EMT-Basic Protocols Region 6

TABLE OF CONTENTS

Cardiac Emergencies Special Situations Chest Pain ...... A02 Abuse and Neglect ...... D02 Cardiopulmonary Arrest...... A03 Behavioral Emergencies ...... D03 Elder Abuse...... D04 Medical Emergencies SIDS ...... D05 Initial Medical Care ...... B02 Airway Obstruction...... B03 Traumatic Emergencies Alcohol-Related Emergencies ...... B04 Glascow Coma Scale ...... E02 Allergic Reaction/Anaphylaxis ...... B05 Initial Trauma Care...... E03 Altered Level of Consciousness ...... B06 Amputation ...... E04 CVA (Stroke)...... B07 Burns ...... E05 Diabetic Emergencies...... B08 Chest Injuries ...... E06 Drug Overdose ...... B09 Field Triage ...... E07 Frostbite...... B10 Head or Spine Injury...... E08 Hazardous Materials...... B11 Load and Go Situations...... E09 Heat Cramps...... B12 Painful, Deformed Extremity...... E10 Heat Exhaustion ...... B13 Shock (Traumatic) ...... E11 Heat Stroke...... B14 Traumatic Arrest...... E12 Hypothermia (Moderate)...... B15 Trauma Field Death Declaration ...... E13 Hypothermia (Severe)...... B16 Hypothermic Arrest ...... B17 Pediatric Emergencies Hypertensive Crisis...... B18 Initial Pediatric Care ...... F02 Hyperventilation ...... B19 Pediatric Coma Scale...... F03 Near Drowning...... B20 Abuse and Neglect ...... F04 Poisoning ...... B21 Airway Care...... F05 Respiratory Difficulty...... B22 Allergic Reaction/Anaphylaxis ...... F06 Seizures...... B23 Altered Level of Consciousness ...... F07 Sexual Assault ...... B24 Burns ...... F08 Shock (Non-Traumatic)...... B25 Cardiopulmonary Arrest ...... F09 Shunts, Grafts, and Fistulas ...... B26 Environmental Hyperthermia...... F10 Syncope...... B27 Epiglottitis ...... F11 Frostbite ...... F12 Obstetrics and Gynecology Hypothermia (Moderate) ...... F13 APGAR Scoring Chart ...... C02 Hypothermia (Severe) ...... F14 Imminent Delivery ...... C03 Load and Go Situations...... F15 Malpresentation ...... C04 Near Drowning ...... F16 Meconium Aspiration ...... C05 Poisoning/Drug Overdose ...... F17 Neonatal Resuscitation...... C06 Respiratory Distress ...... F18 Non-Imminent Delivery ...... C07 Seizures ...... F19 Pre-Eclampsia ...... C08 Shock ...... F20 Pre-Term Delivery...... C09 Tracheostomy...... F21 Prolapsed Umbilical Cord ...... C10 Shoulder Dystocia...... C11 General Protocols Vaginal Bleeding...... C12 BLS Intercept Criteria ...... G02 BLS Radio Report ...... G03 Patient Refusal ...... G04 Triple Zero ...... G05 EMS Involvement in Crime Scene.....G06

CARDIAC EMERGENCIES

BLS Section A 1 Section A 1 Chest Pain Cardiac

NOTE: If patient presents with chest pain that is clearly pleuritic or muscular in description, such as pain that worsens with movement or breathing, perform Initial Medical Care and call Medical Control.

CRITERIA: 1. Chest pain consistent with cardiac ischemia; may include: a. Respiratory difficulty b. Nausea and vomiting c. Diaphoresis d. Dizziness e. Epigastric, neck, jaw, or arm pain. 2. Systolic blood pressure > 90 mmHg.

EXCLUSION: 1. Cardiogenic shock (SBP < 90 mmHg, dyspnea, lung crackles; also known as “rales”). Call for intercept.

TREATMENT: 1. Initial Medical Care protocol. 2. Airway and high flow OXYGEN at 15 liters per minute (LPM) via non-rebreather mask. Apply pulse oximeter if available. 3. Assessment & history. 4. Monitor electrocardiogram (EKG) if available. 5. For apparent cardiac related chest pain with SBP > 90 mmHg, administer NITROGLYCERIN 0.4 mg sublingually (SL). Repeat NITROGLYCERIN every 3-5 minutes to maximum of 3 doses as long as chest pain persists and SBP > 90 mmHg. 6. Administer ASPIRIN 325 mg orally (PO) or 81mg tablets x 4 PO. 7. Transport – consider ALS intercept. 8. Contact Medical Control. ------

BLS Section A 2 Section A 2 Cardiopulmonary Arrest Cardiac

NOTE: If AED is on scene, place AED on the patient within one minute of arrival.

CRITERIA: 1. Patient must be pulseless, apneic, and unresponsive.

EXCLUSION: 1. Indication of obvious death. a. Rigor (stiffening of limbs) b. Lividity (purplish discoloration of skin caused by pooling of stagnant blood) c. Decapitation 2. Assess patient for resuscitative viability. If any questions or family is adamant about resuscitative efforts, begin CPR.

TREATMENT: 1. Check airway, breathing, and circulation. 2. Start CPR. 3. CPR until AED (if available) is attached, then check pulse and analyze. 4. Defibrillate as directed by AED. 5. Consider intercept per BLS Intercept Criteria. 6. If no pulse, resume CPR for two minutes and perform advanced airway control measures as available. 7. Hyperventilate with BVM with airway in place. 8. Check pulse and analyze. If shockable rhythm, repeat shocks as directed by AED. 9. Continue CPR 10. Contact Medical Control. 11. Check pulse and analyze. If shockable rhythm, repeat shocks as directed by AED. 12. Continue CPR. 13. Initiate transport upon: a. Return of spontaneous pulse. b. Six total shocks delivered c. 3 “No Shock Advised” messages. ------

BLS Section A 3 Section A 3

MEDICAL EMERGENCIES

BLS Section B 1 Initial Medical Care Medical

CRITERIA: 1. Any patient presenting with signs and/or symptoms that is non-traumatic in origin.

TREATMENT: 1. Place the patient in a position of comfort and loosen any tight clothing. Reassure and calm the patient. Sit the patient in an upright position if more comfortable and not hypotensive. 2. Administer OXYGEN at 15 LPM via non-rebreather mask or as indicated. Apply pulse oximeter if available. 3. If the patient refuses non-rebreather, administer OXYGEN at 4 LPM via nasal cannula and inform Medical Control. 4. Obtain SAMPLE history and vital signs. Check for medical alert tags or cards. Repeat and record vital signs every 5 to 10 minutes and relay any significant changes to persons who continue patient care. 5. Consider blood sugar determination. 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact the receiving hospital. 8. If patient arrests, begin CPR. Manage the airway and follow Cardiopulmonary Arrest protocol. ------

BLS Section B 2 Airway Obstruction Medical

CRITERIA: 1. Respiratory distress with suspected foreign body airway obstruction (FBAO).

TREATMENT: Conscious patient – able to speak 1. Leave the patient alone; offer reassurance. 2. Encourage coughing. 3. OXYGEN at 15 LPM via non-rebreather or 4 LPM via nasal cannula. 4. Suction as needed to control secretions. 5. Transport without agitating the patient. 6. Contact Medical Control.

Conscious patient – unable to cough or speak 1. Ask the patient if he/she is choking. 2. Administer abdominal thrusts until the foreign body is expelled or until the patient becomes unconscious. 3. After the obstruction is relieved, reassess the airway, lung sounds, skin color, and vital signs. 4. Administer OXYGEN at 15 LPM via non-rebreather or 4 LPM via nasal cannula. 5. Transport. 6. Contact Medical Control.

Patient who becomes unconscious/Patient found unconscious 1. Roll patient to supine position; open the airway (tongue-jaw lift), perform finger sweep. 2. Attempt bag-valve mask (BVM) ventilations; if unable to ventilate, perform 30 chest compressions. 3. Perform finger sweep and attempt to ventilate; perform 30 chest compressions and continue sequences until foreign body is relieved. Perform advanced airway control measures as available. Apply pulse oximeter if available. 4. Monitor EKG if available. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section B 3 Alcohol Related Emergencies Medical

CRITERIA (any of the following): 1. Odor of alcohol. 2. Admitted consumption of alcohol.

EXCLUSION: 1. Altered level of consciousness (LOC) – refer to appropriate protocol. 2. Conditions which may mimic alcohol consumption, including: a. Diabetes b. Pneumonia c. Head injury d. Overdose

TREATMENT: 1. Initial Medical Care. 2. Airway management, OXYGEN at 15 LPM via non-rebreather mask, ventilate if necessary, and suction if needed. Advanced airway control measures if necessary and as available. Apply pulse oximeter if available. 3. Assessment and history. 4. Monitor EKG if available. 5. Treat patient in calm, firm manner. 6. If patient exhibits violent behavior, restrain as necessary per Use of Restraint guidelines. a. Restrain in the presence of law enforcement wherever possible. b. Utilize a minimum of 4 personnel for safety. 7. If patient has decreased LOC or is unconscious, refer to Altered Level of Consciousness protocol. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section B 4 Allergic Reaction/Anaphylaxis Medical

NOTE: For patients experiencing a possible allergic reaction without serious signs or symptoms, perform Initial Medical Care and contact Medical Control.

CRITERIA: 1. Possible exposure to allergen including hives, itching, rash, or swelling in conjunction with: a. Respiratory difficulty/stridor (high pitch wheezing) or b. Signs and symptoms of shock

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Assessment and history. 4. Monitor EKG if available. 5. Administer EPINEPHRINE 0.3 mg intramuscularly (IM) via autoinjector. 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. 8. If patient is in mild respiratory distress or severe cardiorespiratory compromise, give dose of patient’s own INHALER if available. ------

BLS Section B 5 Altered LOC Medical

CRITERIA (all must be present): 1. Altered level of consciousness (LOC). 2. SBP > 90 mmHg.

EXCLUSION: 1. Trauma. 2. SBP < 90 mmHg. 3. Acute suspected stroke.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Assessment and history. 4. Immobilize cervical spine if appropriate. 5. Monitor EKG if available. 6. If glucometer is available and glucose > 60 mg/dL, transport. 7. If glucometer glucose reading < 60 mg/dL (or suspected), administer ORAL GLUCOSE 15 g PO only if patient is responsive with intact gag reflex. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section B 6 CVA (Stroke) Medical

NOTE: Do not treat hypertension in a patient with acute suspected cerebrovascular accident (CVA; also known as “stroke”).

