cardiac catheter faciliprimary cardiac cathetera Transport to Revised cardiology / cardiac catheterization, intens Consider transport to facility capab to facility Consider transport of post-resuscitatThe condition Targeted Temperature Management: Targeted Temperature Titrate fluid resuscitation and vasopressor administrafluidTitrate resuscitation and vasopressor STEMI: Initial End tidal CO2 may be elevatedpost-resuscitation, tidal CO2 may be immediately Initial End but wi Most patients immediately Continue to search for potential cause of car Continue to search for is a significant Hyperventilation Pearls Recommended Exam: Mental Status, Neck, Skin –35 is to 45 mmHg avoid hyperventilation achieve. Arterial Pressure (MAP) of 65 – 80 mmHg. Appropriate post-resuscitationmanagement best maywithcontrol.in consultation medical be planned resuscitation phase and must be avoided at al be avoided at andresuscitation phase must 01/01/2017 Titrate oxygen to the lowest level required to achieve an arterial oxygen saturation of 94% - 99%, toavoid potential oxygen tox Subsequent objectives of post-cardiac arrest care are to: - Control body temperature to optimize survival and neurological recovery. - Identifyacutetreat and coronary syndromes(ACS) - Optimize mechanical ventilation to minimizelung injury. - Reduce the risk of multiorgan injury and support organ function if required. The initial objectives of post-cardiac arrest care are to: are care arrest post-cardiac of objectives initial The - Optimize cardiopulmonary function and vital organ perfusion. - After resuscitation, transport patient to an appropriate hospital with a comprehensive post-cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care,and hypothermia. - Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest. Hyperventilation or “overbagging” the patient is common after cardiac arrest and should be avoided because of potential adverse The goal of immediate post-cardiac arrestcare is to optimize systemic perfusion, restore metabolic homeostasis, and support or hemodynamic effects. Hyperventilation increases intrathoracic pressure and inversely lowers cardiac output. The decrease in in decrease The output. cardiac lowers inversely and pressure intrathoracic increases Hyperventilation effects. hemodynamic 10 at started be may Ventilation directly. flow blood cerebral decrease potentially also can hyperventilation with seen PaCO2 breaths per minute and titrated to achieve an EtCO2 of 35 to 40 mmHg. system function to increase the likelihood of intact neurological survival. The post-cardiac arrest period is often marked by hemodynamic instability as well as metabolic abnormalities. Support and treatment of acute myocardial dysfunction and acute myocardial ischemia can increase the probability of survival. Interventions to reduce secondary brain injury, such as therapeut hypothermia, can improve survival and neurological recovery. Adult Cardiac Protocol Section Post Exit to Cooling Continue Resuscitation Protocol AC 9 transport. temperature assessment not change in rectal Agencies utilizing temperature during are unlikely to see a warranted with these these with warranted Continued temperature temperature Continued cerebral cooling devices devices cooling cerebral devices. Document initial F (32° C) 89.6° Continueto address specificdifferentials arrhythmia the with associated ≥ NO Differential ncludes BIAD) in YES YES AC 10 93.2 F (34C) IV / IO Procedure and groin areas groin and with EtCO2 > 20 20 mmHg > EtCO2 with Temperature as indicated Maximum 10 mg 10 Maximum Maximum 200 mg ≥ Shivering noted Reassess Rectal Reassess Circulation ROSC Circulation ( Range 32 – 36C) Versed 2 – 2.5 mg IV / IO Target: 89.6 – 96.8 °F Vecuronium 10 mg IV / IO Return of Spontaneous Initial rectal temperature temperature rectal Initial Notify Destination or Fentanyl 50 – 75 mcg IV / IO place Benzodiazepine Administration Agency Specific Cooling Device Contact Medical Control Contact Medical Perform Neurological Assessment Neurological Perform Repeat every 5 minutes as needed as minutes 5 every Repeat Repeat every 5 minutes as needed as minutes 5 every Repeat Expose and apply ice packs to axilla Criteria for Induced Hypothermia Advanced Airway (i Hypotension / Shock Protocol AM 5 If shivering uncontrolled following Opioidand Return of Spontaneous Circulation post-cardiac arrest Cardiac arrest B A Signs and Symptoms Signs and P F (32° C) NO NO 89.6° This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This ≤ Airway Exit to as indicated Protocol9 AC Protocol(s) AR 1, 3 2, Post Resuscitation minutes increases Reassess Reassess measures Revised Age 18 or greater All presenting rhythms are permissible in this protocol Non-traumaticcardiac arrests (drownings and hanging / asphyxiation are permissible in protocol.) this Stop cooling 01/01/2017 Continue Post Until temperature Resuscitation Care History temperature every 10 Adult Cardiac Protocol Section ll usually normalize. While goal ll usually normalize. from medical control. from ent including hypothermia therapy, therapy, hypothermia ent including ce of cardiac arrest in the post managing the post-arrest patient and patient the post-arrest managing tion to maintain SBP of90 – mmHg or Mean 100 blunt / penetrating / penetrating trauma or hemorrhage with blunt no purposeful response to verbal commands.no purposeful response re ventilatory assistance. re ventilatory AC 10 ty with evidence of STEMI on 12 Lead ECG. mmended in the prehospital setting. the prehospital in mmended ia and non-shockable arrhythmias. le of managing le the post-arrest pati of managing 94%. es transportof to facility capablees ≥ causeof hypotension and recurren proved neurological outcomes with prehospital initiated cooling. post resuscitation will requi and intensive care service. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Transport to a primary cardiac catheter faciliprimary cardiac cathetera Transport to Return of spontaneous circulation not relatedto ventricular fibrillation / tachycard 93.2°F (34°Temperature C). than greater BIAD) in place withAdvanced airway (including Infusion of cold saline is NOT reco cardiac catherterization hypothermia therapy. continuation induced of No studies to date demonstrate im date demonstrate No studies to Utilization of this protocol mandat of this protocol Utilization UndergarmentsMaintain patient modesty. placeremain may during cooling. in Consider transport to facility capab to facility Consider transport If no advanced airway in place obtained, coolingIf no advancedmay only be initiated airway in place obtained, onorder administrafluidTitrate resuscitation and vasopressor STEMI Initial End tidal CO2 may be elevatedpost-resuscitation, tidal CO2 may be immediately Initial End but wi Most patients immediately Hyperventilation is a significant Hyperventilation of SpO2 maintain to FiO2 Titrate is 35 –35 is to 45 mmHg avoid hyperventilation achieve. Arterial Pressure (MAP) of 65 – 80 mmHg. Criteria for Targeted Temperature Mangement: resuscitation phase and must be avoided at all costs.all be avoided at and must resuscitation phase Revised 01/01/2017 Pearls Adult Cardiac Protocol Section Go to Return of Circulation Spontaneous Protocol AC 9 Protocol AT ANY TIME BIAD if not in place BIAD if not in place Post Resuscitation Responder EMT ALS ty compressions (Hierarchy) Establish IV / IO Establish IV / IO EMS ALS Personnel EMS ALS First Arriving Establish Team Leader Establish Team Continuous Cardiac Monitoring Fire Department or Squad Officer or Squad Department Fire Incident Commander Administer Appropriate Medications Administer Appropriate Medications Initiate Defibrillation Manual Procedure Manual Defibrillation Initiate Establish Airway with Establish Airway with Manages Scene / Bystanders Initiate Defibrillation Automated Procedure Team Leader until ALS arrival Continue Cardiac Arrest Protocol AC 3 Ensures high-quali Ensures frequent compressor change 10 seconds) Fire Department / First Responder Officer P A ≤ Responsible for briefing family prior to arrival ALS to prior family briefing for Responsible 2 inches) 2 inches) ≥ every 6 seconds AC 11 NO if available Place BIAD BLS or ALS BLS or (sooner if fatigued) Push Hard ( Assume Compressionsor Call for additional resources additional for Call Monitor EtCO2 if available Push Fast (100 - 120min) / DO NOT Interrupt Compressions Third Arriving Responder Review DNR / MOST Form Review DNR Initiate Compressions Only CPR Ventilate at 6 to 8 breaths per minute per 8 breaths to 6 at Ventilate First Arriving / ALS BLS Responder Ventilate 1 breath Second Arriving BLS / ALS Responder Team Focused CPR Focused Team Initiate Defibrillation Automated Procedure BeginContinuous CPR Compressions Change Compressors every 2 minutes Criteria for Death / No Resuscitation (Limit changes / pulse checks Initiate Defibrillation Automated / Manual Procedure 30:2 Compression:Ventilation if no Advanced Airway This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Responder Team Leader ALS Personnel BLS EMT YES (Hierarchy) compressions Responsible for patient care patient for Responsible Rotate with Compressor Rotate First Arriving Establish Team Leader Establish Team Responsible for briefing / counseling family life Take direction from Team Leader Team from direction Take Take direction from Team Leader Team from direction Take Policy Fire Department or Squad Officer or Squad Department Fire Follow asystole Rigor mortis To prevent Fatigue and effect high quality resuscitation Do not begin Revised Decomposition Fourth / Subsequent Arriving Responders Continue Cardiac Arrest Protocol AC 3 01/01/2017 Dependent lividity Blunt force trauma Deceased Subjects Injury incompatible with Extended downtime with Adult Cardiac Protocol Section Do not ventilation ratio is 30:2. If AD first to limit interruptions. us compressions with limited interruptions and early and interruptionsus compressions with limited ended; assign responders to predetermined tasks. predetermined ended; assign responders to Agencies may and are encouraged to develop their own. AC 11 airway (BIAD, ETT) compression to ETT) compression airway (BIAD, 10 breaths per minute with continuous, uninterrupted compressions. minute withper uninterrupted 10 breaths continuous, encies practicing Team Focused ApproachTeam Approach. / Pit-Crewencies practicing Team Focused CPR Focused Team evelopment of agency local protocol. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This en indicated. en Revised defibrillation wh defibrillation advanced airway in place, ventilate Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. place endotracheal place to tube. ConsiderDo not BI interrupt compressions oxygenation optional in ag Passive Efforts should be directed at high quality and continuo DO NOT HYPERVENTILATE: no advanced If This protocol is optional and given only as an example. Team Focused Approach / Pit-Crew Approach recomm Refer to optional protocol or d Refer interrupt compressionsto placeendotracheal tube. ConsiderfirstBIAD to limit interruptions. 01/01/2017 Pearls Adult Cardiac Protocol Section Go to Return of Circulation Spontaneous Protocol AC 9 Protocol Continue Continue AT ANY TIME Post Resuscitation Exit to Cardiac Arrest Cardiac Arrest Policy Follow Protocol(s) AC 1, 3, 8 Protocol(s) AC 1, 3, 8 resuscitation Do not begin Deceased Subjects Protocol(s) PC 1, 4, 6 Pediatric Cardiac Arrest YES YES YES YES 20 10 20 18 ≥ ≥ ≥ ≤ 15 minutes 15 ≥ NO NO YES YES AC 12 Age EtCO2 EtCO2 EtCO2 > 30 minutes > 45 minutes > 20 minutes If continuing CPR AED / ECG Monitor No shock indicated FR / EMS BLS + ALS Change BIAD to ETT Downtime FR / EMS BLS + ALS CPR FR / EMS BLS + ALS CPR Contact Control Medical Initial Rhythm Asystole /PEA Termination of CPR of CPR Termination NO NO NO NO On Scene Resuscitation Resuscitation Scene On This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Policy Policy Policy Follow Follow Follow Exit to Deceased Subjects Deceased Subjects Deceased Subjects Cardiac Arrest Terminate CPR Effort Terminate CPR Effort Terminate CPR Effort Protocol(s) AC 1, 3, 8 3, 1, AC Protocol(s) 30 Minutes 20 Minutes Revised 01/01/2017 45 -45 Minutes 60 TIME FROM BLSor ALS CPR Adult Cardiac Protocol Section person on scene as your termine the most legitimate AC 12 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This On Scene Resuscitation / Termination of CPR Termination / Resuscitation Scene On information source such as a spouse, child, or sibling or Durable Health Care Power of Attorney. 1. Determine if a terminal disease is involved? 2. Is there an advanced directive such as a DNR / MOST form? 3. Did the patient express to your historian any desires regarding resuscitation and if so what measures? 4. Remember a living will is not a DNR. Obtain a history while resuscitation efforts are ongoing. De . General approach: Revised 01/01/2017 Pearls Adult Medical Protocol Section Nebulizer if available if if indicated 0.3 –0.3 mg 0.5 SEVERE if indicated if indicated Protocol5 AM Albuterol 2.5 – mg 5 Repeat as needed x 3 Epinephrine 1:1000IM Hypotension / Shock Or Isolated Hypotension Airway Protocol(s) AR 1 - 4 Urticaria (rash only) Urticaria (rash Anaphylaxis (systemic effect) Shock (vasculareffect) Angioedemainduced) (drug Aspiration / Airway obstruction Vasovagal event Asthma or COPD CHF 2 + Body Systems + hypotension + Systems Body 2 + B Differential AM 1 If available 2.5 – mg 5 2.5 – mg 5 See Pearls if available if indicated if indicated 0.3 – 0.5 mg improvement 500 mL IV / IO 25 - 50 mg PO 125 mg IV / IO 0.3 – 0.5 mg IM IV / IO Procedure MODERATE Repeat as needed as Repeat MaximumLiters 2 Diphenhydramine Diphenhydramine Epinephrine IV / IO Albuterol Nebulizer Epinephrine 1:1000 Albuterol Nebulizer Methylprednisolone Normal Saline Bolus Repeatneeded as3 x Repeatneeded as3 x 25 - 50 mg IV / IM / IO 2 + Body Systems 2 + Body +/- Ipratropium 0.5 mg Epinephrine 1:1000 IM if not already given PO Histamine (H2) Blocker Repeat in 5 minutes if no Notify Destination or Notify Destination Coughing / wheezing or respiratory distress Chest or throat constriction Difficulty swallowing shock or Hypotension Edema N/V Itching orhives See Pearls for dosing regimen Contact Medical Contact Control No improvement with IM Epinephrine Epinephrine IM with No improvement Signs and Symptoms Signs and B A P A Assess Symptom Severity / Suspected ExposureAllergen to This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Worsening MILD If available 25 -mg 50 if indicated IV Procedure IV Skin Only Skin 25 -25 mg PO 50 PO / IV / IM / IO Diphenhydramine Diphenhydramine Signs and Symptoms Monitor for Monitor and Reassess and Monitor Histamine (H2)Blocker Revised Past medical history medical Past Medication history Food allergy / exposure exposure / allergy Medication New clothing, soap, detergent Past history of reactions Onset and locationOnset and Insectbite sting or 01/01/2017 History B A B Adult Medical Protocol Section Agency Medical Director . Agency Medical Director al Diphenhydramine should -il. Paramedicmay assist or Agency Medical Director may require require may Director Medical Agency per Agency Medical Director. ease mental status. Or lving the face, lips airway or structures. This can also be potension/poor perfusion or isolated hypotension. ed in acute anaphylaxis / Severe (Moderate Symptoms.) may administer from EMS supply ) with normal blood pressure and perfusion. NOT delay repeated Epinephrine administration. AM 1 prescribed and may administer from EMS supply. NOT delay administration of epinephrine. of IM epinephrine may require IV epinephrine administration by IV push or ed mental status and / or a hypotensive patient as this may cause nausea and may administer from EMS supply. via AutoInjector or manual draw-up Diphenhydraminedecr may us, Skin, Heart, Lungs, Abdominal nhydramine by oral route only and r moderate and severe reactions. involves swelling of the face, lips, airway structures, extremities, and may cause moderate to severe This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This is seen in moderate to severe reactions and is swelling invo Flushing, hives, itching, plus erythema respiratory (wheezing, dyspnea, hypoxia) or gastrointestinal symptoms (nausea, vomiting, abdominal pain) with hy Flushing, hives,normal itching,blood pressure and perfusion. with erythema Flushing, hives, itching, plus erythema respiratory (wheezing, dyspnea, hypoxia) or gastrointestinal symptoms (nausea, vomiting, abdominal pain NOT be given to a patient with decreas and / or vomiting. Severe symptoms: Mild symptoms: Moderate symptoms: Drug of choice and the FIRST that should be drug administer IM Epinephrine should be administered in priority before or during at attempts IV or IO access. Diphenhydramine and steroids have no proven utility in Moderate / Severe anaphylaxis and may be given only After Epinephrine. Diphenhydramine and steroids should anaphylaxisand Severe In Moderate seen in patients taking blood pressure medications like Prinivil / Zestril (lisinopril)-typically end in medication. any administering EMT / EMR to prior control medical of contact require may The shorter the onset from exposure to symptoms the more severe the reaction. EMR / EMT may administer Epinephrine IM EMT may administer diphe EMT may administer if patient Albuterol already abdominal pain. Some patients are prescribed specific medications to aid in reversal of swelling. 12 lead ECG and cardiac monitoring should EMR / EMT may administer Epinephrine IM Hereditary Angioedema Allergic reactions may occur with only respiratory and gastrointestinal symptoms and have no rash / skin involvement. Angioedema epinephrine infusion. Refer to section ABOVE for epi 1:100,000 infusion information. Contact Medical Control for appropriate dosing. Symptom Severity Classification: administer this medication per patient / package instructions. contact of medical control prior to EMR / EMT administering any medication. medication. any administering EMT / EMR to prior control medical of contact require may Anaphylaxis unresponsive to doses repeat Recommended Exam: Mental Stat Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Epinephrine administration: Revised 01/01/2017 Pearls Cardiac monitoring is indicated fo indicated is monitoring Cardiac Epinephrine 1:100,000 infusion may be needed for severe allergic reaction unresolved by initial doses of epi IM/IV. Mix 1mg Epi in 1000ml of NS – Administer1 mL per minute (severe unresolved after initial treatment or infusion – may need 1mg Epi in 1000mL of NS over 10minutes). Adult Medical Protocol Section locally Revised 11/01/2017 69 mg / dl and ≤ symptomatic 250 mg / dl dl / mg 250 500 mL IV / IO ≥ Dextrose - rectal Blood Sugar No venous access venous No Normal Saline Bolus May repeat as needed Then infuse 150 mL / hr Repeat in 15 minutes if needed Blood Glucose Glucose Blood A A Alcohol / drug use Toxic ingestion injury head Trauma; Seizure CVA status mental baseline Altered Differential 80 mg / dl ≥ AM 2 Procedure Procedure Exit to if indicated Every 5 minutes Protocol(s) Cardiac Monitor Appropriate if indicated if indicated if indicated if indicated IV / IO Procedure Blood Sugar Protocol4 UP Protocol AM 5 Protocol AM 7 Monitor and Reassess 70 – 249 mg / dl if condition changes Suspected Stroke Blood Glucose Analysis Analysis Glucose Blood Blood Glucose Analysis Analysis Glucose Blood Notify Destination or 12 Lead ECG Procedure Hypotension / Shock Altered Mental Status Seizure Protocol UP 13 Contact Medical Control Contact Medical Until Blood Glucose Combative / irritable Diaphoresis Seizures Abdominal pain Nausea / vomiting Weakness Dehydration Deep / rapid breathing Altered mental status P A B Signs and Symptoms Signs and This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 80 mg/dL ≥ if available 69 mg / dl 69 mg Consider Oral Consider Oral ≤ Blood Sugar If no improvementIf no Glucose Solution 12.5 - 25 gm IV / IO Glucose May repeat until Blood Solution / Food)(Juices D50% / D25% / D10% / D5% Recent blood glucose check glucose blood Recent Last meal Past medical history medical Past Medications Revised A 01/01/2017 History Adult Medical Protocol Section For essary. locally Revised 11/01/2017 a medical facility. a medical tient Care Protocol UP-1. perfusion, hypotension, and / recurrent hypoglycemia even nd require close monitoring even after decisions. See Universal Pa ment of ment hypoglycemia: aces the patient atpatient risk of aces the depletion, dehydration, poor response to glucagon, D50 can be administered rectally. instructed to contact their physician immediately and instructed to contact their physician immediately and normal neurological examnormal neurologicalno new neurological with deficits. manufacturers recommendation for all glucometers. AM 2 eat and availability of food with responders on scene. with of food eat and availability are not able to swallow or protect their airway. protect swallow or are not able to es and not taking any oral diabetic agents. anytaking es and not Contact Medical Control for advice. facility after treat a my not respond to glucagon. to a my not respond glucagon. ic medications should be encouraged to allow transportation to to ic medications should be encouraged 80, patient has ability to ≥ This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This after a normal blood glucose is established. consume a meal. consume a meal. consume a normalestablished.is blood glucose Not all insulin have prolongedso action to refusePatient’s who meetbeshould care criteria Otherwise contact medical control. Not all oral agents have prolonged action so ContactprolongedNot all oral agents havesofor advice. action Medical Control to refusePatient’s who meetbeshould care criteria or shock. Patient returnsa to normalstatushasand mental Must demonstrate capacity to make informed health care unlessLimit fluid bolusesvolume have theyof signs Many forms of insulin now exist. Longer acting insulin pl Patient must have known history of diabet Patient’s taking oral diabet riskhypogl of recurrentat ycemiaThey are that canbe delayed for hoursa Blood sugar must be Contact medical control for advice. In extremeIn circumstances withno IV / IO access and no Congestive Heart Failure patients who have Blood Glucose > 250: Hypoglycemia with Agents: Hypoglycemia with Insulin Hypoglycemia with Hypoglycemia with Oral Agents: Patient’s refusing transport to medical medical to transport refusing Patient’s Patients with prolonged hypoglycemi with prolonged Patients oralnot administer to patients glucoseDo that Quality control checks should be maintained per Recommended exam: Mental Status, Skin, Respirations and effort, Neuro. Revised 01/01/2017 Pearls any lethargic, stuporous, or comatose hypoglycemic patient or for one who is unable to swallow and to understand or obey your your or obey understand to and swallow to unable is who one for or patient hypoglycemic or comatose stuporous, lethargic, any commands, who would possibly aspirate oral glucose, intravenous/intraosseous or rectal administration of dextrose is indicated. Because diabetics tend to incur a disproportionate incidence of cardiac problems, consider ECG evaluation. If correction of dehydration, hypoglycemia, hyperglycemia, or acidosis fails to abolish a cardiac dysrhythmia, refer to appropriate protocol. Supplemental dextrose provides the best means for reversing hypoglycemia. For the hypoglycemic who merely displaysconfusion and has the ability to swallow and obey commands, oral ingestion of food, drink, or instant glucose is the preferred treatment. If using D50% IV or IO – consider placing the D50% in to 500ml of fluid for administration of the first 12.5g, and repeat if nec Adult Medical Protocol Section Exit to Protocol(s) as indicated Appropriate Cardiac Appropriate Congestiveheart failure Pericarditis Diabetic emergency Sepsis Cardiac tamponade Differential 250 mL 2 gm IV / IO 1 gm IV / IO) Maximum 1 L 50 mEq IV / IO 2 gm IV / IO AM 3 1 gm IV / IO) as indicated Repeat as needed Protocol AM 5 50 mEq IV / IO If lungs remain clear Calcium Gluconate Sodium Bicarbonate Normal Saline Bolus (Or Calcium(Or Chloride Calcium Gluconate Hypotensive / Shock Sodium Bicarbonate (Or Calcium Chloride (Or Calcium Chloride as this will cause clotting of the shunt Apply dressing but avoid bulky dressing Dressing must not compress fistula / shunt fistula compress not must Dressing Notify Destination or Apply firm finger tip pressure to bleeding site Contact Medical Control Contact Medical P A P Bleeding Fever Electrolyte imbalance Nausea and / or vomiting Altered Mental Status Seizure Arrhythmia Hypotension Signs and Symptoms Signs and YES YES YES YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 0.12 sec NO NO NO NO NO ≥ Arrest Cardiac Bleeding Cardiac Monitor IV / IO Procedure IV asindicated asindicated Protocol AC 5 Protocol Pressure < 90 Systolic Blood Shunt / Fistula QRS Peaked T Wave Peaked 12 Lead ECG Procedure Lead 12 Diabetic Protocol AM 2 CHF / Pulmonary Edema Edema Pulmonary / CHF Blood GlucoseAnalysis Procedure Revised Catheter access noted noted access Shunt Hyperkalemia Peritoneal or Hemodialysis Anemia 01/01/2017 History P B A Adult Medical Protocol Section cation of tourniquet with of tourniquet cation bag, which has drained from bag, which has drained give inseparate lines. al Saline. May result in angina, resultMay Saline.or AMS, seizure in al ng weakness, dizziness,ng weakness, nausea and / or vomiting and backbring pain, the PD fluid upted direct pressure, appli hould not be mixed. Ideally be mixed. hould not AM 3 edications like some seizure medications: -dead patient only with no IV or IO access. IO -deador patient IV only with no tremity which has a shunt / fistula in place. tremity which any catheter extending outside the body. edical problems typically. Hypertension and cardiac disease are prevalent. capable of providing Dialysis treatment.providing capable of m hemodialysis at home. ula bleeding is indicated. seizures. arrhythmia. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Dialysis Treatment: Shift of metabolic waste and electrolytes causiShift Air embolism. Bleeding. Electrolyte imbalance. Fever. TypicallyrespondsmL Norm 250 of to small fluid bolus the abdomen, to the hospital. Consider sepsis in a dialysis patient with Consider sepsispatient in a dialysis Hypotension: Disequilibrium syndrome: Process which removes waste from the blood streamProcessfrom and occurswaste which removesabout three timeseach week. Some patients do perfor / or andIf patient pain, complains of fever, abdominal Equipment malfunction: Filtration and decreased blood levels of someFiltration and decreased m blood levels of Revised Renal dialysispatients havenumerous m Always consider Hyperkalemia in all dialysis or renal failure patients.Alwaysrenaldialysis consider or in all Hyperkalemia Sodium BicarbonateChlorides / GluconateCalcium and Fever: uncontrolled dialysis fist uncontrolled Peritoneal dialysis: Access of shunt indicated in the dead or near or the dead in Access of shunt indicated cannot controlled with be firm, uninterr If hemorrhage Hemodialysis: Recommended exam: Mental status. Neurological. Lungs. Heart. MentalRecommendedstatus. exam: to medicalConsider transport facility ex Pressure or start IV in not take Blood Do 01/01/2017 Pearls Complications of Adult Medical Protocol Section d Exit to Exit to Exit to Exit to Appropriate Appropriate Protocol AC 4 Cushing’s Response with with Response Cushing’s Bradycardia and Hypertension Chest Pain / STEMI Protocol(s) AM 7 UP 4 AM Protocol(s) Obstetrical Emergency Protocol(s) AC 5 / AR 4 Protocol(s) 3 AO 1 / AO Hypertensive encephalopathy Primary CNS Injury Myocardial Infarction Aortic Dissection / Aneurysm Pre-eclampsia / Eclampsia Differential YES YES YES YES en, Back, Extremities, Neuro NO NO NO NO Pregnancy Chest Pain Cardiac Monitor CVA / AMS IV / IO Procedure Dyspnea / CHF AM 4 12 Lead ECG Procedure Obtain and Document BP Document and Obtain Measurement in Both Arms Notify Destination or Notify Destination Contact Medical Control Contact Medical Systolic BP 220 or greater greater or BP 220 Systolic greater or BP 120 Diastolic Headache Chest Pain Dyspnea Status Mental Altered Seizure P B A Signs and Symptoms and Signs One of these AND at least one of these YES us, Skin, Neck, Lung, Abdom Heart, treated based on specific protocols and consultation with Medical Control. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Hypertensive Hypertensive Or NO Exit to minutes apart minutes Appropriate Protocol(s) Appropriate Systolic BP 220or greater Diastolic BP 120 or greater or BP 120 Diastolic damage such as MI, CVA or renal failure. This is very difficult to determine in the pre-hospital setting in most cases. Pain and Anxiety are are addressed Anxiety and Pain Elevated blood pressure is based on two to three sets of vital signs. vital of sets three to two on based is pressure blood Elevated Symptomatic hypertension is typically revealed through end organ dysfunction to the cardiac, CNS or renal systems. All symptomatic patients with hypertension should be transported with their head elevated at 30 degrees. habitus. body for utilized cuff pressure blood size appropriate Ensure Recommended Exam: Mental Stat Erectile Dysfunction medications Dysfunction Erectile Pregnancy Medications for Hypertension Compliance with Medications Documented Hypertension Documented Related diseases: Diabetes; CVA; Renal Failure; Cardiac Problems Revised BP taken on 2 occasions at least 5 01/01/2017 only supportive care. Specific complaints such as chest pain, dyspnea, pulmonary edema or altered mental status should be Hypertension is not uncommon especially in an emergency setting. Hypertension is usually transient and in response to stress and / or pain. A hypertensive emergency is based on blood pressure along with symptoms which suggest an organ is suffering Aggressive treatment of hypertension can result in harm. Most patients, even with significant elevation in blood pressure, nee Pearls History Adult Medical Protocol Section locally Revised 11/11/2017 if indicated Obstructive Needle Procedure Chest Decompression- P Ectopic pregnancy Dysrhythmias Pulmonary embolus Tension pneumothorax Medication effect / overdose Vasovagal Physiologic (pregnancy) Sepsis Differential Distributive needed SBP > 90 AM 5 5-10 mcg/min 5-10 Epi 1:100,000 2 L Maximum Normal Saline IV / IO Procedure Repeat to effect if indicated if indicated if indicated Bolus 500 mL IV Cardiac Monitor Protocol6 TB if indicated if indicated To effect SBP > 90 Protocol UP 14 Multiple Trauma Suspected Sepsis Airway Protocol(s) Allergy Protocol AM 1 Protocol Allergy 12 Lead ECG Procedure ECG 12 Lead Push dose Vasopressor if Notify Destination or Notify Destination Diabetic Protocol AM 2 Epi drip 1-10 mcg/min IV / IO Contact Medical Control Medical Contact Weakness, dizziness Weakness, Weak,pulse rapid skin clammy cool, Pale, Delayed capillary refill Hypotension Coffee-ground emesis Tarry stools Blood Glucose Analysis Procedure Restlessness, confusion P A Signs and Symptoms Signs and P A B History and Exam Suggest Type of Shock Hypovolemic This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This STEMI Protocol(s) if indicated Cardiogenic Protocol AC 4 Appropriate Cardiac History of poor oral intake Medications Allergic reaction Pregnancy Fluid loss - vomiting, diarrhea, fever Infection CHF) Cardiac ischemia (MI, Blood loss - loss Blood or vaginal gastrointestinal bleeding, AAA, ectopic Chest Pain: Cardiac and Revised 01/01/2017 History Septic Shock Skin – Varies from flushed pink (if fever is present) to pale and cyanotic, possible petechia, possible purple blotches, possible peeling (general or at palms and soles), red streaks progressing proximally

Blood Pressure – Early: cardiac output increases but toxins may cause loss of peripheral vascular resistance Section Protocol Medical Adult Blood Pressure – Late: Hypotension; precipitous fall in blood pressure Respiration – Dyspnea with altered lung sounds Other – Possible high fever (except some elderly and very young patients), Other – Late: frank pulmonary edema

Septic shock is the result of an overwhelming infection. Sepsis may not be noticed for some time and may be confused with a wide variety of other conditions. Sepsis begins with an infection that sets in motion an overwhelming systemic response from the immune system, eht end results of which are hypotension, hypoperfusion, and end organ dysfunction. The infection can be caused by bacteria, fungus, and some viruses. Gramnegative bacteremia is more likely to cause sepsis (50 percent of infections) compared to gram-positive bacteremia (25 percent of infections). The inflammatory and cellular events are complex and significant. Organisms invade the body through the loodstream or locally. In either case, the organisms release structural components (commonly referred to as toxins, either endotoxins or exotoxins) that trigger our natural immune system to release its own endogenous mediators (e.g., cytokines from monocytes and prostaglandins from neutrophils, along with histamine, heparin, tumor necrosis factor [TNF], and others).

Adrenal crisis, also known as Addisonian crisis and acute adrenal insufficiency, is a medical emergency and potentially life- threatening situation requiring immediate emergency treatment. It is a constellation of symptoms that indicate severe adrenal insufficiency caused by insufficient levels of the hormone cortisol. The signs and symptoms may include: - Pain in the lower back, flank, abdomen, or legs - Severe vomiting and diarrhea, leading to dehydration - Low blood pressure - Loss of consciousness - High potassium (hyperkalemia) and low sodium (hyponatremia)

Pearls Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be interpreted in context and patients typical BP if known. 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. For non-cardiac, non-trauma hypotension, consider Dopamine when hypotension unresponsive to fluid resuscitation. Hypovolemic Shock; Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding. Tranexamic Acid (TXA): Agencies utilizing TXA must have approval from your T-RAC. 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 or Congenital Adrenal Hyperplasia: Body cannot produce enough steroids (glucocorticoids / mineralocorticoids.) May have primary or secondary adrenal disease, congenital adrenal hyperplasia, or more commonly have stopped a steroid like prednisone. Injury or illness may precipitate. Usually hypotensive with nausea, vomiting, dehydration and / or abdominal pain. If suspected Paramedic should give Methylprednisolone 125 mg IM / IV / IO or Dexamethasone 10 mg IM / IV / IO. Use steroid agent specific to your drug list. May administer prescribed steroid carried by patient IM / IV / IO. Patient may have Hydrocortisone (Cortef or Solu-Cortef). Dose: < 1y.o. give 25 mg, 1- 12 y.o. give 50 mg, and > 12 y.o. give 100 mg or dose specified by patient’s physician.

Revised Revised AM 5 locally 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/11/2017 Suspected Stroke: Activase / t-PA

Obtain / Document VS prior to transport

Patient must be stabilized SBP ≥ 185 BEFORE transport initiated YES DBP ≥ 110 SBP < 185 DBP < 110 NO

Assess / Document GCS / Pupil exam Any of following: Nothing by mouth / NPO Severe headache Worsening of neurological exam Prehospital Stroke Screen Nausea / Vomiting Allergic reaction Maintain SaO2 ≥ 94 % Excessive bleeding Cardiac Monitor P Verify Activase / t-PA bolus dose Verify total dose Stop Document time infusion initiated IV Activase / t-PA infusion P Document estimated time of dose completion Reassess VS every 15 minutes Repeat neurological exam every 15 minutes Obtain BP readings in limb without infusion

SBP ≥ 180 and/or DBP ≥ 105 And NO antihypertensive YES P Labetalol 10 mg IV / IO medication infusion initiated by Contact Medical Control transferring hospital or Receiving Facility

NO Labetalol: Increase 2 mg/min every 10 minutes Titrate SBP < 180 mmHg DBP < 105 mmHg Antihypertensive medication Maximum 8mg/min infusion initiated by YES P Or transferring hospital Nicardipine: Increase 2.5 mg/hr every 5 minutes Titrate SBP < 180 mmHg DBP < 105 mmHg Maximum 15 mg/hr NO Stop Anti-hypertensive agent SBP < 140 and/or DBP < 80 YES P Continue NO Activase / t-PA infusion

Reassess VS every 15 minutes P Repeat neurological exam every 15 minutes Obtain BP readings in limb without infusion

Notify Destination or Contact Medical Control

Revised Revised AM 6 locally 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/101/2017 Suspected Stroke: Activase / t-PA (Optional)

Pearls

This protocol is intended for interfacility transfer patients only. Medication must be started at initial treating hospital. Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro Items in Red Text are key performance measures used in protocol compliance. The Reperfusion Checklist should be completed for any suspected stroke patient. 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. Infusion Pump Alarm / No Flow: Remove drip chamber from Activase / t-PA bag. Spike Activase / t-PA drip chamber to NS bag. Restart infusion to complete medication remaining in IV tubing. Medication dosing safety: When IV Activase / t-PA dose administration will continue en route, verify estimated time of completion. Verify with sending hospital that excess Activase / t-PA has been withdrawn from the bottle and wasted. This ensures the bottle will be empty when the full dose is finished. For example, if the total dose is 70 mg, then 30 cc should be withdrawn and wasted since a 100 mg bottle of Activase / t-PA contains 100 mL of fluid when reconstituted. Sending hospital should apply a label to Activase / t-PA bottle with the number of mL of fluid that should be in the bottle in case of pump failure during transit. Allergy / Anaphylaxis: Activase / t-PA, is structurally identical to endogenous t-PA and therefore should not induce allergy, single cases of acute hypersensitivity reactions have been reported. Angioedema: Rapid swelling (edema) of the dermis, subcutaneous tissue, mucosa and submucosal tissues. Typically involves the face, lips, tongue and neck. Almost always self limiting but may progress to interfere with airway / breathing so close monitoring is warranted. Utilize the Allergy / Anaphylaxis Protocol as indicated and also for angioedema. Infusion should be stopped. Give all medications related to the Allergy / Anaphylaxis Protocol by IV route only as patient should remain NPO. Revised Revised AM 6 locally 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/101/2017 Adult Obstetrical Protocol Section Go to Crowning Delivery as indicated Protocol AO 3 Protocol Newly Born Protocol AO 2 Multiple gestation Expedite Transport Priority symptoms: <36 weeks gestation Obstetrical Emergency Abnormal presentation Severe vaginal bleeding Buttock Foot Hand Abnormal presentation cord Prolapsed Placenta previa Abruptio placenta YES Differential pushing Support Support imminent from face Transport Do Not Pull push tissue to refrain from Place 2 fingers Unless delivery along nose and Presenting Parts Breech Birth Breech Encourage Mother NO AO 1 Crowning IV / IO Protocol Inspect Perineum Childbirth Procedure Childbirth Monitor and Reassess Spasmodic pain Spasmodic Vaginal discharge or bleeding Crowning or urge to push Meconium (No digital vaginal exam) vaginal (No digital >36 Weeks Gestation High Flow Oxygen to Mother Notify Destination or Hypertension / Hypotension / Hypertension Signs and Symptoms and Signs Abnormal Vaginal Bleeding / Contact Medical Control Contact Medical A Over cord Over Hips Elevated Hips Notify Receiving Facility Immediately Knees to Chest Saline Dressing vagina to relieve pressure on cord on pressure Insert fingers intoInsert fingers Prolapsed Cord Shoulder Dystocia This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This duration of contractions of No Crowning Left lateral position Monitor and Reassess Document frequency and Medications Gravida / Para Status High Risk pregnancy Rupture of membranes Time / amount of any vaginal bleeding Sensation of fetal activity history delivery and medical Past Due date Time contractions started how/ often Revised 01/01/2017 History Adult Obstetrical Protocol Section Protocol Obstetrical Adult

Pearls Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro Record APGAR at 1 minute and 5 minutes after birth. After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control post-partum bleeding. Document all times (delivery, contraction frequency, and length). Transport or Delivery? Decision to transport versus remain and deliver is multifactorial and difficult. Generally it is preferable to transport. Factors that will impact decision include: number of previous deliveries; length of previous labors; frequency of contractions; urge to push; and presence of crowning. Maternal positioning for labor: Supine with head flat or elevated per mother’s choice. Maintain flexion of both knees and hips. Elevated buttocks slightly with towel. If delivery not imminent, place mother in the left, lateral recumbent position with right side up about 10 – 20°. Umbilical cord clamping and cutting: Place first clamp about 10 cm from infant’s abdomen and second clamp about 5 cm away from first clamp. Multiple Births: Twins occur about 1/90 births. Typically manage the same as single gestation. If imminent delivery call for additional resources, if needed. Most twins deliver at about 34 weeks so lower birth weight and hypothermia are common. Twins may share a placenta so clamp and cut umbilical cord after first delivery. Notify receiving facility immediately. If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.

Revised AO 1 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Adult Obstetrical Protocol Section Secretions Respiratory drive otocol(s) AR 5, 6 5, AR otocol(s) otocol(s) AR 5, 6 5, AR otocol(s) Airway failure Infection Maternal medication effect Hypoglycemia, Hypovolemia, Hypothermia Congenitalheart disease May repeat x 1 Differential BVM Ventilations IV / IO Procedure 10 mL / kg IV / IO 0.01 mg /kg IV / IO Chest Compressions Normal SalineBolus Supplemental Oxygen Epinephrine 1:10,000 Change airway position Check chest movement if no improvement Change BVM Technique Change Cardiac Monitor / 3 – Lead Monitor and Reassess Pulse Oximetry Right Hand Right Oximetry Pulse Clear airway if necessary Provide warmth / Dry infant Every 3 to 5 minutes as needed as minutes 5 3 to Every Infant with motherpossible if Maintain normal temperature Pediatric Airway Pr Pediatric Airway Pr Position and clear airway if necessary if airway clear and Position P B A AO 2 YES YES YES ALL YES Notify Destination or Contact Medical Control Contact Medical Respiratory distress Respiratory Peripheral cyanosis or mottling (normal) Central cyanosis(abnormal) Altered level of responsiveness Bradycardia Signs and Symptoms Signs and 94 % 94 ≥ This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO ANY NO Maintain warmth Heart Rate < 60 Term Gestation? Heart Rate < 100 Supplemental Oxygen Monitor and Reassess Maintain SpO2 Good Muscle Tone? Muscle Good Warm, Dry and Stimulate and Dry Warm, Clear airway if necessary Breathing or Crying? Breathing Heart Rate < 100 / min Agonal breathing or Apnea? breathing Agonal Meconium / Delivery difficulties disease Congenital (maternal) Medications Maternal risk factors such as substance abuse or smoking Due date and gestational age etc.) (twins gestation Multiple Labored breathing or Persistent cyanosis or Persistent breathing Labored History Adult Obstetrical Protocol Section 2-thumbsencircling chest and essure ventilation is l mattress, radiant heat. l ssion to ventilation ratio. muscle tone generally will need no resuscitation. resuscitation. no generally will need tone muscle Neck, Chest, Heart, Abdomen, Extremities,Heart, Chest, Neuro Neck, not vigorous: Positive pr not vigorous: AO 2 respirations / respiratoryheart rate. effort and eumothorax, and/or hypoglycemia (< 40 mg/dL). cap, plastic wrap, therma ents ofbestassessed life and isents by 3-lead ECG. on respond to ventilations / on respond If compressions, BVM, epinephrine. and/or ngs immediately following birth: ngs immediately following longerrecommended. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 1 minute2 minutes3 minutes 60– 65% 4 minutes 65– 70% 5 minutes 70– 75% 75– 80% 80– 85% Infant born through meconium staining who is recommended, direct endotracheal is no longer recommended. suctioning 10 minutes 85– 95% supporting the back isrecommended. Limit interruptions of chest compressions. D10 = D50 diluted (1 ml of D50 with 4 ml of Normal Saline) CPR in infants is 120 compressions/minute with a 3:1 compre Maternalsedationornarcotics will sedate infantLONGER recommended-supportive (Naloxone NO only). care Heart rate is critical during the first few mom upperPulse oximetryappliedshould arm, wrist, or palm. to the right be Expected Pulse Oximetry readi Expected Maintain warmth of infant following delivery; Meconium staining: Term gestation, strong cry / breathing and with good cry / breathing Term strong gestation, Routine suctioning is no Most important vital signs in the newly born are Document 1 and 5 minute Apgars in PCR Apgars minute 5 and Document 1 resuscitati newborns requiring Most infantresponding consider hypovolemia,not pn Recommended Exam: Mental Status, Skin, HEENT, Pearls Adult Obstetric Protocol Section May repeat May repeat x 1 Maximum 10 mg Over 2 –Over minutes 3 Midazolam 2 mg IN Midazolam 5 mg IM Midazolam 2.5 mg IV / IO Pre-eclampsia / Eclampsia Placenta previa Placenta abruptio Spontaneous abortion Magnesium Sulfate 2 g IV / IO every5 minutesto 3 needed as Differential P YES NO AO 3 Diabetic Cardiac Monior if indicated if indicated if indicated if indicated IV / IO Procedure Protocol UP 3 Protocol AO 1 Blood Glucose Glucose Blood Seizure Activity Abdominal Pain Childbirth / Labor / Childbirth Monitor and Reassess Analysis Procedure HypotensionShock / Protocol AM 2 / PM 2 Protocol AM 5 / PM 5 Vomiting and Diarrhea Diarrhea and Vomiting Notify Destination or Left lateral recumbant position Contact Medical Control Contact Medical Vaginal bleeding pain Abdominal Seizures Hypertension Severe headache Visual changes Edema of hands and face P A Signs and Symptoms Signs and YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO Exit to Known or Protocol(s) Appropriate Missed Period Abdominal Pain Vaginal Bleeding Suspected Pregnancy Prenatal care births / pregnancies Prior Gravida / Para Past medical history medical Past meds Hypertension Revised 01/01/2017 History Adult Obstetric Protocol Section Protocol Obstetric Adult