CRITERIA: 1. Signs of symptoms of acute CVA, including: a. Unilateral paralysis or paresthesia (loss of sensation) b. Unilateral pronator drift (arm drift) c. Unilateral facial droop d. Speech disturbance (slurred) e. Monocular blindness (blindness in one eye) 2. Acute onset of above signs/symptoms with previous medical history of: a. Transient ischemic attack (TIA) b. Cerebrovascular accident (CVA/stroke) c. Hypertension d. Cardiac disease e. Sickle cell anemia

EXCLUSION: 1. Unresponsive. 2. SBP < 90 mmHg.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Immobilize cervical spine as appropriate. 4. Assessment and history. 5. Monitor EKG if available. 6. If glucometer available and glucose > 60 mg/dL, transport. 7. If glucometer glucose reading < 60 mg/dL (or suspected), administer ORAL GLUCOSE 15 g PO only if patient is responsive with intact gag reflex. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section B 7 Diabetic Emergencies Medical

NOTE: Hypoventilation generally indicates hypoglycemia; hyperventilation generally indicates hyperglycemia.

CRITERIA: 1. Altered LOC, including: a. Blood glucose < 60 mg/dL b. History of diabetes c. Patient currently taking insulin or oral diabetic medication 2. Signs and symptoms of diabetic ketoacidosis (DKA): a. Nausea and vomiting b. Fruity or acetone breath odor c. Excessive thirst or urination d. Kussmaul respirations (deep, rapid respirations) 3. Signs and symptoms of diabetic hyperosmolar non-ketotic coma, including: a. Blood glucose > 300 mg/dL b. Altered LOC c. Dehydration or hypotension

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Assessment and history. 4. Monitor EKG if available. 5. If glucometer available and glucose > 60 mg/dL, transport. 6. If glucometer glucose reading < 60 mg/dL (or suspected), administer ORAL GLUCOSE 15 g PO only if patient is responsive with intact gag reflex. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section B 8 Drug Overdose Medical

CRITERIA: 1. Any of the following medications taken over prescribed dosage: a. Prescription b. Over-the-counter (OTC) c. Recreational or illegal drugs

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Assessments and history. 4. Save bottles, containers, and inspect vomitus for pills. 5. Monitor EKG if available. 6. If patient refuses treatment or transport: a. Request law enforcement assistance b. Contact Medical Control 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section B 9 Frostbite Medical

NOTE: Do not massage frostbitten extremities.

CRITERIA: 1. Cold exposure. 2. Signs and symptoms of frostbite, including: a. Red, inflamed tissue b. Gray or mottled tissue c. Waxy tissue that is firm upon palpation

TREATMENT: 1. Remove from cold. 2. Initial Medical Care. 3. Cover frostbitten nose or ears with a warm hand. 4. Place frostbitten hand in his/her armpit. 5. Transport without delay. 6. Contact Medical Control. 7. If estimated time of arrival (ETA) at hospital is greater than 60 minutes, begin active rewarming: a. Immerse extremity in water kept at a temperature of 100-105 °F. b. Rewarming should take 30-60 minutes. c. Rewarming is complete when frozen area is warm to touch and deep red or bluish in color. d. After rewarming, dry gently and cover part with dry sterile dressing and elevate on pillow. ------

BLS Section B 10 Hazardous Materials Medical

CRITERIA: 1. Hazardous or radioactive material.

SPECIAL INFORMATION: 1. The degree of risk of contamination is relevant to the type of radiation present, the length of exposure, and the amount of shielding used while in the contaminated area. 2. Risk of contamination can be reduced by removing the patient’s clothing and discarding in an appropriate manner. 3. All open wounds are considered contaminated until proven otherwise. 4. Rescue personnel and their vehicles should be monitored prior to and after transport to receiving facility in order to obtain hazard levels.

TREATMENT: 1. Identify exact location and respond from an upwind direction. Park at least 150 feet away and contact Medical Control. 2. If other agencies are not present, enter only after scene is safe and then only to provide life-saving care. If other agencies are present, locate the Incident Commander and identify yourself. 3. Any personnel entering a contaminated site should wear protective clothing and dosimeters (device that measures exposure to hazardous material), if available. Enter only by direction of the Incident Commander. 4. Perform only life saving care while in contamination area (airway; temporary spinal immobilization; exsanguinating [killer bleed] hemorrhage control), then remove patient and self as soon as possible. 5. Notify the incoming ambulance as soon as possible of your patient status. Decontaminate at the scene if possible. ------

BLS Section B 11 Heat Cramps Medical

NOTE: Do not massage cramping muscles.

CRITERIA: 1. Muscle pain secondary to profuse sweating, may include: a. Cramps in lower or upper extremities b. Cramps in abdomen

TREATMENT: 1. Initial Medical Care. 2. Move to cool environment. 3. If patient is not nauseated, give 1-2 glasses of salt containing solution (i.e. Gatorade) if available. 4. Transport. 5. Contact Medical Control. ------

BLS Section B 12 Heat Exhaustion Medical

CRITERIA: 1. Environmental heat exposure. 2. Signs and symptoms of heat exposure, may include: a. Profuse perspiration b. Headache, fatigue, dizziness, and nausea c. Skin pale and clammy d. Normal or decreased skin temperature e. Rapid, weak pulse and decreased blood pressure f. Shallow respirations

TREATMENT: 1. Initial Medical Care. 2. Remove patient to a cool environment. 3. Place patient in supine position. 4. Cool patient with water and fans; do not induce shivering. 5. Avoid fluids by mouth, especially if patient is nauseated. 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section B 13 Heat Stroke Medical

CRITERIA: 1. Hot, flushed, dry skin 2. Signs and symptoms of heat stroke, may include: a. Temperature > 105 °F b. Altered level of consciousness; may include coma or seizure

TREATMENT: 1. Initial Medical Control. 2. Airway management with OXYGEN at 15 LPM via non-rebreather. 3. Move the patient to a cool environment. 4. Initiate active cooling: a. Remove patient’s clothing; protect privacy. b. Apply cold packs to neck, groin, and axillae (armpits). c. Cover patient with cool, wet sheets and fan. 5. Monitor EKG if available. 6. Be alert of seizures. 7. Transport immediately – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section B 14 Hypothermia (Moderate) Medical

NOTE: Do not massage cold extremities.

CRITERIA: 1. Exposure to cold environment. 2. Signs and symptoms of moderated hypothermia, including: a. Rectal temperature of 84-94 °F b. Patient conscious – may be lethargic (tired) c. Shivering d. Pale, cold skin

TREATMENT: 1. Initial Medical Care. 2. Warm, humidified OXYGEN at 15 LPM via non-rebreather mask. 3. Handle patient gently. 4. Replace any wet clothing with dry sheets and blankets. 5. Hot packs may be applied to axillae, groin, and abdominal areas. 6. Monitor EKG if available. 7. Give sugar and sweet, warm fluids by mouth if conscious. Do not give alcohol. 8. Transport in lateral recumbent position – consider intercept per BLS Intercept Criteria. 9. Assess for other injuries and treat accordingly. 10. Contact Medical Control. ------

BLS Section B 15 Hypothermia (Severe) Medical

NOTE: Do not massage cold extremities.

CRITERIA: 1. Rectal temperature < 84 °F. 2. Signs and symptoms of severe hypothermia, including: a. Decreased LOC b. Cold skin c. Inaudible heart tone d. Unreactive pupils e. Slow respirations

TREATMENT: 1. A “Load and Go” situation. Consider intercept per BLS Intercept Criteria. 2. Initial Medical Care. 3. Establish airway without using mechanical adjuncts; assist ventilations with BVM at 12-14 per minute if patient is breathing less than 5 times per minute. Do not hyperventilate. Give warm OXYGEN at 15 LPM via non-rebreather mask or BVM as needed. Apply pulse oximeter if available. 4. Handle patient gently. 5. Move to warm environment – cut away clothes and replace with dry sheet and blankets. 6. Prepare to transport in supine position. 7. Cautiously check for pulse; take one full minute to assure pulselessness, as unnecessary CPR could potentially cause ventricular fibrillation (v-fib). 8. If pulseless, apneic, and unresponsive, treat accordingly to Hypothermic Cardiac Arrest protocol. 9. Once CPR has begun, it should continue until the patient is evaluated by the Emergency Department physician. ------

BLS Section B 16 Hypothermic Cardiac Arrest Medical

NOTE: Consider that a pulse may be very weak or not palpable in a severely hypothermic patient. Take one full minute to assure pulselessness, as unnecessary CPR could potentially cause ventricular fibrillation (v-fib). Once CPR has begun, it should continue until the patient is evaluated by the Emergency Department physician.

CRITERIA: 1. Cold exposure. 2. Pulseless, apneic, and unresponsive. 3. Consider even mild cold exposure in the: a. Elderly b. Very young c. Chronically debilitated

TREATMENT: 1. A “Load and Go” situation. Consider intercept per BLS Intercept Criteria. 2. Perform CPR per Cardiopulmonary Arrest protocol. 3. Passive external warming: a. Removal of wet clothing b. Blankets on torso c. Warm, humidified OXYGEN if available 4. Transport in supine position. 5. Contact Medical Control. ------

BLS Section B 17 Hypertensive Crisis Medical

NOTE: History of prior episodes and non-compliant with medication or recent cocaine abuse are often the cause of hypertensive crisis.

CRITERIA: 1. Systolic blood pressure > 200 mmHg. 2. Diastolic blood pressure > 130 mmHg. 3. Presenting symptoms may include one of the following: a. Altered mental state b. Chest pain c. Confusion d. Headache e. Pulmonary edema (accumulation of fluid in lungs)

EXCLUSION: 1. Acute suspected CVA (stroke). 2. Patient less than 18 years old. 3. Eclampsia (seizures in pregnant women)/pregnancy. 4. Trauma.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Apply pulse oximeter if available. 3. Assessment and history. 4. Monitor EKG if available. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. 7. If patient has physician-prescribed NITROGLYCERIN, administer NITROGLYCERIN 0.4 mg SL and repeat every 3-5 minutes to maximum of 3 doses as long as patient meets criteria. ------

BLS Section B 18 Hyperventilation Medical

NOTE: An oxygen mask should never be placed on any patient without oxygen flowing.