Pearls Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro Midazolam 5 – 10 mg IM is effective in termination of seizures. Do not delay IM administration with difficult IV or IO access. Magnesium Sulfate should be administered as quickly as possible. May cause hypotension and decreased respiratory drive, but typically in doses higher than 6 g. 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. Ectopic pregnancy: Implantation of fertilized egg outside the uterus, commonly in or on the fallopian tube. As fetus grows, rupture may occur. Vaginal bleeding may or may not be present. Many women with ectopic pregnancy do not know they are pregnant. Usually occurs within 5 to 10 weeks of implantation. Maintain high index of suspicion with women of childbearing age experiencing abdominal pain. Preeclampsia: Occurs in about 6% of pregnancies. Defined by hypertension and protein in the urine. RUQ pain, epigastric pain, N/V, visual disturbances, headache, and hyperreflexia are common symptoms. 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. Risk factors: < 20 years of age, first pregnancy, multigestational pregnancy, gestational diabetes, obesity, personal or family history of gestational hypertension. Eclampsia: Seizures occurring in the context of preeclampsia. Remember, women may not have been diagnosed with preeclampsia. Maintain patient in a left lateral position, right side up 10 - 20° to minimize risk of supine hypotensive syndrome. Ask patient to quantify bleeding - number of pads used per hour. Revised AO 3 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Airway Respiratory Protocol Section 90% 90% ≥ and/or and/or and/or AEMT. Exit to management. Protocol AR 2 attempts by most more unsuccessful Unable to Ventilate intubation attempts . Adult Failed Airway Anatomy inconsistent inconsistent Anatomy and Oxygenate Drug Assisted Airway Airway Assisted Drug Three (3) unsuccessfulThree (3) with continued attempts. experienced Paramedic/ during or after one (1) or Protocols AR 1, 2, and 3 3 and 2, AR 1, Protocols Protocol) as they contain contain as they Protocol) should be utilized together (even if agencyis not using useful information for airway 90% ≥ 90 % 90 94% ≥ ≥ 94 % ≥ Exit to BVM Direct Maintain Consider Consider Consider Procedure Procedure if available if indicated if indicated if indicated if indicated Preferably Protocol AR 8 Protocol AR 3 Laryngoscopy Post-intubation / Supplementaloxygen Preferably Preferably Appropriate Protocol(s) Appropriate BIAD Management Surgical Procedure Surgical Airway Foreign Body Airway Drug Assisted Assisted Drug Airway Chest Decompression Supplemental Oxygen Obstruction Procedure Airway Cricothyrotomy AR 1 AR Airway BIAD Procedure Airway CPAPProcedure Goal oxygen saturation saturation oxygen Goal Oxygen Saturation Notify Destination or Notify Destination Oral / Nasotracheal Intubation Contact Medical Control Contact Medical P P B A A YES YES YES YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO NO Exit to if indicated if indicated if indicated if indicated Oxygenation Protocol AR 10 Support needed? Monitor / Reassess Monitor / Airway Obstructed Tracheostomy Tube Supplemental Oxygen appropriate protocol(s) Breathing / Oxygenation / Breathing Spinal Motion Restriction Basic Maneuvers First -open airway chin lift / jaw thrust -nasaloral or airway (BVM) -Bag-valve mask Procedure / Protocol TB 8 Protocol / Procedure Respiratory Distress with a Assess Respiratory Rate, Effort, Is Airway / Breathing Adequate? Altered Mental Status Protocol UP 4 Revised 01/01/2017 Airway Respiratory Protocol Section be be eck mobility limited. istorted or N D le time, exposing le time, Equipment failure. 90%, it is acceptable to ccess or anatomical ≥ orted airways, increased ICP, bese, obstruction, OB –OB obstruction, bese, 3d and 2d . O neumothorax and and Pneumothorax ontinuous capnography (EtCO2) is strongly Evaluate 3-3-2 (Mouth opening should equal 3 ass or hematoma, A ; M umor. T my tube / ETT, my tube anatomical disruptedor dist and mandatory with monitoring of an endotracheal tube. monitoringan endotracheal and mandatorywith of urgery scars urgery st the teeth or ETT inserted into the nasal passage. the nasal into or ETT inserted the teeth st bese, obstruction, OB – 2d and 3d trimesters; en the patient is receiving appropriate oxygenation and bese, obstruction, OB – 2d and 3d trimesters; AR 1 AR O O aluation Form with any BIAD or Intubation procedure. tain a EtCO2 of 35-45. Avoid hyperventilation. bstructed tracheosto ask seal difficulty (hair, secretions, trauma); quires spontaneous breathing and may require considerab ook externally for anatomical problems; o teeth; Stiff lungso teeth; or neck estricted mouth opening; tiff lungs or neck or Stiff lungs 55; N g maintained with continuousby BVM pulse oximetry values of ≥ ge ge adiation treatment to face, neck, or chest; A protocols AR 2 and 3. ; R This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This trimesters; of patients finger’s width, mental area to neck should equal 3 of patient’s finger’s width, base of chin to thyroid thyroid to chin of base width, finger’s patient’s of 3 equal should neck to area mental width, finger’s patients of disrupted airway; problems isplaced tracheostomy tube / ETT, O Difficult BVM Ventilation (MOANS): M Difficult Laryngoscopy (LEON): L width); finger’s patients 2 of equal should prominence Difficulty BIAD (RODS): R (RODS): Difficulty BIAD Difficulty / SurgicalCricothyrotomy Airway (SMART): S severe facial trauma, basal skull fracture, and head injury. Orotracheal route is preferred. should be used during all patient moves / transfers. DOPE: D Gastric tube placement should be considered in all intubated patients if available or time allows. time or available if patients intubated all in considered be should placement tube Gastric It is important to secure the endotracheal tube well to better maintain ETT placement. Manual stabilization of endotracheal tu Maintain spinal motion restriction for patients with suspected spinal injury. unsuccessful. is intubation oral-tracheal BIAD if a using consider should Paramedics AEMT and During intubation attempts use External Laryngeal Manipulation to improve view of glottis Nasotracheal intubation: Procedure re It is strongly encouraged to complete an Airway Ev recommended for the monitoring of all patients with a BIAD Assessment Airway and Airway the Difficult Anticipating Capnometry or capnography is mandatory with all methods of intubation. C Ventilatory rate should be 8-10 per minute to main If an effective airway is bein Intubation Attempt is passing the laryngoscope blade pa See Pearls section of For the purposes of this protocol a secure airway is wh ventilation. continue with basic airway measures. patient to critical desaturation. Contraindicated in combative, Revised 01/01/2017 Pearls Airway Respiratory Protocol Section locally Revised 11/101/2017 Exit to Continue BVM Call for additional Supplemental Oxygen Appropriate Protocol(s) resources if available YES 90% during during 90% 90 % ≥ ≥ 90 % 94 % 94 ≥ tomy Surgical 94 % ≥ AR 2 AR Maintain Maintain Attempt NO BVM and/or Procedure and/or if available Maintains Maintains Preferably or equipment Device Procedure Protocol8 AR Device Procedure Failed Airway Failed Post-intubation Supplemental oxygen Supplemental Preferably Preferably BIAD Management BVM with Airway Adjuncts BVM with Airway Oxygen Saturation Saturation Oxygen Airway Video Laryngoscopy Airway Blind Insertion Airway Notify Destination or Adjunctive Airway NP / OP Airway Cricothyro Oxygen Saturation ≥ Contact Medical Control Contact Medical P B A Anatomy inconsistent with continuedattempts. Each attempt should include change in approach Unable to Ventilate and Oxygenate NO MORE THAN THREE (3) ATTEMPTS TOTAL or after one (1) or more unsuccessful intubation attempts. Threeunsuccessful (3) attemptsmost by experienced Paramedic/AEMT. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Revised 01/01/2017 contain useful useful contain information for Airway as they utilized together and 3 should be Protocols AR 1, 2, usingAssisted Drug airway management. management. airway (evenagencyif is not Airway Respiratory Protocol Section e

The eck mobility N locally ten this is Revised This can be the level of 11/101/2017 istorted or D Equipment failure. 90%, it is acceptable to ccess or ccess anatomical ≥ bese, obstruction, OB –OB obstruction, bese, 3d and 2d O neumothorax and and Pneumothorax Evaluate 3-3-2 (Mouth opening should equal 3 of ass or hematoma, A ; M bese,obstruction, OB –and 2dtrimesters; 3d umor. patient's difficult / failed airway. T O my tube / ETT, my tube urgery scars urgery en the patient is receiving appropriate oxygenation and bese, obstruction, OB – 2d and 3d trimesters; AR 2 AR fy patients with expected difficult airway, difficult BM O bstructed tracheosto ask seal difficulty (hair, secretions, trauma); ook externally for anatomical problems; an adjustment and then consider: oscopy and / or difficult cricothyrotomy. o teeth; Stiff lungso teeth; or neck estricted mouth opening; tiff lungs or neck or Stiff lungs 55; N g maintained with continuousby BVM pulse oximetry values of ≥ ge ge adiation treatment to face, neck, or chest; A AS EARLY AS POSSIBLE concerning the ; R This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This trimesters; patients finger’s width, mental area to neck should equal 3 of patient’s finger’s width, base of chin to thyroid prominence should equal 2 of patients finger’s width); limited. limited. disrupted airway; problems isplaced tracheostomy tube / ETT, O Medical Control Change head positioning head Change Different laryngoscope blade / Video or other optical laryngoscopy devices laryngoscopy optical other or Video / blade laryngoscope Different Gum Elastic Bougie Different ETT size Difficult BVM Ventilation (MOANS): M Difficult Laryngoscopy (LEON): L Difficulty BIAD (RODS): R (RODS): Difficulty BIAD Difficulty / SurgicalCricothyrotomy Airway (SMART): S Notify DOPE: D During intubation attempts use External Laryngeal Manipulation to improve view of glottis. function. respiratory inadequate with patients all in utilized be should oximetry pulse Continuous Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. AEMT and Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. is intubation oral-tracheal BIAD if a using consider should Paramedics AEMT and If first intubation attempt fails, make Anticipating the Difficult Airway and Airway Assessment Airway and Airway the Difficult Anticipating For the purposes of this protocol a secure airway is wh If an effective airway is bein ventilation. continue with basic airway measures. Revised 01/01/2017 Pearls Use of cot in optimal patient / rescuer position: The cot can be elevated and lowered to facilitate intubation. With the patient on the cot raise until the patient’s nose is at dictated by uncontrolled conditions present at the scene and we must adapt. However many times the rescuer does not optimize th facilitated by raising the head of the cot. your umbilicus which will place you at the optimal position. Position of patient: In the field setting improper position of the patient and rescuer are responsible for many failed and difficult intubations. Of ventilations, difficult BIAD, difficult laryng Please refer to Adult Airway Protocol for more information on how to identify the patient with the potential difficult airway. The most important way to avoid a failed airway isto identi In the obese or late pregnant patient, elevating the torso by placing blankets, pillows or towels will optimize the position. alternative maneuvers. A patient near death or dying. or death near A patient maneuvers. alternative patient and rescuer position. The sniffing position or the head simply extended upon the neck are probably the best positions. goal is to align the ear canal with the suprasternal notch in a straight line. Conditions define which a Failed Airway: 1. Failure to maintain adequate oxygen saturation 90% or greater after 2 more or failed intubation attempts. 2. Three (3) failed attempts at intubation by the most experienced prehosptial provider on scene even when adequate oxygen saturation of 90% or greater can be maintained. 3. Unable to maintain adequate oxygen saturation 90% or greater with BM ventilation techniques and insufficient time to attempt A failed airway occurs when a provider begins a course of airway management by endotracheal intubation and identifies that intubation by that means will not succeed. Airway Respiratory Protocol Section locally Revised 11/101/2017 Red Text Intubation. are the key Form must be Rapid Sequence used to evaluate management. completed on every patient who receives protocol compliance. An Airway Evaluation performance indicators Drug Assisted Airway Airway Assisted Drug Protocols AR 1, 2, and 3 3 and 2, AR 1, Protocols Protocol) as they contain contain as they Protocol) Combative should be utilized together (even if agency is not using useful information for airway Adult Airway as indicated as indicated Protocol AM 5 Airway Management Protocol(s) AR 1, 2 Adult Failed Airway Hypotension / Shock Ketamine 300 – 400 mg IM Ketamine 1.5 - mg/kg 2 IV / IO Ketamine 1.5 - mg/kg 2 IV / IO Correct Hypoxia and / or Hypotension Airway Management + Dangerously P procedure. Must have two (2) have two Must AR 3 AR ability to ventilate. patient’s protective patient’s airway reflexes and and reflexes airway You must be sure of beforethis beginning Paramedics on on Paramedics scene Procedure will remove willProcedure your ability to intubate Notify Destination or YES Contact Medical Control Contact Medical NO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This ay Equipment ay Or Or NO YES Exit to and/or and/or and/or May repeat x 1 May repeat x 1 Hypoxic Or IV / IO Procedure (preferably 2 sites) Protocol AR 8 Protocol Suction equipment after intubation Placement Verified Hypotension Or Hypotension Post-intubation / Intubate trachea BIAD Management Unable to ventilate Preoxygenate 100% O2 AlternativeDevice Airway Awakening or Moving or Moving Awakening Continuous Capnography Unable to oxygenate Assemble Airw Etomidate 0.3 mg/kg IV / IO Rocuronium 1 mg kg IV / IO Dangerously Combative? Ketamine 1.5 - 2 mg/kg IV / IO Failure to protect the airwayFailure to Succinylcholine 1.5 mg / kg IV/ IO Impending airway compromise (if Succinylcholine contraindicated) Consider Restraints Physical Procedure Physical Restraints Consider Consider Gastric Tube Insertion Procedure Indications Assisted AIrway for Drug Revised 01/01/2017 P P P A Airway Respiratory Protocol Section d. d. locally Revised tilation may tilation 11/101/2017 d. tient. should be open 90 %. ≥ ottic view. ottic ation attempt. Optimal attempt. ation atients; and Patients ant patient. If difficulty If patient. ant Equipment failure. IO should be established as IO should be established neumothorax and and Pneumothorax ing airway management IM. IV / IM. IV management ing airway my tube / ETT, my tube AR 3 AR and is very effective in supplying oxygen to the blood stream even without even stream the blood to oxygen supplying in effective is very and ng cardiac disease; Aortic disease; Obese patients; Pregnant p Pregnant patients; Obese disease; Aortic disease; ng cardiac bstructed tracheosto apneic oxygenation oxygenation apneic Change cricoid pressure; No longer routinely recommended and may worsen your view. your worsen may and recommended routinely longer No pressure; cricoid Change positioning. proper / notch sternal with canal auditory external Align Right) to patient’s and Up, [posterior], (Back maneuver BURP applying Consider ● ● ● is population.) This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This soon as possible. possible. soon as and hypotension are corrected, use of a sedative and paralytic can proceed if indicated. indicated. if proceed can paralytic and a sedative of use corrected, are hypotension and isplaced tracheostomy tube / ETT, O Ketamine may NOT be used for purposes of sedation only – only sedation of purposes for be used NOT may Ketamine procedures. management airway during only used be must it Ketamine may be used during airway management of patients who FIT on the Broselow-Luten Tape with a DIRECT, ONLINE ONLINE a DIRECT, with Tape Broselow-Luten the on FIT who patients of management airway during used be may Ketamine ONLY. DIRECTOR MEDICAL ASSISTANT OR DIRECTOR MEDICAL system by the ORDER, MEDICAL tube. endotracheal or BIAD NP, a OP, either with in conjunction agent a paralytic without and with used be may Ketamine hypoxia Once management. airway with conjunction in hypotension or hypoxia of resuscitation the during used be may Ketamine requir patient combative dangerously the in used be may Ketamine though this is not validated and may prove impossible in the neonatal population (verification by two (2) other means is means other (2) two by (verification population neonatal the in impossible prove may and validated is not this though th in recommended Utilize in-line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar front front collar cervical or BIAD the intubation During BVM use. BIAD or intubation, during stabilization cervical in-line Utilize DOPE: D During intubation attempts use External Laryngeal Manipulation to improve view of glottis. glottis. of view improve to Manipulation Laryngeal External use attempts intubation During post-intubation. needed be may paralytics acting Longer off. wear drugs the when from self-extubation patient the Protect saturation oxygen maintain to able when transport) (short setting an urban in recommended is not Airway Assisted Drug needed. if stomach decompress and limit aspiration to patients intubated all in placement tube orogastric or Naso Consider Different laryngoscope blade blade laryngoscope Different size ETT Different positioning head Change unsuccessful. is intubation oral-tracheal if BIAD a using consider should AEMT / Paramedics Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam. neurologic a thorough with contraindications for screen drug, paralytic any administering Before equipment) to addition in provider of change (Consider try again: and adjustment an make fails, attempt intubation First If Continuous Waveform Capnography and Pulse Oximetry are required for intubation verification and ongoing patient monitoring, monitoring, patient ongoing and verification intubation for required are Oximetry Pulse and Capnography Waveform Continuous KETAMINE: This protocol is only for use in patients who are longer than the Broselow-Luten Tape. Broselow-Luten the than longer are who patients in use for only is protocol This See Pearls section of protocols AR 1 and 2. and 1 AR protocols of section Pearls See – workload the Divide Paramedics. 2 least at requires procedure This intubation. drugs, pressure, cricoid suction, ventilate, administere are medication paralytic and a sedative when arrest cardiac of risk at are hypotension and/or hypoxia with Patients Pearls Airway. Assisted to Drug specific Program Improvement Performance separate a maintain must Agencies Hypoxia and hypotension require resuscitation and correction prior to use of these combined agents. Ketamine allows time for for time allows Ketamine agents. combined these of use to prior correction and resuscitation require hypotension and Hypoxia management. airway during occur to resuscitation appropriate Revised 01/01/2017 or removed to facilitate translation of the mandible / mouth opening. mouth / mandible the of translation to facilitate or removed trachea: into tube endotracheal Place view. your improves if it Use some patients. in aspiration of risk may increase and view your may worsen pressure Cricoid gl best the you give to head / or and cartilage thyroid the manipulate to externally hand right your Use laryngoscopy: Bimanual device. CO2 tidal End saturation; oxygen Increasing fall; and rise Chest visualization; Direct by: glottis into tube of endotracheal placement Confirm dislodged. become not does tube endotracheal to assure times at all capnometry waveform continuous Maintain management: Post-intubation 90. than greater pressure blood systolic maintaining sedation maintain to needed as Versed Give RSI. following immediately hypotension transient Expect discourage are paralytics of doses Repeated noted. is movement patient if excessive sedation adequate after only Vecuronium Use needed. as vecuronium and versed restraints, physical of a combination with the airway Protect Most important caveat is determining the patient NOT APPROPRIATE for Rapid Sequence Intubation. Sequence Rapid for APPROPRIATE NOT patient the determining is caveat important Most Patients: Risk High Underlyi disease; respiratory Underlying injury; or illness Brain age > 55. All pre-hospital Rapid Sequence Intubations are to be considered HIGH RISK. HIGH considered be to are Intubations Sequence Rapid pre-hospital All > 55. age ven and oxygenation adequate with CPAP BVM / / maneuvers basic by managed be can who airway difficult anticipated with Patients only. transport rapid require protocols. Airway Failed Adult and Airway, Adult to Refer pa each with Cricothyrotomy and BIAD, Laryngoscopy, Mask, Valve a Bag in using the difficulty assess you sure make Specifically Preparation: and AirTraq Medications, Syringes, BIAD, Bougie, Elastic Gum Laryngoscope, BVM, Suction, Oxygen, equipment. test and Assemble device. Cricothyrotomy preferable. sites 2 with IV bore large Assure Pre-oxygenate: assessment. initial during occur optimally should Pre-oxygenation intubation. sequence rapid before oxygen flow high of 3 minutes at least Provide pre-oxygenation. adequate to provide means effective an is CPAP Sedate: and Paralyze mL. of 10 flushes saline normal with IV push rapid via and succession rapid in paralytic then first Etomidate Give and cannula nasal or mask by oxygen flow high Continue 92%: below de-saturates patient unless VENTILATE NOT DO given are medications Once is This open. airway to keep jaw thrust maintain seconds. 60 30 to about in be reached should condition Position: or pregn obese the in stretcher) or (pillows / torso head elevate to need May notch. sternal with canal auditory external Align umbilicus. your with line in nose patient’s the to place stretcher your use is anticipated Trauma: ventilations as long as airway patency is maintained. Maintain until intubation conditions are reached and you begin your intub your begin you and reached are conditions intubation until Maintain maintained. is patency airway as as long ventilations Airway Respiratory Protocol Section STRIDOR May repeat x 1 repeat May tamponade Repeat as needed x 3 Epinephrine Nebulizer 1 mg (1:1000) / 2 mL NS 2 mL / (1:1000) 1 mg Albuterol Nebulizer 2.5 – mg 5 Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) effusion Pleural Pneumonia embolus Pulmonary Pneumothorax Cardiac (MI or CHF) Pericardial Hyperventilation etc.) monoxide, (Carbon toxin Inhaled B A Differential AR 4 AR Adult Consider 2.5 – mg 5 if indicated Cardiac Monitor IV/ IO Procedure IV/ IO as indicated as indicated 0.3 – 0.5 mg IM Protocol AM 1 as indicated 125 mg IV / IO / IM Albuterol Nebulizer Epinephrine 1:1000 Methylprednisolone Repeatneeded as3 x 12 Lead ECG Procedure +/- Ipratropium 0.5 mg Airway CPAP Procedure Following Assessment Adult Airway Protocol(s) Infuse over 10 – 20 minutes Adult Protocol(s) Airway Notify Destination or Notify Destination Shortness of breath of Shortness Pursed lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi of accessoryUse muscles Fever, cough Tachycardia Magnesium Sulfate 2g IV / IO Allergic Reaction / Anaphylaxis / Anaphylaxis Reaction Allergic Contact Medical Contact Control Signs and Symptoms Signs and P B A P A B This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This WHEEZING Repeat as needed x 3 Albuterol Nebulizer– 2.5 mg 5 Home treatment (oxygen, nebulizer) Medications (theophylline, steroids, inhalers) inhalation smoke exposure, Toxic Asthma; COPD -- chronic bronchitis, emphysema, congestiveheart failure Revised 01/01/2017 History B Airway Respiratory Protocol Section Agency inue until improvement. until inue th viral upper respiratory tract th viral upper peat until improvement. ster from EMS supply. nistering any medication. nistering any albuterol solely with subsequent albuterol solely with subsequent , Asthma, Reactive Airway Disease, or nts, treatments should cont should treatments nts, Neck, Heart,Neck, Lungs, Abdomen, Extremities, Neuro with impending respiratory failure no improvement. and , give immediately and re and not responding to other treatments. used to compliance and care. evaluate protocol used AR 4 AR rol prior to EMT / EMR admirolEMT / EMR prior to g respiratory failure failure and no improvement. g respiratory fit use to continual of ipratropium. wheezing and respiratorydistress wi ider End-tidal CO2 monitoring if available. continuously and consider End-tidal CO2 monitoring , Allergic reactions, and CHF. is a pre-respiratory arrest sign. ng albuterol and ipratropium: albuterol and ng ts with respiratory distress, COPD bulizers,acceptable it iscontinue to This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This treatments as there is no proven benetreatments as there May be used with COPD, Asthma Consider early in treatment course. remains < 100 mmHg if SBP Consider removal If allergic reaction or anaphylaxis is suspected allergic reaction or If If allergic reaction is not suspected, administer Patients may receive more than 3 nebulizer treatme ne combination 3 Following Medical Director may require contact of medical contofrequire medicalMedical Director may contact A silent chest in respiratory distress already prescribed and may admini patient may administer Albuterol if EMT CPAP or Non-InvasivePositiveCPAP or Pressure Ventilation: Consider Magnesium Sulfate with impendin Pulse oximetry should be monitored Epinephrine: Epinephrine: Combination nebulizers nebulizers containi Combination Items in Red Text are key performance measuresText Items in Red all patien This protocol includes have Bronchospasm. Patientsalso may Recommended Exam: Mental Status, HEENT, Skin, infections and pneumonia. pneumonia. and infections Revised 01/01/2017 Pearls Supplemental oxygen Goal oxygen saturation ≥ 90% Assess Respiratory Rate, Effort, Preferably ≥ 94% Oxygenation YES Is Airway / Breathing Adequate? Exit to NO Appropriate Protocol(s)

Basic Maneuvers First -open airway chin lift / jaw thrust -nasal or oral airway -Bag-valve mask (BVM) Spinal Motion Restriction Procedure / Protocol TB 8 if indicated Consider AMS Protocol UP 4 Respiratory Distress with a Tracheostomy Tube

Protocol UP 13 Section Protocol Respiratory Airway if indicated

Airway Foreign Body Obstruction Airway Obstructed YES Procedure A Direct Laryngoscopy Airway Cricothyrotomy P Needle Procedure NO See Pearls Section

Supplemental Oxygen BVM Unable to Ventilate Breathing / Oxygenation YES Maintain and Oxygenate ≥ 90% during Support needed Oxygen Saturation ≥ 90 % or after one (1) or more Preferably ≥ 94 % unsuccessful intubation NO attempts . Airway BIAD Device Procedure and/or B if indicated Anatomy inconsistent with Monitor /Reassess continued attempts. Oral / Tracheal Supplemental Oxygen A and/or if indicated Intubation Procedure Three (3) unsuccessful attempts by most experienced Chest Decompression Procedure Paramedic/AEMT. if indicated Exit to Appropriate Protocol(s) Consider Airway Drug Assisted Exit to Pediatric Failed Airway P Protocol AR 3 if available Protocol AR 6 Post-intubation / BIAD Management Protocol AR 8 if indicated

Notify Destination or Contact Medical Control

Revised AR 5 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Airway RespiratorySection

Pearls For this protocol, pediatric is defined as any patient which can be measured within the Broselow-Luten tape. 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. 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. 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). Ventilatory rate: 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 8 - 10 per minute. Maintain a EtCO2 between 35 and 45 and avoid hyperventilation. Ketamine may be used during airway management of patients who FIT on the Broselow-Luten Tape with a DIRECT, ONLINE MEDICAL ORDER, by the system MEDICAL DIRECTOR OR ASSISTANT MEDICAL DIRECTOR ONLY. Specific use in this population of patients must also be for use in individual agencies by the NC OEMS State Medical Director prior to use. Agencies utilizing Ketamine must submit a local systems plan to State Medical Director detailing how the drug is used in your program. Ketamine may be used with and without a paralytic agent in conjunction with either a OP, NP, BIAD or endotracheal tube. Ketamine may be used during the resuscitation of hypoxia or hypotension in conjunction with airway management. Ketamine may be used in the dangerously combative patient requiring airway management IM. IV / IO should be established as soon as possible. Ketamine may NOT be used for purposes of sedation only – it must be used only during airway management procedures. It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. AEMT and Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. During intubation attempts use External Laryngeal Manipulation to improve view of glottis. 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. DOPE: Displaced tracheostomy tube / ETT, Obstructed tracheostomy tube / ETT, Pneumothorax and Equipment failure.

Revised AR 5 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Airway Respiratory Protocol Section Exit to Exit to Protocol AR 8 Post-intubation / Protocol(s) Appropriate Appropriate BIAD Management Continue BVM Needle Procedure See Pearls Section Supplemental Oxygen AirwayCricothyrotomy P YES YES 90% during during 90% ≥ 94 % 94 ≥ 94 % ≥ 90 % AR 6 AR ≥ Or 90 % 90 Attempt NO NO BVM and/or and/or ≥ Adequate Successful Preferably or equipment Device Procedure Failed Aiway Failed Preferably Preferably BIAD / Cricothyrotomy Airway Blind Insertion Airway Notify Destination or Oxygenation / / Ventilation Oxygenation Supplemental oxygen BVM with Airway Adjunts Maintain Oxygen Saturation Adjunctive Airway NP / OP Contact Medical Control Contact Medical Maintains Oxygen Saturation B Anatomy inconsistent with continuedattempts. Each attempt should include change in approach Unable to Ventilate and Oxygenate NO MORE THAN THREE (3) ATTEMPTS TOTAL or after one (1) or more unsuccessful intubation attempts. Three (3) unsuccessful attempts by most experienced Paramedic / AEMT. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This if available Call for additional Device Procedure Device resources if available if resources Airway Video Laryngoscopy Revised 01/01/2017 A Airway Respiratory Protocol Section Protocol Respiratory Airway

Pearls For this protocol, pediatric is defined as any patient which can be measured within a Length-based Resuscitation Tape. 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. 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). Ventilatory rate: 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 8 – 10 per minute. Maintain a EtCO2 between 35 and 45 and avoid hyperventilation. 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 AEMT and Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. During intubation attempts use External Laryngeal Manipulation to improve view of glottis. 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. DOPE: Displaced tracheostomy tube / ETT, Obstructed tracheostomy tube / ETT, Pneumothorax and Equipment failure.

Revised AR 6 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Airway Respiratory Protocol Section rway infection rway May repeat x 1 repeat May 1.25 - 2.5 mg STRIDOR / Croup / STRIDOR Epinephrine Nebulizer Albuterol Nebulizer 1 mg (1:1000) in 2 mL NS 2 mL in (1:1000) 1 mg Asthma / Reactive Airway Disease Aspiration Foreign body Upper or lower ai Congenitalheart disease / CHF ingestion OD / Toxic Anaphylaxis Trauma A B Differential AR 7 AR IV / IO / IM if indicated Pediatric 1.25 -mg 2.5 Cardiac Monitor 0.01 mg/ kg IM IV / IO Procedure as indicated as indicated as indicated Maximummg 0.3 Protocol PM 1 Maximum 125 mg Epinephrine 1:1000 Albuterol Nebulizer Repeat as needed x 3 needed as Repeat No response: Consider +/- Ipratropium 0.5 mg 12 Lead ECG Procedure Following Assessment ReactionAnaphylaxis / Infuse over 10 – 20 minutes Notify Destination or Methylprednisolone 2 mg / kg Contact Medical Control Contact Medical Pediatric Airway Protocol(s) 5 - 7 Pediatric Airway Protocol(s) 5 - 7 Magnesium Sulfate 40 mg/kg IV / IO Nasal Flaring / Retractions / Grunting Rate Heart Increased AMS Anxiety Attentiveness / Distractability Cyanosis Poor feeding Sputum Frothy JVD / Hypotension Wheezing/ Stridor / Crackles / Rales P P B A A Signs and Symptoms This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 1.25 -1.25 mg 2.5 Albuterol Nebulizer WHEEZING / Asthma Revised Congenital heart disease History of trauma choking of / possibility History Ingestion / OD Past Medical History Medical Past Medications Fever / Illness Sick Contacts Time of onset of Time Possibility of foreign body 01/01/2017 B History Airway Respiratory Protocol Section Agency 15 years 2.5 – 15 years 2.5 5 ≥ itial beta-agonist treatment. inue until improvement. until inue set, possiblestridor, patient th viral upper respiratory tract th viral upper ntthe patient’suse then supply for peat until improvement. ster from EMS supply. ort. They will protect their airway their protectThey will ort. albuterol solely with subsequent albuterol solely with subsequent thma, ReactiveDisease, Airwaythma, croup, or nts, treatments should cont should treatments nts, onths and not responding to in Neck, Heart,Neck, Lungs, Abdomen, Extremities, Neuro with impending respiratory failure no improvement. and 92 % after first beta agonist treatment. , give immediately and re ≤ used to compliance and care. evaluate protocol used AR 7 AR is viral, possiblegradual fever,is viral, onset, no drooling is noted. mmon. Airway manipulationmmon. may worsen the condition. g respiratory failure failure and no improvement. g respiratory fit use to continual of ipratropium. wheezing and respiratorydistress wi ou may use Albuterol for the first treatme Medical Control prior to administration. allow them to assume position of comf to assume position of them allow red continuously in the patientred continuously with respiratory distress. ng albuterol and ipratropium: ipratropium: albuterol and ng bulizers,acceptable it iscontinue to l patients with respiratory distress,with l patients As 1 year of age 1.25 mg; 1 –mg; age 1.25 1 year of 1.25years – 6 – 2.5 mg; 6 2.5 mg; 14 years This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This ≤ treatments as there is no proven benetreatments as there Following 3 combination ne combination 3 Following anaphylaxis is suspected allergic reaction or If If allergic reaction is not suspected, administer Patients may receive more than 3 nebulizer treatme mg. open,to keep airwayupwants drooling sit to is co of requiremedical director may Contact In patientsy using levalbuterol (Xopenex)In already prescribed and may admini patient may administer Albuterol if EMT Croup typically affects children < 2 years of age. It bacterial,onrapid with fever,Epiglottitis It is2 years typically of age. > affects children Bronchiolitis is a viral infectionisBronchiolitis typically affecting infantsresults whichwhichin wheezingto beta-not respond may agonists. Consider Epinephrine nebulizer if patient < 18 m Albuterol dosing: Albuterol accessremains oximetry whenConsider IV Pulse Do not force a child into a position, Consider Magnesium Sulfate with impendin Epinephrine: Epinephrine: position. by their body repeat nebulizers or agency’s supply. Combination nebulizers nebulizers containi Combination Pulse oximetryshould be monito al This protocol includes Recommended Exam: Mental Status, HEENT, Skin, are key performance measuresText Items in Red Bronchospasm. Patients may also have Bronchospasm. Patientsalso may infections and pneumonia. pneumonia. and infections Revised 01/01/2017 Pearls Airway Respiratory Protocol Section Exit to Propofol If available Appropriate Appropriate Protocol / Policy Protocol(s) 1 – 1 Protocol(s) 7 Interfacility Transfer Adult or Pediatric Airway Airway Pediatric or Adult NO NO 90 % 90 ≥ 94 % ≥ every 5 minutes as needed Or AR 8 AR YES YES If available as indicated every 5 minutes as needed as minutes 5 every Successful See Pearls Cardiac Monitor IV / IO Procedure (preferably 2 sites) Maximum 10 mg Maximum 10 mg Maximum 10 mg EtCO2 35 – 35 EtCO2 45 Maximum 300 mcg Maximum 2 mcg / kg Preferably Preferably Morphine 4 mg IV / IO 12 LeadProcedure ECG Not indicated in Pediatrics Awakening or Moving or Moving Awakening May requireMay faster rate Maintain SpO2 Consider long term paralytic 0.5 mcg / kg / mcg 0.5 Notify Destination or Fentanyl 50 - 75 mcg IV / IO Maximum single dose 5 mg Pediatric: 0.1 mg / kg IV / IO Midazolam 2 - 2.5 mg IV / IO Continue Airway Adjuncts Transport Ventilator Procedure If needed for patient movement. Pediatric: 1 mcg / kg IV / IO / IN Contact Medical Control Contact Medical Evidence of Anxiety / Agitation Repeat every 5 minutes as needed Ketamine 1.5 – 2.0mg / kg IV / IO Ventilate 8 – 10 breaths / minute after Intubation / BIAD Placement Repeat every 3 – 5 minutes as needed Pediatric: 0.1 – 0.2 mg / kg IV / IO / IN Vecuronium 10 mg (0.1 mg/kg) IV / IO Repeat 2 mg ETT or Blind Insertion Airway Device Device Airway Insertion ETT or Blind P B A May repeat P This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This management. Revised Drug Assisted Airway 01/01/2017 Protocol) as they contain should be utilized together (even if agency is not using useful information for airway airway for information useful Protocols AR 1, 2, 3, 5, and 6 Airway Respiratory Protocol Section , and prolonged Equipment failure. esentations. Medical director ia, immunosuppression neumothorax and and Pneumothorax experienceand anxiety. pain of elevationto decrease when possible aspiration risk. my tube / ETT, my tube can provide clues to inadequate sedation,to inadequateprovide clues can however ted, disconnect from ventilator to assess lung compliance. . With mechanical ventilationa reasonable tidal volume AR 8 AR ioids are typically theioids are typically first line agents before s of patient’s lack of adequate sedation. e pain / anxiety and providers are poor at recognizing pain / anxiety. bstructed tracheosto a reasonable first choice agent. us, HEENT, Heart, Lungs, Neuro Heart, Lungs, us, HEENT, eased catecholaminerelease, ischem rways and ventilation commonly rways and ventilation This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This isplaced tracheostomy tube / ETT, O hospitalization. Search for dislodged ETT or BIAD, obstruction in tubing or airway, pneumothorax, or ETT balloon leak. DOPE: D Head of bed should be maintained at least 10 –shouldbed be maintained at least 10 of Head 20 degrees With abrupt clinical deterioration, if mechanicallyventila In general ventilation with BVM should cause chest rise Continuous pulse oximetry and capnography should be maintained during transport for monitoring. Pain must be addressed first, before anxiety. Op first, be addressed Pain must to individual patientpr to be tailored Ventilation strategies will need / Ventilator Ventilated patientsVentilated cannot communicat tachycardiasuch hashypertension Vital signs and / or Patients requiring advanced ai to incr lead Unrelieved pain can RecommendedStat Exam:Mental reliablethey both are not always indicator also is Ketamine benzodiazepines. different strategies above. can indicate shouldbeaboutpressures 6 mL/kg and peak shouldbe < 30 cmH20. Revised 01/01/2017 Pearls Airway Respiratory Protocol Section r Exit to YES Equipment failure. Appropriate protocol(s) Disruption of oxygen source Dislodged or obstructed tracheostomy tube Detached or disrupted ventilator circuit Cardiac arrest Increased oxygen requirement/demand Ventilator failure neumothorax and and Pneumothorax operation during transport. Differential NO Other problems Other Notify Destination or Notify Destination Problem with Circulation / my tube / ETT, my tube Contact Medical Control and maintain current settings Transport on patients ventilator AR 9 AR P Emergencies Protocol AR 10 nowledgeable in ventilator Tracheostomy Tube Tracheostomy Correct cause Correct bstructed tracheosto Power or equipment failure at residence Transport requiring maintenance ventilator a mechanical of NO YES YES YES Signs and Symptoms Signs and YES YES Low Power: Internal battery depleted. High Pressure: Plugged / obstructed airway or circuit. 94 %) This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This ≥ Or NO NO NO NO NO YES isplaced tracheostomy tube / ETT, O Tube / ETT Tube / ETT Cause corrected Cause Problem with Airway, Remove patient from ventilator ventilator from patient Remove 90 % (Preferably EtCO2 35 – 35 EtCO2 mmHg 45 Oxygenation saturation Oxygenation and manually ventilate with BVM with ventilate manually and (Ask Caregiver: What is (Ask Caregiver: Dislodged Tracheostomy Detached Oxygen Source Obstructed Tracheostomy Tracheostomy Obstructed Detached Ventilator Circuit ≥ Ventilation or Oxygengation DOPE: D Typical alarms: Low Pressure / Apnea: Loose or disconnected circuit, leak in circuit or around tracheostomy site. Always use patient’s equipment if available and functioning properly. Continuous pulse oximetry and end tidal CO2 monitoring must be utilized during assessment and transport. Unable to correct ventilator problem: Remove patient from ventilator and manually ventilate using BVM. Take patient’s ventilato Always talk to family / caregivers as they have specific knowledge and skills. If using the patient’s ventilator bring caregiver k to hospital even if not functioning properly. Revised Medical condition (bronchopulmonary dysplasia, dystrophy) muscular Surgical complications (damage (damage complications Surgical to phrenicnerve) Trauma (post-traumatic brain or spinal cord injury) Birth defect (tracheal atresia, Birth defect tracheomalacia, craniofacial abnormalities) 01/01/2017 baseline saturation for patient) Pearls History Airway Respiratory Protocol Section Or plug Equipment failure. Remove Inner Cannula Remove Decannulation Remove Speaking Valve Age Appropriate Assist Ventilations via via Ventilations Assist Tracheostomy/ ETT Tube YES A Respiratory Distress Protocol Distress Respiratory Allergic reaction Asthma Aspiration Septicemia body Foreign Infection Congenitaldisease heart Medication or toxin Trauma neumothorax and and Pneumothorax YES Differential NO Procedure Procedure in place in place Inner Cannula Tracheostomy Tube (Double lumen) Advanced Suctioning Speaking Valve / Decannulation plug Decannulation my tube / ETT, my tube A NO Continued Continued AR 10 YES Respiratory Distress Notify Destination or to Contact Medical Control Contact Medical Emergencies bstructed tracheosto Tracheostomy Tube Tracheostomy Or Or Chest wall retractions (with or withoutabnormal breath sounds) Attempts to cough Copious secretions noted coming theout of tube Faint breath sounds on both sides significant despite chest of respiratory effort AMS Cyanosis Nasal flaring Tube Tube Caregiver gone laryngectomy. does not This allow mouth/nasal ventilation by covering stoma. If in place Signs and Symptoms Signs and ETT into stoma Remove Obturator Remove Allow Appropriately sized insert Tracheostomy Place Trachesotomy A A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This YES YES isplaced tracheostomy tube / ETT, O NO NO DOPE: D Suction depth: Ask family / caregiver. No more than 3 to 6 cm typically. Instill 2 – 3 mL of NS before suctioning. Do not suction more than 10 seconds each attempt and pre-oxygenate before and between attempts. DO NOT force suction catheter. If unable to pass, then tracheostomy tube should be changed. Always deflate tracheal tube cuff before removal. Continual pulse oximetry and EtCO2 monitoring if available. Important to ask if patient has under Use patients equipment if available and functioning properly. Estimate suction catheter size by doubling the inner tracheostomy tube diameter and rounding down. Always talk to family / caregivers as they have specific knowledge and skills. Trauma (post-traumatic brain or spinal cord injury) or (bronchial condition Medical muscular dysplasia, pulmonary dystrophy) Surgical complications complications Surgical (accidental damage to phrenic nerve) Birth defect (tracheal atresia, Birth defect tracheomalacia, craniofacial abnormalities) Tube in place Trachesotomy Trachesotomy Trachesotomy Trachesotomy Revised Tube available 01/01/2017 Pearls History History Signs and Symptoms Differential Events leading to arrest Pulseless Respiratory failure Estimated downtime Apneic Foreign body SAMPLE No electrical activity on ECG Infection (croup, epiglotitis) Existence of terminal illness No heart tones on auscultation Congenital heart disease Airway obstruction See Reversible Causes below Hypothermia Suspected abuse Pediatric Pulseless Arrest Protocol Decomposition Rigor mortis Dependent lividity Blunt force trauma Criteria for Death / No Resuscitation Injury incompatible with Review DNR / MOST Form life Extended downtime with YES NO asystole Do not begin Begin Continuous CPR Compressions resuscitation Push Hard (1.5 inches Infant / 2 inches in Children) (≥ 1/3 AP Diameter of Chest) Follow Push Fast (100 - 120 / min) Deceased Subjects Change Compressors every 2 minutes Policy (Limit changes / pulse checks ≤ 10 seconds) Section Protocol Cardiac Pediatric

I Ventilate 1 breath every 6 seconds AT ANY TIME 15:2 Compression:Ventilation if no Advanced Airway

AED Procedure Return of if available Spontaneous Circulation Search for Reversible Causes Blood Glucose Analysis Procedure Reversible Causes Cardiac Monitor Go to P Hypovolemia Consider Chest Decompression-Needle Procedure Post Resuscitation Hypoxia Hydrogen ion (acidosis) IV / IO Procedure Protocol Hypothermia Epinephrine1:10,000 Hypo / Hyperkalemia 0.01 mg/kg IV / IO Maximum Single Dose 1mg Or Tension pneumothorax A Epinephrine 1:1000 0.1 mg / kg ETT Maximum 2.5 mg Tamponade; cardiac Repeat every 3 – 5 minutes Toxins Thrombosis; pulmonary Normal Saline Bolus 20 mL/kg IV / IO May repeat as needed (PE) Maximum 60 mL/kg Thrombosis; coronary (MI)

Consider Epinephrine 0.1 – 1 mcg / kg / min IV / IO P Or Dopamine 2 – 20 mcg /kg / min IV / IO See Pearls

Notify Destination or Contact Medical Control

Revised PC 1 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Pediatric Cardiac Protocol Section Protocol Cardiac Pediatric

Pearls Recommended Exam: Mental Status Beginning compressions first is recommended in pediatric patients during CPR. However, the majority of pediatric arrests stem from a respiratory insult or hypoxic event. Compressions should be coupled with ventilations. When 1 provider is present, perform 30 compressions with 2 ventilations. When 2 providers are present, perform 15 compressions with 2 ventilations. 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 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. High-Quality CPR: Make sure chest compressions are being delivered at 100 – 120 / min. Make sure chest compressions are adequate depth for age and body habitus. Make sure you allow full chest recoil with each compression to provide maximum perfusion. Minimize all interruptions in chest compressions to < 10 seconds. Do not hyperventilate, ventilate every 6 seconds only. Use AED or apply ECG monitor / defibrillator as soon as available. Airway is a more important intervention in pediatric arrests. This should be accomplished quickly with BVM or BIAD. Patient survival is often dependent on proper ventilation and oxygenation / Airway Interventions. Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Consider Team Focused Approach / Pit-Crew Approach assigning responders to predetermined tasks. Refer to optional protocol. Vasopressor agents: Dopamine 2 – 20 mcg / kg / min IV / IO Epinephrine 0.1 – 1 mcg / kg / min IV / IO Norepinephrine 0.1 – 2 mcg / kg / min IV / IO Dose Calculation: mL / hour = kg x dose(mcg / kg / min) x 60 (min / hr) / concentration (mcg / mL) In order to be successful in pediatric arrests, a cause must be identified and corrected. If no IV / IO access may use Epinephrine 1:1000 0.1 mg/kg (0.1 mL/kg) via ETT (Maximum 2.5 mg)

Revised PC 1 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Pediatric Cardiac Protocol Section locally Revised 10/08/2017 Exit to Protocol(s) Exit to Pediatric Appropriate Pediatric Pediatric Appropriate Cardiac Arrest Reversible Causes Protocol PC 1, 4, 6 4, PC 1, Protocol Hypovolemia Hypoxia (acidosis) ion Hydrogen Hypothermia / Hyperkalemia Hypo Tension pneumothorax cardiac Tamponade; Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) Respiratory failure, Foreign body, Secretions, Infection (croup, epiglotitis) (dehydration) Hypovolemia Congenitalheart disease Trauma Tension pneumothorax Hypothermia Toxinmedication or Hypoglycemia Acidosis Differential YES PC 2 otocol(s) AR 5, 6 5, AR otocol(s) Or 70 + 2 x Age + 2 70 NO Titrate to Consider AND ≥ May repeat x 1 Cardiac Monitor Bradycardia 20 ml / kg IV / IO IV / IO Procedure as indicated SBP Cardiac arrest? Normal SalineBolus Repeat as needed x 3 needed as Repeat kg / mL 60 Maximum Identify underlying cause Cardiac Pacing Procedure Poor Perfusion / Shock Poor Perfusion Poor Perfusion / Shock Poor Perfusion Typically HR < 50/min Decreased heart rate Delayed capillary refill or cyanosis Mottled, cool skin Hypotension or arrest Altered level of consciousness Search for reversible causes Notify Destination or Atropine 0.02 mg / kg IV / IO Minimum single dose 0.1 mg Maximum single dose 0.5 mg 0.5 dose single Maximum Causing Hypotension / AMS / Hypotension Causing Contact Medical Control Contact Medical Blood Glucose Analysis Procedure Analysis Glucose Blood Signs and Symptoms Signs and Pediatric Airway Pr Bradycardia / Heart Rate < 60 Persists Epinephrine 0.1 – 1 mcg / kg / min IV / IO P P A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Protocol Medication (maternal or infant) (maternal Medication Respiratory distress or arrest or distress Respiratory Apnea Possible toxic or poison exposure disease Congenital Past medical history medical Past exposure body Foreign Revised Toxicology Toxicology 06/08/2017 Follow Pediatric Follow Suspected Beta- Channel Blocker History Blocker or Calcium Pediatric Cardiac Protocol Section locally Revised 10/08/2017 y intervention. and Monitor ygenation, begin CPR immediately. bdomen, Back, Extremities, Neuro d with known congenital or acquired heart disease. other AV blocks which are not responsive to oxygenation, ations requires no emergenc PC 2 te ventilation and ox evident and no ECG monitor is available. persistent, symptomatic bradycardia. us, HEENT, Skin, Heart, Lungs, A pulses, perfusion, and respir This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Dopamine 2 – 20 mcg / kg / min IV / IO Epinephrine 0.1 – 1 mcg / kg / min IV / IO Norepinephrine 0.1 – 2 mcg / kg / min IV / IO Dose Calculation: mL / hour = kg x dose(mcg / kg / min) x 60 (min / hr) / concentration (mcg / mL) Indicated if bradycardia is due to complete heart block or ventilation, chest compressions, or medications. Indicate Transcutaneous pacing is not indicated for asystole or bradycardia due to postarrest hypoxic / ischemic myocardial insult or respiratory failure. the per patients pediatric for appropriate pads of use the require pacing transcutaneous external requiring patients Pediatric manufacturers guidelines. continue evaluation with reassessments. The majority of pediatric arrests are due toairway problems. Most maternal medications pass through breast milk to the infant so maintain high-index of suspicion for OD-toxins. Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. Many other agents a child ingests can cause bradycardia, often is a single dose. Do not delay therapy when bradycardia is Vasopressor agents: Atropine is second choice, unless there is evidence of increased vagal tone or a primary AV conduction block, then given Atropine first. Transcutaneous pacing: With HR < 60 / min poor and perfusion despite adequa Epinephrine is first drug choice for Use Length-based Resuscitation for drugTape dosages if applicable. Ensure patent airway, breathing, and circulation as needed. Administer oxygen. Reassess if bradycardia persists after adequate oxygenation and ventilation. Bradycardia withadequate Recommended Exam: Mental Stat Revised 06/08/2017 Pearls Pediatric Cardiac Protocol Section Pediatric Anaphylaxis as indicated Protocol PM 1 Protocol Pediatric Airway Allergic Reaction Protocol(s) 5, 6, 7 e underlying cause and may Congestive heart failure Asthma Anaphylaxis Aspiration Pleural effusion Pneumonia Pulmonary embolus Pericardial tamponade Exposure Toxic Differential NO YES NO YES PC 3 if indicated ema may vary depending th on Cardiac Monitor Anaphylaxis IV / IO Procedure Airway Patent Airway if available Allergic Reaction Pulse Oximetry / EtCO2 12 LeadECG Procedure Ventilations adequate Ventilations Oxygenation adequate Notify Destination or Contact Medical Control Contact Medical P B A Child/Adolescent: Respiratory distress, bilateral rales, apprehension, orthopnea, jugular vein distention (rare), pink, frothy sputum, peripheral edema, diaphoresis, chest pain Hypotension, shock Infant: Respiratory distress, poor poor distress, Respiratory Infant: feeding, lethargy, weight gain, +/- cyanosis r consultation of Medical Control. espiratory, Cardiac, Skin, Neuro Transport to a Pediatric Specialty Center Signs/Symptoms Position child with head of bed in up-position (25-40°) congenital heart defect, obtain a precise past medical history. Flexing hips with support under knees so that they are bent 90° ase varies by age: ase varies by This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This known CHF Lasix 1 mg/kg IV / IO. Agency specific vasopressor. < 1 month: Tetralogy of Fallot, Transposition of the great arteries, Coarctation of the aorta. 2 – (ASD). defects Atrioseptal (VSD), defects septal Ventricular 6 months: Any age: Myocarditis, Pericarditis, SVT, heart blocks. Morphine Sulfate: 0.1 mg/kg IV / IO. Max single dose 5mg/dose Fentanyl: 1 mcg/kg IV / IO. Max single dose 50 mcg. Nitroglycerin: Dose determined afte consistent with respiratory History / Signs / Symptoms / Symptoms / Signs History Do not assume all wheezing is pulmonary, especially in a cardiac child: avoid albuterol unless strong history of recurrent wheezing secondary to pulmonary etiology (discuss with Medical Control) include the following with consultation by Medical Control: Treatment of Congestive Heart Failure / Pulmonary ed Contact Medical Control early in thethe pediatric care of cardiacpatient. Most children with CHF have a Congenital heart dise Recommended exam: Mental status, R status, Mental exam: Recommended Congestiveheart failure history medical Past Congenital Heart Disease Disease Lung Chronic distress with crackles / rales / / rales crackles with distress Revised 01/01/2017 Pearls History Pediatric Cardiac Protocol Section YES Pediatric Pediatric Exit to Exit to Tachycardia Protocol PC 6 Protocol PC 5 Protocol(s) 5, 6 Policy Pediatric Airway Pediatric Pediatric VF / VT Follow Newly Born Protocol AC 3 Protocol2 AO resuscitation Do not begin Adult Arrest Cardiac Deceased Subjects Shockable Rhythm YES YES YES YES Respiratory failure: Foreign body, Secretions, Infection (croup,epiglotitis) (dehydration) Hypovolemia Congenital heart disease Trauma Tension pneumothorax, cardiac tamponade, pulmonary embolism Hypothermia Toxin or medication Electrolyte abnormalities (Glucose, K) Acidosis NO PEA Differential Protocol PC 1 Protocol Protocol(s) 5, 6 Pediatric Airway Airway Pediatric 10 seconds) Pediatric Asystole / ≤ 31 days old PC 4 h every 6 seconds ≤ NO NO NO if available 16 years old years 16 ALS Available ≥ Defibrillation Automated 1/3 AP Diameter of Chest) AP Diameter 1/3 Unresponsive Cardiac arrest Push Fast (100 - 120 / min) Notify Destination or (≥ Newly Born Newly / Review DNR / MOST Form Review DNR Contact Medical Control Contact Medical Ventilate 1 breat Signs and Symptoms Signs and Change Compressors every 2 minutes BeginContinuous CPR Compressions Criteria for Death / No Resuscitation Defibrillation Automated (Limit changes / pulse checks YES Push Hard (1.5 inches Infant / 2 inches in Children) 15:2 Compression:Ventilation if no Advanced Airway NO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Continue CPR Shockable Rhythm Shockable Protocol(s) 5, 6 Pediatric Airway Airway Pediatric 5 Cycles / 2 Minutes Repeat and reassess Go to Protocol Return of Circulation Medications Possibility of foreign body Hypothermia Time of arrest Time of Medical history Revised Spontaneous 01/01/2017 NO AT ANYTIME Post Resuscitation History Pediatric Cardiac Section 4 J/kg ) ≥ wever, the majority of the majority wever, should be coupled with should Maximum 2.5mg – Hypoxic associated cardiac arrest de. IV/IO accesspreferablyde. IV/IO above ocol caveats whenocol caveatswith dialysis / faced ociated cardiac arrest. If suspected, AD first to limit interruptions. via ETT ( via ETT th 2 ventilations. ventilate 8 –ventilate 8 continuous, with minute 10 breaths per ease in importance.easenotNaloxone associated is with iority followed by high-quality and continuousiority chest ailable and proximate. Place mother supine and performandPlace mother supineailable and proximate. available and / or difficult IV access anticipated. pproach assigningpproach responders to predetermined tasks. Refer hypoxic event. Compressions PC 4 der Return of Spontaneous Circulation (ROSC) ond defibrillation is 4 J/kg, subsequent shocks ng uterus to the patient’s left sithe patient’s left ng uterus to 1/3 anterior-posterior diameter of chest, in infants1.5 inches and anterior-posteriorchest, of diameter 1/3 ≥ sts, a cause muststs, corrected.and be identified - Refer to Dialysis / Renal Failure prot mmended in pediatric patientsin pediatric during CPR. Ho mmended m 15 compressions with15 compressions 2 ventilations. m 30 compressions wi Epinephrine 1:1000 0.1 mg/kg (0.1 mL/kg) - Naloxone cannotopioid-ass in be recommended -Controlto Medical and mother per appropriateimmediate notification Treat protocol with ndicated. Compress Compress ndicated. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Pacing is NOT effectivecardiacarrestpacingandin cardiac arrest in NOT increase does of chance survival Maternal Arrest rapid transport preferably to obstetrical center if av If EtCO2 is < 10mmHg,< improveIf EtCO2 is chest compressions. If EtCO2 spikes,consi typically > 40 mmHg, Manual Left Uterinemovi Displacement improved outcomes in cardiac arrest. Strike / Lightning Hanging / / Asphyxiation Suffocation / Drowning attention to airway, oxygenation, and ventilation incr and prompt attention to airway and ventilation is pr compressions and early defibrillation. diaphragm. Defibrillationlevels.all energysafe is at Renal Dialysis / Renal Failure renalfailure patient experiencing cardiacarrest. Overdose Opioid If no IV / IO access may use In orderpediatric to be successfulIn arre in Transcutaneous Pacing: Success is basedon properplanningandexecution. Procedures requirespace and patient access. Make room to work. Consider Team FocusedApproachA / Pit-Crew to optional protocol. pediatricfroma respiratory arrests stem insult or ventilations. uninterrupted compressions. Considerations Special (Maximum 10 J/kg or adult dose) or J/kg (Maximum 10 CO2 (EtCO2) Tidal End place endotracheal place to tube. ConsiderDo not BI interrupt compressions Defibrillation:J/kg, sec First defibrillationis 2 DO NOT HYPERVENTILATE:DO NOT place in airway advanced If When 1 provider is present, 1 provider performWhen When 2 providers are perfor present, Efforts should be directed at high quality early and and interruptionsus compressions withcontinuo limited i when defibrillation placement if IO Consider early in children 2 inches. Beginning compressions first is reco is Beginning compressions first Recommended Exam: Mental Status RecommendedMental Exam: Revised 01/01/2017 Pearls Pediatric Cardiac Protocol Section 2 J / Kg 4 J / Kg 4 J IV / IO / IN / IO / IV YES 0.5 – 1 J / kg Consider sedation Or adult maximum adult Or May repeat if needed Cardioversion Procedure Cardioversion May increase to to increase May Do NOT delaycardioversion Maximum Total Dose 5 mg 5 mg Dose Total Maximum Midazolam0.1 – 0.2 mg / kg Maximum Single Dose 2 mg Dose Single Maximum Repeat and increase to Heart disease (Congenital) / Hyperthermia Hypo or Anemia Hypovolemia imbalance Electrolyte Anxiety / Pain / stress Emotional Fever / Infection / Sepsis Hypoglycemia Hypoxia, Medication / Toxin / Drugs (see HX) embolus Pulmonary Trauma, Tension Pneumothorax P Differential NO May repeat Adenosine Adenosine Unstable perfusion AMS / Poor Maximum 6 mg 6 Maximum Possible VT Maximummg 12 0.1 mg / kg IV / IO Hypotension / 0.2 mg / kg IV / IO YES Only if rhythm is regular and QRS are monomorphic P YES PC 5 Infant > 220/bpm Rhythm Converts 12 Lead ECG Procedure Notify Destination or NO Contact Medical Control Contact Medical 0.09 seconds Pale or Cyanosis Pale Diaphoresis Tachypnea Vomiting Hypotension Consciousness of Level Altered Congestion Pulmonary Syncope Heart Rate: Child > 180/bpm ≥ Cardiac Monitor IV / IO Procedure IV Signs and Symptoms Signs and QRS B May repeat Adenosine Adenosine HR Typically > 180 Child HR Typically > 220 Infant 12 Lead ECG Procedure Lead 12 Maximum 6 mg Vagal Maneuvers Maximum 12 mg 0.1 mg / kg IV / IO 0.2 mg / kg IV / IO Probable SVT Unstable / Serious Signs and Symptoms and Signs / Serious Unstable NO P P B A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This (Aminophylline, Diet pills, Thyroid supplements, Digoxin) Decongestants, Exit to Go to Protocol(s) Pulseless arrhythmia Appropriate Tachycardia Congenital Heart Disease Respiratory Distress Syncopeor Near Syncope Drugs (nicotine, cocaine) Past medical history medical Past Medications or Toxic Ingestion Probable Sinus Revised 12 Lead ECG not ECG not Lead 12 Identify and Treat 01/01/2017 Underlying Cause Underlying Arrest Protocol AT ANYTIME diagnose and treat whenpatient is stable. necessary to diagnose Pediatric Pulseless and treat, but preferred History Single lead ECG able to Pediatric Cardiac Section are / minute. Childrenusually/ minute. ck, Extremities, Neuro each therapeutic intervention. careful not to occlude the airway. d together. Consultation with Medical isControl 0.09 seconds.) P waves absent or abnormal. R-R ≤ s. Infants usually < 220 beats Infants s. ild blow out “birthday candles”ild blow or through an obstructed ainamide 15 mg / kg over 30 – 60 minutes IO IV / normal to > 200 / minute. Most children Most with VT have to > 200 / minute. normal ated if Diazepam, Lorazepam, or Midazolam is used. obtain monitor strips with Lung, Heart, Abdomen, Ba Heart, Abdomen, Lung, PC 5 aped) Tachycardia: onset. Infants usually > 220 beats / minute. Children usually > 180 with or without hypotension. or without with 0.09 seconds): 0.09 ≤ phic (multiple sh phic (multiple 0.09 seconds): ≥ This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Magnesium Sulfate 40 mg / kg IV / IO over Cardiac arrest10 minutes. minutes.over given 2 waves not variable. Usually abrupt beats / minute. < 180 beats / minute. underlying heart disease / cardiac surgery / long QT syndrome / cardiomyopathy. recommended agents. They should not be administere advised whenthese agents areconsidered. Atrial / Fibrillation Flutter SVT: > 90 % of children with SVT will have a narrowSVT will have QRS ( with SVT: > 90 % of children Breath holding.HaveBreath ch a balloon. a glove into Blowing Rate is typically 150 to 250 beats / minute. Associated with longsyndrome, QT hypomagnesaemia, hypokalemia, many cardiac drugs. May quicklydeteriorate toVT. Administer the faceupper half of a bag of ice water over the May put straw. Infants: SVT with aberrancy. VT: Uncommon in children. Rates may vary from near Respiratory distress / failure. Respiratory/ distress Signs of / poor shock perfusion AMS Sudden collapse with rapid, weak pulse Sinus tachycardia: P waves present. Variable R-R wave –20kg over / Amiodarone 5 mg Proc 60 minutes or Generally, the maximum sinus tachycardia rate is 220 – the patient’s age in years. Monitor for respiratory depression and hypotension associ Continuous pulse oximetry is required for all SVT Patients if available. Documentrhythm changes all with monitor strips and Separating the child from the caregiver may worsen the child's clinical condition.Separating the child from worsencaregiver the may Pediatricpaddles10 kg or Broselow-Luten should < in childrenbe usedPurplecolor if available. Vagal Maneuvers: Torsades de Pointes / Polymor Wide Complex Tachycardia ( Narrow Complex Tachycardia ( Narrow Serious Signs and Symptoms: and Signs Serious Recommended Exam: Mental Status, Skin, Neck, Revised 01/01/2017 Pearls Pediatric Cardiac Protocol Section locally Revised 10/08/2017 Or May repeat Maximum 2 g 1 – 2 minutes every 5 minutes every Persistent VF / VT Magnesium Sulfate TorsadesPoints de 40 mg/kg IV / IO over Respiratory failure / Airway obstruction Hypovolemia / hypokalemia, Hyper Acidosis Hypoglycemia, Hypothermia, Tension pneumothorax, Tamponade or medication Toxin Thrombosis: Coronary / Pulmonary Embolism Congenitaldisease heart Differential 10 seconds) ≤ 4 J / kg ≥ d resuscitation tape for PC 6 h every 6 seconds Or Or dosing Consider if available Amiodarone IV / IO Procedure Maximummg 2.5 Arrest Protocol compressions. Lidocainemg/kg 1.5 Epinephrine1:10,000 Pediatric Pulseless Defibrillation Automated (5 mg/kg –(5 mg/kg 300mg) max 1/3 AP Diameter of Chest) AP Diameter 1/3 If Rhythm Refractory Repeat every 3 – 5 minutes (Push Fast (100 - / 120 min) Notify Destination or Subsequent shocks (≥ Maximum 10 J / kg or adult dose adult or / kg 10 J Maximum Contact Medical Control Contact Medical 0.01 mg/kg IV / IO Maximum 1mg if availablerhythm and refractory Ventilate 1 breat Epinephrine 1:1000 0.1 mg / kg ETT mg / kg 0.1 1:1000 Epinephrine defibrillate with device charged. Unresponsive Defibrillation Manual Procedure 4 J / Kg Defibrillation Manual Procedure 2 J/ Kg Cardiac Arrest Change Compressors every 2 minutes BeginContinuous CPR Compressions Repeat pattern during resuscitation. Signs and Symptoms Signs and Defibrillation Dual Sequential Manual Procedure (Limit changes / pulse checks arrhythmic(s). Continue epinephrine during Continue CPR and give Agency specific Anti- Push Hard (1.5 inches Infant / 2 inches in Children) See length based color code 15:2 Compression:Ventilation if no Advanced Airway Continue CPR up to ready point where you are to Pediatric Ventricular Fibrillation Ventricular Pediatric A P P Pulseless Ventricular Tachycardia Ventricular Pulseless This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Go to Protocol Return of Circulation Revised Airway obstruction Hypothermia Past medical history medical Past Medications Existence of terminal illness Events leading to arrest Estimated downtime Spontaneous 01/01/2017 AT ANYTIME Post Resuscitation History Pediatric Ventricular Fibrillation Pulseless Ventricular Tachycardia Pediatric Cardiac Protocol Section Protocol Cardiac Pediatric

Pearls Recommended Exam: Mental Status Beginning compressions first is recommended in pediatric patients during CPR. However, the majority of pediatric arrests stem from a respiratory insult or hypoxic event. Compressions should be coupled with ventilations. When 1 provider is present, perform 30 compressions with 2 ventilations. When 2 providers are present, perform 15 compressions with 2 ventilations. 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 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. Defibrillation: First defibrillation is 2 J/kg, second defibrillation is 4 J/kg, subsequent shocks ≥ 4 J/kg (Maximum 10 J/kg or adult dose) End Tidal CO2 (EtCO2) If EtCO2 is < 10 mmHg, improve chest compressions. If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC) Antiarrhythmic agents: Adenosine: First dose: 0.1 mg / kg (Maximum 6 mg) Second dose: 0.2 mg / kg (Maximum 12 mg) Amiodarone 5 mg / kg IV / IO (single dose Maximum 300 mg). May repeat x 2 to a Maximum of 15 mg / kg. Lidocaine 1 mg / kg IV / IO. Infusion 20 – 50 mcg / kg / min. If infusion is initiate > 15 minutes from first bolus, repeat 1 mg / kg bolus. Magnesium Sulfate 40 mg / kg IV / IO over 10 – 20 minutes. In Torsades de pointes give over 1 – 2 minutes. Maximum 2 g. Procainamide 15 mg / kg IV / IO over 30 – 60 minutes. Monitor for increased QRS and increased QT. Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Consider Team Focused Approach / Pit-Crew Approach assigning responders to predetermined tasks. Refer to optional protocol. In order to be successful in pediatric arrests, a cause must be identified and corrected. If no IV / IO access may use Epinephrine 1:1000 0.1 mg/kg (0.1 mL/kg) via ETT (Maximum 2.5 mg)

Revised PC 6 Revised 01/01/2017 locally This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 10/08/2017 Pediatric Cardiac Protocol Section locally Revised 10/08/2017 < 60 mmHg < 70 mmHg 0 –0 Days 31 Age Based > than 1 Year Hypotension 1 Month to 1 Year Utilized < 70 + ( 2 x age) mmHg Arrhythmia Protocol necessary post ROSC post necessary Continue Antiarrhythmic Amiodarone or Lidocaine or Amiodarone resuscitation tape for dose. Refer to Appropriate Pediatric See length based color coded coded color based length See Continue to address specific differentials dysrhythmia original the with associated Anti-arrythmic drips are not always always not are drips Anti-arrythmic Differential P YES 94% 90% ≥ ≥ PC 7 NO as needed as Cardiac Monitor if indicated if indicated if indicated if indicated IV / IO Procedure of pulse During Arrest Protocol8 AR Antiarrhythmic Post-intubation / Medication Given BIAD Management 12 Lead ECG Procedure Respiratory– Rate 8 10 Device Threshold Impedence Remove Maintain SpO2 SpO2 Maintain SpO2 Preferably Advanced airway if indicated – 35 ideally ETCO2 Hg mm 45 Notify Destination or Monitor Vital Signs / Reassess Return Contact Medical Control Contact Medical Blood Glucose Analysis Procedure Analysis Glucose Blood Pediatric Diabetic Protocol PM 2 Protocol Diabetic Pediatric Optimize Ventilation and Oxygenation DO NOT HYPERVENTILATE Pediatric Bradycardia Protocol PC 2 Pediatric Tachycardia Protocol PC 5 Pediatric Airway Protocol(s) 5 - AR 7 Signs/Symptoms Pediatric Hypotension / Shock Protocol PM 3 Protocol Shock / Hypotension Pediatric P B A B This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This arrest after ROSC follow Rhythm Appropriate Protocol If Arrhythmia Persists and usually self limiting Respiratory Respiratory Cardiac arrest Revised Arrhythmias are common 01/01/2017 History Pediatric Cardiac Protocol Section Protocol Cardiac Pediatric

Pearls Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro Goals of care are to preserve neurologic function, prevent secondary organ damage, treat the underlying cause of illness, and optimize prehospital care. Frequent reassessment is necessary. Hyperventilation is a significant cause of hypotension / recurrence of cardiac arrest in post resuscitation phase and must be avoided. Target oxygenation to ≥ 94 %. 100 % FiO2 is not necessary, titrate oxygen accordingly. EtCO2 should be continually monitored with advanced airway in place. Administer resuscitation fluids and vasopressor agents to maintain SBP at targets listed on page 1. This table represents minimal SBP targets. Targeted Temperature Management is recommended in pediatrics, but prehospital use is not associated with improved outcomes. Transport to facility capable of intensive pediatric care. Antiarrhythmic agents: Adenosine: First dose: 0.1 mg / kg (Maximum 6 mg) Second dose: 0.2 mg / kg (Maximum 12 mg) Amiodarone 5 mg / kg IV / IO (single dose Maximum 300 mg). May repeat x 2 to a Maximum of 15 mg / kg. Lidocaine 1 mg / kg IV / IO. Infusion 20 – 50 mcg / kg / min. If infusion is initiated > 15 minutes from first bolus, repeat 0.5 mg / kg bolus. Magnesium Sulfate 40 mg / kg IV / IO over 10 – 20 minutes. In Torsades de pointes give over 1 – 2 minutes. Maximum 2 g. Procainamide 15 mg / kg IV / IO over 30 – 60 minutes. Monitor for increased QRS and increased QT. Vasopressor agents: Dopamine 2 – 20 mcg / kg / min IV / IO Epinephrine 0.1 – 1 mcg / kg / min IV / IO Norepinephrine 0.1 – 2 mcg / kg / min IV / IO Dose Calculation: mL / hour = kg x dose(mcg / kg / min) x 60 (min / hr) / concentration (mcg / mL) If pediatric weight is known, use in drug and fluid calculations. Use actual body weight for calculating initial medication dosages. If unknown then use a body length tape system. Appropriate post-resuscitation management may best be planned in consultation with medical control.

Revised PC 7 Revised 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director locally 10/08/2017 Pediatric Medical Protocol Section )

n s k (

o l i c n o M s M )

o 3 I r I t o c

n i

h ) n e c t M x o e g 0 I

t d o S z c t e i

i f 0 d o e / l u s o f m g r

r 0 c

e d e n p u t e S d d g n l P

1 u ) 5 d 3 m y e s

e b . t :

e e M

o c F t t b d e i t t i c m h b c e 0 E 1 i 5

a o a n

s e

M H a a r E o i e l O ) m 1 t 5 N

+ c

p f

i – n n e c c .

P

i f C

y

R y i i e y a

l y g

l a e n i l t 0 s – e / b s d 3 t i a

E d d

o t u

n

v . H s d o r a r r o n r

d m 5 g n n n o

a V y w 0 c i e D . i i

e h t

d a

p

e d r e k

e s l i f o ( v f t E t 2

P P h a y f f ( p i t

e g i n v

u o i i

t s A u s 0 S e

r e o a k

H y e c O s

y a

r /

i a p 3 b p

l n l

s a

l r

m C 0 p i c x S P e

o ( i

a n a

< a

w e / 3 r A a o p

s l l

v

t y r g o R I a i d i e (

i E y a ≥ t a a d a i b r r i i e A

h k v a o t

a d o m d r

O p c i i o t

B c n n e h

i

a o g s p t a

t e

P

+ r n h n s a s

y r

c U A S A A V A c

2 e i B

l f o f i P

a D · · · · · · · e g n a e h C

t

l y n e o r e c n R o i o t r t m

a r o h e r r i o p

v P t r l O

p e o c O g

e M M S c s

M M

o r P 3 3 y n I I r r n I I e e

i

r t P k

r e

M p / i r m

O e e e e o i t r M M x x i g n

p r

c i I E g g o 0 0 e

I I

z z t

n n n

m r r o n e 5 i i E D / O o i 0 0 O i i d d m l c .

l l

e l

I m m v u o i g g s

n l O o

0 0

e e

C r 0 o d d e v u u s o / k m m V e d e 5 V g g B t

a M l l g i o

1 1 5 5 d d l I P g m I N

m m s s e e I C c r n 1 i b b . . : :

a a

e s c 2

i S )

E t t g

b

g i e e b n e t

r r m m

m e o a M f l

e e c i 0 0 1 1 e n t 1 g 5 5 g

2 h n i a a T n I a

r d e e a

m

h a t i

d d z h u e l l

y o s a o n k i t 1 1 k m 5 5 N N i c c i d i / – – e n n e e H r

i

A . . s / o

s y y i i e y

n c

M

d w P c / ( m o l l

a r e a t w

p i

n n

0 0 i e w t – – P g r e s s h h R d d

t 3 3 M a o S V r i i t s

t v

u o o v h t . . l

o

o I e e p e P g p r r o h l l a a d a n n n n r r e

E e p u a 5 5 s g g r l

y m

a n 0 0 y p i i e O l

n . . r a t m

h h t t

o

e e e

e e v o I w l g f n m i l k k c m n e i m D e i d f e r f i f f t t

y I 2 2

S

a 2 a a

p p i g g h h y i i / / w k a n o x h o t y h r n

M l u u

i 0 0 h D m O 1 e e m

e e t k k s i m / p p s

e S t

t a r

g s p B

i i 3 3 S b b

a V p p t e u n n r I

p

g M l l I e

t o y y o 0 0 i i 5 n n

s g v M e e t D D c i

s

f o + m - < < l E s A n 3 3 d

A A s a e p p i / o M i s

h g

n a t t t R R 2 u t m r i r e f A t + n

E E e n

≥ ≥ g s n i m o H c p i t s r o e i e 1 a n u t e e f p

s h a

f P m s m N o h i y d o i i c e s A u

t C d C D H E I p c C n o o c e g N d A B

i R i

s i · · · · · S · h t r

P A o t t

s e g a n a i h s c t

n e n m o r i e e d t u t r g O c

s s r e y s a P g o s e

S s k t e e / n

p e e e i r

e c m r e S

x O n n n / s o o u d i i O

e M t l

I P e s

e s , y

E

/ r d p

s / r m m a

e B P l o p

r l g n

u e y y e o a a a e ) p m t a o t t b o r r r d c i M i g m x y y 2 R a o s I t a r o o l

e i d d

b

l l t W e s i c

S /

a H e n

c

g

h y y d i

l s r ( / y r ,

D a c l i

o

l k n d h h d o n O V v

o r g o a h L

y I e a / f l a

I n A n n n

a

n

P g i n g c i

n r n n a i r

i e e

r g f i d g M

n f h I k o o o i o d h h I V e t k n i i s t t t l I

i t t m i m l e S o / p p a s n

l

i i n

a a a n a 7 t t g 1 t

m c c c i 1 o g o d

D D i i c e 0 s d t e S i d d 2 s e s M w M s y / m i o

v s e e 1 n r H e a o e 0 1 n / o M F M N P O I R 1 t 0 s i

· · · · · H · · B A B

)

s . r

i

Pediatric Medical Protocol Section . r s t e h

d

t o t l r n t s

f

m i t u c e o a e o A

h r u t o

e e i r m h T

b y i p h s u

l

l e . s

. , s q l l l D u a

n m v i

u s d l l e a a c - a e y o i

r e p e

a o

n n n

r n d r i i S n

c i y n v

i t t i V u e o

e I a t e e n s s t d

m i s i d r M c v

e e e S y

m a i u t t e n n

u r n y M b . r g i M a v r e n n o

c

E d

i i t o n k c e n t e y n

O y y s o o m . o

s l

c S

c o r r i

b e y l y h

i n /

t t t y e / y n b

t g a a

n l r

y s s a o a i l e a i h c d A r e e . a a a i m r

a g t t e D s w s

. t s h

g g . v p r s a u l A a m

s u y i s n i s p o

r

i l y f n r i r r a i n . r a

t e n r i e d h

p c o p n - o o i y t i D t c i o i

e r ) l d p

n

p l ) ) n d l c s a n i m p o p o o a s

u m a a

r e a o

a u i i d e p a

r e s f s d d M i . c p s

b

x x a M r

i u (

t . v a

p

n O n

O o

o o d i S I e e x s

a n n y e t l a

o

s . n n e i

p p

a i p b r i c e h o t , M n a l

s

S i

i

n y y i e x s n o r t a e i y y E r r u d i

s d h h a

r l l M e t c a o c c c

l h i h u i ( u V n , , l h g a u

a E p I o f y d m p s

l p t

o f a a a r . i p o A

t p h e a s o e P s

e r e e

e

n e

. h e r s m a a t p e n l n v

e f n n d m o p n y i i r s s h

o i

a . a

g a i l

s m t t p p n r r

s t p p y e t n

n g f d p p

d a o s s a e e

a n n n e Z E p

g t a t e r n c r p d n

H

y y h

i

e e a / n n p s e a

e t C a

u o . d d d m e i i d

l V t m

o t l v g . m i I s o e , , o e n v i e m n e

s

o l l t t i e u G n n v i r p m g g s o i y t c e i e R

S a b m i o c r o S n y u o C r

s ) n n n a i t m s

n i t i e l v

i i

a t e /

. i s y M h l 2 e

E c t o a d

z z

a c r u

p

n g t r n s . n m s a i a E n e a e i e e a a x e P

q

i d P

n o o t e a r

g

d m e n

i

r i

n e e e r i e r a t g y

r r i a p S c c r s a n r t e m d

r g

h h r i

p e a a r o y n

o y e M u

l s k

e i m c o n i y e s e c

i a / a l i i y E w w n h r i d r d e l

l d l d m r

a ( ( h f d

o 2

e t

a O g e d

t

e

e a d o r e y h h t

r 1 s y o d

r t n d e y y m t t C

d i m n o o a s e e

i i w r r s n e g

l

n i R l N r a i M e n t a 1 m o

l

s d

o o i t o e

T e

a b w w m n e

n r

e i t t s

i M a

r i e t n n a y i s t n l r v

) ) h s e i O i a a i d e i v o t E s a

n a n u a r e m r r

i r n n m

f g i M e t i i N n m i i / a y a s c d

p e i w d

h y e d

a t

i s a m b e p p a a l g i ( o a m e c i t d o P t r a n T g

p l b l e

d g s s l m p p

l r n i

r r e d s s

a n e o d t + e o

e e l i a n u l l e M

R r c y o p

o f a l y r

r r r n

n t

n u

a a s u s o

b i

i t 0 E

p m a l s M e

d e m

a d

y r s i t t e n n s s n l L h 7

p t h a n t i i

d u E o y r

e a t s o l n , s u u l e o

t u y e > i u e i i r r

l l i /

t

h p m r . e u m m r h

u

t r o n

v r o m o u s t i w p p t n

P e o r f

M

o o p T c o y o h a o A t

s m

n i I m d

e d n s l r

l m

i a a a B r a d d s e d h e i a s l M f n

h a n d p d r o p e r o i a b b S s m e m H a

i r m m m

s o

r

E r r p a l a

e r h

e a a u

t t o i

, h o e e e p o

d a n e t r o s c s t

p , , p

o e a l t n r T n D s n

h h h e t o c p o M r a t i

e e

y e

g g t t t n i I a s r h o d e l d i r

t e e t

n M k s

s e b y y y n m r n n e i t

i r s

i C a o

o i i e c v d r r r t o i y v y i E o S

t t t n g x l c

e l r y p h c a e o i i n e e e s n s l a / , d l t

l i n

i e r

a u e

a

p l

n e e s i , , , i a l a r s h

i

r t n

b m m

n o o r i t l

d c a f a R

i g g g t

y t t h

i u t a d o o e

o o a o c s t m

o i e g t n n n h s r n p h d e M

m e

v v n i i i m p t : r d a a t T

e d h

i r n

p e e i e i p t e , , r n E t i h h h d n e f g n t e o u

i t S a i n o a e a a n k S d o m t c c c a o v

w M i o o s r o a r

i

l t t t

n a i R w m e e c t a

l y a e t i i i r t t p I i o t

p e

e h t

d a o r l f

s s a t r r

o h s a , , ,

e c n c p a r F E t

e b t :

r d a o

d

s u u o s s s s

u

e n t a x d e c

e t i

t n r d c n i y t i t r e m t a a r n e e e i c e e a d e

o s t f d e e l e d

c n n e : o i h r n i h p a u n n v v v d c v t t h i a t

t i i i i n ( ( a e a u

s v l s m t n n i o s

e M b

m o t i

s

p

i p e t

l s a h h h y

i t i e o o : s a

e

t

s s d

o n e C

m r n S m r , , , y : n e r a n t . s a d A h a

t i m S h

e n u o t n . f i l

o

f

a m m g g g S

o a p s g n r r c t d p c : s n o a t m n

m r o n

d i o C i i i

o o n n n p m M o n

e e a

a p t s e m a t i i i t t o e n e i o t e e

t t n

e E

n c s D i i d t

s t y r x i a m

h h h

c

p p n P l e i d i y s s a c l n t s m n m e s . a i n i i

i p i c a a s s s a E

n s u r a o r a a y e i n m o e t r

u r

m m l c o m e

n n o y t u u u e q f c

n i i s t h v m d o o n e d n l l l i d s y y d e s

m o i l h i a i e p i e e n

i u

a y p e o v a t d e

s F F s F y r i r d

e v m m g c

r y s h

s c h t

e

e c e

a m t d m h s s h n

M d d t e r f e y

e i i T a

e i n a e S y A r n n e e p a a i m a n o r o d

T m x x n r

d b

r e

i

b s O e e i e i w e

f p / e

o e t r a a r

y y r e n m

M g

m l l r u h n N o

T d o d E d m s h a a i

v h a r d M c u l

y y o o q E t p t

s i i o e

t p O r i e p d p o l n h e / h h c m n m m l s t n M 7 g

o r e p

e s a M M S E I N a D I D i a

p p 1 o e r c d u d

t i n 0 T T R i n e y g a a c e i e t m e o i 2 n s n l / r i u a i l n n e n s M M a M y p h l v 1 h a p o l e 0 / T E D P s c E m A c F E A S A e A E R r R 1 a 0 e

· · · · · · · · · · · · P · Pediatric Medical Protocol Section

. d

l n

e o d )

o t

d

/ g

.

g

O

e e l I s l a n g

g m e O d / b

u I c / o k

n l

i / m a 1

/ u

g t

V

o l L s : I 0 t u

d V

. a m l B m G S 6 I l

n

m n

s

O r

o : u s M 9 e e d a l u > a g 0

s N E t e

6 g / t a

n

m t k

2 g

i r r O a i e / a

e l

h t u ≤

u g e o s x l t

y L l s a

s n i m

b i o S a a e a l

e o m S

r

m c t u

w

s d , a

c m

l M d o t u a 0 e

(

o e l 0 r u c m a

v o n 5 5 l i i k e c g 2 o e t y t

o e

l 2 1 x r g m M a r l u

-

a I a d r p l o

a l

u r m e y ≥ t w B p j o

o g 0 r a m s g e a

M n A l o r

e o 1 e

i

l N u k o t d

e o

n / : n v o t

t i B

b d o l g o s

g e

e p i l

e a d e t o u s t p l v b r n m s s e m i e a e

a a d B a e h y

c

e e 1

G n / y . l b ; g c k S

p

c l

u 0 i a n a e A

e l i d A i o r o f

o t t I c m e R h u c P r i

n u z o A i i x e e a

e c t V l e l l g o r r t n d A T T S C A e A

a f / h

f i C g e

l l s D · · · · · · o

m o s c

r r o e t 0 t o b s s

8 o n

e r s t n

o P ≥

a e

u s s o r a i i S C e i e s n

s s u t i M

l s

e i R 3

y y d

a E l l e s a r o g k 1 m r e O

d a a u

n o c

c c n t l c u i t i n n n 5 P i C t o u d a a

o d d l e e a t d

5 n r N

A A 4 r h e D U r r s 3 h

y

e /

t ) e d d d o a e

G r S r

l e u u P S c c e t e e

s P

a

M e e e l h g

e g o o d d / ( o s s a M t t t t d g M l c t D

i

r n

a c U o v A G u e e i i

M

r o o s t

a a a t

n m o o n c s t l l o o i

w c c P

E c c d S n p C y u e n t c c c i t c

o o a c l o o t i c o i i i h P f t o o 9 i i l l u u o n o e o t E i o m l i l l r r c x b c i d a r O g a s r d d d t 4 d t i

t o I a B d t o r o a o M P P f M f p o

n E

G G d n o 2 n n n P t

s t t i

t i / o e l

i i i r i n

a

t t n p

n i o a e r

l o i r o i d r s l d d t t – p f f f e o r P r N r C e b

A V o a i i i i u r a e o o o

I t n m

B c r P L P 0 /

u t p m m o o

p d C n n s o

f l l i e U 7 i z l i y t t 2 y i v o e e s l p s i B B

n a 1 t e / v H s S a e e i A

m n s a r t a r i

e S

a r m e / a d o d n r i u

m e d b h e k c n u s y p o r o p a z a m u h e i d e d

a e t

o i a e e e b l d s s i C D S A N W D D A P A B h n t

g o e i t

· · · · · · · · S · s e g P n a h c

m k

e ) t c e s

d e

s n y l h o

O S o O O o

I

c I I i a d d d o

:

d

S t r / l e

/ / e e e

F t

e e e

M u r

a l : O d d d l / e

s a V g r E y

e V V i s

b :

I e

e e e r I I o l s o r r

r A

s p s r a O l b a e e e

o l c

r p a

o S g i a f t g g e e

c

d n n n u u a g o e c

k s r

a o l o g k k c

d r i e / / l

T / / i e i

u s s s v Y e g

r u 5 p h s l

L

y L L u s

a a a a Y g d 1 a l 2 p S

n

o 2 d i

J G n

t t t f

m e a

i m m a A ( 2 s c o s m

o l

a a a

o o d

c t Y m n t o u i n l

a

1 5 e e e e l n

> l 9 o 2 C

u o r d

a o 1 i g p p p : : b 1 o 6 o : ½

t G

i e

l e a O e e e t 0 0 m C t 5 a

< ≤ i f n 5 1 7 B m 2 R R R u m c I

x 1 i l

d e t t D D 0 e D a d o c s 2 y s s / i e r e v a 1 S M a e 0 / o R L P M R 1 t 0 s i

· · H · · A

r

Pediatric Medical Protocol Section o

. f

n . 1 l

l - e s o g

t a l v

r i P n . t y c

i a l e c i y i r

U n

l c n f

e . l d i l o t a o e . a i e t o s a e d i i o a t r r C i L d c e c m

m n

i c M l u e l d

o e o . u t s m e t m a t e a e l

r

c y e e c c

c o m 0 o i N i y S a h

r m n l

a d

5 v m d , t g M p e e

g P e o

m . E l e

s o n o t i s c r r e l o

i O y a e e c o s

o e M o p t i r l

n n t e y a

m r t u C y t c b a n o s i l o a h

i i u i u t w t c h t o l d

g

o C

r c e n e

m

t e a i

t i i a r o – l s t t i v s t n c

l e

s n a

r r v o n n m r

u y a r

0 a n e t e r o t l

o w e p d q r i h 5 o i r x r d p i p n a t e a e e t C p t a

D o s r u n

o

E a n

c

f

h r

o e e . c n c o f

o i , t P t a

d b

s o b e

a s p e o n k t l

t

r o n r

d n s – d

t t h c o n

a n n c

n f

a

t L i : e e

. a

a s e h a t e

o o d r t S a t r w i s t g

y L i c i g m a t B c r e

e

c o k N

n t h o i l a c

d , w a u t l l v m r

s 0 m c i o

t f i i

o a % l c o n n c a

r 1

e p u n P i n o

w 0

o

m r h e e t

d t 0 i c r t o

r e o 5 e U a e r t d L

e a 5 g y

s c p m m o

l x

h t n b o

o e g t e n t f d o a i m e e o g e

a

o m n n

t e i h w

e f s l m d v

o

d h

o e e 0 C o d . S o g

l i f t o a e a d u b

l

e p l t i b 4 r c l l . l n a c o o o

t h e y i y a

A r r e a

t c s o w a x

o d p r a r g y

p l o h , s u p c l n v

t t

e

t

g b o i u

w o u s o u S f e l o

l o

l s e n e i a r r i D s c o r g y t d o o a

N P v h e s b c

w

r

t n i t h e s n n n t o a

f a g a S e a r u u c s e l o t n a l o u s

i r n

h i

a o t M

b u e e i

g g y e e a E L e t l d e g l

s n d

e r

l – n L c v O a

, c a

n g l n o b a t m i r d b a c i a a e a

C t t l l r n a m

S c k r f

o c a n u

N d D

l 3 a

u p a

o d

l a l a t N u d

a t m 0

l r . e e t s

g e

e n t r t c u

a

n l h f n n s 4 r o a

t n i t s

a

o n o t i l

H h o a a

u

o o t h M

n o

t t i f t

n l e t h d

u , w

r e l i l o

p n v c o t s e a m s L e P

d a e l n e

b a a

a r s i l i r N t

a e

n

d s r i

0 o t i e e A

f e m f k a . d s

p

r o n m

n e r

l 5 o

h . o a t t

d t a g

l t

S

a a e 5 o r s p u c t

D N i

e a h c n d a , y u a c

2 p

o r i y

i i o s t

. h t t t d t e y h r s m T i e i h l d e

v e l n t l s d c p a e t

t e i e i

i s i h s g N n m l t n r

e a t u i 0 n e r b c y s

d

u o

e a i b r E s t a h r f

5 b o a a o e p c m a a f

n s f m w E n s e e

m t i a t i u n

p y D l i t r s n o

l

a e u g c s

i i o H n a h i t b d e

r a t

o d i a i h r

a n t e

o , t t

d a f

a f e t e h a d i n

a c t . o

a t

.

s i d l n m s s k c l o t a i i s i s L m : m

w L a p d

u

o e m d e i a

h

a n

l t

d e y r . r s t t r o e n

e c

t t V r o e r e t m o a r a e e m i I n e . o e

: s t t s s f a y

n t

t o h t u t n i i

l

i b m t m e e 0 s o n m o o c a o

r s x S e t e w 0 0

s s t c g c 4

e e e i

c i c

e p n a d o e

l g s c

5 5 n

e

g

r l o u s

t i s l v h y t , P l r

a

t n t m d

t e o h e f A o D D u p i

a d t t e w r 0 a t g p

l

e n n i c g r

c

o c c h y f f a o n e o a 8 m i

a n b e

c

u d u e o w i a w i

A h o o r h e l n k c l u d t

l a

≥ m

o b i o m p p . l m s o s

g

s s

e s g l a r i u f M

d

L L n i o t e

d n a s a r i

e l o n t : e l a

o l l s P

s e d s : r l k c m s D n

t b b h o c

m m

a e n n

u o . y k n

o u g a

t

, a r l c a r O I t n e e m S r s w o

e

t

c o c r

0 5 t n m

o e i s a l o v m a a t

o n t c S d e t n e

a h h t 1 2 a i

s i o

v . u b a t r r

t t x r a t r l i M m

n a o s h v f i i

g s t g l t L r h n a e e e E r e n c E o m a

c s d o e n n t a

n

l

a m o v t o w w

r i v v

a e l r i i y r m

l a i n a s y s c d u k n n s

t

p m l o o p a i c u m s g

e a

a a o o

r r t c r u e a o 0 i i r a c u e e r n l e e h r u g t m i o t e

h e m m i i o r t

r 5 f d s e r m f P s t t y m r u T d t m m

i a c

e l e i s

n a

e n n f l o e i n P n

. t s t t

m . e f

e e r

c A w o a

o R A R d d o e e

w e n n n a y d

r

5 c c r

t d

t c y m t e c c : : : t s l i e e e

r

a i n e 2

y y l m m ’ s i i i o n s t

i l l n 0 0 5 t u t t t t v d e e h m y t e o c D t c a u t o 1 1 2 t g g a d l a a r m n n

f d n v i o t a / a 7 m l o o t o

e e i M a a a M O P f e C A B P P D D D 1 x n d i i a 0

p p n c 0 e t t e 2 s / i

u y y o o e 1 a a s v 1 l n e 0 / H H I C P D Q D R P r R 1 a 0 e

· · · · · · · P · · Pediatric Medical Protocol Section - n o e i r s u s d d e e r e e v t c p i e a t o S s m r c c M a i o P u E e

d c r O s t e n e

i n l i i y s

d D d x b f

c b c

i t i t e i o c r d t i c s O e i T e a c m n

e v n k N r e a e e o l l h e o r h g y

n o

g p C l o h v c n o c p i o i i a r t t p o a t o d

i i l r u n t a p a p e n r a a P y a e o a e n o b i i

e d k t t c m H C S N A d i y g c c n n u d h n o e a h a e

f e e o h r y r n c S T I D C M e i l f S o f i P

D · · · · · · e / g n

a h e

C

k n v s l i c e o s t r o c e u u o h o n t b d i o S k i

r e 6 r f a

) t P l c e e l

o e s t t s B

o

S o o ( i s s g l r a a w r T r e 2 i i c O

M

e e e

k D r o I u t r r P , l r p

o o

l 0 E

g g O c / t o /

p p ) n n o y I M u

t

2 O y o s n n

r i o

A A o i o o

c n o i n / T t d o

l L r P g i r r V

C B

s n l o –

k o r I g i x x

t o e o l s

i p p t

1 P y f

N d d o C s s r s i V d d d m 3 l e

s

c e e

o s u

I 5 l

p p o t n e 2 2 e e

l s

f l

e e e

e s a P r e i o

c M r y n t t i 0 t t t a a

m a M h

r

i e e n t e a g

A n g o t + + P s l a a t y 6 c c c

r c y

t m m

o P o n P

k i i i e e n M c g s

A r

p a c c a i c a

t i l i p a l / o

c 0 0 w a i i i / g g i t d d d u m a

e r L r

S o m o l p o o w e , 7 7 o P g O d t d d ( l a a

d l m s n n n a

m r I S l i

l S P o L c r s l s

u i i i i s k

a e n n

t a

o ≥ ≥ u e i

/ p n m o o i i a c s o a o a f a

f f f /

A c c s t t

i

t m p i i i m a d i

i m

a o

c , e t y M f f p D

i t i r r V C l P P V d i i o m

o

s c e a c y t g e e I u n r s 0 i r s

x e r

t S l o r T t t u B B x

r y a c s

P s r D a 2 n

a t i b d P o o c a a

f m G s S S y E e

c e a r r i d

e a d a

c e l

m t a t t i N i t t M t

e y i i

n - t y l e d , p n d i

n d t o i h o D k T T a t o e z e n n P a l r s c l e l p c

i z o H a N

m i y e a e o u l a a P

s u

m y B D T H P D D R

C c M n r

e o

l o g

d t

i o

s s i i v · · · · · · S · c P P A A h o H t i p o t y r s H e t g n a a h c i

m e t d s y S e S

s g M O d e I k E u

)

P l n g l / c / s i

a ( o a r A l

e c t

V L B o I e c o g x

a

l t 4 i

c

a m

c a e i a g

y i d d

2 o i

t C n d n r k 0 e e n o i r

I t t o + A l p / A 1

e

r P a

a a

l o M s e 0 g P r L t C c s e o s

S m E

i 7 t o g

p a n s a :

c i o l a m u r T d l a i n p e o o

n ≥ i o t

i d a i l i i

t t r n r S a t

h 0 r i m d 7 m i a r i o T p

c e P 1 d m d 1 a r o r h i f 0

m y x r P v e o t e i B a

o 2 f u s C r r P i / – i o l a y t e l o

v 1 S n p s o h V D F I B F e 0 5 N M / t r p e R 1 r s 0 A h i A

C · · · · H · · A Hypotension / Shock P e d i a t r i c

M e d i c a l

P r o t o c o l

S e c t i o n

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: Septic Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxic · 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 or Congenital Adrenal Hyperplasia: Body cannot produce enough steroids (glucocorticoids / mineralocorticoids.) May have primary or secondary adrenal disease, congenital adrenal hyperplasia, or more commonly have stopped a steroid like prednisone. Injury or illness may precipitate. Usually hypotensive with nausea, vomiting, dehydration and / or abdominal pain. If suspected Paramedic should give Methylprednisolone 125 mg IM / IV / IO or Dexamethasone 10 mg IM / IV / IO. Use steroid agent specific to your drug list. May administer prescribed steroid carried by patient IM / IV / IO. Patient may have Hydrocortisone (Cortef or Solu-Cortef). Dose: < 1y.o. give 25 mg, 1- 12 y.o. give 50 mg, and > 12 y.o. give 100 mg or dose specified by patient’s physician.

Revised PM 3 01/01/2017 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Special Circumstances Section locally Revised 12/08/2017 Exit to staff Protocol(s) Appropriate apy / Intubation / DO NOT DISPATCH DO Discretely notify EMS FIRST RESPONDERS Dispatch EMS Unit only Supervisor or command Evolving Protocol: change to subject Protocol at any time dependent on changing outbreak locations. protocol for Monitor updates. Fevers: Viral Hemorrhagic many. of one is Ebola NO Refer to page 2 Refer to Page 3 YES BIAD / Suctioning medically necessary medically necessary medically If IV / IO necessary: Place surgical mask on patient on mask surgical Place Donningand Doffing Guidelines Stop vehicle to lessen exposure risk Avoid routine IV or IO access unless unless access IO or IV routine Avoid NIPPV / Nebulizer ther Avoid aerosol generating procedures unless Use Non-rebreather mask if Oxygen Needed SC 1 Ebola patient until instructed / Equipment / / / Equipment EMS NO EMS YES No Routine NO Routine IV or IO Lines AND Decontamination EMS Immediate Concern EMS Dispatch Center EMS Dispatch Transport Unit Requires EMS Personnel Personal Protective Equipment Aerosol Generating Procedures Suspected Viral Hemorrhagic Fever Hemorrhagic Viral Suspected This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Follow entry staff Follow hospital directions from and/or DO NOT ENTER facility with Notify Destination as soon and as discretely as possible Fever, HeadacheVomiting and/or Diarrhea AbdominalPain Bleeding Joint and Muscle aches Weakness, Fatigue Anorexia Typical Flu-Like Symptoms Unexpected Bleeding (not trauma or isolated nose bleed related) EMD 6 Breathing Problem EMD 10 Chest Pain EMD 18 Headache EMD 21 Hemorrhage (medical) EMD 26 Sick Person In the past 21 days have you been to Africa or been exposed to someone who has? If YES: Do you have a fever? 1. Traveler from area with known VHR (Ebola) with or without symptoms 2. Traveler from Sierra Leone, Guinea, or Liberia within past 21 days Revised Obtain a travel history / exposure history and assess for clinical signs and symptoms Do not rely solely on EMD personnel to identify a potential viral hemorrhagic fever patient – by time and constrained caller information 01/01/2017 2. Use EID Card (or equivalent) with the following protocols (or equivalent) following: the Ask 3. 1. Use Emerging Infectious Disease (EID) Surveillance Tool with the following chief complaints: Suspected Viral Hemorrhagic Fever Ebola

PARTICULAR ATTENTION MUST BE PAID TO PROTECTING MUCOUS MEMBRANES OF THE EYES, NOSE, and MOUTH FROM SPLASHES OF INFECTIOUS MATERIAL OR SELF INOCULATION FROM SOILED PPE / GLOVES. THERE SHOULD BE NO EXPOSED SKIN DONNING 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. Section Circumstances Special

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

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 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. 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. Hand Hygiene should be performed by washing with soap and water with hand friction for a minimum of 20 seconds. Alcohol-based hand rubs may be used if soap and water are not available. 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. If the patient is being transported via stretcher then a disposable sheet can be placed over them.