CRITERIA (all should be present): 1. Respiratory rate > 28 with sudden onset. 2. Signs of hysteria or panic. 3. No known reason for high respiratory rate (no sign of diabetes, drug overdose, asthma, COPD, etc.) 4. Room air pulse oximeter > 94% (if available). 5. History of prior episodes.

EXCEPTIONS: 1. If patient has any of the following, administer OXYGEN at 15 LPM via non- rebreather: a. Room air pulse oximetry ≤ 94% (if available) b. Abnormal exam findings, especially respiratory problems c. Underlying medical problems which cause respiratory difficulty

TREATMENT: 1. Initial Medical Care. 2. Assessment and history, including: a. Evidence of trauma and jugular vein distention (JVD) b. Pedal edema (accumulation of fluid in feet), auscultation of breath sounds, and intercostal retractions (muscles between ribs pull inward) c. Diaphoresis (excessive sweating), pallor/cyanosis, and acetone breath 3. Document room air pulse oximetry if available. 4. Attempt to relax and reassure the patient: a. Loosen tight clothing b. Allow patient to be in position of comfort c. Encourage patient to slow down respirations 5. Apply non-rebreather with low flow OXYGEN at 6 LPM. Apply pulse oximeter if available. 6. Contact Medical Control. ------

BLS Section B 19 Near Drowning Medical

NOTE: Aggressive airway management is important. High potential for associated injury (i.e. cervical spine injury and hypothermia) exists. Be conscious of scene safety. Remember, “All patients with low core temperatures should be resuscitated.”

CRITERIA: 1. Submersion

TREATMENT: 1. Initial Medical Care. 2. Perform cervical spine immobilization. 3. Airway management with OXYGEN at 15 LPM via non-rebreather mask, assist with respirations, and suction if necessary. Perform advanced airway control measures as available. Apply pulse oximeter if available. 4. Assessment and history. 5. Monitor EKG if available. 6. If in arrest, begin CPR and treat per Cardiopulmonary Arrest or Hypothermic Cardiac Arrest protocol. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section B 20 Poisoning Medical

CRITERIA (any may be present): 1. Adverse effects of plants, foods, chemicals, or pharmaceutical agents on the body. 2. Generally absorbed in four ways: a. Ingestion b. Inhalation c. Absorption (includes eyes, skin, and mucous membranes) d. Injection (may be accidental or intentional)

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Apply pulse oximeter if available. 3. Absorbed exposure: a. Removal of all necessary clothing b. Large volume of clear water to irrigate skin and/or eyes c. Avoid emergency personnel contamination 4. Assessment and history. 5. Save all bottles and containers, and check all vomitus for pill fragments. 6. Monitor EKG if available. 7. Contact Medical Control. 8. Enlists assistance from law enforcement if necessary. 9. Transport – consider intercept per BLS Intercept Criteria. ------

BLS Section B 21 Respiratory Difficulty Medical

CRITERIA (any may be present): 1. Severe dyspnea (shortness of breath) with tachypnea, including use of accessory muscles. 2. Physical exam including any of these findings: a. Wheezing b. Inspiratory rales (lung crackles) c. Rhonchi (snore-like sounds) d. Decreased breath sounds or decreased air exchange 3. History of: a. Asthma b. Chronic obstructive pulmonary disease (COPD) c. Emphysema d. Bronchitis e. Recent pneumonia

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather. Be prepared to support respirations. Advanced airway control measures as needed and available. Apply pulse oximeter if available. 3. Position patient: a. With head up and feet down or b. Position of comfort 4. Assessment and history. 5. Monitor EKG if available. 6. Consider ALBUTEROL 2.5 mg in 3 mL normal saline (NS) for the following: a. Wheezing b. Diminished breath sounds c. Prolonged expiratory phase 7. May repeat ALBUTEROL as needed for continued symptomatic relief. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section B 22 Seizures Medical

CRITERIA (any may be present): 1. Active seizure 2. Recurrent seizure or prolonged seizures (status epilepticus) 3. Postictal state

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Suction if necessary. Advanced airway measures as needed and available. 3. If glucometer available check glucose < 60 mg/dL glucose (or suspected). Give oral GLUCOSE 15 grams PO if patient is alert, can swallow, and has an intact gag reflex. 4. Assessment including neurological and history. 5. Immobilize cervical spine if appropriate. 6. Monitor EKG if available. 7. If status epilepticus exists, follow BLS Intercept Criteria. 8. Transport. 9. Contact Medical Control. ------

BLS Section B 23 Sexual Assault Medical

NOTE: Whenever possible, give a sexual assault victim a feeling that she is safe and among people she can trust. The sexual assault victim may not trust a male EMT and whenever possible, she may request that a female EMT administer her care.

Preserve evidence, but respect the patient’s feelings: a. Handle the patient’s clothing as little as possible b. Place blood stained articles in separate paper (not plastic) bags. c. Do not disturb the crime scene. d. Discourage the patient from changing clothes, bathing, gargling, etc. to prevent destruction of evidence.

CRITERIA: 1. This protocol is written with the assumption that the majority of sexual assault victims are females. Please consider the possibility of male victims and adapt the protocol appropriately.

TREATMENT: 1. Primary responsibility is to take care of patient’s urgent medical problem: a. Airway b. Breathing c. Circulation 2. Limit physical exam to search for injuries requiring immediate stabilization. 3. Take a medical history, not a history of the assault. 4. Protect patient privacy. 5. Don’t abandon patient at the scene. If not transporting, make sure a support person is available to take her to a medical facility. 6. Transport. 7. Contact Medical Control. ------

BLS Section B 24 Shock (Non-Traumatic) Medical

NOTE: The cause of the low blood pressure may not be obvious.

CRITERIA: 1. Non-traumatic shock or acute blood/fluid loss. Caused by or associated with: a. Severe vomiting, diarrhea, and dehydration b. Severe abdominal pain c. GI bleeding d. Sepsis (blood infection) 2. Signs and symptoms of shock.

EXCLUSION: 1. Trauma. 2. Pregnancy. 3. Pulmonary edema.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Advanced airway control measures as available and needed. Apply pulse oximeter if available. 3. If possible put patient in shock position and keep warm. 4. Assessment and history. 5. Monitor EKG if available. 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section B 25 Shunts, Grafts, and Fistulas Medical

CRITERIA: 1. Shunt – made up of small tubes, one in an artery and one in a vein of the forearm or lower leg. When closed, the tubing forms a loop on the outside of the arm, near the wrist. When used for hemodialysis, the loop is open. Shunt clotting is a serious problem and it should be handled with prompt attention, but it is not an emergency. When the shunt clots, the blood flow is interrupted in the shunt tubing only. It does not interfere with circulation in any other part of the body. Other than the need to declot the shunt before the next dialysis, there is not physical danger to the patient. Even if it becomes necessary to miss one treatment, the patient should feel no ill effects. In many instances, shunts can be declotted successfully and continue to function well for some time. Even when declotting is not successful, the most serious consequence is that the shunt needs to be relocated. 2. Graft – many dialysis patients now have an artificial graft made of Dacron connecting an artery and a vein in the arm. The graft is buried under the skin in the forearm. Prolonged pressure over the graft or above the graft may lead to clotting of the graft. 3. Fistula – a small opening is made in the side of an artery and in the side of a vein, and two vessels are joined together at these openings under the skin. This connection is called an arteriovenous fistula. Because pressure in the artery is much higher than pressure in the vein, there is a rapid flow of blood from the artery into the vein. The usual location for a fistula is near the wrist, and as a result of high blood flow, some of the veins in the forearm will become large, easily seen and felt. The flow through the dilated veins may be so forceful that it can be felt as a “buzz” when the other hand is placed lightly on the arm.

TREATMENT: 1. Do not take blood pressure on arm with shunt, fistula, or arteriovenous graft. 2. In the event a shunt is accidently pulled out of the entrance site, the following must be done: a. Apply direct pressure to site of bleeding b. Apply tourniquet above the site of bleeding as a final effort to control bleeding c. Elevate affected arm 3. If shunt tubing accidentally becomes disconnected, apply copper clips (should be on dressing or in patient’s possession) to the end of the tubing. 4. Relay information to incoming ambulance. ------

BLS Section B 26 Syncope Medical

CRITERIA: 1. Sudden onset of transient or near loss of consciousness. 2. Systolic blood pressure > 90 mmHg.

EXCLUSION: 1. Systolic blood pressure < 90 mmHg or signs and symptoms of shock. 2. Associated symptoms (i.e. chest pain, signs of stroke). 3. Trauma. 4. Pregnancy. 5. Seizure.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Advanced airway control measures as available and needed. Apply pulse oximeter if available. 3. Assessment and history. 4. Monitor EKG if available. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. 7. Consider oral GLUCOSE 15 grams PO if glucometer reading is < 60 mg/dL. 8. If no glucometer is available, Medical Control may consider oral GLUCOSE. ------

BLS Section B 27

OBSTETRICS & GYNECOLOGY

BLS Section C 1 APGAR Scoring Chart OB/GYN

Sign 0 1 2 1 Minute 5 Minutes Body pink Appearance Completely Blue or pale with blue (Color) pink extremities

Pulse Absent Below 100 Over 100

Grimace Some Vigorous No response (Irritability) motion/crying crying

Flaccid or Flaccid or Active Activity limp limp motion

Respiratory Good effort, Absent Absent Effort crying

BLS Section C 2 Imminent Delivery OB/GYN

CRITERIA: 1. Full-term pregnancy (> 36 weeks) gestation with crowning and/or urge to push. 2. Crowning and/or urge to push.

EXCLUSION: 1. Prolapsed cord. 2. Pre-term delivery/labor. 3. Malpresentation.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. 3. Assessment including exam of genital area. 4. If crowning – prepare for delivery. If crowning is not present: a. Prepare for transport. b. Frequently reassess for crowning. 5. Allow delivery to progress spontaneously. In all deliveries, encourage the patient to perform slow, steady pushes with contractions. 6. Support the head as it presents with gentle pressure. a. After delivery of head, suction airway orally then nasally b. Check for and reduce a nuchal cord (cord wrapped around baby’s neck) if present c. Keep baby positioned level with mother’s heart until cord is cut 7. Neonatal Resuscitation (suction/stimulate/oxygen/warm) – see appropriate protocol. 8. The cord should be clamped then cut as soon as time allows after pulsations stop. 9. Wrap baby to preserve warmth, and place on mother’s abdomen or chest. Perform routine post-partum care. 10. Consider massaging uterus to control bleeding. 11. Consider placenta delivery if extended ETA. Never pull on cord in an attempt to hasten delivery. 12. Transport – consider intercept per BLS Intercept Criteria. 13. Contact Medical Control ------

BLS Section C 3 Malpresentation OB/GYN

NOTE: Rapid transport to an appropriate receiving facility is indicated for any breech presentation or other condition causing prolonged labor.

CRITERIA: 1. Imminent delivery. 2. Abnormal presentation, such as: a. Breech presentation (buttocks first as opposed to head) b. Limb presentation

EXCLUSION: 1. Shoulder dystocia – see appropriate protocol.

TREATMENT: 1. Initial Medical Care. 2. Assessment of perineum (genital area). 3. Assess fetal heart tones via Doppler if available. 4. If breech presentation, baby is not delivering (labor stopped), and baby’s head is accessible by digital exam: a. Insert sterile glove b. With your fingers form a V around the baby’s nose c. Transport rapidly to an appropriate receiving facility 5. If breech delivery is imminent: a. Deliver with steady traction to the shoulder level b. Sweep each arm over the chest c. Deliver the head with traction and extension 6. Clamp and cut the cord as soon as time allows after cord stops pulsating. 7. Resuscitate if indicated. 8. Immediate transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section C 4 Meconium Aspiration OB/GYN

NOTE: It may not be possible to clear the airway of all meconium (fetal stool) before the need to initiate ventilation.

CRITERIA: 1. Meconium present in amniotic fluid noted on or before delivery.

TREATMENT: 1. Immediately upon delivery of head: a. Suction mouth and nose of neonate b. Check for and reduce nuchal cord (cord wrapped around baby’s neck) if present 2. Suction (orally then nasally) prior to first ventilation. May require repeated suctioning. 3. Complete delivery. 4. High-flow OXYGEN at 15 LPM via non-rebreather mask. Assist with ventilations as needed. 5. Record APGAR score. 6. Proceed with routine postpartum care 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section C 5 Neonatal Resuscitation OB/GYN

NOTE: Priorities for neonatal resuscitation include management of airway, breathing, circulation, and temperature.

CRITERIA: 1. Rigor mortis. 2. Sloughing of skin. 3. Obvious signs of decomposition.

TREATMENT: 1. Initial Pediatric Care. a. Keep baby warm and stimulate b. APGAR 1 minute after delivery and repeat every 5 minutes 2. Suction mouth, nose, and posterior pharynx as needed. 3. If thick/particulate meconium present after delivery: a. Visualize and suction hypopharynx b. Ventilate between suctioning attempts with BVM 4. Airway management including high-flow oxygen. Support ventilation with BVM using OXYGEN at 15 LPM at a respiratory rate of 40-60/minute as needed. 5. Monitor EKG if available. 6. If heart rate < 80 bpm: a. Continue ventilation at 40-60/minute b. Chest compressions at 120/minute c. Compressions to ventilations ratio --- 3:1 7. If heart rate is between 80-100 bpm, continue ventilation. 8. If heart rate is > 100 bpm, monitor and transport. 9. Evaluate skin color: a. If skin is pink or pink with peripheral cyanosis, monitor and transport. b. If skin is cyanotic throughout, provide OXYGEN via blow-by and transport. 10. Contact Medical Control. ------

BLS Section C 6 Non-Imminent Delivery OB/GYN

CRITERIA (any may be present): 1. Full-term (> 36 weeks) gestation. 2. Regular contractions > 3 minutes apart. 3. Absence of crowning.

EXCLUSIONS: 1. Prolapsed cord. 2. Presenting part. 3. Pre-eclampsia (hypertension due to pregnancy).

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. 3. Assessment and exam of perineum. 4. Transport in left lateral recumbent position if possible. 5. Contact Medical Control. ------

BLS Section C 7 Pre-Eclampsia OB/GYN

NOTE: If seizure activity occurs in the pre-eclamptic patient, refer to Seizure protocol and contact Medical Control.

CRITERIA: 1. Last trimester through 2 weeks following delivery with both of the following: a. SBP > 140 mmHg b. Facial or extremity edema

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM per non-rebreather mask. Apply pulse oximeter if available. 3. Assessment and history. Attempt to minimize external stimuli. 4. Place patient in left lateral recumbent position. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section C 8 Pre-Term Delivery OB/GYN

NOTE: If pre-term delivery occurs, refer to Neonate Resuscitation protocol.

CRITERIA: 1. Less than full term (< 36 weeks) gestation. 2. Contractions regular.

EXCLUSION: 1. Prolapsed cord. 2. Severe bleeding. 3. Malpresentation.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. 3. Assessment and exam of perineum. 4. Obtain history of pregnancy and pre-natal care. 5. Place patient in left lateral recumbent position. Refer to Imminent Delivery protocol if appropriate. 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section C 9 Prolapsed Umbilical Cord OB/GYN

CRITERIA (any may be present): 1. Umbilical cord presents first. 2. Umbilical cord is pinched.

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. 3. Assessment and exam of perineum. 4. Assess umbilical cord with Doppler if available. 5. Assist mother to flex her knees to her chest. 6. Relieve pressure on umbilical cord: a. Insert sterile gloved hand into vagina and lift baby off umbilical cord b. Do not remove your hand 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section C 10 Shoulder Dystocia OB/GYN

CRITERIA: 1. Imminent delivery. 2. Shoulder dystocia (unable to deliver baby past shoulders).

TREATMENT: 1. Initial Medical Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather. 3. Assessment and exam of perineum. 4. Immediate and rapid transport to an appropriate receiving facility. 5. If head is delivered, apply steady downward and posterior traction. This may dislodge shoulder. 6. If shoulder is not dislodged, have an assistant flex patient’s knees on her abdomen, and continue steady traction. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section C 11 Vaginal Bleeding OB/GYN

CRITERIA: 1. Vaginal bleeding anytime during pregnancy as well as during and after delivery.

TREATMENT: 1. Initial Medical Care. 2. Airway management including OXYGEN at 15 LPM via non-rebreather mask. 3. Assessment and exam or perineum. 4. Obtain history of pregnancy and prenatal care. 5. Massage uterus if bleeding is post-delivery. 6. Transport in left lateral recumbent position if possible. 7. Elevate legs 10 degrees if possible. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section C 12

SPECIAL SITUATIONS

BLS Section D 1 Abuse and Neglect Special Situations

NOTE: Illinois Civil Statute 50/3.230 requires all licensed EMS providers to report suspected cases of child abuse or neglect in accordance with the requirements of the Abused and Neglected Child Reporting Act.

CRITERIA (any may be present): 1. Physical abuse – hitting, biting, sexual abuse, or physical restraint. 2. Psychological abuse – verbal threat, causing fear, humiliation, intimidation, or insults. 3. Neglect (active and passive) – withholding medication or food.

TREATMENT: 1. Initial Medical Care. 2. Airway management and OXYGEN as needed. 3. Assessment and history. 4. Treat obvious injuries. 5. Transport. 6. If spouse or guardian refuses to let you transport the patient after treatment: a. Call for law enforcement assistance b. Contact Medical Control 7. Contact Medical Control. ------

BLS Section D 2 Behavioral Emergencies Special Situations

NOTE: 1. Primary consideration is for EMT’s safety. 2. Maintain a safe distance. Do not let patient leave your sight as he/she may go to another room for a weapon. 3. Talk in an even, reassuring tone (one on one, avoid multiple people talking). 4. If threatened with a weapon or other form of physical violence, retreat to a safe location and call for law enforcement assistance. 5. Never let the patient get between you and the exit. 6. Avoid threatening gestures and body language.

CRITERIA (any may be present): 1. Emotional emergencies. 2. Psychiatric emergencies. 3. Potential or attempted suicide. 4. Aggressive or hostile behavior.

TREATMENT: 1. Initial Medical Care. 2. Airway and OXYGEN as needed. 3. Assessment and history: a. Patient’s behavior b. Neurological assessment 4. Restrain patient as needed for frankly suicidal or combative behavior: a. A minimum of 4 rescuers is required for safe restraint b. Restrain in accordance with Region 6 Patient Restraint Guidelines c. Attempt to contact Medical Control prior to restraint if possible 5. Transport. 6. Contact Medical Control. ------

BLS Section D 3 Elderly Abuse Special Situations

NOTE: You are required by law to report suspected elder abuse. Document and report your suspicions to 1-800-252-8966. For Nursing Home abuse/neglect, call 1-800-252-4343.

CRITERIA (any may be present): 1. Physical abuse – hitting, biting, sexual abuse, or physical restraint. 2. Psychological abuse – verbal threat, causing fear, humiliation, intimidation, or insults. 3. Financial or material abuse – theft or misuse of money, property, or forced relocation from one dwelling to another. 4. Neglect (active and passive) – withholding medication, food, exercise, or bathroom assistance.

TREATMENT: 1. Initial Medical Care. 2. Assessment and history. 3. Monitor EKG if available. 4. Treat obvious injuries. 5. Transport. 6. If a caregiver refuses to let you transport the patient after treatment, call for law enforcement assistance. 7. Contact Medical Control. ------

BLS Section D 4 SIDS Special Situations

NOTE: All pediatric arrests should be given the benefit of a resuscitation attempt, unless one of the conditions listed under EXCLUSION exists.

CRITERIA: 1. Infant or child with no pulse and/or no respiration. 2. No apparent cause for the arrest; suspect SIDS (sudden infant death syndrome).

EXCLUSION: 1. Obvious signs of decomposition. 2. Physician or coroner on scene has officially pronounced the child dead.