Pearls Transmission to another individual is the greatest after a patient develops fever. Once there is fever, the viral load in the bodily fluids appears to be very high and thus a heightened level of PPE is required. Patient contact precautions are the most important consideration. Incubation period 2-21 days Ebola must be taken seriously; however using your training, protocols, procedures and proper Personal Protective Equipment (PPE), patients can be cared for safely. When an infection does occur in humans, the virus can be spread in several ways to others. The virus is spread through direct contact (through broken skin or mucous membranes) with a sick person's blood or body fluids (urine, saliva, feces, vomit, and semen) objects (such as needles) that have been contaminated with infected body fluids. 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. Ebola Information: For a complete review of Ebola go to: http://www.cdc.gov/vhf/ebola/index.html 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 Revised SC 1 locally This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 12/08/2017 Suspected Viral Hemorrhagic Fever Ebola

EMS Personal Requires Decontamination

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;

EMS Equipment / Transport Unit Requires Decontamination Section Circumstances Special

1) EMS personnel performing decontamination / disinfection should wear recommended PPE When performing Decontamination EMS Personnel MUST wear appropriate PPE, which includes: •Gloves (Double glove) •Fluid resistant (impervious) Tyvek Like Full length (Coveralls) •Eye protection (Goggles) •N-95 face mask •Fluid resistant (impervious)-Head covers •Fluid resistant (impervious)-Shoe / Boot covers 2) Face protection (N-95 facemask with goggles) 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 after transport. 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 for viruses that share some technical similarities to Ebola (such as, norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions. (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. 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 in biohazard bags (double-bagged) and labeled for decontamination and disinfection. 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.

Pearls 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

SC 1 Revised locally This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 12/08/2017 Suspected Viral Hemorrhagic Fever Ebola

Decedent Known or suspected carrier of HVF / Ebola Requires Transportation

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.

Donning / Doffing PPE

PPE should be in place BEFORE contact with the body PPE should be removed immediately after and 1) Prior to contact with body, postmortem care discarded as regulated medical waste. personnel must wear PPE consisting of: surgical scrub suit, surgical cap, impervious Tyvex- 1) Use caution when removing PPE as to avoid Coveralls, eye protection (e.g., face shield, contaminating the wearer. goggles), facemask, shoe covers, and double

surgical gloves. 2) Hand hygiene (washing your hands thoroughly Section Circumstances Special with soap and water or an alcohol based 2) Additional PPE (leg coverings,) might be required in hand rub) should be performed immediately certain situations (e.g., copious amounts of blood, following the removal of PPE. If hands are vomit, feces, or other body fluids that can visibly soiled, use soap and water. contaminate the environment).

Preparation of Body Prior to Transport

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 gown 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 150 μm 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 disinfectants which can kill a wide range of viruses. 2) Follow the product’s label instructions. Once the visible soil has been removed, reapply the disinfectant to the entire bag surface and allow to air dry. 3) Following the removal of the body, the patient room should be cleaned and disinfected. 4) Reusable equipment should be cleaned and disinfected according to standard procedures.

Transportation of VHV / Ebola Remains

PPE is required for individuals driving or riding in a vehicle carrying human remains. DO NOT handle the remains of a suspected / confirmed case of Ebola The remains must be safely contained in a body bag where the outer surface of the body bag has been disinfected prior to the transport.

Pearls 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 SC 1 Revised locally This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 12/08/2017 Special Operations Section locally Revised Extend Extend Improve Improve 12/08/2017 Responder Exit to Cannot Wear Wear Cannot Rehabilitation Rehabilitation Time Until VS Time Until VS Protocol Protective Gear Protective Responder Scene Rehabilitation YES YES COLD STRESS Rest 10 – 20 minutes YES Rehydration Techniques Active Warming Measures Active Warming Measures Active Warming Hot packs to axilla and / or groin of fluid betweenchange-outSCBA Dry responder, place in warm area 110 HR NO NO 100.6 12 – 32 oz Oral Fluid over 20 minutes Firefighters should consume 8 ounces Oral Rehydration may occur along with Temp ≥ ≥ YES 80 80 YES ≤ YES Haz-Mat Suits,Haz-Mat Turnout Gear, Reports for Reassignment Discharge Responder from SO 1 110 or HR General Rehabilitation Section NO NO NO NO 100.6 Heat Temp ≥ ≥ Reassess VS Reassess Initial Process Cold stress Significant Injury General RehabilitationSection Respiratory Rate < 8 or > 40 Systolic Blood Pressure Reassess responder after 20 Minutes in YES Cardiac Complaint: Signs / Symptoms CarbonMonoxide monitoring if indicated Other equipment as indicated Respiratory Complaint: Serious Signs / Symptoms 1. Personnel logged into General Rehabilitation Section 2. VS Assessed / Recorded (If HR > 110 then obtain Temp) 3. Personnel assessed for signs / symptoms 4. PPE, Remove Body Armor, Scene Rehabilitation: General Rehabilitation: Scene 160 or ≥ This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 100 may need cool mist fans etc. ≥ HEAT STRESS Rest 10 – 10 Rest Minutes 20 Active Cooling Measures Cooling Active Rehydration Techniques Active Cooling Measures Cooling Active VITAL SIGN CAVEATS Forearm immersion, cool shirts, of fluid between SCBA change-out 12 – 32 oz Oral Fluid over 20 minutes Firefighters should consume 8 ounces ounces 8 consume should Firefighters Oral Rehydration may occur along with with along occur may Rehydration Oral oral or IV hydration. or IV oral Revised Temperature: extended rehabilitation. However this does not necessarily prevent them from returning to duty. Diastolic BP Firefighters may have increased rehabilitation. during temperature Firefighters with Systolic BP Firefighters have elevated blood blood elevated have Firefighters exertion physical to due pressure and is not typically pathologic. Blood Pressure: Prone to inaccuracy on scenes. Must be interpreted in context. appropriate treatment 01/01/2017 should be treated using protocol beyond need for Injury / Illness / Complaint Scene Rehabilitation: General Special Operations Section Operations Special

Pearls

Rehabilitation officer has full authority in deciding when responders may return to duty and may adjust rest / rehabilitation time frames depending on existing conditions. Rehabilitation goals: Relief from climatic conditions. Rest, recovery, and hydration prior to incident, during, and following incident. Active and / or passive cooling or warming as needed for incident type and climate conditions. 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. General indications for rehabilitation: 20-minute rehabilitation following use of a second 30-minute SCBA, 45-minute SCBA or single 60-minute SCBA cylinder. 20-minute rehabilitation following 40 minutes of intense work without SCBA. General work-rest cycles: 10-minute self-rehabilitation following use of one 30-minute SCBA cylinder or performing 20 minutes of intense work without SCBA. Serious signs / symptoms: Chest pain, dizziness, dyspnea, weakness, nausea, or headache. Symptoms of heat stress (cramps) or cold stress. Changes in gait, speech, or behavior. Altered Mental Status. Abnormal Vital Signs per agency SOP or Policy / Procedure. Rehabilitation Section: Integral function within the Incident Management System. Establish section such that it provides shelter / shade, privacy and freedom from smoke or other hazards Large enough to accommodate expected number of personnel. Separate area to remove PPE. Accessible to EMS transport units and water supply. Away from media agencies and spectators / bystanders. Revised Revised SO 1 locally 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 12/08/2017 Special Operations Section locally Revised 12/08/2017 100 ≤ An 100 mmHg ≥ Protocol of additional rehabilitation Maximum 2 L 2 Maximum 500 mL IV / IO after 30 minutes No improvement improvement No SBP Titrate to HR Titrate to Important Normal Saline Bolus General Rehabilitation Rehabilitation General Use in conjunction with with conjunction in Use Rehydration is Most Mandatory RestPeriod Re-evaluate in 10 minutes A YES YES YES YES YES uretics or stimulants are at increased risk for cold and 100 160 100.6 ≥ ≥ ≥ SO 2 Or NO NO NO NO NO Reports for for Reports SPCO > 10 % 10 > SPCO Initial Process from General Reassignment law enforcement, rescue, EMS and training scenes. Systolic BP Diastolic BP ciding when responders may return to duty. Temperature Rehabilitation Section Discharge Responder Responder Discharge 20 Minute Rest Period Pulse oximetry% 90 < Respirations < 8 or > 40 Age Predicted Maximum Maximum Predicted Age Notify Destination or Pulse Rate > 85 % NFPA Contact Medical Control Contact Medical Section s, blood pressure medication, di 2. VS Assessed and Recorded / Orthostatic Vital Signs 3. Pulse oximetry and SPCO (if available) / symptoms signs for assessed Personnel 4. 1. Personnel logged into Responder Rehabilitation Scene Rehabilitation: Responder Rehabilitation: Scene This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This 132 160 155 152 148 140 136 170 165 Section Continue: Establish section such that it provides shelter, privacy and freedom from smoke or other hazards. May be utilized with adult responders on fire, Responders taking anti-histamine Rehabilitation Section is an integral function within the Incident Management System. Rehabilitation officer has full authority in de Utilized when responder is not appropriate for General Rehabilitation Protocol. heat stress. Revised Maximum Heart Rate Maximum Heart 01/01/2017 oral or IV hydration. or IV oral from General Rehab Rehab General from 51 -55 41 -41 45 -46 50 -55 60 -61 65 20 -20 25 -26 30 -31 35 -36 40 treatment techniques Heat and Cold Stress appropriate treatment NFPA Age Predicted 85 % 85 Predicted Age NFPA should be treated using Pearls protocol beyond need for Remove: PPE Body Armor Chemical Suits SCBA Gear Turnout as equipment Other indicated Injury / Illness / Complaint Trauma and Burn Protocol Section Degree) blistering Degree) nd Degree) painless/charred as indicated rd Age Appropriate Degree) red - painful (Don’t st Airway Protocol(s) AR 4, 7 or leathery skin include in TBSA) Superficial (1 Partial Thickness (2 Full Thickness (3 injury Thermal Chemical – Electrical injury Radiation injury Blast injury YES Differential TB 1 NO if indicated if indicated if indicated Cardiac Monitor if indicated if indicated if indicated if indicated if indicated IV / IO Procedure as indicated as indicated to appropriate destination using Age Appropriate Blast Lung Injury Trauma and Burn: Triage Protocol UP 2 Decontamination Procedure Notify Destination or Crush Injury Protocol TB 3 Thermal Burn Protocol TB 9 Pain Control Protocol UP 11 Protocol Control Pain Contact Medical Control Contact Medical Multiple Trauma Protocol TB 6 Radiation Incident Protocol TB 7 Protocol Incident Radiation ge Patients / Load and Go / with Assessment Treatment Enroute Airway Protocol(s) AR 1, 2, 3, 5, 6 5, 3, 2, 1, AR Protocol(s) Airway EMS Triage and Destination Plan Dizziness consciousness of Loss Hypotension/shock Airway compromise/distress could hoarseness/ by indicated be wheezing / Hypotension Burns, pain, swelling pain, Burns, Chemical and Electrical Burn Protocol TB 2 Signs and Symptoms Signs and Rapid Transport P A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Open / Closed. Interveningprotective barrier. Other environmental hazards, Incendiary / Explosive Agent / Amount. Industrial Explosion. Terrorist Incident. ImprovisedExplosive Device. Blunt Trauma / Crush Injury / Compartment Syndrome / Traumatic Brain Injury / Concussion / Tympanic Membrane Scene Safety / Quantify and Tria Rupture / Abdominal hemorrhage or Evisceration, Blast Lung Injury and Penetrating Trauma. Explosions (See Pearls) Other trauma Loss of Consciousness status Tetanus/Immunization Inhalation injury Time of Injury / history medical Past Medications Type of exposure (heat, gas, gas, (heat, exposure of Type chemical) History Accidental / Intentional Nature of Device: Method Delivery: of Nature of Environment: DistanceDevice: from Evaluate for: Trauma and Burn Section Burn and Trauma

Pearls Types of Blast Injury: Primary Blast Injury: From pressure wave. Secondary Blast Injury: Impaled objects. Debris which becomes missiles / shrapnel. Tertiary Blast Injury: Patient falling or being thrown / pinned by debris. Most Common Cause of Death: Secondary Blast Injuries. Triage of Blast Injury patients: Blast Injury Patients with Burn Injuries Must be Triaged using the Thermal / Chemical / Electrical Burn Destination Guidelines for Critical / Serious / Minor Trauma and Burns Patients may be hard of hearing due to tympanic membrane rupture. Care of Blast Injury Patients: Patients may suffer multi-system injuries including blunt and penetrating trauma, shrapnel, barotrauma, burns, and toxic chemical exposure. Consider airway burns which should prompt early and aggressive airway management. Cover open chest wounds with semi-occlusive dressing. Use Lactated Ringers (if available) for all Critical or Serious Burns. Minimize IV fluids resuscitation in patients with no sign of shock or poor perfusion. Blast Lung Injury: Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur (rarely) in patients without external thoracic trauma. More likely in enclosed space or in close proximity to explosion. Symptoms: Dyspnea, hemoptysis, cough, chest pain, wheezing and hemodynamic instability. Signs: Apnea, tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid hyperventilation. 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. Accidental Explosions or Intentional Explosions: All explosions or blasts should be considered intentional until determined otherwise. Attempt to determine source of the blast to include any potential threat for aerosolization of hazardous materials. Evaluate scene safety to include the source of the blast that may continue to spill explosive liquids or gases. Consider structural collapse / Environmental hazards / Fire. Conditions that led to the initial explosion may be returning and lead to a second explosion. Greatest concern is potential threat for a secondary device. Patients who can, typically will attempt to move as far away from the explosive source as they safely can. 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 there are 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. TB 1 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 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

Assure Chemical Source is NOT Hazardous to Responders. Assure Electrical Source is NO longer in contact with patient before touching patient.

Assess Burn / Concomitant Injury Severity

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn < 5% TBSA 2nd/3rd Degree Burn Suspected inhalation injury or requiring Burns with Multiple Trauma No inhalation injury, Not Intubated, intubation for airway stabilization Burns with definitive airway Normotensive Hypotension or GCS 13 or Less compromise GCS 14 or Greater (When reasonably accessible, (When reasonably accessible, Minor Burn transport to a Burn Center) transport to a Burn Center)

Serious Burn Critical Burn Section Protocol Burn and Trauma

Age Appropriate Airway Protocol(s) AR 1, 2, 3, 4, 5, 6, 7 if indicated

Identify Contact Points Eye Involvement Irrigate Involved Eye(s) with Normal Saline for 15 – 30 minutes May repeat as needed Chemical Exposure / Burn Flush Contact Area with Normal Saline for 15 minutes Decontamination Procedure if indicated Age Appropriate Cardiac Protocol(s) if indicated Thermal Burn Protocol TB 9

Rapid Transport to appropriate destination using Trauma and Burn: EMS Triage and Destination Plan

Notify Destination or Contact Medical Control

TB 2 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Chemical and Electrical Burn Trauma and Burn Protocol Section

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 Triage systems. 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 and use 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 the 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. TB 2 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Trauma and Burn Protocol Section Exit to if indicated Cardiac Arrest Age Appropriate Protocol AC 3 / PC 4 Arrhythmia Protocol(s) Entrapment without crush syndrome Vascular injury with perfusion deficit syndrome Compartment Altered mental status Differential Or Consider Pediatric: Pediatric: IV / IO / IN 2.5 – mg 5 May repeat x 3 repeat May 50 mEq IV / IO Maximum 5 mg Maximum Over 2- 3 minutes Albuterol Nebulizer TB 3 Sodium Bicarbonate Sodium 1 Liter 1 Liter per hour IV / IO Maintenance fluid rate Midazolam 1 – mg 2 IN Normal Saline Infusion 500 mL per 500 mL per IV hour / IO Pediatric Maximum 2 mg 3 x maintenance fluid rate Pediatric:0.1 – 0.2 mg / kg Pediatric: 20 mg / kg IV / IO Pediatric: 1 mEq / kg IV / IO Midazolam 0.5 – 2 mg IV / IO to appropriate destination using Over 2 – 3 minutes as needed (Calcium Chloride 1 g IV / IO) Calcium Gluconate 2 g IV / IO Decrease Normal Saline Infusion Trauma and Burn: Notify Destination or P P Contact Medical Control Contact Medical A A EMS Triage and Destination Plan Hypothermia Hypothermia ECG findings Abnormal Pain Anxiety Hypotension Rapid Transport Signs and Symptoms Signs and This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Or Or 0.12 seconds 0.12 Airway 0.46 seconds ≥ Cardiac Monitor ≥ if indicated if indicated as indicated as as indicated as IV / IO Procedure Protocol TB 2 Protocol Loss of P wave Abnormal ECG Age Appropriate Peaked T Waves Peaked T QT 12 Lead ECG Procedure Entrapped > 2 hours Entrapped < 2 hours QRS Asystole / PEA / VF / VT Thermal Burn Protocol TB 9 Pain Control Protocol UP 11 Chemical and Electrical Burn Hemodynamically Unstable Multiple Trauma Protocol TB 6 Extremity / body crushed crushed body / Extremity Building collapse, trench collapse, industrialaccident, pinned under heavy equipment Entrapped and crushed under heavy load > 30 minutes Protocol(s) AR 1, 2, 3, 4, 5, 6, 7 History P B A Trauma and Burn Protocol Section Protocol Burn and Trauma

Pearls Recommended exam: Mental Status, Musculoskeletal, Neuro Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call for appropriate resources. 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. 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. Crush syndrome typically manifests after 2 – 4 hours of crush injury, but may present in < 1 hour. Fluid resuscitation: If access to patient and initiation of IV fluids occurs after 2 hours, give 2 liters of IV fluids in adults and 20 mL/kg of IV fluids in pediatrics and then begin > 2 hour dosing regimen. 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. Patients may become hypothermic even in warm environments. 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. TB 3 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Trauma and Burn Protocol Section Locally Revised 11/01/2017 Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation or or Differential Kefzol 1 gm IV ANCEF 1 gm IV ANCEF Cefazolin 1 gm IV so thatdestinationappropriate the and place in air tight container. container. tight air in place and Place container on ice if available. if ice on container Place Clean amputated part, Wrap part in sterile dressing soaked in normal saline saline normal in soaked dressing sterile P YES TB 4 ations have a high incidence of vascular compromise. in 6 hoursinjury. fromin 6 time of the Pain, swelling Deformity Altered sensation / motor function Diminished pulse / capillary refill Decreased extremity temperature Signs and Symptoms and Signs th Direct Pressure port and notify medical control immediately, NO Consider if available if indicated if indicated Wound care Wound if indicated if indicated if indicated if indicated IV / IO Procedure as indicated Open Fracture Open Age Appropriate Splintingindicated as Monitor and Reassess Amputation and / or Pain Protocol UP 11 Protocol AM 5 / PM 3 Notify Destination or Contact Medical Control Multiple Trauma Protocol TB 6 Crush Syndrome Protocol TB 3 Wound Care - Tourniquet Procedure This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Topical Hemostatic Agent / Dressing Control Hemorrhage wi Hemorrhage Control Age Appropriate Hypotension / Shock Airway Protocol(s) AR 1, 2, 3, 4, 5, 6, 7 A can be determined. Multiple casualtyTourniquet incident:be considered may Proceduredirectfirst pressure. instead of Urgently transport any injury with vascular compromise. losswithBloodapparentbe concealed injuries. extremity may or not Lacerations mustwithrepair be evaluated for Peripheral neurovascularimportantis status Trans critical. time is In amputations, Hip dislocations and knee and elbow fracture / disloc Recommended Exam: Mental Status, Extremity, Neuro Medical history Medications Time of injury of Time vs. closedOpen wound/ fracture Wound contamination Type of injury Mechanism: crush penetrating/ / amputation Revised 01/01/2017 Pearls History Trauma and Burn Protocol Section See Pearls Evidence of Pupils / Posturing Brain Herniation: HYPERVENTILATE EtCO2 30 – 30 EtCO2 mmHg 35 DO NOT ROUTINELY DO NOT Hyperventilate to maintain Skull fracture Skull Brain injury (Concussion, Contusion, HemorrhageLaceration) or hematoma Epidural Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse Unilateral or Bilateral Dilation of Differential 90% ≥ TB 5 94% ≥ using using if indicated to appropriate destination 35 –mmHg 45 Maintain EtCO2 Maintain Cardiac Monitor if indicated if indicated if indicated if indicated if indicated if indicated if indicated Preferably IV / IO Procedure Protocol UP 4 Protocol Altered mental status Unconscious Respiratory distress/ failure Vomiting Major traumatic mechanism of injury Seizure Pain, swelling, bleeding swelling, Pain, Age Appropriate Age Appropriate Supplemental oxygen Maintain SpO2 Monitor and Reassess Trauma and Burn: Trauma Hypotension / Shock Obtain and Record GCS Obtain and Record Protocol AM 5 / PM 3 AM 5 / Protocol Altered Mental Status Mental Altered Signs and Symptoms Seizure Protocol UP 13 Protocol Seizure Notify Destination or Spinal Motion Restriction ProcedureProtocol8 / TB Pain Control Protocol UP 11 Protocol Control Pain Contact Medical Control Contact Medical Blood Glucose Analysis Procedure Analysis Glucose Blood Multiple Trauma Protocol TB 6 Airway Protocol(s) AR 1, 2, 3, 5, 6 5, 3, 2, AR 1, Protocol(s) Airway EMS Triage and Destination Plan Prevent Oxygen desaturation events < 90% Rapid Transport A P This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Evidence for multi-trauma Loss of consciousness Bleeding history medical Past Medications Time of injury of Time Mechanism (blunt vs. penetrating) Revised 01/01/2017 History Trauma and Burn Protocol Section Protocol Burn and Trauma

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. A single episode of hypoxia and / or hypotension can significantly increase morbidity and mortality with head injury. Hyperventilation in head injury: Hyperventilation lowers CO2 and causes vasoconstriction leading to increased intracranial pressure (ICP) and should not be done routinely. Use in patient with evidence of herniation (blown pupil, decorticate / decerebrate posturing, bradycardia, decreasing GCS). If hyperventilation is needed, ventilate at 14 – 18 / minute to maintain EtCO2 between 30 - 35 mmHg. Short term option only used for severe head injury typically GCS ≤ 8 or unresponsive. Do not place in Trendelenburg position as this may increase ICP and worsen blood pressure. Poorly fitted cervical collars may also increase ICP when applied too tightly. In areas with short transport times, Drug Assisted Airway protocol is not recommended for patients who are spontaneously breathing and who have oxygen saturations of ≥ 90% with supplemental oxygen including BIAD / BVM. Hypotension: Limit IV fluids unless patient is hypotensive. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Usually indicates injury or shock unrelated to the head injury and should be aggressively treated. Fluid resuscitation should be titrated to maintain at least a systolic BP of > 70 + 2 x the age in years. 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. 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. Concussions: 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. EMS Providers should not make return-to-play decisions when evaluating an athlete with suspected concussion. This is outside the scope of practice.

Revised TB 5 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Trauma and Burn Protocol Section Flail chest Pericardial tamponade Open chest wound Hemothorax Abnormal if indicated if indicated Monitor and Reassess and Monitor Protocol AM 5 / PM 3 5 / AM Protocol Chest: Tension pneumothorax Intra-abdominal bleeding Pelvis / Femur fracture Spine fracture / Cord injury Head injury (see Head Trauma) Extremity fracture / Dislocation obstruction) HEENT (Airway Hypothermia TXA 1 gm over 10 minutes IV / IO Differential (Life threatening) Age Appropriate Hypotension / Shock P 10 minutes ≤ TB 6 if indicated Cardiac Monitor if indicated if indicated if indicated if indicated if indicated IV / IO Procedure Protocol UP 4 Protocol Age Appropriate Consider Pelvic Binding Trauma and Burn: Obtain and Record GCS Altered Mental Status VS / Perfusion / GCS Splint Suspected Fractures Notify Destination or Spinal Motion Restriction Control External Hemorrhage Procedure / Protocol TB 8 Head Injury Protocol TB 5 Pain Control Protocol UP 11 Protocol Control Pain Provide Early Notification Contact Medical Control Contact Medical Pain, swelling Deformity, lesions,bleeding Altered mental status or unconscious shock or Hypotension Arrest Airway Protocol(s) AR 1, 2, 3, 5, 6 5, 3, 2, 1, AR Protocol(s) Airway Limit Scene Time EMS Triage and Destination Plan Chest Decompression-Needle Procedure Signs and Symptoms Signs and P P A to appropriate destination using using destination appropriate Rapid Transport to This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Normal Monitor and Reassess Repeat Assessment Adult Procedure Past medical history medical Past Medications Location in structure or vehicle Others injured or dead Speed and details of MVC Restraints / protective equipment Time and mechanism of injury vehicle or structure to Damage Revised 01/01/2017 History Trauma and Burn Protocol Section Protocol Burn and Trauma

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. Control external hemorrhage and prevent hypothermia by keeping patient warm. Consider Chest Decompression with signs of shock and injury to torso and evidence of tension pneumothorax. Trauma Triad of Death: Metabolic acidosis / Coagulopathy / Hypothermia Appropriate resuscitation measures and keeping patient warm regardless of ambient temperature helps to mitigate metabolic acidosis, coagulopathy, and hypothermia. Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained ≥ 90% Tranexamic Acid (TXA): Agencies utilizing TXA must have approval from your T-RAC. Trauma in Pregnancy: Providing optimal care for the mother = optimal care for the fetus. After 20 weeks gestation (fundus at or above umbilicus) transport patient on left side with 10 – 20° of elevation. Pediatric Trauma: Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age)mmHg and 11 years and older > 90 mmHg. Geriatric Trauma: Evaluate with a high index of suspicion. Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning. Risk of death with trauma increases after age 55. SBP < 110 may represent shock / poor perfusion in patients over age 65. Low impact mechanisms, such as ground level falls might result in severe injury especially in age over 65. See Regional Trauma Guidelines when declaring Trauma Activation. Severe bleeding from an extremity not rapidly controlled with direct pressure may necessitate the application of a tourniquet. Maintain high-index of suspicion for domestic violence or abuse, pediatric non-accidental trauma, or geriatric abuse.

Revised TB 6 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Trauma and Burn Protocol Section Exit to Apply Follow stretcher AMBULATORY NONAMBULATORY Appropriate protocol(s) Appropriate secure patient to stretcher Restrict Spinal Movement Spinal Restrict Spinal Precautions Procedure Cervical Immobilization Device the device, then secure to stretcher. log roll / straddle slide to maintain spinal precautions without a device, then secure to Bring stretcher to patient, assist patient onto equivalent devices) to TRANSFER patient to Use Long Spine Board (OR any of the multiple May use multiple providers to transfer patient to stretcher using in-line spinal techniques such as as such techniques spinal in-line using stretcher stretcher with minimal spinal movement, remove stretcher with minimal spinal movement, and then

NOT require use of the long spine board for immobilization. S Lungs, Abdomen, Back, Extremities, Neuro

-line spine stabilization during any necessary movement/ E or spine habitus preventing them from lying flat. TB 8

ritis, cancer, dialysis, underlying spine or bonedisease. Y YES YES YES YES YES o with no signs / symptoms of spinal injury. cessary where: vice, or pedestrian-vehicle crash us, Skin, Neck, Heart, board is not ne 5 stairs or steps NO NO NO NO NO NO This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This pain to ROM? Not Required 3 feet and/or ≥ and/or 3 feet ≥ Spinal Motion Restriction Motion Spinal Includes Drugs and / or Alcohol / and Drugs Includes and abrupt deceleration crashes 30 mph, rollover, and/or ejection from the painof a c-spine injury? ≥ MVC Fall from Penetrating trauma to the head, neck or tors Motorcycle, bicycle, other mobile de spine to load axial or Diving Electric shock istracting Injury: lertness: Alteration in mental status? euro Exam: focal Any deficit? Any painful injury that might distract the patient pinal Exam: ignificant mechanism of injury? High-energy events such as ejection, high falls, falls, high ejection, as such events High-energy ntoxication:evidence? Any Point tenderness over the spinous process(es) or S D A I S N Immobilization on a long spine Concerning mechanisms that may result in spinal column injury: Consider spinal motion restriction in patients with arth Range of motion (ROM) is tested by touching chin to chest (look down), extending neck (look up), and turning head from side to spinal midline has patient if assessed NOT be should ROM pain. mid-line cervical posterior without shoulder) to (shoulder side tenderness. Patient's range of motion should not be assisted. Spinal motion restriction is always utilized in at-risk patients. These include cervical collar, securing to stretcher, minimizing movement / transfers and maintenance of in Long spine boards are NOT standard of care considered in most cases of potential spinal injury. Spinal motion restriction with cervical collar and securing patient to cot, while padding all void areas is appropriate. True spinal immobilization is not possible. Spine protection and spinal motion restriction do not equal long spine board. Recommended Exam: Mental Stat Patients meeting all the above criteria do not require spinal motion restriction. However, patients who fail one or more criteria above require spinal motion restriction, but does transfers. This includes the elderly or others with body Revised 01/01/2017 B B B B B B B Pearls Trauma and Burn Protocol Section Degree Burn rd /3 nd compromise Critical Burn Degree) blistering nd Degree) painless/charred or leathery transport to a Burn Center) Burn a to transport Burns with definitive airway Burns with Multiple Trauma rd (When reasonably accessible, accessible, reasonably (When Degree) red - painful (Don’t include in >15% TBSA 2 >15% TBSA st skin Superficial (1 TBSA) (2 Thickness Partial Full (3 Thickness Thermal injury Chemical – Electrical injury Radiation injury injury Blast Differential Degree Burn rd /3 TB 9 nd Normal Saline if indicated if indicated if indicated IV / IO Procedure as indicated Serious Burn (More info below) (More info to appropriate destination using Monitor and Reassess Trauma and Burn: for up to the first hours.8 Pain Control Protocol UP 11 Protocol Control Pain Notify Destination or Dry Clean Sheet or Dressings 0.25 mL / kg ( x % TBSA) / hr Lactated Ringers if available transport to a Burn Center) Contact Medical Control Contact Medical (When reasonably accessible, accessible, reasonably (When Multiple Trauma Protocol TB 6 Hypotension or GCS 13 or Less GCS 13 or Hypotension intubation for airway stabilization Airway Protocol(s) AR 1, 2, 3, 5, 6 5, 3, 2, 1, AR Protocol(s) Airway 5-15% TBSA 2 EMS Triage and Destination Plan Burns, pain, swelling Dizziness Loss of consciousness Hypotension/shock Airway compromise/ distress could be by indicated hoarseness/wheezing Suspected inhalation injury or requiring Carbon Monoxide / Cyanide Protocol TE 2 Consider 2 IV sites if greater than 15 % TBSA Remove Rings, Bracelets / Constricting Items Assess Burn / ConcomitantInjury Severity Signs and Symptoms Rapid Transport A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Degree Burn rd /3 nd Minor Burn Normotensive GCS 14 or Greater 1. Lactated Ringers preferred over Normal Saline. Use if available, if not change over once available. 2. Formula example; an 80 kg (196 lbs.) patient with 50% TBSA will need 1000 cc of fluid per hour. Other trauma Other Loss of Consciousness Tetanus/Immunization status Inhalation injury Injury of Time and history medical Past Medications Type of exposure (heat, gas, chemical) < 5% TBSA 2 No inhalation injury, Not Intubated, History Trauma and Burn Protocol Section itical ) rd st degree burns. burns. degree ) or full (3 full ) or th nd and 6 and th 5 th Back, and Neuro degree) burns but do not include include not but do burns degree) st patient’s palm as 1 % 1 % as palm patient’s referring to a burn that destroys dermis, dermis, destroys that burn to a referring referring to a burn that destroys the dermis dermis the destroys that burn to a referring dermis, destroys that burn to a referring th th th 6 4 5 destroys muscle tissue, and penetrates or penetrates and tissue, muscle destroys tissue. bone destroys and involves muscle tissue. muscle involves and tissue involves and tissue, muscle penetrates the around bone. thickness burns. burns. thickness There is significant debate regarding the actual value value actual the regarding debate significant is There the of that beyond injury burn a of identifying at least at burn thickness full and partial superficial, our For care. primary and emergent of level the burns. Thickness Full in included are all work, those burns in your TBSA estimate. TBSA in your burns those Seldom do you find a complete isolated body part part body isolated a complete find you do Seldom of Nines. Rule in the described as is injured that of portions area, one of be portions will it likely, More needed. will be approximation an and another, serious of extent the determining of purpose the For 1 minimal or with area the differentiate injury, (2 of partial those from burn degree Surface Body Total determining of purpose the For Area (TBSA) of burn, include onlyPartial and Full other of observation the Report burns. Thickness (1 superficial Some texts will refer to 4 include: general in classifications burn Other men, Extremities, Rule of Nines Estimate spotty areas of burn by using the size of the TB 9 degree burns, or rd or 3 or nd Status, HEENT, Neck, Heart, Lungs, Abdo This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This degree burns > 5% any age group,TBSA for or rd 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 3 > 5-15% total body surface area (TBSA) 2 interventions such as airway management are not available in the field. Never administer IM pain injections to a burn patient. 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 geriatric abuse with burn injuries in the elderly. 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. Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or cr excessive is Center Burn to distance if only utilized be should facility Local Center. Burn a to transport direct Require Green, Yellow and Red In burn severity do not apply to the Start / JumpStart Triage System. Critical or Serious Burns: Recommended Exam: Mental Pearls Trauma and Burn Protocol Section 15 minutes minutes 15 ≥ life Policy Follow Rigor mortis resuscitation Do notbegin with asystole Decomposition Dependent lividity Blunt force trauma DNR / MOST Form DNR Deceased Subjects Injury incompatible with Downtime NO NO YES Pupil YES YES YES Policy Apnea Follow Arrest Reflexes PEA < 40 Pulseless Asystole or Penetrating resuscitation Do not begin begin not Do Spontaneoius Body Movement Deceased Subjects Deceased YES NO NO NO YES YES TB 10 to or 10 minutes ≤ Binding Fractures Airway if indicated Consider Pelvic Pelvic Consider Hemorrhage Hemorrhage Protocol(s) Procedure If indicated if indicated IV / IO Procedure IV appropriate Control External NO Splint Suspected Needle Procedure Needle AR 1, 2, 3, 5, 6 5, 3, 2, 1, AR Protocol TB 8 Nearest ER Nearest destination using using destination Cardiopulmonary Chest Decompression- Trauma and Burn: Rapid Transport Resuscitation Procedure Resuscitation P A Spinal Motion Restriction Provide Early Notification Limit Scene Time EMS Triage and Destination Plan Review DNR / MOST Form Review DNR This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Criteria for Death /Resuscitation No NO NO NO YES YES YES YES Blunt Policy Follow Apnea Arrest PEA < 40 Pulseless Asystole or resuscitation Do not begin Deceased Subjects Revised 01/01/2017 Trauma and Burn Protocol Section ons and early defibrillation patient, but patient, rather make ventilations are 30:2. If advanced 15 minutes with no ROSC consider ≥ suscitationshould be initiated. should not cool the trauma ssions limited with interrupti oncerning agonal respirations, pulselessness, asystole or Lung, Abdomen, Extremities, Back, Neuro TB 10 ed ReverseedpulselesswhereTriage: apneic / Begin CPR airway (BIAD, ETT) compressions to nutes use of ECG monitor may delay resuscitation. blunt and penetrating trauma victims who meet is appropriate.criteria performed during rapid transport.performedduring rapid situations causing hypothermia re nd spontaneous body movements. should make the assessment c This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Exam: Mental Status, Skin, HEENT, Heart, HEENT, Skin, Status, Mental Exam: From the time cardiac arrest is identified, if CPR is performed terminationresuscitation. of From the time cardiac arrest is identified, if transport time to closest Trauma Center is > 15 termination of resuscitation. consider minutes . PEA < 40, pupillary reflexes a when indicated. Consider early IO placement if available and difficult IV anticipated. airway in place ventilate 8 – 10 breaths per minute. Lightning strike, drowning or in drowning or Lightning strike, multiple lightningWherefound us are strike victims Agencies utilizing Targeted Temperature Management Protocol ALS procedures should optimally be Time considerations: Efforts should be directed at high quality and continuous compre DO NOT HYPERVENTILATE: If no advanced Organized rhythms for the purposes of this protocol include Ventricular Tachycardia, Ventricular Fibrillation and PEA. Wide, bizarre rhythms such as Idioventricular and severely brachycardic rhythms < 40 BPM are organized not rhythms. First arriving EMS personnel If transport time to Trauma Center is < 15 mi Rhythm determination is more helpful in rural settings or where transport to nearest facility is > 15 minutes. Omit from algorithm where appropriate. warmth. to maintain effort every Recommended Recommended Withholding resuscitative efforts with Revised 01/01/2017 Pearls Toxin-Environmental Protocol Section Officer Officer contact Control Document with Animal Contact and NO If Needed 1-800-222-1222 Carolinas Poison Control YES Transport Animal bite bite Animal Human bite (poisonous) bite Snake Spider bite (poisonous) Insect sting / bite (bee, wasp, ant, tick) Infection risk Rabies risk risk Tetanus Mammal Bite Mammal Differential if able if Notify Destination or TE 1 TE Contact Medical Control Snake Bite clothingbands / if indicated Redness and Time bands / jewelry DO NOT apply ICE DO NOT if indicated if indicated if indicated if indicated if indicated Pain Control Immobilize Injury IV / IO Procedure Monitor and Reassess Protocol UP 11 Protocol Remove any constricting constricting any Remove Mark Margin of Swelling / Age Appropriate Age Appropriate Keep bite at level of heart Protocol(s) TB 4, 5, 6 Protocol AM 5 / PM 3 Protocol AM 1 / PM 1 HypotensionShock / Identification of Animal Age Appropriate Trauma General Wound Care Procedure Pain, soft tissue swelling, redness Blood oozing from the bite wound Evidence of infection Shortnessbreath, of wheezing Allergic reaction, hives, itching Hypotensionshock or Rash, skin break, wound Removeconstricting any clothing/ Allergic Reaction/ Anaphylaxis Extremity Trauma Protocol TB 4 Signs and Symptoms Signs and A This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This if able Pediatrics: IV / IO / IM / IN Muscle Spasm Muscle Apply Ice Packs Maximum 10 mg Maximum 5 mg IM mg 5 Maximum Over 2 to 3 minutes Over 2 to 3 minutes Keep bite at level of heart Midazolam IN See Page 2 resources Midazolam 0.1 – 0.2 mg / kg Midazolam 2 – 2.5 mg IV / IO Spider Bite / Bee or Wasp Sting Immunocompromised patient Immunocompromised Time, location, size of bite / sting Previous reaction to bite / sting Domestic vs. Wild risk Rabies and Tetanus Type of bite / sting Description / photo for identification Revised Stage until scene safe scene until Stage 01/01/2017 Call for help / additional History P Toxin-Environmental Protocol Section herapy, transplant mplete Neck, Lung, Heart, itially but tissue necrosis at -- red on black fellow, a kill lack." venom ion: diabetes, chemot Little reaction is noted in cation of injury), and a co and animal or insect for identification purposes. identification for insect or animal and but over a few hours,but muscularpain andsevere abdominal TE 1 TE to a specific bacteria (Pasteurella multicoda). on Control Center for guidance (1-800-222-1222). ainage, fever, red streaks proximal to wound. ainage,proximal to red streaks fever, han animal bites due to normal due tobites mouth bacteria. animal han e pain but very toxic. "Red on yellow e, generally worse with largergenerallyspring. snakeswith worsee, and early in ation is unlikely.is About ation bites“dry”are 25 % of snake bites. ents are at an increased risk for infect This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Amount of envenomationvariabl isAmount If no pain or swelling, envenom Black Widow spiderWidowBlack painful,tend to be minimally bites pain may develop (spider is black with red hourglass on belly). Brown Recluse spider bites are minimally painful to painless. Carnivorelikelymuch moreareto become infected bitesRabieshaveexposure. risk of and all Cat bites may progress to infection rapidly due Poisonoussnakesviperaregenerallyin this area pit of the family: rattlesnake and copperhead. littl Very are rare: bites Coral snake Human bites have higher infection rates t the site of the bite develops over the next few days (brown spider with fiddle shape on back). Revised patients. Spider bites: Snake bites: Dog / Cat / Carnivorebites: Do not put responders in danger attempting in danger attempting to capture put responders Do not Evidence of infection: dr swelling, redness, Human bites: Immunocompromised pati the North Carolina Pois contacting Consider Recommended Mental Exam: Status, Skin, Extremities(Lo Abdomen, Back, and Neuro exameffects if systemicNeuro Back, are noted and Abdomen, 01/01/2017 Pearls Toxin-Environmental Protocol Section Diabetic related Infection MI Anaphylaxis Renal failure / dialysis problem Head injury / trauma Co-ingestant or exposures Differential n, Extremities If available Maximum 5 g TE 2 TE Hydroxocobalamin 70 mg / kg IV / IO P Notify Destination or t, Lungs, Abdome t, Lungs, Contact Medical Control Contact Medical Malaise,weakness, illness flu like Dyspnea GI Symptoms; N/V; cramping Dizziness Seizures Syncope Reddened skin Chest pain AMS YES Signs and Symptoms This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO Diabetic of Cyanide if indicated if indicated if indicated if indicated Continue Care IV/ IO Procedure High Suspicion High as indicated High Flow Oxygen Protocol UP 4 Protocol Age Appropriate Age Appropriate Age Appropriate Head Injury TB 5 Monitor and Reasses 12 Lead ECG Procedure Lead 12 Hypotension / Shock / Hypotension Protocol AM 2 / PM 2 Protocol AM 5 / PM 3 Altered Mental Status Cardiac Monitor / CO Monitor Continue High Flow Oxygen Blood Glucose Analysis Procedure Multiple Trauma Protocol TB 6 Protocol Trauma Multiple Immediately Remove from Exposure from Remove Immediately Appropriate Airway Protocol(s) 1 - Protocol(s) Airway Appropriate 7 Continue high flow oxygenreadings.ox regardlesspulse of Consider CO and Cyanide with any product of combustion Normal environmentalCO levelnot does excludeCO poisoning. Symptomspregnancy, presentchildrenlower withCO levels in elderly. and the Recommended exam: Neuro, Skin, Hear safety is priority. Scene Revised Past Medical History Medical Past Time / Duration of exposure Eating large quantity of fruit pits exposure Industrial Trauma Reason: Suicide, criminal, accidental Smoke inhalation Smoke cyanide of Ingestion 01/01/2017 P A B Pearls History Toxic-Environmental Protocol Section a.

port. NO Pulse Exit to Airway as tolerated mouth-to-mouth information as indicated Protocol TB 8 Cardiac Arrest Unresponsive 5 Breaths via BVM / 1-919-684-9111 Age Appropriate 25 minutes. Protocol(s) AR 1 - 7 ≤ Divers Alert Divers Alert Network Protocol(s) AC 3 / PC 4 Spinal Motion Restriction Hypoglycemia Cardiac Dysrhythmia Barotrauma Decompression sickness Agency specific hyperbaric Dive Accident / Barotrauma YES ung sounds,ung due to hypoxia) Trauma Pre-existing medical problem Pressure injury (SCUBA diving) Post-immersion syndrome Differential e equally important to high-quality CPR. would-be rescuers. (any respiratory symptom) from submersion / known submersion time of scuers should remove patients from areas of danger. 1 hour consider moving to recovery phase instead of rescue. then apply appropriate supplemental oxygen.mode of TE 3 TE ≥ as tolerated as tolerated as indicated as indicated Protocol UP 4 Cardiac Monitor if indicated Age Appropriate IV / IO Procedure as indicated Protocol TB 8 Protocol Dry / Warm Patient Protocol(s) 1-7 Remove wet clothing wet Remove Supplemental Oxygen Altered Mental Status Awake but with AMS Airway Protocol(s) AR 1 - 7 Age Appropriate Airway Notify Destination or Notify Destination Contact Medical Contact Control status, Trauma Survey, Skin, Neuro Mentalstatus changes Decreased or absent vital signs FoamingVomiting / Coughing, Wheezing, Rales, Rhonchi, Stridor Apnea Unresponsive y be copious, DO NOT waste time attempting to suction. Ventilate with BVM 5 Breaths via BVM / mouth-to-mouth ng cause of death among Spinal Motion Restriction Procedure / ng respiratory impairment Signs and Symptoms Signs and by hypoxia, airway and ventilation ar and ventilation airway by hypoxia, P A – resuscitate all patients with This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This r regardless of r regardless 6 hours if indicated if indicated as tolerated as indicated Cardiac Monitor IV / IO Procedure evaluation even if Dry / Warm Patient / Warm Dry minimal symptoms Remove wet clothing Awake and Alert and Awake Supplemental Oxygen Supplemental Monitor and Reassess and Monitor asymptomatic or with Asymptomatic drowning drowning Asymptomatic Procedure / Protocol TB 8 Protocol / Procedure Spinal Motions Restriction Encourage transport and patients (refusing transport) medical care/call 911 if they Spinal motion restriction is usually unnecessary. When indicated it should not interrupt ventilation, oxygenation and / or CPR. / and oxygenation ventilation, interrupt not should it indicated When unnecessary. usually is restriction motion Spinal Predicting prognosis in prehospital setting is difficult and does not correlate with mental status. Unless obvious death, trans Hypothermia is often associated with drowning and submersion injuries even with warm ambient conditions. Drowning patient typically has <1 – mL/kg 3 of water in lungs (does not require suction) Primary treatment is reversal of hypoxi through foam (suction water and vomit only when present.) Cardiac arrest in drowning is caused Encourage transport of all symptomatic patients (cough, foam, dyspnea, abnormal l When feasible, only appropriately trained and certified re certified and trained appropriately only When feasible, water temperature Regardless of Regardless of water temperature – If submersion time Foam is usually present in airway and ma Begin with BVM ventilations, if patient does not tolerate Ensure scene safety. Drowning is a leadi Recommended Exam: Respiratory, Mental Drowning is process of experienci the immersion in a liquid. potential worsening over the next 6 hours. depth Possible history of trauma / immersion submersion of Duration Temperature of water or possibility of hypothermia Submersion in wate Revised should be instructed to seek Slammed into shore wavebreak develop any symptoms within 01/01/2017 Pearls History P A Toxic-Environmental Protocol Section (Thyroid Storm) Hot, dry skin HEAT STROKE Hypotension, AMS / Coma Fever, usually > 104°F (40°C) 104°F > usually Fever, Age Fever (Infection) Dehydration Medications Hyperthyroidism (DT's) tremens Delirium Heat cramps, exhaustion, stroke CNS lesions or tumors x Differential 70 + 2 70 ≥ Maximum 2 L 500 mL IV / IO Cardiac Monitor IV / IO Procedure IV as indicated as indicated as indicated Protocol UP 4 Protocol SBP Age Appropriate Age Appropriate Maximum 60 mL/kg 60 Maximum Monitor and Reassess and Monitor Normal SalineBolus Active cooling measures 12 Lead ECG Procedure Lead 12 Hypotension / Shock Shock / Hypotension ProtocolAM 5 / PM 3 Altered Mental Status Repeat to effect SBP > 90 Notify Destination or Notify Destination PED: Bolus 20 mL/kg IV / IO IV / mL/kg Bolus 20 PED: Target Temp < 102.5° F (39°C) Airway Protocol(s) AR 1 - 1 AR Protocol(s) Airway 7 Contact Medical Contact Control Repeat to effect Age appropriate Age effect to Repeat P B A A TE 4 TE environment as indicated Cooling measures Cooling Cool, moist skin Age Appropriate Remove tight clothing HEAT EXHAUSTION Altered mental status / coma Hot, dry or sweaty skin Hypotension or shock Seizures Nausea Assess Symptom Severity Elevated body temperature Remove from heat source to cool Diabetic Protocol AM 2 / PM 2 Blood Glucose Analysis Procedure Analysis Glucose Blood Weakness, Anxious, Tachypnea Anxious, Weakness, Signs and SymptomsSigns and This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Directored by by OEMS Directored EMS Medical local by the NCCEP Protocol the original from been altered has protocol This Procedure if available hyperthermia HEAT CRAMPS Warm, moist skin PO Fluids as tolerated Monitor and Reassess and Monitor TemperatureMeasurement TemperatureMeasurement should NOT delay treatment of Fatigue and / or muscle cramping Past medical history / Medications history medical Past Time and duration of exposure Poor PO intake, extreme exertion Age,very young and old temperatures increased to Exposure and / or humidity Revised Weakness, Muscle cramping 01/01/2017 B History Normal to elevated body temperature Toxic-Environmental Protocol Section Protocol Toxic-Environmental

Pearls Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro Extremes of age are more prone to heat emergencies (i.e. young and old). Obtain and document patient temperature if able. Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. Cocaine, Amphetamines, and Salicylates may elevate body temperatures. Intense shivering may occur as patient is cooled. Heat Cramps: Consists of benign muscle cramping secondary to dehydration and is not associated with an elevated temperature. Heat Exhaustion: Consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature. Heat Stroke: Consists of dehydration, tachycardia, hypotension, temperature ≥ 104°F (40°C), and an altered mental status. Sweating generally disappears as body temperature rises above 104°F (40°C). The young and elderly are more prone to be dry with no sweating. Exertional Heat Stroke: In exertional heat stroke (athletes, hard labor), the patient may have sweated profusely and be wet on exam. Rapid cooling takes precedence over transport as early cooling decreases morbidity and mortality. If available, immerse in an ice water bath for 5 – 10 minutes. Monitor rectal temperature and remove patient when temperature reaches 102.5°F (39°C). Your goal is to decrease rectal temperature below 104°F (40°C) with target of 102.5°F (39°C) within 30 minutes. Stirring the water aids in cooling. Other methods include cold wet towels below and above the body or spraying cold water over body continuously. Neuroleptic Malignant Syndrome (NMS): Neuroleptic Malignant Syndrome is a hyperthermic emergency which is not related to heat exposure. It occurs after taking neuroleptic antipsychotic medications. This is a rare but often lethal syndrome characterized by muscular rigidity, AMS, tachycardia and hyperthermia. Drugs Associated with Neuroleptic Malignant Syndrome: Prochlorperazine (Compazine), promethazine (Phenergan), clozapine (Clozaril), and risperidone (Risperdal) metoclopramide (Reglan), amoxapine (Ascendin), and lithium. Management of NMS: Supportive care with attention to hypotension and volume depletion. Use benzodiazepines such as diazepam or midazolam for seizures and / or muscular rigidity.

Revised TE 4 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Toxic-Environmental Protocol Section NO Pulse Exit to Cardiac Protocol(s) See Pearls Unresponsive Age Appropriate YES Stroke Head injury Spinal cord injury Sepsis exposure Environmental Hypothyroidism Hypoglycemia dysfunction CNS Differential Systemic Hypothermia TE 5 TE 70 + 2 Age + 2 x 70 ≥ Maximum 2 L 500 mL IV / IO Cardiac Monitor IV / IO Procedure as indicated as indicated as indicated as indicated Protocol UP 4 Protocol Dry / Warm Patient SBP Age Appropriate Age Appropriate Age Appropriate Remove wet clothing MonitorReassess and Normal SalineBolus Maximum 60 mL / kg / mL 60 Maximum Hypotension/ Shock 12 Lead ECG Procedure Lead 12 Altered mental status / coma Cold, clammy Shivering Extremity pain or sensory abnormality Bradycardia Hypotension or shock Active warmingmeasures Protocol AM 5 / PM 3 Altered MentalStatus Hypothermia / Frost Bite Passive warming measures Pediatric: 20 mLkg / IV / IO Notify Destination or Airway Protocol(s) AR 1 -1 AR Airway Protocol(s) 7 Awake with / without AMS / with without Awake Repeat to titrate Age Appropriate Repeat to titrate > 90 SBP mmHg Diabetic Protocol AM 2 / PM 2 AM 2 / Protocol Diabetic Signs and SymptomsSigns and Blood Glucose Analysis Procedure Multiple Trauma Protocol TB 6 Contact Medical Control Contact Medical P A B Hypothermia / Frostbite Hypothermia This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This Skin to warm Procedure if available hypothermia DO NOT Massage General WoundCare DO allow refreezing DO NOT Localized Cold Injury Rub Skin to warm DO NOT Temperature Measurement Temperature Measurement Length of exposure / Wetness / Wind chill Past medical history / Medications history medical Past Drug use: Alcohol, barbituates Infections / Sepsis Age,very young and old Exposure to decreased temperatures but may occur in normal temperatures Revised should NOT delay treatment of of treatment NOT delay should 01/01/2017 History B Toxic-Environmental Protocol Section Protocol Toxic-Environmental

Pearls Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro NO PATIENT IS DEAD UNTIL WARM AND DEAD (Body temperature ≥ 93.2° F, 32° C.) Many thermometers do not register temperature below 93.2° F. Hypothermia categories: Mild 90 – 95° F ( 32 – 35° C) Moderate 82 – 90° F ( 28 – 32° C) Severe < 82° F ( < 28° 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°F (30° C) antiarrhythmics may not work and if given should be given at increased intervals. Contact medical control for direction. Epinephrine / Vasopressin can be administered. Below 86° F (30°C) pacing should not utilized. Consider withholding CPR if patient has organized rhythm or has other signs of life. Contact Medical Control. If the patient is below 86° F (30° 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 60 seconds to palpate a pulse. Active Warming: Remove from cold environment and to warm environment protected from wind and wet conditions. Remove wet clothing and provide warm blankets / warming blankets. 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 TE 5 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Toxic-Environmental Protocol Section If Needed if indicated if indicated Immobilize injury Protocol TB 4 Protocol TB 6 1-800-222-1222 Large Organism Multiple Trauma Extremity Trauma Carolinas Poison Control Jellyfish sting Jellyfish sting Urchin Sea barb ray Sting Coral sting Swimmers itch Cone Shell sting Fish bite sting Fish Lion Differential TE 6 TE if available if indicated if indicated Lion Fish Sting Ray Sting Cardiac Monitor if indicated if indicated if indicated if indicated Immobilize injury Immobilize Pain Control IV / IO Procedure Sea Creature Identification of Protocol UP 11 Urchin / Starfish Age Appropriate Age Appropriate Immerse in Hot Water Hot in Immerse Monitor and Reassess Remove Barb or Spine 110 – 114°F (43 - 46°C) If large Barb in thorax or abdomen stabilize object Hypotension Shock/ Allergy / Anaphylaxis / Anaphylaxis Allergy Protocol AM 1 / PM 1 Protocol AM 5 / PM 3 Drowning Protocol TE 3 Protocol Drowning Notify Destination or General Wound Care Procedure Contact Medical Control Contact Medical Increased oral secretions Nausea / vomiting Abdominal cramping Allergic reaction / anaphylaxis Intenselocalized pain P A Signs and SymptomsSigns and This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This DO NOT seawater If available Immobilize injury Jelly Fish Anemone Lift away tentacles Man-O-War Do Not brush or rubNot brushDo or Apply Vinegar Rinse Vinegar Apply use fresh water or ice Otherwise wash with clean clean with wash Otherwise Previous reaction to marine organism Immunocompromised pet Household Type of bite / sting Identification of organism Revised 01/01/2017 History Toxic-Environmental Section e nematocyst to fire even if detached from the jellyfish. the organism as they may impart further sting / injury. TE 6 TE This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This not delay transport if indicated. similar effects. similar initially. Typical injury is swimmer stepping on ray and muscular tail drives 1 – 4 barbs into victim. Venom released when barb is broken. Typical symptoms are immediate pain which increases over 1 – hours. 2 Bleeding may be profuse due to deep puncture wound. occur. may salivation and urination increased and cramping muscle diarrhea, vomiting, Nausea, Seizures, hypotension and respiratory or cardiovascular collapse may occur. Irrigate wound with saline. Extract the spine or barb unless in the abdomen or thorax, contact medical control for advise. Immersion in hot water if available for 30 to 90 minutes but do not delay transport. In North Carolina this would typically occur in the homeas they are often kept as pets in saltwateraquariums. Remove any obvious protruding spines and irrigate area with copious amounts of saline. The venom is heat labile so immersion in hot water, 110 – 114 degrees for 30 to 90 minutes is the treatment of choice but do Wash the area with fresh seawater to remove tentacles and nematocysts. Do not apply fresh water or ice as this will cause nematocysts firing as well. Recent evidence does not demonstrate a clear choice of any solution that neutralizes nematocysts. Vinegar (immersion for 30 seconds), 50:50 mixture of Baking Soda and Seawater, and even meat tenderizer may have Immersion in warm water for 20 minutes, 110 – 114°F (43 - 46°C), has recently been shown to be effective in pain control. Shaving cream may be useful in removing the tentacles and nematocysts with a sharp edge (card). Stimulation of the nematocysts by pressure or rubbing cause th Coral is covered by various living organisms which are easily dislodged from the structure. Victim may swim into coral causing small cuts and abrasions an d the coral may enter to cuts causing little if any symptoms The next 24 – 48 hours may reveal an inflammatory reaction with swelling, redness, itching, tenderness and ulceration. Treatment is flushing with large amountsof fresh water or soapy water then repeating Lift away tentacles as scrapping or rubbing will cause nematocysts firing. nematocysts cause will or rubbing scrapping as tentacles away Lift Typically symptoms are immediate stinging sensation on contact, intensity increases over 10 minutes. occur. usually itching and Redness Papules, vesicles and pustules may be noted and ulcers may form on the skin. Increased oral secretions and gastrointestinal cramping, nausea, pain or vomiting may occur. Muscle spasm, respiratory and cardiovascular collapse may follow. Ensure good wound care, immobilization and pain control. pain and immobilization care, wound good Ensure 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. Stingrays: Lionfish: Jelly Fish / Anemone / Man-O-War: Priority is removal of the patient from the water to prevent drowning. Coral: Ensure your safety: Avoid the organism or fragments of Revised 01/01/2017 Pearls Toxin-Environmental Protocol Section Locally Revised Airway 11/01/2017 Protocol(s) as indicated Age Appropriate Appropriate Age Cardiac Monitor IV / IO Procedure See Page 2 12 Lead ECG Procedure Tricyclic antidepressants (TCAs) Acetaminophen (Tylenol) Aspirin Depressants Stimulants Anticholinergic Cardiac medications Solvents, Alcohols, Cleaning agents Insecticides (organophosphates) For Specific Treatment Options Treatment For Specific P B A Differential YES Peds: 0.1 mg/kg 0.1 Peds: Peds: 0.1 mg/kg IM IV / IO / IM / IN / ETT Naloxone 0.4 – 2 mg Naloxone 0.4 – 2 mg IM TE 7 TE NO as indicated Contact Age Appropriate Age Appropriate Evaluation AMS Protocol UP 4 Hypotension / Shock Protocol AM 5 / PM / PM 3 AM 5 Protocol 1-800-222-1222 Behavioral Protocol UP 5 Protocol Behavioral NOT GIVENRESTORE CONCIOUSNESS TO Titrate to adequate ventilation and oxygenation Poison ControlAdvises Diabetic Protocol AM 3 / PM 2 AM 3 / Protocol Diabetic Hypotension / hypertension / Hypotension Decreased respiratory rate dysrhythmias Tachycardia, Seizures S.L.U.D.G.E. D.U.M.B.B.E.L.S Mentalstatus changes Need for EMS Intervention provided by Poison Control. Carolinas Poison Control A Need for Transport / Hospital Following ALS Assessment and consultation with PoisonControl Signs and SymptomsSigns and Disposition per local agency policy monitoring and telephone follow-up: home with close telephone follow-up If patient is deemed suitable for home It is appropriate for patient to remain at YES YES YES YES This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This NO NO NO NO Poor Perfusion Evaluation ARM Evaluation Stable Condition Stable Shock / Hypotension Normal Mental Exam Alerted Mental Status Oxygenation / Ventilation Inadequate Respirations / / Respirations Inadequate Follow Transport / Hospital Follow Transport No other medical concerns Normal Neurological Exam Past medical history, medications history, medical Past Substance ingested, route, quantity route, ingested, Substance ingestionTime of Reason (suicidal, accidental, criminal) Available medications in home Ingestion suspectedor ingestion of a potentially toxic substance Revised 01/01/2017 History Acetaminophen Tylenol® YES APAP Containing Product If Time of Ingestion ≤ 1 Hour NO B Activated Charcoal 1 gm/kg PO If available Aspirin YES Salicylate Containing Product

NO

If Time of Ingestion ≤ 1 Hour Beta Blocker or YES B Activated Charcoal 1 gm/kg PO Calcium Channel Blocker If available

NO This space intentionally left blank A Toxin-Environmental Protocol Section Protocol Toxin-Environmental Consider Cardiac External Pacing Procedure for Severe Cases

Calcium Gluconate 2 g IV / IO P Or (Calcium Chloride 1 g IV / IO) Pediatric: 20 mg / kg IV / IO Over 2- 3 minutes Age Appropriate Hypotension / Shock Protocol AM 5 / PM 3 if indicated

Cyanide / Exit to YES Carbon Monoxide Carbon Monoxide / Cyanide Protocol TE 2 NO

Organophosphate Exit to YES WMD / Nerve Agent Exposure WMD / Nerve Agent Protocol TE 8

NO If Time of Ingestion ≤ 1 Hour Tricyclic YES B Activated Charcoal 1 gm/kg PO Antidepressant if available QRS ≥ 0.12 sec or Peds: 0.09 sec Sodium Bicarbonate 50 mEq IV / IO Peds: 1 mEq/kg IV / IO Repeat in 10 minutes as needed P Symptomatic Care Sodium Bicarbonate Infusion as needed Monitor and Reassess

Notify Destination or Contact Medical Control

Revised Revised TE 7 Locally 01/01/2017 This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director 11/01/2017 Toxin-Environmental Section Locally Revised 11/01/2017 n circumstances 10up to mg. 16 kg remaining at 1 mL each. Total is 76 mL / hour) , Abdomen, Extremities, Neuro prove respiration, in certai recommend the routine use of charcoal in poisonings. who is alert and awake such that they can self-administer self-administer can that they such and awake alert who is nd may administer from EMS supply. medical Agency director one hour from ingestion medicalcontact control or Poison NOT administer unless known to be and airway adsorbed, ≥ TE 7 TE and the substance and amount ingested and any co-ingestants. ination, Defecation, GI distress, Emesis TIME OF INGESTION higher doses of Naloxone to im atus, Skin, HEENT, Heart, Lungs the North Carolina Poison Control Center for guidance, Policy reference 18. dysrhythmias and mental status changes This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils rapid progression from alert mental status to death. to status mental alert from progression rapid and 11 years andand 11 years older > 90 mmHg. 20 mL, kg = 10 Second mL, kg = 40 10 First kg child: 36 extended release agent(s) are involved and Center for direction. secured by intubation and ingestion is less than confirmed ONE HOUR and potentially lethal. the medication. increased HR, increased BP, increased temperature, dilated pupils, seizures pupils, dilated temperature, increased BP, increased HR, increased nausea, coughing, vomiting, and mental status changes 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; : Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal 2. Every effort should be made to elicit this information before leaving the scene. Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - year 1 > 70 mmHg, 1 - 10 years > 70 + (2 x age)mmHg Maintenance IV Rate: By weight of child: First 10 kg = 4 mL, Second 10 kg = 2 mL, Additional kg = 1 mL. (Example: The American Academy of Clinical Toxicology DOES NOT 1. Most important aspect is the 1. Consider Charcoal within the FIRST HOUR after ingestion. If a potentially life threatening substance is ingested or DO then Charcoal to administer necessary NG is If 2. 3. Charcoal in general should only be given to a patient Time of Ingestion:Time of may require Contact of Medical Control prior to administration and may restrict locally. Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. EMR and EMT may administer naloxone by IN route only a contact When appropriate Solvents: Insecticides: or administration self for autoinjector an in pralidoxime of mg 600 and Atropine of 2 mg Nerve Agent Antidote kits contain Destruction. Mass of Weapons for preparedness domestic the of part as available be may kits These care. patient Depressants: Stimulants: increasedAnticholinergic: HR, increased temperature, dilated pupils, mental status changes Cardiac Medications: Acetaminophen: Aspirin dysfunction, liver failure, and or cerebral edema among other things can take place later. S.L.U.D.G.E: Salivation, Lacrimation, Ur D.U.M.B.B.E.L.S: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation. Tricyclic: Bring bottles, contents, emesis to ED. Pediatric: Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. Charcoal Administration: Opioids and opiates may require Recommended Exam: Mental St Revised 01/01/2017 Pearls Toxic-Environmental Protocol Section e Go to Seizure Activity Seizure Protocol IV / IO / IM IV / IO / IM Arrest if available Over 30 minutes 30 Over 3 Doses Rapidly IV / IO Procedure symptoms resolve 600 mg IV / IO / IM Nerve Agent Kit IM Pralidoxime (2PAM) Pediatric: See Pearls Major Symptoms: Nerve agent exposure (e.g., VX, Sarin, Soman,etc.) Organophosphate exposure (pesticide) Vesicant exposure (e.g., Mustard etc.) Gas, Respiratory Irritant Exposure (e.g., Hydrogen Sulfide,Ammonia, Chlorine, etc.) Atropine 2 mg IV / IO / IM Pediatric: 15 – 25 mg / kg age, 2 Nerve Agent Kits from 8 to 14 Repeat every 3 to 5 minutes until Differential Altered Mental Status, Seizures, Respiratory Distress, Respiratory P A ent weighs between 40 to 90 pounds atric atropines (if atric atropines (if available). Lungs, Gastrointestinal, Neuro 40 kg). ≥ contamination as indicated. TE 8 TE sure to another agent (e.g., narcotics, vesicants, etc.) on and use of personal protective equipment. Symptom Severity Kit for patients less than 7 years of Notify Destination or if available Obtain history of exposure uscle Twitching uscle Contact Medical Control Contact Medical I Upset; Abdominal pain / cramping 90 pounds ( rination; increased, loss of control efecation / Diarrhea acrimation L U D G Emesis M Seizure Activity Arrest Respiratory Salivation 2 Doses Rapidly Doses 2 IV / IO Procedure IV Minor Symptoms: Observe specificfor toxidromes Nerve Agent Kit IM Signs and Symptoms Signs and 40 pounds (18 kg), 1 mg dose if pati upply of Nerve Agent Kits, use pedi ne by any route is acceptable. ≤ Respiratory Distress + SLUDGEM atus, Skin, HEENT, Heart, Initiate triage and/or de A contains 600 mg of Pralidoxime (2-PAM) and 2 mg of Atropine. This protocol has been altered from the original NCCEP Protocol by the local EMS Medical Director Medical EMS the local by Protocol NCCEP original the from altered been has protocol This it years of age, and 3 Nerve Agent Kits for patients 15 years of age and over. (18 to 40 kg), and 2 mg dose ≥ symptoms resources If Triage / MCI issues exhaust s Usual pediatric doses: 0.5 mg Confirmed attack: Begin with 1 Nerve Agent Appropriate Arm Appropriate Every 15 minutes for Asymptomatic Initiate Treatment per MonitorReassess and For patients with major symptoms, there is no limit for atropine dosing. Carefully evaluate patients to ensure they not from expo The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves. EMS personnel, public safety officers and EMR / EMT may carry, self-administer or administer to a patient atropine / pralidoxim Each Nerve Agent K Seizure Activity: Any benzodiazepi Recommended Exam: Mental St Follow local HAZMAT protocols for decontaminati Adult / Pediatric Atropine Dosing Guides: by protocol. Agency medical director may require Contact of Medical Control prior to administration. Potential exposure to unknown unknown to exposure Potential substance/hazard Exposure to chemical, biologic, hazard nuclear or radiologic, Revised Stage until scene safe scene until Stage 01/01/2017 Call for help / additional Pearls History General Medical EMS Triage and Destination Plan nce nce 2014 2009 aphically closest an Medical Center ington Medical Center tion Medical Center exington Medical Center exington Medical transported totransported the geogr emon based North Carolinas EMS ansported to a geographically distant CMC – Northeast CMC – Northeast based on complaint: Based on complaint, Iredell Memorial Hospital Iredell Memorial Hospital Appropriate Facility Listed king on transport destinations Wake Forest Baptist Health Wake Forest Baptist Health Medical Center Medical Regional Davis Davis Regional Medical Center Stanly Regional Medical Center Stanly Regional Medical Center Transport to geographically closest Lake Norman Regional Medical Center Lake Norman Regional Medical Center Novant Health – Rowan Medical Center Novant Health – Row Novant Health – Forsyth Medical Center Veterans AdministrationVeterans Medical Center Novant Health – Forsyth Medical Center Veterans Administra Appropriate Triage and Destination Plan Transport Facility to of Preference Listed WF Baptist Health – Davie Medical Center WF Baptist Health– Medical Davie Center STEMI, Stroke, Pediatric, STEMI, Stroke, Pediatric, and Burn Trauma WF HealthBaptist – L WF Baptist Health – Lex orted using this plan. This plan is in effect 24/7/365 effectThis plan is in plan. orted using this No No Yes Yes Yes Yes Identify general patients medical who call 911 or present to EMS Minimize ma field decision Identify those be patients that should Identify those patients that may be tr t and facility capabilities facility based on complain utilization resource EMS system Maximize Provide service and patient quality EMS care to Systems citizens the EMS Continuously evaluate Syst the EMS performance measures. t and facility capabilities facility based on complain The purpose of this plan is to: plan is of this purpose The Rowan County EMS System EMS County Rowan Yes EMS Triage and Destination Plan Destination Triage and EMS s and/or symptomss and/or No No No No = a hospital which provides emergency care 24/7/365 that is determined, based on complaint, to be capable capable be to complaint, on based determined, is that 24/7/365 care emergency provides which a hospital = Yes = Any non life-threatening complaint (illness) that meets the guidelines for medical necessity of ambulance = Injuries that may be considered time sensitive but not life threatening, i.e. fracture with loss of PMS This plan has been altered from the original NCCEP Protocol by the local EMS Medical Director EMS Medical local the by Protocol NCCEP original the from altered been has plan This = Any potentially life-threatening complaint that does not meet the criteria for STEMI, Stroke, Pediatric or Trauma requiring immediate attention immediate requiring complaint, past medial history and illness signs/symptoms identifying: Non-Critical injury or Critical illness past physician/patient relationship(s) AcuteStroke, STEMI, Trauma or Burn Patient without life threatening injury or General MedicalGeneral Patient Non-Critical injury requiring interventions Critical illness requiring immediate attention available at the geographically closest facility closest geographically the at available Individual insurance plan requirements should not be a factor in determining the appropriate facility. Consideration of insura of addressing the primary patient condition. Non-Critical Injury Critical Illness Non-Critical Illness transport. All General Medical patients should be triaged and transp and triaged be patients should All General Medical Appropriate Facility and Burn TriageDestination and Plans. plan requirements may be construed as treatment based on the ability to pay and such practices are prohibited. that cannot be categorized into categorized be that cannot STEMI, Stroke,or Trauma Pediatric and Destination and Burn Triage Plans. A patient with sign Non-Critical illness with a destination preference Non-Critical illness without a destination preference Updated: Updated: 09/25/2014 supported by the need for evaluation based on current Pearls and Definitions Pediatric EMS Triage and Destination Plan 2014 based on symptom onset pital prior to the patient arrival. ric life-threatening illness for EMS ent care Community to the EMS eatment and predicted transport time atric patients who call 911 or present to EMS Iredell Memorial Hospital st hospital destination Davis Regional Medical Center Stanly Regional Medical Center Novant Health–Rowan Medical Center Lake Norman Regional Medical Center WF Baptist Health – Davie Medical Center WF Baptist Health - Lexington Center Medical Early Notification/Activation If Life Threatening Transport to closest Community Hospital Listed Hospital Community to closest Transport iaged and transported using this plan. This plan is in effect be used for all injured patients regardless of age treatment and stabilization Rapidly identify acute Pedi Rapidly identify with a life-threatening illness Minimize the to definitive care contact time from EMS Quickly diagnose patients with pediat Rapidly identify the be Early activation/notification to the hos Minimize scene time with a ‘load and go” approach Provide service and pati quality EMS Continuously evaluate System based the EMS Carolinas on North EMS performance measures time, vital signs, response to tr No Yes The purpose of this plan is to: plan is of this purpose The = an air or ground based specialty care transport program that has specific specific has that program transport care specialty based or ground air an = (and Rowan County EMS System EMS County Rowan EMS Triage and Destination Plan Destination Triage and EMS = a hospital which provides emergency and pediatric intensive care capability including but not c Capable Hospital Listed No = a local hospital within the EMS Systems service area which provides emergency care but does not meet Yes This plan has been altered from the original NCCEP Protocol by the local EMS Medical Director EMS Medical local the by Protocol NCCEP original the from altered been has plan This EMS transport? CMC - Northeast (Not trauma/injury) (Not Pediatric Patient Pediatric Wake Forest Baptist Health Early Notification/Activation beyond the closest hospital? Life Threatening Illness Life Threatening Emergency Department staffed 24 hours per day with board certified Emergency Physicians. An inpatient Pediatric Intensive Care Unit (with a physician pediatric intensivist available in-house or on call 24/7/365) Accepts all patients regardless of bed availability Provides outcome and performance measure feedback to the EMS including case review Novant Health - Forsyth Medical Center Pediatric Patient unstable too to transport Pediatric Patient with Life Threatening Illness Threatening Life with Patient Pediatric Pediatric Capable Hospital within 50 minute Pediatric Specialty Care Transport Program Community Hospital Hospital Capable a Pediatric of criteria the pediatric training and equipment addressing the needs of a pediatric patient that can assume care of a pediatric patient from EMS or a Community hospital and transport to a Pediatric Capable Hospital. The Trauma and Burn Triage and Destination Plan should All patient care is based on EMS Suspected Stroke Protocol Pediatric Capable Hospital limited to: All Pediatric patients with a life threatening illness must be tr 24/7/365 Children with Special Healthcare Needs Status Epilepticus Status Potential Dangerous Envenomation Life Threatening Ingestion/ChemicalExposure destination choice based on parental request) Intubation Post Cardiac Arrest Non-responsive Hypotension (shock) Severe Hypothermia or Hyperthermia Decreased mental Status (GCS<13) Distress Non-responsive respiratory Any patient less than 16 years ageof with a life-threatening illness (Not Trauma) Updated: Updated: 09/25/2014 Pearls and Definitions Transport to closest Pediatri EMS Triage and Destination Plan

STEMI Patient The purpose of this plan is to: (ST Elevation Myocardial Infarction) Rapidly identify STEMI patients who call 911 or present to EMS Minimize the time from onset of STEMI symptoms to coronary reperfusion Cardiac Symptoms greater than 15 Quickly diagnose a STEMI by 12 lead ECG minutes and less than 12 hours Complete a reperfusion checklist (unless being transported directly to a PCI And hospital) to determine thrombolytic eligibility 12 lead ECG criteria of 1mm ST Rapidly identify the best hospital destination based on a symptom onset time, elevation in 2 or more contiguous reperfusion checklist and predicted transport time leads. Early activation/notification to the hospital prior to the patient arrival or Minimize scene time to 15 minutes or less (including a 12 lead ECG) Left Bundle Branch Block Provide quality EMS service and patient care to the EMS Systems citizens. Continuously evaluate the EMS System based on North Carolinas EMS NOT KNOWN to be present in the past performance measures

Active Symptoms of Cardiac Pain Transport to closest PCI Capable Hospital Listed 12 Lead ECG findings = STEMI Early Notification/Activation

Yes Novant Health – Rowan Medical Center STEMI EMS Triage and Destination Plan PCI Capable Hospital within 30 minutes CMC – Northeast EMS transport time? Novant Health – Forsyth Medical Center Wake Forest Baptist Health No

Reperfusion Checklist Closest Non-PCI hospital within 50 minutes Contraindications to Thrombolysis No EMS transport time?

Yes No

Air Medical SCTP within 30 minutes of Yes patient location? No Yes Transport to closest NON-PCI Capable Hospital Listed Activate Air SCTP Early Notification/Activation Transport to closest PCI Capable HospitalListed Davis Regional Medical Center Early Notification/Activation Lake Norman Regional Medical Center Stanly Regional Medical Center CMC – Main Iredell Memorial Hospital Novant Health – Forsyth Medical Center WF Baptist Health – Lexington Medical Center Wake Forest Baptist Health WF Baptist Health – Davie Medical Center

Pearls and Definitions All STEMI patients must be triaged and transported using this plan. This plan is in effect 24/7/365 All patient care is based on EMS Chest Pain and STEMI Protocol Consider implementing a prehospital thrombolytic program if a STEMI patient cannot reach a hospital within 90 minutes using air or ground EMS transport PCI (Percutaneous Coronary Intervention) Capable Hospital = a hospital with an emergency interventional cardiac catheterization laboratory capable of providing the following services to acute STEMI patients. Free standing emergency departments and satellite facilities are not considered part of the PCI hospital. 24/7 PCI capability within 30 minutes of notification (interventional cardiologist present at the start of the case) Single Call Activation number for use by EMS Accepts all patients regardless of bed availability Provides outcome and performance measure feedback to the EMS including case review Non-PCI Hospital = a local hospital within the EMS Systems service area which provides emergency care including thrombolytic administration to an Acute STEMI patient but does not provide PCI services Specialty Care Transport Program = an air or ground based specialty care transport program which can assume care of an acute STEMI patient from EMS or a Non-PCI hospital and transport the patient to a PCI capable hospital Updated: Rowan County EMS System 2014 09/25/2014 This plan has been altered from the original NCCEP Protocol by the local EMS Medical Director Stroke EMS Triage and Destination Plan 2014 Air or Ground SCTP based on North Carolinas Stroke EMS Yes pital prior to the patient arrival tination based on symptom onset time, s who call 911 or presents who call to EMS CMC – Northeast Stroke symptoms to care definitive CMC – Northeast This plan is in effect 24/7/365 Iredell Memorial Hospital Iredell MemorialHospital Wake Forest Baptist Health Early Notification/Activation NEW onset stroke patient? NEW stroke onset Wake ForestWake Baptist Health Early Notification/Activation Stroke Capable Hospital Listed No Air Medial SCTP within 30 minutes Lake Norman RegionalMedicalCenter Novant Health – Rowan Medical Center Novant Health – Forsyth Medical Center Lake Norman Regional Medical Center Novant Health – Rowan Medical Center Novant Health – Forsyth Medical Center of patients location and a patient clearly Consider Activating Transport to closest Primary Stroke Center or Transport to closest Primary Stroke Center Listed Center Stroke Primary Transport to closest Yes Yes reperfusion checklist, and predicted transport time Rapidly identify acute Stroke patient Rapidly identify Minimize thetime from onset of Quickly diagnose a Stroke Screen validated EMS Stroke using Complete a reperfusion (unless checklist being directly transported to a Stroke Capable Hospital) determine thrombolytic to eligibility Rapidly identify the best hospital des to the hos Early activation/notification Minimize scene time to 10 minutes or less Provide service and patient quality EMS care to Systems citizens the EMS Continuously evaluate System the EMS performance measures. The purpose of this plan is to: plan is of this purpose The Rowan County EMS System EMS County Rowan d and transported using this plan. plan. this using transported and d = an air or ground based specialty care transport program which can assume care of an an of care assume can which program transport care specialty based or ground air an = EMS Triage and Destination Plan Destination Triage and EMS = a hospital which provides emergency care with a commitment to Stroke and the following free (i.e. the the sleep period) the r = a hospital that is currently accredited by the Joint Commission as a Primary Stroke Center. Free Free Center. Stroke a Primary as Commission Joint by the accredited currently is that r a hospital = = a local hospital within the EMS Systems service area which provides emergency care but does not meet No No This plan has been altered from the original NCCEP Protocol by the local EMS Medical Director EMS Medical local the by Protocol NCCEP original the from altered been has plan This Positive Stroke Screen Reperfusion Checklist Stroke Patient Stroke Iredell MemorialHospital Symptoms Stroke of Acute Early Notification/Activation Provides outcome and performance measure feedback to the EMS including case review CT availability with in-house technician availability 24/7/365 Ability to rapidly evaluate an acute stroke patient to identify patients who would benefit from thrombolytic administration Ability and willingness to administer thrombolytic agents to eligible acute Stroke patients. Accepts all patients regardless of bed availability Davis Regional Medical Center Stanly Regional Medical Center Medical Regional Stanly Time of Symptom Onset Symptom of Time Contraindications to Thrombolysis Lake Norman Regional Medical Center WF Baptist Health – Davie Medical Center Community Hospital Specialty Care Transport Program standing emergency departments and satellite facilities are not considered part of the Primary Stroke Center. Stroke Primary the of part considered not are facilities satellite and departments emergency standing the criteria for a Primary Stroke Center or Stroke Capable Hospital acute stroke patient from EMS or a hospital and transport thepatient to a Primary Stroke Center. Stroke Capable Hospital Capable Stroke All patient care is based on EMS Suspected Stroke Protocol Primary Stroke Cente capabilities: All Stroke patients must be triage Defined as the last time witnessed the patient was symptom A patient with acute of an symptoms identifiedstroke as by EMS Strokethe Screen time of onset for a patient awakeningonset for time of be the would with stroke symptoms last time he/she was known to be symptom free before greater than 50 minutes EMS transport time? greater than 50 minutes EMS transport WF Baptist Health – Lexington Medical Center hours onsetfrom of patients symptoms and no Transport to closest Community Hospital Listed Updated: Updated: 09/25/2014 Stroke Center or Stroke Capable Hospital within 2 Pearls and Definitions Trauma and Burn EMS Triage and Destination Plan 2014 Yes 2009 ington Medical Center No Yes equal time CMC – Main CMC – Northeast to a Trauma Center location helipad? or Iredell Memorial Hospital Wake Forest Baptist Health Early Notification/Activation Early Notification/Activation Activate Air or Ground SCTP Davis Regional Medical Center (Burn Center for isolated burn) (Burn Center for isolated Stanly Regional Medical Center TransportNearest to Hospitalfor Transport to closest Trauma Center Lake Norman RegionalMedicalCenter Novant Health – Rowan Medical Center Choose a Level3 if EMS transport time is less a to compared minutes 30 than Level 1 or 2 Trauma Center WF Baptist Health – Davie Medical Center Injury) within 45 minutes Transport of EMS ed Trauma Center Stabilization Unless minimal Additional time Trauma center (Burn Center for isolated Burn WF Baptist Health – Lex Air Medical SCTP within 30 minutes of patients Unless Trauma Center can be reached in a near Transport to closest Community Hospital Listed No jury and predicted transport time Yes ported using this plan. This plan is in effect 24/7/365 Yes Yes Yes ally injured or patient burned prior to patient arrival patient extrication with a ‘load andpatient extrication with go” approach on North Carolinas EMS performance measures. Rowan County EMS System EMS County Rowan Any patient (regardless of age) with significant injury or burn Any patient injury or with significant of age) (regardless care to the EMS Systems citizens. care Systems to the EMS = an air or ground based specialty care transport program which can assume care of an an of care assume can which program transport care specialty based or ground air an = ive care critical injuries for or burns ng injuries for EMS treatmentng injuries for and stabilization EMS EMS Triage and Destination Plan Destination Triage and EMS destinationbased on time of in = a hospital that is currently designated as a Trauma Center by the North Carolina Officeof No No No No = a local hospital within the EMS Systems service area which provides emergency care but has not been >18 inchesside any (<20 in infant age<1 (<20 in age<1 year) infant This plan has been altered from the original NCCEP Protocol by the local EMS Medical Director EMS Medical local the by Protocol NCCEP original the from altered been has plan This = an ABA verified Center co-located with a designat burn Ejection Death in same vehicle Vehicle telemetry with high risk injury Significant Mechanism? Special Considerations? Trauma or Burn Patient = Patient Burn or Trauma Any Abnormal Vital Signs? Critical injury by Assessment? Acutely injured or Burned Patient Community Hospital Specialty Care Transport Program Burn Center Center a Trauma as designated acutely injured patient from EMS or a Community Hospital and transport the patient to a Designated Trauma Center All Injury and Burn patients must be andtriaged trans All patient care is based on EMS Trauma Protocols Center Trauma Designated Emergency Medical Services.Trauma Centers are designated as Level 1, 2, or 3 with Level 1 being the highest possible Center Trauma the of part considered not are facilities satellite and departments emergency standing Free designation. Early activation/notification to the hospitalEarly activation/notification of a critic Minimize scene time to 10 minutes or less from and service Provide quality EMS patient Continuously evaluate based the EMS System Minimize from injury to definit the time Quickly identify life or limb threateni Rapidly identify the best hospital Rapidly identify injured orRapidly identify burned patients or who call 911 present to EMS Auto vs pedestrian/bicyclist thrown, run over Motorcycle crash >20 mph Falls:MVC: Adults >20 ft, Children >10 ft intrusion >12 inches occupant side Anticoagulation and bleeding disorders bleeding and Anticoagulation >20 weeks Pregnancy Pelvic fracture Pelvic fracture skull depressed or open Visibily Paralysis Protocol) EMS Burn (per burns Serious or Critical Flail chest or Pneumothorax or chest Flail fractures bone long proximal more or Two extremity or mangled degloved Crushed, ankle and to wrist proximal Amputation Penetrating injury to head, neck, torso or extremities or extremities torso neck, to head, injury Penetrating knee and to elbow proximal Systolic Blood Pressure :<90 Pressure Blood Systolic mmHg Rate:Respiratory per minute >29 breaths or <10 Glasgow Coma Score: Glasgow intubated <13 or Updated: Updated: 09/25/2014 Evidence of extreme shock or un-manageable airway Pearls and Definitions The purpose ofThe purpose this plan is to:

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Acetaminophen  1000 mg po  See Color Coded List (Tylenol)  15 mg/kg po

NCCEP Protocol:  7- Pain Control-Adult  46-Pain Control-Pediatric  72-Fever

Indications/Contraindications:  Indicated for pain and fever control  Avoid in patients with severe liver disease Adenosine  6 mg IV push over 1-3 seconds. If  0.1 mg/kg IV (Max 6 mg) push (Adenocard) no effect after 1-2 minutes, over 1-3 seconds. If no effect  Repeat with 12 mg IV push over 1- after 1-2 minutes, NCCEP Protocol: 3 seconds.  Repeat with 0.2 mg/kg IV (Max  16-Adult Tachycardia Narrow  Repeat once if necessary 12 mg) push over 1-3 seconds. Complex  Repeat once if necessary  17-Adult Tachycardia Wide  (use stopcock and 20 ml Normal Complex Saline flush with each dose)  (use stopcock and Normal Saline flush with each dose)  52-Pediatric Tachycardia

Indications/Contraindications:  Specifically for treatment or diagnosis of Supraventricular Tachycardia Albuterol  2.5-5.0 mg (3cc) in nebulizer  See Color Coded List Beta-Agonist continuously x 3 doses, if no  2.5mg (3cc) in nebulizer history of cardiac disease and continuously x 3 doses, if no NCCEP Protocol: Heart Rate < 150. history of cardiac disease and  24- Allergic Reaction Anaphylaxis Heart Rate < 200.  26-COPD Asthma  56-Pediatric Allergic Reaction  61-Pediatric Respiratory Distress

Indications/Contraindications:  Beta-Agonist nebulized treatment for use in respiratory distress with bronchospasm

1 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric

Amiodarone V-fib / pulseless V-tach V-fib / pulseless V-tach (Cordarone)  300 mg IV push  5 mg/kg IV push over 5 minutes  Repeat dose of 150 mg IV push  May repeat up to 15 mg/kg IV NCCEP Protocol: for recurrent episodes  17-Adult Tachycardia Wide Complex V-tach with a pulse V-tach with a pulse  18-Adult Shockable  150 mg in 100cc D5W over 10 min  5 mg/kg IV push over 5 minutes  52-Pediatric Tachycardia  May repeat up to 15 mg/kg IV  53-Pediatric Shockable  Avoid in Length Tape Color Pink  54-Pediatric Post Resuscitation

Indications/Contraindications:  Antiarrhythmic used mainly in wide complex tachycardia and ventricular fibrillation.  Avoid in patients with heart block or profound bradycardia.  Contraindicated in patients with iodine hypersensitivity Aspirin  81 mg chewable (baby) Aspirin NCCEP Protocol: Give 4 tablets to equal usual adult dose.  7-Pain Control Adult  14-Chest Pain and STEMI Ø

Indications/Contraindications:  An antiplatelet drug for use in cardiac chest pain Atropine Bradycardia  See Color Coded List  0.5 - 1.0 mg IV every 3 – 5 minutes NCCEP Protocol: up to 3 mg. Bradycardia

 12-Bradycardia Pulse Present  0.02 mg/kg IV, IO (Max 0.5 mg Organophosphate  49-Pediatric Bradycardia per dose, max total dose 1 mg  84-WMD Nerve Agent  1-2 mg IM or IV otherwise as per IV) medical control  (Min 0.1 mg) per dose Indications/Contraindications:  May repeat in 3 - 5 minutes  Anticholinergic drug used in bradycardias. Organophosphate  In Organophosphate toxicity, large  0.02 mg/kg IV or IO otherwise as doses may be required (>10 mg) per medical control

2 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Atropine and  One auto-injector then per medical  See Color Coded List Pralidoxime Auto- control  One pediatric auto-injector then Injector as per medical control Nerve Agent Kit

NCCEP Protocol:  84-WMD Nerve Agent

Indications/Contraindications:  Antidote for Nerve Agents or Organophosphate Overdose Calcium Chloride  1 gm IV/IO  See Color Coded List NCCEP Protocol:  Avoid use if pt is taking digoxin  20 mg/kg IV or IO slowly  28-Dialysis Renal Failure  31-Overdose Toxic Ingestion  60-Ped OD Toxic Ingestion  83-Marine Envenomations  88-Crush Syndrome

Indications/Contraindications:  Indicated for severe hyperkalemia Dextrose 10%, 25%,  See Color Coded List See protocol for concentration and See protocol for concentration and 50% dosing dosing Glucose solutions

NCCEP Protocol:  Multiple

Indications/Contraindications:  Use in unconscious or hypoglycemic states

3 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Diazepam  See Color Coded List  4 mg IV initially then 2 mg IV every  0.1 - 0.3 mg/kg IV/IO (Valium) 3 - 5 minutes up to 10 mg max  (Max dose 4 mg IV, IO) unless med control dictates Benzodiazepene  O.5 mg/kg rectally (Dia-Stat)  Do not administer IM. The drug is  (Max dose 10 mg rectally) NCCEP Protocol: not absorbed.  Repeat as directed by medical  32-Seizure  10 mg Rectally if unable to obtain control.  39-Obstetrical Emergency an IV.  62-Pediatric Seizure

Indications/Contraindications:  Seizure control  Mild Sedation Dilaudid  1-2 mg IM/IV/IO bolus then 1 mg  See Color Coded List (Hydromorphone) IM/IV/IO every 20-30 minutes until  0.015 mg/kg IM/IV/IO a maximum of 5 mg or clinical single bolus only (Max 2 mg) Narcotic Analgesic improvement  Minimum Age = 5 years or 20 kg) NCCEP Protocol:  7-Pain Control Adult  46-Pain Control Pediatric

Indications/Contraindications:  Narcotic pain relief  Antianxiety  Possible beneficial effect in pulmonary edema  Avoid use if BP < 110 Diltiazem  0.25 mg/kg IV over 2 minutes (Cardizem) Calcium Channel Ø Blocker

NCCEP Protocol:  16-Adult Tachycardia Narro Complex Indications/Contraindications:  Calcium channel blocker used to treat narrow complex SVT  Contraindicated in patients with heart block, ventricular tachycardia, an/or acute MI

4 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Diphenhydramine  25-50 mg IV/IO/IM/PO  See Color Coded List (Benadryl)  1 mg/kg IV/IO/IM

 Do not give in infants < 3 mo NCCEP Protocol:

 24-Allergic Reaction Anaphylaxis  56-Pediatric Allergic Reaction

Indications/Contraindications:  Antihistamine for control of allergic reactions Dopamine  2 - 20 micrograms/kg/min IV/IO  See Color Coded List NCCEP Protocol: titrate to BP systolic of 90 mmHg  2 - 20 micrograms/kg/min IV or  Multiple IO, titrate to BP systolic appropriate for age Indications/Contraindications:  A vasopressor used in shock or hypotensive states Epinephrine 1:1,000  0.3 mg IM (if age < 50 yrs)  See Color Coded List NCCEP Protocol:  0.15 mg IM (if age > 50 yrs)  0.01 mg/kg IM  Multiple  (Max dose 0.3 mg) Nebulized Epinephrine Indications/Contraindications:  1 mg mixed with 2 ml of Normal Nebulized Epinephrine  Vasopressor used in allergic Saline  1 mg mixed with 2 ml of Normal reactions or anaphylaxis Saline Epinephrine 1:10,000  1.0 mg IV/IO  See Color Coded List NCCEP Protocol:  Repeat every 3 - 5 minutes until  0.01 mg/kg IV or IO  Multiple observe response  (Max dose 1 mg)

 Repeat every 3 - 5 minutes until Indications/Contraindications: observe response  Vasopressor used in cardiac arrest.