TREATMENT: 1. Initial Medical Care. 2. High-flow OXYGEN at 15 LPM via BVM. 3. Perform CPR. Refer to Pediatric Arrest protocol. 4. Provide, or arrange provision for, parental psychological support. 5. Load patient and transport immediately; scene time should be minimized. Consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section D 5

TRAUMATIC EMERGENCIES

BLS Section E 1 Glascow Coma Scale Trauma

Indicator Response Score Spontaneous 4 To voice 3 Eye Opening To pain 2 No response 1 Oriented 5 Confused 4 Verbal Response Inappropriate words 3 Incomprehensible 2 No response 1 Obeys command 6 Localizes pain 5 Withdraws to pain 4 Motor Response Flexion to pain 3 Extension to pain 2 No response 1

BLS Section E 2 Initial Trauma Care Trauma

NOTE: Appropriate body substance isolation precautions must be used.

TREATMENT: 1. Perform the Basic Traumatic Life Support (BTLS) primary patient assessment (airway, breathing, circulation, neurological, physical). a. If a “Load and Go” situation is present: i. Advise receiving hospital and transport rapidly ii. Perform secondary (detailed) survey if patient is packaged and ambulance has not arrived b. If a “Load and Go” situation is not present: i. Continue with secondary survey and provide supportive care ii. Scene time should be limited to 10 minutes or less, unless patient is entrapped 2. Contact Medical Control to report assessment findings. 3. Airway management, OXYGEN at 15 LPM via non-rebreather mask, ventilate if necessary, suction if needed. Advanced airway control measures if necessary and as available. Apply pulse oximeter if available. 4. Obtain signs/symptoms, allergies, medications, pertinent medical history, last oral intake, events leading up to crisis (SAMPLE) information and vital signs. Repeat and record vital signs every 5-10 minutes and relay any significant changes to receiving facility. 5. Continue reassessment of the patient while waiting on the ambulance. a. Pay particular attention to re-evaluating patient’s LOC and ABC’s b. Report any changes in the patient’s condition to Medical Control ------

BLS Section E 3 Amputation Trauma

NOTE: Do not delay transport of patient to retrieve an entrapped or lost part. Do not complete partial amputations.

CRITERIA: 1. Partial or complete amputation of body part.

TREATMENT: 1. Initial Trauma Care. 2. High-flow OXYGEN at 15 LPM via non-rebreather mask. 3. Bleeding control. 4. Treat for shock if indicated. 5. Tissue preservation: a. Rinse part gently with normal saline if gross contamination (do not scrub) b. Wrap part in moist sterile gauze (part should never be immersed in water) c. Place wrapped part in water-tight bag and seal d. Label bag with name, date, and time e. Place sealed bag into container filled with water and ice, and transport with patient (do not place directly on ice) 6. Transport 7. Contact Medical Control ------

BLS Section E 4 Burns Trauma

CRITERIA (any may be present): 1. Inhalation injury. 2. Electrical injury. 3. Significant partial or full thickness burns. 4. Chemical injury.

TREATMENT: 1. Assure scene and rescuer safety. 2. Initial Trauma Care. 3. Remove patient from source of burn, and extinguish flames on patient: a. Thermal: cover with moist dressings. b. Chemical: flush with water or saline (brush off dry chemical). c. Tar: cool with water or saline (do not attempt to remove tar). d. Electrical: remove from contact with current only if fully trained and properly equipped (note any secondary fractures or exit wounds caused by current). 4. High-flow oxygen via non-rebreather mask at 15 LPM, ventilate manually if necessary. 5. Perform advanced airway measures as available and needed. 6. Obtain burn history: a. Type of burn / causative agent / time of burn b. Location of burn c. Estimate degree and percent of surface area burned (Rule of Nines or use patient’s palm of hand to represent 1% of body surface) d. Injury environment e. SAMPLE history 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section E 5 Chest Injuries Trauma

CRITERIA (any may be present): 1. Penetrating or sucking chest wounds. 2. Unstable chest wall segment. 3. Signs of blunt trauma to chest. 4. Paradoxical movement (uneven chest rise and fall). 5. Tachypnea (rapid breathing) or respiratory distress with suspected chest injury.

TREATMENT: 1. Initial Trauma Care. 2. High-flow OXYGEN at 15 LPM via non-rebreather mask or manual ventilation per BVM as needed. 3. Perform advanced airway control measures as available and needed. 4. Consider spinal immobilization based on mechanism of injury. 5. Treat any obvious chest injuries as indicated: a. Apply occlusive dressing to sucking chest wounds, leaving one corner open b. Support any unstable chest wall segments with gauze or hand 6. Transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section E 6 Field Triage Trauma

CRITERIA (any may be present): 1. Multiple injured patients beyond immediate capability. 2. Mass EMS Incident.

TREATMENT: 1. Secure scene and park unit in safe location. Active Region 6 Disaster Plan. 2. Establish Incident Command System, designating: a. Incident Commander b. Triage Officer 3. Count total number of patients involved including: a. Uninjured b. Dead c. Refusals 4. Rapidly categorize injured patients according to treatment priority MET⋅TAGs (Medical Emergency Triage Tags): a. Priority 0 (Black) – Obvious Death; non-breathing patients without spontaneous respiration even after repositioning airway. b. Priority 1 (Red) – Immediate; life threatening injures, respiratory compromise, shock, and altered mental status. c. Priority 2 (Yellow) – Delayed; injuries that can withstand up to an hour delay without treatment, extremity fractures, burns. d. Priority 3 (Green) – Ambulatory; all walking wounded and uninjured patients. 5. Establish treatment and loading areas for wounded patients. 6. Treat and transport according to priority: a. All red patients should be transported as soon as possible. b. Yellow patients may be taken to treatment area, and transported as soon as all red patients have been evacuated. c. Green patients may be transported by public transportation or other vehicles. 7. Ascertain family relationships of victims and transport family members to the same hospital destination if possible. 8. Log patient information and provide updates to Incident Commander. 9. Reassign patient priorities as needed to expedite care and as patient conditions change. 10. Contact Medical Control. ------

BLS Section E 7 Head or Spine Injury Trauma

CRITERIA (any may be present): 1. Unresponsive or GCS ≤ 13. 2. Posturing (involuntary flexion or extension of arms/legs – indicates brain injury). 3. Unequal pupils. 4. Loss of motor or sensory function. 5. Mechanism that indicates potential for injury.

EXCLUSION: 1. SBP < 90 mmHg.

TREATMENT: 1. Initial Trauma Care. 2. Maintain airway as necessary while securing cervical spine. 3. High-flow OXYGEN at 15 LPM via non-rebreather mask or manual ventilation per BVM as needed. Do not hyperventilate unless specifically directed by Medical Control. Apply pulse oximeter if available. 4. Perform advanced airway measures as available and needed. 5. Immobilize patient and control bleeding. 6. Assessment factors to consider: a. Restlessness can be a sign of hypoxia b. Assume cervical injury in all patient with significant head injury c. Observe patient closely for changes in LOC d. Avoid the use of nasal airways with suspected facial fractures e. Do not treat hypertension in the head-injured patient. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section E 8 “Load and Go” Situations Trauma

NOTE: Activation of the trauma system should occur for any patient meeting one or more of these criteria.

CRITERIA (any may be present): 1. Traumatic arrest. 2. Penetrating injury to chest, abdomen, head, neck, and/or groin. 3. Two or more proximal long bone fractures. 4. Head injury with prolonged loss of consciousness (> 5 minutes), seizure activity, or unilateral dilated pupil. 5. Burns greater than 15% body surface area. 6. Severe burns involving the face or airway. 7. Flail chest segment. 8. Amputation of extremity. 9. Paralysis or suspected spinal cord injury. 10. Evidence of high speed impact, including: a. Falls from 20 feet or more (or 3x greater than individual’s height). b. Crash speed greater than 20 mph for motorcycle, 40 mph for automobile. c. Deformity to automobile greater than 30 inches. d. Passenger compartment intrusion of 18 inches or more. e. Ejection from vehicle. f. Rollover of vehicle. g. Death of occupant in same vehicle. h. Motorcycle accident. i. Pedestrian struck at greater than 20 mph. 11. Revised Trauma Score less than 10. 12. Glasgow Coma Scale less than 8. 13. Pediatric multiple trauma. 14. Extrication time greater than 20 minutes. 15. Any traumatic injury with BP less than 100 mmHg, respiratory distress, or altered LOC.

TREATMENT: 1. Assure rescuer safety. 2. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 3. Maintain inline stabilization throughout assessment and treatment. 4. Assess circulation and control bleeding. 5. Consider rapid extrication only if significant immediate threat to life exists. 6. Initiate rapid transport with maximum 10-minute scene time limit. 7. Activate trauma system. 8. Contact Medical Control. ------

BLS Section E 9 Painful, Deformed Extremity Trauma

CRITERIA (any may be present): 1. Obvious open fracture. 2. Deformity. 3. Swelling. 4. Point tenderness. 5. History of injury consistent with a fracture.

TREATMENT: 1. Initial Trauma Care. 2. Evaluation of pulse, motor, and sensory (PMS) functions distal to the injury. 3. Immobilize fracture, covering open injuries with sterile dressing. 4. Reassess extremity PMS. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section E 10 Shock (Traumatic) Trauma

CRITERIA (any may be present): 1. Systemic hypotension. 2. Altered LOC. 3. Inadequate perfusion (pale, cool, mottled). 4. Massive blood loss. 5. Crush Syndrome. 6. Suspected pelvis or long bone fractures.

TREATMENT: 1. Assure rescuer safety. 2. Initial Trauma Care. 3. Manually stabilize cervical spine while opening airway. 4. High-flow OXYGEN at 15 LPM via non-rebreather mask or manual ventilation per BVM as needed. Apply pulse oximeter if available. 5. Perform advanced airway control measures as available and as needed. 6. Control bleeding. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section E 11 Traumatic Arrest Trauma

CRITERIA: 1. Pulseless and apneic trauma patient not meeting the Trauma Field Death Declaration criteria.

TREATMENT: 1. Assure rescuer safety. 2. Attempt to maintain inline stabilization throughout assessment and treatment. 3. Airway control with OXYGEN at 15 LPM via BVM. Begin CPR. 4. Perform advanced airway management as needed. Apply pulse oximeter if available. 5. Monitor EKG if available. 6. Load and Go within 10 minutes of extrication if ambulance has arrived. 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section E 12 Trauma Field Death Declaration Trauma

Significant traumatic injury and patient found pulseless and apneic NO upon EMS arrival?

YES

Injury incompatible with life? (decapitation, torso transection)

NO Initiate Traumatic Arrest Protocol and Transport*

YES Presence of significant time interval since death? (lividity, rigor mortis, decomposition)

NO

Patient less than 14 years of age?

Call Medical Control for Death Declaration at scene (call Coroner) NO YES

Witnessed EMS arrest?

NO

NO Any signs of life reported/observed? (organized EKG activity, spontaneous movement, pupillary reflexes)

*EMS witnessed cardiopulmonary arrest and 15 minutes of CPR per protocol and unsuccessful resuscitation may be pronounced dead in the field as per Medical Control.

BLS Section E 13

PEDIATRIC EMERGENCIES

BLS Section F 1 Initial Pediatric Care Pediatric

NOTE: The pediatric patient is determined by weight as well as age. On average, persons under the age of 14 years old and less than 90 pounds may fit criteria for pediatric protocol. However, it is up to the discretion of the resource hospital physician to treat as a pediatric patient or adult.

CRITERIA: 1. Any patient under 14 years of age and 90 pounds, who presents with a medical or traumatic problem.

TREATMENT: 1. Assess ABC’s. 2. Administer OXYGEN via one of the following methods: a. Non-rebreather mask at 8-15 LPM if respiratory distress or altered mental status and if tolerated. Support ventilation with BVM as indicated. b. Nasal cannula at 2-6 LPM if tolerated and patient is stable. c. “Blow-by” method at 8-15 LPM. 3. Complete initial assessment; obtain SAMPLE history. Repeated assessments should be performed at least every 5 minutes on the unstable patient, and at least every 15 minutes on the stable patient. 4. Obtain vital signs. Repeat and record vital signs every 5-10 minutes and relay any significant changes to persons who continue patient care. 5. Apply pulse oximeter if available. Attempt to keep oxygen saturation above 97%. 6. Consider blood sugar determination. 7. Keep patient warm. 8. Consider intercept per BLS Intercept Criteria. 9. Contact Medical Control for further direction or questions. 10. Perform detailed secondary assessment (usually performed waiting on ambulance) and provide care for those conditions/injuries. 11. If patient arrests, begin CPR and follow Pediatric Arrest protocol. ------

BLS Section F 2 Pediatric Coma Scale Pediatric

Indicator Child Score Infant Score Spontaneous 4 Spontaneous 4 To voice 3 To voice 3 Eye Opening To pain 2 To pain 2 No response 1 No response 1 Oriented 5 Coos & babbles 5 Confused 4 Irritable cries 4 Verbal Response Inappropriate words 3 Cries to pain 3 Incomprehensible 2 Moans to pain 2 No response 1 No response 1 Obeys command 6 Moves spontaneously 6 Localizes pain 5 Withdraws to touch 5 Withdraws to pain 4 Withdraws to pain 4 Motor Response* Flexion to pain 3 Decorticate posturing 3 Extension to pain 2 Decerebrate posturing 2 No response 1 No response 1

*If the patient is intubated, unconscious, or preverbal, the most important part of this score is motor response. This section should be carefully evaluated.

Decorticate posturing = arms flexed, wrists flexed, hands clenched Decerebrate posturing = arms extended, wrists flexed, hands clenched, arched back

BLS Section F 3 Abuse and Neglect Pediatric

CRITERIA (any may be present): 1. A discrepancy exists between history of injury and physical exam. 2. Caregiver provides a changing or inconsistent history. 3. There is a prolonged interval between injury and the seeking of medical help. 4. Child has a history of repeated trauma. 5. Caregiver responds inappropriately or does not comply with medical advice. 6. Suspicious injuries are present (long bone fractures, old scars/bruises, bites, cigarette burns, rope marks, belt imprints, genital/perianal trauma, sharply demarcated burn scalds). 7. Child < 10 years left unattended or unsupervised. 8. Abandonment. 9. Caregiver incapacitated (drug/alcohol intoxication, disabling psychiatric symptoms). 10. Child appears inadequately fed, clothed, or sheltered. 11. Child is found to be intoxicated with alcohol or drugs. 12. Environment dangerous to child (weapons within reach, unsanitary conditions, playing near open windows). 13. Caregiver has not provided, or refuses to permit, medical treatment of child’s illness.

TREATMENT: 1. Initial Pediatric Care. 2. Treat obvious injuries. Refer to Trauma protocols as indicated. 3. Note discrepancies in child and parent history: a. Injuries b. Environmental surroundings c. Child’s interaction with parents 4. If transport refused by parent/caregiver: a. Assess scene safety b. Contact Medical Control c. Contact law enforcement d. Don’t confront caregivers 5. Transport. 6. Report suspicions to ED physician/nurse and/or Department of Children and Family Services (DCFS) at 1-800-25-ABUSE. 7. Contact Medical Control. ------

BLS Section F 4 Airway Care Pediatric

CRITERIA (any may be present): 1. Pediatric partial or full foreign body airway obstruction. 2. Signs and symptoms of epiglottitis. 3. Pediatric tracheostomy.

TREATMENT: 1. Initial Pediatric Care. 2. Airway management and OXYGEN at 8-15 LPM via non-rebreather mask; assist ventilations as needed. 3. If partial or complete airway obstruction: a. Encourage patient to cough; reposition airway b. Perform chest compressions and/or back blows as appropriate to patient’s age 4. If patient presents with stridor or signs of epiglottitis: a. Keep patient stimulation to a minimum b. Place child upright in position of comfort c. Administer OXYGEN at 8-15 LPM via “blow-by” d. Refer to Epiglottitis protocol 5. If pediatric tracheostomy: a. Apply OXYGEN via tracheostomy collar or mask b. Suction as necessary c. If tracheostomy is obstructed, remove inner cannula and have caregiver replace tracheostomy tube if able d. Refer to Tracheostomy protocol 6. Transport patient in position of comfort. 7. Contact Medical Control. ------

BLS Section F 5 Allergic Reaction/Anaphylaxis Pediatric

NOTE: For patients experiencing a possible allergic reaction without serious signs or symptoms, perform Initial Medical Care and contact Medical Control.

CRITERIA: 1. History of recent exposure to allergen including hives, itching, rash, or swelling in conjunction with: a. Respiratory difficulty/stridor or b. Signs and symptoms of shock

TREATMENT: 1. Initial Pediatric Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Assist ventilations with BVM as needed. Apply pulse oximeter if available. 3. Assessment and history. 4. Administer EPINEPHRINE via pediatric autoinjector (patient must weigh between 33-66 pounds [15-30 kg] for child dose of 0.15 mg; if over 66 pounds [30 kg] refer to adult protocol). 5. If patient is in mild respiratory distress or severe cardiorespiratory compromise, give dose of patient’s own INHALER. 6. Transport rapidly and call for intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section F 6 Altered LOC Pediatric

CRITERIA: 1. Patient less than 14 years old and less than 90 pounds. 2. Altered level of consciousness.

EXCLUSION: 1. Signs of hypoperfusion (in which case see Shock protocol). 2. Signs of respiratory distress (in which case see Respiratory Distress protocol).

TREATMENT: 1. Initial Pediatric Care. 2. Airway management with OXYGEN at 15 LPM via non-rebreather. Assist ventilations via BVM as needed. Apply pulse oximeter if available. 3. Check blood glucose if able. If glucose ≤ 60 mg/dL (or suspected), ORAL GLUCOSE 15 g PO may be administered only if patient is conscious, can protect own airway, and has intact gag reflex. 4. Monitor EKG if available. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section F 7 Burns Pediatric

NOTE: Use the palm of child’s hand to represent 1% of body surface. All burns in the pediatric patient should be assessed for abuse potential.

CRITERIA: 1. Patient under 14 years of age and under 90 pounds. 2. Signs and symptoms of burn injury, including: a. Inhalation injury. b. Electrical injury. c. Significant partial or full thickness burns. d. Chemical injury.

TREATMENT: 1. Assure scene and rescuer safety. Remove patient to safety. 2. Initial Pediatric Care. 3. Airway management with OXYGEN at 8-15 LPM via non-rebreather. Assist ventilations as needed. Apply pulse oximeter if available. 4. Refer to Respiratory Distress, Shock, or Trauma protocols as needed. 5. Assess and treat burn according to type: a. Thermal burns (1st degree) i. Assess percentage and depth of burn ii. Cool burned area with water or saline iii. If less than 20% burned surface area involved, apply sterile saline soaked dressings b. Thermal burns (2nd and 3rd degree) i. Wear sterile gloves/mask ii. Cover burn with dry sterile dressings iii. Place patient on clean sheet and cover with dry clean sheet c. Electrical burns i. Immobilize as indicated ii. Identify and document any entrance/exit wounds iii. Cover with dry sterile dressings iv. Assess neurovascular status of affected part d. Chemical burns i. Brush away any powdered chemical prior to flushing ii. Remove affected clothing if possible iii. If eye involvement, irrigate immediately and continuously during transport with sterile saline (do not contaminate uninjured eye during irrigation) 6. Keep warm and transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section F 8 Cardiopulmonary Arrest Pediatric

CRITERIA (any of the following): 1. Child who is: a. Unresponsive b. Apneic c. Pulseless d. Abnormally slow pulse with signs of poor perfusion

TREATMENT: 1. Initial Pediatric Care. 2. Assess and maintain airway. 3. Assist respirations and hyperventilate with 15 LPM of OXYGEN if: a. Neonate less than 1 month old and respirations < 40/minute. b. Infant between 1-6 months old and respirations < 25/minute. c. Child between 6 months and 6 years old and respirations < 20/minute. 4. Assess circulatory status. Start CPR if, despite ventilation and OXYGEN, you find: a. No pulse present. b. Neonate with pulse < 60/minute. c. Neonate with pulse < 80/minute and severe signs of deterioration (loss of consciousness and signs of hypoperfusion/shock) or loss of airway. 5. CPR for 1 minute, then attach AED and analyze. 6. If shock is indicated, defibrillate according to AHA guidelines and/or manufacturer’s recommendations. 7. Assessment and history. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section F 9 Environmental Hyperthermia Pediatric

CRITERIA (any may be present): 1. Patient under 14 years of age and under 90 pounds. 2. Signs and symptoms of environmental hyperthermia, including: a. Hot, dry, flushed, or ashen skin b. Tachycardia c. Tachypnea (rapid respirations) d. Diaphoresis (excessive sweating) e. Decreasing consciousness f. Profound weakness and fatigue g. Vomiting, diarrhea h. Hypoperfusion i. Muscle cramps

TREATMENT: 1. Initial Pediatric Care. 2. Secure and maintain airway with OXYGEN at 15 LPM via non-rebreather mask. Assist ventilations via BVM as needed. Apply pulse oximeter if available. 3. Place patient in cool environment. Remove clothing as appropriate. 4. If normal level of consciousness, diaphoresis, and no signs of hypoperfusion, give cool liquids PO. 5. Monitor EKG if available. 6. If decreased consciousness, dry skin, or signs of hypoperfusion, initiate active cooling. a. Cold pack to head, neck, armpits, groin, behind knees, and lateral chest b. Tepid (lukewarm) water via sponge or spray c. Manually fan body to evaporate and cool d. Stop cooling if shivering occurs 7. Transport. 8. Contact Medical Control. ------

BLS Section F 10 Epiglottitis Pediatric

NOTE: Epiglottitis is a serious medical emergency in children and can be life threatening. Patients with the following signs and symptoms should be transported sitting upright, with high-flow oxygen via non-rebreather mask. Be advised that signs and symptoms of epiglottitis are similar for partial airway obstruction. Do not insert anything into the child’s mouth. Stimulation of the epiglottitis can cause complete airway obstruction. If the patient stops breathing, ventilate with BVM and use oral airways only as a last resort.