5 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Etomidate  0.3 mg/kg IV/IO (Amidate)  Usual adult dose = 20 mg Ø NCCEP Protocol:  4-Airway Rapid Sequence Intubation  20-Induced Hypothermia

Indications/Contraindications:  Hypnotic sedative used in Drug Assisted Intubation Famotidine  20 mg IV  0.5 mg/kg IV / PO (Pepcid)  20-40 mg PO  Maximum 10mg Histamine-2 Blocker

NCCEP Protocol:  24-Adult Allergic Reaction  56-Pediatric Allergic Reaction

Indications/Contraindications:  Medication used to control stomach acid and to assist in severe allergic reactions Furosemide  20 mg IV or dose to equal patient’s  Requires Medical Control Order (Lasix) normal single home PO dose  1 mg/kg IV (Maximum dose = 160 mg) NCCEP Protocol:  15-CHF Pulmonary Edema  50-Pediatric CHF Pulmonary Edema

Indications/Contraindications:  Diuretic for pulmonary edema or CHF but no proven benefit in prehospital care

6 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Glucagon  1 - 2 mg IM  See Color Coded List NCCEP Protocol:  Repeat blood glucose  0.1 mg/kg IM  27-Diabetic; Adult measurement in 15 minutes, if <  Repeat blood glucose  31-Overdose Toxic Ingestion 69 mg/dl repeat dose. measurement in 15 minutes, if <  58-Pediatric Diabetic 69 mg/dl repeat dose.  60-Ped OD Toxic Ingestion

Indications/Contraindications:  Drug acting to release glucose into blood stream by glycogen breakdown  Use in patients with no IV access Glucose Oral  See Color Coded List  One tube or packet Glucose Solutions  One Tube or packet  Repeat based on blood glucose  Repeat based on blood glucose

results result NCCEP Protocol:  27-Diabetic; Adult  Consider patient’s ability to  58-Pediatric Diabetic swallow and follow directions based on age

Indications/Contraindications:  Use in conscious hypoglycemic states Haloperidol  2.5-10 mg IM (Haldol)  May repeat as per Medical Control Phenothiazine Ø Preperation

NCCEP Protocol:  6-Behavioral

Indications/Contraindications:  Medication to assist with sedation of agitated patients

7 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Ibuprofen  400-800 mg po  See Color Coded List (Motrin)  10 mg/kg po Non-steroidal Anti-  Do not use in patients 6 months inflammatory Drug of age or younger

NCCEP Protocol:  72-Fever  7-Pain Control Adult  46-Pain Control Pediatric

Indications/Contraindications:  Avoid NSAIDS in women who are pregnant or could be pregnant.  A nonsteroidal anti-inflammatory drug (NSAID) used for pain and fever control.  Not to be used in patients with history of GI Bleeding (ulcers) or renal insufficiency.  Not to be used in patients with allergies to aspirin or other NSAID drugs  Avoid in patients currently taking anticoagulants, such as coumadin. Ipratropium  2 puffs per dose of MDI (18  Use in Pediatrics as a combined (Atrovent) mcg/spray) Therapy with a Beta Agonist --- OR --- such as Albuterol NCCEP Protocol:  500 mcg (0.5mg) per nebulizer  2 puffs per dose of MDI (18  24-Allergic Reaction Anaphylaxis treatment mcg/spray)  26-COPD Asthma --- OR ---  56-Pediatric Allergic Reaction  500 mcg (0.5mg) per nebulizer  61-Pediatric Respiratory Distress treatment

Indications/Contraindications:  Medication used in addition to albuterol to assist in patients with asthma and COPD

8 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Ketamine  1-2 mg/kg IV NCCEP Protocol:  3-Airway Drug Assisted Intubation Ø  20-Induced Hypothermia

Indications/Contraindications:  Hypnotic used in Drug Assisted Intubation Ketorolac  30 mg IV / IO or 60 mg IM  0.5 mg/kg IV / IO / IM – (Toradol) Maximum 30 mg Non-steroidal Anti- inflammatory Drug

NCCEP Protocol:  7-Pain Control Adult  46-Pediatric Pain Control

Indications/Contraindications:  Avoid NSAIDS in women who are pregnant or could be pregnant  A nonsteroidal anti-inflammatory drug used for pain control.  Not to be used in patients with history of GI bleeding (ulcers), renal insufficiency, or in patients who may need immediate surgical intervention (i.e. obvious fractures).  Not to be used in patients with allergies to aspirin or other NSAID drugs such as motrin  Avoid in patients currently taking anticoagulants such as coumadin

9 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Levalbuterol  0.63-1.25 mg (3cc) in nebulizer  See Color Coded List (Xopenex) continuously x 3 doses, if no  0.31-0.63 mg (3cc) in nebulizer history of cardiac disease and continuously x 3 doses, if no Beta-Agonist Heart Rate < 150. history of cardiac disease and NCCEP Protocol: Heart Rate < 200.  30-Respiratory Distress  46-Pediatric Respiratory Distress  52-Drowning

Indications/Contraindications:  Beta-Agonist nebulized treatment for use in respiratory distress with bronchospasm Lidocaine  1.5 mg/kg IV / IO bolus up to  See Color Coded List NCCEP Protocol: 3mg/kg max bolus dose  1 mg/kg IV, IO bolus – Maximum  4-Airway Rapid Sequence  Initial Dose 0.75 mg/kg in patients 100mg per bolus Intubation > 60 years of age.  Repeat 1/2 initial bolus in 10  18-Shockable Rhythm  Repeat 1/2 initial dose in 10 minutes – Maximum 3mg/kg total  53-Pediatric Shockable Rhythm minutes.  No Drip Administration  No Drip Administration Indications/Contraindications:  Antiarrhythmic used for control of ventricular dysrrythmias  Anesthetic used during intubation to prevent elevated intracranial pressures during intubation

Lorazepam (Ativan) 2-4 mg IV/IM  See Color Coded List Benzodiazepene May repeat q 5-10 minutes if seizures  0.05-0.1 mg/kg IV/IM (max 2 not controlled NCCEP Protocol: mg/dose)  Multiple protocols  May repeat q 5-10 minutes (Maximum of 3 doses) if seizures Indications/Contraindications: not controlled Benzodiazepine used to control seizures and sedation

10 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Magnesium Sulfate  2 g slow IV / IO – over 10 minutes  40 mg/kg slow IV over 20 NCCEP Protocol:  dose may be repeated once minutes (Max 2 gms)  Multiple  dose may be repeated once

Indications/Contraindications: Obstetrical Seizure:  Elemental electrolyte used to treat  2 g IV / IO over 2-3 minutes eclampsia during the third  Dose may be repeated once trimester of pregnancy.  A smooth muscle relaxor used in refractory respiratory distress resistent to beta-agonists Methylprednisolone  125 mg IV  See Color Coded List (Solu-medrol)  May be given IM if necessary  2 mg/kg IV / IO (Max 125 mg) Steroid Preparation  IM if necessary

NCCEP Protocol:  24-Allergic Reaction Anaphylaxis  26-COPD Asthma  56-Pediatric Allergic Reaction  61-Pediatric Respiratory Distress

Indications/Contraindications:  Steroid used in respiratory distress to reverse inflammatory and allergic reactions Midazolam  0.5-2 mg IV slowly over 2-3  See Color Coded List (Versed) minutes. May slowly titrate dose  0.1-0.2 mg/kg IV or IO slowly up to 5 mg total if needed. Usual over 2 – 3 minutes (Max 2 mg) Benzodiazepine total dose: 2.5-5 mg

NCCEP Protocol:  1-2 mg Nasally via Atomizer. Usual total dose: 2-5 mg  Multiple protocols  IM dosage: 5 mg Indications/Contraindications:  Benzodiazepine used to control seizures and sedation  Quick acting Benzodiazepine  Preferred over Valium for IM use  Use with caution if BP < 110

11 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Morphine Sulfate  4 mg IM/IV/IO bolus then 2 mg  See Color Coded List Narcotic Analgesic IM/IV/IO every 5-10 minutes until a  0.1 mg/kg IV or IO maximum of 10 mg or clinical single bolus only (Max 5 mg) NCCEP Protocol: improvement May repeat every 5 minutes  Multiple Maximum single dose 5 mg Maximum dose 10 mg Indications/Contraindications:  Narcotic pain relief  Antianxiety  Possible beneficial effect in pulmonary edema  Avoid use if BP < 110 Naloxone  0.5 - 2 mg IV bolus titrated to  See Color Coded List (Narcan) patient’s respiratory response  0.1 mg/kg IV / IN or IO (Max 2 Narcotic Antagonoist  May be given IM or IN if unable to mg) establish IV in a known narcotic  May repeat in 5 minutes if no NCCEP Protocol: overdose effect.  31-Overdose Toxic Ingestion  60- Ped OD Toxic Ingestion

Indications/Contraindications:  Narcotic antagonist Normal Saline  KVO for IV access  See Color Coded List Crystalloid Solutions  Bolus in 250-500 ml for cardiac  KVO for IV or IO access

 Bolus in 500 to 1000 ml amount for  Bolus in 20ml/kg for volume NCCEP Protocol: volume (May be repeated x 3)  Multiple  Bolus in 1000 ml amount for burns  See Burn Protocol or Reference Indications/Contraindications: or electrical injuries. See Burn Materials for IV rates. Protocol or Reference Materials for  The IV fluid of choice for IV rates. access or volume infusion

12 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Nitroglycerin Chest Pain  1 spray/tablet SL every 5 minutes NCCEP Protocol: until painfree or 3 doses  If SBP < 100, contact medical  14-Chest Pain and STEMI  15-CHF Pulmonary Edema control Ø  1” paste after pain free or 3 doses Indications/Contraindications: Pulmonary Edema  Vasodilator used in anginal  1 spray/tablet SL every 1-2 syndromes, CHF and minutes if BP >110 Systolic Hypertension.  Mean Arterial Blood Pressure should not be decreased more than 30% Hypertension  1 spray/tablet SL every 1-2 minutes until BP <110 Diastolic  Mean Arterial Blood Pressure should not be decreased more than 30% Ondansetron  4 mg IV / IO / IM / PO / ODT  0.15 mg/kg IV / IO / IM (Max 4 (Zofran) mg)  0.2 mg/kg PO / ODT (Max 4 mg) Anti-emetic

NCCEP Protocol:  15-Abdominal Pain  21-Chest Pain and STEMI  37-Vomiting and Diarrhea

Indications/Contraindications:  Anti-Emetic used to control Nausea and/or Vomiting  Ondansetron (Zofrin) is the recommended Anti-emetic for EMS use since it is associated with significantly less side effects and sedation.

13 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Oxygen  1-4 liters/min via nasal cannula  1-4 liters/min via nasal cannula

 6-15 liters/min via NRB mask  6-15 liters/min via NRB mask NCCEP Protocol:  15 liters via BVM  15 liters via BVM  Multiple

Indications/Contraindications:  Useful in any condition with cardiac work load, respiratory distress, or illness or injury resulting in altered ventilation and/or perfusion.  Required for pre-oxygenation whenever possible prior to intubation.

14 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Oxymetazoline  2 sprays in affected nostril  See Color Coded List (Afrin or Otrivin)  1-2 sprays in affected nostril Nasal Decongestant Spray

NCCEP Protocol:  71-Epistaxis

Indications/Contraindications:  Vasoconstrictor used with nasal intubation and epistaxis  Relative Contraindication is significant hypertension Rocuronium  1 mg/kg IV / IO NCCEP Protocol:  May repeat per protocol  4-Airway Rapid Sequence Intubation  19-Post Resuscitation  20-Induced Hypothermia Ø Indications/Contraindications:  Non-depolarizing paralytic agent used as a component of drug assisted intubation (Rapid Sequence Intubation), when succinylcholine is contraindicated.  Onset of action is longer than succinylcholine, up to 3 minutes, patient will NOT defasciculate.

Sodium Bicarbonate  50 mEq IV / IO initially, then 25  See Color Coded List NCCEP Protocol: mEq IV / IO every 10 minutes as  1 meq/kg IV, IO initally, then 1/2 needed  28-Dialysis Renal Failure meq/kg IV every 10 minutes as  31-Overdose Toxic Ingestion  In TCA (tricyclic), 50 mEq bolus, needed.  60-Ped OD Toxic Ingestion then 100 mEq in 1 liter of NS for  TCA (trycyclic) overdose per infusion at 200 ml/hr  88-Crush Syndrome medical control.

Indications/Contraindications:  A buffer used in acidosis to increase the pH in Cardiac Arrest or Tricyclic Overdose.

15 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Succinylcholine  1.5 mg/kg IV / IO Paralytic Agent

NCCEP Protocol:  4-Airway Rapid Sequence Intubation

Indications/Contraindications:

Paralytic Agent used as a Ø  component of Drug Assisted Intubation (Rapid Sequence Intubation)  Avoid in patients with burns >24 hours old, chronic neuromuscular disease (e.g., muscular dystrophy), ESRD, or other situation in which hyperkalemia is likely. Vasopressin  40 units IV / IO X 1 as the first or (Pitressin) second dose of a vasopressor

NCCEP Protocol: Ø  11-Asystole  18-Shockable Rhythm Adult

Indications/Contraindications:  Medication used in place of and/or in addition to epinephrine in the setting of ventricular fibrillation/pulsesless ventricular tachycardia

16 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Vecuronium  0.1 mg/kg IV / IO Paralytic Agent

NCCEP Protocol:  4-Airway Rapid Sequence Ø Intubation  19-Post Resuscitation  20-Induced Hypothermia

Indications/Contraindications:  Long-acting non-depolarizing paralytic agent  Avoid in patients with chronic neuromuscular disease (e.g., muscular dystrophy). Zemuron  0.6 mg/kg IV / IO (Rocuronium)  Recommended adult dose for prehospital intubation = 10mg Paralytic Agent Ø NCCEP Protocol:  4-Airway Rapid Sequence Intubation  19-Post Resuscitation  20-Induced Hypothermia

Indications/Contraindications:  Paralytic  Avoid in patients with chronic neuromuscular disease (e.g., muscular dystrophy).  Varies depending on med Antibiotics Adult:  Follow exist orders or label Indications:  Varies depending on med instructions  Treat or prevent infections  Follow existing orders or label instructions Pearls:  Report any adverse reaction, i.e. urticaria, nausea/vomiting to Medical Control

17 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Heparin Drip  Follow existing orders or label  N/A instructions Indications:  Anticoagulation therapy

Pearls:  Observe for bleeding Magnesium Sulfate  Follow existing orders or label  N/A instructions Drip

Indications:  Hypomagnesium, Torsades de points, Preeclampsia, Eclampsia

Pearls:  Dissappearance of knee jerk/patellar reflex indicates toxic level  May cause respiratory depression, hypotension, heart block Nitroglycerin Drip  Follow existing orders or label  N/A instructions Indications:  May increase infusion rate by 5-20  Chest Pain, CHF, Pulmonary mcg/min until: Edema - Systolic BP falls below 100mmHG Pearls: - Heart Rate increases 20 BPM - Chest Pain is relieved  May cause hypotension, headache, flushing  Frequent vital signs are indicated

18 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Platelet Glycoprotein  Variable depending on med, follow  N/A existing orders or label instructions IIb / IIIa Inhibitors

Indications:  Inhibits platelet aggregation in acute coronary syndrome including PCI

Pearls:  Contraindicated: Hypersensitivity, recent surgery, bleeding or bleeding disorders, recent CVA, uncontrolled severe hypertension, hypotension and renal dialysis dependency  SE: Bleeding, CVA, thrombocytopenia, bradycardia and rash Potassium Chloride  Follow existing orders or label  Follow existing orders or label instructions instructions Indications:  Hypokalemaia

Pearls:  Cardiac monitor indicated for rates aboove 10mEq/hr  May cause arrhythmias, nausea, vomiting, phlebitis at IV site Thrombolytics (i.e.  Varies depending on medication  Varies depening on medication  Follow existing orders or label  Follow existing orders or label Urokinase, instructions instructions Streptokinase, TPA)

Indications:  To dissolve thrombi

Pearls:  IM injections, venipuncture contraindicated during therapy  Many possbile side effects depending on medication. Most common include bleeding, fever, urticaria, hypotension, arrhythmias

19 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director

This document contains only medications approved for use in the Rowan County EMS System For a full list of medications approved for use by EMS professionals, please refer to the North Carolina Medical Board document entitled: Approved Medications for Credentialed EMS Personnel. Drug Adult Pediatric Whole Blood and  All products should be infused  All products should be infused within four hours, whole blood may within four hours, whole blood Components be as fast as patient can tolerate. may be as fast as patient can Fresh frozen plasma/platelets tolerate. Fresh frozen Indications: usually 10 ml/min plasma/platelets usually  Restore circulating volume, 10ml/min. replace clotting factors, improve oxygen carrying capacity of blood

Pearls:  Discontinue infusion immediately if any of the following occur: fever with or without chills, chest pain, pain at infusion site, lower back pain, hypotension, nausea, flushing, dyspnea, bleeding, blood in urine, shock, absent or decreased urine output. Notify both sending and receiving facilities

20 18 This formulary is provided as a reference only. It does not contain all of the contraindications and potential adverse reactions for each listed drug. It is the responsiblity of each EMS System, Agency, and Medical Director to assure that each EMS professional is knowledgeable about the use each drug in this formulary. This drug list has been altered from the original 2009 NCCEP Drug List by the local EMS Medical Director Pediatric Color Coded Drug List Weight 3-5 Kg (Avg 4.0 Kg) Acetaminophen 64 mg Epinephrine 1:10,000 0.04 mg Vital Signs Adenosine 1st Dose- 0.3 mg Epinephrine 1:1000 Nebulized2.0 mg Heart Rate 120-150 Repeat Dose- 0.6 mg Epinephrine 1:1000 IM 0.05 mg Respirations 24-48 Afrin Nasal Spray HOLD Fentanyl 8.0 mcg Albuterol 2.5mg Glucagon 0.5 mg BP Systolic 70 (+/-25) Amiodarone 20 mg Ibuprofen N/A Atropine 0.10 mg Ipratropium 500 mcg Calcium Chloride 80 mg Levalbuterol 0.31 mg Equipment Charcoal N/A Lidocaine 4 mg Dextrose 10% 20 ml Lorazepam 0.2 mg ET Tube 2.5 - 3.5 Diazepam (IV) 0.8 mg Magnesium Sulfate 200 mg Blade Size 0 - 1 (Rectal) 2.0 mg Methylprednisolone 6.25 mg Dilaudid HOLD Midazolam 0.5 mg Diphenhydramine 6.5 mg Morphine Sulfate 0.4 mg Defibrillation Dopamine (800 mg in 500 cc) Naloxone 0.4 mg 2 mcg/kg/min 0.3 ml/hr Ondansetron 0.6 mg

Length < 59.5Defibrillation cm 8 J, 15 J Cardioversion 2 J,4 J 5 mcg/kg/min 0.9 ml/hr Prednisone 4.0 mg Gray (0-3 months) 10 mcg/kg/min 1.7 ml/hr Sodium Bicarbonate 4 mEq Normal Saline 80 ml 20 mcg/kg/min 3.3 ml/hr Weight 6-7 Kg (Avg 6.5 Kg) Acetaminophen 96 mg Epinephrine 1:10,000 0.06 mg Vital Signs Adenosine 1st Dose- 0.6 mg Epinephrine 1:1000 Nebulized2.0 mg Heart Rate 120-125 Repeat Dose- 1.2 mg Epinephrine 1:1000 IM 0.06 mg Respirations 24-48 Afrin Nasal Spray HOLD Fentanyl 13.0 mcg Albuterol 2.5 mg Glucagon 0.5 mg BP Systolic 85 (+/-25) Atropine 0.13 mg Ibuprofen N/A Amiodarone 30 mg Ipratropium 500 mcg Calcium Chloride 130 mg Levalbuterol 0.31 mg Equipment Charcoal HOLD Lidocaine 6 mg Dextrose 10% 35 ml Lorazepam 0.33 mg ET Tube 3.5 Diazepam (IV) 1.3 mg Magnesium Sulfate 300 mg Blade Size 1 (Rectal) 3.2 mg Methylprednisolone 12.5 mg Dilaudid HOLD Midazolam 0.5 mg Diphenhydramine 5 mg Morphine Sulfate 0.6 mg Defibrillation Dopamine (800 mg in 500 cc) Naloxone 0.6 mg Defibrillation 10 J, 20 J 2 mcg/kg/min 0.5 ml/hr Ondansetron 1.0 mg 5 mcg/kg/min 1.3 ml/hr Prednisone 6.5 mg Pink (3-6 Months)

Length 59.5-66.5 cm Cardioversion 2 J, 5 J 10 mcg/kg/min 2.5 ml/hr Sodium Bicarbonate 6 mEq Normal Saline 130 ml 20 mcg/kg/min 5.0 ml/hr Weight 8-9 Kg (Avg 8.5 Kg) Acetaminophen 128 mg Epinephrine 1:10,000 0.08 mg Vital Signs Adenosine 1st Dose- 0.9 mg Epinephrine 1:1000 Nebulized2.0 mg Heart Rate 120 Repeat Dose- 1.8 mg Epinephrine 1:1000 IM 0.08 mg Respirations 24-32 Afrin Nasal Spray HOLD Fentanyl 17.0 mcg Albuterol 2.5 mg Glucagon 0.5 mg BP Systolic 92 (+/-30) Atropine 0.17 mg Ibuprofen 4.0 ml Amiodarone 40 mg Ipratropium 500 mcg Calcium Chloride 170 mg Levalbuterol 0.31 mg Equipment Charcoal HOLD Lidocaine 8 mg Dextrose 10% 43 ml Lorazepam 0.43 mg ET Tube 3.5-4.0 Diazepam (IV) 1.7 mg Magnesium Sulfate 400 mg Blade Size 1 (Rectal) 4.25 mg Methylprednisolone 12.5 mg Dilaudid HOLD Midazolam 0.85 mg Diphenhydramine 10 mg Morphine Sulfate 0.8 mg Defibrillation Dopamine (800 mg in 500 cc) Naloxone 0.8 mg Defibrillation 20 J, 40 J 2 mcg/kg/min 0.7 ml/hr Ondansetron 1.2 mg Red (7-10 Months) Length 66.5-74 cm Cardioversion 5 J, 9 J 5 mcg/kg/min 1.6 ml/hr Prednisone 8.5 mg 10 mcg/kg/min 3.2 ml/hr Sodium Bicarbonate 8 mEq Normal Saline 170 ml 20 mcg/kg/min 6.5 ml/hr

Drug List B (Page 1 of 3) 2012 Pediatric Color Coded Drug List Weight 10-11 Kg (Avg 10.5 Kg) Acetaminophen 160 mg Epinephrine 1:10,000 0.1 mg Vital Signs Adenosine 1st Dose- 0.9 mg Epinephrine 1:1000 IM 0.1 mg Heart Rate 115-120 Repeat Dose- 1.8 mg Epinephrine 1:1000 Nebulized2.0 mg Respirations 22-30 Afrin Nasal Spray HOLD Fentanyl 21.0 mcg Albuterol 2.5 mg Glucagon 1.0 mg BP Systolic 96 (+/-30) Atropine 0.2 mg Ibuprofen 5.0 ml Amiodarone 50 mg Ipratropium 500 mcg Calcium Chloride 210 mg Levalbuterol 0.63 mg Equipment Charcoal HOLD Lidocaine 10 mg Dextrose 10% 50 ml Lorazepam 0.53 mg ET Tube 4.0 Diazepam (IV) 1.0 mg Magnesium Sulfate 500 mg Blade Size 1 (Rectal) 5.0 mg Methylprednisolone 18.75 mg Dilaudid HOLD Midazolam 1.0 mg Diphenhydramine 10 mg Morphine Sulfate 1.0 mg Defibrillation Dopamine Naloxone 1.0 mg Defibrillation 20 J, 40 J (800 mg in 500 ml Normal Saline) Ondansetron 1.6 mg Length 74-84.5 cm Cardioversion 5 J, 10 J 2 mcg/kg/min 0.8 ml/hr Prednisone 10.5 mg 5 mcg/kg/min 2.0 ml/hr Sodium Bicarbonate 10 mEq Purple (11-18 Months) Normal Saline 210 ml 10 mcg/kg/min 4.0 ml/hr 20 mcg/kg/min 8.0 ml/hr Weight 12-14 Kg (Avg 13 Kg) Acetaminophen 192 mg Epinephrine 1:10,000 0.10 mg Vital Signs Adenosine 1st Dose- 1.2 mg Epinephrine 1:1000 IM 0.10 mg Heart Rate 110-115 Repeat Dose- 2.4 mg Epinephrine 1:1000 Nebulized2.0 mg Respirations 20-28 Afrin Nasal Spray 1 spray Fentanyl 26.0 mcg Albuterol 2.5 mg Glucagon 0.5 mg BP Systolic 100(+/-30) Atropine 0.26 mg Ibuprofen 6.5 ml Amiodarone 65 mg Ipratropium 500 mcg Calcium Chloride 260 mg Levalbuterol 0.63 mg Equipment Charcoal 15 gms Lidocaine 14 mg Dextrose 10% 60-80 ml Lorazepam 0.65 mg ET Tube 4.5 Diazepam (IV) 2.6 mg Magnesium Sulfate 650 mg Blade Size 2 (Rectal) 6.5 mg Methylprednisolone 25.0 mg Dilaudid HOLD Midazolam 1 mg Diphenhydramine 10 mg Morphine Sulfate 1.0 mg Defibrillation Dopamine Naloxone 1.3 mg Defibrillation 30 J, 50 J (800 mg in 500 ml Normal Saline) Ondansetron 2.0 mg 2 mcg/kg/min 0.8 ml/hr Prednisone 13.0 mg

Length 84.5-97.5 cm Cardioversion 6 J, 15 J 5 mcg/kg/min 2.5 ml/hr Sodium Bicarbonate 13 mEq Yellow (19-35 Months) Normal Saline 260 ml 10 mcg/kg/min 5.0 ml/hr 20 mcg/kg/min 10 ml/hr Weight 15-18 Kg (Avg 16.5 Kg) Acetaminophen 240 mg Epinephrine 1:10,000 0.16 mg Vital Signs Adenosine 1st Dose- 1.8 mg Epinephrine 1:1000 IM 0.20 mg Heart Rate 100-15 Repeat Dose- 3.6 mg Epinephrine 1:1000 Nebulized2.0 mg Respirations 20-26 Afrin Nasal Spray 1 spray Fentanyl 33.0 mcg Albuterol 2.5 mg Glucagon 0.5 mg BP Systolic 100(+/-20) Atropine 0.32 mg Ibuprofen 8.0 ml Amiodarone 80 mg Ipratropium 500 mcg Calcium Chloride 330 mg Levalbuterol 0.63 mg Equipment Charcoal 15-30 gms Lidocaine 15 mg Dextrose 10% 80 ml Lorazepam 0.83 mg ET Tube 5.0 Diazepam (IV) 3.3 mg Magnesium Sulfate 800 mg Blade Size 2 (Rectal) 8.25 mg Methylprednisolone 31.25 mg Dilaudid HOLD Midazolam 1.5 mg Diphenhydramine 15 mg Morphine Sulfate 1.0 mg

Defibrillation Dopamine Naloxone 1.6 mg White (3-4 yrs) Defibrillation 30 J, 70 J (800 mg in 500 ml Normal Saline) Ondansetron 2.4 mg 2 mcg/kg/min 1.2 ml/hr Prednisone 16.5 mg Length 97.5-110 cm Cardioversion 8 J, 15 J 5 mcg/kg/min 3.0 ml/hr Sodium Bicarbonate 16 mEq Normal Saline 330 ml 10 mcg/kg/min 6.0 ml/hr 20 mcg/kg/min 12 ml/hr

Drug List B (Page 2 of 3) 2012 Length 137-150 cm Length 122-137 cm Length 110-122 cm omlSaline J Normal 30 J J, 150 15 J, 60 Cardioversion Defibrillation Defibrillation 3 6.5 Size Blade Tube ET Equipment 115(+/-20) 16-22 Systolic 85-90 BP Respirations Rate Heart Signs Vital Saline J Normal 30 J J, 100 15 J, 50 Cardioversion Defibrillation Defibrillation 2-3 6.0 Size Blade Tube ET Equipment 105(+/-15) 18-22 Systolic 90 BP Respirations Rate Heart Signs Vital Saline J Normal 20 J J, 85 10 J, 40 Cardioversion Defibrillation Defibrillation 2 5.5 Size Blade Tube ET Equipment 100(+/-15) 20-24 Systolic 100 BP Respirations Rate Heart Signs Vital egt1-2K Ag2.5Kg) 20.75 (Avg Kg 19-22 Weight 2 ml 720 ml 540 ml 410 egt3-0K Ag3 Kg) 36 (Avg Kg 32-40 Weight Kg) 27 (Avg Kg 24-30 Weight eiti oo Coded Color Pediatric ctmnpe 4 mg 544 1 Adenosine Acetaminophen mg 384 1 Adenosine Acetaminophen mg 288 1 Adenosine Acetaminophen iadd03 mg 0.31 mg 25.0 Saline) mg Normal 4.0 gms ml 20-40 500 ml in 100 mg (800 Dopamine (IV) mg 0.4 Diphenhydramine mg 100 mg mg 420 Dilaudid 2.5 Diazepam 10% Dextrose spray 1 Charcoal Chloride Calcium Amiodarone Atropine Albuterol Spray Nasal Afrin iadd05 mg 0.54 mg 35 Saline) mg Normal 4.0 gms ml 25-50 500 ml in 180 mg (800 Dopamine (IV) mg 0.5 Diphenhydramine mg 180 mg mg 700 Dilaudid 2.5 Diazepam 10% Dextrose spray 2 Charcoal Chloride Calcium Amiodarone Atropine Albuterol Spray Nasal Afrin mg 0.4 mg 25 Saline) mg Normal 4.0 gms ml 25-50 500 ml in 135 mg (800 Dopamine (IV) mg 0.5 Diphenhydramine mg 135 mg mg 540 Dilaudid 2.5 Diazepam 10% Dextrose spray 1 Charcoal Chloride Calcium Amiodarone Atropine Albuterol Spray Nasal Afrin rgLs Pg f3 2012 Drug ListB(Page 3of 3) 0mgk/i 6ml/hr 16 ml/hr 7.8 ml/hr 3.9 ml/hr 1.6 mcg/kg/min 20 mcg/kg/min mcg/kg/min 10 mcg/kg/min 5 2 0mgk/i 80ml/hr 28.0 ml/hr 14.0 ml/hr 7.0 ml/hr 2.7 mcg/kg/min 20 mcg/kg/min mcg/kg/min 10 mcg/kg/min 5 2 ml/hr 20 ml/hr 10 ml/hr 5 ml/hr 2 mcg/kg/min 20 mcg/kg/min mcg/kg/min 10 mcg/kg/min 5 2 rgList Drug eetDs-41mg 4.1 Dose- Repeat eetDs-72mg 7.2 Dose- Repeat mg 5.4 Dose- Repeat st st st Rca)1. mg 10.0 (Rectal) Rca)1. mg 10.0 (Rectal) mg 10.0 (Rectal) oe . mg 2.1 Dose- oe . mg 3.6 Dose- mg 2.7 Dose- rdioe2. mg 20.0 mg 2.0 mg 3.0 mEq 20 mg 2.0 mg 2.0 Bicarbonate Sodium mg 1.0 Prednisone mg 20 mg 37.5 Ondansetron mg 1000 Naloxone mg 0.63 mcg Sulfate 500 Morphine ml 10.0 Midazolam mg 1.0 mcg 40.0 Methylprednisolone Sulfate Magnesium Lorazepam Lidocaine Levalbuterol Ipratropium Ibuprofen mg 0.2 Glucagon mg 0.2 Fentanyl mg Nebulized2.0 1:1000 Epinephrine IM 1:1000 Epinephrine 1:10,000 Epinephrine rdioe3. mg 36.0 mg 2.0 mg 4.0 mEq 36 mg 2.0 mg 3.0 Bicarbonate Sodium mg 1.8 Prednisone mg 36 mg 62.5 Ondansetron mg 1800 Naloxone mg 0.63 mcg Sulfate 500 Morphine ml 18 Midazolam mg 1.0 mcg 62.0 Methylprednisolone Sulfate Magnesium Lorazepam Lidocaine Levalbuterol Ipratropium Ibuprofen mg 0.3 Glucagon mg 0.3 Fentanyl mg Nebulized2.0 1:1000 Epinephrine IM 1:1000 Epinephrine 1:10,000 Epinephrine mg 27.0 mg 2.0 mg 4.0 mEq 27 mg 2.0 mg 2.0 Bicarbonate Sodium mg 1.35 Prednisone mg 20 mg 54.0 Ondansetron mg 1350 Naloxone mg 0.63 mcg Sulfate 500 Morphine ml 13 Midazolam mg 1.0 mcg 54.0 Methylprednisolone Sulfate Magnesium Lorazepam Lidocaine Levalbuterol Ipratropium Ibuprofen mg 0.3 Glucagon mg 0.27 Fentanyl mg Nebulized2.0 1:1000 Epinephrine IM 1:1000 Epinephrine 1:10,000 Epinephrine

Green (10-12 yrs) Orange (7-9 yrs) Blue (5-6 yrs) EMS System Patient Care Policies & Procedures

Released July 2013

Revised December 2017 Standards Procedure (Skill)

Clinical Indications: Suspected cardiac patient B EMT B Suspected tricyclic overdose I EMT- I I Electrical injuries P EMT- P P Syncope

Procedure: 1. Assess patient and monitor cardiac status with the 3 lead ECG. 2. Administer oxygen as patient condition warrants. 3. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after treatment, perform a 12 Lead ECG. A 12 lead ECG should be performed before the administration of nitroglycerin. 4. Prepare ECG monitor and connect patient cable with electrodes. 5. Enter the required patient information (patient name, etc.) into the 12 lead ECG device. 6. Expose chest and prep as necessary. Modesty of the patient should be respected. 7. Apply chest leads and extremity leads using the following landmarks: RA -Right arm LA -Left arm RL -Right leg LL -Left leg V1 -4th intercostal space at right sternal border V2 -4th intercostal space at left sternal border V3 -Directly between V2 and V4 V4 -5th intercostal space at midclavicular line V5 -Level with V4 at left anterior axillary line V6 -Level with V5 at left midaxillary line 8. Instruct patient to remain still. 9. Press the appropriate button to acquire the 12 Lead ECG. 10. If the monitor detects signal noise (such as patient motion or a disconnected electrode), the lead acquisition will be interrupted until the noise is removed. 11. Once acquired, transmit the ECG data to the appropriate hospital if available. 12. Contact the receiving hospital to notify them that a 12 Lead ECG has been sent. 13. Monitor the patient while continuing with the treatment protocol. 14. The second 12 lead should be obtained by applying the V4 chest lead to the 5th intercostal space at the midclavicular line on the right side of the chest, the V5 chest lead to the V8 position at the midscapular line and the V6 chest lead to the V9 position at the left paraspinal line. 15. Instruct the patient to remain still. 16. Press the appropriate button to acquire the 12 Lead ECG. 17. If the monitor detects signal noise (such as patient motion or a disconnected electrode), the lead acquisition will be interrupted until the noise is removed. 18. Label the printed 12 lead to identify V4 as V4R, V5 as V8 and V6 as V9 and notify the hospital if there is indication of posterior or right heart involvement.

Procedure 1 (Page 1 of 2) This procedure has been altered from the original 2012 NCCEP Procedure by the local EMS Medical Director 2012 Standards Procedure (Skill)

19. Monitor the patient while continuing with the treatment protocol. 20. Download data as per guidelines and attach a copy of the 12/15 lead to the ACR. 21. Document the procedure, time, and results on/with the patient care report (PCR)

Certification Requirements:

Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

EMT and EMT-Intermediate personnel should maintain the knowledge and technical skills to acquire the ECG’s as described. However, interpretation is still the role of the EMT- Paramedic.

Procedure 1 (Page 2 of 2) This procedure has been altered from the original 2009 NCCEP Procedure by the local EMS Medical Director 2009 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: BIAD-Combitube Clinical Indications for Blind Insertion Airway Device (BIAD) Use: x Inability to adequately ventilate a patient with a Bag Valve Mask (BVM) or longer EMS transport distances require a more advanced airway. x Appropriate intubation is impossible due to patient access or difficult airway anatomy. x Inability to secure an endotracheal tube in a patient who does not have a gag reflex where at least one failed intubation attempt has occurred. x Patient must be > 5 feet and >16 years of age and must be unconscious. B EMT B Procedure: 1. Preoxygenate and hyperventilate the patient. I EMT- I I 2. Lubricate the tube. P EMT- P P 3. Grasp the patient’s tongue and jaw with your gloved hand and pull forward. 4. Gently insert the tube until the teeth are between the printed rings. 5. Inflate line 1 (blue pilot balloon) leading to the pharyngeal cuff with 100 cc of air. 6. Inflate line 2 (white pilot balloon) leading to the distal cuff with 15 cc of air. 7. Ventilate the patient through the longer blue tube. x Auscultate for breath sounds and sounds over the epigastrium. x Look for the chest to rise and fall. 8. If breath sounds are positive and epigastric sounds are negative, continue ventilation through the blue tube. The tube is in the esophagus. x In the esophageal mode, stomach contents can be aspirated through the #2, white tube relieving gastric distention. 9. If breath sounds are negative and epigastric sounds are positive, attempt ventilation through the shorter, #2 white tube and reassess for lung and epigastric sounds. If breath sounds are present and the chest rises, you have intubated the trachea and continue ventilation through the shorter tube. 10. The device is secured by the large pharyngeal balloon. 11. Confirm tube placement using end-tidal CO2 detector or esophageal bulb device. 12. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 13. It is strongly recommended that an Airway Evaluation Form be completed with any BIAD use. x Endotracheal intubation with a Combitube in Place (Only if ventilation unsuccessful): x If you cannot ventilate with the Combitube in place, you should remove the tube, open and suction the airway, and ventilate with a BVM prior to intubation or re-establishment of another BIAD.

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 2 9/10/2012 2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: BIAD King Clinical Indications for Blind Insertion Airway Device (BIAD) Use: x Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport distances require a more advanced airway. x Appropriate intubation is impossible due to patient access or difficult airway anatomy. x Inability to secure an endotracheal tube in a patient who does not have a gag reflex where at least one failed intubation attempt has occurred. x Patient must be unconscious. B EMT B Procedure: I EMT- I I 1. Preoxygenate and hyperventilate the patient. P EMT- P P 2. Select the appropriate tube size for the patient. 3. Lubricate the tube. 4. Grasp the patient’s tongue and jaw with your gloved hand and pull forward. 5. Gently insert the tube rotated laterally 45-90 degrees so that the blue orientation line is touching the corner of the mouth. Once the tip is at the base of the tongue, rotate the tube back to midline. Insert the airway until the base of the connector is in line with the teeth and gums. 6. Inflate the pilot balloon with 45-90 ml of air depending on the size of the device used. 7. Ventilate the patient while gently withdrawing the airway until the patient is easily ventilated. 8. Auscultate for breath sounds and sounds over the epigastrium and look for the chest to rise and fall. 9. The large pharyngeal balloon secures the device. 10. Confirm tube placement using end-tidal CO2 detector. 11. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 12. It is strongly recommended that an Airway Evaluation Form be completed with any BIAD use.

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 3 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: BIAD-Laryngeal Mask Airway (LMA)

Clinical Indications for Blind Insertion Airway Device (BIAD) Use: B EMT B I EMT- I I x Inability to adequately ventilate a patient with a Bag Valve Mask P EMT- P P or longer EMS transport distances require a more advanced airway. x Inability to secure an endotracheal tube in a patient who does not have a gag reflex where at least one failed intubation attempt has occurred. x Appropriate intubation is impossible due to patient access or difficult airway anatomy. x This airway does not prevent aspiration of stomach contents.

Clinical Contraindications:

x Deforming Facial Trauma x Pulmonary Fibrosis x Morbid Obesity

Procedure:

1. Select the appropriate tube size for the patient. 2. Check the tube for proper inflation and deflation. 3. Completely deflate the tube prior to insertion. 4. Lubricate with a water-soluble jelly. 5. Pre-Oxygenate the patient with 100% Oxygen 6. Insert the LMA into the hypopharynx until resistance is met. 7. Inflate the cuff until a seal is obtained. 8. Connect the LMA to an ambu bag and assess for breath sounds and air entry. 9. Confirm tube placement using end-tidal CO2 detector or esophageal bulb device. 10. Monitor oxygen saturation with pulse oximetry and heart rhythm with ECG 11. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 12. Re-verify LMA placement after every move and upon arrival in the ED 13. Document the procedure, time, and result (success) on/with the patient care report (PCR) 14. It is strongly recommended that an Airway Evaluation Form be completed with any BIAD use.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation once per certification cycle.

Revised Procedure 4 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: CPAP

I EMT- I I P EMT- P P Clinical Indications for Continuous Positive Airway Pressure (CPAP) Use:

x CPAP is indicated in all patients whom inadequate ventilation is suspected that is not associated with Asthma. This could be as a result of pulmonary edema, pneumonia, COPD, etc.

Clinical Contraindications for Continuous Positive Airway Pressure (CPAP) Use:

x Decreased Mental Status. x Facial features or deformities that prevent an adequate mask seal. x Excessive respiratory secretions.

Procedure:

1. Ensure adequate oxygen supply to ventilation device. 2. Explain the procedure to the patient. 3. Consider placement of a nasopharyngeal airway. 4. Place the delivery mask over the mouth and nose. Oxygen should be flowing through the device at this point. 5. Secure the mask with provided straps starting with the lower straps until minimal air leak occurs. 6. If the Positive End Expiratory Pressure (PEEP) is adjustable on the CPAP device adjust the PEEP beginning at 0 cmH20 of pressure and slowly titrate to achieve a positive pressure as follows: o 5 – 10 cmH20 for Pulmonary Edema, Near Drowning, possible aspiration or pneumonia o 3 – 5cmH20 for COPD 7. Evaluate the response of the patient assessing breath sounds, oxygen saturation, and general appearance. 8. Titrate oxygen levels to the patient’s response. Many patients respond to low FIO2 (30-50%). 9. Encourage the patient to allow forced ventilation to occur. Observe closely for signs of complications. The patient must be breathing for optimal use of the CPAP device. 10. Document time and response on patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 5 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Cricothyrotomy-Surgical Clinical Indications: P EMT- P P x Failed Airway Protocol x Management of an airway when standard airway procedures cannot be performed or have failed in a patient > 12 years old. Procedure: 1. Have suction and supplies available and ready. 2. Locate the cricothyroid membrane utilizing anatomical landmarks. 3. Prep the area with an antiseptic swab (Betadine). 4. Attach a 5-cc syringe to an 18G - 1 & 1/2-inch needle. 5. Insert the needle (with syringe attached) perpendicularly through the cricothyroid membrane with the needle directed posteriorly. 6. During needle insertion, gentle aspiration should be applied to the syringe. Rapid aspiration of air into the syringe indicates successful entry into the trachea. Do not advance the needle any further. Attach forceps and remove syringe. 7. With the needle remaining in place, make a 1-inch vertical incision through the skin and subcutaneous tissue above and below the needle using a scalpel. Using blunt dissection technique, expose the cricothyroid membrane. This is a bloody procedure. The needle should act as a guide to the cricothyroid membrane. 8. With the needle still in place, make a horizontal stabbing incision approx. 1/2 inch through the membrane on each side of the needle. Remove the needle. 9. Using (skin hook, tracheal hook, or gloved finger) to maintain surgical opening, insert the cuffed tube into the trachea. (Cric tube from the kit or a #6 endotracheal tube is usually sufficient). 10. Inflate the cuff with 5-10cc of air and ventilate the patient while manually stabilizing the tube. 11. All of the standard assessment techniques for insuring tube placement should be performed (auscultation, chest rise & fall, end-tidal CO2 detector, etc.) Esophageal bulb devices are not accurate with this procedure. 12. Secure the tube. 13. If Available apply end tidal carbon dioxide monitor (Capnography) and record readings on scene, en route to the hospital, and at the hospital. 14. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’s teeth or lips on/with the patient care report (PCR). Document all devices used to confirm initial tube placement and after each movement of the patient. 15. Consider placing an NG or OG tube to clear stomach contents after the airway is secured. 16. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 17. It is strongly recommended that an Airway Evaluation Form be completed with all intubations Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 6 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Standards Procedure (Skill)

Clinical Indications: P EMT- P P Pediatric Failed Airway Protocol Management of an airway when standard airway procedures cannot be performed or have failed in a patient < 11 years of age. Procedure: 1. Have suction and supplies available and ready. 2. Locate the cricothyroid membrane utilizing anatomical landmarks. 3. Prep the area with an antiseptic swab (Betadine). 4. Use a 14G - 1 & 1/2-inch needle, or appropriate selected size for patient size. 5. Insert the needle perpendicularly through the cricothyroid membrane with the needle directed posteriorly. 6. Be careful during insertion as to not progress posteriorly but in a caudil direction. 7. Remove needle leaving the catheter in place. 8. Attach the BVM adapter from a 3.0 or 3.5 ET Tube to the catheter and provide oxygenation with oxygen attached to the BVM. 9. Monitor pulse ox – SPO2 should improve if circulation is adequate. ETCO2 will be of limited benefit since elimination of CO2 through a needle cric is difficult. 10. Secure the catheter in place. 11. Document needle/catheter size, time, result (success). 12. Document all devices used to confirm oxygenation and after each movement of the patient. 13. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Pulse Oximetry. 14. It is strongly recommended that an Airway Evaluation Form be completed with all intubations Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Procedure 6a This procedure has been altered from the original 2012 NCCEP Procedure by the local EMS Medical Director 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Endotracheal Tube Introducer (Bougie)e) Clinical Indications: x Patients meet clinical indications for oral intubation I EMT- I I x Initial intubation attempt(s) unsuccessful P EMT- P P x Predicted difficult intubation Contraindications: x Three attempts at orotracheal intubation (utilize failed airway protocol) x Age less than eight (8) or ETT size less than 6.5 mm Procedure: 1. Prepare, position and oxygenate the patient with 100% oxygen; 2. Select proper ET tube without stylet, test cuff and prepare suction; 3. Lubricate the distal end and cuff of the endotracheal tube (ETT) and the distal 1/2 of the Endotracheal Tube Introducer (Bougie) (note: Failure to lubricate the Bougie and the ETT may result in being unable to pass the ETT); 4. Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick’s/BURP as needed; 5. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized; 6. Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do not meet resistance you have a probable esophageal intubation and insertion should be re- attempted or the failed airway protocol implemented as indicated); 7. Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie; 8. Gently advance the Bougie and loaded ET tube until you have hold-up again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie; 9. While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the Bougie passing the tube to its appropriate depth; 10. If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn the bevel of the ETT posteriorly. If this technique fails to facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the ETT(this will require an assistant to maintain the position of the Bougie and, if so desired, advance the ETT); 11. Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie; 12. Confirm tracheal placement according to the intubation protocol, inflate the cuff with 3 to 10 cc of air, auscultate for equal breath sounds and reposition accordingly; 13. When final position is determined secure the ET tube, reassess breath sounds, apply end tidal CO2 monitor, and record and monitor readings to assure continued tracheal intubation. Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 7 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Foreign Body Obstructionn

MR B EMT B Clinical Indications: I EMT- I I P EMT- P P

x Sudden onset of respiratory distress often with coughing, wheezing, gagging, or stridor due to a foreign-body obstruction of the upper airway.

Procedure:

1. Assess the degree of foreign body obstruction x Do not interfere with a mild obstruction allowing the patient to clear their airway by coughing. x In severe foreign-body obstructions, the patient may not be able to make a sound. The victim my clutch his/her neck in the universal choking sign. 2. For an infant, deliver 5 back blows (slaps) followed by 5 chest thrusts repeatedly until the object is expelled or the victim becomes unresponsive. 3. For a child, perform a subdiaphragmatic abdominal thrust (Heimlich Maneuver) until the object is expelled or the victim becomes unresponsive. 4. For adults, a combination of maneuvers may be required. x First, subdiaphragmatic abdominal thrusts (Heimlich Maneuver) should be used in rapid sequence until the obstruction is relieved. x If abdominal thrusts are ineffective, chest thrusts should be used. Chest thrusts should be used primarily in morbidly obese patients and in the patients who are in the late stages of pregnancy 5. If the victim becomes unresponsive, begin CPR immediately but look in the mouth before administering any ventilations. If a foreign-body is visible, remove it. 6. Do not perform blind finger sweeps in the mouth and posterior pharynx. This may push the object farther into the airway. 7. In unresponsive patients, EMT-Intermediate and EMT-Paramedic level professionals should visualize the posterior pharynx with a laryngoscope to potentially identify and remove the foreign-body using Magil forceps. 8. Document the methods used and result of these procedures in the patient care report (PCR).

Certification Requirements:

Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 8 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway Intubation Confirmation – End-Tidal CO2 Detector

Clinical Indications: B EMT B I EMT- I I x The End-Tidal CO detector shall be used with any Endotracheal 2 P EMT- P P Tube or Blind Insertion Airway Device use.

It is strongly recommended that continuous Capnography be used in place of or in addition to the use of an End-Tidal CO2 detector.

Procedure:

1. Attach End-Tidal CO2 detector to the Blind Insertion Airway Device or the Endotracheal Tube. 2. Note color change. A color change or CO2 detection will be documented on each respiratory failure or cardiac arrest patient. 3. The CO2 detector shall remain in place with the airway and monitored throughout the prehospital care and transport unless continuous Capnography is used. Any loss of CO2 detection or color change is to be documented and monitored as procedures are done to verify or correct the airway problem. 4. Tube placement should be verified frequently and always with each patient move or loss of color change in the End-Tidal CO2 detector. 5. Document the procedure and the results on/with the Patient Care Report (PCR) as well as on the Airway Evaluation Form.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 9 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Intubation Confirmation-Esophageal Bulb

B EMT B Clinical Indications: I EMT- I I P EMT- P P x To assist in determining and documenting the correct placement of an Endotracheal or Nasotracheal tube.