CRITERIA: 1. Patient less than 14 years old and less than 90 pounds. 2. Signs and symptoms of epiglottitis including: a. Acute onset b. High fever c. Shallow breathing d. Dyspnea e. Inspiratory stridor f. Wheezing g. Drooling h. Hoarseness i. Choking

TREATMENT: 1. Initial Pediatric Care. 2. Keep patient stimulation to a minimum. 3. Allow children to remain in position of comfort. 4. Deliver OXYGEN at 8-15 LPM via “blow-by” method unless patient is in acute distress (in which case assist respirations via BVM). Do not use airway adjuncts unless airway compromise exists (in which case call Medical Control). 5. Allow parents/guardians to assist in calming patient. 6. Rapid and gentle transport – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section F 11 Frostbite Pediatric

NOTE: Do not massage the frostbitten area at any time.

CRITERIA (any may be present): 1. Cold exposure. 2. Signs and symptoms of frostbite, including: a. Red, inflamed tissue. b. Gray or mottled tissue. c. Waxy tissue that is firm upon palpation.

TREATMENT: 1. Remove from cold. 2. Initial Pediatric Care. 3. Cover frostbitten nose or ears with a warm hand. 4. Place frostbitten hand in his/her armpit. 5. All other areas should be covered and protected from exposure. 6. Transport without delay. 7. Contact Medical Control. 8. If estimated time of arrival (ETA) at hospital is greater than 60 minutes, begin active rewarming: a. Immerse extremity in water kept at a temperature of 100-105 °F. b. Rewarming should take 30-60 minutes. c. Rewarming is complete when frozen area is warm to touch and deep red or bluish in color. d. After rewarming, dry gently and cover part with dry sterile dressing and elevate on pillow. ------

BLS Section F 12 Hypothermia (Moderate) Pediatric

CRITERIA: 1. Exposure to cold environment. 2. Signs and symptoms of moderate hypothermia, including: a. Rectal temperature 84-94 °F b. Patient conscious – may be lethargic c. Shivering d. Pale, cold skin

TREATMENT: 1. Initial Pediatric Care. Consider trauma situation and cervical spine precautions. 2. Secure and maintain OXYGEN at 15 LPM via non-rebreather mask. Apply pulse oximeter if available. 3. Replace any wet clothing with dry sheets and blankets. 4. Hot packs may be applied to axillae, groin, and abdominal areas; avoid direct skin contact if no cardiorespiratory compromise. 5. Monitor EKG if available. 6. Assess and treat for other injuries as necessary. 7. Transport. 8. Contact Medical Control. ------

BLS Section F 13 Hypothermia (Severe) Pediatric

CRITERIA (any may be present): 1. Rectal temperature less than 84 °F. 2. Signs and symptoms of severe hypothermia, including: a. Decreased LOC b. Cold skin c. Inaudible heart tones d. Unreactive pupils e. Slow respirations

TREATMENT: 1. Initial Pediatric Care. Consider trauma situation and cervical spine precautions. 2. Secure and maintain airway with warm OXYGEN at 15 LPM via non-rebreather mask. Assist ventilations with BVM as needed. Apply pulse oximeter if available. 3. Replace any wet clothing with dry sheets and blankets. 4. Hot packs may be applied to axillae, groin, and abdominal areas; avoid direct skin contact. 5. Monitor EKG if available. 6. If cardiopulmonary compromise: a. “Load and Go” situation b. Avoid unnecessary manipulation and rough handling c. Avoid airway adjuncts d. Do not hyperventilate e. Take one full minute to establish pulselessness (difficult to determine in a hypothermic patient) in order to avoid unnecessary CPR and its potential complications f. Perform chest compressions if pulseless g. Refer to Pediatric Cardiopulmonary Arrest protocol as indicated. Once CPR has begun, it should continue until the patient is evaluated by the Emergency Department physician. h. Place hot packs to axillae, groin, and abdominal areas; avoid direct skin contact 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section F 14 “Load and Go” Situations Pediatric

NOTE: Activation of the trauma system should occur for any patient meeting one or more of these criteria.

CRITERIA (any may be present): 1. Penetrating injury to chest, abdomen, head, neck, and/or groin. 2. Two or more proximal long bone fractures. 3. Burns greater than 15% total body surface area (TBSA). 4. Severe burns involving the face or airway. 5. Flail chest segment. 6. Amputation of extremity. 7. Paralysis or suspected spinal cord injury. 8. Evidence of high speed impact, including: a. Falls from 20 feet or more. b. Crash speed greater than 20 mph. c. Deformity to automobile greater than 30 inches. d. Passenger compartment intrusion of 18 inches or more. e. Ejection from vehicle. f. Rollover of vehicle. g. Death of occupant in same vehicle. h. Motorcycle accident. i. Pedestrian struck at greater than 20 mph. 9. Revised Trauma Score less than 10. 10. Glasgow Coma Scale less than 8. 11. Pediatric multiple trauma. 12. Extrication time greater than 20 minutes. 13. Any traumatic injury with BP < 100 mmHg, respiratory distress, or altered LOC.

TREATMENT: 1. Assure rescuer safety. 2. Initial Pediatric Care; immobilize spine as indicated. 3. Airway management with OXYGEN at 15 LPM via non-rebreather; perform advanced airway control as needed. Apply pulse oximeter if available. 4. Determine Pediatric Coma Score; children with PCS ≤ 12 generally require assisted ventilations with BVM. 5. Assess circulation and control bleeding. 6. If signs of hypoperfusion, refer to Shock or Pediatric Cardiopulmonary Arrest protocols as indicated. 7. Initiate rapid transport with maximum 10-minute scene time limit. Activate trauma system. 8. Monitor EKG if available. 9. Splint or immobilize secondary injuries as time permits. 10. Contact Medical Control. ------

BLS Section F 15 Near Drowning Pediatric

NOTE: Aggressive airway management is important. High potential for associated injury (i.e. cervical spine injury, hypothermia) exists. All patients with low core temperatures should be resuscitated.

CRITERIA: 1. Patient younger than 14 years old and less than 90 pounds. 2. Submersion.

TREATMENT: 1. Assure rescuer safety and remove patient from water with cervical spine immobilization. 2. Initial Pediatric Care. Maintain cervical spine immobilization. 3. Secure and maintain airway with OXYGEN at 15 LPM via non-rebreather. a. Relieve upper airway obstruction as indicated b. Assist ventilations via BVM as needed 4. Refer to Pediatric Arrest, Respiratory Distress, or Hypothermia protocols as indicated. 5. Monitor EKG if available. 6. Rewarming: a. Remove patient to warm environment b. Remove wet clothing to prevent further heat loss c. Place heat packs to axillae and groin; avoid direct skin contact 7. Transport – consider intercept per BLS Intercept Criteria. 8. Contact Medical Control. ------

BLS Section F 16 Poisoning/Drug Overdose Pediatric

NOTE: Anticipate vomiting, seizure, respiratory arrest, and dysrhythmias; refer to appropriate protocol. Do not induce vomiting in cases where caustic substance ingestion is suspected.

CRITERIA (any may be present): 1. Patient younger than 14 years old and less than 90 pounds. 2. Adverse effects of plants, foods, chemicals, or pharmaceutical agents on the body. 3. Generally absorbed in four ways: a. Ingestion. b. Inhalation. c. Absorption (includes eyes, skin, and mucous membranes). d. Injection (may be accidental or intentional).

TREATMENT: 1. Assess scene safety. Avoid self-exposure and stop patient exposure. 2. Initial Pediatric Care. 3. Airway management with OXYGEN at 15 LPM via non-rebreather mask. Assist ventilations as needed. Apply pulse oximeter if available. 4. In case of absorbed exposure: a. Remove all clothing as needed b. Use large volume of clear water to irrigate skin and/or eyes c. Avoid emergency personnel contamination 5. Assessment and history. 6. Save all bottles and containers, and check all vomitus for pill fragments. 7. It patient’s guardian refuses treatment or transport, request assistance from law enforcement. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section F 17 Respiratory Distress Pediatric

NOTE: Respiratory distress may be caused by bacterial or viral infections. Healthcare workers should utilize appropriate universal precautions for safety of self and others.

CRITERIA: 1. Severe dyspnea with tachypnea, including use of accessory muscles. 2. Physical exam including noisy respirations which may include any of these findings: a. Wheezing. b. Grunting. c. Inspiratory rales. d. Rhonchi. e. Decreased breath sounds or decreased air exchange. 3. History of trauma, asthma, COPD, epiglottitis, bronchitis, recent pneumonia, or foreign body obstruction.

TREATMENT: 1. Initial Pediatric Care. 2. Maintain open airway and cervical spine control. Administer OXYGEN at 8-15 LPM via non-rebreather mask. Assist with BVM and suction as necessary. Apply pulse oximeter if available. 3. Check any obvious injuries (i.e. flail chest, sucking chest wound). 4. Monitor EKG if available. 5. Transport – consider intercept per BLS Intercept Criteria. 6. Contact Medical Control. ------

BLS Section F 18 Seizures Pediatric

CRITERIA (any may be present): 1. Active seizure. 2. Recurrent seizure or prolonged seizures (status epilepticus). 3. Postictal state.

TREATMENT: 1. Initial Pediatric Care. 2. Establish patent airway, administer OXYGEN at 15 LPM via non-rebreather mask, and suction if necessary. Pulse oximeter if available. 3. If blood sugar ≤ 60 mg/dL (or suspected), administer ORAL GLUCOSE at 15 g PO may be administered only if patient is conscious, can protect own airway, and has an intact gag reflex. 4. Monitor EKG if available. 5. Protect patient from self-inflicted injury during clonic/tonic movements. 6. Immobilize cervical spine if appropriate. 7. Obtain history of events. 8. If patient has signs and symptoms of febrile seizure, in addition to above: a. Attempt to cool the patient by removing excessive clothing layers b. May use towels moistened with cool water 9. If status epilepticus exists, follow intercept procedure. 10. Transport – consider intercept per BLS Intercept Criteria. 11. Contact Medical Control. ------

BLS Section F 19 Shock Pediatric

NOTE: Smaller body mass in children results in hypoperfusion more quickly from vomiting and diarrhea.

CRITERIA (any may be present): 1. Increased respiratory effort. 2. Cyanosis despite oxygen administration. 3. Truncal pallor and coolness. 4. Hypotension (ominous sign). 5. Bradycardia (late sign). 6. Weak, thready, or absent peripheral pulses. 7. Delayed capillary refill. 8. No palpable blood pressure. 9. Decreasing consciousness; lethargy

TREATMENT: 1. Initial Pediatric Care. 2. Maintain airway and administer OXYGEN at 15 LPM via non-rebreather mask. Assist respirations with BVM if needed. Apply pulse oximeter if available. 3. Stop any external bleeding by direct pressure. 4. Maintain cervical spine immobilization and spinally immobilize if trauma-related. 5. Monitor EKG if available. 6. Maintain warmth. 7. If blood glucose ≤ 60 mg/dL (or suspected), administer ORAL GLUCOSE at 15 g PO only if patient is conscious, can protect own airway, and has intact gag reflex. 8. Transport – consider intercept per BLS Intercept Criteria. 9. Contact Medical Control. ------

BLS Section F 20 Tracheostomy Pediatric

CRITERIA: 1. Tracheostomy.

TREATMENT: 1. Initial Pediatric Care. 2. Administer OXYGEN via tracheostomy collar at 15 LPM. If necessary, assist with bag valve device attached to tracheostomy port. Suction as needed. Apply pulse oximeter if available. 3. If tracheostomy is patent, perform frequent reassessments and repeat suctioning as necessary. 4. If tracheostomy is obstructed, repeat suctioning after removing the inner cannula (if present). If still obstructed, have caregiver change tracheostomy tube. Reassess patency. 5. If tracheostomy is still obstructed even after changing the tracheostomy tube, ventilate with mask to mouth. If no chest rise, ventilate with infant mask to stoma. 6. Transport in position of comfort – consider intercept per BLS Intercept Criteria. 7. Contact Medical Control. ------

BLS Section F 21

GENERAL PROTOCOLS

BLS Section G 1 BLS Intercept Criteria General

NOTE: The appropriate ILS or ALS vehicle will be dispatched to meet a BLS unit or team in the following situations.

CRITERIA (any may be present): 1. The BLS unit or team requests intercept. 2. The ECRN or MD at the resource hospital deems intercept necessary based upon the condition of the patient. 3. Any of the following categories of patients: a. Active seizures, acute MI, cardiogenic shock. b. Active seizures. c. Acute exacerbation of COPD. d. Anaphylaxis. e. Any patient situation that higher level of care may benefit the patient. f. Asthma attack. g. Cardiac and respiratory arrest. h. Croup. i. Diabetic reaction. j. Drowning/near drowning. k. Electrical injuries. l. Epiglottitis. m. Obstetrical emergencies. n. Obstructed airways that cannot be cleared. o. Patients that meet trauma criteria including patients with tension pneumothorax, cardiac tamponade (fluid fills up space between myocardium and pericardium), sucking chest wounds, traumatic asphyxia, and flail chest. p. Pulmonary edema or severe CHF. q. Symptomatic overdose/poisoning. r. Symptomatic hypertension (i.e. CVA with high BP, headache, blurred vision, weakness). s. Unconscious for unknown reasons.

VARIABLES: 1. The decision to utilize an intercept may be influenced by various factors such as: a. Availability of higher-level providers. b. Road conditions. c. Weather conditions. d. Geographic location. e. Improvement of patient condition. f. Refusal of higher-level care by patient with appropriate documentation.

The decision not to request an intercept, or to disregard an intercept on a patient who meets the intercept criteria should always be made in the patient’s best interest. The BLS agency should contact Medical Control for guidance in these situations. ------

BLS Section G 2 Radio Report General

RADIO PROCEDURE: 1. Unit must identify call letters, level of service, and city of origin. a. Non-transport agencies may use MERCI (Medical Emergency Radio Channel for Illinois), local radio frequency, or cellular phone to communicate with Medical Control. b. Report should be called to receiving facility on all transports. 2. Standard report: a. ETA b. Age and sex c. Mechanism of injury/Nature of illness d. Pertinent findings 3. Orders must be confirmed when received from Medical Control by repeating them verbatim back to Medical Control for verification. 4. In the event of communications system failure, protocols may be used as listed including Medical Control considerations. Protocol usage must be documented by risk screen or incident report and submitted to EMS system office within 24 hours. 5. In the event that a provider deviates from these protocols, a complete written explanation must be completed and submitted to the EMS Medical Director within 24 hours of the occurrence. ------

BLS Section G 3 Patient Refusal General

NOTE: In situations in which the EMS provider is not completely certain that a patient is impaired, it is always safer to err on the side of calling the physician for advice and/or providing medical care and transportation.

CRITERIA: 1. Patient refuses to be taken to the hospital. 2. Patient is 18 years of age or older, or is an emancipated minor. 3. Patient under 18 years of age* who has a legal guardian that is present or is contacted from the scene and asks for/agrees with the refusal. 4. Patient or legal guardian is competent (judgment not impaired) to make refusal decision** (i.e. not intoxicated with drugs/alcohol, not psychologically impaired).

TREATMENT: 1. If criteria not met, initiate care under implied consent***. 2. If criteria met, ask patient or guardian to explain reasons for refusal and explain risks of refusal of medical care. 3. If patient or guardian does not demonstrate a reasonable understanding of #2, initiate care under implied consent. 4. If the refusal represents a significant risk to the patient (based on gross trauma or mechanism of injury, severity of medical illness), contact hospital/physician for advise. 5. If all criteria met for refusal and risks explained and understood, patient/guardian should sign refusal form (if unable or unwilling, document circumstances).

*Minors may not refuse medical care for themselves under specific circumstances if their parent or guardian is not present to make this decision for them.

**Incompetent patient/guardians may include the following: patients in severe pain, shock, dazed from the situation, mentally unstable, drug or alcohol influenced, hypoxic, head-injured, the elderly, postictal patients, patients recovered from hypoglycemia.

***Implied consent: if a person were capable of giving consent he/she would do so in these circumstances. An impaired individual may not recognize his/her need for medical treatment, thus his/her consent is assumed under the circumstances. ------

BLS Section G 4 Triple Zero General

CRITERIA: 1. Patient is pulseless, no detectable blood pressure, and not breathing. 2. Exhibits one or more of the following long-term indications of death: a. Rigor mortis. b. Lividity. c. Decomposition. d. Mummification. e. Decapitation. f. Full arrest that has been unequivocally present for at least 20 minutes without efforts at resuscitation prior to arrival.

EXCLUSION: 1. Valid DNR order. 2. Associated with hypothermia, drowning, sedation, intoxication, uncertain time of arrest, or found in a cold environment.

TREATMENT: 1. Contact Medical Control to confirm Triple Zero. 2. Notify the county coroners/medical examiner office and law enforcement immediately. 3. If patient confirmed Triple Zero, the patient may be transferred to another ambulance service, appropriate police department, or an agency that is appropriate for the circumstance who agrees to transport the patient to the hospital to have death pronounced by an individual legally authorized to do so. 4. The EMT shall standby until the coroner arrives on the scene or the coroner’s office requests a transfer of the victim to the morgue. 5. In those cases in which there is obvious death associated with a fire, Fire Department personnel may “recognize” the obvious death and report said death to the coroner. 6. When law enforcement personnel are involved in an investigation, please refer to the EMS Involvement in Crime Scene protocol. ------

BLS Section G 5 EMS Involvement in Crime Scene General

PURPOSE: To define those situations in which Police personnel, who have examined the victim, determine in their judgment that a victim is dead and rightly deny entry to Fire/EMS personnel in order to maintain the integrity of a potential crime scene.

PROCEDURE: 1. When Police personnel arrive before Fire/EMS personnel at the scene of an incident that involves what appears to be the death of a victim, they shall report the general condition of the victim to the Fire/EMS personnel. 2. If the victim shows signs of lividity, rigor mortis, decomposition, or has been decapitated, then they shall report the condition of the victim to the Fire/EMS personnel in these terms. If the victim is reported by Police personnel to show any of these conditions, then Fire/EMS personnel will not be required to examine the victim or run an EKG strip. 3. If the previous conditions are not present, then Police personnel shall allow two Fire/EMS personnel to check the condition of the patient (obtain history, determine pulselessness/no respirations/unresponsiveness). Personnel should then contact Medical Control immediately. 4. Fire/EMS personnel who are involved in providing care for a victim that may not be a viable patient need to be cognizant of the need to maintain the integrity of a potential crime scene. 5. Other conditions will be dealt with on a case-by-case basis. If other conditions are present that are obviously inconsistent with life, such as total evisceration or extreme disfigurement and distortion of the body, the Police personnel must describe the condition of the victim to the Fire/EMS personnel. The Fire/EMS personnel will then make a determination as to whether or not the victim should be evaluated for signs of life and the ultimate decision in this case rests with Fire/EMS personnel. ------

BLS Section G 6