It is strongly recommended that continuous Capnography be used in place of or in addition to the use of an Esophageal Bulb device.

Procedure:

1. Complete intubation as per Airway-Intubation Oral or Airway-Intubation Nasal procedures. 2. Place the bulb device over the proximal end of the ETT or NTT. Squeeze the bulb to remove all air prior to securing the bulb on the tube. 3. Once secured on the tube, release the bulb. 4. If the bulb expands evenly and easily, this indicates probable tracheal intubation. Assessment of the patient’s breath sounds bilaterally should also be performed. 5. If the bulb does not expand easily, this indicates possible esophageal intubation and the need to reassess the airway. 6. Document time and result in the patient care report (PCR). 7. Do not repeat test since a false positive test can result from instillation of air into the esophagus.

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 10 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Rapid Sequence Intubation Clinical Indications: P EMT- P P x Need for advanced airway control in a patient who has a gag reflex x or trismus (jaw clinching) x Failure to protect the airway. Unable to ventilate and / or oxygenate. Impending airway compromise x A minimum of 2 EMT-Paramedics on scene able to participate in patient care Clinical Contraindications: x Age ≤ 11 years of age. x Refer to drug list for contraindications regarding use of Succinylcholine and Rocuronium. Procedure: 1. Perform focused neurological exam 2. Evaluate for difficult airway (LEMON)-see appendix 3. Prepare equipment (intubation kit, BVM, suction, RSI medications, BIAD, Cricothyrotomy kit, waveform capnography, other airway adjuncts as available) 4. Pre-oxygenate patient with 100% oxygen via NRB mask or BVM. Apneic oxygenation: May continue high-flow oxygen via NC during entire procedure 5. Monitor oxygen saturation with pulse oximetry and heart rhythm with ECG 6. Ensure functioning IV / IO access. Two (2) IV sites are preferable 7. Stroke / head trauma suspected? If yes, Lidocaine 1.5 mg/kg (per local medical director) 8. In-line c-spine stabilization by second caregiver (in setting of trauma) 9. Administer Etomidate (preferred agent) or Ketamine by rapid IV push 10. Administer Succinylcholine (preferred agent), await fasciculation and jaw relaxation or Rocuronium 11. Apply cricoid pressure (by third caregiver). This is optional and may improve or worsen view 12. Intubate trachea 13. Verify ET placement through auscultation, Capnography, and Pulse Oximetry 14. May repeat Succinylcholine or Rocuronium if inadequate relaxation 15. Release cricoid pressure (if utilized) and secure tube 16. Continuous Capnography and Pulse Oximetry is required for RSI. Pre-intubation, minimal during intubation, and post-intubation readings must be recorded in the PCR. 17.Re-verify tube placement after every move and upon arrival in the ED 18. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’s teeth or lips on/with the patient care report (PCR). Document all devices/methods used to confirm initial tube placement initially and with patient movement. 19. Consider placing a gastric tube to clear stomach contents after the airway is secured. 20. Completion of the Airway Evaluation Form is required including a signature from the receiving physician at the Emergency Department confirming proper tube placement. Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. Revised Procedure 11 12/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Intubation Nasotracheal

I EMT- I I Clinical Indications: P EMT- P P x A spontaneously breathing patient in need of intubation (inadequate respiratory effort, evidence of hypoxia or carbon dioxide retention, or need for airway protection). x Rigidity or clenched teeth prohibiting other airway procedures. x Patient must be 12 years of age or older.

Procedure:

1. Premedicate the patient with nasal spray. 2. Select the largest and least obstructed nostril and insert a lubricated nasal airway to help dilate the nasal passage. 3. Preoxygenate the patient. Lubricate the tube. The use of a BAAM device is recommended. 4. Remove the nasal airway and gently insert the tube keeping the bevel of the tube toward the septum. 5. Continue to pass the tube listening for air movement and looking for to and fro vapor condensation in the tube. As the tube approaches the larynx, the air movement gets louder. 6. Gently and evenly advance the tube through the glottic opening on the inspiration. This facilitates passage of the tube and reduces the incidence of trauma to the vocal cords. 7. Upon entering the trachea, the tube may cause the patient to cough, buck, strain, or gag. Do not remove the tube! This is normal, but be prepared to control the cervical spine and the patient, and be alert for vomiting. 8. Auscultate for bilaterally equal breath sounds and absence of sounds of the epigastrium. Observe for symmetrical chest expansion. The 15mm adapter usually rests close to the nostril with proper positioning. 9. Inflate the cuff with 5-10 cc of air. 10. Confirm tube placement using an end-tidal CO2 monitoring or esophageal bulb device. 11. Secure the tube. 12. Reassess airway and breath sounds after transfer to the stretcher and during transport. These tubes are easily dislodged and require close monitoring and frequent reassessment. 13. Document the procedure, time, and result (success) on/with the patient care report (PCR). 14. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 15. It is strongly recommended that an Airway Evaluation Form be completed with all intubations

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 12 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Intubation Oral Tracheal

I EMT- I I Clinical Indications: P EMT- P P

x Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport distances require a more advanced airway. x An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort. x A component of Drug Assisted Intubation

Procedure:

1. Prepare, position and oxygenate the patient with 100% Oxygen. 2. Select proper ET tube (and stylette, if used), have suction ready. 3. Using laryngoscope, visualize vocal cords. (Use Sellick maneuver/BURP to assist you). 4. Limit each intubation attempt to 30 seconds with BVM between attempts. 5. Visualize tube passing through vocal cords. 6. Confirm and document tube placement using an end-tidal CO2 monitoring or esophageal bulb device. 7. Inflate the cuff with 3-to10 cc of air; secure the tube to the patient’s face. 8. Auscultate for bilaterally equal breath sounds and absence of sounds over the epigastrium. If you are unsure of placement, remove tube and ventilate patient with bag- valve mask. 9. Consider using a Blind Insertion Airway Device if intubation efforts are unsuccessful. 10. If Available apply end tidal carbon dioxide monitor (Capnography) and record readings on scene, en route to the hospital, and at the hospital. 11. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’s teeth or lips on/with the patient care report (PCR). Document all devices used to confirm initial tube placement. Also document positive or negative breath sounds before and after each movement of the patient. 12. Consider placing an NG or OG tube to clear stomach contents after the airway is secured with an ET tube. 13. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 14. It is strongly recommended that an Airway Evaluation Form be completed with all intubations

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 13 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway – Nebulizer Inhalation Therapy Clinical Indications: B EMT B x Patients experiencing bronchospasm. I EMT- I I P EMT- P P Procedure:

1. Gather the necessary equipment. 2. Assemble the nebulizer kit. 3. Instill the premixed drug (such as Albuterol or other approved drug) into the reservoir well of the nebulizer. 4. Connect the nebulizer device to oxygen at 4 - 6 liters per minute or adequate flow to produce a steady, visible mist. 5. Instruct the patient to inhale normally through the mouthpiece of the nebulizer. The patient needs to have a good lip seal around the mouthpiece. 6. The treatment should last until the solution is depleted. Tapping the reservoir well near the end of the treatment will assist in utilizing all of the solution. 7. Monitor the patient for medication effects. This should include the patient’s assessment of his/ her response to the treatment and reassessment of vital signs, ECG, and breath sounds. 8. Assess and document peak flows before and after nebulizer treatments. 9. Document the treatment, dose, and route on/with the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 14 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Respirator Operation Clinical Indications: I EMT- I I x Transport of an intubated patient P EMT- P P

Procedure:

1. Confirm the placement of tube as per airway protocol. 2. Ensure adequate oxygen delivery to the respirator device. 3. Preoxygenate the patient as much as possible with bag-valve mask. 4. Remove BVM and attach tube to respiration device. 5. Per instructions of device, set initial respiration values. For example, set an inspiratory:expiratory ratio of 1:4 (for every 1 second of inspiration, allow 4 seconds and expiration) with a rate of 12 to 20. 6. Assess breath sounds. Allow for adequate expiratory time. Adjust respirator setting as clinically indicated. 7. It is required that patients on a transport ventilator should be monitored continuously through Capnography and Pulse Oximetry. The ventilatory rate should adjusted to maintain a pulse oximetry of >90 (or as high as possible) while maintaining a pCO2 of 30-35. 8. If any worsening of patient condition, decrease in oxygen saturation, or any question regarding the function of the respirator, remove the respirator and resume bag-valve mask ventilations. 9. Document time, complications, and patient response on the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 15 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Suctioning-Advanced

I EMT- I I Clinical Indications: P EMT- P P

x Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient currently being assisted by an airway adjunct such as a naso-tracheal tube, endotracheal tube, Combitube, tracheostomy tube, or a cricothyrotomy tube.

Procedure:

1. Ensure suction device is in proper working order. 2. Preoxygenate the patient as is possible. 3. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. 4. Using the suprasternal notch and the end of the airway into the catheter will be placed as guides, measure the depth desired for the catheter (judgment must be used regarding the depth of suctioning with cricothyrotomy and tracheostomy tubes). 5. If applicable, remove ventilation devices from the airway. 6. With the thumb port of the catheter uncovered, insert the catheter through the airway device. 7. Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and remove the suction catheter slowly. 8. A small amount of Normal Saline (10 ml) may be used if needed to loosen secretions for suctioning. 9. Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient 10. Document time and result in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 16 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Suctioning-Basic

B EMT B I EMT- I I Clinical Indications: P EMT- P P

x Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who cannot maintain or keep the airway clear.

Procedure:

1. Ensure suction device is in proper working order with suction tip in place. 2. Preoxygenate the patient as is possible. 3. Explain the procedure to the patient if they are coherent. 4. Examine the oropharynx and remove any potential foreign bodies or material which may occlude the airway if dislodged by the suction device. 5. If applicable, remove ventilation devices from the airway. 6. Use the suction device to remove any secretions, blood, or other substance. 7. The alert patient may assist with this procedure. 8. Reattach ventilation device (e.g., bag-valve mask) and ventilate or assist the patient 9. Record the time and result of the suctioning in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 17 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Tracheostomy Tube Change Clinical Indications: I EMT- I I x Presence of Tracheostomy site. P EMT- P P x Urgent or emergent indication to change the tube, such as obstruction that will not clear with suction, dislodgement, or inability to oxygenate/ventilate the patient without other obvious explanation.

Procedure:

1. Have all airway equipment prepared for standard airway management, including equipment of orotracheal intubation and failed airway. 2. Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a #6.0 Shilley, then have a 6.0 and a 5.5 tube). 3. Lubricate the replacement tube(s) and check the cuff. 4. Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to pre-oxygenate the patient as much as possible. 5. Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages. 6. If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure. 7. Remove the tracheostomy tube. 8. Insert the replacement tube. Confirm placement via standard measures except for esophageal detection (which is ineffective for surgical airways). 9. If there is any difficultly placing the tube, re-attempt procedure with the smaller tube. 10. If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation (as per protocol). More difficulty with tube changing can be anticipated for tracheostomy sites that are immature – i.e., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites. 11. Document procedure, confirmation, patient response, and any complications in the PCR

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment for this skill should include direct observation at least once per certification cycle.

Revised Procedure 18 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Airway: Ventilator Operation

Clinical Indications: P EMT- P P

x Management of the ventilation of a patient during a prolonged or interfacility transport of an intubated patient.

Procedure:

1. Transporting personnel should review the operation of the ventilator with the treating personnel (physician, nurse, or respiratory therapy) in the referring facility prior to transport if possible. 2. All ventilator settings, including respiratory rate, FiO2, mode of ventilation, and tidal volumes should be recorded prior to initiating transport. Additionally, the recent trends in oxygen saturation experienced by the patient should be noted. 3. Prior to transport, specific orders regarding any anticipated changes to ventilator settings as well as causes for significant alarm should be reviewed with the referring medical personnel as well as medical control. 4. Once in the transporting unit, confirm adequate oxygen delivery to the ventilator. 5. Frequently assess breath sounds to assess for possible tube dislodgment during transfer. 6. Frequently assess the patient’s respiratory status, noting any decreases in oxygen saturation or changes in tidal volumes, peak pressures, etc. 7. Note any changes in ventilator settings or patient condition in the PCR. 8. Consider placing an NG or OG tube to clear stomach contents. 9. It is strongly recommended that the airway (if equipment is available) be monitored continuously through Capnography and Pulse Oximetry. 10. If any significant change in patient condition, including vital signs or oxygen saturation or there is a concern regarding ventilator performance/alarms, remove the ventilator from the endotracheal tube and use a bag-valve mask with 100% O2. Contact medical control immediately.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 19 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Arterial Access: Blood Draw Clinical Indications: P EMT- P P x Arterial blood gas (ABG) analysis x Other needs for arterial blood as indicated by medical control

Procedure:

1. Assemble ABG kit, ice, alcohol wipes, and gloves. 2. Determine if there is any history of trauma or any other difficulties with circulation to either hand. If a problem does exist, do not use that extremity for the blood draw. 3. Palpate the radial pulse just proximal to the wrist. 4. Clean the skin with an alcohol wipe. 5. Insert the ABG syringe at a 45 to 60 degree angle over the area of the pulse. 6. Slowly advance the syringe, watching for return of arterial blood. You do not need to aspirate but rather allow the syringe to fill from the arterial pressure. 7. Once the sample has been acquired, remove and discard the needle in an approved fashion. 8. Place the small airtight cap over the needle port on the syringe. Remove air from the sample by inverting the syringe and pressing the plunger on the syringe until a small amount of the sample enters the airtight cap. 9. Place the sample on ice as soon as possible 10. Hold pressure over the blood draw sight for at least 5 minutes before checking to ensure hemostasis. 11. Record procedure, time, and any complications in patient care report (PCR)

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 20 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Arterial Access: Line Maintenancee Clinical Indications: P EMT- P P x Transport of a patient with an existing arterial line.

Procedure:

1. Make certain arterial line is secured prior to transport, including intersection of arterial catheter and IV/Monitoring lines. 2. Use available equipment for monitoring of arterial pressures via arterial line. 3. Do not use the arterial line for administration of any fluids or medications. 4. If there is any question regarding dislodgement of the arterial line and bleeding results, remove the line and apply direct pressure over the site for at least five minutes before checking to ensure hemostasis.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 21 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Assessment: Adult

MR B EMT B I EMT- I I P EMT- P P Clinical Indications:

x Any patient requesting a medical evaluation that is too large to be measured with a Broselow- Luten Resuscitation Tape.

Procedure:

1. Scene size-up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction 2. Assess need for additional resources. 3. Initial assessment includes a general impression as well as the status of a patient’s airway, breathing, and circulation. 4. Assess mental status (e.g., AVPU) and disability (e.g., GCS). 5. Control major hemorrhage and assess overall priority of patient. 6. Perform a focused history and physical based on patient’s chief complaint. 7. Assess need for critical interventions. 8. Complete critical interventions and perform a complete secondary exam to include a baseline set of vital signs as directed by protocol. 9. Maintain an on-going assessment throughout transport; to include patient response/possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints/conditions. 10. Document all findings and information associated with the assessment, performed procedures, and any administration of medications on the PCR.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 22 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Pain Assessment and Documentation Clinical Indications: MR x Any patient with pain. Definitions: B EMT B x Pain is an unpleasant sensory and emotional experience I EMT- I I associated with actual or potential tissue damage. P EMT- P P x Pain is subjective (whatever the patient says it is). Procedure: 1. Initial and ongoing assessment of pain intensity and character is accomplished through the patient’s self report. 2. Pain should be assessed and documented in the PCR during initial assessment, before starting pain control treatment, and with each set of vitals. 3. Pain should be assessed using the appropriate approved scale. 4. Three pain scales are available: the 0 – 10, the Wong - Baker "faces", and the FLACC. x 0 – 10 Scale: the most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever. x Wong – Baker “FACES” scale: this scale is primarily for use with pediatrics but may also be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from 0-10. This scale can be documented with the numeric value.

From Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby. x FLACC scale: this scale has been validated for measuring pain in children with mild to severe cognitive impairment and in pre-verbal children (including infants).

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 23 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Assessment: Pediatric Clinical Indications: MR x Any child that can be measured with the B EMT B Broselow-Luten Resuscitation Tape. I EMT- I I P EMT- P P

Procedure:

1. Scene size-up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction 2. Assess patient using the pediatric triangle of ABCs: x Airway and appearance: speech/cry, muscle tone, inter-activeness, look/gaze, movement of extremities x Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning x Circulation to skin: pallor, mottling, cyanosis 3. Establish spinal immobilization if suspicion of spinal injury 4. Establish responsiveness appropriate for age (AVPU, GCS, etc.) 5. Color code using Broselow-Luten tape 6. Assess disability (pulse, motor function, sensory function, papillary reaction) 7. Perform a focused history and physical exam. Recall that pediatric patients easily experience hypothermia and thus should not be left uncovered any longer than necessary to perform an exam. 8. Record vital signs (BP > 3 years of age, cap refill < 3 years of age) 9. Include Immunizations, Allergies, Medications, Past Medical History, last meal, and events leading up to injury or illness where appropriate. 10. Treat chief complaint as per protocol

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 24 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Blood Glucose Analysis Clinical Indications:

x Patients with suspected hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.) MR B EMT B Procedure: I EMT- I I P EMT- P P 1. Gather and prepare equipment. 2. Blood samples for performing glucose analysis can be obtained through a finger-stick or when possible simultaneously with intravenous access. 3. Place correct amount of blood on reagent strip or site on glucometer per the manufacturer's instructions. 4. Time the analysis as instructed by the manufacturer. 5. Document the glucometer reading and treat the patient as indicated by the analysis and protocol. 6. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol. 7. Perform Quality Assurance on glucometers at least once every 7 days, if any clinically suspicious readings are noted, and/or as recommended by the manufacturer and document in the log.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 25 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Capnography

B EMT B I EMT- I I Clinical Indications: P EMT- P P

x Capnography shall be used when available with the use of all invasive airway procedures including endotracheal, nasotracheal, cricothyrotomy, or Blind Insertion Airway Devices (BIAD). x Capnography should also be used when possible with CPAP.

Procedure:

1. Attach capnography sensor to the BIAD, endotracheal tube, or oxygen delivery device. 2. Note CO2 level and waveform changes. These will be documented on each respiratory failure, cardiac arrest, or respiratory distress patient. 3. The capnometer shall remain in place with the airway and be monitored throughout the prehospital care and transport. 4. Any loss of CO2 detection or waveform indicates an airway problem and should be documented. 5. The capnogram should be monitored as procedures are performed to verify or correct the airway problem. 6. Document the procedure and results on/with the Patient Care Report (PCR) and the Airway Evaluation Form.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 26 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Cardiac: External Pacing

P EMT- P P Clinical Indications:

x Patients with symptomatic bradycardia (less than 60 per minute) with signs and symptoms of inadequate cerebral or cardiac perfusion such as: x Chest Pain x Hypotension x Pulmonary Edema x Altered Mental Status, Confusion, etc. x Ventricular Ectopy x Asystole, pacing must be done early to be effective. x PEA, where the underlying rhythm is bradycardic and reversible causes have been treated.

Procedure:

1. Attach standard four-lead monitor. 2. Apply defibrillation/pacing pads to chest and back: x One pad to left mid chest next to sternum x One pad to mid left posterior chest next to spine. 3. Rotate selector switch to pacing option. 4. Adjust heart rate to 70 BPM for an adult and 100 BPM for a child. 5. Note pacer spikes on EKG screen. 6. Slowly increase output until capture of electrical rhythm on the monitor. 7. If unable to capture while at maximum current output, stop pacing immediately. 8. If capture observed on monitor, check for corresponding pulse and assess vital signs. 9. Consider the use of sedation or analgesia if patient is uncomfortable. 10. Document the dysrhythmia and the response to external pacing with ECG strips in the PCR.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 27 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Cardiopulmonary Resuscitation (CPR)

Clinical Indications: MR x Basic life support for the patient in cardiac arrest B EMT B Procedure: I EMT- I I P 1. Assess the patient’s level of responsiveness (shake and shout) EMT- P P 2. If no response, open the patient’s airway with the head-tilt, chin-lift and look, listen, and feel for respiratory effort. If the patient may have sustained C-spine trauma, use the modified jaw thrust while maintaining immobilization of the C-spine. For infants, positioning the head in the sniffing position is the most effective method for opening the airway. 3. Check for pulse (carotid for adults and older children, brachial for infants) for at least 10 seconds. If no pulse, begin chest compressions based on chart below: Age Location Depth Rate

Over sternum, between nipples Infant 1.5 inches At least 100/minute (inter-mammary line), 2-3 fingers

Over sternum, just At least 100/minute cephalad from Child 2 inches (3 compressions xyphoid process, Every 2 seconds) heel of one hand

Over sternum, just cephalad from At least 100/minute Adult xyphoid process, At least 2 inches (3 compressions hands with Every 2 seconds) interlocked fingers 4. If patient is an adult, go to step 5. If no respiratory effort in a pediatric patient, give two ventilations. If air moves successfully, go to step 5. If air movement fails, proceed to the Airway Obstruction Procedure. 5. Go to Cardiac Arrest Procedure. Begin ventilations in the adult as directed in the Cardiac Arrest Procedure 6. Provide 8 - 10 breaths per minute with the BVM. Use EtCO2 to guide your ventilations as directed in the Cardiac Arrest Protocol. 7. Chest compressions should be provided in an uninterrupted manner. Only brief interruptions ( < 5 seconds with a maximum of 10 seconds) are allowed for rhythm analysis, defibrillation, and performance of procedures 8. Document the time and procedure in the Patient Care Report (PCR). Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Revised Procedure 28 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Cardioversion

P EMT- P P Clinical Indications:

x Unstable patient with a tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia, ventricular tachycardia) x Patient is not pulseless (the pulseless patient requires unsynchronized cardioversion, i.e., defibrillation)

Procedure:

1. Ensure the patient is attached properly to a monitor/defibrillator capable of synchronized cardioversion. 2. Have all equipment prepared for unsynchronized cardioversion/defibrillation if the patient fails synchronized cardioversion and the condition worsens. 3. Consider the use of pain or sedating medications. 4. Set energy selection to the appropriate setting. 5. Set monitor/defibrillator to synchronized cardioversion mode. 6. Make certain all personnel are clear of patient. 7. Press and hold the shock button to cardiovert. Stay clear of the patient until you are certain the energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to “synchronize”, so there may a delay between activating the cardioversion and the actual delivery of energy. 8. Note patient response and perform immediate unsynchronized cardioversion/defibrillation if the patient’s rhythm has deteriorated into pulseless ventricular tachycardia/ventricular fibrillation, following the procedure for Defibrillation-Manual. 9. If the patient’s condition is unchanged, repeat steps 2 to 8 above, using escalating energy settings. 10. Repeat until maximum setting or until efforts succeed. Consider discussion with medical control if cardioversion is unsucessful after 2 attempts. 11. Note procedure, response, and time in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle., or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 29 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Chest Decompression

Clinical Indications: P EMT- P P

x Patients with hypotension (SBP <90), clinical signs of shock, and at least one of the following signs: x Jugular vein distention. x Tracheal deviation away from the side of the injury (often a late sign). x Absent or decreased breath sounds on the affected side. x Hyper-resonance to percussion on the affected side. x Increased resistance when ventilating a patient.

x Patients in traumatic arrest with chest or abdominal trauma for whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above.

Procedure:

1. Don personal protective equipment (gloves, eye protection, etc.). 2. Administer high flow oxygen. 3. Identify and prep the site: x Locate the second intercostals space in the mid-clavicular line on the same side as the pneumothorax. x If unable to place anteriorly, lateral placement may be used at the fourth ICS mid-axillary line. x Prepare the site with providone-iodine ointment or solution. 4. Insert the catheter (14 gauge for adults) into the skin over the third rib and direct it just over the top of the rib (superior border) into the interspace. 5. Advance the catheter through the parietal pleura until a “pop” is felt and air or blood exits under pressure through the catheter, then advance catheter only to chest wall. 6. Remove the needle, leaving the plastic catheter in place. 7. Secure the catheter hub to the chest wall with dressings and tape. 8. Consider placing a finger cut from an exam glove over the catheter hub. Cut a small hole in the end of the finger to make a flutter valve. Secure the glove finger with tape or a rubber band. (Note – don’t waste much time preparing the flutter valve; if necessary control the air flow through the catheter hub with your gloved thumb.)

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation once per certification cycle.

Revised Procedure 30 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Childbirth Clinical Indications: B EMT B x Imminent delivery with crowning I EMT- I I P EMT- P P

Procedure:

1. Delivery should be controlled so as to allow a slow controlled delivery of the infant. This will prevent injury to the mother and infant. 2. Support the infant’s head as needed. 3. Check the umbilical cord surrounding the neck. If it is present, slip it over the head. If unable to free the cord from the neck, double clamp the cord and cut between the clamps. 4. Suction the airway with a bulb syringe. 5. Grasping the head with hands over the ears, gently pull down to allow delivery of the anterior shoulder. 6. Gently pull up on the head to allow delivery of the posterior shoulder. 7. Slowly deliver the remainder of the infant. 8. Clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps. 9. Record APGAR scores at 1 and 5 minutes. 10. Follow the Newly Born Protocol for further treatment. 11. The placenta will deliver spontaneously, usually within 5 minutes of the infant. Do not force the placenta to deliver. 12. Massaging the uterus may facilitate delivery of the placenta and decrease bleeding by facilitating uterine contractions. 13. Continue rapid transport to the hospital.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 31 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) CNS Catheter: Epidural Catheter Maintenancee Clinical Indications: P EMT- P P x Presence of an epidural catheter in a patient requiring transport

Procedure:

1. Prior to transport, ensure catheter is secure and that transport personnel are familiar with medication(s) being delivered and devices used to control medication administration. 2. No adjustments in catheter position are to be attempted. 3. No adjustments in medication dosage or administration are to be attempted without direct approval from on-line medical control. 4. Report any complications immediately to on-line medical control. 5. Document the time and dose of any medication administration or rate adjustment in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 32 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) CNS Catheter: Ventricular Catheter Maintenance

Clinical Indications: P EMT- P P

x Transport of a patient with an intra-ventricular catheter in place

Procedure:

1. Prior to transport, ensure the catheter is secure. 2. Prior to transport, determine from the referring hospital/physician the desired patient position (e.g., supine, head of bed elevated 30 degrees, etc.). 3. Prior to transport, determine the height at which the drain is to be maintained, given the patient position desired from #2 above (if applicable). 4. Do not manipulate or move the drain. 5. If the patient or height of the drain is altered, immediately correct based on the pre-determined configuration in step 2 and 3 above. 6. Report any problems immediately to on-line medical control. 7. Document the time and any adjustments or problems in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 33 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Decontamination

MR B EMT B I EMT- I I Clinical Indications: P EMT- P P x Any patient who may have been exposed to significant hazardous materials, including chemical, biological, or radiological weapons.

Procedure: 1. In coordination with HazMAT and other Emergency Management personnel, establish hot, warm and cold zones of operation. 2. Ensure that personnel assigned to operate within each zone have proper personal protective equipment. 3. In coordination with other public safety personnel, assure each patient from the hot zone undergoes appropriate initial decontamination. This is specific to each incident; such decontamination may include: • Removal of patients from Hot Zone • Simple removal of clothing • Irrigation of eyes • Passage through high-volume water bath (e.g., between two fire apparatus) for patients contaminated with liquids or certain solids. Patients exposed to gases, vapors, and powders often will not require this step as it may unnecessarily delay treatment and/or increase dermal absorption of the agent(s). 4. Initial triage of patients should occur after step #3. Immediate life threats should be addressed prior to technical decontamination. 5. Assist patients with technical decontamination (unless contraindicated based on #3 above). This may include removal of all clothing and gentle cleansing with soap and water. All body areas should be thoroughly cleansed, although overly harsh scrubbing which could break the skin should be avoided. 6. Place triage identification on each patient. Match triage information with each patient’s personal belongings which were removed during technical decontamination. Preserve these personnel affects for law enforcement. 7. Monitor all patients for environmental illness. 8. Transport patients per local protocol.

Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 34 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Defibrillation: Automated Clinical Indications: MR x Patients in cardiac arrest (pulseless, non-breathing). B EMT B x Age < 8 years, use Pediatric Pads if available. I EMT- I I P EMT- P P Contraindication:

x Pediatric patients who are so small that the pads cannot be placed without touching one another.

Procedure:

1. If multiple rescuers available, one rescuer should provide uninterrupted chest compressions while the AED is being prepared for use. 2. Apply defibrillator pads per manufacturer recommendations. Based on 2010 guidelines, place pads preferably in AP or AL position when implanted devices (pacemakers, AICDs) occupy preferred pad positions and attempt to avoid placing directly over device. 3. Remove any medication patches on the chest and wipe off any residue. 4. If necessary, connect defibrillator leads: white to the anterior chest pad and the red to the posterior pad. 5. Activate AED for analysis of rhythm. 6. Stop CPR and clear the patient for rhythm analysis. Keep interruption in CPR as brief as possible. 7. Defibrillate if appropriate by depressing the “shock” button. Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. The sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic defibrillators will determine the correct joules accordingly. 8. Begin CPR (chest compressions and ventilations) immediately after the delivery of the defibrillation. 9. After 2 minutes of CPR, analyze rhythm and defibrillate if indicated. Repeat this step every 2 minutes. 10. If “no shock advised” appears, perform CPR for two minutes and then reanalyze. 11. Transport and continue treatment as indicated. 12. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation. 13. If pulse returns please use the Post Resuscitation Protocol

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 35 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Defibrillation: Manual

P EMT- P P Clinical Indications:

x Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia

Procedure:

1. Ensure that Chest Compressions are adequate and interrupted only when absolutely necessary. 2. Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation. 3. After application of an appropriate conductive agent if needed, apply defibrillation hands free pads (recommended to allow more continuous CPR) or paddles to the patient’s chest in the proper position x Paddles: right of sternum at 2nd ICS and anterior axillary line at 5th ICS x Pads: anterior-posterior position For patients with implanted pacers/defibrillators, paddles or pads can be in AP or AL positions. The presence of implanted pacers/defibrillators should not delay defibrillation. Attempt to avoid placing paddles or pads directly above device. 4. Set the appropriate energy level 5. Charge the defibrillator to the selected energy level. Continue chest compressions while the defibrillator is charging. 6. If using paddles, assure proper contact by applying 25 pounds of pressure on each paddle. 7. Hold Compressions, assertively state, “CLEAR” and visualize that no one, including yourself, is in contact with the patient. 8. Deliver the countershock by depressing the discharge button(s) when using paddles, or depress the shock button for hands free operation. 9. Immediately resume chest compressions and ventilations for 2 minutes. After 2 minutes of CPR, analyze rhythm and check for pulse only if appropriate for rhythm. 10. Repeat the procedure every two minutes as indicated by patient response and ECG rhythm. 11. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 36 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Gastric Tube Insertion

Clinical Indications: P EMT- P P

x Gastric decompression in intubated patients or for administration of activated charcoal in patients with altered mental status.

Procedure:

1. Estimate insertion length by superimposing the tube over the body from the nose to the stomach. 2. Flex the neck if not contraindicated to facilitate esophageal passage. 3. Liberally lubricate the distal end of the tube and pass through the patient’s nostril along the floor of the nasal passage. Do not orient the tip upward into the turbinates. This increases the difficulty of the insertion and may cause bleeding. 4. In the setting of an intubated patient or a patient with facial trauma, oral insertion of the tube may be considered or preferred after securing airway. 5. Continue to advance the tube gently until the appropriate distance is reached. 6. Confirm placement by injecting 20cc of air and auscultate for the swish or bubbling of the air over the stomach. Additionally, aspirate gastric contents to confirm proper placement. 7. Secure the tube. 8. Decompress the stomach of air and food either by connecting the tube to suction or manually aspirating with the large catheter tip syringe. 9. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 37 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Injections: Subcutaneous and Intramuscular

I EMT- I I Clinical Indications: P EMT- P P

x When medication administration is necessary and the medication must be given via the SQ (not auto-injector) or IM route or as an alternative route in selected medications.

Procedure:

1. Receive and confirm medication order or perform according to standing orders. 2. Prepare equipment and medication expelling air from the syringe. 3. Explain the procedure to the patient and reconfirm patient allergies. 4. The most common site for subcutaneous injection is the arm. x Injection volume should not exceed 1 cc. 5. The possible injection sites for intramuscular injections include the arm, buttock and thigh. x Injection volume should not exceed 1 cc for the arm x Injection volume should not exceed 2 cc in the thigh or buttock. 6. The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc. 7. Expose the selected area and cleanse the injection site with alcohol. 8. Insert the needle into the skin with a smooth, steady motion SQ: 45-degree angle IM: 90-degree angle skin pinched skin flattened 9. Aspirate for blood 10. Inject the medication. 11. Withdraw the needle quickly and dispose of properly without recapping. 12. Apply pressure to the site. 13. Monitor the patient for the desired therapeutic effects as well as any possible side effects. 14. Document the medication, dose, route, and time on/with the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 38 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Orthostatic Blood Pressure Measurement

MR B EMT B Clinical Indications: I EMT- I I P EMT- P P

x Patient situations with suspected blood, fluid loss, or dehydration with no indication for spinal immobilization. Orthostatic vital signs are not routinely recommended. x Patients > 8 years of age, or patients larger than the Broselow-Luten tape x Orthostatic Vital Signs are not sensitive nor specific for volume loss / dehydration and may induce syncope in some cases. Assessment of orthostatic vital signs are not routinely recommended. Local Medical Director should indicate and educate on situations where they may be helpful.

Procedure:

1. Gather and prepare standard sphygmomanometer and stethoscope. 2. With the patient supine, obtain pulse and blood pressure. 3. Have the patient sit upright. 4. After 30 seconds, obtain blood pressure and pulse. 5. If the systolic blood pressure falls more than 30 mmHg or the pulse rises more than 20 bpm, the patient is considered to be orthostatic. 6. If a patient experiences dizziness upon sitting or is obviously dehydrated based on history or physical exam, formal orthostatic examination should be omitted and fluid resuscitation initiated.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 39 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Pulse Oximetry Clinical Indications: MR x Patients with suspected hypoxemia. B EMT B I EMT- I I Procedure: P EMT- P P

1. Apply probe to patient’s finger or any other digit as recommended by the device manufacturer. 2. Allow machine to register saturation level. 3. Record time and initial saturation percent on room air if possible on/with the patient care report (PCR). 4. Verify pulse rate on machine with actual pulse of the patient. 5. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary. 6. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia. 7. In general, normal saturation is 97-99%. Below 94%, suspect a respiratory compromise. 8. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 9. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain. Supplemental oxygen is not required if the oxyhemoglobin saturation is >= 94%, unless there are obvious signs of heart failure, dyspneic, or hypoxic to maintain to 94%. 10. Factors which may reduce the reliability of the pulse oximetry reading include but are not limited to: x Poor peripheral circulation (blood volume, hypotension, hypothermia) x Excessive pulse oximeter sensor motion x Fingernail polish (may be removed with acetone pad) x Carbon monoxide bound to hemoglobin x Irregular heart rhythms (atrial fibrillation, SVT, etc.) x Jaundice x Placement of BP cuff on same extremity as pulse ox probe.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 40 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Reperfusion Checklist Clinical Indications: Rapid evaluation of a patient with suspected acute stroke and/or MR acute myocardial infarction (STEMI) to: B EMT B x Determine eligibility and potential benefit from fibrinolysis.. I EMT- I I x Rapid identification of patients who are not eligible for P EMT- P P fibrinolysis and will require interventional therapy.

Procedure: 1. Follow the appropriate protocol for the patient’s complaint to assess and identify an acute condition which could potentially benefit from fibrinolysis. If a positive finding is noted on one of the following assessments, proceed to step 2. x Perform a 12-lead ECG to identify an acute ST elevation myocardial infarction (STEMI). x Perform the Los Angles Pre-hospital Stroke Screen to identify an acute stroke 2. Complete the Reperfusion Check Sheet to identify any potential contraindications to fibrinolysis. (See Appendix) x Systolic Blood Pressure greater than 180 mm Hg x Diastolic Blood Pressure greater than 110 mm Hg x Right vs. Left Arm Systolic Blood Pressure difference of greater than 15 mm Hg x History of structural Central Nervous System disease (age >= 18, history of aneurysm or AV-malformation, tumors, masses, hemorrhage, etc.) x Significant closed head or facial trauma within the previous 3 months x Recent (within 6 weeks) major trauma, surgery (including laser eye surgery), gastrointestinal bleeding, or severe genital-urinary bleeding x Bleeding or clotting problem or on blood thinners x CPR performed greater than 10 minutes x Currently Pregnant x Serious Systemic Disease such as advanced/terminal cancer or severe liver or kidney failure. 3. Identify if the patient is currently in heart failure or cardiogenic shock. For these patients, a percutaneous coronary intervention is more effective. x Presence of pulmonary edema (rales greater than halfway up lung fields) x Systemic hypoperfusion (cool and clammy) 4. If any contraindication is noted using the check list and an acute Stroke is suspected by exam or a STEMI is confirmed by ECG, activate the EMS Stroke Plan or EMS STEMI Plan for fibrinolytic ineligable patients. This may require the EMS Agency, an Air Medical Service, or a Specialty Care Transport Service to transport directly to an specialty center capable of interventional care within the therapeutic window of time. 5. Record all findings in the Patient Care Report (PCR). Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 41 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Restraints: Physical

B EMT B I EMT- I I Clinical Indications: P EMT- P P x Any patient who may harm himself, herself, or others may be gently restrained to prevent injury to the patient or crew. This restraint must be in a humane manner and used only as a last resort. Other means to prevent injury to the patient or crew must be attempted first. These efforts could include reality orientation, distraction techniques, or other less restrictive therapeutic means. Physical or chemical restraint should be a last resort technique.

Procedure:

1. Attempt less restrictive means of managing the patient. 2. Request law enforcement assistance and Contact Medical Control. 3. Ensure that there are sufficient personnel available to physically restrain the patient safely. 4. Restrain the patient in a lateral or supine position. No devices such as backboards, splints, or other devices will be on top of the patient. The patient will never be restrained in the prone position. 5. The patient must be under constant observation by the EMS crew at all times. This includes direct visualization of the patient as well as cardiac and pulse oximetry monitoring. 6. The extremities that are restrained will have a circulation check at least every 15 minutes. The first of these checks should occur as soon after placement of the restraints as possible. This MUST be documented on the PCR. 7. Documentation on/with the patient care report (PCR) should include the reason for the use of restraints, the type of restraints used, and the time restraints were placed. Use of the Restraint Checklist is highly recommended. 8. If the above actions are unsuccessful, or if the patient is resisting the restraints, consider administering medications per protocol. (Chemical restraint may be considered earlier.) 9. If a patient is restrained by law enforcement personnel with handcuffs or other devices EMS personnel can not remove, a law enforcement officer must accompany the patient to the hospital in the transporting EMS vehicle.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 42 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Spinal Immobilization Clinical Indications: MR x Need for spinal immobilization as determined by protocol B EMT B I EMT- I I Procedure: P EMT- P P

1. Gather a backboard, straps, C-collar appropriate for patient’s size, tape, and head rolls or similar device to secure the head. 2. Explain the procedure to the patient 3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine. This stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applied the collar. 4. Once the collar is secure, the second rescuer should still maintain their position to ensure stabilization (the collar is helpful but will not do the job by itself.) 5. Place the patient on a long spine board with the log-roll technique if the patient is supine or prone. For the patient in a vehicle or otherwise unable to be placed prone or supine, place them on a backboard by the safest method available that allows maintenance of in-line spinal stability. 6. Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization. 7. NOTE: Some patients, due to size or age, will not be able to be immobilized through in-line stabilization with standard backboards and C-collars. Never force a patient into a non-neutral position to immobilize them. Such situations may require a second rescuer to maintain manual stabilization throughout the transport to the hospital. Special equipment such as football players in full pads and helmet may remain immobilized with helmet and pads in place. 8. Document the time of the procedure in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 43 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Splinting

MR B EMT B Clinical Indications: I EMT- I I P EMT- P P x Immobilization of an extremity for transport, either due to suspected fracture, sprain, or injury. x Immobilization of an extremity for transport to secure medically necessary devices such as intravenous catheters

Procedure:

1. Assess and document pulses, sensation, and motor function prior to placement of the splint. If no pulses are present and a fracture is suspected, consider reduction of the fracture prior to placement of the splint. 2. Remove all clothing from the extremity. 3. Select a site to secure the splint both proximal and distal to the area of suspected injury, or the area where the medical device will be placed. 4. Do not secure the splint directly over the injury or device. 5. Place the splint and secure with Velcro, straps, or bandage material (e.g., kling, kerlex, cloth bandage, etc.) depending on the splint manufacturer and design. 6. Document pulses, sensation, and motor function after placement of the splint. If there has been a deterioration in any of these 3 parameters, remove the splint and reassess 7. If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, the following procedure may be followed for placement of a femoral traction splint: x Assess neurovascular function as in #1 above. x Place the ankle device over the ankle. x Place the proximal end of the traction splint on the posterior side of the affected extremity, being careful to avoid placing too much pressure on genitalia or open wounds. Make certain the splint extends proximal to the suspected fracture. If the splint will not extend in such a manner, reassess possible involvement of the pelvis x Extend the distal end of the splint at least 6 inches beyond the foot. x Attach the ankle device to the traction crank. x Twist until moderate resistance is met. x Reassess alignment, pulses, sensation, and motor function. If there has been deterioration in any of these 3 parameters, release traction and reassess. 8. Document the time, type of splint, and the pre and post assessment of pulse, sensation, and motor function in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 44 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Stroke Screen: LA Prehospital Clinical Indications: MR x Suspected Stroke Patient B EMT B I EMT- I I Procedure: P EMT- P P 1. Assess and treat suspected stroke patients as per protocol. 2. The Los Angeles Prehospital Stroke Screen (LAPSS) form should be completed for all suspected stroke patients (see appendix). There are six screening criteria items on the LAPSS form. 3. Screen the patient for the following criteria: x Age over 45 years x No history of a seizure disorder x New onset of symptoms in last 24 hours x Patient ambulatory prior to event x Blood glucose between 60-400 4. The final criterion consists of performing a patient exam looking for facial droop, unilateral grip weakness/absence, or unilateral arm weakness. One of these exam components must be positive to answer “yes” on the screening form. 5. If all of the LAPSS screening criteria are met (“yes” to all criteria OR if unknown), follow the EMS System Stroke Plan and alert the receiving hospital of a possible stroke patient as early as possible. 6. All sections of the LAPSS form must be completed. 7. The completed LAPSS form should be attached or documented in the PCR.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 45 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Temperature Measurement

MR B EMT B Clinical Indications: I EMT- I I P EMT- P P

x Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to assist in evaluating resuscitation efforts.

Procedure:

1. For adult patients that are conscious, cooperative, and in no respiratory distress, an oral temperature is preferred (steps 3 to 5 below). For infants or adults that do not meet the criteria above, a rectal temperature is preferred (steps 6 to 8 below). 2. To obtain an oral temperature, ensure the patient has no significant oral trauma and place the thermometer under the patient’s tongue with appropriate sterile covering. 3. Have the patient seal their mouth closed around thermometer. 4. If using an electric thermometer, leave the device in place until there is indication an accurate temperature has been recorded (per the “beep” or other indicator specific to the device). If using a traditional thermometer, leave it in place until there is no change in the reading for at least 30 seconds (usually 2 to 3 minutes). Proceed to step 9. 5. Prior to obtaining a rectal temperature, assess whether the patient has suffered any rectal trauma by history and/or brief examination as appropriate for patient’s complaint. 6. To obtain a rectal temperature, cover the thermometer with an appropriate sterile cover, apply lubricant, and insert into rectum no more than 1 to 2 cm beyond the external anal sphincter. 7. Follow guidelines in step 5 above to obtain temperature. 8. Record time, temperature, method (oral, rectal), and scale (C° or F°) in Patient Care Report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 46 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Urinary Catheterization Clinical Indications: P EMT- P P x Monitoring a patient’s fluid status and/or response to therapy during transport. x Collection of urine for laboratory analysis. x Patients with medical (but NOT TRAUMA) complaints over the age of 16.

Procedure:

1. Explain the procedure to the patient. Maximize patient privacy. Have a second crewmember or other chaperone if performing the procedure on a member of the opposite sex. 2. If there is any question of traumatic injury in the Genitourinary (GU) region, do not perform this procedure. 3. Open the catheter kit. Test the balloon at the catheter tip. Connect the catheter to the urine collection system. Maintain the sterility of contents. 4. Use sterile gloves from the kit. Use one hand to come in contact with the patient and the other to use items from the kit. Recall that once your hand touches the patient, it is no longer sterile and cannot be used to obtain items from the kit. 5. Using the Betadine swabs from the kit, thoroughly cleanse the area surrounding the urethra. For males, this will require retracting the foreskin for uncircumcised males and cleansing of the glans for all males. For females, this will require retraction of the labia majora and cleansing of the area around the urethra. 6. Once the patient has been prepped with Betadine, place sterile sheet(s). 7. Lubricate the tip of the catheter. 8. Gently guide the catheter through the external opening of the urethra. Advance the catheter slowly until there is return of urine. Do not force the catheter through resistance. If resistance is encountered, withdraw the catheter slightly and gently re-direct the catheter. 9. Once urine is returned, gently inflate the balloon and secure the urine collection device. 10. Record procedure and amount of urine returned in the Patient Care Report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 47 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Blood Draw Clinical Indications: I EMT- I I x Collection of a patient’s blood for laboratory analysis P EMT- P P

Procedure:

1. Utilize universal precautions as per OSHA. 2. Select vein and prep as usual. 3. Select appropriate blood-drawing devices. 4. Draw appropriate tubes of blood for lab testing. 5. Assure that the blood samples are labeled with the correct information (a minimum of the patients name, along with the date and time the sample was collected). 6. Deliver the blood tubes to the appropriate individual at the hospital.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 48 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Central Line Maintenance Clinical Indications: P EMT- P P x Transport of a patient with a central venous pressure line already in place

Procedure:

1. Prior to transportation, ensure the line is secure. 2. Medications and IV fluids may be administered through a central venous pressure line. Such infusions must be held while the central venous pressure is transduced to obtain a central venous pressure, but may be restarted afterwards. 3. Do not manipulate the central venous catheter. 4. If the central venous catheter becomes dysfunctional, does not allow drug administration, or becomes dislodged, contact medical control. 5. Document the time of any pressure measurements, the pressure obtained, and any medication administration in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 49 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Existing Catheters Clinical Indications: P EMT- P P x Inability to obtain adequate peripheral access. x Access of an existing venous catheter for medication or fluid administration. x Central venous access in a patient in cardiac arrest.

Procedure:

1. Clean the port of the catheter with alcohol wipe. 2. Using sterile technique, withdraw 5-10 ml of blood and discard syringe in sharps container. 3. Using 5cc of normal saline, access the port with sterile technique and gently attempt to flush the saline. 4. If there is no resistance, no evidence of infiltration (e.g., no subcutaneous collection of fluid), and no pain experienced by the patient, then proceed to step 4. If there is resistance, evidence of infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or dislodged, do not use the catheter. 5. Begin administration of medications or IV fluids slowly and observe for any signs of infiltration. If difficulties are encountered, stop the infusion and reassess. 6. Record procedure, any complications, and fluids/medications administered in the Patient Care Report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 50 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: External Jugular Access

I EMT- I I Clinical Indications: P EMT- P P

x External jugular vein cannulation is indicated in a critically ill patient > 8 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein is not obtainable. x External jugular cannulation can be attempted initially in life threatening events where no obvious peripheral site is noted.

Procedure:

1. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism. 2. Turn the patient’s head toward the opposite side if no risk of cervical injury exists. 3. Prep the site as per peripheral IV site. 4. Align the catheter with the vein and aim toward the same side shoulder. 5. “Tourniqueting” the vein lightly with one finger above the clavicle, puncture the vein midway between the angle of the jaw and the clavicle and cannulate the vein in the usual method. 6. Attach the IV and secure the catheter avoiding circumferential dressing or taping. 7. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 51 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Extremity Clinical Indications: I EMT- I I x Any patient where intravenous access is indicated (significant P EMT- P P trauma, emergent or potentially emergent medical condition). Procedure: 1. Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS professional. 2. Paramedics can use intraosseous access where threat to life exists as provided for in the Venous Access-Intraosseous procedure. 3. Use the largest catheter bore necessary based upon the patient’s condition and size of veins. 4. Fluid and setup choice is preferably: • Lactated Ringers with a macro drip (10 gtt/cc) for burns • Normal Saline with a macro drip (10 gtt/cc) for medical conditions, trauma or hypotension • Normal Saline with a micro drip (60 gtt/cc) for medication infusions 5. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles. 6. Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line. 7. Place a tourniquet around the patient’s extremity to restrict venous flow only. 8. Select a vein and an appropriate gauge catheter for the vein and the patient’s condition. 9. Prep the skin with an antiseptic solution. 10. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in the catheter. 11. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper container without recapping. 12. Draw blood samples when appropriate. 13. Remove the tourniquet and connect the IV tubing or saline lock. 14. Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated. Rates are preferably: • Adult: KVO: 60 cc/hr (1 gtt/ 6 sec for a macro drip set) • Pediatric: KVO: 30 cc/hr (1 gtt/ 12 sec for a macro drip set) If shock is present: • Adult: 500 cc fluid boluses repeated as long as lungs are dry and BP < 90. Consider a second IV line. • Pediatric: 20 cc/kg blouses repeated PRN for poor perfusion. 15. Cover the site with a sterile dressing and secure the IV and tubing. 16. Label the IV with date and time, catheter gauge, and name/ID of the person starting the IV. 17. Document the procedure, time and result (success) on/with the patient care report (PCR). Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Revised Procedure 52 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Femoral Line – Page 1 of 2

P EMT- P P Clinical Indications:

x Central venous access in a patient with an urgent need for fluid or medication administration. x Inability to obtain adequate peripheral access. x Patient aged greater than 16 years. x No evidence of pelvic trauma. x No evidence of trauma in the extremity in which the catheter is to be placed.

Procedure:

1. Obtain central access kit with 6.0 to 8.0 French cordis and equipment to place catheter by Selinger technique. 2. Completely expose the groin area on the side where the catheter is to be placed. 3. Palpate the femoral pulse in the inguinal crease. Recall that the inguinal ligament connects the pubic symphysis with the anterior, superior iliac spine and that all attempts at access should be made inferior to this ligament to avoid inadvertent entry into the abdominal cavity. 4. Once the femoral pulse has been palpated distal to the ilio-inguinal ligament, prep a large area of the skin with Betadine. 5. Use sterile gloves and place sterile drapes around the Betadine-prepped field. 6. With one hand, palpate the femoral pulse. The femoral vein will be located medially when compared with the femoral artery. 7. With the introducing needle from the kit, enter the skin over the anticipated position of the femoral vein. Gently aspirate as the needle is advanced. Angle the needle approximately 45 to 60 degrees in reference to the skin on the thigh. 8. Once non-pulsatile, venous blood is obtained, stop advancing the needle and hold the needle in position. Remove the syringe and observe the hub for pulsatile flow. If the blood appears arterial and/or is pulsatile, immediately remove the needle and apply direct pressure over the site. Once bleeding is controlled, return to step 7 above or consider the other extremity, if there are no contraindications. 9. If the needle appears to be in the femoral vein, insert the guide wire with sterile technique. Stop advancing the wire if there is any resistance; you may gently withdraw the wire and attempt re-insertion so long as sterility is maintained. 10. Stop advancing the wire in order to leave approximately 10 cm of the wire external to the hub of the needle. 11. DO NOT LET GO OF THE WIRE. 12. Holding the wire in the distal hand, remove the needle over the wire. Once the needle reaches the end of the wire, use the proximal hand to control the wire and the distal hand to remove the needle from the wire. 13. Use the scalpel to create a small incision in the skin at the base of the wire. Make certain the incision extends completely to the wire so there is no skin tag.

CONTINUED VENOUS ACCESS: FEMORAL LINE - PAGE 2

Revised Procedure 53 (Page 1 of 2) 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Femoral Line – Page 2 of 2

14. Place the catheter over the wire; use the wire a guide to place the catheter. Some 15. Gentle force may be required as the catheter enters the skin; this should not, however, require excessive force. Again, one hand should always maintain control of the wire. 16. Once the catheter is completely inserted, remove the wire. 17. Attach a syringe to the port of the catheter, release the clamp, and aspirate for blood. There should be an easy flow of venous blood. 18. Once all of the air has been removed from the catheter by aspirating blood, re-clamp the line. 19. Attach the desired IV fluid/blood/etc and begin infusion. Note that “wide-open” lines will deliver large amounts of fluid quickly – monitor the patient’s fluid status closely. 20. Secure the catheter with sterile dressing or sutures. 21. Document procedure, complications, and clinical results in the patient care report (PCR)

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 53 (Page 2 of 2) 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Intraosseous

P EMT- P P Clinical Indications: x Patients where rapid, regular IV access is unavailable with any of the following: x Cardiac arrest. x Multisystem trauma with severe hypovolemia. x Severe dehydration with vascular collapse and/or loss of consciousness. x Respiratory failure / Respiratory arrest. x Burns. Contraindications: x Fracture proximal to proposed intraosseous site. x History of Osteogenesis Imperfecta x Current or prior infection at proposed intraosseous site. x Previous intraosseous insertion or joint replacement at the selected site. Procedure: 1. Don personal protective equipment (gloves, eye protection, etc.). 2. Identify anteromedial aspect of the proximal tibia (bony prominence below the knee cap). The insertion location will be 1-2 cm (2 finger widths) below this. If this site is not suitable, and patient >12 years of age, identify the anteriormedial aspect of the distal tibia (2 cm proximal to the medial malleolus). Proximal humerus is also an acceptable insertion site: for patients > 40 Kg, lateral aspect of the humerus, 2 cm distal to the greater tuberosity. 3. Prep the site recommended by the device manufacturer with providone-iodine ointment or solution. 4. For manual pediatric devices, hold the intraosseous needle at a 60 to 90 degree angle, aimed away from the nearby joint and epiphyseal plate, twist the needle handle with a rotating grinding motion applying controlled downward force until a “pop” or “give” is felt indicating loss of resistance. Do not advance the needle any further. 5. For the EZ-IO intraosseous device, hold the intraosseous needle at a 60 to 90 degree angle, aimed away from the nearby joint and epiphyseal plate, power the driver until a “pop” or “give” is felt indicating loss of resistance. Do not advance the needle any further. Utilize the yellow needle for the proximal humerus. The pink needle is only intended for use in neonatal patients. 6. For the Bone Injection Gun (BIG), find and mark the manufacturers recommended site. Position the device and pull out the safety latch. Trigger the BIG at 90° to the surface and remove the injection device. 7. Remove the stylette and place in an approved sharps container. 8. Attach a syringe filled with at least 5 cc NS; aspirate bone marrow for manual devices only, to verify placement; then inject at least 5 cc of NS to clear the lumen of the needle. 9. Attach the IV line and adjust flow rate. A pressure bag may assist with achieving desired flows. 10. Stabilize and secure the needle with dressings and tape. 11. You may administer 10 to 20 mg (1 to 2 cc) of 2% Lidocaine in adult patients who experience infusion-related pain. This may be repeated prn to a maximum of 60 mg (6 cc). 12. Following the administration of any IO medications, flush the IO line with 10 cc of IV fluid. 13. Document the procedure, time, and result (success) on/with the patient care report (PCR). Certification Requirements: x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle.

Revised Procedure 54 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Venous Access: Swan-Ganz Catheter Maintenance

Clinical Indications: P EMT- P P

x Transport of a patient with a Swan-Ganz catheter that is in place prior to transport.

Procedure:

1. Make certain catheter is secure prior to transport. 2. Under the supervision of the nurse or physician caring for the patient, make certain the transport personnel are aware of the depth at which the catheter is secured. 3. UNDER NO CIRCUMSTANCES SHOULD TRANSPORT PERSONNEL ADVANCE THE SWAN-GANZ CATHETER. 4. The sterile plastic sheath that surrounds the catheter should not be manipulated. 5. The ports of the catheter may be used to continue administration of medications or IV fluids that were initiated prior to transport. These should be used as any other IV port with attention to sterile technique. 6. If applicable, measurements from the catheter may be obtained during transport and used to guide care as per local protocols and medical control orders. 7. If at anytime during the transport difficulties with the function of the Swan-Ganz catheter is noted, contact medical control. 8. Document the time and any adjustments or problems associated with the catheter in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 55 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Wound Care-General Clinical Indications: MR x Protection and care for open wounds prior to and during transport. B EMT B I EMT- I I P EMT- P P Procedure:

1. Use personal protective equipment, including gloves, gown, and mask as indicated. 2. If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on “compression” bandage to control bleeding. Direct pressure is much more effective. 3. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may have to be avoided if bleeding was difficult to control). Consider analgesia per protocol prior to irrigation. 4. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight. 5. Monitor wounds and/or dressings throughout transport for bleeding. 6. Document the wound and assessment and care in the patient care report (PCR).

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 56 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Wound Care-Hemostatic Agent Clinical Indications: MR x Serious hemorrhage that can not be controlled by other means. B EMT B I EMT- I I Contraindications: P EMT- P P

x Wounds involving open thoracic or abdominal cavities.

Procedure:

1. Apply approved non-heat-generating hemostatic agent per manufacturer’s instructions. 2. Supplement with direct pressure and standard hemorrhage control techniques. 3. Apply dressing.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 57 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Wound Care-Taser® Probe Removal

MR B EMT B I EMT- I I Clinical Indications: P EMT- P P

x Patient with uncomplicated conducted electrical weapon (Taser®) probes embedded subcutaneously in non-sensitive areas of skin. x Taser probes are barbed metal projectiles that may embed themselves up to 13 mm into the skin.

Contraindications:

x Patients with conducted electrical weapon (Taser®) probe penetration in vulnerable areas of body as mentioned below should be transported for further evaluation and probe removal x Probes embedded in skin above level of clavicles, female breasts, or genitalia x Suspicion that probe might be embedded in bone, blood vessel, or other sensitive structure.

Procedure:

x Ensure wires are disconnected from weapon. x Stabilize skin around probe using non-dominant hand. x Grasp probe by metal body with pliers or hemostats to prevent puncture wounds to EMS personnel. x Remove probe in single quick motion. x Wipe wound with antiseptic wipe and apply dressing.

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 58 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Procedure (Skill) Wound Care-Tourniquet

MR B EMT B I EMT- I I P EMT- P P

Clinical Indications: x Life threatening extremity hemorrhage that can not be controlled by other means. x Serious or life threatening extremity hemorrhage and tactical considerations prevent the use of standard hemorrhage control techniques.

Contraindications: x Non-extremity hemorrhage x Proximal extremity location where tourniquet application is not practical

Procedure: 1. Place tourniquet proximal to wound 2. Tighten per manufacturer instructions until hemorrhage stops and/or distal pulses in affected extremity disappear. 3. Secure tourniquet per manufacturer instructions 4. Note time of tourniquet application and communicate this to receiving care providers 5. Dress wounds per standard wound care protocol 6. If delayed or prolonged transport and tourniquet application time > 45 minutes: consider reattempting standard hemorrhage control techniques and removing tourniquet

Certification Requirements:

x Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

Revised Procedure 59 9/10/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 North Carolina College of Emergency Physicians Standards Policies

Policy 1. Air Transport 2. Child Abuse Recognition and Reporting 3. Children with Special Healthcare Needs ( NC Kidbase) 4. Criteria for Death or Withholding Resuscitation 5. Deceased Subjects 6. Discontinuation of Prehospital Resuscitation 7. Disposition (Patient Instructions) 8. DNR and MOST 9. Documentation and Data Quality 10. Documentation of Vital Signs 11. Domestic Violence (Partner and/or Elder Abuse) Recognition and Reporting 12. EMS Back in Service Time 13. EMS Dispatch Center Time 14. EMS Wheels Rolling Turn-Out Time 15. Infant Abandonment 16. Patient Without a Protocol 17. Physician on Scene 18. Poison Control 19. Safe Transport of Pediatric Patients 20. Transport 21. Rapid Sequence Induction 22. Corrections to the Patient Care Report

Policies Any local EMS System changes to this document must follow the NC OMES Protocol Change Policy and be approved by OEMS 2012 Rowan County Standards Policy Emergency Services

Policy:

Air transport should be utilized whenever patient care can be improved by decreasing transport time or by giving advanced care not available from ground EMS services, but available from air medical transport services (i.e. blood).

Purpose:

The purpose of this policy is to:

Improve patient care in the prehospital setting. Allow for expedient transport in serious, mass casualty settings. Provide life-saving treatment such as blood transfusion.

Procedure:

Patient transportation via ground ambulance will not be delayed to wait for helicopter transportation. If the patient is packaged and ready for transport and the helicopter is not on the ground, or within a reasonable distance, the transportation will be initiated by ground ambulance. Air medical services may be rerouted to a helipad located at or near a medical facility.

If the transport plan includes delivery of the patient to a helipad located at a qualified medical facility, it may be appropriate to bypass the Emergency Department. When bypassing the emergency Department, the following will apply: Notify the facility via radio of the “Bypass”. It is important to use the term “Bypass”. This will be the phrase that initiates the event for the facility. Provide a full encode to the facility as if the patient were being delivered to the Emergency Department. Update the Emergency Department to any changes in the patient condition. Be prepared to divert to the Emergency Department if conditions warrant. Follow facility specific guidelines outlined in this document. This policy may only be utilized at facilities with specific guidelines.

Air transport should be considered if any of the following criteria apply: High priority patient with > 20 minute transport time Entrapped patients with > 10 minute estimated extrication time Multiple casualty incident with red/yellow tag patients Multi-trauma or medical patient requiring life-saving treatment not available in prehospital environment (i.e., blood transfusion, invasive procedure, operative intervention)

When the need for air medical services is identified, a request should be made through Rowan Communications. Only EMT-P personnel can activate air medical resources. EMT-P personnel should be on the scene or in contact with individuals on the scene in order to make an informed decision on transport. It is not necessary to check the availability of flight services and this practice is to be avoided. Policy 1 (Page 1 of 2) This policy has been altered from the original 2009 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

If the scene conditions or patient situation improves after activation of the air medical transport service and air transport is determined not to be necessary, paramedic or administrative personnel may cancel the request for air transport.

Minimal Information which should be provided to the air medical transport service include: Number of patients Age of patients Sex of patients Mechanism of injury or complaint (MVC, fall, etc)

Facility Specific Guidelines

Rowan Regional Medical Center

Approach the Emergency Department in the same manner as a normal emergency response. Remove the patient from the EMS unit and stage inside the ED entrance between the Emergency Department and the elevator lobby. Remain in the staging area until the aircraft is on the helipad. Under no circumstances will an EMS crew wait in any area other than the staging area or Emergency Department. Proceed to the helipad when the aircraft is available. Do not wait for the flight crew to come to the patient. The flight crew should accept the patient on the helipad. Should the patient deteriorate or need additional stabilization prior to transport, the patient may be delivered to the Emergency Department. Upon delivery to the Emergency Department, care is transferred to the facility and all patient care decisions and documentation become the responsibility of Rowan Regional Medical Center.

CMC-Northeast

Approach the Emergency Department in the same manner as a normal emergency response. Stage the EMS unit in the area adjacent to the helipad entrance. Remain in the EMS unit until the aircraft is on the helipad. Under no circumstances will an EMS crew wait in any area other than the staging area or Emergency Department. Allow the flight crew to accept the patient in the EMS unit. Proceed to the helipad at the direction of the flight crew. Should the patient deteriorate or need additional stabilization prior to transport, the patient may be delivered to the Emergency Department. Upon delivery to the Emergency Department, care is transferred to the facility and all patient care decisions and documentation become the responsibility of CMC-Northeast.

Policy 1 (Page 2 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

Child abuse is the physical and mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare. The recognition of abuse and the proper reporting is a critical step to improving the safety of children and preventing child abuse.

Purpose: Assessment of a child abuse case based upon the following principles: Protect the life of the child from harm, as well as that of the EMS team from liability. Suspect that the child may be a victim of abuse, especially if the injury/illness is not consistent with the reported history. Respect the privacy of the child and family. Collect as much evidence as possible, especially information.

Procedure:

1. With all children, assess for and document psychological characteristics of abuse, including excessively passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, fussy behavior, hyperactivity, or other behavioral disorders

2. With all children, assess for and document physical signs of abuse, including especially any injuries that are inconsistent with the reported mechanism of injury.

3. With all children, assess for and document signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition.

4. Immediately report any suspicious findings to both the receiving hospital (if transported) and to agency responsible for Social Services in the county. After office hours, the child protective services worker on call can be contacted by the EMS System’s 911 communications center. While law enforcement may also be notified, North Carolina law requires the EMS provider to report the suspicion of abuse to DSS. EMS should not accuse or challenge the suspected abuser. This is a legal requirement to report, not an accusation. In the event of a child fatality, law enforcement must also be notified.

Policy 2 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy Child with Special Health Care Needs (NC Kidbase)

Policy:

Medical technology, changes in the healthcare industry, and increased home health capabilities have created a special population of patients that interface with the EMS system. It is important for EMS to understand and provide quality care to children with special health care needs.

Purpose:

The purpose of this policy is to:

Provide quality patient care and EMS services to children with special health care needs. Understand the need to communicate with the parents and caregivers regarding healthcare needs and devices that EMS may not have experience with. Promote, request, and use the “Kidbase” form, which catalogs the health care problems, needs, and issues of each child with a special healthcare need.

Procedure:

1. Caregivers who call 911 to report an emergency involving a child with special health care needs may report that the emergency involves a “Kidbase child” (if they are familiar with the NC Kidbase program) or may state that the situation involves a special needs child.

2. Responding EMS personnel should ask the caregiver of a special needs child for a copy of the “Kidbase Form”, which is the North Carolina terminology for the Emergency Information Form (EIF).

3. EMS personnel may choose to contact the child’s primary care physician for assistance with specific conditions or devices or for advice regarding appropriate treatment and/or transport of the child in the specific situation.

4. Transportation of the child, if necessary, will be made to the hospital appropriate for the specific condition of the child. In some cases this may involve bypassing the closest facility for a more distant yet more medically appropriate destination.

Policy 3 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy Criteria for Death / Withholding Resuscitation

Policy:

CPR and ALS treatment are to be withheld only if the patient is obviously dead or a valid North Carolina MOST and/or Do Not Resuscitate form (see separate policy) is present.

Purpose:

The purpose of this policy is to:

Honor those who have obviously expired prior to EMS arrival.

Procedure:

1. If a patient is in complete cardiopulmonary arrest (clinically dead) and meets one or more of the criteria below, CPR and ALS therapy need not be initiated:

Body decomposition Rigor mortis Dependent lividity Blunt force trauma Injury not compatible with life (i.e., decapitation, burned beyond recognition, massive open or penetrating trauma to the head or chest with obvious organ destruction) Extended downtime with Asystole on the ECG

2. If a bystander or first responder has initiated CPR or automated defibrillation prior to an EMS paramedic’s arrival and any of the above criteria (signs of obvious death) are present, the paramedic may discontinue CPR and ALS therapy. All other EMS personnel levels must communicate with medical control prior to discontinuation of the resuscitative efforts.

3. If doubt exists, start resuscitation immediately. Once resuscitation is initiated, continue resuscitation efforts until either: a) Resuscitation efforts meet the criteria for implementing the Discontinuation of Prehospital Resuscitation Policy (see separate policy) b) Patient care responsibilities are transferred to the destination hospital staff.

Policy 4 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

EMS will handle the disposition of deceased subjects in a uniform, professional, and timely manner.

Purpose:

The purpose of this policy is to:

Organize and provide for a timely disposition of any deceased subject Maintain respect for the deceased and family Allow EMS to return to service in a timely manner.

Procedure:

1. Do not remove lines or tubes from unsuccessful cardiac arrests/codes unless directed below.

2. Notify the law enforcement agency with jurisdiction if applicable.

3. If subject was found deceased by EMS, the scene is turned over to law enforcement.

4. If EMS has attempted to resuscitate the patient and then terminated the resuscitative efforts, the EMS personnel may assist law enforcement with contacting the family physician (medical cases) or medical examiner (traumatic cases or family physician unavailable) to provide information about the resuscitative efforts.

5. Transport arrangements should be made in concert with law enforcement and the family’s wishes.

6. If the deceased subject’s destination is other than the county morgue, any line(s) or tube(s) placed by EMS should be removed prior to transport.

7. Document the situation, name of Physician or Medical Examiner contacted, the agency providing transport of the deceased subject, and the destination on the patient care report form (PCR).

Policy 5 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy Discontinuation of Prehospital Resuscitation

Policy:

Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support (ALS) interventions may be discontinued prior to transport or arrival at the hospital when this procedure is followed.

Purpose:

The purpose of this policy is to:

Allow for discontinuation of prehospital resuscitation after the delivery of adequate and appropriate ALS therapy.

Procedure:

1. Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met:

Patient must be 18 years of age or older Adequate CPR has been administered Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal intubation, nasotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy IV or IO access has been achieved No evidence or suspicion of any of the following: -Drug/toxin overdose -Active internal bleeding -Hypothermia -Preceding trauma Rhythm appropriate medications and defibrillation have been administered according to local EMS Protocols for a total of 3 cycles of drug therapy without return of spontaneous circulation (palpable pulse) All EMS paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate

2. If all of the above criteria are not met and discontinuation of prehospital resuscitation is desired, contact Medical Control.

3. The Deceased Subjects Policy should be followed.

Document all patient care and interactions with the patient’s family, personal physician, medical examiner, law enforcement, and medical control in the EMS patient care report (PCR).

Policy 6 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy Disposition (Patient Instructions)

Policy:

All patient encounters responded to by EMS will result in the accurate and timely completion of:

The Patient Care Report (PCR) for all patients transported by EMS The Patient Disposition Form for all patients not transported by EMS

Purpose:

To provide for the documentation of:

The evaluation and care of the patient The patient’s refusal of the evaluation, treatment, and/or transportation The patient’s disposition instructions The patient’s EMS encounter to protect the local EMS system and its personnel from undue risk and liability.

Procedure:

1. All patient encounters, which result in some component of an evaluation, must have a Patient Care Report completed.

2. All patients who refuse any component of the evaluation or treatment, based on the complaint, must have a Disposition Form completed.

3. All patients who are NOT transported by EMS must have a Disposition (patient instruction) Form completed including the Patient Instruction Section.

4. A copy of the Patient Disposition Form should be maintained with the official Patient Care Report (PCR)

Policy 7 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy North Carolina Do Not Resuscitate and MOST Form

Policy:

Any patient presenting to any component of the EMS system with a completed North Carolina Do Not Resuscitate (DNR) form (yellow form) and/or MOST (Medical Orders for Scope of Treatment) form (bright pink form) shall have the form honored. Treatment will be limited as documented on the DNR or MOST form.

Purpose:

To honor the terminal wishes of the patient To prevent the initiation of unwanted resuscitation

Procedure:

1. When confronted with a patient or situation involving the NC DNR and/or MOST form(s), the following form content must be verified before honoring the form(s) request.

The form(s) must be an original North Carolina DNR form (yellow form - not a copy) and/or North Carolina MOST form (bright pink – not a copy) The effective date and expiration date must be completed and current The DNR and/or MOST Form must be signed by a physician, physician’s assistant, or nurse practitioner.

2. A valid DNR or MOST form may be overridden by the request of:

The patient The guardian of the patient An on-scene physician

If the patient or anyone associated with the patient requests that a NC DNR and/or MOST form not be honored, EMS personnel should contact Medical Control to obtain assistance and direction

3. A living will or other legal document that identifies the patient’s desire to withhold CPR or other medical care may be honored with the approval of Medical Control. This should be done when possible in consultation with the patient’s family and personal physician.

Policy 8 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

The complete EMS documentation associated with an EMS events service delivery and patient care shall be electronically recorded into a Patient Care Report (PCR) within 24 hours of the completion of the EMS event with an average EMS Data Score of 5 or less.

Definition: The EMS documentation of a Patient Care Report (PCR) is based on the appropriate and complete documentation of the EMS data elements as required and defined within the North Carolina College of Emergency Physician’s EMS Standards (www.NCCEP.org). Since each EMS event and/or patient scenario is unique, only the data elements relevant to that EMS event and/or patient scenario should be completed.

The EMS Data Score is calculated on each EMS PCR as it is electronically processed into the North Carolina PreHospital Medical Information System (PreMIS). Data Quality Scores are provided within PreMIS and EMS Toolkit Reports. The best possible score is a 0 (zero) and with each data quality error a point is added to the data quality score.

A complete Patient Care Report (PCR) must contain the following information (as it relates to each EMS event and/or patient):

Service delivery and Crew information regarding the EMS Agency’s response Dispatch information regarding the dispatch complaint, and EMD card number Patient care provided prior to EMS arrival Patient Assessment as required by each specific complaint based protocol Past medical history, medications, allergies, and DNR/MOST status Trauma and Cardiac Arrest information if relevant to the EMS event or patient All times related to the event All procedures and their associated time All medications administered with their associated time Disposition and/or transport information Communication with medical control Appropriate Signatures (written and/or electronic)

Purpose: The purpose of this policy is to:

Promote timely and complete EMS documentation. Promote quality documentation that can be used to evaluate and improve EMS service delivery, personnel performance, and patient care to the county’s citizens. Promote quality documentation that will decrease EMS legal and risk management liability. Provide a means for continuous evaluation to assure policy compliance.

Policy 9 (Page 1 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 North Carolina College of Emergency Physicians Standards Policy

Procedure: The following procedures shall be implemented to assure policy compliance: 1. The EMS Patient Care Report (PCR) shall be completed as soon as possible after the time of the patient encounter. Documentation should be completed prior to leaving the destination facility unless call demand dictates otherwise, in which case documentation must be completed prior to the end of the personnel’s shift.

2. A copy of the patient care report form SHOULD be provided to the receiving medical facility. If the final PCR is not available at the time the patient is left with the emergency department or other healthcare facility, an interim report such as the PreMIS Preliminary Report Form MUST be provided.

3. The PCR must be completed in the PreMIS System or electronically submitted to the PreMIS System within 24 hours of the EMS event or patient encounter’s completion. The EMS data quality feedback provided at the time of the electronic submission into PreMIS should be reviewed and when possible any identified errors will be corrected within each PCR. Each PCR may be electronically resubmitted to PreMIS as many times as needed.

4. The EMS Data Quality Scores for the EMS System, EMS Agency, and individual EMS personnel will be reviewed regularly within the EMS System Peer Review Committee.

Policy 9 (Page 2 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

Every patient encounter by EMS will be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component.

Purpose:

To insure:

Evaluation of every patient’s volume and cardiovascular status Documentation of a complete set of vital signs

Procedure:

1. An initial complete set of vital signs includes: Pulse rate Systolic AND diastolic blood pressure Respiratory rate Pain / severity (when appropriate to patient complaint) GCS for Injured Patients

2. When no ALS treatment is provided, palpated blood pressures are acceptable for REPEAT vital signs.

3. Based on patient condition and complaint, vital signs may also include:

Pulse Oximetry Temperature End Tidal CO2 (If Invasive Airway Procedure) Breath Sounds Level of Response

4. If the patient refuses this evaluation, the patient’s mental status and the reason for refusal of evaluation must be documented. A patient disposition form must also be completed.

5. Document situations that preclude the evaluation of a complete set of vital signs.

6. Record the time vital signs were obtained.

7. Any abnormal vital sign should be repeated and monitored closely.

Policy 10 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy Domestic Violence (Partner and/or Elder Abuse) Recognition and Reporting

Policy:

Domestic violence is physical, sexual, or psychological abuse and/or intimidation, which attempts to control another person in a current or former family, dating, or household relationship. The recognition, appropriate reporting, and referral of abuse is a critical step to improving patient safety, providing quality health care, and preventing further abuse.

Elder abuse is the physical and/or mental injury, sexual abuse, negligent treatment, or maltreatment of a senior citizen by another person. Abuse may be at the hand of a caregiver, spouse, neighbor, or adult child of the patient. The recognition of abuse and the proper reporting is a critical step to improve the health and wellbeing of senior citizens.

Purpose:

Assessment of an abuse case based upon the following principles: Protect the patient from harm, as well as protecting the EMS team from harm and liability. Suspect that the patient may be a victim of abuse, especially if the injury/illness is not consistent with the reported history. Respect the privacy of the patient and family. Collect as much information and evidence as possible and preserve physical evidence.

Procedure:

1. Assess the/all patient(s) for any psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, behavioral disorders, substance abuse, medical non-compliance, or repeated EMS requests. This is typically best done in private with the patient. 2. Assess the patient for any physical signs of abuse, especially any injuries that are inconsistent with the reported mechanism of injury. Defensive injuries (e.g. to forearms), and injuries during pregnancy are also suggestive of abuse. Injuries in different stages of healing may indicate repeated episodes of violence. 3. Assess all patients for signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition. 4. Immediately report any suspicious findings to both the receiving hospital (if transported). If an elder or disabled adult is involved, also contact the Department of Social Services (DSS) or equivalent in the county. After office hours, the adult social services worker on call can be contacted by the 911 communications center. 5. EMS personnel should attempt in private to provide the patient with the phone number of the local domestic violence program, or the National Hotline, 1-800-799-SAFE.

Policy 11 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy: All EMS Units transporting a patient to a medical facility shall transfer the care of the patient and complete all required operational tasks to be back in service for the next potential EMS event within 30 minutes of arrival to the medical facility, 90% of the time. Definition: The EMS Back in Service Time is defined as the time interval beginning with the time the transporting EMS Unit arrives at the medical facility destination and ending with the time the EMS Unit checks back in service and available for the next EMS event. Purpose: The purpose of this policy is to: Assure that the care of each EMS patient transported to a medical facility is transferred to the medical facility staff in a timely manner. Assure that the EMS unit is cleaned, disinfected, restocked, and available for the next EMS event in a timely manner. Assure that an interim or complete EMS patient care report (PCR) is completed and left with the receiving medical facility documenting, at a minimum, the evaluation and care provided by EMS for that patient (It is acceptable to leave the PreMIS Preliminary Report or equivalent if the final PCR cannot be completed before leaving the facility). Provide quality EMS service and patient care to the county’s citizens. Provide a means for continuous evaluation to assure policy compliance. Procedure: The following procedures shall be implemented to assure policy compliance: 1. The EMS Unit’s priority upon arrival at the medical facility will be to transfer the care of the patient to medical facility staff as soon as possible. 2. EMS personnel will provide a verbal patient report on to the receiving medical facility staff.

3. EMS personnel will provide an interim (PreMIS Preliminary Report or equivalent) or final Patient Care Report (PCR) to the receiving medical facility staff, prior to leaving the facility, that documents at a minimum the patient’s evaluation and care provided by EMS prior to arrival at the medical facility. A complete PCR should be completed as soon as possible but should not cause a delay in the EMS Back in Service Time. 4. The EMS Unit will be cleaned, disinfected, and restocked (if necessary) during the EMS Back in Service Time interval. 5. Any EMS Back in Service Time delay resulting in a prolonged EMS Back in Service Time will be documented in Patient Care Report (PCR) as an “EMS Turn-Around Delay” as required and defined in the North Carolina College of Emergency Physicians (NCCEP) EMS Dataset Standards Document. 6. All EMS Turn-Around Delays will be reviewed regularly within the EMS System Peer Review Committee. Policy 12 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

The EMS Dispatch Center Time will be less than 90 seconds, 90% of the time, for all events identified and classified as an emergent or hot (with lights and siren) response.

Definition: The EMS Dispatch Center Time is defined as the time interval beginning with the time the initial 911 phone call rings at the 911 Communications Center requesting emergency medical services and ending with the dispatch time of the EMS Unit responding to the event. Purpose: The purpose of this policy is to:

Provide the safest and most appropriate level of response to all EMS events within the EMS System. Provide a timely and reliable response for all EMS events within the EMS System. Provide quality EMS service and patient care to the county’s citizens. Provide a means for continuous evaluation to assure policy compliance.

Procedure: The following procedures shall be implemented to assure policy compliance: 1. A public calls into the 911 Communications Center requesting emergency medical assistance will never be required to speak with more than two persons before a formal EMS Unit is dispatched.

2. In EMS Dispatch Centers where Emergency Medical Dispatch (EMD) has been implemented, EMS Units will be dispatched by EMD certified personnel in accordance with the standards developed by the Medical Director and the Emergency Medical Dispatch Protocols.

3. EMS Units will be dispatched hot (with lights and sirens) or cold (no lights and sirens) by the 911 Call Center based on predetermined criteria. If First Responders are dispatched as a component of the EMS response, they should typically be dispatched hot (with lights and sirens).

4. Without question, exception, or hesitation, EMS Units will respond as dispatched (hot or cold). This includes both requests to respond on active calls and requests to “move-up” to cover areas of the System that have limited EMS resources available.

5. EMS Units may, at their discretion, request for a First Responder on Non-First Responder calls in situations where additional resources are required such as manpower, extreme response time of the EMS Unit, need for forcible entry, etc.

Policy 13 (Page 1 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 North Carolina College of Emergency Physicians Standards Policy

6. EMS Units dispatched with a cold (no lights and sirens) response, will not upgrade to a hot (with lights and sirens) response UNLESS: Public Safety personnel on-scene requests a hot (with lights and sirens) response. Communications Center determines that the patient’s condition has changed, and requests you to upgrade to a hot (with lights and sirens) response.

7. An EMS Unit may divert from a current cold (no lights and sirens) call to a higher priority hot (with lights and sirens) call ONLY IF: The EMS Unit can get to the higher priority call before it can reach the lower priority call. Examples of High Priority Calls: Chest Pain, Respiratory Distress, CVA, etc. The diverting EMS Unit must notify the EMS Dispatch Center that they are diverting to the higher priority call. The diverting EMS Unit ensures that the EMS Dispatch Center dispatches an EMS Unit to their original call. Once a call has been diverted, the next EMS Unit dispatched must respond to the original call. A call cannot be diverted more than one (1) time.

8. Any EMS Dispatch Center Time delays resulting in a prolonged EMS Dispatch Center Time for emergent hot (with lights and sirens) events will be documented in Patient Care Report (PCR) as an “EMS Dispatch Delay” as required and defined in the North Carolina College of Emergency Physicians (NCCEP) EMS Dataset Standards Document.

9. All EMS Dispatch Delays will be reviewed regularly within the EMS System Peer Review Committee.

Policy 13 (Page 2 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy: The EMS Wheels Rolling (Turn-out) Time will be less than 180 seconds, 90% of the time, for all events identified and classified as an emergent or hot (with lights and siren) response. Definition: The EMS Wheels Rolling (Turn-out) Time is defined as the time interval beginning with the time the EMS Dispatch Center notifies an EMS Unit to respond to a specific EMS event and ending with the time the EMS Unit is moving en route to the scene of the event. Purpose: The purpose of this policy is to: Provide a timely and reliable response for all EMS events within the EMS System. Provide quality EMS service and patient care to the county’s citizens. Provide a means for continuous evaluation to assure policy compliance. Procedure: The following procedures shall be implemented to assure policy compliance: 1. In EMS Dispatch Centers where Emergency Medical Dispatch (EMD) has been implemented, EMS Units will be dispatched by EMD certified personnel in accordance with the standards developed by the Medical Director and the Emergency Medical Dispatch Protocols. 2. The EMS Unit will acknowledge dispatch within 90 seconds. If a unit fails to check en route within 2:59 (mm:ss), the next available EMS unit will be dispatched. 3. Without question, exception, or hesitation, EMS Units will respond as dispatched (hot or cold). This includes both requests to respond on active calls and requests to “move-up” to cover areas of the System that have limited EMS resources available. 4. An EMS Unit may divert from a current cold (no lights and sirens) call to a higher priority hot (with lights and sirens) call ONLY IF: The EMS Unit can get to the higher priority call before it can reach the lower priority call. Examples of High Priority Calls: Chest Pain, Respiratory Distress, CVA, etc. The diverting EMS Unit must notify the EMS Dispatch Center that they are diverting to the higher priority call. The diverting EMS Unit ensures that the EMS Dispatch Center dispatches an EMS Unit to their original call. Once a call has been diverted, the next EMS Unit dispatched must respond to the original call. A call cannot be diverted more than one (1) time. 5. Any EMS Wheels Rolling (Turn-out) Time delay resulting in a prolonged EMS Response Time for emergent hot (with lights and sirens) events will be documented in Patient Care Report (PCR) as an “EMS Response Delay” as required and defined in the North Carolina College of Emergency Physicians (NCCEP) EMS Dataset Standards Document. 6. All EMS Response Delays will be reviewed regularly within the EMS System Peer Review Committee.

Policy 14 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

The North Carolina Infant Homicide Prevention Act provides a mechanism for unwanted infants to be taken under temporary custody by a law enforcement officer, social services worker, healthcare provider, or EMS personnel if an infant is presented by the parent within 7 days of birth. Emergency Medical Services will accept and protect infants who are presented to EMS in this manner, until custody of the child can be released to the Department of Social Services.

“A law enforcement officer, a department of social services worker, a health care provider as defined in G.S. 90-21.11 at a hospital or local or district health department, or an emergency medical technician at a fire station shall, without a court order, take into temporary custody an infant under 7 days of age that is voluntarily delivered to the individual by the infant's parent who does not express an intent to return for the infant. An individual who takes an infant into temporary custody under this subsection shall perform any act necessary to protect the physical health and well-being of the infant and shall immediately notify the department of social services. Any individual who takes an infant into temporary custody under this subsection may inquire as to the parents' identities and as to any relevant medical history, but the parent is not required to provide this information.”

Purpose:

To provide: Protection to infants that are placed into the custody of EMS under this law Protection to EMS systems and personnel when confronted with this issue

Procedure:

1. Initiate the Pediatric Assessment Procedure. 2. Initiate Newly Born Protocol as appropriate. 3. Initiate other treatment protocols as appropriate. 4. Keep infant warm. 5. Call local Department of Social Services or the county equivalent as soon as infant is stabilized. 6. Transport infant to medical facility as per local protocol. 7. Assure infant is secured in appropriate child restraint device for transport. 8. Document protocols, procedures, and agency notifications in the PCR.

Policy 15 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

Anyone requesting EMS services will receive a professional evaluation, treatment, and transportation (if needed) in a systematic, orderly fashion regardless of the patient’s problem or condition.

Purpose:

To ensure the provision of appropriate medical care for every patient regardless of the patient’s problem or condition.

Procedure:

1. Treatment and medical direction for all patient encounters, which can be triaged into an EMS patient care protocol, is to be initiated by protocol.

2. When confronted with an emergency or situation that does not fit into an existing EMS patient care protocol, the patient should be treated by the Universal Patient Care Protocol and a Medical Control Physician should be contacted for further instructions.

Policy 16 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

The medical direction of prehospital care at the scene of an emergency is the responsibility of those most appropriately trained in providing such care. All care should be provided within the rules and regulations of the state of North Carolina.

Purpose:

To identify a chain of command to allow field personnel to adequately care for the patient To assure the patient receives the maximum benefit from prehospital care To minimize the liability of the EMS system as well as the on-scene physician

Procedure:

1. When a non medical-control physician offers assistance to EMS or the patient is being attended by a physician with whom they do not have an ongoing patient relationship, EMS personnel must review the On-Scene Physician Form with the physician. All requisite documentation must be verified and the physician must be approved by on-line medical control.

2. When the patient is being attended by a physician with whom they have an ongoing patient relationship, EMS personnel may follow orders given by the physician if the orders conform to current EMS guidelines, and if the physician signs the PCR. Notify medical control at the earliest opportunity. Any deviation from local EMS protocols requires the physician to accompany the patient to the hospital.

3. EMS personnel may accept orders from the patient’s physician over the phone with the approval of medical control. The paramedic should obtain the specific order and the physician’s phone number for relay to medical control so that medical control can discuss any concerns with the physician directly.

Policy 17 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy: The state poison center should be utilized by the 911 centers and the responding EMS services to obtain assistance with the prehospital triage and treatment of patients who have a potential or actual poisoning. Purpose: The purpose of this policy is to: Improve the care of patients with poisonings, envenomations, and environmental/biochemical terrorism exposures in the prehospital setting. Provide for the most timely and appropriate level of care to the patient, including the decision to transport or treat on the scene. Integrate the State Poison Center into the prehospital response for hazardous materials and biochemical terrorism responses Procedure: 1. The 911 call center will identify and if EMD capable, complete key questions for the Overdose/ Poisoning, Animal Bites/Attacks, or Carbon Monoxide/Inhalation/HazMat emergency medical dispatch complaints and dispatch the appropriate EMS services and/or directly contact the State Poison Center for consultation. 2. If no immediate life threat or need for transport is identified, EMS personnel may conference the patient/caller with the Poison Center Specialist at the State Poison Center at 800-222- 1222. If possible, dispatch personnel should remain on the line during conference evaluation. 3. The Poison Center Specialist at the State Poison Center will evaluate the exposure and make recommendations regarding the need for on-site treatment and/or hospital transport in a timely manner. If dispatch personnel are not on-line, the Specialist will recontact the 911 center and communicate these recommendations. 4. If the patient is determined to need EMS transport, the poison center Specialist will contact the receiving hospital and provide information regarding the poisoning, including treatment recommendations. EMS may contact medical control for further instructions or to discuss transport options. 5. If the patient is determined not to require EMS transport, personnel will give the phone number of the patient/caller to the Poison Center Specialist. The Specialist will initiate a minimum of one follow-up call to the patient/caller to determine the status of patient. 6. Minimal information that should be obtained from the patient for the state poison center includes: ● Name and age of patient ● Substance(s) involved ● Time of exposure ● Any treatment given ● Signs and symptoms 7. Minimal information which should be provided to the state poison center for mass poisonings, including biochemical terrorism and HazMat, includes: ● Substance(s) involved ● Time of exposure ● Signs and symptoms ● Any treatment given

Policy 18 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

Without special considerations children are at risk of injury when transported by EMS. EMS must provide appropriate stabilization and protection to pediatric patients during EMS transport.

Purpose:

To provide: Provide a safe method of transporting pediatric patients within an ambulance. Protect the EMS system and personnel from potential harm and liability associated with the transportation of pediatric patients.

Procedure: 1. Drive cautiously at safe speeds observing traffic laws. 2. Tightly secure all monitoring devices and other equipment. 3. Insure that all pediatric patient less than 40 lbs are restrained with an approved child restraint device secured appropriately to the stretcher or captains chair. 3. Insure that all EMS personnel use the available restraint systems during the transport. 4. Transport adults and children who are not patients, properly restrained, in an alternate passenger vehicle, whenever possible. 5. Do not allow parents, caregivers, or other passengers to be unrestrained during transport. 6. NEVER attempt to hold or allow the parents or caregivers to hold the patient during transport.

Policy 19 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2009 Standards Policy

Policy:

All individuals served by the EMS system will be evaluated, treated, and furnished transportation (if indicated) in the most timely and appropriate manner for each individual situation. Rowan County EMS should be considered for out of county transfers from local hospitals and medical facilities after other reasonable transport agencies have been exhausted. Rowan County EMS’ primary mission is to give pre-hospital emergency care to the citizens of the county. Individuals calling for EMS services are considered unstable until and unless they receive an evaluation by qualified medical personnel.

Purpose:

To provide: Rapid emergency EMS transport when needed. Appropriate medical stabilization and treatment at the scene when necessary Protection of patients, EMS personnel, and citizens from undue risk when possible.

To maintain: The ability to care for prehospital medical emergencies occurring in the jurisdiction.

Procedure:

1. All trauma patients with significant mechanism or history for multiple system trauma will be transported as soon as possible. The scene time should be 10 minutes or less.

2. All acute Stroke and acute ST-Elevation Myocardial Infarction patients will be transported as soon as possible. The scene time should be 10 minutes or less for acute Stroke patients and 15 minutes or less (with 12 Lead ECG) for STEMI patients

3. Other Medical patients will be transported in the most efficient manner possible considering the medical condition. Advanced life support therapy should be provided at the scene if it would positively impact patient care. Justification for scene times greater than 20 minutes should be documented.

4. No patients will be transported in initial response non-transport vehicles.

5. In unusual circumstances, transport in other vehicles may be appropriate when directed by EMS administration.

6. The hospital should make arrangements with critical care transport services whenever possible for transports to out of county destinations. Critical care transport services have more personnel and equipment. These agencies are better able to handle complex, critical patients.

Policy 20 (Page 1 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

6. Rowan County will not approve ambulance transfers in severe and dangerous weather conditions. Such examples include icy roads, hail storms, high wind warnings and hurricanes.

7. When out of county transports cannot be avoided, only one EMS unit will generally be committed to any out of county assignment at a time.

8. When EMS is called for a transport, all of the patients medical records and transfer forms should be ready. This expedites the process for EMS and the patient.

9. Support personnel such as nurses or respiratory therapists should be available to assist EMS with critical patients.

10. Facilities that are required to provide transportation services for their respective clients should be utilized.

11. Supervisors will have discretion in managing any requests for EMS transportation.

Policy 20 (Page 2 of 2) This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Standards Policy

Policy:

Rapid Sequence Induction (RSI) requires an EMS System or Agency to follow these guidelines to ensure that this invasive procedure is performed in a safe and effective manner to benefit the citizens and guests of North Carolina.

Purpose:

The purpose of this policy is to: Ensure that the procedure is performed in a safe and effective manner Facilitate airway management in appropriate patients

Procedure: 1. In addition to other monitoring devices, waveform capnography and pulse oximetry are required to perform Drug-Assisted Intubation and must be monitored throughout the procedure.

2. Two EMT-Paramedics or higher-level providers must be present and participate in the airway management of the patient during the process.

3. All staff must be trained and signed off by the EMS Medical Director prior to performing Rapid Sequence Induction.

4. A printed copy or electronic download from the monitor defibrillator including the pulse oximetry, heart rhytm, waveform capnography, and blood pressure must be stored with the patient care report.

5. An EMS Airway Evaluation Form must be completed on all Rapid Sequence Induction attempts.

6. The EMS Airway Evaluation Form must be reviewed and signed by the EMS Medical Director within 7 days of the Rapid Sequence Induction.

7. All Rapid Sequence Inductions must be reviewed by the EMS System or Agency and issues identified addressed through the System Peer Review Committee.

8. A copy of the EMS Airway Evaluation Form for each Rapid Sequence Induction must be forwarded to the appropriate OEMS Regional Office at the end of each month for state review. Rowan County Emergency Services will forward the forms to the following: Western Regional Office 3305-4 16th Avenue SE Conover, NC 28613 Telephone: 828-466-5548 Fax: 828-466-5651

Policy 21 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012 Rowan County Standards Policy Emergency Services

Policy:

Supervisors will review all patient care reports for completeness and accuracy. Missing information and unclear or incomplete work will be corrected.

Purpose:

Specifically, reports will be audited for the information required in Policy 9, EMS Documentation and Data Quality. Supervisors will have employees correct or clarify missing or unclear information.

Procedure:

1. The supervisor will fill in missing information that can be pulled from other sources such as: the computer aided dispatch system, a hospital record or nursing facility paperwork.

2. Supervisors filling in missing facts or correcting verifiable information will be recorded electronically by the reporting software. Recorded information will include the changes, time and date. Acceptable changes for the supervisors to enter include adding missing zip codes, correcting addresses based on hospital information not available to the crew at the time of the trip or filling in call times from the dispatch sheet.

3. The EMT delivering patient care must correct any missing data or unclear information on patient assessments or treatment. The other EMT on the ambulance may assist if the primary attendant is unavailable to make corrections in a timely manner.

4. The author of the patient care report can add missing information as an addendum to the report.

5. Additional facts overlooked when the call was submitted should be submitted as a separate addendum.

6. Delayed entries and addendums will be electronically signed and dated by the reporting software.

7. Late entries may not change the substantial facts of the call or misrepresent in anyway the care.

Policy 22 This policy has been altered from the original 2012 NCCEP Policy by the local EMS Medical Director 2012